Hepatitis A Virus: Essential Knowledge and a Novel Identify-Isolate-Inform Tool for Frontline Healthcare Providers

Kristi L. Koenig, MD; Siri Shastry, MD; Michael J. Burns, MD

Disclosures

Western J Emerg Med. 2017;18(6):1000-1007. 

In This Article

Identify-isolate-inform

The identify-isolate-inform tool, initially developed for Ebola virus disease,[9] can be modified and applied to the ED evaluation and management of patients presenting with symptoms suggestive of HAV infection (Figure). The first branch of the algorithm entails identifying suspected cases based on clinical signs/symptoms and exposure history. Of note, patients are contagious prior to symptom onset and some patients may never develop symptoms. In addition, a typical milder relapsing hepatitis may occur two weeks or more after initial symptom onset in approximately 2-20% of patients (10% in the 2017 San Diego outbreak) making it important to query patients about whether their symptoms are recurrent.

Figure 1.

Identify-Isolate-Inform tool adapted for Hepatitis A virus.

As transmission of HAV is mainly fecal-oral, patients require standard and enteric precautions, but airborne and respiratory droplet isolation precautions are not required. Blood samples should be obtained from patients with suspected HAV to confirm the diagnosis. Providers caring for patients with suspected HAV infection should observe strict standard precautions and hand hygiene with soap and warm water in all cases. Healthcare providers should ensure to wash hands for at least 10–20 seconds.[46,50] Healthcare workers should additionally use contact precautions when caring for incontinent or diapered patients.

Patients should be counseled on the importance of hand hygiene. Affected patients should also be instructed to avoid food preparation for others and patients who work in food service, health service or in child care facilities should be advised to avoid work until two weeks after onset of initial symptoms or jaundice (whichever occurs later). Patients presenting within two weeks of exposure should be offered PEP (vaccination or IG as appropriate, based on age and comorbidities). A healthcare advisory released July 20, 2017, followed by a CDC publication on September 15, 2017, recommended an increase in the dosage for IG for pre- and post-exposure prophylaxis.[42]

Healthcare providers should promptly inform the local public health department of suspected and confirmed cases of HAV. Timely notification is particularly important when homeless and illicit drug users are affected as these patient populations can be difficult to trace once dischar ged from the ED. Providers should also notify hospital infection control personnel of suspected cases and abide by any additional legal requirements such as notification of exposed prehospital personnel.[43,51]

Because vaccination is a key component of outbreak control, some public health experts have recommended adding another "I" to the algorithm, specifically to represent "immunize."52 Immunization of at-risk populations who present to the ED for unrelated reasons is an important public health intervention.[8] To assist providers with remembering to vaccinate, the "Identify" branch of the 3I algorithm can be thought of as "Identify/Immunize" for management of both infected and vulnerable populations. Of note, it takes approximately two weeks for immunity to develop after vaccination administration.

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