Immunize to Prevent Cases and Control the Indiana Hepatitis A Outbreak

Indiana State Department of Health Logo
April 26, 2018 Clinical Advisory

The Indiana State Department of Health (ISDH) is urging Hoosiers to get vaccinated and take other steps to protect themselves from hepatitis A. Indiana, which typically sees fewer than 20 cases of hepatitis statewide each year, has confirmed 95 statewide cases since January 2018, many of which are related to the outbreaks in southern Indiana and Kentucky. Surveillance data since November 2017 has identified 76 outbreak related cases in Indiana. Ongoing outbreaks of hepatitis A have been identified in Arizona, Kentucky, California, Michigan, and Utah. Transmission is presumed to occur person-to-person; no commercial food product has been identified as being contaminated. Based on current information, populations who are homeless, use illicit drugs, or men who have sex with men are considered at increased risk of exposure to hepatitis A.

Healthcare providers are encouraged to ask symptomatic patients about risk factors for hepatitis A, which include:

  • Travel within the past 50 days to states with ongoing outbreaks
  • Men who have sex with men
  • Injection drug use
  • History of homelessness
  • Direct contact with individuals who have hepatitis A

For a complete list of populations that might be at higher risk for hepatitis A, visit the Centers for Disease Control and Prevention (CDC) website.

Updated Indiana outbreak case counts will be provided every Friday on the ISDH website at

Hepatitis A Reporting Requirements
In accordance with Indiana Administrative Code 410 1-2.5-75 cases of hepatitis A are to be reported immediately by telephone or other instantaneous means of communication to the local health department upon first knowledge or suspicion of the diagnosis. Laboratories must also report cases of hepatitis A immediately to the ISDH.

Hepatitis A Specimen Submission Request
The ISDH Laboratories is requesting the submission of all positive hepatitis A blood specimens from Indiana facilities so additional testing can be performed.

  • If your laboratory performs in-house serologic IgM testing for hepatitis A, please send all positive specimens to the ISDH Laboratory for additional epidemiology testing.
  • Until further notice, if your laboratory normally sends specimens to an out of state reference lab for hepatitis A testing, please send them instead to ISDH Laboratories. This testing will be free of charge.

For laboratory questions regarding hepatitis A, please contact Dr. Nicolas Epie at 317-921-5555 or at

The Indiana State Department of Health recommends:

To prevent and control hepatitis A outbreaks, offer single-antigen hepatitis A (Hep A) vaccine to persons who are homeless, those who report using injection or non-injection illicit drugs, and men who have sex with men.

In jurisdictions with hepatitis A outbreaks, also offer Hep A vaccine to persons who have frequent close contact with persons who are homeless or using illicit drugs (e.g., in homeless shelters, jails, food pantries, drug rehabilitation programs, etc.).

Hep A vaccine is routinely recommended for:

  • Persons with chronic liver disease, including those with hepatitis B or C virus (HBV or HCV) infection
  • Users of injection and non-injection illicit drugs
  • Men who have sex with men
  • Persons traveling to or working in countries that have high or intermediate levels of HAV transmission
  • Any person wishing to obtain immunity to HAV
  • Persons who have been exposed to HAV in the prior 2 weeks and are not known to be immune (immune globulin is an alternative to vaccine or given in addition to vaccine in some instances)
Individuals who do not have risk factors associated with the hepatitis A outbreak but who still wish to be vaccinated should receive vaccine through private providers or pharmacies.

Additional information

  • The first dose of single-antigen Hep A vaccine appears to provide protection to more people than the first dose of the combined Hep A/Hepatitis B (Twinrix┬«) vaccine (see Table 3, product insert). This apparent advantage disappears when the respective series are completed. Providers should consider the short-term risks of exposure to HAV, the likelihood of follow-up to complete multi-dose immunization and the need for protection from HBV when selecting vaccines for those at risk. Immunization against HAV with existing supplies should not be delayed to obtain a different formulation of vaccine.
  • Hepatitis B vaccine is also recommended for injection drug users who are not known to be immune. A complete vaccination series is needed for full protection.
  • If a provider suspects acute hepatitis A based on clinical assessment, additional molecular testing for HAV is recommended. The provider should consider drawing an additional tube of blood for serum to be saved by the submitting lab, especially if the likelihood of loss to follow-up (e.g. homeless patient) if high. This specimen should then be sent to the ISDH Laboratories for additional testing.
  • Serologic testing for HAV infection is not recommended for asymptomatic people, nor is serologic testing for HAV immunity recommended as screening before vaccination.