Hepatitis A Outbreak Investigation in Bluegrass Region - 2007 ERRT Conference

1. Hepatitis A Outbreak Andrew Waters Regional Epidemiologist Bluegrass Region 2 2007 ERRT Conference October 2nd, 2007

2. Objectives • Provide overview of Hepatitis A • Review Hepatitis A case definitions • Initial case background • Additional cases and contacts • Describe investigation progress • After action

3. HepatitisA • Hepatitis A is an inflammation of the liver with a viral etiology • Infectious • Fecal-oral route of transmission • Symptoms include fever, fatigue, nausea, malaise, and jaundice

4. Events in Hepatitis A Infection Clinical illness Viremia HAV in stool IgG Infection Response IgM ALT 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Week

5. Case Definition • RDDR • A case that meets the clinical case definition and is laboratory confirmed OR epidemiologically linked to a laboratory confirmed case Sensitive Specific

6. Initial Case • On May 16th, LFCHD was notified of a positive lab result for Hepatitis A in a Lexington resident • 37yo, white male presented to ER with severe back pain • Medical record stated patient ingested ~50 Tylenol over 4 day period to ease back and testicular pain • Transferred to another hospital for consult with hepatitic specialist for further review

7. Initial Case • Hepatitis panel and liver function tests were performed • Anti-HAV IgM – positive • Anti-HBc IgM -- negative • HBsAg and anti-HCV – negative • ALT – above normal • AST – above normal • Bilirubin -- normal

8. Initial Case • Medical record suggested that high liver enzymes were due to Tylenol toxicity and subsequent treatment for hepatic failure • No phone number listed for patient • Contact was made by patient on ~May 18 • ICN interviewed patient to determine patient’s status

9. Initial Case • Recently moved from San Diego in mid April • Homeless -- ? • Drug rehab • 10 year history of drug abuse • Currently drug free • Denied experiencing any symptoms • Due to start job at food service establishment next week

10. Is initial case a case? • Based on the information we had at the time -- not a case!!! • Patient was allowed to begin work in food service • Recommended he continue follow-up with physician to monitor liver function

11. But why? • Hepatitis A IgM labs have a high rate of false positives • History of drug abuse • High doses of Tylenol -- ~30g

12. Additional Cases • June 13 – report of 3 patients, one with jaundice • Mentioned someone in their household sick with yellow eyes in May and had been told he had liver damage • Blood was drawn on all 3 patients and sent to lab for testing of viral hepatitis

13. Additional Cases • Contact with 3 additional cases confirmed association with our initial case • Index case was tested again for Hep A IgM, results were positive • 4 Hepatitis A cases from at least two different households

14. Household A Mother 1 – Sx Boyfriend 1 – No Sx Daughter 1 – No Sx Mother 2 – No Sx Boyfriend 2 – Sx Daughter 2 – No Sx

15. Household B Father 1 – Sx Girlfriend 1 – No Sx 2 Daughters – No Sx 1 Son – No Sx 1 Male Babysit – No Sx 1 Male – No Sx

16. Household C Male – No Sx

17. Our Circles Household B Household A Mother 1 – Sx Boyfriend 1 – No Sx Daughter 1 – No Sx Mother 2 – No Sx Boyfriend 2 – Sx Daughter 2 – No Sx Father 1 – Sx Girlfriend 1 – No Sx 2 Daughters – No Sx 1 Son – No Sx 1 Male Babysit – No Sx 1 Male – No Sx Male – No Sx Household C

18. Social Contacts • Very social group • Household B was a gathering place for young children in the neighborhood because of an in-ground pool • 15-20 additional visitors daily

19. More Circles 15-20 visitors to in-ground pool Mother 1 – Sx Boyfriend 1 – No Sx Daughter 1 – No Sx Mother 2 – No Sx Boyfriend 2 – Sx Daughter 2 – No Sx Father 1 – Sx Girlfriend 1 – No Sx 2 Daughters – No Sx 1 Son – No Sx 1 Male Babysit – No Sx 1 Male – No Sx Male – No Sx

20. Department Operations Center • COO activated DOC to coordinate our agency’s response • Core group consisted of: • Epidemiology • Environmental Health • Public Health Clinic • Administration • COO, Commissioner, PIO

21. Epi Curve Index Case

22. Epidemiology • Identified all contacts of the household and determined status • Visited Household B for further information • Made preparations for contacts to come to HD to receive IG and Hep A vaccine • Index Case was lost to contact

23. Epidemiology • Developed criteria to determine exposure of visitors • Length of time at house • Consumption • Drug use • Sharing of drinks or cigarettes • Sexual contact • One visitor fit the criteria

24. Environmental Health • Inspected in-ground pool of Household B • Inspected restaurant for potentially ill co-workers of index case and hand washing facilities • Coordinated LFCHD activities with main headquarters of O’Charley’s

25. Restaurant Exposure End of Infectious period

26. Restaurant Exposure • Released restaurant name into the media • Poor historian • Unsure about dates • Lost to follow-up • No clear onset of symptoms • Used first positive IgM result

27. PH Clinic • Prepared and staffed to provide IG and Hep A vaccine to all contacts • Coordinated with clerical staff to identify contacts on arrival and treat ASAP • Organized and staffed two separate vaccination clinics to O’Charley’s employees

28. IG and Hep A vaccine • Provided IG and Hep A vaccine to 9 the of contacts to the cases • 2 contacts did not receive prophylaxis • Never showed up, “afraid of shots” • Only 8 restaurant employees took advantage of the vaccination paid for by the company

29. After Action • Hepatitis A protocol • Provides steps to take when dealing with an outbreak • Generalizes a procedure for identifying atypical cases • Evaluation of response was used to identify areas to correct for future outbreaks