Infographic of Hepatitis

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It only takes one – one person carrying a virus like hepatitis A — to start an outbreak.

In early November, Riverside County public health officials reported the first known link between a county resident who contracted hepatitis A and a deadly outbreak of a strain of the disease that originated in San Diego. According to reports, the individual, who had worked in San Diego County, recovered from the illness and appeared not to have spread the virus to others.

That’s good news for Riverside County and the Coachella Valley, but it could be short-lived. California Gov. Jerry Brown declared a statewide public health emergency in October as cases of the San Diego virus turned up in Los Angeles and Santa Cruz counties. Hepatitis A illness traced to the San Diego outbreak, which was identified in a single individual in late 2016, has since emerged in Arizona and Colorado.

Hepatitis A rears its ugly head on occasion in outbreaks across the U.S. In late 2016, the Centers for Disease Control and Prevention connected a multi-state outbreak of the virus to contaminated frozen strawberries imported from Egypt. The outbreak hospitalized 56 people and prompted a product recall.

An eruption of the disease, however, appears to have struck the U.S. particularly hard in 2017. As of October, the nationwide incidence of hepatitis A surged 28% over the same period in the previous year. New York reported 95 cases as of Oct. 21, at the same time communities in southeast Michigan struggled to contain an outbreak topping 450 cases.

But the San Diego outbreak has proven thus far to be the largest — and deadliest. November public health reporting put the number of individuals sickened by the outbreak at least at 530; that month also saw the death count in San Diego County rise to 20 people. That’s four times higher than the national average. The data make the San Diego outbreak the worst the U.S. has seen in more than two decades.

Heightened Concern

Beyond the terrible toll the spread of the disease has taken in states like California (where cases of hepatitis A have jumped 210% in the last year), outbreaks like those in San Diego and southeast Michigan haven’t followed a usual pattern, prompting heightened concern among public health officials.

Contaminated food typically serves as the principal source of hepatitis A transmission. In this year’s outbreak, unsanitary conditions among homeless individuals and illicit drug users appear to be the likely culprit.

The likely causes of this year’s outbreaks have raised more than eyebrows among the nation’s public health experts. The CDC took action in August to alert health departments across the country for possible surges in hepatitis A infections among homeless and drug-using populations in their communities.

Some health officials note the unusual nature of the San Diego outbreak could signal an anything-goes scenario.

Jeff Duchin, MD, a medical epidemiologist, serves as the chief health officer for Seattle, which claims the nation’s third largest homeless population. Although his city has not experienced a hepatitis A outbreak to date, Duchin told the Huffington Post in early November that concerns over the rising incidence of the virus shouldn’t be limited to homeless populations or illicit drug users alone.

“The rapidity at which [hepatitis A is] going through the population and potentially getting into the general community is a real threat,” he said.

An Epidemic Among the Homeless

A high ick factor associated with hepatitis A transmission — person-to-person fecal-oral spread of the virus or ingestion of feces-contaminated food — doesn’t prompt a great deal of public discourse about the disease, but some experts would say neither does homelessness. Both these things exist; they just don’t typically affect the majority of the population.

Little research has probed hepatitis A, according to A. Naveen Gara, MBBS, a University of California San Diego hepatologist and assistant professor of medicine, because the virus frequently doesn’t affect healthy people. In those without underlying health conditions, the illness tends to run its course with few, if any, long-term effects, Gara told UC San Diego Health.

The medical community does know the hepatitis A virus, or HAV, is a communicable disease that affects the liver. According to the CDC, symptoms of HAV infection are consistent with other forms of acute viral hepatitis (of the B and C variety) and include nausea, anorexia, fever, malaise, abdominal pain, dark urine, clay-colored bowel movements, and joint pain along with either jaundice or elevated serum aminotransferase levels.

A positive serologic test for immunoglobulin M antibody to the virus confirms HAV diagnosis. Diagnosis is also made in affected individuals who meet the clinical case definition of HAV and who are epidemiologically connected to someone in whom the virus has been confirmed by laboratory testing.

The incubation period for HAV averages 28 days but can stretch between 15 and 50 days. Symptoms typically last less than 60 days, although research estimates some symptomatic patients experience prolonged or relapsing disease for as many as six months.

Infection with hepatitis A is neither chronic nor recurring. People who contract the virus develop lifelong antibodies to the disease and cannot become re-infected. Handwashing offers a proven defense against the virus; and vaccination against HAV, introduced in 1995, has contributed to a dramatic drop in hepatitis A cases in the U.S. and other developed nations. The CDC recommends all U.S. children at the age of one year and immunocompromised adults receive the vaccine.

Most Americans over age 30, however, have not been vaccinated against HAV, nor, it’s presumed, have the majority of homeless individuals.

Homelessness, with its lack of health insurance and routine access to healthcare services, has long been known to compromise health or exacerbate existing health conditions. Rising rates of homelessness in San Diego and elsewhere, coupled with insufficient sanitary facilities in shelters or other areas in which homeless individuals congregate, account for the disproportionate affect of the current outbreak on unsheltered populations, health officials say.

“You’re seeing increasing numbers of homeless people in encampments, and these types of arrangements have unsatisfactory sanitation and hygiene facilities available,” Duchin told Huffington Post. “So it’s kind of like a refugee camp in that … it’s perfect for the transmission of disease spread through fecal matter.”

Playing Catch Up

Even with evidence of its growing homeless population, particularly in its downtown area, San Diego officials were surprised by the rapid spread and virulence of hepatitis A in its community.

Playing catch up to prevent further transmission of the virus, the city has taken extraordinary steps to power-wash city streets, set up handwashing stations, distribute hygiene kits, and vaccinate some 90,000 homeless individuals, drug users, and others at high risk of contracting the illness. Area food handlers also have been advised to seek vaccination. To ease the burden of vaccine administration on nurses and physicians, local officials obtained unprecedented permission from the state Emergency Medical Services Authority to allow EMT professionals to administer vaccines.

In light of the Riverside County case, news reports say health officials there have begun to closely monitor the crisis across the state. Although the individual infected with the virus was neither homeless nor a recreational drug user, county officials acknowledge that homeless people can be mobile. (Cases of the San Diego virus that turned up in Arizona and Colorado serve as examples of that mobility.) The county has also experienced a more than 11% increase in homeless individuals in 2017, the first such rise since 2011.

“If we do detect further cases, the [health] system is already in place to respond quickly and to make sure all our residents stay protected,” said Cameron Kaiser, MD, the county’s public health officer in a November press report.

It’s Not Over

Despite preparedness in Riverside County and municipalities across California since the San Diego outbreak, public health officials worry the costs to contain this or similar eruptions of hepatitis A cases could hamper future prevention efforts.

San Diego’s work to control the outbreak has topped $4 million thus far, according to the city’s director of public health services. The city expects to spend an additional $1.5 million per month in public information and vaccination campaigns until the outbreak is contained. Critics bemoan what they consider to be a measly federal budget for prevention of hepatitis of all types (A, B, and C) — just $34 million for all 50 states, according to estimates.

And a potential shortage of HAV vaccine could compound the crisis in California and other states. The CDC has identified “constrained” availability of the vaccine due to unexpected demand in the U.S. and around the globe. California’s emergency declaration cleared the way for the state’s purchase of additional doses of the vaccine to control the epidemic.

Vaccine availability aside, public health nurses and physicians on the frontlines of the outbreak, as well as those in emergency departments and clinics, will need to be on the lookout for new hepatitis A cases for months to come or more. With an incubation period up to 50 days, new cases could continue to sprout, even despite prevention efforts, in San Diego and beyond.

As Eric McDonald, MD, an official with the San Diego County public health department told the Los Angeles Times, “I don’t think the worst is over.”

Eisenhower Medical Center is committed to keeping healthcare professionals apprised of developments in the health needs of the communities we serve. To learn ways you can improve the health of homeless individuals and families, see our infographic; and to learn more about healthcare careers at our world-class medical center, visit our Careers page.

Originally posted on 28/11/2017

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