Update - Outbreak of Hepatitis A Infections Among Persons Who Use Drugs and Persons Experiencing Homelessness

Posted August 23, 2019. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Since our last Health Alert on this topic (sent June 6), an additional six cases of acute hepatitis A virus (HAV) infection have been reported in people experiencing homelessness, for a total of nine cases in Spokane residents. Additional cases have been identified in other counties. The locally acquired cases had jaundice onsets of May 24 to July 14.  All cases have a history of homelessness and drug use during their incubation periods. No common link has been established. SRHD continues to target outreach and immunizations towards persons living homeless and entities serving persons living homeless.

  • 89% hospitalized
  • 67% male, 33% female
  • Age range 28 to 46 (median 35

Widespread HAV outbreaks have been reported across the country since 2016, largely in the same populations. A significant percentage of the 22,500 reported cases have resulted in hospitalizations (59% of cases) and at least 221 deaths, representing the vulnerability of these populations.

Recommendations

  • Consider HAV as a diagnosis in anyone with jaundice and clinically compatible symptoms including fatigue, fever, headache, joint pain, nausea, vomiting, abdominal pain, loss of appetite, dark urine, and clay-colored stools.
  • Collect specimens for laboratory testing on patients with suspected HAV infection.
    • Consider ordering an acute hepatitis panel and complete metabolic panel/hepatitis function panel to assist with the diagnosis.
    • Consider drawing a specimen for PCR testing and genotyping at the WA State Public Health Lab.
  • Provide persons who have been exposed recently to HAV and have not been vaccinated with one dose of single-antigen HAV vaccine or immune globulin (IG) as soon as possible, within two weeks after exposure. Guidelines vary by age and health status. (Please see https://www.cdc.gov/hepatitis/outbreaks/InterimOutbreakGuidance-HAV-VaccineAdmin.htm for additional information.)
  • Ensure all suspect or diagnosed cases of HAV are reported to SRHD Epidemiology (509-324-1442) within 24 hours, as required by WAC 246-101-101. During an outbreak, suspect cases are reportable.
  • Provide/Encourage HAV vaccination for any homeless individuals.
  • Provide/Encourage HAV vaccination for persons who report drug use or other risk factors. The Centers for Disease Control recommends the following groups be vaccinated against HAV:
    • All children at age 1 year.
    • Persons who are at increased risk for infection:
      • Persons traveling to or working in countries that have high or intermediate endemicity of HAV;
      • Men who have sex with men;
      • Persons who use injection and non-injection drugs;
      • Persons who have occupational risk for infection;
      • Persons who have chronic liver disease;
      • Persons who have clotting-factor disorders;
      • Household members and other close personal contacts of adopted children newly arriving from countries with high or intermediate HAV endemicity; and
      • Persons with direct contact with persons who have HAV.
    • Persons who are at increased risk for complications from HAV, including people with chronic liver diseases, such as cirrhosis, hepatitis B virus (HBV) or hepatitis C virus (HCV).
    • Any person wishing to obtain immunity.

HAV Background

The primary means of HAV transmission in the United States is typically person-to-person through the fecal-oral route (i.e., ingestion of something that has been contaminated with the feces of an infected person). Symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, and jaundice. Although rare, atypical extra-hepatic manifestations include rash, pancreatitis, renal disease, arthritis, and anemia. Severe infections can result in cholestatic hepatitis, relapsing hepatitis, and fulminant hepatitis leading to death. Average incubation of HAV is 28 days, but illness can occur up to 50 days after exposure. An HAV-infected person can be viremic up to six weeks through their clinical course and excrete virus in stool for up to two weeks prior to becoming symptomatic, making identifying exposures particularly difficult. Illness from HAV is typically acute and self-limited; however, when this disease affects populations with already poor health (e.g., HBV and HCV infections, chronic liver disease), infection can lead to serious outcomes, including death. Eighty-nine percent of local cases in this outbreak have been hospitalized, which is a significantly higher percentage than the national average of 59% for recent outbreaks in other communities across the country.

The best way to prevent HAV infection is through vaccination with the HAV vaccine. The immunogenicity of one dose of HAV vaccine is 94-100%. The second dose helps ensure lifetime immunity. The number and timing of the doses depends on the type of vaccine administered. Vaccines containing HAV antigen that are currently licensed in the United States are the single-antigen vaccines HAVRIX® (manufactured by GlaxoSmithKline, Rixensart, Belgium) and VAQTA® (manufactured by Merck & Co., Inc., Whitehouse Station, New Jersey) and the combination vaccine TWINRIX® (containing both HAV and HBV antigens; manufactured by GlaxoSmithKline). All are inactivated vaccines. GamaSTAN S/D (Grifols Therapeutics, Inc., Research Triangle Park, North Carolina) immune globulin (IG) for intramuscular administration is the only IG product approved for HAV prophylaxis. The efficacy of IG or vaccine when administered greater than two weeks after exposure has not been established.

HAV is a disease of poor sanitation conditions therefore practicing good hand hygiene—including thoroughly washing hands with warm water and soap after using the bathroom, changing diapers, and before preparing or eating food—plays an important role in preventing the spread of HAV in all segments of the community.

For more information: https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm

NEW Free continuing education activity available from CDC’s MMWR and Medscape -- Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness.