Hepatitis A is a liver disease caused by a highly contagious virus. A large outbreak in San Diego, along with outbreaks in Los Angeles and in Salt Lake City has Public Health officials concerned that a hepatitis A outbreak could occur in King County. Dr. Jeff Duchin, King County’s Health Officer, explains who’s at risk and what can be done to prevent an outbreak.

Dr. Duchin, what is happening with hepatitis A in San Diego?

San Diego is experiencing a large outbreak that began last fall, and more than 400 people have gotten infected by mid-September of this year. Two-thirds of the ill people have had to be hospitalized, and unfortunately, at least 16 people have died. While hepatitis A is not an uncommon illness, an outbreak of this size is unusual.

Who has gotten ill in this outbreak?

The majority of people who have contracted hepatitis A in San Diego are living homeless and/or are known to use illicit drugs. Some of the people who got sick have been neither homeless nor using drugs. Recently, there has been concern that people in the food service industry may have been exposed to hepatitis A, which can present a risk to restaurant customers.

How does hepatitis A make a person sick?

Hepatitis A is a liver disease in which the symptoms can range from mild to very serious, and it can last from several weeks to several months. Although most cases in children are mild or without symptoms, adults with hepatitis A usually develop an illness with symptoms that can be serious and at times leads to death from liver failure.

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). Not everyone experiences any or all of these symptoms. Hepatitis A does not persist in the body once an infected person recovers, like hepatitis B and hepatitis C can.

How is hepatitis A spread?

Person-to-person transmission through close contact is the primary way people get hepatitis A. Hepatitis A gets into the body through the mouth after a person touches an object, food, or drink that is contaminated with the virus. The hepatitis A virus is found in the feces of infected persons for weeks, starting before the person feels sick and lasting until after the person feels better.

If an infected person doesn’t wash his/her hands well, especially after toileting, invisible amounts of the virus can spread from the hands of that person to other objects, surfaces, and foods. Anything that contacts the fecal residue of an infected person can transmit hepatitis A virus.

Who is at highest risk for getting hepatitis A?
Anyone can get hepatitis A. At this time, we are particularly concerned about people living homeless because of what is happening in California.

Studies have shown that people who are homeless are at an increased risk for hepatitis A, and many of the people who are part of the San Diego outbreak are homeless. For this reason, we suggest that people who are homeless here and who are living around others get immunized against hepatitis A.

People who are at increased risk include:

• People living homeless, especially those living unsheltered with poor access to 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.

All people with these risk factors for hepatitis A infection should get the hepatitis A vaccine to protect themselves.

Why would people who are living homeless be at higher risk for hepatitis A?

People are often at high risk for hepatitis A when living in areas that are overcrowded, with poor sanitary conditions and lacking adequate facilities for personal hygiene. Anyone who does illegal drugs or has a chronic liver infection is also at an increased risk for serious infection.

You’ve said that we aren’t seeing an outbreak here. But can it happen here?

Yes, we should be concerned about a possible outbreak here, since we have thousands of people who are living without homes, often in encampments or on the street where they may not have access to clean toilets or hand washing facilities. We need to find ways to provide hygiene opportunities for everyone, including handwashing stations for use after using the toilet, and before cooking and eating. Soap and water are best, but in a pinch, an alcohol-based hand gel is better than nothing.

What else can people do to prevent the spread of this disease?

In addition to careful hand washing, people affected by a hepatitis A outbreak shouldn’t share food, drinks, needles or other drug equipment, or cigarettes. In general, people also should not share towels, toothbrushes, or utensils.

And if you think you may have hepatitis A and have any of the symptoms I described, see a healthcare provider.

You mentioned a vaccine for hepatitis A. Is that an option?

Anyone who wants to reduce his or her risk for contracting hepatitis A should be immunized, and no one who became ill in San Diego had been fully immunized. Two doses, administered six months apart, are recommended for full protection. The vaccine is highly effective, and people will begin to be protected about 2 to 4 weeks after the first injection. The second injection provides long-term protection.

What is Public Health doing to help prevent an outbreak?

We are working to educate everyone about how hepatitis A is spread and how to prevent it. We are 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 for hepatitis A. We are advising on appropriate steps that people who serve the homeless can do, and that includes providing adequate hygiene and sanitation that includes places for people to wash their hands. Our mobile medical van that serves people living homeless will also provide hepatitis A vaccinations, and we are looking into ways to offer the vaccinations at other locations as well.

Where can people go for more information?

Our website has a lot of information about hepatitis – and in multiple languages. We also created a one page flyer that includes the basic information for anyone to print and share!

Originally posted on September 27, 2017.