The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Pediatrics (AAP) recommend routine administration of hepatitis A vaccine for household members and close contacts, including baby-sitters, when children are adopted from countries with high or intermediate rates of hepatitis A infection. This policy expands previous AAP recommendations to immunize travelers to countries who are seeking to adopt a child in countries with high or medium hepatitis A endemicity. All previously nonimmune unvaccinated people who anticipate close exposure to international adoptees during the 60 days after their arrival should receive hepatitis A immunization, ideally 2 or more weeks before the arrival of the adopted child.

Hepatitis A virus (HAV) causes an acute liver infection that is most commonly acquired from exposure to people shedding virus in feces. Most infected children younger than 6 years are asymptomatic. Fewer than 10% of children younger than 4 years develop any symptoms after infection. Thirty percent to 40% of children 4 through 9 years of age are noted to have jaundice. Transmission is highest during the 1 to 2 weeks before jaundice or elevation of liver enzyme levels occurs and during the week after symptoms develop. Risk of transmission diminishes over time, but HAV can be found in stool for extended periods, particularly in neonates and young children. The incubation period is 15 to 50 days (average of 28 days). Some recent HAV outbreaks have been traced to international adoptees. Hepatitis A vaccine is recommended for all children 12 through 23 months of age, for people who are at increased risk of infection, for people who are at increased risk of severe hepatitis A disease, and for any person who desires immunity.1 

During the period 1998–2008, approximately 18 000 children were adopted annually from foreign countries. Of these children, 99.8% were from countries with high or intermediate rates of HAV infection,2  and 85% were younger than 5 years. The incidence of HAV infection in these countries is highest in children younger than 5 years. Hepatitis A vaccine is not routinely administered in these countries. In 2007, a case of fulminant HAV infection was reported in a grandmother of an asymptomatic 1-year-old adopted from Ethiopia who had a laboratory-confirmed HAV infection. An investigation of this event identified 20 additional cases of acute hepatitis A in patients who had no international travel but had close personal contact with newly arriving internationally adopted children.3 

Since 2007, the Centers for Disease Control and Prevention has received reports of 14 more clusters of acute HAV infection after exposure to asymptomatic newly arriving adoptees. In a 1998 outbreak, 12 secondary cases were identified, and there were 2 hospitalizations and tertiary cases in an elementary school. Data from 3 adoption clinics in the United States revealed that 1% to 6% of adoptees were acutely infected with HAV.

The risk of HAV infection in close contacts of international adoptees is estimated to be 106 per 100 000 contacts within the initial 60 days of arrival.4  This rate is 100 times greater than that estimated for symptomatic HAV infection in the general US population.

On February 25, 2009, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention updated its policy for hepatitis A vaccine. Hepatitis A vaccine is now recommended for all previously unvaccinated people who anticipate close personal contact with an international adoptee from a country of high or medium endemicity (see www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm#Fig4) during the 60-day period after arrival. Close contacts include household members and baby-sitters. The first dose of the 2-dose series should be given as soon as adoption is planned, ideally 2 or more weeks before arrival of the adopted child. The second dose should be given to provide long-term immunity.

Michael T. Brady, MD, Chairperson

Henry H. Bernstein, DO

Carrie L. Byington, MD

Kathryn M. Edwards, MD

Margaret C. Fisher, MD

Mary P. Glode, MD

Mary Anne Jackson, MD

Harry L. Keyserling, MD

David W. Kimberlin, MD

Yvonne A. Maldonado, MD

Walter A. Orenstein, MD

Gordon E. Schutze, MD

Rodney E. Willoughby, MD

Robert Bortolussi, MD

Canadian Paediatric Society

Marc A. Fischer, MD

Centers for Disease Control and Prevention

Bruce Gellin, MD

National Vaccine Program Office

Richard L. Gorman, MD

National Institutes of Health

Lucia Lee, MD

Food and Drug Administration

R. Douglas Pratt, MD

Food and Drug Administration

Jennifer S. Read, MD

National Institutes of Health

Jane Seward, MBBS, MPH

Centers for Disease Control and Prevention

Jeffrey R. Starke, MD

American Thoracic Society

Jack Swanson, MD

Committee on Practice Ambulatory Medicine

Tina Q. Tan, MD

Pediatric Infectious Diseases Society

Carol J. Baker, MD

Red Book Associate Editor

Sarah S. Long, MD

Red Book Associate Editor

H. Cody Meissner, MD

Red Book Associate Editor

Larry K. Pickering, MD

Red Book Editor

Lorry G. Rubin, MD

Jennifer Frantz, MPH

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

HAV

hepatitis A virus

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