At a time of year when health plans typically focus on flu shots, insurers in California must confront the spread of another potentially deadly infectious disease: hepatitis A. Insurers are keeping a close eye on the outbreak of the highly contagious liver disease now being tracked in Los Angeles County as well as in the San Diego and Santa Cruz areas.

Public health officials describe it as the largest outbreak of hepatitis A in California in decades. Hepatitis A is considered to be a vaccine-preventable illness and, despite sporadic outbreaks, its rates have fallen more than 90% following the vaccine’s launch in 1996, CDC says, along with a corresponding drop in medical expenditures for hospitalizations and ambulatory care visits.

Local health departments are responsible for planning and implementing disease control efforts within their jurisdictions and, since this is a multi-jurisdictional outbreak, the California Department of Public Health (CDPH) is coordinating efforts at the state level, the department says. Covered California, the state’s Affordable Care Act (ACA) exchange, has notified its plans of the outbreak and steps to take to prevent additional cases of hepatitis A. And CDPH has provided guidance to clinicians broadly throughout the state irrespective of health plan.

San Diego, which declared a public health emergency on Sept. 1, reported 461 cases, 17 deaths and 315 hospitalizations related to hepatitis A as of Sept. 26. Los Angeles County announced a local outbreak on Sept. 19, citing 10 confirmed cases of hepatitis A at that time among high-risk individuals. Further updates were unavailable at HPW‘s press time.

Among its containment strategies, San Diego County is washing its buses and downtown streets with bleach. And as of Sept. 25, public health workers had given about 28,000 hepatitis A vaccinations, a number which is growing daily, spokesperson Craig Sturak of the San Diego County Health and Human Services Agency tells AIS Health.

“We’ve got a pretty coordinated effort to get vaccinations out there, particularly to at-risk populations” of homeless individuals and intravenous drug users, along with social workers and others who provide services to them, he says.

In San Diego County, “there hasn’t been a single source” of contamination, Sturak notes. “This is being passed person to person, not from a single food or drug source — so it’s required us to think outside of the box in terms of response.”

That includes having public health nurses head into San Diego’s homeless communities and continuing efforts to ensure that first responders — from hospital emergency department staff to police, fire fighters and social workers engaging with the homeless — are properly immunized. It also includes significant outreach to the health care community, he says.

Kaiser Uses Internal, External Strategies

Health care organizations say they are responding with significant efforts of their own.

“At Kaiser Permanente, we are actively monitoring and responding to the current hepatitis A outbreak that began in the San Diego area and has now spread to other counties including Los Angeles. Efforts are being taken both internally and externally to address this outbreak,” spokesperson Venusse Navid said Sept. 21.

Kaiser Permanente, in areas affected by the outbreak, is working with community leaders and departments of health and human services to address local needs, Navid said, and is communicating internally on the importance of following all proper infection prevention protocols.

“The most effective way to combat hepatitis A is for at-risk people to get vaccinated. At-risk populations include homeless and those working with them, intravenous drug users, food handlers, janitorial workers and first responders,” Navid says. “Also, thorough hand hygiene, such as handwashing with soap and water for 20 seconds, is effective in helping to prevent hepatitis A.”

Asked for further information, Navid said Sept. 22 the hepatitis A outbreak in California is “a fluid situation at this juncture and should we have additional detail to share, we will [do so].”

According to the Los Angeles County Department of Public Health, its outreach teams and clinics are offering free hepatitis A vaccine to homeless individuals, active drug users and those who provide services and support to them. The department said it continues its surveillance for hepatitis A cases and is working closely with health care providers and organizations serving the homeless, providing education to the homeless and those who work with them, and working with other organizations that provide services for the homeless.

“L.A. Care Health Plan is concerned about the Hepatitis A outbreak, is watching the situation closely and is developing an outreach strategy on this issue,” spokesperson Amy Gurango told AIS Health on Sept. 21. “We think this is an appropriate public health response,” she said of Los Angeles County health officials’ ongoing efforts.

In a June 2017 “Stakeholder Communication Update,” the California Dept. of Health Care Services (DHCS) touted its receipt of an award in May from the National Adult and Influenza Immunization Summit “for expanding Medicaid coverage to include all routine adult vaccines as a pharmacy benefit, making California one of only a few states that do so.”

Previously, Medi-Cal covered only a few vaccines for adults through the pharmacy benefit, DHCS says.

Then in 2016 the department issued a letter to providers and Medi-Cal managed care plans requiring them to cover, as part of the pharmacy benefit, adult vaccines in the routine immunization schedules published by the CDC’s Advisory Committee on Immunization Practices.Hepatitis A and B, influenza and pneumonia are among 15-plus vaccines covered; as a pharmacy benefit, pharmacists are able to follow protocols to administer the vaccines themselves.

Medi-Cal Applies New Vaccination Policy

The state’s public health department tells AIS Health that Medi-Cal’s new vaccination policy is helping to manage the current outbreak.

“Medi-Cal members covered in both the fee-for-service program and managed care plans may be vaccinated in network pharmacies. CDPH has disseminated this information broadly to clinicians, local health departments, and others serving at-risk populations. Since not all clinics stock all adult vaccines, this new pharmacy benefit should help more Medi-Cal members get vaccinated to address the hepatitis A outbreak.”

“CDPH continues to work with [DHCS] to notify all Medi-Cal providers and Medi-Cal managed care plans of the hepatitis A outbreak and Medi-Cal coverage of immunization.”

Find updated San Diego information at