What is the issue?
Cases of hepatitis A continue to rise in Victoria with two deaths confirmed as part of the outbreak. As of 23 November 2018, there were 211 confirmed outbreak cases, 10 probable, 13 possible cases and two deaths. Most cases are male adults reporting male-to-male sexual activity. A number of cases have also identified as people who inject drugs (PWID). Although the outbreak has slowed, we are continuing to see localised cases.
To further control the hepatitis A outbreak in Victoria, the free two-dose hepatitis A vaccination program has been extended. The two-dose hepatitis A vaccination is free until 30 June 2019 for all MSM, people who have injected drugs in the past 12 months, homeless rough sleepers and adult prisoners.
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. A similar outbreak was reported earlier in 2017 in New South Wales.
Who is at risk?
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. Other risk groups are the homeless rough sleeper population and adult prisoners in Victoria.
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.
- All MSM, people who have injected drugs in the past 12 months, homeless rough sleepers and adult prisoners are strongly encouraged to get the free two-dose vaccination from their local GP, sexual health clinic or community health centre.
- 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.
- Advise PWID to 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.
- 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.
- If your patient presents with symptoms compatible with hepatitis, include a request for serology (IgM) for hepatitis A, in addition to usual tests.
- 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 enable rapid post-exposure prophylaxis for close contacts.
- 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.
Online vaccine order forms
Important health information for men who have sex with men: a guide for health professionals and immunisation providers
Free hepatitis A vaccine for men who have sex with men in Victoria
Important health information to people who inject drugs: a guide for health professionals and immunisation providers
Free hepatitis A vaccine for people who inject drugs in Victoria
Important information for homeless rough sleepers
Immunisation provider information: adult prisoners information sheet
Better Health Channel: Time to Immunise and Hepatitis A factsheet