Government of Western Australia
Department of Health
OPERATIONAL DIRECTIVE
Enquiries to:
Telephone:
Supersedes:
Communicable Disease Control Directorate OD/IC number: OD 0228/09
9388 4863
22/10/2009
Date:
OD 0074/07 (10/10/2007)
EHB-01939
File No:
Subject:
Hepatitis A: National Guidelines for Public Health Units
This document supersedes the Management of Hepatitis A – October 2007.
PURPOSE
The purpose of this document is to advise public health staff that all State and Territory Health
Departments have worked collaboratively to develop the national guidelines for the public health
management of hepatitis A.
Hepatitis A is a notifiable disease and considered to be a high public health priority for public
health staff with cases being followed up within one working day of notification.
Public health staff should follow the recommendations outlined in these national guidelines on
receipt of suspected or confirmed hepatitis A cases.
Dr Peter Flett
DIRECTOR GENERAL
DEPARTMENT OF HEALTH WA
This information is available in alternative formats upon a request from a person
with a disability.
1
Table of Content
Page
1.
Summary.......................................................................................................................... 3
1.1
Public health priority ............................................................................................... 3
1.2
Case management ................................................................................................. 3
1.3
Contact management ............................................................................................. 3
2.
The Disease ..................................................................................................................... 3
2.1
Infectious agent ...................................................................................................... 3
2.2
Mode of transmission ............................................................................................. 3
2.3
Timeline .................................................................................................................. 3
2.4
Clinical presentation ............................................................................................... 4
3.
Risk Assessment............................................................................................................. 4
3.1
Routine prevention activities................................................................................... 4
3.2
Threat and vulnerability .......................................................................................... 4
3.3
Risk mitigation ........................................................................................................ 4
4.
Surveillance Objectives .................................................................................................. 4
5.
Data Management............................................................................................................ 4
6.
Communications ............................................................................................................. 5
7.
Case Definition ................................................................................................................ 5
7.1
Confirmed case ...................................................................................................... 5
7.2
Probable case......................................................................................................... 5
8.
Laboratory Testing.......................................................................................................... 5
9.
Case Investigation........................................................................................................... 6
9.1
Response times...................................................................................................... 6
9.2
Response procedure .............................................................................................. 6
10.
Control of Environment .................................................................................................. 7
11.
Contact Management ...................................................................................................... 8
12.
Special Situations ........................................................................................................... 9
12.1 A child in a child care setting .................................................................................. 9
12.2 A case in a school, hospital, or work setting ........................................................... 10
12.3 A case in a food handler......................................................................................... 10
13.
Additional Sources of Information................................................................................. 13
14.
Jurisdiction Specific Issues ........................................................................................... 13
Appendix 1: Hepatitis A Fact Sheet......................................................................................... 14
Appendix 2: Hepatitis A Case Report...................................................................................... 17
Hepatitis A: National Guidelines for Public Health Units
2
1.
SUMMARY
1.1
Public health priority
•
1.2
1.3
Case management
•
Respond to probable and confirmed cases within 1 working day.
•
Enter probable and confirmed cases in Notifiable Diseases Database within 1
working day.
•
While infectious, the case should not attend preschool or childcare, provide
personal care to others, or work as a food handler.
Contact management
•
2.
High
Counsel and arrange post exposure prophylaxis for susceptible exposed
contacts.
THE DISEASE
2.1
Infectious agent
The hepatitis A virus (HAV).
2.2
Mode of transmission
Hepatitis A is transmitted almost entirely by the faecal-oral route. Transmission may
occur through ingestion of: food that is not further cooked after being contaminated
at source or by an infectious food handler, drinking water that is not treated after
contamination or faecal material transferred directly from an infectious case on
hands or during sexual activity.
In recent years, outbreaks of hepatitis A have been linked to contaminated oysters,
childcare centres, infectious food handlers, men who have sex with men, illicit drug
users and homeless youth. A large proportion of Australian cases of hepatitis A are
in people who have travelled to developing countries.
The virus may be present in faeces for two weeks before the onset of jaundice and
faecal shedding rapidly declines thereafter. Faecal shedding of HAV may continue
for longer periods in infants and children.
Parenteral transmission is rare because viraemia is brief and the concentration of
virus in blood is low. Urine may be infective during this brief period of viraemia.
Saliva has not been shown to be a source of infection.
2.3
Timeline
The incubation period is 15 to 50 days, but more commonly 28 to 30 days.
The concentration of virus in the stool, and therefore infectivity, is highest just before
onset of jaundice or peak transaminitis. Cases are considered infectious from a few
days before onset of prodomal symptoms to a few days after onset of jaundice (or
peak transaminitis), and non-infectious one week after onset of jaundice (if it occurs)
or two weeks after onset of prodromal symptoms, whichever comes first. This period
may be longer in immunocompromised persons.
Hepatitis A: National Guidelines for Public Health Units
3
2.4
Clinical presentation
The usual clinical presentation is acute fever, malaise, anorexia, nausea and
abdominal discomfort, followed a few days later by dark urine and jaundice.
Symptoms usually last several weeks. The likelihood that symptoms will follow
infection increases with age: jaundice occurs in only a small proportion of infants and
young children, but a majority of adults. Infants and children infected with HAV may
have mild or no symptoms.
3.
RISK ASSESSMENT
3.1
Routine prevention activities
The prevention of hepatitis A rests largely on the provision of contamination-free
potable water, adequate hand-washing facilities, safe sewage disposal and hygienic
handling of food throughout the chain of production to consumption.
Hepatitis A vaccine is highly effective and recommended for people at higher than
background risk of disease. These include – but are not limited to – people travelling
to or expatriates living in developing countries, men who have sex with men, illicit
drug users, and people living in or working in remote indigenous communities.
3.2
Threat and vulnerability
th
Until the mid 20 Century hepatitis A was probably endemic in many parts of
Australia. The incidence of infection has subsequently declined in most parts of
Australia, possibly related to improved water supplies, safer food handling practices,
improved home hygiene and smaller family size. A seroprevalence study in 1998
estimated that 38% of the population had evidence of previous infection. This varied
from 70% of people aged 60-69 years to 10-20% in persons aged less than
20 years. Seroprevalence and notification rates are higher in the Northern Territory
and it is likely that infection remains endemic in many aboriginal and remote
communities. The majority of the community is now vulnerable to infection should
exposure occur. Although a highly effective vaccine has been available in Australia
since the mid 1990s, only a small proportion of the population is likely to have
received it.
3.3
Risk mitigation
The risk of hepatitis A is reduced by maintaining high quality drinking water, safe
food, and promoting vaccination and hygiene in people at risk of exposure to
infection through their travel, occupational, recreational or social activities.
4.
SURVEILLANCE OBJECTIVES
•
•
•
•
5.
To prevent disease in contacts already exposed
To prevent further transmission of infection from cases
To identify and control the source of the infection in outbreaks
To monitor the epidemiology of hepatitis A and so inform the development of better
prevention strategies.
DATA MANAGEMENT
Within 1 working day of notification enter probable and confirmed cases on the Notifiable
Disease Database.
Hepatitis A: National Guidelines for Public Health Units
4
6.
COMMUNICATIONS
Notify the State/Territory Communicable Diseases Branch about each case, including the
person’s age, sex, whether died and whether linked to other cases.
7.
CASE DEFINITION
7.1
Confirmed case
A confirmed case requires laboratory definitive evidence only.
Laboratory definitive evidence
1.
2.
7.2
Detection of anti-hepatitis A IgM, in the absence of recent vaccination, OR
Detection of hepatitis A virus by nucleic acid testing.
Probable case
A probable case requires clinical evidence AND epidemiological evidence.
Clinical evidence
Clinical hepatitis (jaundice and/or bilirubin in urine) without a non-infectious cause.
Epidemiological evidence
1. Contact between two people involving a plausible mode of transmission at a time
when:
a. one of them is likely to be infectious (from two weeks before the onset of
jaundice to a week after onset of jaundice), AND
b. the other has an illness that starts within 15 to 50 (average 28 - 30) days after
this contact, AND
2. At least one case in the chain of epidemiologically linked cases (which may
involve many cases) is laboratory confirmed.
8.
LABORATORY TESTING
In a patient who has not recently been vaccinated for hepatitis A, diagnosis is largely
established by the presence of IgM anti-HAV antibodies. IgM antibodies usually become
detectable before the onset of clinical symptoms and persist for ≥4 months in most persons
(and occasionally up to 1 year).
Approximately three percent of HAV infected people will be IgM negative if blood is taken
on or before the onset of jaundice. Probable cases with negative IgM results from early
specimens should be retested in 4 to 7 days. IgM antibodies are detectable in subclinically
infected persons as well as symptomatic cases. False positive hepatitis A IgM antibodies
have been documented in some people who have undergone screening tests but have no
clinical indication of hepatitis.
Anti-HAV IgG antibodies are markers of any exposure to the disease or immunisation and
they persist for life after infection. Although useful for identifying persons who are currently
immune to HAV infection, they are not useful indicators of recent infection. Nucleic acid
testing can detect virus in blood and stool but is not routinely used for diagnosis.
Hepatitis A: National Guidelines for Public Health Units
5
9.
CASE INVESTIGATION
9.1
Response times
Begin the follow-up investigation within 1 working day of notification of a probable or
confirmed case.
9.2
Response procedure
Case investigation
The response to a notification will normally be carried out in collaboration with the
case’s health carers. But regardless of who does the follow-up, PHU staff should
ensure that action has been taken to:
•
Confirm the onset date and symptoms of the illness.
•
Confirm results of relevant laboratory tests, or recommend the tests be done.
•
Find out if the case or relevant care-giver has been told what the diagnosis is
before beginning the interview.
•
Seek the doctor’s permission to contact the case or relevant care-giver.
•
Review case and contact management, ensuring that relevant exclusions have
been made.
•
Determine the likely source of infection.
•
Assess the number of contacts requiring prophylaxis.
•
Ensure proper control measures are taken to prevent further spread.
Exposure investigation
Information regarding history of prior immunisation and of exposures during the
period 15 to 50 days before onset of jaundice should be sought. This should include:
•
Household and sexual contacts who have had an illness consistent with hepatitis.
•
Restaurants where the case has eaten or worked.
•
Social gatherings where the case has eaten.
•
All sources of drinking water.
•
•
Consumption of raw or partially cooked shellfish.
Attendance or employment at child care services by case or household contacts.
•
Illicit drug use.
•
Travel (by the case or household contacts) to countries with endemic hepatitis A.
•
Recreational water exposure.
•
Exposure to sewage, or failed sewage disposal systems.
•
Hospitalisation.
•
Male to male sexual contact.
•
Attendance at educational/residential facility, association with Indigenous
community.
•
Association with an Aboriginal or Torres Strait Islander community.
•
Prison/remand centres.
•
Whether the case is a HCW.
Hepatitis A: National Guidelines for Public Health Units
6
Case management
Treatment is supportive only.
Education
The case or relevant care-giver should be informed about the nature of the infection
and the mode of transmission. Education should include information about hygienic
practices, particularly hand-washing before preparing food and eating and after
going to the toilet.
While infectious period, cases should:
•
Not donate blood.
•
Not prepare or handle food to be consumed by other people.
•
Not have sex.
•
Not attend preschool, childcare, school, work, or to provide personal care to
others.
•
Not share drug paraphernalia.
Isolation and restriction
Confirmed and probable cases should not attend child care facilities, provide
personal care to people in child care or health care settings or handle food for others
while infectious (for at least 7 days after onset of jaundice or dark urine, or 2 weeks
after onset of the prodrome).
Active case finding
Where cases are identified in settings such as child care facilities, schools and
residential care facilities where transmission might be expected to occur, work with
health care providers and administrators to identify other possible infectious cases.
10.
CONTROL OF ENVIRONMENT
Hepatitis A virus can contaminate water ways and remain viable for weeks.
Water supply
Drinking water systems are potential sources of HAV infection if there is opportunity for
faecal contamination. Where an unexpected cluster is reported, an evaluation may include
review of water treatment procedures and bacteriological quality.
Sewage disposal
Determine if the case has been exposed to a failed sewage disposal system.
Food service facility
Where contaminated food is a suspected source, PHU staff should arrange for a review of
the premises where food was prepared and served in order to determine the likelihood of
disease transmission in that setting, and to ensure current food safety practices protect
against the transmission of hepatitis A. Review records of illness among staff and ascertain
if food handling staff worked while ill.
Child care facility
PHU staff should ensure that the facility’s infection control procedures are reviewed to
determine the likelihood of disease transmission, and establish if carers of children <2 years
old have changed nappies and prepared food in the same shift.
Hepatitis A: National Guidelines for Public Health Units
7
11.
CONTACT MANAGEMENT
The purpose of public health intervention/contact management is to reduce the risk of
further transmission and clinical disease among those people who were close contacts of
the case during the case’s infectious period.
The following is a general list of persons considered to be contacts if exposed to infectious
cases:
•
immediate family, household members and sexual partners, including people who
stayed and shared their primary bathroom facilities with the case.
•
persons who consumed food not subjected to further cooking that was prepared by the
case.
•
If the case is a food handler, other food handlers in the same establishment.
•
if the case is in nappies, persons who provided direct care to the case.
•
If the case attends child care or preschool, other children and adults in the same
classroom or care group.
The available interventions for contacts include Normal Human Immune Globulin (NHIG)
and monovalent inactivated hepatitis A vaccine. Traditionally, post exposure prophylaxis
(PEP) of hepatitis A has consisted of administration of NHIG. Recent evidence indicates
that monovalent hepatitis A vaccine has similar efficacy to NHIG for PEP, at least for people
aged between 1 and 40 years. US, Canadian and UK health authorities recommend
vaccine over NHIG for people aged 1 to 40 years, but recommend NHIG over vaccine for
immunosuppressed people. Their recommendations diverge on what should be used for
otherwise well people >40 years.
(see: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm,
http://www.phacaspc.gc.ca/publicat/cig-gci/p04-hepa-eng.php#ru,
http://www.hpa.org.uk/cdph/issues/CDPHvol4/No3/HepAguidelines0901.pdf).
PEP should be offered to contacts within 2 weeks of last exposure to an infectious case as
follows:
•
Monovalent hepatitis A vaccine is recommended for contacts over the age of 1 year who
are not immunosuppressed, who have not had chronic liver disease diagnosed, and for
whom vaccine is not contraindicated.
•
NHIG is recommended to be reserved for the following contacts:
•
•
•
•
<12 months of age,
immunosuppressed
chronic liver disease, or
for whom vaccine is contraindicated.
PEP is not indicated for contacts of sporadic cases in the school or work settings.
•
Public Health Units should ensure that they have hepatitis A vaccine available to
vaccinate within the recommended timeframe. Regional PHU should consider the
potential costs incurred for emergency delivery of vaccines from CSL.
Passive immunisation
Normal human immunoglobulin (NHIG, also called gamma globulin) is a preparation of
pooled antibodies. Its efficacy declines rapidly within days of exposure, and becomes
ineffective about 2 weeks after exposure. NHIG should be given in a single intramuscular
dose at the following dosage:
Hepatitis A: National Guidelines for Public Health Units
8
Weight
<25 kg
25-50 kg
>50 kg
Dose
0.5 mL
1.0 mL
2.0 mL
NHIG may not prevent excretion of HAV, so those given NHIG may still transmit the virus,
even if they do not develop clinical illness.
The administration of NHIG may interfere with the immune response from live virus
vaccines. Consult the latest edition of the Australian Immunisation Handbook for detailed
advice.
Supply of NHIG is by local arrangement within each jurisdiction.
Active immunisation
A single dose of monovalent hepatitis A vaccine gives protection to most recipients within 2
weeks. A two-dose course is recommended for long-lasting protection. Persons given a
single dose for PEP should be advised to complete the course through their General
Practitioner. Not all vaccines are licensed for children aged down to one year of age –
check details in the Australian Immunisation Handbook. Note also that recent immunisation
may confuse the interpretation of follow-up serology.
•
Indigenous children: Hepatitis A vaccine is available on the Immunisation Schedule and
given to Indigenous children at 1 year and 18 months.
The immunisation status of Indigenous children should be checked before proceeding
with PEP if the child is aged 1 year or above.
Antibiotic prophylaxis
None.
Education
Provide contacts (or parents/guardians) with a Hepatitis A Fact Sheet, including advice on
the risk of infection; counsel them to watch for signs or symptoms of hepatitis occurring
within 50 days of exposure and seek medical attention early if symptoms develop. Parents
of infants or young children should be reminded that jaundice may not occur in young
children. Advice about careful hygiene should be given, particularly about hand washing
after going to the toilet and changing nappies.
It is especially important that any food handlers monitor their own development of hepatitis
symptoms after contact with the disease and seek medical attention promptly if symptoms
are detected.
Isolation and restriction
Nil.
12.
SPECIAL SITUATIONS
12.1
A case in a child care setting
Because most HAV infections in young children are asymptomatic, illness among
staff members or household contacts is often the first (and only) indication of child
care centre outbreaks. Staff of child care centres are recommended to receive preexposure vaccination with hepatitis A vaccine (complete course).
Hepatitis A: National Guidelines for Public Health Units
9
Hepatitis A vaccine or NHIG should be administered to all previously unvaccinated
staff members and attendees of child care facility if:
•
one or more cases of hepatitis A are recognised in children or employees, or
•
cases are recognised in two or more households epidemiologically linked to the
centre.
For a single case, hepatitis A vaccine or NHIG needs be administered only to
classroom contacts of the index patient. Written advice should be provided to
parents and staff caring for children in other groups. For multiple cases, careful
consideration should be given to whether other contacts within the facility should be
offered PEP.
When an outbreak occurs (i.e., hepatitis A cases in three or more families), hepatitis
A vaccine or NHIG also should be considered for members of households who have
children (centre attendees) in nappies.
In order to quickly identify new infections, the PHU should institute surveillance for
hepatitis-like illness among households connected to the centre for 50 days after
onset of the last case; this is usually done by letter. All such households should be
provided with basic information about hepatitis A, and instructed to contact the PHU
immediately should suspicious symptoms develop.
The critical role of good personal hygiene (especially hand washing) should be
reviewed with child-care staff. Staff involved in food handling should not be involved
in changing nappies on the same shift. Affected centres should be discouraged from
accepting new children for 50 days after onset of the last case, unless hepatitis A
vaccine or NHIG is given before admission. Transferring children to other centres
should be discouraged during this period.
12.2
A case in a school, hospital, or work setting
Hepatitis A PEP is not routinely indicated when a single case occurs in a school or
work setting, and the source of infection is outside the school or work setting.
Similarly, when a person who has hepatitis A is admitted to a hospital, staff members
should not routinely be administered hepatitis A PEP. Careful hygienic practices
should be emphasised. Hepatitis A vaccine or NHIG should be administered to
persons who have close contact with index patients if an epidemiologic investigation
indicates HAV transmission has occurred among students in a school or among
patients or between patients and staff members in a hospital and circumstances
suggest that further protection over and above improvements in hygienic practices is
warranted.
12.3
A case in a food handler
Most food handlers with hepatitis A do not transmit hepatitis A to others. The public
health response is based on a careful risk assessment, conducted as part of a site
visit. The risk assessment includes whether the food handler was working while
infectious, reports from the food handler and his/her supervisor and co-workers
about illness (including diarrhoea) and hygiene practices (glove use, hand hygiene),
evidence of hygiene training, and previous assessments of the sanitation practices in
the facility. Other food handlers at the facility are usually considered at increased
risk if they ate food handled by the case or shared toilets or washing facilities with
the case.
Follow up of patrons should be considered if: the food handler, while infectious,
directly handled food that was not subsequently cooked prior to serving AND had
Hepatitis A: National Guidelines for Public Health Units
10
diarrhoea or poor hygienic practices AND patrons can be identified and provided with
PEP within 2 weeks of exposure. Use of PEP should be considered in institutional
settings where multiple exposures among patrons may have occurred.
PHU staff must work in close collaboration with the jurisdictional food safety officers
in managing the risk to other staff and patrons.
Risk to other food handlers and patrons from a food handler diagnosed with
hepatitis A infection
Food handlers can transmit hepatitis A to patrons and co-workers through
contaminated food, and possibly utensils or surfaces. If the investigation shows that
other food handlers at the facility are at risk because they either ate food prepared
by the case, or because they shared toilets or washing facilities with the case, then
PEP should be provided to other unimmunised food handlers at the facility. Where
other cases are suspected among food handlers, blood should be collected (with
consent) for serology.
Alerting patrons when a risk is identified
It can be difficult to identify all people who may have been exposed to food prepared
by a case. It is therefore important to evaluate the degree of risk to patrons by
assessing the risk behaviours of the case. Where a risk is identified, there are two
primary reasons to alert patrons:
•
To provide PEP to potentially exposed individuals, in order to prevent further
cases.
•
To warn persons who may be already incubating the infections (and their doctors)
about their exposure, educating them about the symptoms and signs of hepatitis,
in order to facilitate rapid diagnosis and prevent a subsequent generation of
cases. (Public announcements can be worthwhile even if it is too late to offer
NHIG to exposed individuals).
These measures can be readily applied in a setting with an easily located clientele,
such as a school, childcare centre or private home. Identification and follow-up of
consumers is not as easy in other food service settings such as restaurants and
sandwich shops. In these situations, it sometimes becomes necessary to notify
those at risk through the news media or other forms of public announcement. The
food service facility operators should be counselled about their responsibility to
protect the public’s health and the need to cooperate in public alerts.
Going public
The following guidelines are designed to assist in deciding whether potentially
exposed patrons should be alerted via the news media. In applying these criteria
and judging the risk of further spread of infection, the PHU should:
•
Make every possible effort to obtain accurate information.
•
Exercise considerable judgment about the accuracy of information received,
especially the consistency of hygiene information received from different sources.
•
Consider the history of the facility’s food inspections records while under its
current management.
•
Determine whether the manager has had food safety training and applies it
through employee training, supervision and hazard control systems at the facility.
Good practices include:
Hepatitis A: National Guidelines for Public Health Units
11
•
Management supervises and inspects food protection and food handling
practices of all shifts on a routine basis.
•
Training addresses personal hygiene and supervision of food handler hand
washing practices.
•
Management has established a routine means of evaluating employee
performance such as watching that all food handlers wash their hands upon
entering a food preparation area in addition to restroom hand washing.
•
Hand washing facilities are checked frequently each day for adequate
supplies and operation and records are kept.
•
High risk food handling tasks are designed so that direct handling of food and
cross-contamination are minimised.
•
An effective management policy is in place for encouraging employees not to
work with symptoms that could indicate a communicable disease (e.g.,
diarrhoea or vomiting), thereby encouraging employees to report illnesses to
management.
High Risk Food is defined as food that is handled and not subsequently cooked
before consumption (e.g., salad fixings, cake icing, and sliced fruit).
General principles for decision-making
Generally, infectious food handler situations fall into one of three categories. The
decision-making process is unique for each of them. In all cases, other food handlers
at the establishment in question should be evaluated to determine whether any have,
or recently have had, hepatitis A. If other food handlers are found to be infected, the
risk to patrons should be re-evaluated. The PHU and food service managers should
monitor other food handlers who are at risk for hepatitis A for one incubation period
(50 days) after their last exposure to the index case.
1.
Food handler has not handled any high risk food.
Notification of potentially exposed patrons is rarely necessary.
2.
Food handler handles high risk foods, but facility manager has received
food service safety training and uses a hazard control system.
If the case always uses gloves or utensils appropriately, then public notification
generally is rarely necessary. Glove use per se is not a panacea, however, and
at worst can create a false sense of security. The potential for breaks in proper
practices should be carefully evaluated.
If the food handler has handled high risk foods with bare hands, but the facility
manager can document receipt of approved training and implementation of an
approved hazard control system, public notification is usually not indicated, if the
following conditions are met:
•
No transmission within the facility to co-workers or to patrons has been
documented
•
The record of inspections of the facility under present management indicates
that both personal hygiene of food handlers and the facilities for food handlers
to wash hands have met inspection standards
•
Inspection of the facility after identification of the case reveals that hand
washing facilities for employees are adequate
Hepatitis A: National Guidelines for Public Health Units
12
3.
•
Information obtained from the infected food handler, supervisor, and other
reliable sources indicates that the infected food handler followed good hand
washing practices
•
The infected employee, while potentially infectious, did not handle high risk
foods on days when experiencing diarrhoea.
The food handler handles high risk food, and the manager has not
received training and/or does not have an approved hazard control system.
If the food handler has handled high risk foods and the facility manager has not
received training within the last three years and/or does not use a hazard control
system, notification of potentially exposed patrons through the news media
should be considered, especially if one or more of the following criteria is met:
•
Transmission within the facility to co-workers or to patrons has already been
documented.
•
Inspection of the facility after identification of the case reveals that hand
washing facilities for employees in the food preparation area or the employees
toilet facility are inadequate (e.g., no soap, no towels, no running water).
•
One or more food handlers are not conforming to good hygienic practices
(e.g., food handlers are not washing their hands on arrival at work or after
using the toilet).
•
The record of inspections of the facility under the present management
indicates that personal hygiene of food handlers or facilities for food handlers
to wash their hands have been a problem two or more times during the
previous two years.
•
The infected employee, while potentially infectious, handled high risk foods on
days when experiencing diarrhoea.
•
Information obtained from the infected food handler, supervisor, or other
reliable source indicates that the infected food handler did not follow good
hand washing practices or failed to appropriately use gloves or utensils, (e.g.,
didn’t change gloves when food preparation was interrupted for a non-food
preparation task).
•
The infected food handler in the facility handled high risk foods with bare
hands, (e.g., failed to use gloves or utensils).
Consult with the state/territory Communicable Disease Branch (CDB) staff and the Media
Unit before going public. The CDB may convene an expert panel to advice in difficult cases.
13.
ADDITIONAL SOURCES OF INFORMATION
•
•
14.
The Australian Immunisation Handbook
Heymann DL, ed. Control of Communicable Diseases Manual
JURISDICTION SPECIFIC ISSUES
•
Links to State and Territory Public Health Legislation, the Quarantine Act, and the
National Health Security Act 2007
http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-state-legislation-links.htm
•
www.public.health.wa.gov.au
Hepatitis A: National Guidelines for Public Health Units
13
APPENDIX 1
Government of Western Australia
Department of Health
Public Health
Communicable Disease Control Directorate
Hepatitis A
July 2009
Hepatitis A is a viral infection of the liver. The
virus is spread by ingesting contaminated food or
water or direct contact with an infected person.
Vaccination and good hygiene prevents infection.
What is hepatitis A?
'Hepatitis' means inflammation or swelling of the liver. It can be caused by chemicals or drugs, or
by different kinds of viral infections. One common cause of infectious hepatitis is hepatitis A virus.
Infection with one type of hepatitis virus does NOT give protection against infection with other
hepatitis viruses.
What are the symptoms?
•
Symptoms include feeling unwell, aches and pains, fever, nausea, lack of appetite, abdominal
discomfort, followed by dark urine, pale stools and jaundice (yellowing of the eyeballs and
skin).
•
Illness usually lasts one to three weeks (although some symptoms can last longer) and is
almost always followed by complete recovery. Small children who become infected usually
have no symptoms.
•
Hepatitis A does NOT cause long-term liver disease and deaths caused by hepatitis A are rare.
•
The period between contact with the virus to the development of symptoms is usually about
four weeks, but can range from two to seven weeks.
How is it spread?
Infected people can pass on the virus to others from two weeks before the development of
symptoms until one week after the appearance of jaundice (about three weeks in total).
Large amounts of the virus are found in faeces (stools) of an infectious person during the
infectious period. The virus can survive in the environment for several weeks in the right
conditions (for example, in sewage).
Hepatitis A is usually transmitted when virus from an infected person is swallowed by another
person through:
•
•
•
•
eating contaminated food
drinking contaminated water
handling nappies, linen and towels soiled with the faeces of an infectious person
direct contact (including sexual) with an infectious person.
Outbreaks of hepatitis A have been traced to:
•
•
•
•
person-to-person spread, including among men who have sex with men
drinking water contaminated with sewage
eating food that has been contaminated with sewage such as shellfish
eating food contaminated by an infectious food handler.
Hepatitis A: National Guidelines for Public Health Units
14
Infection with hepatitis A continues to be a problem for people travelling overseas, especially
people visiting developing countries where hepatitis A is common.
Who is at risk?
Those who have not had hepatitis A and who have not been vaccinated against it are at risk of
catching the disease.
How is it prevented?
Vaccination
A safe and effective vaccine is available against hepatitis A. The vaccine may take up to two
weeks to provide protection. Vaccination is recommended for the following higher risk groups of
people:
•
•
•
•
•
•
•
•
•
•
•
travellers to countries where hepatitis A is common (most developing countries).
frequent visitors to rural and remote indigenous communities.
men who have sex with men.
child day-care and pre-school workers.
the intellectually disabled and their carers.
some health care workers who work in or with indigenous communities.
sewage workers.
plumbers.
injecting drug users.
patients with chronic liver disease.
people with haemophilia who may receive pooled plasma concentrates.
Overseas travel
If you are travelling to places where hepatitis A is common (including most developing countries),
take special care to avoid infections. Be very careful when you choose or prepare food and drink.
“Cook it, peel it, boil it or forget it” is good advice. See your doctor and discuss your travel plans at
least 6 weeks in advance. Vaccination against hepatitis A gives long term protection.
How do I get vaccinated against hepatitis A?
Talk to your GP or doctor of choice if you are thinking about hepatitis A. A 3 dose course of
vaccine given at 6 and 12 months will provide long term protection.
What else can be done to avoid hepatitis A?
Everyone should always wash their hands thoroughly with soap and running water for at least 10
seconds and dry them with a clean towel:
•
•
•
•
after going to the toilet.
before eating.
before preparing food or drink.
after handling objects such as nappies and condoms.
What can be done to avoid infecting others?
If you have hepatitis A, as well as washing your hands thoroughly, you should avoid the following
activities while infectious (that is, until at least one week after onset of jaundice):
•
•
do NOT prepare food or drink for other people.
do NOT share eating or drinking utensils with other people.
Hepatitis A: National Guidelines for Public Health Units
15
•
•
•
do NOT share linen and towels with other people.
do NOT have sex.
wash eating utensils in soapy water, and machine wash linen and towels.
The following people who have hepatitis A should not attend work and school while
infectious:
•
•
•
•
people who handle food or drink.
people whose work involves close personal contact, such as child carers and health workers.
staff and children should not attend childcare facilities while infectious.
all patients should check with their doctor before returning to work or school.
How is it diagnosed?
Diagnosis is based on the patient's symptoms and confirmed by a blood test showing IgM
antibodies to hepatitis A.
How is it treated?
There is no specific treatment for hepatitis A. Household contacts and sexual partners of an
infectious person may need to be immunised. Immunisation may prevent illness if given within two
weeks of contact with the infectious person.
What is the public health response?
•
Doctors, hospitals and laboratories must confidentially notify cases of hepatitis A infection to
the local Public Health Unit.
•
Public Health Unit staff will work with the doctor, the patient or the patient's family to identify
close contacts at risk of infection and arrange for those at risk to receive information about the
disease. Public Health Unit staff follow special guidelines for managing cases of hepatitis A in
people who attend or work at a child care centre, and in people who handle food for sale.
•
Public Health Unit staff also investigate outbreaks of hepatitis A to identify the cause of the
outbreak, control its spread and prevent further infections.
For more information:
For further information please contact your local Public Health Unit.
Public Health Unit
Telephone/Fax No.
Public Health Unit
Telephone/Fax No.
North Metropolitan
(Perth)
South Metropolitan
(Perth)
Great Southern
(Albany)
Southwest
(Bunbury)
Midwest
(Carnarvon)
Tel: 9380 7700
Fax: 9380 7719
Tel: 9431 0200
Fax: 9431 0223
Tel: 9842 7500
Fax: 9842 2643
Tel: 9781 2350
Fax: 9781 2382
Tel: 9941 0570
Fax: 9941 0563
Kimberley
(Broome)
Midwest
(Geraldton)
Goldfields
(Kalgoorlie)
Wheatbelt
(Northam)
Pilbara
(Port Hedland)
Tel: 9194 1630
Fax: 9194 1633
Tel: 9956 1985
Fax: 9956 1991
Tel: 9080 8200
Fax: 9080 8201
Tel: 9622 4320
Fax: 9622 4342
Tel: 9172 8333
Fax: 9172 8370
Hepatitis A: National Guidelines for Public Health Units
16
APPENDIX 2
Government of Western Australia
Department of Health
Public Health
Hepatitis A Case Report
Communicable Disease Control Directorate
Fax: 9388 4848
Communicable Disease Control Directorate
Date:
/
This is a:
/
Interviewer:
Person interviewed
(if not case):
Laboratory confirmed case - IgM
Doctor’s notification
(Suspected current infection – probable case)
WANIDD number
WA 2
0
Outbreak no. (choose one):
/
/
WANIDD updated?
not applicable
Hepatitis A
019-200___-______
no
yes ____________
Interpreter used?
If yes, language:
Probable source
SECTION 1: DEMOGRAPHIC DATA
Surname:
Other names:
Street address:
Suburb/town:
Telephone:
Postcode:
H: (
Date of birth:
)
/
W: (
/
)
Mobile:
Sex: … male
or Age:
female
Language spoken
at home:
Country of birth:
Of Aboriginal or Torres Strait Islander origin?
no
yes
Occupation (incl. part-time/casual work):
Name /address of
employer or school or
child care attended:
Telephone:
Date last attended:
/
Fax:
/
High risk group?‡
no … yes
e.g. those at high risk of transmitting hep A to others
‡
High risk groups include institutional residents, health care workers, food handlers, child care workers, children less than 6
years of age
SECTION 2: TREATING DOCTOR / HOSPITAL / LABORATORY
Name of treating Doctor:
Hospital (if admitted):
UR No:
Address:
Telephone:
Date of admission / visit
(circle appropriate one)
Facsimile:
not applicable
/
/
Name of laboratory:
Require doctor’s notification
Confirmation of diagnosis
Date of blood test : ___/___/___
Date of discharge/death
/
/
Telephone:
no … yes
Patient informed by doctor
no … yes
serology … serology pending
clinical only
Result: …IgM –negative …IgM+ve …IgG-negative …IgG+ve
Hepatitis A: National Guidelines for Public Health Units
17
SECTION 3: ILLNESS (SUMMARY)
Symptoms
Fever
no
unknown
yes
Dark Urine
no
unknown
yes, onset date: __________
Nausea
no
unknown
yes
Body aches
no
unknown
yes
Vomiting
no
unknown
yes
ÕHeadache
no
unknown
yes
ÕDiarrhoea
no
unknown
yes, onset date: _______
duration: _______
Abdominal
pain
no
Jaundice
no … unknown
yes, onset date: __________
unknown
yes
Other (specify)
_____________________________
_____________________________
History of illness:
Onset date of illness: ____/____/____Time of onset:……… am / pm
Total duration of illness: ………days
Immunisation details
Usual GP/Vax provider details:
__________________________________________________
Has case received Hepatitis A vaccination in the past?
no
unknown
yes, if so provide details from doctor
Dose 1: ____/____/____ … date unknown
Dose 2: ____/____/____ … date unknown … not given
Did case receive immunoglobulin (Ig) instead of vaccine?
no
unknown
yes, date received ____/____/____
Validation of vaccination information
Validated source/confirmed record. Please specify:
ACIR
doctor/clinic
DoHWA
Not validated - self or parental recall only
Not known/no information
Hepatitis A: National Guidelines for Public Health Units
18
SECTION 4: RISK FACTORS)
It may be helpful for the case to have a calendar or diary nearby. The following questions relate to activity
during the Incubation Period:
/
/
to
/
/
(date 8 weeks prior to onset)
Risk Factor for
acquisition of disease
Applies
Travel
(date 2 weeks prior to onset)
If yes during the incubation period, provide details
Places Visited: …………………………………………………
Domestic
no
yes
International
no
yes
Departure: ___ / ___ / ___
no
yes
Case name: ……………………………………………………..
no
yes
Resident of indigenous
community
no
yes
Visited indigenous
community
no
yes
Visitors from indigenous
community
no
yes
Household / Close
contact of person known
to have Hepatitis A
or
Similar illness
Type of Accommodation: ……………………………………
Return: ___ / ___ / ___
WANIDD no (if confirmed):.…………………………………….
Community name: ……………………………………………...
Community name: ………………………………………………
Dates of visit: ………………………to…………………………
Community name: ………………………………………………
Dates of visit: ………………………to…………………………
Male-to-male sexual activity
no
yes
Injecting drug use
no
yes
Pipe, bong, cigarettes,
tobacco or marijuana use
no
yes
Institutional resident
no
yes
Specify:
Child in child care /
preschool
no
yes
Name of CCC / Preschool:…………………….………………
Child care worker /
Preschool teacher
no
Non-household contact
with child under 5 yrs old
Days & hrs attends:………………….…………..………………
yes
Room / Age group cares for:..………..…….………..…………
Premises provides food?
Changes / wears nappies?
no
yes
no
yes
Other contact with a
known case of Hep A
no
yes
In prison or
remand centre
no
yes
Exposure to untreated
sewage
Who with?
Hepatitis A: National Guidelines for Public Health Units
no
no
yes
yes
Relationship:
Name of CCC / Preschool attends:……………………………
Date: _____/_____/_____
Exposure/activity:………………………………………………
Contact name(s):
19
SECTION 5: POSSIBLE FOOD OR WATER SOURCES
* Do not complete Section 6 if case has travelled overseas during the incubation period.
During the Incubation Period
/
/
(date 8 weeks prior to onset)
to
/
/
(date 2 weeks prior to onset)
Visited any restaurants / cafes / takeaway food premises during incubation period
no
yes
or attended social gatherings?
Record the takeaway / restaurants / cafes that the patient visited or social gatherings attended in the
incubation period, and food eaten there: (Consider functions such as weddings, birthday parties,
conferences, concerts, sporting events)
Possible source
Applies
Details
Date: _____/_____/_____
Ate oysters?
no
yes
Were they raw or partially
cooked?
no
yes
Ate mussels?
no
yes
Date: _____/_____/_____
Were they raw or partially
cooked?
no
yes
Type / Brand:………………………………………………..
Type / Brand:………………………………………………..
Where
purchased:……………………………………………
Where purchased:…………………………………………
Date: _____/_____/_____
Ate other shellfish?
no
yes
Type / Brand:………………………………………………..
Where purchased:…………………………………………
Date: _____/_____/_____
Ate fresh / frozen berries?
no
yes
Type / Brand:………………………………………………..
Where purchased:…………………………………………
Specify:
Sporting groups or clubs?
no
Hepatitis A: National Guidelines for Public Health Units
yes
20
Possible source
Applies
Details
Specify type: ……………………………………………...
Main source of drinking
water?
Location: …………………………………………………..
Is water treated?
Drank untreated water?
no
yes
no
unknown
yes
Specify type:
………………………………………………………….......
Location:
………………………………………………………………..
Activity: …………………………………………………….
Participated in swimming /
water sports?
Type of water (e.g. pool, river, etc): …………………….
no
yes
Address:
……………………………………………………………….
Date : _____/_____/_____
SECTION 6: EDUCATION
Hygiene and preventing transmission discussed
Information requested
No
No
N/A
N/A
Yes
Yes, date sent: ____/____/____
SECTION 7: FOLLOW-UP AND EXCLUSIONS FOR CASE
For the Incubation Period
/
/
to
(date 8 weeks prior to onset)
/
/
(date 2 weeks prior to onset)
Tick box that describes case:
High risk
groups for
transmission
Institutional resident
Health care worker
none of the above
CCC worker
Child less than 6 years — CCC — pre-school
Food handler
OTHER
Hepatitis A: National Guidelines for Public Health Units
21
SECTION 7A: For all cases, please provide the following information
Exclusion required?
no
yes
Exclusion discussed
with case / parent /
guardian.
no
yes
Letter sent to contacts
at premises?
no
yes
If the case is in a high risk setting / occupation, they
must be excluded from attendance / work until
asymptomatic (diarrhoea has ceased and 7 days after
onset of jaundice).
Date sent:
____/____/____
Contact date: ____/____/____
LGA informed?
no
yes
Contact name: ………………………………………………..
Action required: ……………………………………………
Feed back received:
no
yes, ………………………..
SECTION 7B: For cases in high risk groups only, please provide the following information
Name of related
premises:
………………………………………………………………………………………….
Date last attended: ____/____/____
Movements of case at work / CCC / institution:
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………
SECTION 8: COMMENTS OR CONCLUSIONS
Comments:
Signature: ______________________________________
Hepatitis A: National Guidelines for Public Health Units
Date: _____ /_____ /_____
22
ATTEMPTS TO CONTACT CASE (include summary of all agencies consulted to facilitate contact)
DATE
TIME
Hepatitis A: National Guidelines for Public Health Units
COMMENTS
23
SECTION 9: CONTACT DATA† AND PROPHYLAXIS (for 2 weeks before to 2 weeks after onset of symptoms or 1 week after jaundice onset) ‡
A general list of persons considered to be contacts if exposed to infectious cases: immediate family, household members and sexual partners, including people who stayed and
shared their primary bathroom facilities with the case; persons who consumed food not subjected to further cooking that was prepared by the case; if the case is a food handler, other
food handlers in the same establishment; if the case is in nappies, persons who provided direct care to the case; if the case attends child care or preschool, other children and adults
in the same classroom or care group.
•
•
Monovalent hepatitis A vaccine is recommended for contacts over the age of 1 year who are not immunosuppressed, who have not had chronic liver disease diagnosed, and for
whom vaccine is not contraindicated http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home (page 146)
NHIG is recommended to be reserved for the following contacts: <12 months of age; immunosuppressed; chronic liver disease; or for whom vaccine is contraindicated.
Index Case: ………………………………………
WA
Indicate if a person in a high risk group has been identified:
Child Care
Name: ………………………………………
School
Other
………………………………………
Contact person:
2
0
…………………………………………………………………………
Phone:
………………………………………
High risk groups include institutional residents, health care workers, food handlers, child care workers, children less than 6 years of age
Name
Telephone
Previous
HepA
vaccination
N
Y
Parental consent
Information
IG
Referred to GP for prophylaxis
Hep A vaccine
IG
Hep A vaccine
serology
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
Community Nurse:
Telephone:
Community Health Centre:
Date:
Page of
Hepatitis A: National Guidelines for Public Health Units
24
INVESTIGATIONS NOTES
Attach extra investigation sheets if necessary
Hepatitis A: National Guidelines for Public Health Units
25