Hepatitis A Outbreak in West Virginia Information for Our Hospital Partners Emergency Preparedness Taskforce Meeting September 7, 2018 Stonewall Jackson Resort

Background Started in November 2016 - San Diego County, California 704 outbreak cases reported in California 65% hospitalized 21 deaths Cases among individuals experiencing homelessness and/or using illicit drugs in settings of limited sanitation Outbreak declared over April 11, 2018 An increase in hepatitis A cases were reported in November 2016 in Sand Diego County, California. The outbreak spread to Santa Cruz, Los Angeles, and Monterey counties. San Diego and Santa Cruz have reported the greatest number of cases. The majority of people infected with hepatitis A virus in this outbreak were people experiencing homelessness and/or using illicit drugs in settings of limited sanitation. California reported 704 outbreak cases reported with a 65% hospitalization rate and 21 deaths. California deployed intensive efforts to vaccinate populations at risk including foot teams to reach the at risk population. A total of 123,000 vaccine does were distributed during this outbreak. Outbreak was declared over April of this year following the slowdown in reported hepatitis A cases across the state.

Multi-State Hepatitis A Outbreak* Cases Hospitalizations Deaths Arkansas 108 56 (52%) 1 Indiana 414 178 (43%) Kentucky 1495 852 (57%) 12 North Carolina 21 17 (81%) Massachusetts 23-27 21-25 (93%) Michigan 877 707 (80%) 27 Missouri 178 76 (43%) Ohio 286 177 (62%) Tennessee 179 108 (60%) Utah 275 148 (55%) 2 West Virginia 1031 567 (55%) *As of August 28, 2018

Multi-State Epidemic Curve

Reporting Requirements Hepatitis A is a Category II condition - reportable to the local health department (LHD) within 24 hours of diagnosis Cases of hepatitis A are to be reported to Division of Infectious Disease Epidemiology (DIDE) within 24 hours of receipt from the LHD

Hepatitis A Virus Communicable disease of the liver caused by the hepatitis A virus Vaccine preventable disease Transmitted person to person through the fecal oral route or consumption of contaminated food or water Symptoms include: Jaundice Fever Loss of appetite Nausea Malaise and sometimes diarrhea

Transmission Incubation Period: Average is 28 days (15-50 days) Period of Communicability: Infectious period of the disease is from two weeks before the onset of symptoms to one week after illness onset

Hepatitis A in West Virginia Averages nine cases per year Increase in cases in February 2018 Outbreak declared in March 2018 Cases primarily in Kanawha, Putnam, and Cabell counties Cases genetically linked to 1B strain outbreaks

Case Definition: Clinical Criteria An acute illness with a discrete onset of any sign or symptom consistent with acute viral hepatitis Fever Headache Malaise Anorexia Nausea Vomiting, diarrhea, and abdominal pain, AND Either a) jaundice, or b) elevated serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels .

Case Definition: Laboratory Criteria Immunoglobulin M (IgM) antibody to hepatitis A virus (anti-HAV) positive

Outbreak Statistics 1,166 outbreak cases Age range 12-82 years Medium age is 37 years 52.6% hospitalized 2 deaths

Case Counts By County

Geographic Distribution

West Virginia Epidemic Curve Cases reported by week of onset of symptoms

Risk Factors Co-infections: (information available for 989 cases) Hepatitis C – 610 (61.7%) Hepatitis B - 110 (11.1%) Illicit Drug Use: (information available for 975 cases) 763 (78.3%) Homeless: 139 (11.9%)  

Individuals at Highest Risk for Infection IV and non-IV drug users Persons who are homeless, highly mobile, or have unstable homes Persons who have been incarcerated within the last six weeks Persons in close contact with high risk individuals Close contact of a case of hepatitis A Not general public or worried well

Laboratory Testing Hospital laboratories are requested to submit specimens for genetic testing to the Office of Laboratory Services for all patients positive for hepatitis A until molecular testing can confirm the presence of the hepatitis A 1B strain in a county No further specimens are required once the outbreak has been confirmed in a county For cases in counties where a genetic link has been established specimens may be submitted where there is no identified risk factors for hepatitis A

Outbreak Counties with Genetic Testing Berkeley Boone Cabell Calhoun Clay Fayette Greenbrier Jackson Kanawha Lincoln Mason Mercer Nicholas Putnam Raleigh Wayne Wood

Challenges for Public Health Officials As many as a third of the population will never develop symptoms or symptoms could be confused with poor living conditions or indications of drug use Can take up to 50 days from infection for symptoms to appear-virus can easily spread before an infected person realizes that he or she is sick Reaching and vaccinating populations most effected Highly mobile population-often leaves against medical advice making contact investigation challenging Experience tells us that it can take up to 9 months to see decreases in new cases-outbreaks may last 1-2 years Mixed messaging

Occupational Risk Advisory Committee on Immunization Practices (APIC) states no populations have been demonstrated to be at increased risk for hepatitis A because of occupational exposure Healthcare employees should use standard precautions when in contact with patients to prevent transmission of various infectious conditions including hepatitis A and should practice good hand hygiene with soap and water Alcohol sanitizers are not effective against hepatitis A virus Facilities should use a cleaning disinfectant that is effective against Norovirus (List G: EPA Registered Antimicrobial Products Effective Against Norovirus) For individuals who are in ongoing, close contact with high risk individuals vaccine can be considered

Vaccine Availability There are two manufacturers of HAV vaccine in the US: Merck: temporary stopped manufacturing adult vaccine GSK: keeping up with the demand, and providers can privately purchase any amount they want Publicly supplied vaccine: Purchased off the Centers for Disease Control and Prevention (CDC) contract in response to the outbreaks in different states CDC has placed this vaccine under allocation West Virginia’s outbreak vaccine: Vaccinate close contacts of confirmed cases Vaccinate population at highest risk for disease Can be used regardless of insurance status Open to public health agencies and other public health partners Providers will pay full price for hepatitis A vaccine f

Vaccine Requisition Process All WV counties may request state-funded hepatitis A vaccine Any facility may request state-funded hepatitis A vaccine An algorithm has been developed to help determine whether someone qualifies for state-funded hepatitis A vaccine A non-public health agency can request vaccine and must submit a vaccine requisition form to request vaccine Located on the DIDE webpage (www.hepawarewv.org) Submit completed form via fax to DIDE (304-558-8736) Any state-funded hepatitis A vaccine administered must be documented in WV Statewide Immunization Information System (WVSIIS) or the Vaccine Administration Log if not entered into WVSIIS

Local Outbreak Response LHDs investigate cases using standardized case investigation worksheets and submit information in to WV Electronic Disease Surveillance System (WVEDSS) LHDs and Regional Epidemiologists will communicate to DIDE for any case involving a food service employee, school, daycare and if any death is associated LHDs will target vaccine campaigns to high-risk populations Regional Epidemiologists are responsible for compiling a regional data to be submitted weekly to the state

State Outbreak Response Coordinating and supporting outbreak response DHHR Health Command activated Collaboration and consultation with CDC-West Virginia tier 1 state Monitoring outbreak and providing epidemiological support Buying, distributing, and monitoring hepatitis A vaccine Maintaining communications with public, stakeholders, and media Securing funding opportunities to support outbreak response and vaccine

State Vaccine Initiatives Screen and Vaccinate Program 76 Federally Qualified Health Centers 40 Rural Health Centers Comprehensive Treatment Centers 7 independent facilities ~5,000 client visits a month Medicated Assisted Therapy Sites Clinics that provide clients medicated assisted therapy for substance abuse Regional Jails Southwestern, Southern, Southcentral, Western, Central Population vaccinated and opt out on intake 30% of inmates re-enter system within 6 months

Health Alert 149 August 3, 2018 Health Alert was issued to healthcare providers including emergency departments: Report all suspect and confirmed cases of hepatitis A to local health department within 24 hours of identification Screen patients for possible high-risk behaviors related to hepatitis Maintain high index of suspicion for hepatitis A among high-risk individuals with elevated liver function tests and jaundice Order complete hepatitis panel Patients should be offered vaccine if they fall into a high-risk group and are not currently symptomatic

How Can Hospitals Play a Role Screen all emergency department patients for risk factors Offer vaccine to patients at risk for hepatitis A Report all confirmed or suspected hepatitis A cases to your LHD within 24 hours of diagnosis Consider completing case report form while patient is hospitalized or inform someone from public health will follow-up Fax complete medical record or H&P to LHD Educate staff and patients on transmission and prevention Hand washing Vaccination Standard precautions

Use of One Dose Vaccine To conserve vaccine supply and maximize the availability, vaccinate persons at highest risk for hepatitis A Protective anti-hepatitis A virus antibody levels after a single dose of inactivated hepatitis A vaccine can persist for at least 14 years a single dose of this vaccine has been shown to successfully control outbreaks of hepatitis A

Outbreak Webpage www.hepawarewv.org

Contact Shannon McBee, MPH, CHES Syndromic Surveillance Director West Virginia Department of Health and Human Resources Bureau for Public Health Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology 350 Capitol Street, Room 125 Charleston, West Virginia 25301 Office: (304) 356-4019 Fax: (304) 558-8736 Email: Shannon.M.Mcbee@wv.gov