Health Officials Puzzled at Rise in Hepatitis A

A sharp rise in hepatitis A cases in Los Angeles County that might have its cause on skid row is worrying county health officials, who say the outbreak is still a mystery that needs further investigation.

The number of reported hepatitis A cases increased nearly fourfold last month, compared with October 2004, according to estimates from the county Department of Health Services. That upsurge is troublesome, officials said, because hepatitis A cases had declined in the last six years.

“It is something we are looking carefully at,” said Dr. Jonathan Fielding, the county’s public health director.

The virus that causes hepatitis A, a liver disease, is spread through fecal and oral contact, usually when carriers don’t wash their hands; through contaminated food or water; or through sexual contact. It is more easily spread in areas where sanitary conditions are poor.

At first, Fielding said, the outbreak appeared to be focused among the area’s homeless population.

Subsequent reports have confirmed that it was more widespread, though Dr. Laurene Mascola, director of the county’s acute communicable disease control unit, said the outbreak was “centralized in two or three areas around downtown.”

One problem has been getting health professionals into skid row and finding patients amid the highly transient population. The county Board of Supervisors approved a motion by Supervisor Don Knabe that called on a number of county departments to make a big push on skid row.

John King, president and chief executive of the Weingart Center, said workers there had noted an increase of hepatitis A on the streets and had seen county health officials around skid row, trying to determine a source.

King said they were paying particular attention to places where people might have eaten, including church handouts, food trucks and other sources of food in the area.

The county had seen a long downward trend in hepatitis A cases since 1999, when health officials began recommending that parents vaccinate their children against the disease.

But this outbreak raises questions for healthcare workers.

Mascola said officials began to see a slight increase of suspected cases in August, and in September, they identified a cluster of cases among the homeless population.

But the biggest jump occurred last month, when 115 suspected cases were reported -- dwarfing the 31 cases reported the previous October.

Officials are working to confirm the reported cases and are conducting follow-up interviews with a sampling of the infected patients, Fielding said.

“We’re looking for patterns,” he said. “In the past, [outbreaks were] sometimes traced to foods or eating at a particular place or issues of water contamination. We really don’t know.”

Their efforts are hampered in part by the disease’s two- to eight-week incubation period, with an average of 28 to 30 days between the time of transmission and the onset of symptoms.

“We could be seeing the height of the outbreak,” Fielding said. Or, he added, the numbers could continue to climb.

About 100 people die from hepatitis A each year in the United States. Symptoms can occur abruptly and may include fever, fatigue, loss of appetite, nausea, abdominal discomfort, dark urine and jaundice.

In most cases, rest is the only cure, and doctors can do little but order blood tests to measure the progress of the infection. On rare occasions, a patient needs a liver transplant.

Most people recover within three months, and the disease confers lifetime immunity.

Celia Woodfill, an epidemiologist in the state Department of Health Services’ immunization branch, said hepatitis A levels are at “an all-time low across the state.” She said no other California counties had reported an uptick in suspected or confirmed hepatitis A cases.

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Times staff writer Charles Ornstein contributed to this report.