Hepatitis A

1. Educate providers and laboratories to report cases of hepatitis A to the local health department in the patient’s county of residence within 24 hours of diagnosis.
   
   
2. Upon receipt of a report of hepatitis A:

1. Look carefully at the laboratory result. Only persons with a positive IgM anti-HAV antibody are acutely infected with hepatitis A. Asymptomatic persons with a positive "total anti-HAV antibody" may have either recent or remote hepatitis A infection and do not need to be investigated or reported. HAV stands for "hepatitis A virus."
   
   
2. Collect all the information necessary for case ascertainment, and record on the reportable disease card and the CDC supplemental hepatitis form:

1. Date of onset of symptoms (date of jaundice is considered the most reliable sign) and type of symptoms;
   
   
2. Liver function tests; and
   
   
3. IgM antibody to hepatitis A virus (anti-HAV IgM).

3. Calculate the infectious period using a calendar. Persons with acute hepatitis A are most infectious from two weeks before onset of symptoms to one week after onset. A hypothetical example follows:
   
   

4. Investigate forward to identify persons who may be at risk for acquiring infection from this case.

1. Administer immune globulin (IG) (0.02 mL/kg IM) to high-risk contacts if IG can be administered within two weeks of the last contact with the case while the case was infectious. These persons include:

1. Household contacts;
   
   
2. Sexual contacts; and
   
   
3. Persons who have shared illegal drugs.

2. Identify high-risk settings for transmission of hepatitis A:

1. Day care centers. IG should be administered to all staff and attendees of day care centers or homes if a) one or more cases of hepatitis A are recognized in children or employees, or b) cases are recognized in two or more households of center attendees. In centers that do not provide care to children who wear diapers, IG need be given only to classroom contacts of an index case-patient. When an outbreak occurs (i.e. hepatitis cases in three or more families), IG also should be considered for members of households that have children (center attendees) in diapers.
   
   
2. Foodhandlers. If a foodhandler is diagnosed with hepatitis A, IG should be administered to other foodhandlers at the same location. Administration of hepatitis A vaccine to these other foodhandlers might also be considered. Because common-source transmission to patrons is unlikely, IG administration to patrons may be considered if the foodhandler both 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 two weeks after the exposure. In settings where repeated exposures to HAV may have occurred (e.g. institutional cafeterias), stronger consideration of IG use may be warranted. In the event of a common-source outbreak, IG should not be administered to exposed persons after cases have begun to occur because the two-week period during which IG is effective will have been exceeded.

5. Investigate backward:

1. Determine the incubation period for the case of hepatitis A. Again, use a calendar. The incubation period is two to six weeks prior to onset.
   
   

2. Identify any potential source. Symptomatic persons identified during contact investigation should be tested for anti-HAV IgM. Persons found to be positive for anti-HAV IgM should be investigated and reported as cases of hepatitis A according to steps 2a through 2f.
   
   
3. Identify any risk factors for HAV infection during the two- to six-week incubation period. Risk factors include:

1. Close contact with a person with confirmed or suspected hepatitis A;
   
   
2. Employment or attendance in a nursery, day care center, or preschool;
   
   
3. Travel outside of the United States or Canada;
   
   
4. Illegal drug use;
   
   
5. Number of male sexual partners; and
   
   
6. Number of female sexual partners.

4. Investigate vaccination history and record as part of the investigation, including:

1. Hepatitis A vaccination status (number of doses, dates of vaccination);
   
   
2. Missed opportunities for prevention/vaccination:

1. Household contact of persons with acute hepatitis A;
   
   
2. Sought medical care prior to foreign travel; or
   
   
3. Ever in treatment for illegal drug use.

6. Report cases of hepatitis A to the West Virginia Infectious Disease Epidemiology Program (IDEP) by submitting a completed reportable disease card, a completed CDC supplemental investigation form, and all laboratory documentation.

3. For small clusters of hepatitis A (two to five individuals reported in a short time frame):

1. Investigate as in steps 2a through 2f. Most small clusters of hepatitis A are due to person-to-person spread. This will become apparent through good contact tracing of cases of hepatitis A.
   
   
2. Contact IDEP for assistance – urgently if cases are not linked to one another.

4. For larger clusters and outbreaks (> five individuals reported in a short time frame):

1. Begin enhanced passive surveillance or active surveillance for additional cases.
   
   
2. Investigate as in steps 2a through 2f.
   
   
3. Contact IDEP immediately – urgently if cases are not attributable to person-to-person spread.

Disease Control Objectives

1. By timely and appropriate use of immune globulin (IG), prevent cases resulting from a reported case of hepatitis A due to:

1. Household or sexual contact with the case; or
   
   
2. Contact with the case in a high-risk setting such as in day care or a commercial food establishment.

2. Prevent unnecessary transmission of hepatitis A through the early recognition and investigation of outbreaks so that control measures can be instituted in a timely fashion.

1. Reduce the incidence of hepatitis A through education of:

1. The general public about appropriate handwashing;
   
   
2. Food service workers about appropriate handwashing and not working while sick; and
   
   
3. Day care operators about appropriate handwashing and exclusion of ill children and staff.

2. Reduce the incidence of hepatitis A through appropriate use of the hepatitis A vaccine for:

1. Persons traveling to or working in countries that have high or intermediate endemicity of infection;
   
   
2. Men who have sex with men;
   
   
3. Illegal drug users;
   
   
4. Persons who have occupational risk for infection;
   
   
5. Persons who have clotting factor disorders; and
   
   
6. Persons with chronic liver disease including persons with chronic infection due to hepatitis B or C.

1. To determine the incidence of Hepatitis A in West Virginia.
   
   
2. To identify demographic characteristics of persons with hepatitis A.
   
   
3. To detect any increase in the incidence of hepatitis A or any change in the usual pattern of disease transmission.

Relapsing disease occasionally occurs. Chronic disease does not occur.

Point source outbreaks are those that result from one common exposure or infected person. Hepatitis A outbreaks of this nature are generally recognized after a larger than expected number of cases of hepatitis A are reported within a limited time period. Since the incubation period of hepatitis A is long, 15 to 50 days, and the infectious period can be as long as three weeks, the onset dates for cases with a common source are usually spread over several weeks. Examples include community-based outbreaks due to a single infected foodhandler or due to contaminated food items such as produce and shell fish.

Propagated outbreaks are those that involve person-to-person transmission and result in two or more generations of cases. Hepatitis A outbreaks of this nature are generally recognized when more than one case occurs in an institution (day care centers), or links are recognized between cases in the community (e.g. friends in a mobile home park). Cases in these outbreaks usually have widely spaced onset dates (three to six weeks) with little clustering in time.

An acute illness with

1. discrete onset of symptoms (e.g. fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting), and
   
   
2. jaundice or elevated serum aminotransferase levels.

IgM antibody to hepatitis A virus (anti-HAV) positive.

Confirmed: a case that meets the clinical case definition and is laboratory confirmed, or a 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 an infected person during the 15 to 50 days before the onset of symptoms).

Collect a blood specimen in a red top tube or a red and grey striped tube. Due to the number of tests that are run along with hepatitis A, the larger the collection tube, the better. Submit the specimen to the West Virginia Office of Laboratory Services with a completed hepatitis form. The test currently takes overnight to run, so immediate transport to OLS is necessary to get results in a timely fashion.

1. Hepatitis A (inactivated) vaccine is recommended for:

1. Children who live in states where the average annual hepatitis A rate during 1987 to 1997 was > 20 cases per 100,000 population (roughly twice the national average); and
   
   
2. Persons at increased risk for hepatitis A infection, including

1. Persons traveling to or working in countries that have high or intermediate endemicity of infection;
   
   
2. Men who have sex with men;
   
   
3. Illegal drug users;
   
   
4. Persons who have occupational risk for infection;
   
   
5. Persons who have clotting factor disorders; and
   
   
6. Persons with chronic liver disease including persons with chronic hepatitis B or C infections.

2. Hepatitis A (inactivited) vaccine may be recommended for children who live in states where the average annual hepatitis A rate during 1987 to 1997 was > 10 cases per 100,000 population but less than 20 cases per 100,000 population.
   
   
3. The vaccine has also been used in control of community outbreaks. For more information, refer to MMWR October 1, 1999; Vol. 48; No. RR-12.

1. Close personal contacts. Includes household and sexual contacts and persons who share illegal drugs. Other forms of ongoing close personal contact (e.g. babysitting) should be considered.
   
   
2. Day care centers. Immune globulin should be administered to all previously unvaccinated staff and attendees of day care centers or homes if one or more cases are recognized in children or employees or cases are recognized in two or more households of center attendees. In centers that do not care for diapered children, immune globulin need only be administered to classroom contacts of an index case. IDEP should be consulted about outbreak management in these settings.
   
   
3. Common source exposure. If a foodhandler is diagnosed with hepatitis A, immune globulin should be administered to foodhandlers at the same establishment. Immune globulin administration to patrons may be considered if the foodhandler directly handled uncooked foods or foods after cooking while infectious and the foodhandler had diarrhea or poor hygienic practices and patrons can be identified and treated within two weeks after the exposure.
   
   
4. Schools, hospitals, and work settings. Immune globulin is not routinely indicated when a single case occurs in an elementary or secondary school, or in an office or other work setting. IDEP should be consulted about outbreak management in these settings.

• Proportion of investigations with complete clinical and demographic information.
  
  
• Proportion of cases with complete risk factor history from two to six weeks before the onset of symptoms.
  
  
• Proportion of cases with vaccination history and history of missed opportunities.