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

Posted Nov. 21, 2019. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Since June 2019, 58 cases of hepatitis A virus (HAV) infection have been reported in Spokane residents. Infections have largely occurred in people experiencing homelessness and/or using drugs. Additional cases have been identified in other counties, including a smaller number of cases in King and Yakima counties. SRHD continues to target outreach and immunizations towards persons living homeless and entities serving persons living homeless. SRHD has provided more than 1,500 vaccinations to persons at risk since the start of the outbreak.

  • Total cases: 58
  • 69% hospitalized
  • 60% male, 40% female
  • Age range 24 to 72 (median 41.5)
  • 86% with risk factors of known substance abuse and/or homelessness
  • 35% with evidence of viral hepatitis co-infection
  • 2% (n=1) partially immunized, the rest unvaccinated
  • >50% with incarceration within the 12 months preceding onset of symptoms

In an outbreak, suspect cases of hepatitis A infection are reportable. If a patient presents with risk factors and clinically compatible symptoms (jaundice with abdominal pain, fatigue, nausea, vomiting, and diarrhea), please call SRHD Epidemiology at 509.324.1442 during business hours or 509.869.3133 after hours. Assistance is requested to engage with the suspect case about their close contacts and living situation in order to assist with providing post-exposure prophylaxis for exposed individuals. Once a case is discharged from the hospital, emergency department or urgent care, it has been very difficult for SRHD staff to locate the case for a contact investigation.

Please recommend post-exposure prophylaxis to all close contacts of someone with hepatitis A. Close contacts include significant others; household contacts or equivalent (i.e., people who camp together); and people who share items such as food, cigarettes, or drugs with a case while contagious (two weeks prior to onset of jaundice and one week after). Single antigen hepatitis A vaccine is recommended as soon as possible and up until two weeks after an exposure. Immune globulin (IG) can be offered to patients over 40, depending on a provider’s risk assessment. Persons who are over 12 months of age and are immunocompromised or have chronic liver disease should receive both hepatitis A vaccine and IG simultaneously. GamaSTAN™ S/D is the only IG product approved in the United States for HAV post-exposure prophylaxis and is only locally available at Providence Sacred Heart Medical Center in very limited supply. HAV vaccine is available from many pharmacies and can be given for free to at-risk persons at the Providence House of Charity Clinic (32 W 2nd Ave). See guidance for HAV post-exposure prophylaxis available from the CDC website.

Someone with hepatitis A infection is contagious for two weeks prior to onset of jaundice until one week after. Please consider this when discharging someone from the hospital back to the street or a shelter.

Vaccination against hepatitis A is extremely effective and the primary strategy for interrupting this outbreak. Vaccination is recommended for people living homeless, people using injection and non-injection drugs, and anyone who wishes to be immune to hepatitis A. Widespread vaccination campaigns have been shown to stop outbreaks of hepatitis A. Please consider vaccinating patients who present with risk factors with either single antigen HAV vaccine or hepatitis A/B combination vaccine when appropriate, as protection for hepatitis A is high with both types of vaccine after just one dose (≈93.8% with TWINRIX®, higher for single antigen vaccine). See outbreak-specific guidance for HAV vaccine administration from the CDC.

Additionally, while there is no requirement that food service workers be vaccinated against hepatitis A, SRHD recommends vaccination to people working in food service to avoid potential transmission related to this outbreak. Past alerts and advisories containing information on hepatitis A and other communicable-disease topics can be found here: srhd.org/for-health-care-providers.