hepatitis a outbreak: san diego, california, 2016-18 · based on the san diego outbreak experience,...
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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
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
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:
https://www.cdc.gov/mmwr/volumes/65/su/su6501a6.htm
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
200
300
400
500
600
7001
99
4
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
Hepatitis A Cases, San Diego County1994 - 2016
Vaccine introduced
Routine vaccination for children in high-incidence states
(including California)
Routine vaccination for all U.S. children
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
0
5
10
15
20
25
30
35
40
11
/6/1
6
12
/4/1
6
1/1
/17
1/2
9/1
7
2/2
6/1
7
3/2
6/1
7
4/2
3/1
7
5/2
1/1
7
6/1
8/1
7
7/1
6/1
7
8/1
3/1
7
9/1
0/1
7
10
/8/1
7
11
/5/1
7
12
/3/1
7
12
/31
/17
1/2
8/1
8
2/2
5/1
8
3/2
5/1
8
4/2
2/1
8
5/2
0/1
8
6/2
4/1
8
7/2
2/1
8
8/1
9/1
8
9/1
6/1
8
10
/14
/18
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
.
Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 2/5/19
0
100
200
300
400
500
600
7001
99
4
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
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20
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20
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20
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20
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20
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Hepatitis A Cases, San Diego County1994 - 2018
Vaccine introduced
Routine vaccination for children in high-incidence states
(including California)
Routine vaccination for all U.S. children
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)
HEPATITIS A, SAN DIEGO
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)
HEPATITIS A, SAN DIEGO
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)
HEPATITIS A, SAN DIEGO
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
40,000
45,000
50,000
0
20
40
60
80
100
120
140
Nov-1
6
Dec-1
6
Jan
-17
Feb
-17
Ma
r-17
Apr-
17
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
Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 2/4/19
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
(Photo: San Diego Union Tribune)
City contractor cleaning a street in downtown San Diego on 9/11/17
(Photo: San Diego Union Tribune)
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
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