Have We Turned the Corner On Kentucky’s Hepatitis-A Epidemic?

The drama surrounding Kentucky’s epidemic of Hepatitis-A continues. Chris Kenning reported today for the Courier-Journal that Dr. John Bennett, current infectious disease branch manager, was dismissed last Friday. No specific reason was offered, but this is the second dismissal from that position in less than a year. His predecessor, Dr. Robert Brawley, was similarly dismissed less than a year ago after he lobbied for a more aggressive approach for what became the worst the Hep-A epidemic in the country. No doubt Governor Bevin’s administration will continue to deny that there was any connection between Dr. Brawley’s recommendation and his dismissal.

Dr. Bennett inherited a mess. A reasonable person might speculate that he is taking the fall for criticism that has been directed toward higher-ups in the administration. We may never know.  However, turmoil as we deal with a new outbreak of serious, food-born E. Coli infection is not what we need now.  Hep-A and E. coli pathogens are both transmitted by feces of infected individuals– basic sanitation stuff.  There are other threats of serious infections on the horizon that we may need to deal with including a drug-resistant fungus, Candida auris.

Above is an updated graph from Frankfort showing new cases of Hep-A up to the week through March 23. It appears to show a sharp drop  for the most recent week, but I assert that it is premature to conclude that the epidemic is ending. The report from which the figure is extracted warns that all cases in the current period have not yet been incorporated into the totals. Indeed, charts from earlier weeks that initially showed apparent trends downward before all the cases were counted ended up hovering around 40 new Non-Jefferson County cases per week. Over the last 4 reporting weeks, the number of counties having new cases decreased only from 21 to 19. The number of counties having at least one case during the epidemic continues to increase, now up to 105 counties. We are not yet home-free.  I do not have access to updated data for Kentucky’s ongoing Hepatitis-B, Hepatitis-C, and HIV epidemics which remain endemic threats.  We deserve some stability and are owed more confidence than we  now enjoy.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
April 8, 2019

Kentucky’s Hepatitis-A Epidemic: Could We Have Done Better?

A society is only as healthy as the sickest individual within it.

Kentucky is in the middle of, and hopefully emerging from a major epidemic of Viral Hepatitis-A (Hep-A).  Hepatitis-B and Hepatitis-C, are caused by different viruses and commonly result in more serious chronic liver disease.  Classically, the spread of Hep-A is attributed to contamination and ingestion of food or water by the feces of infected persons or related poor hygiene practices.  Nonetheless, illicit drug use appears to be the major risk factor  in Kentucky’s current outbreak.  Hep-A is rarely fatal to otherwise healthy people but can cause debilitating symptoms. It can be fatal however, especially to individuals with preexisting liver disease such as alcoholic hepatitis or other forms of viral hepatitis. It is not clear when the first cases of the current outbreak began to emerge, but in the 21 months between Aug 1, 2017 and Feb 23, 2019; some 4229 presumed or suspected cases of Hep-A have been reported, including 2036 hospitalizations and 43 deaths. This can be compared to only 9 reported cases in all of 2016! Our current outbreak is the most severe in the nation. Concern has been expressed that, compared to the aggressive and successful response by the Board of Health of Jefferson County, that the best advice from experienced state public health experts within Kentucky’s Public Health Department in Frankfort was ignored allowing the statewide epidemic to expand and be prolonged. My independent analysis of available data supports this criticism. In my opinion, the appointment of an inexperienced public health commissioner by the Bevin administration– probably for political and ideological reasons– likely played a significant role in what occurred. Kentucky remains in the middle of upsurges of Hepatitis B and C. All three varieties of viral hepatitis have roots in poverty, substance abuse, exclusion from healthcare systems, despair, and other non-medical fellow-travelers that will be difficult to fix. It is therefore important that the current responses to the Hepatitis-A epidemic be independently reviewed so that we may be better prepared for the next time– which will surely come. Continue reading “Kentucky’s Hepatitis-A Epidemic: Could We Have Done Better?”