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.”
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
Originally posted on April 18, 2019.
Thank you for shining light on this issue, Meredith! I completely agree that the Hepatitis A vaccine is the best way to prevent the spread of the disease. I currently volunteer at a homeless shelter in the University District Area of Seattle, and it is so easy to see how the infection of one person can easily spread to others. There are about 50 guests plus anywhere from 5-15 volunteers/staff staying each night in very close quarters. Also, the sanitation and hygiene within the shelter could be improved and may contribute to the easy spread of infection. Although not on the same scale, we recently had a lice outbreak in the shelter – several people became infected! Communicable diseases spread so easily in these types of environments and I am glad to see that King County Public Health is providing those in homeless shelters specific steps to get the vaccine. This is so important to preserving the health of our city and county. I hope that these efforts will continue until Hepatitis A is eradicated from our region.
Meredith,
This article about hepatitis A has intrigued me. Since this communicable disease is more rare in the U.S. population, due to the high rates of vaccination in our country, I don’t know very much about the risks of Hepatitis A. It is valuable to understand that this disease is still affecting our communities and to educate ways that minimize the danger of this disease. I do, however, still have some questions to ask you:
Is there a requirement for hepatitis A vaccination in Washington State? In order to minimize cases of Hepatitis A in vulnerable populations such as those experiencing homelessness, it may be beneficial to have such a policy. If there is a policy like this already in place, what are the barriers to providing the hepatitis A vaccination to children in our state?
To my knowledge, the Hepatitis A vaccination is taken in two doses 6 months apart; how does this affect programs in place to vaccinate persons experiencing homelessness? I would imagine that this must make it difficult to follow through with both vaccine doses in the appropriate amount of time to provide immunity.
Hi Emma. Thanks for your interest. I forwarded your questions to our immunizations staff and they were able to provide some information:
Hepatitis A vaccination is routinely recommended for all people aged one year and older who are experiencing homelessness and for all children at age one, with a second dose six months later. However, hepatitis A vaccinations are not required for school entry because hepatitis A is not typically transmitted in school settings. Routine vaccination against hepatitis A is not required for other groups, like food service workers, sewage workers, and health care providers because hepatitis A outbreaks in these populations are very uncommon.
We are focusing on vaccinating as many people as possible in the high risk groups with at least the first dose of hepatitis A vaccine. We are educating people that hepatitis A is a two-dose series, and we are letting them know where they can get the second dose. If we are able to verify that someone is due for their second dose, we are administering that as well.
Although the hepatitis A vaccine is a two-dose series, the first dose offers significant protection on its own. In fact, in most healthy individuals, one dose can offer as much protection as two doses. Because one dose is highly effective, the CDC recommends administering the first dose of hepatitis A vaccine even if the second dose can’t be given on schedule. Protection from one dose of hepatitis A vaccine has been shown to last for at least ten years.
Hi Meredith,
Thank you for your wonderful insight. Knowing that there are vulnerable population that is disproportionately affected by this public health issue, I wonder if there could be better interventions/programs to address the issue. I know on the comment above you have talked about requirements for the vaccinations and steps to prevent Hepatitis A but that does not seem to address the disparity we see between populations. Are there any programs/interventions or protocols within interventions that specifically targets the homeless population? For instance, a lot of clinics nowadays use platforms such as MyChart to remind patients of their upcoming vaccinations or preventative care treatments before they even schedule an appointment. Seeing as there would be lack of access to computers/internet in homeless population, are there any ways that a program/intervention is targeting them to take the needed steps?
If not, what do you think would be the next steps to tackling this PH issue within this vulnerable population?