June 12, 2018
Dear Colleague:
The Virginia Department of Health (VDH) recently identified a cluster of hepatitis A virus (HAV) infections in the central region of the state in men who have sex with men (MSM). In addition, several other states have reported hepatitis A outbreaks involving different populations, including MSM, persons with history of injection and non-injection drug use, persons who are homeless or in transient housing, and individuals with history of incarceration.
Clinical characteristics are the same for all types of acute viral hepatitis and include discrete onset of symptoms (e.g., nausea, anorexia, fever, malaise, or abdominal pain), plus either jaundice or elevated serum aminotransferase levels. Hepatitis A diagnosis is confirmed by a positive serologic test for immunoglobulin M (IgM) antibody to hepatitis A virus (IgM anti-HAV).
Because of the possibility of continued disease transmission, please consider viral hepatitis in your differential diagnosis in patients presenting with jaundice or elevated serum aminotransferase levels, and test accordingly. When testing for HAV infection, you may also consider testing for other sexually transmitted infections, when clinically indicated. In addition, many of the risk behaviors noted above can increase the risk for multiple forms of hepatitis; therefore, we recommend that health care providers consider ordering an entire viral hepatitis panel to confirm the diagnosis.
Since 1996, the Advisory Committee on Immunization Practices (ACIP) has recommended that all MSM receive two doses of HAV vaccine administered at least 6 months apart. People who use injection and non-injection drugs, persons traveling to countries with higher rates of HAV, or any person wishing to obtain immunity are also recommended to receive hepatitis A vaccination. ACIP also recommends Hepatitis B vaccine for the MSM population; the hepatitis A and B vaccines can be given separately or as a combination vaccine using a recommended schedule.
Please report cases of viral hepatitis to your local health department according to the Board of Health Regulations for Disease Reporting and Control. HAV infection requires immediate reporting, preferably by telephone, to ensure that public health prevention and control steps are initiated in a timely manner, including post-exposure prophylaxis (via single-antigen hepatitis A vaccine or IG) for individuals who have had recent (within 2 weeks), direct contact with a person with hepatitis A.
Thank you for your efforts to report cases of viral hepatitis and to increase hepatitis vaccination in susceptible populations. Please contact your local health department to report cases or for more information on where patients can receive vaccination.
Sincerely,
M. Norman Oliver, MD, MA
State Health Commissioner