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COUNTY OF MONTEREY

HEALTH DEPARTMENT

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For Health Care Providers - Hepatitis A

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Current Situation: June 21, 2018

During 2017 and 2018, the San Diego, Los Angeles, Santa Cruz, and Monterey County Health Departments investigated local hepatitis A (HAV) outbreaks among individuals who are homeless or use illicit drugs. Following intensive efforts by the Monterey County Health Department, the California Department of Public Health, and our clinical and community partners, the number of reported outbreak-associated cases has substantially decreased in Monterey County. Because there have been no new outbreak-related cases of HAV in Monterey County for at least two incubation periods, Monterey County Health Officials have declared an end to the local outbreak. However, Health Officials urge local providers to remain vigilant. Due to ongoing HAV outbreaks in other parts of the United States, sporadic cases of HAV may continue to occur at a higher rate than usual.

Recommendations

  • Consider hepatitis A among individuals presenting with clinically compatible illness (acute onset of jaundice with abdominal pain, vomiting and/or diarrhea) and the following risk factors:
    • Travel to Mexico, Central and South America, Asia, and Africa in the 8 weeks prior to symptom onset,
    • Travel to areas within the United States with current HAV outbreaks including Indiana, Kentucky, Michigan, Missouri, Utah, and West Virginia in the 8 weeks prior to symptom onset,
    • Homelessness, or
    • History of illegal drug use.
  • Order an IgM antibody test for HAV (IgM anti-HAV) for individuals who present with clinically compatible illness.
    • Total anti-HAV alone cannot distinguish between current disease, past disease, and vaccination-induced immunity.
    • IgM anti-HAV testing should be limited to individuals with evidence of clinical hepatitis. Due to a high rate of false positives, it should not be used as a screening tool for asymptomatic patients or for patients without clinically compatible illness.
    • Save the patient blood specimen for submittal to the Monterey County Public Health Laboratory for additional testing.
  • Continue to offer routine vaccination to the following groups.
    • Travelers to countries where hepatitis A is common.
    • People with clotting factor disorders.
    • People who conduct laboratory research with the virus.
    • People in close personal contact with adopted children from countries where hepatitis A is common.
  • Consider vaccination among other high risk groups including:
    • Homeless individuals.
    • Users of illegal drugs.
    • Men who have sex with men.
    • People with chronic liver disease, such as cirrhosis, hepatitis B, or hepatitis C. They may not be at increased risk of getting hepatitis A but are at increased risk of poor outcomes if infected.
    • If adult single antigen hepatitis A vaccine is not immediately available, providers may consider using the combined hepatitis A and hepatitis B vaccine (Twinrix®) for pre-exposure prophylaxis or deferring immunization until additional vaccine becomes available. Vaccine may also be available in pharmacies and is covered as a pharmacy benefit for several insurance sources, including Medi-Cal fee for service and managed care, as well as several qualified health plans through Covered California. (See http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_26320.asp)
  • Continue to offer routine vaccination to children against HAV. Pediatric vaccine supplies are ample and recommendations for routine childhood immunizations are unchanged.

All confirmed or suspected hepatitis A cases, including all positive laboratory tests for IgM anti-HAV antibody, must be immediately reported to the Communicable Disease Unit while the patient is still in the facility (phone 831-755-4521 or fax 831-754-6682; after hours call 831-755-5100 and ask for the Hazardous Materials Team, who will connect you with the on-call Health Officer).  It may be difficult to locate the individual once he/she is released.  Once a case of confirmed or suspect hepatitis A has been reported, the Health Department will make recommendations for postexposure prophylaxis as needed for close contacts, day care situations, common-source exposures, schools, hospitals and work settings.  

Post-exposure Prophylaxsis (PEP) for Hepatitis A

On July 7, 2017, Grifols Therapeutics increased the recommended dosages of its product (GamaSTAN S/D) for pre- and post-exposure prophylaxis of hepatitis A virus infection.  Susceptible people exposed to hepatitis A should receive a single dose of sign-antigen hepatitis vaccine or intramuscular IG (0.1 mL/kg) or both as soon as possible within 2 weeks of last exposure.  The newly recommended dose for HAV post-exposure prophylaxsis (0.1 mL/kg) is 5 times greater than the previously recommended dose.  The efficacy of Twinrix for PEP has not been evaluated, so it is not recommended for PEP.

HAV vaccine is preferred over IG for PEP in patients 1-40 years of age because the effectiveness of vaccine for PEP has been studies only in this age group.  Data on vaccine efficacy at older ages are limited.  However, other countries recommend vaccine for PEP in people >40 years of age and there is evidence that HAV vaccine is immunogenicity in older people.  Therefore, the California Department of Public Health (CDPH) suggests consideration of HAV vaccine for PEP in people 41-59 years of age because it confers long-term immunity.

Age in Years  <1  1-40   41-59  60-74 75+ 
 Healthy  IG Vaccine Preferred   Vaccine and/or IG  IG; vaccine if IG is in short supply  IG
 Immunocompromised  IG*  IG*  IG*  IG*  IG*

*Consider vaccine + IG for posisible longer-term protection.  Individuals with chronic liver disease or who are immunocompromised, regardless of age, should always receive at least IG PEP because they are at increased risk of severe HAV infection or may have a decreased immune response to vaccine.