Communicable Disease & Epidemiology

KCHD Response to Hepatitis A Outbreak

From August 1, 2016 to October 31, 2018 there have been 899 cases of hepatitis A reported in residents of 34 Michigan counties, with most of the cases occurring in southeast Michigan. Of those cases, 722 (80.3%) have been hospitalized and 28 (3.1%) have died.* Transmission appears to be through direct person-to-person spread and illicit drug use. Individuals with a history of injection and non-injection drug use, homelessness or transient housing, and incarceration are thought to be at greater risk for infection. Recently, the Kent County Health Department was notified of a fourth case in a Kent County resident that is linked to this outbreak. Because this case was diagnosed within 100 days of a previous case, the Michigan Department of Health and Human Services now includes Kent County as part of the state’s outbreak jurisdiction. This web page is intended to provide information and resources to assist community partners in preventing the spread of infection if additional cases are identified.

Hepatitis A Overview

Hepatitis A is a serious, highly contagious liver disease caused by the hepatitis A virus (HAV). HAV is found in the feces (poop) of people with hepatitis A. You can get hepatitis A by eating contaminated food or water, during sex, or just by living with an infected person. Illness can appear 15-50 days after exposure and you can be sick for several weeks. In some cases, people can die. Although not all people infected with hepatitis A experience illness, symptoms can include:

• nausea and vomiting
• belly pain
• feeling tired
• fever
• loss of appetite
• yellowing of the skin and eyes
• dark urine
• pale-colored feces (poop)
• joint pain

What can the public do to protect themselves and their communities?

• Wash hands after using the restroom and before eating or preparing meals for yourself or others
• Get vaccinated against hepatitis A. Vaccine supply is currently limited, so please check with your health care provider about availability.
• Use your own towels, toothbrushes, and eating utensils
• Do not have sex with someone who has HAV infection
• Do not share food, drinks, drugs, or smokes with other people
• If you think you may have hepatitis A, see your medical provider
• If you have hepatitis A, please cooperate with your local public health to help protect others

Information for Specific Groups

Health Care Providers (HCPs)

Maintain a high index of suspicion for Hepatitis A infection in high-risk individuals who present with nausea, anorexia, fever, malaise, abdominal pain or jaundice.  Individuals in the following groups are at the highest risk of transmission:

• Persons with a history of substance use
• Persons currently homeless or in transient living
• Men who have sex with men (MSM)
• Persons incarcerated in correctional facilities
• Food handlers
• Healthcare workers
• Persons with underlying liver disease
• Persons who are in close contact with any of the above risk groups

When cases are suspected in a high-risk patient, they should be reported immediately to KCHD by calling the Communicable Disease and Epidemiology Unit at 616-632-7228. The ability for public health to contact the patient prior to leaving the health care facility can be key to preventing missed opportunities to implement control measures.

Suspect patients should be tested for serum aminotransferase levels to assess liver function. While Hepatitis A IgM is confirmatory for diagnosis, providers are encouraged to order a complete serology panel (Hepatitis A, B and C) as information garnered from these tests can be informative to the public health investigation.

There is currently a national shortage of adult Hepatitis A vaccine as US manufacturers have been unable to meet increased demand in the US and globally. HCPs with adequate vaccine supply are encouraged to promote the delivery of vaccine to those in high-risk groups. The Michigan Department of Health and Human Services has recommended postponing the administration of the second dose of Adult Hepatitis A vaccine to ensure vaccine supply for the high-risk groups.

Food Service Establishments and Food Handlers

• All food employees must practice diligent handwashing and good personal hygiene
• Food employees shall thoroughly wash their hands and arms with soap and warm water for at least 20 seconds; thoroughly rinse with clean running water and properly dry their hands and arms.
• Ensure handwashing signs are posted in the appropriate locations.
• Use utensils or gloves to eliminate bare hand contact with ready- to-eat food.
• Thoroughly and continuously disinfect the facility and food areas. If hepatitis A is suspected or confirmed in your facility, disinfect using the cleaning guidelines below.

Employee Responsibilities

• Notify the Person in Charge if you have been diagnosed with a Hepatitis A infection.
• You should not work with food or utensils if you are sick with acute gastrointestinal illnesses. Acute gastrointestinal illness is diarrhea, either alone or with vomiting, fever or abdominal cramps.

Person in Charge Responsibilities

• REPORT to the Kent County Health Department when a food employee is diagnosed with hepatitis A. Call (616) 632-7228.
• EXCLUDE a food employee from the food facility if diagnosed with Hepatitis A. Only the Kent County Health Department can clear an excluded employee to return to work.
• RESTRICT a food employee from working with exposed food, clean equipment, clean linens, clean utensils and unwrapped single-service articles if the food employee is suffering from symptoms of acute gastrointestinal illness or experiencing persistent coughing, sneezing or nasal discharges. Restrictions can be removed by the Person in Charge when the food employee states they no longer have symptoms of illness.

Facilities that Service High-Risk Individuals

(e.g. Substance Use Treatment, Homeless and Housing Assistance Providers, Food Pantry Providers)

• Assess clients for potential signs of hepatitis A infection during and after intake
  • Screen clients for fever, fatigue, nausea, loss of appetite, yellowing of skin or eyes, stomach pain, vomiting, dark urine, pale stools and diarrhea.
  • Refer people with signs of hepatitis A for medical evaluation.
  • Report suspected cases to the Kent County Health Department at 616-632-7228
• Remind staff and clients of the importance of handwashing with soap and warm water after using the bathroom and before preparing, serving or eating food. Waterless hand sanitizers are not effective against hepatitis A.  Consider posting hand washing posters in bathrooms and kitchens.
  • English Handwashing Sign
  • Spanish Handwashing Sign
• Ensure routine and consistent cleaning of bathrooms used by staff and clients. If hepatitis A is suspected or confirmed in your facility, follow the Environmental Cleaning guidelines listed below.

Environmental Cleaning Guidelines

Effective Disinfection for Surfaces Exposed to Hepatitis A

Chlorine Bleach: Mix the chlorine solution immediately before use and use it promptly.  Leave the solution on the surface you are cleaning for one minute and then rinse with clean water.

5000 ppm: 1 and 2/3 cups of bleach in 1 gallon of water.  This can be used on stainless steel, items that have contact with food, tile floors, non-porous surfaces, counters, sinks and toilets.

Other Disinfectants: If a surface will be damaged by the use of bleach, other products that are effective against hepatitis A can be used.  Some examples of products that are labeled as effective against hepatitis A include VIRKON and KLORSEPT.

Proper Cleaning Methods and Handling of Cleaning Agents

• Wear rubber disposable gloves and protect your clothing when preparing/handling chemical products and while cleaning.
• Use chemicals in well-ventilated areas
• Avoid mixing chemicals
• Prevent chemical contact with food while cleaning
• Handle vomit or feces spills as little as possible. Clean up visible debris with disposable absorbent materials (paper towels or other disposable cloths).  Consider covering the spill with disposable towels or cloth while cleaning to avoid spreading germs to other surfaces.
• Manage all waste safely and dispose in a secure trash container
• Always wash your hands after handling any contaminated material, trash or waste

* Updated statistics and additional resources are available on the Michigan Department of Health and Human Services website at www.mi.gov/hepatitisAoutbreak