August 6, 2019
Situation:
Washington State Department of Health (DOH) has announced the outbreak of Hepatitis A within Washington State. Multiple states across the country have reported outbreaks of Hepatitis A, primarily among persons experiencing homelessness and persons who use illicit drugs. Since the outbreaks were first identified nationally in 2017, 25 states have publicly reported over 22,500 cases and 13,000 hospitalization. Rates of hospitalization are higher than typical for Hepatitis A infections, and severe complications have been reported, including liver transplantation or death; at least 221 deaths have occurred nationwide.
As of 7/31/19, DOH reports a total of fourteen cases of people who are living homeless or who use drugs since April 1, including one confirmed case in Snohomish County and three confirmed cases in King County. Nine confirmed cases live in Spokane County.
Action requested:
- Screen patients for the risk factors of a history of homelessness or injection drug use and offer Hepatitis A vaccination
- Report suspect cases of Hepatitis A to Snohomish Health District, 425.339.5278
Hepatitis A Clinical Presentation and Testing:
- An acute illness with a discrete onset of any sign or symptom consistent with acute viral hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal pain, or dark urine)
- AND a) jaundice or elevated total bilirubin levels ≥ 3.0 mg/dL, OR b) elevated serum alanine aminotransferase (ALT) levels >200 IU/L, AND c) the absence of a more likely diagnosis.
- If symptomatic and elevated liver enzymes, order a PCR test for hepatitis A virus. The benefit to a + PCR (vs. hepatitis A IgM) is that genotyping can be done on PCR.
People at highest risk for getting hepatitis are:
- People living homeless, especially those living unsheltered without good access to sanitation, hygiene and handwashing facilities
- People who are living with or caring for a person who already has Hepatitis A
- People who have sex with people with Hepatitis A
- Men who have sex with men (MSM)
- Illicit drug users (does not have to be injection drugs)
- People with clotting disorders like hemophilia
- International travelers
- People with chronic liver disease, including Hepatitis B and Hepatitis C are at increased risk for severe infection
Confirmed Case Criteria for Hepatitis A:
- A case that meets the clinical criteria and is IgM anti-HAV positive OR
- A case that has Hepatitis A virus RNA detected by PCR OR
- A case that meets the clinical criteria and occurs in a person who had contact (e.g., household or sexual) with a laboratory-confirmed hepatitis A case 15-50 days prior to onset of symptoms.
- And not otherwise ruled out by IgM anti-HAV or NAAT for Hepatitis A virus testing performed in a public health laboratory.
Transmission and Infection Control:
Hepatitis A can spread easily in communities experiencing homelessness and crowded settings where handwashing facilities are limited and sanitation is poor. Healthcare providers should be vigilant for potential Hepatitis A infections among persons who are at increased risk, including persons living homeless, persons who use illicit drugs (injection and noninjection), alcohol, and men who have sex with men (MSM).
The best way to prevent Hepatitis A infection is through vaccination with the Hepatitis A vaccine. In February 2019, CDC recommended all persons aged ≥1 year experiencing homelessness be immunized against Hepatitis A. Primary care providers, acute care facilities, and emergency departments should offer Hepatitis A vaccine during clinical encounters to persons at increased risk, Including persons experiencing homeless.
Additional Resources
https://www.doh.wa.gov/HepatitisA2019
https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders
https://www.cdc.gov/hepatitis/hav/