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Biological Health Hazard – Public Health Threat | Fatal Hepatitis A (HAV) Outbreak (Homeless): California [update]



The hepatitis A virus is transmitted primarily by the faecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. In families, this may happen though dirty hands when an infected person prepares food for family members. Waterborne outbreaks, though infrequent, are usually associated with sewage-contaminated or inadequately treated water.

The virus can also be transmitted through close physical contact with an infectious person, although casual contact among people does not spread the virus.

The disease can lead to significant economic and social consequences in communities. It can take weeks or months for people recovering from the illness to return to work, school, or daily life. The impact on food establishments identified with the virus, and local productivity in general, can be substantial.

Key Facts

  1.  Hepatitis A is a viral liver disease that can cause mild to severe illness.
  2.  The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
  3.  Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis.
  4.  The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands).
  5.  Epidemics can be explosive and cause substantial economic loss.
  6.  A safe and effective vaccine is available to prevent hepatitis A.
  7.  Safe water supply, food safety, improved sanitation, hand washing and the hepatitis A vaccine are the most effective ways to combat the disease.

Source: WHO | Hepatitis A (edited)

Published Date: 2017-08-02 12:43:41
Subject: PRO/EDR> Hepatitis A – USA (17): (CA) fatal
Archive Number: 20170802.5222462

In this update:
[1] Los Angeles County
[2] San Diego County

[1] Los Angeles County
Date: Mon 31 Jul 2017
Source: Los Angeles Daily News [edited]

Outbreaks of hepatitis A among the homeless populations in San Diego and Santa Cruz counties prompted an alert by Los Angeles County health officials Monday [1 Aug 2017] to urge physicians and health care workers to look for and report any confirmed cases. The alert was issued because the disease has the potential to spread to Los Angeles County, health officials warned. The outbreaks in San Diego and Santa Cruz counties are among homeless people who may or may not be using drugs and is being spread “person-to-person through close contact or through contact with a fecally contaminated environment,” according to the alert.

A similar alert was issued by public health officials in Orange County, where one resident developed hepatitis after spending time in San Diego. The man had a history of homelessness. Los Angeles County health officials identified 2 confirmed cases of hepatitis A in local homeless patients who lived in San Diego during their exposure period, according to the alert. Two other people were identified in a health facility.

Health officials said the best way to prevent an outbreak in Los Angeles County is to vaccinate those who are homeless and/or who use illicit drugs.

Hepatitis A is a liver disease whose symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, and a yellowing of the skin or eyes or jaundice.

As of last week, there were 275 cases reported and 8 deaths in San Diego County [now 295 and 10; see below. – Mod.LL]. In Santa Cruz County, 38 cases have been confirmed.

“These cases and the proximity of Los Angeles County and San Diego highlight the possibility that additional cases may be introduced into Los Angeles County in the future and could result in an outbreak,” health officials said in the alert. “It is unknown how long the outbreaks in San Diego and Santa Cruz counties will continue.”

[byline: Susan Abram]

communicated by:

[2] San Diego County
Date: Tue 1 Aug 2017
Source: County of San Diego Health and Human Services Agency [edited]

Since early 2017, the Public Health Services Division in the County of San Diego Health and Human Services Agency has been investigating a local hepatitis A outbreak. The outbreak investigation is ongoing. It has been challenging because of the long incubation period of the disease (15 to 50 days) and the difficulty experienced to contact many individuals sickened with the illness who are homeless and/or illicit drug users. To date, no common source of food, beverage, or other cause has been identified; as a result, the source of the outbreak remains undetermined.

Vaccination efforts are being implemented in targeted locations by county staff and in collaboration with health care partners. Health providers are asked to inform the Epidemiology Program if they have a patient suspected to have the hepatitis A infection before the patient leaves the emergency department or provider’s office.

The table below will provide a weekly update of total cases, deaths, and hospitalizations. Following this update is information about hepatitis A to educate the community and help prevent the continual spread of this viral infection.

San Diego County hepatitis A outbreak cases and deaths as of 1 Aug 2017
Cases / Deaths / Hospitalizations
295 / 10 / 202 (68 per cent)

The table does not include all reported hepatitis A cases in the county, only those that are local-outbreak-related. Also, data are provisional and subject to change.

communicated by:

[The number of cases of diagnosed hepatitis A in San Diego County in southern California continues to increase.

Date / Cases / Hospitalized (percentage) / Deaths (percentage)
5 Apr 2017 / 39 / 33 (85) / 1 (3)
4 May 2017 / 80 / 66 (83) / 3 (4)
31 May 2017 / 133 / 103 (80) / 3 (2)
12 Jun 2017 / 160 / 120 (75) / 4 (2.5)
27 Jun 2017 / 196 / 142 (72) / 4 (2)
26 Jul 2017 / 275 / 194 (71) / 7 (2.5)
1 Aug 2017 / 295 / 202 (68) / 10 (3.4)

In the past week, 20 cases have been reported and 3 deaths. Since many cases of HAV infection are asymptomatic or anicteric (without jaundice), the total number of cases is likely to have been significantly higher. It is not clear whether the newer cases are truly new or just newly reported older cases. An epidemiologic curve showing the date of onset of symptoms of cases over time could assist in this regard.

Thus, it remains unclear whether the persistent increase is related to slow reporting, increased awareness and testing, secondary cases, or the persistent source or sources in the environment. The very high hospitalization rate may be related to the homelessness of the cohort but could represent a more virulent strain. HAV infection occurred in some individuals chronically infected with either hepatitis B or C, but it is not clear whether the fatalities occurred in those individuals.

Homelessness and illicit substance use seem to be relevant risk factors, while MSM practices are not. It remains unclear how and from what vehicle the virus is spreading.

The state of California can be located on the HealthMap/ProMED-mail interactive map at San Diego County can be seen on the map at – Mod.LL]

See Also

Hepatitis A – USA (16): (CO) 20170730.5215580
Hepatitis A – USA (15): (CA) fatal 20170726.5205912
Hepatitis A – USA (14): (CO) RFI 20170725.5201341
Hepatitis A – USA (13): (CA) fatal 20170713.5173051
Hepatitis A – USA (12): (MI) fatal, RFI 20170707.5158430
Hepatitis A – USA (11): (CA) 20170629.5139711
Hepatitis A – USA (10): (CA) additional counties, RFI 20170615.5107437
Hepatitis A – USA (09): (CA) 2nd county, RFI 20170614.5105051
Hepatitis A – USA (08): (CA) fatal, RFI 20170613.5102106
Hepatitis A – USA (07): (CA) fatal 20170606.5087079
Hepatitis A – USA (06): (CO) MSM 20170512.5031179
Hepatitis A – USA (05): (CA) fatal 20170511.5028824
Hepatitis A – USA (04): (CA) fatal, RFI 20170506.5017836
Hepatitis A – USA (03): (OR) food workers 20170410.4959609
Hepatitis A – USA (02): (CA) fatalities 20170408.4956398
Hepatitis A – USA: (MI) increased incidence 20170324.4923927


Hepatitis A – USA (19): (MI) prepared food 20161022.4578285
Hepatitis A – USA (18): (HI) frozen scallops 20160930.4527512
Hepatitis A – USA (17): (HI) frozen scallops 20160915.4490624
Hepatitis A – USA (16): fruit smoothies, strawberries ex Egypt 20160915.4490623
Hepatitis A – USA (15): comment 20160910.4477503
Hepatitis A – USA (14): fruit smoothies, strawberries ex Egypt 20160909.4477372
Hepatitis A – USA (13): fruit smoothies, strawberries ex Egypt 20160903.4461205
Hepatitis A – USA (12): (HI) frozen scallops 20160903.4463425
Hepatitis A – USA (11): (MI) raw sewage contact 20160827.4445808
Hepatitis A – USA (10): (VA) fruit smoothies, imported strawberries 20160822.4431203
Hepatitis A – USA (09): (HI) frozen scallops 20160817.4422480
Hepatitis A – USA (08): (HI) 20160810.4405316
Hepatitis A – USA (07): (HI) 20160729.4376124
Hepatitis A – USA (06): (HI) 20160721.4360060
Hepatitis A – USA (05): (HI) 20160713.4342961
Hepatitis A – USA (04): (HI) RFI 20160707.4330783
Hepatitis A – USA (03): (HI) 20160703.4323888
Hepatitis A – USA (02): (PR) hospital workers 20160630.4314683

A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases


Detroit: Hepatitis A cases up eight-fold in city, surrounding counties

Alternate view: Maintaining Homeostasis through the Use of Biological Control Methods on the homeless and illicit drug users

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