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Andrew Waters
Regional Epidemiologist
Bluegrass Region 2
Objectives
Provide overview of Hepatitis A
Review Hepatitis A case definitions
Initial case background
Additional cases and contacts
Describe investigation progress
After action
Hepatitis A
IgM
ALT
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Week
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
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
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
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
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
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
But why?
Hepatitis A IgM labs have a high rate of
false positives
Mother 1 – Sx
Boyfriend 1 – No Sx
Daughter 1 – No Sx
Mother 2 – No Sx
Boyfriend 2 – Sx
Daughter 2 – No Sx
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
Household C
Male – No Sx
Our Circles
Household B
Household A
Mother 1 – Sx Father 1 – Sx
Boyfriend 1 – No Girlfriend 1 – No Sx
Sx 2 Daughters – No Sx
Daughter 1 – No Sx 1 Son – No Sx
Mother 2 – No Sx 1 Male Babysit – No
Boyfriend 2 – Sx Sx
Daughter 2 – No Sx 1 Male – No Sx
Male – No Sx
Household C
Social Contacts
Very social group
Male – No Sx
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
Epi Curve
Epi Curve Hep A Outbreak 2007
Hep A Cases
3
No. of Cases
Index Case
2
0
0
1
/1
/3
/5
/9
/7
/1
/1
/1
/1
/2
/2
/2
/3
/1
/2
/2
/1
6
6
5
6
Date of Onset
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
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
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
Restaurant Exposure
Index Case Infectious Period
Index Employment
3
2
Event
0
10
12
14
16
18
20
22
24
26
28
30
11
1
9
6/
6/
6/
6/
6/
5/
5/
5/
5/
5/
5/
5/
5/
5/
5/
5/
6/
Date
Restaurant Exposure
Released restaurant name into the media
Poor historian
– Unsure about dates
– Lost to follow-up