The Centers for Disease Control and Prevention (CDC) recently reported that several states across the US have witnessed a rise in outbreaks of hepatitis A, especially among homeless and people using injection or non-injection drugs.
As of December 1, California has reported 672 cases, of which 430 have been hospitalized, and 21 have died. San Diego, with the fourth largest community of homeless in the US, faces the brunt of this with 567 cases, 382 hospitalizations and 20 deaths. Santa Cruz and Los Angeles have also reported a rise in hepatitis A cases.
The outbreak in Southeast Michigan started in August 2016. By December 13, 2017, 610 cases had been reported, with 501 hospitalizations and 20 deaths. The City of Detroit and Macomb, Wayne, Oakland and St. Clair counties are most affected.
Other states with rising cases of hepatitis A are Utah and Kentucky. Arizona and Colorado have reported incidents of hepatitis A as a byproduct of the epidemic in California.
In October 2017, Governor Jerry Brown of California declared a statewide state of emergency in an attempt to procure funds and resources and mobilize services to manage the outbreak. The above mentioned California cities have declared the local outbreaks and have distributed more than 80,000 doses of the hepatitis A vaccine. The cause of the outbreak in Southern California is attributed to the large homeless population in this region of the country and the rise of unaffordable housing. Access to clean restrooms, bathing and laundry facilities is also a major factor.
According to the Detroit Free Press, the cause for the outbreak in Michigan remains unknown, though officials are probing links to the opioid and heroin crisis seen across the state. Macomb County Health Department Director Bill Ridella attributes approximately half the cases in the county to drug use. Michigan’s Department of Health and Human Services spokesperson Angela Minicuci stated, “Typically what we would see this time of year is about 14 times lower than what we’re currently dealing with.”
The hepatitis A virus is a highly contagious infection that affects the liver. The virus is transmitted via the fecal-oral route. From surfaces or food and water contaminated with the feces of infected individuals, the virus passes to susceptible people, infecting them. The virus is hearty and can persist for many months on surfaces. There is usually a 15- to 50-day incubation period before symptoms associated with liver inflammation, such as fever, nausea and vomiting, abdominal pain and jaundice, begin abruptly.
Laboratory abnormalities seen in hepatitis A patients include elevation in liver enzymes and bilirubin. Infected individuals are contagious during the incubation period and remain so for about a week after jaundice appears. Fulminant (sudden onset) hepatic failure usually occurs in less than 1 percent of infected individuals, but requires care at centers with liver transplantation capabilities. The course of the disease is usually self-limited, requiring supportive care. Once the disease runs its course individuals will develop immunity against future infections.
The hepatitis A vaccine is highly effective, but a majority of adults have not been inoculated. A shortage of the vaccine across the country has contributed to the difficulty of public health officials to contain the epidemic.
Currently, GlaxoSmithKline and Merck are the only two pharmaceuticals that are approved by the FDA to sell the vaccine in the US. In statements to the major news media, Merck is assuring the public they are working with the states and the CDC to shore up the shortages and ensure the vaccines are being distributed to needed regions. “At the end of October, we began shipping single-dose vials for adults, which previously had been on backorder,” Merck said. “We anticipate the availability of adult and pediatric pre-filled syringes of the vaccine in the first quarter of 2018.”
Since the introduction of the hepatitis A vaccine, there hasn’t been a large outbreak such as the present one for more than 25 years. The number of reported cases in the US from 2011 to 2015 had been essentially stable, ranging from a low of 1,239 cases in 2014 and 1,781 cases in 2013. This corresponds to a rate of about 0.4 cases per 100,000. In the current epidemic, the rate in Michigan has risen to approximately 5.3 and in California 1.7 cases per 100,000. Though vaccination rates for younger people had increased over the decade since its introduction, many older adults remain unvaccinated and susceptible.
The rise in homelessness in San Diego has been sharp, as home prices have climbed making finding affordable housing extremely difficult. Tent cities in the downtown area are proliferating, leading to conditions that predispose to hepatitis A epidemics. Additionally, it is estimated that about a half a million people in San Diego are simply a missed paycheck from homelessness.
The California Budget and Policy Center reported that around 8 million Californians, 1 in 5 residents, cannot adequately support themselves and their families. California has the highest poverty rate among the 50 states specifically because of the high housing costs. Two-thirds of 2-bedroom apartments in California rent for more than $1,500 per month.
According to the Washington Post, as a result of the budget crisis that haunted the state six years ago, Governor Brown directed funds marked for low-income housing construction toward debt servicing and schools. The city lost an estimated $200 million in affordable housing funds.
In Michigan, public health officials are not sure why the particular strain of the virus is so virulent. The number of deaths and rate of hospitalizations is considerably more than would be expected for hepatitis A. Also, no common source for the outbreak has been found. The Health Department has activated what they are calling the Community Health Emergency Coordination center to assist in coordinating multiple public health jurisdictions in their prevention responses to further cases.
Michigan ranks 15th in the nation for drug overdose deaths with 20.4 deaths per 100,000. The highest rates are in West Virginia, New Hampshire and Kentucky, with 30 to 40 deaths per 100,000. Besides the current epidemic of hepatitis A, the CDC is also reporting a rise in cases of hepatitis C. The blood-borne disease is being transmitted through the sharing of needles. According to the CDC, the number of new cases of hepatitis C nationwide rose from 853 in 2010 to 2,436 in 2015. Unlike hepatitis A and B, there is no vaccine for hepatitis C.
Such epidemics should not come as a surprise where the infrastructure to ensure public health and safety are woefully lacking. A study from 2009 conducted on the cost of housing and homelessness in Los Angeles found that the typical cost for services for residents in supportive housing was $605 a month, while costs for the homeless were $2,897 per month, which included funding of shelters and emergency room visits.