Updates and Resources for Clinicians



Hepatitis A Infections

July 1, 2016

The Hawaii Department of Health (HDOH) is investigating at least 12 cases of hepatitis A virus (HAV) infection on Oahu. Onset dates have ranged from June 16–27, 2016, suggesting exposure during the month of May. The source of infections has not been identified.

HDOH is urging providers to be vigilant and consider HAV infection in patients with a consistent clinical presentation. Cases of HAV infection, which is URGENTLY NOTIFIABLE, should be reported by telephone as soon as illness is suspected—do not wait for laboratory confirmation to report. Please be prepared to provide your patient’s AST (SGOT) and ALT (SGPT) values.


HAV transmission is usually person-to-person by fecal-oral route or through a contaminated vehicle such as food. Infected persons are most infectious during the 1–2 weeks before onset of jaundice or elevation of liver enzymes, when concentration of virus in the stool is highest, until one week after jaundice or symptom onset. The incubation period for HAV infection may be 15–50 days (average 28 days).


Onset of symptoms is usually abrupt with fever, malaise, anorexia, nausea, dark urine, abdominal discomfort, and jaundice. Diarrhea may also occur. Many cases, especially children, have mild or asymptomatic infection. Clinical illness typically last several weeks and resolves within 2 months. Household and sexual contacts are at increased risk of infection.


Diagnosis requires detection of IgM antibodies against HAV (anti-HAV IgM) in serum of acutely or recently ill patients. IgM generally becomes detectable 5–10 days before symptom onset and may remain detectable for up to 6 months.


Persons who have recently been exposed to HAV and who previously have not received HAV vaccine should receive a single dose of single-antigen hepatitis A vaccine or immune globulin (IG; 0.02 mL/kg) as soon as possible, within 2 weeks after exposure. The efficacy of IG or vaccine when administered greater than 2 weeks after exposure has not been established.

  • 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 with chronic liver disease, and persons for whom vaccine is contraindicated, IG should be used.

HDOH encourages Hawaii residents to consider getting vaccinated for hepatitis A, and advises that they talk to their healthcare provider about hepatitis A if they are interested. Vaccination for hepatitis A is strongly recommended for certain individuals who are especially at risk (see here for a CDC list of groups recommended to be vaccinated for hepatitis A).

Hepatitis A vaccine is readily available at local pharmacies, visit here for a list of participating pharmacies. Please have your patients call ahead to make sure they have the vaccine on-hand and that they don’t have any restrictions or requirements.

Persons with HAV infection should be excluded from food-handling and direct-care occupations for the first 2 weeks of illness and at least 7 days after onset of jaundice. Children with HAV infection should be excluded from preschool for 10 days after illness onset.

A hepatitis A factsheet for healthcare workers can be found at this link.

For more information, go to Hepatitis A Questions and Answers for Health Professionals.

Hepatitis A Post-Exposure Prophylaxis Guidance and Immune Globulin Distributor Information


Congenital Zika Virus Infection 

January 15, 2016

The Hawaii Department of Health (DOH) has received laboratory confirmation of congenital Zika virus infection in a microcephalic infant born in Hawaii to a mother who emigrated from Brazil early in her pregnancy. Maternal infection likely occurred in the first trimester while the family was still living in Brazil; mother and child pose NO risk for Zika virus transmission in Hawaii.

Zika virus is a mosquito-borne viral infection transmitted by Aedes species mosquitoes, which can be found throughout the state (and can also transmit other viruses like dengue). Zika is not endemic in Hawaii. Hawaii providers must be alert for Zika infection in persons who develop illness within 2 weeks of returning from affected areas as well as in pregnant women who report having had compatible illness during their travel. Zika virus is endemic in parts of Africa and Asia, but disease activity has been reported in other parts of the world, including the Pacific Islands and Latin America.

Symptoms and Treatment

Zika virus infection generally causes a mild dengue-like illness. Infected persons present approximately 3–12 days after bite by an infected mosquito with acute onset low-grade fever, rash, arthralgia, and conjunctivitis; myalgia, headache, retro-orbital pain, and emesis may also occur. Up to 80% of infections may be subclinical or asymptomatic. Patient symptoms self-resolve within 2-7 days, and hospitalization is uncommon. Treatment is supportive.


Zika virus infection can be diagnosed serologically to detect IgM and neutralizing antibodies; however, cross-reaction with dengue and West Nile viruses is common. Polymerase chain reaction (PCR) at the DOH State Laboratories Division to detect virus RNA can be performed on blood specimens collected during the first week of illness. Healthcare providers should report suspect cases to DOH to assure coordination and routing of specimens as well as any necessary immediate public health response.

As with any mosquito-borne infection, individuals suspected to have Zika virus infection should be advised to stay indoors and avoid mosquito bites during their first week of illness. Travelers to affected areas should use mosquito repellents containing 20–30% DEET and wear long sleeves and pants when possible.

Please note Zika virus infection is an urgent category notifiable condition and must be reported by phone.

For further information please refer to http://www.cdc.gov/zika/ as well as http://wwwnc.cdc.gov/travel/notices for specific country travel advisories.



Dengue Fever

November 5, 2015

The Hawaii Department of Health (HDOH) is investigating a cluster of locally-acquired (autochthonous) dengue fever cases on the Big Island of Hawaii.

Dengue is not endemic in Hawaii, however it is intermittently imported from endemic areas by infected travelers. This is the first cluster of locally-acquired dengue fever since the 2011 outbreak on Oahu.

Clinicians should be aware of dengue and other mosquito-borne infections when patients present with compatible findings (i.e., fever, myalgias/arthralgias, rash, AND exposure to or bites from mosquitoes without alternative underlying etiology, especially with travel from an endemic area) and report all such patients to HDOH at the time dengue fever is first suspected. Delay in reporting directly impedes identifying and abating potential areas of mosquito transmission and places the public’s health at risk.


Dengue fever presents 5–7 (range 3–10) days after a bit by an infected mosquito. Symptoms include high fever, arthralgias, myalgias, severe headache, retro-orbital eye pain, maculopapular rash, and mild hemorrhagic manifestations (e.g., petechiae). Mild cases may have only a nonspecific febrile syndrome. Uncomplicated dengue fever resolves within 2–7 days. In some, symptoms can progress to severe dengue, which can be fatal and present after initial fevers resolve. Hemorrhage and extensive plasma leakage, requiring critical, aggressive supportive care and monitoring, are characteristic. Early laboratory values in dengue fever typically demonstrate leukopenia and thrombocytopenia; patients with severe dengue can have an abruptly increased hematocrit.

Treatment and Diagnosis

Treatment for dengue infection is supportive; patients should be monitored for potential progression to severe dengue. Diagnosis can be made by serological methods to detect IgM and neutralizing antibodies. Because dengue infection can cross-react with other mosquito-borne illnesses on serological testing, it is critical to involve HDOH as soon as possible to obtain polymerase chain reaction (PCR) testing and/or confirmatory serological testing. PCR testing generally can be performed on blood specimens to detect virus during the first 5–7 days of illness.

Individuals suspected or confirmed to have dengue fever should be instructed to stay indoors and avoid mosquito bites during their first week of illness (i.e., especially while febrile). Patients should be encouraged to aggressively control and eliminate mosquitoes around their homes and businesses by eliminating areas of standing water. Windows and door screens should be checked for holes/tears and repaired. Individuals should use mosquito repellents containing 20–30% DEET and wear long sleeves and pants when possible.

Please note dengue fever is an URGENT CATEGORY NOTIFIABLE CONDITION and must be reported by phone.

For more information about dengue, please refer to http://health.hawaii.gov/docd/dib/disease/dengue/ or http://www.cdc.gov/Dengue/.




Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Updated August 17, 2015

The Middle East Respiratory Syndrome (MERS) outbreak that had been occurring in the Republic of Korea has been brought under control according to the World Health Organization (WHO). The last case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection reported by the Republic of Korea was on July 4, 2015; on July 27, 2015 all remaining case contacts being held in quarantine were released with no symptomatic individuals identified. In total, there have been 186 confirmed cases of MERS-CoV infection in Korea with 36 deaths. Although the MERS outbreak in the Republic of Korea has abated, there continues to be new cases reported elsewhere, almost entirely all in individuals with a history of travel within the Arabian Peninsula.

Persons with Middle East Respiratory Syndrome (MERS), the viral respiratory illness caused by MERS-CoV, may have symptoms ranging from mild or no respiratory symptoms to severe acute respiratory illness, respiratory failure, and death.  Common symptoms on presentation include fever, non-productive cough, dyspnea, rigors, headache, and myalgia; pneumonia is a frequent finding, and gastrointestinal symptoms has been reported.  Individuals with comorbidities (e.g., diabetes, chronic lung disease or renal failure, immunocompromise) may be more likely to have severe disease.  The median incubation period for cases associated with limited human-to-human transmission is estimated to be 5 days (range 2–14 days).  Treatment is supportive and may involve a prolonged intensive care unit (ICU) stay; no specific treatment for MERS-CoV infection is currently available.

MERS was first identified in Saudi Arabia in 2012, and until the recent outbreak in the Republic of Korea, almost all cases, with the exception of a small number of secondary cases, had been linked to countries in or around the Arabian Peninsula; the index case of the recent Republic of Korea outbreak had a recent history of travel to the Middle East.  To date, there have only been two cases identified in the United States.  Although separate, both occurred in May 2014 and were linked to travel to the Arabian Peninsula.  Although it is not completely understood how MERS-CoV is transmitted, there has been no evidence for sustained human-to-human transmission in the community.  Limited human-to-human spread has been seen in healthcare settings and/or associated with close contact with an individual infected with MERS-CoV.


Clinicians should be continue to be aware of the situation and evaluate patients for MERS-CoV if the criteria in either #1, #2, or #3 below are met:

#1. Fever AND pneumonia or acute respiratory distress syndrome (ARDS)


  • A history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, or
  • Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula, or
  • Are part of a cluster of patients with severe acute respiratory illness of unknown etiology in which MERS-CoV is being evaluated

#2. Fever AND symptoms of respiratory illness AND being in a healthcare facility (in any capacity) within 14 days before symptom onset in a country or territory in or near the Arabian Peninsula in which recent healthcare-associated cases of MERS have been identified

#3. Fever OR respiratory illness symptoms AND close contact with a confirmed MERS case while the case was ill


The CDC’s travel advisory for the Republic of Korea is currently “Watch – Level 1, Practice Usual Precautions”. For more information, visit: CDC’s MERS in the Republic of Korea

The risk of MERS-CoV infection to the general public in the United States is low. However, given the speed and frequency of global travel, there is still the potential for importation of additional cases to the United States. If a clinician suspects MERS-CoV in a patient, they should IMMEDIATELY report it to the Hawaii Department of Health (HDOH) by calling (808) 586-4586.

HDOH will continue to monitor the situation and provide updates.

For more information, go here: WHO MERS


Upcoming COCA Call: Thursday, June 11, 2015 

Updated Information and Guidelines for Evaluation for MERS

(added June 10, 2015)

On May 20, 2015, the Republic of Korea (Korea) reported to the World Health Organization an initial case of laboratory-confirmed MERS-CoV infection, the first case in what is now the largest single outbreak of MERS-CoV outside of the Arabian Peninsula. During today’s call, clinicians will be provided information about the global situation and the current status of the MERS-CoV outbreak in the Republic of Korea, updated guidance to healthcare providers and state and local health departments regarding who should be evaluated and tested for MERS-CoV infection, and further guidance on “Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Possible MERS-CoV.”


Susan Gerber, MD
Team Lead
Division of Viral Diseases
National Center for Immunization and Respiratory Diseases — CDC

David Kuhar, MD
Medical Officer
Division of Healthcare Quality Promotion
National Center for Emerging and Zoonotic Infectious Diseases — CDC

Date: Thursday, June 11, 2015

Time:  8:00 – 9:00 am (HST)

Audio only, there are no presentation slides and registration is not required.

Participate by Phone:

888-810-4792 (U.S. Callers)

630-395-0368 (International Callers)

Passcode: 754982

 Join by Live Audio Web Streaming: Listen only.


For additional information and to access call recordings (audio and transcript), which will be available a few days after the live call, please visit the call webpage at emergency.cdc.gov/coca/calls/2015/callinfo_061115.asp




Ebola Virus Disease (EVD)

(Updated June 8, 2015)

 EVD Clinician Resources


EVD Update (updated June 8, 2015)

As of May 9, 2015, the World Health Organization (WHO) has declared Liberia to be Ebola virus disease (EVD) free, defined as 42 days (the length of two incubation periods of EVD) elapsing without any new cases occurring. The CDC’s travel alert for Liberia has been reduced to Level 2 (Practice enhanced precautions). Guinea and Sierra Leone, however, continue to report new cases and are still considered to have widespread transmission of EVD.

The Hawaii Department of Health (HDOH) is continuing to monitor individuals traveling to Hawaii from Guinea and Sierra Leone. Case-by-case risk assessments of all such identified travelers is conducted, and any restrictions on movement or other monitoring requirements will be determined based on known medical and scientific evidence as well as sound public health practice to ensure both the individual’s and the public’s health, safety, and welfare.  Restrictions in movement may include requesting that individuals avoid mass transit, interisland travel, or mass gatherings.  Those who are felt to have sufficiently high risk to merit quarantine in their home will be asked to do so voluntarily, but if required, the department is prepared to seek enforcement of movement restrictions.

As of June 2, 2015, the Hawaii Department of Health (HDOH) has monitored a total of 34 individuals that have traveled to Hawaii after having potential exposure to EVD in the affected regions of West Africa. To date, there have been no cases of EVD identified among these travelers.

It remains critical to obtain a detailed travel history in evaluating patients presenting with febrile illness. Emerging infectious pathogens (such as MERS-CoV) will continue to be a threat clinicians need to be prepared to identify.  Additionally, clinicians should also remain aware of other potentially fatal diseases in the differential diagnosis for a patient with fever and recent international travel, including:

-Typhoid Fever
-Lassa Fever
-Yellow Fever
-Rift Valley Fever
-Other bacterial, rickettsial infections

For more information go here: Ebola Virus Disease (EVD) or visit the CDC’s website.


COCA Call: 

Emergency Preparedness for Clinicians – From Guidelines to the Front Line

(added March 13, 2015)

Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. A barrage of patients with various clinical needs can quickly exhaust the care delivery capacity of a healthcare system. It is important for clinicians to have a disaster response plan that addresses approaches to maintaining quality care during times of patient surge and resource scarcity. During this COCA Call, participants will learn about the series of suggestions that focus on the management of multiple critically ill patients during a disaster or pandemic, and the importance of collaboration among front-line clinicians, hospital administrators, professional societies, and public health or government officials.

This COCA call has already occured – For additional information and to access call recordings (audio, webinar, and transcript), please visit the call webpage at http://emergency.cdc.gov/coca/calls/2015/callinfo_032615.asp


Multistate Measles Outbreak Associated with Travel to Disneyland

(February 2, 2015)

As of February 2, 2015, the California Department of Public Health has identified 59 confirmed cases of measles in their state with epidemiologic links to either Disneyland or Disney California Adventure Park in Orange County. Initial exposures are thought to have occurred in December, but additional cases reported visiting Disney parks while infectious in January. (http://www.cdph.ca.gov/HealthInfo/discond/Pages/Measles.aspx) Additional confirmed cases have been reported in Arizona, Colorado, Nebraska, Oregon, Utah, Washington, and Mexico. Additional suspect cases are under investigation. The majority of cases were unvaccinated. (http://emergency.cdc.gov/han/han00376.asp)

Although measles has been eliminated in the United States since 2000, this outbreak serves as an important reminder to clinicians that measles continues to pose a risk to their patients, even within the United States; it is critical that patients are kept up-to-date on their immunizations. Additionally, clinicians should remain vigilant and consider measles in a non-immunized person with a febrile rash, particularly if they have an appropriate travel history.

Measles is an URGENT CATEGORY NOTIFIABLE CONDITION and should be reported to the Hawaii Department of Health by telephone as soon as the diagnosis of measles is considered. For more information, visit: http://health.hawaii.gov/docd/home/imm/measles/.


Influenza Activity in Hawaii

(January 22, 2015)

The Hawaii Department of Health continues to monitor influenza and influenza-like illnesses (ILIs) in the state as this flu season progresses. Our surveillance for both influenza and ILI has shown increased activity, as well as an increase in the number of tests performed for influenza. Although there has been a rise in the number of positive influenza tests, it is notable that a substantial number of these tests have been negative. Limited data from testing done for other respiratory pathogens show that other viruses such as respiratory syncytial virus (RSV) and rhinovirus are also still circulating. More information on Hawaii’s flu surveillance as well as the weekly flu surveillance report can be found at http://health.hawaii.gov/docd/flu-hawaii/surveillance/.

Clinicians should emphasize the value of preventative measures with their patients to decrease the burden of influenza in the community, including: frequent hand hygiene; avoiding close contact with ill persons when well; avoiding touching one’s eyes, nose, or mouth; and staying home from work, school, and errands when ill. Additionally, the influenza vaccine is still an important preventative measure, even after the influenza season has begun. Although CDC has reported that the influenza A H3N2 virus strain predominating this season is drifted from the H3N2 component of this year’s influenza vaccine, partial protection may be achieved. Vaccine recipients would also be protected against the other strains of influenza included in the vaccine, some of which have also been detected in Hawaii this season.

Clinicians should continue to consider influenza when a patient presents with fever with either cough or sore throat; antiviral treatment may be of benefit if instituted early in the course of disease. All hospitalized, severely ill, and high-risk patients* should be treated as soon as possible with an antiviral active against influenza. (http://emergency.cdc.gov/han/han00375.asp)

*Patients at higher risk for influenza complications include:
·         children < 2 years (although all children younger than 5 years are considered at higher risk for complications from influenza, the highest risk is for those younger than 2 years);
·         adults > 65 years;
·         persons with chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), and metabolic disorders (including diabetes mellitus), or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);
·         persons with immunosuppression, including that caused by medications or by HIV infection;
·         women who are pregnant or postpartum (within 2 weeks after delivery);
·         persons < 19 years who are receiving long-term aspirin therapy;
·         American Indians/Alaska Natives;
·         persons who are morbidly obese (i.e., body-mass index > 40); and
·         residents of nursing homes and other chronic-care facilities.


Enterovirus-D68 (EV-D68) 

(updated September 23, 2014)

Hospitals in Missouri and Chicago, IL, have reported higher numbers of children with severe respiratory illness than usual for this time of year. Diagnostic testing has determined EV-D68 as the cause of illness in a large number of these cases. Although many other states have reported at least one confirmed case of EV-D68, no other large clusters have been reported.

EV-D68 is one of many types of enteroviruses, which are very common and tend to circulate in the summer and fall. EV-D68 was first identified in 1962; although relatively rarely identified compared with other enteroviruses, EV-D68 has caused sporadic illnesses in the past as well as occasional clusters of illness in the United States and globally.

Recent illnesses from EV-D68 have been reported to present with acute, severe respiratory illness with reactive airway features in children, often without fever. Clinicians seeing an increased number of severe respiratory illness in their facilities, in particular those with the above features, should contact HDOH.

CDC is also currently investigating a cluster of nine Colorado pediatric patients, who were hospitalized with acute neurologic illness, characterized by focal limb weakness and abnormalities of the spinal cord gray matter on MRI. Eight of the patients had nasopharyngeal specimens tested; six were positive for rhinovirus/enterovirus. Further testing typed four of these specimens as EV-D68; the remaining two are pending results. However, the connection between the neurologic illness and EV-D68, if any, is still unclear.

If clinicians are concerned about the possibility of EV-D68 and/or have a possible case of acute flaccid paralysis otherwise unexplained in a patient

For more information on EV-D68, please see the CDC’s website.