Two Confirmed Cases of Hepatitis A Among Persons Experiencing Homelessness in Boston

On November 17 and 20, BPHC was notified of two positive cases among unsheltered residents. Both have been connected to health care. Neither have required hospitalization.  

Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus (HAV). It ranges in severity from mild infection that lasts a few weeks to severe disease that lasts several months. HAV is primarily spread person-to-person through the fecal-oral route and contact with a fecal-contaminated environment. Populations at particular risk include individuals experiencing homelessness and people with injection drug use. Effective prevention and response measures include early identification of cases, vaccination, enhanced sanitation processes and education of vulnerable populations.   

Recommendations for Providers:  

Reporting  

• Regulations require healthcare providers and institutions in Boston to report all cases of hepatitis A virus (HAV) infection, hepatitis B virus (HBV) infection or meningococcal meningitis diagnosed in Boston residents to the Boston Public Health Commission (Phone: 617-534-5611, 24/7 coverage.  For assistance identifying close contacts, please contact BPHC.) 

• Reporting forms for Boston healthcare providers and for laboratories are available at: https://www.boston.gov/government/cabinets/boston-public-health-commission/infectious-diseases/disease-reporting  
• Cases residing outside Boston should be reported to the local board of health where the patient lives or to MDPH (617-983-6800, available 24/7). 

 Testing  

• Test all individuals demonstrating symptoms of hepatitis A, especially those who are unsheltered or use drugs. Common symptoms of hepatitis A include abdominal pain, jaundice, loss of appetite, fever, diarrhea, nausea, and exhaustion.   

Vaccination and Referral to Treatment:

We suggest that vaccination efforts focus on the following: 

• Vaccination of all persons at high risk including persons experiencing homelessness, who use injection or non-injection drugs, who have chronic liver disease (including chronic hepatitis C infection or chronic hepatitis B infection), and men who have sex with men. Vaccine options include single antigen hepatitis A vaccine (HAVRIX® or VAQTA®) and the combination hepatitis A and B vaccine (Twinrix®). Please keep in mind that Twinrix requires 3 doses for maximum efficacy and that it should not be used for postexposure prophylaxis. 
• Offer vaccines at point of care including Emergency Department or Urgent Care encounters, inpatient admissions, observation stays, and outpatient clinic visits. If possible, vaccination information should be captured within the facility’s electronic medical record to assist with monitoring of vaccine coverage.  
• Targeted street-based workers and mobile van units serving these high-risk populations are encouraged to provide HAV and other vaccines to unsheltered individuals, persons living in encampments or otherwise not utilizing services within the shelters. 
• For clients in Boston, connect clients to a BHCHP clinic site. For a list of BHCHP clinics, go to: https://www.bhchp.org/patient-services/primary-care  
• Refer clients with SUD to syringe services programs. 

• In Boston, refer to AHOPE Harm Reduction Services located at 774 Albany Street. For more information on hours and services, go to: https://www.boston.gov/government/cabinets/boston-public-health-commission/recovery-services/services-active-users 

• Recommend HAV vaccination to all staff at facilities serving these high-risk populations, who are under- or un-immunized. 
• Immunize all close contacts of persons diagnosed with acute HAV with single antigen hepatitis A vaccine (and/or immune globulin, if indicated and available). For more information see: https://www.cdc.gov/hepatitis/hav/havfaq.htm. Please note, Twinrix is not recommended for postexposure prophylaxis. 
• For persons presenting with signs or symptoms consistent with acute HAV infection, connect immediately to a BHCHP clinic or the closest Emergency Department for further evaluation. 

Hygiene and Sanitation:

• Facilities serving high-risk populations should increase opportunities for hand hygiene at entrances and exits and encourage frequent handwashing. Hand washing with antimicrobial soap and hot water should be encouraged.  Portable hand hygiene stations utilizing hot water are suitable.  

• Alcohol-based hand sanitizers (ABHS) may not be effective against HAV and are not recommended. 

• Implement enhanced hygiene and sanitation control measures, including cleaning of all high touch surfaces and bathroom facilities at least twice daily (and as needed) with a disinfectant labeled by the EPA as active against feline calicivirus, norovirus or hepatitis A virus, or as sporicidal. Diluted bleach solution (1:100) is also effective.  

Education:

Education should be provided to all high-risk populations and agencies serving these populations about signs and symptoms of HAV, the need for vaccination, and hygiene measures to reduce transmission. 

• Hospitals, clinics, and other agencies serving these populations should educate residents, nurses, community health workers, intake staff, etc.  
• Strengthen education and outreach efforts to sheltered and unsheltered homeless, with a focus on necessary enhanced hygiene practices, referral for vaccination, and connecting potentially exposed and ill persons to care. 

For more information on hepatitis A, please visit cdc.gov/hepatitis/hav or the Massachusetts Department of Public Health’s website.