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Maryland one of several states with a hepatitis A outbreak; 190 hospitalized this year

As Maryland deals with a record number of people hospitalized due to COVID-19, state officials also are working to contain an outbreak of hepatitis A, a highly contagious infectious disease for which a vaccine exists.

State health officials have identified 265 active cases of hepatitis A this year, said Charles Gischlar, a Maryland Department of Health spokesman. Of those, 190 have been hospitalized this year, he said.

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Its part of a nationwide outbreak, according to the U.S. Centers for Disease Control and Prevention, that originated in 2016, resulting in more than 36,000 cases, some 22,000 hospitalizations and 348 deaths.

Hepatitis A is a virus that can spread via contaminated food or person-to-person contact. It occurs most virulently in people who use drugs, those experiencing homelessness, men who have sexual intercourse with other men, incarcerated individuals, and people with chronic liver disease, according to the CDC.

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Maryland’s hepatitis outbreak started in December 2019 but rose along with the coronavirus pandemic, amid excessive strain on hospital resources and medical personnel. A record number of people — 1,799 — were hospitalized Tuesday due to COVID-19.

“Certainly, with COVID-19 hospitalizations increasing and the seasonal flu upon us, any additional hospitalizations are concerning,” Gischlar said in an email.

The number of active hepatitis A infections is many times the normal number, according to state figures. In 2018, the latest year for which data is available, 52 people in Maryland were infected with the virus. Cases and hospitalizations in some states have risen into the thousands.

Dr. Anurag Maheshwari, a liver transplant specialist at Mercy Medical Center and clinical assistant professor of medicine at the University of Maryland School of Medicine, said he usually sees about three hepatitis A patients a year, but he’s seen three in the past week.

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The outbreak has run parallel to the worsening opioid epidemic during the pandemic, Maheshwari said. Some of his patients have relapsed due to stress, joblessness or lack of access to treatment facilities, and have contracted hepatitis A through drug use. Vaccine costs also pose barriers for some patients, he said.

“The hepatitis A vaccine should be universally mandated for all people because it’s a preventable, communicable disease,” he said. “If we made it a point to eradicate polio and smallpox, why not target hepatitis A? The problem is, at the public health level, our experts do not deem this to be a serious problem because people rarely, if ever, die from it.”

Hepatitis A is an acute disease, meaning that it appears suddenly but eventually recedes. Those experiencing hepatitis A might experience jaundice, which commonly signals liver disease, as well as nausea, dehydration, a fever and fatigue.

It can take up to four weeks to recover, Maheshwari said, and most cases do require hospitalization. Certain factors, such as chronic liver disease and the contraction of hepatitis B or C, can lead to more severe cases and cause complications.

In Baltimore, where some 112 cases of hepatitis A have emerged this year, officials said they are working to administer vaccinations at no cost and identify vulnerable individuals with the help of community partners, said Mary Grace White, the director for acute communicable diseases at the Baltimore City Health Department.

White, whose team has been integrated into contact tracing efforts for COVID-19, said the hepatitis A outbreak began to swell around the same time as the coronavirus, creating a “perfect storm” for transmission. Baltimore has a concentrated population of people experiencing homelessness and drug users vulnerable to infection, she said.

“A significant portion of the adult population is not immune to hepatitis A, and the virus can spread rapidly in congregate settings with poor hand hygiene and poor sanitation,” White said. “But we have a really good way to prevent people from getting the disease.”

One dose of the hepatitis A vaccine provides protection for about 11 years, White said, and two doses can offer lifetime protection. But the number of vaccinated adults remains low, as the CDC’s Advisory Committee on Immunization Practices did not recommend routine vaccination of children until May 2006.

Data from the 2014 and 2015 National Health Interview Surveys found that 19.4% of adults, aged 18 and older, with chronic liver disease reported receiving at least one dose of a hepatitis A vaccine, compared with 14.7% of adults without liver disease. Time constraints, cost and patients not disclosing high-risk behaviors to their physicians were found to be major barriers associated with vaccination, the study found.

Aside from offering free vaccinations at targeted sites such as sexual health clinics, Baltimore’s health department is conducting case investigations similar to COVID-19 contact tracing, which helps identify and eliminate chains of transmission, White said.

Dr. Leonard Friedland, a vaccine researcher and vice president and director for scientific affairs and public health for pharmaceutical company GSK’s vaccine division, said the public is at increased risk because of the outbreak.

“The risk is always there and the bottom line is, we’re all at risk if we’re not vaccinated,” said Dr. Friedland, adding that as people order more carryout, the chances of contracting a foodborne illness might be higher.

Many people simply don’t know that a hepatitis A vaccine exists, Friedland said, or that other immunizations are recommended specifically for adults.

“We tend to think vaccines are recommended for children,” he said. “It’s something we need to work at as a public health community, that vaccines that can keep people healthy as adults.”

The public health sector also can help by crafting more concrete policy guidelines for hepatitis vaccinations, which would relieve pressure on hospitals during future public health crises, Maheshwari said. People can also take such precautions as frequent hand-washing.

“Unfortunately our reaction to hepatitis A has been a knee-jerk reaction,” he said. “There needs to be consistent action across the board, policy-wise, because this is a preventable illness that can be easily dealt with and taken care of.”

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