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. 2020 Jun 24;71(1):14-21.
doi: 10.1093/cid/ciz788.

Homelessness and Hepatitis A-San Diego County, 2016-2018

Corey M Peak  1   2   3 , Sarah S Stous  2 , Jessica M Healy  4 , Megan G Hofmeister  5 , Yulin Lin  5 , Sumathi Ramachandran  5 , Monique A Foster  5 , Annie Kao  2 , Eric C McDonald  2
Affiliations

Homelessness and Hepatitis A-San Diego County, 2016-2018

Corey M Peak et al. Clin Infect Dis. .

Abstract

Background: Hepatitis A is a vaccine-preventable viral disease transmitted by the fecal-oral route. During 2016-2018, the County of San Diego investigated an outbreak of hepatitis A infections primarily among people experiencing homelessness (PEH) to identify risk factors and support control measures. At the time of the outbreak, homelessness was not recognized as an independent risk factor for the disease.

Methods: We tested the association between homelessness and infection with hepatitis A virus (HAV) using a test-negative study design comparing patients with laboratory-confirmed hepatitis A with control subjects who tested negative for HAV infection. We assessed risk factors for severe hepatitis A disease outcomes, including hospitalization and death, using multivariable logistic regression. We measured the frequency of indications for hepatitis A vaccination according to Advisory Committee on Immunization Practices (ACIP) guidelines.

Results: Among 589 outbreak-associated cases reported, 291 (49%) occurred among PEH. Compared with those who were not homeless, PEH had 3.3 (95% confidence interval [CI], 1.5-7.9) times higher odds of HAV infection, 2.5 (95% CI, 1.7-3.9) times higher odds of hospitalization, and 3.9 (95% CI, 1.1-16.9) times higher odds of death associated with hepatitis A. Among PEH, 212 (73%) patients recorded other ACIP indications for hepatitis A vaccination.

Conclusions: PEH were at higher risk of infection with HAV and of severe hepatitis A disease outcomes compared with those not experiencing homelessness. Approximately one-fourth of PEH had no other ACIP indication for hepatitis A vaccination. These findings support the recent ACIP recommendation to add homelessness as an indication for hepatitis A vaccination.

Keywords: hepatitis A; hepatitis A vaccine; homelessness.

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Conflict of interest statement

Potential conflicts of interest.

The authors report no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Risk of hospitalization (A, B) and death (C, D) among confirmed and probable cases by homelessness and age quintile (ie, 0 to <33, 33 to <39, 39 to <55, and ≥55 years).
See this image and copyright information in PMC

References

    1. Centers for Disease Control and Prevention. Hepatitis A. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Washington, DC: Public Health Foundation, 2015.
    1. County of San Diego Health and Human Services Agency. San Diego County Annual Communicable Disease Report. 2016.
    1. County of San Diego Health and Human Services Agency. Hepatitis A virus outbreak associated with homelessness, drug use in San Diego County. 2017; Available at: https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/cahan/c.... Accessed 21 August 2019.
    1. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep 2006; 55:1–23. - PubMed
    1. World Health Organization. WHO position paper on hepatitis A vaccines—June 2012. Wkly Epidemiol Rec 2012; 87:261–76. Available at: https://www.who.int/wer/2012/wer8728_29/en/. Accessed 21 August 2019.

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