Locally-acquired hepatitis A case in person living homeless

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

A King County man in his forties has been hospitalized with a confirmed case of hepatitis A, a highly contagious virus that can cause severe liver disease.

The patient has been living without permanent housing and has a history of illicit drug use.  

Because he has not travelled outside King County during the period in which he was exposed to the virus, we have determined that this infection was likely acquired locally.

The patient also did not leave the county during his contagious period. However, he did report spending time at multiple day and overnight shelters, meal services for people living homeless, and on the streets during this time.

An increasing number of hepatitis A outbreaks have been occurring across the country since 2016, especially among people living homeless and people who use drugs (injection and non-injection). In these outbreaks, a high proportion of cases have had severe infections. 

This is the first known case of locally acquired hepatitis A in an individual living homeless since the national outbreaks began in the fall of 2016.

Although the exact source of his infection is unknown, this case indicates that there may be other unrecognized cases of hepatitis A occurring in the community. 

“This is a reminder of the importance of taking steps to ensure vaccination to prevent hepatitis A from spreading in our community. This is critical for people at high-risk, including those who are homeless, using illicit drugs, men who have sex with men, people who travel internationally, and anyone who may be exposed to someone with hepatitis A,” said Dr. Jeff Duchin, Health Officer for Public Health – Seattle & King County.

“We will be tracking this situation very closely along with our local healthcare providers in order to detect any future cases that may indicate ongoing transmission,” Dr. Duchin said.

Public Health – Seattle & King County is reaching out to shelters and other service providers where the individual reported spending time during his period of contagion to provide hepatitis A vaccinations.

Hepatitis A vaccinations can be used to help prevent illness from hepatitis A, including among those who may have been exposed to the virus if given within two weeks of exposure.

Environmental health staff will work with locations where this individual visited to assist with thorough cleaning.

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. 

In 2018 there were fourteen cases of hepatitis A reported in King County and to-date in 2019, there have been eight cases reported; none of the previous, locally-acquired cases were in people living homeless.  

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.

If you don’t have a health care provider, the STD clinic at Harborview Medical center has a limited supply of free hepatitis A vaccine. Visit www.kingcounty.gov/STD for walk-in clinic hours.

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

Public Health’s role

Since the fall of 2017, Public Health – Seattle & King County has been working with the City of Seattle, and encampment, shelter, and day use operators to spread the word about steps to prevent hepatitis A, including the need to vaccinate people at risk.

We have provided guidance on hygiene and sanitation and our mobile medical van and communicable disease staff have provided hepatitis A vaccinations to people living homeless. 

With this new case of hepatitis A, we are working with community health care providers and closely monitoring to promptly identify any possible additional cases.

Our Immunization Program and Healthcare for the Homeless Network are coordinating with healthcare facilities and other community partners to provide greater access to hepatitis A vaccination. Outreach to homeless service providers and community organizations is another important part of our work to ensure that people living homeless get the information needed to protect themselves and prevent the spread of hepatitis A. 

For more information on hepatitis A, including information about vaccination for people living homeless: www.kingcounty.gov/hepA