Hepatitis A Infection—Child Care and Schools

What are the signs or symptoms?

• Children younger than 6 years usually have few or no signs or symptoms. Symptoms are common in older children and adults.

• Fever.

• Jaundice (ie, yellowing of skin or whites of eyes).

• Abdominal discomfort.

• Fatigue.

• Dark-brown urine.

• Nausea, loss of appetite.

• Occasionally, diarrhea can occur.

What are the incubation and contagious periods?

• Incubation period: 15 to 50 days, with an average of 28 days.

• Contagious period: Most infectious in the 2 weeks before onset of signs or symptoms; the risk of transmission is minimal 1 week after onset of jaundice.

How is it spread?

Fecal-oral route: Contact with feces of children who are infected. This generally involves an infected child contaminating his own fingers and then touching a surface, an object, or food that another child touches. The child who touched the contaminated surface then puts her fingers into her own mouth or another person's mouth or on shared food.

How do you control it?

• Hepatitis A is a vaccine-preventable disease. The vaccine is recommended for all children 12 months and older. The immunization requires 2 doses, an initial dose and a second dose 6 to 18 months later.

• In an outbreak situation (a case of hepatitis A in a child or caregiver in a group child care program or 2 or more cases of hepatitis A in household members of children in group care), contacts should be vaccinated if not previously vaccinated or receive immune globulin shots. To be effective, immune globulin should be given within 2 weeks of exposure. Local health authorities should be notified as soon as possible. They can help ensure all contacts have been notified and receive immune globulin or the hepatitis A vaccine. Giving hepatitis A vaccine immediately following exposure for those older than 12 months and younger than 40 years is equally effective as giving immune globulin. Furthermore, the vaccine will protect the person for a longer time against future hepatitis A infection than the immune globulin.

• Staff members who work in child care programs do not require the hepatitis A vaccine. However, the Centers for Disease Control and Prevention recommends hepatitis A vaccination for close personal contacts of children adopted from some countries where hepatitis A is common. The potential for exposure of teachers/caregivers to newly arrived international adoptees or children of newly immigrated families should be considered in deciding whether to get hepatitis A vaccine.

• Use good hand-hygiene technique at all the times listed in Chapter 2, especially after diaper changing.

• Child care and school settings have been found to play a significant role in the community-wide spread of hepatitis A. Because young children usually have few or no signs or symptoms, spread within and outside a group care setting may occur before the initial case is recognized.

What are the roles of the teacher/caregiver and the family?

• Report the infection to the staff member designated by the child care program or school for decision-making and action related to care of ill children. That person, in turn, alerts possibly exposed family and staff members and the parents of unvaccinated children to watch for symptoms and notifies the health consultant.

• Report the infection to the local health department. If the health professional who makes the diagnosis does not inform the local health department that the infected child or staff member is a participant in a child care program or school, this could lead to a delay in controlling the spread.

• Use good hand-hygiene technique at all the times listed in Chapter 2, with special attention after toileting or changing diapers.

• Teach children and remind adults to wash their hands after using the toilet and before any activity that potentially involves food or the mouth.

• Clean and disinfect surfaces in all areas. Hepatitis A virus can survive on surfaces for weeks.

• Contact a health professional and the local health department promptly to review the need for using vaccine or immune globulin for attendees and household members of attendees.

• Routinely check that children complete the hepatitis A vaccine series according to the most recent immunization recommendations.

Exclude from group setting?

Yes.

• Children and adults, especially food handlers, with hepatitis A should be excluded for 1 week after onset of illness.

• Refer to health professional.

Readmit to group setting?

Yes, when all the following criteria have been met:

• One week after onset of illness and after all contacts have received vaccine or immune globulin as recommended

• When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group

Comments

• When an individual is infected and sick with hepatitis A treatment is limited to comfort measures.

• Hepatitis A outbreaks can occur in child care settings. The first sign of an outbreak may be in adult caregivers (parents/guardians, staff members) because young children may not have symptoms.

• Outbreaks of hepatitis A infections in schools have been associated with home-prepared snacks that were served in schools. Any treat or snack served in a school or child care setting should be commercially prepared and, ideally, individually wrapped.