New Recommendations on Hepatitis A Vaccine, 2-Dose Hepatitis B Vaccine, and 2019 Immunization Schedules

May 2019

Kim Moore, RN, MSN, FNP-C

Franklin D. Pratt, MD, MPHTM, FACEP

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The Advisory Committee on Immunization Practices (ACIP) recently released recommendations, which were approved by the Centers for Disease Control and Prevention (CDC). This article highlights the new immunization schedules and other CDC resources, changes to the recommendations regarding hepatitis A vaccine (for people who are experiencing homelessness or who travel internationally), and the new 2-dose hepatitis B vaccine.

 

CDC Immunization Resources: 2019 Schedules, Revised Vaccine Information Statements, and Updated Website

CDC has published the 2019 immunization schedules and updated its immunization resources. The updated Immunization Schedules for Health Care Providers website links to the new child and adult immunization schedules and resources for health care professionals. The changes to the childhood and adult immunization schedules for 2019 are clearly summarized by vaccine type.

Each schedule’s homepage now provides instructions on how to use the schedule and lists routinely recommended vaccines and their standardized abbreviations. CDC has also included notes and additional information highlighting best practices for vaccine administration, including intervals, travel vaccine requirements, and immunizations for persons with immunodeficiencies. The notes have been reordered alphabetically by vaccine to make it easier to locate recommendations for specific vaccines.

We encourage you to post the 2019 color child/adolescent and adult schedules in your facility and share them with health care personnel, especially those who provide immunization services.

There are several updated Vaccine Information Statements (VIS) from the CDC that should replace older versions:

  • Meningococcal ACWY (MCV) VIS
  • Diphtheria, Tetanus, Pertussis (DTaP) VIS
  • Hepatitis B VIS
  • Rotavirus VIS
  • Anthrax VIS

New and Updated Recommendations for Hepatitis A Vaccine

Persons Experiencing Homelessness

In February 2019, ACIP released a new recommendation to routinely immunize all persons aged 1 year and older experiencing homelessness with hepatitis A vaccine (HAV).1 This has been a recommendation in Los Angeles County, since July 2017 due to outbreaks of hepatitis A among persons experiencing homelessness and/or who use illicit drugs.

Routine vaccination consists of a 2-dose schedule or a 3-dose schedule when administering combined hepatitis A and B vaccine (Twinrix®). Concerns about loss to follow-up should not be a deterrent to initiating the hepatitis A vaccine series in persons experiencing homelessness. ACIP recommendations state that one dose of hepatitis A vaccine provides personal protection and can contribute to herd immunity, although long-term protection might be suboptimal.

For more detailed information on this new recommendation see Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness.

For a summary of the current ACIP and Los Angeles County Department of Public Health (LAC DPH) hepatitis A vaccine recommendations, see box.

 

ACIP and LAC DPH Recommendations for Hepatitis A Vaccination

 

ACIP hepatitis A vaccine recommendations:

  • All children at age 12-23 months
  • Persons at increased risk for hepatitis A infection
    • Persons traveling to or working in countries that have endemic infection
    • Men who have sex with men
    • Persons experiencing homelessness
    • Users of injection and non-injection drugs (IDUs)
    • Persons who have occupational risk for infection (e.g., who work with HAV infected primates)
    • Persons with clotting-factor disorders
    • Close personal contact with an international adoptee from a country with elevated risk
  • Persons with chronic liver disease (e.g., hepatitis B or C infection)
  • Anyone wishing to obtain immunity

In addition, LAC DPH recommends hepatitis A vaccine for:

  • Persons with HIV
  • Persons who have close frequent contact with persons experiencing homelessness or IDUs (e.g., food-handlers or persons who provide personal care, janitorial, maintenance, or sanitation services to these populations).

 

Postexposure and Preexposure Prophylaxis for International Travel

ACIP also updated recommendations for postexposure protection and preexposure prophylaxis with HAV and/or immune globulin (IG) for persons traveling internationally.2 The updated recommendations are as follows:

  • Postexposure Prophylaxis (PEP)
    • Administer HAV to anyone 12 months and older for PEP.
    • Providers may also administer IG to adults aged 40 years and older, if indicated.
    • The dosage for IG has been updated from 0.02 mL/kg to 0.1–0.2 mL/kg.

HAV for PEP provides advantages over IG, including induction of active immunity, longer duration of protection, ease of administration, and greater acceptability and availability.

  • Preexposure Protection
    • Administer 1 dose of HAV to infants aged 6–11 months traveling outside the United States when protection against the hepatitis A virus is recommended. If infants in this age group are given a travel-related dose, they should still start the routine 2-dose series at 12 months of age.

See the CDC table below for a summary. For more detailed information see 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.

 

ACIP Recommendations for Postexposure Prophylaxis and Preexposure Protection for International Travel by Age Group and Risk Category.2

 
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.

 

New 2-Dose Hepatitis B Vaccine

On February 21, 2018, ACIP recommended the new hepatitis B vaccine, Heplisav–B (HepB-CpG) for use in persons aged 18 years and older.3 Key points about HepB-CpG include:

  • The vaccine is administered as a 2-dose series at 0 and 1 month.
  • It appears to be at least as effective as the 3-dose hepatitis B vaccines.*
  • It is a yeast-derived vaccine prepared with a novel adjuvant.

This is an important new hepatitis B vaccination option, as there are clear benefits to achieving protection against hepatitis B with only 2 doses over 1 month. Last minute travelers and adults who face challenges returning to the clinic are examples of persons likely to benefit from vaccination with the shorter interval 2-dose HepB-CpG. For more detailed information on HepB-CpG see Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant.

For a summary of the ACIP hepatitis B vaccine recommendations for adults, see box.

*Antibodies to hepatitis B surface antigen levels were achieved in 90%–100% of subjects receiving this vaccine, compared with 70.5%–90.2% of subjects receiving Engerix-B.3

 

For More Information

For additional information on the immunization schedules, including recommended routine intervals, and contraindications and precautions to immunization, visit the Los Angeles County DPH Vaccine Preventable Disease Control Program Healthcare Provider website at: publichealth.lacounty.gov/ip/providers.htm.

 

References

  1. Doshani M, Weng M, Moore KL, Romero JR, Nelson NP. Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness. MMWR Morb Mortal Wkly Rep. 2019;68(6):153–156. doi:10.15585/mmwr.mm6806a6    
  2. 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(43):1216–1220. doi:10.15585/mmwr.mm6743a5
  3. Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N. Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant. MMWR Morb Mortal Wkly Rep. 2018;67(15):455–458.  doi:10.15585/mmwr.mm6715a5  
 

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Author Information:

Kim Moore, RN, MSN, FNP-C
Education Coordinator

Franklin D. Pratt, MD, MPHTM, FACEP
Medical Director

Vaccine Preventable Disease Control Program
County of Los Angeles
Department of Public Health

ip@ph.lacounty.gov

publichealth.lacounty.gov/ip

 

 


Rx for Prevention, 2019
May;9(1).


Published: May 1, 2019