Editor’s note: This is the main story of a two-piece news package we are presenting today. The companion story includes additional information about Hepatitis A and a state-by-state breakdown of Hepatitis A cases. Most case counts in both stories are as of April 30. However, some of the main outbreak states have since updated their counts, which are reflected in this news story but not on accompanying maps.

In recent months, these headlines popped up in a Google search for “Hepatitis A Outbreak” — “KY hepatitis A outbreak kills 3 people, hospitalizes hundreds” “20th death reported in San Diego’s hepatitis A outbreak” “Michigan posts 25th hepatitis A death.”

And on May 4, the Indiana State Department of Health posted an outbreak update reporting 91 confirmed cases, with a 48 percent hospitalization rate. States with outbreak cases are using different starting dates for their outbreaks. Indiana started counting outbreak cases in November 2017. The state usually averages 20 cases per year.

To view a larger version of this map, please click on the image.

Hepatitis A is most commonly spread when a person eats or drinks something contaminated with microscopic traces of fecal matter from an infected person, according to the Mayo Clinic. It does not spread through sneezing or coughing.

The genotype of some cases in Indiana matches that responsible for the ongoing outbreaks in Arizona, Kentucky, California, Michigan and Utah, the Indiana health department reported.

The Centers for Disease Control and Prevention declared the multi-state outbreak in March 2017. Since then, at least 1,200 cases have been reported, and more than 40 people have died of the highly contagious liver infection. The federal agency is no longer posting information on a regular basis, instead leaving outbreak updates to individual states.

Food Safety News surveyed all 50 states in recent weeks about their Hepatitis A cases. At least 14 reported increases in their number of Hepatitis A cases during the outbreak period, when compared to their usual average annual case counts.

While officials are pointing primarily to cases among people who are homeless and/or substance abusers and their close direct contacts. However, there are increasing reports of infected people who are neither homeless nor substance abusers.

More cases of the highly contagious virus are also being confirmed in foodservice employees in the outbreak states. Public health officials warn that large numbers of people can be exposed to the virus by foodservice workers. People are usually contagious before their symptoms, further increasing the danger of spreading the virus to others.

What is it and what are the consequences

“Hepatitis A, if it doesn’t kill you initially, you will recover,” said Seattle food safety attorney Bill Marler. “But it does have a pretty significant morbidity rate and it does have a pretty significant rate of people whose livers fail and who need a transplant.”

Hepatitis A is a vaccine-preventable, communicable disease of the liver caused by the Hepatitis A virus, according to the Centers for Disease Control and Prevention. It is usually transmitted person-to-person through the fecal-oral route or consumption of contaminated food or water. Hepatitis A is a self-limited disease that does not result in chronic infection.

Most adults with Hepatitis A have symptoms including fatigue, low appetite, stomach pain, nausea and jaundice. For otherwise healthy adults, most symptoms usually resolve within a couple of months. Most children younger than 6 do not have symptoms or have an unrecognized infection. The best way to prevent Hepatitis A infection is to get vaccinated.

The vaccination is a two-injection treatment with the shots given six months apart.  Getting a vaccine or an injection of the antibody immunoglobulin within two weeks of exposure to Hepatitis A can protect against the infection.

For elderly people, pregnant women and people with suppressed immune systems, Hepatitis A can be life-changing.

“Even people who are modestly sick will feel like they have the worst case of the flu for about a month — that’s kind of a minimum,” Marler said. “The liver is a hugely important part of your body, and when your liver’s off you feel horrible.”

The virus is endemic in many parts of the world, often infecting people through the water. Antibodies produced in response to the infection last for life and protect against reinfection, so the people who live in places where it is common often have that lifetime protection and don’t need to be vaccinated.

But in the United States, most people are not immune — hence the outbreak sweeping the nation.

The states named by the CDC in the outbreak, with case counts tabulated by the states’ public health officials are:

• California, which had 919 cases in 2017.
• Indiana, which had 20 cases in 2017 and 71 so far this year.
• Kentucky, with 448 cases since August 2017, including 315 hospitalizations and four deaths. The most recent death was reported this past week.
• Michigan, with 828 cases, 665 hospitalizations and 26 deaths since the outbreak was declared there in August 2016.
• Utah, 149 cases in 2017 and 82 so far this year, with two deaths.

In addition, public health officials in Hawaii, Idaho, New York, Rhode Island, Washington, West Virginia, Wisconsin and Maryland say cases in those states are or could be linked to outbreaks elsewhere, according to a survey responses provided to Food Safety News.

Missouri reported 27 cases in 2017 and 73 so far this year. Officials there say the cases are the result of an outbreak there and said none of the people affected reported traveling to states with ongoing outbreaks during their likely period of exposure.

Officials don’t know where or exactly when the outbreak started. They haven’t found what Marler calls an index case, or the first illness. They know many cases in different states are part of one outbreak because samples from infected people have undergone whole genome sequencing and they have the same genetic fingerprint.

The start could have come from an unvaccinated person who traveled to a country or area where the virus is endemic, or someone who ate, say, imported frozen sushi or strawberries that carried the virus.

In recent days, Indiana public health officials warned that people going to Kentucky should be vaccinated. Kentucky health officials, meanwhile, insist it’s safe to come to their state.

“I don’t remember any other time where people were warned about going to another state,” Marler said. “A lot of states and cities – Detroit, San Diego, Salt Lake City, Louisville – are (encouraging) foodservice workers to get vaccinated. … That just makes sense.”

While the CDC in 2006 urged that all 1- to 2-year-old children should be vaccinated, it has not taken the step of requiring foodservice workers to get the vaccine.

In response to the ongoing outbreak, Kentucky has enacted a requirement that all children, regardless of age, who attend public school must be vaccinated before the 2018-19 school year begins.

The current outbreak has been spreading quickly through the homeless population, in part because people who are homeless often don’t have access to restrooms and hand-washing facilities. It’s also prevalent among people who share needles when using illegal drugs. Other groups at risk are men who have sex with men and people who travel to places where the virus is endemic.

The Mayo Clinic offers these suggestions to people traveling to such places:

• Wash and peel all fresh fruits and vegetables yourself.
• Don’t eat raw or undercooked meat and fish.
• Drink bottled water and use it when brushing your teeth.
• Avoid all beverages of unknown purity, with or without ice.
• If bottled water isn’t available, boil tap water before drinking it.

Hepatitis A signs and symptoms typically don’t appear until a person has had the virus for a few weeks. They include fatigue, sudden nausea and vomiting, abdominal pain or discomfort, especially on the upper right side between the lower ribs near the liver, clay-colored bowel movements, loss of appetite, low-grade fever, dark urine, joint pain, yellowing of the skin and whites of the eyes and intense itching.

People who have such signs or symptoms should see a doctor.

In rare cases, hepatitis A can cause a sudden loss of liver function, especially in older adults or people with chronic liver diseases. Acute liver failure requires a stay in the hospital for monitoring and treatment. Some people with acute liver failure may need a liver transplant.

(To sign up for a free subscription to Food Safety News, click here.)

Note: Seattle attorney Bill Marler is publisher of Food Safety News.