Andrew Waters

1
Hepatitis A Outbreak
2007 ERRT Conference October 2nd, 2007

• Andrew Waters
• Regional Epidemiologist
• Bluegrass Region 2

2
Objectives

• Provide overview of Hepatitis A
• Review Hepatitis A case definitions
• Initial case background
• Additional cases and contacts
• Describe investigation progress
• After action

3
Hepatitis A

• Hepatitis A is an inflammation of the liver with
  a viral etiology
• Infectious
• Fecal-oral route of transmission
• Symptoms include fever, fatigue, nausea, malaise,
  and jaundice

4
Events in Hepatitis A Infection
Clinical illness
Viremia
HAV in stool
IgG
Infection
Response
IgM
ALT
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Week
5
Case Definition

• RDDR
• A case that meets the clinical case definition
  and is laboratory confirmed OR epidemiologically
  linked to a laboratory confirmed case

Sensitive
Specific
6
Initial Case

• On May 16th, LFCHD was notified of a positive lab
  result for Hepatitis A in a Lexington resident
• 37yo, white male presented to ER with severe back
  pain
• Medical record stated patient ingested 50
  Tylenol over 4 day period to ease back and
  testicular pain
• Transferred to another hospital for consult with
  hepatitic specialist for further review

7
Initial Case

• Hepatitis panel and liver function tests were
  performed
• Anti-HAV IgM positive
• Anti-HBc IgM -- negative
• HBsAg and anti-HCV negative
• ALT above normal
• AST above normal
• Bilirubin -- normal

8
Initial Case

• Medical record suggested that high liver enzymes
  were due to Tylenol toxicity and subsequent
  treatment for hepatic failure
• No phone number listed for patient
• Contact was made by patient on May 18
• ICN interviewed patient to determine patients
  status

9
Initial Case

• Recently moved from San Diego in mid April
• Homeless -- ?
• Drug rehab
• 10 year history of drug abuse
• Currently drug free
• Denied experiencing any symptoms
• Due to start job at food service establishment
  next week

10
Is initial case a case?

• Based on the information we had at the time --
  not a case!!!
• Patient was allowed to begin work in food service
• Recommended he continue follow-up with physician
  to monitor liver function

11
But why?

• Hepatitis A IgM labs have a high rate of false
  positives
• History of drug abuse
• High doses of Tylenol -- 30g

12
Additional Cases

• June 13 report of 3 patients, one with jaundice
• Mentioned someone in their household sick with
  yellow eyes in May and had been told he had liver
  damage
• Blood was drawn on all 3 patients and sent to lab
  for testing of viral hepatitis

13
Additional Cases

• Contact with 3 additional cases confirmed
  association with our initial case
• Index case was tested again for Hep A IgM,
  results were positive
• 4 Hepatitis A cases from at least two different
  households

14
Household A
Mother 1 Sx Boyfriend 1 No Sx Daughter 1 No
Sx Mother 2 No Sx Boyfriend 2 Sx Daughter 2
No Sx
15
Household B
Father 1 Sx Girlfriend 1 No Sx 2 Daughters
No Sx 1 Son No Sx 1 Male Babysit No Sx 1 Male
No Sx
16
Household C
Male No Sx
17
Our Circles
Household B
Household A
Mother 1 Sx Boyfriend 1 No Sx Daughter 1 No
Sx Mother 2 No Sx Boyfriend 2 Sx Daughter 2
No Sx
Father 1 Sx Girlfriend 1 No Sx 2 Daughters
No Sx 1 Son No Sx 1 Male Babysit No Sx 1 Male
No Sx
Male No Sx
Household C
18
Social Contacts

• Very social group
• Household B was a gathering place for young
  children in the neighborhood because of an
  in-ground pool
• 15-20 additional visitors daily

19
More Circles
15-20 visitors to in-ground pool
Mother 1 Sx Boyfriend 1 No Sx Daughter 1 No
Sx Mother 2 No Sx Boyfriend 2 Sx Daughter 2
No Sx
Father 1 Sx Girlfriend 1 No Sx 2 Daughters
No Sx 1 Son No Sx 1 Male Babysit No Sx 1 Male
No Sx
Male No Sx
20
Department Operations Center

• COO activated DOC to coordinate our agencys
  response
• Core group consisted of
• Epidemiology
• Environmental Health
• Public Health Clinic
• Administration
• COO, Commissioner, PIO

21
Epi Curve
Index Case
22
Epidemiology

• Identified all contacts of the household and
  determined status
• Visited Household B for further information
• Made preparations for contacts to come to HD to
  receive IG and Hep A vaccine
• Index Case was lost to contact

23
Epidemiology

• Developed criteria to determine exposure of
  visitors
• Length of time at house
• Consumption
• Drug use
• Sharing of drinks or cigarettes
• Sexual contact
• One visitor fit the criteria

24
Environmental Health

• Inspected in-ground pool of Household B
• Inspected restaurant for potentially ill
  co-workers of index case and hand washing
  facilities
• Coordinated LFCHD activities with main
  headquarters of OCharleys

25
Restaurant Exposure
End of Infectious period
26
Restaurant Exposure

• Released restaurant name into the media
• Poor historian
• Unsure about dates
• Lost to follow-up
• No clear onset of symptoms
• Used first positive IgM result

27
PH Clinic

• Prepared and staffed to provide IG and Hep A
  vaccine to all contacts
• Coordinated with clerical staff to identify
  contacts on arrival and treat ASAP
• Organized and staffed two separate vaccination
  clinics to OCharleys employees

28
IG and Hep A vaccine

• Provided IG and Hep A vaccine to 9 the of
  contacts to the cases
• 2 contacts did not receive prophylaxis
• Never showed up, afraid of shots
• Only 8 restaurant employees took advantage of the
  vaccination paid for by the company

29
After Action

• Hepatitis A protocol
• Provides steps to take when dealing with an
  outbreak
• Generalizes a procedure for identifying atypical
  cases
• Evaluation of response was used to identify areas
  to correct for future outbreaks