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Published Date: 2018-05-31 14:00:48
Subject: PRO/EDR> Hepatitis A - USA (21): update
Archive Number: 20180531.5830692
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Wed 30 May 2018
Source: CNN [edited]

Hepatitis A outbreak cases on rise across US
Tennessee is the most recent state to report an outbreak of hepatitis A, with Nashville claiming 14 confirmed cases since December 2017.

Hepatitis A is a viral infection that causes inflammation of the liver. Over the past 2 years, 6 other states have experienced outbreaks, and although demand for the vaccine outpaced supply earlier in 2018, there is enough supply to satisfy current needs, according to the CDC.

California, Indiana, Kentucky, Michigan, Utah and West Virginia have reported outbreaks of hepatitis A since March 2017. Cases in these states, with the exception of Michigan, have been genetically identical or similar, according to the CDC. Laboratory reports have not determined whether the viral strains from cases in Nashville are also genetically linked.

Hepatitis A is typically spread when people eat contaminated food or water; more rarely, the virus is transmitted person-to-person through poor hygiene and close contact. Although there are no special treatments, doctors recommend rest, adequate nutrition and fluids.

Generally, people get sick between 15 and 50 days after their 1st exposure to the virus. Infected people can spread the virus one to 2 weeks before their own symptoms appear and up to one week after they develop jaundice, usually a late-appearing symptom.

Vaccination is the best way to prevent an infection, according to the CDC, which has worked with public health officials in affected areas to provide guidance about targeting the vaccine to at-risk populations and has collaborated with manufacturers to increase the national supply. "The supply for children is fine, and there is enough adult supply to meet demand," CDC spokeswoman Kristen Nordlund said. "As for people talking to their doctors, it would depend on whether their doctor stocks the vaccine."

She added that the CDC does not have a preferential recommendation among the hepatitis A vaccines licensed by the FDA, which include Havrix and Twinrix, both produced by GlaxoSmithKline, and Vaqta, produced by Merck. CDC and vaccine manufacturers continue to monitor ongoing demand for hepatitis A vaccine closely, Nordlund said. Due to the outbreak, the CDC recommends hepatitis A vaccination for people who are homeless and who use drugs, the 2 populations most at risk for becoming infected.

Generally, inoculation with the vaccine is recommended for all children at age 1; men who have sex with other men; users of recreational drugs; people with chronic or long-term liver disease; people with clotting-factor disorders; people with direct contact with people infected with hepatitis A; travelers to countries where hepatitis A is common and family and caregivers of adoptees from those countries; and anyone else who wants protection against the disease.

California was the 1st state to announce an outbreak in 2017, saying it began in November 2016. The state reported a demobilization of response as of [11 Apr 2018], though state, county and local health authorities continue to monitor the situation. As of [11 April 2018], California reported 704 cases, 461 hospitalizations and 21 deaths. The majority of cases -- 587 -- occurred in San Diego, though Santa Cruz, Los Angeles, Monterey and other counties were also affected. Subsequent hepatitis A cases will be included in the state's annual surveillance reports.

[The latest report that could be found https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/Hepatitis_A.htmlreported 588 cases, 403 hospitalizations (68 percent) and 20 deaths (3.4 percent). The other cases may be not related to the outbreak strain. - Mod.LL]

"The majority of people who have been infected with hepatitis A virus in this outbreak are people experiencing homelessness and/or using illicit drugs in settings of limited sanitation," according to the California Department of Public Health website. "Other states are experiencing outbreaks in similar populations of at-risk people."

Since November 2017, the Indiana State Department of Health has identified an increase of hepatitis A cases in the southern part of the state, with most patients residing in Clark and Floyd Counties. The state reported a total of 107 hepatitis A outbreak-related cases as of [25 May 2018], with 51 hospitalizations. Many of the infected people have an association with patients in the large outbreak in neighboring Kentucky, according to the health department's website, which also notes that, generally, the state averages just 20 cases of hepatitis A per year.

In November 2017, the Kentucky Department for Public Health identified an outbreak of hepatitis A. The state reported 629 total cases, 401 hospitalizations and 6 deaths as of [21 May 2018].

"Similar to hepatitis A outbreaks in other states, the primary risk factors have been homelessness and illicit drug use," the health department noted. "It's a rare disease," said Dr. Jeffrey Howard, acting commissioner of the Department of Public Health, in a presentation recorded on Facebook. The state normally reports 20 cases annually, he added. "This outbreak is occurring across the country," Howard said, adding that it is believed the outbreak started in San Diego and then spread from there. "I suspect many, many states across the country will declare an outbreak, and they will see a rising number of cases."

Michigan has been dealing with an outbreak of hepatitis A since August 2016, with 837 total cases as of [23 May 2018], including 671 hospitalizations and 27 deaths. Most of the illness has occurred in Macomb, Wayne and Oakland counties as well as in the city of Detroit. The state reported that it is continuing to see an elevated number of hepatitis A cases as of 23 May 2018.

Though the confirmed number of Nashville patients since December 2017 is only in the mid-teens, "national experts at CDC are involved and providing laboratory testing and technical consultation and support as needed," said Brian Todd, a spokesman for Music City's Metro Public Health Department. "Part of the overall effort is to try to identify the source of the outbreak; however, it is too early to make that determination."

According to Todd, the Metro Public Health Department had a supply of vaccine on hand and received an additional 1000 doses from the Tennessee Department of Health. "We still have a good supply of vaccine, and additional vaccine is available as needed," he said.

Based on confirmed cases, the city's immediate priority for vaccination includes men who have sexual contact with men and illicit drug users, Todd added. "We are considering those experiencing homelessness as an at-risk group even though there have been no cases," he said. "We have typically seen an average of 2 cases each year in Nashville over the past few years."

Utah, which identified its own outbreak of hepatitis A beginning in January 2017, reported 266 confirmed cases related to the outbreak as of [Tue 29 May 2018]. Salt Lake County, which has reported 148 total cases including 2 deaths as of [2 Apr 2018], has carried most of this burden. "In response to the outbreak, public health officials have been working to identify cases and contacts, provide education, and ensure opportunities for vaccination of close contacts to cases and vulnerable populations," according to state health authorities.

[As of 29 May 2018, the number of cases linked to the outbreak strain was 248 http://health.utah.gov/epi/diseases/hepatitisA/HAVoutbreak_2017. The other cases may not be related to the outbreak strain. - Mod.LL]

West Virginia
West Virginia reported 106 cases of hepatitis A as of [23 May 2018]. Kanawha and Putnam counties have experienced most of these cases. In response to the outbreak, the state health department is providing hepatitis A vaccination clinics for restaurant and food service employees in those 2 counties, since at least one worker in 8 food establishments have confirmed infections.

[Byline: Susan Scutti]

Communicated by:

[As these outbreaks continue to occur, it seems clear that cities should preemptively address their homeless situations before outbreaks begin. Ignoring these marginalized populations is clearly part of the problem. - Mod.LL

HealthMap/ProMED-mail maps
California, United States: http://healthmap.org/promed/p/204
Indiana, United States: http://healthmap.org/promed/p/217
Kentucky, United States: http://healthmap.org/promed/p/220
Michigan, United States: http://healthmap.org/promed/p/225
Tennessee, United States: http://healthmap.org/promed/p/244
Utah, United States: http://healthmap.org/promed/p/246]

See Also

Hepatitis A - USA (20): (KY,TN) 20180527.5820929
Hepatitis A - USA (19): (MI, UT, IN) 20180518.5798559
Hepatitis A - USA (18): (MI, UT, KY) 20180512.5792086
Hepatitis A - USA (17) 20180509.5789924
Hepatitis A - USA (16): (AR,KY,IN) 20180503.5780360
Hepatitis A - USA (15): (OH, MI) 20180425.5769100
Hepatitis A - USA (14) : (KY, WV, UT) 20180424.5762837
Hepatitis A - USA (13): (UT, MI) 20180406.5729135
Hepatitis A - USA (12): (MI, UT, IN) 20180328.5716201
Hepatitis A - USA (11): (KY, IN) 20180318.5694916
Hepatitis A - USA (10): (KY, UT, MI) 20180307.5671905
Hepatitis A - USA (09): (KY, UT, MI) 20180222.5645053
Hepatitis A - USA (08): (WY) 20180216.5632464
Hepatitis A - USA (07): (CA, UT, MI) 20180215.5629167
Hepatitis A - USA (06): (CA) 20180208.5615970
Hepatitis A - USA (05): (MI, UT, CA) 20180128.5589100
Hepatitis A - USA (04): (MI,KY) 20180115.5559179
Hepatitis A - USA (03): (UT) 20180111.5552496
Hepatitis A - USA (02): (CA,MI,UT) 20180108.5544747
Hepatitis A - USA: (HI) 20180107.5543399
Hepatitis A - USA (62): (MI, UT) 20171231.5530386
Hepatitis A - USA (61) 20171224.5522033
Hepatitis A - USA (60): (WY) 20171223.5521171
Hepatitis A - USA (59): (CA,MI,UT) 20171211.5490041
Hepatitis A - USA (58): (KY) 20171122.5459962
Hepatitis A - USA (57): (MI,UT) vaccine shortage 20171120.5452198
Hepatitis A - USA (56): (MI) western spread 20171117.5448927
Hepatitis A - USA (55): (CA, UT) 20171116.5445389
Hepatitis A - USA (54): (MI, CA) 20171112.5439275
Hepatitis A - USA (53): (CA) fatal 20171107.5429761
Hepatitis A - USA (52): (MI) fatal 20171106.5426879
Hepatitis A - USA (51): (CA,MI) 20171101.5417867
Hepatitis A - USA (50): (CA, CO) 20171031.5416392
Hepatitis A - USA (49): (MI) fatal 20171030.5413115
Hepatitis A - USA (48): (MI) increase in MSM cases 20171027.5408410
Hepatitis A - USA (47): (MI) fatal 20171020.5394454
Hepatitis A - USA (46): (CA) fatal 20171017.5386460

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