By: Kathleen Gaines BSN, RN, BA, CBC
The Center for Disease Control and Prevention (CDC) recently issued a health warning due to widespread hepatitis A outbreaks throughout the United States, the epidemic affects mainly those who suffer from homelessness and who use drugs.
In August, Florida was the latest state to join the list of states to report an outbreak of hepatitis A.
In the United States, since the outbreaks were first identified, 30 states have publicly reported the following statistics on Hepatitis A:
- Cases: 24.952
- Admissions: 14.984 (60%)
- Dead: 244
While hepatitis A is on the rise in the United States, it has been an ongoing problem in countries suffering from high levels of poverty and individuals who do not have access to clean drinking water.
The statistics on the world contraction are much more staggering. The World Health Organization has estimated that in 2016, 7,134 people died of hepatitis A worldwide. One of the biggest hotbeds was in 1988 in Shanghai, China, related to food and water, which affected more than 300,000 people.
What is hepatitis A?
According to World Health Organization (WHO), hepatitis A is a viral disease that mainly affects the liver. The virus usually spreads when an uninfected and unvaccinated person ingests food or water contaminated by the faeces of an infected person.
More recently, serious outbreaks have been linked to food products, particularly those that have been imported.
Hepatitis A, although fatal, does not cause permanent liver disease and people who are successfully treated often have immunity after treatment. Symptoms can range from mild to severe and affect very different individuals. Moreover, not everyone will have all the symptoms.
The symptoms of hepatitis A include:
- Low fever
- Abdominal discomfort
- Jaundice (a yellowing of the skin and whites of the eyes)
- Dark colored urine
- Loss of appetite
- Nausea and vomit
- Muscle aches and pains
- Clay-colored stool
Adults tend to have more severe symptoms than children. Most children who develop hepatitis A will have flu-like symptoms including cough and sore throat and some will develop jaundice.
Hepatitis A is more concerning for the adult population.
Individuals over the age of 50 or who already have long-term liver disease are at a higher risk of developing the most severe form of hepatitis A. Symptoms for these subjects include:
- Spontaneous bleeding or bruising
- Confusion and changes in supervision
- Worsening of the jaundice
- Worsening of liver function
Who is at greatest risk of contracting hepatitis A?
Unfortunately, all those who have not been vaccinated are at risk of contracting hepatitis A. The CDC and the WHO have identified those at higher risk of contracting hepatitis A. They include individuals who:
- Use recreational drugs (injectable and non-injectable)
- Lack of safe water
- Live in a family with an infected person
- I am a sexual partner of someone with acute hepatitis A infection
- They have unstable or homeless housing
- Men who have sex with men (MSM)
- Currently or have recently been jailed
- Living in poor sanitary areas
- Travel to areas of high endemicity without being immunized especially in Asia, South or Central America, Africa and the Middle East
- They have chronic liver disease, including cirrhosis, hepatitis B or hepatitis C.
- Living in a nursing home or a long-term care facility
- Working in the health, food or wastewater sector
- Eat raw crustaceans such as clams and oysters
Diagnosis and treatment of hepatitis A.
The blood test is the only way to accurately diagnose hepatitis A. Doctors will order the following laboratories:
- Serum aminotransferase
- Serum bilirubin
- Anti-hepatitis A (HAV) IgG virus
- Transcriptase-reverse polymerase chain reaction (RT-PCR)
There is no specific treatment for hepatitis A. Individuals who can spot exactly when they got the virus can get a hepatitis A vaccine or hepatitis A immunoglobulin to prevent symptoms. It will only work if it is administered very soon after coming into contact with the virus.
The symptoms will resolve automatically from several weeks to months. Most people will be completely healed in a year. With the exception of those with acute liver failure, hospitalization is rarely necessary and outpatient management is often sufficient.
How to prevent hepatitis A?
The easiest and most effective way to prevent hepatitis A is to Get vaccinated!
According to the WHO, almost 100% of people develop protective levels of antibodies against the virus within 1 month of the injection of a single dose of vaccine. The recommendation is to receive 2 doses of vaccine to ensure long-term protection from about 5 to 8 years after vaccination.
Other prevention strategies include,
- Adequate supplies of safe drinking water
- Proper disposal of waste water within the communities
- Personal hygiene practices such as normal hand washing before meals and after going to the bathroom
- Improve sanitation
The hepatitis A vaccine, initially developed for mass distribution in 1995/1996, is an inactivated vaccine that should be administered in two doses at least six months apart. There is a live oral dose that is used in China in children over the age of one year.
As of May 2019, 34 countries have used the vaccine against hepatitis A in the routine immunization of children in specific risk groups. Some of these countries include:
- New Zeland
- Czech Republic
- Saudi Arabia
Most other countries recommend the vaccine for people in high-risk categories.
The Florida epidemic was not the first since the CDC and WHO began monitoring epidemics in 2016. According to Florida general surgeon Dr. Scott Rivkees, from January 1, 2019 to 27 July 2019, 2,034 cases of hepatitis A have been reported..
A 2016 multi-state outbreak was one of the most serious in the United States. Frozen strawberries imported from Egypt have been identified as the probable source of the epidemic. People were infected when they drank smoothies containing frozen strawberries in the Tropical Smoothie Cafe's locations mainly in Maryland, North Carolina, Virginia and West Virginia. th
During this outbreak, 143 people with hepatitis A status were reported from nine states:
- Arkansas (1)
- California (1)
- Maryland (12)
- New York (5)
- North Carolina (4)
- Oregon (1)
- Virginia (109)
- West Virginia (7)
- Wisconsin (3)
In August 2016, the Hawaii Department of Health identified the raw scallops served at Genki Sushi restaurants on the islands of Oahu and Kauai as a probable source of the epidemic.
In 2013, 165 people developed hepatitis A from pomegranate seeds imported from Turkey that were included in the organic antioxidant blend of Townsend Farms. This outbreak has affected ten states, including:
- Arizona (23)
- California (79)
- Colorado (28)
- Hawaii (8)
- New Hampshire (1)
- New Jersey (1)
- New Mexico (11)
- Nevada (6)
- Utah (3)
- Wisconsin (2)
In 2018, the city of Philadelphia declared an outbreak of hepatitis A due to the reporting of 171 cases in 36 counties over the course of a couple of months.
An outbreak was concentrated among the homeless population of San Diego in 2016, sick almost 600 people and killed 20 people. 20% of these individuals were also infected with hepatitis C and 5% had chronic hepatitis B.
Since 2016, there have been 555 cases reported in Michigan that led to 457 hospitalizations and about 20 deaths. Most infected people suffered from homelessness and illicit drug use.
Hepatitis A epidemic cases reported by the state
The WHO and the CDC have collaborated with local governments to help reduce the incidence of hepatitis A. In May 2016, the World Health Assembly adopted the first "Global health sector strategy on viral hepatitis, 2016-2021". The goal is to reduce the global incidence of new viral hepatitis infections by 90% and reduce deaths by 65% by 2030.
For World Hepatitis Day 2019, the OMS is focusing on the topic "Invest in the elimination of hepatitis". The goal is to highlight the need for more national and international funding to increase the prevention and testing services for hepatitis and treatment
The CDC recommends that hospitals and health workers should do so during an outbreak
- Increase the availability of the hepatitis A vaccine.
- Perform pre-vaccination tests to identify those that are immune and do not need the vaccine
- Postpone the second dose of the vaccine in case of deficiency
- Offer free vaccines to high-risk individuals
- Community awareness for the homeless
Hepatitis A is an ongoing global epidemic of which all health professionals must be aware. It is important to understand risk factors, symptoms and prevention strategies in order to adequately educate patients.