Objective: Tuberculosis (TB) is a public health problem, especially among people experiencing homelessness (PEH). The Advisory Council for the Elimination of Tuberculosis issued recommendations in 1992 for TB prevention and control among PEH. Our goal was to provide current guidelines and information in one place to inform medical and public health providers and TB programs on TB incidence, diagnosis, and treatment among PEH. Methods: We reviewed and synthesized diagnostic and treatment recommendations for TB disease and latent TB infection (LTBI) as of 2022 and information after 1992 on the magnitude of homelessness in the United States, the incidence of TB among PEH, the role of public health departments in TB case management among PEH, and recently published evidence. Results: In 2018, there were 1.45 million estimated PEH in the United States. During the past 2 decades, the incidence of TB was >10 times higher and the prevalence of LTBI was 7 to 20 times higher among PEH than among people not experiencing homelessness. TB outbreaks were common in overnight shelters. Permanent housing for PEH and the use of rapid TB diagnostic tests, along with isolation and treatment, reduced TB exposure among PEH. The use of direct observation enhanced treatment adherence among PEH, as did involvement of social workers to help secure shelter, food, safety, and treatment for comorbidities, especially HIV and substance use disorders. Testing and treatment for LTBI prevented progression to TB disease, and shorter LTBI regimens helped improve adherence. Federal agencies and the National Health Care for the Homeless Council have helpful resources. Conclusion: Improvements in TB diagnosis, treatment, and prevention among PEH are possible by following existing recommendations and using client-centered approaches.

Background:People who use drugs are at increased risk for hepatitis A virus infection. Since 1996, the Advisory Committee on Immunization Practices has recommended hepatitis A vaccination for people who use drugs. Since 2016, the U.S. has experienced widespread hepatitis A outbreaks associated with person-to-person transmission.Purpose:To describe the prevalence of drug use, route of use, and drugs used among hepatitis A outbreak-associated patients.Methods:State outbreak and medical records were reviewed to describe the prevalence, type, and route of drug use among a random sample of 812 adult outbreak-associated hepatitis A patients from Kentucky, Michigan, and West Virginia during 2016-2019. Differences in drug-use status were analyzed by demographic and risk-factor characteristics using the X 2 test.Results:Among all patients, residents of Kentucky (55.6%), Michigan (51.1%), and West Virginia (60.1%) reported any drug use, respectively. Among patients that reported any drug use, methamphetamine was the most frequently reported drug used in Kentucky (42.3%) and West Virginia (42.1%); however, opioids were the most frequently reported drug used in Michigan (46.8%). Hepatitis A patients with documented drug use were more likely (p<0.05) to be experiencing homelessness/unstable housing, have been currently or recently incarcerated, and be aged 18-39 years compared to those patients without documented drug use.Implications:Drug use was prevalent among person-to-person hepatitis A outbreak-associated patients, and more likely among younger patients and patients experiencing homelessness or incarceration. Increased hepatitis A vaccination coverage is critical to prevent similar outbreaks in the future.

Background and Aims During 2016‐2020, the United States experienced person‐to‐person hepatitis A outbreaks that are unprecedented in the vaccine era, during which case–fatality ratios reported by some jurisdictions exceeded those historically associated with hepatitis A. Approach and Results To identify factors associated with hepatitis A–related mortality, we performed a matched case–control study (matched on age [±5 years] and county of residence in a 1:4 ratio) using data collected from health department and hospital medical records of outbreak‐associated patients in Kentucky, Michigan, and West Virginia. Controls were hepatitis A outbreak–associated patients who did not die. There were 110 cases (mean age 53.6 years) and 414 matched controls (mean age 51.9 years); most cases (68.2%) and controls (63.8%) were male. Significantly (P < 0.05) higher odds of mortality were associated with preexisting nonviral liver disease (adjusted odds ratio [aOR], 5.2), history of hepatitis B (aOR, 2.4), diabetes (aOR, 2.2), and cardiovascular disease (aOR, 2.2), as well as initial Model for End‐Stage Liver Disease (MELD) score ≥ 30 (aOR, 10.0), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio > 2 (aOR, 10.3), and platelet count < 150,000/μL (aOR, 3.7) among hepatitis A outbreak–associated patients in the independent multivariable conditional logistic regression analyses (each model adjusted for sex). Conclusions Preexisting liver disease, diabetes, cardiovascular disease, and initial MELD score ≥ 30, AST/ALT ratio ≥ 1, and platelet count < 150,000/μL among hepatitis A patients were independently associated with higher odds of mortality. Providers should be vigilant for such features and have a low threshold to escalate care and consider consultation for liver transplantation. Our findings support the recommendation of the Advisory Committee on Immunization Practices to vaccinate persons with chronic liver disease, though future recommendations to include adults with diabetes and cardiovascular disease should be considered.

Background: Safe and effective hepatitis A vaccines have been recommended in the United States for at risk adults since 1996; however, adult vaccination coverage is low. Methods: Among a random sample of adult outbreak-associated hepatitis A cases from three states that were heavily affected by person-to-person hepatitis A outbreaks, we assessed the presence of documented Advisory Committee on Immunization Practices (ACIP) indications for hepatitis A vaccination, hepatitis A vaccination status, and whether cases that were epidemiologically linked to an outbreak associated hepatitis A case had received postexposure prophylaxis (PEP). Results: Overall, 74.1% of cases had a documented ACIP indication for hepatitis A vaccination. Fewer than 20% of epidemiologically linked cases received PEP. Conclusions: Efforts are needed to increase provider awareness of and adherence to ACIP childhood and adult hepatitis A vaccination and PEP recommendations in order to stop the current person-to-person hepatitis A outbreaks and prevent similar outbreaks in the future. Published by Elsevier Ltd.

Hepatitis A virus (HAV) genotype IA was most common among strains tested in US outbreak investigations and surveillance during 1996–2015. However, HAV genotype IB gained prominence during 2016–2019 person-to-person multistate outbreaks. Detection of previously uncommon strains highlights the changing molecular epidemiology of HAV infection in the United States.

Background. Since 2016, the United States has experienced person-to-person hepatitis A outbreaks unprecedented in the vaccine era. The proportion of cases hospitalized in these outbreaks exceeds historical national surveillance data. Methods. We described the epidemiology, characterized the reported increased morbidity, and identified factors associated with hospitalization during the outbreaks by reviewing a 10% random sample of outbreak-associated hepatitis A cases in Kentucky, Michigan, and West Virginia-3 heavily affected states. We calculated descriptive statistics and conducted age-adjusted log-binomial regression analyses to identify factors associated with hospitalization. Results. Participants in the random sample (n = 817) were primarily male (62.5%) with mean age of 39.0 years; 51.8% were hospitalized. Among those with available information, 73.2% reported drug use, 14.0% were experiencing homelessness, 29.7% were currently or recently incarcerated, and 61.6% were epidemiologically linked to a known outbreak-associated case. Residence in Michigan (adjusted risk ratio [aRR] = 1.8), being a man who has sex with men (aRR = 1.5), noninjection drug use (aRR = 1.3), and homelessness (aRR = 1.3) were significantly (P<.05) associated with hepatitis A-related hospitalization. Conclusions. Our findings support current Advisory Committee on Immunization Practices recommendations to vaccinate all persons who use drugs, men who have sex with men, and persons experiencing homelessness against hepatitis A.

Strategies for Successful Vaccination Among Two Medically Underserved Populations: Lessons Learned From Hepatitis A Outbreaks Martha P. MontgomeryMD, MHS, Maribeth EckertMPH, Megan G. HofmeisterMD, Monique A. FosterMD, Mark K. WengMD, MSc, Ryan AugustineMPH, Neil GuptaMD, and Laura A. CooleyMD Affiliation The authors are with the Centers for Disease Control and Prevention, Atlanta, GA. Martha P. Montgomery, Megan G. Hofmeister, Monique A. Foster, Mark K. Weng, Ryan Augustine, Neil Gupta, and Laura A. Cooley are with the Division of Viral Hepatitis. Maribeth Eckert is with the Immunization Services Division. CopyRightCorrespondence should be sent to Martha P. Montgomery, MD, MHS, 1600 Clifton Rd, MS US12-3, Atlanta, GA 30329 (e-mail: lwx6@cdc.gov). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link. CONTRIBUTORS M. P. Montgomery was responsible for writing the original draft and overseeing the editing. M. Eckert, M. G. Hofmeister, M. A. Foster, M. K. Weng, and R. Augustine were responsible for writing, reviewing, and editing the article. N. Gupta was responsible for conceptualization and writing, reviewing, and editing the article. L. A. Cooley was responsible for conceptualization, writing the original draft, and providing supervision. https://doi.org/10.2105/AJPH.2021.306308 Accepted: March 24, 2021 Published Online: August 31, 2021

In March 2018, the Kanawha-Charleston Health Department (KCHD) in West Virginia began investigating a cluster of reported hepatitis A virus (HAV) infections. Twelve specimens tested by CDC’s Division of Viral Hepatitis laboratory confirmed that patients were infected with an HAV strain (genotype 1B) reported in ongoing hepatitis A outbreaks in multiple states, primarily among persons who use drugs and persons experiencing homelessness (1). In August 2018, because of ongoing reporting of cases, the West Virginia Bureau of Public Health requested epidemiologic assistance from CDC in responding to the outbreak. Upon retrospective review, KCHD identified a total of 664 outbreak-associated hepatitis A cases that occurred from January 1, 2018 to August 28, 2018. Outbreak cases met the 2012 Council of State and Territorial Epidemiologists’ case definition for an acute hepatitis A infection* and had either an epidemiologic link to an identified outbreak case, a laboratory specimen matching the outbreak strain, or occurred in a person at high risk for infection (e.g., reported injection or noninjection drug use, experienced homelessness or unstable housing, or was recently incarcerated) or who resided in a county where the outbreak genotype had been previously identified through laboratory testing. Median age of the patients was 37 years (range = 14–77 years); 398 of the patients (60%) were male, 380 (57%) were hospitalized, and one (0.1%) died. Current or past illicit drug use was reported by 540 (81%) patients, and being homeless or having a transient living situation was reported by 100 (15%). Evidence of past or current hepatitis C virus infection was identified in 314 (47%) outbreak-associated cases, and 65 (10%) patients had evidence of past or current hepatitis B virus infection. HAV is typically shed in the stool of infected persons and primarily spread by the fecal-oral route, either through direct person-to-person contact or consumption of contaminated food or water. In this outbreak, transmission was primarily person-to-person among persons with a current or past history of injection or noninjection drug use.

Objective To estimate the cost of establishing and operating a comprehensive syringe service program (SSP) free to clients in the United States. Methods We identified the major cost components of a comprehensive SSP: (one-time start-up cost, and annual costs associated with personnel, operations, and prevention/medical services) and estimated the anticipated total costs (2016 US dollars) based on program size (number of clients served each year) and geographic location of the service (rural, suburban, and urban). Results The estimated costs ranged from $0.4 million for a small rural SSP (serving 250 clients) to $1.9 million for a large urban SSP (serving 2,500 clients), of which 1.6% and 0.8% is the start-up cost of a small rural and large urban SSP, respectively. Cost per syringe distributed varied from $3 (small urban SSP) to $1 (large rural SSP), and cost per client per year varied from $2000 (small urban SSP) to $700 (large rural SSP). Conclusions Estimates of the cost of SSPs in the United States vary by number of clients served and geographic location of service. Accurate costing can be useful for planning programs, developing policy, allocating funds for establishing and supporting SSPs, and providing data for economic evaluation of SSPs.