1 Hepatitis A and B Vaccination and the New York State Adult Hepatitis Vaccination Program Elizabeth Rausch-Phung, MD MPH Medical Director, NYSDOH Bureau of Immunization

2 Hepatitis A Virus (HAV) Transmission fecal-oral. Symptoms include fatigue, abdominal pain, jaundice; children often asymptomatic. Acute phase only, never chronic, complete recovery with lifelong immunity within 3-6 months. No specific treatment – supportive only. Hepatitis A is vaccine preventable!!

3 Hepatitis B Virus (HBV) Transmitted through blood/body fluids. Symptoms similar to HAV; often asymptomatic. Acute phase – 90% clear the virus & develop lifelong immunity. 10% develop chronic infection – can lead to cirrhosis and liver cancer. Treatment only for chronic infections on case-by-case basis. ~5000 deaths annually in the U.S. from HBV. Hepatitis B is vaccine preventable!!

4 Hepatitis A Vaccine Two inactivated whole virus vaccines available: Vaqta ® (Merck) and Havrix ® (GSK) – – Up to age 18: 0.5mL – – Age 19 and over: 1.0mL Efficacy: Highly immunogenic. – – 94% to 100% seroconvert within a month after 2 doses. No boosters are currently recommended. Administration: Dose 1 followed by dose 2 at least 6 months after dose 1. If dose 2 is late, it is NOT necessary to repeat dose 1.

5 Hepatitis B Vaccine Two inactivated vaccines available: Engerix-B® (GSK) and Recombivax HB® (Merck) – – Up to age 19: 0.5mL – – Age 20 and over: 1.0mL Efficacy: Protection ~ 50% after 1 dose; 85% after 2 doses; 98% after 3 doses. Administration: 0, 1-2 and 4-6 months – – Minimum spacing of 4 weeks between dose 1 and dose 2. – – Minimum 8 weeks between dose 2 and dose 3. – – Minimum of 16 weeks between dose 1 and dose 3.

6 Hepatitis A and B Vaccine Twinrix ® – –Combination hepatitis A & B vaccine (GSK). – –Approved for persons aged 18 yrs and older in the US. – –Indicated for persons at risk for both hepatitis A and hepatitis B. Administered in a 3 dose series at 0, 1 and 6 months – –Dose 1 and dose 2 should be separated by at least 4 weeks. – –Dose 2 and dose 3 should be separated by at least 8 weeks. – –Dose 1 and dose 3 should be separated by at least 6 months.

7 Hepatitis A & B Vaccine Administration

8 Hepatitis A Vaccination Who should be vaccinated – Adults: – –International travelers, – –Men who have sex with men, – –Users of either injectable or non-injectable drugs, – –Persons with HIV/AIDS, – –Persons with chronic liver disease, – –Persons with a diagnosis of clotting factor disorder, and – –Persons with occupational risks.

9 Hepatitis B Vaccination Who should be vaccinated – Adults: – –Household contacts and sex partners of persons infected with HBV, – –Persons with > 1 sex partner in 6 months, – –Men who have sex with men, – –Persons seeking evaluation or treatment for an STD, – –Users of injectable drugs, – –Persons with HIV/AIDS, – –Persons with chronic liver disease, – –Persons with end-stage kidney disease, and – –Persons with jobs that expose them to human blood.

10 Risk Assessment & Pre-Vaccination Screening Three questions that should be asked prior to hepatitis vaccination: 1. 1.Are you sick today? 2. 2.Do you have any allergies to medications, food or any vaccine? 3. 3.Have you ever had a serious reaction after receiving a vaccination?

11 Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose, or Moderate or severe acute illness.

12 Types of Vaccine Reactions in Adults Local Reaction, Systemic Reaction, Allergic Reaction (anaphylactic), and Post-Vaccination Syncope.

13 Local Reactions Symptoms include pain, swelling, and redness at the injection site. These reactions occur about 50% of the time. These reactions occur within a few hours after vaccination and are mild and self-limited. If patient has soreness, redness, itching or swelling, apply a cold compress and give analgesics if necessary. If patient has slight bleeding, apply adhesive over the injection site. If patient continues bleeding, apply gauze pads and firm pressure; raise bleeding site above level of heart.

14 Systemic Reaction Fever, malaise, myalgias, headache, loss of appetite, etc. Rarely occur when inactivated vaccines are used, as in the case with Hepatitis A and B vaccines. Typically mild and self-limited. Treat fever, myalgia and/or headache with analgesics, if necessary.

15 Allergic Reaction (anaphylactic) Extremely rare, life-threatening reactions. Itching, redness, hives, swelling of lips, face or throat, wheezing, shortness of breath, shock, cramping or cardiovascular collapse. If itching & swelling confined to injection site, observe patient for other symptoms. Call 911 and seek emergency help if symptoms are generalized.

16 Post-Vaccination Syncope Vaccine providers should strongly consider observing patients for 15 minutes after they are vaccinated. – –Having patients sit or lie down for 15 minutes following vaccination could prevent most syncopal episodes and secondary injuries. If syncope develops, patients should be observed until symptoms resolve.

17 Reporting Adverse Reactions for Hepatitis A & B Vaccination Vaccine Adverse Events Reporting System (VAERS) Adverse events following vaccination may be reported by providers or the vaccinee. For more information and to download report forms:

18 Vaccination Documentation Vaccine Information Statements – It’s a Federal Law! Must be provided with each dose of vaccine. Available in many languages. – – – – Explains benefits and risks of a vaccine.

19 Vaccination Documentation Vaccination Documentation Providers must document: Which VIS was given, Date of publication of VIS, Date VIS was given, Name and title of person administering vaccine, Date of administration, Site of administration, and Vaccine manufacturer and lot number.

20 Vaccine Storage and Handling Hepatitis A and B Vaccines When vaccine is received, immediately store between 2° - 8°C (35° - 46°F). – – Frozen vaccine loses potency and effectiveness. Refrigerators for vaccine should be combination household or stand-alone commercial style, not dormitory style.

21 Vaccine Storage and Handling Food and drink should NOT be stored in refrigerator. Storage should be in middle of refrigerator and not in the door. Ø

22 Vaccine Storage and Handling Assign a staff member and backup to be in charge of vaccine storage and handling. Keep a thermometer in the refrigerator. – –Check and record the temperature twice a day. Keep extra containers of water in the refrigerator to stabilize temperatures. Please do not leave my door open. Thank you!

23 Vaccine Storage and Handling Rotate vaccine stock using shortest expiration date first. Have a DO NOT UNPLUG sign posted near refrigerator’s outlet. Have a back up plan in event of power outage.

24 Don’t Miss An Opportunity to Vaccinate !!!!!!!!!

25 We can prevent this!!!!! Photo courtesy of Patricia Walker, MD, Ramsey Clinic Associates, St. Paul, MN Severe ascites (abdominal swelling) in a woman with chronic Hepatitis B infection

26 Additional References NYSDOH Hepatitis Vaccine Information: /vaccine.htm /vaccine.htm CDC: ACIP Recommendations for Hepatitis A Vaccination: ACIP Recommendations for Hepatitis B Vaccination:

27 Additional References (con’t) NYSDOH Immunization Page: CDC Vaccine Page: Immunization Action Coalition: NYSDOH Bureau of Immunization NYSDOH Bureau of Immunization phone: (518)