An outbreak of hepatitis A has been identified in Minnesota, prompting state health officials to appeal for broader vaccination efforts in high-risk areas such as homeless shelters and jails.

While Minnesota has been insulated somewhat from a national hepatitis A outbreak — which has sickened more than 23,000 individuals and caused 233 deaths since 2016 — state officials said Wednesday that a recent uptick in cases is cause for concern. None of the Minnesotans has died, but 23 infections have been identified and 13 patients required hospital care for a virus that can cause severe liver damage.

“The states that have had outbreaks have seen them go on for months to years,” said Kris Ehresmann, infectious disease director for the state Health Department. “We don’t want to be one of those states.”

Health officials have been quietly preparing over the past year to protect the state against hepatitis A, which spreads primarily through a lack of sanitary conditions or ingestion of human fecal matter due to inadequate hand-washing.

But specifically with hepatitis A, Ehresmann said officials had to declare a state outbreak to unlock federal resources, including heightened access to an adult vaccine that is in limited supply.

Vaccination has been standard for children born in 2006 or later, but that means that most teens and adults aren’t protected.

Infection risks are greatest in the current outbreak for people living in unsanitary conditions, because of the virus’ ability to linger on surfaces. The close confines of prisons and shelters also increase risks. Illicit drug users also are at heightened risk if needles or paraphernalia are contaminated by the virus.

The Hennepin County Health Care for the Homeless program started offering hepatitis A vaccine last summer to any adults seeking care at its nine Minneapolis shelter clinics. The organization also has offered vaccine at outreach events, such as the National Night Out event at the Harbor Lights shelter on Tuesday, to target people who aren’t regularly in shelters or seeking clinic care.

“We’re really focusing on trying to reach that population,” said Martha Trevey, a clinic service manager for the program.

A few cases of hepatitis A occur in Minnesota every year but usually result from travel to foreign countries where the virus is prevalent. The state has reported 32 total cases since December, but the outbreak is focused on 23 cases that were spread domestically.

Initial cases appeared in east-central Minnesota and involved people who had known contact with one another, Ehresmann said. But since that time cases have been reported in a broader region of nine counties, and among people whose infection sources are unknown. Counties reporting cases are Chisago, Dakota, Hennepin, Kanabec, Kandiyohi, Mille Lacs, Pine, St. Louis and Washington.

Mend Correctional Care has worked with state health officials over the past month to obtain vaccines for all staff and inmates at the 38 jails for which it provides medical services.

While this might be a reactive measure after infections were found in jails, the organization is trying to get ahead of the outbreak now to protect inmates, said Dr. Todd Leonard, Mend’s president and chief medical officer.

“It can look like a small outbreak,” he said, “but if you don’t get in front of it quickly, it can turn into a much larger problem.”

Leonard said inmates have had mixed reactions and that some have declined vaccines. The organization has vaccinated some workers already and is awaiting doses from the state to provide to willing inmates.

Jaundice, liver failure

Like other hepatitis viruses, the A strain has been a known public health threat for decades. Unlike the C strain, hepatitis A is not chronic and clears from the body over weeks or months. Some infections cause mild flu-like reactions, along with characteristic symptoms such as jaundice and dark urine, but the worst cases result in liver failure that can be fatal without organ transplants.

Why hepatitis A is on the rise nationally is unclear, but health officials believe the opioid epidemic has increased the number of heroin users who share needles and risk infection.

Case counts are highest in states such as Kentucky, Ohio and West Virginia, where rates of opioid painkiller prescribing and heroin abuse have been substantial. Kentucky has reported 4,793 cases and 59 deaths.

“That may in fact be part of it,” Ehresmann said. “It’s sort of become a perfect storm” when combining that drug epidemic with the lack of adults vaccinated against hepatitis A, she added.

Ehresmann said she hopes people won’t dismiss the announcement just because the current risk is highest for those in jails or shelters. If unaddressed, the outbreak could spread to more public locations, such as restaurants, if people don’t practice good hygiene and hand-washing.

“These are human beings, these are people,” Ehresmann said. “They may not be at the peak of their self-actualization, but they are people and we care about them. That’s the No. 1” reason for concern.