1. Hepatitis A Outbreak and Response, Indiana 2018
Nicole Stone, Foodborne and Waterborne Epidemiologist
Epidemiology Resource Center

2. No conflict of interest.

3. Hepatitis A Reservoir: Humans
Mild to severe disease, rarely can cause death (Fatality %)
Short-term infection, but relapse for as long as to one year can occur in 15% of cases
Incubation days (avg. 28)
Cases have declined by more than 95% since vaccine became available in 1995
Highly contagious
Can last from a few weeks to several months
; rarely chimpanzees, and other primates

4. Signs and Symptoms of Hepatitis A
Fever
Fatigue
Loss of appetite
Nausea
Vomiting
Diarrhea
Abdominal pain
Dark urine
Clay-colored stool
Joint pain
Jaundice
Some persons, particularly young children, are asymptomatic. When symptoms are present, they usually occur abruptly and can include: Fever, Fatigue, Loss of appetite, Nausea, Vomiting, Abdominal pain, Dark urine, Clay-colored bowel movements, Joint pain, Jaundice.
In children aged <6 years, 70% of infections are asymptomatic; if illness does occur, it is typically not accompanied by jaundice. Among older children and adults, infection is typically symptomatic, with jaundice occurring in >70% of patients.

5. Jaundice
Jaundice is a yellow color of the skin, mucus membranes, or eyes. This can also be a symptom of other health problems, so it alone will not confirm a case as having hepatitis A.

6. Additional Information
Hepatitis A virus (HAV) can survive outside of the body for months, depending on environmental conditions
Killed by heating to >185°F for one minute
Adequate chlorination of water kills HAV that enters the water supply
5000 ppm bleach solution for disinfection
Hepatitis A cannot become chronic
A person cannot become re-infected after recovering from hepatitis A
The hepatitis A virus can live outside the body for months, depending on the environmental conditions. The virus is killed by heating to more than 185 degrees Fahrenheit for one minute. However, the virus can still be spread from cooked food if it is contaminated after cooking. Adequate chlorination of water, as recommended in the United States, kills HAV that enters the water supply.
Hepatitis A cannot become chronic
A person cannot become re-infected with HAV after recovering from hepatitis A. IgG antibodies to HAV, which appear early in the course of infection, provide lifelong protection against the disease.

7. Hepatitis A: Transmission
Routes
Person to person through fecal-oral*
Contaminated food, drinks, ice
Sexual contact with an infected person
Sharing needles or close contact while using illicit drugs due to poor personal hygiene
There is no cure, but there is a vaccine
All children at age 1 year
Indiana school requirement since 2014
At-risk populations
* Most infections result from close personal contact with an infected household member or sex partner

8. Hospital and Infection Prevention Guidance
Report Immediately, upon suspicion
Recognize the at-risk groups
Homeless, recently incarcerated, MSM, illicit drug use, contact of a confirmed case of hepatitis A
Does not include health care workers due to routine handwashing, PPE, and other standard precautions
Disinfection vs. sanitization guidelines for hospitals
Disinfectants stronger and used ONLY for response to vomitus/diarrheal incident
Sanitizing solution should be used for routine cleaning purposes
Subscribe to IHAN for information and updates

10. Hepatitis A: Diagnosis
HAV IgM
HAV IgG or
Total AB
Interpretation
Positive
Not Done
Acute or recent HAV infection
Negative
No active infection, but previous exposure, developed immunity or recently vaccinated
Exposure to HAV but does not rule out acute infection
No previous infection or vaccination
If the total antibody test or hepatitis A IgG result is positive and someone has never been vaccinated against HAV, then the person has had past exposure to the virus. About 30% of adults over age 40 have antibodies to hepatitis A.
*Total AB detects both IgM and IgG antibody

11. ISDH Recommended Conditions for Hepatitis A Specimen Submissions--Genotyping
Acceptable human specimen types:
Serum
Minimum 0.5 mL; any additional is helpful
Storage conditions
Please freeze (preferred) or refrigerate specimen as soon as possible
Please ship overnight on dry ice or ice packs
Frozen whole blood specimens will not be accepted
Hemolyzed or heparinized specimens will not be accepted

12. LimsNet Submission Guidelines
Specimens must have 2 identifiers on the tube: i.e. first/last name, DOB, patient ID
Specimens must be submitted via ISDH LimsNet system
On the LimsNet HIV/HEP form, use the check box labeled for Hepatitis A Genotyping;
All data on refrigeration/freeze and specimen conditions will be assistive
Ship Cat B; overnight to ISDH Labs

14. Hepatitis A: Acute Case Classification Flow Chart

15. What if the patient is a confirmed case?
Contact the patient or patient’s parent/guardian
Interview case and record exposure history, including:
Food history
Vaccination status
Travel history
Determine if additional cases may have been exposed
Post-exposure prophylaxis to contacts, if applicable
Follow the CD Rule guidance
High risk settings (e.g., daycare, food handler, health care worker)
Drug use
Household and sexual contacts
For cases that meet the CSTE case definition requirements, then we need to contact that patient or patient’s parent or guardian to interview and record relevant exposures. Information we need to obtain includes a food history, hepatitis A vaccination status, recent travel history, exposure to high risk settings (such as daycares, food handlers, and health care workers), illicit drug use, and household and sexual contacts. We also need to determine if there may be additional individuals exposed to the case, if post-exposure prophylaxis needs to be administered to case contacts, and if the patient needs to be excluded according to the CD Rule.

16. Post-exposure Prophylaxis
Within two weeks of the last exposure for:
Household and sexual contacts
Classroom contacts in a daycare facility or preschool
Food handlers at the same location if a food handler is diagnosed with hepatitis A (unless already immune)
Food handlers who refuse prophylaxis should be restricted for 50 days
Food establishment patrons who ate in an establishment with an infected food handler, IF:
The food handler worked while infectious and directly handled uncooked foods or cooked foods
Deficiencies in personal hygiene are noted or the food handler worked while ill with diarrhea
Post-exposure prophylaxis should be given close contacts of a confirmed hepatitis A case as soon as possible and within two weeks of the last exposure. These contacts include: household and sexual contacts; classroom contacts in a daycare facility or preschool; food handlers at the same location if a food handler is diagnosed with hepatitis A (this does not apply to cases already immune by the hepatitis A vaccine) and food handlers who refuse prophylaxis are to be restricted for 50 days according to the CD Rule; and food establishment patrons who ate in an establishment with an infected food handler, ONLY IF: the food handler worked while infectious and directly handled uncooked foods or cooked foods, or deficiencies in personal hygiene are noted or the food handler worked while ill with diarrhea.

17. National Hepatitis A Outbreak
>6,000 outbreak-associated cases reported since July 1, 2016
First cases in San Diego, CA
Multiple ongoing outbreaks (AR, IN, KY, MI, MO, OH, TN, WV)
Transmission: person-to-person through contact with fecally-contaminated environments
Population: mostly homeless and/or persons who use injection or non-injection drugs
HAV Genotype: 1B

18. Multistate Update
On June 11, 2018 CDC issued a Health Alert Network (IHAN) Advisory with an update about the outbreak and guidance to assist in identifying and preventing new infections
On June 11, 2018 CDC issued a Health Alert Network (HAN) Advisory
10 states included on the outbreak website

19. Hepatitis A: Indiana
*Data preliminary

20. Indiana Hepatitis A Outbreak
Active surveillance in August 2017
Outbreak-related cases beginning December 2017, many linked to Jefferson County, Kentucky
Increase in cases statewide, but not all cases have epi-links to the outbreak
Many Indiana cases meet the risk factors:
Homelessness
Illicit drug use
Jail visit
Contact with an ill individual

21. Current Indiana Status
New outbreak definition as of 7/18/18
Indiana outbreak case definition: confirmed hepatitis A cases (hepatitis A IgM positive with acute symptom onset AND either jaundice OR elevated liver enzymes) acquired since Nov. 1, 2017, through person to person transmission within the United States. Cases may be excluded from the outbreak if a confirmed case has no known risk factors (illicit drug use, homelessness, incarceration, men who have sex with men, contact with a confirmed case or domestic travel to an area with a known outbreak), AND has traveled outside of the United States to a country with endemic hepatitis A OR if a confirmed case has a specimen identified as any genotype (laboratory test link) other than 1B.
Cases continue to increase
50 Counties with outbreak-related cases

22. Indiana Outbreak-Related Cases as of 10/5/18

23. Indiana Outbreak-Related Cases as of 10/5/18
County
Number of Cases
Allen 36
Kosciusko 6
Clark 75
Lawrence 52
Crawford 8
Marion 12
Elkhart
Monroe 5
Fayette 11
Orange 16
Floyd 47
Scott
Grant
Vanderburgh
Harrison 14
Washington 19
Huntington
Wayne
112
Jackson 10
Counties with less than 5 cases are suppressed.

25. Number of Cases Reporting Demographic (n=518)
Epidemiological Summary for Hepatitis A Outbreak-Related Cases as of 10/5/18
Demographic Information
Number of Cases Reporting Demographic (n=518)
Total # of Cases (By Onset)
518
Illness onset range:
12/1/2017 – 9/29/2018
Female, n (%)
217 (41.0%)
Hospitalized, n (%)
231 (44.6%)
Deaths, n (%)
1 (0.2%)
Min Age (years) 10
Max Age (years) 79
Median Age (years) 36

26. Number of Cases Reporting Risk Factor (n=518)
Epidemiological Summary for Hepatitis A Outbreak-Related Cases as of 10/5/18
Risk Factor Information
Number of Cases Reporting Risk Factor (n=518)
Any Illicit Drug Use, n (%)
268 (51.7%)
Any Homelessness, n (%)
53 (10.2%)
Illicit Drug Use and Homelessness, n (%)
46 (8.9%)
No Illicit Drug Use or Homelessness, n (%)
148 (28.6%)
Correctional Facility Inmates, n (%)
91 (17.6%)
Men Who Have Sex with Men (MSM), n (%) (male cases only)
20 (3.9%)
Close Contact with a Case, n (%)
101 (19.5%)
History of Hepatitis B (HBV), n (%)
7 (1.4%)
History of Hepatitis C (HCV), n (%)
161 (31.1%)
HBV & HCV, n (%)
14 (2.7%)
Lost to Follow-up, n (%)
133 (25.7%)

33. ISDH Website hepAfacts.isdh.in.gov
Continue to update by noon every Friday
Will include counties with greater than five cases meeting the updated outbreak case definition

35. Outreach and Communication
Indiana Health Alert Network (IHAN)
Press Releases
Letters targeting at-risk populations
Media Toolkit
Templates for notifications and press releases
Infographics

38. Thank you!
Nicole Stone, MPH Foodborne and Waterborne Epidemiologist

39. References https://www.cdc.gov/hepatitis/hav/havfaq.htm#general