Clinical Advisory  Hepatitis A Among Persons Experiencing Homelessness and Who Use Injection and Non-injection Drugs

Date:	12/11/2023
Referenced Sources:	Download the Advisory

Between November 1 and November 29, 2023, six cases of hepatitis A infection have been reported in Suffolk, Norfolk, Hampden, and Plymouth counties; additional suspect cases are under investigation. Some of these illnesses have been severe with four individuals requiring hospitalization. No deaths have been reported. Four of the six individuals are male with ages ranging from 36 to 60. Several individuals reported recent homelessness/unstable housing, injection drug use, and/or other drug use, and reported recently seeking services at Boston-area clinics, shelters, and substance use treatment facilities. These cases have no history of travel outside of Massachusetts and there are no common sources of food, beverages or drugs identified with this cluster.

These cases are similar to a large outbreak that began in Massachusetts in 2018 and ended in 2020, eventually involving 563 cases with 9 deaths. At that time, there were additional large Hepatitis A infection clusters in California, Indiana, Kentucky, Michigan, Tennessee, Utah, and West Virginia.

Hepatitis A is a highly contagious liver infection caused by the Hepatitis A virus (HAV) ranging in severity from mild infection lasting a few weeks to severe disease lasting several months. HAV is primarily spread person-to-person through the fecal-oral transmission route and contact with a fecal- contaminated environment. Populations at particular risk include individuals experiencing homelessness and persons who inject drugs. Others at increased risk include international travelers to areas with high or intermediate hepatitis A endemicity, men who have sex with men, persons with chronic liver disease, person with clotting factor disorders, and persons who anticipate close contact with an international adoptee from a country of high or intermediate endemicity . Hepatitis A is preventable by administration of hepatitis A vaccine, even when the vaccine is administered up to 2 weeks after exposure.

Given the pattern of significant HAV outbreaks previously seen involving similar populations, here and in other jurisdictions, there is concern that additional hepatitis A transmission and morbidity will likely occur in the Commonwealth.  Effective prevention and response measures include early identification of cases, vaccination, enhanced sanitation processes, and education of populations who may be at risk.

Prevention and Response Activities

Statewide, hepatitis A is treated as a high priority disease for follow-up by MDPH and each case is investigated promptly to determine close contacts and obtain a risk history. MDPH is working with local Boards of Health and relevant stakeholders to further enhance education and prevention among people at high risk.

Recommendations for Healthcare Providers

Identify cases of hepatitis A

Maintain vigilance for symptoms of hepatitis A, especially in persons experiencing homelessness and/or who inject or use drugs. Symptoms include fever, fatigue, loss of appetite, stomach pain, nausea, diarrhea, jaundice (yellowing of skin or eyes), and clay or grey colored feces. Test all suspected patients for hepatitis IgM antibody, and other laboratory tests such as liver function tests as clinically indicated. Samples testing positive for hepatitis A should be sent by clinical laboratories to the Massachusetts State Public Health Laboratory for further evaluation.

Report

Regulations require healthcare providers and institutions in Massachusetts to report all cases of HAV infection to the Massachusetts Department of Public Health or to local public health departments. Cases may be reported to the MDPH’s Epidemiology Division at [phone], which is available 24/7 or to the local board of health.

Vaccination and Referral to Treatment

At the current time, the goal is to prioritize vaccination efforts to the groups identified to be most at risk, as outlined below.

1. Vaccinate all persons at high risk including persons experiencing homelessness or unstable housing, persons who inject drugs or use non-injection drugs or have chronic liver disease (including chronic hepatitis C infection or chronic hepatitis B infection), and men who have sex with men. Vaccine options include single antigen hepatitis A vaccine (HAVRIX® or VAQTA®) and the combination hepatitis A and B vaccine (Twinrix®). While routine hepatitis A vaccination consists of a 2-dose schedule (or a 3-dose schedule for the combination hepatitis A and B vaccine Twinrix®), one dose of single-antigen hepatitis A vaccine (HAVRIX® or VAQTA®) has been shown to successfully control outbreaks of hepatitis A. Please keep in mind that Twinrix requires 3 doses for maximum efficacy and that it should not be used for postexposure prophylaxis or outbreak control.
2. Vaccination history should be obtained to check hepatitis A vaccination status when feasible. Pre-vaccination serological testing to test for prior immunity is not required in order to administer hepatitis A vaccine. Vaccination of a person who is immune because of previous infection or vaccination does not increase the risk for adverse events from vaccination. Therefore, hepatitis A vaccination should not be postponed if vaccination history cannot be obtained or records are unavailable.
3. Offer vaccines at point of care including Emergency Department or Urgent Care encounters, inpatient admissions, observation stays, and outpatient clinic visits. If possible, vaccination information should be captured within the facility’s electronic medical record to assist with monitoring of vaccine coverage.
4. Street-based community health workers and mobile van units serving these populations are encouraged to provide HAV and other vaccines to unsheltered individuals, persons living in encampments or otherwise not utilizing services within shelters.
5. For unsheltered individuals in Boston , clients can be connected to a Boston Health Care for the Homeless Program (BHCHP) clinic site. For a list of BHCHP clinics, go to: Primary Care | bhchp.org
6. Refer clients with substance use disorders (SUD) to syringe services programs.
   1. Refer to this site for syringe service sites and contact information: Syringe Service Programs
   2. In Boston, refer to AHOPE Harm Reduction Services located at 774 Albany Street. For more information re hours and services, go to: Services or Active Users | Boston.gov
7. Consider recommending HAV vaccination to all potentially exposed staff at facilities serving these high-risk populations, who are under-immunized or un-immunized.
8. Immunize all close contacts of persons diagnosed with acute HAV with single antigen hepatitis A vaccine (and/or immune globulin, if indicated and available). For more information see: Hepatitis A Questions and Answers for Health Professionals | CDC.gov. Please note, Twinrix is not recommended for postexposure prophylaxis.
9. For persons presenting with signs/symptoms consistent with acute HAV infection, connect them immediately to the closest Emergency Department for further evaluation.

Hygiene and Sanitation

1. Facilities serving high-risk populations should increase opportunities for hand hygiene at entrances/exits and encourage frequent handwashing. Hand washing with antimicrobial soap and hot water should be encouraged. Portable hand hygiene stations utilizing hot water are suitable.
   1. Note: Alcohol-based hand sanitizers (ABHS) may not be effective against HAV and are not recommended.
2. Implement enhanced hygiene and sanitation control measures, including cleaning of all high touch surfaces and bathroom facilities at least twice daily (and more frequently as needed) with a disinfectant labeled by Environmental Protection Agency (EPA) as active against feline calicivirus, norovirus or hepatitis A virus, or sporicidal. Dilute bleach solution (1:100) is also effective.

Education

Education should be provided to all high-risk populations and agencies serving these populations about signs/symptoms of HAV, need for vaccination, and hygiene measures to reduce transmission.

1. Hospitals, clinics, and other agencies serving these high-risk populations should educate clients/patients, healthcare providers, community health workers, intake staff, etc.
2. Strengthen education and outreach efforts to sheltered and unsheltered homeless persons, with a focus on necessary enhanced hygiene practices, referral for vaccination, and connecting potentially exposed and ill persons to care.
3. Educational materials in English, Spanish, and Portuguese can be downloaded here.