This map of Missouri indicates the prevalence of hepatitis A cases, by county, in the state since September 2017. Counties shown in the darkest shade of purple reported at least 11 cases of hepatitis A during that period.
Missouri Department of Health and Senior Services
A two-year outbreak of hepatitis A in Southeast Missouri appears to be slowing, but state and county health officials say vaccinations are needed to be sure the viral outbreak doesn’t rekindle.
What is hepatitis A?
A viral infection of the liver, hepatitis A often spreads as a result of insufficient hand washing followed by the ingestion of food or drinks contaminated by undetected amounts of stool from an infected person. In addition to drug users, other high-risk populations include the homeless, men who have sex with other men, people who are in treatment or counseling for substance abuse or are receiving drug substitution treatment, inmates and those who work in a jail or prison environment and those who have close contact with anyone in an “at risk” group.
Symptoms of hepatitis A sometimes don’t appear for up to seven weeks after a person is exposed to the virus and can include loss of appetite, nausea, tiredness, fever, stomach pain, brown-colored urine and light-colored stools. Yellowing of the skin or eyes can also occur.
Source: Missouri Department of Health and Senior Services
According to the U.S. Centers for Disease Control and Prevention, 426 cases of hepatitis A have been reported in Missouri since Sept. 1, 2017.
The Missouri Department of Health and Senior Services reports Scott, Stoddard and Butler counties accounted for 185 of those cases — 35 in Scott County, 39 in Stoddard County and 111 in Butler County, which health authorities believe was the “epicenter” of the Missouri outbreak.
“It exploded here in Butler County,” said Whitney Preslar, communicable disease nurse and emergency response planner for the Butler County Health Department. “Between September 2017 and November of 2018, we saw 109 cases, and since May we’ve received a couple more, so we’ve actually had 111 confirmed cases.”
Although the exact origin of Butler County’s first cases could not be pinpointed, Preslar said “we know it was connected to drug use,” adding, “in about 80% of our cases, they either self-identified as having used some type of recreational drug or they were in close personal contact with someone who did.” Specifically, she said many of the cases reported in Butler County were related to the use of methamphetamine, heroin and marijuana.
“But the main ones we were seeing were meth and marijuana,” she said, theorizing the initial outbreak was connected to some contaminated methamphetamine from Michigan, which experienced a hepatitis A outbreak in 2016.
At one point, Preslar said she was tracking as many as five new cases a day in Butler County, where the health department initiated a series of vaccination clinics focusing on high-risk populations.
“It was all we did for multiple days and weeks and months,” Preslar said. Between February and November 2018, the Butler County Health Department conducted more than 100 vaccination clinics and administered the hepatitis A vaccine to more than 2,500 people, including inmates and staff at the Butler County Jail.
Still, the virus spread to adjoining Missouri counties.
“Both Butler and Stoddard counties had a lot of cases initially,” said Amy Hector, public health nurse at the Stoddard County Health Department. “Butler County started off in September 2017, and we had our first case in December of that year. It snowballed for a while after that,” but most of the cases came during near the beginning of the year, with only one case since October 2018.
Cape Girardeau County has had four reported cases while most other counties in Southeast Missouri reported five or fewer cases since the outbreak began in the fall of 2017.
Barry Cook, administrator of the Scott County Health Department in Sikeston, Missouri, said Scott County experienced a “surge” of hepatitis A cases during the outbreak’s initial months.
“I can’t give you the specific date that it dropped off, but our higher numbers were earlier in that time frame,” he said. “We’re still getting some cases, but it seems to be better here. It’s not down to zero, by any means, but it’s not like it was.”
As in other counties, Cook said the Scott County Health Department is providing vaccinations to high-risk populations, “especially people who were or are in jail, and we’ve also had quite a few food handlers coming in and getting the shots, which is great.”
Cook noted many counties require food service workers to receive the hepatitis A vaccine and believes it should be required statewide.
“I know some states do that, and I’d love to see Missouri do it as well,” he said.
More than half of the cases reported in Missouri required hospitalization and two deaths have been attributed to the state’s hepatitis A outbreak over the past two years.
Hector said the “reported” cases of hepatitis A are probably just “the tip of the iceberg.” She explained “when people have mild cases, they often don’t go to the doctor.”
More often than not, people with hepatitis A don’t seek medical care until their symptoms become acute.
“A lot of them are literally glowing yellow and that’s what brings them to the doctor,” she said.
At the Cape Girardeau County Public Health Center, administrator Jane Wernsman said the four cases reported in Cape Girardeau County all had a connection to someone in either Butler County or Stoddard County.
She attributed Cape Girardeau County’s low number of hepatitis A cases, in part, to public education and prevention programs and vaccinations to various populations.
“We’ve administered hundreds of vaccinations over the past two years, including routine vaccinations for children,” she said. “It’s not required for school attendance or anything like that, but it’s recommended, and so we immunize children, with parental consent.”
She and representatives of other county health departments said the hepatitis A vaccine is inexpensive and highly effective, especially when administered within two weeks of exposure to the virus.
According to the CDC, Missouri is one of 28 states with ongoing hepatitis A outbreaks. Kentucky has reported the most cases, 4,879, since August 2017, resulting in 2,361 hospitalizations and 61 deaths. Nationwide, 25,484 cases of hepatitis A — contributing to 254 deaths — have been reported since the first outbreak began in Michigan in August 2016.
For more information about hepatitis A, visit the Centers for Disease Control and Prevention’s website at www.cdc.gov/hepatitis/hav/index.htm and the Missouri Department of Health and Senior Services’ website at www.health.mo.gov/living/healthcondiseases/communicable/hepatitisa/index.php.
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