EXECUTIVE SUMMARY

Recently, several regions in the United States have experienced unusual outbreaks of hepatitis A (HAV). The most severe of these outbreaks is in San Diego, where emergency providers have taken extra steps to identify patients with HAV promptly and to offer vaccinations to patient groups deemed most at risk. Health officials there report they have been impressed by the range of acuity, the severity of illness, and the vague symptomatology that patients with HAV present with when they come to the ED. Health officials warn that HAV might not come to the top of the list of potential diagnoses immediately considered by providers.

  • The ED at the University of California, San Diego Medical Center has identified at least 150 patients with HAV.
  • A prompt in the hospital’s electronic medical record will flag patients at risk for HAV so they can be offered vaccinations while in the ED.
  • During the current outbreak, investigators have found that at least half the patients identified with HAV are homeless, illicit drug users, or recently incarcerated.
  • Most patients identified with HAV in the ED have been admitted to the hospital so they can receive appropriate treatment and follow-up care.

Despite the availability of a vaccine for hepatitis A virus (HAV), there have been serious outbreaks in several U.S. regions this year. In particular, public health authorities in San Diego declared a local health emergency in early September 2017. In that city, there have been more than 540 cases of HAV, including 20 patients who have died and more than 350 who have been hospitalized.

Since August 2016, there have been more than 450 confirmed cases of HAV in Michigan, including 18 patients who have died from the ailment and more than 300 who have been hospitalized. Several other states and cities have reported outbreaks of HAV, too, a reality that should be raising the alert level of emergency providers, given the highly contagious nature of the virus.

Increase Screening

The ED at the University of California, San Diego (UCSD) Medical Center has taken several steps to manage the outbreak, including creating a vaccination program for HAV within the ED, explains Ted Chan, MD, FACEP, FAAEM, professor and chair of the department of emergency medicine. “Our EMR [electronic medical record] will flag patients who are homeless or at risk for HAV, and we will offer the vaccination,” he explains. “We have given more than 400 patients the HAV vaccination, which is not a common vaccination to give in the ED. This has been coordinated with our county agency so that all of this information is recorded in an immunization registry.”

In addition to making sure appropriate patients are offered the vaccination, the hospital has made sure that staff members are protected with vaccinations as well, especially frontline clinicians who are most at risk, Chan offers. “We have done a fair amount of education with our staff in terms of recognizing patients who are at risk for HAV,” he says. “We have diagnosed HAV in more than 150 patients who have presented to our department.”

During the current outbreak, investigators have found at least half the infected individuals have been homeless, illicit drug users, or recently incarcerated. Other outbreaks have been tied to contaminated food. Close contact with an infected person puts individuals at risk, as the virus spreads easily.

Maintain Awareness

When a patient is diagnosed with HAV in the ED at UCSD Medical Center, standard precautions are taken to prevent transmission to others, and most of the time the patient is admitted to the hospital, Chan explains. “Hepatitis A is not always a diagnosis that requires hospitalization, but because of these patients’ social situation in terms of their lack of a home and the ability for follow-up, most of these patients have been admitted to the hospital for their care,” he says, noting that many of the patients carry chronic diseases and/or present with other complications.

One of the biggest challenges in confronting the outbreak has been spreading awareness about the fact that the region is experiencing the largest outbreak of HAV in the country in many years. “We don’t see many outbreaks like this ... we see sporadic cases,” Chan observes. “This has been unusual ... so we just need to make sure it is on everybody’s radar screen so that they think about HAV when patients have vague symptoms with nausea, belly pain, and that sort of thing in the right patient population.”

Typical symptoms of HAV also may include fever, vomiting, anorexia, and malaise, which can be followed by jaundice. However, Chan says his team has noted a wide range of presentations in patients with HAV who have presented to his ED. “Some of the presenting symptoms have been very mild and some have involved patients who were significantly ill,” he says. “I have been impressed by the range of acuity, the severity of illness, and also the vague symptomatology that these patients have come in with. Hep A might not come to the top of the list [of potential diagnoses] immediately.”

The ED has worked closely with the county public health department to follow the outbreak and keep clinicians informed. In fact, local public health authorities visited the hospital and presented information about the outbreak to all the physicians, Chan explains. “They have been sending out regular alerts on the outbreak to all emergency physicians in the county,” he says.

Chan adds that the hospital also has worked closely with the fire department because these officials often are the ones who make first contact with the patient population most at risk for HAV. “There has been a high level of engagement with our city and our county on this issue,” he says.

Employ Contact Precautions

Similar to what is happening at UCSD Medical Center, all patients entering the EDs at Scripps Mercy Hospital in San Diego and Scripps Mercy Hospital in Chula Vista, CA, undergo screening for risk factors for HAV, according to Craig Uejo, MD, a preventive medicine specialist at Scripps Health who is helping lead the health system’s clinical response to the outbreak. “Those patients identified as being at risk are being offered the hepatitis A vaccine,” he explains.

To protect against transmission, the hospitals use the “Education, Sanitation, and Vaccination” recommendations suggested by the County of San Diego and the San Diego mayor’s office, Uejo relays. “Those measures include sending notices out to our staff members containing critical information about the pathogen, disease risk factors, signs of illness, and reminders of proper contact precautions,” he says. The measures also include sanitizing bathrooms and waiting areas in the EDs with bleach solutions and offering the HAV vaccine to all Scripps staff members who work in the EDs.

Uejo adds that Scripps hospitals are in direct contact with county public health authorities regarding vaccine supply as well as outreach to patients. “Also, in conjunction with the county, we are sending our Scripps Medical Response Team out into the community to provide hepatitis A vaccinations to those who are considered at risk,” he says. “The county is providing us with locations and contact information to assist in these efforts.”

Ask About Travel

While San Diego is at the center of this latest HAV outbreak, Chan advises emergency providers in other cities to be on the alert for HAV as well. “When we focus on travel questions, we always ask questions about travel outside the country, but it may be worth asking patients about travel from other parts of the country that have an active outbreak,” he says.

Chan also advises frontline providers to stay aware of what is happening in their local public health agency. “The first case [of HAV] in your local community might not be at your hospital. It might be at another hospital, and the place that would know about that would be your local public health agency,” he says.

Editor’s Note: A tool originally developed in the midst of the Ebola outbreak has been adapted for use by frontline providers in the identification and management of patients with hepatitis A. The “Identify-Isolate-Inform” instrument is available, along with supporting research material, at: http://bit.ly/2ABEKLQ.

SOURCES

  • Ted Chan, MD, FACEP, FAAEM, Professor and Chair, Department of Emergency Medicine, University of California, San Diego School of Medicine, San Diego. Email: tcchan@ucsd.edu.
  • Craig Uejo, MD, Preventive Medicine Specialist, Scripps Health, San Diego. Phone: (858) 678-6963.