Alberta Health Public Health Notifiable Disease Management Guidelines April 2013

Transcription

1 April 2013 Hepatitis A Revisin Dates Case Definitin Reprting Requirements Remainder f the Guideline (i.e., Etilgy t References sectins inclusive) Updated Prphylaxis Table and Algrithm (Pages 9, 12) Case Definitin May 2012 April 2013 April 2013 September 2017 Cnfirmed Case Labratry cnfirmatin f infectin: Detectin f immunglbulin M antibdy t hepatitis A virus (anti-hav IgM) in the absence f recent immunizatin [1] with hepatitis A vaccine AND acute clinical illness [2] OR Detectin f anti-hav IgM, in the absence f recent immunizatin with hepatitis A vaccine [1] AND an epidemilgical link t a cnfirmed case. OR Acute clinical illness [2] and HAV PCR psitive result Prbable Case Acute clinical illness [2] in a persn withut labratry cnfirmatin f infectin wh is epidemilgically linked t a cnfirmed case OR Detectin f anti-hav IgM in the absence f clinical illness [2] r recent immunizatin [1] with Hepatitis A vaccine OR Acute clinical illness [2] in a persn with a lw psitive anti-hav IgM [3,4] and PCR negative [1] Anti-HAV IgM has been detected up t 2-3 weeks after ne dse f hepatitis A vaccine.(1) [2] Acute clinical illness is characterized by discrete nset f symptms usually including fever, malaise, anrexia, nausea and abdminal pain fllwed by jaundice. Elevated serum amintransferase levels (ALT) accmpanied by any f these symptms is indicative f disease. [3] Lw psitive anti-hav IgM results may be cnfirmed by PCR at Prvincial Labratry fr Public Health (PrvLab) by special request. PCR is nt dne rutinely n initial screening [4] Rarely, HAV IgM can remain detectable years after an acute infectin. False psitive anti-hav IgM results can ccur, especially in an lder persn withut cnsistent symptms.(2) Acute/recent infectin shuld be cnfirmed with clinical histry, symptms and/r by repeat titre after 7-10 days (if indicated) r by PCR (if required) after cnsultatin with virlgist-n-call. 1 f 13

2 Reprting Requirements 1. Physicians, Health Practitiners and thers Physicians, health practitiners and thers listed in Sectins 22(1) r 22(2) f the Public Health Act shall ntify the Medical Officer f Health (MOH) (r designate) f all cnfirmed and prbable cases by the Fastest Means Pssible (FMP) i.e., direct vice cmmunicatin. 2. Labratries All labratries, including reginal labratries and the PrvLab shall, in accrdance with Sectin 23 f the Public Health Act, reprt all psitive labratry results: By FMP t the: MOH (r designate) and Attending/rdering physician. By mail, fax, r electrnic transfer within 48 hurs (tw days) t the: Chief Medical Officer f Health (CMOH) (r designate). 3. Alberta Health Services and First Natins Inuit Health Branch The MOH (r designate) f the zne where the case currently resides shall frward the preliminary Ntifiable Disease Reprt (NDR) f all cnfirmed and prbable cases t the CMOH (r designate) within tw weeks f ntificatin and the final NDR (amendment) within fur weeks f ntificatin. Fr ut-f-zne reprts, the MOH (r designate) first ntified shall ntify the MOH (r designate) f the zne where the client currently resides by FMP and immediately fax a cpy f the psitive labratry reprt. Fr ut-f-prvince and ut-f-cuntry reprts, the fllwing infrmatin shuld be frwarded t the CMOH (r designate) by FMP, including: name, date f birth, ut-f-prvince health care number, ut-f-prvince address and phne number, attending physician (lcally and ut-f-prvince) and psitive labratry reprt (faxed). Fr ut-f-zne cntacts wh may be eligible fr pst-expsure prphylaxis, the MOH (r designate) f the zne first ntified shall ntify the MOH (r designate) where the cntact resides with the fllwing infrmatin by FMP including: name, date f birth and cntact infrmatin i.e., address and phne number. Fr ut-f-prvince and ut-f-cuntry cntacts wh may be eligible fr pst-expsure prphylaxis, the fllwing infrmatin shuld be frwarded t the CMOH (r designate) by FMP including: name, date f birth and ut-f-prvince address and phne number Gvernment f Alberta 2 f 13

3 Etilgy Hepatitis A virus (HAV) is a 27-nm picrnavirus (i.e., a psitive-strand RNA virus). It has been classified a Hepatvirus, a member f the family Picrnaviridae.(3) Clinical Presentatin Hepatitis A is ne f the ldest diseases knwn t mankind. In persns infected with HAV, the virus replicates in the liver, is excreted in bile and shed in stl.(1) The infectin is typically an acute, selflimited illness. Acute clinical illness typically has an abrupt nset f fever, malaise, anrexia, nausea and vmiting, abdminal discmfrt, dark urine and pale stls (referred t as prdrmal phase), fllwed by an icteric phase, during which jaundice develps. The icteric phase generally begins within 10 days f the nset f the initial symptms.(4) The disease varies in clinical severity frm a mild illness lasting 1 2 weeks, t a severely disabling disease lasting several mnths, althugh this is rare.(3) Prlnged r relapsing disease lasting up t twelve mnths can ccur in apprximately 15% f cases.(3,5) Fulminant hepatitis is rare but can ccur mre frequently in individuals with underlying liver disease.(5) The likelihd f develping symptmatic illness frm HAV infectin is directly related t age, with nly 30% f infected children yunger than 6 years f age shwing symptms; (6) if illness des ccur, few f these children will have jaundice. Older children and adults are mre likely t have symptmatic illness with jaundice ccurring in mre than 70% f cases.(4) Generally, severity increases with age, but cmplete recvery withut sequelae r recurrences is the rule.(3) Chrnic infectin des nt ccur. The reprted case fatality rate amng reprted cases f all ages is apprximately 0.3%, but can be higher amng lder persns (apprximately 2% amng persns 40 years f age r greater).(6) Diagnsis Hepatitis A is nt clinically distinguishable frm ther frms f viral hepatitis; therefre the diagnsis is established by the demnstratin f IgM antibdy t HAV (anti-hav IgM) in the serum f acutely r recently ill persns. Anti-HAV IgM usually becmes detectable 5 10 days befre the nset f symptms and may remain detectable fr up t 6 mnths. IgG appears in the cnvalescent phase f infectin and persists fr life, cnferring lifelng immunity.(6) Epidemilgy Reservir The reservir is typically humans and rarely chimpanzees and ther primates.(3) Transmissin HAV infectin is primarily spread by the fecal-ral rute either directly thrugh persn-t-persn cntact r indirectly by ingestin f cntaminated fd r water. Cmmn surce utbreaks have been linked t cnsumptin f cntaminated ice/water r by ingestin f fd cntaminated by infected fd handlers (including uncked fds r fds handled after cking); eating raw r undercked shellfish harvested frm cntaminated waters; r fruits, vegetables and ther fds that are eaten uncked and that were cntaminated during harvesting r subsequent handling.(3) Hepatitis A virus is partially resistant t heat. It is relatively stable at mderate temperatures but can be inactivated by high temperatures (185 F [85 C] r higher), frmalin r chlrine.(6) Gvernment f Alberta 3 f 13

4 HAV can be acquired thrugh sexual cntact (anal-ral) and rarely thrugh bld transfusins. In the case f transmissin by bld transfusin, the dnr must be in the viremic prdrmal phase f infectin at the time f bld dnatin.(4) Men having sex with men (MSM) and intravenus drug users (IDU) are at higher risk fr acquiring infectin.(7) Mst transmissin ccurs amng clse cntacts, particularly in husehlds and extended family settings.(6) Incubatin Perid The incubatin perid can be between 15 and 50 days, depending n the infectius dse, with an average f days.(3) Surce: American Medical Assciatin, 2004 (8) Perid f Cmmunicability Maximum infectivity ccurs during the latter half f the incubatin perid and cntinues fr a few days after nset f jaundice (r during peak amintransferase activity in cases where jaundice des nt develp). Mst cases wuld be cnsidered nn-infectius after the first week f jaundice, hwever prlnged viral excretin (up t six mnths) has been dcumented in infants and children.(3) Fr purpses f public health fllw-up, the perid f cmmunicability can be cnsidered frm 14 days prir t nset f symptms t ne week after nset f jaundice. Hst Susceptibility Susceptibility is general. Occurrence General Hepatitis A ccurs wrldwide. The risk f infectin is inversely prprtinal t levels f sanitatin and persnal hygiene.(4) In develping cuntries, especially thse with limited access t clean water and pr envirnmental hygienic cnditins, HAV infectins are mst frequently acquired during early childhd and usually are asymptmatic r mild. A high prprtin f adults in these ppulatins are immune t HAV and epidemics f hepatitis A are uncmmn.(9) As hygienic and sanitary cnditins imprve, transmissin shifts t lder age grups and the incidence f symptmatic disease is seen t increase.(4) In develped cuntries, HAV infectin is less cmmn, but cmmunitywide utbreaks may ccur.(9) In these cuntries, disease transmissin is mst frequent amng husehld and sexual cntacts f Gvernment f Alberta 4 f 13

5 acute cases, and ccurs spradically in day care centers with children in diapers, travellers t endemic cuntries, IDU and MSM.(3) Canada Hepatitis A was first reprted in Canada in Like mst industrialized cuntries, Canada has a relatively lw incidence f hepatitis A. Since the intrductin f hepatitis A vaccine in 1996, the rates f disease have slwly declined. Between 1990 and 2008, the number f cases reprted annually varied frm 2978 in 1991 t 298 in 2008 representing rates f 10.6 cases per 100,000 t 0.9 cases per 100,000 respectively. The age-specific incidence is highest amng 5 9 years lds with a rate f 2.1 per 100,000, fllwed by 1 4 year lds with a rate f 1.5 per 100,000. Generally, it has been estimated that due t asymptmatic infectins, underdiagnsis and underreprting, the actual numbers f cases may be seven times higher than reprted. In the 1990 s, utbreaks invlving MSM had ccurred in majr Canadian cities. Since then, there have been n utbreaks reprted in these cmmunities. This may be attributable t the impact f targeted immunizatin prgrams.(7) Alberta The incidence rate f hepatitis A in Alberta between 1999 and 2012 ranged frm 0.61 t 2.87 cases per 100,000 (average 1.4 cases per 100,000).(10) A prvince-wide utbreak ccurred in 2004 (2.1 cases per 100,000) but since then the rates have declined. An investigatin cnducted in 2004 was unable t determine a cmmn surce f infectin in the higher number f cases reprted that year. Between , 226 cases f hepatitis A were reprted in the prvince fr an average rate f 1.0 case per 100,000 ppulatin.(10) 56.2% (127/226) f the cases were related t travel utside f Alberta r recent immigratin; 15.5% (35/226) were reprted as lcally acquired within Alberta and fr 28.3% (64/226) f the cases, the surce was reprted as unknwn. The highest rate during this perid was seen in the 1 19 year ld age grup. Number f Cases Cases and Rates f Hepatitis A in Alberta, 1999 t Cases Rate Rate per 100,000 Surce: Alberta Health (AH) Cmmunicable Disease Reprting System (CDRS) March 6, 2013(10) Key Investigatin Single Case/Husehld Cluster Cnfirm the diagnsis. Obtain a histry f illness including date f nset, signs and symptms, nset date f jaundice. Fr the purpse f public health fllw-up, date f nset is the first day f prdrme OR the 7 th day prir t the nset f jaundice, if prdrme is nt knwn. Prdrme refers t the early symptms suggestive f the nset f disease and, in this case, may include abrupt nset f Gvernment f Alberta 5 f 13

6 fever, malaise, anrexia, nausea and vmiting, abdminal discmfrt, dark urine and pale stls. Determine the dates f cmmunicability (perid f infectiusness). Determine ccupatin f the case (e.g., fd handler, childcare facility wrker, healthcare wrker, etc) and identify specific duties at wrk When assessing fd handlers, determine if their wrk invlves activities such as: tuching unwrapped fd t be cnsumed raw r withut further cking and/r handling equipment r utensils that tuch unwrapped fd t be cnsumed raw r withut further cking. If the case is a child, determine attendance at a childcare facility (e.g., daycare, dayhme) r ther childcare arrangements r schl attended and grade. Determine the pssible surce f infectin taking int accunt the incubatin perid, reservir and mde f transmissin.(3) Assessment shuld include: determining histry f travel, btaining a detailed fd histry especially cnsumptin f cntaminated ice/water, uncked r undercked fd r fd washed in cntaminated water, determining histry f living in areas with pr sanitatin including imprper water treatment and sewage dispsal, and include recent immigratin, identifying any risk behaviurs including lifestyle risks fr infectin (e.g., MSM, IDU), determining if the case attends a childcare facility r ther type f institutinal setting (e.g. living is a crrectinal facility r residential/institutinal setting), determining if there was any cntact with a cnfirmed case f hepatitis A r cntact with an ill persn wh had symptms that were clinically cmpatible with hepatitis A infectin, assessing fr similar symptms in ther members f the husehld (histrical and present) and inquiring abut receipt f bld r bld prduct transfusin, r rgan transplantatin. Identify all cntacts wh may have had expsure during the perid that the case was infectius (perid f cmmunicability): Cnsider the fllwing when identifying cntacts: clse persnal cntacts (e.g., husehld cntacts, sexual cntacts including MSM, regular babysitter/childcare prvider, cntacts in lng-term care facilities ), persns wh have spent 24 hurs r mre in the husehld, persns wh have eaten fd prepared r handled by the case during the infectius perid, persns wh have had r may have had indirect cntact thrugh sharing ptentially cntaminated items with the case (i.e., items that culd be cntaminated with feces due t handling by the case), childcare facility cntacts including staff, persns wh have shared illicit drugs with the case and thers wh may have had cntact with the feces f the case (e.g., in the case f diapered children r thers wh are incntinent) where gd standards f hygiene have nt been met. Cntrl Management f a Case Prvide infrmatin abut disease transmissin and the apprpriate infectin preventin and cntrl measures t be implemented t minimize the pssibility f fecal-ral transmissin Gvernment f Alberta 6 f 13

7 including thrugh handwashing especially after using the washrm, changing diapers and befre eating and preparing/handling fds. Fr hspitalized patients, additinal precautins (i.e., cntact precautins) shuld be implemented in additin t rutine practices, especially fr diapered and incntinent patients fr at least 1 week after nset f symptms.(5) Advise the case t refrain frm preparing fd fr thers fr the duratin f the perid f cmmunicability. Ntify and invlve the Envirnmental Health Officer (EHO) in the fllw-up when a fd surce is suspected. Exclude cases invlved in sensitive ccupatins r situatins (i.e., thse wh pse a higher risk f transmissin t thers) fr 14 days frm the nset f their illness r fr at least 7 days after the nset f jaundice. These wuld generally include: fd handlers whse wrk invlves: tuching unwrapped fd t be cnsumed raw r withut further cking and/r handling equipment r utensils that tuch unwrapped fd t be cnsumed raw r withut further cking. NOTE: Generally, fd handlers wh d nt tuch fd, equipment r utensils in this way are nt cnsidered t pse a transmissin risk hwever, circumstances fr each case shuld be assessed n an individual basis. healthcare wrkers prviding direct patient care and persns invlved in the care f yung children, elderly, highly susceptible r dependent persns, children attending a childcare facility r similar facilities wh are diapered r unable t implement gd standards f persnal hygiene and any individual (child r adult) wh is unable t implement gd standards f persnal hygiene (e.g., mentally r physically challenged). Advise all ther cases (i.e., thse nt invlved in sensitive ccupatins r situatins) t remain at hme while they are acutely ill. Treatment N specific therapy; treatment is supprtive. Management f Cntacts Prvide infrmatin abut HAV disease and apprpriate infectin preventin and cntrl measures. Stress the measures t be taken t minimize pssible fecal-ral transmissin including thrugh handwashing, especially after using the washrm, changing diapers, and befre eating and preparing/handling fds. Assess all cntacts, including visitrs t the husehld fr ptential f expsure during perid f cmmunicability fr the case. Identify cntacts that wuld be cnsidered t have immunity against hepatitis A. A persn wuld be cnsidered immune if they had: histry f cnfirmed hepatitis A disease, cmpleted an apprpriately spaced series f hepatitis A cntaining vaccine (e.g., Havrix, Vaqta, Twinrix), received ne dse f hepatitis A cntaining vaccine between ne and six mnths prir t expsure, r received immune glbulin (Ig) within the last 3 5 mnths (dependent n the dse) prir t expsure t the hepatitis A case.(5,7) A dse f 0.02 ml/kg is effective fr apprximately three mnths. A dse f 0.06 ml/kg is effective fr apprximately 3 5 mnths. Refer symptmatic cntacts fr STAT serlgy fr anti-hav IgG (immunity) and anti-hav IgM Gvernment f Alberta 7 f 13

8 Exclude symptmatic cntacts wh are invlved in sensitive ccupatins r situatins until they have been assessed t rule ut hepatitis A disease. Sensitive ccupatins r situatins wuld include persns wh are: fd handlers whse wrk invlves: tuching unwrapped fd t be cnsumed raw r withut further cking and/r handling equipment r utensils that tuch unwrapped fd t be cnsumed raw r withut further cking. NOTE: Generally, fd handlers wh d nt tuch fd, equipment r utensils in this way are nt cnsidered t pse a transmissin risk hwever, circumstances fr each case shuld be assessed n an individual basis. healthcare wrkers prviding direct patient care and persns invlved in the care f yung children, elderly, highly susceptible r dependent persns, children attending a childcare facility r similar facilities wh are diapered r unable t implement gd standards f persnal hygiene and any individual (child r adult) wh is unable t implement gd standards f persnal hygiene (e.g., mentally r physically challenged). Exclusin f asymptmatic cntacts, with n knwn immunity t hepatitis A, may be cnsidered in special circumstances such as fd handlers wh have had nging expsure t the case during the perid f cmmunicability and have nt received pst-expsure prphylaxis within 14 days f initial cntact with the case. It is recmmended t test fr anti-hav IgM and anti-hav IgG (immunity) and exclude frm wrk pending serlgy results. If HAV IgM and IgG are bth reprted negative prvide pst-expsure prphylaxis (as utlined belw) and lift exclusin. If HAV IgM is negative and IgG is psitive, lift exclusin. If HAV IgM is psitive, treat as a case. Advise all asymptmatic cntacts t mnitr fr symptms and cnnect with their physician fr assessment and ntify public health if they develp symptms f hepatitis A. Pst-expsure Prphylaxis The recmmendatins fr pst-expsure prphylaxis that are detailed in Table 1 have been updated and replace the previus directive frm the Office f the Prvincial Health Officer Hepatitis A vaccine (HAV) and/r immune glbulin (Ig) fr pst-expsure prphylaxis June Offer recmmended hepatitis A pst-expsure prphylaxis t all eligible susceptible (i.e., nn immune) husehld and nn-husehld cntacts as detailed in Table 1 and utlined in Annex 1. Pst-expsure prphylaxis shuld be given ASAP within 14 days f last expsure t the case when the expsure ccurred while the case was in the infectius perid. Hepatitis A vaccine may still be cnsidered if mre than 14 days have elapsed since last expsure, as there is n data n the uter limit f efficacy.(7) This wuld be at the discretin f the MOH, n a case-by-case basis, and culd be cnsidered in high-risk situatins Gvernment f Alberta 8 f 13

9 CONTACT TABLE 1: Pertussis PEP Recmmendatins PEP (give ASAP) 1. Thse at risk f develping severe cmplicatins f hepatitis A: thse with chrnic liver disease hepatitis B carriers anti-hcv psitive individuals thse wh have had r will be underging liver transplantatin 2. Immuncmprmised individuals (as per CIG(7)) * * Vaccine efficacy may be reduced in the immunsuppressed hwever, the vaccine will prvide sme prtectin and shuld be cnsidered alng with Ig fr pst-expsure use when indicated.(7) 3. Infants < 6 mnths f age 4. Individuals in whm vaccine is cntraindicated (e.g., anaphylaxis t vaccine cmpnent) HAV and Ig (bth dses f HAV will be prvincially funded) Ig nly 5. All thers 6 mnths f age (nt in categries 1-4) HAV nly If the individual is eligible fr prvincially funded pre- expsure hepatitis A vaccine as utlined in the current Alberta Immunizatin Plicy (AIP), (11) then BOTH dses f hepatitis A vaccine will be prvincially funded. If the individual is NOT eligible fr prvincially funded pre-expsure hepatitis A vaccine as utlined in the current AIP, (11) then nly ONE dse f hepatitis A vaccine will be prvincially funded fr this expsure, hwever the individual shuld be encuraged t receive the secnd dse. Refer t the current AIP (11) fr vaccine and Ig infrmatin. pre-immunizatin serlgy (anti-hav IgG) is recmmended fr specific grups wh are cntacts t the case f HAV (11) and shuld be drawn prir t the administratin f Ig r vaccine, hwever, Ig shuld be given as sn as pssible and shuld nt be unnecessarily delayed. Serlgy is recmmended fr: persns brn prir t persns frm endemic cuntries. All cuntries/areas f the wrld except thse with very lw risk fr hepatitis A are t be cnsidered endemic.(11) Refer t AIP fr list f cuntries; als see CDC s Health Infrmatin fr Internatinal Travel (Yellw Bk) at wwwnc.cdc.gv/travel/yellwbk/2012/chapter-3-infectiusdiseases-related-t-travel/hepatitis-a.htm fr map shwing the estimated prevalence f hepatitis A wrldwide.(9) Gvernment f Alberta 9 f 13

10 adults wh are diagnsed with hepatitis C. adults wh are diagnsed with hepatitis B. Cmmn Surce Expsure and Infected Fd Handler Circumstances wuld be evaluated n a case-by-case basis in cnsultatin with MOH. Pst-expsure prphylaxis shuld be ffered (as utlined in Table 1) t ther fd handlers wrking at the same establishment as the infected fd handler.(7,12) Pst-expsure prphylaxis is generally nt indicated fr patrns f the fd establishment, hwever, in cnsultatin with the MOH, it may be cnsidered if: the case was likely t be infectius while wrking AND was invlved in preparatin/handling f fds (either cked r uncked) and pr hygienic practices r had diarrhea AND cntacts can be identified and prvided with prphylaxis within 14 days f the last expsure t the case during the perid f cmmunicability.(7,12) Childcare facilities (e.g., daycare, dayhme) Ntify MOH (r designate) immediately if hepatitis A is reprted in a childcare facility (in children r staff) Prvide pst-expsure prphylaxis t all susceptible cntacts (staff and attendees) f a case in a childcare facility if: ne r mre cases f hepatitis A are recgnized in children r emplyees OR cases are recgnized in tw r mre husehlds f attendees.(3,5,12) Prvide pst-expsure prphylaxis t cntacts nly in the same rm as the index case, in childcare facilities that d nt prvide care t diapered children.(5,12) Keep the daycare perating and reassure parents that every effrt is being taken t prevent further spread. Discurage parents frm enrlling their child in anther daycare fr the next 7 weeks. Cnsider pst-expsure prphylaxis fr husehld cntacts f diapered children wh attend childcare facilities when utbreaks ccur and cases have ccurred in tw r mre families at the childcare facility.(5) Kindergarten Prvide pst-expsure prphylaxis as utlined in Table 1 t all susceptible cntacts (staff and attendees) f a case that ccurs in kindergarten.(7) Schls and Wrk Settings Pst-expsure prphylaxis is nt rutinely indicated when a single case ccurs in a schl r wrk setting.(3,5,7,12) Cntacts with significant expsures, where there culd be pssible transmissin f hepatitis A virus by the fecal-ral rute shuld be assessed and ffered pst-expsure prphylaxis n a case-by-case basis. Hspitals Pst-expsure prphylaxis is nt rutinely recmmended fr healthcare wrkers in cntact with hepatitis A infected patients unless there is evidence f pssible transmissin f the virus by the fecal-ral rute. Apprpriate infectin preventin and cntrl practices shuld be adhered t including strict hand hygiene.(12) Gvernment f Alberta 10 f 13

11 Preventive Measures Emphasize the imprtance f gd sanitatin and persnal hygiene including thrugh handwashing especially after using the washrm, changing diapers and befre eating and preparing/handling fds. Educate abut prper fd handling practices. Advise abut the recmmended infectin preventin and cntrl measures t be implemented when handling ptentially cntaminated articles (e.g., siled diapers) r when there is ptential f cntaminatin frm any bdy fluid. Prmte hepatitis A immunizatin fr persns at high risk f expsure r develping severe cmplicatins frm the disease (as utlined in the current AIP).(11,13) Encurage immunizatin fr travellers t cuntries where hepatitis A is endemic and fr anyne that wishes t decrease the risk f acquiring hepatitis A infectin. Advise travellers t develping cuntries abut eating prperly cked fds and being cautius f uncked vegetables and shellfish.(13) Gvernment f Alberta 11 f 13

12 ANNEX 1: Pst-Expsure Prphylaxis Algrithm 1 Susceptible Cntacts thse wh have n previus histry f hepatitis A disease, have nt previusly cmpleted a tw-dse series f HAV, have nt received ne dse f HAV between 1 and 6 mnths prir t expsure, r have nt received IG within 3 5 mnths prir t expsure (dependent n dsing). NOTE: One dse IG 0.02ml/kg IM cnfers prtectin fr <3 ms. One dse IG 0.06ml/kg IM cnfers prtectin fr 3 5 ms. (1,7) 2 Perid f Cmmunicability frm 1 2 weeks prir t nset f symptms t ne week after nset f jaundice. 3 Individuals at risk f develping severe cmplicatins f hepatitis A: thse with chrnic liver disease; hepatitis B carriers; anti-hcv psitive individuals; and thse wh have had r will be underging liver transplantatin. 4 Vaccine efficacy may be reduced in the immunsuppressed, hwever, the vaccine will prduce sme prtectin and shuld be cnsidered alng with IG fr pst-expsure use when indicated. 5 Hepatitis A vaccine may still be cnsidered if mre than 14 days have elapsed since last expsure, as there is n data n the uter limit f efficacy. This wuld be at the discretin f the MOH, n a case-by-case basis, and culd be cnsidered in high risk situatins. 6 Individuals eligible fr prvincially funded pre-expsure HAV the pprtunity shuld be taken t prvide HAV t individuals eligible fr pre-expsure HAV (persns at high risk f expsure r develping severe cmplicatins f hepatitis A). This includes; thse with hemphilia A r B receiving plasma-derived replacement cltting factrs, thse with chrnic liver diseases, thse with lifestyle risks f infectin, thse in specific ccupatinal grups, thse wh live in cmmunities with high rates f hepatitis A infectin including inmates f prvincial crrectinal facilities, and residents and staff f institutins fr develpmentally challenged in which there is evidence f sustained hepatitis A transmissin. Fr thse grups in whm pre-immunizatin serlgy fr anti-hav IgG is recmmended, serlgy shuld be dne prir t administratin f Ig. Hwever, Ig shuld be given as sn as pssible and its administratin shuld nt be unnecessarily delayed Gvernment f Alberta 12 f 13

13 References (1) Advisry Cmmittee n Immunizatin Practices (ACIP), Fire AE, Wasley A, Bell BP. Preventin f hepatitis A thrugh active r passive immunizatin: recmmendatins f the Advisry Cmmittee n Immunizatin Practices (ACIP). MMWR Recmm Rep 2006 May 19;55(RR-7):1-23. (2) Centers fr Disease Cntrl and Preventin (CDC). Psitive test results fr acute hepatitis A virus infectin amng persns with n recent histry f acute hepatitis--united States, MMWR Mrb Mrtal Wkly Rep 2005 May 13;54(18): (3) Heymann D editr. Cntrl f Cmmunicable Diseases manual. 19th ed. Washingtn, DC: American Public Health Assciatin; (4) Wrld Health Organizatin. Hepatitis A. Department f Cmmunicable Disease Surveillance and Respnse (5) Pickering LK editr. Red Bk: 2009 Reprt Cmmittee n Infectius Diseases. 28th ed. Elk Grve Village, IL: American Academy f Pediatrics; (6) Centers fr Disease Cntrl and Preventin (CDC). Epidemilgy and Preventin f Vaccine- Preventable Diseases. In: Atkinsn W, Wlfe S, Hambrsky J, editrs.. 12th, secnd printing ed. Washingtn DC: Public Health Fundatin; (7) Public Health Agency f Canada. Canadian Immunizatin Guide (Evergreen editin). 2012; Available at: Accessed March 09, (8) American Medical Assciatin, American Nurses Assciatin-American Nurses Fundatin, Centers fr Disease Cntrl and Preventin, Center fr Fd Safety and Applied Nutritin, Fd and Drug Administratin, Fd Safety and Inspectin Service, US Department f Agriculture. Diagnsis and management f fdbrne illnesses: a primer fr physicians and ther health care prfessinals. MMWR Recmm Rep 2004 Apr 16;53(RR-4):1-33. (9) Centers fr Disease Cntrl and Preventin (CDC). CDC Health Infrmatin fr Internatinal Travel wwwnc.cdc.gv/travel/page/yellwbk-2012-hme.htm ed. New Yrk, NY: Oxfrd University Press; (10) Alberta Health, Surveillance and Assessment. Cmmunicable Disease Reprting System (CDRS) (11) Alberta Health, Health and Wellness Prmtin. Alberta Immunizatin Plicy. Edmntn: Alberta Health and Wellness; (12) Advisry Cmmittee n Immunizatin Practices (ACIP) Centers fr Disease Cntrl and Preventin (CDC). Update: Preventin f hepatitis A after expsure t hepatitis A virus and in internatinal travelers. Updated recmmendatins f the Advisry Cmmittee n Immunizatin Practices (ACIP). MMWR Mrb Mrtal Wkly Rep 2007 Oct 19;56(41): (13) Wasley A, Feinstne S, Bell B. Hepatitis A Virus. In: Mandell G, Bennett J, Dlin R, editrs. Principals and Practice f Infectius Disease. 7th ed. Philadelphia, PA: Churchill Livingstne; p Gvernment f Alberta 13 f 13