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PUBLIC HEALTH ADVISORY CONCERNING FENTANYL AND FENTANYL-LACED SUBSTANCES

Tennessee Hepatitis A Outbreak

Since December 2017, the Tennessee Department of Health has identified an increase in hepatitis A cases in the state, primarily in Davidson County, many of which are tied to a large multi-state outbreak that began in early 2017.

TDH is working with local health officials and other partners to respond to this outbreak. Those considered at high risk for hepatitis A infection in this outbreak include people who abuse drugs, people experiencing homelessness and men who have sex with men. Notably, this outbreak has had a high hospitalization rate among those infected with hepatitis A.

Hepatitis A can be prevented by a safe and effective vaccine. People who believe they have been exposed to hepatitis A or are experiencing homelessness, use injection or non-injection drugs, are men who have sex with men or had contact with someone who has hepatitis A should contact a health care provider about hepatitis A vaccine.

To reduce the risk of hepatitis A transmission, people who have not received two doses of hepatitis A vaccine may ask their health care provider for protection. Additionally, always wash your hands with soap and water after going to the bathroom, after changing diapers and before preparing meals for yourself and others.

What is Hepatitis A?

Hepatitis A is a contagious, vaccine-preventable liver infection that is spread in the feces of infected people. People most at risk for hepatitis A infection in this current outbreak include those experiencing homelessness, people who use drugs recreationally and close contacts of these groups. Men who have sex with men are also at risk. Individuals with hepatitis A infection can be contagious for two weeks before and one week after they show symptoms.

Most people become sick about a month after being infected. The illness can range from mild to serious illness and in some situations, result in death. Over the last five years, Tennessee has seen an average of 13 cases per year, often associated with travel to countries where hepatitis A is common.

Tennessee cases sharing the risk factors seen in the multi-state outbreak began to be detected at the end of December 2017. Transmission is presumed to occur person-to-person and through recreational (injection and non-injection) drug use. Hepatitis A vaccine is extremely effective. The first dose of the two dose series will protect most people for several years. The two dose series is all that is needed for a lifetime; it does not require booster doses. Hepatitis A vaccine is routinely recommended for certain groups even in the absence of an outbreak including the following:

  • All children at age 1 year
  • Travelers to countries that have high rates of hepatitis A
  • Family members and caregivers of recent adoptees from countries where hepatitis A is common
  • Men who have sexual contact with other men
  • People who use recreational drugs, whether injected or not
  • People with chronic (lifelong) liver diseases, such as hepatitis B or hepatitis C
  • People who are treated with clotting-factor concentrates
  • People who work with hepatitis A infected animals or in a hepatitis A research laboratory

Hepatitis A vaccine is covered by most insurance plans; people who wish to be vaccinated should check with their healthcare provider or pharmacist. Vaccine is also available through local public health departments, especially for adults at risk. Individuals travelling to countries where hepatitis A is common are also recommended to receive vaccine from their health care provider or travel clinic.

Pediatric hepatitis A vaccine is recommended for all children and has been required for kindergarten entry in Tennessee since 2011. Hepatitis A vaccine should be considered for any child who has not been vaccinated.

For additional information about this outbreak, please refer to the Centers for Disease Control and Prevention Hepatitis A multi-state outbreak webpage: https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm

Total Confirmed Cases of Hepatitis A in Tennessee (December 01, 2017 – Septemeber 14, 2018)

Last updated 9/14/18.

Cases

Hospitalizations

Deaths

232

131 (56%)

0

Total Confirmed Cases of Hepatitis A in Tennessee by Region (December 01, 2017 – September 14, 2018)

Published case counts may differ due to case reporting timelines. Last updated 9/14/18.

Tennessee 13 Health regions

Resources for Health Care Providers

Recommendations for Health Care Providers:

TDH urges health care provides to take the following important steps now to protect high risk patients and mitigate the spread of illness.

  1.  Consider vaccinating at risk patients who need hepatitis A vaccine now:
    • People who use recreational drugs (injection or non-injection)
    • Men who have sex with men
    • People experiencing homelessness
    • People with chronic liver disease, including chronic hepatitis B or C
  2. Pediatric hepatitis A vaccine is recommended for all children and has been required for kindergarten entry in Tennessee since 2011. Consider hepatitis A vaccine for any child who has not had it.
  3. Recognize and report cases of acute hepatitis to public health. People with the acute onset of symptoms of hepatitis and no alternative diagnosis should have serologic testing for acute viral hepatitis, including hepatitis A IgM.
    • For people suspected of acute hepatitis A, collect and hold at your lab an extra red top tube of blood that may be submitted to the State Public Health Laboratory for confirmation and possible genotype testing at CDC if the initial hepatitis A IgM result is positive.
    • When taking the history of someone with suspected acute hepatitis A, please specify the date of onset of acute illness and collect key risk factors (drug use, sexual behavior, contact with other cases, homelessness, travel history) during the time they could have been exposed (15-50 days before illness) and the time they could have infected others (2 weeks before through 1 week after onset). This information is vital to public health in the event that the case patient cannot be located for a full investigation after confirmation.
    • Do not test people without signs of acute hepatitis: false positive IgM results can occur in persons without acute clinical hepatitis illness, especially in the elderly.
    • Acute hepatitis A is reportable to your local health department: post-exposure prophylaxis with vaccine can protect at-risk contacts if administered within 2 weeks of their exposure.

Additional Resources:

Note: Please report any suspected case of hepatitis A to your local health department immediately so a case investigation can be initiated.