For months a hepatitis A outbreak has been described in terms of homeless and drug-addicted victims in San Diego. New information this week from local, state and federal health officials shows a much broader geographic scope that is not limited by socio-economic boundaries.
On Tuesday, Sacramento authorities urged recent patrons Haggis Oaks Golf Course to immediately ask their doctors about taking the post-exposure hepatitis A vaccination after an employee of a restaurant at the course was confirmed infected.
Also on Tuesday, San Diego officials reported the local confirmed victim count had reached 418, with 70 percent requiring hospitalization and 17 having died.
Two-thirds of the sick in San Diego are designated homeless or drug users, meaning 33 percent of the confirmed victims are not members of those marginalized populations.
On Wednesday, San Diego officials reported the state had finally OK’d an emergency request they had filed Sept. 20 seeking temporary permission paramedics to be allowed to help vaccinate at-risk vaccinations. About 54,000 people in the county have been vaccinated through emergency programs.
Today, epidemic investigators from the federal Centers for Disease Control and Prevention are scheduled to present research documenting that an outbreak of hepatitis A at a Maricopa County, AZ, homeless shelter in February this year coincided with the arrival of a person from San Diego. At least three samples from the Arizona shelter were molecularly identical to the virus strain in San Diego victims.
Restaurant customers must act now
People who ate or drank at MacKenzie’s Sports Bar and Grille from Sept. 12 through Sept. 22 should ask their doctors about taking the post-exposure vaccine, Sacramento County Public Health Officer Olivia Kasirye said earlier this week.
There is only a two-week window of opportunity after exposure when the vaccine is effective. People who ate and drank at the restaurant are at relatively high risk of infection because it is known that the infected employee handled food.
For those who miss the chance for the post-exposure vaccine, it is important to watch for symptoms in the coming weeks because the incubation time for the virus in humans is 15 to 50 days, according to the CDC.
Sacramento officials reported it is not known how the restaurant employee became infected.
Numbers increasing despite control measures
In April this year, San Diego officials reported they had confirmed 42 hepatitis A cases in the region since November 2016, quadruple the monthly average usually reported. Of those people, 36 had symptoms so severe they required hospitalization. Two of them died.
Efforts in the ensuing months to eradicate the highly contagious virus, which can lead to liver damage and failure, have included cleaning human waste from streets in areas frequented by homeless people and dismantling so-called encampments where they sleep.
Some have been working to increase accessibility to restrooms and hand-washing facilities for the high-risk populations. Other than being vaccinated, public health officials say frequent and thorough hand washing is the most effective way to curb the spread of the hepatitis A virus.
On Wednesday, the San Diego City Council’s Public Safety and Livable Neighborhoods Committee heard updates on the situation from the city’s assistant chief operating officer and the county’s public health officer.
Assistant COO Stacey LoMedico told the council committee that street cleaning and increased availability of restrooms and hand-washing facilities would likely need to continue beyond the end of the outbreak.
Wednesday evening, San Diego County Emergency Medical Service Director Dr. Kristi Koenig told the Union-Tribune newspaper she had finally received email confirmation from state officials on Tuesday, granting a temporary expansion of state law to allow paramedics to administer emergency vaccinations to at-risk populations.
With the temporary measure, paramedics will be able to perform hepatitis A vaccinations under the supervision of nurses at special events created to inoculate those who are at high risk of infection.
“… getting the state to approve the request took a fair bit of back-and-forth with California regulators,” according to the San Diego Union-Tribune. “Assemblyman Todd Gloria, D-San Diego, added a letter of his own, urging approval on Sept. 27.”
Brutal, bitter irony
This week, in a twist of fate straight out of a Hollywood disaster movie, infectious disease experts from across the country are gathered at the San Diego Convention Center for “IDWeek,” an annual scientific conference of the Infectious Diseases Society of America.
San Diego County’s Director of Epidemiology and Immunization Dr. Eric McDonald joined with the one of the CDC’s epidemiologists, Dr. Monique Foster, to discuss the ongoing hepatitis A outbreak and the virus in general.
Public health officials like McDonald and Foster have been watching the virus make “huge” increases in the past 15 months across the nation. Foster reported 1,400 cases have been confirmed. Most of the victims have been infected with a “1B” strain, which is uncommon in the United States.
Today, the conference again turns attention toward hepatitis A with a presentation scheduled from Sally Ann Iverson, a CDC epidemic intelligence officer stationed in Phoenix, which is the county seat of Maricopa County, AZ. The research report by Iverson and the team she leads for CDC is entitled “Hepatitis A Outbreak Among Persons Experiencing Homelessness — Maricopa County, Arizona, 2017.”
It documents how molecular and epidemiologic data allowed the disease investigators to determine the source of the Arizona outbreak was a person who had come to the state from San Diego. The report provides evidence that the outbreak strain is not restricted to the Southern California city and that it has been brewing for months.
The analysis from the CDC’s Arizona team also suggests the length and severity of the outbreak could have been lessened.
“… the patient with the earliest onset arrived Feb. 5 from San Diego, CA, an area with an ongoing hepatitis A outbreak,” according to Iverson’s team, which found three samples from Arizona patients were “molecularly identical to samples from patients in San Diego.
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