Hepatitis A in Indiana
On May 10, 2012, the Vanderburgh (Indiana) County Health Department issued a health alert regarding hepatitis A associated with a local restaurant. A person with hepatitis A had worked at the restaurant as a bartender, handling food and drinks, between April 20 and May 3, 2012, when the person would have been contagious. Because hepatitis A vaccine is useful in preventing hepatitis A only for 14 days after exposure, some of the people who were exposed did not qualify for vaccination. They were asked to seek medical care if they showed signs and symptoms of hepatitis A. However, those who ate at this restaurant between April 27 and May 3 had an opportunity to be immunized until May 17, 2012. As of May 14, 2012, more than 500 people had requested the vaccination from the health department.
Hepatitis A is a disease of the liver due to an infection with the hepatitis A virus (HAV). The virus causes inflammation of the liver. Symptoms of the disease include fatigue, abdominal pain, diarrhea, and jaundice -- a yellowing of the skin and the white of the eyes. The virus is transmitted from person to person through contaminated food or drink. While the disease is not very common in the United States, with only about 2,000 cases reported in 2009, hepatitis A is endemic -- meaning that it is found in abundance -- in several countries around the world, accounting for 1.4 million global cases annually.
On average, people who acquire hepatitis A may not know they are infected until symptoms appear 28 days after infection. This is known as the incubation time, and it can range between 15 and 50 days. A person who is infected can transmit the infection to others well before symptoms appear, about two weeks before jaundice or other symptoms are noticed. This is why the person working at the restaurant was able to work and may have exposed many people. Because these factors are known about hepatitis A, it is possible to set a range of dates for visitors of the restaurant, both in terms of when they could have been exposed and when the vaccine will be most effective for them.
The hepatitis A vaccine was developed in the early 1990’s and licensed for use in 1995. Since then, the vaccine has been recommended for children 1 year of age and older. Persons considered to be at a greater risk for infection or bad outcomes from infection include men who have sex with men, persons in institutional settings (e.g. hospitals or jails), persons with liver disease, and persons who use or abuse illegal drugs. People planning to travel to areas of the world where hepatitis A is endemic should consider being vaccinated before their departure. Since 2007, the hepatitis A vaccine has been recommended for use as prophylaxis (for the prevention of disease) for up to 14 days after exposure for individuals between 1 and 40 years of age. For persons older than 40 years of age and infants under one year of age, immune globulin (a solution of antibodies against hepatitis A and other pathogens) is recommended for prophylaxis.
When a case of hepatitis A is identified, public health authorities interview the person and determine if the person is at risk of infecting others. They are asked when the onset of symptoms was, and the person is deemed to have been infectious for 14 days before and seven days after symptom onset, a total of 21 days. They are then asked about their employment, hobbies, and activities in those 21 days. As it happened in Indiana, if the person is a food service worker, special steps will be taken to limit the spread of HAV in those who were in contact with the person or any food/drinks that he or she may have handled. This includes offering hepatitis A vaccine or immune globulin, as recommended, to exposed individuals. If more than 14 days have passed since exposure, then those who are exposed are counseled to seek medical care if they develop any of the signs and symptoms associated with hepatitis A.
Although cases of hepatitis A are rare in the United States, and outbreaks are even rarer, a single case in a person who can potentially expose scores of other people requires an intense response from public health. This is to contain the infection through the use of prophylaxis and to prevent similar exposures if more people are infected. As health authorities in Indiana have recently experienced, this response takes much time and many resources and can be of great social concern. In addition to observing proper hand washing and food handling procedures, food service workers should consider being vaccinated against hepatitis A.
 Hepatitis A exposure information from the Vanderburgh County Health Department, available at http://www.vanderburghgov.org/Index.aspx?page=2648
 “Official: 500 have sought vaccinations since Hepatitis A exposure at restaurant”, Evansville Courier & Press, published May 14, 2012, available at http://www.courierpress.com/news/2012/may/14/no-headline---ev_hepatitis/
 “What I need to know about hepatitis A,” National Digestive Diseases Information Clearinghouse, National Institutes of Health, available at http://digestive.niddk.nih.gov/ddiseases/pubs/hepa_ez/
 “Ask the experts: Hepatitis A,” Immunization Action Coalition