Hepatitis A Vaccine Information

Indications for use of vaccine

Hepatitis A vaccine is recommended for:

• Travellers (who do not have natural immunity to hepatitis A) visiting areas of moderate or high hepatitis A endemicity, especially if sanitation and food hygiene are likely to be poor.
• Travellers with chronic liver disease. Although not at greater risk of hepatitis A infection, the disease can produce a much more serious illness in this group.
• Travellers whose sexual behaviour is likely to put them at an increased risk. A significant increase in hepatitis A has been noted in men who have sex with men. [1,2]
  Other specific indications for vaccination can be found in Immunisation Against Infectious Disease

Availability of vaccine

There are several vaccines licensed for use in the UK, all of which are inactivated.

Details of these and manufacturers can be found in the summary table below.

There are also combined hepatitis A and B, and hepatitis A and typhoid vaccines available.

Vaccine schedules

Vaccine Manufacturer/distributor	Schedule	Length of Protection*	Age range
Avaxim Aventis Pasteur MSD	2 doses, given 6-12 months apart	10 years following booster*	Adults from 16 years
Epaxal Berna Boitech/Masta Ltd	2 doses, given 6-12 months apart	Estimated 20 years following booster*	Adults & children from 1year
Havrix Monodose GlaxoSmithKline	2 doses, given 6-12 months apart	10 years following booster*	Adults from 16 years
Havrix Junior Monodose GlaxoSmithKline	2 doses, given 6-12 months apart	10 years following booster*	Children from 1 to 15 years
Vaqta Paediatric Aventis Pasteur MSD	2 doses, given 6-12 months apart	10 years following booster*	Children form 1 to 17 years

It is good practice to continue a course of hepatitis A with the same brand of vaccine. However, evidence suggests that hepatitis A vaccines are likely to be compatible with each other, [3,4,5] and if necessary a different brand of hepatitis A vaccine could be given.

* Anti-hepatitis A antibodies, which are considered a marker for protection against hepatitis A, have been demonstrated for up to 12 years in adults and 5 years in children. [6,7] Different mathematical models based on different vaccine products have consistently predicted titres to last for > 20 years. Some have predicted antibody persistence up to 55 years. [8]

Given this information, there may be no need to provide a booster dose of vaccine following a primary series of hepatitis A vaccine in immune competent children and adults. The duration of protection from the primary response can be expected to be at least 20 years and probably indefinite. The Joint Committee on Vaccination and Immunisation (see Immunisation against infectious disease) has accepted a 20 year interval for a booster dose of vaccine for those at ongoing risk.

Interrupted Courses

The SPC states that for Havrix Monodose and Havrix Junior Monodose, a booster that is delayed for up to 3 years can be expected to induce similar antibody levels as a booster given within the recommended 6-12 months.

The SPC states that for Avaxim the reinforcing dose may be administered up to 36 months after the primary immunisation.

Vaqta Paediatric booster doses can be administered up to 18 months following the primary dose.

The SPC for Epaxal states that the second dose may be given up to 4 years following the first dose, based on experience in adult travellers.

Although booster doses delayed beyond the recommended intervals described above are not covered by the product licence, research indicates that a second dose given at long intervals will still result in a boosting immune response. [8,9,10,11] A second dose of Havrix given up to 8 years after the first dose boosted the primary dose. [9,11] Good protective antibody levels have also been achieved when the second dose of Epaxal was given up to 56 months after the primary dose. [10]

Thus, based on evidence from available studies, there is no interval which would require restarting a course of hepatitis A vaccine.

Contraindications

• Current severe febrile illness
• Individuals who develop symptoms suggestive of hypersensitivity after vaccination should not receive further doses

Specifically to Epaxal

• Hypersensitivity to eggs and chicken protein

Adverse events

Adverse reactions following hepatitis A vaccine tend to be mild and transient. They include tenderness, redness and swelling at the injection site. Less commonly, fever, headaches, dizziness and malaise have been reported

References

1. CDC. Hepatitis A amongst homosexual men. MMWR 1992;41:155 pp161-4

2. Lemon SM. The value of immunisation against hepatitis A. Infectious Agents Dis 1994;3 (1): 38-49  www.worldwidevaccines.com

3. Clarke P, Kitchin N, Souverbie F. A randomised comparison of two inactivated hepatitis A vaccines, Avaxim and Vaqta, given as a booster to subjects primed with Avaxim. Vaccine 2001; 19(31):4429-33

4. Zuckerman JN, Kirkpatrick CT, Huang M. Immunogenicity and reactogenicity of Avaxim (160 AU) as compared with Havrix (1440 EL.U) as a booster following primary immunization with Havrix (1440 EL.U) against hepatitis A. Journal of Travel Medicine 1998;5(1):18-22

5.  Herzog C, Angst F, Beck BR, et al Boosting healthy travellers with a virosome-formulated hepatitis A vaccine after basic immunization with an alum-adsorbed hepatitis A vaccine. Abstract of the 37th ICAAC, Toronto, 1997; abstract No H-5

6. Van Herck K, Van Damme P, Lievens M and Stoffel M. Hepatitis A vaccine: indirect evidence of immune memory 12 years after the primary course. J Med Virol 2004; 72: 194-196

7. Fan PC, Chang MH, Lee PI et al. Follow-up immunogenicity of an inactivated hepatitis A vaccine in healthy children: results after 5 years. Vaccine 1998; 16: 232-235

8. Van Damme P, Banatvala J, Fay O et al. Hepatitis A booster vaccination: is there a need? Lancet 2003; 362: 1065- 71

 

9. Landry  P, Tremblay S, Darioli R, Genton B. Inactivated hepatitis A vaccine booster given >/=24 months after primary dose. Vaccine 2001; 19: 399-402

 

10.  Beck B, Hatz C, Broennimann R, Gluek R, Herzog C. Immunogenicity of two doses of a virosome formulated hepatitis A vaccine administered 18 to 56 months apart (abstract). Clin. Microbiolo.Infect. 2000;6 (suppl 10:We07)

11. Iwarson S, Lindh M and Widerstrom L. Excellent booster response 4 to 8 years after a single primary dose of an inactivated hepatitis A vaccine. J Travel Med 2004; 11: 120-121