Monday, June 11, 2018

CDC HAN Advisory On Outbreak of Hepatitis A Virus (HAV) Infections among Drug Users & The Homeless



#13,358


Increasingly, we're seeing outbreaks of disease (infectious and noninfectious) among street drug users, often with tragic results. In April and May of this year, we looked at a multi-state outbreak of Coagulopathy Associated With Synthetic Cannabinoids Use, while in April, from San Diego we saw 6 Cases Of Wound Botulism Among Injection Drug User.
In the spring of 2015, in CDC HAN Advisory & MMWR: HIV & HCV Among Injectable Drug Users, we saw more than 140 people infected with HIV and Hepatitis C via shared needles in two Indiana counties. A number that would grow considerably in the year that followed.
Playing on people’s perception that marijuana is relatively harmless (and indeed, legal in some states) - synthetic cannabinoids, which are often sold as `synthetic pot' - have gained increasing popularity as a street drug, although most people have no clue about the toxic chemical brew they are really buying.
Although generally less serious than Hepatitis C, for more than a year we've seen multiple reports of outbreaks of Hepatitis A around the country - often linked to drug use and/or homelessness - with the following alert issued by Indiana's Health Department last March fairly typical.

Increase in Hepatitis A Cases, Southern Indiana—Prevention and Control

An increase in hepatitis A cases has been identified in southern Indiana, many of which are tied to a large outbreak in Louisville, Kentucky. Cases have been confirmed in several counties, with the majority of cases being reported in Clark and Floyd counties. In the last month, 17 cases have been reported (year-to-date: 40 cases; average is 20 cases per year). Many of the southern Indiana cases have involved inmates in the Clark County Jail. However, an elementary school in Clark County and a restaurant in Floyd County also have been impacted.
The genotype of two of these cases matches that of ongoing outbreaks in Arizona,  Kentucky, California, Michigan, and Utah. Transmission is presumed to occur person-to-person and through injection drug use; no commercial food product has been identified as being contaminated. Based on current information, populations who are homeless or use illicit drugs are considered at increased risk of exposure to hepatitis A.
Symptoms of hepatitis A appear 15-50 days after exposure and include abdominal pain, fatigue, nausea, vomiting, diarrhea, dark urine, pale stool, and jaundice. Healthcare providers are encouraged to ask patients about risk factors for hepatitis A, which include:
  • Travel within the past 50 days to states with ongoing outbreaks
  • Injection drug use
  • History of homelessness
  • Direct contact with individuals who have hepatitis A


Today the CDC has published a HAN Advisory as these outbreaks continue to occur. The CDC’s Health Alert Network (HAN) is designed to ensure that communities, agencies, health care professionals, and the general public are able to receive timely information on important public health issues.
You can sign up for HAN messages, and scores of other CDC and HHS email notifications, by going to the CDC - Quick Subscribe GovDelivery page
Due to its length, I've only posted a link and an excerpt from the advisory. Follow the link to read the full message in its entirety, including guidance for public health departments and health care providers.

Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness
Distributed via the CDC Health Alert Network

June 11, 2018, 0800 ET (8:00 AM ET)

CDCHAN-00412

Summary

The Centers for Disease Control and Prevention (CDC) and state health departments are investigating hepatitis A outbreaks in multiple states among persons reporting drug use and/or homelessness and their contacts. This Health Alert Network (HAN) Advisory alerts public health departments, healthcare facilities, and programs providing services to affected populations about these outbreaks of hepatitis A infections and provides guidance to assist in identifying and preventing new infections.


Background

Hepatitis A infection is a vaccine-preventable illness. The primary means of hepatitis A virus (HAV) transmission in the United States is typically person-to-person through the fecal-oral route (i.e., ingestion of something that has been contaminated with the feces of an infected person).1 Symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, and jaundice. Although rare, atypical extra hepatic manifestations include rash, pancreatitis, renal disease, arthritis, and anemia.2 


Severe infections can result in cholestatic hepatitis, relapsing hepatitis, and fulminant hepatitis leading to death.3 Average incubation of HAV is 28 days, but illness can occur up to 50 days after exposure.4 An HAV-infected person can be viremic up to six weeks through their clinical course and excrete virus in stool for up to two weeks prior to becoming symptomatic, making identifying exposures particularly difficult.5-7

Illness from hepatitis A is typically acute and self-limited; however, when this disease affects populations with already poor health (e.g., hepatitis B and C infections, chronic liver disease), infection can lead to serious outcomes, including death.


The best way to prevent hepatitis A infection is through vaccination with the hepatitis A vaccine. The number and timing of the doses depends on the type of vaccine administered. Vaccines containing HAV antigen that are currently licensed in the United States are the single-antigen vaccines HAVRIX® (manufactured by GlaxoSmithKline, Rixensart, Belgium) and VAQTA® (manufactured by Merck & Co., Inc., Whitehouse Station, New Jersey) and the combination vaccine TWINRIX® (containing both HAV and hepatitis B virus antigens; manufactured by GlaxoSmithKline). All are inactivated vaccines. GamaSTAN S/D (Grifols Therapeutics, Inc., Research Triangle Park, North Carolina) immune globulin (IG) for intramuscular administration is the only IG product approved for HAV prophylaxis. 


The efficacy of IG or vaccine when administered >2 weeks after exposure has not been established. Additionally, practicing good hand hygiene—including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food—plays an important role in preventing the spread of hepatitis A.


From January 2017 to April 2018, CDC has received more than 2,500 reports of hepatitis A infections associated with person-to-person transmission from multiple states. Of the more than 1,900 reports for which risk factors are known, more than 1,300 (68%) of the infected persons report drug use (injection and non-injection), homelessness, or both.8-11
During this time, responses conducted in various states resulted in increased vaccine demand and usage, resulting in constrained supplies of vaccine. As available vaccine supply has increased and progress has been made towards controlling ongoing outbreaks in some jurisdictions, vaccine is more readily available. However, both CDC and vaccine manufacturers continue to closely monitor ongoing demand for adult hepatitis A vaccine in the United States.

During the mid-1980s, drug use was a risk factor for >20% of all hepatitis A cases reported to CDC, but no large outbreaks have occurred among persons who use drugs since adoption of the recommendation for hepatitis A vaccination of persons who use injection and non-injection drugs was made in 1996.12,13 Outbreaks of hepatitis A infections among homeless persons have occurred in other countries, but large outbreaks among the homeless have not been described previously in the United States.14-17


Person-to-person transmission of HAV between persons who report drug use and/or homelessness could result from contaminated needles and other injection paraphernalia, specific sexual contact and practices, or from generally poor sanitary conditions.13 Transience, economic instability, limited access to healthcare, distrust of public officials and public messages, and frequent lack of follow-up contact information makes this population difficult to reach for preventive services such as vaccination, use of sterile injection equipment, and case management and contact tracing. These challenges make outbreaks among these groups difficult to control.


Rapid identification, a comprehensive response, and novel public health approaches may be required to address needs unique to these populations. Urgent action is needed to prevent further HAV transmission among these risk groups.

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