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CDC includes ‘homelessness’ as indication for hepatitis A vaccine

The CDC recently announced that all persons aged 1 year or older experiencing homelessness should be routinely immunized for hepatitis A, based on a review of recent data.

“Among persons experiencing homelessness, effective implementation of alternative strategies to prevent exposure to HAV, such as strict hand hygiene, is difficult because of living conditions among persons in this population,” Mona Doshani, MD, from the Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, and colleagues wrote. “Integrating routine HepA vaccination into health care services for persons experiencing homelessness can reduce the size of the at-risk population over time and thereby reduce the risk for large-scale outbreaks.”

According to Doshani and colleagues, HAV infection is associated with poor sanitation and hygiene and is transmitted by ingesting contaminated food or water or direct contact with a patient with HAV. The “congregate living conditions” of people experiencing homelessness can increase the risk for disease transmission and result in outbreaks.

“Recent outbreaks with direct HAV transmission among persons reporting homelessness signal a shift in HAV infection epidemiology in the United States,” they wrote.

During 2017, 1,521 outbreak-associated HAV cases were reported from California, Kentucky, Michigan, and Utah, with 1,073 hospitalizations and 41 deaths. Most of those infected reported homelessness or drug use. As of October 12, 2018, approximately 7,000 outbreak-associated cases have been reported from 12 states.

From February 2018 to October 2018, the Advisory Committee on Immunization Practices Hepatitis Vaccines Work Group reviewed and discussed relevant scientific evidence to support homelessness as an indication for HAV vaccine. Evidence from published studies showed that the benefits of vaccinating individuals experiencing homelessness were substantial and the costs and risks were lower compared with not vaccinating.

“Concern about loss to follow-up before HepA vaccine series completion should not be a deterrent to initiating the vaccine series in persons experiencing homelessness,” Doshani and colleagues wrote. “One dose of HepA vaccine provides personal protection and can contribute to herd immunity, although long-term protection might be suboptimal.”

The researchers noted that because of the difficulty in distinguishing the type of homelessness a person is experiencing — sheltered vs. unsheltered — any person considered “homelessness” should be vaccinated for HAV. – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.