Case Study: Hepatitis A Cluster with Unknown Source

FACILITATOR VERSION

Objectives
 List the steps in an outbreak investigation
 List sources of data within the local health department
 Interpret surveillance data
 Choose an appropriate public health response based upon interpretation of
surveillance data
 Define the Incident Command System and identify triggers for activating it
 Create a table shell for a line listing

Instructions
Convene your local Epi Team, and provide each Epi Team member with a copy of the
case study (participant version). Choose one person to act as the facilitator. This person
should use the facilitator’s version of the case study.

Guidance for facilitating the case study can be found on page 3. The case study begins on
page 4.

Time Allotted: 1.5 hours

Background Materials
The following trainings, found at the North Carolina Center for Public Health
Preparedness Training Web site (http://nccphp.sph.unc.edu/training/), are recommended
for Epi Team members without prior outbreak investigation experience. They can be
viewed prior to completing the case study.

1. An Overview of Outbreak Investigations (FOCUS on Field Epidemiology

Volume 1, Issue 1)
2. Federal Public Health Surveillance and Analysis of Surveillance Data (E is for
Epi Session 4.2)
3. Case Finding and Line Listing: A Guide for Investigators (FOCUS on Field
Epidemiology Volume 1, Issue 4)
4. Incident Command System (ICS) for Public Health

1
Resources
Centers for Disease Control and Prevention. Hepatitis A Fact Sheet. 2007. Available at
http://www.cdc.gov/Ncidod/diseases/hepatitis/a/fact.htm.

Centers for Disease Control and Prevention. Update: prevention of Hepatitis A after
exposure to Hepatitis A virus and in international travelers. MMWR Morb Mortal Wkly
Rep 2007;56:1080-1084.

Heymann DL, ed. Control of Communicable Diseases Manual. 18th ed. Washington DC,
USA: American Public Health Association; 2004.

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 Guidance for Facilitators

Goal
The goal of working through a case study is active learning through engaged
participation by each Epi Team member.

Role of Facilitator
Reminder
As a facilitator, your job is to:
As the facilitator, you are the
 Guide the Epi Team through the case study only team member with the
 Involve every team member suggested answers to
 Moderate discussion drawing on the discussion questions and
suggested answers to discussion questions activities. Other Epi Team
 Ensure key points are covered for each members have only the
question scenario updates and questions.
 Keep an eye on the clock

Active Participation
All team members should be involved in the discussion. One strategy for getting
everyone involved is to have team members take turns reading aloud and attempting to
answer questions. Facilitators should:
1. Ensure that the room set-up encourages group participation, ie. everyone seated
around a table or chairs in a circle.
2. Select one team member to read aloud the first update and the first question.
3. Encourage that team member to attempt to answer the first question (regardless of
his/her background).
4. Encourage other team members to add information and discuss the question.
5. Use the suggested answers to cover key point(s) that were not addressed during
the discussion.
6. Have the next person read aloud the next update or question and begin an
attempted answer as above – move in sequence to include everyone.
Follow this sequence until the scenario is completed, pacing discussion in order to finish
the entire scenario.

Facilitation Tips
 Read the case study ahead of time so you are prepared for the discussion.
 Always remember the learning objectives for the case study.
 If one person is dominating the conversation, call on other team members.
 If someone in the group is not participating, ask his or her opinion.
 When someone asks a question, encourage other team members to provide the
answer.
 Do not spend too much time providing the suggested answers to the group.
Instead, encourage the team to share their opinions about possible responses to the
given scenario.

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JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

3 confirmed cases of
hepatitis A reported.

Background - Thursday, August 16th

It’s your second week working at the county health department in County K, North
Carolina. When you arrived at work this morning, you had the following voicemail
message from a communicable disease nurse at the county hospital.

“I’m just calling to let you know that we’ve had 3 patients test positive
for hepatitis A in the last week. This is pretty unusual, so I’m afraid it
might be part of something larger. Call me back at 987-6543.”

Being new to the county, you are unfamiliar with local incidence rates of hepatitis A
and are not sure what to do next. You wonder whether it is appropriate to initiate an
outbreak investigation.

Question 1: What is the first step in an outbreak investigation?

Suggested answer: The first step in an outbreak investigation is to verify the diagnosis
and confirm the outbreak. In order to verify the diagnosis you need to get information
from each patien, such as description of symptoms, date of symptom onset, relevant
medical history, and demographic information. You would also get more information
about the type of laboratory tests that were conducted and ask for copies of the
laboratory results. Next, you need to confirm the outbreak. An outbreak is defined as an
increase in the observed number of cases of a disease compared with the expected
number of cases among a specific group of people in a given place over a particular
period of time.

At this time, you may also notify other members of your local Epi Team of the possible
hepatitis A cluster.

Question 2: How could disease surveillance data be useful during this investigation? Why
is it important to perform surveillance on diseases like hepatitis A?

Suggested answer: Surveillance data can give you information about trends in hepatitis A
incidence and help you determine whether an outbreak is occurring. To confirm the
existence of an outbreak, compare the usual rate of disease in a given population with the
observed rate during the possible outbreak. The usual rate of disease is often obtained
from surveillance data.

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JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

3 confirmed cases of
hepatitis A reported.

It is important to perform surveillance for other reasons besides detecting outbreaks.

Surveillance data can also be used to:
 Monitor risk factors of disease;
 Assess disease burden;
 Identify infected persons requiring counseling and medical follow-up;
 Identify contacts of infected people requiring counseling and/or post-exposure
prophylaxis;
 Detect changes in health practice;
 Assess the safety of drugs or procedures;
 Identify research needs;
 Facilitate planning of public health interventions;
 Respond to media inquiries; and
 Evaluate public health control measures.

Question 3: Where should you look for baseline surveillance data about hepatitis A in
County K and throughout North Carolina?

Suggested answer: [Facilitator’s note: There are several possible sources of surveillance
data, and Epi Team members should discuss the specific location of this information in
their own health department.] Some health departments have annual reports with
communicable disease surveillance data. Since hepatitis A is a reportable disease, it
should be included in these surveillance reports. The epidemiologist and/or
communicable disease nurse on your Epi Team should know how to access these data.
State level surveillance data about hepatitis A can be found on the North Carolina
Communicable Disease Control Branch Web site
(http://www.epi.state.nc.us/epi/gcdc.html). Documents containing state-level surveillance
data from 1991 to the present are listed under “Statistics”. There are also some reports
with county-level data on the Web site.

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JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Update - Baseline Surveillance Data

From your health department’s records, and the NC Communicable Disease Control
BranchWeb site, you gather the following information about the total number of cases
of hepatitis A in North Carolina and your county over the past several years.

Hepatitis A Cases
Year NC County K
2001 94 9
2002 41 6
2003 51 1
2004 84 14
2005 49 2
2006 118 1

Question 4: Based on this information, do you think the 3 cases in your county represent
an outbreak?

Suggested answer: Yes, the 3 cases probably indicate an outbreak. This many cases in
your county in the same week is certainly an increase over the expected number of cases
since County K averages between 5-6 cases of hepatitis per year and there were less than
3 cases per year for 3 of the past 6 years.

Question 5: At this point, should you contact any other public health agencies? If so,
which ones?

Suggested answer: Yes, you should report the hepatitis A cases. Hepatitis A is reportable
by law within 24 hours of the report, and all communicable disease outbreaks (whether a
reportable disease or not) must be reported. Begin by contacting the NC Communicable
Disease Control Branch to notify them of the outbreak, and then contact your Public
Health Regional Surveillance Team (PHRST). If your health department does not have
enough resources to conduct an outbreak investigation, the PHRST and/or
Communicable Disease Control Branch should be available to assist. You should also
meet with the rest of your health department’s Epi Team to share information and plan
next steps. Finally, you probably want to notify other North Carolina counties by posting

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 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

information about the hepatitis cases on the NC Health Alert Network (HAN). If any of
the 3 cases live in another county, it would be wise to contact that local health
department directly.

Update - Friday, August 17th

You contact the NC Communicable Disease Control Branch and your PHRST to ask
for assistance investigating this possible outbreak. The earliest someone will be able
to come to County K to assist you is in 2-3 days. You are to continue with the
outbreak investigation in the meantime.

Question 6: What do you know about hepatitis A that will help you in your investigation?
Complete the chart below with disease information. Hint: You do not need to memorize
all of this information. Instead, consult the Control of Communicable Diseases Manual.

Hepatitis A Facts

Symptoms

Incubation Period

Mode of Transmission

Duration of Illness

Diagnosis

Treatment

Other

Suggested answer:

Symptoms Abrupt onset of fatigue, loss of appetite, nausea, diarrhea, and

fever followed a few days later by jaundice

Incubation Period Average: 28 days, Range: 15-50 days

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JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Mode of Transmission
Usually spread by putting something in the mouth that has been
contaminated by the feces of an infected person (fecal-oral
transmission)
Sexual transmission
Foods associated with hepatitis A transmission include raw
shellfish and uncooked fruits and vegetables

Duration of Illness <2 months, but may be up to 6 months

A person can spread hepatitis A one week before symptoms
appear and during the first week of symptoms.

Diagnosis Blood testing for IgM antibodies is required for confirmatory

diagnosis; otherwise not distinguishable from other viral
hepatitides

Treatment No specific treatment

Other Children may be asymptomatic

Vaccine available for prevention
Vaccine or immune globulin (IG) used for post-exposure
prevention

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 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Update - Afternoon of August 17th

You call the communicable disease nurse back and ask her questions about the cases.
She informs you that one person is a 58 year-old male who lives on a farm in a remote
part of the county, and that the other 2 cases are adults who visited the same farm
from July 1-3. Besides their connection to the farm, the nurse has not identified any
other common factors among the cases.

You contact the farm owners and arrange to visit the farm tomorrow. Here is a
summary of the information about the 3 cases. All 3 have positive IgM antibody
results for hepatitis A.

Case #1: 58 year-old male, onset of fatigue, fever, and abdominal pain on July 15th,
jaundice on July 18th.

Case #2: 45 year-old male, onset of fatigue, loss of appetite, vomiting, and nausea on
August 1st, followed by jaundice on August 3rd.

Case #3: 39 year-old female, onset of fever, nausea and loss of appetite on July 29th,
followed by jaundice on August 2nd.

Question 7: After verifying the diagnosis and confirming the outbreak, what are the next
steps that you should take in this outbreak investigation?

Suggested answer: The next step is to define a case, and conduct case finding. A case
definition provides a standard and simple way to determine who should be considered a
case and who should not. Case finding strategies are important to control the outbreak
and identify people who may need treatment. One early case finding strategy is to
interview the confirmed cases and get names of their contacts.

Question 8: Do you recommend any public health control measures? If so, please
describe appropriate control measures.

Suggested answer: For hepatitis A, control measures include identifying and removing
the source of the outbreak, administering vaccine and/or immune globulin (IG), and
providing education about prevention of future outbreaks.

The process of identifying and removing the source of the outbreak will begin with your
visit to the farm, where you will probably collect environmental samples. If the farm sells

9
 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

produce or meat, you may work with the NC Department of Agriculture to recommend
appropriate control measures (e.g. stop sale of farm produce).

The Advisory Committee on Immunization Practices (ACIP) recommends the following

postexposure prophylaxis for unvaccinated persons as soon as possible after exposure:
 For healthy persons aged 12 months-40 years, single-antigen hepatitis A vaccine at
the age-appropriate dose is preferred.
 For persons aged >40 years, IG is preferred; vaccine can be used if IG cannot be
obtained.
 For children aged <12 months, immunocompromised persons, persons who have had
chronic liver disease diagnosed, and persons for whom vaccine is contraindicated, IG
should be used.
There is no documentation of vaccine efficacy if administered >2 weeks after exposure.
Consult the NC Communicable Disease Control Branch at the Division of Public Health
for recommendations specific to the situation.

It is not too early to prepare educational materials for the general public about
prevention of hepatitis A. Your health educator or public information officer should be
preparing these materials, as well as drafting a possible press release about the current
outbreak based on the information you know so far.

Activity
Defining a case is an important step in an outbreak investigation. Case definitions provide
a simple, uniform way to determine who should be considered a case and who should not.
As a team, decide upon an initial (working) case definition. Keep in mind that your case
definition will change as you obtain more information. A case definition should always
include both clinical information and elements related to person, place, and time.

Clinical Information (e.g. disease signs and

symptoms, lab results)

Person

Place

Time

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 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Suggested answer: At the beginning of an outbreak, a case definition may be general. It

is important to remember that a case definition may change as more information is
gathered during an outbreak. The following is an initial definition for a suspect case. A
confirmed case would also have a positive IgM antibody test for hepatitis A.

Clinical Information (e.g. disease Jaundice and/or elevated serum aminotransferase levels
signs and symptoms, lab results) AND at least two of the following symptoms: fatigue, fever,
loss of appetite, nausea, vomiting, or diarrhea

Person Any person

Place Associated with Farm A

Time With onset of symptoms between July 1 and present*

*Note that the date range for the case definition may vary, and that the case definition
may be expanded to include symptomatic contacts of confirmed cases.

Update - Saturday, August 18th

Your health director tells you that she is activating the health department’s Incident
Command System or ICS to respond to this outbreak.

Question 9: What is the purpose of ICS?

Suggested answer: ICS, or Incident Command System, is a management and

organizational tool used to prepare for and respond to emergencies. ICS provides all
responders--public health, fire, police, and emergency management—with a common
language and structure. ICS can be used in any stage of incident management, and
becomes increasingly useful in situations that involve more than one agency or more than
one jurisdiction. ICS is scalable, so it can be adapted to the size of the event.

Increasingly health departments are encouraged to use ICS to respond to more

traditional disease outbreaks to gain experience working within the ICS framework.

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 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Group Brainstorm
Choose one member of your Epi Team to record responses on a flip chart. As a group,
discuss the following question.

Question 10: Generally, what are some triggers for activating ICS in your health
department?

Suggested Answer: Triggers for activating ICS may include:

 Disease outbreaks, particularly those involving cases in multiple states or
jurisdictions;
 Acts of terrorism or bioterrorism;
 Incidents affecting populations with language or cultural differences;
 Extreme shortage of resources following a disaster;
 High media demand situation;
 High risk of life and property situations; or
 Incidents involving several agencies with on-scene responsibility

Update - August 19th

An Epidemic Intelligence Service (EIS) officer from the NC Communicable Disease
Control Branch comes to your health department to help with the outbreak
investigation. Together you, your environmental health specialist, and the EIS officer
visit the farm implicated in the outbreak where the index case lives with his wife and
child. The farm has a greenhouse and a fruit and vegetable garden and they
occasionally sell their produce at local markets. However, the farm owner says no
produce has been sold at the market since early April.

The farm is adjacent to a popular state park and it has a camping area away from the
main house where hikers often stay, sometimes without the knowledge of the owners.
The camping area is near a stream that runs through the property, and is downhill from
the house. In addition to the stream, there is also a spring that provides water to the
house, as well as to spigots used to irrigate the gardens and a hose near the camping
area. The septic tank sits directly over the spring water that is used in the house and
greenhouse (see diagram). The team decides to take water samples.

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 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Question 11: If you were the environmental health specialist, what water
sources/environmental specimens would you collect for hepatitis A testing?

Suggested answer: You should test the water supply at several points, including the
stream, spring, spigot, and overflow hose. You should also test water in food preparation
areas, bathroom facilities, and areas used for growing produce. It is always a good idea
to contact the North Carolina State Laboratory of Public Health for specific instructions
about the type of samples to collect.

Question 12: Should you offer hepatitis A vaccine and/or immune globulin (IG) to the
wife and child of the farm owner? Why or why not?

Suggested answer: Because the disease onset date for the 58 year-old man was July 15th,
it is likely that the wife and child were exposed to hepatitis A more than 2 weeks ago.
There is no documentation of vaccine efficacy >2 weeks after exposure. However, it may
be advisable to offer IG to the wife and/or child. You should consult with the NC
Communicable Disease Control Branch for guidance specific to this situation.

13
 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

Health department
requests assistance
from PHRST and state
health department.

3 confirmed cases of
hepatitis A reported.

Question 13: Are you concerned that the produce grown on the farm could be a source of
hepatitis A transmission? Why or why not? If so, do you make any recommendations
about the produce?

Suggested answer: Hepatitis A has been transmitted via raw fruits and vegetables
contaminated with fecal matter. If the produce was contaminated directly by an ill
person, or through contact with the septic system, it could be a source of disease
transmission. The NC Department of Agriculture and Consumer Services is the
appropriate agency to make recommendations about the produce. It is probably safest for
the produce to be destroyed; at the least, it should not be sold at local markets.

Update: Later on August 19th

Together with the EIS officer, you interview the owners of the farm about people that
have visited their property. Since the average incubation period of hepatitis A is
almost a month long, you ask them about any visitors since June 1st. They admit to not
knowing all of their visitors, and having very little information about some of them
since there is no registration system for people camping on the property. Here are your
notes from that conversation:

June 12 – Joy and Steve from New Jersey (stayed for about 3 days)
June 15 – young guy (mid-20s) from Statesville, NC
June 16 or 17 – Ann and Alice Bennington from Oakwood, Virginia (stayed 2 nights)
June 24 or 25 – Brian Hack
July 1 – Pam, Linda, Jeff, Bernice, and Marcus from Modesto, California (stayed for 1
week)
July 3 – several hikers, names unknown
July 10 – Clarence and Jen from Wilmington, NC (stayed for 1 night)
July 22 – Bobby Cunningham
July 24 – three or four hikers (stayed for 1 night)
July 29 – Roy and Sheryl from Richmond, Virginia (stayed 2 nights)

You begin case finding activities on Monday, August 20th.

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JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

The three cases Health department Sept. 10, 19 cases

visited the same requests assistance Health Epi Team performs associated with outbreak.
farm July 1-3. from PHRST and department case finding activities. Sept. 20, Abatement
DPH. visits farm. Order issued.

3 confirmed cases of Water tests

hepatitis A reported. Health director positive for HAV
activates ICS.

Question 14: You would like to interview these contacts to find out if they’ve been sick.
What are some strategies that you can use to find these individuals?

Suggested answer: It will be difficult to find all of these people. For the individuals with
a full name and city of residence, you can look them up in the phone book. If you get in
touch with anyone, you can ask them for the names of others who stayed at the farm
during the same time. However, it may be impossible to track down everyone with so
little information. Because of this, it is important to enhance passive surveillance by
posting notices on the NC Health Alert Network, or HAN, (http://www.nchan.org) and the
national Epi-X network (http://www.cdc.gov/mmwr/epix/epix.html). An Epi-X alert is
appropriate in this situation since you know some of the campers were from states other
than North Carolina. In most situations, the state epidemiologist will post the Epi-X alert.
The HAN and Epi-X notices should provide your case definition and advise other public
health professionals to report suspect and confirmed cases of hepatitis A to your health
department.

You should also remind local healthcare providers and laboratories to report possible
cases. Many health departments use blast fax or email notification to contact local health
care providers.

Update: August 20th

The North Carolina State Laboratory of Public Health (SLPH) confirms that the water
samples taken from a spigot outside the farm house contained fecal coliform bacteria.
Spring water samples are being sent to the Department of Environmental Sciences and
Engineering at the University of North Carolina School of Public Health, where the
samples will be tested for hepatitis A virus (HAV) using PCR techniques.

Question 15: What actions should you take now?

Suggested answer: Although you may have already recommended some disease control
measures, the laboratory confirmation of fecal coliforms in the spring water should lead
to stricter control measures. For example, you might issue a boil water advisory for
residents of the farm, recommend the use of bottled water, prohibit the sale or sharing of
produce grown on the property, destroy crops, eliminate the spring as a potential water
source, defer planting for at least 6 months, and limit visits to the farm by anyone without
documented immunity to hepatitis A.
 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

The three cases Health department Sept. 10, 19 cases

visited the same requests assistance Health Epi Team performs associated with outbreak.
farm July 1-3. from PHRST and department case finding activities. Sept. 20, Abatement
DPH. visits farm. Order issued.

3 confirmed cases of Water tests

hepatitis A reported. Health director positive for HAV
activates ICS.

If you have not done so already, it would be important to notify the NC Division of Water
Quality about the presence of fecal coliforms in a drinking water source.

Since the state park is next to the farm, it would be a good idea to notify the park of the
investigation results.

This is an appropriate time for your health educator and/or public information officer to
provide education to the farmer and his family about preventing transmission of hepatitis
A. You may also want to use this opportunity to educate health care providers and the
general public.

Update: September 10th

On August 26th, you received confirmation of hepatitis A virus in the spring water
samples.

You have not had much success tracking down and interviewing visitors to the farm.
However, you receive several reports of suspect cases through other health
departments, private health care providers, and laboratories. Through all of these
methods, you identify 16 additional cases; 5 men and 11 women. Onset dates range
from July 5th to September 1st. These additional cases live in North Carolina, Virginia,
and California. None of the cases had received the hepatitis A vaccination prior to their
visit to the farm. There are now a total of 19 cases associated with this outbreak.

Question 16: How should you organize information about the cases?

Suggested answer: After you have created the case definition and conducted case finding,
you need to tabulate and orient the data regarding person, place, and time. In other
words, you need to create a line listing.

Group Brainstorm
Choose one member of the Epi Team to record responses on a flip chart. As a group,
discuss the following question.
 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

The three cases Health department Sept. 10, 19 cases

visited the same requests assistance Health Epi Team performs associated with outbreak.
farm July 1-3. from PHRST and department case finding activities. Sept. 20, Abatement
DPH. visits farm. Order issued.

3 confirmed cases of Water tests

hepatitis A reported. Health director positive for HAV
activates ICS.

Question 17: The Incident Commander has requested that your Epi Team create a line
listing of the 19 cases. What information would you include in the line listing?

Suggested Answer: A line listing should include identifying information (e.g. name,
contact info), demographic information (e.g. gender, age, occupation), clinical
information (e.g. signs and symptoms, dates of onset, laboratory tests and results,
vaccination history), and risk factor information (e.g. date of farm visit, food consumed
on the farm, water source, etc.) The specific variables used in a line listing may vary by
outbreak. A partial example of a line listing table is shown below. The actual line listing
would probably include additional information about possible sources of exposure.

Name S D Onset J F N V D App Fat Vax IgM Date Water

e O Date of Source
x B Farm at Farm
Stay

DOB = Date of Birth, J = Jaundice, F = Fever, N = Nausea, V = Vomiting, D = Diarrhea, App =

Loss of Appetite, Fat = Fatigue, Vax = Hepatitis A Vaccine, IgM = IgM antibodies to hepatitis A
virus
 AUGUST
JULY 16 17 18 19 20 21 22 23 24 25 26 SEPT

The three cases Health department Sept. 10, 19 cases

visited the same requests assistance Health Epi Team performs associated with outbreak.
farm July 1-3. from PHRST and department case finding activities. Sept. 20, Abatement
DPH. visits farm. Order issued.

3 confirmed cases of Water tests

hepatitis A reported. Health director positive for HAV
activates ICS.

Conclusion: September 30th

Thanks to your efforts, the outbreak appears to be contained. All of the people with
hepatitis A have either recovered or are recovering, and no additional cases have been
reported. After consulting with the NC Department of Agriculture and Consumer
Services, the health director issued a declaration and abatement order to the owners of
the farm on September 20th. The order required that all crops stored or cultivated on
the property be destroyed, and the spring be eliminated as a possible water source.
They were also advised to limit visits from anyone without documented hepatitis A
immunity (either a history of hepatitis A or two doses of hepatitis A vaccine) until a
safe water source was in place.

Your health department will continue to conduct surveillance for hepatitis A cases
associated with the contaminated spring. You will also continue to follow up with the
farm owners to ensure the abatement orders are followed.

To date, your investigation has not uncovered the original source of hepatitis A that
resulted in water contamination.
Group Brainstorm
Often, after an outbreak investigation, an Epi Team reviews the investigation in a “hot
wash” or after-action review. The questions below are examples of questions that could
be used in such a review. Choose one member of the Epi Team to record responses on a
flip chart. As a group, discuss one or more of the following questions.

 What aspects of the investigation were successful?

 All outbreaks present unique challenges. What characteristics of this outbreak made it
challenging?

 What areas of the investigation could have been improved?

 If a similar outbreak occurred in your county, do you think that your Epi Team would
be prepared to handle it?

References
Moore Z. Trip Report: Hepatitis A Outbreak, Madison County, NC, 2006.

Moore Z, Sobsey M, Ganova-Raeva L, et al. Hepatitis A associated with contaminated

spring water -- North Carolina, 2006. Poster presented at the Infectious Diseases Society
of America 45th Annual Meeting; October 4-7, 2007; San Diego, CA.