Immune Globulin
When you interviewed Anna B., she admitted that she had had mild diarrhea for a couple of days last week and had felt a little more tired than usual, but she didn't have any nausea, vomiting, or fever. She only gets paid for the hours she works, so she didn't report her illness to her supervisor.
You now have the results of Anna's blood tests. Her liver function tests are somewhat elevated, and she tested positive for IgM anti-HAV, indicating that she has newly acquired hepatitis A, although she had minimal symptoms.
Anna was also the foodhandler who you found preparing a sandwich with her bare hands, and she admits, "I don't always wash my hands real well if we get busy." Today is May 20. The epidemic has been dwindling, but Anna appears to be one of the last cases to have acquired hepatitis from James R.
This new information raises the question of what to do about people who may have been recently exposed to hepatitis A but do not yet have symptoms. In order to make a decisions about this, you should first review this module page on active and passive immunity. Pay particular attention to the CDC guidelines for post-exposure prophylaxis for hepatitis A.
The Decision to Give Immune Globulin
The decision to give immune globulin to all of the personal contacts and all of the patrons who may have been exposed to an infected food handler should not be taken lightly. Organizing an IG clinic is difficult, time consuming, very costly, and consumes large quantities of immune globulin, which is a precious resource. The decision depends on a judgment regarding the likelihood of exposure to patrons.
If you were convinced that Anna B. followed proper food handling and hygienic procedures, an IG clinic would not be justified, even if she were infected. However, since Anna B. did not follow procedures, the results of her blood tests are important in decision making. Since she was positive for IgM anti-HAV (indicating that she had hepatitis), an IG clinic is clearly warranted, but if her blood tests had been negative, an Ig clinic would not be necessary.
The results of her blood tests are important to decision making here, but what if she had refused give a blood sample? She can't be forced to provide a blood specimen, but she can be excluded from work. The course of action is critically dependent on an assessment of whether the situation presents an "imminent health hazard."
Alfred DeMaria, Jr., MD
Chief Medical Officer and State Epidemiologist,
Massachusetts Department of Public Health
(1:12)
Insights on IG Clinics
Christine Connolly's comments. (1:50)
News clip on a local IG clinic. (1:24)
Al DeMaria's comments. (1:02)
Alan Balsam's thoughts. (3:47)
The CDC has clear cut guidelines on post-exposure prophylaxis in people who may have been exposed to hepatitis A.
