What You Need to Know: West Virginia’s Action to the Nationwide Hepatitis A Outbreaks

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the United States wrestles with widespread outbreaks of hepatitis A; we'll find out what's being done to stop the spread of the infection and hear from one state that has weathered the worst.

DR. NEIL GUPTA:
One thing that's been really striking in this outbreak is that we've seen that in 60% of the reported cases of hepatitis A, the patients have been hospitalized, which is really quite staggering. When we look historically, these hospitalization rates are much higher than what we have seen previously.

DR. CATHY SLEMP:
I think understanding the role of vaccine and quickly moving to using vaccine broadly in the population is key in these outbreaks.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: coping with outbreaks of hepatitis A in 30 states; helping those hit hardest—people who use drugs and those experiencing homelessness; getting them immunized to stop the spread of infection.

Among those, West Virginia saw its number of reported cases skyrocket from only a handful to more than 2000; but thankfully, the state now appears to have the worst behind it. We'll talk about that with Dr. Cathy Slemp, commissioner and state health officer for the West Virginia Bureau for Public Health.

But first, we get the national view from Dr. Neil Gupta, the incident manager for the hepatitis A outbreak response and the chief of the epidemiology and surveillance branch in the division of viral hepatitis at the Centers for Disease Control and Prevention.

GUPTA:
Hepatitis A is a virus that replicates in the liver, and it can cause symptoms like fever and vomiting, abdominal pain, and yellowing of the skin. And we're seeing an increase of hepatitis A primarily in outbreaks that are occurring around the country.

These outbreaks are primarily occurring among people who use drugs, people experiencing homelessness, and men who have sex with men; and because we are seeing the problems that we're struggling with with the drug crisis in the United States, we are seeing an increase in hepatitis A cases that's associated with these outbreaks.

JOHNSON:
You have used the term "outbreak" many times.

I think for people who aren't familiar with it, that can be a little overwhelming, if not scary.

GUPTA:
We've seen a remarkable public health success in the country with the vaccine for hepatitis A.

If you look historically at rates of hepatitis A, we've seen a marked decrease over the years since a vaccine was introduced in the late '90s, and we really reached a low in hepatitis A rates from 2011-2015.

So, when I say outbreaks, I'm really referring to an increase in the number of cases that we have seen in recent years. And so, in the beginning of the end of 2016 is really when we started to notice these outbreaks being transmitted person to person; and we've seen a pretty dramatic increase in 2018 and this year, in 2019.

We now have 30 states that are declaring outbreaks among people who use drugs, people experiencing homelessness, and men who have sex with men; and we now have about 27,000 cases that have been reported as part of these outbreaks.

JOHNSON:
You've also referred a couple of times already in this conversation, too, the populations most at risk.

Can you dive into those a little bit more? Tell us why?

GUPTA:
So, with hepatitis A, what we're seeing now is that it's an infectious consequence of the drug crisis that we're struggling with currently in the United States. Without a doubt, drug use is the primary risk factor that all states are reporting in their outbreaks.

We know that hepatitis A is transmitted in the fecal-oral route, which we know hepatitis A has the ability to persist in the environment for weeks to a month, and people who use drugs may find themselves in environments where hygiene is poor or maybe crowding, and these environments really facilitate the transmission of hepatitis in these settings.

Similarly, I think people experiencing homelessness may also find themselves in these settings where hygiene is poor; and we know that, although some of these populations—specifically, people who use drugs or men who have sex with men—have been recommended to receive vaccine by advisory committee on immunization practices, we know that coverage for vaccine among these at-risk populations is actually quite low.

JOHNSON:
As far as outcomes once a person becomes infected, how often is it fatal?

GUPTA:
Normally, hepatitis A is a self-limited disease, which means that most people will recover.

One thing that's been really striking in this outbreak is that we've seen that in 60% of the reported cases of hepatitis A, the patients have been hospitalized. That's really quite staggering. When we look historically, these hospitalization rates are much higher than what we've seen previously.

I think part of the reason that is happening is that we know that people who are becoming infected with hepatitis A have other illnesses; we're seeing high rates of co-infection with hepatitis b or hepatitis C. We know that these are vulnerable populations that are unstably housed and, because of that, their outcomes have been worse.

So, in these outbreaks, we've seen more hospitalizations, we've seen about 275 tests deaths have been reported among the 27,000 cases thus far, and we're also seeing other types of complications that aren't usually reported with hepatitis A, such as liver transplants.

JOHNSON:
If you are not in one of these target populations, do you have to worry about getting it?

GUPTA:
Hepatitis A is transmitted person-to-person, and because it's transmitted through the fecal-oral route, it's usually associated in settings where hygiene is poor or there's a potential for the environment to be a contaminated with fecal matter.

So, there are certain situations or risk factors that might place someone at increased risk for hepatitis A, but certainly anybody who has not received the vaccination may potentially be exposed.

The most important thing is to follow routine practices for hand hygiene and best practices for preparing food as well. But the most important aspect of this response is to focus our prevention efforts upon those primary risk groups that are more likely to become infected with hepatitis A.

JOHNSON:
So far, as we've discussed, about 30 states have reported outbreaks.

Are the rest in danger of joining those ranks?

GUPTA:
We've seen more and more states report these person-to-person outbreaks, and one thing I say to every state when we speak on national webinars is that every state could potentially experience an outbreak.

So, it is important to remain vigilant, to look and to respond quickly as soon as an outbreak is identified or an increase in cases. And it's also important that all states to be aware of the response that their neighbors may already be doing. So, to the extent that they can: think about how they would respond to an outbreak; where they would get vaccine supply; and surge staffing to get out in the field would be important.

It's also really valuable to think about the partnerships that you have: are there existing partnerships with correctional facilities; substance use disorder facilities; facilities serving people experiencing homelessness? Because building those partnerships now will be important in launching a response if they see that there is an outbreak in their jurisdiction.

And it's also important, if they can, to start proactively vaccinating those populations, as it is recommended by ACIP [Ed. note: Advisory Committee on Immunization Practices at CDC].

JOHNSON:
As you look around the country, what are some of the best practices you think the states are following right now that ought to be shared with everyone else?

GUPTA:
I think the most important thing to remember is that these populations that have been affected are not necessarily going to be people who have received a vaccination, or will seek care regularly, or have regular encounters with the healthcare system. And because vaccine is the cornerstone for this public health response, successful jurisdictions have to really thought of novel strategies to get vaccine out to the at-risk populations.

So, to the extent that they can, they are getting out into the field, on foot, setting up mobile vaccine events in high-risk facilities—and those facilities could be places like: correctional facilities, particularly county jail, where they're able to reach people who use drugs they may not be able to reach at other times; partnering with substance use disorder treatment facilities; or syringe service programs; homeless shelters; clinics providing sexually transmitted disease services.

They're working with those facilities—non-traditional facilities—to administer vaccine, to meet these populations where they are. That's been incredibly important.

I'd add that to do that well not only requires intensive resources—vaccine and staff—to get out into the field and technical skills, it also relies on people that have the communication skills, people with the soft skills to understand the needs of these populations, who know how to communicate with them, and engage them in order to effectively meet their needs and provide vaccinations.

JOHNSON:
That's exactly what I was thinking.

How hard is it to get an inmate to consent to a vaccination or a homeless person to allow you to give them the shot?

GUPTA:
After many months of working with jurisdictions, they have really been able to come up with the best practices for doing this.

A lot of it really depends on how they can engage the individuals and what the initial communication messages, whether these individuals are aware of an outbreak happening in their community, what their fear or risk of hepatitis A is, and what their understanding of how severe the disease is and how they could become ill. I think the more they are able to, upfront, provide the context of what is happening around the country, the more likely that someone is to receive a vaccination.

So, if you fast forward to where we are today, in fact, I think the incarcerated population—particularly the county jail—has actually been one of the more successful venues where we've been able to administer a large number of vaccines, in the sense that in one setting and one event, they are able to administer many vaccines to at-risk populations.

And I think this is a large part due to the success of jurisdiction in being able to provide the information, and communication, and education necessary for people to indeed understand that they are at risk.

JOHNSON:
Do you have any thoughts, then, about if and when we will be able to get this nation-wide outbreak under control?

GUPTA:
One thing we can say is that, despite the fact that many states have experienced prolonged community outbreaks, they have been able to get past it.

We've had a couple of states declare their outbreaks over, we've had a number of other states that show convincing evidence that they're on a steady decline, and we know that they can beat this after dedicated vaccine outreach efforts. It's difficult to know what the long-term situation will look like nationally, but we do know that it is possible that we'll get back to baseline.

One thing I do want to highlight is that—although early on we were seeing very large outbreaks in the states, thousands of cases going on for months and months—now, as we have a much better understanding of how to respond quickly, we have toolkits available to us and states have the benefit of being able to work with their colleagues to understand and work through any technical challenges.

We're seeing that the outbreaks that are reported today are smaller, and the time from when they notice an outbreak to reaching their peak is shorter than some of the states in the early days.

So, I'm confident that we'll be able to get past us on a national scale. It'll just take some time before we can get enough vaccine into the at-risk population to contain these outbreaks.

JOHNSON:
Of course, the stakes in terms of public health are obvious; but in a call we had together before this interview, you pointed out the economic costs also are very high.

Can you talk a little bit about what those are and how they figure into this plan of attack?

GUPTA:
I mentioned earlier that of the 27,000 cases that we're seeing today, over about 60% of reported cases are hospitalized—so, that's over 16,000 hospital patients.

And it's always difficult to get exact numbers—but even if you take really conservative published estimates of how much it costs for just for the hospitalization for someone hospitalized with hepatitis A—if you take those numbers, multiply that by 16,000 hospitalizations, we're estimating over $200 million in hospitalization costs of alone.

And if you think about it from a state's perspective or a local perspective, many of these individuals do not have health insurance and the cost of hospitalization oftentimes born by the state. And so, of course, while we're mostly concerned about the health burden on the population, the financial burden is certainly affecting states as well.

JOHNSON:
What, as you consider the audience of public health professionals listening today, is the bottom line?

What's your message to them? What do they need to know from you about this battle going forward?

GUPTA:
I think the most important thing to recognize is that hepatitis A is really an infectious consequence of the drug crisis that we're seeing today; and, in my mind, it's really quite tragic that we are witnessing outbreaks of this size, of this magnitude.

And this is happening because, unfortunately, despite recommendation to vaccinate these at-risk adults, vaccination coverage among these adults has been really quite low for years.

We really need to think about novel ways to bring vaccine to these at-risk populations where they are and continue to proactively vaccinate these individuals as part of routine primary care practice and public health practice.

JOHNSON:
What do you do when the number of hepatitis A cases in your state goes from less than 10 to more than 2000? That was the challenge facing West Virginia's public health team over the last year.

Dr. Cathy Slemp is commissioner and state health officer for the West Virginia Bureau for Public Health. She was appointed during the outbreak, working from the start to support her staff as they carried out a statewide response effort.

SLEMP:
Typically, West Virginia sees about nine cases of hepatitis A year, and it's individuals that we investigate and follow up with in partnership with local health departments. So, this outbreak was really unprecedented.

We look back now to January of 2018 when we had our first cases begin to appear. We have now had, over those almost two years now, about 2,600 cases. So, we went from nine cases a year to 1300 a year on average with that. Now, of course, that bulk of those happened last year, and we are now are really tapering down to very, very few cases.

But it's quite the experience of thinking about how to ramp up with that kind of response in a whole different environment than we were used to with hepatitis A.

JOHNSON:
What was behind that dramatic rise in cases?

SLEMP:
You know, it's really fascinating.

It really was related to our substance use epidemic. About 70% of the cases were among individuals who use illicit drugs. It was a very difficult population to connect with and to reach sometimes. They also were individuals who have had other underlying health issues—so, about 55% were contracted with hepatitis C, about 10% with hep B, about 10% were homeless, dealing with all the other complicating factors that can be present when folks are dealing with and wrestling with a disease of addiction.

So, it was a population that really was at high risk, and that was a high risk of complications when they got infected. If you look at the individuals that we have worked with, 50% of our cases were hospitalized—that's pretty unusual for hepatitis A—and we had 23 individuals die. So, it's really been a different population than we had seen previously with hep A, and it has been one of the infectious disease consequences of our underlying substance use disorder epidemic.

JOHNSON:
But you say now that number is starting to come down almost as quickly as it went up?

SLEMP:
It really peaked—we kind of began to see that the surge up in March of 2018, but in retrospect peaked about August or September of that year, in 2018, and has dropped down so that we are down to fairly few cases now as about April, May, June of this year.

We're not back to our baseline yet, but we definitely are in a much more manageable stage.

JOHNSON:
You took over the state's health department right in the middle of this outbreak.

What was that like as an executive leading a team trying to get its arms around this issue?

SLEMP:
It was a place where you learned to trust staff quickly, and then to think through things collectively with folks. It really was one of those parts of the new job that I needed to jump into quickly and really connect with folks on, learn a lot about, think about our strategies, and could also offer new eyes to that.

So, I connected our detecting disease epi staff, of course, who were actively engaged in working in the outbreak. But we also had activated—before I came—our disaster preparedness response plan. And so, our work was being coordinated through the preparedness; we really had added additional staff and organizational skills to that response.

So, they were already doing meetings regularly that I was able to tap into, and both see the magnitude of where we were in the outbreak but also begin to think through, with them, the long-term sustainability of this response given the magnitude of what we are dealing with.

I think that's probably where we had the most dialogue, at the point that I came in, was thinking about that strategy of how much do we do hands on ourselves versus supporting others in getting this work done and facilitating partnership at the community level that can really make the difference.

JOHNSON:
Let's get into the response. Lots of things going on in West Virginia to attack this problem, to reduce the number of hepatitis A cases.

Can you give us a rundown of the sorts of activities, strategies, and approaches that the team took to help get that number back to a manageable workload?

SLEMP:
Yeah, it was interesting.

First, of course, I think this is an example. These kinds of outbreaks are examples that really highlight the importance of public health work, that we have the ability and the responsibility to really understand what's happening in communities. And so, that whole area—public health surveillance, and understanding the population at risk, and epidemiology of the outbreak—was really key because we needed to know who was at risk and how we could best to intervene. So, that preliminary work was just core and critical.

I think we quickly learned, as the number just ramped up and we began a new magnitude—you know, initially we historically had been used to individual case investigations of hep A, and the standard hand hygiene and post-exposure prophylaxis, back tracing of contacts, and all those kinds of things.

But we quickly saw that that traditional model wasn't going to work moving forward because the magnitude was just too large. That was not sufficient by itself. It really had to expand out to, really quickly, thinking about the role of proactive vaccination of the population at risk, the full population at risk. And so, that shift early on, I think, was really key and is a critical piece of a response to these outbreaks, so that was a key area.

And so, when we make that shift, it really makes us think about how we reach that population differently. At that point, we really were working in terms of how do we meet people where they are. Our population at risk with not necessarily going to be walking into our clinics if we said, "Please come get a vaccine." And they weren't necessarily going to be coming to the doctors' office and say, "I'd like the hep A vaccine."

So, we really had to think about where are folks that are already in communities? Who already has trusting relationships with them? Where can we connect with those partners and reach folks where they are to get this done, both to educate folks of the risk and to provide them vaccination?

That's when we really began to work with a host of community partners.

JOHNSON:
Your people and the partners you worked with had to go out into the community, and find those who were at most risk, and then convince them to get the vaccine.

SLEMP:
Exactly.

We really kind of thought through, strategically, where can we best access folks? So, we worked with homeless service providers, meal programs, behavioral health centers, correctional facilities, our methadone clinic—a host of locations where we might the opportunity to intersect with individuals who would be at risk.

And so, that really was key. And so, as we talk with those partners, we really learn what might they need to vaccinate the population and to work with us collaboratively there. That's really where the traction began to get made.

We made those linkages, and we saw that we couldn't just say, "Hey, you see these folks, can you vaccinate them?" We need to work with them in partnership and kind of say, "How do we make that feasible? What can we do to support you in doing that?"

I think at the beginning, we actually did a lot of linking with them and then trying to do it for them; and then, I think, over time we have learned that we can't do that. We really needed to be the facilitator in communities to create those linkages between local health departments and service providers, to make sure that the partnerships are in place, and that we could provide the technical assistance and the tools and the resources that would help them do that job in there locally.

JOHNSON:
You talked about the number of people who were infected, who got sick with hepatitis A, but what we haven't talked about is the other impact, which is to the budget, to the communities, to the state at large.

You did some evaluation there—what did you find?

SLEMP:
We did some internal evaluations of our own costs, but also looked at our Medicaid cost with some of this; and with our own costs, I think it really speaks, again, to the importance of public health having access to some flexible funding that can be used in these disasters and these responses that occur unexpectedly.

So, I know—just looking at the Bureau Public Health in the first eight month of the outbreak—we had spent an extra million and a half dollars in personnel time, and then the vaccine costs, et cetera.

About half of that was state and half of that was federal. So, we really were trying to pull from 16 different places to meet those needs. And I think that's an important lesson, that we think about how do we have access to ready resources to address these issues—and that didn't begin to talk about the staff time at local levels, et cetera.

But if that was the internal analysis and sort of the lessons learned that we had a look at, we also had the opportunity to work with our partners in our Medicaid program. And we did an analysis of the total cost of claims for Medicaid recipients between January and November of 2018, and found that, overall, that $870,000 had been spent on just the Medicaid recipients alone in this outbreak. And they were probably about a quarter of the population that we had seen cases in.

We also looked at that and said, "Okay, what would it have cost us to vaccinate that population?" And the cost of vaccinating in that population would have been about $40,000. So, the cost of a single dose of hep A vaccine came out to be about roughly 5% of the average cost of providing medical care to a Medicaid patient with a principal diagnosis of hep A.

What I really mean to say is vaccination is important and, if we focus our efforts on prevention upfront, we can make a much bigger difference down the road in terms of the costs to the state and to society more broadly.

JOHNSON:
I wanted to explore the idea of trust.

That seems to be a recurring theme in this conversation, and one that is central to getting a handle on the outbreak wherever it is.

SLEMP:
Absolutely.

I mean, I think trust in public health is core of everything that we do.

I think we have to be able to create that trust, and that space of trust, and that caring, respectful relationship with individuals—often individuals that don't hear and feel that from others around the community—so that we can really be present and understand the issue more holistically and to help folks take responsibility to protect themselves and others with this kind of infection. So, I think that trust was really core in working with the population at risk.

It was also really core in building new partnership with folks that could help us reach our goals. So, we really found things, like when you work with hospitals: be there to think through with them the logistics of how to do what they wanted to do and to do the right thing; you know, helping project-management-wise, and screening tools, and vaccination logs, and access to vaccine—building that good partner trust that we can do that together.

JOHNSON:
Have you, in the process, built a new—maybe even more robust—infrastructure that you can use the next time something happens?

SLEMP:
You, it's absolutely a great question, and it was the silver lining—to be honest—of the outbreak.

I think every disaster response, every outbreak, has both challenges and opportunities, and building those partnerships and new partnerships—many of them we already had, but others that we could build on more—has definitely been a positive.

It helped us get through the hep A outbreak together, but it's also laid the groundwork for much of our work around hepatitis C and now HIV—we are seeing increases among our population of individuals who use injecting drugs of cases of HIV.

And so, these partnerships—we're building upon those that we had with hep A.

JOHNSON:
Stepping back and taking a look at this experience, what is your most prevalent, personal observation?

What was your biggest takeaway?

SLEMP:
You know, I think it's really what we were speaking about in terms of the power of partnership and the need to see public health not only as just doing hands-on delivery of service, but on being that strategic partner who can think about how we can address a larger need together.

And how do we facilitate those connections? How do we build those systems of care? How do we build those opportunities to really work together in a community so that we can reach the population at risk and help folks to strengthen their own health?

In my mind, it was thinking through partnerships, and roles, and development of trust, and the ability to be flexible and creative together that really was most effective.

JOHNSON:
We are always like to leave our audience with something to learn—not just from the conversation, but from the guest.

What is your advice for other public health professionals who might be dealing with a hep A outbreak right now, or don't know they're about to deal with one?

What do you say to them?

SLEMP:
Certainly, it's always important to make sure that we have good surveillance capacity and that we're on the lookout for these things.

You know, I think it's the community that's at risk. It's really important to think about how you build those partnerships now to reach that at-risk population so that you really are able to identify things early and meet people where they are. I think those are the core things that can be done now.

I think understanding the role of vaccine and quickly moving to using vaccine broadly in that population is key in these outbreaks; and so integrating that more into primary care for at-risk populations, integrating that into other services, and making sure that the systems are in place that you could ramp up with that kind of response are really key take-home messages to doing that.

JOHNSON:
Links to information about hepatitis A, CDC resources, and West Virginia's experience can be found in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.