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

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1 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Hepatitis A Virus United States, nd AFDO Annual Educational Conference, June 9-13, 2018, Burlington, VT Vincent J Radke, MPH, RS, CP-FS, DAAS, CPH Sanitarian Centers for Disease Control and Prevention

2 Replicates in the liver, excreted in bile Short illness Average incubation period: 28 days Peak infectious period days prior to symptoms, 7-10 days after symptom onset Clinical manifestations: fever, jaundice, muscle pain, loss of appetite, malaise, diarrhea Hepatitis A Virus Graph created by Jan Drobeniuc

3 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 2010.

4 Hepatitis A Virus Endemicity in the US The United States is now considered a 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 2016.

5 Incidence of reported hepatitis A cases, by county National Notifiable Diseases Surveillance System (NNDSS), United States, Murphy TV, et al. MMWR Suppl 2016.

6 Incidence of reported hepatitis A cases, by county NNDSS, United States, 2007 Murphy TV, et al. MMWR Suppl 2016.

7 Incidence of hepatitis A virus by age group United States, yrs yrs yrs yrs yrs yrs 60+ yrs 6 Reported cases/100,000 population Year CDC. Surveillance for Viral Hepatitis-- United States, 2015.

8 40 Hepatitis A Outbreaks Identified in the United States Number of HAV Outbreaks Reported Total Outbreaks Foodborne Outbreaks Community Outbreaks Craig AS, et al. Am J Med Sci 2007 CDC FoodTool Year

9 1600 Reported Cases Associated with Hepatitis A Outbreaks United States, Number of Reported Outbreak Cases Year Craig AS, et al. Am J Med Sci 2007; Collier MG, et al. Lancet Infect Dis 2014.; CDC Unpublished data 9

10 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

11 Hepatitis A Virus Outbreaks United States, CDC has assisted in multiple HAV outbreaks since July 1, 2016 Foodborne Transmission Hawaii-Frozen Scallops Multistate- Frozen Strawberries Person-to-Person Transmission Homeless individuals and injection/non-injection drug users Men who have sex with men (MSM) 2,800 outbreak associated cases reported since July 1,

12 Foodborne Outbreaks Susceptible adults exposed to contaminated food imported from HAV endemic countries Hepatitis A is vaccine preventable Foodborne transmission of HAV is underreported and misdiagnosed Contamination can occur at point of service, during growing, harvesting, processing or distribution Collier et al. Lancet Infection Diseases 2014; Ly KN, Klevens RM. J Infect Dis 2015 ; Amon et al. J Med Virol 2006; Fiore Clin Infect Dis

13 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

14 Summary Vaccination recommendations and widespread use of the vaccine have decreased HAV incidence in the US Many adults have no immunity to the disease Increase in HAV outbreaks reported over the last two years Homelessness may need to be considered an independent risk factor for HAV infection

15 Acknowledgements Monique A. Foster, MD MPH, Medical Epidemiologist, CDC

16 Thank You! Vince Radke,