From the Guidelines
Hepatitis A in the elderly requires immediate attention and preventive measures due to the increased risk of severe disease and complications, and the hepatitis A vaccine should be administered as two doses given 6-12 months apart, with immune globulin also considered for post-exposure prophylaxis. Elderly patients are more likely to have severe manifestations of hepatitis A, with a case-fatality rate reaching 1.8% among persons aged >60 years, and fulminant hepatitis reported more frequently in this age group 1. The performance of hepatitis A vaccine as postexposure prophylaxis in the elderly was not assessed in recent clinical trials, but immune globulin has been recommended and used successfully for many years in this group 1.
For post-exposure prophylaxis in the elderly, both the vaccine and immune globulin (0.1 mL/kg) should be administered within two weeks of exposure for optimal protection. The standard adult formulation (Havrix 1440 EL.U. or VAQTA 50 U) is appropriate for elderly patients. However, limited data are available comparing HepA vaccine and IG in healthy adults aged >40 years, and available data indicate reduced response to HepA vaccine in older age groups compared with response in younger adults 2.
Elderly patients with hepatitis A infection typically need supportive care including:
- Adequate hydration
- Rest
- Nutritional support Hospitalization may be necessary for elderly patients with severe symptoms, dehydration, or liver dysfunction. The elderly are at higher risk for severe hepatitis A manifestations including fulminant hepatitis and prolonged cholestatic disease due to age-related decline in immune function and higher prevalence of underlying liver conditions. Regular monitoring of liver function tests is essential during the course of illness, and recovery may take longer in elderly patients, sometimes extending to several months, during which they should avoid alcohol and hepatotoxic medications to prevent further liver damage.
From the Research
Hepatitis A in the Elderly
- Hepatitis A can cause severe and serious symptoms in unprotected adults, with the risk of morbidity and mortality increasing with age 3.
- The immune response to hepatitis A vaccine may be diminished in older adults, especially in the very oldest age groups 4.
- Studies have shown that the seroprotection rate after a single dose of hepatitis A vaccine is lower in older adults, ranging from 65% to 73%, compared to younger adults 4, 3.
- However, a booster dose can improve the seroprotection rate in older adults, with one study showing a seroprotection rate of 98% after a booster dose in subjects over 50 years old 3.
- The Centers for Disease Control and Prevention (CDC) recommends that hepatitis A vaccine be administered as soon as possible within 14 days after exposure to achieve the best possible immune response 4.
- Other jurisdictions have also recommended the use of hepatitis A vaccine for post-exposure prophylaxis in older adults, either alone or in conjunction with immune globulin 4.
- A study comparing hepatitis A vaccine with immune globulin for postexposure prophylaxis found that both provided good protection, but the vaccine had the advantage of long-term protection 5.
- The American Academy of Pediatrics recommends the use of hepatitis A vaccine for prevention of hepatitis A infections in children and adults, including travelers to areas with high endemic rates and patients with chronic liver disease 6.
Vaccination Strategies
- Screening elderly travelers to areas endemic for HAV for the presence of naturally acquired immunity is recommended, and if found susceptible, they should be immunized well in advance of their trip 3.
- Administration of a booster dose may be necessary to achieve optimal protection in older adults 3.
- The use of combined hepatitis A and B vaccine has shown similar seroprotection rates against HAV compared to monovalent vaccine after receiving three doses 3.