Bureau of Epidemiology
Bureau of Epidemiology February 1997 Utah Department of Health
Prevention of Hepatitis A Through Active or Passive Immunization
Toxic Shock Syndrome is Still a Reportable Disease
Monthly Morbidity Summary  


Prevention of Hepatitis A Through Active or Passive Immunization

This report provides excerpts from the recommendations for use of the newly licensed hepatitis A vaccines (HAVRIX manufactured by SmithKline Beecham Biologicals, and VAQTA , manufactured by Merck and Company Inc.) in persons > 2 years of age and updates previous recommendations for use of immune globulin (IG) for protection against hepatitis A (superseding MMWR 1990; 39 {No. RR-2}: 1-5). For preexposure protection, hepatitis A vaccine can now be used instead of IG in many circumstances; for postexposure prophylaxis, the recommendations for IG use are unchanged. A complete copy of this publication is available through the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report, Prevention of Hepatitis A Through Active or Passive Immunization. Recommendations of the Advisory Committee on Immunization ,Practices (ACIP), December 27, 1996/Vol. 45/No. RR-15.

Pre-exposure Protection Against Hepatitis A Virus Infection

Hepatitis A vaccination provides preexposure protection from Hepatitis A Virus (HAV) infection in children and adults. Hepatitis A vaccination is recommended for persons who are at increased risk for infection and for any person wishing to obtain immunity.

Populations at Increased Risk for HAV Infection or the Adverse Consequences of Infection

•Persons traveling to or working in countries that have high or intermediate endemicity of infection. All susceptible persons traveling to or working in countries that have high or intermediate HAV endemicity should be vaccinated or receive IG before departure. Hepatitis A vaccination at the age appropriate dose is preferred for children, adolescents, and adults who plan frequent travel or who reside for long periods in a high-risk area. IG is recommended for travelers <2 years of age because the vaccine is currently not licensed for use in this age group. Prevaccination testing should be considered for older travelers or for younger persons in certain population groups.

Travelers to North America (except Mexico and Central America), western Europe, Japan, Australia, or New Zealand are at no greater risk for infection than in the United States. Data are not available regarding the risk for hepatitis A for persons traveling to developed areas of the Caribbean, although vaccine or IG should be considered if travel to areas that have questionable sanitation is anticipated.

Travelers who are administered vaccine should receive the first vaccine dose at least 4 weeks before travel. Persons can be assumed to be protected by 4 weeks after receiving the first vaccine dose, although a second dose 6-12 months later is necessary for long-term protection. Because protection may not be complete until 4 weeks after vaccination, persons traveling to a high-risk area <4 weeks after the initial dose also should be administered IG (0.02 mL/kg), but at a different anatomic injection site.

Travelers who are allergic to a vaccine component or who elect not to receive vaccine should receive a single dose of IG (0.02 mL/kg), which provides effective protection against hepatitis A for up to 3 months. Travelers whose travel period exceeds 2 months should be administered IG at 0.06 mL/kg; administration must be repeated if the travel period exceeds 5 months.

•Children in communities that have high rates of hepatitis A and periodic hepatitis A outbreaks. Children living in communities that have high rates of hepatitis A should be routinely vaccinated beginning at > 2 years of age. In addition to effectively preventing epidemics of hepatitis A in these communities, vaccination of previously unvaccinated older children is recommended within five years of initiation of routine childhood vaccination programs. Although rates differ among areas, available data indicate that a reasonable cutoff age in many areas is 10-15 years of age because older persons often are already immune and vaccination of younger children will indirectly protect older persons who may be susceptible. Vaccination of children before they enter school should receive highest priority, followed by vaccination of older children who have not been vaccinated. Prevaccination serologic testing is not indicated for vaccination of previously unvaccinated children in this setting.

•Men who have sex with men. Sexually active men who have sex with men (both adolescents and adults) should be vaccinated. Prevaccination testing is not indicated for the vaccination of adolescents in this group, yet may be warranted for adults, especially those >40 years of age, who practice such behaviors.

•Illegal-drug users. Vaccination is recommended for injecting and noninjecting illegal-drug users if local epidemiologic and surveillance data indicate current or past outbreaks among persons with such risk behaviors. Prevaccination testing is not indicated for the vaccination of adolescent illegal-drug users but may be warranted for adults, especially those >40 years of age, who practice such behaviors.

•Persons who have occupational risk for infection. Persons who work with HAV-infected primates or with HAV in a research laboratory setting should be vaccinated. No other groups have been shown to be at increased risk for HAV infection because of occupational exposure.

•Persons who have chronic liver disease. Susceptible persons who have chronic liver disease should be vaccinated. Persons who are either awaiting or have received liver transplants also should be vaccinated.

•Persons who have clotting-factor disorders. Susceptible persons who are administered clotting-factor concentrates, especially solvent-detergent-treated preparations, should be administered hepatitis A vaccine.

•Other groups. Persons who work as food handlers can contract hepatitis A and potentially transmit HAV to others. To decrease the frequency of evaluations of food handlers with hepatitis A and the need for postexposure prophylaxis of patrons, consideration may be given to vaccination of employees who work in areas where state and local health authorities or private employers determine that such vaccination is cost effective.

Hepatitis A Vaccination in Outbreak Settings

•Outbreaks in communities that have high rates of hepatitis A. Routine vaccination of children 2 years of age and accelerated vaccination of older children who have not been previously vaccinated should be implemented to control an ongoing outbreak. The upper age for vaccination of older, previously unvaccinated children should be determined by using age-specific rates of hepatitis A (or seroprevalence data, if available). In communities that have begun a vaccination program (i.e., routine vaccination of children 2 years of age and vaccination of older children who have not been previously vaccinated), the vaccination component directed toward older children who have not been previously vaccinated should be accelerated so that at least 70% coverage is achieved as quickly as possible.

•Outbreaks in communities that have intermediate rates of hepatitis A. Hepatitis A vaccination of children or adolescents may have the potential to control hepatitis A outbreaks in these communities. These communities often are located in large cities or counties; thus, widespread vaccination may not be feasible. Targeting vaccination to subpopulations or groups that have the highest rates of disease may be more feasible; however, the effectiveness of using vaccine in these settings and under these conditions has not been determined.

To determine candidate groups for vaccination, local surveillance and epidemiologic data should be used to define populations (e.g., age groups or risk groups) or areas within the community (e.g., census tracts) that have the highest rates of disease. Factors to consider in deciding whether to vaccinate persons in a certain group include a) the feasibility of rapidly vaccinating the target populations of children, adolescents, or young adults; b) program cost; and c) the ability to sustain ongoing vaccination of young children to maintain high levels of immunity and prevent future epidemics.

In some communities, day care centers play a role in sustaining communitywide outbreaks. In this situation, consideration should be given to adding hepatitis A vaccine to the immunoprophylaxis regimen for children and staff in the involved center or centers and, possibly, vaccinating children in day care centers where cases of hepatitis A have not been detected.

Because experience when using hepatitis A vaccine to control hepatitis A in communities that have intermediate rates of hepatitis A is limited, evaluation of the effectiveness of vaccination should be an essential element of programs in these settings.

•Outbreaks in other settings. The frequency of outbreaks in day care centers, hospitals, institutions (e.g., institutions for the developmentally disabled and prisons), and schools is not high enough to warrant routine hepatitis A vaccination of persons in these settings. When outbreaks are recognized in day care centers, aggressive use of IG is effective in limiting transmission to employees and families of attendees . When outbreaks occur in hospitals, institutions, and schools, use of IG in persons in close contact with infected patients or students who have hepatitis A is recommended. The role of hepatitis A vaccine in controlling outbreaks in these settings has not been investigated.

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Toxic Shock Syndrome Is Still A Reportable Disease

Toxic Shock Syndrome (TSS) has not been dropped from the reportable disease list. As of January 1995, the active surveillance for cases of TSS was discontinued. In 1996, only one case of TSS was reported to the Utah Department of Health. This case was reported by California on a Utah resident that became ill while traveling to California. From 1990 to 1996 there has been a total of 40 cases of TSS reported in Utah. Of the cases, 34 (85%) were female with an age range of 4 months to 45 years (mean of 25.15 years). There were six males reported with TSS during the same time period. The males’ ages ranged from 2 to 36 years (mean of 21.17 years).

Potential cases should still be reported to either the state or local health department. Should you need a copy of the Toxic Shock Syndrome worksheet please contact the Utah Department of Health, Bureau of Epidemiology, at (801) 538-6191.

Surveillance Case Definition for Toxic Shock Syndrome
Council of State & Territorial Epidemiologists

Fever - temperature greater than 102 degrees F.

Rash - diffuse macular erythroderma.

Desquamation - 1-2 weeks after onset of illness, particularly palms and soles.

Hypotension - systolic blood pressure < 90 mm Hg for adults or less than fifth percentile by age for children < 16 years of age; orthostatic drop in diastolic blood pressure > 15 mm Hg from lying to sitting, orthostatic syncope, or orthostatic dizziness.

Multisystem involvement - three or more of the following:

                -Gastrointestinal: vomiting or diarrhea at onset of illness.
                -Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal for laboratory.                 -Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia.
                -Renal: blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment                       with pyuria (> 5 leukocytes per high-power field) in the absence of urinary tract infection.
                -Hepatic: total bilirubin, serum glutamic-oxaloacetic transaminase (SGOT), or serum glutamic-pyruvic
                     transaminase (SGPT) at least twice the upper limit of normal for laboratory.
                -Hematologic: platelets < 100,000/mm3.
                -Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever                       and hypotension are absent.

Negative results on the following tests, if obtained:

                -Blood, throat, or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus).
                -Rise in titer to Rocky Mountain spotted fever, leptospirosis, or measles.

          Case classification

                 Probable: a case with five of the six clinical findings described above.

                 Confirmed: a case with all six of the clinical findings described above, including  desquamation, unless the
                     patient dies before desquamation.


Utah Department of Health, Bureau of Epidemiology

Monthly Morbidity Summary - February 1997 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to:
The Bureau of Epidemiology Box 142870 Salt Lake City, UT 84114-2870 or call (801) 538-6191
Approval 8000008:  Appropriation 3705
Rod Betit, Executive Director Utah Department of Health
Charles Brokopp, Dr.P.H. Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director, Bureau of Epidemiology
Cristie Chesler, BA Managing Editor