Hepatitis A Protocol Update

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Hepatitis A Protocol Update

• 2008 1st Quarter Training
• Suzanne Wilson, MPH
• Food and Waterborne Disease Epidemiologist

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Objectives

• Clinical presentation of acute Hepatitis A
• Epidemiology of Hepatitis A virus
• Case Definition for acute Hepatitis A
• Public Health Action steps

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Symptoms of Acute Hepatitis

• Fever (Hep A)
• Malaise
• Nausea/Vomiting
• Abdominal discomfort

• Anorexia
• Jaundice
• Joint pain (Hep B)
• Dark Urine

Recovery is the norm. No treatment available.
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Epidemiology of Hepatitis A

• Agent
• Hepatitis A virus- family Picornaviridae
• Reservoir
• Humans
• Incubation Period
• 28-30 days average
• Infectious Period
• 2 weeks before and 1 week after symptom onset
• Mode of Transmission
• Fecal-oral, foodborne, waterborne

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Case Definition

• Clinical Description
• An acute illness with
• Discrete onset of symptoms AND
• Jaundice or elevated serum aminotransferase
  levels
• Lab Criteria
• IgM antibody to hepatitis A (anti-HAV) positive

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Case Definition

• Case Classification
• Confirmed
• Case that meets the clinical case definition and
  is laboratory confirmed OR
• Case that meets the clinical case definition and
  occurs in a person who has an epidemiologic link
  with a person who has laboratory confirmed
  hepatitis A (i.e. household or sexual contact
  with the infected person in the 15 to 50 days
  before onset of symptoms)

There are no Suspect or Probable
classifications for Hep A
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Case Ascertainment

• First step in investigation of a reported case of
  hepatitis A
• Does the case have a () Anti-HAV-IgM?
• Does the case have acute illness with discrete
  onset of symptoms?
• Does the case have jaundice or elevated serum
  aminotransferase levels
• Must answer yes to all 3 questions to meet case
  definition of acute Hep A

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Reporting of Hepatitis A
WV Communicable Disease Rule (WV Code 16-3-1
64CSR7)

• All cases of Hepatitis A and all IgM HAV lab
  results are reportable to the LHD of the
  patients county of residence within
• 24 hours of diagnosis

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Disease Control

• The first priority (!)

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Infectious Period (yellow)onset jaundice gt
symptoms
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Control Measures

• Household and sexual contacts
• Educate
• Signs and symptoms of disease
• Preventing transmission
• Administer PEP if exposed to infectious case
  within the last 2 weeks
• Exclusion from work / school
• Only if symptomatic

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Prevention

• Prevention messages
• Always wash your hands after using the bathroom.
• Always wash your hands after cleaning the toilet.
• Always wash your hands after changing diapers.
• Always wash your hands after handling soiled
  towels or linens.
• Always wash your hands before fixing food or
  eating.
• If exposed to hepatitis A, ask your doctor about
  post exposure prophylaxis (PEP)

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Post Exposure Prophylaxis (PEP)

• Persons recently exposed to HAV (within 14 days)
  and who previously have not received hepatitis A
  vaccine...
• For healthy persons aged 12 mos to 40 years 1
  dose (age-appropriate) of single antigen HAV
  vaccine
• Persons aged gt 40 yrs, IG is preferred vaccine
  can be used if IG is not available
• Children lt 12 mos, immunocompromised persons,
  persons with chronic liver disease, or persons
  for whom vaccine is contraindicated, IG should be
  used

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Hepatitis A PEP Recommendations
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Infectious Period (yellow)If the 21st is the
last day of exposure, the 4th is the last day you
can give PEP!!
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Control Measuresfor High Risk Settings

• PEP should be administered to all staff and
  attendees of a day care center or home if
• 1 or more cases of Hepatitis A are recognized in
  children or employees
• or
• Cases are recognized in 2 or more households of
  center attendees

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Control Measuresfor High Risk Settings

• In day care centers that do not provide care to
  children in diapers, PEP need be given only to
  classroom contacts of the index case-patient

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Control Measuresfor High Risk Settings

• If a foodhandler is diagnosed with Hepatitis A
• Appropriate PEP should be given to other
  foodhandlers at the same location
• PEP administration to patrons may be considered
  if
• the foodhandler directly handled uncooked foods
  or foods after cooking during the infectious
  period and
• had diarrhea or poor hygienic practices and
• patrons can be identified and treated within 2
  weeks after exposure

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Control Measures

• Health care workers infected with HAV should be
  excluded from hands on patient care for 7 days
  following the onset of symptoms
• In a health care setting
• Nosocomial transmission rare
• Use standard precautions (also use contact
  precautions for diapered or incontinent patients)

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Summary

• Cases and positive labs reported in 24 hours
• Start investigation immediately
• Case ascertainment
• Follow up household and sexual contacts
• Investigate high risk occupations
• Recommend/Administer appropriate PEP

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Location of Protocol

• http//www.wvdhhr.org/idep/pdfs/idep/hepatitisA/he
  p_a_protocol.pdf

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Questions?