Michigan has been hit particularly hard amid a series of ongoing outbreaks of hepatitis A which have affected several other states including Utah, Arizona, Kentucky, and California. California has experienced over 672 cases, with at least 430 requiring hospitalization and 21 resulting in death.
The Center for Disease Control (CDC) has stated that the outbreak in Michigan is unrelated to the one in California but that both outbreaks have been similar in terms of affected population. That is, primarily the homeless and those reporting drug use have been affected.
From August of 2016 to December 23 of this year, approximately 630 cases of hepatitis A were reported throughout the state of Michigan, concentrated in the southeastern portion of the state which includes the Detroit metropolitan area. More than 500 of these cases occurred in 2017 alone, giving Michigan the highest per capita rate of hepatitis A in the US. Of those 630 cases, 517 have required hospitalization and 20 have resulted in death.
The death rate of those affected is approximately 3.2 percent and the hospitalization rate is approximately 82 percent. These rates are far beyond what has occurred in past outbreaks of hepatitis A. Between 2011 and 2016 there were four deaths determined to be caused by hepatitis A in the state, three in 2013 and one in 2016.
In a presentation to county commissioners, Midland County Health Director Mike Krecek stated that infected individuals do not typically die from hepatitis A.
“People are dying from this and that is not normally the case with [hepatitis A],” Krecek said. “Usually that number is zero and we see a hospitalization rate of around 4 percent. This is a much stronger strain than we are accustomed to.”
Health officials have not yet been able to determine why the current strain of the virus is particularly virulent, nor have they been able to identify the source of the outbreak—either in Michigan or elsewhere nationwide.
“The incubation period of at least 15 days makes it very hard to trace things back,” Krecek noted. “If you suspect food, you have to think about what you ate 15 days ago, 16 days, 18 days. It’s very challenging.”
Those considered high risk for hepatitis A include the homeless or those in transient living, those with a substance abuse history, users of injectable or non-injectable drugs, those in close contact with someone who has the virus, individuals with multiple sex partners and men having sex with men. People who have died from the disease tend to be older with a median age of 58 years old.
But more and more individuals not fitting in the high-risk categories are becoming infected with the hepatitis A virus. Livingston County Medical Director Dr. Don Lawrenchuk stated that many of those infected have just been exposed to the virus—whether through person to person contact or contaminated food or water.
As a result of the outbreak a number of counties have expanded clinics to increase the number of individuals receiving vaccinations. Over 1,800 people were vaccinated in the week between December 12 and 19 in Monroe County just south of the Detroit metro area.
A majority of Americans under the age of 20 have received the vaccine, which is highly effective and provides lifetime immunity, as a part of routine childhood immunizations. Health officials have expressed the greatest concern over those over the age of 20, as most likely have not gotten the vaccine and are thus at risk of getting the disease now as a result of the outbreak.
However, the effort to vaccinate the most at-risk populations has been hindered by a nationwide shortage of the hepatitis A vaccine. Detroit Health Department Director Dr. Joneigh Khaldun reported that the department has had to turn to purchasing vaccines from private vendors. This has only somewhat alleviated the problem as there is a limit to how many doses can be purchased. “[W]e’ve literally been everyday purchasing 400 [doses], our max,” Khaldun told a conference call of health professional last week, according to Michigan Radio.
High-risk populations have been targeted for vaccination as well as Detroit city workers who routinely cross paths with the high-risk, or have the potential to contaminate water supplies or otherwise spread the disease. The vaccination effort has been expanded now to include the vaccination of food service workers.
In Detroit, city officials have denied that the high death rate has been a result of the hepatitis A outbreak. Khaldun has claimed that of the 8 deaths in Detroit, it cannot be stated that all 8 individuals died from hepatitis A. However, all 8 individuals were infected with the recent strain of hepatitis A, as well as the 12 other reported deaths throughout the state.
Khaldun also stated that mass sanitation efforts, like the sanitization of sidewalks in San Diego, are not worth conducting in Southeast Michigan because the high-risk population is more dispersed. In addition, Khaldun denied any connection between the mass water shutoffs that the city of Detroit has conducted over the last few years, and the spread of the disease.
Earlier this year in July, however, a panel of experts gathered at the Wayne State University (WSU) Law School in Detroit to call for a declaration of a public health emergency in the city. This was done after a study conducted by Henry Ford Hospital researchers examined samples from hospital patients with skin and soft tissue infections and water-borne bacterial infections.
The study, which was performed by three Henry Ford researchers using block-level address data, analyzed 37,441 cases of water-borne illness in Detroit and compared those cases with Detroit addresses whose water was shut off during the same time period.
It was found that patients diagnosed with skin and soft tissue diseases were 1.48 times more likely to live on a block that experienced water shutoffs. Despite denials about the conclusiveness of the study several doctors, educators, civil rights advocates and a city resident called for the declaration of a public health emergency.
“Water-related diseases are now occurring in Detroit as the result of water shutoffs,” stated Dr. Wendy Johnson, clinical assistant professor at the University of Washington, at the conference at WSU. “Access to clean and safe water is a basic human right that is essential from a public health standpoint to prevent infectious diseases. We have run out of time and solutions must be immediate.”
Johnson went on to explain that people without access to water tend to wash their hands less frequently and are, consequently, at higher risk of contagious diseases and water-borne illness, such as methicillin-resistant staphylococcus aureus, or MRSA. Those cut off from clean drinking water suffer more from dehydration, which puts diabetics and heart disease patients at higher risk of serious illness, she said.