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When is discectomy indicated for lumbar disc disease?
EMERGENT DISCECTOMY is indicated in the presence of cauda equina and severe, progressive neuromotor deficits (strength of recommendation [SOR]: C, expert opinion).
Elective discectomy for sciatica caused by lumbar disc disease provides faster relief of symptoms than conservative management, but long-term outcomes are equivalent (SOR: A, a systematic review and randomized controlled trial [RCT]).
Evidence summary
Lumbar disc disease is the most common cause of sciatica.1 In the absence of red flags, the initial approach to treatment is conservative and includes physical therapy and analgesic medications. In 90% of patients, acute attacks of sciatica improve within 4 to 6 weeks without surgical intervention.1,2
Experts agree that cauda equina syndrome is an absolute indication for urgent surgical intervention.3 Most also would consider surgery for patients with progressive or severe neuromotor deficit, although no controlled studies exist to support this recommendation.3 If surgery is necessary, discectomy to relieve nerve compression is the current standard of care.3
Surgery provides relief, at least in the short term
A Cochrane review of 4 RCTs compared open and microdiscectomy with nonoperative management of lumbar disc disease in patients with sciatica.1 All the studies showed a tendency toward improved early outcomes with surgery. However, the results of the studies were limited by lack of adherence to treatment, with high crossover rates from conservative treatment to surgical intervention.
Microdiscectomy produced comparable results to standard open discectomy. The reviewers concluded that, for patients with sciatica caused by lumbar disc prolapse, surgery provides faster relief from the acute attack than conservative management; long-term differences in outcome are unclear.1
A more recent systematic review of 5 studies that compared surgery with conservative management of sciatica concluded that early surgery provides better short-term relief of sciatica but no benefit after 1 or 2 years.4
Despite faster recovery with surgery, questions remain
A subsequent study randomized 283 patients with severe sciatica for 6 to 12 weeks to early surgery or prolonged conservative treatment with surgery if needed.5 Primary outcomes were functional disability, intensity of leg pain, and the patient’s self-perceived recovery. Of patients in the early surgery group, 89% (125/141) underwent microdiscectomy after a mean of 2.2 weeks.
At 1 year, intention-to-treat analysis showed no significant difference in disability, pain, or perceived recovery between the 2 groups. However, patients who underwent early surgery reported faster relief of leg pain and a faster rate of perceived recovery. The median time to perceived recovery was 4 weeks (95% confidence interval [CI], 3.7-4.4) for early surgery and 12.1 weeks (95% CI, 9.5-14.9) for prolonged conservative treatment. Both groups had a 95% recovery rate at 52 weeks.
Thirty-nine percent (55/142) of patients randomized to conservative management underwent surgery after a mean of 18.7 weeks, and this lack of adherence to intention to treat may limit the validity of the results. A follow-up study at 2 years continued to show no difference in outcomes between surgery and conservative treatment.6
Recommendations
The Institute for Clinical Systems Improvement (ICSI) recommends conservative management initially for acute low back pain with sciatica/radiculopathy because the condition usually improves in 4 to 6 weeks. Surgery is indicated in the following cases:
- cauda equina syndrome
- progressive or significant neuromotor deficit
- neuromotor deficit that persists after 4 to 6 weeks of conservative treatment
- chronic sciatica with positive straight leg raise longer than 6 weeks or uncontrolled pain.
The ICSI recommends that patients being considered for nonemergent surgery have an epidural steroid injection, which may allow them to advance in a nonoperative treatment program.2
The American College of Physicians guidelines agree that most patients with lumbar disc herniation will improve within the first month with conservative management. They recommend discectomy or epidural steroid injections as potential treatment options for patients whose symptoms persist despite conservative therapy.7
1. Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007;(2):CD001350.
2. Institute for Clinical Systems. Health Care Guideline: Adult Low Back Pain. 14th ed. Bloomington, MN: Institute for Clinical Systems Improvement; 2010. Available at: www.icsi.org/low_back_pain/adult_low_back_pain__8.html. Accessed March 2, 2011.
3. Awad JN, Moskovich R. Lumbar disc herniations: surgical vs nonsurgical treatment. Clin Orthop Relat Res. 2006;443:183-197.
4. Jacobs WC, Van Tulder M, Arts M, . Surgery versus conservative management of sciatica due to a lumber herniated disc: a systematic review. Eur Spine J. 2011;20:513-522.
5. Peul WC, Van Houwelingen HC, Van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245-2256.
6. Peul WC, Van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008;336:1355-1358.
7. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
EMERGENT DISCECTOMY is indicated in the presence of cauda equina and severe, progressive neuromotor deficits (strength of recommendation [SOR]: C, expert opinion).
Elective discectomy for sciatica caused by lumbar disc disease provides faster relief of symptoms than conservative management, but long-term outcomes are equivalent (SOR: A, a systematic review and randomized controlled trial [RCT]).
Evidence summary
Lumbar disc disease is the most common cause of sciatica.1 In the absence of red flags, the initial approach to treatment is conservative and includes physical therapy and analgesic medications. In 90% of patients, acute attacks of sciatica improve within 4 to 6 weeks without surgical intervention.1,2
Experts agree that cauda equina syndrome is an absolute indication for urgent surgical intervention.3 Most also would consider surgery for patients with progressive or severe neuromotor deficit, although no controlled studies exist to support this recommendation.3 If surgery is necessary, discectomy to relieve nerve compression is the current standard of care.3
Surgery provides relief, at least in the short term
A Cochrane review of 4 RCTs compared open and microdiscectomy with nonoperative management of lumbar disc disease in patients with sciatica.1 All the studies showed a tendency toward improved early outcomes with surgery. However, the results of the studies were limited by lack of adherence to treatment, with high crossover rates from conservative treatment to surgical intervention.
Microdiscectomy produced comparable results to standard open discectomy. The reviewers concluded that, for patients with sciatica caused by lumbar disc prolapse, surgery provides faster relief from the acute attack than conservative management; long-term differences in outcome are unclear.1
A more recent systematic review of 5 studies that compared surgery with conservative management of sciatica concluded that early surgery provides better short-term relief of sciatica but no benefit after 1 or 2 years.4
Despite faster recovery with surgery, questions remain
A subsequent study randomized 283 patients with severe sciatica for 6 to 12 weeks to early surgery or prolonged conservative treatment with surgery if needed.5 Primary outcomes were functional disability, intensity of leg pain, and the patient’s self-perceived recovery. Of patients in the early surgery group, 89% (125/141) underwent microdiscectomy after a mean of 2.2 weeks.
At 1 year, intention-to-treat analysis showed no significant difference in disability, pain, or perceived recovery between the 2 groups. However, patients who underwent early surgery reported faster relief of leg pain and a faster rate of perceived recovery. The median time to perceived recovery was 4 weeks (95% confidence interval [CI], 3.7-4.4) for early surgery and 12.1 weeks (95% CI, 9.5-14.9) for prolonged conservative treatment. Both groups had a 95% recovery rate at 52 weeks.
Thirty-nine percent (55/142) of patients randomized to conservative management underwent surgery after a mean of 18.7 weeks, and this lack of adherence to intention to treat may limit the validity of the results. A follow-up study at 2 years continued to show no difference in outcomes between surgery and conservative treatment.6
Recommendations
The Institute for Clinical Systems Improvement (ICSI) recommends conservative management initially for acute low back pain with sciatica/radiculopathy because the condition usually improves in 4 to 6 weeks. Surgery is indicated in the following cases:
- cauda equina syndrome
- progressive or significant neuromotor deficit
- neuromotor deficit that persists after 4 to 6 weeks of conservative treatment
- chronic sciatica with positive straight leg raise longer than 6 weeks or uncontrolled pain.
The ICSI recommends that patients being considered for nonemergent surgery have an epidural steroid injection, which may allow them to advance in a nonoperative treatment program.2
The American College of Physicians guidelines agree that most patients with lumbar disc herniation will improve within the first month with conservative management. They recommend discectomy or epidural steroid injections as potential treatment options for patients whose symptoms persist despite conservative therapy.7
EMERGENT DISCECTOMY is indicated in the presence of cauda equina and severe, progressive neuromotor deficits (strength of recommendation [SOR]: C, expert opinion).
Elective discectomy for sciatica caused by lumbar disc disease provides faster relief of symptoms than conservative management, but long-term outcomes are equivalent (SOR: A, a systematic review and randomized controlled trial [RCT]).
Evidence summary
Lumbar disc disease is the most common cause of sciatica.1 In the absence of red flags, the initial approach to treatment is conservative and includes physical therapy and analgesic medications. In 90% of patients, acute attacks of sciatica improve within 4 to 6 weeks without surgical intervention.1,2
Experts agree that cauda equina syndrome is an absolute indication for urgent surgical intervention.3 Most also would consider surgery for patients with progressive or severe neuromotor deficit, although no controlled studies exist to support this recommendation.3 If surgery is necessary, discectomy to relieve nerve compression is the current standard of care.3
Surgery provides relief, at least in the short term
A Cochrane review of 4 RCTs compared open and microdiscectomy with nonoperative management of lumbar disc disease in patients with sciatica.1 All the studies showed a tendency toward improved early outcomes with surgery. However, the results of the studies were limited by lack of adherence to treatment, with high crossover rates from conservative treatment to surgical intervention.
Microdiscectomy produced comparable results to standard open discectomy. The reviewers concluded that, for patients with sciatica caused by lumbar disc prolapse, surgery provides faster relief from the acute attack than conservative management; long-term differences in outcome are unclear.1
A more recent systematic review of 5 studies that compared surgery with conservative management of sciatica concluded that early surgery provides better short-term relief of sciatica but no benefit after 1 or 2 years.4
Despite faster recovery with surgery, questions remain
A subsequent study randomized 283 patients with severe sciatica for 6 to 12 weeks to early surgery or prolonged conservative treatment with surgery if needed.5 Primary outcomes were functional disability, intensity of leg pain, and the patient’s self-perceived recovery. Of patients in the early surgery group, 89% (125/141) underwent microdiscectomy after a mean of 2.2 weeks.
At 1 year, intention-to-treat analysis showed no significant difference in disability, pain, or perceived recovery between the 2 groups. However, patients who underwent early surgery reported faster relief of leg pain and a faster rate of perceived recovery. The median time to perceived recovery was 4 weeks (95% confidence interval [CI], 3.7-4.4) for early surgery and 12.1 weeks (95% CI, 9.5-14.9) for prolonged conservative treatment. Both groups had a 95% recovery rate at 52 weeks.
Thirty-nine percent (55/142) of patients randomized to conservative management underwent surgery after a mean of 18.7 weeks, and this lack of adherence to intention to treat may limit the validity of the results. A follow-up study at 2 years continued to show no difference in outcomes between surgery and conservative treatment.6
Recommendations
The Institute for Clinical Systems Improvement (ICSI) recommends conservative management initially for acute low back pain with sciatica/radiculopathy because the condition usually improves in 4 to 6 weeks. Surgery is indicated in the following cases:
- cauda equina syndrome
- progressive or significant neuromotor deficit
- neuromotor deficit that persists after 4 to 6 weeks of conservative treatment
- chronic sciatica with positive straight leg raise longer than 6 weeks or uncontrolled pain.
The ICSI recommends that patients being considered for nonemergent surgery have an epidural steroid injection, which may allow them to advance in a nonoperative treatment program.2
The American College of Physicians guidelines agree that most patients with lumbar disc herniation will improve within the first month with conservative management. They recommend discectomy or epidural steroid injections as potential treatment options for patients whose symptoms persist despite conservative therapy.7
1. Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007;(2):CD001350.
2. Institute for Clinical Systems. Health Care Guideline: Adult Low Back Pain. 14th ed. Bloomington, MN: Institute for Clinical Systems Improvement; 2010. Available at: www.icsi.org/low_back_pain/adult_low_back_pain__8.html. Accessed March 2, 2011.
3. Awad JN, Moskovich R. Lumbar disc herniations: surgical vs nonsurgical treatment. Clin Orthop Relat Res. 2006;443:183-197.
4. Jacobs WC, Van Tulder M, Arts M, . Surgery versus conservative management of sciatica due to a lumber herniated disc: a systematic review. Eur Spine J. 2011;20:513-522.
5. Peul WC, Van Houwelingen HC, Van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245-2256.
6. Peul WC, Van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008;336:1355-1358.
7. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
1. Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007;(2):CD001350.
2. Institute for Clinical Systems. Health Care Guideline: Adult Low Back Pain. 14th ed. Bloomington, MN: Institute for Clinical Systems Improvement; 2010. Available at: www.icsi.org/low_back_pain/adult_low_back_pain__8.html. Accessed March 2, 2011.
3. Awad JN, Moskovich R. Lumbar disc herniations: surgical vs nonsurgical treatment. Clin Orthop Relat Res. 2006;443:183-197.
4. Jacobs WC, Van Tulder M, Arts M, . Surgery versus conservative management of sciatica due to a lumber herniated disc: a systematic review. Eur Spine J. 2011;20:513-522.
5. Peul WC, Van Houwelingen HC, Van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245-2256.
6. Peul WC, Van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008;336:1355-1358.
7. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
Evidence-based answers from the Family Physicians Inquiries Network
Who should get hepatitis A vaccination?
The following groups are at increased risk of contracting or having severe outcomes from hepatitis A and should receive vaccination.
- Persons traveling to or working in countries that have high or intermediate rates of infection. Specific country recommendations are available at www.cdc.gov/travel/destinat.htm (strength of recommendation [SOR]: B)
- Men who have sex with men (SOR: B)
- Illegal-drug users (whether drug is injected or not) (SOR: B)
- Persons who have occupational risk for infection (eg, research settings working with nonhuman primates) (SOR: C)
- Persons with clotting-factor disorders (SOR: C)
- Persons with chronic liver disease (SOR: B)
- Children (age 2 to 18) living in states, counties, and communities where rates of hepatitis A are at least twice the national average. These states include: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. The rates of hepatitis A for individual counties can be found at the Centers for Disease Control and Prevention (CDC) web site (www.cdc.gov/ncidod/diseases/hepatitis/a/vax/index. htm). Consider giving hepatitis A vaccine to children (age 2 to 18) in areas with rates greater than the national average but less than twice the national average. These states include Arkansas, Colorado, Missouri, Montana, Texas, and Wyoming (SOR: B).
Evidence summary
Infection with hepatitis A virus (HAV) is a reportable illness in all 50 states, and it continues to be one of the most reported vaccine-preventable illnesses. The persistence of extensive community-wide outbreaks indicates that hepatitis A remains a major public health problem.
The costs associated with HAV are substantial: 11% to 22% of individuals with HAV are hospitalized, and adults who become ill lose an average of 27 days of work. The average cost of hepatitis A ranges from $1817 to $2459 per case for adults and $433 to $1492 for children. In 1989, the estimated annual direct and indirect costs of HAV in the United States were more then $300 million (in 1997 dollars).1
Hepatitis A can produce either asymptomatic or symptomatic infection in humans after an average incubation period of 28 days. The illness is usually marked by a sudden onset of symptoms including fever, malaise, nausea, anorexia, abdominal discomfort, jaundice, and dark urine. The illness usually lasts less than 2 months. Though not usually life threatening, an estimated 100 deaths annually are attributed to acute liver failure due to hepatitis A. Patients with chronic liver disease may be at higher risk of developing fulminant hepatitis A.2,3 The likelihood of symptomatic disease is directly related to age, with 70% of adults developing jaundice and most infections in children aged <6 years having no symptoms.
HAV is transmitted primarily from fecal-oral route by either person-to-person contact or ingestion of fecally contaminated food or water. Although rare, it is possible for transmission by blood or blood products collected from donors during the viremic phase of their infection. Although HAV has been detected in saliva, transmission by saliva has not been demonstrated. Under the right conditions HAV can be stable in the environment for months. Heating foods to >185° F for 1 minute or disinfecting surfaces with 1:100 dilution of bleach in tap water is necessary to inactivate HAV.1
Vaccination against HAV is recommended for those at high risk for contracting the illness or for any person wishing to obtain immunity. Prospective studies indicate that persons traveling in areas with high rates of HAV are themselves at 44 times increased risk.4 Among men who have sex with men, numerous cohort studies reveal increased rates of infection due to anal-oral sexual practices and higher number of sexual partners.5-7 Intravenous drug users and non-IV illicit drug users are both at increased risk of HAV infection.8-10 In the United States, children living in states with increased HAV incidence rates are also considered to be at high risk.1 Less strong evidence exists for vaccinating those with occupational hazards (for example, working in a research setting with nonhuman primates) or persons with clotting factor disorders.11,12
A corollary question is who does not routinely need hepatitis A vaccine. In general, food service workers, sewerage workers, healthcare workers, children aged <2 years, day-care attendees, and residents of institutions for the developmentally disabled do not need routine immunization
The currently licensed inactivated hepatitis A vaccines are highly immunogenic and clinically effective in children 2 to 18 years and in adults. In a double-blind, controlled, randomized study of 1000 children in New York revealed clinical efficacy of 100%.13 A second study of 40,000 children in Thailand had a clinical efficacy of 94%.13 Numerous other studies have supported findings of near 100% immuno-genicity in all age groups and clinical efficacy in all age groups.1
Anyone who does not want to get hepatitis A should receive the vaccine
Richard Sams, II, MD
Camp Pendleton Naval Hospital
A good information master needs to know his resources. The question posed in this clinical inquiry is a good example. Questions about who should receive which vaccine are determined by the Advisory Committee on Immunization Practices, and their recommendations are available on the CDC’s web site (www.cdc.gov/nip/publications/acip-list.htm).
With that said, anyone who does not want to get hepatitis A should receive the vaccine. Hepatitis A is the most common vaccine preventable disease, which on occasion can be severe, especially in adults. The vaccine has no serious side effects, is highly effective and, if widely adopted, would dramatically decrease the incidence of hepatitis A in the population.
1. Prevention of hepatitis A through active or passive immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999;48(RR-12):1-37.
2. Vento S, Garofano T, Renzini C, et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 1998;338:286-290.
3. Keeffe EB. Is hepatitis A more severe in patients with chronic hepatitis B and other chronic liver diseases? Am J Gastroenterol 1995;90:201-205.
4. Steffen R, Rickenbach M, Wilhelm U, Helminger A, Schar M. Health problems after travel to developing countries. J Infect Dis 1987;156:84-91.
5. Villano SA, Nelson KE, Vlahov D, Purcell RH, Saah AJ, Thomas DL. Hepatitis A among homosexual men and injection drug users: more evidence for vaccination. Clin Infect Dis 1997;25:726-728.
6. Henning KJ, Bell E, Braun J, Barker ND. A community-wide outbreak of hepatitis A: risk factors for infection among homosexual and bisexual men. Am J Med 1995;99:132-136.
7. Corey L, Holmes KK. Sexual transmission of hepatitis A in homosexual men: incidence and mechanism. N Engl J Med 1980;302:435-438.
8. Bell BP, Shapiro CN, Alter MJ, et al. The diverse patterns of hepatitis A epidemiology in the United States—implication for vaccination strategies. J Infect Dis 1998;178:1579-1584.
9. Schade CP, Komorwska D. Continuing outbreak of hepatitis A linked with intravenous drug abuse in Multnomah County. Public Health Rep 1988;103:452-459.
10. Harkess J, Gildon B, Istre GR. Outbreaks of hepatitis A among illicit drug users, Oklahoma, 1984-87. Am J Public Health 1989;79:463-466.
11. Hinthorn DR, Foster MT, Jr., Bruce HL, Aach RD. An outbreak of chimpanzee associated hepatitis. J Occup Med 1974;16:388-391.
12. Mannucci PM, Gdovin S, Gringeri A, et al. Transmission of hepatitis A to patients with hemophilia by factor VIII concentrates treated with organic solvent and detergent to inactivate viruses. The Italian Collaborative Group. Ann Intern Med 1994;120:1-7.
13. Innis BL, Snitbhan R, Kunasol P, Laorakpongse T, Poopatanakool W, Kozik CA, et al. Protection against hepatitis A by an inactivated vaccine. JAMA 1994;271:1328-1334.
The following groups are at increased risk of contracting or having severe outcomes from hepatitis A and should receive vaccination.
- Persons traveling to or working in countries that have high or intermediate rates of infection. Specific country recommendations are available at www.cdc.gov/travel/destinat.htm (strength of recommendation [SOR]: B)
- Men who have sex with men (SOR: B)
- Illegal-drug users (whether drug is injected or not) (SOR: B)
- Persons who have occupational risk for infection (eg, research settings working with nonhuman primates) (SOR: C)
- Persons with clotting-factor disorders (SOR: C)
- Persons with chronic liver disease (SOR: B)
- Children (age 2 to 18) living in states, counties, and communities where rates of hepatitis A are at least twice the national average. These states include: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. The rates of hepatitis A for individual counties can be found at the Centers for Disease Control and Prevention (CDC) web site (www.cdc.gov/ncidod/diseases/hepatitis/a/vax/index. htm). Consider giving hepatitis A vaccine to children (age 2 to 18) in areas with rates greater than the national average but less than twice the national average. These states include Arkansas, Colorado, Missouri, Montana, Texas, and Wyoming (SOR: B).
Evidence summary
Infection with hepatitis A virus (HAV) is a reportable illness in all 50 states, and it continues to be one of the most reported vaccine-preventable illnesses. The persistence of extensive community-wide outbreaks indicates that hepatitis A remains a major public health problem.
The costs associated with HAV are substantial: 11% to 22% of individuals with HAV are hospitalized, and adults who become ill lose an average of 27 days of work. The average cost of hepatitis A ranges from $1817 to $2459 per case for adults and $433 to $1492 for children. In 1989, the estimated annual direct and indirect costs of HAV in the United States were more then $300 million (in 1997 dollars).1
Hepatitis A can produce either asymptomatic or symptomatic infection in humans after an average incubation period of 28 days. The illness is usually marked by a sudden onset of symptoms including fever, malaise, nausea, anorexia, abdominal discomfort, jaundice, and dark urine. The illness usually lasts less than 2 months. Though not usually life threatening, an estimated 100 deaths annually are attributed to acute liver failure due to hepatitis A. Patients with chronic liver disease may be at higher risk of developing fulminant hepatitis A.2,3 The likelihood of symptomatic disease is directly related to age, with 70% of adults developing jaundice and most infections in children aged <6 years having no symptoms.
HAV is transmitted primarily from fecal-oral route by either person-to-person contact or ingestion of fecally contaminated food or water. Although rare, it is possible for transmission by blood or blood products collected from donors during the viremic phase of their infection. Although HAV has been detected in saliva, transmission by saliva has not been demonstrated. Under the right conditions HAV can be stable in the environment for months. Heating foods to >185° F for 1 minute or disinfecting surfaces with 1:100 dilution of bleach in tap water is necessary to inactivate HAV.1
Vaccination against HAV is recommended for those at high risk for contracting the illness or for any person wishing to obtain immunity. Prospective studies indicate that persons traveling in areas with high rates of HAV are themselves at 44 times increased risk.4 Among men who have sex with men, numerous cohort studies reveal increased rates of infection due to anal-oral sexual practices and higher number of sexual partners.5-7 Intravenous drug users and non-IV illicit drug users are both at increased risk of HAV infection.8-10 In the United States, children living in states with increased HAV incidence rates are also considered to be at high risk.1 Less strong evidence exists for vaccinating those with occupational hazards (for example, working in a research setting with nonhuman primates) or persons with clotting factor disorders.11,12
A corollary question is who does not routinely need hepatitis A vaccine. In general, food service workers, sewerage workers, healthcare workers, children aged <2 years, day-care attendees, and residents of institutions for the developmentally disabled do not need routine immunization
The currently licensed inactivated hepatitis A vaccines are highly immunogenic and clinically effective in children 2 to 18 years and in adults. In a double-blind, controlled, randomized study of 1000 children in New York revealed clinical efficacy of 100%.13 A second study of 40,000 children in Thailand had a clinical efficacy of 94%.13 Numerous other studies have supported findings of near 100% immuno-genicity in all age groups and clinical efficacy in all age groups.1
Anyone who does not want to get hepatitis A should receive the vaccine
Richard Sams, II, MD
Camp Pendleton Naval Hospital
A good information master needs to know his resources. The question posed in this clinical inquiry is a good example. Questions about who should receive which vaccine are determined by the Advisory Committee on Immunization Practices, and their recommendations are available on the CDC’s web site (www.cdc.gov/nip/publications/acip-list.htm).
With that said, anyone who does not want to get hepatitis A should receive the vaccine. Hepatitis A is the most common vaccine preventable disease, which on occasion can be severe, especially in adults. The vaccine has no serious side effects, is highly effective and, if widely adopted, would dramatically decrease the incidence of hepatitis A in the population.
The following groups are at increased risk of contracting or having severe outcomes from hepatitis A and should receive vaccination.
- Persons traveling to or working in countries that have high or intermediate rates of infection. Specific country recommendations are available at www.cdc.gov/travel/destinat.htm (strength of recommendation [SOR]: B)
- Men who have sex with men (SOR: B)
- Illegal-drug users (whether drug is injected or not) (SOR: B)
- Persons who have occupational risk for infection (eg, research settings working with nonhuman primates) (SOR: C)
- Persons with clotting-factor disorders (SOR: C)
- Persons with chronic liver disease (SOR: B)
- Children (age 2 to 18) living in states, counties, and communities where rates of hepatitis A are at least twice the national average. These states include: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. The rates of hepatitis A for individual counties can be found at the Centers for Disease Control and Prevention (CDC) web site (www.cdc.gov/ncidod/diseases/hepatitis/a/vax/index. htm). Consider giving hepatitis A vaccine to children (age 2 to 18) in areas with rates greater than the national average but less than twice the national average. These states include Arkansas, Colorado, Missouri, Montana, Texas, and Wyoming (SOR: B).
Evidence summary
Infection with hepatitis A virus (HAV) is a reportable illness in all 50 states, and it continues to be one of the most reported vaccine-preventable illnesses. The persistence of extensive community-wide outbreaks indicates that hepatitis A remains a major public health problem.
The costs associated with HAV are substantial: 11% to 22% of individuals with HAV are hospitalized, and adults who become ill lose an average of 27 days of work. The average cost of hepatitis A ranges from $1817 to $2459 per case for adults and $433 to $1492 for children. In 1989, the estimated annual direct and indirect costs of HAV in the United States were more then $300 million (in 1997 dollars).1
Hepatitis A can produce either asymptomatic or symptomatic infection in humans after an average incubation period of 28 days. The illness is usually marked by a sudden onset of symptoms including fever, malaise, nausea, anorexia, abdominal discomfort, jaundice, and dark urine. The illness usually lasts less than 2 months. Though not usually life threatening, an estimated 100 deaths annually are attributed to acute liver failure due to hepatitis A. Patients with chronic liver disease may be at higher risk of developing fulminant hepatitis A.2,3 The likelihood of symptomatic disease is directly related to age, with 70% of adults developing jaundice and most infections in children aged <6 years having no symptoms.
HAV is transmitted primarily from fecal-oral route by either person-to-person contact or ingestion of fecally contaminated food or water. Although rare, it is possible for transmission by blood or blood products collected from donors during the viremic phase of their infection. Although HAV has been detected in saliva, transmission by saliva has not been demonstrated. Under the right conditions HAV can be stable in the environment for months. Heating foods to >185° F for 1 minute or disinfecting surfaces with 1:100 dilution of bleach in tap water is necessary to inactivate HAV.1
Vaccination against HAV is recommended for those at high risk for contracting the illness or for any person wishing to obtain immunity. Prospective studies indicate that persons traveling in areas with high rates of HAV are themselves at 44 times increased risk.4 Among men who have sex with men, numerous cohort studies reveal increased rates of infection due to anal-oral sexual practices and higher number of sexual partners.5-7 Intravenous drug users and non-IV illicit drug users are both at increased risk of HAV infection.8-10 In the United States, children living in states with increased HAV incidence rates are also considered to be at high risk.1 Less strong evidence exists for vaccinating those with occupational hazards (for example, working in a research setting with nonhuman primates) or persons with clotting factor disorders.11,12
A corollary question is who does not routinely need hepatitis A vaccine. In general, food service workers, sewerage workers, healthcare workers, children aged <2 years, day-care attendees, and residents of institutions for the developmentally disabled do not need routine immunization
The currently licensed inactivated hepatitis A vaccines are highly immunogenic and clinically effective in children 2 to 18 years and in adults. In a double-blind, controlled, randomized study of 1000 children in New York revealed clinical efficacy of 100%.13 A second study of 40,000 children in Thailand had a clinical efficacy of 94%.13 Numerous other studies have supported findings of near 100% immuno-genicity in all age groups and clinical efficacy in all age groups.1
Anyone who does not want to get hepatitis A should receive the vaccine
Richard Sams, II, MD
Camp Pendleton Naval Hospital
A good information master needs to know his resources. The question posed in this clinical inquiry is a good example. Questions about who should receive which vaccine are determined by the Advisory Committee on Immunization Practices, and their recommendations are available on the CDC’s web site (www.cdc.gov/nip/publications/acip-list.htm).
With that said, anyone who does not want to get hepatitis A should receive the vaccine. Hepatitis A is the most common vaccine preventable disease, which on occasion can be severe, especially in adults. The vaccine has no serious side effects, is highly effective and, if widely adopted, would dramatically decrease the incidence of hepatitis A in the population.
1. Prevention of hepatitis A through active or passive immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999;48(RR-12):1-37.
2. Vento S, Garofano T, Renzini C, et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 1998;338:286-290.
3. Keeffe EB. Is hepatitis A more severe in patients with chronic hepatitis B and other chronic liver diseases? Am J Gastroenterol 1995;90:201-205.
4. Steffen R, Rickenbach M, Wilhelm U, Helminger A, Schar M. Health problems after travel to developing countries. J Infect Dis 1987;156:84-91.
5. Villano SA, Nelson KE, Vlahov D, Purcell RH, Saah AJ, Thomas DL. Hepatitis A among homosexual men and injection drug users: more evidence for vaccination. Clin Infect Dis 1997;25:726-728.
6. Henning KJ, Bell E, Braun J, Barker ND. A community-wide outbreak of hepatitis A: risk factors for infection among homosexual and bisexual men. Am J Med 1995;99:132-136.
7. Corey L, Holmes KK. Sexual transmission of hepatitis A in homosexual men: incidence and mechanism. N Engl J Med 1980;302:435-438.
8. Bell BP, Shapiro CN, Alter MJ, et al. The diverse patterns of hepatitis A epidemiology in the United States—implication for vaccination strategies. J Infect Dis 1998;178:1579-1584.
9. Schade CP, Komorwska D. Continuing outbreak of hepatitis A linked with intravenous drug abuse in Multnomah County. Public Health Rep 1988;103:452-459.
10. Harkess J, Gildon B, Istre GR. Outbreaks of hepatitis A among illicit drug users, Oklahoma, 1984-87. Am J Public Health 1989;79:463-466.
11. Hinthorn DR, Foster MT, Jr., Bruce HL, Aach RD. An outbreak of chimpanzee associated hepatitis. J Occup Med 1974;16:388-391.
12. Mannucci PM, Gdovin S, Gringeri A, et al. Transmission of hepatitis A to patients with hemophilia by factor VIII concentrates treated with organic solvent and detergent to inactivate viruses. The Italian Collaborative Group. Ann Intern Med 1994;120:1-7.
13. Innis BL, Snitbhan R, Kunasol P, Laorakpongse T, Poopatanakool W, Kozik CA, et al. Protection against hepatitis A by an inactivated vaccine. JAMA 1994;271:1328-1334.
1. Prevention of hepatitis A through active or passive immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999;48(RR-12):1-37.
2. Vento S, Garofano T, Renzini C, et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 1998;338:286-290.
3. Keeffe EB. Is hepatitis A more severe in patients with chronic hepatitis B and other chronic liver diseases? Am J Gastroenterol 1995;90:201-205.
4. Steffen R, Rickenbach M, Wilhelm U, Helminger A, Schar M. Health problems after travel to developing countries. J Infect Dis 1987;156:84-91.
5. Villano SA, Nelson KE, Vlahov D, Purcell RH, Saah AJ, Thomas DL. Hepatitis A among homosexual men and injection drug users: more evidence for vaccination. Clin Infect Dis 1997;25:726-728.
6. Henning KJ, Bell E, Braun J, Barker ND. A community-wide outbreak of hepatitis A: risk factors for infection among homosexual and bisexual men. Am J Med 1995;99:132-136.
7. Corey L, Holmes KK. Sexual transmission of hepatitis A in homosexual men: incidence and mechanism. N Engl J Med 1980;302:435-438.
8. Bell BP, Shapiro CN, Alter MJ, et al. The diverse patterns of hepatitis A epidemiology in the United States—implication for vaccination strategies. J Infect Dis 1998;178:1579-1584.
9. Schade CP, Komorwska D. Continuing outbreak of hepatitis A linked with intravenous drug abuse in Multnomah County. Public Health Rep 1988;103:452-459.
10. Harkess J, Gildon B, Istre GR. Outbreaks of hepatitis A among illicit drug users, Oklahoma, 1984-87. Am J Public Health 1989;79:463-466.
11. Hinthorn DR, Foster MT, Jr., Bruce HL, Aach RD. An outbreak of chimpanzee associated hepatitis. J Occup Med 1974;16:388-391.
12. Mannucci PM, Gdovin S, Gringeri A, et al. Transmission of hepatitis A to patients with hemophilia by factor VIII concentrates treated with organic solvent and detergent to inactivate viruses. The Italian Collaborative Group. Ann Intern Med 1994;120:1-7.
13. Innis BL, Snitbhan R, Kunasol P, Laorakpongse T, Poopatanakool W, Kozik CA, et al. Protection against hepatitis A by an inactivated vaccine. JAMA 1994;271:1328-1334.
Evidence-based answers from the Family Physicians Inquiries Network