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Hepatitis A

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					Hepatitis A



 Rich Kaplan MD,MS,FACEP
           CHI CHI’s
As of 11/20/03:
 555 people with HA
 13 food service workers

 3 deaths

 The green onions




        MMWR 2003;52:1155-57
                 CHI CHI’s
Majority of ill patrons were exposed
during a 3-day period in early October
Genetic sequence was very similar to
viral sequences in HA outbreaks in :
   Tennessee, Georgia, North Carolina (9/03)
        Linked epidemiologically to green onions
           CHI CHI’s
Mixing of uncontaminated and
contaminated green onions in a
common bucket for 5 days with ice
Serving contaminated items with a
relatively long shelf life to a large
proportion of patrons over several days
               Case
34 y.o. male presents to ED
2 weeks after returning from trip to India
6 days of :
 Anorexia
 Vomiting
 Malaise
 Fatigue
 Dark urine
                  Case
ALT 7330
Bilirubin 8
IGM Ab HA positive




       Craig AS NEJM 2004;350:476-81
            Hepatitis A
Fecal-oral
Blood, liver, bile, stool
Greatest period of infectivity
   2 week period prior to jaundice
Marked decrease in viremia, fecal
shedding and infectivity at time of
icterus
         Hepatitis A
Fecal contamination of water supply
Contaminated food
                Hepatitis A
Incubation 2-7 weeks
   Average 28 days
Preicteric
   4-14 days
        Weakness, malaise, anorexia, nausea, vomiting
        May have RUQ pain
        Loss of taste “for smokes”
Dark urine frequently heralds icterus
Jaundice in the minority
              Hepatitis A
Variable convalescence
Weakness and malaise may last for months
ALT rises late in the incubation phase, just
before the onset of symptoms
Symptomatic period- 4-5 weeks after
exposure, Anti-HAV IgM begin to rise
   Implies recent infection
   Undetectable after 4-5 months
Later- Anti-HAV IgG –
   Detectable for life
              Evaluation
AST
   Cytoplasmic enzyme
   Released with hepatocellular injury
   Normal value excludes hepatocellular disease
Transaminase > 10X suggests viral or toxic
injury
   Transaminase elevations 2-3 X normal with AST>
    ALT suggest alcoholic injury
Elevated AP and bilirubin
   Intrahepatic or extrahepatic obstruction
           Outcome
~ 100 deaths in US/year from fulminant
HA infection
1/3 of U.S. population has serologic
evidence of prior HA infection
           Management
IVF
Vit K, if needed
Immune globulin-
   Of no help if patient has contracted
    hepatitis
           Exposure
Risk of contracting Hepatitis A:
 Household and sexual contacts of persons
  with HA
 Staff and attendees at day care

 Staff and contacts at custodial care
  institutions
             HA Vaccine
Not approved if < 2 y.o.
Not studied in pregnancy- likely to be safe
Havrix
Vaqta
2 dose schedule:
   Neutralizing Ab in >94% one month after 1st dose
   2nd dose in 6-18 months
          HA Vaccine
To all high-risk persons > 2 y.o.
Travelers to countries with high or
intermediate rates of disease
MSM
Users of illicit drugs
Chronic liver disease
Persons using clotting-factor concentrates
Lab personnel who work with HA virus
      Immune Globulin
Travel to countries with high or
intermediate rates of disease within 2
weeks
Children < 2 y.o. who will be traveling to
countries with high rates of disease
Postexposure prophylaxis within 14
days of exposure
   Prevents disease in > 85%
    Immune Globulin
Derived from pooled human serum
Does not transmit HIV
0.02 cc/kg IM immune globulin
 ASAP within 2 weeks of exposure
 Casual contacts do not need to be treated

				
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posted:4/25/2013
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