Hepatitis A is no longer mainly a travel and food-related infection, as the majority of infections from 2016 to 2020 related to drug use or homelessness, according to the CDC.
Fully 56% of hepatitis A infected persons in the U.S. were using drugs (injected or not), 14% were homeless, and 12% were recently incarcerated in data from 33 states for the period from August 2016 through December 2020.
Co-infections with hepatitis B were seen in 5.2% of reported cases, and 30.3% were co-infected with hepatitis C, as Megan Hofmeister, MD, MS, MPH, of the CDC Division of Viral Hepatitis, and colleagues reported in Morbidity and Mortality Weekly Report.
"These outbreaks mark a shift in hepatitis A epidemiology in the United States," the CDC researchers wrote.
Hepatitis A data for the prior 15-year span from 2000-2015 showed drug use associated with infection in 3.5% of cases. Incidence was reported most often in the Hispanic population.
"International travel and exposure to foodborne outbreaks were previously the most frequently reported risk factors," Hofmeister and colleagues wrote. "Before the introduction of hepatitis A vaccines, ... transmission was driven largely by spread from asymptomatically infected children, and hepatitis A disproportionately affected racial and ethnic minority populations."
In the 2016-2020 analysis, cases occurred predominantly among males, white individuals, and adults ages 30 to 49.
The retrospective data included 37,553 outbreak-related cases reported during that 5-year span. By contrast, cases of reported hepatitis A were lower in the prior period, with 1,398 cases reported in 2011 and 1,390 in 2015, for example.
Of all cases in 2016-2020, 61.4% of individuals were hospitalized, and 380 deaths were attributed to hepatitis A. That was an increase from 42% hospitalized in 2016 data exclusively from the National Notifiable Diseases Surveillance System. Hofmeister's group noted that older age of patients and corresponding increased likelihood of comorbidities (including coinfection with hepatitis B or C) might be responsible for higher hospitalization rates.
Recent initiatives have helped drive down the numbers since the outbreak was declared in 2016. The outbreak remains active in 13 states, while 24 states have officially declared their outbreaks over.
"Increased hepatitis A vaccination coverage, particularly through implementation of successful, nontraditional vaccination strategies among disproportionately affected populations, is needed to continue progress in halting current outbreaks and preventing similar outbreaks in the future," the researchers wrote.
From 2016 through mid-September 2022, there have been 44,650 cases, 27,250 hospitalizations, and 415 deaths attributed to hepatitis A.
Vaccination for the homeless was recommended by the CDC's Advisory Committee on Immunization Practices in 2019, when the outbreak was at a peak. The CDC advised that overcoming stigma and mistrust and addressing vaccine hesitancy are important to improving vaccination. Ongoing initiatives since 2017 that have been contributing to controlling infection include satellite programs and nontraditional vaccination and staffing strategies at correctional facilities, vaccination, and substance use treatment centers, as well as syringe services programs and homeless shelters.
Limitations to the data included that risk factors were self reported and subject to recall bias, lack of systematic ascertainment of ethnicity, and variations in the way hepatitis A-related deaths are classified across states. Also, since hepatitis A surveillance is passive in the U.S., cases might be underestimated, the researchers noted. Moreover, a substantial proportion of data was missing.
Disclosures
The researchers had nothing to disclose.
Primary Source
Morbidity and Mortality Weekly Report
https://www.medpagetoday.com/infectiousdisease/hepatitis/100978
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