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      Increase in Hepatitis A Virus Infections — United States, 2013–2018

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          Hepatitis A virus (HAV) is primarily transmitted fecal-orally after close contact with an infected person ( 1 ); it is the most common cause of viral hepatitis worldwide, typically causing acute and self-limited symptoms, although rarely liver failure and death can occur ( 1 ). Rates of hepatitis A had declined by approximately 95% during 1996–2011; however, during 2016–2018, CDC received approximately 15,000 reports of HAV infections from U.S. states and territories, indicating a recent increase in transmission ( 2 , 3 ). Since 2017, the vast majority of these reports were related to multiple outbreaks of infections among persons reporting drug use or homelessness ( 4 ). In addition, increases of HAV infections have also occurred among men who have sex with men (MSM) and, to a much lesser degree, in association with consumption of imported HAV-contaminated food ( 5 , 6 ). Overall, reports of hepatitis A cases increased 294% during 2016–2018 compared with 2013–2015. During 2016–2018, CDC tested 4,282 specimens, of which 3,877 (91%) had detectable HAV RNA; 565 (15%), 3,255 (84%), and 57 (<1%) of these specimens were genotype IA, IB, or IIIA, respectively. Adherence to the Advisory Committee on Immunization Practices (ACIP) recommendations to vaccinate populations at risk can help control the current increases and prevent future outbreaks of hepatitis A in the United States ( 7 ). Hepatitis A infections among persons who meet the Council of State and Territorial Epidemiologists (CSTE) hepatitis A case definition (https://wwwn.cdc.gov/nndss/conditions/hepatitis-a-acute/) are notified to CDC through the National Notifiable Diseases Surveillance System (NNDSS). Cases reported to CDC through NNDSS during 2013–2018 were used to calculate percent change (2013–2015 versus 2016–2018) by state and mapped using RStudio software (version 1.2.1335; RStudio, Inc.). Serum specimens from CSTE confirmed cases submitted to the CDC laboratory were tested for HAV RNA by polymerase chain reaction, and isolated virus was amplified to characterize a 315–base-pair fragment of the VP1/P2B region, which defines the genotype of the virus. Overall, reports of hepatitis A cases increased 294% during 2016–2018 compared with 2013–2015 (Figure). Eighteen states had lower case counts during 2016–2018 compared with 2013–2015. Nine states and Washington, DC had an increase of approximately 500%. During 2013–2018, 4,508 HAV anti-immunoglobulin M–positive specimens underwent additional testing at CDC. During 2013–2015, 226 specimens underwent additional testing, of which 197 (87%) had detectable HAV RNA; of the RNA-positive specimens, 76 (39%), 121 (61%), and 0 (0%) tested positive for a genotype IA, IB, or IIIA viral strain, respectively. In comparison, 4,282 specimens were tested by CDC during 2016–2018, of which 3,877 (91%) had detectable HAV RNA; 565 (15%), 3,255 (84%), and 57 (<1%) of these specimens were genotype IA, IB, or IIIA, respectively. FIGURE Percent change in reported hepatitis A infections, by state — National Notifiable Diseases Surveillance System, United States, 2013–2015 and 2016–2018* Abbreviation: DC = District of Columbia. * 2017 and 2018 case counts are provisional. The figure is a map showing the percent change in reported hepatitis A infections in the United States, during 2013–2015 and 2016–2018, using data from the National Notifiable Diseases Surveillance System. Discussion The number of hepatitis A infections reported to CDC increased during 2016–2018, along with the number of specimens from infected persons submitted to CDC for additional testing. In the past, outbreaks of hepatitis A virus infections occurred every 10–15 years and were associated with asymptomatic children ( 8 ). With the widespread adoption of universal childhood vaccination recommendations (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm), asymptomatic children are no longer the main drivers of hepatitis A outbreaks ( 3 , 9 ). Although the overall incidence rate of HAV infections has decreased within all age groups, a large population of susceptible, unvaccinated adults who were not infected by being exposed to the virus during childhood remain vulnerable to infection by contaminated foods (typically imported from countries with endemic HAV transmission) and recently, on a much larger scale, through behaviors that increase risk for infection in certain vulnerable populations, such as drug use ( 3 ). Increasingly, molecular epidemiology is employed by public health laboratories to better characterize hepatitis A transmission patterns. When combined with reliable epidemiologic data, these laboratory data can be used to identify transmission networks and confirm the source of exposure during common-source outbreaks, facilitating prompt and effective public health response. Historically, genotype IA has been the most common genotype circulating in North and South America. During 2013–2018, HAV genotype IB predominated in the United States. Increasing numbers of genotype IIIA were seen, a genotype that is considered rare in the United States. Decreasing new infections from hepatitis A virus can be achieved and sustained by maintaining a high level of population immunity through vaccination. There is no universal vaccination recommendation for adults in the United States; however, ACIP does recommend vaccination for adults who plan travel to HAV-endemic countries, MSM, persons who use drugs, persons with chronic liver disease, and recently, persons experiencing homelessness ( 7 ). Continued efforts to increase hepatitis A vaccination coverage among the ACIP-recommended risk groups is vital to halting the current hepatitis A outbreaks and reducing overall hepatitis A incidence in the United States. Summary What is already known about this topic? Hepatitis A is a vaccine-preventable viral infection of the liver that is primarily transmitted through consumption of microscopic amounts of feces. What is added by this report? During 2016–2018, reports of hepatitis A infections in the United States increased by 294% compared with 2013–2015, related to outbreaks associated with contaminated food items, among men who have sex with men, and primarily, among persons who report drug use or homelessness. What are the implications for public health practice? Increasing vaccination among groups at risk for hepatitis A infection might halt ongoing outbreaks and prevent future outbreaks.

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          Hepatitis A Virus Outbreaks Associated with Drug Use and Homelessness — California, Kentucky, Michigan, and Utah, 2017

          During 2017, CDC received 1,521 reports of acute hepatitis A virus (HAV) infections from California, Kentucky, Michigan, and Utah; the majority of infections were among persons reporting injection or noninjection drug use or homelessness. Investigations conducted by local and state health departments indicated that direct person-to-person transmission of HAV infections was occurring, differing from other recent, large HAV outbreaks attributed to consumption of contaminated commercial food products. Outbreaks with direct HAV transmission among persons reporting drug use or homelessness signals a shift in HAV infection epidemiology in the United States, and vaccination of these populations at high risk can prevent future outbreaks. Epidemiologic Investigation Outbreak cases were defined as those meeting the 2012 CDC-Council of State and Territorial Epidemiologists’ (CSTE) definition of acute hepatitis A infection,* having a specimen matching an outbreak strain, or an epidemiologic link to a previously identified case. Local and state health department personnel reviewed clinical charts and interviewed patients using standard questionnaires that evaluated risk factors associated with infection, including recent drug use, sexual history, housing status, recent international travel, and contact with another person with HAV infection. Among states reporting increases in HAV infections to CDC outside or inside the National Notifiable Disease Surveillance System, only California, Kentucky, Michigan, and Utah reported sustained within-state transmission. This report includes outbreaks that occurred during 2017 in these four states. Additional cases reported from other states were excluded because they were attributed to HAV exposure during travel to one of the four outbreak states, and because prolonged, ongoing transmission did not occur in the other states. During 2017, a total of 1,521 outbreak-associated HAV cases were reported from California, Kentucky, Michigan, and Utah, with 1,073 (71%) hospitalizations and 41 (3%) deaths (Table 1). Among patients for whom clinical or laboratory records were available for review, 42 (3%) had confirmed or probable hepatitis B virus coinfection, and 341 (22%) had confirmed or probable hepatitis C virus coinfection. Overall, 866 (57%) patients reported drug use, homelessness, or both (Table 2). Among all cases, 818 (54%) had an indication for hepatitis A vaccination before becoming infected (i.e., using drugs or being men who had sex with men [MSM]) as recommended by the Advisory Committee on Immunization Practices (ACIP) ( 1 ). TABLE 1 Demographic and clinical characteristics of hepatitis A outbreak–associated cases, by state — four states, 2017 Characteristic California Kentucky Michigan Utah Total Total cases, no. 682 59 632 148 1,521 Male, no. (%) 471 (69) 39 (66) 412 (65) 97 (66) 1,019 (67) Median age, yrs (range) 42 (5–87) 36 (1–84) 41 ( 100 because of men who had sex with men being included independently and as part of “homelessness,” “drug use,” and “neither homeless nor drug use” categories. Laboratory Investigation When available, serum specimens from patients who met the CSTE case definition were sent to CDC’s Division of Viral Hepatitis laboratory for HAV RNA isolation, genotyping, and genetic characterization. HAV RNA was extracted from immunoglobulin M antibody-positive serum samples and used to amplify and Sanger-sequence a 315–base-pair fragment of the VP1/P2B region ( 2 ). During 2017, 1,169 specimens from outbreak-associated cases from the four affected states were sent to CDC for additional testing. A total of 1,054 (90%) specimens had HAV confirmed by polymerase chain reaction, 1,014 (96%) of which tested positive for a genotype 1b viral strain. The strains circulating in California, Kentucky, and Utah were genetically different from those circulating in Michigan. Public Health Response CDC worked with affected local and state health departments to apply control measures through health advisories, public education, and vaccination clinics that provided outreach and vaccination to the targeted populations. Vaccine was administered in jails, emergency departments, syringe exchange programs, drug treatment facilities, and homeless shelters. In certain jurisdictions, investigation teams also visited homeless encampments to educate and vaccinate unsheltered homeless groups. Although reporting of new outbreak cases in California has ended, new case investigations continue in Kentucky, Michigan, and Utah. Vaccination campaigns also continue for MSM and persons who use drugs or report homelessness in the affected states. Discussion After the introduction of hepatitis A vaccine in 1996, the incidence of reported HAV infection steadily decreased in the United States until 2011 and then stabilized at an annual average of approximately 1,600 reported cases, mostly among international travelers returning from countries with endemic HAV or as part of foodborne outbreaks ( 1 , 3 ). HAV outbreaks among illicit drug users were common in the prevaccine era; during the mid-1980s, drug users accounted for >20% of all HAV cases reported to CDC ( 3 , 4 ). However, large community outbreaks within this population rarely occurred after 1996, when hepatitis A vaccine was first recommended for persons who use illicit drugs ( 3 , 4 ). Person-to-person transmission of HAV between those who report drug use or homelessness can result from unsafe sanitary conditions or specific sexual contact or practices, or it can be parenterally transmitted through contaminated needles or other injection paraphernalia ( 4 – 6 ). Transient housing, economic instability, limited access to health care, and distrust of government services make outbreaks among affected populations more difficult to control, requiring tailored comprehensive public health interventions that address their specific circumstances and needs ( 5 – 7 ). During 2016, U.S. hospitalization and mortality rates associated with HAV infections were 42% and 0.7%, respectively ( 3 ). Increased hospitalization and mortality rates observed in the 2017 HAV outbreaks might be attributable to preexisting illnesses, including chronic hepatitis B and hepatitis C infections, other comorbidities, age, and risk behaviors common among persons reporting drug use and homelessness (e.g., heavy alcohol use) ( 8 ). Increasingly, investigations of HAV infections are using molecular epidemiology to confirm outbreaks ( 2 ). Laboratory data, when combined with reliable epidemiologic data, can be effective in understanding transmission networks, particularly among populations distrustful of investigators. The majority of surveillance specimens tested by CDC’s laboratory before 2017 were genotype 1a, the most common genotype in North and South America, but expansion of genotype 1b attributed to the current outbreaks is leading to increased detection of this previously uncommon genotype ( 2 , 9 ). Vaccination rates among existing ACIP-identified risk groups are unknown but are believed to be low ( 10 ). On October 24, 2018, ACIP voted unanimously to add “homelessness” as an indication for ACIP-recommended HAV vaccination ( 1 ). † Although the outbreak has ended in California, hepatitis A outbreaks among persons reporting drug use or homelessness continue in Kentucky, Michigan, and Utah, and, as of October 12, 2018, >7,000 outbreak associated cases have been reported from 12 states. § Increasing vaccination coverage among all at-risk groups recommended by ACIP to receive hepatitis A vaccine might halt ongoing outbreaks and prevent future large community outbreaks ( 1 ). CDC has recommended that local health jurisdictions experiencing HAV outbreaks among persons who report drug use or homelessness ensure procedures are in place for identifying these risk factors and that these groups are vaccinated against HAV infection. ¶ State and local health departments and CDC should be notified of any new suspected clusters of acute HAV infections. Summary What is already known about this topic? Hepatitis A is a vaccine-preventable viral infection of the liver that is commonly transmitted through consumption of microscopic amounts of feces. Outbreaks of hepatitis A infections are infrequent in the United States and are typically associated with contaminated food items. What is added by this report? During 2017, California, Kentucky, Michigan, and Utah reported 1,521 hepatitis A infections, mostly among persons who reported drug use or homelessness, signaling a shift in hepatitis A epidemiology from point-source outbreaks associated with contaminated food to large community outbreaks with person-to-person transmission. What are the implications for public health practice? Increasing vaccination among groups at risk for hepatitis A infection might halt ongoing outbreaks and prevent future outbreaks.
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            Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness

            Hepatitis A (HepA) vaccination is recommended routinely for children at age 12–23 months, for persons who are at increased risk for hepatitis A virus (HAV) infection, and for any person wishing to obtain immunity. Persons at increased risk for HAV infection include international travelers to areas with high or intermediate hepatitis A endemicity, men who have sex with men, users of injection and noninjection drugs, persons with chronic liver disease, person with clotting factor disorders, persons who work with HAV-infected primates or with HAV in a research laboratory setting, and persons who anticipate close contact with an international adoptee from a country of high or interme­diate endemicity ( 1 – 3 ). Persons experiencing homelessness are also at higher risk for HAV infection and severe infection-associated outcomes. On October 24, 2018, the Advisory Committee on Immunization Practices (ACIP)* recommended that all persons aged 1 year and older experiencing homelessness be routinely immunized against HAV. The ACIP Hepatitis Vaccines Work Group conducted a systematic review of the evidence for administering vaccine to persons experiencing homelessness, which included a set of criteria assessing the benefits and adverse events associated with vaccination. HepA vaccines are highly immunogenic, and >95% of immunocompetent adults develop protective antibody within 4 weeks of receipt of 1 dose of the vaccine ( 1 ). HAV infections are acquired primarily by the fecal-oral route by either person-to-person transmission or via ingestion of contaminated food or water. Among persons experiencing homelessness, effective implementation of alternative strategies to prevent exposure to HAV, such as strict hand hygiene, is difficult because of living conditions among persons in this population. Integrating routine HepA vaccination into health care services for persons experiencing homelessness can reduce the size of the at-risk population over time and thereby reduce the risk for large-scale outbreaks. Introduction In 2017 in the United States, 1.42 million persons used an emergency shelter or transitional housing program at some point during the year ( 4 ). Estimates of homelessness are higher when unsheltered persons are considered. Some studies estimate that 2.3 million to 3.5 million persons experience homelessness each year ( 5 ), and persons of color are disproportionately affected ( 4 , 5 ). In 2017, on a single night, an estimated 553,742 persons experienced homelessness in the United States, approximately 35% of whom were in unsheltered locations ( 4 ). Although the number of persons experiencing homelessness has declined overall since 2007, the number of unsheltered persons experiencing homelessness in major cities has increased, and disparities remain ( 4 ). Persons experiencing homelessness are at 1.5 to 11.5 times the risk for mortality compared with the general population ( 6 ). Homelessness has been associated with substantial health inequalities, including shorter life expectancy; poor access to health care, resulting in delayed clinical presentation; higher morbidity; and greater use of acute hospital services, often for preventable conditions ( 6 , 7 ). HAV infection is associated with poor sanitation and hygiene and is transmitted by the ingestion of contaminated food or water or by direct contact with an infectious person. Congregate living conditions, both within and outside shelters, increase the risk for disease transmission, which can result in outbreaks ( 6 ). Recent outbreaks with direct HAV transmission among persons reporting homelessness signal a shift in HAV infection epidemiology in the United States ( 8 ). During 2017, a total of 1,521 outbreak-associated HAV cases were reported from California, Kentucky, Michigan, and Utah, with 1,073 (71%) hospitalizations and 41 (3%) deaths; the majority of infections were among persons reporting homelessness or injection or noninjection drug use ( 8 ). The person-to-person HAV outbreaks involving persons who use drugs or persons experiencing homelessness are ongoing, and case counts and geographic dispersion increased substantially in 2018. † As of October 12, 2018, approximately 7,000 outbreak-associated cases had been reported from 12 states ( 8 ). Hepatitis A vaccines are critical to the prevention of HAV infection among persons experiencing homelessness. Detectable antibodies persist for at least 20 years after HepA vaccination in childhood ( 9 ), and antibodies persist for an estimated 40 years or longer based on mathematical modeling and anti-HAV kinetic studies ( 9 ). Although recommended as a 2-dose series, evidence of protection for up to 11 years exists for 1 dose of single-antigen vaccine ( 10 ); clinical and outbreak response experience suggests that lifelong protection is possible after 1 dose. Owing to limited access to health care and historically low rates of insurance coverage, the majority of adults who experience homelessness have low rates of immunization coverage with vaccines routinely recommended for adults. Community health centers provide preventive and primary health services to meet the specific needs of persons experiencing homelessness, including vaccination. Street or shelter-based interventions for targeted populations have been used as efficient methods for vaccinating persons experiencing homelessness during outbreaks ( 11 ). Thirty-six states and the District of Columbia have expanded Medicaid under the Affordable Care Act, providing an increase in coverage and access to care among persons experiencing homelessness; an estimated 77% had access to some form of insurance in 2017 ( 12 ). This report provides recommendations for use of HepA vaccine among persons experiencing homelessness and updates previous ACIP recommendations for HepA vaccine that did not include homelessness as an indication for use of HepA vaccine for preexposure protection against HAV infection ( 1 ). Methods During February 2018–October 2018, the ACIP Hepatitis Vaccines Work Group § held monthly conference calls to review and discuss relevant scientific evidence ¶ supporting inclusion of homelessness as an indication for HepA vaccine. The work group evaluated the quality of evidence related to the benefits and harms of administering HepA vaccine to persons experiencing homelessness using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework (https://www.cdc.gov/vaccines/acip/recs/grade/table-refs.html). At the October 2018 ACIP meeting, the following proposed recommendations were presented to the committee: all persons aged 1 year and older experiencing homelessness should be routinely immunized against hepatitis A. After a period for public comment, the recommendations were approved unanimously by the voting ACIP members.** Summary of Key Findings Homelessness as an indication for hepatitis A vaccination. Little is known about HAV seroprevalence among homeless populations in the United States. Review of the literature found few studies that considered homelessness as an independent risk factor. Based on the evidence to recommendations framework, other considerations were assessed, such as recent HAV outbreaks ( 8 ), HAV-related hospitalizations and deaths, treatment costs for liver transplants, and the benefits and costs associated with HepA vaccination (https://www.cdc.gov/vaccines/acip/recs/grade/table-refs.html). These studies concluded that the benefits of vaccinating persons experiencing homelessness were substantial and the cost and risk of vaccinating persons experiencing homelessness is much lower than the risk of not vaccinating. The clinical trial and observational studies that were included in the GRADE review had several limitations, and some did not report any quantitative data. The studies had limitations in design and execution. No comparison/control groups were present, and there was a serious risk of bias, inconsistency, indirectness, and imprecision. Only one study was found with vaccine immunogenicity data among the homeless population, and it reported on a non-U.S. population. GRADE quality of evidence summary for HepA vaccine among homeless persons. The evidence assessing benefits and harms of administering HepA vaccine to prevent HAV infection in persons experiencing homelessness was determined to be GRADE evidence type 4 (i.e., evidence from clinical experience and observations, observational studies with important limitations, or randomized controlled trials with several major limitations) for benefits and for harms. The balance of consequences for the evidence to recommendation framework was determined to be that desirable consequences clearly outweigh undesirable consequences in most settings (https://www.cdc.gov/vaccines/acip/recs/grade/table-refs.html). Recommendation for Hepatitis A Vaccine for Persons Experiencing Homelessness All persons aged 1 year and older experiencing homelessness should be routinely immunized against hepatitis A (Box 1). Routine vaccination consists of a 2-dose schedule or a 3-dose schedule when combined hepatitis A and B vaccine is administered. BOX 1 Recommendations for routine preexposure use of hepatitis A vaccine — Advisory Committee on Immunization Practices All children at age 12–23 months. Persons traveling to or working in countries that have high or intermediate HAV endemicity. Persons who anticipate close contact with an international adoptee from a country of high or interme­diate endemicity during the first 60 days following arrival of the adoptee in the United States. Men who have sex with men. Users of injection and noninjection drugs. Persons with chronic liver disease. Persons with clotting factor disorders. Persons who work with HAV-infected primates or with HAV in a research laboratory setting. Persons experiencing homelessness. Anyone wishing to obtain immunity. Sources: CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2006;55(No. RR-7). CDC. Updated recommendations from the Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees. MMWR Morb Mortal Wkly Rep 2009;58:1006–7. Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: recommendations of the Advisory Committee on Immunization Practices for use of hepatitis a vaccine for postexposure prophylaxis and for preexposure prophylaxis for international travel. MMWR Morb Mortal Wkly Rep 2018;67:1216–20. Clinical Considerations Concern about loss to follow-up before HepA vaccine series completion should not be a deterrent to initiating the vaccine series in persons experiencing homelessness. One dose of HepA vaccine provides personal protection and can contribute to herd immunity, although long-term protection might be suboptimal ( 10 ). Multiple definitions of homelessness have been published in the United States; however, the definitions are similar in content. The U.S. Department of Health and Human Services definition is used for the purpose of this recommendation (Box 2). Because of the difficulty distinguishing the type of homelessness a person is experiencing (e.g., sheltered versus unsheltered) and the associated risks for HAV infection, all persons experiencing homelessness should routinely receive HepA vaccine. BOX 2 Homeless definition: U.S. Department of Health and Human Services A homeless person is defined as an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g., shelter) that provides temporary living accommodations and an individual who is a resident in transitional housing; without permanent housing who may live on the streets; stay in a shelter, mission, single-room occupancy facility, abandoned building or vehicle; or in any other unstable or nonpermanent situation; who is “doubled up,” a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members. In addition, previously homeless individuals who are to be released from a prison or a hospital may be considered homeless if they do not have a stable housing situation to which they can return. A recognition of the instability of an individual’s living arrangements is critical to the definition of homelessness. Sources: National Health Care for the Homeless Council. https://www.nhchc.org/faq/official-definition-homelessness/. U.S. Department of Health and Human Services [Section 330 of the Public Health Service Act (42 U.S.C., 254b)]. HRSA/Bureau of Primary Health Care, Program Assistance Letter 99–12, Health Care for the Homeless Principles of Practice. Rationale for Recommendation Advantages of HepA vaccine for persons experiencing homelessness. Persons experiencing homelessness might have difficulty implementing recommended nonvaccine strategies to protect themselves from exposure (e.g., access to clean toilet facilities, regular handwashing, and avoidance of crowded living conditions). For this reason, vaccination is the most reliable protection from HAV infection for persons experiencing homelessness. HepA vaccination of persons experiencing homelessness will provide individual protection and increase herd immunity over time, reducing the risk of large-scale, person-to-person outbreaks in this population. The recommendation facilitates routine HepA vaccination of persons experiencing homelessness through facilities that already provide health care services for the homeless population. Summary What is already known about this topic? Hepatitis A (HepA) vaccine is highly safe and effective, and a complete HepA vaccine series provides long-term protection against hepatitis A virus (HAV) infection. Person-to-person HAV outbreaks among persons using drugs or experiencing homelessness are widespread and ongoing. What is added by this report? All persons aged ≥1 year experiencing homelessness should be routinely immunized against HAV. Vaccination of homeless persons facilitates integration of HepA vaccine into routine preventive services. What are the implications for public health practice? HepA vaccination of homeless persons would improve protection of persons at increased risk of exposure to HAV and complications of hepatitis A disease and reduce the risk for large-scale outbreaks by increasing immunity to HAV among homeless persons living in congregate settings where HAV can spread readily.
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              Progress Toward Eliminating Hepatitis A Disease in the United States

              Hepatitis A virus (HAV) disease disproportionately affects adolescents and young adults, American Indian/Alaska Native and Hispanic racial/ethnic groups, and disadvantaged populations. During 1996-2006, the Advisory Committee on Immunization Practices (ACIP) made incremental changes in hepatitis A (HepA) vaccination recommendations to increase coverage for children and persons at high risk for HAV infection. This report examines the temporal association of ACIP-recommended HepA vaccination and disparities (on the absolute scale) in cases of HAV disease and on seroprevalence of HAV-related protection (measured as antibody to HAV [anti-HAV]). ACIP-recommended childhood HepA vaccination in the United States has eliminated most absolute disparities in HAV disease by age, race/ethnicity, and geographic area with relatively modest ≥1-dose and ≥2-dose vaccine coverage. However, the increasing proportion of cases of HAV disease among adults with identified and unidentified sources of exposure underscores the importance of considering new strategies for preventing HAV infection among U.S. adults. For continued progress to be made toward elimination of HAV disease in the United States, additional strategies are needed to prevent HAV infection among an emerging population of susceptible adults. Notably, HAV infection remains endemic in much of the world, contributing to U.S. cases through international travel and the global food economy.
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                10 May 2019
                10 May 2019
                : 68
                : 18
                : 413-415
                Affiliations
                [1 ]Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.
                Author notes
                Corresponding author: Monique A. Foster, ydg9@ 123456cdc.gov , 404-718-8561.
                Article
                mm6818a2
                10.15585/mmwr.mm6818a2
                6542191
                31071072
                b4d65e6e-8d21-4c14-a699-c173919a2014

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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