HEPATITIS A

High risk areas All countries outside Western Europe, Scandinavia, North America, Japan, New Zealand, Australia; particularly those with poor sanitation and public hygiene.

Transmission Spread by faecal-oral route.

Recommendations for travellers Active vaccination with 'non-live' inactivated vaccine, is used to give longterm protection against hepatitis A. Active vaccination can be used from one year of age.
In children hepatitis A is usually mild but asymptomatic infected children can spread virus to others.(Discuss with the parents)
Normal pooled Immunoglobulin (passive vaccination) is an alternative when active vaccination is contraindicated or when insufficient time is available before departure (less than 2 weeks) for protection to have been achieved.

Active Vaccine

Always confirm details with manufacturer's literature

Adults
Havrix (Smith Kline Beecham), Avaxim (Pasteur Merieux), Vaqta (MSD
Type: non-live (inactivated).
Age: For those over 16 years of age.
Primary course: 1 dose.
Dose: 1ml (Havrix), 0.5ml (Avaxim and Vaqta).
Route: I/M (deltoid not gluteal region)
Protection achieved: after 2 weeks.
First booster: 6-12mths (Havrix), 6mths (Avaxim and Vaqta).
Length of protection: At least 1 year after primary dose and 10 years after the first booster.
Delayed first boosters
The manufacturer's do not give clear advice on what to do if the patient fails to return within 6-12 months for their first booster.
If delayed the first booster will give at least one year's protection, as does the primary dose.
However it is suggested you restart the course if this first booster is delayed by more than 1 year.
Further boosters: 10 yearly.

Children
Havrix Junior Monodose (Smith Kline Beecham) and Vaqta paediatric (MSD, distributed by Pasteur Merieux)
Type: non-live, inactivated
Age: For those 1yr to 15yrs of age.
Primary course: 1 dose
Dosage: 0.5ml.
Site: Deltoid - not gluteal region.
Protection achieved: 2-4 weeks after vaccination.
First booster: After 6-12 months (Havrix Junior), 6-18 months (Vaqta paediatric)
Length of protection: At least 1 year after primary dose 10 years after booster.
Further boosters: 5-10 yearly. Side effects: Usually mild and most commonly local redness and swelling. Less commonly fever, malaise, headache and nausea. Contraindications: Hypersensitivity to components of the vaccine. Febrile infections. In common with other inactivated viral vaccines it is not advised in pregnancy and lactation unless risk is substantial.

Serotesting
Serology testing for immunity after vaccination.
The usual IgG test used to confirm previous "naturally acquired" infection is notreliable in this context since it is not sufficiently sensitive. If in doubt it is more logical to give unnecessary extra doses rather than risk inadequate protection.

Combined Hepatitis A and Hepatitis B Vaccine (Smith Kline Beecham).
For adults (TWINRIX)
This combined hepatitis A and B vaccine, introduced in 1997, can be used in adults and adolescents over 16yrs.
For For children (TWINRIX JUNIOR)
This can be used from 1 year up to and including 15 years of age.
Primary schedule: 3 doses
Schedule: 3 doses with 4 wks between 1st and 2nd doses and 5 mths between 2nd and 3rd doses.
Boosters: 10 yearly for hepatitis A. The duration of immunity after hepatitis B vaccination is not yet clear but it is thought boosters will not be needed more often than 5 yearly.

Notes:
04/11/98
Hepatitis B immunisation and the lack of any proven link with de-myelinating disease.
The World Health Organisation has issued a statement (WER 1998,73,329) expressing concern that the French Ministry of Health has suspended immunisation of teenagers and that this decision could influence the success of the international campaign to include hepatitis B immunisation in national programmes.
WHO states that 'none of the evidence gathered by WHO from numerous scientifically reliable sources supports the causal link between hepatitis B vaccine and de-myelinating disease.