the outbreak , resource limitations such as budgetary constraints on availability of vaccine and staff have also created challenges . Though this is an “ outbreak ,” it has not yet been declared a public health emergency , so additional federal funding and resources are not readily available . The outbreak has also gone largely under the media radar , in part due to other medical concerns this time of year , including this taxing flu season .
Because of these challenges , we have had to be creative in our response . The idea of a “ mass vaccine ” campaign is likely to panic the general public unnecessarily , and send the “ worried well ” to get vaccinated , using up our limited supply of vaccine . Instead , we have approached this in a “ seek and find ” manner . We have sought out the most likely locations that we would find the population at risk , the homeless and PWUD , and brought vaccine to them . LMPHW has been vaccinating at homeless shelters and feeding sites , the LMPHW Syringe Exchange Program ( SEP ) and the Volunteers of America mobile SEP .
We even have a team of dedicated people ( a great thank you to Paul and volunteer Nancy Kern ) who have been vaccinating those in homeless encampments . We have been providing vaccinations to those in Louisville Metro correctional facilities and drug recovery locations in order to reach those at highest risk . We have also partnered with other local agencies , such as the University of Louisville and Kroger Little Clinic , to help provide vaccine to insured populations who may also be at risk due to their work with those at highest risk in the outbreak , for example homeless service providers , emergency medical service providers , correctional facility workers , police , firefighters , and medical personnel .
In these combined efforts to date , we have provided more than 4,000 hepatitis A and Twinrix vaccines . This is a great feat , considering in most of these locations , we may only provide a few vaccines in a given day . It has brought long hours of additional duties to the LMPHW staff , a staff who is incredibly dedicated , and I am thankful for that !
We were recently visited by the Center for Disease Control Epi- AID team to help evaluate our response so far and offer additional suggestions in our ongoing efforts . They were in awe of our efforts and results so far . However , the outbreak is far from over , and they have estimated that we will be dealing with this for at least six more months , unfortunately taking us into the Kentucky Derby season . Despite the best of efforts , these things just don ’ t go away quickly , and can even last for several years .
We at LMPHW are asking for your help as physicians as we continue to fight the spread of this outbreak . Here are some tangible things you can do to help improve our community response to this outbreak :
1 . Expand your differential diagnosis . Think of hepatitis A in your patient workup , particularly if they have jaundice or the outbreak risk factors for hepatitis A of homelessness or drug use .
2 . Order a hepatitis A IgM antibody test for confirmatory testing ( a hepatitis A total antibody does not help distinguish acute from prior infection or vaccination and should only be ordered to confirm immunity to HAV ). [ 2 ]
3 . Take a good history . Find out if infected patients have been in contact with anyone with hepatitis A , exactly when symptoms began ( particularly jaundice , as this helps us to determine their infectious period in which they could have spread the virus to others ), and where they have been living ( i . e . homeless , correctional facilities or other congregate settings ). Do they use drugs ? Do they have other co-morbid diseases such as hepatitis B or C that may put them at risk for severe outcomes ?
4 . Promptly report any suspected or laboratory confirmed case of hepatitis A to LMPHW . Call communicable diseases staff at ( 502 ) 574-6675 or fax EPID-200 form to ( 502 ) 574- 5865 . All communicable diseases are reportable to the health department ( acute hepatitis A within 24 hours ) [ 6,7 ] and the sooner we receive this information , the more time we have to contact the case patient , identify his / her contacts , and provide post-exposure prophylaxis , further preventing disease . Please don ’ t rely on someone else to do this . The hospital lab reporting is often delayed . You , who are caring for the patient , are the first to suspect and often the first to respond to the positive lab result . The infection prevention nurse at your hospital can help with the reporting . Please consider using our epidemiology data collection tool for obtaining historical information that can assist us at LMPHW with the outbreak investigation .
5 . Recommend hepatitis A vaccination to your patients ! As a routine preventive health measure , HAV vaccine is covered by insurance . It is an incredibly effective vaccine , with 96 – 100 percent seroconversion within four weeks of vaccination . Even one dose of vaccine can be effective for up to 10 years and completion of the two-part vaccine series confers 20 or more years of immunity . [ 1 ]
If your clinical environment ( clinic , urgent care or emergency room ) does not already have HAV vaccine on hand , consider purchasing it for those wishing to be vaccinated or those at risk .
If you do not have vaccine in your clinical environment , refer patients to local pharmacies for vaccination .
The Advisory Committee on Immunization Practices ( ACIP ) recommends that the following persons be vaccinated against hepatitis A :
• All children at age one year ,
PUBLIC HEALTH
• Persons who are at increased risk for infection ,
• Persons who are at increased risk for complications from hepatitis A , and
• Any person wishing to obtain immunity ( protection ). [ 2 ] ( continued on page 10 )
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