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The American Liver Foundation recognizes the significant burden of hepatitis A infection for U.S. families and communities. Each year, more than 180,000 children and adults are infected with this virus, making it the sixth most commonly reported infectious disease in the United States.1,2 In 1999, public health costs for hepatitis A control and management exceeded $500 million.3 There is no treatment for hepatitis A disease, but prevention is available with immunization. The American Liver Foundation endorses the position of the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) that routine childhood vaccination is the most effective way to reduce hepatitis A incidence nationwide over time.4 In addition, American Liver Foundation supports a comprehensive plan for vaccination of at risk adults and public health action that includes outreach to families and communities, professional education, and nation-wide coalition building for expanded immunization services and research.
By some estimates, 10 million people worldwide acquire the hepatitis A virus (HAV) every year.5 In the United States, hepatitis A is one of the most frequently reported vaccine-preventable diseases, ranking sixth among the top ten causes of food-borne illness.6 The Centers for Disease Control and Prevention (CDC) estimates that more than 180,000 asymptomatic and symptomatic hepatitis A infections occur each year, with approximately one-third involving children < 15 years of age.7 Each year, hepatitis A disease causes approximately 100 deaths.
Hepatitis A often occurs in community-wide epidemics, as occurred in five states in March 1997.9 Cyclic increases of hepatitis A occur approximately every decade in the U.S., but relatively high rates for the disease continue between epidemics. Within the United States; states, counties and communities can be considered to have high, intermediate, or low rates of hepatitis A on the basis of epidemiological characteristics.10
Over the past several decades, areas in the western U.S. have had substantially higher rates of hepatitis A disease than the rest of the country. According to the CDC, most hepatitis A cases result from person-to-person transmission during community-wide outbreaks in these regions. During the period 1987-1997, 68% of U.S. cases occurred in these endemic western states.11
High rate states are those with the average annual hepatitis A rate during 1987-1997 greater than 20 cases per 100,000 population (approximately twice the national average). These states include: Arizona, Alaska, Oregon, New Mexico, Utah, Washington, Oklahoma, South Dakota, Idaho, Nevada, and California.12
Intermediate rate states are those with the average annual rate of hepatitis A during 1987-1997 was greater than 10 cases per 100,000 population (approximately the national average) but less than 20 cases per 100,000. These states include: Missouri, Texas, Colorado, Arkansas, Montana and Wyoming.3
Historically in the United States, certain populations are at increased risk for hepatitis A disease. Native Americans, Hispanic Americans, Alaskan Natives, migrant populations and certain religious groups have had a higher incidence of hepatitis A in past decades. Some of these rates are now changing as a result of hepatitis A vaccination programs, but without immunization these communities continue at increased risk for the disease.14
According to the CDC, other persons are also at increased risk for HAV infection:
Persons traveling to or working in countries that have high or intermediate rates of infection, especially frequent short-term travelers and persons staying for extended periods of time. Geographic areas with increased risk include: Asia, Africa, South America, Latin America, the Middle East, European countries bordering the Mediterranean, and Eastern European countries. Risk for HAV infection in these regions increases with duration of travel.
Men who have sex with men.
Persons who use injection and non-injection illegal drugs
Persons who have an occupational risk for infection including persons working with HAV-infected primates and with the HAV in a research laboratory setting.
Persons who have clotting-factor disorders, especially those administered solvent-detergent-treated preparations.15
In addition, the CDC considers persons with chronic liver disease at increased risk for the serious sequela of hepatitis A infection, including acute liver failure.16
The American Liver Foundation recognizes other groups for which HAV infection may pose a special risk. These include groups historically associated with common source outbreaks and persons with regular or increased risk for exposure to fecal material:
Day care personnel and children attending day care, as well as their parents, siblings and close contacts19
Health care workers20
Staff of institutions for the developmentally disabled21
Consumers of certain high risk foods (e.g. raw shellfish)22
Hepatitis A is a serious viral infection of the liver with a variable incubation period of 15 to 50 days.23 It is a systemic disease characterized by an abrupt onset of symptoms that can include fever, fatigue, malaise, anorexia, nausea, abdominal pain, dark urine, and jaundice.24 Hepatitis A symptoms are age-related. Most cases (70%) in children less than 6 years are asymptomatic, while greater than 70% of older children and adult patients develop jaundice.25,26 Older children and adults can experience debilitating symptoms that persist for 2 to 8 weeks. For most of these patients, the illness usually resolves within 2 months, but 10-15% of symptomatic cases can persist or relapse for up to 6 months.27 Persons older than 50 years of age and those with chronic liver disease are at increased risk of acute liver failure due to hepatitis A, a life-threatening event. The mortality rate for adults over age 50 is 27 per 1000 cases. Each year an estimated 100 persons die in the U.S. due to acute liver failure from Hepatitis A.28
The hepatitis A virus (HAV) is highly contagious and is primarily transmitted by the fecal-oral route, through person-to-person contact, or through the ingestion of contaminated food or water. HAV transmission has been linked to uncooked fruits and vegetables, shellfish, and contaminated ice.29 The virus can survive on a surface (e.g. toys, cutting boards) for up to one month.30 CDC documents that approximately 25% of infection with hepatitis A is through household/personal contact; 15% though daycare settings; 7% from international travel and 7% of the cases are outbreak-related. In almost 50% of hepatitis A cases the source of infection is unknown.31
Hepatitis A in young children is often a mild or asymptomatic infection, but young children with unrecognized infections play an important role in HAV transmission. Children infected with the virus have a longer incubation period than adults and can continue to shed virus in their stool for as long as 180 days. They can serve as a significant “invisible” source of infection for others, especially in highly endemic states and in outbreak communities. Care givers in the household and at day care centers risk hepatitis A exposure when changing diapers of infected, asymptomatic children.32,33 Several studies document the role of children < 6 years with HAV transmission within households. In one study of adults without an identifiable source of transmission, over 50% of their households included a child under age 6 associated with the transmission of the disease to family members.34
The economic costs of hepatitis A are significant. Between 11% and 22% of persons who have the disease are hospitalized. A typical adult case of hepatitis A will result in 27 lost days of work.35 Average costs (direct and indirect) of hepatitis A range from $1,817 to $2,459 per case for adults and from $433 to $1492 per case for children less than 18 years of age.36 Health departments incur substantial costs responding to outbreaks. A 1996 Denver, Colorado food-borne outbreak affected 43 persons and cost the community $800,000.37 Restaurants with hepatitis infected food workers also risk economic consequences. Recently, a Seattle law firm won a $1.06 million settlement on behalf of 29 hepatitis A outbreak victims at a local fast food franchise.38
The total economic burden of hepatitis A disease is significant and growing. In 1989 the annual cost of this disease was estimated at $200 million.39 A 1999 analysis estimated that the annual cost of hepatitis A among adolescents and adults now approximated $500 million.40
Good personal hygiene, including hand washing, is recommended for the prevention of any food-borne illness. Other preventive public health measures include good sanitation, a safe water supply, and careful food preparation. HAV can be inactivated by boiling or cooking to greater than 185 degrees F or chlorinating the water supply.41
Longer-term prevention against hepatitis A is available with immunization. Currently, there are 2 inactivated single antigen virus vaccines available for protection against hepatitis A in the United States: Havrix and Vaqta. Clinical studies for both have demonstrated excellent protective efficacy, immunogenicity, and safety.42,43 The CDC and others have documented the ability of routine childhood immunization with these vaccines to effectively interrupt and prevent community outbreaks of hepatitis A disease in highly endemic areas.44 Recently the FDA has approved Twinrix, another inactivated vaccine for hepatitis A protection. For use in adults only, Twinrix is a combination vaccine against hepatitis A and B.
To prevent hepatitis A during international travel, persons over age two going to endemic areas can receive hepatitis A vaccine and education about personal hygiene and food and beverage safety. Accompanying children under age two and persons departing in less than four weeks can receive immune globulin for short-term protection against HAV.
In the event of a community-wide outbreak, immune globulin can be offered as post-exposure prophylaxis to persons with close contact to identified cases. At this time, hepatitis A vaccine can also be offered concomitantly for longer-term protection.
There is no curative treatment for hepatitis A disease and clinical management for symptomatic cases is supportive care.
I. Public Health Recommendations
The American Liver Foundation endorses the recommendations of the Advisory Committee on Immunization Practices (ACIP) for the immunization of children and adults at increased risk for hepatitis A infection and for any person wishing to obtain immunity.45
A. Recommendations for Children at Increased Risk for Hepatitis A Infection
1. Routine vaccination for pre-exposure prevention is recommended for children living in areas where the rates of hepatitis A are at least twice the national average or greater than 20 cases per 100,000 population during 1987-1997. Beginning at age 2, these children should be routinely immunized against hepatitis A and catch-up vaccination of pre-school children should be a highest priority. These states and communities include:
Arizona, Alaska, Oregon, New Mexico, Utah, Washington, Oklahoma, South Dakota, Idaho, Nevada, and California.
American Indian, Alaskan Native, and selected Hispanic, migrant, and religious communities.
The American Academy of Pediatrics also recommends that children 2 years and older who live in defined and circumscribed communities with high endemic rates should be vaccinated against hepatitis A.46
2. Routine vaccination for pre-exposure prevention should be considered for children who live in areas where the annual rates of hepatitis A are greater than the national average, but lower than twice the national average (e.g. children who lives in intermediate-rate states where the average annual rate of hepatitis A during 1987-1997 was greater than 10 cases per 100,000 population but less than 20 cases per 100,000). These states and counties include:
Missouri, Texas, Colorado, Arkansas, Montana and Wyoming.
Children who live in select counties or communities where rates are greater than the national average but lower than twice the national average.
The American Academy of Pediatrics also recommends that children 2 years and older residing in defined communities with periodic outbreaks of hepatitis A be vaccinated.47
B. Recommendations for Persons at Increased Risk for Hepatitis A Infection
1. Routine vaccination is recommended for persons traveling to or working in countries that have high or intermediate rates of infection. These areas include: Asia, Africa, South America, Latin America, the Middle East, European countries bordering the Mediterranean, and Eastern European countries and for;
Children greater than 2 years of age, adolescents and adults who plan frequent travel or who reside for long periods in high-risk areas should receive the age appropriate dose of the hepatitis A vaccination.
Children less than 2 years of age who should receive immune globulin because the vaccine is currently not licensed for this age group.
Persons traveling to a high-risk area <4 weeks after the initial hepatitis A vaccine dose also should be administered IG for protection.
2. Men who have sex with men;
3. Persons who use injection and non-injection illegal drugs;
4. Persons who have an occupational risk for infection including persons working with HAV-infected primates and with the HAV in a research laboratory setting;
5. Persons who have clotting-factor disorders, especially those administered solvent-detergent-treated preparations.
C. Recommendations for Persons with Chronic Liver Disease
1. Routine vaccination is recommended for persons with evidence of chronic liver disease who are at increased risk for acquiring hepatitis A and for;
2. Susceptible persons who are either awaiting or have received liver transplants.
D. Recommendations for Hepatitis A Vaccination During Outbreaks
1. In communities with high rates of hepatitis A, vaccination efforts among preschool and school-age children should be intensified during an outbreak to achieve at least a 70% vaccination coverage level.
2. In communities with intermediate rates of hepatitis A, outbreak recommendations include:
Routine childhood vaccination should be initiated during the outbreak, if this recommendation has not yet been implemented.
Accelerated vaccination can be considered using local surveillance and epidemiological data to define populations and community areas at highest risk for hepatitis A infection.
Evaluation of the effectiveness of vaccination programs to control outbreaks in these communities should be an essential element of programs in these settings.
3. In communities with low rates of hepatitis A, community-wide outbreaks are uncommon. However, if outbreaks do occur, vaccination programs should focus on identified risk groups of adults or children.
4. For outbreaks in other settings, including day care center, hospitals, institutions for the developmentally disabled, prisons, and schools, recommendations include:
Post-exposure prophylaxis with immune globulin is for individuals who had close contact with the infected person(s)
However, the following issues should be noted:
The frequency of outbreaks in these settings is not high enough to warrant routine hepatitis A vaccination of persons specifically because they are in these settings.
Few data exist regarding the role of hepatitis A vaccine in controlling outbreaks in these settings.
II. Other ALF Recommendations
In addition to the CDC guidelines for the prevention and eradication of hepatitis A in the U.S., ALF recommends:
A. Administration of hepatitis A vaccine to food handlers. Food handlers have a critical role in common-source food-borne HAV transmission. This group should be vaccinated to reduce the frequency of medical evaluations of food handlers with hepatitis A and to eliminate the need for post-exposure prophylaxis for patrons. 48
B. Expanded vaccine use should be considered for groups often associated with common source outbreaks including: military personnel, day care personnel, health care workers, staff of institutions for the developmentally disabled, children at day care centers, as well as their parents, siblings and other close contacts, persons who repeatedly contract sexually transmitted diseases, and consumers of high risk foods (e.g. raw shellfish).
C. Administration of hepatitis A vaccine to persons who test positive for hepatitis C, with or without evidence of chronic liver disease.49
D. Educational outreach to individuals, families and communities: The American public continues to be largely unaware of its risk for this disease. There is a need for ongoing education about hepatitis A transmission, its economic impact and the availability of a safe and effective vaccine.
E. Endemic communities and persons at high risk should receive customized educational messages.
F. Enhanced Professional Education: Health professionals can benefit from updated information on the epidemiology of hepatitis A within the U.S., the efficacy and safety of hepatitis A vaccines, and the revised ACIP vaccination recommendations. AS well, updated patient educational materials, available in multiple languages and different literacy levels, should be readily available to help clinicians meet their hepatitis A vaccination goals with targeted ethnic and cultural populations.
G. Coalition-Building in Endemic States: ALF chapters will work to gain the support of critical partners in this public health effort. Potential partners include state and community health departments, school boards and parent-teacher associations, school nurses, day care organizations, parent advocacy groups, pediatricians, hepatologists and gastroenterologists, restaurant associations, and organizations with high-risk group members. ALF chapters will work with state and local legislative groups to fully implement this action plan.
H. Support for Ongoing Research to Eliminate HAV Transmission: Vaccine research is needed to address the issue of infant immunogenicity and develop vaccines that protect children < 2 years of age. Research is needed to test the value of hepatitis A vaccine as post-exposure prophylaxis. As well, outreach techniques must be refined to effectively reach target groups with the hepatitis A prevention message, especially in endemic areas.
1, 2 CDC. Summary of notifiable diseases, United States, 1997. MMWR 1998; 46:1-87..CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999;48 (No. RR-12): 5.
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4 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48 (No. RR-12): 1
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6 CDC. Summary of notifiable diseases, United States, 1997. MMWR 1998; 46:1-87.
7 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 5
8 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 4
9 Hutin YJ, et al. A multistate, food borne outbreak of hepatitis A. N Engl J Med 1999; 340(8): 595-602.
10 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 9
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12 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 8
13 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 9
14 Koff RS. Seroepidemiology of hepatitis A in the United States. J Infect Dis. 1995; 171 (suppl 1): S19-S23.
15 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 11-12
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18 Jefferson TO, et al. Should British soldiers be vaccinated against hepatitis A? An economic analysis. Vaccine 1994; 12: 1379-83
19 Hadler SC, et al. Hepatitis A in day-care centers: a community wide assessment. N Engl J Med 1980; 302:1222-7.
20 Rosenblum LS et al. Hepatitis A outbreak in a neonatal intensive care unit: risk factors for transmission and evidence of prolonged viral excretion among preterm infants. J Infect Dis 1991; 164:476-82.
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22 Desenclos JA et al. A multistate outbreak of hepatitis A caused by the consumption of raw oysters. Am J Public Health 1991; 81
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24 Koff RS. Clinical manifestations and diagnosis of hepatitis A virus infection. Vaccine. 1992; 10 (suppl 1): S15-S17.
25,26 Hadler SC, et al. Hepatitis A in day-care centers: a community wide assessment. N Engl J Med 1980; 302:1222-7. Lednar WM et al. Frequency of illness associated with hepatitis A virus infection in adults. Am J Epidemiol 1985; 122:226-33.
27 Glikson M, et al. Relapsing hepatitis A. Review of 14 cases and literature survey. Medicine 1992; 71:14-23.
28 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 4.
29 Beller M. Hepatitis A outbreak in Anchorage, Alaska traced to ice slush beverages. West J Med 1992; 156:624-627.
30 Hollinger FB and Glombicki AP. Hepatitis A virus. In: Mandell GL et al, eds. Principles and Practice of Infectious Diseases, 3rd ed., New York, NY: Churchill Livingston, 1990: 1383-1396.
31 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 5
32, 33 American Academy of Pediatrics. Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin (RE9646). Pediatrics 1996; 98:1207-1215.
34 Staes C, Schlenker T, Risk I, et al. Source of infection among persons with acute hepatitis A and no identified risk factors, Salt Lake City, Utah, 1996. Clin Infect Dis 1997; 25:411.
35 American Academy of Pediatrics. Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin (RE9646). Pediatrics 1996; 98:1207-1215.
36 CDC. Prevention of hepatitis A through active or passive immunization. MMWR 1999; 48 (RR-12): 4
37 Dalton CB, Haddix A, Hoffman RE, Mast EE. The cost of a food-borne outbreak of hepatitis A in Denver, Colorado. Arch Intern Med 1996; 156:1013-6.
38 Marler Clark, LLP. “Seattle law firm obtains $1.06 million settlement on behalf of hepatitis outbreak victims.” Accessed @ www.marlerclark.com.
39 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 5.
40 Jacobs J. “The cost effectiveness of childhood hepatitis A vaccination.” American Liver Foundation Meeting “Strategic Directions for Reducing Hepatitis A in High Endemic States”, St Louis, MO, June 10, 2000.
41 Favero MS, Bond WW. Disinfection and sterilization. In: Zuckerman AJ, Thomas HC, eds. Viral hepatitis, scientific basis and clinical management. New York, NY: Churchill Livingston, 1993: 565-75.
42, 43 Innis BL, Snitbhan R, Kunasol P, et al. Protection against hepatitis A by an inactivated vaccine. JAMA 1994; 271:1328-1334. Werzberger A, Mensch B, Kuter B, et al. A controlled trial of a formal in-inactivated hepatitis A vaccine in healthy children. N Engl J Med 1992; 327:453-457.
44 Wersberger A, Kuter B, Nalin D. Six years’ follow-up after hepatitis A vaccination (Letter). N Engl J Med 1998; 338:1160.
45 CDC. Prevention of hepatitis A through active and passive immunization. MMWR 1999; 48(No. RR-12): 25-30.
46 American Academy of Pediatrics. Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin (RE9646). Pediatrics 1996; 98:1207-1215.
47 American Academy of Pediatrics. Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin (RE9646). Pediatrics 1996; 98:1207-1215.
48 American Academy of Pediatrics. Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin (RE9646). Pediatrics 1996; 98:1207-1215.
49 NIH. Management of hepatitis C-NIH consensus statement, NIH Consensus Development Conference, March 24-25, 1997, Bethesda, Maryland. Accessed @ http://odp.od.nih.gov/consensus/cons/105.htm
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