[CME no longer available]

November 2019

This article has been updated. Please see the November 2024 article “Clinical Recognition and Management of Hepatitis A: Preventing Outbreaks in Los Angeles County” CME Available Soon

Prabhu Gounder, MD, MPH, FACP

Sharon Balter, MD

Between June 2017 and January 2018, Los Angeles County experienced a local outbreak of hepatitis A among persons reporting drug use and/or homelessness as well as a concerning increase in hepatitis A illness among men who have sex with men (MSM). While the number of hepatitis A cases among MSM in LA County has declined since January 2018, sporadic cases and small outbreaks of hepatitis A have continued to occur among persons with a history of homelessness or illicit drug use (IDU). The Centers for Disease Control and Prevention (CDC) reports widespread person-to-person outbreaks of hepatitis A across the United States related to outbreaks occurring primarily among persons who report drug use or homelessness. The CDC now recommends that all persons experiencing unstable housing or homelessness be routinely immunized against hepatitis A in addition to other high-risk groups (see table Recommendations for Hepatitis A Vaccination).

This article will summarize the local 2017-2018 outbreaks and will review actions clinicians can take to improve the recognition, reporting, management, and prevention of hepatitis A.

Background

Hepatitis A virus (HAV) is an RNA picornavirus and humans are its only known reservoir.¹ The virus infects the liver and is then secreted into feces where it is present from 2 weeks before until about a week after symptom onset.² HAV can persist on environmental surfaces and is resistant to the processes usually used to eliminate bacterial pathogens from food.³ It is transmitted through the fecal-oral route, for example by ingesting food or water contaminated with the feces of an infected person, touching a contaminated surface or objects, or having sexual contact with an infected partner.⁴ Vaccination is recommended for persons at increased risk for hepatitis A, including persons traveling to or working in countries that have high or intermediate rates of infection, MSM, IDUs, persons experiencing homelessness, and persons with occupational risk of infection.⁵ Vaccination is also recommended for persons with clotting-factor disorders, although changes in clotting factor preparation and donor screening have markedly reduced the risk in this group.

Outbreaks Among Homeless Persons

The hepatitis A outbreak in LA County among persons experiencing homelessness or using illicit drugs followed a large outbreak among these risk groups in San Diego County that began in November 2016. In San Diego County between November 2016 and the end of the outbreak in January 2018, there were 592 hepatitis A cases, including 20 (3.4%) deaths; most persons who died had underlying liver disease, often from hepatitis C.⁶ Almost 69% of San Diego cases were hospitalized. Three-quarters of the cases occurred among those were homeless and/or reported IDU. San Diego cases also occurred among persons who provided services to or had significant contact with the homeless, including volunteers at shelters and sanitation workers. Health officials in Santa Cruz County also identified an increase in hepatitis A cases with most occurring among the same risk groups.⁶

Beginning in May 2017, cases of hepatitis A were observed among persons in LA County who had recent exposure in San Diego or Santa Cruz County. LA County health officials declared a hepatitis A outbreak among persons who were homeless or using illicit drugs in September 2017. The final outbreak-associated case in LA County was in January 2018. Between May 2017 and January 2018 there were a total of 18 outbreak associated cases, 12 hospitalizations, and no deaths (see LAC DPH Hepatitis A Outbreak webpage for more information). Since January 2018, sporadic cases and small outbreaks of hepatitis A have continued to occur in LA County among persons with a history of homelessness or IDU.

Increased Risk Among MSM

In addition to the LA County outbreak among homeless persons and IDUs, there was an increase in hepatitis A illness among MSM. Locally in 2017, there were 23 confirmed cases among MSM compared with 9 cases in 2016 and no reported cases in 2015. Several of the LA County MSM cases reported travel to San Diego or other U.S. and international locations with ongoing outbreaks. Between 2016 and 2018, several European Union/European Economic Area (EU/EEA) countries experienced large outbreaks of hepatitis A infections mainly affecting MSM.^7,8 In the U.S. during the same time frame, hepatitis A outbreaks in MSM were identified in New York City and Colorado while San Francisco experienced an increase in hepatitis A cases among MSM.^9,10 The number of hepatitis A cases among MSM in LA County declined in 2018 with a total of 8 cases reported.

Healthcare providers should be aware that MSM continue to be at increased risk for hepatitis A and should routinely promote hepatitis A vaccination.

Clinical Presentation

The time between hepatitis A infection and onset of symptoms is about 4 weeks but can range from 15–50 days.¹¹ Approximately 70% of adults with hepatitis A infection will experience symptoms such as fever, malaise, nausea, vomiting, and abdominal pain.^12,13 These are followed in several days by signs of hepatic dysfunction including jaundice, which develops in approximately 70% of symptomatic persons, scleral icterus, dark urine, and clay colored stools. Symptoms generally last for several weeks. Some persons may have prolonged disease up to 6 months or a relapsing course.^14,15 Those with prolonged and relapsing disease also will shed virus and be infectious for longer periods.

Diagnosis

Clinicians should suspect hepatitis A in patients who have risk factors for infection and who have abrupt onset of prodromal symptoms (nausea, anorexia, fever, malaise, or abdominal pain) and jaundice or elevated serum aminotransferase levels.¹² Diagnosis of hepatitis A is supported by demonstration of an antibody response to infection. Anti-HAV IgM becomes detectable several days before the onset of symptoms and typically remains positive for 3–6 months after infection (Table 1).¹⁶ Rarely, detectable anti-HAV IgM has been reported to persist for up to 5 years.¹⁷ Generally, the presence of anti-HAV IgG and the absence of IgM indicates immunity to hepatitis A through vaccination or previous infection.¹⁶ Because HAV IgM has a high false-positive rate, testing of asymptomatic individuals is not recommended.¹⁷ A serology panel should be obtained to detect other potential causes of viral hepatitis as the groups at risk in the current LA County outbreak are also at risk for other infectious etiologies. HIV testing is also recommended for those whose HIV-status is undocumented.

Table 1. Interpretation of Hepatitis A Virus (HAV) Serologies

Management

No specific treatment exists for acute hepatitis A illness. Supportive therapy is recommended. Hospitalization may be needed for patients who are dehydrated or have fulminant liver disease.

For persons who are homeless or use illicit drugs, hospitalization can facilitate improved nutrition, reduce the risk of transmission, and enable linkage with services including the provision of housing. The LA County Department of Public Health (DPH) has access to several beds in a recuperative care facility for patients who would benefit from ongoing care. Among hepatitis A infected persons in the San Diego and LA County outbreaks, almost 70% were hospitalized, a proportion substantially higher than for sporadic disease or in most other hepatitis A outbreaks.⁶

Infected persons should be counseled to wash their hands after using the bathroom and before handling food, especially for 2 weeks after the onset of symptoms. Infected occupational food handlers should be advised to not return to work until 2 weeks after the onset of symptoms or 7 days after the onset of jaundice.

Reporting and Infection Control

Any homeless person with symptoms or signs consistent with hepatitis A infection should be immediately reported to DPH instead of waiting for anti-HAV IgM results. Immediate reporting allows the health department to interview cases on-site, which facilitates investigation and prevention of transmission if the patient tests positive. DPH also can facilitate expedited anti-HAV IgM testing through the DPH Public Health Laboratory, if needed. Importantly, homeless persons should not be discharged to the street because they may be lost to follow-up. If necessary, DPH can assist with finding housing for persons with suspected hepatitis A who are ready for discharge from the hospital.

For cases of hepatitis A in persons who are not homeless, clinical providers should continue to report infected persons (defined by the presence of compatible symptoms or risk factors and presence of positive anti-HAV IgM) to DPH within 1 working day of receiving the laboratory results. See box below for reporting information.

DPH investigates all acute hepatitis A case reports to confirm infection, identify and control the source of infection, and protect those who already have been exposed. DPH will attempt to identify and provide post-exposure prophylaxis (PEP) to persons who had close personal contact with the case such as household members or persons with intimate contact. For the homeless, this would include persons who are in the same encampment as a case. Hepatitis A illness occurring in a food handler is investigated urgently to assess the likelihood of transmission to facility patrons during the infectious period. A public notification might be considered if potentially exposed patrons can be identified and provided with PEP within 2 weeks of exposure.

Post-Exposure Prophylaxis Recommendations

PEP should be given to contacts of hepatitis A cases within 2 weeks of the last exposure and, ideally, as soon as possible.¹⁸ As mentioned above, DPH will assist in the management of contacts including recommendations for PEP. PEP recommendations are detailed in the California Department of Public Health Quicksheet. Vaccination as PEP, is recommended to prevent illness and provide durable protection for persons aged 1 to 59 years. Immune globulin (IG) should be used to prevent illness for infants under 1 year of age, persons aged 60 years and over, those who are immunocompromised or who have chronic liver disease, and those for whom vaccine is contraindicated. Healthy persons >60 years of age should receive the vaccine in addition to IG for long-term protection.

GamaSTAN^® S/D is the only IG product that is FDA approved for PEP. In July 2017, the recommended dose for IG for HAV PEP was increased by the manufacturer due to declining HAV antibody levels in the U.S. blood supply.¹⁹ Consequently, the current recommended dose is 0.1 mL/kg, administered intramuscularly.

Vaccination Recommendations

Persons at risk for hepatitis A infection should be vaccinated to increase immunity among risk groups, prevent infection, and reduce the risk of transmission. Attaining 80% immunity to hepatitis A in a population can stop outbreaks.²⁰ The CDC’s Advisory Committee on Immunization Practices (ACIP) and DPH recommendations for groups recommended to receive the hepatitis A vaccine are synthesized in Table 2.

Table 2. ACIP and LAC DPH Recommendations for Hepatitis A Vaccination

Hygiene and Sanitation

Good handwashing is important to prevent the spread of hepatitis A infection. Soap and water are preferred to hand sanitizer. If using the latter, alcohol concentrations of 70% or higher are most effective. Some cities in LA County have installed handwashing stations and restroom facilities that can be accessed by homeless persons but hygiene and sanitation remain a challenge for this population.

HAV is resistant to many commonly used commercial disinfectants. A 10% bleach (>5,000 ppm) solution is effective if it is left on the surface to be cleaned for 1 minute before rinsing with water. Two percent glutaraldehyde and a quaternary ammonium formulation containing 23% hydrochloric acid (toilet bowl cleaner) also have been shown to be effective.²¹ In several studies, phenolics; iodine-based products; alcohols; and solutions of acetic, peracetic, citric, and phosphoric acids were ineffective. To assess other products, review the product label or product specification sheet for effectiveness against hepatitis A. Patient education materials, and information on hygiene and sanitation for hepatitis A is available on the LAC DPH hepatitis A webpage.

Conclusions

Preventing a resurgence of hepatitis A in LA County will require continued collaboration between practicing clinicians and DPH to ensure effective diagnosis, reporting, investigation, and prevention of cases. Providers are encouraged to visit the DPH hepatitis A webpage for resources for patients and providers. Clinical consultations regarding hepatitis A can be made by phoning 213-240-7941 (weekdays 8:30am-5pm).

References

1. Feinstone SM, Kapikian AZ, Purceli RH. Hepatitis A: detection by immune electron microscopy of a viruslike antigen associated with acute illness. Science. 1973;182(4116):1026-1028.
2. Lima LR, De Almeida AJ, Tourinho Rdos S, Hasselmann B, Ximenez LL, De Paula VS. Evidence of hepatitis A virus person-to-person transmission in household outbreaks. PLoS One. 2014;9(7):e102925.
3. World Health Organization. Hepatitis A. Fact sheet http://www.who.int/mediacentre/factsheets/fs328/en/. Updated July 2017. Accessed November 1, 2017.
4. Klevens RM, Miller JT, Iqbal K, et al. The evolving epidemiology of hepatitis a in the United States: incidence and molecular epidemiology from population-based surveillance, 2005-2007. Arch Intern Med. 2010;170(20):1811-1818.
5. Centers for Disease Control and Prevention. Hepatitis A ACIP Vaccine Recommendations; https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html. Updated February 15, 209. Accessed. October 30, 2019.
6. California Department of Public Health. Hepatitis A Outbreak Associated with Drug Use and Homelessness in California, 2016-2018; https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/2016-18CAOutbreakAssociatedDrugUseHomelessness.pdf. Updated April 11, 2018. Accessed November 14,2019
7. European Centre for Disease Prevention and Control. Staying healthy during Pride season: practice safer sex and check vaccination status; https://www.ecdc.europa.eu/en/news-events/staying-healthy-during-pride-season-practice-safer-sex-and-check-vaccination-status. Published August 2, 2019. Accessed October 28, 2019.
8. European Centre for Disease Prevention and Control. Epidemiological update: Hepatitis A outbreak in the EU/EEA mostly affecting men who have sex with men; https://www.ecdc.europa.eu/en/news-events/epidemiological-update-hepatitis-outbreak-eueea-mostly-affecting-men-who-have-sex-men-2. Published September 12, 2018. Accessed October 28, 2019.
9. Latash J, Dorsinville M, Del Rosso P, et al. Notes from the Field: Increase in Reported Hepatitis A Infections Among Men Who Have Sex with Men - New York City, January-August 2017. MMWR Morb Mortal Wkly Rep. 2017;66(37):999-1000.
10. San Francisco Department of Public Health. Health Advisory: Hepatitis A among Men Who Have Sex with Men, San Francisco. Sept 28, 2017. http://sfcdcp.org/healthalerts.html. Accessed November 3, 2017.
11. Lemon SM. Type A viral hepatitis. New developments in an old disease. N Engl J Med. 1985;313(17):1059-1067.
12. Lednar WM, Lemon SM, Kirkpatrick JW, Redfield RR, Fields ML, Kelley PW. Frequency of illness associated with epidemic hepatitis A virus infections in adults. Am J Epidemiol. 1985;122(2):226-233.
13. Tong MJ, el-Farra NS, Grew MI. Clinical manifestations of hepatitis A: recent experience in a community teaching hospital. J Infect Dis. Mar 1995;171 Suppl 1:S15-18.
14. Glikson M, Galun E, Oren R, Tur-Kaspa R, Shouval D. Relapsing hepatitis A. Review of 14 cases and literature survey. Medicine. 1992;71(1):14-23
15. Sjogren MH, Tanno H, Fay O, et al. Hepatitis A virus in stool during clinical relapse. Ann Intern Med. 987;106(2):221-226.
16. US Centers for Disease Control and Prevention. Hepatitis A Questions and Answers for Health Professionals. https://www.cdc.gov/hepatitis/hav/havfaq.htm. Updated October 25, 2017. Accessed November 1, 2017.
17. Positive test results for acute hepatitis A virus infection among persons with no recent history of acute hepatitis--United States, 2002-2004. MMWR Morb Mortal Wkly Rep. 2005;54(18):453-456.
18. Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084.
19. Nelson NP. Updated Dosing Instructions for Immune Globulin (Human) GamaSTAN S/D for Hepatitis A Virus Prophylaxis. MMWR Morb Mortal Wkly Rep. 2017;66(36):959-960.
20. McMahon BJ, Beller M, Williams J, Schloss M, Tanttila H, Bulkow L. A program to control an outbreak of hepatitis A in Alaska by using an inactivated hepatitis A vaccine. Arch Pediatr Adolesc Med. 1996;150(7):733-739.
21. Mbithi JN, Springthorpe VS, Sattar SA. Chemical disinfection of hepatitis A virus on environmental surfaces. Appl Environ Microbiol. 1990;56(11):3601-3604.