World Hepatitis Day is July 28th, and this year we highlight the recent surge in Hepatitis A virus (HAV) outbreaks across the United States. HAV is a vaccine-preventable viral infection of the liver transmitted through the consumption of tiny amounts of feces or through contact with an effected person. HAV can cause mild to severe illness resulting in sudden nausea and vomiting, abdominal pain, joint pain, and in some causes death. In 2016 alone, there were approximately 7,134 reported HAV deaths worldwide, 216 within the United States between 2016 and July 2019

In the past, the highest rates of HAV were found in children. As infections are asymptomatic in 70% of children under the age of 6, these cases typically went undetected by routine disease surveillance, and were revealed when outbreaks among children occurred primarily in western U.S. states which accounted for 50 percent of HAV cases from 1987-1997, but housed only 22 percent of the nation’s population. However, transmissions from children to adults usually resulted in symptomatic adult infections in 70% of cases. Due to various childhood vaccination campaigns, these children are no longer the face of HAV, signaling a significant change in the landscape of the infection.

The incidence of HAV infections in the U.S. has surged in recent years. 2016-2018 saw 15,000 reported HAV infections, a 294% increase from 2013-2015. From 2016 through July 19, 2019, the CDC reports 22,295 cases of HAV have been reported from just 25 reporting states. Such an increase is compared to a 95% decline in HAV infections occurring from 1996-2011, following the introduction of the HAV vaccine in 1996. Why have infection rates risen? In 2017, outbreaks of HAV were reported across several states (California, Kentucky, Michigan, Utah) among drug users and individuals experiencing homelessness.

HAV outbreaks can sometimes occur as a result of exposure to the virus from an infected food handler, or eating HAV contaminated food or drinking HAV contaminated water. However the 2017 HAV outbreaks in the U.S. occurred as a result of crowded unsanitary conditions, contaminated needles or other injection paraphernalia, and specific sexual contact or practices among drug users and individuals experiencing homelessness. Circumstances that tend to exacerbate HAV transmission in these populations are transient housing, economic instability, limited access to health care, and distrust of government services.

The 2017 HAV outbreak landscape consisted specifically of 1,521 acute cases of HAV across California, Kentucky, Michigan, and Utah among populations of injection and non-injection drug users as well as individuals experiencing homelessness. HAV was contracted through direct person-to-person transmission as opposed to the traditional transmission through contaminated commercial food products. With the outbreak taking place within these communities, control measures were targeted in a manner to best address these populations. In San Diego, California prevention methods were comprised of vaccines being administered in jails and emergency departments, drug treatment facilities, homeless shelters, and syringe exchange programs. In certain areas teams visited homeless encampments to educate and vaccinate homeless groups. San Diego California deemed the outbreak severe enough to install handwashing stations, sanitize streets including bleaching the streets and buildings at night, and distributing sanitation packets to local homeless populations. Los Angeles, California opened the Skid Row Refresh Spot in an effort to tackle the many needs of individuals experiencing homelessness. The Refresh Spot provides free showers, laundry, restrooms, and support services to individuals in need. Individuals who utilize such services have an opportunity to improve hygiene free of charge, ultimately working to prevent the spread of HAV among this community. In Philadelphia, Pennsylvania an HAV outbreak prompted the Health Department to vaccinate 450 people, specifically those experiencing homelessness, and persons using drugs. Cities are taking it upon themselves to protect their residents from the harms of HAV while it is on the rise.

Such an outbreak landscape led many health professionals to advocate for achieving and sustaining high levels of population immunity through vaccination campaigns. With no required HAV vaccination for adults in the U.S., efforts are being made to target at-risk populations  like in states mentioned above, in an effort to tamp down on HAV outbreaks. Tennessee is encouraging residents to get the HAV vaccination following a spike in cases, and the state health department is providing the vaccine free of charge.

More strategies that emphasize prevention and awareness are needed to effectively address this public health issue. Comprehensive programs that improve the health and welfare of people who use drugs are at the core of preventing outbreaks and reversing increasing rates of viral hepatitis in the U.S. Harm reduction measures that include syringe exchange programs, access to means to maintain personal hygiene, and access to long-term housing will significantly lessen the spread of viral among people and inform people of ways to protect themselves and others from future infections and other adverse health consequences.

Alexis Gbemudu is a student at the University of Maryland Francis King Carey School of Law and a 2019 Law and Policy intern at the O’Neill Institute for National and Global Health Law. Alexis will graduate in 2020 with her J.D. concentrated in health law. She graduated from American University with an undergraduate degree in international studies with a minor in public health. Her international health law passions have sent her to Rwanda, England, and Jamaica focusing on topics ranging from women and youth development in a post-conflict region to comparative health systems. Alexis seeks to use her time at the O’Neill Institute to expand her knowledge of domestic health issues in an effort to gain a firm understanding of how policy is shaping health outcomes in the U.S.

Images Courtesy of: The World Health Organization and The Mayo Clinic