Outbreak of Hepatitis A Virus (HAV) Infections – Update

The Pennsylvania Department of Health (DOH) is releasing the following advisory to healthcare providers, “Outbreak of Hepatitis A Virus (HAV) Infections – Update.” This is a statewide follow up to Health Advisory #431. Please report any suspected clusters of hepatitis A by calling DOH at 1-877- PA-HEALTH (1-877-724-3258) or your local health department. Additionally, all cases of acute hepatitis A should be reported via PA-NEDSS. New information is bolded.

Pennsylvania has seen an increase in hepatitis A cases beginning in 2018, and has continued in 2019. A total of 102 cases were reported in 2018, and 34 hepatitis A cases have been reported to date in 2019. Concurrently, multiple U.S. states have been experiencing large, ongoing hepatitis A outbreaks affecting people who use drugs and/or people who are homeless, including neighboring states such as Ohio and West Virginia. In Ohio, 1,931 outbreak-related cases have been reported, and 2,415 cases have been reported in West Virginia.

Arkansas, California, Illinois Indiana, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, New Jersey, Ohio, Tennessee, Utah and West Virginia have also reported outbreaks of Hepatitis A virus since March 2017 (see: https://emergency.cdc.gov/han/han00412.asp https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm).

Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus (HAV) ranging in severity from mild infection lasting a few weeks to severe disease lasting several months. Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person. Hepatitis A can also spread from close personal contact with an infected person such as through sex or caring for someone who is ill. Populations at particular risk during the current outbreaks identified in multiple U.S. states include persons who use injection and non-injection drugs, and/or persons who are homeless, and their close direct contacts, as well as men who have sex with men (MSM).

Given the significant HAV outbreaks seen in other states, there is concern that hepatitis A transmission could rapidly increase in Pennsylvania. Prompt action now can help prevent this from happening. Effective measures include early identification of cases, vaccination of contacts and at-risk populations, enhanced sanitation processes and education.

Recommendations for Health Care Providers and Drug and Alcohol Treatment Centers

1. Consider hepatitis A as a diagnosis in anyone with jaundice or elevated liver enzymes and clinically compatible symptoms of acute hepatitis.
2. Confirm a hepatitis A diagnosis by testing serum for presence of immunoglobulin M (IgM) antibodies to hepatitis A virus
3. 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 2 weeks after exposure. Guidelines vary by age and health status (please see https://www.cdc.gov/hepatitis/outbreaks/InterimOutbreakGuidance-HAV-VaccineAdmin.htm for additional information).
4. 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 the public health department for assistance with submitting specimens for molecular characterization.
5. Ensure all persons diagnosed with hepatitis A are reported to PA-NEDSS in a timely manner.
6. Encourage hepatitis A vaccination for the homeless individuals, persons who report drug use or other risk factors for hepatitis A, such as MSM.
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:
      1. Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A;
      2. Men who have sex with men;
      3. Persons who use injection and non-injection drugs;
      4. Persons who have occupational risk for infection;
      5. Persons who have chronic liver disease; Persons who have clotting-factor disorders;
      6. Household members and other close personal contacts or adopted children newly arriving from countries with high or intermediate hepatitis A endemicity; and
      7. Persons with direct contact with persons who have hepatitis A.
      8. Patients aged 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).
   3. Persons who are at increased risk for complications from hepatitis A, including people with chronic liver diseases, such as hepatitis B or hepatitis C.
   4. Any person wishing to obtain immunity.
8. Please report any suspected clusters of Hepatitis A by calling DOH at 1-877-PA-HEALTH (1-877-724-3258) or your local health department.

Originally released by the Pennsylvania Department of Health on March 13, 2019.