An outbreak of hepatitis A: school toilets as a source of transmission

An outbreak of hepatitis A associated with a Middle school involved 23 cases; 17 were pupils attending the Middle school, one was a teacher, one was a relative of a case, and four were from the associated First school, of whom three had siblings in the Middle school. The probable source case was a male pupil infected by a sibling who had contracted hepatitis A while abroad on holiday. A questionnaire survey and salivary IgG and IgM anti-HAV testing of the pupils demonstrated a statistically significant association between infection and the use of a changing room toilet for defecation. An inspection of the school showed that toilets lacked toilet paper, soap and hand towels. Advice was given to pupils, parents and staff on hygiene. Human normal immunoglobulin was administered to susceptible family contacts, pupils and staff at the school. The school outbreak might have been prevented if the source case for the school had been given immunoglobulin when his sibling developed hepatitis A.