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Health Advisory: Hepatitis A in Person Living Homeless and Using Drugs

Requested actions

  • Suspect hepatitis A in patients with acute onset of jaundice, vomiting, anorexia and elevated liver function test results—especially those living homeless or using drugs.
  • Perform serologic testing on suspect cases—hepatitis A IgM or acute hepatitis panel, plus liver function test.
  • Immediately report suspect cases to (253) 798-6410.
  • Give hepatitis A vaccine to unvaccinated patients living homeless or using drugs.


On Dec. 17, 2019, a Pierce County adult tested positive for hepatitis A. This case meets the statewide outbreak definition including risk factors of homelessness and drug use. The person spent time and accessed services in Puyallup, Fife and Seattle. People exposed to this person could present with symptoms at any time.

On July 30, 2019, Washington State Department of Health declared an outbreak in multiple counties of hepatitis A in people living homeless or using drugs. As of Jan. 3, 2020, they have received reports of 154 cases throughout the state, resulting in 86 hospitalizations and 3 deaths.

Hepatitis A virus spreads through infected feces. The incubation period is 2 to 6 weeks. People typically become sick 3 to 4 weeks after exposure. People are contagious 14 days before onset of jaundice until 7 days after onset. Those who share living space or have close contact with people living homeless or using drugs should receive post-exposure prophylaxis with vaccine or immune globulin.

Immediately report suspect cases to (253) 798-6410. This allows us to coordinate post-exposure prophylaxis for close contacts as soon as possible.

To stop the outbreak, it is critical to vaccinate people living homeless. The Advisory Committee on Immunization Practices (ACIP) recently recommended people living homeless receive routine hepatitis A immunization.1 One dose of vaccine effectively protects within 2 to 4 weeks. A second dose should be given 6 months later.

Overall, adult vaccination levels are low—only 16% of adults age 19 to 49 have received 2 doses of hepatitis A vaccine.2 Additionally, less than 23% of people age 20 to 59 have serologic evidence of immunity.3

Large hepatitis A outbreaks are occurring in other areas of the United States. Since they began in 2017, more than 23,000 cases and 233 deaths have occurred. Sixty percent of cases were hospitalized.

For more information about hepatitis A, see our hepatitis A page.

For information about the statewide outbreak, see Department of Health’s hepatitis A outbreak page.

1 Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness. MMWR. Feb. 15, 2019. 68(6); 153–156.

2 2017 National Health Interview Survey.