Hepatitis A Virus: A Novel Identify-Isolate-Inform Tool

Abstract and Introduction

Abstract

Infection with hepatitis A virus (HAV) causes a highly contagious illness that can lead to serious morbidity and occasional mortality. Although the overall incidence of HAV has been declining since the introduction of the HAV vaccine, there have been an increasing number of outbreaks within the United States and elsewhere between 2016 and 2017. These outbreaks have had far-reaching consequences, with a large number of patients requiring hospitalization and several deaths. Accordingly, HAV is proving to present a renewed public health challenge. Through use of the "Identify-Isolate-Inform" tool as adapted for HAV, emergency physicians can become more familiar with the identification and management of patients presenting to the emergency department (ED) with exposure, infection, or risk of contracting disease. While it can be asymptomatic, HAV typically presents with a prodrome of fever, nausea/vomiting, and abdominal pain followed by jaundice. Healthcare providers should maintain strict standard precautions for all patients suspected of having HAV infection as well as contact precautions in special cases. Hand hygiene with soap and warm water should be emphasized, and affected patients should be counseled to avoid food preparation and close contact with vulnerable populations. Additionally, ED providers should offer post-exposure prophylaxis to exposed contacts and encourage vaccination as well as other preventive measures for at-risk individuals. ED personnel should inform local public health departments of any suspected case.

Introduction

The incidence of hepatitis A virus (HAV) infection steadily decreased in the United States (U.S.) and other developed countries following the introduction of the HAV vaccine. Although vaccine became available in the U.S. in 1995, vaccination was not routinely recommended for children in California until 1999, and across the U.S. in 2006. The incidence of HAV decreased from six cases per 100,000 in 1999 to 0.4 cases per 100,000 in 2011.1,2 However, there has been a resurgence in the incidence of HAV in the U.S., with recent outbreaks occurring in San Diego, Los Angeles, New York City, Michigan, Hawaii, and several other counties and states. Between August 1, 2016, and October 12, 2017, there have been 397 confirmed cases of HAV in Michigan with 15 fatalities and 320 hospitalizations (85.6%). The Michigan Department of Health and Human Services has not yet identified a common source of the outbreak as of October 12, 2017.3 San Diego's public health officer declared a local health emergency on September 1, 2017, due to the ongoing outbreak of HAV. As of October 17, 2017, the county has identified a total of 507 cases with 19 deaths and 351 (69%) hospitalizations related to the outbreak.^[4] Between June and October 2016, Hawaii reported 292 confirmed cases of HAV with 74 patients requiring hospitalization.^[5] This outbreak was linked to raw scallops served at a local sushi chain and a subsequent product recall was instated with no new cases reported as of July 11, 2017.6 A 2016 multistate outbreak of HAV linked to contaminated frozen strawberries resulted in 143 recognized cases and 56 hospitalizations.^[7]

These HAV outbreaks pose a unique challenge for public health officials for several reasons: the prolonged incubation period (15–50 days); infected individuals can transmit the disease up to two weeks prior to symptom onset; many infected persons remain asymptomatic; and many patients affected in these outbreaks are homeless and/or illicit drug users (both injection and non-injection), causing difficulty in contacting and following up infected persons.^[3,4] Emergency Department (ED) providers in affected areas may encounter and treat a large number of these patients. Additionally, if the disease arises in other regions, it is likely that ED providers would be the first point of contact for many symptomatic patients. Given the contagious nature of HAV, as well as potential morbidity and mortality associated with the disease, it is of great importance that cases of the infection be accurately recognized, isolated and treated, with prompt notification of public health authorities. ED providers have a unique opportunity to advocate for vaccination of vulnerable populations, and EDs have enacted vaccination programs during acute outbreaks.^[8] After a thorough review of HAV infection, this paper describes a novel 3I tool, initially developed for Ebola virus and subsequently adapted for measles, MERS and mumps,^[9–12] for use by ED providers in the initial detection and management of HAV patients.