Welcome to the California Immunization Coalition Education Hour

Transcription

1 Welcome to the California Immunization Coalition Education Hour 1

2 . Hepatitis A Outbreaks: Response and Prevention Webinar Objectives Describe Hepatitis A modes of transmission, morbidity and mortality Describe the unique characteristics of the current California outbreak Identify strategies that California counties have employed in response to this outbreak Identify strategies to increase Hepatitis A vaccination 2

3 Audio Options for the Webinar Today Listen over your computer speakers Turn up your computer speakers Make sure they are not on Mute Plug in earphones or headset to computer or handheld device (phone or tablet ) All lines will be on mute during the conference You may ask questions using the Q&A Panel

4 Frequently Asked Questions 1. Will I be able to get a copy of the slides after the webinar? Yes a copy will be posted on the ImmunizeCA.org site 2. Will there be a recording of today s webinar? Yes - a copy will be posted on the ImmunizeCA.org site

5 Questions for Presenters? Ask Questions Here

6 Submit Written Questions at Any Time Using the Q&A Panel 1.) Type your question into the small 1) Type your question into the box at the bottom box at the bottom 3) Click Send 3) Click the Send Button 3.) Click the Send Button 2.) Address your question to All Panelists 2) Address your questions to All Panelists

7 Sayone Thihalolipavan, MD, MPH Deputy Public Health Officer Public Health Services, County of San Diego Health & Human Services Agency

8 HEPATITIS A OUTBREAK SAN DIEGO COUNTY Sayone Thihalolipavan MD, MPH Deputy Public Health Officer Health and Human Services Agency County of San Diego CA Immunization Coalition Education Hour December 5, 2017 Image: CDC 8

9 COUNTY OF SAN DIEGO Population of 3.2 million (1% of our Nation and more residents than 21 states) Distinct Boundaries (size of Connecticut) 48% W, 32% L, 11% A/PI, 5% B, 5% O. 18 incorporated cities 18 Indian Sovereign nations 5 th largest County in the United States (urban & rural) World s busiest border crossing

10 HEPATITIS A OVERVIEW Caused by a virus Hepatitis A can easily spread from person-to-person Can cause liver disease lasting a few weeks to a serious illness lasting several months Can cause death in some cases

11 HEPATITIS A VIRUS OVERVIEW Average incubation period for Hepatitis A infection is 28 days (range: days) The virus can live outside the body for months, depending on the environmental conditions An individual can be contagious up to two weeks before developing symptoms or 1-2 weeks after onset of symptoms Adequate chlorination of water kills the virus that enters the water supply Vaccination with the full, two-dose series is the best way to prevent infection 11

12 HOW DOES IT SPREAD? Ingestion of fecal matter, even in microscopic amounts, from: Touching objects or eating food that someone with a Hep A infection handled Close person-toperson contact with an infected person Use of recreational drugs, whether injected or not Sexual contact with someone who has a Hep A infection

13 HEPATITIS A - SYMPTOMS Fever Fatigue Nausea Loss of Appetite Jaundice Stomach Pain Vomiting Dark Urine, Pale Stools and Diarrhea

14 Incidence* of reported acute hepatitis A cases National Notifiable Diseases Surveillance System, United States, (pre-vaccine) and 2007 * Rate per 100,000 population. Annual average incidence. Source: CDC. Downloaded 7/1/17 from: 14

15 HEPATITIS A, SAN DIEGO 700 Vaccine introduced All Hepatitis A Cases, San Diego County * Routine vaccination for children in high-incidence states (including California) Routine vaccination for all U.S. children *Year to date. Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization 15 Services, 11/20/17

16 HEPATITIS A OUTBREAKS, UNITED STATES PRESENT YEAR LOCATION METHOD OF SPREAD/SOURCE 2003 PA & OH Food (Green Onions) SAN DIEGO Close Person to Person Contact MICHIGAN Close Person to Person Contact 2016 HAWAII Food (Raw Scallops) states Food (Pomegranate Seeds) #CASES #HOSPITA LIZATIONS #DEATHS 660 Unknown 3 (0.5%) (67%) 20 (3.5%) (82%) 20 (3.6%) (25%) (43%) 0 16

17 HEPATITIS A, SAN DIEGO 567 confirmed/probable outbreak cases Onset dates from 11/22/16 through 11/21/ (67%) hospitalizations, 20 (3.5%) deaths 386 (68%) male, 181 (32%) female Age range 5-87 (median 43) Suspected exposure type 184 (32%) homeless and illicit drug use 88 (16%) homeless only 69 (12%) illicit drug use only 164 (29%) neither 62 (11%) insufficient information to classify 17

18 HEPATITIS A, SAN DIEGO Co-infections 77/449 (17.1%) with hepatitis C 23/461 (5.0%) with hepatitis B 37 non-outbreak cases meet CSTE definition (not included in count) 6 suspect cases under investigation Linked cases in other CA counties, AZ, KY, CO, RI, UT 18

19 HEPATITIS A IN SAN DIEGO 3/8/17 Outbreak Determined Cases likely to increase due to day incubation period and reporting delays 19

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21 OUTBREAK MANAGEMENT Activation of Incident Command System and response to the outbreak focused on a three-pronged strategic approach to: Vaccinate Sanitize Educate Conducted surveillance, case investigations, and post-exposure prophylaxis. Worked closely with Department of Environmental Health on possible food sources and collaboration with other partners at local, state, and federal levels. Local health emergency declared on 9/1/17. Governor declared a State of Emergency on 10/13/17.

22 CHALLENGES Disease-specific Long incubation period; infectious period before & after symptom onset Lack of effectiveness of hand sanitizer Relapse Population-specific May be difficult to reach for interview May not interface with or be able to access existing vaccination sites May not have adequate access to sanitation Other Low vaccination rates amongst adults with CDC indications Isolation of discharged medically stable yet infectious homeless individuals Potential of cross over into other populations or general public Risk communication as relates to those at risk vs. worried well

23 VACCINATION SITES Over 108,000 vaccinations offered at: Public Health Centers Medical institutions Enhanced Approach Jails during intake and to inmates Substance use disorder treatment programs Homeless service providers New Approach Single Room Occupancy hotels Encampments, ravines, culverts, and other areas in the field with homeless outreach workers, sometimes including homeless outreach team workers or police officers; Emergency Departments

24 EXPANDING VACCINATION CAPACITY Vaccinations offered by: County-employed nurses, including behavioral health settings Contract or temp agency nurses Local Medical Reserve Corps volunteers Medical community, including pharmacists County Medical Society Foundation volunteers Paramedics required local scope of practice expansion Note: Coupling with flu vaccinations and other services when possible

25 SANITIZE (HYGIENE) Indoor sanitation Disinfection guidance for indoor areas available Food inspectors provide guidance information to operators during more than 12,340 inspections Outdoor sanitation and access to hygiene Sanitation of streets being conducted in some areas 158 handwashing stations placed Public restroom access expanded where possible 9,362 hygiene kits distributed

26 EDUCATE 17 news stories, 2 press conferences 10 CA Health Alert Network (CAHAN) notifications Provided 162 education events, with a total reach to over 7,561 attendees Conducted meetings with homeless service providers (more recently with HUD), behavioral health providers, and city leadership of local jurisdictions Distributed flyers, posters, FAQs, and more available on webpage Activated 2-1-1, non-emergency hotline, for general inquiries Food inspectors have provided guidance information to operators during more than 10,161 inspections. Created guidance for infrequent volunteers during holidays and for annual Point in Time Count of homeless Enhanced communication to MSM population to prevent crossover given other outbreaks

27 EDUCATE MEDICAL PARTNERS 10 CA Health Alert Network (CAHAN) notifications Convened health care providers and attended high level health care stakeholder meetings to encourage: Recognition and active reporting of suspect cases to allow interviews to be conducted before patient lost to follow up Vaccination of population at risk and/or those recommended by CDC Checking of San Diego Immunization Registry before vaccination to avoid redundant doses and noting doses given afterwards Avoiding discharge of infectious patients to the street by using established temporary housing process Use of standard precautions

28 MAP OF HANDWASHING STATIONS AND PUBLIC BATHROOMS ON 211 PAGE org/resources/healt h-wellness 28

29 IT TAKES A VILLAGE Multiple County Departments involved Local medical providers, medical society, hospital association, San Diego Health Connect (health information exchange) Local homeless service and behavioral health providers and related organizations Local municipalities Other local partners including but not limited to local restaurant association, food and beverage association, faith-based organizations, food banks and pantries, hotel motel association, farmers market and agricultural growers, chamber of commerce, State partners including but not limited to California Department of Public Health, California Emergency Medical Services Authority, California Department of Pesticide Regulation, and San Diego River Conservancy Federal partners Centers for Disease Control and Prevention Housing and Urban Development

30 QUESTIONS? 30

31 For more information contact: Sayone Thihalolipavan, MD, MPH Deputy Public Health Officer Public Health Services County of San Diego Health and Human Services Agency 3851 Rosecrans Street (MS-P578) San Diego, CA Phone: (619) Webpage: epidemiology/dc/hepatitis_a.html

32 Sharon Balter, MD Director, Acute Communicable Disease Control Program Los Angeles County Department of Public Health

33 Responding to a Potential Hepatitis A Emergency in Los Angeles County

34 Los Angeles County Population >10 million More than 25% of California residents live in LAC Most populous county in the US - larger than 41 states Size - 4,058 square miles Larger than Rhode Island and Delaware combined Population density is very high: 2,420 people per square mile Los Angeles County has the highest number of millionaires and the largest number of homeless people of any county in the US

35 Los Angeles County Estimated 57, 000 homeless spread over the community Many large tent encampments Additional smaller sites Proximity to San Diego and Santa Cruz elevated concern A lot of travel between jurisdictions 400,000 MSM Recent increases both nationally and internationally along with other recent outbreaks in this community elevated concern for 44

36 Cases 70 Hepatitis A in LA County Year In LA County there are approximately cases each year Highest rates in people years old No cases among homeless population in recent years 45

37 Current Outbreak in LA County 15 outbreak associated cases June- July 1 from SD to a board and care 1 to a health facility, 3 secondary cases Vaccination of contacts, no additional spread 46

38 Current Outbreak in LA County Beginning in September Cases reported among homeless from San Diego and Santa Cruz arriving by bus and living on the streets 1 case released from jail worked briefly as a food handler Cases among homeless or IDU to are LA County residents without clear links to San Diego or Santa Cruz Because of concern for spread among an underserved population, announced an outbreak 47

39 Hepatitis A among MSM Not surprisingly increase beginning among MSM 19 cases to date this year, 9 in all of last year Estimated 400,000 MSM in LA County Persons with HIV May have longer course of illness May see an increase in HIV viral load May have to stop HIV medications that are hepatotoxic 48

40 Vaccine distribution among the homeless Started in August Began more aggressively after outbreak declaration Community Health nurses Shelters, feeding sites and other locations in the community Go with homeless outreach workers who know the community well Offer vaccine in our free public health clinics Shared Vaccine with partners Community Based Clinics Hospitals Jails Total number of vaccines administered or distributed to partners is 26,299 49

41 Other efforts working with hospitals Worked to obtain recuperative beds for patients who are still infectious but do not need a hospital bed so they are not discharged to the street or jail Outreach to providers via HAN For homeless patients with suspected hepatitis A asked providers to notify health department even before diagnosis Facilitate interviewing Facilitate finding housing while awaiting testing Facilitate testing at the Public Health Laboratory for hospitals that send the test out and will not receive results within 24 hours 50

42 Other efforts - Sanitation Department of Public Health is doing surveys of homeless encampments to assess sanitation and the availability of handwashing stations and toilets Working with Cities to encourage building to of handwashing facilities and toilets in areas around homeless encampments Issues around security and cleaning Working with restaurant inspectors to do outreach to restaurants and area business that open their bathrooms to homeless to provide information about hepatitis A and cleaning 51

43 Other efforts: Awareness campaign Promoting awareness and vaccination through media and social media Conducting health education and promoting vaccination Palm cards, posters in bus stations 52

44 Outbreak Response Plan Initial response will focus on aggressive vaccination and education in areas with early cases to prevent a larger outbreak. 53

45 Case in the jail Efforts at providing vaccine to jail inmates Over 6400 inmates vaccinated Recent case in the jail highlights challenges Delayed diagnosis Exposures in receiving area large Need to vaccinate primary and secondary contacts over 1200 To date no additional cases 54

46 Frequently Asked Questions 1. Will I be able to get a copy of the slides after the webinar? Yes a copy will be posted on ImmunizeCA.org site 2. Will I receive a copy of the webinar recording? Yes - a copy will be posted site

47 Question and Answer Session 56

48 Please Complete Online Evaluation! 57

49 Thank you County of San Diego Health & Human Services Agency Los Angeles County Department of Public Health California Department of Public Health Immunization Branch