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

Spokane Regional Health District (SRHD) has been notified of three acute hepatitis A infections since late April in people experiencing homelessness. The first case was acquired out of state and had a jaundice onset of April 12. The other two cases were likely acquired locally with jaundice onsets of May 24 and June 1. All three cases have a history of homelessness and drug use during their incubation periods. Widespread hepatitis A outbreaks have been reported across the country since 2016, largely in the same populations. A significant percentage of the nearly 11,000 reported cases have resulted in hospitalizations (57% of cases) and at least 185 deaths, representing the vulnerability of these populations.

Recommendations
  1. Consider hepatitis A 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.
  2. Collect specimens for laboratory testing on patients with suspected HAV infection.
    1. Consider ordering an acute hepatitis panel and complete metabolic panel/hepatitis function panel to assist with the diagnosis.
  3. Encourage persons who have been exposed recently to HAV and have not been vaccinated to be administered one dose of single-antigen hepatitis A 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/... for additional information.)
  4. Ensure all persons diagnosed with hepatitis A are reported to Spokane Regional Health District (SRHD) Epidemiology (509-324-1442) within 24 hours of diagnosis, as required by WAC 246-101-101.
  5. Encourage hepatitis A vaccination for homeless individuals.
  6. Encourage hepatitis A vaccination for persons who report drug use or other risk factors for hepatitis. The CDC recommends the following groups be vaccinated against hepatitis A:
    1. All children at age 1 year.
    2. Persons who are at increased risk for infection:
      1. Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A;
      2. Men who have sex with men;
      3. Persons who use injection and non-injection drugs;
      4. Persons who have occupational risk for infection;
      5. Persons who have chronic liver disease;
      6. Persons who have clotting-factor disorders;
      7. Household members and other close personal contacts of adopted children newly arriving from countries with high or intermediate hepatitis A endemicity; and
      8. Persons with direct contact with persons who have hepatitis A.
    3. Persons who are at increased risk for complications from hepatitis A, including people with chronic liver diseases, such as cirrhosis, hepatitis B or hepatitis C.
    4. Any person wishing to obtain immunity.
Hepatitis Background

Hepatitis A infection is a vaccine-preventable illness. The primary means of hepatitis A virus (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 hepatitis A is typically acute and self-limited; however, when this disease affects populations with already poor health (e.g., hepatitis B and C infections, chronic liver disease), infection can lead to serious outcomes, including death.

The best way to prevent hepatitis A infection is through vaccination with the hepatitis A vaccine. 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 hepatitis B virus 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. Additionally, practicing good hand hygiene—including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food—plays an important role in preventing the spread of hepatitis A.

Person-to-person transmission of HAV between persons who report drug use and/or homelessness could result from contaminated needles and other injection paraphernalia, specific sexual contact and practices, or from generally poor sanitary conditions. Transience, economic instability, limited access to healthcare, distrust of public officials and public messages, and frequent lack of follow-up contact information makes this population difficult to reach for preventive services, such as vaccination, use of sterile injection equipment, and case management and contact tracing. These challenges make outbreaks among these groups difficult to control. Rapid identification, a comprehensive response, and novel public health approaches may be required to address needs unique to these populations. Urgent action is needed to prevent further HAV transmission among these risk groups. For more information: https://www.cdc.gov/hepatitis/...