San Diego County is in the midst of a Hepatitis A outbreak. It started in November of 2016, and as of Tuesday accounted for 333 cases, 232 hospitalizations and 11 deaths. For a county of 3.3 million that may not sound like much, but it should give us pause. We have the tools and information to prevent most of these cases, yet we continue to choose not to.
It’s easy to think of Hepatitis A outbreaks as sporadic and inevitable, because those that make the news usually involve infection through a specific food. We don’t know who is at risk until some people get sick, after which epidemiologists track the outbreak to a common exposure. Once the dangerous food is identified, other potentially exposed patients are monitored, the food is removed from the market, and the cases end.
That is not what is happening in San Diego. According to the County, the outbreak has not been related to a specific food or drug, but instead has involved San Diegans who are homeless and/or use illicit drugs, and have been clustered around people accessing the same homeless services or facilities. They also note that the majority of the patients involved had an indication for Hepatitis A vaccination, and only one patient is known to have been infected despite vaccination.
In short, we have an effective intervention, data on where to deploy that intervention and patients engaged in services. That’s a good start on the “cascade of care,” a public health framework for treating or preventing disease popularized by efforts to combat HIV/AIDS. Yet there remains a gap between our knowledge and implementation.
The step that is missing is facilitating appropriate medical care at the places potential patients engage in services. The two major risk factors in this outbreak, drug use and homelessness, highlight two needed interventions: needle and syringe exchanges and permanent housing for the homeless with connections to healthcare.
The Centers for Disease Control (CDC) supports the use of needle and syringe exchanges, or Syringe Service Programs (SSP), because they decrease the transmission of HIV and Hepatitis C in patients who inject drugs. They also offer an important chance to engage those patients in other care, including vaccines, mental health services, pre-exposure prophylaxis for HIV (PrEP) and screening for other diseases. With regard to the current outbreak of Hepatitis A, which is not typically transmitted by blood, a robust needle exchange program might have led to more injection drug users being vaccinated and saved lives.
San Diego County does not have a municipal needle exchange program. While there are exchanges run by other organizations in some areas, County government is better equipped to ensure a comprehensive program with direct access to public health records that could connect patients to the care they need. While injection drug use should never have been dismissed as a “downtown” problem, prescription opioid abuse has clearly moved injection drug use into the suburbs, as shown by cases of Hepatitis A in San Diego, El Cajon and La Mesa. A robust needle exchange program should have been part of the County’s “Getting to Zero” plan for HIV, but the current Hepatitis A outbreak demands it as a gateway to basic healthcare including vaccines.
Other San Diegans who contracted Hepatitis A could have been vaccinated when they accessed homeless services. As with needle exchanges, there are effective models, like Connections Housing, but they aren’t available County-wide. Homelessness is a public health issue; local governments should treat it as such. Where there is not affordable permanent housing, the County and other municipalities should be more aggressive in partnering to create it, ensuring safer water supplies and facilities. Where housing exists, it should connect residents to public health interventions directly or through clinic networks.
The last foodborne Hepatitis A outbreak tracked by the CDC was linked to frozen strawberries. Of 143 cases, only 56 patients were hospitalized (39 percent) and none died. Numbers from the current San Diego outbreak (70 percent hospitalized, 3.3 percent died) show we can, and must, do better. We know where to find the San Diegans at risk and how to engage them. We know what they need: vaccines, safe water, and clean facilities for handwashing. We should demand that our leaders show the political will to bring it all together to prevent further sickness and death from Hepatitis A.
