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Outbreak of Hepatitis A Associated  with Long Beach Restaurant

KEY MESSAGES
  • The Long Beach Department of Health and Human Services (Health Department) is investigating a hepatitis A outbreak associated with 555 East American Steakhouse in Long Beach in patients who visited the restaurant on or around December 24, 2019.
  • Seven cases of hepatitis A have now been confirmed among people who dined at the restaurant on the same date.
  • The source of the illness is still under investigation, however there does not appear to be an ongoing risk to the public.
  • Providers should consider hepatitis A in patients who present with symptoms and report eating at 555 East American Steakhouse on or around December 24, 2019. Contact the Long Beach Communicable Disease Control Program to report suspect cases at 562.570.4302.
BACKGROUND
The Long Beach Department of Health and Human Services (LBDHHS), in coordination with the California Department of Public Health (CDPH), is investigating an outbreak of hepatitis A associated with 555 East American Steakhouse in downtown Long Beach.

Seven confirmed cases of hepatitis A from three local health jurisdictions (LHJs) reported eating at 555 East American Steakhouse in downtown Long Beach on December 24, 2019. The case-patients are unknown to each other and have no other common exposures. Reported illness onset dates ranged from January 22 through February 2, 2020. The median age of patients is 55.5 years (range 37-80); 57% are male. Five (71%) patients have been hospitalized and no deaths have been reported.  
 
Given the location, date of exposure, and popularity of this particular restaurant among tourists, it is likely that there are additional cases related to this outbreak throughout the region. 
RECOMMENDATIONS FOR CLINICIANS
Providers are asked to:
  • Be alert for suspect cases of hepatitis A, and ask patients if they have dined at 555 American Steakhouse from December 1, 2019 to the present.  Clinical jaundice may be a late sign, especially in children.
  • Order HAV IgM antibody serology rather than HAV total antibody serology when working up patients for acute disease. Total HAV antibody positivity may indicate immunity due to previous infection or immunization and is not sufficient evidence of an acute infection. 
  • Avoid ordering serology for people who have no symptoms nor elevated liver function tests, but report eating at the restaurant. False positive HAV IgM test results are common when asymptomatic people are tested.  
  • Advise patients in sensitive occupations not to work with suspected or confirmed HAV infection.  Individuals employed in food service, health care, or child care should not be allowed to work in these settings for at least one week after jaundice onset or two weeks after symptom onset (if no jaundice), whichever is later. These individuals are at increased risk of spreading the infection to others via the fecal-oral route. 
  • Promptly report all suspect and confirmed cases to the Communicable Disease Control Program by faxing a Confidential Morbidity Report (CMR) or by calling 562.570.4302 during business hours and 562.500.5537 on evenings and weekends.
CLINICAL GUIDANCE
Symptoms
Hepatitis A is a vaccine preventable, communicable disease of the liver caused by the hepatitis A virus (HAV).  It is usually transmitted person-to-person through fecal-oral route or consumption of contaminated food or water.  Hepatitis A is a self-limited disease that does not result in chronic infection.  Symptoms usually occur abruptly and can include the following:
  • Fever
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting 
  • Abdominal pain
  • Dark urine
  • Diarrhea
  • Clay-colored stool
  • Joint pain
  • Jaundice
Hepatitis A symptoms usually resolve within 2 months of infection; most children less than 6 years of age do not have symptoms or have an unrecognized infection.  Antibodies produced in response to hepatitis A infection last for life and protect against reinfection. The best way to prevent hepatitis A infection is to get vaccinated.

Incubation period 
A range of 15-50 days with a mean of 28 days. 

Laboratory testing
IgM anti-HAV is present at the onset of illness. It usually disappears <4 months. IgM anti-HAV is also occasionally detectable in adults 2 weeks after receiving HAV vaccine. IgG anti-HAV is detectable shortly after the appearance of IgM and is lifelong.

Post-exposure Prophylaxis
Persons who have been exposed recently to hepatitis A virus (HAV) and who have not been vaccinated should be administered one dose of single-antigen hepatitis A vaccine or immune globulin (IG) as soon as possible, within 2 weeks after exposure. While it is too late to administer post-exposure prophylaxis (PEP) for the exposure that occurred at the restaurant on December 24, 2019, PEP may be used to prevent secondary infections in unimmunized close contacts.

The guidelines vary by age and health status:
  • Healthy persons aged ≥12 months who have been exposed to HAV within the prior 14 days and have not previously completed the 2-dose HepA vaccine series should receive a single dose of HepA vaccine as soon as possible. In addition to HepA vaccine, IG (0.1 mL/kg) may be administered to persons aged >40 years depending on the providers’ risk assessment.  For long-term immunity, the HepA vaccine series should be completed with a second dose at least 6 months after the first dose; the second dose is not necessary for PEP.
  • Persons aged ≥12 months who are immunocompromised and persons with chronic liver disease who have been exposed to HAV within the prior 14 days and have not previously completed the 2-dose Hep A vaccine series should receive both IG (0.1 mL/kg) and Hep A vaccine simultaneously in a different anatomical site as soon as possible after exposure. For long-term immunity, the Hep A vaccine series should be completed with a second dose at least 6 months after the first dose; the second dose is not necessary for PEP.
  • For infants aged <12 months and persons for whom vaccine is contraindicated (who are allergic to a vaccine component) should receive IG (0.1 mL/kg) instead of vaccine as soon as possible and within 2 weeks after exposure.
Visit Updated Dosing Instructions for Immune Globulin (Human) GamaSTAN S/D for Hepatitis A Virus Prophylaxis for additional guidance.
REPORTING
Reports of suspect hepatitis A cases can be reported to the Long Beach Health Department's Communicable Disease Control Program at 562.570.4302 during regular business hours.                              
ADDITIONAL RESOURCES
Long Beach: Hepatitis A
CDC: Hepatitis A for Clinicians
CDPH: Hepatitis A
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Communicable Disease Control Program · 2525 Grand Ave · Long Beach, CA 90815-1765 · USA

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