11/5/2018. Hepatitis A Outbreaks HEPATITIS A. Hepatitis A DX, RX. Hepatitis A - SYMPTOMS HEPATITIS A - SYMPTOMS. Arnold Leff, M.D. REHS, FAAFP, AAHIVS

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1 11/5/218 Hepatitis A Outbreaks Arnold Leff, M.D. REHS, FAAFP, AAHIVS Primarily transmitted via the fecal-oral route Health Officer and Medical Services Director Interim Environmental Health Director Santa Cruz County Thanks to Dr MacDonald, San Diego County HEPATITIS A Incubation period ranges from 15 to 5 days (mean 28 days) Period of communicability from two weeks before through one week after the onset of jaundice or elevation of liver enzymes Virus viable outside body for months, depending on environmental conditions HEPATITIS A HEPATITIS A - SYMPTOMS HAV virus inactivated by: Heating to >185 F (>85 C) for one minute Routine water chlorination 1:1 dilution of household bleach to water on surfaces Quaternary ammonium formulations with HCl Fever Fatigue Nausea Loss of Appetite 2% glutaraldehyde Alcohol-based hand sanitizer not effective, need soap and running water Vaccination with the full, 2-dose series of Hepatitis A virus vaccine is the best way to prevent infection Jaundice Stomach Pain Vomiting Dark Urine, Pale Stools and Diarrhea Reference: Mbithi JN, Springthorpe VS, Sattar SA. Appl Environ Microbiol. 199;56(11): Hepatitis A - SYMPTOMS Hepatitis A DX, RX In kids <6 years, 7% of infections are asymptomatic; if illness does occur, typically no jaundice Among older children and adults, infection is typically symptomatic, with jaundice in >7% Symptoms usually last <2 months, although 1% 15% of symptomatic persons have prolonged or relapsing disease for up to 6 months Hospitalization required in about 2%, higher (>4%) in older adults Hepatitis IgM is part of most hospital viral hepatitis panels IgM is sensitive, but not specific (lots of cross-reactivity with other acute viral illnesses) IgM test may exhibit interference collected when from someone consuming supplements with a high dose of biotin (vitamin B7 or B8, vitamin H, or coenzyme R) Do not order IgM/IgG before vaccination not useful for determining presence of immunity to HAV from either past HAV infection or vaccination against HAV Treatment is supportive 1

2 /5/218 Hepatitis A complications Hepatitis A complications Relapsing hepatitis up to 1% have relapse in the 6 months after acute illness Duration of clinical relapse is generally less than 3 weeks, although biochemical relapse may last as long as 12 months. Cause unknown, no predisposing factors identified Clinical course usually consists of apparent clinical recovery after acute infection with near normalization of the serum aminotransferases, followed by biochemical (and, in some cases, clinical) relapse Clinical manifestations of relapse are often milder than the initial episode. Multiple relapses can occur. Cholestatic hepatitis reported in 5% Prolonged cholestasis is characterized by a protracted period of jaundice (lasting >3 months Course usually characterized by marked jaundice, pruritus, fever, weight loss, diarrhea, and malaise Laboratory findings include markedly elevated serum bilirubin (often >1 mg/dl) and alk phos, modest elevation of serum aminotransferases, and elevated serum cholesterol; peak bilirubin levels may be reached in 8th week or later. Resolves spontaneously with no sequelae; recognition is important to avoid unnecessary testing. US appropriate to exclude biliary obstruction; cholangiography, liver biopsy are usually not needed Hepatitis A complications Fulminant hepatic failure less than.1% Development of severe acute liver injury with encephalopathy and impaired synthetic function (international normalized ratio [INR] 1.5) Occurs most commonly in individuals >5 years of age and individuals with other liver diseases such as hepatitis B or C Autoimmune hepatitis rare HAV infection may serve as a trigger for development of autoimmune hepatitis in susceptible individuals Chronic hepatitis characterized by hyperglobulinemia, presence of circulating autoantibodies (such as antinuclear, anti-smooth muscle, and/or anti-actin antibodies), & inflammatory changes on liver histology Hepatitis A At Risk Travelers to countries with high or intermediate endemicity of HAV infection Men who have sex with men Homeless Intravenous and non-intravenous illicit drug users People with chronic liver disease Persons with clotting factor disorders? Persons working with nonhuman primates Vaccine introduced Hepatitis A Cases, San Diego County Routine vaccination for children in high-incidence states (including California) Routine vaccination for all U.S. children hepatitis A, San Diego confirmed outbreak cases from 11/22/16 thru 1/8/18 47 (68%) hospitalizations, 2 (3.4%) deaths 44 (68%) male (14 MSM), 188 (32%) female Age range 5-87 (median 43.) Suspected Exposure Type 21 (34%) homeless and illicit drug use 91(15%) homeless only 79 (13%) illicit drug use only 167 (28%) neither 54 (9%) unknown. Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 1/8/18 2

3 11/5/218 hepatitis A, San Diego Co-infections 83/477 (17.4%) with hepatitis C 26/491 (5.3%) with hepatitis B 19 non-outbreak cases in 218 One case under investigation Linked cases in other CA counties, AZ, CO, IN, KY, OH, RI, TN, UT, WV 91 days since last case illness onset! Outbreak-associated Hepatitis A Cases by Onset Week 11/1/216 1/8/218, N = 592 PHE Declared PHE Ended N = 6 N = 571 N = 15 Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 1/8/18 Cases Outbreak-Associated Hepatitis A Cases & Vaccinations by Month, November 216 through August 218 Vaccinations 5, 45, 4, HEPATITIS A A NATIONAL PROBLEM! , 3, 25, 2, 15, 1, 5, ,466 1, Confirmed/Probable Cases Pre Response Vaccinations Response Vaccinations Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/11/18 Map prepared on 1/8/18 using data from state department of health websites and software on: Hepatitis A Outbreak Santa Cruz County 217 Santa Cruz County (CA) Population: 275, 897 (217) 34% Latino/a 58% White (non-latino) 5% Asian Homeless Census: 2,249 (217) 38% Drug or Alcohol abuse 69% Unemployed 29% in jail past year 3

4 17-Apr 24-Apr 1-May 8-May 15-May 22-May 29-May 5-Jun 12-Jun 19-Jun 26-Jun 3-Jul 1-Jul 17-Jul 24-Jul 31-Jul 7-Aug 14-Aug 21-Aug 28-Aug 4-Sep 11-Sep 18-Sep 25-Sep 2-Oct 9-Oct 16-Oct 23-Oct 3-Oct 11/5/ Vaccin e introdu ced Acute Hepatitis A Cases by Year, Santa Cruz County, 1994 to 217 Routine vaccination for children in highincidence states (including CA) Routine vaccination for all children Hepatitis A (HepA) Virus VACCINE PREVENTABLE, DISEASE OF THE LIVER, 15 5 DAY INCUBATION USUALLY TRANSMITTED PERSON-TO-PERSON THROUGH THE FECAL-ORAL ROUTE; SELF-LIMITED INFECTIOUS 2 WEEKS PRIOR TO JAUNDICE AND 1 WEEK POST OUTBREAK CHARACTERISTICS Between April and October of 217, there were 76 confirmed cases Over half (54%) were persons who inject drugs (PWID) AND experiencing unstable housing At least 31 cases were regular clients of the county s Syringe Services Program (SSP) One Food Service Outlet related Cases Percent Hospitalizations 33 43% Deaths 1 1% AGE % % % RISK FACTORS PWID 43 57% Poorly Housed, non-pwid 18 24% Neither 15 2% HCV % SSP Client 31 41% TOTAL 76 1% Hepatitis A in Santa Cruz County (CA) April 1, 217 October 31, 217 LA County Summary 76 outbreak cases 33 (43%) hospitalizations 1 (1%) death 48 (63%) male (1 MSM), 28 (37%) female Age range 21-7 (median 37 years) 31 of 7 with data (44%) HCV antibody Suspected Exposure Type 46 (61%) homeless and illicit drug use 12 (16%) homeless only 3 (4%) illicit drug use only 15 (2%) neither Epidemic Curve of Confirmed Acute Hepatitis A Cases by Week of Onset (n=76), Santa Cruz County (CA), April - October, vaccinations 17 Cases April May June July Aug Sept Oct DOC Activation V.I.S.E Level 1: Minimum IC at or near the DOC Other Command, General staff as needed ICS Structure and Processes used Staff work from desks, other work continues V: Vaccination I: Investigation S: Sanitation E: Education 4

5 11/5/218 Vaccination-over 19 provided Sustained, ongoing for high risk groups Jail Planned Parenthood Federally Qualified Health Center Rota Care (mobile van) Behavioral Health clientele Homeless Persons Health Project Syringe Services Program Street teams Vaccination-Continued Investigation Episodic/Mass Vax efforts Several taking place weekly for 7-8 months Used mostly for those who were known exposure risks or as a way to reach the vulnerable population (Food kitchens, geographic hot spots) Investigation was tricky Homeless would go to ED and be released 24/7 capacity for CD was a challenge We used advisories, phone calls, visits to communicate with medical community Sanitation Education Environmental Health: Guidelines for sanitizing indoor areas with public access such as parks and public restrooms Handwashing stations, increased restroom hours, installing portable restrooms with security in hot spots or known locations for people without access to sanitation. County and Department Public Information Officer, County Health Education unit, Environmental Health participation (>1 businesses visited) 5

6 11/5/218 What worked well? Challenges: went on for months Decision to move immediately to an ICS (Incident Command structure) and activate the DOC (department operations center). Decision to proactively vaccinate vulnerable population as quickly as possible Prioritization Grid Partnership/collaboration with Environmental Health 3-deep pre-planning for DOC Retirees as Extra Help Surge Capacity: our biggest challenge DOC coordination work, planning Actual Operationsvaccinations, education, EH 3-deep wasn t enough EH-not enough Everyone had another or more full time jobs Challenges Switching the Public Health culture to an ICS culture Challenges Vulnerable populations challenges BURN OUT: lost senior staff Nursing Contractor needed regular schedules Identifying ways to vaccinate as many people as possible in the shortest amount of time. Time requirement for creating operational plans in addition to the operational demands Recommendations Activate early Train people on ICS. Help them understand why it works. Practice it. 214 Tuesdays Immunize the world for Hep A Figure out how to surge for extended period of time: months. Outreach to substance users and homeless: make SSP a State requirement 6