LAC DPH Health Advisory: New Cases of Hepatitis A Among Persons Experiencing Homelessness and/or Using Illicit Drugs December 6, 2018 Tag 6416 This message is intended for infectious disease, primary care, emergency medicine, urgent care, emergency medical services, and health care personnel who provide services to persons experiencing homelessness and/or who use illicit drugs. Please distribute as appropriate. Key Messages The Los Angeles County Department of Public Health (LAC DPH) has identified three new cases of hepatitis A virus (HAV) among persons who are experiencing homelessness and/or who use illicit (injection and non-injection) drugs. Promote hepatitis A vaccine to persons experiencing homelessness and/or who use illicit drugs and to persons with frequent close contact with these at-risk populations. Immediately report suspect cases of hepatitis A infection by phone--while the patient is still at the clinical facility-- if the patient is experiencing homelessness and/or uses illicit drugs. This will facilitate an on-site interview by a public health investigator and prophylaxis of contacts. Call 888-397-3993. After hours, call 213-974-1234. Patients suspected or confirmed to have hepatitis A should not be discharged to the street or to congregate settings while still infectious. Situation Since mid-October, LAC DPH has identified 3 cases of hepatitis A in individuals currently experiencing homelessness and/or who use illicit drugs. The cases are known to each other, although the original source of infection has not been identified. The fatality rate of hepatitis A in this population is higher than the rate observed in healthy individuals. These are the first reported cases of hepatitis A in Los Angeles County among persons experiencing homelessness since February of this year. It is important that clinicians remain vigilant for additional hepatitis A cases due to the long period between exposure and onset of illness. Proactive vaccination in these high-risk populations will help prevent further disease transmission. Actions Requested of Providers Suspect hepatitis A infection in any patient presenting with jaundice or hepatitis symptoms who reports experiencing homelessness or using illicit drugs within the last 2 months. This also applies to persons with close contact with these groups. Consider hepatitis in patients with abrupt onset of prodromal symptoms (nausea, anorexia, fever, malaise, or abdominal pain) and jaundice or elevated serum aminotransferase levels. A complete serology panel with testing for hepatitis A (for acute HAV order IgM), B, and C is recommended in symptomatic patients. Please hold an additional serology specimen, which LAC DPH will collect. HIV testing is also recommended for those with an undocumented HIV-status. Do not test asymptomatic people for HAV infection as the false positive rate is high. Immediately report all suspect and confirmed hepatitis A cases in persons experiencing homelessness or using illicit drugs to the LAC DPH Morbidity Unit by calling 888-397-3993 (after hours call 213-974-1234). Providers must report while suspected cases are still at the health care facility to facilitate immediate interview by a public health investigator and prophylaxis of contacts. Report acute hepatitis A infection in other patients within 1 working day from identification. Do not discharge patients with hepatitis A to the street or communal shelter until at least 7 days after the onset of jaundice (14 days after the onset of symptoms if no jaundice). LAC DPH may be able to assist with finding placement for infectious but medically stable patients who are ready for discharge. Health Officer orders are available to facilitate holding patients for discharge planning. For assistance, call: 888-397-3993 during business hours and 213-974-1234 after hours. Provide post-exposure prophylaxis (PEP) for close contacts of confirmed hepatitis A cases as directed by LAC DPH. Susceptible people exposed to HAV should receive PEP as soon as possible within 2 weeks of last exposure. Single-antigen HAV vaccine and immune globulin (IG) are effective HAV PEP therapies. Recommendations for PEP vary with patient age and risk for severe infection and can be found on the CDPH Hepatitis A Post-exposure Prophylaxis Guidance Quicksheet. Vaccination with single antigen HAV vaccine generally is recommended as part of the PEP regime to provide more long-lasting protection; exceptions include infants and in uncommon situations when vaccination is contraindicated. LAC DPH will assist in the management of contacts. Follow standard environmental sanitation protocols to prevent the spread of infectious diseases, including HAV. Promote hepatitis A vaccine to all persons at increased risk for acquiring hepatitis A infection or for experiencing complications from hepatitis (see table).Providers are also encouraged to review the Rx for Prevention article, Clinical Recognition and Management of Hepatitis A in the Context of an Ongoing Outbreak in Los Angeles County for more detailed information about hepatitis A diagnosis, management, and control. Free CME is available. HAV Vaccine Resources Medi-Cal: HAV vaccine is covered for patients enrolled in both fee-for-service and managed care plans. Vaccine administration is covered if administered in a provider's office or by an in-network pharmacy. No prior authorization is required. Patients or those assisting them can call the plan's member services number listed on the back of the patient's Medi-Cal Benefits Identification Card to obtain information on pharmacy services. Prior to referring a patient to an in-network pharmacy for HAV vaccination, please contact the pharmacy to verify vaccine availability. AIDS Drug Assistance Program (ADAP): HAV vaccine is included on the ADAP formulary. LAC DPH Clinics: Free HAV vaccine is available at the LAC DPH Public Health Centers for any at-risk people. View the Hepatitis A Vaccination Clinics flyers (available in English and Spanish) for clinic times and locations. For questions regarding HAV vaccine and/or supply, contact the LAC DPH Vaccine Preventable Diseases Control Program at 213-351-7800. Reporting Immediately report suspect or confirmed hepatitis A infections in persons experiencing homelessness and/or using illicit drugs. Los Angeles County DPH Acute Communicable Disease Control: Weekdays 8:30am–5pm: call 888-397-3993. After-hours: call 213-974-1234 and ask for the physician on call. Pasadena Public Health Department: Weekdays 8am-5pm (closed every other Friday): call 626-744-6089. After hours: call 626-744-6043. Long Beach Health and Human Services: Weekdays 8am-5pm: call 562-570-4302. After hours: call 562-500-5537 and ask for the duty officer. Resources LAC DPH HAV webpage: http://publichealth.lacounty.gov/acd/Diseases/HepA.htm LAC DPH Rx for Prevention article with free CME, Clinical Recognition and Management of Hepatitis A in the Context of an Ongoing Outbreak in Los Angeles County:http://rx.ph.lacounty.gov/RxHepA1117rev0618 ACIP, Hepatitis A Vaccine Recommendations: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm Centers for Disease Control and Prevention (CDC), Hepatitis A Information for Healthcare Providers: https://www.cdc.gov/vaccines/vpd/hepa/hcp/index.html CDC, Hepatitis A Questions and Answers for Health Professionals:https://www.cdc.gov/hepatitis/hav/havfaq.htm CDC, Hepatitis A General Fact Sheet For Patients: https://www.cdc.gov/hepatitis/hav/pdfs/hepageneralfactsheet.pdf CDPH, Hepatitis A Postexposure Prophylaxis Guidance Quicksheet:https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/HepatitisA-PEPQuicksheet.pdf This Health Advisory was sent by Dr. Sharon Balter, Director, Division of Communicable Disease Control and Prevention, Los Angeles County Department of Public Health. 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