Notification from the Los Angeles County Department of Public Health
Notification from the Los Angeles County Department of Public Health
LAC DPH Health Alert:
Local Outbreak of Hepatitis A among Persons Experiencing Homelessness and/or who use Illicit Drugs
May 10, 2024
This message is intended for infectious disease, primary care, emergency medicine, urgent care, emergency medical services, and healthcare personnel who provide services to populations experiencing homelessness and/or using illicit drugs.
Please distribute as appropriate.
Key Messages
  • There is a hepatitis A outbreak in LA County among persons experiencing homelessness and/or who use illicit (injection and non-injection) drugs.
  • Providers should suspect hepatitis A infection in patients presenting with jaundice or hepatitis symptoms and who either 1) report experiencing homelessness and/or using illicit drugs or 2) have close contact with these at-risk populations.
  • Test for anti-HAV IgM in patients with suspected hepatitis A infection. Immediately report all patients with a positive anti-HAV IgM if they are experiencing homelessness and/or use illicit drugs by calling 213-240-7941. After hours call 213-974-1234. Non-outbreak related acute hepatitis A is reportable within 1 working day.
  • Offer 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. Vaccination and hand hygiene with soap and water offer the best prevention against HAV.
Current Situation
Los Angeles County Department of Public Health (LAC DPH) has observed a sharp increase in hepatitis A virus (HAV) infections among persons experiencing homelessness (PEH) and persons who use illicit drugs (PWUD). Since mid-March 2024, LAC DPH has identified 5 cases of HAV in PEH/PWUD, compared with 4 cases in this population during the prior 6 months. At least 3 of these cases are genetically linked based on subgenomic sequencing of viral samples, suggesting a chain of transmission among PEH/PWUD in LA County. Sequencing results are still pending for one case; no specimen was available for fifth. LAC DPH suspects HAV is primarily being transmitted person-to-person through close contact, such as sharing drug use equipment or through ingestion of food/water with HAV contamination from inadequate environmental sanitation. Though no deaths have been reported during this outbreak at this time, the fatality rate of HAV in the PEH/PWUD is higher than the rate observed in healthy individuals.
Actions Requested of Providers
  • Suspect HAV in PEH/PWUD or persons who have had close contact with PEH/PWUD presenting with symptoms of acute hepatitis. Signs and symptoms of HAV include abrupt onset of prodromal symptoms (nausea, anorexia, fever, malaise, or abdominal pain) and jaundice or elevated serum aminotransferase levels. (Note: Up to 30% of adults with acute hepatitis A will not develop jaundice.)
  • Order anti-HAV IgM in patients with suspected HAV. Evaluate for alternative causes of acute hepatitis including other viral hepatitis. Please instruct the laboratory to hold any positive anti-HAV IgM and transport to LAC DPH Public Health Laboratory for additional testing. Do not test asymptomatic people for HAV infection as the false positive rate is high.
  • Immediately report all patients with a positive anti-HAV IgM who are PEH/PWUD or who have had close contact with PEH/PWUD to the LAC DPH by calling 213-240-7941. After hours call 213-974-1234. Providers are requested to report PEH/PWUD with a positive anti-HAV IgM while they are still at the healthcare facility, which will facilitate immediate interview by a public health investigator to identify contacts who could benefit from post-exposure prophylaxis. Please note that acute HAV in non-outbreak populations can be reported the next working day.
  • Do not discharge patients to the street or shelters who are diagnosed with HAV until at least a week after the onset of jaundice. If the patient does not have jaundice, the patient should not be discharged until 14 days after symptom onset. If the hospital or clinic case manager is unable to find a safe place for discharge of otherwise medically stable patients, please call LAC DPH for assistance: 213-240-7941 during business hours.
  • Provide post-exposure prophylaxis (PEP) for close contacts of confirmed HAV cases as directed by LAC DPH. Susceptible people exposed to HAV should receive PEP within 2 weeks of last exposure and ideally as soon as possible. Single-antigen hepatitis A vaccine and immune globulin (IG) are effective for HAV PEP; recommendations for PEP vary with patient age and risk for severe infection and can be found on the CDPH Hepatitis A Postexposure Prophylaxis Guidance Quicksheet. Vaccination with single antigen hepatitis A vaccine generally is recommended as part of the PEP regime to provide more long-lasting protection; exceptions include infants and in individuals who are allergic a previous dose of vaccine or to a component of the vaccine. DPH will assist in the management of contacts.
  • Offer hepatitis A vaccine to PEH, PWUD, and to persons who work in settings providing direct services to PEH/PWUD (e.g., shelters, needle exchange programs). Serologic testing for HAV immunity is not recommended prior to vaccination. Hepatitis A vaccines are highly effective at preventing disease. More than 95% of adults will develop protective antibody within 4 weeks of a single dose of vaccine, and nearly 100% will seroconvert after receiving 2 doses. Vaccinate with either single antigen hepatitis A vaccine or the combined HAV/HBV (Twinrix) vaccine. See the Hepatitis A vaccine resources below for more information regarding vaccine coverage and availability.
Hepatitis A Vaccine Resources
LAC DPH Clinics: Hepatitis A vaccine is available at no cost at the LAC DPH Public Health Centers as well as participating community clinics for eligible people (e.g., PEH and PWUD) as well as people who are uninsured/underinsured. Refer to the Nurse Clinic information in English and Spanish for clinic times and locations.
In addition, LAC DPH is conducting outreach events to offer hepatitis A vaccine in conjunction with community partners that serve the homeless community.
Medi-Cal: Hepatitis A vaccine is covered for patients enrolled in both fee-for-service and managed care plans. Vaccine administration is covered if administered in a patient’s established 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 their 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): Hepatitis vaccine is included on the ADAP formulary.
For questions regarding hepatitis A vaccine and/or supply related to this outbreak contact the LAC DPH Vaccine Preventable Disease Control Program at 213-351-7800.  
Reporting
Immediately report positive anti-HAV IgM in patients associated with the current outbreak (PEH/PWUP and those who have had close contact with PEH/PWUD) 
Los Angeles County DPH Acute Communicable Disease Control:
  • Weekdays 8:30 am–5:00 pm: call 213-240-7941.
  • After-hours: call 213-974-1234 and ask for the physician on call.
Long Beach Health and Human Services:
  • Weekdays 8:00 am-5:00 pm: call 562-570-4302.
  • After hours: call the duty officer at 562-500-5537.
Pasadena Public Health Department:
  • Weekdays 8:00 am-5:00 pm: call 626-744-6089.
  • After hours: call 626-744-6043.
Report acute HAV within 1 working day for patients NOT experiencing homelessness and/or using illicit drugs. See Acute Communicable Disease Reporting.
Additional Resources
This Health Alert was sent by Dr. Sharon Balter, Chief, Acute Communicable Disease Control Program, Los Angeles County Department of Public Health.
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