By Meredith Li-Vollmer, Public Health – Seattle & King County

A newly confirmed case of hepatitis A infection has occurred in a King County resident. The patient, a man in his forties who lives homeless and uses injection drugs, was hospitalized for his illness but is no longer hospitalized nor contagious. 

Genotype testing from the Centers for Disease Control and Prevention (CDC) found that the strain of hepatitis from this recent case matches a previous hepatitis A case in a person living homeless who uses injection drugs in King County. The previous case was identified in April of 2019. 

In addition, disease investigators are tracking two other likely cases of locally-acquired hepatitis A infection among King County residents living homeless and using injection drugs. 

“A match between the newly identified case and the case we reported in April indicates that there has been transmission of hepatitis A locally,” said Dr. Jeff Duchin, Health Officer for Public Health — Seattle & King County.

“It’s not unexpected that we would see additional cases linked to the April case given the infectious nature of hepatitis A and the relatively long contagious period for hepatitis A infections,” he said.

“To prevent a large-scale outbreak, robust community-wide vaccination efforts are needed focusing on high-risk populations,” Duchin added. “We’re asking emergency rooms, clinics, and healthcare providers to routinely screen for hepatitis A risk factors and offer hepatitis vaccination and prevention counseling every time they see a patient who is living homeless or using injection drugs.”

Total hepatitis A cases in 2019

In addition to the two confirmed and two suspected cases of hepatitis A reported in people living homeless, there have been eleven other hepatitis A cases in King County residents so far in 2019; these eleven other cases were in people with permanent housing and not connected to the two cases in people living homeless.  None of the cases were previously vaccinated against hepatitis A.  In comparison, there were fourteen cases in all of 2018.  

Hepatitis A situation nationwide

Hepatitis A outbreaks have been widespread across the United States, with current outbreaks involving hundreds and even thousands of cases in states such as Kentucky, Florida, and Ohio. The latest data from the CDC reports current outbreaks in 23 states with nearly 22,300 reported hepatitis A cases. The state of Washington reports a total of eleven cases since April 1, including the two confirmed cases in King County. 

Public Health’s hepatitis A vaccination strategy 

Since the first case in a person living homeless was confirmed on April 17, Public Health has vaccinated over 1,500 people at over 100 hepatitis A vaccination clinics at shelters, day centers, meal sites, King County correctional facilities, and other homeless service providers as well as through the Mobile Medical Van. Withnew county investments, Public Health’s Healthcare for the Homeless Network is continuing to increase availability of vaccine clinics to high risk populations.

Public Health has partnered with several healthcare systems to provide free hepatitis vaccine (supplied by the Washington State Department of Health) to high-risk populations at:

• Downtown Public Health Center
• Needle Exchange
• HealthPoint
• ICHS

Public Health has also requested all healthcare emergency departments and primary clinics in King County to screen patients for the risk factors of a history of homelessness or injection drug use and offer vaccination on the spot.

Prior to any local cases, Public Health had already stepped up efforts following an outbreak in San Diego in 2016, where there were nearly 600 cases. In 2017 and 2018, over a thousand King County residents were vaccinated at homeless service providers. 

About hepatitis A

Hepatitis A virus infects the liver and can cause illness that range from a mild infection that has no symptoms to a more severe illness that can last for months. Hepatitis A virus spreads easily. It gets into the body through the mouth after someone touches an object, food, or drink that is contaminated with the virus. If an infected person doesn’t wash their hands well, especially after toileting, undetectable amounts of the virus can spread from the hands of that person to other objects, surfaces, and foods. 

Symptoms of hepatitis A

Common symptoms include tiredness, nausea, vomiting, abdominal pain, loss of appetite, low-grade fever, clay-colored bowel movements and dark urine, joint pain and yellow discoloration of the whites of the eyes and skin (jaundice). Some people get infected with hepatitis A but do not experience all of these symptoms, or even have no symptoms.

People at highest risk for getting hepatitis A

People who are at highest risk are:

• People living homeless, especially those living unsheltered without good access to sanitation, hygiene and handwashing facilities
• People who are living with or caring for a person who already has hepatitis A
• People who have sex with people with hepatitis A
• Men who have sex with men
• Illicit drug users (does not have to be injection drugs)
• People with clotting disorders like hemophilia
• International travelers
• People with chronic liver disease, including hepatitis B and hepatitis C are at increased risk for severe infections.

Preventing hepatitis A 
Hepatitis A vaccination is the best way to prevent hepatitis A. The shot is safe and effective; anyone who wants to reduce their risk of hepatitis A should get vaccinated. Anyone who is in the higher risk groups should be sure to get the hepatitis A vaccine to protect themselves. 

To get a hepatitis A vaccine, visit your doctor, nurse, or clinic. You can also check www.vaccinefinder.org for pharmacies that offer hepatitis A vaccine. For information about where to get free hepatitis A vaccine for people living homeless: www.kingcounty.gov/hch

Practicing good hand hygiene also plays an important role in preventing the spread of hepatitis A, including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food. People in high risk groups should also avoid sharing food, drinks, drug paraphernalia, and other personal items.

For more information on hepatitis A: www.kingcounty.gov/hepA