ATLANTA -- All homeless people should be offered hepatitis A vaccinations, said members of the CDC's Advisory Committee for Immunization Practices (ACIP) in a unanimous vote here Wednesday.
ACIP members recommended 11-0 that all persons at least 1 year old who are "experiencing homelessness should be routinely immunized against hepatitis A."
With this vote, the committee essentially endorsed the hepatitis A workgroup's recommendation to add homelessness to the groups at increased risk of hepatitis A or severe hepatitis A disease. Current risk groups include travelers, men who have sex with men, and users of injection and non-injection illicit drugs.
Ultimately, the workgroup identified a number of benefits to this recommendation, including that providers would be more likely to administer vaccine to homeless persons if homelessness were an ACIP-indicated recommendation for vaccination -- and that this would protect a vulnerable population and "increase herd immunity over time."
Cost was also cited as a factor, with routine vaccination being "likely less costly than vaccination as part of an outbreak response." Recently, the CDC reported unrelated data showing that over 40% of hepatitis A infections in 2017 were connected to outbreaks. Hepatitis A outbreaks among the homeless, such as those in San Diego, have been a major public health concern regarding this disease for the past couple years.
At the meeting here, Noele Nelson, MD, of the CDC said that because the homeless population is not stable, it is important to adopt a "national approach" to vaccinating the homeless.
Chief concerns raised by the ACIP were the feasibility and practicality of implementing this recommendation, specifically regarding tracking of immunizations. ACIP member and hepatitis A workgroup chair Kelly Moore, MD, of Vanderbilt University in Nashville, said there has been "more of an effort in reporting adult immunization" to registries and state health departments as part of the multi-state response.
Liaison member Sandra Fryhofer, MD, of the American Medical Association, raised a question about the effectiveness of one dose of vaccine, due to the concern that homeless patients may not complete the two-dose series. Nelson responded that "based on modeling and experience, we believe that one-dose protection is longer than the 11 years presented" in a prior study.
Other questions raised by committee members included variable definitions of "homelessness," and uncertainty over how long it may truly last. Moore said these issues came up during the workgroup discussions, that "certain populations will be more at risk and more vulnerable."
"Using the [Department of HHS] standard definition allows clinical judgment to be exercised," she said, adding that the focus would be on clinics that provide services to the homeless and the implementation focus would hit those who were more likely to be homeless for a longer term. "We recognize that transient and unstable housing is difficult to predict, and we can provide guidance on who we consider to be ... the most critical to receive this [vaccine]."
In a separate vote on hepatitis A unrelated to homelessness, the ACIP agreed 11-0 to streamline prior language on catch-up vaccination as part of the Vaccines for Children program, which was voted on at the group's meeting in February.
As always, all ACIP recommendations are not considered final until they appear in the CDC's Morbidity and Mortality Weekly Report.
ACIP Approves 2019 Immunization Schedules
The 2019 vaccination schedules for adults and for children and adolescents added vaccines that were recommended in prior ACIP meetings, such as the use of live attenuated influenza vaccine (LAIV), a CpG-adjuvanted hepatitis B vaccine, as well as the already-mentioned indication for homelessness for hepatitis A vaccination.
A single vote was taken on both schedules and they passed unanimously, 11-0.
The new vaccination schedules underwent a cosmetic face-lift — with a redesigned cover page, new colors and a new streamlined format. Other changes included the addition of two new categories, particularly for pregnant women: delay vaccination until after pregnancy and “precaution,†where providers can weigh the risks and benefits of vaccination for a particular patient.
Other changes included a link about outbreak guidance on the front page, referring providers to public health authorities in the event of an outbreak.
Approval of the vaccination schedule is necessary prior to publication in the MMWR in January/February, and partner organizations including the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists also approve the schedules prior to publication.