National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Hepatitis A Virus

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1 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Hepatitis A Virus Monique A. Foster, MD MPH LCDR, United States Public Health Service Medical Epidemiologist, Division of Viral Hepatitis Centers for Disease Control and Prevention CACDC 2017, Oakland, California October 24, 2017

2 Nothing to Disclose

3 Hepatitis A Virus Picornavirus Replicates in the liver, excreted in bile Acute illness Average incubation period: 28 days Clinical Manifestations: Fever, myalgia, anorexia, malaise, nausea and vomiting

4 Small but Mighty Stable outside the body for months Stable at low ph Stable frozen Inactivated by high temperature at 85 C (185 F or higher) for one minute; formalin, chlorine Spread from cooked food if it is contaminated after cooking Adequate chlorination of water kills HAV that enters the water supply 4

5 Hepatitis A Virus Transmission Person-to-person transmission Travelers MSM Persons who use illicit drugs Common-source outbreaks and sporadic cases Foodborne Waterborne Nosocomial 5

6 Global Patterns of Hepatitis A Virus Transmission Endemicity Age at Infection Transmission Pattern High Early childhood Person-to-person, outbreaks uncommon Intermediate Low Late childhood/young adults Late Childhood/Young Adults Person-to-person, food and waterborne outbreaks Person-to-person, food and waterborne outbreaks Very Low Adults Travelers, outbreaks uncommon Jacobsen KH, Wiersma ST. Vaccine

7 Global Hepatitis A Virus Jacobsen KH, Wiersma ST. Vaccine (2010) 28:

8 Hepatitis A Virus Endemicity in the United States The United States is now considered a very low endemic HAV country In the pre-vaccine era, cyclical increases occurred every years The number of reported cases in the pre-vaccine era was 21,000 annually Fiore AE, et al. Advisory Committee on Immunization Practices (ACIP) ; CDC. Surveillance for Viral Hepatitis-- United States, 2015.; Murphy TV, et al. MMWR Suppl

9 Incidence of reported hepatitis A cases, by county National Notifiable Diseases Surveillance System (NNDSS), United States, Murphy TV, et al. MMWR Suppl

10 Incidence of reported hepatitis A cases, by county NNDSS, United States, 2007 Murphy TV, et al. MMWR Suppl

11 Reported cases/100,000 population Incidence of hepatitis A virus by age group United States, yrs yrs yrs yrs yrs yrs 60+ yrs Year 11 CDC. Surveillance for Viral Hepatitis-- United States, 2015.

12 Number of HAV Outbreaks Reported 40 Hepatitis A Outbreaks Identified in the United States Year Craig AS, et al. Am J Med Sci 2007 CDC FoodTool Total Outbreaks Foodborne Outbreaks Community Outbreaks 12

13 Number of HAV Outbreaks Reported 40 Hepatitis A Outbreaks Identified in the United States Year Craig AS, et al. Am J Med Sci 2007 CDC FoodTool Total Outbreaks Foodborne Outbreaks Community Outbreaks 13

14 Number of HAV Outbreaks Reported 40 Hepatitis A Outbreaks Identified in the United States Year Craig AS, et al. Am J Med Sci 2007 CDC FoodTool Total Outbreaks Foodborne Outbreaks Community Outbreaks 14

15 Shifting Hepatitis A Virus Epidemiology Past outbreaks were associated with asymptomatic children A large population of adults are not immune to hepatitis A virus Older individuals are more likely to experience severe disease and adverse outcomes Vaccination uptake among at-risk adults is low Collier M, et al. Hepatology 2015., Ly KN, Klevens RM. J Infect Dis 2015., Epson E, et al. Public Health, 2015., Murphy TV, et al. MMWR Suppl

16 Foodborne Outbreaks Susceptible adults exposed to contaminated food imported from HAV endemic countries HAV is the only vaccine preventable foodborne disease in the US Foodborne HAV is underreported and misdiagnosed Contamination can occur at point of service, during growing, harvesting, processing or distribution Collier et al 2014; Ly et al. 2015; Amon et al. 2005; Fiore

17 Traceback Collier, MG, et al. Lancet Infect Dis. 2014; 14:

18 HAV in Travelers Approximately 46% of HAV cases in the US are attributable to international travel Risk ranges from 3 to 20 per 1,000 travelers Includes cases who were exposed to a traveler Vaccine coverage among travelers was 16% in 2015 Khuroo 2003, Fiore et al. 2006; Klevens et al. 2010; Liu et al. 2015; Williams et al

19 HAV among MSM Transmission likely due to close personal contact and specific sexual practices Current outbreak in Europe >3000 cases 16 countries present Hep A vaccine has been recommended since 1996 Cotter et al. 2003; Bialek et al. 2011; Williams et al

20 HAV among illicit substance users High incidence of HAV among this population No evidence that injection puts users more at risk Transmission is likely direct person-to-person related to poor hygiene Villano et al

21 Hepatitis A among homeless populations Little is known about hepatitis A immunity among homeless populations in the US Homelessness is not considered an independent risk factor for HAV infection Older age, duration of homelessness, and injection drug use may indicate HAV immunity Hennessey KA, et al. Public Health Reports

22 Hepatitis A Virus Outbreaks United States, CDC has assisted in multiple HAV outbreaks since July 1, Foodborne Transmission 3 Person-to-Person Transmission 1,400 outbreak associated cases reported since July 1,

23 An Emerging Genotype? Genotype IA commonly circulates in North and South America Recent outbreaks are genotype IB 23

24 Summary Universal childhood vaccination recommendations have decreased HAV incidence in the US Many adults have no immunity to the disease Increases in disease complications during HAV outbreaks is expected Increase in HAV outbreaks reported over the last year ( ) Homelessness may need to be considered an independent risk factor for HAV infection HAV genotype IB has caused the majority of outbreak cases in the last year 24

25 Acknowledgments Division of Viral Hepatitis John Ward Scott Holmberg Eyasu Teshale Noele Nelson Megan Hofmeister Winston Abara San Diego Health Department Eric McDonald Jessica Healy Sarah Stous Corey Peak California Department of Health Kathleen Harriman Jennifer Zipprich Cynthia Yen Division of Viral Hepatitis Laboratory Amanda Poe Yulin Jin Guo-Liang Xia Suma Ramachandran Other Jurisdictions Caroline Castillo Susan Bohm Danielle Donovan Jeff Eason Bree Barbeau Sally Ann Iverson Julia Latash Alicia Cronquist Alexis Burakoff 25

26 Thank You!

27 Rate per 100,000 Rates of Reported Acute Hepatitis A Cases United States, : 59,606 cases, Rate = : Vaccine recommended 31,032 cases, Rate = : 1,390 cases, Rate = 0.4 Year : 95.5% decrease in reported cases National Notifiable Diseases Surveillance System (NNDSS); Armstrong GL. Pediatrics 2007;119:e

28 Prevalence of anti-hav by age group NHANES, United States and * * * * * 31.2% 26.5% Overall *P <0.01 Age group NHANES, National Health and Nutrition Examination Survey Murphy TV et al. Progress Toward Eliminating Hepatitis A Disease in the United States. MMWR Suppl Feb 12;65(1):29-41.

29 Rates per 100,000 persons Hepatitis A hospitalization trends, National Inpatient Sample (Healthcare Utilization Project or HCUP) Primary discharge diagnosis of hepatitis A Mean age of persons hospitalized for hepatitis A has increased significantly over the study time period (mean age 37.6 years in compared to 45.5 years in , P < ) Mean age in years Collier MG, Tong X, Xu F. Hepatitis A hospitalizations in the United States, Hepatology Sep

30 Trends in Disease and Complications of Hepatitis A Virus Infection in the United States, Ly et al. JID Jul 15;212(2):