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

2. 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.

3. 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

4. Multi-State Epidemic Curve

5. 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

6. 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

7. 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

8. 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

9. 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 .

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

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

12. Case Counts By County

13. Geographic Distribution

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

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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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 (
Submit completed form via fax to DIDE ( )
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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Outbreak Webpage

30. 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 Office: (304) Fax: (304)