Since an initial outbreak in Michigan in August 2016, hepatitis A (HAV) continues to flare up across the country, according to newly-updated Center for Disease Control and Prevention data—and these outbreaks predominantly affect people who use drugs (PWUD). States hit hardest by opioid-involved deaths are also seeing surging infections of HAV—a preventable, non-chronic illness that has a vaccine.
Appalachian states are seeing the highest numbers of new infections. Kentucky is worst impacted, with more than 4,600 people diagnosed with HAV since August 2017. West Virginia has reported over 2,500 cases since March 2018, with almost 70 percent being PWUD. Ohio, Indiana, Tennessee and Florida are all seeing high infection numbers, too. West Virginia and Ohio are also the states worst impacted by the overdose crisis—with the former seeing almost 50 deaths per 100,000 people per year, and the latter nearly 40 deaths per 100,000 per year.
Source: CDC
HAV is not to be confused with another virus for which PWUD are at risk: Hepatitis C (HCV). HAV is transmitted by oral exposure to fecal matter, while the later is blood-borne. HCV has a straightforward route into the bodies of people who inject drugs—through shared syringes or needles. HAV is disproportionately infecting PWUD because of “unsafe sanitary conditions or specific sexual contact or practices, or…transmitted through contaminated needles or other injection paraphernalia,” wrote the CDC in 2018 report.
“This is really not a hepatitis A problem, and it’s not solvable by giving everybody a vaccine,” Dr. Marc Siegel, a professor of medicine at NYU Langone Medical Center in New York City, told WebMD. “We have to realize it’s a public health issue and it’s a matter of cleaning up places where the virus breeds.”
That, in part, might mean making sure people who inject drugs can do so in safe, sanitary spaces. The director of the Public Health Department in Detroit, a jurisdiction that saw an early HAV outbreak in 2016, expressed openness in 2018 to the idea of a safer consumption space “given the alarming number of deaths from the opioid epidemic, as well as the rising levels of Hepatitis C and the recent Hepatitis A outbreak.”
Some have questioned whether Michigan’s HAV outbreak was driven by the Detroit water shut-offs initiated in 2014—a policy that the United Nations considered to be “contrary to human rights.” In 2017 a state senator called on the attorney general to launch an investigation into the relationship between the water shut-offs and the HAV outbreak, which was hitting Detroit Metro Area drug users the hardest.
For public health experts like Todd Lucas, a Wayne State University associate professor, the correlation is “conceivable, but there’s still a lot that needs to be established to determine the source of an outbreak,” he told Michigan Live.
A 2017 study found that “Those who were diagnosed with a water-associated illness,” particularly gastrointestinal and skin infections, “were 1.42 times more likely to have lived on a block that had experienced a water shutoff.” The study did not consider hepatitis A infections. Although a causal relationship cannot be drawn because of this, it should be noted that people who do not have access to running water are at greater risk of contracting HAV.
In an email to Filter, the Detroit Department of Health declined to recognize “any correlation between Hepatitis A and water shut-offs,” adding that the “Communicable Disease Program actively investigates any cases of Hepatitis A in Detroit residents.”
In addition to making sure people who inject drugs do so in the safest way possible, such as by meeting basic needs, like having access to clean water, public health officials are working to end HAV-related deaths, which have totaled 185 people across the states that have declared outbreaks. Kentucky has seen 57 recorded deaths since August 2017.
But HAV infections have proven to be disproportionately deadly in Michigan. As the first state to declare an outbreak, Michigan has drastically cut the number of new HAV infections, going from 169 in the first half of 2018 to just four reported new infections for the first half of 2019. But of the 914 people infected with HAV since 2016, 3 percent—28 Michigan residents—have died as a result. The mortality rate was at its highest at the start of the outbreak, reaching almost 7 percent in the second half of 2016.
Doctors say that with adequate care these deaths wouldn’t be happening. “Hepatitis A is more of a nuisance” than a potentially life-threatening illness, Doctor Nicholas Gilpin, the medical director of infection control/epidemiology at Detroit’s Beaumont Hospital, told Detroit Free Press. “There’s a very, very slim chance that a hepatitis A infection would lead to serious complications.”
Symptoms of an HAV infection include fever, fatigue, nausea, jaundice, stomach pain, vomiting, loss of appetite and discolored excrement. The CDC warns that patients “may feel sick for a few weeks to several months but usually recover completely and do not have lasting liver damage.”
Graphic by the Center for Disease Control and Prevention
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