1. Florida Hepatitis A Outbreak
Robert Kopec, MD
April 2019

2. Objectives State of the state of FL Pathogenesis Signs/symptoms
PE/Labs
Other manifestations
Complications
Prevention

4. Hep A cases

6. Other states involved as well
At least 15 other states are experiencing hepatitis A outbreaks. According to a February report in the publication Food Safety News, "public health investigators across the country have not found a common source of the infections, but more than 70 percent of the victims in many areas are homeless people, substance abusers, or both."

7. Hepatitis A Epidemiology/Pathogenesis
Transmitted person-to-person 
 fecal-oral route or
 consumption of contaminated food or water (though no common source identified during this outbreak)
Hepatic injury result of immune response
Viral replication
Hepatocyte damaged
Destruction of infected hepatocytes
NK cells
HAV- specific CD8 cells
Excessive response (low circulating HAV RNA) a/w severe hepatitis

8. Risk factors
Over half (59%) of the 1,206 cases likely acquired in Florida since January 1, 2018 reported at least one of the risk factors below, while 41% reported no or unknown risk factors.
Any drug use
Injection drug use
Non-injection drug use
Homelessness
Men who have sex with men (MSM)
Worse disease with any liver disease

9. Signs/Symptoms
70% adults will be symptomatic; 1% fulminant hepatic failure
Fever
Fatigue
Loss of Appetite
Nausea
Vomiting
Diarrhea
Abdominal pain
Dark Urine
Clay-colored stools
Jaundice

10. Symptoms Usually self-limited disease
Incubation period avg 28 days (range 15-50)
Early s/s: abrupt N/V, anorexia, fever, malaise, abd pain
Days to a week: dark urine and pale stools
Early s/s diminish when jaundice appears, and jaundice peaks within 2 weeks

11. PE/Labs
Fever, jaundice, scleral icterus, hepatomegaly, RUQ tender (80%)
AST/ALT 1,000s
Bilirubin < 10
Alk phos ~ 400
Contagious during incubation up to a week after jaundice
HAV (liver) -> stool high concentrations 2-3 wk before to 1 week after onset of clinical illness
Full clinical & lab recovery by 3 months in 85% cases

13. Less common manifestations
Fulminant hepatic failure < 1%
Above plus
Encephalopathy
Impaired synthetic function (INR > 1.5)
Occcurs in age > 50, hep b/c, cirrhosis
Rash/arthralgias 10-15%
Immune complex disease:
Leukocytoclastic vasculitis (legs & buttocks); HAV IgM & complement
Arthritis GN

14. Complications Relapsing hepatitis ~ 10% Cholestatic hepatitis ~ 5%
During 6 months after acute illness
Lasts < 3 wks, up to 12 months
Cause is unknown
Usu milder than initial episode
HAV IgM may persist throughout course and HAV recovered from stool
Cholestatic hepatitis ~ 5%
Protracted jaundice (> 3 months!!!)
Also pruritus (tx cholestyramine), fever, weight loss, diarrhea, malaise
Labs: Markedly elevated Bilirubin & Alk Phos; AST/ALT (5-15x ULN)
Treatment both is supportive, not steroids
DO NOT OVERTEST; get US r/o biliary obstruction; no ERCP/MRCP or biopsy!

15. Patient with HAV infection is admitted to a hospital
Since Jan 1, % FL cases (n=885) have been hospitalized
8 deaths 
staff members should NOT routinely be administered PEP
 appropriate infection control practices should be emphasized, i.e., standard and contact precautions for diapered or incontinent patients.
In a setting containing multiple enclosed units or sections (e.g., psychiatric facility), PEP administration can be limited only to health care personnel in the area where there is exposure risk

16. Handwashing Alcohol hand rub does not kill Hep A
Soap and water is best (20 seconds minimum)
Benzalkonium chloride hand rub/wipes are being used as alternative in the field where soap and water not available (used in recent California outbreak)

17. Vaccinate during outbreaks:
People who use drugs (injection or non-injection)
People experiencing unstable housing or homelessness
Men who have sex with men (MSM)
People who are, or were recently, incarcerated
People with chronic liver disease
Cirrhosis
Hepatitis B or C
NOT food handlers (standard sanitation practices prevents spread)

18. Vaccinate !