Aetna considers hepatitis A vaccine a medically necessary preventive service according to the recommendations of the Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) for the following at-risk groups:

• Children 12 to 23 months of age.  Children who are not vaccinated by age of 2 years can be vaccinated at subsequent visits
• Ethnic and geographic populations with high endemic rates or periodic outbreaks of hepatitis A infection, such as Native Americans and Alaskan Natives
• Hemophiliacs
• Homosexual and bisexual men
• Individuals who anticipate close personal contact (e.g., household contact or regular babysitting) with an international adoptee from a country of high or intermediate endemicity during the first 60 days after arrival of the adoptee in the United States
• Individuals with chronic liver disease
• Individuals with occupational risk of exposure, such as child-care and institutional workers, as well as primate-animal handlers*
• Injection and illicit drug users
• Laboratory workers who handle live hepatitis A virus*
• Migrant Hispanics
• Military personnel*
• Travelers to areas where hepatitis A is endemic*

* Note: Most Aetna HMO plans exclude coverage of immunizations required for travel or work.  Please check benefit plan descriptions for details.

Aetna considers hepatitis A vaccine medically necessary for prophylaxis when initiated within 2 weeks after hepatitis A exposure.

Hepatitis A vaccine is approved for people 12 months of age and older and is given in a 2-dose schedule at least 6 months apart (AAP, 2003).  Currently licensed vaccines (Havrix and Vaqta) are given intra-muscularly.

A combination hepatitis A/hepatitis B vaccine (Twinrix, GlaxoSmithKline Biologicals, Rixensart, Belgium) is approved for people 18 years of age and older and is given in a 3-dose schedule (0, 1, and 6 months) or an accelerated 4-dose schedule (0, 7, and 21 to 30 days, and a 4th dose at 1 year).  The first 3 doses of the 4-dose schedule are intended to provide protection equivalent to the first 2 doses of the original schedule.  The new schedule is useful if travel or potential exposure is expected before the 2nd dose (at 1 month) on the original schedule.

The annual recommended childhood and adolescent immunization schedule for approved by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (Fiore et al, 2006) recommends universal administration to all children at 1 year (12 to 23 months) of age.  Furthermore, the 2 doses in the series should be separated by at least 6 months.  Children who are not vaccinated by age 2 years can be vaccinated at subsequent visits to their pediatricians.

Either vaccine can be used for either dose, but use of the same vaccine for both doses is preferable.  The recommended dose interval is 6 to 18 months for Vaqta and 6 to 12 months for Havrix.

The AAP recommends that regions with immunization programs for 2- to 18-year old children should continue them and expand them to include 12- to 23-month olds.  In areas without existing hepatitis A immunization programs, catch-up immunization of unvaccinated 2- to 18-year old children should be considered.  In addition, previously unvaccinated children who will be living in, or traveling to, areas with intermediate or high hepatitis A endemicity should be immunized before departure.

Immunization is especially recommended for adolescent and adult males who have sex with males, users of injectable or non-injectable illicit drugs, recipients of clotting factors, and individuals who work with hepatitis A virus in the laboratory setting.

The AAP recommends vaccinating children with immunocompromising conditions, as the vaccines do not contain living organisms.  Hypersensitivity to vaccine components such as aluminum hydroxide and phenoxyethanol are contraindications to use of hepatitis A vaccines.  Hepatitis A vaccine may be co-administered with other vaccines in the childhood immunization series.

The ACIP of the CDC recommends post-exposure prophylaxis with hepatitis A vaccine for healthy individuals between the ages of 1 and 40 years (CDC, 2007).  Persons who have recently been exposed to hepatitis A virus and who have not been vaccinated previously should be administered a single dose of single-antigen hepatitis A vaccine or immune globulin (0.02 ml/kg) as soon as possible, within 2 weeks after exposure.  All others should receive immune globulin, if possible.

The guidelines vary by age and health status (CDC, 2007).  For healthy persons aged 12 months to 40 years, single-antigen hepatitis A vaccine at the age-appropriate dose is preferred to immune globulin because of vaccine’s advantages, including long-term protection and ease of administration, as well as the equivalent efficacy of vaccine to immune globulin.  For persons aged more than 40 years, immune globulin is preferred because of the absence of information regarding vaccine performance in this age group and because of the more severe manifestations of hepatitis A in older adults.  Vaccine can be used if immune globulin can not be obtained.  The magnitude of the risk of hepatitis A virus transmission from the exposure should be considered in decisions to use vaccine or immune globulin in this age group.  For children aged less than 12 months, immunocompromised persons, persons with chronic liver disease, and persons who are allergic to the vaccine or a vaccine component, immune globulin should be used.

The ACIP recommendation is based upon evidence that hepatitis A vaccine is as effective as immune globulin in preventing transmission.  Researchers randomized 1,090 susceptible household or day-care contacts of patients in Kazakhstan to prophylaxis with either hepatitis A vaccine or immune globulin within 2 weeks of exposure (Victor et al, 2007).  The investigators found that the effect of the vaccine would be similar to immune globulin.  Between 2 and 8 weeks after exposure, vaccine recipients showed a 1.35 relative risk (95 % confidence interval: 0.70 to 2.67) for developing symptomatic infection as compared with those receiving immune globulin.

The ACIP recommends hepatitis A vaccination for unvaccinated individuals who anticipate close personal contact (e.g., household contact or regular babysitting) with an international adoptee from a country of high or intermediate endemicity during the first 60 days after arrival of the adoptee in the United States.  The first dose of the 2-dose hepatitis A vaccine series should be administered as soon as adoption is planned, preferably 2 weeks or more before the arrival of the adoptee.

The ACIP annually reviews the recommended adult immunization schedule to ensure that the schedule reflects current recommendations for the licensed vaccines. 

Rowe et al (2012) stated that hepatitis A virus (HAV) super-infection in persons with hepatitis C virus (HCV) infection has been associated with a high mortality rate, and vaccination is recommended.  The incidence of HAV is low, and the aim of this study was to determine the mortality risk of HAV super-infection and the consequences of routine vaccination in persons with HCV infection.  To determine the mortality risk of HAV super-infection, a meta-analysis including studies reporting mortality in HCV-infected persons was performed.  Data were extracted independently by 2 investigators and recorded on a standardized spread-sheet.  The pooled mortality estimate was used to determine the number needed to vaccinate (NNV) to prevent mortality from HAV super-infection.  The total vaccine cost was also calculated.  A total of 239 studies were identified using a defined search strategy.  Of these, 11 appeared to be relevant, and of these, 10 were suitable for inclusion in the meta-analysis.  The pooled odds ratio (OR) for mortality risk in HAV super-infection of HCV-infected persons was 7.23 (95 % confidence interval: 1.24 to 42.12) with significant heterogeneity (I(2) = 56 %; p = 0.03) between studies.  Using the pooled OR for mortality, this translates to 1.4 deaths per 1,000,000 susceptible persons with HCV per year.  The NNV to prevent 1 death per year is therefore 814,849, assuming 90 % vaccine uptake and 94.3 % vaccine efficiency.  The vaccine cost for this totals $162 million, or $80.1 million per death prevented per year.  The authors concluded that these data challenge the use of routine HAV vaccination in HCV-infected persons and its incorporation into clinical practice guidelines.  HAV vaccination of all HCV-infected persons is costly and likely to expose many individuals to an intervention that is of no direct benefit.