The Journal of the Arkansas Medical Society Med Journal April 2020 | Page 10

EDITORIAL PANEL: Chad T. Rodgers, MD, FAAP | Elena M. Davis, MD, MPH | Shannon Edwards, MD | William L. Mason, MD | J. Gary Wheeler, MD, MPS
Update on Arkansas’ Ongoing
Hepatitis A Outbreak
JENNIFER DILLAHA, MD; MICHAEL CIMA, PhD, MPH; JOEL TUMLISON, MD, DIPLOMATE ABFM; and ALAN MAY
S
ince 2016, the United States
has experienced a multi-state
outbreak of hepatitis A among
persons using or injecting
drugs, the homeless and men who
have sex with men (MSM).
Hepatitis A, caused by the
hepatitis A virus, infects the liver
and generally leads to a self-limited
disease. Symptoms include fever,
loss of appetite, nausea, vomiting,
diarrhea, body aches, jaundice,
dark urine, and/or light stools.
Symptoms considered more specific
to hepatitis, such as jaundice, are
not always present. Diagnosis is
difficult because of the overlap of
hepatitis A’s general symptoms with
those of other common illnesses,
such as viral gastroenteritis.
The virus is transmitted per-
son-to-person through the fecal-oral
route. Transmission can occur from
close personal contact (household
members or sexual contact), con-
taminated food or water, or blood
exposure. 1,2 Prior to the 1995 advent
of the hepatitis A vaccine, which con-
fers greater than 90% immunity with
one dose, there were typically 20,000
to 30,000 cases reported per year. 3,4
After the vaccine was added to the
recommended childhood immuni-
226 • The Journal of the Arkansas Medical Society
zation schedule, the yearly incidence
of hepatitis A dropped by 95% from
1995 to 2011. However, a subsequent
increase of 140% occurred between
2011 and 2017. 4
In November 2016, California first
identified an outbreak of hepatitis A
among the homeless and drug-using
populations. Since then, outbreaks
have occurred in 29 other states,
resulting in nearly 30,000 cases by
January 2020; 61% required hospital-
ization and 302 individuals have died
from their infections. 5
In Arkansas, the first cluster of
hepatitis A cases in this outbreak was
identified in Clay County during Feb-
ruary 2018 and was largely attribut-
able to drug use. Through January 9,
2020, 450 individuals have become
infected with hepatitis A, leading to
236 (52%) hospitalizations and three
deaths. During this outbreak, 38
counties have reported at least one
case. Clay, Greene, Craighead and
Poinsett counties have the highest
burden of disease. In recent months,
sizable numbers of cases have also
been observed in Jefferson and
Washington counties.
Demographically, this outbreak’s
cases have occurred more often
in men than women (64% vs 36%).
More whites (92%) than any other
race have been infected. Patient
ages range from 2 to 80 (media
39). Table 1 shows the risk factors
and co-morbidities that have been
identified among these cases. Most
cases (60%) have reported drug
use as a risk factor. Among these
persons, 58% reported injecting
drugs. A quarter of hepatitis A cases
have tested positive for hepatitis C,
substantially more than the preva-
lence in the U.S. general population
(estimated at 1.7%). 6 Other identified
risk factors include MSM (2%), home-
lessness (3%), recent incarceration
(5%) and food handlers with 21 cases
(5%). Hepatitis A among food han-
dlers potentially exposes restaurant
patrons to the virus if proper sanita-
tion and handwashing guidelines are
not followed. Public notification and
mass vaccination were warranted
in response to some food handler
cases. Foodborne transmission has
not played a significant role in the
spread of this outbreak.
Since February 2018, the
Arkansas Department of Health
(ADH) has continuously monitored
and responded to the hepatitis A
outbreak. Over 35,000 vaccinations
have been given at over 30
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