Updated recommendations for prevention of hepatitis A infection (November 2018, Modified February 2019)
The United States Advisory Committee on Immunization Practices (ACIP)는 2018년 11월과 2019년 2월, HAV 감염 예방을 위한 수정된 권고사항을 발행하였습니다. 이제는 여행 예정인 6-11개월 유아에게 HAV 예방접종으로 preexposure prophylaxis를 권고합니다. 이 새로운 가이드라인은 또한 40세 초과 성인에게 감소된 면역 글로블린 효능으로 인하여 면역 글로블린 단독보다는 HAV 백신(면역글로블린을 하던지 하지 않던지)으로 postexposure prophylaxis를 권고합니다. 게다가 1세 이상 가운데 homelessness인 경우는 HAV 예방접종의 새로운 적응증입니다. 왜냐하면 이 그룹에서 감염이 최근에 증가했기 때문입니다.
Recommendations for hepatitis A postexposure prophylaxis and pre-exposure protection, by age group and risk category
|
Indication/age group |
Risk category/health status |
Hepatitis A vaccine |
Immune globulin*¶ |
|
Postexposure prophylaxis |
|||
|
<12 months |
Healthy |
No |
0.1 mL/kg IM |
|
12 months to 40 years |
Healthy |
1 doseΔ |
None |
|
>40 years |
Healthy |
1 doseΔ |
0.1 mL/kg◊ IM |
|
≥12 months |
Immunocompromised or chronic liver disease |
1 doseΔ |
0.1 mL/kg§ IM |
|
≥12 months |
Vaccine contraindicated¥ |
No |
0.1 mL/kg IM |
|
Pre-exposure protection‡ |
|||
|
<6 months |
Healthy |
No |
0.1 to 0.2 mL/kg† IM |
|
6 to 11 months |
Healthy |
1 dose** |
None |
|
12 months to 40 years |
Healthy |
1 dose¶¶ |
None |
|
>40 years |
Healthy |
1 dose¶¶ |
0.1 to 0.2 mL/kg†,ΔΔ IM |
|
>6 months[1] |
Immunocompromised or chronic liver disease |
1 dose¶¶ |
0.1 to 0.2 mL/kg†,ΔΔ IM |
|
>6 months |
Persons who elect not to receive vaccine or for whom vaccine is contraindicated |
No |
0.1 to 0.2 mL/kg† IM |
IM: intramuscular.
* Suggested dose volumes are based on the IM preparation GamaSTAN (15 to 18%) available in the United States and some other countries.
¶ Measles, mumps, and rubella vaccine should not be administered for at least 3 months after receipt of immune globulin.
Δ A second dose is not required for postexposure prophylaxis; however, for long-term immunity, the hepatitis A vaccination series should be completed with a second dose at least 6 months after the first dose.
◊ The provider's risk assessment should determine the need for immune globulin administration. If the provider's risk assessment determines that both vaccine and immune globulin are warranted, hepatitis A vaccine and immune globulin should be administered simultaneously at different anatomic sites.
§ Vaccine and immune globulin should be administered simultaneously at different anatomic sites.
¥ Life-threatening allergic reaction to a previous dose of hepatitis A vaccine, or allergy to any vaccine component.
‡ Immune globulin should be considered before travel for persons with special risk factors for either hepatitis A virus infection or increased risk for complications in the event of exposure to hepatitis A virus.
† 0.1 mL/kg for travel up to 1 month; 0.2 mL/kg for travel up to 2 months, 0.2 mL/kg every 2 months for travel of ≥2 months' duration.
** This dose should not be counted toward the routine 2-dose series, which should be initiated at age 12 months.
¶¶ For persons not previously vaccinated with hepatitis A vaccine, administer dose as soon as travel is considered, and complete series according to routine schedule.
ΔΔ May be administered, based on providers' risk assessment.
Reference:
Erratum: Vol. 67, No. 43. MMWR Morb Mortal Wkly Rep 2019; 68:233.
Reproduced from: Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: Recommendations of the Advisory Committee on Immunization Practices for use of hepatitis A vaccine for postexposure prophylaxis and for preexposure prophylaxis for international travel. MMWR Morb Mortal Wkly Rep 2018; 67:1216.
TABLE 1. Recommendations for postexposure prophylaxis and preexposure protection, by age group and risk category
|
Indication/Age group |
Risk category/Health status |
Hepatitis A vaccine |
Immune globulin |
|
Postexposure prophylaxis |
|||
|
<12 mos |
Healthy |
No |
0.1 mL/kg* |
|
12 mos–40 yrs |
Healthy |
1 dose† |
None |
|
>40 yrs |
Healthy |
1 dose† |
0.1 mL/kg§ |
|
≥12 mos |
Immunocompromised or chronic liver disease |
1 dose† |
0.1 mL/kg¶ |
|
≥12 mos |
Vaccine contraindicated** |
No |
0.1 mL/kg |
|
Preexposure protection†† |
|||
|
<6 mos |
Healthy |
No |
0.1–0.2 mL/kg§§ |
|
6–11 mos |
Healthy |
1 dose¶¶ |
None |
|
12 mos–40 yrs |
Healthy |
1 dose*** |
None |
|
>40 yrs |
Healthy |
1 dose*** |
0.1–0.2 mL/kg§§,††† |
|
All ages |
Immunocompromised or chronic liver disease |
1 dose*** |
0.1–0.2 mL/kg§§,††† |
|
>6 mos |
Persons who elect not to receive vaccine or for whom vaccine is contraindicated** |
No |
0.1–0.2 mL/kg§§ |
* Measles, mumps, and rubella vaccine should not be administered for at least 3 months after receipt of IG.
† A second dose is not required for postexposure prophylaxis; however, for long-term immunity, the hepatitis A vaccination series should be completed with a second dose at least 6 months after the first dose.
§ The provider’s risk assessment should determine the need for immune globulin administration. If the provider’s risk assessment determines that both vaccine and immune globulin are warranted, HepA vaccine and immune globulin should be administered simultaneously at different anatomic sites
¶ Vaccine and immune globulin should be administered simultaneously at different anatomic sites.
** Life-threatening allergic reaction to a previous dose of hepatitis A vaccine, or allergy to any vaccine component.
†† IG should be considered before travel for persons with special risk factors for either HAV infection or increased risk for complications in the event of exposure to HAV.
§§ 0.1 mL/kg for travel up to 1 month; 0.2 mL/kg for travel up to 2 months, 0.2mL/kg every 2 months for travel of ≥2 months’ duration.
¶¶ This dose should not be counted toward the routine 2-dose series, which should be initiated at age 12 months.
*** For persons not previously vaccinated with HepA vaccine, administer dose as soon as travel is considered, and complete series according to routine schedule.
††† May be administered, based on providers’ risk assessment.
TABLE 2. Vaccines used to prevent hepatitis A virus (HAV) infection
|
Vaccine |
Trade name (manufacturer) |
Age group (yrs) |
Dosage |
Route |
Schedule |
Booster |
|
Hepatitis A vaccine, inactivated |
Havrix (GlaxoSmithKline) |
1–18 |
0.5 mL (720 ELU) |
IM |
0, 6–12 mo |
None |
|
≥19 |
1 mL (1,440 ELU) |
IM |
0, 6–12 mo |
None |
||
|
Hepatitis A vaccine, inactivated |
Vaqta (Merck and Co.) |
1–18 |
0.5 mL (25 U) |
IM |
0, 6–18 mo |
None |
|
≥19 |
1 mL (50 U) |
IM |
0, 6–18 mo |
None |
||
|
Combined hepatitis A and B vaccine* |
Twinrix (GlaxoSmithKline) |
≥18 (primary) |
1 mL (720 ELU HAV + 20 μg HBsAg) |
IM |
0, 1, 6 mo |
None |
|
≥18 (accelerated) |
1 mL (720 ELU HAV + 20 μg HBsAg) |
IM |
0, 7, 21–30 days |
12 mo |
Abbreviations: ELU = ELISA units of inactivated HAV; HBsAg = hepatitis B surface antigen; IM = intramuscular; U = units of HAV antigen.
* Combined hepatitis A and B vaccine (Twinrix) should not be used for postexposure prophylaxis.
TABLE 3. Categories of persons with increased risk for hepatitis A virus (HAV) infection or increased risk for complications in the event of exposure to HAV
|
Type of risk |
Risk category |
Examples |
|
Increased risk for HAV infection |
Close contacts of persons with HAV infection* |
Household contacts |
|
Caretakers |
||
|
Sexual contacts |
||
|
Occupational risk |
Persons working with nonhuman primates |
|
|
Persons working with HAV in a research laboratory |
||
|
Increased risk for HAV-associated complications |
Immunocompromised persons |
Congenital or acquired immunodeficiency |
|
HIV infection |
||
|
Chronic renal failure/Undergoing dialysis |
||
|
Solid organ, bone marrow, or stem cell transplant recipients |
||
|
Persons with diseases requiring treatment with immunosuppressive drugs/biologics (e.g., tumor necrosis alpha inhibitors), long-term systemic corticosteroids, radiation therapy |
||
|
Chronic liver disease |
Hepatitis B infection |
|
|
Hepatitis C infection |
||
|
Cirrhosis (any etiology) |
||
|
Fatty liver disease (hepatic steatosis) |
||
|
Alcoholic liver disease |
||
|
Autoimmune hepatitis |
||
|
Alanine aminotransferase (ALT) or aspartate amino transferase (AST) level more than twice the upper limit of normal or persistently elevated for 6 months |
Abbreviation: HIV = human immunodeficiency virus.
* Excludes health care personnel using appropriate personal protective equipment.
참고문헌 : UpToDate 2019.05.05
Weekly / November 2, 2018 / 67(43);1216–1220
Weekly / February 15, 2019 / 68(6);153–156
