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					Hepatitis A and B Vaccination and
    the New York State Adult
 Hepatitis Vaccination Program




          Elizabeth Rausch-Phung, MD MPH            1

  Medical Director, NYSDOH Bureau of Immunization
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!!

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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!!
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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.
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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.              5
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.




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Hepatitis A & B Vaccine
Administration




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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.

                                                            8
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.
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Risk Assessment &
Pre-Vaccination Screening
Three questions that should be asked prior
   to hepatitis vaccination:

1. Are you sick today?
2. Do you have any allergies to medications, food
   or any vaccine?
3. Have you ever had a serious reaction after
   receiving a vaccination?

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Contraindications and
Precautions

• Severe allergic reaction to a vaccine component
  or following a prior dose, or
• Moderate or severe acute illness.




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




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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.
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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.


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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.

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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.



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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:
   http://www.vaers.hhs.gov/.




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Vaccination Documentation

• Vaccine Information Statements – It’s a Federal
  Law!
• Must be provided with each dose of vaccine.
• Available in many languages.
  – www.cdc.gov/vaccines
  – www.immunize.org/vis
• Explains benefits and risks of a vaccine.


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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.

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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.

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Vaccine Storage and
Handling

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



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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!

                                                     22
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.




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




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         We can prevent this!!!!!




Severe ascites             Photo courtesy of
(abdominal                 Patricia Walker, MD,
swelling) in a             Ramsey Clinic
woman with chronic         Associates, St. Paul,
Hepatitis B                MN                25
infection
Additional References
NYSDOH Hepatitis Vaccine Information:
http://www.nyhealth.gov/diseases/communicable/hepatitis
/vaccine.htm

CDC: www.cdc.gov/hepatitis

ACIP Recommendations for Hepatitis A Vaccination:
http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#hepa

ACIP Recommendations for Hepatitis B Vaccination:
http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#hepb
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Additional References (con’t)
NYSDOH Immunization Page:
http://www.nyhealth.gov/prevention/immunization/

CDC Vaccine Page: http://www.cdc.gov/vaccines/

Immunization Action Coalition: http://www.immunize.org/

NYSDOH Bureau of Immunization e-mail:
immunize@health.state.ny.us

NYSDOH Bureau of Immunization phone: (518) 473-4437

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