The Boston Public Health Commission (BPHC) urges the city’s health care providers, especially those who work closely with unsheltered populations and drug users, to remain vigilant for signs of hepatitis A in their patients.
Between November 17 and 20, BPHC was informed of two positive cases among unsheltered residents. Both are related to health care. Neither required hospitalization.
Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus (HAV). Its severity ranges from a mild infection that lasts a few weeks to a severe illness that lasts several months. Hepatitis A virus is mainly transmitted from person to person through the fecal-oral route and through exposure to fecal contaminated environments. Particularly at-risk populations include the homeless and people who inject drugs. Effective prevention and response measures include early detection of cases, vaccination, enhanced hygiene procedures and education of vulnerable groups.
Recommendations for providers:
Report
- Regulations require Boston’s health care providers and facilities to report all cases of hepatitis A virus (HAV) infection, hepatitis B virus (HBV) infection, or meningococcal meningitis diagnosed among Boston residents to the Boston Public Health Commission (tel: 617-534-5611, 24/7 coverage. For help identifying close contacts, please contact BPHC.)
test
- Test everyone who shows symptoms of hepatitis A, especially those who are homeless or using drugs. Common symptoms of hepatitis A include abdominal pain, jaundice, loss of appetite, fever, diarrhea, nausea and fatigue.
Vaccinations and referrals for treatment:
We recommend that vaccination efforts focus on the following aspects:
- Vaccinate all high-risk groups, including homeless people, people who use injectable or non-injectable drugs, people with 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 combined hepatitis A and B vaccine (Twinrix®). Remember, Twinrix requires 3 doses for maximum effectiveness and should not be used for post-exposure prophylaxis.
- Vaccines are offered at the point of care, including emergency departments or urgent care, hospitalizations, observation and outpatient visits. If possible, vaccination information should be recorded in the facility’s electronic medical record to assist in monitoring vaccine coverage.
- Targeted street workers and mobile van units serving these at-risk populations are encouraged to provide HAV and other vaccines to unsheltered individuals, those living in encampments, or those not using services within shelters.
- For customers in Boston, connect the customer to the BHCHP clinic site. For a list of BHCHP clinics, please visit: https://www.bhchp.org/patent-services/primary-care
- Refer SUD clients to syringe services program.
- HAV vaccination is recommended for all under- or unimmunized staff in facilities serving these high-risk populations.
- Immunize all close contacts of a person diagnosed with acute HAV using single-antigen hepatitis A vaccine (and/or immunoglobulin, if indicated and available). For more information, see: https://www.cdc.gov/hepatitis/hav/havfaq.htm. Please note that Twinrix is not recommended for post-exposure prophylaxis.
- For persons who develop signs or symptoms consistent with acute HAV infection, please contact the BHCHP clinic or nearest emergency department immediately for further evaluation.
Hygiene and sanitation:
- Facilities serving at-risk populations should increase hand hygiene opportunities at entrances and exits and encourage frequent hand washing. Handwashing with antibacterial soap and hot water should be encouraged. Portable hand hygiene stations using hot water are suitable.
- Alcohol-based hand sanitizers (ABHS) may not be effective against HAV and are not recommended.
- Implement enhanced personal hygiene and sanitation controls, including cleaning at least twice daily (and as needed) with disinfectants labeled by the EPA as active against feline calicivirus, norovirus, or hepatitis A virus or as sporicidal ) all high-touch surfaces and bathroom facilities. A diluted bleach solution (1:100) also works.
educate:
Education about the signs and symptoms of hepatitis A, the need for vaccination, and hygiene measures to reduce transmission should be provided to all at-risk populations and institutions serving these populations.
- Hospitals, clinics, and other institutions that serve these populations should educate residents, nurses, community health workers, intake staff, and others.
- Increase education and outreach to sheltered and unsheltered homeless individuals with a focus on promoting necessary hygiene practices, referrals for vaccinations, and connecting potentially exposed and sick individuals to care.
For more information about hepatitis A, visit cdc.gov/hepatitis/hav or Massachusetts Department of Public Health website.