An Emergency Department-Based Response to the Hepatitis A Outbreak in Michigan: Improving Hepatitis A Vaccination Rates in High-Risk Populations.

Document Type

Conference Proceeding - Restricted Access

Publication Date


Publication Title

Annals of Emergency Medicine


Study Objectives

A non-food-borne hepatitis A outbreak occurred in Michigan between August 2016 and September 2019, resulting in 920 cases, 738 hospitalizations, and 30 deaths. To support the Michigan Department of Health and Human Services’ efforts to increase hepatitis A vaccination rates among high-risk individuals, our multicenter health system implemented an electronic medical record (EMR)-based vaccination intervention across its nine emergency departments (ED). The primary objective of this retrospective cohort and survey analysis was to quantitatively determine whether this intervention was successful in increasing vaccination rates. The secondary objective was to qualitatively assess the attitudes towards, and barriers to use of, the computerized vaccine reminder system.


All patients 18 years or older who arrived to any of the nine EDs between August 2018 and January 2020 were screened using an electronic nursing questionnaire embedded in the EMR (Epic). If a patient was determined to be high-risk based on the questionnaire (homeless, incarceration history, illicit drug use, liver disease, or a man who has sex with men), an electronic best practice advisory (BPA) would trigger and give the patient’s physician the option to order the hepatitis A vaccine. If consented, patients would receive a one-time dose of the hepatitis A vaccine in the ED. We also administered a survey to physicians and nurses to evaluate perceptions and barriers to use of the EMR intervention.


During the pre-intervention period from August 2016 to July 2018, 885,344 patients visited the EDs. 49 vaccines were ordered (5.5 per 100,000 patients) and 34 were administered (3.8 per 100,000 patients). During the intervention period from August 2018 to January 2020, 774,034 patients visited the EDs and 574,865 (74.3%) were screened. Of those screened, 11,016 patients were found to be high-risk and triggered the BPA. Among this group of patients, 1,929 vaccines were ordered (249 per 100,000 patients) and 883 were administered (114 per 100,000 patients). We also found that during the intervention period, an additional 565 vaccines were ordered and 322 vaccines were administered without a BPA prompt. Nurses consistently screened 70-80% of patients per month. Physicians were initially more compliant with the BPA’s use (301 vaccines in September 2018), but compliance declined over time (67 vaccines in January 2020) (Graph 1). Surveys revealed that two major barriers to consistent BPA use by physicians was lack of time and the perception that vaccinations are low-priority in the ED.


EMR screening tools and BPAs can be utilized in the ED as an effective strategy to vaccinate high-risk individuals. This may be translatable to outbreaks of other vaccine-preventable illnesses like influenza, measles, or SARS-CoV-2. Providing recurrent education about the importance of public health initiatives and eligibility criteria for vaccine administration are needed to sustain compliance. It is essential to frequently audit and provide feedback to physicians on their compliance, and address their concerns about barriers to use.





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American College of Emergency Physicians Research Forum, Boston, MA, October 25-28, 2021.