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July 6, 2020

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  • Be aware of five confirmed cases of locally-acquired hepatitis A virus (HAV) infection since June 1, 2020 among persons living with HIV (PLWH) and a history if illicit drug use. Three of five cases identified as male; two cases identified as transgender female.
    • Illness onset occurred between 5/18/20 and 6/23/20. All cases are stably housed in either private apartments or permanent supportive housing.
    • Three of 5 cases have previously documented evidence of immunity or vaccination, including 2 cases with HAV IgG documented in 2017, and a third case with one documented dose of Havrix in 2014, but for whom no subsequent HAV IgG results are available.
    • Four cases reported sexual activity with male partners during their exposure period. All reported drug use or close contact with persons reporting injection/non-injection drug use.
    • Additionally, Public Health - Seattle & King County (PHSKC) identified 1 locally acquired-case who is HIV-negative on HIV PrEP and who reports sexual activity with male partners and non-IVDU methamphetamine use.
    • Molecular testing is pending to determine if these cases are associated with the ongoing hepatitis A outbreak among persons living homeless and/or persons who use drugs.

  • 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.

  • Be aware that HAV infection can occur in people with HIV that have been vaccinated or have previously documented immunity.

  • Collect specimens for laboratory testing from patients with suspected HAV infection:
    • Serum for hepatitis A IgM and IgG and liver enzymes (including ALT, AST).
    • Test for hepatitis B (HBsAg; IgM) & hepatitis C (antibody/EIA).

  • 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.
  • Counsel patients with HAV infection about the importance of practicing good hand hygiene – including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food, and 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.

  • Suspected or confirmed cases should be excluded from volunteering and working in sensitive areas (food handling, health care, childcare settings), until assessed by Public Health.

  • Patients with suspected or confirmed hepatitis A who are living homeless should be isolated while infectious.
    • Public Health can assist with coordinating housing of patients living homeless with confirmed or suspected hepatitis A and who do not require hospitalization.
    • Public Health will also work to identify exposed contacts and recommend/offer HAV PEP.

  • HAV postexposure prophylaxis (PEP) regimens vary by age and health status, see link below.
    • Public Health recommends acute care facilities and emergency departments offer hepatitis A vaccine to susceptible individuals at increased risk and when indicated, administer PEP as soon as possible within 2 weeks after exposure.
    • Public Health is available for consultation regarding indications for use of PEP.

  • Report confirmed and suspected HAV cases to Public Health at (206) 296-4774.

  • To avoid missed opportunities, primary care providers, emergency departments, healthcare systems and clinics should routinely offer HAV vaccine at all clinical encounters to persons at increased risk, including those living homeless* and persons who inject drugs, and healthcare providers should counsel patients regarding risk for HAV infection. In addition, HAV vaccine should be offered to anyone who wishes to reduce their risk of infection.
    • Pre-vaccination serologic testing is not necessary before administration of hepatitis A vaccine, and vaccinations should not be postponed if vaccine history is unavailable.
    • ACIP does not currently have recommendation regarding hepatitis A revaccination of PLWH
    • For PLWH & illicit drug use, clinicians should vaccinate persons not previously vaccinated and for previously vaccinated persons may consider additional strategies including:
      • Test for immunity (HAV IgG) and if not immune, repeat the 2-dose hepatitis A vaccine series (with option to repeat HAV IgG testing 1 month later to evaluate response).
      • Administer one dose of hepatitis A vaccine to persons suspected of poor response or waning immunity (i.e., persons who were vaccinated with low CD4 count or who now have low CD4 count; persons with other chronic health conditions).

Outbreaks of hepatitis A are currently occurring in multiple states among persons who use drugs and/or experiencing homelessness and their contacts. Additional risk factors may also include sexual transmission among men who have sex with men (MSM). 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 disease 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).

* In February 2019, CDC recommended all persons aged > 1 year experiencing homelessness be routinely immunized against HAV.