Controlling Spread of Hepatitis A

Table of Contents

A. Isolation and Quarantine Requirements

Minimum Period of Isolation of Patient

All hospitalized patients are on Standard Precautions.

Diapered or incontinent patients should be placed on Contact Precautions:

  • Infants and children <3 years of age for duration of hospitalization
  • Children 3-14 years of age for 2 weeks after onset of symptoms
  • >14 years of age for I week after onset of symptoms  

At home, counsel the patient to modify activities in order to prevent transmission until the end of the infectious period or one week after onset of symptoms. The patient should not prepare food for others, and practice good handwashing after toileting.  Persons assisting a patient with toileting should practice good hand washing and wash the patient’s hands after toileting.

Persons who are child care or healthcare providers and food handlers should not work until 7 days after onset of jaundice or two weeks after the onset of symptoms.

Minimum Period of Quarantine of Contacts

None

B. Protection of Contacts of a Case

Persons who have documentation of previous hepatitis A disease or of receiving hepatitis A vaccine at least one month before an HAV exposure do not need post-exposure prophylaxis. For public health intervention, a case is considered to be potentially infectious from 14 days before the onset of symptoms to 7 days after onset of symptoms. Fecal shedding of the virus peaks during the 2 weeks before onset of symptoms until several days after onset. If diarrhea exists, it greatly enhances a case’s ability to transmit virus.  Control measures are implemented through the administration of hepatitis A vaccine or immune globulin (IG) to the people who had contact (see definition of contact directly below) with the case during their infectious period. HAV vaccine is preferred over IG for PEP for persons aged 1-40 years. The effectiveness of vaccine for PEP has been studied only in this age group and data on vaccine efficacy at older ages are limited. However, other countries and states recommend vaccine for PEP in people greater than 40 years of age and there is evidence HAV vaccine is immunogenic in older people. Therefore, IDPH also recommends HAV vaccine for persons 41-59 years of age. For persons greater than 59 years of age, vaccine may be administered simultaneously (in different anatomical sites) with IG to potentially provide longer-term protection.  IG should be used for children under the age of 12 months.

The safety of hepatitis A vaccination during pregnancy has not been determined; however, because hepatitis A vaccine is produced from inactivated hepatitis A virus, the theoretic risk to the developing fetus is expected to be low. The risk associated with vaccination should be weighed against the risk for hepatitis A in pregnant women who might be at high risk for exposure to hepatitis A.

Post exposure prophylaxis should be administered as soon as possible and within 14 days of last exposure to an infectious case. Persons who receive immune globulin and for whom hepatitis A vaccine is recommended for other reasons should receive a dose of hepatitis A vaccine to provide long term protection at the same time they receive IG. This would include persons routinely recommended to receive hepatitis A vaccine as listed below. For persons who receive vaccine, the second dose should be administered through their healthcare provider according to the licensed schedule to complete the series. Combination hepatitis A and B vaccine is not to be used for post exposure prophylaxis. In persons exposed more than 14 days ago, vaccine or IG treatment will not prevent the illness. Those persons should watch for symptoms of hepatitis A and practice good hygiene, including frequent hand washing with soap and water.  They should see their healthcare provider and notify public health if symptoms develop. 

A contact is defined as:

All household members; sexual contacts; persons who have shared illicit drugs with the case, food handling employees who work with the case; and anyone consuming uncooked foods or foods handled after cooking prepared by an infectious case that had diarrhea or poor hygienic practices at the time of food preparation. Other household-like contacts (e.g. baby sitter that comes in routinely).

Immune Globulin

The following persons should not receive immune globulin:

  1. Persons with known immunoglobulin A (IgA) deficiency.
  2. Persons with severe thrombocytopenia or any blood coagulation disorder which would contraindicate intramuscular injections.

Caution should be used in giving IG to a patient with a history of anaphylactic reactions to immune globulins. IG is not recommended for persons who have clinical symptoms strongly indicative of hepatitis A.

Immune globulin may interfere with immunizations for measles, mumps, rubella, and chickenpox. 

These live attenuated vaccines should not be given for at least three (3) months after administration of IG. Also, if it is necessary to administer IG within the 2 weeks following MMR or varicella vaccine the vaccine should be repeated. The repeat dose of MMR or varicella vaccine should not be given sooner than three (3) months after IG.

Hepatitis A Vaccine

Persons routinely recommended to receive hepatitis A vaccine:

  • Children at 12 – 23 months of age. Vaccination should be integrated into the routine childhood vaccination schedule. Children who are not vaccinated by 2 years of age can be vaccinated at subsequent visits.
  • Travelers to high or intermediate risk countries.
  • Men who have sex with other men.
  • Persons who use illegal drugs.
  • Persons who have clotting factor disorders.
  • Those who work with hepatitis A-infected primates or with hepatitis A virus in a laboratory setting.
  • Susceptible persons who have chronic liver disease.
  • Susceptible persons who either are awaiting or have received liver transplants should be vaccinated.
  • Any person one year old or older who wants protection from Hepatitis A.

C. Managing Special Situations

Child Care

If a confirmed case of hepatitis A occurs in a child care setting, parents and staff must be notified. Hepatitis A fact sheets should be provided at that time.  Hepatitis A vaccine or IG should be administered to all previously unvaccinated staff members and attendees of child care or homes if:

  1. One or more cases of hepatitis A are recognized in children or employees. In centers that do not provide care to children who wear diapers, hepatitis A vaccine or IG need be administered only to classroom contacts of the index case.
  2. Cases are recognized in two or more households of center attendees. In centers that do not provide care to children who wear diapers, hepatitis A vaccine or IG need be administered only to classroom contacts of the index case.

When an outbreak occurs (i.e., hepatitis A cases in three or more families), hepatitis A vaccine or IG should also be considered for members of households that have children (center attendees) in diapers.

  • Enforce policies about hand hygiene (with children and staff) and disinfection of objects and environmental surfaces with appropriate bleach solutions or other solutions that state they kill HAV.
  • Make sure all parents and staff notify the health department if any person in their household is diagnosed with hepatitis A.

Exclusion Guidelines

People who are sick with hepatitis A can return to the program no less than two weeks after the illness started or one week after onset of jaundice.

Schools and Work Settings

Hepatitis A postexposure prophylaxis is not routinely indicated when a single case occurs in an elementary or secondary school or other work setting and the source of the infection is outside the school or work setting. Careful hygienic practices should be emphasized, including availability of hand hygiene supplies. Hepatitis A vaccine or IG should be administered to persons who have had close contact with the index case if an epidemiologic investigation indicates HAV transmission has occurred among students in a school.

Hospitals

When a person who has hepatitis A is admitted to a hospital, staff members should be using standard precautions and therefore not be exposed to hepatitis A. Routine administration of hepatitis A post-exposure prophylaxis should not be needed: instead, careful hygienic practices should be emphasized. Hepatitis A vaccine or IG should be administered to persons who have close contact with index patients if an epidemiologic investigation indicates HAV transmission has occurred among patients or between patients and staff members in a hospital.

If a hospital staff member is diagnosed with hepatitis A and is considered a food handler then the food handler guidelines must be followed.  

Cases who are healthcare providers should not work until 7 days after onset of jaundice or two weeks after the onset of symptoms.

Community Residential Programs

Actions taken in response to a case of HAV in a community residential program should be handled on a case-by-case basis. Management of contacts will depend on the level of hygiene of the case and the type of facility. Roommates should be given hepatitis A vaccine or IG as soon as possible, and within 14 days of last exposure. If hepatitis A occurs in a staff member of a residential program, the case should be considered a food handler if there was an opportunity to feed, distribute medication, prepare foods or perform oral hygiene during the 2 weeks prior to symptom onset and 1 week after symptom onset. Consult with an epidemiologist at CADE by calling (800) 362-2736.

Food Handler

A food handler is any person directly preparing or handling food, including a patient care or child care provider, or homemaker.  

A confirmed case of hepatitis A in a food handler is a public health emergency and requires that risk for both co-workers and the public be assessed immediately. If a food handler is a laboratory-confirmed case of hepatitis A, all other food handling employees in the facility must receive hepatitis A vaccine or IG as soon as possible, unless the contact can produce documentation of hepatitis A virus (HAV) vaccination or can show serologic immunity to HAV disease. Even after receiving hepatitis A vaccine or IG, they should wash hands correctly and protect READY-TO-EAT FOOD from contamination introduced by bare hand contact for the next 6 weeks to prevent the spread of infection.  If the employee does become sick, the employee should stop working immediately and be tested for HAV IgM antibodies.

In order to determine if the public needs to be notified of possible exposure to HAV, a complete food handling history of the case for the 2 weeks before and one week after symptom onset needs to be done. This history should include consistency of correct handwashing procedure, presence of diarrhea, dates worked, job duties, foods prepared, and whether gloves or other barrier protection were used by the food handler. See the Epi Manual’s Hepatitis A section for the food handler assessment worksheet. Please call CADE at (800) 362-2736 to help determine the risk to the general public and to arrange shipment of prophylactic hepatitis A vaccine or IG.

Cases who are food handlers should not work until 7 days after onset of jaundice or two weeks after the onset of symptoms.

Refer to Acute Hepatitis A Management in the Food Handler flowchart.

Hepatitis A vaccine or IG administration to patrons is usually not recommended, but can be considered if:

  • During the time when the food handler was likely to be infectious they had diarrhea or poor hygienic practices and directly handled foods served uncooked or handled foods after cooking, and
  • Patrons can be identified and treated within 2 weeks after the exposure.
  • In settings where repeated exposures to HAV might have occurred (e.g., institutional cafeterias), stronger consideration for more widespread hepatitis A vaccine IG use may be warranted.

Reported Incidence Is Higher than Usual/Outbreak Suspected

If the number of reported cases in a city/town is higher than usual, or if an outbreak is suspected, investigate clustered cases in the area or institution to determine the source of infection and mode of transmission. A common vehicle (such as food or association with a child care center) should be sought and applicable preventive or control measures should be instituted. Control of person-to-person transmission requires special emphasis on personal cleanliness and sanitary disposal of feces. Consult with the epidemiologist at CADE by calling (800) 362-2736. CADE can help determine a course of action to prevent further cases and can perform surveillance for cases that may cross several county lines and therefore be difficult to identify at a local level.

D.  Preventive Measures

Personal Preventive Measures/Education

Individuals can avoid exposure to the virus by taking the following measures.

  • Wash hands thoroughly with soap and water, especially before handling or eating food, after toilet use, and after changing diapers.
  • In child care or residential programs, dispose of feces in a sanitary manner.
  • Avoid sexual practices that may permit fecal-oral transmission. Latex barrier protection should be emphasized as a way to prevent the spread of HAV to a case’s sexual partners as well as being a way to prevent exposure to and transmission of other pathogens.
  • Consider vaccination of those at high-risk of contracting hepatitis A. Iowa residents who should be vaccinated include the following:
    • Persons (> 12 months of age) traveling to or working in countries with high or intermediate rates of hepatitis A, such as Central or South America, the Caribbean, Mexico, Asia (except Japan), Africa, and southern or eastern Europe.  The second dose should be given 6 months or later after the first.
    • Men who have sex with men.
    • Illegal drug users, whether injecting or not.
    • Persons with chronic liver disease (not just infection), including those who are awaiting or have received liver transplants.
    • Persons who receive clotting factor concentrates.
    • Persons who have occupational risk for infection; specifically, those who work with HAV-infected primates or with HAV in a research laboratory setting. Sewage workers do not need to be vaccinated.
    • Persons experiencing homelessness or unstable housing.

International Travel

Travelers to areas where hepatitis A is endemic should receive hepatitis A vaccine before travel. The first dose of hepatitis A vaccine should be administered as soon as travel is considered. One dose of single-antigen hepatitis A vaccine administered at any time before departure may provide adequate protection for most healthy individuals. For optimal protection, older adults, immunocompromised persons, and persons with chronic liver disease or other chronic medical conditions who are traveling to an area where risk of transmission is high less than two weeks after the initial dose, may also be administered IG, but at a different anatomic injection site. Completion of the vaccine series according to the licensed schedule is necessary for long-term protection. However, contraindications to the vaccine may preclude individuals from receiving it. If an individual is allergic to a component of the vaccine or is <12 months old (vaccine is not licensed for this age group), that individual should not receive the vaccine. In addition, travelers should pay attention to what they eat and drink. This step is extremely important because the vaccine is not 100% effective and immunity conferred from IG wears off over time (3-6 months). Taking precautions such as those listed below will help prevent other illnesses as well, including travelers’ diarrhea, cholera, dysentery, and typhoid fever.

Recommendations to travelers include the following.

  • "Boil it, cook it, peel it, or forget it." 
  • Drink only bottled or boiled water, keeping in mind that bottled carbonated water is safer than non-carbonated water.
  • Ask for drinks without ice unless the ice is made from bottled or boiled water.
  • Avoid Popsicles and flavored ices that may have been made with contaminated water.
  • Eat foods that have been thoroughly cooked and are still hot and steaming.
  • Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well.
  • Peel your own raw fruits or vegetables and do not eat the peelings.
  • Avoid foods and beverages from street vendors.

For more information regarding international travel and hepatitis A, contact the CDC’s Traveler’s Health Office at (877) 394-8747 or through the Internet at http://www.cdc.gov/travel