Hepatitis A and Stigmatized Populations

“There was northerly weather toward the winter solstice. Patients became thoroughly jaundiced: some shivered, some did not. Their tongues were burnt on the third day. Upsets toward the sixth and seventh, which lasted a long time… then the sun turned, winter was stormy… then it was snowy for fourteen days. In that part of the year jaundices, deep-colored ones, without clear crises; tendencies to relapse… Flows of phlegm broke through, both with and without fever… there were hoarseness and inflamed pharynxes… soft swellings developed beside the ears and by the jaw with fever… Thence come hepatic diseases and among them are the jaundices from the liver” (Hippocrates, 1994/1525).

Over two thousand years ago Hippocrates described Hepatitis-like illness in Hippocrates: Volume VII, Epidemics (translated by Wesley D. Smith, 1994). While it’s not clear which specific disease this “benign epidemic jaundice” was, it sounds remarkably similar to Hepatitis A. In 1953, Hepatitis A was differentiated from other types of hepatitis after the virus found in the feces of those afflicted was found to be infectious (Meyer, 1952). This discovery was made after a major outbreak of the illness occurred in WWII prompted the British and the Americans to initiate studies of viral hepatitis (Feinstone, 2019).

According to DHHS (n.d.), Hepatitis A is a viral liver infection which can have few to no symptoms in some individuals. When symptoms do appear, they may be mistaken for symptoms of the flu. Symptoms include gastrointestinal issues like nausea, vomiting, and diarrhea. Jaundice occurs frequently, alongside fever and abdominal pain. Rarely, acute liver failure may occur (USFDA, n.d.).

The fecal-oral route is the most common means of transmission for Hep A (DHHS, n.d.). Subsequently, developing areas with poor hygiene and sanitation are most commonly impacted by Hep A outbreaks. Foodborne outbreaks occur rarely in the United States (USFDA, n.d.). Marginalized populations are at a higher risk of Hep A in the US – these include individuals experiencing homelessness, men who have sex with me, people who have unprotected sex, and folks who use illicit drugs (DHHS, n.d.). These communities typically have lower access to hygiene and proper medical care, and they frequently experience stigmatization, which acts as a barrier to care-seeking behaviors (CDC, 2019).

The Hep A vaccine, first introduced in 1996, drastically lowered the incidence of new Hep A infections in the United States (DHHS, n.d.). All children are recommended for vaccination, in addition to pregnant women and folks who are at increased risk of infection or severe outcomes (DHHS, n.d.). Hep A incidence was lowest in 2014 but has been steadily increasing due to infections among people who use drugs and people experiencing homelessness (DHHS, n.d.).

Vaccination remains a critical intervention for prevention and mitigation of Hep A in homeless populations (CDC, 2019). Community health centers often serve as primary health services for folks experiencing homelessness; as such, they are vital for vaccination for that population. During outbreaks, street- and/or shelter-based vaccination programs have been effective interventions to increase vaccination in the homeless populations (CDC, 2019).

CDC (2019) recommends regular Hep A testing for persons who use drugs, in addition to provision of sterile injection and drug preparation equipment through syringe services. However, due to low availability of needle exchanges in many areas, persons who inject drugs should receive Hep A vaccination. Many states have expanded access to Medicaid, which increased access to care among persons who inject drugs and persons experiencing homelessness (CDC, 2019).

References

U.S. Food and Drug Administration. (n.d.). Hepatitis A virus (HAV). Retrieved March 18, 2023, from https://www.fda.gov/food/foodborne-pathogens/hepatitis-virus-hav

Feinstone, S. M. (2018). History of the discovery of hepatitis A virus. Cold Spring Harbor Perspectives in Medicine, 9(5). https://doi.org/10.1101/cshperspect.a031740

Hippocrates. (1994). Epidemics. In Hippocrates (Vol. 7). Translated by Smith, W. D. Harvard University Press.

Meyer, K. F. (1952). Infective Hepatitis. Studies in East Anglia during the Period 1943-47. American Journal of Public Health and the Nations Health, 42(8), 1009–1010. doi:10.2105/ajph.42.8.1009-b

U.S. Department of Health and Human Services. (n.d.). Hepatitis A - NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved March 18, 2023, from https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/hepatitis-a

Centers for Disease Control and Prevention. (2019, February 14). Recommendations of the Advisory Committee on Immunization Practices for use of hepatitis a vaccine for persons experiencing homelessness. Retrieved March 18, 2023, from https://www.cdc.gov/mmwr/volumes/68/wr/mm6806a6.htm