Guidance for the public health management of hepatitis A

Overview

This Public Health Scotland (PHS) guidance is a standalone document that presents and adapts the United Kingdom Health Security Agency (UKHSA) Guidance for the public health management of hepatitis A for use in Scotland.

This has been developed by a multi-disciplinary Guidance Development Group (GDG) using Scottish Health Protection Network (SHPN) methods. A full methods statement is available in the guidance development methods section.

You can download a version for printing but please regularly check the most recent version of the guidance available online is being referred to.

This guidance is primarily non-statutory, meaning it is not a legal requirement to implement the recommendations made.

This guidance does not replace individual expert judgement or local response arrangements.

Any comments or suggested improvements can be sent to the PHS Guidance Team on phs.guidance@phs.scot

Intended audience

This guidance is for all professionals involved in the health protection or public health response to hepatitis A cases, contacts and outbreaks.

This includes:

• health protection teams (HPTs)
• environmental health departments
• microbiologists
• epidemiologists

Other people who require advice should contact their local health protection team.

What the guidance covers

This guidance has been developed to support the public health management of hepatitis A infection.

It aims to reduce the occurrence of secondary infections and to prevent and control outbreaks.

In scope

The guidance is for the public health management of hepatitis A infections.

This guidance covers:

• information on hepatitis A virus (HAV) including:
  • epidemiology
  • measures to prevent infection
• case and contact definitions
• public health actions for cases and contacts
• testing recommendations and pathways
• management of outbreaks

Out of scope

The guidance does not cover:

• the management of hepatitis A outbreaks in hospital settings
• clinical management of hepatitis A

Using this guidance

This guidance serves as a standalone guide for the public health management of hepatitis A in Scotland.

The UKHSA Guidance for the Public Health Management of Hepatitis A provides the evidence base for the recommendations in this guidance. See the guidance development methods section for details of the appraisal and adaptation process.

This guidance occasionally refers to the UKHSA guidance to explain the rationale for specific recommendations and provide additional evidence.

However, this PHS guidance has been developed to be comprehensive. It contains key recommendations and most of the supporting information. It is expected that those applying the guidance in Scotland will rarely need to refer to both documents.

Background information on hepatitis A

Hepatitis A is a vaccine-preventable infection. It is endemic in countries where hygiene and sanitation are inadequate.

The virus is transmitted predominantly via the faecal-oral route.

It can also be transmitted via contact with blood from someone with hepatitis A.

Infection can occur from consuming contaminated food or drink or from person-to-person spread. For example, through sexual activity or between people who inject drugs.

Symptoms

Symptoms associated with hepatitis A virus (HAV) include:

• jaundice
• dark urine
• pale stools

There can also be non-specific symptoms such as:

• fatigue
• nausea
• diarrhoea
• fever

HAV mostly causes a mild or asymptomatic infection in children with severity generally increasing with age.

Incubation period

Typically, the incubation period is 28 to 30 days. However, it can range from 15 to 50 days.

Infectious period

The infectious period is taken from 2 weeks before onset of first symptoms and until one week after the onset of jaundice.

If jaundice is not reported then this is from one week after the onset of dark urine or pale stools.

If there are no symptoms of jaundice, dark urine or pale stools, then onset of other symptoms (such as fatigue, nausea, and fever) should be used to determine the infectious period.

It is also possible for asymptomatic cases to be identified.

This can be through:

• the Scottish National Blood Transfusion Service (SNBTS) screening – see blood, tissue and cell donors section
• an outbreak investigation – for example, they are linked to a case

The infectious period for asymptomatic cases should be estimated using both:

• the timing of contact with the source if known – such as contact with an index case or consumption of contaminated food
• laboratory test results

HPTs may wish to draw on laboratory and specialist public health input to support such assessments.

Those at higher risk of infection

Individuals most at risk of acquiring HAV are:

• those travelling to endemic regions – see NaTHNaC information on hepatitis A for information on risk areas
• gay, bisexual or men who have sex with men (GBMSM)
• people who inject drugs

PHS does not routinely receive information on risk factors or overseas travel.

Epidemiology

Laboratory reports of hepatitis A in Scotland have remained relatively stable over the past ten years. There are typically 20 to 40 confirmed cases of hepatitis A each year.

There was a large foodborne outbreak involving 91 cases in 2017. There was also an increase in cases of hepatitis A among GBMSM in 2017 – this was also seen in England, Wales and across Europe.

Refer to the PHS gastrointestinal and zoonoses biennial report for more information on the epidemiology of hepatitis A in Scotland.

Preventing infection

Hygiene measures

As HAV is transmitted from person to person by the faecal-oral route, good hygiene is essential for prevention.

Individuals should thoroughly wash their hands with soap and water:

• after using the toilet
• before preparing or eating food

Since faecal-oral transmission can occur during sexual activity – particularly among gay, bisexual and other men who have sex with men (GBMSM) – it is important to provide guidance on hygiene measures.

This includes:

• using protection for sexual activities
• not sharing sex toys
• changing condoms between anal and oral sex
• washing after sex

Travel advice

HAV in Scotland has been associated with travel to endemic regions.

Advice for professionals

For up-to-date travel health information that is written for health care professionals in Scotland, visit TRAVAX.

Also refer to NaTHNaC hepatitis A information for more information on risk areas.

Advice for the public

For advice for the public in Scotland visit:

• the travel health section of NHS inform
• fitfortravel

Pre-exposure immunisation

There are currently the following vaccines licenced for use in the UK:

• three monovalent inactivated hepatitis A vaccines
• two combined hepatitis A and hepatitis B vaccines
• two combined hepatitis A and typhoid vaccines

Refer to local guidance for more information – including patient group directions (PGDs).

The following groups are recommended to receive pre-exposure immunisation:

• people travelling to or going to reside in areas of high or intermediate prevalence
  • clinicians should be encouraged to opportunistically consider the travel immunisation needs of those who visit friends or relatives in high or intermediate prevalence countries, as they are particularly at risk of acquiring infection and may not seek pre-travel health advice
• people with chronic liver disease
• people with haemophilia
• gay, bisexual and other men who have sex with men (GBMSM)
• people who inject drugs
• individuals at occupational risk

Further information for health professionals on hepatitis A immunisation information is available in chapter 17 of the Green Book.

Case definitions

Case definitions

Scenarios

Examples scenarios of applying the case definitions are available in the UKHSA guidance which may be useful to refer to.

Note that in Scotland routine hepatitis A testing produces qualitative results that will be interpreted by the laboratory.

Samples should be referred to the local laboratory where the UKHSA guidance advises to send to the reference laboratory (VRD).

Refer to the testing recommendations and pathways section for more information.

Confirming cases

Attempts to confirm a probable case should always be made.

Serology and PCR tests are available to help confirm probable cases. It is advisable to obtain a laboratory sample whenever possible.

Contact your local laboratory to discuss. 

Refer to the testing recommendations and pathways section for more information.

Close contact definitions

Close contacts are individuals at high risk of being exposed to hepatitis A through close contact with the index case during the infectious period. This is equivalent to a household type exposure.

Undertake a risk assessment to identify close contacts. Also consider those that have shared food and toilet facilities with the index case.

There should be a low threshold for considering someone a close contact.

Close contacts may include the following.

The risk of transmission in all settings should be assessed on a case-by-case basis by the local health protection team.

Public health actions for cases and close contacts

Public health action should be taken for all confirmed and probable cases.

Hygiene advice

Hygiene advice should be provided by the HPTs.

This advice will be tailored to the setting and situation.

The IPC advice provided by HPTs will generally cover:

• hand hygiene
• environmental cleaning
• symptom awareness
• communications with parents and guardians

HPTs can share this UKHSA hepatitis A information sheet with cases and contacts.

Hand hygiene

Cases and close contacts should receive verbal and written guidance on the importance of hand washing:

• after using the toilet
• after changing nappies
• before preparing and eating food

It is important that enhanced hygiene is practised by all family members as some may already have acquired hepatitis A infection and be excreting hepatitis A virus.

Individuals whose personal hygiene is likely to be inadequate – for example, young children or people with learning disabilities – should be supervised to ensure that they wash their hands properly after using the toilet.

Refer to the NIPCM hand hygiene information leaflets for the public and encourage cases and contacts to review the leaflet. Translated versions of the leaflet are also available.

Children and young people settings

The health protection in children and young people settings (including education) guidance contains information and additional resources (including posters) relevant for these settings.

Sexual activity

If transmission during sex is the likely route, particularly between GBMSM, advice on how to prevent spread of hepatitis A during sex should also be given.

See the preventing infections (hygiene measures) section.

Exclusion advice

All cases should be excluded from work, school or nursery until 7 days post onset of jaundice.

When jaundice is not present, this is from the onset of compatible symptoms such as:

• fatigue
• nausea
• fever

Exclusion of close contacts is not typically advised.

However, there are instances where exclusion from a childcare setting or place of work may be advised.

See the section on public health actions for non-immune close contacts for more information.

Risk assessment of cases

This information should be collected for each case. This will support the risk assessment.

When collecting the above information for risk assessment it may also be an opportunity to ask if the case has donated blood, tissue or cells as outlined in the blood, tissue and cell donor section.

Questionnaire

Complete a surveillance questionnaire for all probable and confirmed cases.

Use the UKHSA questionnaire or local HPT questionnaire.

Completed questionnaires should be added to HPZone and emailed to PHS GIZ Team at phs.giz@phs.scot, if required.

Blood, tissue and cell donors

HAV infection can be transmitted by blood transfusion or tissue/cell transplant.

HPTs should check if cases and contacts are blood or tissue/cell donors.

Blood donation includes giving:

• whole blood
• plasma
• platelets

 Tissue and cell donation includes:

• bone
• stem cells
• gametes

For cases 

Ask if they have donated blood or tissue/cells anywhere in the UK in the 12 weeks prior to the onset of their symptoms, or any time after their symptoms started.

For contacts of a confirmed case of hepatitis A

Ask if they have donated blood or tissue/cells anywhere in the UK either in the 12 weeks prior to the onset of symptoms in the case, or any time since the case became symptomatic.

Reporting to Scottish National Blood Transfusion Services

HPTs should contact the Scottish National Blood Transfusion Service (SNBTS) to report:

• all UK blood and tissue/cell donors with recent hepatitis A infection
• those who are a close contact of a hepatitis A case

SNBTS should be notified if an individual has, or thinks they may have, donated anywhere in the UK at any time in the past 12 weeks.

SNBTS should also be notified if a case has received a donation/transplant in the last 2 months.

HPTs should contact both blood donor services and tissues and cell donor services, if applicable.

For HAV outbreaks or clusters

SNBTS should be advised if a HAV cluster or outbreak is suspected.

HPTs should notify SNBTS of any cases or contacts linked to these clusters who are known to have donated blood or tissue/cells within the parameters described in this guidance.

While HPTs do not need to provide specific details of cases and contacts who have not recently donated, SNBTS should be alerted to the general presence of clusters or outbreaks.

SNBTS may take additional actions regarding other donors, donations in affected areas or postcodes.

SNBTS should be included in the incident management team (IMT).

SNBTS notification details

HPTs should provide SNBTS with the following details:

• name
• date of birth
• CHI number
• address
• date of donation
• date symptoms started
• date of positive result or when designated as a close contact
• details of any close contacts who have also given blood, tissue, cells or plasma (for cases)
• if this is an isolated case or part of wider cluster or outbreak

Donating after hepatitis A infection

Cases should be advised to wait at least six months before donating any substance of human origin again. 

Contacts should be advised to wait at least six months before donating blood products, regardless of vaccination or immune status.

See the assessing immune status of close contacts section for definitions of immune and non-immune.

Immune contacts may be able to donate other substances of human origin e.g. bone or organs. Potential tissue donors should seek further advice from SNBTS.

See the Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee transfusion guidelines for further information about blood donation.

Asymptomatic cases

As part of the Plasma for Medicines programme, SNBTS commenced universal testing of all donations for hepatitis A virus in 2024 using nucleic acid testing (NAT).

A reactive NAT is considered by SNBTS to represent active infection with hepatitis A and merits public health action at this early stage.

Confirmatory results will follow from the SNBTS reference laboratory. It is expected that almost all reactive NAT results will be confirmed.

Public health actions should not be delayed while waiting for confirmatory testing.

When a donation has a reactive NAT for hepatitis A, SNBTS will contact the donor as soon as possible to notify them of this result and provide them with brief general health and public health advice.

They will inform them that their details will be passed to the HPT for public health follow up.

SNBTS will then:

• notify the local HPT and the patient's GP of the positive NAT at the earliest opportunity within normal working hours
• inform the donor’s local HPT that the donor has been given the diagnosis and is expecting a call from the HPT to commence public health assessment and follow up

The local HPT should consider them as a confirmed case for the purposes of public health action. This requires a risk assessment by the local HPT when deciding appropriate public health advice for asymptomatic cases.

The local HPT should bring in relevant laboratory expertise where necessary.

Assessing immune status of close contacts

The immune status of close contacts determines eligibility for prophylaxis. The key hepatitis A post-exposure prophylaxis is hepatitis A vaccine. Human normal immunoglobulin (HNIG) may also be recommended.

HPTs should be aware of potential challenges related to prophylaxis. For example, vaccine hesitancy or refusal of blood products due to religious beliefs.

Prophylaxis is only recommended for close contacts who are considered non-immune.

For more details, see the following sections for the definition of:

• immune close contacts
• non-immune close contacts

The recommendation for prophylaxis of non-immune close contacts is also affected by time since last exposure to the case.

See public health actions for non-immune close contacts.

Definition of immune close contacts

Close contacts should be considered ‘immune’ - not susceptible - and do not require vaccine or HNIG if they have any of the following:

• a reliable history or evidence of a complete course of hepatitis A vaccine in the past 10 years (for example, two monovalent doses or equivalent)
• a reliable history or evidence of one dose of monovalent vaccine - or equivalent - within the past 12 months
• a reliable history of hepatitis A infection or previous laboratory-confirmed hepatitis A (previous anti-HAV IgG positive, or HAV RNA positive)

Definition of non-immune close contacts

Close contacts who meet the criteria for either 'susceptible but primed' or 'fully susceptible' are considered non-immune close contacts.

The distinction between these two categories of non-immune close contacts exists to guide recommendations for administering HNIG.

Public health actions for immune close contacts

Close contacts of hepatitis A cases that meet the definition of 'immune' do not require prophylaxis.

The hepatitis A vaccine is highly effective. Refer to Hepatitis A: the green book, chapter 17 for more information on the vaccine.

HPTs should ensure that immune close contacts are:

• provided with hygiene advice
• alert to the development of symptoms
• asked if they have donated blood or tissue/cells anywhere in the UK either in the 12 weeks prior to the onset of symptoms in the case, or any time since the case became symptomatic – if they have donated then see the section on reporting to Scottish National Blood Transfusion Services

Public health actions for non-immune close contacts

Actions for non-immune close contacts

Refer to the definition of non-immune close contacts section for the criteria that determines individuals in this category for public health action.

Individuals should be considered immunosuppressed if they are identified as 'immunosuppressed' as listed in chapter 6 of the green book. If this is unclear then discuss with their clinician.

This algorithm is for non-immune close contact of a case of hepatitis A. There is a full text, accessible version following this image.

Close

Figure 1: Algorithm for non-immune close contact of a case of hepatitis A

Key to figure 1:

1. Refer to section assessing immune status of close contacts.
2. Only those who are fully susceptible are eligible for HNIG in addition to the hepatitis A vaccine. Refer to sections definitions of non-immune close contacts and considerations for anti-HAV IgG testing to get more information about whether someone is fully or partially susceptible.
3. If vaccinating carers is not possible then those aged 2 months or older should be immunised (unlicensed).
4. Refer to infant contacts section if they attend childcare.
5. Refer to food handler contacts section.

Note that the numbered steps in the flowchart are not necessarily intended to be followed in numerical sequence.

Download a copy of figure 1:

Vaccine

Vaccine should be offered to contacts as recommended in figure 1: actions for non-immune close contact of a case of hepatitis A.

Where figure 1 recommends post-exposure vaccine, a second dose of vaccine is recommended 6 to 12 months after the first dose to ensure long term protection.

There are several hepatitis A vaccines currently licensed for use in the UK.

Refer to Hepatitis A: the green book, chapter 17 for information on types of available vaccines and how they should be used.

Use of human normal immunoglobulin (HNIG)

Eligibility

Contacts who may be eligible for HNIG in addition to vaccine are outlined in figure 1: actions for non-immune close contact of a case of hepatitis A.

Where actions for non-immune close contacts recommends HNIG, only the non-immune contacts who are in the fully susceptible category are eligible.

Contacts who are considered immune or non-immune contacts in the susceptible but primed category (regardless of age or comorbidities) are not eligible.

Timing

Where HNIG is indicated, it is recommended to be given within 14 days from the last exposure to a case.

It should not be given more than 7 days after the first dose of hepatitis A vaccine.

See the following section on accessing HNIG for information on obtaining and administering.

Considerations for anti-HAV IgG testing

Anti-HAV IgG testing is not a pre-requisite for HNIG issue and anti-HAV IgG testing should not delay the administration of post-exposure vaccine.

Rapid anti-HAV IgG testing prior to administration of HNIG can be done, if feasible and immunity is suspected.

Rapid anti-HAV IgG testing requires a discussion with the local virology/microbiology team to confirm availability in advance of collecting and sending samples. The results can be provided within 24 to 48 hours if there has been a prior discussion with the laboratory before sending the sample.

Anti-HAV IgG testing can be considered prior to HNIG issue, provided results will be available within 3 days, and if:

• it is less than 10 days since last exposure
• it is less than 7 days since HAV vaccine

Factors to consider

The decision on whether to conduct anti-HAV IgG testing prior to HNIG issue requires consideration of several factors, including:

• time since exposure
• intensity of exposure
• likelihood of pre-existing immunity
• the time it will take to carry out an anti-HAV IgG test and get the result

For example, it may be reasonable to consider anti-HAV testing in older persons born overseas in a hepatitis A endemic country.

Testing may be less helpful and introduce delays where there has been continuous close contact from before the onset of jaundice (for example, household contacts). For these individuals, administration without testing may be warranted to achieve maximum potential benefit from HNIG.

Accessing HNIG

A variety of HNIG brands may be used in Scotland. These are all obtained through local hospital pharmacies. This is also the process during out-of-hours as the on-call pharmacist at the hospital pharmacy will support.

Local arrangements should be in place for administering HNIG.

The UKHSA hepatitis A immunoglobulin guidance contains details on alternative HNIG / subcutaneous immunoglobulin (SCIg) products, dosage and administration (including off-label intramuscular use in the community).

It is English guidance but health protection professionals in Scotland may find it useful. 

Infants and young children contacts

This section provides advice on managing non-immune contacts who are infants or young children.

Infants refer to children under the age of 12 months.

14 days or less since exposure

Contacts less than 12 months old

Contacts aged one or older

A single dose of monovalent hepatitis A vaccine should be given to infant close contacts aged one or older.

A risk assessment should be carried out to determine whether the contact is at continued risk of hepatitis A infection.

For example, they fulfil the criteria for requiring immunisation as pre-exposure prophylaxis - see pre-exposure immunisation.

A second dose of vaccine is recommended 6 to 12 months after the first dose to ensure long term protection.

More than 14 days since exposure

There should be enhanced hygiene measures at the childcare setting of the infant contact to reduce the risk of asymptomatic transmission of infection.

If there are concerns that enhanced hygiene measures cannot be maintained in the childcare setting, then the infant contact should be excluded from the childcare setting for 30 days from last exposure to prevent tertiary infection.

Immunisation with monovalent hepatitis A vaccine can be offered to children aged 2 months or older and to staff in the childcare setting if exclusion is likely to have serious adverse consequences. For example, loss of employment for those caring for the infant contact who is excluded from their childcare setting.

Food handler contacts post 14 days exposure

Risk assessment

A risk assessment should be undertaken by the HPT when close contacts are food handlers and have not received vaccine within 14 days of exposure.

Environmental health colleagues may also support this.

The risk assessment should consider:

• assessment of susceptibility of acquiring HAV – definitions of non-immune contacts and immune contacts are available in the section on assessing immune status of close contacts
• likelihood of developing secondary infection
• the risk of onward transmission
• a review of work duties - which may require a visit to the workplace

Public health actions

Reinforce hygiene measures if the food handler close contact has not been vaccinated within 14 days and is both:

• considered non-immune to HAV
• at high risk of acquiring infection

Workplace management should ensure hand washing facilities are adequate. They should also emphasise the importance of handwashing.

Those considered at high-risk of infection are close contacts where any of the following apply.

Index case:

• is a child less than 6 years old
• regularly cooked for the contact
• had poor personal hygiene or diarrhoea
• had sex with the contact

Where possible, the close contact should be advised to restrict activities to those that do not include preparing and handling unwrapped ready-to-eat food. This includes food that does not have a further cooking step. This is recommended until 30 days post exposure unless the contact demonstrates they are immune.

Exclusion from work should only be considered if effective hygiene cannot be achieved.

See Figure 2 for information.

You can also use the risk assessment tool.

This algorithm is for the public health management of close contacts who are food handlers. There is a full text, accessible version following this image.

Close

Figure 2: Algorithm for the public health management of close contacts who are food handlers

Download a copy of figure 2:

Risk assessment tool

Household contacts of probable cases

Hygiene advice should be given to household contacts of probable cases.

Post exposure vaccination of close contacts in the household setting of a probable case, where indicated, should not be delayed whilst awaiting the test results for the probable case.

If public health action is likely to extend beyond the household setting – for example, vaccination in a school – then confirmation should be obtained before starting that.

Contacts who are pregnant or breastfeeding

Close contacts who are pregnant or breastfeeding should be managed the same as non-pregnant or breastfeeding contacts.

There may be a greater level of concern amongst pregnant and breastfeeding women regarding the risk to their unborn child or their child. The supporting evidence for this recommendation is in part 2 of the UKHSA guidance.

It is English guidance but health protection professionals in Scotland may find it useful.

Management of contacts where index case attends a high risk setting

This section provides advice on managing contacts when the index case works or spends time in a place (outside their home) where their role, duties, or interactions with others are similar to close household contacts.

In addition to the settings included in this section, prisons may be another setting where interactions may be equivalent to close contacts in a household.

Additional information on the rationale for the advice provided in this section is available in the UKHSA guidance.

It is important to note that oral fluid testing not available in Scotland. Therefore, where the UKHSA guidance recommends oral fluid testing, this is not applicable in Scotland.

Food handler including those working in the health and social care setting

The local HPT and Environmental Health colleagues should risk assess the possibility that transmission of infection occurred in the workplace.

Visiting the workplace and interviewing the index case and their supervisors to understand their duties may support the risk assessment.

Individuals (including staff and patients) who have had repeated potential faecal-oral exposure to the index case - such as eating food prepared by them or assisting with feeding and toileting - should be offered the vaccine (and HNIG if indicated) if identified within 14 days of their last exposure.

Refer to the section on assessing immune status of close contacts for details.

Early years childcare or primary one

HPTs should identify close contacts in this setting. This may be a restricted group of individuals whose risk of acquiring infection is equivalent to the risk in a household setting. They should be managed as close contacts if the index case is identified within 14 days. Those in this restricted group may include those working, or being cared for, in the same room or group as the index case.

If vaccine cannot be administered to close contacts within 14 days of exposure to the index case, then consider wider immunisation (whole classroom or beyond) on a case-by-case basis. This may include:

• extending immunisation to all children in that setting
• immunising household contacts to prevent tertiary transmission

If more than one case occurs in this setting, wider immunisation should also be considered as it could be considered a cluster.

In an outbreak situation see the section on outbreaks in closed or community settings - education settings.

Source of infection

Consider the source of infection. For example, recent travel or known contact with hepatitis A outside the setting. When children attend multiple childcare settings, all childcare settings should be considered as a potential source.

If no source of infection can be identified outside of the setting then the case may have acquired the infection through asymptomatic transmission within the setting.

Primary school setting (excluding primary one)

An assessment should be conducted to identify the source of infection when a single case of hepatitis A occurs in a primary school in a child (see section above for cases in primary one) or a staff member.

If no source of infection can be identified outside the school, then the case may have acquired the infection through asymptomatic transmission within the school.

In these circumstances offering hepatitis A vaccine to all children and adults within a defined group at risk in the school may prevent continuing transmission.

A risk assessment is required to determine whether a small group at risk can be defined (for example, close friends of the index case within the school) or whether wider immunisation in the same class, year, multiple years or whole school may be appropriate.

Consider:

• the degree of mixing between classes and years at play and mealtimes
• whether different years share hand washing and toilet facilities

In an outbreak situation see the section on outbreaks in closed or community settings - education settings.

Other school, higher education or workplace settings

Hepatitis A post-exposure prophylaxis is generally not recommended for single cases in secondary schools, colleges, universities, workplaces, or hospitals.

In secondary school settings, the focus should be on reinforcing hygiene measures. The HPT should risk assess if any warn and inform messaging is required and who this should be provided to. Information on a potential exposure may cause anxiety and risk deductive disclosure.

Additional consideration may be needed for cases in non-residential additional educational needs schools. Further actions would depend on a local risk assessment.

In hospital settings, it is assumed that the Infection Control Team (ICT) will be consulted if a healthcare worker is infected.

In an outbreak situation see the section on outbreaks in closed or community settings - education settings.

Residential home setting

There may be an increased risk of onward transmission and risk of severe disease among vulnerable residents if the index case assists with toileting and eating in residential home settings.

Residential home settings in this context include:

• care homes
• nursing homes
• residential setting for people with learning disability

If notified of a single case in a carer then assess the risk of onward transmission and identify close contacts within the residential home.

Consider wider immunisation of staff and residents within the home to prevent transmission and poor outcomes among vulnerable residents.

Risk assessment for vulnerable contacts

• What were the carer’s duties (e.g., feeding, toileting, food handling)?
• Did they care for one resident or multiple residents?
• If a food handler, did they prepare or serve food during the infectious period? How often?
• Did they directly handle food at any point? If yes, offer post-exposure prophylaxis to relevant close contacts.
• Did they have diarrhoea at work and assist with feeding or personal care? If yes, then consider resident as a close contact and offer post-exposure prophylaxis.
• How is their understanding and application of infection control practices? For example, was PPE consistently used?

Risk assessment for workplace transmission

• Did the carer share accommodation or food with other staff? If so, consider them as household contacts and offer post-exposure prophylaxis.
• Did they regularly share toilet facilities with other staff? If yes, assess handwashing practices, toilet cleaning, and diarrhoea history to determine close contact risk.
• Consider visiting the setting to assess infection control practices.

In an outbreak situation see the section on outbreaks in closed or community settings - care homes.

Calculating time since exposure for decisions on prophylaxis

When there is continuous exposure (for example contacts in a shared household), the limit for administering prophylaxis should be timed from 14 days since the onset of jaundice or onset of symptoms such as fatigue, nausea, fever in the absence of jaundice.

In the case of a single exposure in the infectious period, time since exposure should be calculated from day of the exposure. 

See the sections on incubation period and infectious period.

Testing recommendations and pathways

Serology testing

Arranging serology testing

IgG and/or IgM assays are available in some local boards.

If they are not available locally then samples should be referred for testing in line with locally agreed pathways.

Some NHS health boards only have IgM locally and need to refer all positive IgM samples to confirm – see the confirmation of samples section.

Rapid serology testing

Rapid serology testing may be available from your local laboratory. This takes approximately 24 to 72 hours from receipt of the sample.

Availability may vary - please contact the laboratory to discuss in advance of sending the sample.

Interpreting serology results

IgM and IgG testing provides qualitative results. The results from this testing will be based on the assay used and interpretation of the results should be sought from the laboratory that performed the test.

The laboratory findings should be considered in the broader clinical and epidemiological context.

Figure 11 (immunological response to hepatitis A infection) is contained in the UKHSA guidance. Referring to this figure may support discussions on interpretation of results.

IgM considerations

IgM testing may be negative if the sample was taken within 5 days after symptom onset. A repeat sample should be taken in this situation.

If an IgM positive result has been detected, then further testing should be undertaken using an alternative IgM assay, PCR and/or IgG. This is because HAV IgM assays have poor specificity and can lead to false positive results.

Individuals with an IgM positive result only (for example, probable cases or those persons who do not meet the case definitions) should be discussed with the local / reference laboratory and interpretation should be based on the laboratory cut-off for the assay and in the context of the epidemiology data.

Communicating results

Local HPTs will be informed of any positive IgM or HAV RNA PCR results suggesting hepatitis A infection.

PCR testing

If laboratories do not have HAV RNA PCR testing available, then this service is offered by the West of Scotland Specialist Virology Centre (WoSSVC). It is a chargeable test.

Laboratories should contact WoSSVC to discuss.

View the West of Scotland Specialist Virology Centre contact information.

Communicating results

The results of the PCR testing will be communicated by specialist virology centre (SVC) to the laboratory who referred the sample.

WoSSVC only contact the HPT directly to communicate PCR results if the referring laboratory was within the NHS Greater Glasgow and Clyde health board (NHS GGC).

WoSSVC will also contact the requesting clinician if the patient is hospitalised within the NHS GGC health board.

Confirmation of samples

Refer samples for confirmation according to the locally agreed pathway.

If the sample is required to be sent to the SVC, then the local laboratory should notify the SVC via email before sending.

Samples will be tested within 48 to 72 hours from receipt of the sample in the SVC. 

View the specialist virology centres contact information.

HAV surveillance testing

All hepatitis A PCR positive samples and samples from clinically confirmed serological HAV cases should be forwarded to the WoSSVC in Glasgow. This is part of the national enhanced molecular surveillance of hepatitis A for genotyping.

Email WoSSVC to request this.

View the West of Scotland Specialist Virology Centre contact information.

Reporting

Genotyping reports are issued to phs.giz@phs.scot for appropriate distribution and communication.

If a NHS health board contacts WoSSVC directly then a genotyping report will also be sent to that NHS health board.

Oral fluid testing

Oral fluid testing is not offered as a testing service in Scotland.

Where the UKHSA guidance recommends oral fluid testing this does not apply in Scotland.

Specialist Virology Centre (SVC) details

Contact your SVC for advice.

Management of outbreaks

An outbreak should be considered when epidemiological and/or microbiological associations suggesting wider spread have been established.

Multi-agency response

A multi-agency response is required to manage local outbreaks of hepatitis A.

For example, in:

• a school
• a hospital
• residential care
• prisons
• migrant accommodation
• the community

A problem assessment group (PAG) or incident management team (IMT), should be convened by the local HPT.  

For details of membership and actions of an IMT refer to the management of public health incidents: guidance on the roles and responsibilities of NHS led incident management teams.

Where the source of infection is unknown then a PAG may also be used to risk assess a setting attended by the case.  

Membership

The membership of a PAG or IMT is based on the judgement of the local Consultant in Public Health (CPH).

The PAG or IMT may include representation from:

• Any relevant PHS topic teams
  • PHS Gastrointestinal and Zoonoses (GIZ) Team
  • PHS Border Health and Emerging Infections (BHEI) Team
  • PHS Bloodborne Virus and Sexually Transmitted Infections (BBVSTI) Team
  • PHS Vaccine and Immunisations Division (VAID)
• Food Standards Scotland (for foodborne outbreaks)
• infection prevention and control team (IPCT)
• local authority environmental health team
• local infectious disease team (adult or paediatric)
• local virology laboratory
• NHS health protection teams
• NHS board or local authority communications team
• reference laboratory
• Scottish National Blood Transfusion Service (SNBTS)
• setting representative – for example, head teacher or care home manager 

Membership is not limited to the these agencies. It should be adapted based on the context of each situation.

For example, sexual health representatives should be included if a cluster has been identified within the GBMSM community.

Considerations of the PAG/IMT

Gather as much information as possible to inform the risk assessment before the PAG / IMT is convened.

The PAG/IMT should:

• discuss and confirm the initial outbreak response by confirming the validity of information on which outbreak is based
• consider the epidemiology
• review laboratory results
  • serology or PCR results and consider the timing of samples in relation to onset of symptoms
  • sequencing results
• risk assess the likelihood of continuing public health risk to guide decision-making and implement immediate control measures
• consider the operational details for implementing immunisation in schools, community or residential care settings. For example:
  • funding
  • staffing
  • patient group direction (PGD)
  • procurement
  • cold chain
  • venue options
  • suitability
• agree communications strategy and lead organisation for media responsibility
• review actions already taken and consider future control interventions. For example:
  • post exposure prophylaxis
  • local authority environmental health assessment
  • reinforcing hygiene
  • communications
  • wider immunisation
  • exclusions from work
• Agree the definition for end of the outbreak – for example, no linked cases over 2 incubation periods

Foodborne outbreak

Where an IMT undertakes an investigation of a potentially foodborne hepatitis A outbreak, guidance on the management of outbreaks of foodborne illness in Scotland should be followed.

This guidance includes advice on:

• roles and responsibilities during a foodborne investigation
• the use of trawling questionnaires and analytical epidemiology
• food chain investigations, including the seizure or detention of implicated products and inspection of premises
• laboratory investigation, including the use of sequencing
• communications

Overseas travel outbreak

In the event of an outbreak associated with overseas travel, email the PHS Gastrointestinal and Zoonoses (GIZ) Team at phs.giz@phs.scot

The GIZ Team will then communicate with other relevant teams as required.

If close contacts are identified who would be subject to follow-up in the UK but have travelled overseas, contact the PHS GIZ Team in the first instance for advice. The GIZ Team will redirect if appropriate.

Sexual transmission outbreak

If a cluster of cases suggests a potential outbreak associated with sexual transmission, email the PHS Bloodborne Virus and Sexually Transmitted Infections (BBVSTI) Team at phs.bbvsti@phs.scot

They can support communications and engagement with sexual health colleagues.

Gay, bisexual and men who have sex with men (GBMSM) are already recommended as an eligible group to receive pre-exposure immunisation. For more information, see Hepatitis A: the green book, chapter 17.

Further transmission of HAV may be reduced by control measures to reduce sexual transmission noting sex that may involve contact with faeces – such as anal sex or ano-oral contact – increases the risk. 

Engagement with healthcare may also be used as an opportunity to advise GBMSM to seek sexual health advice and testing for other sexually transmitted infections (STIs), including HIV.

Information on sexual health services available to GBMSM is on NHS inform.

Outbreak control measures

Vaccine and human immunoglobulin (HNIG)

Monovalent hepatitis A vaccine is the preferred prophylaxis for use in an outbreak setting.

Those immunised should be informed that they should receive a second dose of vaccine 6 to 12 months after the first dose to ensure long term protection. However, this second dose is not necessary as part of outbreak control.

HNIG should be offered in addition to vaccine only for those:

• who are at particular risk of severe disease (see actions for non-immune close contacts)
  and
• if they fulfil the criteria for a close contact after a detailed risk assessment has been conducted.

HNIG is given as post-exposure prophylaxis in this situation.

If they do not fulfil the close contact criteria but immunisation is being offered to this individual to interrupt wider transmission in the population then vaccine only should be offered.

Vaccine and HNIG procurement

Vaccine supplies are managed by local vaccine holding centres.

Refer to the accessing HNIG section for information on how to obtain HNIG.

Vaccine delivery

Venues for delivering prophylaxis vaccination in Scotland include:

• schools
• local vaccination centres
• mobile vaccine bus
• places of worship
• community centres

Excellent community communications and social mobilisation are needed for adequate vaccine coverage to interrupt transmission in the wider community.

Infection prevention and control

HPTs should provide support and advice to non-hospital settings on infection prevention and control (IPC) required during an outbreak.

This includes advice on:

• enhanced environmental cleaning, including cleaning regimes and any additional products required
• hand washing

See the hygiene advice section for more information.

Outbreaks in closed or community settings

Oral fluid testing is not available in Scotland. Therefore, advice in the UKHSA guidance recommending oral fluid testing is not applicable in Scotland.

Educational settings

A risk assessment should be undertaken when there is an outbreak in an educational setting.

It should consider whether:

• a human source in school is most likely
• a population at risk can be defined (same class, same year, multiple years or whole school or nursery)
• improved hygiene will be sufficient to interrupt transmission
• there is evidence of spread in the wider community which may require a broader approach

Control measures

Transmission of the virus is more likely to occur in early years and primary classes as children are less likely to have practiced hand hygiene effectively.

Wider immunisation is recommended.

Wider immunisation is not typically recommended in secondary schools if hygiene practices are considered sufficient to interrupt transmission.

The IMT should assess the need for:

• proactive vaccination
• strategies to improve vaccine uptake
• ways to investigate transmission within the setting

Consult additional resources to support these actions.

For example:

• vaccine hesitancy resources
• Health protection in children and young people settings (including education) guidance

Care homes

In addition to post-exposure vaccination, consider wider immunisation of staff and residents during outbreaks in care homes.

This is due to the limited impact of hygiene alone in these settings and the complex mixing of staff and residents.

Conduct a risk assessment to determine whether immunisation should target a defined subgroup – for example, a specific unit or floor – or the entire home.

Factors to consider

• Are the cases among staff, residents, or both?
• Is the source likely food-related or person-to-person?
• Are the cases located in the same area or linked by shared staff?
• Do genotyping and sequencing suggest linked cases?
• Can an at-risk group be clearly defined?
• How long has it been since symptom onset in the cases?
• What are the logistical challenges (e.g., size of the home) in offering vaccine or HNIG?

A visit to assess the home's layout, staff duties, infection control, and hygiene practices may be helpful to support the assessment.

See Care Home Infection Prevention and Control Manual (CHIPCM) for IPC advice in care home settings.

Community settings

In a community outbreak with person-to-person transmission:

• reinforce hygiene practices and raise awareness of importance
• consider vaccination strategies, for example, mass vaccination or targeting household and close contacts

Vaccination strategy

The risk assessment for selecting a vaccination strategy should consider:

• transmission networks – for example, household, social networks, adults versus children – to define the at-risk population
• community size – for example, small area (such as village or town) or a large urban area
• proportion of population that are susceptible and expected vaccine uptake

Implementation of community-wide vaccination depends on:

• local intelligence – for example, if school-aged children are driving the outbreak, vaccinating in schools can be effective by targeting a high-risk group and creating a buffer of immune children to prevent further spread
• public acceptance
• staffing and financial resource
• availability of suitable vaccination venues

Guidance development methods

This guidance (adaptation) is for health protection staff in Scotland.

It is adapted from UKHSA Hepatitis A: public health management guidance.

Guidance development process

Method

This guidance was developed in line with the the health protection guidance: method for guidance development.

Guidance development group (GDG)

A multidisciplinary Guidance Development Group (GDG) was convened to produce this guidance.

The GDG had representation from:

• NHS board health protection teams (HPT)
• PHS Bloodborne Virus and Sexually Transmitted Infections Team
• PHS Gastrointestinal and Zoonoses Team
• PHS Guidance Team
• PHS Public Health Microbiology Team
• PHS Vaccine and Immunisations Division
• Reference laboratory
• Scottish Government
• UKHSA

Evidence base

As set out in the method, an Appraisal of Guidelines for Research and Evaluation (AGREE2) assessment was undertaken by PHS.

The purpose of this was to assess the quality of the UKHSA guidance and determine whether it would be suitable to adapt for use in Scotland. The AGREE2 assessment was informed by the content of UKHSA guidance and through an interview with the authors of the UKHSA guidance.

Based on the findings from this review it was agreed by the GDG that adaptation of the UKHSA guidance was acceptable.

The GDG agreed that the evidence base underpinning the UKHSA guidance recommendations should be used to inform the Scottish adaptation to support the use of the guidance in Scotland.

No additional literature search or review was conducted by the GDG for the Scottish adaptation. Instead, expert input from the GDG was sought to address areas where processes and pathways differ from the UKHSA guidance.

Evidence to recommendation

The GDG considered the UKHSA guidance recommendations in the Scottish context. They also developed recommendations for the specific Scottish processes and pathways.  

The draft guidance underwent multiple rounds of review by the GDG through email exchanges and meetings.

Final recommendations were agreed upon through informal consensus.

Consultation

The UKHSA guidance and the Scottish adaptation were circulated for consultation with a wide range of stakeholders.

The consultation took place in September 2024 and was open for around 2 weeks.

The consultation responses were reviewed by the GDG and the guidance was updated accordingly.

Approval and review

This guidance has been approved by the SHPN and PHS.

In line with the SHPN method the guidance will be reviewed at least every five years.

Equality impact assessment (EIA)

An EQIA was undertaken to consider any unintended or differential impact or risks arising from implementing the recommendations in the guidance.

It evaluated the variable impact of the guidance on different groups in society.

For example:

• children versus adults
• deprived versus wealthy
• by gender

Where variable impacts were identified, the GDG discussed and adapted the guidance to minimise impacts.

Download the EQIA

View the external guidance

When using this guidance, remember to check whether the recommendations for use in Scotland provided by SHPN have been updated.