1. Hepatitis A

2. Hepatitis A (HAV) Background
Acute, self-limiting viral illness associated with abrupt onset of fever, malaise, jaundice, anorexia, nausea, abdominal discomfort, and dark urine.
Development of clinical symptoms is highly age dependent
among older children and adults, infection is typically symptomatic with 70% presenting with jaundice
in children less than six years of age, 70% of infections are asymptomatic
older persons and persons with chronic liver disease are more likely to have severe disease and HAV prevention in these groups is particularly vital

3. Modes of Transmission
Primarily fecal-oral transmission, e.g., consuming fecally contaminated foods or liquids
HAV is present in the blood and feces days after infection
HAV is rarely transmitted by blood (e.g., via transfusion) or saliva
Incubation period is days with a mean of 28 days

4. Period of Communicability
The highest levels of virus in the stool and the greatest likelihood of transmission occur during the one to two weeks before the onset of illness
After symptom onset, the risk of transmission diminishes and is minimal by one week after the onset of jaundice
HAV can be detected in the stool for longer periods (up to 10 weeks after illness onset), particularly in infants and young children

5. Case Definition
Clinical: Acute illness with discrete onset of symptoms and jaundice or elevated ALT and AST levels
Confirmed:
A patient who meets the clinical case definition and
is IgM anti-HAV positive; or
meets the clinical case definition and has an epidemiologic link with a laboratory-confirmed case
In a CDC study, the median ALT was 1945 and the median AST was 1075 for persons who met the clinical case definition; minimally elevated results are unlikely to be related to acute HAV infection

6. Laboratory Testing
IgM anti-HAV is present at the onset of illness and usually disappears within four months, but may persist six months or longer
IgM anti-HAV is also occasionally detectable in adults two weeks after receiving HAV vaccine
IgG anti-HAV is detectable shortly after the appearance of IgM and remains for the person’s lifetime
Because false positive test results can occur, only symptomatic or exposed people should be tested

7. Definition of HAV Immunity
Persons are considered immune if they have:
received two doses of HAV vaccine; or
a history of IgM or total anti-HAV positivity during or up to four months after consistent clinical illness; or
are IgG anti-HAV positive
Post-vaccination testing is not indicated because of the vaccine’s high efficacy; most adults will be protected within two to four weeks after one dose of vaccine

8. Close Contact Definition
Household and sexual contacts, drug sharers and childcare center staff/attendees
Also consider persons with other types of ongoing, close contact (e.g., regular babysitters)
Coworkers of infected food handlers; patrons may be considered exposed an infected food handler directly handled uncooked or cooked foods; and
had diarrhea or poor hygienic practices (it should be ensured that handwashing facilities are available); and
patrons can be identified and treated no later than two weeks after exposure

9. HAV outbreak associated with frozen berries
On May 21, the CO Department of Public Health and Environment and the NM Department of Health announced an investigation of a cluster of hepatitis A (HAV) cases.
At that time , six cases of HAV infection had been confirmed; two in NM residents, and four in CO residents.
Initial interviews indicated that the six patients had not traveled outside the US or Canada during the incubation period and that all reported regularly shopping at Costco and purchasing a variety of produce items including salad greens and berries.
A request was made for other southwestern and western states (in the same Costco product distribution region) to look for HAV cases without traditional risk factors for HAV infection, i.e., travel to HAV endemic countries, illegal drug use or contact with an HAV case.

10. Investigation
Other cases with similar shopping histories and absence of other risk factors were quickly identified by other states.
By Thursday, May 30st a link had been identified between HAV infection and consumption of Townsend Farms brand frozen Organic Antioxidant Blend (containing cherries, blueberries, raspberries, strawberries and pomegranate seeds) sold by Costco stores.
On Friday, May 31st, this information was announced by CDC and CDPH provided guidance to LHDs on the investigation and postexposure prophylaxis.

11. Current status of outbreak
As of June 3, 2013, 34 people with acute hepatitis A virus infection that may be associated with the consumption of Townsend Farms Organic Antioxidant blend, a frozen berry and pomegranate seed mix, are under investigation from five states: Colorado, New Mexico, Nevada, Arizona, and California. (See CDC webpage
As of June 4, 2013, there are 14 California residents who reported consuming Townsend Farms Organic Antioxidant Blend before becoming ill with HAV infection. An additional 2 patients likely consumed the product, and their cases are considered as probable. These case-patients are from 11 counties: Alameda, Contra Costa, Humboldt, Los Angeles (2), Modoc, Orange (3), Riverside, San Bernardino (2), San Diego (2), Santa Barbara, and Shasta. Illness onsets have been between 5/1/13 through 5/24/13. Seven (44%) have been hospitalized, there have been no deaths. Over 30 additional suspect cases are under investigation nationally, including in other states including Utah and Hawaii.

12. Investigation is continuing
FDA is investigating to determine the likely source of the contamination and if there are other brands or products associated with the source; the specific component of the blend that is the source of contamination has not been definitively identified.
On Monday, June 3, 2013, Townsend Farms, Inc., of Fairview, Oregon announced a voluntary recall of Townsend Farms Organic Antioxidant Blend sold through Costco stores primarily in the southwestern and west coast states. The same blend was sold under the product name Harris Teeter Organic Antioxidant Berry Blend through Harris Teeter grocery stores and has also been recalled. Details of the recall may be found at:
In California, the only retail outlet for this product are Costco stores. There are no Harris Teeter grocery stores in California. Costco has already removed the product from their shelves and are notifying customers who purchased this product

13. Routine Postexposure Prophylaxis
Susceptible close contacts should receive single-antigen HAV vaccine or IG (0.02 mL/kg) or both as soon as possible <2 weeks of exposure; efficacy of PEP when given >2 weeks of exposure is unknown, but vaccine will protect against ongoing or future exposures
For persons aged 1-40 years, vaccine is preferred
For persons >40 years, CDC prefers IG (although vaccine can be used if IG is not available) because of limited immunogenicity data for older people in the setting of an outbreak
However, there is evidence that vaccine is immunogenic in people <70 years of age and CDPH suggests consideration of vaccine in older persons because it confers long-term immunity

14. HAV vaccine vs. IG for PEP
Because IG is in short supply, most exposed persons > 6 months of age are recommended to receive vaccine; CDPH has posted guidance at:
Persons who have received one dose of vaccine and are not due for their next dose, do not need to have the second dose accelerated.
Testing for immunity before PEP is not recommended.
Testing asymptomatic people for HAV infection is not recommended.
If adult HAV vaccine is not available, two doses of the same pediatric vaccine may be used for adults.

15. Use of IG IG should be prioritized for: immunocompromised people
people with chronic liver disease
infants <6 months of age
people with contraindications for the vaccine

16. California local health department response
On June 3, local health jurisdictions were surveyed about their response to this outbreak.
Of the 28 responses to date, all but one responding jurisdiction has a mechanism to provide vaccine to uninsured adults.
Two jurisdictions (Los Angeles and Orange hosted HAV vaccine and IG clinics over the weekend.

17. Vaccine Supply and Ordering
The State Immunization Branch is re-directing limited 317 funds to purchase vaccines for PEP during this outbreak.
317-funded Hepatitis A vaccines (pediatric and adult) can be administered to insured children and adults seen at LHD clinics in response to an outbreak
Refer to footnotes in the state’s Vaccine Eligibility Guidelines  

19. Vaccine Ordering Information
Pediatric doses:
Submit your vaccine requests directly through MYVFCVaccines
 Adult doses:
your IZ Branch Field Representative with the following information:
PIN
Clinic Name & Address
Doses needed
Will doses to be administered through routine IZ clinics? or is the county planning special outreach clinics?

20. Order Processing Information
Vaccine orders related to a disease outbreak are placed as urgent orders
Orders received by 3pm are transmitted to McKesson and shipped the same day for next day delivery
Vaccine delivery time is usually by 4pm
The unit of berries sold in the LHJ should be considered when placing initial orders.
Product selection/brand choice
Because of rapidly changing inventory numbers for Adult Hep A products, brand choice cannot be guaranteed.
Orders will be placed for the products with better inventory availability at McKesson. 
Alternative products for patients with Latex Allergies

21. Eligibility/Tracking
Tracking and documentation must still occur. 
Document eligibility as State/317-GF eligible in CAIR or paper logs.
Please note that CDPH’s PEP guidelines state that in the absence of adult doses, pediatric vaccine doses can be doubled up.  This clinical guidance only applies to privately funded vaccines.   

22. Private Vaccine Supply
Adequate vaccine supply for both pediatric and adult hepatitis A product is available from Merck and GSK.

23. Questions