Hepatitis A: The Need For Vaccination

Hepatitis A
The need for vaccination
Hepatovirus in the picornavirus

group1,2
Single serotype worldwide1
3
VP
VP
1
Hepatitis A virus
VP2
Causes acute disease and

asymptomatic infection3
Chronic infection does not occur3
Hepatitis A virus
1. WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7

2. WHO, Enteric hepatitis viruses, 2007
3. CDC, Hepatitis A, Pink book, 2007
Hepatitis A Virus Transmission
Faecaloral transmission:
person-to-person contact
contaminated food or
water
contaminated water
supplies
Sexual transmission
Blood transfusion
WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7
Hepatitis A: clinical features
Incubation period: 1550 days (mean 28 days)1
Usually asymptomatic in young children1
Signs and symptoms:1
jaundice
fever
fatigue
loss of appetite
nausea
abdominal discomfort
dark urine
Recovery is slow1,2
1. CDC, Hepatitis A, Pink book, 2007
2. WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7
Hepatitis A Clinical sequelae

Infection
Incubation
Symptomatic HA
Asymptomatic HA
Protracted HA
Recovery &
immunity
Relapsing HA
Fulminant HA
No chronic cases
Recovery &
immunity
Death
HA, hepatitis A
Glikson, et al. Medicine 1992; 71: 1423

Tabor. Hepatitis A, 1984
Why Vaccinate
Against Hepatitis A?
1. The Burden of Hepatitis A is Increasing

Reassessment of the global burden of disease
(WHO, preliminary results)
Global
increase in the number of infections

117 million
in 1990
121 million
in 2005
Increase
in incidence in 2-14 yr and in >30 yrs age group
Increase
in deaths
30283 deaths
in 1990
35245 deaths
in 2005
The Immunological Basis for Immunization Series Module 18: Hepatitis A; Immunization, Vaccines and Biologicals, WHO by Daniel Shouval,
February
2011
http://whqlibdoc.who.int/publications/2011/9789241501422_eng.pdf
accessed 30th May 2011
2. Hepatitis A is CHANGING in Indonesia
The epidemiology of
Hepatitis A in Indonesia is
changing
from High to
Intermediate
Fiore A, et al. (2008) Hepatitis A . In Plotkin S, et al (Eds) Vaccines (5th ed)

Perubahan epidemiologi
dari daerah yang endemik tinggi ke endemik
sedang
Seroprevalence of Hepatitis A Virus Antibody in Yogyakarta
Susceptible
Hepatitis A
antibody positive
Age Group
Juffrie M, et al. Seroprevalence of Hepatitis A Virus and VaricellaZoster Antibodies in a Javanese Community
(Yogyakarta, Indonesia). Southeast Asian J Trop Med Public Health.2000;31:21-24

Perubahan epidemiologi
dari daerah yang endemik tinggi ke endemik
sedang
Seroprevalence
of Hepatitis
Tingginya
angka
orang A Virus Antibody in Yogyakarta
dewasa yang terserang
penyakit Hep A
Susceptible
Hepatitis A
antibody positive
Age Group
Juffrie M, et al. Seroprevalence of Hepatitis A Virus and VaricellaZoster Antibodies in a Javanese Community
(Yogyakarta, Indonesia). Southeast Asian J Trop Med Public Health.2000;31:21-24
What does this CHANGE in Epidemiology mean?

infection is nearly
universal in early
childhood

infection is nearly
universal in early
childhood
Predominant age of
infection is older

Clinical features of hepatitis A are
dependent on the age of the patient
Children < 5yo
5%
95
%
In early childhood,
asymptomatic infection predominates
World Health Organization. WHO/CDS/CSR/EDC/2000.7: Hepatitis A
Adults
10
%
90%

Disease severity, morbidity, and
mortality
increases with age
<5
514
1539
4059
60+
Age (years)
Nothdurft HD. Hepatitis A Vaccines. Expert Review of Vaccines. 2008; 7:535-545

Graph data from: CDC, Hepatitis surveillance report 61, 2006

Increasing disease burden due to
shift in the epidemiological pattern of the disease

Outbreak in Jogjakarta 2008
Distribusi Kasus Menurut Kelompok Umur di Propinsi
DIY Bulan Januari s/d September 2008
Courtesy of Dr. Sarminto presentation, Dinkes DIY Province
Sumber data : Rumah Sakit & Laboratorium

Outbreak in Jogjakarta 2008
Distribusi Penderita Hepatitis A menurut Pekerjaan di Propinsi DIY th
2008 (235 kasus)
Mahasiswa
Courtesy of Dr. Sarminto presentation, Dinkes DIY Province
3. Hepatitis A can have Serious Consequences
35 out of 100 people with

hepatitis A are hospitalized1
10-15% have prolonged or

relapsing infections2
1% develop fulminant
hepatitis3
Up to 60% mortality rate
Hepatitis is fatal in up to 2.1%

of cases3
1. Immunization Action Coalition. Hepatitis A: Questions and Answers.

2. Centers for Disease Control and Prevention. Hepatitis A in the Pink Book 2009
3. World Health Organization. WHO/CDS/CSR/EDC/2000.7: Hepatitis A
4. Large Proportion with NO IDENTIFIABLE Risk Factors

Risk factors associated with
reported cases of hepatitis A, USA 2004
CDC, Hepatitis surveillance report 61, 2006
4. Large Proportion with NO IDENTIFIABLE Risk Factors
Incidence rate for

unprotected travellers to
a developing country,
even those staying in
luxury hotels
3 per 1000 travellers

per month
ffen R et al. JAMA. 1994;272(11):885-889
6. The Economic Burden is considerable
$US1.53 billion
30 days of work
lost per patient
WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7
7. Vaccination is Cost Effective
Vaccination 2
doses
Hepatitis A
without complications
Hepatitis A with cholestasis

Hepatitis A leading to liver failure
Thai
Baht
(2002)
200
0
400
0
600
0
800
0
10000
12000
100000
South East Asian J Trop Med Public Health 2002; 33(1):118-27
8. Vaccination is Recommended
World Health Organization:1
consider vaccination in areas of intermediate
endemicity
US Advisory Committee on Immunization Practices /

Centers for Disease Control and Prevention (ACIP/CDC):2
All children at 1223 months
Persons at increased risk
Persons travelling to or working in countries that have high or intermediate endemicity of

infection
Users of injection and non-injection illegal drugs
People with chronic liver diseases
Men who have sex with men
Persons who have occupational risk for infection

1. WHO, Wkly Epidemiol Rec 2000; 5: 3844
2. Fiore, et al. MMWR Recomm Rep 2006; 55 (RR07): 123
8. Vaccination is Recommended
Sari Pediatri Vol. 13 No 1 Juni 2011
Hepatitis A Vaccine FAQS
How long does protection from Hepatitis A vaccine

last?
Are Booster Doses Needed?
1.
2.
Antibodies estimated to persist for at least 25 years1
Booster doses are unnecessary in fully vaccinated

individuals2

Van Damme & Van Herck, Travel Med Infect Dis 2007; 5: 7984
Why does a 15-year old who weighs 80 kgs receive a

pediatric dose of hepatitis A vaccine while his 50 kg
mother receives an adult dose (twice the pediatric
dose)?
Efficacy data were based on age at time of vaccination,

and not on the weight of the individual
Higher response rates are expected in younger

persons, even if their weights are above the norm
http://www.immunize.org/askexperts/experts_hepa.asp. Accessed on October 2011
What should be done if the second (last) dose of Hepatitis A

vaccine is delayed?
The second dose should be administered as soon as possible.
The first dose does not need to be readministered.
Is it harmful to administer an extra dose(s) of Hepatitis A or

Hepatitis B vaccine or to repeat the entire vaccine series if
documentation of vaccination history is unavailable?
If necessary, administering extra doses of Hepatitis A vaccine is

not harmful.
http://www.cdc.gov/hepatitis/HAV/HAVfaq.htm. Accessed on October 2011
Should prevaccination testing be performed before

administering Hepatitis A vaccine?
Prevaccination testing is recommended only in specific

circumstances to reduce the costs of vaccinating people
Should postvaccination testing be performed?
Postvaccination testing is not indicated because of the high rate of

vaccine response among adults and children.
Not all routine testing methods have the sensitivity to detect low,
but protective, anti-HAV concentrations after vaccination.
http://www.cdc.gov/hepatitis/HAV/HAVfaq.htm. Accessed on October 2011

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Hepatitis A

The need for vaccination

Hepatovirus in the picornavirus

Single serotype worldwide1

Causes acute disease and

Chronic infection does not occur3

1. WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7

Hepatitis A Virus Transmission

WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7

Hepatitis A: clinical features

Incubation period: 1550 days (mean 28 days)1

Usually asymptomatic in young children1

Signs and symptoms:1

Hepatitis A Clinical sequelae

Glikson, et al. Medicine 1992; 71: 1423

1. The Burden of Hepatitis A is Increasing

increase in the number of infections

in incidence in 2-14 yr and in >30 yrs age group

2. Hepatitis A is CHANGING in Indonesia

2. Hepatitis A is CHANGING in Indonesia

2. Hepatitis A is CHANGING in Indonesia

What does this CHANGE in Epidemiology mean?

Fiore A, et al. (2008) Hepatitis A . In Plotkin S, et al (Eds) Vaccines (5th ed)

What does this CHANGE in Epidemiology mean?

Fiore A, et al. (2008) Hepatitis A . In Plotkin S, et al (Eds) Vaccines (5th ed)

What does this CHANGE in Epidemiology mean?

What does this CHANGE in Epidemiology mean?

Nothdurft HD. Hepatitis A Vaccines. Expert Review of Vaccines. 2008; 7:535-545

What does this CHANGE in Epidemiology mean?

Nothdurft HD. Hepatitis A Vaccines. Expert Review of Vaccines. 2008; 7:535-545

What does this CHANGE in Epidemiology mean?

Courtesy of Dr. Sarminto presentation, Dinkes DIY Province

Sumber data : Rumah Sakit & Laboratorium

What does this CHANGE in Epidemiology mean?

Courtesy of Dr. Sarminto presentation, Dinkes DIY Province

3. Hepatitis A can have Serious Consequences

35 out of 100 people with

10-15% have prolonged or

Up to 60% mortality rate

Hepatitis is fatal in up to 2.1%

1. Immunization Action Coalition. Hepatitis A: Questions and Answers.

4. Large Proportion with NO IDENTIFIABLE Risk Factors

CDC, Hepatitis surveillance report 61, 2006

4. Large Proportion with NO IDENTIFIABLE Risk Factors

Incidence rate for

3 per 1000 travellers

ffen R et al. JAMA. 1994;272(11):885-889

6. The Economic Burden is considerable

WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7

7. Vaccination is Cost Effective

Hepatitis A with cholestasis

South East Asian J Trop Med Public Health 2002; 33(1):118-27

consider vaccination in areas of intermediate

US Advisory Committee on Immunization Practices /

All children at 1223 months

Persons at increased risk

Persons travelling to or working in countries that have high or intermediate endemicity of

Users of injection and non-injection illegal drugs