Group Community Health Promotion 1/2 -1 page

Hepatitis A Campaign for the Homeless Population

NUR 631

Charles R. Drew University

Mervyn Dymally School of Nursing

Professor Lingad

October 29, 2020

Group 6

Jacquelyn Taylor, Sean Theus, Angel Uzoma

Janelle Vaughan, Andrea Williams, LaShon Williams

Unikka Wilson, Jenna Zommick, Jacquelyn Zommick

Introduction

Homelessness is a significant public health issue that adversely affects overall population health and well-being. According to HUD’s Annual Point-in-Time Count, approximately 567,715 people in the United States were homeless on a single night back in January 2019. In other words, seventeen out of every 10,000 people in the United States were experiencing homelessness in January 2019.

Homelessness has led to an increase in Hepatitis A outbreaks throughout the United States. Hepatitis A is characterized by jaundice, diarrhea, fatigue, and many other symptoms of acute liver infection. “Transmission of Hepatitis A virus follows the fecal-oral route through person-to-person contact or ingestion of contaminated water or food, but can be interrupted through improvements in drinking water, sanitation, hygiene, and vaccination” (Peak et al., 2019). Practicing good hygiene including frequent handwashing, especially after using the restroom and before eating has been shown to prevent the spread of HAV infection.

The homeless population are a vulnerable, at-risk population for contracting hepatitis A due to many factors. Living in substandard conditions that lack sanitation and hygiene increases their risk for HAV transmission. In addition, many homeless individuals engage sexual and drug-related behaviors that increases their risk significantly.

From November 2016-May 2018, San Diego experienced a huge outbreak of Hepatitis A cases primarily in the homeless population or people who used illicit drugs during their exposure period. At the time of the outbreak, the Advisory Committee on Immunization Practices (ACIP) recommended vaccination for people who were at a higher risk of getting Hepatitis A, such as men having sex with men, people who travel to countries with high incidences of HAV, people who use illicit drugs, and people with chronic liver disease. Homelessness was not recognized as an independent risk factor for HAV infection. On October 24th, 2018, the ACIP voted to recommend homeless people to be added to the list of Hepatitis A vaccine indications.

Hepatitis A virus (HAV) is a vaccine-preventable liver infection. The Hepatitis A vaccine was introduced in 1995 and “was initially recommended for international travelers, men who what sex with men, those who use and inject illicit drugs, and children living in high risk areas of exposure” (Duncan, 2018). Since Hepatitis A vaccine was not part of the routine childhood immunizations in the United States until 2006, many adults (including the homeless) remain susceptible to contracting HAV.

Literature Review

Peak et al. (2019) researched whether homelessness is an independent risk factor and increased the severity of the San Diego outbreak including patients that had one or more other known ACIP indications other than homelessness. In addition, Peak et al. (2019) tested the association between homelessness and Hepatitis A virus using a test-negative study design comparing patients with laboratory-confirmed hepatitis A with control subjects who tested negative for HAV infection.

The patients were determined confirmed cases as “isolation of HAV genotype IB in a resident of San Diego County with acute onset of hepatitis A symptoms during 1 November 2016–23 May 2018” (Peak et al., 2019). Some of the patients were unable to do the actual testing; however, they were defined as probable cases due to their symptoms and the control groups were the false positives.

To determine the severity of Hepatitis A in association with homeless population, cases that had hospitalizations and deaths in association with Hepatitis A were compared in relationship to homeless cases.

Among 589 outbreak-associated cases reported, 291 (49%) occurred among people experiencing homelessness (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. (Peak et al., 2019)

There are limitations in this research study such as the possibility that certain cases were misclassified as illicit drug use or homelessness. Also, the patients that stated they were vaccinated and were cross-referenced with the San Diego Immunization Registry were accounted for, but the patients that did not get their vaccinations in San Diego were not accounted.

It is also important to note that there is a possibility that “the prevalence of comorbidities may be underestimated by using coinfection status with Hepatitis B virus (HBV) or Hepatitis C virus (HCV) as an incomplete surrogate for chronic liver disease caused by risk factors such as chronic alcoholism” (Peak et al., 2019).

The researchers of the article do not necessarily represent the opinions from the Centers of Disease Control (CDC), and they do not state any potential conflicts of interest. However, the International Committee of Medical Journal Editors (ICMJE) Form for Disclosure of Potential Conflicts of Interest was submitted, and the CDC deemed the research as “non-research” despite the fact that the patients’ information was collected confidentially, and human subjects’ protections were kept.

Snyder et al. (2019) conducted a study based on data obtained from firsthand experiences of public health practitioners that were affected by the Hepatitis A epidemic that began in March 2017. The purpose of this study was to identify and analyze the common challenges that these different communities faced when planning for and/or responding to an outbreak of Hepatitis A. Furthermore, this study helped identify operational lessons in order to better prepare for similar future public health emergencies.

From January to October 2018, the authors conducted semi-structured, qualitative interviews via teleconference with health officials from nine different city and/or county public health departments throughout the United States. In order to make the study more credible, they used purposeful random sampling of senior public health officials that were directly engaged in responding to or preparing for a Hepatitis A outbreak in their community.

According to the Robert Wood Johnson Foundation Qualitative Research Guidelines Project, purposeful random sampling is a process of identifying a population of interest and developing a systematic way of selecting cases that is not based on advanced knowledge of how the outcomes would appear. The purpose is to increase credibility not to foster representativeness (RWJF - Qualitative Research Guidelines Project | random purposeful | Purposeful Random Sampling, 2020).

Preventing the spread of HAV during an outbreak poses many problems for public health care providers. Many of the outbreaks in the United States were among individuals that were homeless or used illicit drugs. Most of the homeless population do not have adequate access to water, sanitation, and hygiene which increases their risk of contracting Hepatitis A. Some communities have solved this problem by setting up portable toilets and handwashing stations in homeless encampments. However, most communities lack the financial resources to make this possible since it requires frequent cleaning and maintenance.

People experiencing homelessness may not have access to medical care or they may choose not to see a medical provider when they are sick. In addition, homeless individuals may move around a lot and may even reside at multiple locations. These factors make it extremely difficult to “track” homeless people, which hinders controlling an outbreak or preventing a potential epidemic.

There are limitations to this study since the majority of those interviewed were from major urban and suburban areas. The interviewees largely represented major urban and suburban areas, and the characteristics of their public health, health care, and response agencies and organizations may differ from those of other jurisdictions, particularly rural or remote jurisdictions (Snyder et al., 2019). In addition, not being able to accurately track homeless individuals hinders the validity of this study.

A journal article from the American Journal of Infection Control (AJIC) written by Lisa Duncan (2018) discussed how a federally qualified health center, Family Health Centers of San Diego (FHCSD), responded to a Hepatitis A outbreak that occurred in 2017. Through the efforts of FHCSD and its community partners, they were able “to educate and vaccinate 7,521 adults in 7 months” (Duncan, 2018, p. 1057).

On March 10, 2017, the California Health Alert Network (CAHAN) released a health alert to all San Diego CAHAN participants about an HAV outbreak. The outbreak disproportionally affected homeless individuals (53%) and illicit drug users (68%). The alert advised consideration of HAV infection, the immediate reporting of all confirmed and suspect cases, post-exposure prophylaxis for close contacts of confirmed cases, and the vaccination of unvaccinated homeless individuals and illicit drug users. (Duncan, 2018, p. 1057)

According to Duncan (2018), “the 2017 San Diego outbreak had no ties to a particular food or to places where food is served. It was spread through close contact with infected individuals in multiple locations in San Diego” (p. 1058).

The importance of community health preparedness in response to an outbreak cannot be understated. Public health departments and community organizations must respond and act quickly when faced with a public health crisis. Financial resources are not enough: a health care organization must be an effective community partner as well. To direct and coordinate their efforts during an outbreak, local public health departments need to develop close relationships with executive leaders and other organizations within their community. Forming a network of service providers for food, clothing, sanitation, and transitional housing is needed for vulnerable, at-risk populations.

“On September 1, 2017, the San Diego County public health officer declared a local public health emergency due to the HAV outbreak” (Duncan, 2018, p. 1058). The news coverage that followed created a dramatic increase in public awareness that resulted in San Diego County providing FHCSD with thousands of additional doses of HAV vaccine to administer.

The journal article by Duncan (2018) was very informative and demonstrated how one community clinic in San Diego Country was able to make a difference. However, this journal is limited in that there was no definitive distinction in the methodology that was used. In addition, there is no scientific evidence mentioned in this article about how the author was able to conclude that the outbreak in San Diego was not related to a particular food or to a place where food was served. Furthermore, the author seems to have a personal bias towards the homeless population; the author leads the reader to believe that the 2017 San Diego Hepatitis A outbreak was caused by the homeless population.

Conceptual Framework

Project Plan

Data Collection

Surveillance for viral hepatitis is needed to direct and evaluate prevention and control activities. CDC recommends that all states and territories conduct surveillance for acute viral hepatitis, including Hepatitis A, B, C, and non-ABC hepatitis. In addition, states and territories should consider establishing computerized databases of persons who test positive for Hepatitis B surface antigen (HBsAg) or antibody to Hepatitis C virus (anti-HCV) to facilitate the notification, counseling and management of persons with chronic Hepatitis B virus (HBV) or Hepatitis C virus (HCV) infections. The purpose of this document is to 1) provide guidance to clinicians, state and local health departments, and other health agencies regarding case ascertainment, reporting, investigation, and follow-up of persons with acute viral hepatitis; and 2) provide a framework for the development of systems for identifying and following up persons who may have chronic HBV or HCV infections. These guidelines describe the essential elements and best practices for conducting surveillance for viral hepatitis and were developed based on consultation with representatives from state and local health departments who met in Atlanta in January 1999. (CDC, 2015)

Information on cases of viral hepatitis reported nationally has been maintained at CDC in two surveillance systems. Information collected by the National Notifiable Disease Surveillance System (NNDSS) includes diagnosis, event dates (e.g., illness onset), and basic demographic data (e.g., state, county, age, race, ethnicity). Additional information collected by the Viral Hepatitis Surveillance Program (VHSP) includes clinical features, serologic test results, and risk factors for infection. This information is needed to confirm the diagnosis, determine a source of infection, and identify others at risk of infection that would benefit from preventive intervention. (CDC, 2015)

As an element of the planned National Electronic Data Surveillance Systems (NEDSS), substantial changes in the structure and function of NETSS are expected. The development of a person-based system that collects and stores public health information according to widely used, standardized definitions and formats and that uses unique identifiers to link information from different disease reports and other health data sources will significantly enhance the capacity to conduct surveillance for viral hepatitis.

To date, nationwide surveillance efforts for viral hepatitis have focused on cases of newly acquired clinically apparent disease, and historically, most cases of acute viral hepatitis have been identified based on a clinician’s report of a patient with an illness compatible with acute hepatitis. With the implementation of laboratory reporting requirements in many states, laboratory-based reporting of serologic markers for viral hepatitis is an increasingly common route by which suspected cases are identified to state and local health departments. Although laboratory-based reporting can increase the completeness and timeliness of case identification, it also identifies asymptomatic individuals with newly acquired infections, individuals with chronic infection, and individuals for whom there is insufficient information to verify the diagnosis based on laboratory testing alone. (CDC,2015)

Because no chronic infection develops after Hepatitis A, reported cases of acute disease provide a valid measure of ongoing transmission and the overall burden of disease due to HAV. Investigation of reported cases to determine their characteristics and source for infection provides the best information for monitoring trends in transmission patterns. Monitoring changes in overall and age-specific disease rates is the only means available to assess the effectiveness of Hepatitis A vaccination programs. (CDC,2015)

Demographic and risk factor information collected through surveillance can be used to direct ongoing prevention efforts by identifying new target groups or areas in which vaccination programs should be initiated. Missed opportunities for vaccination can be assessed by investigating cases occurring in persons belonging to a group for which vaccination is recommended to determine where they have received health care and other recommended vaccinations. Intensive investigation of cases occurring in persons who received Hepatitis A vaccine may be used to evaluate the frequency and causes of vaccine failure. (CDC,2015)

Conclusion

References

Guidelines for Viral Hepatitis Surveillance and Case Management | Statistics & Surveillance | Division of Viral Hepatitis | CDC. (2015, May). Https://Www.Cdc.Gov/Hepatitis/Statistics/Surveillanceguidelines.Htm. https://www.cdc.gov/hepatitis/statistics/surveillanceguidelines.htm

Duncan, L. (2018). A community clinic’s response to a hepatitis A outbreak. American Journal of Infection Control, 46(9), 1057–1059. https://doi.org/10.1016/j.ajic.2018.02.0077

Peak, C. M., Stous, S. S., Healy, J. M., Hofmeister, M. G., Lin, Y., Ramachandran, S., Foster, M. A., Kao, A., & McDonald, E. C. (2019). Homelessness and Hepatitis A—San Diego County, 2016–2018. Clinical Infectious Diseases, 71(1), 14–21. https://doi.org/10.1093/cid/ciz788

RWJF - Qualitative Research Guidelines Project | random purposeful | Purposeful Random Sampling. (2020). Qualres.Org. http://www.qualres.org/HomeRand-3812.html

Snyder, M. R., McGinty, M. D., Shearer, M. P., Meyer, D., Hurtado, C., & Nuzzo, J. B. (2019). Outbreaks of Hepatitis A in US Communities, 2017–2018: Firsthand Experiences and Operational Lessons from Public Health Responses. American Journal of Public Health, 109(S4), S297–S302. https://doi.org/10.2105/ajph.2019.305139

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