Health Advisory
HEPATITIS A OUTBREAK IN PENNSYLVANIA: INCREASE VACCINATION OF HIGH RISK PATIENTS TO PREVENT AND CONTROL TRANSMISSION

The Delaware Division of Public Health (DPH) is issuing this health advisory to advise health care providers of an ongoing outbreak in multiple states among persons reporting drug use and/or homelessness and their contacts.

Summary

Across the United States, several states, including West Virginia and Ohio, continue to experience large, ongoing Hepatitis A Virus (HAV) outbreaks primarily among people who use drugs and/or are experiencing homelessness. An HAV outbreak was recently declared in Pennsylvania, as an 80 percent increase in reported HAV cases among persons with and without specific risk factors has occurred statewide in 2018. Allegheny County in western Pennsylvania experienced a sudden case increase last month. In Philadelphia, HAV transmission has been elevated since July 2017, with the majority of cases (21 of 38, or 55 percent) occurring among men who have sex with men (MSM).

Background

HAV infection is a vaccine-preventable illness. The primary means of HAV transmission in the United States is typically person-to-person through the fecal-oral route. 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., hepatitis B and C infections, chronic liver disease), infection can lead to serious outcomes, including death.

The sudden HAV increases in western Pennsylvania along with ongoing outbreaks across the U.S. highlight the potential for additional HAV increases in Philadelphia as well as Delaware due to proximity to larger outbreaks and/or expanded transmission among risk groups, especially people who use drugs and/or are homeless.

Recommendations

To prevent further HAV increases, area providers should increase efforts to provide HAV vaccine during health care visits. In addition to routine vaccination for all children ages 12 to 23 months, providers should routinely screen and offer HAV to high-risk children and adults, including:

• Patients ages 12 months and older who are currently homeless or who have had periods of homelessness in the past (newly-approved Advisory Committee on Immunization Practices' [ACIP] recommendation)
• Patients who use injection or non-injection drugs
• Patients who identify as MSM or who have a sex partner identifying as MSM

Safe and highly effective HAV vaccines are available for persons ages 12 months and older and should be administered in accordance with ACIP recommendations (two doses given 6 to 18 months apart).

While Delaware has not seen an increase in HAV infections to date, DPH is encouraging those at risk to seek HAV vaccination and offering free vaccine to high-risk individuals in homeless shelters:

Those without insurance can receive the HAV vaccine at the DPH clinics listed below.

New Castle County:

• Porter State Service Center, 509 W. 8th St., Wilmington, DE 19801 302-777-2860
• Hudson State Service Center, 501 Ogletown Road, Newark, DE 19711 302-283-7587

Kent County:

• Williams State Service Center, 805 River Road, Dover, DE 19901, 302-857-5140

Sussex County:

• Thurman Adams State Service Center, 544 S. Bedford St., Georgetown, DE 19947, 302-515-3220

Prompt recognition of HAV is important to control transmission and allow time-sensitive administration of post-exposure prophylaxis (PEP) to exposed contacts.

• Consider HAV for patients, particularly those who are high risk, who present with fever, fatigue, and signs of liver damage — dark urine, clay colored or pale stools, jaundice, abdominal pain, nausea, and vomiting.
• Test serum from suspected, symptomatic cases for HAV IgM and perform liver function tests.
• Educate HAV cases on measures to prevent transmission (i.e., handwashing, safe sex practices, etc.).
• Recommend HAV Post-Exposure Prophylaxis for susceptible, close contacts (i.e., household members, sex partners). Updated guidance from CDC is available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6743a5.htm?s_cid=mm6743a5_e.

Reporting

• Promptly report acute HAV cases to DPH by calling 302-744-4990 (after hours, call 1-888-295-5156).

Additional Information

• Centers for Disease Control and Prevention. Division of Viral Hepatitis A Outbreak Website.
  https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm
• Centers for Disease Control and Prevention's Hepatitis A Virus Website.
  https://www.cdc.gov/hepatitis/hav/index.htm
• Centers for Disease Control and Prevention. Viral Hepatitis Surveillance – United States, 2016.
  https://www.cdc.gov/hepatitis/statistics/2016surveillance/pdfs/2016HepSurveillanceRpt.pdf
• Centers for Disease Control and Prevention. Hepatitis A General Information Fact Sheet.
  https://www.cdc.gov/hepatitis/hav/pdfs/hepageneralfactsheet.pdf
• Centers for Disease Control and Prevention. The Pink Book. Chapter 9: Hepatitis A.
  https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepa.pdf
• Delaware Adult Viral Hepatitis Program
  http://www.dhss.delaware.gov/dph/dpc/hepatitis.html
• Delaware Immunization Program
  http://www.dhss.delaware.gov/dph/dpc/immunize.html
• Call DPH Bureau of Communicable Diseases 302-744-1050

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