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April 15, 2020

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  • Be aware of 15 confirmed cases of locally acquired hepatitis A virus (HAV) since March 1, 2020 in persons living homeless in the Ballard neighborhood. Five additional cases reported no risk factors other than living, working or visiting Ballard or adjacent neighborhoods. Molecular testing has confirmed two of these cases (reported in February) are linked to the ongoing outbreak in King County among persons living homeless and/or persons who use drugs. Molecular testing is in progress for the remaining three cases.
  • Consider HAV infection in patients with compatible symptoms including:
    • Fatigue, fever, headache, joint pain, nausea, vomiting, abdominal pain, loss of appetite, dark urine, clay-colored stools, and jaundice.
    • 70% of older children and adults develop symptoms including jaundice; 70% of infections in children < 6 years of age are asymptomatic.
  • Collect specimens for laboratory testing on patients with suspected HAV infection:
    • Serum for hepatitis A IgM and IgG and liver enzymes (including ALT, AST).
    • Test for hepatitis B (HBsAg and IgM) and hepatitis C (antibody/EIA) to rule out other types of viral hepatitis.
  • Ask patients about risk factors, including homelessness or unstable housing, sexual history, travel history, injection and non-injection drug use, contact with other ill persons, and obtain information about potentially exposed household members and other contacts.
  • Counsel patients with HAV infection about the importance of practicing good hand hygiene – including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food; and, that they are most contagious (fecal-oral route) for 2 weeks before through 1 week after the onset of jaundice, and possibly longer if they have persistent diarrhea.
  • Suspected or confirmed cases should be excluded from volunteering and working in sensitive areas (food handling, health care, childcare settings), until assessed by Public Health.
  • Patients with suspected or confirmed hepatitis A who are living homeless should be isolated while infectious.
    • Public Health can assist with coordinating housing of patients living homeless with confirmed or suspected hepatitis A who do not require hospitalization.
    • Public Health will also work to identify exposed contacts and facilitate HAV postexposure prophylaxis (PEP).
  • HAV PEP regimens vary by age and health status, see link below. Public Health is available for consultation on when PEP is indicated.
  • Report confirmed and suspected HAV cases to Public Health at 206-296-4774.
To avoid missed opportunities, emergency departments, healthcare systems and clinics should routinely offer HAV vaccine at all clinical encounters to persons at increased risk, including those living homeless and persons who inject drugs, and healthcare providers should counsel patients regarding risk for HAV infection. In addition, HAV vaccine should be offered to anyone who wishes to reduce their risk of infection (See CDC hepatitis A vaccine recommendations in the resources tab above).

Since January 1, 2020, Public Health has identified 74 locally-acquired cases of confirmed HAV infection. Sixty seven of these cases are potentially associated with an outbreak among persons living homeless and/or persons who use drugs. In March 2020, Public Health identified 30 locally-acquired cases of confirmed HAV infection. Fifteen cases reported living homeless in the Ballard neighborhood and utilizing several local services, including the Ballard Public Library, Ballard Food Bank, St. Luke's Episcopal Church, Urban Rest Stop Ballard, and nearby local businesses. Five additional cases reported no risk factors other than living or working in Ballard or adjacent neighborhoods. Molecular testing has confirmed two of these five cases (reported in February) are linked to the ongoing outbreak among persons living homeless and/or persons who use drugs. Molecular testing is in progress for the remaining three cases.

Healthcare providers should be vigilant for potential HAV infections among persons who are at increased risk, including persons living homeless, persons who use drugs (injection and non-injection), and men who have sex with men (MSM).