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State of California—Health and Human Services Agency
California Department of Public Health

AFL 17-21
October 17, 2017

Hospital Emergency Departments, Hospital Infection Preventionists, and Hospital Administrators

California Hepatitis A Outbreak and Use of Hepatitis A Vaccine for At-risk Health Care Personnel including Health Care-based Environmental Services Staff

All Facilities Letter (AFL) Summary

The purpose of this AFL is to provide updated California Department of Public Health (CDPH) vaccination recommendations to health care facilities in light of constrained hepatitis A virus (HAV) vaccine supplies and review infection control recommendations for preventing HAV transmission. Other recommendations related to hepatitis A that are provided in AFL 17-13 remain in effect.

Currently, there is an ongoing HAV outbreak in California. Homeless populations and persons using injection or non-injection illicit drugs are considered at risk of exposure to HAV, particularly those in settings of limited sanitation. Use of adult hepatitis A vaccine to help control recent outbreaks has resulted in concerns that the supplies for adult immunization for the last quarter of 2017 could become limited. Therefore, CDPH recommends:

  • Healthcare facilities consult with their local health departments to identify which patients should receive hepatitis A vaccination.
  • Healthcare facilities follow their local health department’s guidance with regard to offering hepatitis A vaccination to health care personnel (HCP)

HAV transmission occurs person-to-person through the fecal-oral route, including contact with fecally-contaminated environments. Like norovirus, HAV can remain viable in the health care environment if surfaces are not thoroughly cleaned using a hospital-grade cleaner/disinfectant active against hepatitis A. Alcohol-based hand rubs may not be effective against hepatitis A. 

HCP are not considered at risk of HAV infection when routine infection control precautions are followed. Nevertheless, some confirmed cases of HAV reported in HCP may have been acquired while caring for patients with HAV infection or interacting in the infected person’s environment. Offering vaccination to HCP at risk of exposure when recommended by the local health department will further protect HCP from HAV infection.

When recommended by the local health departments, healthcare facilities should:

  • Offer hepatitis A vaccination to HCP who have ongoing, close personal contact with patients who have risk factors for HAV infection as defined by the local health department.
  • Offer hepatitis A vaccination to environmental services’ staff who clean HAV patient areas or restrooms used by patients or visitors who have risk factors for HAV infection, as defined by the local health department.

All healthcare facilities should:

  • Ensure appropriate cleaning of HAV patient areas with a hospital grade cleaner/disinfectant effective against hepatitis A. In areas with ongoing transmission of HAV, restrooms frequented by patients or visitors who have risk factors for HAV infection should be appropriately cleaned. Implement environmental cleaning methods similar to those used for norovirus (see resources below).
  • Use Standard precautions in the care of continent patients with HAV infection.
  • Use Contact precautions in addition to Standard precautions in the care of diapered or incontinent HAV patients.
  • Ensure HCP practice proper hand hygiene before and after patient care, after eating, and after using the restroom. Appropriate hand hygiene for HCP is hand washing with soap and running water for at least 20 seconds.
  • Ensure that HCP use employee-designated restrooms when available.
  • Provide post-exposure prophylaxis, which consists of hepatitis A vaccine and/or immune globulin, for any HCP who may have been exposed to HAV (see guidance in resources below) even if vaccination is not being recommended as pre-exposure prophylaxis for HCP. 

Title 8, California Code of Regulations, Section 3203 - Injury and Illness Prevention Program
Cal/OSHA requires that every employer establish, implement, and maintain an effective Injury and Illness Prevention Program (IIPP). The IIPP’s procedures for identifying and evaluating workplace hazards must include assessment of changing conditions to detect and address the introduction of new occupational safety and health hazards. The program must also include methods for correcting unsafe or unhealthy conditions in a timely manner, and providing hazard-specific employee training.

In an area with ongoing transmission, HAV should be addressed in the employer’s IIPP or other exposure control plan. Implement CDPH recommended control measures, as outlined above, including provision of hepatitis A vaccination, if recommended by the local health department. Monitor HCP adherence to recommended infection control precautions, including hand hygiene and standard/contact precautions, and provide feedback to improve HCP performance. The IIPP should specify which control measures apply to employees by job title or job tasks. Employers should bear the cost of occupational control measures necessary to protect their employees. 

Helpful Links and Documents

If you have any questions, please contact CDPH at 916-650-6400. Thank you for your efforts to protect HCP, including environmental services staff, working in California healthcare facilities from HAV infection.



Original signed by Christopher Howard for

Jean Iacino
Deputy Director

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