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Frequently Asked Questions: Hepatitis A outbreaks among people who use drugs and/or people who are homeless in multiple states

What are the signs and symptoms of hepatitis A virus (HAV) infection?

Older children and adults typically have symptoms. If symptoms develop, they can appear abruptly and can include:

  • Fever
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting
  • Abdominal pain
  • Dark urine (Brown in color)
  • Diarrhea
  • Clay-colored stools
  • Joint pain
  • Jaundice (yellowing of the skin and eyes)

Does CDC recommend that anyone traveling to states with a hepatitis A outbreak be vaccinated against hepatitis A?

No. CDC does not recommend vaccinating people who do not have known risk factors for hepatitis A infection when they are traveling to U.S. states experiencing hepatitis A outbreaks. In accordance with the Advisory Committee on Immunization Practices for hepatitis A, adults with risk behaviors (e.g., people who use drugs or men who have sex with men), or people who are at increased risk of complications from hepatitis A (e.g., people with chronic liver disease) should be vaccinated, regardless of travel plans.

Who should get vaccinated against hepatitis A in states experiencing outbreaks?

The state and local health departments in affected areas are recommending vaccination of individuals at highest risk of acquiring infection (e.g., people who use injection/non-injection drugs, men who have sex with men, homeless, people who have been recently incarcerated, and people with chronic liver disease).

The following are CDC guidelines for vaccination:

  • During the ongoing U.S. outbreaks among people who use injection and non-injection drugs and/or people who are homeless, CDC recommends that  state and local health departments  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 or people who are homeless

Who should be vaccinated against hepatitis A in places where there is no ongoing HAV outbreak?

The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis A vaccination for the following people:

  • All children at age 1 year
  • Travelers to countries where hepatitis A is common
  • Family and caregivers of adoptees from countries where hepatitis A is common
  • Men who have sexual encounters with other men
  • Users of injection and non-injection drugs
  • Persons with chronic liver disease
  • Persons with clotting-factor disorders
  • Persons who work with HAV-infected primates or with HAV in a research laboratory setting
  • People with direct contact with others who have hepatitis A
  • Any person wishing to obtain immunity (protection)

Are the number of hospitalizations and deaths associated with the outbreaks among people who use drugs and people who are homeless higher than usual? Why?

The numbers of hospitalizations and deaths during these hepatitis A outbreaks have been higher than what is normally reported through national surveillance of hepatitis A. While routine childhood hepatitis A vaccination practices since 1996 have provided higher immunity protections in younger populations, many adults remain susceptible. Hepatitis A often results in severe disease among older people who are not immune from previous vaccination or community-acquired infection. Higher than expected hospitalization rates have been noted in the past among people with pre-existing chronic illnesses (i.e., diabetes, chronic liver disease, cirrhosis). Fulminant liver failure and death from hepatitis A infection are both rare, but are more common in older people when infected.

Are the outbreaks among people who use drugs and/or people who are homeless spreading because of contaminated foods, drinks, or infected food handlers?

No. In these outbreaks, the virus is being spread from person-to-person primarily among people who use injection and non-injection drugs, people who are homeless, and their close direct contacts. Although cases in food handlers occur, common sources of food or drinks have not been identified as potential sources of infection in the jurisdictions experiencing hepatitis A outbreaks.

Why does CDC not recommend all food handlers be vaccinated if an infected food handler can spread disease during outbreaks?

CDC does not recommend vaccinating all food handlers because doing so would not prevent or stop the ongoing outbreaks primarily affecting individuals who report using illicit drugs and people experiencing homelessness. Food handlers are not at increased risk for hepatitis A because of their occupation. During ongoing outbreaks, transmission from food handlers to restaurant patrons has been extremely rare because standard sanitation practices of food handlers help prevent the spread of the virus. Individuals who live in a household with an infected person or who participate in risk behaviors previously described are at greater risk for HAV infection.

What should I do if I have eaten at a restaurant that has reportedly had a hepatitis A-infected food handler?

If you have any questions about potential exposure to hepatitis A, call your health professional or your local or state health department who can help you to learn if you were recently exposed to hepatitis A virus at that restaurant, have not been vaccinated against hepatitis A, and might benefit from an injection of either immune globulin or hepatitis A vaccine. However, the vaccine or immune globulin are only effective if given within the first 2 weeks after exposure. A health professional can decide what is best based on your age, overall health, and the other factors mentioned previously.