Hepatitis A Case With History of Illicit Drug Use in Orange County
December 3, 2018
O range County Public Health received a report last week of one case of hepatitis A virus (HAV) infection in a county resident with no history of travel outside the county or exposure to HAV. The case had a history of illicit drug use but no history of experiencing homelessness. Since mid-October of this year, the Los Angeles County Department of Public Health has identified three cases of hepatitis A virus (HAV) amongst individuals who use illicit (injection and non-injection) drugs and/or who are experiencing homelessness. Genotypic testing indicates that the Orange County case is unrelated to the Los Angeles cases.

HAV infections in Orange County have historically occurred after travel internationally to an HAV-endemic area, but five cases have of hepatitis A have been reported in 2018 in Orange County residents with no history of international travel or exposure to HAV. The case reported last week is the first of this year’s OC cases to have a history of illicit drug use; none had a history of experiencing homelessness.

Last year’s outbreak in San Diego has subsided, but significant outbreaks of HAV focused on persons with a history of illicit drug use and/or homelessness continue in other parts of the United States. In this setting, there is an ongoing risk for transmission and morbidity in Orange County.

Additional information on the Los Angeles situation can be found at http://publichealth.lacounty.gov/acd/Diseases/HepA.htm .

See https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm for details on HAV outbreaks around the United States.
  • HAV infection should be considered in persons with signs and/or symptoms of hepatitis, particularly in those who report a history of experiencing homelessness, injection or non-injection drug use, or men who have sex with men.
  • Providers should report any suspect or confirmed hepatitis A patients promptly to Orange County Public Health Epidemiology by phone at 714-834-8180 or by fax at 714-564-4050.
  • Patients suspected or confirmed to have hepatitis A should not be discharged to the street or to congregate settings while still infectious.
  • The Centers for Disease Control and Prevention (CDC) recommends HAV vaccination for all persons experiencing homelessness or a history of using illicit injection or non-injection drugs. Orange County providers should assure HAV immunization for patients with these risk factors.
Symptoms and Transmission
  • HAV infection signs and symptoms include jaundice, dark urine, fever, malaise, anorexia, nausea, diarrhea, and abdominal discomfort, and increased transaminases (AST/ALT).
  • The incubation period for HAV infection ranges from 15–50 days. Most immunocompetent persons shed virus in the stool and are infectious from two weeks before through one week after the onset of jaundice.
  • HAV is generally transmitted through the fecal-oral route. Transmission occurs from close contact with a person infected with hepatitis A or exposure to feces-contaminated food, drinks, or other objects.
Laboratory Testing
  • All patients with confirmed HAV infection should have serum forwarded to Orange County Public Health Laboratory to arrange for genotypic testing. Genotyping testing enhances public health surveillance and helps to identify outbreaks.
Two doses of HAV vaccination are recommended for all children at one year of age, as well as persons with high risk conditions or behaviors including:
  • Users of illicit injection and non-injection drugs
  • Persons experiencing homelessness
  • Persons with chronic liver disease, including those with hepatitis B or C virus (HBV or HCV) infection
  • Men who have sex with men
  • Persons traveling to or working in countries that have high or intermediate levels of HAV transmission
  • Persons who have been exposed to HAV in the prior 2 weeks and are not known to be immune

In October, the CDC’s Advisory Committee on Immunization Practices (ACIP) added persons experiencing homelessness to the list of those at elevated risk of HAV who should receive vaccination, see https://www.cdc.gov/vaccines/acip/recommendations.html for additional details.

For a summary of ACIP/CDC recommendations for HAV vaccination, see https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm .
Contact Information
For questions or concerns please contact the Epidemiology and Assessment Program at 714-834-8180.
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