CA, WY (USA) - Hepatitis A outbreaks

February 10, 2018
State Health Agencies


Since early 2017, the San Diego and Santa Cruz County Health Departments (California) have been investigating local hepatitis A outbreaks among individuals who are homeless or use illicit drugs. Unfortunately, disease levels in Monterey County have now reached outbreak levels.  Since October 2017, hepatitis A has been diagnosed in 9 individuals with a history of homeless in Monterey County.  These individuals did not travel outside of Monterey County so are assumed to have become ill due to transmission within the homeless and illegal drug use communities in Monterey County.

Monterey County Health Department has been working with medical providers, businesses, and homeless service providers to educate individuals about hepatitis A and how to prevent transmission, vaccinate homeless individuals and illicit drug users, and promote disinfection of areas frequented by these populations.  Monterey County’s Health Officer, Dr. Edward Moreno, states, “Despite our efforts, hepatitis A continues to spread among the at-risk population.  To stop the outbreak, we must as a community collectively increase our efforts to end transmission of the hepatitis A virus.”  The Health Department recommends 4 basic strategies:

  1. Vaccination.The Monterey County Health Department recommends that all providers serving the homeless, injection drug users, incarcerated individuals, international travelers, and men who have sex with men actively seek opportunities to vaccinate their patients in these high-risk groups.  Individuals who work closely with homeless people and illicit drug users on a frequent and ongoing basis, such as those who work or volunteer at homeless service agencies and syringe exchange programs, as well as health care workers who provide ongoing direct medical care to these populations, should also consider vaccination against hepatitis A at this time.
  2. Education.Health care providers, businesses, and community service providers should inform their at-risk clients and patients about the spread of hepatitis A in Monterey County and how they can protect themselves.Easy-to-read handouts in English and Spanish about hepatitis A are available for download at
  3. Increased Hand Hygiene.Everyone can play a role in addressing this public health issue by stressing the importance of hand-washing with soap and warm water after using the bathroom and before preparing, serving, or eating food. Hand sanitizers do not replace the need for hand washing.
  4. Disinfection.Businesses with public restrooms should increase the frequency of cleaning AND disinfecting bathroom surfaces. For heavily used restrooms, clean and then disinfect multiple times per day. Use a chlorine-based disinfectant (bleach) with a ratio of 1 and 2/3 cup of bleach to one gallon of water. Remind employees of the importance of wearing disposable gloves and hand-washing with soap and warm water after cleaning restrooms. Additional guidance is available on the Health Department’s website at


The Wyoming Department of Health (WDH) and the Casper-Natrona County Health Department continue to investigate a growing Natrona County hepatitis A outbreak that began in October.

Since October, 14 cases have been confirmed among Natrona County residents, which is a significant increase over the usual total for Wyoming. Previously, the long-term average statewide was two cases annually with the last reported local Hepatitis A infection in 2012.

“While some of the Natrona County cases did not have a clear hepatitis A exposure risk, recent cases have been concentrated among current injection drug users,” said Clay Van Houten, Infectious Disease Epidemiology Program manager with WDH.

Infection with hepatitis A typically results in symptoms in older children and adults. Symptoms usually occur abruptly and include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored stools, joint pain and jaundice.

There can be a significant delay between when someone who is exposed to the virus and when they show symptoms. “People recently exposed to hepatitis A who have not been vaccinated should receive a vaccine as soon as possible,” Van Houten said.

Specific risk factors for hepatitis A include:

  • Persons with direct contact with a person who has hepatitis A
  • Men who have sex with men
  • Users of injection and non-injection drugs
  • Travelers to countries with high rates of hepatitis A infectionHepatitis A can cause infection in the liver. The virus is primarily spread person-to-person through oral contact with contaminated items such as swallowing food or drink tainted with a tiny amount infected feces.

Van Houten said the best way to prevent hepatitis A is through vaccination. Handwashing, especially after using the bathroom, changing diapers, and before preparing or eating food, plays an important role in preventing the spread of the virus.

Vaccination to prevent hepatitis A is routinely recommended. Children aged at least 12 months and less than 24 months should receive two doses of the vaccine separated by at least 6 months and no less than 18 months. The vaccine series is also recommended for people aged 2 years or older who have not already received it. The Casper-Natrona County Health Department offers the hepatitis A series vaccine; some people may qualify for free or discounted vaccine.

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