- In October 2018, the CDC’s vaccine policymaking committee, ACIP, voted to recommend the hepatitis A vaccine to be routinely given to homeless persons.
- Hepatitis A infections are associated with poor sanitation and living conditions and the decision was made because outbreaks have occurred among homeless populations in the last few years.
- Hepatitis A is transmitted through the fecal-oral route and is easily prevented by improving sanitary conditions in homeless encampments.
During the meeting on Oct. 25, 2018, the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) voted to add a new policy recommending that everyone ages one and older who experience homelessness routinely be vaccinated against hepatitis A (HAV).1
At the meeting, the hepatitis A work group did a presentation showing that since 2016, hepatitis A outbreaks have occurred in 11 states with 7,500 cases, about 4,400 hospitalizations and 74 deaths. The group argued that homelessness is independently associated with two to three times higher odds of infection with HAV and two to three times higher chance of severe outcomes such as hospitalization or death.1 As a result, the ACIP voted unanimously to recommend adding homeless individuals to the list of those who are at increased risk of contracting HAV infection or severe disease.1
What is Hepatitis A?
According to the World Health Organization (WHO), hepatitis A is a viral liver disease. HAV is transmitted primarily through the fecal-oral route when an uninfected person ingests food or water that has been contaminated with the feces of an infected person,2 In families, this may happen though dirty hands when an infected person prepares food for family members.2 Waterborne outbreaks, although infrequent, are usually associated with sewage contaminated or inadequately treated water. Some outbreaks of hepatitis A have been traced to raw undercooked shellfish, such as raw oysters, and raw produce.3
The virus can also be transmitted through close physical contact with an infectious person, although casual contact among people does not spread the virus.2
Hepatitis A causes symptoms of jaundice (yellowing of the skin and eyes), fatigue, stomach pain, nausea, diarrhea and fever that comes and goes for six to nine months. Most children and adults recover without complications. The WHO acknowledges on its website that almost everyone recovers fully from hepatitis A with a lifelong immunity.2
Unlike hepatitis B and C, the HAV infection does not cause chronic liver disease and is rarely fatal.2 The WHO website goes on to further state that safe water supply, food safety, improved sanitation and hand washing are effective ways to combat the disease.2 In developed countries with good sanitation and hygienic conditions such as the United States, infection rates are low.2
Hepatitis A Outbreaks Have Occurred Beyond Homeless Populations
In 2017, there was an outbreak of hepatitis A among 1,200 people in five states with about 800 hospitalizations and 40 deaths.4 While many of the victims of the outbreak were homeless persons and/or substance abusers, a third of the 644 confirmed ill people in California and a fourth of the 495 confirmed ill people in Southeast Michigan are neither homeless nor substance abusers.2
The outbreaks included restaurant workers in California and Michigan but officials at all levels say food service employees were not the cause of the outbreak.4 Restaurant owners have the potential be on the hook for HAV outbreaks related to food that was contaminated before they took possession of it.4 For example, in 2016, an HAV outbreak was traced to frozen strawberries imported from Egypt and served at Tropical Smoothie restaurants that sickened 134 people in nine states. Thorough food safety regulations and inspections can also prevent outbreaks.4
Sanitation: Addressing the Root Causes of the Disease and Poor Health
The problem with modern medicine is that it fails to address the underlying causes of diseases and poor health, which leads to a life long dependency on pharmaceutical drugs and vaccines.5 History provides ample evidence that poverty, poor sanitation and unhygienic conditions are breeding grounds for infectious viruses and bacteria.6
Hepatitis A is not a major disease threat in the United States because of the improved sanitation. HAV outbreaks in homeless encampments are preventable because as mentioned above, the infection is spread through the fecal-oral route, which means the unsanitary conditions often found in homeless encampments play a large role in the spread of the disease.
There are numerous solutions to addressing the root cause of the problem by improving living and sanitary conditions in homeless populations in order to nip the problem at its origin, but city officials and public health officials have to be willing to address root causes of disease instead of simply vaccinating homeless populations.
Hepatitis A Vaccine Adverse Reactions
There are two inactivated hepatitis A virus vaccines licensed in the U.S., GlaxoSmithKline’s Havrix and Merck & Co’s Vaqta.
Havrix pre-licensure clinical trials found the most common reactions to be injection site soreness (21-56 percent) and headache (9-14 percent) followed by loss of appetite, nausea, fatigue and fever in between one and 10 percent of injections. Less than one percent of injections were followed by upper respiratory infection, swollen lymph nodes (lymphadenopathy), stiff muscles (hypertonia), joint, muscle or abdominal pain, itching, rash, or other adverse events.
Post marketing surveillance of Havrix included reports of anaphylaxis, syncope (fainting), convulsions, encephalopathy, Guillain Barre syndrome, neuropathy, vasculitis, thrombocytopenia and serum-sickness like syndrome and other adverse events.7
Havrix contains inactivated hepatitis A virus. Among the vaccine’s other ingredients are aluminum, polysorbate 20, MRC-5 cellular proteins, formalin, and neomycin sulfate.
Vaqta pre-licensure clinical trials found the most common reactions in all age groups (more than 15 percent of injections) to be injection site pain and soreness (18-67 percnt) and fever in children under 23 months (16-27 percent) and headache in adults (16 percent). Pre-licensure clinical trials revealed the most frequently reported reactions in healthy children aged 12 to 23 months were injection site pain and swelling, fever, irritability, upper respiratory tract infection and dermatitis (eczema) with less common serious adverse events including febrile seizures, dehydration, gastroenteritis and cellulitis.8
Between one and 10 percent of Vaqta injections were followed by conjunctivitis, otitis media, viral infection, croup, strep throat, bronchitis, gastroenteritis, loss of appetite, insomnia, crying, cough, rash and other adverse events. In adults 19 years and older, over five percent of injections were followed by fatigue, chills, nausea, muscle pain, headache and upper respiratory infection.
Post-marketing adverse events reported after Vaqta have included thrombocytopenia, encephalitis, Guillain Barre syndrome (GBS), and cerebellar ataxia (inability to control muscle movements, such as balance, gait, limb and eye movements).
Vaqta contains inactivated hepatitis A virus. Among the vaccine’s other ingredients are aluminum, non-viral protein, DNA, bovine albumin, and formaldehyde.
The Issue of Medical Informed Consent
Homeless individuals have the right to exercise informed consent to medical risk taking just like everyone else.
If public health officials and other healthcare professionals are indeed going into homeless encampments to vaccinate individuals who live there, are they providing them with all the necessary information regarding the benefits AND risks of the HAV vaccine or other vaccines prior to vaccination? Are they asking questions about every individual’s medical history prior to vaccination? Are they monitoring every individual following vaccination to observe for adverse reactions? Are they reporting any adverse reactions to the Vaccine Adverse Event Reporting System (VAERS)?
Regardless of one’s living conditions, the right to exercise informed consent to medical risk taking is a human right for all.9
1 American Academy of Family Physicians. ACIP Recommends Hep A Vaccine for Homeless Patients. AAFP.org Oct. 31, 2019.
2 World Health Organization. Hepatitis A. Who.int Sept. 18, 2018.
3 Food Safety. Hepatitis A. FoodSafety.gov.
4 Beach C. Hepatitis A reaches beyond homeless; vaccine dwindling. Food Safety News Nov. 10, 2017.
5 Parpia R. Medicine’s Symptomatic Focus. The Vaccine Reaction Jan. 22, 2018.
6 Parpia R. The Plight of Infectious Diseases, Vaccines, Sanitation and Nutrition in Poor Nations. The Vaccine Reaction June 2, 2015.
7 GlaxoSmithKline. Havrix (Hepatitis Vaccine) Highlights of Prescribing Information. FDA.gov.
8 Merck & Co. Vaqta (Hepatitis A vaccine) Highlights of Prescribing Information. December 2019.
9 YouTube. Why is Informed Consent to Vaccination a Human Right? The Vaccine Reaction Jan. 2, 2018.