CDC committee recommends routine hepatitis A vaccination in homeless

Issue: November 2018

The CDC’s Advisory Committee on Immunization Practices voted unanimously to add homelessness as an indication for routine inactivated 2-dose hepatitis A virus vaccination.

The vote came amid an ongoing multistate outbreak of HAV during which 10 states have reported more than 6,500 infections, 3,800 hospitalizations and 70 deaths associated with person-to-person transmission.

A large percentage of cases during the outbreak have occurred among the homeless, including 40% of cases in an outbreak in San Diego and more than 10% of cases in outbreaks in Kentucky, Michigan, Tennessee and West Virginia. It is the first reported large outbreak of HAV among homeless persons in the United States.

The ACIP viral hepatitis working group that made the recommendation said it would “allow homeless to be vaccinated using the services and facilities that already provide established health care for the homeless population.” The group said the recommendation makes it more likely that HAV vaccination will be considered by these providers.

“The benefit that we achieve by vaccinating homeless individuals is significant and the cost and risk of vaccinating the homeless is much lower vs. not vaccinating these individuals,” said Mona Doshani, MD, MPH, from the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

According to the working group, an unpublished analysis of HAV cases reported between November 2016 to May 2018 in San Diego showed that homelessness was independently associated with two to three times higher odds of infection and two to four times higher odds of severe outcomes from HAV infection, specifically hospitalization and death. The study also showed that more than 25% of homeless patients did not have an existing recommended indication for HAV vaccination.

“The ACIP’s vote was unanimous, and I think that expressed the opinion of everyone in the audience, myself included, because the homeless/HAV problem is one that is now affecting a number of sites across the United States, including my hometown of Nashville,” Infectious Disease News Editorial Board member William Schaffner, MD, professor of preventive medicine at Vanderbilt University and medical director for the National Foundation for Infectious Diseases, said in an interview.

“Although health departments have been extending vaccines to the homeless population in response to the outbreak, this makes it possible for communities all across the country to get ahead of the curve and do this in a prospective fashion in order to prevent these outbreaks in the future.”

After 100 days without a case, the San Diego Health and Human Services Agency recently announced the end of the county’s HAV outbreak, which resulted in 529 cases and 20 deaths. The county has been vaccinating since March 2017, giving out more than 203,850 HAV vaccines.

Amy Denhart, director of the San Diego branch of Funders Together to End Homelessness, a national network of grant makers, called the ACIP recommendation “a great thing.”

“We had a really bad HAV outbreak here in San Diego, and it hit people who are homeless especially hard,” Denhart told Infectious Disease News. “Another reason is because it is a national issue. While San Diego had this problem, we saw other communities — including Michigan — where outbreaks of HAV hit people experiencing homelessness. Because that community is so vulnerable to HAV, we applaud the CDC for making this recommendation at the national level so that doctors are more inclined to give these vaccinations to people who are experiencing homelessness.”

Denhart explained that during the HAV crisis in San Diego, people with HAV were being treated in hospitals. Then, as a preventive measure, the county department of health began sending people into the community to give vaccinations on the street, in emergency shelters and wherever they could find homeless persons.

“Because there were not CDC recommendations prior to this, we were reacting to a problem,” she said. “If vaccination is part of a regular routine that doctors and nurses are recommending, then you are going to get homeless people coming through the system. They may go to the ED for something, they may come to a health center for something, they may go into an emergency shelter. If they are coming through the health system and the CDC recommendation is to advise them to have a vaccine for HAV, then I think it is going to be that much better, because you are seeing more and more people getting these vaccines.” – by Bruce Thiel and Gerard Gallagher

Disclosures: Denhart, Doshani, Schaffner and the voting ACIP members report no relevant financial disclosures.