Health Alert
OUTBREAK OF HEPATITIS A VIRUS (HAV) INFECTIONS AMONG PERSONS WHO USE DRUGS AND PERSONS EXPERIENCING HOMELESSNESS

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

Summary

The Centers for Disease Control and Prevention (CDC) and state health departments are investigating hepatitis A virus (HAV) outbreaks in 10 states among persons reporting drug use and/or homelessness and their contacts. This Health Alert Network (HAN) notification alerts health care providers, facilities, and programs providing services to affected populations, about these outbreaks of HAV infection and provides guidance to assist in identifying and preventing new infections.

To date, Delaware does not have any reported HAV infections associated with this outbreak or with person-to-person transmission, but DPH is heightening surveillance and providing CDC recommendations to medical providers.

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.

From January 2017 to April 2018, the CDC received more than 2,500 reports of HAV infections associated with person-to-person transmission from multiple states. Of the more than 1,900 reports for which risk factors are known, more than 1,300 (68 percent) of the infected persons report drug use (injection and non-injection), homelessness, or both. As of July 6, health departments in 10 states reported 3,793 cases, including 2,445 hospitalizations and 57 deaths. State response to the outbreaks increased vaccine demand resulting in constrained supplies but vaccine is now more readily available. The CDC and vaccine manufacturers continue to monitor demand for adult hepatitis A vaccine.

DPH is increasing surveillance, monitoring high risk populations, contacting homeless shelters to advise them of the outbreak and implementing a risk-based plan for vaccination.

Recommendations

1. Consider HAV as a diagnosis in anyone with jaundice and clinically compatible symptoms.
2. Encourage persons who have been exposed recently to HAV and who 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 (see https://www.cdc.gov/hepatitis/outbreaks/InterimOutbreakGuidance-HAV-VaccineAdmin.htm for additional information).
3. Consider saving serum samples for additional testing to assist public health officials in the investigation of transmission (i.e., confirmation of antibody test, HAV RNA test, genotyping, and sequencing). Contact DPH for assistance with submitting specimens for molecular characterization.
4. Ensure all persons diagnosed with hepatitis A are reported to DPH in a timely manner:
   1. Call 302-744-4990 during regular hours or toll-free at 1-888-295-5156 (available 24/7)
   2. Fax: 302-223-1540
   3. Lab reports also reach DPH electronically via DERSS
5. Encourage hepatitis A vaccination for homeless individuals in areas where hepatitis A outbreaks are occurring.
6. Encourage hepatitis A vaccination for persons who report drug use or other risk factors for hepatitis A.
7. 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:
      • Persons traveling to, or working in, countries that have high or intermediate endemicity of hepatitis A;
      • 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 or adopted children newly arriving from countries with high or intermediate hepatitis A endemicity; and
      • Persons with direct contact with persons who have hepatitis A.
      • Persons who are at increased risk for complications from hepatitis A, including people with chronic liver diseases, such as hepatitis B or hepatitis C.
      • Any person wishing to obtain immunity.

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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