Outbreaks of hepatitis A on at least three continents suggest a preventable public-health crisis for the homeless and men who have sex with men worldwide.
One of the downstream effluents of thinking you’ve gotten on top of a disease is complacency. We’ve seen it recently with polio, which is making a worrying comeback on the islands of Africa.
Then there are the sexually transmitted diseases (STDs), which no one thought we had gotten on top of. Still, public information about “safer” and “protected” sex during the peak years of the AIDS epidemic did seem to be making them submit. Now that anti-retrovirals have, in the world’s more developed zones, domesticated HIV, the big cats such as syphilis and gonorrhea are baring their claws again more menacingly.
Of late it’s been Hepatitis A, which is dangerous and potentionally fatal, coming back for another life, making what in principle could be a perfectly preventable return. It’s transmitted among humans by contact with and contamination from human feces. Adequate hygiene and an effective vaccine that’s been in place for nearly two decades should long ago have shown it the one-way, going-out cat door.
Nevertheless, there have been two greatly worrying outbreaks in the prosperous, “first-world” countries and cultures. Well, within their borders, and then across their borders.
Last summer, health service networks in southern California started putting out the word that sexually active men should be sure to get vaccinated for hepatitis A. That followed an outbreak of the disease among the populations of homeless people and "street"-drug users in San Diego, then Los Angeles counties.
Cases were on the rise in numbers not seen since the introduction of the vaccine, and the deaths from it were topping this-century levels by a disturbing margin. California Governor Jerry Brown declared a state of emergency. The outbreak is being addressed as it had not been, but no one would call it under control.
Independently, at least so it appears, an outbreak of hepatitis A among gay men and other men who have sex with men (MSM) across Europe led the World Health Organization (WHO) to issue a warning on June 7. It reported an alarming case spike from June 2016 to May 2017, with infections breaking out in 15 European countries, the U.S., and Chile.
The report stressed that the virus could be spread through sexual contact, particularly but not only oral-anal. It also noted that outbreaks seemed to some degree correlated with international gay-pride celebrations to which men traveled.
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Are the two outbreaks connected or related?
To this point, such connection seems more anecdotal than clinically demonstrable. For one thing, the hepatitis A virus sweeping American homeless communities—eventually, across the country—was of a single, familiar strain. Three strains of hepatitis A are circulating in Europe and the Americas among MSM.
The American LGBT magazine The Advocate was among the earlier media instututions sounding the warning out a potentially disastrous outbreak. It’s not to denigrate their reporting that we call attention to a grammatically unfortunate sentence in its November 12 article: “And men who have sex with men, in addition to homeless people, first responders, and members of law enforcement, are considered an at-risk group.”
With "in addition to," you can see the effort to break the series, such that it does not issue its warning to “men who have sex with men, homeless people, first responders, etc." But it also points to the seemingly deep illogic of gay men having, or seeking, sex with the homeless, etc. Therein lurk dangerously misleading stereotypes.
Roll up the stigmas and stereotypes, and it’s nearly a comic idea that gay men (at least as represented in movies and on TV today) would seek or tolerate sex with filthy, disgusting homeless trolls. Retract the slurs all around, and a different picture emerges.
A point of contact between the two “communities” surrounding the sales and consumption of “street drugs,” particularly injectables, becomes plausible. But so does a sex-based point of contact when you merely subtract the stereotype of the homeless person as only someone living in a cardboard box without a change of clothes.
The “homeless” now include men worldwide who either lived or now live in poverty themselves and who have sex with men. This now so famously includes the refugee populations in Europe that movies and TV shows are being made about that nexus, with its inherently dramatic (and sexy) dangers. A far-less-discussed interface is that between indigent, refugee, and otherwise poor men willing to supply sex for money and the men seeking those sub-groups for cheap sex.
Another stereotype about the homeless in affluent cultures is that they are, nearly by definition, at the end of the line. Going nowhere. But public-health officials now addressing the crisis find that one of their principal challenges is the mobility of the population.
Add to that there is another equally misleading over-generalization, to which there is also obvious, documentable proof: Gay men famously travel.
The hepatitis A basics
In response to the recent outbreaks, the California Department of Public Health has issued a helpful review.
Perhaps the most important to keep in mind is that “Hepatitis A virus is spread when virus is ingested by mouth from contact with hands, objects, food, or drinks that are contaminated by the feces of an infected person.”
One of the things that means is that it could be spread by food-preparers at fast-food restaurants where, increasingly, poor and ill-paid food preparers work. It also means that it could be spread by food preparers anywhere, including at five-star restaurants, depending wholly on where their hands (and fingernails) have been, and how careful they are about hand-washing.
Symptoms include fever, jaundice, lack of appetite, and nausea. The time period between infection and showing symptoms ranges from 15 to 50 days. Infected people are most contagious in the two weeks prior to the yellowing of the skin (and sometimes eyeballs). The hepatitis A virus is “hardy” and can live for months outside the body.
It concludes, verbatim:
“Common risk factors for hepatitis A include: traveling to a country where hepatitis A is common, being in the same household as or having sexual contact with a person with hepatitis A, being a man who has sex with men, and using illicit drugs (whether injected or not).
“Hepatitis A outbreaks can be the result of people passing the virus from person-to-person when an infected person starts a chain of transmission in a population or from a group of people being exposed to a common source such as contaminated food.”
A not infrequent irony in such cases is that precisely because there is an effective vaccine, one that gives immunity within one to two doses, people become complacent about the illness—and don’t get vaccinated. When outbreaks spike, supplies of the vaccine are often short at hand.
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The outbreak among the homeless
The dire health conditions among America’s homeless would have included late reporting of the outbreak of the single strain within the population. The presence of the homeless in American cities is now perceived by the public, and most politicians, as an intractable problem, a feature of the landscape that cannot be eliminated. The solution, such as it can be called that, is a resentful “Walk on By,” even on the part of people whose natural inclination would be to help.
America’s onetime “war on poverty” has, in the opinion of many observers, morphed into a war on the poor. The most desperate of the poor are, ironically, in makeshift “communities” of the urban homeless. There, inadequate sanitation, when any, and lack of access to clean toilets, if any, creates a staging ground for hepatitis A.
Perhaps tellingly, the factor most often cited for inadequate or interrupted vaccination programs worldwide is war, or prolonged conflict. Public-health officials, even at their most intent on getting the homeless population vaccinated, find comparable "war" scenarios in their work. They are faced with the difficulties of getting to populations that, however stuck socio-economically, are at once highly mobile and unhealthily concentrated in small spaces.
Revitalizing vaccination programs for hepatitis A in homeless communities shows promise, both because it is not costly and the target populations are, by and large, amenable to vaccination when not outright avid for it. It is clear, however, that until sanitation, arguably including portable showers, is improved, the source of the virus itself remains—this the most ironic of words—protected.
The outbreak among MSM
Recently enough—before it was hobbled by a political administration hostile to both the poor and the LGBT populations—the CDC estimated that 10% of the cases of hepatitis A annually were in the LGBT and MSM populations. The outbreaks in those communities internationally are recent enough that simplistic explanations for them would be premature.
That said, it is not to be judgmental about specific sexual practices to note that sex between—and, the more so, among—men is associated with some vulnerabilities to the hepatitis A virus that are, if not unique to men, anecdotally far more common to those sub-groups. Oral-anal contact (“rimming”) poses the most conspicuous risk. Oral contact with a penis that has previously penetrated an anus is equally unsafe.
Lack of awareness and even basic knowledge about the transmission of sexually transmitted viruses among men who have sex with men in many, mostly poorer, regions of the world remains a fundamental problem. It asks more public education coordinated with access to appropriate medications and vaccines.
We’re not breaking any news here to observe that, in the “developed world,” the welcome breakthroughs in treatment of HIV with anti-retrovirals has brought with it a decline in the emphasis on protected, “safe” sex among gay men. The concomitant, pronounced increase in cases of STDs, particularly including syphilis and gonorrhea, among gay men and MSM is well documented.
Outbreaks of “treatable” Hepatitis B among sexually active gay men and MSM were prevalent features of the pre-HIV landscape. The more dangerous and, until very recently, untreatable Hepatitis C, similarly brought with it more public information, and weaponized fear. The resurgence of treatable, preventable, but still potentially lethal Hepatitis A slipped back in the shadows of far scarier viruses.
Word is getting out through established channels in the LGBT health community about the recent hepatitis A outbreak and the importance of vaccination for all sexually active men. Whether it's soon enough remains to be seen.
It’s not too much to hope that the social media that drive the recreational-drug-fueled “party scene” worldwide—only heightened at pride festivals that draw international crowds—could co-ordinate the urgent public-health message.
There is now a very real outbreak of hepatitis A worldwide. Methods of preventing it are well known, and an effective vaccine is available. And a virus so long contained or controlled that general populations have become complacent about it has once again reared its potentially death-dealing head.
The outbreak in general and among the homeless:
The outbreak specifically among MSM:
https://www.aidsmap.com/Hepatitis-A-outbreak-in-gay-and-bisexual-men-in-Europe-is-growing/page/3153278/ [particularly good and informative]
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