An alarming number of hepatitis A cases have swept across southeast Michigan since August 2016 in what public health officials said is one of the largest outbreaks to occur in the United States since a vaccine was widely introduced two decades ago.
In 2017 alone, Michigan has led the nation in hepatitis cases per capita, according to a Free Press analysis. More than 500 cases have been reported this year.
The far-reaching outbreak — which has heavily impacted Wayne, Macomb and Oakland counties — has created a coalition of sorts among local and state officials who are working to keep the disease from spreading among the region’s most vulnerable, at risk populations. Detroit and Macomb County have the highest rate of outbreak related cases at about 2 cases per 10,000 residents.
The cause of the outbreak is not yet known but officials say they're probing a link to the ongoing opioid and heroin crisis seen across Michigan, as well as other potential exposure routes.
"We're continuing to see new cases almost every day so it is a concern," said Macomb County Health Department Director Bill Ridella. "I think there is a strong connection to a number of these cases with the opioid and heroin problem. About half of the cases in Macomb County has some connection with drug use and/or heroin."
But state officials said since other exposure routes have been found, it hasn't been easy to discern the exact origin.
"Typically what we would see this time of year is about 14 times lower than what we’re currently dealing with," said Angela Minicuci, Michigan Department of Health and Human Services spokesperson. "I don’t know if we’ve seen a hepatitis A outbreak like this before."
To put the outbreak in perspective, Wayne County's Department of Health, Veterans & Community Wellness Medical Director Ruta Sharangpani said only two to three cases are typically seen in a given year within the county.
And a shortage of vaccinations across the country has also created an uphill battle for public health officials. The Centers for Disease Control is exploring options to increase vaccine supply, and one manufacturer has said it might be able to supply more to support the demand. Since hepatitis A is a vaccine-preventable illness, officials are urging people to speak with their medical providers to determine if they should obtain it.
"The demand for adult hepatitis A vaccine(s) has increased substantially over the past six months and vaccine supply to meet this unexpected demand in the U.S. has become constrained," the CDC said in a statement to the Free Press. "While CDC and state/local public health officials are targeting vaccine to manage outbreaks and carry on routine vaccination, current supply is not sufficient to support demand for vaccine."
20 deaths reported in Michigan
Hepatitis A is a serious, highly contagious liver disease caused by the hepatitis A virus, according to the CDC. HAV is found in the feces of people with hepatitis A and can be spread by eating contaminated food or water or during sex. The risk also increases by living with someone who has been infected.
Illness can appear 15-50 days after exposure and an individual can be sick for several weeks. Symptoms include nausea and vomiting, abdominal pain, yellowing of the skin and eyes.
Statewide, there have been 20 deaths associated with the current hepatitis A outbreak which began Aug. 1, 2016.
Eight of those deaths were Detroit residents who had a case of hepatitis A when they died.
Detroit Health Department Director Dr. Joneigh Khaldun said while she can’t share specific information about the eight reported deaths due to privacy laws, she said some of the individuals may have had other underlying illnesses that ultimately led to their deaths.
“Someone who died might have had hepatitis A and it’s not necessarily the reason for their actual death,” Khaldun said. “To pick apart every single death that had an association with hepatitis A, I think that is not the real point here. The most important point is we want to make sure we’re protecting our citizens. We want to make sure we’re getting ahead of it and vaccinating. We want to make sure that our clinicians are being very vigilant and looking for people who might have symptoms so we can get ahead of this outbreak. That’s the most important thing to talk about.”
Three deaths also each occurred in Macomb, Oakland and Wayne counties (not including Detroit) -- for a total of 9 additional deaths associated with the outbreak. While one death associated with hepatitis A happened in Ingham, Livingston and Monroe counties.
Minicuci says there's usually about a one-year lag from the date of death to when the state compiles and releases information on the number of deaths caused by hepatitis A.
Yet, in an e-mail to the Free Press she shared that death certificates are available for 18 of the 20 deaths and "six of the 18 specifically list hepatitis A." Three list a cause of death related to liver failure or liver disease and nine died while hospitalized with hepatitis A or within 30 days of discharge.
People who have died from the disease tend to be older with a median of 58 years old, according to an analysis by the state.
There are usually very few deaths caused solely by hepatitis A.
Between 2011 and 2016 there were four deaths determined to be caused by hepatitis A in the state, three deaths in 2013 and one in 2016, according to vital statistics data.
But Minicuci said Michigan isn’t the only state experiencing an outbreak of some nature.
“It’s certainly something that we’re treating as a very unique situation here in Michigan but so are a lot of other states nationally,” Minicuci said.
In Michigan, in 2017 alone, the state had 527 cases, which is a rate of 5.3 per 100,000 residents. Other states being monitored by the CDC during the current outbreak include: Utah with 101 cases this year- a rate of 3.3 per 100,000 residents; California with 666 cases, or 1.7 cases per 100,000 residents; and Kentucky with 31 cases -- a rate of 0.7 cases per 100,000 residents. California has reported 21 deaths since the outbreak began.
In 2015, the latest nationwide data available, there were 1,390 hepatitis A cases - a rate of 0.4 cases per 100,000 people, according to the CDC.
The CDC stated in an e-mail that Michigan's outbreak is unrelated to the one in California but similar in terms of the affected population - mainly homeless people and people who report drug use. According to the CDC, an outbreak in San Diego led to outbreaks of hepatitis A in other California cities, Arizona and Utah.
“The outbreak is caused by related strains of the same hepatitis A virus genotype (IB),” the CDC said in a statement to the Free Press. “These strains are not commonly seen in the United States, but are common in other parts of the world. … While what is occurring in Michigan and San Diego, a large community wide outbreak, has not happened in the last 25 years (since the widespread use of vaccine), outbreaks of this nature have occurred historically.”
Just under half, 48%, of cases in Michigan are related to drug use and a majority of cases are men -- 65%. About 12% of individuals with the disease are homeless.
Macomb County District Judge Linda Davis, president of the grassroots organization Families Against Narcotics (FAN), said she's not surprised by a potential link to the opioid and addiction crisis.
"There's going to be lots of consequences (of the crisis,)" Davis said. "It's not just hepatitis A, it's AIDS, it's hepatitis A, B and C, they are all aftermaths of addiction. A large number of the people in drug courts and that we just deal with generally through FAN have hepatitis A and have been treated for it or awaiting treatment for it. The numbers are large."
Among hepatitis A outbreak cases, about 1 in 3 cases, 31%, have a history of hepatitis B or C.
Hepatitis and the food industry
Many in the public learn of hepatitis cases only when someone who works in the food service industry is diagnosed with having it. Since August of last year, local health departments have sent out regular releases, alerting the public to new cases at restaurants across the tri-county area.
At the end of November, the Detroit health department announced a Greektown Casino employee had been diagnosed with hepatitis A. The announcement came just two days after it announced a separate case at a McDonald's on West Grand Boulevard.
And just last week, Oakland County announced an employee at a Papa Romano's in Southfield had been diagnosed with hepatitis A. Oakland County announced last week that it plans to hold two clinics aimed at vaccinating food service workers.
As the cases continue to roll in, Dr. Katherine Reyes, medical director of Infection Prevention & Control for the Henry Ford Health System, said she's been troubled by the high number of hospitalizations in connection with the outbreak. About 83% of cases have included hospitalization, according to the latest data from the state.
Other at risk populations include people who have close contact with someone who has hepatitis A, gay men, travelers to countries with high or medium rates of hepatitis A and people with chronic liver disease.
"We have had patients admitted with hepatitis A," Reyes said. "We have seen a number who come in with symptoms and the diagnosis is made during admission. We have also had patients who were transferred to us with known diagnosis of hepatitis A and are getting transferred for escalation of care. ...This is tragic."
Response to the outbreak
Multiple counties across the region have taken similar, proactive approaches to the outbreak. According to the MDHHS, the best way to reduce the risk of getting hepatitis A is to receive two doses of the vaccine. Proper hygiene, including thorough hand-washing, is also urged.
In Detroit, Khaldun said her department has been on the ground working with not just at-risk populations but also local hospitals, clinics and individuals who work within the community such as police and emergency technicians.
In November, health officials announced a case of hepatitis A had been found in a worker at the Detroit Water and Sewerage Department but officials said it was a single instance.
"We’ve done over 20 outreach clinics in the community," Khaldun said. "We also are working internally with various city agencies. ... We’re actually vaccinating all of the city’s first responders, EMS, Detroit Water and Sewerage, and the police department. There's been no indication that those agencies are the cause of the outbreak or have spread it in anyway but we’re doing it as precautionary measure. We’re also working with our food service workers across the entire city."
Detroit Recovery Project, a multi-service agency that has provided a variety of support services to Detroit's recovery community for the past 10 years, has been working hand-in-hand with the city's health department to increase awareness of the outbreak and reach some of the at-risk population.The recovery project has two locations, one on the east side of the city and the other on the west, and averages about 400 to 500 clients a month, who are battling varying degrees of drug or alcohol addiction.
"We’re kind of boots on the ground because of the work we do," said Andre Johnson, president of Detroit Recovery Project near McNichols and I-75 . "You see where we’re located, we’re in the belly of the beast. Hepatitis has been known to be a silent killer in urban communities for many years. Unfortunately, Detroit, we get the brunt of everything. So this (outbreak) doesn't surprise me. ... Our program is about infusing hope and providing them with the tools to sustain long-term recovery."
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