The basic principles of a hepatitis A vaccine schedule

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Hepatitis A vaccine information has always caused many queries, but the general rules really make it quite easy to follow these days.  This information applies to the MONOVALENT vaccines (ie single hepatitis A vaccines) discussed below.

There are 5 different hepatitis A vaccines at the current time as follows:

A course of hepatitis A vaccine comprises 2 doses: a 1st dose and a completing (or booster) dose.  If you clicked on any of the named vaccines above you would be taken to the Electronic Medicines Compendium (EMC) which provides details of the Summary of Product Characteristics (SPC) or 'license' of a drug and the Patient Information Leaflet (PIL).  The licenses of the hepatitis A vaccines vary as to when the booster dose would be given and the length of protection provided.  

Immunisation against infectious disease which we call the GREEN BOOK is our national guidance in the UK for all vaccine preventable diseases.  This lays out the recommended schedules of vaccines.  However, sometimes this guidance is not exactly the same as the information within the SPC.  But the first paragraph of chapter 4 of the green book says:  

Recommendations on immunisation procedures are based on currently available evidence and experience of best practice. In some circumstances, this advice may differ from that in vaccine manufacturers’ Summaries of Product Characteristics (SPCs). When this occurs, the recommendations in this book (which are based on current expert advice received from the Joint
Committee on Vaccination and Immunisation JCVI) should be followed.

As a result we would follow the Green Book advice for a hepatitis schedule A vaccine.  Chapter 17 page 154 says: 

The primary immunisation course for hepatitis A vaccine consists of a single dose. A booster dose of hepatitis A vaccine should be given at six to 12 months after the initial dose. This results in a substantial increase in the antibody titre and will give immunity beyond ten years, however, effective protection beyond ten years cannot be assured until this booster is given. Until further evidence is available on persistence of protective immunity, a further booster at 25 years is indicated for those at ongoing risk.  

The image below is my attempt to explain it in a diagram! 

Hep A Course

CONCLUSION - so we say

  • Give 2 doses of hepatitis A vaccine 6-12 months apart
  • This information would apply to all the above vaccines 
  • The traveller then has 25 years of protection from the DATE of the COMPLETING DOSE of the course (which includes the paediatric vaccines)
  • If the traveller did not attend for the booster dose on time, you would not restart the course but boost when they turn up (see below *)
  • This length of protection is taken to apply to ALL hepatitis A products discussed in the Green book once a course of hepatitis A vaccine is given (including combination vaccines which have hepatitis A in them!)  

Other rules for hepatitis A vaccine include

  • Monovalent hepatitis A vaccines are interchangeable, although it's always best to complete with the brand you started with
  • Always use an age appropriate vaccine (ie. one licensed for that specific age)
  • Hepatitis A vaccine is always an NHS vaccine in an NHS setting 

*Booster doses - in chapter 11 page 81 it says:

If any course of immunisation is interrupted, it should be resumed and completed as soon as possible. There is generally no need to start any course of immunisation again, as immunological memory from the priming dose(s) is likely to be maintained. Where vaccination was commenced some time previously, however, the product received may have changed and the relevant chapter should therefore be consulted

 

COMBINATION HEPATITIS A + B vaccines (from the hepatitis A perspective)

There are three relevant vaccines -  Twinrix AdultTwinrix paediatricAmbirix.  

  • The content of hepatitis A in Twinrix Adult (720 ELISA units) is half the dose of hepatitis A that would be found in Havrix Monodose (1440 ELISA units)
  • The content of hepatitis A in Twinrix Paediatric (360 ELISA units) is half the dose of hepatitis A that would be found in Havrix Junior Monodose (720 ELISA units)
  • Ambirix is also a paeditric vaccine (used age 1-15) but the amount of hepatitis A in it is equivalent to a Havrix Junior Monodose (720 ELISA units) 

Many errors occur in regard to the combined hepatitis A and B vaccines. Once the content and schedules are understood, there is nothing particularly difficult about their use. Follow these additional guidelines as well to ensure mistakes aren’t made when using twinrix adult or paediatric:

1. If giving a course of Twinrix you MUST ensure you give two doses of the vaccine prior to departure to obtain maximum protection for hepatitis A

2. If you start a course of hep A and hep B protection using either Twinrix Adult or Twinrix Paediatric vaccines then COMPLETE the course using these vaccines.

3. If you start a course of hep A and B protection using monovalent hep A and hep B vaccines, then you cannot use a combined hep A and hep B vaccine to complete the course. (this is all because of the content value of hepatitis A).

More information regarding FAQs on Twinrix is also found in the FAQ document below.  

 

VERY USEFUL RESOURCES  to understand the subject further are: 

NaTHNaC Hepatitis A factsheet from TravelHealthPro 

TRAVAX FAQ document for hepatitis A - permission has been very kindly given by TRAVAX to make this document accessible here, please make sure you read the information from me at the beginning if you choose to download it.  To register and access further FAQs from TRAVAX click here 

Green Book Chapter 17 on Hepatitis A

Vaccine chart with all the current schedules include those for hepatitis A - see item no. 3 here