What is the issue?
Cases of hepatitis A continue to increase in Victoria, with one death having been confirmed as part of the outbreak. There are now 68 confirmed outbreak cases, seven probable cases and one death. An additional 14 cases of hepatitis A are under early investigation. Most cases are adults with most reporting male-to-male sexual activity, and many have not travelled overseas. A number of cases have also identified as people who inject drugs (PWID). There is increasing evidence that homeless rough sleepers are at risk of infection.
Detailed laboratory analysis has found that the strains of hepatitis A virus in this outbreak are very similar to a currently circulating strain in Europe. Since mid-2016, several hepatitis A outbreaks associated with MSM sexual activity have been reported in many European countries and in the United States of America. A similar outbreak was reported earlier in 2017 in New South Wales.
Who is at risk of getting hepatitis A?
A food handler has been identified who worked while infectious at Cumulus Inc. at 45 Flinders Lane in Melbourne, between 26 February and 19 March 2018. There is a risk that food may have been contaminated with hepatitis A virus and any person who ate food - especially uncooked foods - during that period, or who worked at the restaurant, may have been exposed and could develop hepatitis A infection. A clean-up of the restaurant has been undertaken.
Most people are susceptible to hepatitis A infection, unless there was exposure in an endemic country or they have received a course of hepatitis A virus vaccine.
In this outbreak, adults who identify as MSM and/or PWID appear to be at highest risk, however local transmission to others has also been found. An emerging risk group is the homeless rough sleeper population.
Symptoms and transmission
The incubation period for hepatitis A infection is between 15 to 50 days with an average of 28 days.
Transmission is through the faecal-oral route and can occur when traces of virus are ingested, usually via contaminated hands, objects, water or food. Transmission can also occur through oral-anal sexual activity. People are infectious two weeks prior to symptom onset until around one week after the onset of jaundice or dark urine. This means people may transmit the infection to others for an extended period even before becoming unwell.
Initial symptoms typically include fever, malaise, anorexia, nausea, vomiting and abdominal discomfort, followed a few days later by dark urine and jaundice. Prodromal symptoms may mimic influenza, so hepatitis A should be considered in the differential diagnosis for patients presenting with an influenza-like illness who have recent overseas travel to a high-risk country and/or other risk factors.
Symptoms usually last several weeks although convalescence may sometimes be prolonged. People with pre-existing liver disease may have poorer outcomes if infected with hepatitis A virus. Death from hepatitis A is uncommon, and is estimated to occur in up to two per cent of infected adults.
Young children under five years of age infected with hepatitis A virus may have a mild illness with few or no symptoms, but can still transmit infection to others.
Collect blood for serology (IgM) in any patients presenting with symptoms consistent with hepatitis A. If hepatitis A is confirmed, further testing will be undertaken by the public health reference laboratory, which is the Victorian Infectious Diseases Reference Laboratory.
Prevention and treatment
Advice for patients
- All MSM and people who have injected drugs in the past 12 months are strongly encouraged to get the free two-dose vaccination from their local GP, sexual health clinic or community health centre.
- Patients suspected to have hepatitis A should not prepare food or drink or share utensils, provide personal care for others, share linen or towels, have sex or donate blood until infection is excluded.
- Advise MSM against engaging in high risk sexual practices, including oral-anal sexual activity (rimming), or attending sex on premises venues, as such practices may increase the potential for transmission.
- Advise PWID not to share or re-use needles, spoons, swabs, water, or any other injecting equipment.
- PWID should wash their hands in warm soapy water before and after injecting, and swab the injection site with alcohol swabs. Special care should be taken when injecting in groups, or when being injected by others. Label or mark your syringe.
Advice for health professionals
- Offer the free, two dose hepatitis A vaccine to all MSM and PWID. Consider offering vaccine to homeless rough sleepers.
- If your patient presents with symptoms compatible with hepatitis, include a request for serology (IgM) for hepatitis A, in addition to usual tests.
- While waiting for results of hepatitis A testing, advise your patient to avoid sexual activity, and advise your patient to avoid work as a food handler, as a child care worker and as a health care worker. They should also not prepare food for others during this time.
- If hepatitis A is confirmed, your patient should avoid any sexual activity, and should not prepare food or drink or share utensils, nor provide personal care for others, share linen or towels.
- People who have had confirmed hepatitis A are excluded from donating blood for 12 months after their infection
- People who have been exposed to a confirmed case of hepatitis A are excluded from donating blood for two months after their exposure, as a precaution. If your patient ate at Cumulus Inc. or worked at Cumulus Inc. during the risk period, they are excluded from donating blood for two months.
- If your patient consumed food from Cumulus Inc. or worked at Cumulus Inc. during the risk period and has already donated blood please ask them contact the Blood Service on 13 14 95.
- If hepatitis A is confirmed, your patient should avoid any sexual activity, and should not prepare food or drink or share utensils, nor provide personal care for others, share linen or towels, or donate blood until one week after the onset of jaundice, or if no jaundice was present, two weeks after the onset of symptoms.
- If you suspect acute viral hepatitis, notify immediately by calling 1300 651 160. This will assist with patient assessment, consideration of public health control measures and will and enable rapid post-exposure prophylaxis for close contacts.
Frequently asked questions
Key questions regarding Cumulus Inc
Important information for homeless rough sleepers
Online vaccine order forms
Important health information for men who have sex with men: a guide for health professionals and immunisation providers - factsheet
Important health information for people who inject drugs: a guide for health professionals and immunisation providers - factsheet
Hepatitis A - Infectious diseases information and advice
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