Public Health Role of Academic Medical Center in Community Outbreak of Hepatitis A, San Diego County, California, USA, 2016–2018

Abstract

H epatitis A virus (HAV) is transmitted through the fecal-oral route either by person-to-person contact or by ingestion of contaminated food or water (1). With the availability of the hepatitis A vaccine in 1995 and the routine vaccination of children in highincidence states (including California) since 1999 and nationally since 2006, the incidence of HAV infection has declined dramatically in the United States (2,3). Hepatitis A vaccine is highly effective; it has a sero-conversion rate of ≈100% (4). Nevertheless, despite the substantial decline in HAV infection, sporadic cases and outbreaks continue to occur. During 2016-2018, San Diego County, California, experienced one of the largest hepatitis A outbreaks in the United States in 2 decades (5). This outbreak was characterized by hepatitis A spread through person-to-person contact among persons experiencing unstable housing situations with or without illicit drug use (5). Since 2017, similar outbreaks have been reported in 25 states; some of the index cases in those outbreaks were linked to San Diego. As of November 1, 2019, a total of 27,634 cases, 16,679 hospitalizations, and 275 deaths have been recorded in the United States (6). The public health response to the outbreak in San Diego focused on a 3-pronged strategy to vaccinate, sanitize, and educate (7). Local health systems, including University of California San Diego Health (UCSDH), closely and proactively collaborated with San Diego County Public Health (SDCPH) to participate in the outbreak control initiatives. We report the public health contribution of the academic medical center through the implementation of hospital-level prevention and outbreak management activities. Methods Study Setting Our study was a retrospective review of hepatitis A diagnoses and vaccinations administered by SD-CPH and UCSDH. SDCPH first declared a hepatitis A outbreak on March 8, 2017, and traced the first case to November 22, 2016 (Figure 1). The outbreak control vaccination initiatives began on March 10,

Strategies to improve vaccination rates in people who are homeless: A systematic review

“… (33) A final total of 23 articles were included. [30] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] .…”

“…); staff costs funded by hospital. [38] Automated computerised alert in emergency department (see [35] ; coincided with mass vaccination events, foot vaccination teams, mobile vaccination vans, targeted vaccinations at healthcare centres Hepatitis A (OUTBREAK) 1x hospital emergency department Not applicable 18 months; duration of Hepatitis A outbreak Healthcare workers in emergency department Regularly-scheduled emails to staff about Hepatitis A outbreak and vaccinations Communi-cations on hepatitis A published in community newsletters; nurses distributed information to at-risk populations; vaccination offered to eligible people at presentation Communi-cations on hepatitis A published in community newsletters; nurses distributed information to at-risk populations Not applicable None Vaccination of emergency department staff Not specified Not specified [39] Vaccination clinic Herpes zoster (ROUTINE) 1x homeless shelter clinic Not applicable; vaccination given at participant’s third appointment 2 years and 10 months, 5x immunisation days where vaccines administered Family physician; nurse Not specified Vaccination offered to eligible people at health appointments Physician delivered a 30-minute talk to shelter residents Not applicable None Alternative immunisation options – to be vaccinated at national retail chain pharmacy nearby, or to bring vaccination frozen from any outside pharmacy Participant insurance/co-payment; uninsured = vaccine manufacturer Not specified [5] Vaccination clinic Influenza – seasonal (ROUTINE) 1x crisis centre Not applicable At least 1 day per site Nurse immunisers Not specified Promotional materials sent to each site before each visit; vaccines were offered to clients at each site Not specified Not applicable None None Federal government funded under National Immunisation Program Not specified [40] Vaccination clinic Influenza – seasonal (ROUTINE) 1x day shelter Not applicable 1 da...…”

“…Three studies involved strategies to identify people experiencing homelessness as they presented to hospital emergency departments, to flag them for vaccination. [35] , [37] , [38] There were three instances where data from a single strategy was reported in > 1 article, so nineteen unique strategies are examined.…”

“… (50) Most (N = 19) involved vaccination for routine disease prevention; others involved disease outbreaks. [35] , [37] , [38] , [51] .…”

“… [34] , [36] Some strategies were delivered in healthcare settings, including primary clinics (standard or for under-served groups), [34] , [48] , [52] , [54] , [43] , [44] , [45] a clinic in a shelter, (39) and emergency departments. [35] , [37] , [38] One study reported vaccinations being delivered via pharmacies, hospitals, mass vaccination events, foot teams, and mobile vans. (38) .…”