For US Homeless, Hepatitis A Persists

Hepatitis A continues to make headlines as health officials from several states across the country—California, Kentucky, Michigan, Utah, and Colorado—struggle to get outbreaks of the virus under control.

The severity of the issue is underscored by the fact that the Centers for Disease Control and Prevention (CDC) recently created a page on their website dedicated to tracking the different outbreaks, with a warning to other public health jurisdictions to be cognizant of any increases disease incidence. The CDC has also released interim outbreak-specific guidance on hepatitis A vaccine administration.

The guidance includes additional information on the following:

• Use of TWINRIX for pre- and post-exposure prophylaxis
• Use of pediatric vs. adult formulations of hepatitis A vaccine
• Use of one dose of hepatitis A vaccination
• Pre-vaccination serological testing

Since our last hepatitis A update, the case count in Utah has risen to 102 confirmed cases and Kentucky and Colorado case counts remain at 31 and 62 confirmed cases, respectively. As for Michigan, a restaurant worker employed at a Tim Hortons location within the state reportedly tested positive for the virus, which has led health officials to recommend restaurant patrons to receive post-exposure treatment immediately. The case count in the Michigan outbreak has reached 583—up 57 cases since our last update—and the virus has claimed 20 lives so far.

It’s California, however, that holds the title for “the largest [hepatitis A] outbreak in the United States in the past 20 years,” with homelessness being the root cause, according to a perspective piece recently published in the New England Journal of Medicine. The CDC reports that homeless individuals account for the majority of the cases involved in all the outbreaks, followed by injection and non-injection drug users. Many of the environmental factors associated with homelessness assist in the transmission of harmful infectious diseases.

Although several efforts have been made to control the outbreak in California—with a primary focus on vaccination, raising awareness, and installing portable hygiene facilities—the underlying cause of the outbreak still needs to be addressed, that is, the homelessness crisis, and the need for permanent supportive housing.

“Although the effects on health and health services outcomes are unclear, permanent supportive housing has proved highly effective at achieving its primary goal: helping chronically homeless people with disabling behavioral conditions regain and retain permanent housing,” Margot Kushel, MD, wrote in the perspective piece. In order to prevent and end homelessness, access to affordable and stable housing is needed, but this need has not received much attention from the medical community.

“Health care providers understand that solving health problems involves not only treating symptoms but also understanding and addressing root causes,” Dr. Kushel stressed. “The same approach is needed to end homelessness. Because health care providers must manage the enormous toll that homelessness takes on health, they have a role to play in bringing an end to the homelessness crisis.”

What can health care providers do to address the crisis? According to Dr. Kushel, they can do any of the following to make a difference:

• Screen for and document their patients’ homelessness or risk of becoming homeless; refer patients to available resources. Screening also increases understanding of the effect homelessness has on health.
• Learn more about the effects homelessness has on health and speak out about it; this will help the public better understand the human and monetary costs of the crisis.
• Voice support for permanent supportive housing.
• Understand the role that the affordable housing crisis has on homelessness and help shape public dialogue on the issue.

By addressing what lies at the heart of the issue, perhaps future infectious disease outbreaks can be prevented, and thus, hundreds of individuals can be spared from illness or even death.

For current case counts on all of the ongoing hepatitis A outbreaks in the United States, be sure to visit the Contagion ® Outbreak Monitor.