ST. PAUL — Nine Minnesota counties are involved in an outbreak of hepatitis A declared Thursday by the Minnesota Department of Health.

The outbreak is occurring among people who use street drugs, are experiencing homelessness or unstable housing or have been recently incarcerated, the state health department said Aug. 8.

The outbreak includes 23 cases in nine counties. Five cases have been reported in Pine County in east-central Minnesota. Hennepin, Kanabec, Mille Lacs, St. Louis and Washington counties have each had three cases. One case each has been reported in Chisago, Dakota and Kandiyohi counties.

While the initial cases were clustered in east-central Minnesota and had links to each other, more recent cases have occurred in other parts of the state, health officials said. The infection source is not known for some cases, suggesting some community transmission among those in high-risk groups, according to the health department.

Minnesota began seeing an increase in hepatitis A in May. Cases had similar risk factors to national outbreaks of hepatitis A that have been occurring since 2016. Nationally there have been more than 23,600 cases in 29 states.

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The Minnesota Department of Health has been monitoring the national trend and has been conducting heightened surveillance of hepatitis A since mid-2018 to help quickly identify cases in Minnesota.

"We have been working with our public health partners to respond to individual cases and prevent future cases," said Kris Ehresmann, the state's infectious disease director. "Declaring an outbreak is a significant step because it allows us to access additional resources to fight the outbreak."

Hepatitis A is a contagious liver infection caused by a virus. It can range from a mild infection with no symptoms lasting a few weeks to a severe illness lasting several months that can result in liver failure and death. Early diagnosis and medical care are key to preventing more serious health outcomes.

Hepatitis A is usually spread person-to-person when someone unknowingly eats food, drinks a beverage or places an object in their mouth that has been contaminated with microscopic trace amounts of stool from someone who has the virus.

Anyone who is not vaccinated can get hepatitis A but people who are homeless or who use drugs are at higher risk, particularly if they don’t have access to sanitation, restroom facilities and handwashing stations. People who are currently or were recently incarcerated are also at higher risk.

The most effective way to prevent hepatitis A is vaccination. Vaccination is recommended for all children starting at 1 year, for travelers to certain countries and for people at high risk for infection, state health officials said. Although hepatitis A vaccination has been recommended for children since 2006, many adults have not been vaccinated for hepatitis A.

Since the increase in hepatitis A cases in this risk group first surfaced, the state health department has been working with partners who can help reach people who are at highest risk. The goal is to promote vaccination and in some cases provide vaccine directly so it is convenient and accessible. Partners include local public health departments, syringe exchange services, homeless shelters, jails and more.