Hepatitis A Outbreaks and the Social Determinants of Health
“We need to create a culture where hand-washing is the thing to do, ... If we can just wash our hands, we will have an impact on some of the most common problems, as well as some of the most serious health problems we face.” Julie Gerberding, former director U.S. Center for Disease Control and Prevention
“It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.” Rudolph Virchow
Chances are you are unaware there’s been an alarming increase in the number of cases of hepatitis A throughout the United States. As of December 20, 2019, 30 states have reported 29,330 cases with 17,801 hospitalizations and 291 deaths since the uptick was first identified in 2016. Ignorance of the problem by most members of the general public is largely due to two factors. First, hepatitis A (also called infectious hepatitis) cases were previously in sharp decline due in part to a highly effective vaccine. Second, those most impacted by hepatitis A virus are for the most part out of our view—a growing number of homeless Americans without access to good sanitation.
What is hepatitis A? In the United States, viral hepatitis is most commonly caused by hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). These viruses all can result in acute disease with symptoms of nausea, abdominal pain, fatigue, malaise, and jaundice. While all three viruses cause acute inflammation of the liver, there are several notable differences. For one, HAV is usually transmitted person-to-person through the fecal-oral route or by consumption of food or water contaminated with feces. HBV virus, on the other hand, is usually transmitted sexually or through sharing contaminated needles by injection drug users. Similarly, injection drug use is the most common route of infection by HCV. Unlike HBV and HVC, which can cause chronic fatal liver disease, HAV usually resolves within 2 months without development of chronic liver disease.
How is HAV prevented? Another notable difference among the three most common hepatitis viruses is that for HAV and HBV, but not for HCV, effective vaccines are available and are recommended for routine use in early childhood. So, in part, the HAV outbreaks in recent years reflect underutilization of the HAV vaccine. Adequate chlorination of water, as recommended in the United States, and proper cooking of contaminated food kills the virus. (Worldwide in 2015, HAV occurred in 114 million people, most of whom had inadequate access to clean water and safe food.)
The current outbreaks of HAV in the United States are associated with a general breakdown of hygienic conditions, more specifically inadequate handwashing. Given that the virus is transmitted through the fecal-oral route, good hand hygiene—including handwashing after using the bathroom, changing diapers, and before preparing or eating food—is crucial to prevention of HAV.
The World Health Organization (WHO) has promoted a six step hand hygiene technique to ensure thorough cleansing of hands. In 2019, a musical mnemonic based on the popular nursery rhyme “Brother John” (also known as “Frere Jacques”) was reported to help school-aged children learn and remember the proper technique. But sadly, this program has no impact on those who need it most—the burgeoning number of homeless Americans.
What are the social determinants of health? At the end of the day, the re-emergence of HAV reflects a societal breakdown in the United States. An understanding of the important connection between social conditions and health can be traced to Rudolph Virchow, a 19th century German physician who at one and the same time was father of the disciplines of pathology and of social medicine. He carried the results of his research to the public arena by advocating medical care for the poor and improvement of public sanitation.
A Commission on Social Determinants of Health was established by the WHO in 2005 to support countries and global health partners in addressing the social factors leading to poor health and health inequities. Examples of social determinants of health include: income level, educational opportunities, occupation and employment status, gender inequity, racial segregation, social support, exposure to violent behavior, neighborhood conditions and physical environment, and access to safe drinking water, sanitation, and housing.
In January 2018, 552,830 people were counted as homeless in the United States. Of those, 194,467 (35%) were unsheltered. The overall homeless population on a single night represented 0.2 percent of the U.S. population, or 17 people per 10,000 in the population. The leading causes of homelessness were: (1) lack of affordable housing, (2) unemployment, (3) poverty, (4) mental illness, and (5) substance abuse.
While the potential solutions to the HAV outbreaks in the United States are, on the surface, quite simple—proper handwashing and universal use of the HAV vaccine—correcting the social determinants underlying the resurgence of HAV is another matter. There is no vaccine against poverty. And, it seems, society would just as soon wash its hands of homeless people.