Use of Molecular Epidemiology to Inform Response to a Hepatitis A Outbreak - Los Angeles County, California, October 2018-April 2019

Abstract

Los Angeles County comprises 4,058 square miles and is home to approximately 10 million residents (1), an estimated 59,000 (0.6%) of whom experience homelessness on a given night (2). In late 2018, Los Angeles County Department of Public Health (LAC DPH) was notified of a case of hepatitis A virus (HAV) infection in a person experiencing homelessness. LAC DPH conducted an investigation to determine the source of infection, identify additional cases, and identify contacts for postexposure prophylaxis (PEP). Over the next week, LAC DPH identified two additional hepatitis A cases in persons experiencing homelessness who knew one another socially and were known to congregate at a specific street intersection. To identify and respond rapidly to additional outbreak-associated cases, LAC DPH implemented enhanced surveillance procedures, including immediately obtaining specimens for molecular testing from all patients with suspected hepatitis A in the same geographic area. Enhanced surveillance identified four additional cases in persons linked to a senior living campus within two blocks of the intersection where the initial three patients reported congregating. These four cases were linked to the cluster in persons experiencing homelessness through HAV genotyping. Overall, DPH identified seven outbreak-associated hepatitis A cases during October 2018-January 2019. The DPH response to this community hepatitis A outbreak included conducting vaccination outreach to persons at risk, conducting environmental health outreach to restaurants in the outbreak area, and issuing health care provider alerts about the increased occurrence of hepatitis A. Implementation of near real-time molecular testing can improve hepatitis A outbreak responses by confirming HAV infections, linking additional cases to the outbreak, and informing the targeting of prevention efforts.

FIGURE

Timeline of confirmed outbreak-associated hepatitis A virus (HAV) cases and public health response — Los Angeles County, California, October 2018–January 2019^†,§ * Outbreak cases were defined as HAV infections occurring in persons who 1) resided or spent time in the outbreak area and 2) either had infections caused by HAV genotype IB CA cluster A strain or were epidemiologically linked to a person infected with the outbreak strain. ^† Dates have been shifted to preserve patient confidentiality. ^§ Enhanced surveillance continued until the outbreak was declared over in April 2019. Los Angeles County Department of Public Health declared the outbreak over after 100 days without additional outbreak-associated HAV cases (representing two HAV infection incubation periods).