CDC Health Advisory: Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness

June 11, 208

Original content :

The Centers for Disease Control and Prevention (CDC) and state health departments are investigating hepatitis A outbreaks in multiple states among persons reporting drug use and/or homelessness and their contacts. This Health Alert Network (HAN) Advisory alerts public health departments, healthcare facilities, and programs providing services to affected populations about these outbreaks of hepatitis A infections and provides guidance to assist in identifying and preventing new infections.

Recommendations for Health Departments

  1. Review the most recent sources of data on hepatitis A diagnoses. Attributes of communities at risk for unrecognized clusters of hepatitis A infection may include the following:
    • Recent increases in the:
      • Number of hepatitis A infections in persons who report drug use;
      • Number of hepatitis A infections in persons who report homelessness;
      • Number of hepatitis A infections in men who have sex with men; and
      • Number of hepatitis A infections in persons who report recent incarceration.
    • High rates of drug use, drug-related overdose, drug treatment admission, or drug arrests.
    • High rates of homelessness.
  2. Ensure standard operating procedures to identify and interview cases, perform contact tracing for all new hepatitis A diagnoses, and provide post-exposure vaccination of contacts as soon as the diagnosis is made.
  3. Ensure persons who report drug use (injection and non-injection) or are at high-risk for drug use (e.g., participating in drug substitution programs, receiving substance abuse counseling or treatment, recently or currently incarcerated) are vaccinated against hepatitis A virus, and specifically:
    • Consider programs to provide hepatitis A vaccinations in jails, syringe service programs, substance abuse treatment programs, and to at-risk persons in emergency departments, homeless shelters, warming centers, food distribution centers, and any venues where the at-risk populations may congregate or seek medical care.
      • Engage in “Participatory Planning.” Ask the facility what they feel is the best way to provide outreach to their population and what is the best way to provide vaccinations or improve vaccination uptake.
      • Have a consistent presence at the service provider if vaccinations are planned on-site. If repeat visits must occur, they should occur on scheduled days and times.
      • Adequately advertise vaccination events beforehand.
    • Engage stakeholders who care for persons who use drugs or may interact more frequently with facilities serving this population (e.g., behavioral specialists, disease intervention specialists).
    • Provide education to persons who report drug use and/or homelessness through targeted media campaigns encouraging vaccination and proper hand hygiene.
  4. Remind venues that may encounter undiagnosed infections, such as emergency departments and community-based clinical practices (e.g., family medicine, general medicine) of the importance of reporting hepatitis A infections to the health department.18
  5. Local health departments should notify their state health department and CDC ( of any suspected clusters of acute hepatitis A.

Recommendations for Health Care Providers

  1. Consider hepatitis A as a diagnosis in anyone with jaundice and clinically compatible symptoms.
  2. Encourage persons who have been exposed recently to HAV and who have not been vaccinated to be administered one dose of single-antigen hepatitis A vaccine or immune globulin (IG) as soon as possible, within 2 weeks after exposure. Guidelines vary by age and health status (please see for additional information).
  3. Consider saving serum samples for additional testing to assist public health officials in the investigation of transmission (i.e., confirmation of antibody test, HAV RNA test, genotyping, and sequencing). Contact the public health department for assistance with submitting specimens for molecular characterization.
  4. Ensure all persons diagnosed with hepatitis A are reported to the health department in a timely manner.
  5. Encourage hepatitis A vaccination for homeless individuals in areas where hepatitis A outbreaks are occurring.
  6. Encourage hepatitis A vaccination for persons who report drug use or other risk factors for hepatitis A.
  7. CDC recommends the following groups be vaccinated against hepatitis A:
    • All children at age 1 year
    • Persons who are at increased risk for infection:
      • Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A;
      • Men who have sex with men;
      • Persons who use injection and non-injection drugs;
      • Persons who have occupational risk for infection;
      • Persons who have chronic liver disease;
      • Persons who have clotting-factor disorders;
      • Household members and other close personal contacts or adopted children newly arriving from countries with high or intermediate hepatitis A endemicity; and
      • Persons with direct contact with persons who have hepatitis A.
    • Persons who are at increased risk for complications from hepatitis A, including people with chronic liver diseases, such as hepatitis B or hepatitis C.
    • Any person wishing to obtain immunity.