Update on Hepatitis A Management

To the Editor

Drs Desai and Kim¹ provided a brief overview of hepatitis A management. Their JAMA Insights article was timely considering the widespread person-to-person outbreaks of hepatitis A across the US since 2016.² However, we note some discrepancies between this publication and the Advisory Committee on Immunization Practices (ACIP) recommendations that could affect the public health response to hepatitis A.^3,4

First, Desai and Kim noted that food service workers may be vaccinated in the setting of large-scale outbreaks. However, because transmission of hepatitis A virus from infected food handlers to susceptible consumers or restaurant patrons in the workplace is rare, recently estimated at less than 1%,⁵ the ACIP does not recommend hepatitis A vaccination of food handlers during outbreaks. Second, it was listed in the Table that individuals who work in health care settings that have services for injection and noninjection drug users should be vaccinated against hepatitis A virus infection. However, health care personnel are not considered at substantially increased risk of hepatitis A virus infection through occupational exposure, especially in facilities with good infection control practices. Therefore, health care personnel are not routinely recommended to receive hepatitis A vaccine in any setting because of their health care personnel status alone.^3,4

Third, Desai and Kim emphasized the use of immunoglobulin for preexposure and postexposure prophylaxis. However, the hepatitis A vaccine is preferred because it induces active immunity, provides long-term protection, and is associated with greater ease of administration and availability.^3,4 Immunoglobulin can be administered concurrently with vaccine when protection from vaccine alone is inadequate.^3,4 Fourth, the prevaccination and postvaccination serologic testing recommendations noted by Desai and Kim were recently updated in the new ACIP hepatitis A vaccine recommendations published on July 3, 2020.⁴ Key updates stress that prevaccination testing should not be a barrier to vaccination of susceptible persons, especially in populations that are difficult to access. Postvaccination testing is now recommended for persons whose future clinical management depends on knowledge of their immunity status and for persons for whom revaccination might be indicated, such as people with HIV or other immunocompromising conditions.⁴