What vaccinations are recommended for patients with Hepatitis C (HCV)?

Recommended Vaccinations for Hepatitis C Patients

All patients with Hepatitis C should receive vaccinations against Hepatitis A and Hepatitis B, with additional vaccines including influenza, pneumococcal, and COVID-19 based on their liver disease status. 1

Core Vaccine Recommendations

Hepatitis A Vaccination

• Vaccinate all HCV-positive patients who lack immunity to Hepatitis A virus (HAV). 1 This is critical because HAV superinfection in patients with chronic HCV has been associated with fulminant hepatitis, severe disease, and significantly higher mortality rates. 1, 2, 3
• The standard two-dose HAV vaccine schedule (1440 ELISA units) achieves seroconversion in approximately 92% of HCV patients with chronic liver disease. 4
• Post-vaccination antibody testing is generally not required for HAV due to high response rates. 5

Hepatitis B Vaccination

• All HCV patients without evidence of HBV immunity should receive HBV vaccination. 1 HBV coinfection with HCV accelerates progression to cirrhosis, hepatic decompensation, and hepatocellular carcinoma. 2, 3
• Use a double-dose regimen (40 µg) rather than standard dosing (20 µg) in patients with cirrhosis, as standard doses achieve only 57-74% seroconversion compared to >90% in healthy individuals. 6, 5, 4
• Administer HBV vaccine early in the disease course before cirrhosis develops, as vaccine response deteriorates significantly with advancing liver disease. 6, 2, 5
• Check post-vaccination hepatitis B surface antibody titers, especially in patients with cirrhosis or HCV genotype 1, to identify non-responders who need booster doses. 6, 5
• Protective antibody levels may wane over time—more than 60% of HCV patients lose seroprotective anti-HBs levels within 4 years. 7

Pneumococcal Vaccination

• All HCV patients with cirrhosis should receive pneumococcal vaccination. 1, 6 The American College of Physicians recommends both PCV13 and PPSV23, with PCV13 given first followed by PPSV23 at least 8 weeks later. 6

Influenza Vaccination

• Annual inactivated influenza vaccine is recommended for all HCV patients, particularly those with chronic liver disease or cirrhosis. 6 Note that effectiveness may be reduced compared to healthy individuals. 6

COVID-19 Vaccination

• All HCV patients should receive COVID-19 vaccination (mRNA or adenoviral vector vaccines) without discontinuing their HCV therapy. 1, 6
• Patients on the liver transplant waiting list should complete a two-dose COVID-19 series before transplantation. 6

Vaccination Timing Considerations

Pre-Transplant Patients

• Complete all indicated vaccinations before liver transplantation, as immune response is significantly impaired post-transplant. 1, 6
• Patients awaiting transplant should receive two doses of COVID-19 vaccine before the procedure. 1, 6

Post-Transplant Patients

• Postpone vaccination for 3-6 months after transplantation when immunosuppression levels are lower. 1, 6
• If the first vaccine dose was given pre-transplant, the second dose can be administered 4 weeks to 3 months post-transplant. 1
• Withhold vaccination in liver transplant recipients with active acute cellular rejection or those receiving high-dose corticosteroids until resolved. 1

Additional Screening and Counseling

Coinfection Screening

• Screen all HCV-positive patients for HIV, syphilis, gonorrhea, chlamydia, and HBV due to overlapping risk factors. 1
• These coinfections can accelerate liver damage and worsen outcomes during pregnancy and in general. 1

Lifestyle Counseling

• Counsel patients to abstain completely from alcohol, as even modest amounts accelerate liver disease progression in HCV patients. 1
• Provide education on preventing HCV transmission: avoid sharing personal hygiene items (razors, nail clippers, toothbrushes), needles, or drug paraphernalia. 1

Critical Pitfalls to Avoid

• Do not delay vaccination until decompensation occurs—immune response deteriorates significantly with advancing liver disease, making early vaccination essential. 6, 2, 5
• Do not use standard single-dose HBV vaccination in cirrhotic patients—this frequently fails and requires double-dose regimens with antibody monitoring. 6, 5
• Do not assume vaccine-induced immunity persists indefinitely—HBV antibody levels wane over time in HCV patients, requiring periodic monitoring and potential boosters. 7
• Do not overlook HAV vaccination—while less commonly discussed, HAV superinfection carries particularly high mortality risk in chronic HCV patients. 1, 2, 3