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Patient Care

Hepatitis A in the Homeless

1809 hepatitis A
hierarchy of controls

Recently there have been several outbreaks of hepatitis A viral (HAV) infection among homeless populations. Most coverage has focused on a group in the San Diego area; however, there have also been outbreaks in other cities in California, including Santa Cruz and Los Angeles. As of November 2017 there had been a total of 644 cases reported, with 360 hospitalized and 21 deaths (20 in San Diego, another in Santa Cruz). 

The outbreak in California is the largest person-to-person hepatitis A outbreak not related to contaminated food or a single source, and cases have also been noted among drug users. The California outbreak, unlike others, has resulted in deaths. Death associated with hepatitis A infection is rare; the disease has traditionally been described as self-limiting and not resulting in chronic infection. Generally HAV infection runs its course with no long-term effects. Those who have had HAV acquire immunity and cannot get it again. 

Beyond California, other states have had HAV outbreaks among the same population groups, including Utah, Michigan, and Colorado. One common element is their occurrence in the homeless population at a rate higher even than that of IV drug users in the same area. 

What can be done to bring such outbreaks under control? 

Hepatitis A Viral Infection

The hepatitis A virus (HAV) is transmitted by the fecal-oral route. The virus is excreted in the stool of an infected person and then ingested by mouth following contact with unwashed hands or contaminated objects. With no bathroom or hand-washing facilities, the homeless present a ripe environment for its transmission. 

HAV can survive for months outside the body. It does not survive in freezing temperatures but does well when it’s warmer. It is also difficult to kill with the usual disinfectant agents. Standard hand-wash products, even alcohol-based ones, do not kill this virus.

There are six genotypes of HAV. Those that cause illness in humans are genotypes I, II, and III. There are also two subtypes, A and B. In North and South America, genotype 1A is the most common; however, testing has shown that the cases in California are genotype 1B, which is rare in the United States.

This strain is more commonly seen in the Middle East and North Africa and is generally associated with persons with liver disease. This suggests this genotype is more virulent and likely to result in a serious case. Two cases of HAV in homeless persons in Colorado have also been of the 1B genotype, linking the cases to California.

Each HAV genotype presents with the same signs and symptoms. The type is only identified by serotype testing. The signs and symptoms for all types of hepatitis (A, B, and C) are the same: They begin like a flulike illness, with fever, malaise, headache, nausea/vomiting, and abdominal pain.

This progresses to jaundice (yellowing of the skin and eyes), dark-colored urine, gray-colored stools, and joint pain. These are important screening factors for patient assessment. 

Outbreak Response

Outbreak response typically follows the familiar hierarchy of controls depicted by the safety pyramid. This pyramid is not often applied to infection control but fits it well. 

In this outbreak the Centers for Disease Control and Prevention (CDC) dispatched teams to investigate cases and conduct testing. It sent notice across the state and to local health departments to be on the watch for HAV 1B infections, ensure due attention to identification of HAV infections, and send specimens for testing to the CDC Division of Viral Hepatitis laboratory.

Health department officials have been advised to provide hepatitis A vaccines to people who are homeless, using drugs, or with other established risk factors for HAV infection. This includes anyone with ongoing contact with the homeless or drug users.

This represents the top layer of the hierarchy of controls: elimination, or removal of the risk. This does not routinely apply to EMS providers. The HAV vaccine is not recommended for EMS providers (see sidebar), nor even for responders to disasters in the United States. However, California public health authorities have offered HAV vaccines to EMS personnel who work with the homeless in the San Diego area. 

Outreach groups are working to get people off the streets. As one example, local organization Father Joe’s Villages is refurbishing old hotels that are sitting vacant. A tent was erected to house 700 persons. Some are looking at the use of shipping containers to create housing, as has been done for homeless veterans in San Francisco. Such creative repurposing can be accomplished at low cost.

Moving down the hierarchy of controls/pyramid of safety, engineering controls are implemented to isolate people from the hazard. This is a preferred approach to administrative controls and PPE. In this case it involved the use of portable hand-wash stations, toilets, and showers.

We routinely see portable toilets and hand-wash stations at large events such as concerts, and homeless camps show a similar need for such resources. Denver authorities recognized the need and made portable facilities available, as did their counterparts in San Francisco, who also provided tents for housing. 

Engineering controls generally cost more than administrative controls and the use of PPE; however, they have been found to be less costly over the long term.

Administrative controls and work practices consist of various policies and procedures such as the use of personal protective equipment. For example, when cleaning feces, using a high-pressure washer may not be the best choice, as it could result in splashback. Chlorine (sodium hypochlorite) at dilution of 5,000 ppm (1:10) bleach and water translates to high-level disinfection. Keep the solution on the surface for at least one minute. Mix it fresh daily. 

Education and training to reduce the duration and frequency of exposure also fall under administrative controls. Here it is important to teach that soap and water is needed for hand-washing because waterless hand sanitizers are not effective against the hepatitis A virus. Here a 1:10 dilution is used instead of the routine 1:100 mixture used for cleaning vehicles and equipment.

Standard precautions, in this case, would involve the use of gloves and good hand washing for patient assessment. Cover gowns and masks are only needed if there is likely contact with patient excretions.

Pre-, Postexposure Issues

In response to the current outbreak of HAV in the San Diego area, vaccines are being offered to at-risk persons and EMS personnel. The HAV vaccine first became available in 1995. Since then the case numbers for HAV in this country have dropped dramatically. There were 31,000 cases reported each year before the vaccine; now there are about 1,500. It is an inactivated (killed) virus vaccine given in two doses six months apart. About 95% of vaccinated persons will develop protective antibodies within four weeks of a single dose of the vaccine; that extends to 100% after the second dose. 

Postvaccine serology testing is not indicated or recommended. Side effects are minimal and might include soreness at the site of injection, low-grade fever, headache, and feeling tired. These usually last 1–2 days. It is currently believed that the vaccine is protective for at least 20 years and may be protective for life. If an unprotected exposure were to occur, hepatitis A preservative-free immune globulin (IG) may be offered by IM injection. GamaSTAN S/D is the only immune globulin approved by the FDA for HAV prophylaxis in the United States.

Using the hepatitis A vaccine for postexposure prophylaxis provides numerous public health advantages, including the induction of active immunity and longer protection, greater ease of administration, higher acceptability and availability, and a cost per dose similar to IG. The vaccine is also easy to administer, which may help increase the number willing to receive postexposure prophylaxis. There are two hepatitis A vaccines available, Havrix and Vaqta. Both are equally effective.

Public Health Over Politics

This outbreak is unfortunate, but hopefully national efforts can reduce the issue of the homeless in this county and prevent occurrences. It will require public health interests taking priority over politics. That’s being demonstrated in this outbreak.

San Diego has implemented a new program called the Alpha Project, which is built on a program established in Albuquerque. The new approach begins by placing the homeless in shelters or tents and “hiring” them at a rate of $11.50 an hour to clean up the streets. This plan started with a donation from an emergency physician that will fund the program for six months. Homeless persons are also given work and assistance in finding jobs, as well as in dealing with the circumstances that led to their homelessness.

In addition San Diego County plans to allocate $22 million to provide healthcare to the homeless over the next three years. Services focus on those who have been frequent users of emergency care services.
These efforts demonstrate what can be achieved when community groups and politicians come together to combat a public health threat. This will benefit everyone.  

Sidebar: Vaccination: Not Recommended for EMS

The hepatitis A vaccine is not routinely recommended for healthcare personnel, including fire/EMS, or for persons who work in solid waste management. Twinrix, the combination (hepatitis A and B) vaccine, is also not routinely recommended for healthcare workers, sewer workers, or plumbers. This is addressed in the NFPA 1581 infection-control standard. These recommendations are evidence-based and reflect science driving practice.


California Department of Pesticide Regulation. Pesticide Regulatory Guidance on Control of Hepatitis A with Sodium Hypochlorite, Applicator Licensing, and Business Licensing Requirements,  

California Department of Public Health. Hepatitis A Outbreak in California, 

Centers for Disease Control and Prevention. 2017—Outbreaks of hepatitis A in multiple states among people who are homeless and people who use drugs, 

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th ed. Atlanta: Centers for Disease Control and Prevention, 2015, pp. 135–48. 

Centers for Disease Control and Prevention. Hepatitis A Questions and Answers for Health Professionals, 

Centers for Disease Control and Prevention. Immunization Recommendations for Disaster Responders, 

Centers for Disease Control and Prevention. Vaccine Information Statements: Hepatitis A VIS, 

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Hierarchy of Controls, 

Department of Labor, Occupational Safety and Health Administration. Recommended Practices for Safety and Health Programs, 

Warth G. New program puts San Diego’s homeless to work. San Diego Union-Tribune, 2018 Feb 26; 

Warth G. Program aims to save money by paying homeless healthcare. San Diego Union-Tribune, 2018 Feb 6; 

Katherine West, RN, BSN, MSEd, is an infection-control consultant with Infection Control/Emerging Concepts in Clearwater, Fla., and a member of the EMS World editorial advisory board.

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