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2017 – Outbreaks of hepatitis A in multiple states among people who use drugs and/or people who are homeless

Overview

Since March 2017, CDCs Division of Viral Hepatitis (DVH) has been assisting several state and local health departments with hepatitis A outbreaks, spread through person to person contact, that have occurred primarily among persons who use injection and non-injection drugs, and/or persons who are homeless, and their close direct contacts.

See related Health Advisory June 11, 2018.  

CDC’s Response:

In response to all hepatitis outbreaks, CDC provides ongoing epidemiology and laboratory support as well as support on vaccine supply and vaccine policy development. When requested, CDC sends “disease detectives” to affected areas to evaluate and assist in an outbreak response.

CDC alerts other public health jurisdictions of any increases in disease. On August 25, 2017, CDC notified all state and local health departments about the investigation of a cluster of hepatitis A, genotype IB infections in people who use injection and non-injection drugs and/or people who are homeless. On June 11, 2018 CDC issued a Health Alert Network (HAN) Advisory to public health departments, healthcare facilities, and public health programs with an update about the outbreaks and guidance to assist in identifying and preventing new infections. All U.S. jurisdictions are encouraged to be watchful for increases in hepatitis A cases and consider submitting recently confirmed hepatitis A virus (HAV) specimens to CDC’s Division of Viral Hepatitis Laboratory. CDC’s Division of Viral Hepatitis Laboratory uses advanced molecular detection to confirm and monitor outbreaks and has tested over 2,500 specimens related to various outbreaks from January 2017 to April 2018. CDC also works with state and local health officials to ensure hepatitis A vaccine is targeted to the correct at-risk populations and that supply is adequate.

Hepatitis A Case Definition

The clinical case definition for acute viral hepatitis A is discrete onset of symptoms consistent with hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and abdominal pain) AND either jaundice or elevated serum aminotransferase levels. Because the clinical characteristics are the same for all types of acute viral hepatitis, hepatitis A diagnosis must be confirmed by a positive serologic test for immunoglobulin M (IgM) antibody to hepatitis A virus, or the case must meet the clinical case definition and occur in a person who has an epidemiologic link with a person who has laboratory-confirmed hepatitis A (i.e., household or sexual contact with an infected person during the 15–50 days before the onset of symptoms).

CDC provides guidance on viral hepatitis surveillance and case management and training on hepatitis A serology.

Advice to Public Health Officials

For the current U.S. outbreaks among people reporting drug use and/or homelessness and their contacts, CDC has encouraged state and local health departments to:

  • Work with community partners to provide hepatitis A vaccine to people who use injection and non-injection drugs, people who are homeless, and others with established risk factors who are not yet immunized
  • Consider hepatitis A vaccination for anyone with ongoing, close contact with people who use injection and non-injection drugs and/or people who are homeless and their contacts

CDC has provided interim outbreak-specific guidance on hepatitis A vaccine administration.

Post exposure prophylaxis (PEP) is recommended for unvaccinated people who have been exposed to hepatitis A virus (HAV) in the last 2 weeks; those with evidence of previous vaccination do not require PEP.

PEP consists of:

 

NOTE: CDC recommends that all children be vaccinated against hepatitis A at age 1 year. Parents or caregivers who are unsure if a child has been vaccinated should consult the child’s health-care provider to confirm vaccination status.

Hepatitis A Vaccination Recommendations

CDC recommends the following groups be vaccinated against hepatitis A:

  • All children at age 1 year
  • Travelers to countries that have high rates of hepatitis A
  • Family members and caregivers of recent adoptees from countries where hepatitis A is common
  • Men who have sexual contact with other men
  • People who use recreational drugs, whether injected or not
  • People with chronic (lifelong) liver diseases, such as hepatitis B or hepatitis C
  • People who are treated with clotting-factor concentrates
  • People who work with hepatitis A infected animals or in a hepatitis A research laboratory

For Additional Information

If you are a state or local health department with questions about outbreak investigation, management, and/or specimens, please email DVH staff.

If you are a practicing clinician with a concern about a potential case of hepatitis A virus infection, please contact your local or state health department.

For all other inquiries, please contact CDC-INFO at 800-CDC-INFO (800-232-4636), TTY: 888-232-6348 or Email CDC-INFO

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