Hepatitis A Outbreaks in Multiple States: CDC Recommendations and Guidance
Moderator: Kondra Williams
Presenters: Sapna Bamrah Morris, MD, MBA; Monique Foster, MD, MPH; Noele Nelson, MD, PhD, MPH
Date/Time: November 29, 2018, 2:00 – 3:00 pm ET
Good afternoon. I’m Kondra Williams, and I’m representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention. I’d like to welcome you today to today’s COCA Call-Hepatitis A Outbreaks in Multiple States: CDC Recommendations and Guidance. You may participate in today’s presentation via webinar or you may download the slides if you are unable to access the webinar. The PowerPoint slides and the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Again, the web address is emergency.cdc.gov/coca.
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At the conclusion of the session, participants will be able to accomplish the following: Describe the epidemiology of the current hepatitis A outbreaks occurring in multiple states. Discuss the ongoing transmission of hepatitis A among high-risk populations. Review the indications for hepatitis A vaccination and use of hepatitis A vaccine in contacts as post-exposure prophylaxis. Discuss how to coordinate with local and state health departments on understanding hepatitis A in local jurisdictions.
We’d like to welcome our three presenters for today. Dr. Sapna Morris, Dr. Noele Nelson, and Dr. Monique Foster. Dr. Morris is a medical officer at the Centers for Disease Control and Prevention and she is currently serving as CDC’s Incident Manager for the hepatitis A outbreaks occurring in 13 states. Dr. Morris has had a long-standing interest in providing healthcare for persons experiencing homelessness. Today she will be providing an introduction to the current hepatitis A outbreaks in multiple states.
Today’s second presenter is Dr. Noele Nelson. Dr. Nelson is the Lead Medical Officer for Hepatitis Prevention in the Division of Viral Hepatitis- National Center for HIV Hepatitis, STD, and TB Prevention at CDC. Dr. Nelson has been the lead medical epidemiologist in coordinating all prevention efforts since the onset of the hepatitis A outbreaks since 2016. Her presentation will focus on the role of hepatitis A vaccination in controlling outbreaks and will discuss recent changes to the Advisory Committee on Immunization Practices recommendation for hepatitis A vaccine.
Today’s third presenter is Dr. Monique Foster. Dr. Foster is the Lead Medical Officer for Hepatitis A epidemiology in the Division of Viral Hepatitis- National Center for HIV, Hepatitis, STD, and TB Prevention at CDC. Dr. Foster has been the Lead CDC Investigator of Hepatitis A outbreaks since 2016. Dr. Foster’s presentation will describe the epidemiology and characteristics of the recent hepatitis A outbreaks compared to historic hepatitis A transmission in the United States.
I’ll now turn it over to Dr. Morris. Dr. Morris, please unmute yourself, and you may begin.
Thank you, Miss Williams. I just wanted to thank everyone for joining us on this COCA Call today. Since mid-March 2018, we’ve seen a sharp increase in the already elevated incidence of hepatitis A cases throughout the United States, affecting more than 13 states at this point, resulting in the diagnosis of over 8000 cases. We’ve been disproportionately noting that the cases have been reported in persons using drugs or persons experiencing homelessness, and that the ability to reach those populations with vaccination has been challenging. And, and we’ve seen barriers to providing the much-needed intervention of preventive vaccination.
We wanted to just highlight really quickly that CDC has been involved in the ongoing investigation and response of these outbreaks. Since early 2017, and that we have instituted an ICS structure since May of 2018. We continue to work with all of the states that are experiencing cases and believe to, would like to continue to support states in their efforts of identifying cases early, and working to build partnerships and reach the at-risk populations and ensure that vaccination is getting to the people that are the most at risk. That certainly involves utilizing our, all healthcare facilities that may be providing care to these patients. And increasing the access to vaccination in order to –. [ Inaudible ] these outbreaks. To just highlight that CDC does have deployed staff in states that are experiencing extremely high levels of cases. And we will continue to work to respond and work with states in addressing these outbreaks and hope to prevent increasing incidence throughout additional states that have not yet seen an uptick in their increase in cases. So with that, I would like to just introduce Dr. Nelson and Dr. Foster who will give you some of the background around hepatitis A outbreaks historically. and currently with this outbreak that we’ve been experiencing in these multiple states. And then talk about what is the most important intervention which is vaccination. With that, I’ll turn it over to Dr. Nelson.
Thank you, Dr. Morris. Good afternoon. I will start by giving a brief refresher of hepatitis A serology. The single-stranded RNA virus. Sorry, next slide. A single-stranded RNA virus member of the picornavirus family that replicates in the, in the liver then is excreted in bile and stool. Illness from hepatitis A is typically acute and self-limited. Clinical symptoms are indistinguishable from any other viral hepatitis or other infections from non-infectious causes of hepatitis. The average incubation is 28 days but ranges from 15 to 50 days. An infected person can excrete virus in stool for up to two weeks prior to becoming symptomatic, making identification of exposures and initial detection of outbreaks particularly difficult. Next slide.
In the United States, transition to very low endemicity occurred during the second half of the last century. During this period, temporal increases in hepatitis A infections and person to person outbreaks led to cyclic increases approximately every ten to 15 years. Prior to when the hepatitis A vaccine became available in 1996, in non-outbreak years, the number of reported surveillance cases remained around 21,000 annually. When you account for under diagnosis and under reporting, the actual number of cases is estimated to be at least twice as high. For example, it was estimated that there were 80,000 cases in 1994. Next slide.
Hepatitis A vaccination was introduced incrementally in the US from 1996 to 1999. In 1996, vaccine was recommended for children at age two years in communities with high rates of disease and children through teen years and outbreaks. In 1999, vaccine was recommended for children at age two years of age in 11 states, shown in dark purple on the slide, with average annual hepatitis A rates of two times the national average, of greater than or equal to 20 cases per 100,000 population. Vaccine was considered in six states, shown in light purple, with rates above the national average of greater than or equal to ten cases per 100,000 population. Next slide.
Rates of reported acute hepatitis A cases have shifted since the introduction of vaccine. From 1996 to 2011, there was a 95. 5% decrease in reported cases. Rates of reported cases reached, of hepatitis A reached a low point in 2014 for all age groups except those aged ten to 19 years for which the low point occurred in 2015.
Rates increased for all age groups in 2015 through 2016 except those aged zero to nine years whose rates remained stable. When comparing the 2016 hepatitis A rates of all age groups persons aged 20 to 29 years and 30 to 39 years had the highest rate:. 9 cases per 100,000 population, and persons aged zero to nine years had the wellest rate. And this is likely due to the universal childhood vaccination. Next slide, please.
The prevalence of antibody to hepatitis A virus by age group is shown from 2009 to 2010 based on data from the National Health and Nutrition Examination Survey, or NHANES. Compared to previous surveys, significant increases occurred in the proportion of children with protection for ages six to 11 years and 12 to 19 years, most likely due to vaccination. However, significant decreases occurred in the proportion of adults with protection for ages 40 to 60 years and older. Overall, the prevalence of antibody to hepatitis A virus among US residents is about 26. 5%, indicating that less than one-third of the US population has protection against hepatitis A infection in 2009 to 2010. Next slide.
In addition to the recommendations for children, overall groups at increased risk of hepatitis A viral infection or severe hepatitis A viral disease were recommended to receive hepatitis A vaccine. These groups include travelers, men who have sex with men, users of injection and non-injection drugs, persons with clotting factor disorders, persons who work with non-human primates, persons who anticipate close personal contact with an international adoptee, persons with chronic liver disease, and in October 2018, CDC’s Advisory Committee on Immunization Practices, ACIP, voted unanimously to recommend hepatitis A vaccinations for all homeless people ages one and older to protect against hepatitis A infection. The recommendation was adopted by the CDC Director and will become official once published in MMWR. In addition to the recommendation shown on the slide, there was a recent update published in November in MMWR weekly. And this provides new information on post-exposure prophylaxis for hepatitis A.
Previously, immunoglobulin was preferred for persons aged greater than 40 years. However, the new recommendation states that hepatitis A vaccines should be administered for post-exposure prophylaxis for all persons age greater than or equal to 12 months of age. In addition, in addition to Hepatitis A vaccine, immunoglobulin or IG may be administered to persons aged greater than 40 years, depending on the provider’s risk assessment. Factors to consider in the decision to use IG in addition to vaccine include the age of a person, immune status and underlying conditions, and the type of exposure, meaning the risk of viral transmission. Another factor is the availability of immunoglobulin. The supplemental paper is include with this MMWR that provides specific provider guidance in administering post-exposure prophylaxis. The next slide, please.
Protection following natural infection of hepatitis A virus is lifelong. The antibody to hepatitis A virus has been shown to persist in vaccine recipients lifelong. The antibody to hepatitis A virus has been show to persist in vaccine recipients for at least 20 years in adults administered inactivated vaccine as children with a three-dose schedule. When hepatitis A vaccine was first recommended, it was in a three-dose schedule back in 1996. However, it is believed that the current two-dose schedule is equivalent to that previous three-dose schedule. A least 20 year antibody to hepatitis A viral persistence has been demonstrated among adults vaccinated with the two-dose schedule as adults. Detectible antibodies are estimated to persist for 40 years or longer based on mathematical modeling and antibody to hepatitis A viral kinetic studies. Therefore, it is thought that a two-dose schedule likely leads to lifelong protection similar to natural infection. After antibody to hepatitis A virus, after a single dose of vaccine can persist for almost 11 years. However, it is thought that a single dose in a healthy individual likely lasts even longer. Next slide, please.
The hepatitis A vaccine coverage in 2016 is as follows. The greater than equal to two-dose coverage was 60. 6% for children aged 19 to 35 months. We know this is likely underestimated since the first dose can be given up to age 23 months, with the second dose administered at least six months after the first. The greater than equal to one dose coverage was 86. 1% for children age 19 to 35 months. Similar vaccine coverage was recently published for 2017. The greater than equal to two dose vaccine coverage for adolescents aged 13 to 17 years was 64. 4% and the one-dose coverage was 73. 9%. The greater than equal to two dose vaccine coverage for adults, however, was much lower: 9. 5% for adults greater than equal to 19 years, 13. 4% for adults 19 to 49 years. For travelers, 19%, and for persons with chronic liver disease, 24%, despite these groups being recommended to receive hepatitis A vaccine. And coverage was 5. 4% for adults greater than or equal to 50 years. So looking at the vaccine coverage, along with the population immunity, it is clear that many adults are not protected against hepatitis A. Next slide please.
I would now like to introduce Dr. Monique Foster who will continue with this presentation.
Thanks, Noele. We’re going to get into a little bit about the outbreaks. Prior to July 1, 2016, there hadn’t been a large multi-state hepatitis A outbreak in the United States since the 2013 outbreak associated with frozen pomegranate arils. And there hadn’t been a large person to person community-wide outbreak since 2003. In 2016, two outbreaks associated with contaminated food items imported from hepatitis A endemic countries occurred, followed by the community-wide person to person outbreaks that continue to this day. Over 8000 outbreak cases have been reported to CDC in this time with the Division of Viral Hepatitis Laboratory sequencing over 3000 specimens. Next slide.
We are asked a lot, “why is this happening now?” In the past, large community outbreaks were associated with asymptomatic children infecting the adults who care for them, who then transmitted the virus to other adults. With the widespread adoption of the universal childhood vaccination recommendations asymptomatic children are no longer the main drivers of these outbreaks. Although the overall incidence rate of hepatitis A infection has decreased within all age groups as Dr. Nelson showed, there’s a large adult population that is not immune to infection because they have been vaccinated and they were not infected naturally when they were children. Therefore, susceptible adults are exposed through contaminated food, imported from hepatitis A endemic countries or through behaviors that increase risk of infection with a fecally oral transmitted virus. Older individuals are more likely to be symptomatic and thus reported. And hepatitis infection among older individuals is more likely to result in severe disease and adverse consequences such as hospitalization, fulminant liver failure and death. There are currently no universal vaccination recommendation for all adults. And for the at-risk adults for which vaccination recommendations do exist, which include people who use drugs, both injection and non-injection drugs, men who have sex with men; there are not a lot of data, but uptake is presumably low. Why are these recent outbreaks among individuals who report drug use and homelessness? Next slide.
Little is really known about hepatitis A virus immunity whether through vaccination or natural disease among homeless populations in the United States. While homelessness has been linked to hepatitis A outbreaks in the past, it has only recently been considered an independent risk factor for infection as many individuals may have other known risk factors, particular substance use, and/or underlying liver disease. The serum prevlance studies of immunity in this population that have been done found a higher than expected level of immunity with older age duration of homelessness and injection drug use as significant predictors of being immune to hepatitis A infection. Next slide.
Hepatitis A virus infection is also found at high frequency among people who use drugs. During the 1980s, drug use contributed to more than 20% of all cases of hepatitis A infections reported to CDC. Relatively frequent clusters among infection in these groups led to the ACIP recommendation in 1996 that people who use drugs, again both injection and non-injection, receive hepatitis A vaccination. Although blood-borne transmission is known to occur evidence is mixed on whether injection of drugs contributes substantially to a high prevalence of hepatitis A infection in these populations. Because direct person to person contact related to close contact and hygiene is a primary factor in a fecal/orally transmitted virus. Next slide.
We have seen an increased case morbidity and mortality reported in these recent outbreaks. Hepatitis A-related hospitalizations were already increasing prior to 2016 from seven percent in 1999. To 46% in 2015. Hospitalizations related to the outbreaks during 2016 to current day range from 25% in the food-borne outbreaks associated with frozen scallops to 81% in the outbreak in Michigan, associated with drug use and homelessness. All age mortality for hepatitis A infection is typically less than 1%. But the case mortality rate in these outbreaks associated with drug use and homelessness is around 3%. We are currently seeing a three to 13% of cases co-infected with hepatitis B virus in a range of 17 to 61% co-infection with hepatitis C. The increased mortality is likely due to an acute or chronic infection of an already damaged liver. There is no indication that there is an increased virulence of the circulating strains that are causing these outbreaks. Next slide.
So the big question is how do we stop these outbreaks? Luckily, hepatitis A is vaccine preventable. Vaccination is the cornerstone of outbreak control. Because the virus does not typically produce a long-lasting infection. Reduction in new cases can be obtained and really sustained by maintaining a high level of population immunity through vaccination. Controlling large community outbreaks through vaccinating only contacts of cases or what’s commonly understood as post-exposure prophylaxis is limited because persons are frequently unaware of exposure and cases may be reported to the public health authorities may be too late for PEP to be effective. Promotion of good hand hygiene alone would also require reliance on behavioral change to end these large outbreaks. Therefore, proactive vaccination of the groups at highest risk is what is recommended. Ideally, these groups should be identified and targeted early in the outbreak. But this can be logistically difficult and costly and often there might not be a dramatic effect on the outbreak for some time. So primary prevention, ensuring vaccination of these groups before outbreaks occur is definitely preferable. Next slide.
Public health outreach to people who use drugs and the homeless can be very challenging for many reasons including mistrust of the government due to arrest or mental illness and limited ability to access routine medical care. Engaging stakeholders who routinely interact with this population can also be difficult as they may have other important issues to address, such as addiction treatment and housing instability. Syringe service programs, homeless shelters and substance abuse treatment centers are important settings for engaging people in needed healthcare and disease prevention.
In clinical trials in New York and California, vaccination onsite and treatment centers were shown to significantly increase vaccine initiation and completion of series compared with referral for free offsite vaccination. Hepatitis A vaccination in correctional settings are also an important component of community-based strategies to control hepatitis A outbreaks among people who use drugs. The most common criminal charges are typically related to drugs in 60 to 80% of inmates self-report current or previous drug use. Jails really do make a unique vaccination venue because the large number of persons who would benefit from vaccination but are usually difficult to reach are concentrated in one setting. Vaccinations also can be tracked in a safe medical care setting and potentially other medical problems related to drug use can be addressed. Next slide.
Similarly, emergency departments provide to patients who may be at risk but are difficult to reach. Emergency departments have successfully provided vaccinations during community outbreaks of hepatitis A virus in the past. And emergency departments also provide opportunities for rapidly responding to public health threats and have been shown to be effective venues for conducting immunization campaigns. Use of peer mentors to relay education and promote vaccination is also an important way to overcome mistrust in this population. Peer mentors have been found to be particularly successful in identifying and approaching friends and other individuals who they know participate in behaviors that put them at risk. Persons who choose to be peer mentors are often already recognized as leaders in their communities or may be respected as “old timers.” It has been shown that the more these individuals work with outreach programs, peer mentors become more confident communicators and more effectively use intervention tools such as slogans, harm reduction, and education materials. Next slide.
To summarize, prior to the vaccine, hepatitis A increases occurred in ten to 15-year cycles. The universal childhood vaccination recommendations have decreased hepatitis A incidents in the US among all age groups. However, many adults have no immunity to the disease through vaccination or natural infection, including adults in high risk groups for which vaccination is recommended. Community-wide outbreaks of hepatitis A are often prolonged and challenging to control. The hepatitis A outbreaks have increased over the last two years. Particularly among individuals who report non-injection and injection drug use, as well as homelessness. And while outreach and vaccination to these important risk populations is resource-intense vaccination to control outbreaks is cost effective compared to hospitalizations resulting from infections and saves lives by preventing infections in individuals with other comorbidities. Next slide.
With that, there are many people we’d like to thank here in the Division of Viral Hepatitis in our laboratory and also our state and local health jurisdiction partners. Thank you.
Thank you so much, Dr. Morris, Dr. Nelson, and Dr. Foster. We will now go into our Q&A session. Please remember, you may submit questions through the webinar system by clicking the Q&A button at the bottom of your screen and then typing your question. We have a couple of questions that have come in through our webinar system. So now for our first question. Presenters, please remember to state your name and unmute yourselves before answering. Our first question is- Is it recommended to run titers before vaccinating users of illicit drugs?
Hello, this is Noele Nelson. I’ll answer that. So it, first and foremost, it’s important to vaccinate. So though someone who has used drugs may have already previously been exposed, infected or vaccinated, it is not necessary or required to do pre-vaccination testing prior to vaccination. Additionally, getting additional vaccines, more than two doses is not considered to be a problem. It’s considered that it’s safe to, to give extra vaccines if more than two doses are inadvertently given, either because records are not available or the person doesn’t know if they were previously vaccinated. However, in a, in a population where it might be cost effective to do pre-vaccination testing and you know that you will be able to contact that patient again it could be a strategy that’s employed. But in an outbreak situation, pre-vaccination testing is likely of low yield and can lead to missed vaccination opportunities. Thank you.
Thank you, Dr. Nelson. Our next question. We’re seeing fluctuation in vaccine availability. Can you please discuss that?
Sure. So vaccine, how did, there was a constrained supply of vaccine in 2017 into early 2018. However, the supply has increased and we no longer consider the supply to be constrained. However, the Division of Viral Hepatitis at CDC works very closely with Immunization Services Division at CDC in order to, to monitor the supply and to ensure that the states with outbreaks are able to get as much vaccine as needed. If there are any concerns about vaccine supply in your clinic, region, state, it is very important that you contact CDC and/or the manufacturer to inquire about the vaccine supply. There should not be any issues in getting vaccine if it’s needed at this time. Thank you.
Thank you, Dr. Nelson. Our next question. Regarding vaccinations of persons at risk there was a reference to better uptake when vaccine was provided at prescription centers rather than via appointment-based clinics. Can you cite that source and/or expand more on that success?
I’m not, I’m not sure I’m aware of, of this issue.
Hi, this is Monique. Yeah, so that source is listed in our slides among the slides talking about vaccinations of person at risk. There’s multiple sources that have shown that during outbreaks among similar populations back in the early 2000’s, vaccinations occurred at both substance treatment centers, emergency departments, and in correction facilities where the uptake was better than asking those populations to come to the health department for free vaccine. But the references are provided at the bottom of the slide.
Thank you, Dr. Foster. Can you address diagnosis, challenges in light of high false positive rates of IGM?
This is Dr. Foster again. That’s a great question. CSTE case definitions require that individuals have symptoms that are consistent with hepatitis A. Which most of you know look like the symptoms that are present when a person is infected with other viruses that cause hepatitis or even other insults to the liver. Symptoms being fatigue, jaundice, nausea, vomiting, diarrhea and, and so on. Those symptoms have to be present with a positive hepatitis A IGM. But we know that that test can be falsely positive particularly in the settings of other viruses that can cause similar symptoms and that’s probably the number-one thing. The case definition also requires an elevation of liver function tests, ALT and AST. The new CST case definition will allude to dismissing or not counting cases that have an alternative diagnosis for the symptoms that they’re having to weed out some of the cases that may have a pulse, false positive hepatitis A IGM. And for areas where hepatitis A RNA testing is available, if, if the testing is shown to be negative, that also will rule out true infection with hepatitis A.
Thank you, Dr. Foster. Next question. What are the recommendations for vaccinating first responders who often come into contact with persons experiencing homelessness and people who misuse drugs?
This is Dr. Nelson. So there are no recommendations for vaccinating first responders or for vaccinating healthcare workers. If there are first responders that are going on, on foot teams, for example, into areas where there’s known to be high number, concentration of hepatitis A cases then it might be reasonable to vaccinate that first responder. However, in general, healthcare workers should, should not be at increased risk and are not considered a group for, for vaccination in general for hepatitis A. Thank you.
Thank you, Dr. Nelson. Our next question. Is it recommended to isolate a hospitalized patient that is positive with active hepatitis A in a mental health facility that shares a bathroom with others in Tennessee?
Hi, this is Dr. Foster. It’s more important to vaccinate and provide post-exposure prophylaxis to others who may have interacted with this individual. Particularly anyone who shared a, a bathroom or eating facilities with that individual.
Thank you, Dr. Foster. If given in the emergency department, how would you recommend follow-up for the second dose of a hep A vaccine?
Hi, this is, this is Dr. Nelson. So the, the second dose of hepatitis A vaccine is important for long-term protection and it’s not necessary for post-exposure prophylaxis. If a person is seen in an emergency department, and they are found to, it’s been greater than six months since their initial vaccine, and it’s feasible for the emergency department to administer that, that second dose that, that you know is reasonable. However, if the concern is about the person having been exposed and they’re, to the hepatitis A virus, and they’ve already been vaccinated previously, then there is, they do not necessarily need that second dose in the ER setting and it would be reasonable to have them get the second dose at their, at their healthcare provider. Thanks.
Thank you, Dr. Nelson. Our next question. Does genetic testing give any insights into whether the current Hepatitis A vaccine outbreaks are linked? Differences in the viruses might suggest if transmission is occurring between states or otherwise states are having unrelated outbreaks.
Hi, this is Dr. Foster. Yes, we do molecular epidemiologic testing and we can see which states are seeing circulation of the same strains, and which strains are circulating that may indicate separate cluster that might be associated with different risk factors such as contaminated food or, or other risk behaviors. So we have looked at that and we can see what linkages are occurring in the current outbreaks.
Thank you, Dr. Foster. Our next question. Why have the morbidity and mortality been higher in current outbreaks compared to previous?
Hi, this is Dr. Foster again. Yes, the, we suspect that the current morbidity and mortality is higher in these outbreaks because of the overall health of the at-risk populations. Many of the individuals who are becoming infected in these outbreaks already have damaged livers either due to decreased nutritional status from being in transient housing situations, having chronic liver disease, being infected with other viruses that cause viral hepatitis, having alcoholic liver disease. Also an increased morbidity and mortality had already been seen with hepatitis A. Due to the, I don’t want to say aging population. But now that kids are being vaccinated, we’re seeing older individuals who may have increased co-morbidities becoming ill with hepatitis A in general.
Thank you, Dr. Foster. Next question. How long is hepatitis A viable on surfaces?
Hi, it’s Dr. Foster again. That really depends on the surface. It can be quite a long time if that surface is not being cleaned with a chlorinated bleach or things like that. It’s a little bit different with soft surfaces. But that might be best answered by our environmental health colleagues.
Thank you, Dr. Foster. Our next question. Is there any reason to give a booster in an immunized patient, re-exposure to hep A, if the duration since immunization was greater than ten years?
This is Dr. Nelson. No, there is currently no recommendation to give a booster vaccination. If the person is, is healthy and they are, have been vaccinated greater than ten years ago, certainly feasible you could give the second dose if they have not received the, the second dose yet. However, if they’ve already received two doses, then there’s no indication for any additional doses of hepatitis A vaccine. Thanks.
Thank you, Dr. Nelson. Our next question. What are recommendations for vaccination, vaccinating food service workers?
This is Dr. Nelson. There are no recommendations for vaccinating food service workers. It has been, been shown in a number of studies that there’s not an increased risk of transmission of virus to, to patrons in a restaurant if the, if a food handler is sick with hepatitis A. In addition, the food handler would need to be actively symptomatic, meaning having like diarrhea at the time of handling food along with poor hygienic practices. And even then the risk of transmission is believed to be very, very low. So there are currently, in addition there, food handlers are not at increased risk of infection because of their, their profession. So there currently are no recommendations for specifically vaccinating food handlers unless the food handler also has another risk factor or indication for vaccination. Such as the food handler is known to be a drug user or MSM or have chronic liver disease or, or have transient homelessness. Thank you.
Thank you, Dr. Nelson. Our next question. Have there been other interventions in outbreak areas providing hand hygiene or general hygiene opportunities for homeless people, bringing vaccination opportunities to homeless shelters, anything else?
Hi, this is Dr. Foster. Yes. And outbreak in San Diego, hand-washing stations were installed in various locations throughout the city because a lot of the population becoming infected were unsheltered homeless and unfortunately, alcohol-based sanitizers are not always the best for inactivating hepatitis A virus. So it really is the, the mechanics of washing your hands with soap and water that is the best. The same for warming shelters. If there’s not enough hand-washing stations within bathrooms, those have been erected in certain local, local jurisdictions. We are recommending that vaccinations occur in homeless shelters and warming centers. And that has been occurring in almost all the jurisdictions that are currently experiencing outbreaks among these vulnerable populations.
Thank you, Dr. Foster. Our next question. Will a catch-up hepatitis A vaccination strategy for adults be presented to ACIP members at 2019 meetings?
Hello, this is Dr. Nelson. The, it’s, the plan is that the full updated routine vaccination recommendations will be hopefully presented to ACIP in 2019. I can’t give you a definite time or meeting yet. Catch-up vaccination is currently permissive for children age greater than two years. And so a discussion of the full routine recommendations will occur at an upcoming meeting. As mentioned, the routine recommendations are back from 2006, so definitely due for, for an update. But I cannot comment specifically on what updates will be available in those new recommendations. Thanks.
Thank you, Dr. Nelson. Any recommendations for hepatitis A vaccine administration to healthcare workers in the GI endos– endoscopy suite?
This is Dr. Nelson. No, not currently. As mentioned, there are no specific recommendations for vaccination, vaccinating healthcare workers. Thanks.
Thank you, Dr. Nelson. What is the best way for clinicians to help stop the spread of hepatitis A infections in current outbreaks?
Hi, this is Dr. Foster. That’s a great question. And I think the most important thing that clinicians can do on the front line is have a low suspicion for hepatitis A when they see patients with consistent symptoms. So obviously get the testing done, and as soon as you’re notified, don’t rely on the laboratory to report that case to the public health officials. So ensure that that case is reported to your local public health officials so they could be counted and interviewed and post-exposure prophylaxis can be offered to that individuals contacts.
In addition, this is Dr. Morris. Ensuring that your patients that you’re interacting with are screened for their housing status and any other risk factors, assessing their use of substances, illicit substances, and knowing that patients may not always report completely accurately. I think we should consider that we should err on the side of people reporting frequent illicit drug use should, should be indicated to, to have a vaccination. And so I think being proactive with that is extremely helpful. Whether that’s in community health centers or federally qualified health centers or in specific emergency departments particularly if you’re in a state where it’s currently being affected by the outbreak- outbreaks.
Thank you, Dr. Morris. Our next question. With positive titer, would you still recommend vaccinating again for a close contact?
This is Dr. Nelson. No, if a person has a, has a positive titer, then they, they’ve either been vaccinated previously or they’ve been exposed to the virus and so they do not need vaccination.
Thank you, Dr. Nelson. Our next question. What is the main source for the latest hepatitis A outbreak?
Hi, this is Dr. Foster. This is not a point-source outbreak. This is being transmitted person to person. So there’s no identifiable point source as, as the source of these outbreaks. Did not come from one place.
Thank you, Dr. Foster. Our next question. Should a person who travels get the vaccine or is it just for certain areas you travel to?
This is Dr. Nelson. So a person should get a vaccine if they are traveling to intermediate or high endemic countries. They do not need the vaccine if they are traveling to countries where hepatitis A is low endemicity. So for example, they would not, they, they would need the vaccine if they are traveling to Southeast Asia, parts of South America, and other areas where hepatitis A virus is known to be endemic.
Thank you, Dr. Nelson. Our next question. For international travel, travelers who wait until the last minute for vaccines, how long does the first dose of hepatitis A vaccine take before protective antibody levels occur?
This is Dr. Nelson. That’s a great question. It takes usually takes up to two weeks in healthy individuals. In older adults, in persons who are immunocompromised or have other chronic medical conditions, it can take longer. Perhaps up to a month or longer. We currently recommend that persons with chronic liver disease, for example who are, who are older should get immunoglobulin along with vaccine if they are traveling within two weeks and are not previously vaccinated. Thanks.
Thank you, Dr. Nelson. Our next question. Is this hepatitis A outbreak linked to the opioid epidemic? Especially with the increase in drugs, drug use in homeless populations.
Hi, this is Dr. Foster. We’re definitely seeing the highest number of cases in areas that are most affected by the opioid epidemic. So there is a link there. I, I can’t say how direct that link is. But definitely we want to protect these vulnerable populations in any way we can. And it’s great that we have a vaccine against this disease.
Okay, thank you, Dr. Foster. Okay, if hepatitis A is oral/fecal transmitted, how is IV drug use a risk factor?
This is Dr. Foster again. While there have been reports of bloodborne transmission of hepatitis A in the past. And we know that it is, it can be transmitted that way. The studies that have been done among injection drug users are still unclear. It may not be the injecting itself. But contamination of injection materials by the hands that are not thoroughly cleaned. And, and other, other behavior such as smoking marijuana at the same time as doing other injection drug use. So it’s not just the injecting, it’s probably a close-contact and hygiene issue.
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