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April 18, 2019

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  • Be aware of a case of locally-acquired acute hepatitis A virus (HAV) in a King County adult who is living homeless.
  • We estimate the patient was most likely to be infectious from March 25th through April 19th, 2019 and spent significant time at the following locations:
    • Jefferson Day Center, operated by the Salvation Army (Seattle)
    • Victory Outreach Church (White Center)
    • Seattle City Hall Shelter
    • On the street along downtown Seattle’s 3rd Ave corridor (“The Blade”)
  • Consider HAV infection in patients with compatible symptoms including:
    • Fatigue, fever, headache, joint pain, nausea, vomiting, abdominal pain, loss of appetite, dark urine, clay-colored stools and jaundice.
    • 70% of older children and adults develop symptoms including jaundice; 70% of infections in children <6 years of age are asymptomatic.
  • Collect specimens for laboratory testing on patients with suspected HAV infection:
    • Serum for hepatitis A IgM and liver enzymes (including ALT, AST).
    • Consider testing for hepatitis B (HBsAg and IgM) and hepatitis C (antibody/EIA) virus infections.
  • Ask patients about risk factors, including homelessness or unstable housing, sexual history, travel history, injection and non-injection drug use, contact with other ill persons, and obtain information about potentially exposed household members and other contacts.
  • Educate patients with HAV infection that they are most contagious (fecal-oral route) for 2 weeks before through 1 week after the onset of jaundice, and possibly longer if they have persistent diarrhea.
  • HAV postexposure prophylaxis (PEP) regimens vary by age and health status, see link below. Public Health is available for consultation on when PEP is indicated.
  • Routinely offer and/or recommend HAV vaccine to persons at increased risk, including those living homeless, and educate patients regarding risk for HAV infection. In addition, HAV vaccine should be offered to anyone who wishes to reduce their risk of infection.
  • Report confirmed and suspected HAV cases to Public Health at (206) 296-4774.

On April 17, 2019, Public Health received a report of locally-acquired HAV infection in a person living homeless. During the exposure period, as far as we are aware, this person primarily resided on the street in downtown Seattle (3rd Ave corridor) and in the King County Correctional Facility (500 5th Ave, Seattle), but also spent time at multiple Seattle area shelters and day centers, and received meals from multiple locations serving communities experiencing homelessness. HAV 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 HAV infections among persons who are at increased risk, including persons living homeless, persons who use drugs (injection and non-injection), and men who have sex with men (MSM). The best way to prevent HAV infection is through vaccination with the hepatitis A vaccine.

Multiple states across the country have reported outbreaks of HAV, primarily among persons living homeless and persons who use drugs. Nationally, since 2016, more than 15,000 cases have been reported. Rates of hospitalization are higher than typical for HAV infections, and severe complications have been reported, including liver transplantation or death; at least 140 deaths have occurred nationwide.

Suspected or confirmed cases should be excluded from volunteering and working in sensitive areas (food handling, health care, child care settings), until assessed and released to volunteer/work by Public Health. In addition, identify exposed contacts and recommend/offer HAV PEP.

In February 2019, CDC recommended all persons aged >1 year experiencing homelessness should be routinely immunized against HAV. Primary care providers, acute care facilities, and emergency departments should offer HAV vaccine during clinical encounters to persons at increased risk, including persons living homeless.