Contributed by David Wilson, MS, RNC
Hepatitis A has been recognized as a growing child health problem within the last decade. This disease is easily transmitted via the fecal-oral route and from person-to- person. In some cases hepatitis A may be spread through contaminated water and food but rarely by contaminated blood products. This acute illness has a sudden onset with fever, malaise, jaundice, anorexia, and nausea being the most common clinical manifestations. In infants and preschool children, however, infection may occur without the presence of jaundice, and mild nonspecific symptoms may be the only manifestation. It is estimated that about 100 persons die yearly as a result of hepatitis A infection. These deaths are primarily in adults over 50 years of age. Children may easily spread the infection to household adults who demonstrate more serious clinical manifestations and subsequent liver disease. The highest incidence of infection is among children who are 5 to 14 years old. Chronic infection as a result of hepatitis A is very unusual and fulminant cases of infection are rare unless the individual also has hepatitis B (Prevention of hepatitis A, 1999).
In previous years recommendations for immunization against hepatitis A was issued primarily for travelers who might come in contact with contaminated food and water and persons who were particularly susceptible to hepatitis A infections. However, epidemiologic evidence demonstrating a high rate of infection among children (greater than or equal to 20 cases per 100,000 population) has prompted the Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention, to recommend routine mandatory immunization for hepatitis A in states with high infection rates. The western United States is the primary focus of the current recommendation for childhood hepatitis A immunizations: Nevada, New Mexico, California, Oregon, Oklahoma, South Dakota, Idaho, Arizona, Washington, Utah, and Alaska. High infection rates were seen among American Indian/Alaskan populations, with the next highest being among Hispanics, while non-Hispanics and Asians had the lowest rates of infection in the 1987-1997 epidemiologic surveys (Prevention of hepatitis A, 1999). The American Academy of Pediatrics (2000) has recently affirmed the ACIP recommendation for childhood vaccination against hepatitis A.
Two hepatitis A vaccines are currently licensed for use in children 2- to -18 years of age: HAVRIX (SmithKline Beecham Biologicals), and VAQTA (Merck & Co.). Both HAVRIX and VAQTA are inactivated viral vaccines and may be given via the intramuscular route into the deltoid muscle. The vaccines are administered in a 2-dose regimen at 6 to12 month intervals in children between 2 to 18 years of age. HAVRIX and VAQTA are available in 2 formulations that are age-specific. For children 2 to18 years HAVRIX is available in a 720 EL. U. (enzyme-linked immunoassay [ELISA] unit) per dose and for persons over 18 years, a 1440 EL. U. dose. Likewise VAQTA, has a formulation of 25 units per dose for children 2 to 17 years, and a 50 unit per dose formulation for those over 17 years. Reported side effects in children vaccinated with HAVRIX were pain and induration at the injection site, feeding problems, and headache. In those children vaccinated with VAQTA the most common side effects were pain, tenderness, and warmth at the injection site (Prevention of hepatitis A, 1999). Children who live in areas considered to be high risk for hepatitis A infection should be immunized according to the age-appropriate regimen. Neither vaccine has been licensed for use in children under 2 years of age. The primary goal for instituting mandatory hepatitis A vaccination among children aged 2-18 in the high-risk states is to decrease viral transmission among children and adults, subsequent illness and hospitalization, and improve the quality of life among those at risk for infection. It is expected that the recommended hepatitis A immunization schedule will substantially decrease infection rates among children and adults in the United States.
Nurses should be aware of the recommendation for hepatitis A administration in their particular state or community based upon the risk status. To decrease pain at the injection site EMLA cream may be applied two and one-half hours before administration or a vapocoolant spray may be used immediately before the injection.
Immunization Protects Children 2004 Immunization Schedule
Recommended Childhood Immunization Schedule — United States, January-December 2000
Keeping Current On Vaccine Recommendations
A Cooling Spray (Fluori-Methane) Reduces Immunization Injection Pain
See Chapter 12 in Nursing Care of Infants and Children, 6th edition.
See Chapter 10 in Essentials of Pediatric Nursing, 5th edition.
March 15, 2002