1. Andrew Waters Regional Epidemiologist Bluegrass Region 2 Hepatitis A Outbreak 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. Hepatitis A  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. 012345678910111213 Week Response Clinical illness ALT IgM IgG HAV in stool Infection Viremia Events in Hepatitis A Infection

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 16 th, 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 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 A Household B 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 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 15-20 visitors to in-ground pool

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