The Bureau of Epidemiology is available 24 hours a day, 7 days a week for consultation at our main number (SunCom 205-4401 or 850/245-4401) PLEASE NOTE: Consultation after 5 p.m. & on weekends is intended for emergencies.

The Broward County Health Department (BCHD) is investigating an apparent increase in the number of cases of hepatitis A virus (HAV) infection among Broward County residents. The preliminary investigation indicates that the HAV outbreak is occurring primarily among Fort Lauderdale residents who are either bisexual or men who have sex with men (MSM).

The BCHD Hepatitis Program investigated 20 cases of HAV infection in late May and early June. This total was approximately 3 times higher than the expected level of HAV cases based on the 1998-2000 historical average of 5.9 cases per month.

The distribution of HAV cases by gender was 16 males (80%), 4 females (20%). Only a few cases could be attributed to recent foreign travel or consumption of raw fish or shellfish. The main risk factors for HAV infection appeared to be MSM or bisexual activity with multiple sex partners. Several cases with dates of onset in May were either bisexual or MSM partners of earlier cases. Half of the cases resided in 3 adjacent zip codes in Fort Lauderdale.

On June 14 the BCHD Hepatitis Program issued an outbreak alert by email and fax to members of the Broward-Palm Beach Chapter of the Association of Practitioners of Infection Control (APIC). A brief summary of the preliminary investigation was included along with requests for APIC members to assist with the search for additional cases and promptly report any such cases to the BCHD.

APIC members were asked to notify physicians to call the BCHD Communicable Disease Surveillance staff immediately at (954) 847-3567 whenever they confirmed or suspected any new case of HAV. A confidential fax number was included with a request to fax confirmatory laboratory results and liver function studies to (954) 467-4870.

On June 15 the BCHD HIV/AIDS Surveillance staff forwarded the APIC alert to physicians whose practices include high proportions of gay clients.

In ensuing days APIC members and local physicians reported 3 additional confirmed or suspected HAV cases among Broward residents. This increased the outbreak working total to 23 cases.

On June 18 a conference call was held with Dr. MaryJo Trepka and Hepatitis Program staff at the Miami-Dade CHD. Reporting information was exchanged about Broward cases that had named Miami-Dade residents as sex contacts and vice versa. Dr. Dolly Katz, regional epidemiologist, is also examining the data.

Immunization of susceptible persons at high risk and prompt investigation of newly diagnosed and suspected cases are key components of an effective HAV control program. Two large barriers to HAV prevention and control have been identified in this outbreak.

The main barrier to prevention has been a consistent lack of timely reporting of cases to the BCHD Hepatitis Program. Most of the case investigations were initiated after the BCHD received laboratory reports of positive HAV test results. Most of the cases that occurred in May were not reported to the BCHD until June. Case interviews, identification of susceptible contacts, and recognition of the outbreak were delayed substantially because medical providers did not report HAV cases as required.

Immune serum globulin (ISG) may be offered to contacts of cases if the contacts are identified within the 14-day window period during which ISG may be protective. The BCHD missed several opportunities for prevention during this outbreak because the medical provider failed to report cases promptly. These cases were not investigated in a timely manner, thus thwarting identification of contacts and administration of ISG.

Another major barrier to prevention and control of this outbreak is the lack of high HAV immunity levels among Broward bisexual men and MSM. Major urban areas such as Seattle, WA, and Denver, CO, have conducted successful immunization campaigns in the gay community and achieved high protective immunity levels against both HAV and hepatitis B virus (HBV) infection. Broward County needs to conduct a similar campaign in the gay community to prevent future outbreaks of both HAV and HBV.

The following prevention and control measures are in effect:

• Hepatitis Program staff continue to interview cases, elicit contacts, and administer ISG prophylaxis if indicated.
• Collaboration with community partners continues in the search for additional cases.
• Hepatitis screening and immunization of susceptible persons continues in the BCHD Hepatitis Clinic.
• The Gay & Lesbian Center has been asked to provide HAV information in community newspapers and encourage readers to get vaccinated against both HAV & HBV.
• The BCHD AIDS Program staff has placed posters in the rest rooms of local gay bars & clubs to promote HAV and HBV immunization.
• Staff members from the BCHD AIDS, Hepatitis and STD Programs plan to attend the Stonewall Street Festival and Parade on June 24. The Pride of Greater Fort Lauderdale organization sponsors this annual event for the gay and lesbian community. Hepatitis Program staff will distribute hepatitis prevention brochures, encourage HAV and HBV vaccination, and answer questions about the referral process for testing and immunization in the Hepatitis Clinic.