No Letup in NJ’s Outbreak of Hepatitis A; Cases in All 21 Counties

Lilo H. Stainton | November 4, 2019 | Health Care
Hundreds of residents have been infected since end of 2018; experts urge vaccination and some testing
Credit: Twenty20
Hepatitis A can be prevented with a vaccine.

A growing outbreak of hepatitis A has infected more than 500 New Jerseyans since last December with cases ranging among homeless individuals in Camden to food workers in Paterson to golf club patrons in Mendham Township. Six of those who were infected have died.

Reports of the highly contagious blood-borne disease — which is preventable with a vaccine — have increased eightfold over this time last year, state figures show, with infections identified in all 21 counties. Almost all of the patients have required hospitalization.

Most of the Garden State’s cases are considered part of the same outbreak that has infected nearly 27,500 people nationwide and killed 275 since 2016, according to data collected by the federal Centers for Disease Control and Prevention; some 6% of New Jersey’s 533 total cases are tied to other strains of the virus. (Kentucky has reported nearly 5,000 cases in the national outbreak and there have been more than 3,000 in both Ohio and Florida, the latter of which declared the issue a public emergency in August.)

New Jersey’s Department of Health has been working since February to help combat the spread of the Hep A virus (HAV), partnering with local officials to educate and encourage vaccinations among vulnerable populations. More than 1,600 hep A immunizations have been administered to low-income residents by local health departments, the DOH said, including hundreds of shots supplied by the state in the spring.

The recent outbreak has also prompted hepatitis experts to renew their focus on hep A, which is far less common than hep B and C; all three can cause fatal liver infections, but hep A involves a one-time illness that does not result in long-term damage, such as cancer, like the other forms. (In 2018, New Jersey recorded more than 400 new cases of hep B; more than 7,100 diagnoses of hep C; and 70 hep A reports.)

“Because of this outbreak we’re going to include hep A in our pledge” to end all forms of the disease in New Jersey, said Dr. Su Wang, a primary care doctor with RWJBarnabas Health who hosted a summit in late October focused on eliminating hepatitis. “There’s so little awareness of all three of them,” added Wang, who also heads the World Hepatitis Alliance.

How to reach those most at risk

In New Jersey, some experts are now thinking about how else government officials can work with providers and community organizations to better reach individuals most in need of protection from hep A. Utah, where the outbreak ended in February, deployed medical teams that worked as mobile “foot clinics” in order to reach at-risk individuals living on the street, reports note.

One in four of New Jersey’s recent hep A cases were identified in Camden County and approximately one in eight originated in Gloucester County; Mercer, Passaic and Burlington counties also had among the highest numbers, according to an Oct. 26 update from the DOH. (In Pennsylvania, the City of Philadelphia had recorded close to 300 cases midyear and declared a public health emergency in August.)

Hepatitis B and C are transmitted through blood and other bodily fluids; hep C rates have escalated significantly in recent years along with a rise in intravenous drug use. Hepatitis A comes from contact with contaminated feces, making gay men, homeless individuals and IV drug users particularly vulnerable.

Occasionally hep A infections are linked to contaminated food, like at the Mendham club, where dozens were sickened in June, resulting in the death of an elderly woman whose family has since filed a lawsuit against the club, according to news reports. Cases among food market workers in Paterson were also linked to the outbreak.

Former Gov. James McGreevey, who runs a statewide program dedicated toward smoothing individuals’ transition from jail to the community, said his team has witnessed a “significant increase” in hep A cases among their clients, including those who are staying at homeless shelters. Many are already struggling with chronic conditions, like HIV or hep C, making them more vulnerable to another infection, he added.

Many children now receive the vaccine  

The DOH has urged individuals who develop symptoms of hep A to get tested and it has urged clinicians to provide vaccinations to anyone at risk, even without first performing a test for the infection. (It also recommends a vaccine for hep B, which is also required for children to attend kindergarten; a hep C vaccine is still under development.)

Credit: Twitter
Dr. Su Wang

While it is not required by state law, Wang said many children now also receive the hep A vaccine as part of a normal series of inoculations, “but a lot of us adults have never had it.”

Emergency room clinicians have tried to inoculate homeless individuals or others at risk against the virus — a process that involves two shots within six months — which Wang said is helpful. But ERs aren’t typically focused on preventive health, she said, so local clinics or community-based health programs may be better positioned to reach more of these vulnerable residents.

“That came up a lot at the meeting” in October about ending hepatitis, Wang noted.  “We need to integrate (preventive care like vaccines into other services), rather than refer them out” for treatment elsewhere, she said.

McGreevey said most of the adults he works with have not been vaccinated against hep A and getting this protection isn’t that easy, even if they can get to an emergency room or local health department that offers free or low-cost shots. “There’s a practical problem” with the current formula, which requires two doses, he said. “For our clients, it’s often difficult to receive the second shot due to work and life demands.”

Kathy Ahearn-O’Brien, executive director of the Hyacinth Foundation, which works to support those living with AIDS and HIV, said the state’s clean-syringe programs would be a sensible option through which to expand hep A vaccine capacity in communities most at risk. Hyacinth runs several needle exchanges where nurses or other staff are trained to administer vaccines, she said.

“If we could incorporate hep A into some of our programs that would be great,” O’Brien said, but resources are a constant challenge for the nonprofit.

While some people infected with hep A have no symptoms at all — fueling the likelihood of transmission — others can experience yellowing skin and eyes, dark urine and stool, and symptoms not unlike the flu: exhaustion, pain, fever, nausea, vomiting and diarrhea. Hand-washing and other sanitary habits can help prevent its spread.