Hepatitis A outbreak among at-risk populations in Hennepin County has been contained

Hennepin County officials say they have contained a two-year outbreak of hepatitis A that had been spreading among homeless populations and those at risk of transmission.

The county launched an aggressive community outreach to find and treat those with the rare and dangerous virus, leading the state Department of Health to declare an end to the hepatitis A outbreak in the county this month.

"One of the best weapons we had to battle hepatitis A is the street outreach by our public health nurses," said Martha Trevey, Hennepin County Health Care for the Homeless clinical services manager and a family nurse practitioner. "They build trusting relationships over time and create safe places to give accurate medical information and care for the people who need it the most."

Hennepin County is among a growing number of communities across the country experiencing outbreaks of hepatitis A, a highly contagious virus that attacks the liver. In 2019, the Centers for Disease Control and Prevention recommended that anyone experiencing homelessness get vaccinated against the disease as cases soared during the COVID pandemic.

As of last week, 22 states were experiencing active hepatitis A outbreaks, including Illinois and Michigan. The CDC has declared an end to the outbreak in 15 states, with Minnesota among the most recent to meet the CDC's threshold for containing the virus.

The initial outbreak advisory surprised officials in Minnesota because a vaccine for hepatitis A had led to a huge decline in cases in the late 1990s. But the state's growing homeless population, particularly in the Twin Cities, became a focus of concern.

"If you are experiencing homelessness and live outside, you are very vulnerable to this infection," Trevey said. "You might not have access to bathrooms or be able to wash your hands. The disease can also spread from food insecurity or sharing food and water. It sets the stage for an outbreak in this population."

In 2016, Minnesota Department of Health notified Hennepin County that a nationwide outbreak of the disease had reached the state.

By Nov. 19, the CDC reported 42,936 cases of hepatitis A as the outbreak spread to 37 states, with 402 deaths. Since December 2018, Minnesota has logged 129 cases.

During the past two years, Hennepin County reported 44 cases of hepatitis A, accounting for nearly one-third of total cases in the state. More than 70% of people who contracted the disease statewide were hospitalized, although it is rarely fatal. The only death in the state was a person in Hennepin County.

The virus can cause a dangerous liver infection, with symptoms that include fatigue, vomiting and abdominal pain.

Hepatitis A is spread from close contact with another person, either sexual contact, drug use or sharing food or drink.

This makes the homeless population especially vulnerable, said Kelzee Tibbetts, Hennepin County Public Health epidemiologist.

The disease has the potential to affect underlying health conditions or lead to hepatitis C, which causes liver damage.

All reports of hepatitis A are submitted to the state Health Department, and the information is passed to local authorities. Since so many people with the virus landed in the hospital, it "made it easier to collect information and find out where the person was exposed, where they worked and any behavioral risk factors that might come into play," Tibbetts said. "We can also try and get people vaccinated."

Street outreach was critical in eliminating the outbreak. Workers would go out with a cooler in hand and hold vaccination clinics. That could be at a homeless shelter or under a bridge, said Molly Dolan, Hennepin County Health Care for the Homeless public health nurse.

"We do education on why they would want a vaccine," she said. "But importantly, we met them where they are at."

The homeless were located at bus stops with the help of Metro Transit's homeless action team, which identifies people without housing, provides food and clothing and steers them toward assistance.

Workers also went to apartment buildings, shelters, group homes and other places to find at-risk people, said Sarah Keaveny, Hennepin County Health Care for the Homeless public health nurse.

The effort to stop the hepatitis A outbreak has overlapped with a new jump in HIV infections in Hennepin County, health workers said.

In May, county statistics showed 54 people had tested positive for HIV in the past two years from intravenous drug use or sexual transmission. In a typical year, the county averages less than three people who contract the virus from those causes.

"The HIV outbreak is being driven by the overdose crisis by synthetic overdoses," Keaveny said.

The state Health Department continues to monitor any new cases of hepatitis A in Hennepin County. But for now, county officials have been told the outbreak has ended, Tibbetts said.

"The successful collaboration between county public health officials, street health care workers who did outreach and other partners made this happen," she said.