hepatitis a outbreak: san diego, california, 2016-18 · based on the san diego outbreak experience,...

HEPATITIS A OUTBREAK:SAN DIEGO, CALIFORNIA, 2016-18

Eric C. McDonald, MD, MPH, FACEP

Medical Director, Epidemiology and Immunizations Services

Public Health Services

County of San Diego Health and Human Services Agency

West Coast PulseNET Meeting

6 February 2019

DISCLOSURE STATEMENTS

I have no relevant financial relationships with any

commercial supporters.

Unlabeled/Investigational products and/or

services will not be mentioned in this talk.

All data in this presentation are preliminary and

subject to change.

Primarily transmitted via the fecal-oral route

Incubation period ranges from 15 to 50 days

(mean 28 days)

Period of communicability from two weeks before

through one week after the onset of jaundice or

elevation of liver enzymes

Virus viable outside body for months, depending

on environmental conditions

HEPATITIS A OVERVIEW

HAV virus inactivated by:

Heating to >185˚ F (>85˚ C) for one minute

Routine water chlorination

1:100 dilution of household bleach to water on surfaces

Quaternary ammonium formulations with HCl

2% glutaraldehyde

Alcohol-based hand sanitizer not effective, need

soap and running water

Vaccination with the full, 2-dose series of Hepatitis A

virus vaccine is the best way to prevent infection

Reference: Mbithi JN, Springthorpe VS, Sattar SA. Appl Environ Microbiol. 1990;56(11):3601-4.

HEPATITIS A OVERVIEW

http://aem.asm.org/content/56/11/3601.full.pdf+html

Source: CDC (adapted). Downloaded 3/7/17 from

https://www.cdc.gov/hepatitis/hav/havfaq.htm

Vaccine introduced

Routine vaccination for children in high-incidence

states (including California)

Routine vaccination for all U.S. children

https://www.cdc.gov/hepatitis/hav/havfaq.htm

Source: CDC. Downloaded 7/1/17 from:

https://www.cdc.gov/mmwr/volumes/65/su/su6501a6.htm

* Rate per 100,000 population. † Annual average incidence.

1987–1997† (pre-vaccine)

Incidence* of reported acute hepatitis A cases

National Notifiable Diseases Surveillance System, United States


Source: CDC. Downloaded 7/1/17 from:


Incidence* of reported acute hepatitis A cases

National Notifiable Diseases Surveillance System, United States

* Rate per 100,000 population.

2007 (post-vaccine)


.

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 2/6/17

0

100

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Hepatitis A Cases, San Diego County1994 - 2016

Vaccine introduced

Routine vaccination for children in high-incidence states

(including California)


HEPATITIS A

Reportable in California within one working day of

identification by laboratory & provider

(CCR Title 17 Sections 2500, 2505)

Surveillance noted increase in cases above

baseline in early March 2017

11/16 to 2/17: 7- 9 cases expected,

19 cases reported

Instead of international travel, predominant risks

are drug use and homelessness.

Health alert on outbreak on March 10, 2017

HEPATITIS A

Investigation approach

Standard HAV investigation questionnaire

Supplemental questionnaire (drug use,

homeless service access, restroom use)

Identification of cases with sensitive

occupations

Identify and provide prophylaxis to contacts

Investigate common food, water, drug sources

CDC laboratory provides confirmation of HAV RNA

HEPATITIS A, SAN DIEGO

11

592 confirmed outbreak cases from 11/22/16 thru 10/18/18

407 (68%) hospitalizations, 20 (3.4%) deaths

404 (68%) male (14 MSM), 188 (32%) female

Age range 5-87 (median 43.0)

Suspected Exposure Type

201 (34%) homeless and illicit drug use

91(15%) homeless only

79 (13%) illicit drug use only

167 (28%) neither

54 (9%) unknown

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Co

nfi

rme

d a

nd

Pro

ba

ble

Cas

es

Rep

ort

ed

10/13/17 State

Emergency

Declared

3/8/17

Outbreak

Determined

9/1/17 Public Health

Emergency Declared

1/23/18

Public Health

Emergency

Undeclared10/18/18

Outbreak

Declared Over

| 2017

Onset WeekData as of 10/18/18

2016 | 2018N = 6 N = 571 N = 15

Outbreak-associated Hepatitis A Cases by Onset Week

San Diego County Residents, 11/1/2016 – 10/18/2018*, N = 592

.


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Hepatitis A Cases, San Diego County1994 - 2018

Vaccine introduced

Routine vaccination for children in high-incidence states

(including California)


Co-infections

81/474 (17.1%) with hepatitis C

25/474 (5.1%) with hepatitis B

20 (3.4%) cases diagnosed in jails

15 primary, 5 secondary

Sensitive occupations

24 food handlers (1 secondary case ID’ed)

7 healthcare workers (1 secondary case ID’ed)

70 non-outbreak CSTE HAV cases

(not included in outbreak count)


Case vaccination histories:

55% had ACIP indication(s) for vaccination

25% of homeless had no ACIP indication

None completed full two-dose series

39 (6.6%) received one dose prior to

symptom onset:

<1 week - 9

1-2 weeks - 9

> 2 weeks - 21 (range 15 - 242 days)


16

Based on the San Diego outbreak experience, persons

experiencing homelessness had:

risk for HAV: aOR = 3.1 (95%CI 1.4-7.4)

risk for HAV hospitalization: aOR = 3.8 (95% CI 2.2–6.6)

risk of death from HAV: aOR = 3.9 (95% CI 1.1–17)


Vaccinate

Sanitize/hygiene

Educate

PUBLIC HEALTH STRATEGY

Vaccinate

Sanitize/hygiene

Educate

PUBLIC HEALTH STRATEGY

www.sdepi.org

Local recommendations for vaccination

3/17: Homeless individuals

5/17: Homeless services providers and volunteers

5/17: Public safety workers who work with at-risk

5/17: Behavioral health who work with at-risk

5/17: Selected healthcare workers who work with at-

risk (expanded 7/17)

6/17: Sanitation and janitorial workers

8/17: All food handlers in county

ACIP recommendation: ANY person who desires

immunity should be given vaccine

HEPATITIS A VACCINATION

Immunizing those at-risk

Mass vaccination events at social service

providers, substance abuse facilities, etc.

At medical providers

Clinics

ED’s

Behavioral health

In jails/detention centers

Post-exposure prophylaxis

Offer at booking & while incarcerated

Required for all food handlers

In the field – “foot teams”

PHN paired with homeless outreach

workers

HEPATITIS A VACCINATION

Vaccination Provider Count* Percent

County

Post-exposure prophylaxis 1,015 0.5%

Jails 9,768 4.9%

Psychiatric Hospital 467 0.2%

Public Health Centers (IZ) 12,119 6.1%

Public Health Clinics (TB,STD) 1,626 0.8%

Field Events – Mobile Van 848 0.4%

Field Events – Foot Teams 5,787 2.9%

Field Events – POD/mass vaccination 26,521 13.3%

Non-County

FQHC 28,843 14.5%

Healthcare systems (ED, hospitals, clinics) 94,025 47.2%

Pharmacies 10,407 5.2%

Occupational health 7,800 3.9%

Total 199,226 100%

70.8%

29.1%

Adult HAV Vaccinations Registered

San Diego Immunizations Registry 3/10/17 through 9/5/18

2 41

7

28

51

87

73

86

94

80

35

21

8 7

1 3 1 1 1 1 0 0 0 0 00

5,000

10,000

15,000

20,000

25,000

30,000

35,000

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45,000

50,000

0

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Nov-1

6

Dec-1

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Jan

-17

Feb

-17

Ma

r-17

Apr-

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Ma

y-1

7

Jun

-17

Jul-

17

Aug-1

7

Sep-1

7

Oct-

17

Nov-1

7

Dec-1

7

Jan

-18

Feb

-18

Ma

r-18

Apr-

18

Ma

y-1

8

Jun

-18

Jul-

18

Aug-1

8

Sep-1

8

Oct-

18

Nov-1

8

Dec-1

8

Outbreak-Associated Hepatitis A Cases & Vaccinations by Month, November 2016 through December 2018

Confirmed/Probable Cases Pre Response Vaccinations Response Vaccinations


Cases Vaccinations

PHS staff member with

“Hepatitis A prevention

kits” for distribution to

raise awareness among

homeless about hepatitis.

They contain water, non-

alcohol hand sanitizer,

cleaning wipes, soap,

clinic location information,

and plastic bags.

Handwashing station being installed in downtown San Diego on 9/2/17

(Photo: San Diego Union Tribune)

Portable restrooms with security in downtown San Diego on 9/2/17


City contractor cleaning a street in downtown San Diego on 9/11/17


11 health advisories

16 news stories

Website established

Education campaigns

(medical, homeless

services, business,

at-risk groups)

Poster developed for

ad campaign at mass

transit and other

public locations

HEPATITIS A - LESSONS

Infection control issues

Adult vaccinations – we need to do better!

Public health/behavior health partnerships are critical

Homelessness is an independent risk factor for HAV

Plan for data collection

HAV PCR and genotype/strain information very useful

Food handlers rarely pass on the disease

Source: Washington Post. Downloaded 10/26/18 from: https://www.washingtonpost.com/health/2018/10/24/expert-panel-urges-hepatitis-shots-homeless-us/?noredirect=on&utm_term=.43477ff4d349

ACIP voted on

10/24/18

to recommend HAV

vaccine to homeless

persons over one

year of age

https://www.washingtonpost.com/health/2018/10/24/expert-panel-urges-hepatitis-shots-homeless-us/?noredirect=on&utm_term=.43477ff4d349

ACKNOWLEDGMENTS

County of San Diego

Public Health Services• Sarah Stous

• Melissa Thun

• Annie Kao

• Whitney Pinto

• Jeff Johnson

• Hepatitis A Team

• Public Health Laboratory

• Tracy Basler

CDPH

• Jennifer Zipprich

• Kathy Harriman

CDC EIS Program

• Corey Peak

• Jessica Healy

• Wences Arvelo

CDC Division of Viral

Hepatitis

• Monique Foster

• Megan Hofmeister

• Sumathi

Ramachandran

• Yulin Lin

• Yury Khudyakov

Stakeholders in San Diego County

• Hospitals, health systems, FQHC’s, behavioral health and substance abuse

providers, pharmacies throughout the county

• Homeless service providers

• San Diego County Sheriff’s Medical Services Division

• Law enforcement homeless outreach teams

• County of San Diego Health and Human Services

• County of San Diego Department of Environmental Health

• 18 incorporated cities in San Diego County + MORE!

QUESTIONS ?

For more information contact:

Eric C. McDonald, MD, MPH, FACEPMedical Director, Epidemiology and Immunizations Services

Public Health Services

County of San Diego Health and Human Services Agency

3851 Rosecrans Street (MS-P578)

San Diego, CA 92110

Phone: (619) 692-8436

Fax: (858) 715-6458

hepatitis a outbreak: san diego, california, 2016-18 · based on the san diego outbreak experience,...

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