Update: This story originally appeared on April 25, 2018. On June 27, the Courier Journal reported that the outbreak of hepatitis A in Louisville and Kentucky had become “the worst in the nation,” with at least 969 cases and six deaths, three of them in Louisville.
Week 1, Sept. 3-9, 2017:
One case of hepatitis A
Rui Zhao hunkers behind his twin computer monitors. Most visitors to the epidemiologist’s uncomfortably cramped office talk to his brow and the short black hair on the top of his head. They may glimpse his eyes when he looks up from his screens. On the wall to his left are small stuffed toys of irregular shapes, each a cuddly version of some nasty germ. From this third-floor office at the Louisville Metro Department of Public Health and Wellness, Zhao watches other germs work their way across Louisville. In the 90-degree days of early September, it’s a bit too soon to think about influenza, which will sweep through nursing homes in cold weather, taking lives as it does most every year. More of interest now: the chronic liver diseases hepatitis B and C. In fact, cases of hepatitis B are dancing upward in the metro area. Hepatitis C is already considered an epidemic, although the number of new cases is tiny.
Of hepatitis A, there’s a single case. And there’s no case the following week. It’s meaningless noise in the ebb and flow of the 25 or so infectious diseases surveilled by the state. Each year, one or two people in the city — and, rarely, as many as five — will contract the hepatitis A virus. They travel to a country where it’s common, endemic. They bring it home from mission trips or as a souvenir from an exotic vacation. More frequently, travelers never know they have it. About 30 percent of adults with hepatitis A produce no symptoms.
But for the unlucky, it can be brutal, bringing low-grade fever, headache, weakness and exhaustion, diarrhea, sudden nausea and vomiting, and abdominal pain, especially under the ribs on the right side, where the liver sits. Stools turn pale and urine dark. There may be intense itching. The white of the eye and skin often yellow, another sign that the virus is in the liver. And that’s the end of it, usually. Unlike hepatitis B and C, hepatitis A doesn’t settle in for a lifetime, grinding away at the liver. Uncomfortable? Absolutely. Miserable? Often. Life-threatening? Only in people older than 50 and those with other health problems. And it’s self-resolving, with no cure but time. It’s also highly contagious, most likely to spread while its host feels tip-top, before discomfort sets in. Any virus shed during infection lingers on surfaces for months. It is frequently transmitted by food, and while it succumbs to soap and water, or near-boiling temperatures, gel sanitizers can’t touch it.
Hepatitis B and C, on the other hand, infect via body fluids like blood, semen or vaginal secretions — the same pathways taken by the virus that causes AIDS. Since February 2017, a combined hepatitis A-B vaccine has been offered to visitors at the syringe-exchange sites operated by Metro Health and Wellness. There is no vaccine against the relatively new virus hepatitis C, which was discovered in 1989 and originally called non-A, non-B hepatitis. The syringe-exchange clinic is one sure way for the health department to reach a group of people normally driven into the shadows, a population vulnerable to a variety of diseases.
The importance of such contact is about to increase. The question is, will it be enough? By April, few will think so.
Weeks 2-5, Sept. 10-Oct. 7:
Three new cases of hepatitis A. Total: 4
The Courier Journal is full of the troubles facing the University of Louisville basketball program as October rolls in with 70- and 80-degree days and enough sunshine to convince anyone that summer will stretch on forever. Zhao notes that hepatitis A cases are now double the number seen in a normal year. But whether those four cases are significant isn’t clear. There’s also an unusual surge in false-positive hep A tests. He always sees a few. Every year, three or four people will test positive, yet their illness makes no sense. Usually, these cases of mistaken viral identity involve women 60 and older who have symptoms that would fit any number of diseases, including hepatitis A. It’s essentially a bad joke played by an aging immune system. Immune defenses lose precision with each passing year; our bodies are more prone to interpret any number of ailments as an attack on the liver and ramp up antibody production to fight a phantom infection.
But the bump in false positives this year doesn’t add up. “We’re seeing false positives at a rate that we haven’t seen before,” Zhao says. “What’s going on? Were the tests messed up? That’s a possibility. Or are doctors testing more?” It creates a signal-to-noise problem. Is Louisville heading into an epidemic or just dealing with flukes?
Or, what if what looks like a rise in false positives isn’t false at all?
Weeks 6-9, Oct. 8-Nov. 4:
10 new cases. Total: 14
Although the number of hepatitis A cases is just over a dozen, people in public health are concerned. Dr. Sarah Moyer, the director and chief health strategist of Metro Health and Wellness, thinks, “Oh, no. We’re going to have an outbreak like California.” (The health department uses “outbreak” and “epidemic” interchangeably.) San Diego has battled a hep A epidemic since fall 2016. Moyer hopes Louisville will instead go the way of Utah, which in October seems to have halted its own hep A outbreak at 40 cases. (In truth, Utah will eventually follow San Diego’s lead, slammed by climbing case numbers.) Outbreaks also emerge in Arizona and Colorado in October. And Michigan fights an outbreak that began a few months before San Diego’s.
In October, Moyer has led the department and its 220 employees for two months. Although new to the director position, for the two years previous she was the department’s medical director while also practicing family medicine. Working in public health was a long-time goal. In 2004, when she graduated from Colorado College with a degree in physics, she realized that every person doing work that interested her had an M.P.H. (Master of Public Health) after their name. Moyer earned her own master’s in public health at Dartmouth in 2006, then completed her medical degree at Temple University in 2010.
San Diego nags at Zhao, too. He has been following the Southern California epidemic, tracking what his fellow epidemiologists have to say, following news reports of that city’s outreach efforts and its headline-grabbing sidewalk-bleaching campaign. At first, it was just professional curiosity, the kind he considers essential for a man in his position. “I get alerts from all over the world for various cases, because you never know who might show up in your backyard, right?” he says. “I kept it on my radar. I’m saying, ‘Well, they’re seeing it in the homeless and in the drug-use population.’”
He wonders how he would investigate disease in people without addresses. How would his team make inroads in drug-using populations that fear any kind of scrutiny? With the San Diego and Utah epidemics looming, Metro Health and Wellness officials sense the risk to Louisville’s homeless population. Restaurant inspectors take fliers to shelters throughout the county, explaining that people can protect themselves from the virus with handwashing, safe food-handling practices and vaccination.
San Diego’s epidemic began in November 2016 with the diagnosis of two hep A cases. A month later, there were four. In January 2017, there was a single case: a misleading calm. Seven more cases in February triggered official recognition of an outbreak, primarily in the homeless and drug-using population. By May, the city of 1.4 million had 86 cases in a single month. In August, there were 95. Before the epidemic slowed, 20 of the 587 known hepatitis A patients had died.
But there’s a continent between Louisville and San Diego, and so far, nothing suggests a link between the Derby City and the coastal metropolis. So where are Louisville’s cases coming from?
Weeks 10 and 11, Nov. 5-18:
Seven new cases. Total: 21
In the argot of infection specialists, a vector is an agent that transmits germs: mosquitoes for West Nile virus, ticks for Lyme disease, lice for typhus. For hepatitis A, it’s dirty hands. Traditionally, hepatitis A outbreaks begin with food handlers. An infected restaurant employee who doesn’t yet feel sick fails to wash his hands well. When contaminated feces contacts mucous membrane — usually in the mouth, but the eye, the nose or the urogenital tract work just as well — infection follows. Vigorous handwashing with soap and water — long enough to sing “Happy Birthday” twice — is a critical preventive factor. Resolving such epidemics comes down to changing habits and discovering where patients ate.
That’s what Dr. David T. Allen faced in 1988. Louisvillians from every walk of life and every part of town were coming down with vicious cases of hepatitis A. As medical director for the Board of Health, it was Allen’s responsibility to triangulate the source from patient interviews. But patients weren’t naming a single restaurant. The 216 people diagnosed in February and March of that year named 379 different restaurants. Allen eventually concluded that a shipment of contaminated iceberg lettuce caused the outbreak, and every restaurant that served lettuce from that semi-trailer load helped spread the virus. To contain the outbreak, the health department printed half a million brochures to educate the public about handwashing. “We papered every bathroom. Every commercial restaurant had these brochures in their bathrooms. We had a major ‘Wash Your Hands’ campaign,” Allen says. Not long after the outbreak, the health department instituted a mandatory food-preparation class to educate restaurant workers on safe food handling. A vaccine didn’t exist in 1988. Handwashing alone stopped the spread.
Could a restaurant be behind the current hepatitis A rise? The scanty data Zhao analyzes doesn’t suggest it. Zhao contacts his counterparts in the Kentucky Cabinet of Health and Family Services, and together they hash out what they know. It’s not much. Zhao’s interviews with patients are dead ends. Those he can reach appear to have little in common. No single restaurant or food source emerges as a probable epicenter of infection. Several times, he can’t arrange a patient interview. Infected people leave the hospital against medical advice before Zhao and his team can reach them. Some he does find are simply uncommunicative. “We’re just not sure how these cases are tied together,” Zhao says. “People don’t want to tell us.”
What he needs is a way to look at the virus itself. And the U.S. Centers for Disease Control and Prevention has one — a genetic test to read the RNA encoding the virus, the gold standard for determining hepatitis A. To run the test, Zhao needs patient blood. He contacts two of the people he has already interviewed. Both agree to a blood draw.
Zhao is close to cracking the case.
Week 12, Nov. 19-25:
Three new cases. Total: 24
In mid-November, Dr. Lori Caloia, a physician at Norton Healthcare and a former flight surgeon in the U.S. Air Force, takes director Moyer’s previous job as medical director of Metro Health and Wellness. Moyer warns her what’s on the horizon. “We might be leading into a hepatitis A outbreak here, so just be on the lookout,” she tells Caloia on her first day on the job. “You’ll probably have to spend some time doing that.” The next day, the day before Thanksgiving, Kentucky declares a hepatitis A outbreak.
The genetic tests on the two blood samples from Louisville reveal that the city’s cases are the same strain of hepatitis A in San Diego and Utah. The genetic linkage leads state epidemiologist Jonathan Ballard to declare the outbreak, even though the number of cases statewide — 31 so far — isn’t much higher than the 20 cases Kentucky averages from year to year. The state backdates the epidemic to Aug. 1 to account for the disease incubation period, which can range from seven to 49 days. The tests also solve the signal-to-noise problem. One of the two blood samples was from a suspected false positive case — a person with no recognizable ties to any risk factor. It turns out some of those false positives weren’t false at all — they were evidence of a new epidemic.
With the announcement, the Louisville health department swings into crisis mode, reconfiguring itself into “the Incident Command System.” Job duties shift overnight as employees gear up to deal with the outbreak. Some 25 people meet daily — including a few from the state on speakerphone — to launch the department’s constantly updated Outbreak Support Plan. Ken Luther, manager of public health preparedness for the health department for the last two years, moves into the foreground to coordinate the response and guide the daily briefing. It will be Luther’s first health emergency at the department, but hardly his first emergency. The former Army colonel learned emergency management during two tours in Iraq, two in Afghanistan and several operations across eastern Africa in his 23 years of service. “I’ve been running things like this in bigger situations for a long, long time,” he says. Based on that experience, he knows the Outbreak Support Plan will change daily. “No plan survives first contact with the enemy,” Luther says. “Plans are useless, but planning is essential.” It feels like one of those truths he’s been explaining to people for a long time.
Weeks 13-16, Nov. 26-Dec. 23:
19 new cases. Total: 43
It’s an evening in early December, and Paul and Nancy Kern pack for their first mission. It takes both to hoist a giant cooler into Paul’s Jeep. It’s essential equipment, safeguarding several doses of hepatitis A vaccine at the mandated temperature range of 36 to 46 degrees. By happenstance, the Kerns will become the health department’s street outreach team. They’re looking for people who don’t go to shelters. During the day, Paul is the public health planner for the health department and the planning section chief for epidemic response. Nancy is a nurse practitioner and an associate professor at Spalding University. Inspired by their son Chuck’s work with a homeless-outreach organization in Indianapolis, they recently began volunteering at the Hip Hop Cares meal site under the Interstate 65 overpass at Broadway and First Street. With the epidemic on their doorstep, a transition into hepatitis outreach is natural, even inevitable. The first night, they tag along with an experienced group from Fern Creek United Methodist. They surmise that if they want homeless people to accept them, they need to be part of trusted groups. The Fern Creek church is just one among many organizations in Louisville’s extensive homeless outreach network that the health department will partner with as it wrestles hep A.
The Kerns set up operation in the back of Paul’s Jeep, working that first night in the dark. In the coming weeks, they’ll add lights and a marine battery to power them. Although December came in like a lamb, as the new year approaches temperatures fall below 10 degrees. In this bitter weather, the Kerns keep the Jeep heater running so people can slide inside before they peel off layers to bare an arm. Eventually, the couple receives smaller coolers with which to transport the vaccine and Nancy adds hot cocoa to their offerings. “It’s: ‘Would you like some hot cocoa? And by the way, I can give you a hep A injection. You know, there’s an outbreak,’” she says. It works.
The severe weather is bad news on another front. Ballard, the state epidemiologist, says it may accelerate the disease spread. Utah saw its hep A numbers surge as temperatures fell. “Winter came and people congregated. People are indoors more and in close contact with each other. That may lead to a spike in hepatitis A,” Ballard says.
Louisville’s hepatitis A cases are at 43 and growing, which makes the Kerns operation a tiny canoe bobbing on a flood-swollen Ohio River. But theirs isn’t the only boat. As the weeks pass, the health department establishes regular vaccination initiatives in several locations targeting the homeless and drug users. People who work mosquito control in the warm seasons help deliver vaccines. Nurses add shift upon shift. Health educators, public facility inspectors and top management all pick up duties to push out more vaccine. Volunteers from the Medical Reserve Corps, Norton Healthcare and the U of L Global Health Initiative step up. But it’s a mad scramble at the start. Paul Kern says daily briefings are a cascade of questions. “What’s available to us? How do we get vaccines? What can we get? How soon can we get it? What do we need to be able to administer everything? How do we prioritize where we go with it?”
Although the first vaccines arrived quickly, “the whole process was a quagmire,” Kern says. Obtaining and handling the CDC-supplied vaccines requires special protocols. Only state-registered people can handle them. The health department can’t hand them off to a third party to use, even if it’s to nurses giving shots to at-risk groups. Every dose demands paperwork. Vaccine losses must be recorded and explained, and there better not be too many. Slip up anywhere along the line, and the CDC can close the vaccine spigot. It’s a potent threat. One morning briefing features a PowerPoint slide detailing the five-step procedure required to handle the patient encounter forms required with each inoculation.
Those at the greatest risk for hepatitis A are priority targets for the CDC vaccine. And there’s no question who that is: drug users and the homeless, just as in San Diego and Salt Lake City. From the start, at least half of all hep A cases in Louisville are among people who use illegal drugs — and not just injection drug users. Further, most of the time the drug users are also homeless or in unstable housing, which means they live in shelters, are couch surfing or have other temporary arrangements. Although unstable housing is always a part of the problem, by December, only 6 percent of the people with hepatitis A have housing as their only risk factor. Ninety-four percent are drug users, half of whom are also homeless or likely to become so soon.
If the virus is going to jump from the at-risk groups to the general population, it will be under the power of drugs. “Drugs, unfortunately, are one of the great unifiers of all classes of society,” Zhao says. “People get together — homeless, non-homeless — and get high, whether that’s shooting, snorting, smoking or crushing pills.” And all of those practices can transmit hepatitis A.
That makes the department’s five syringe-exchange sites essential in hep A prevention. A few months ago, the syringe-exchange program began offering hepatitis B vaccinations. That vaccine also inoculated against hepatitis A — a fringe benefit that’s now the featured act. To encourage syringe-exchange visitors to accept vaccination, the health department adopts a strategy of gentle assertiveness. A greeter meets every person who comes through syringe clinic doors and tells them about the epidemic and the vaccine. Employees from all parts of the health department take turns in this friendly persuasion, traveling, eventually, to outreach sites all over the city.
By focusing on the people at greatest risk, health officials aim to prevent disease in those least able to withstand it, and at the same time keep the epidemic from breaking into the rest of the community. The worry is that it won’t be enough.
Weeks 17-20, Dec. 24-Jan. 20, 2018:
18 new cases. Total: 61
Early on, state health officials arranged conference calls with health officials in San Diego and Utah. Zhao says the goal was brain picking: “How did they go about reaching these populations?” Officials of both Western cities pointed to one critical nexus: the constantly churning, highly vulnerable jail population.
Every day, about 90 people check in at the Louisville Metro Department of Corrections. In 2017, there were enough jail bookings to raise the population of Jeffersontown (26,500) by 6,000. On any given day, 2,200 occupy corrections beds. “We knew, due to our target population, that hepatitis A was going to make it into the jail sooner or later,” Nick Hart says. Normally, Hart’s duties as an environmental health manager keep him focused on hazardous material response, childhood lead poisoning and mosquito-borne diseases. Now, he coordinates vaccine outreach to the jail. “It doesn’t matter how well your jail is run,” Hart says. “It doesn’t matter how clean your jail is. When you put a bunch of people in close proximity to one another, you’re creating a situation for transmission of disease.” Hart estimates that 22 hepatitis A cases so far may have a jail connection. “The city is the jail and the jail is the city,” Hart says.
In early December, Zhao created a map showing where drug and alcohol arrests took place in Louisville last year. Then he added dots to represent hepatitis A patient addresses. The overlap is suggestive: The most hepatitis A cases come from the neighborhoods where drug and alcohol arrests are highest.
The first step in a jail-hep A response was easy — vaccinating corrections staff. That began Dec. 4. Vaccinating inmates has been a more complicated problem. Because every person booked into the jail must meet with an intake nurse, intake seemed like the perfect moment to offer a shot. But not everyone is at their best just then. They may be drunk. They may be high. They may be just uncooperative, angry about getting in trouble. Further, booking is a 24-hour operation. There aren’t enough overtime hours, let alone health department nurses, to staff it round-the-clock. The compromise was to send nurses during the busiest booking time, Hart says, roughly between 4 p.m. and 9 p.m. The effort was both a success and a flop. Although the nurses vaccinated a significant share of the new inmates, that still left 19 hours of booking and scores of inmates uncovered. After a week, it was clear: The payback didn’t justify the cost. It was time to find a new plan.
Weeks passed before jail vaccination resumed, this time by “deputizing” the intake nurses to the health department and getting them certified to handle the CDC vaccine. Immunization started again in early January.
Week 21, Jan. 21-27:
Eight new cases. Total: 69
The Department of Public Health and Wellness on Gray Street, between Chestnut Street and Broadway, does its best to model global climate change on a local scale, with some rooms so warm people crank open windows and others cold enough to safely preserve perishables. The building was born in 1968. So was Will Smith, but he’s aging a lot better.
In the overheated second-floor conference room, Ken Luther leads the hepatitis A briefing group through the day’s update. A week ago, the team changed from daily to twice-weekly meetings, even as the department’s response to the 21-week-old epidemic grows new tentacles daily. The department has administered more than 1,700 vaccines. (From the start of the outbreak, health department workers were encouraged to get vaccinated, covered by insurance.)
For a moment, the conversation turns to April. In 90 days, three-quarters of a million people will crowd the riverfront for Thunder Over Louisville. On the heels of Thunder, several hundred thousand from all over the world will fill Churchill Downs for the Kentucky Derby. More crowds will gather for dozens of Derby Festival events. At some point, those in the group agree, protecting this surge of visitors needs to be in the planning mix.
Weeks 22-24, Jan. 28-Feb. 17:
24 new cases. Total: 93
Kern increases his efforts to find more vaccination sites in the Portland neighborhood. Although hepatitis A cases dot the map from east Louisville to west, Portland is clearly a hot spot. Kern’s list of priority vaccination sites is four times longer than it was just weeks ago. One of his jobs is making the community connections that lead to more ways to reach those at risk. Making connections was something he did when he worked in disaster preparedness with the Red Cross until 2016. “You just talk to people and you get other names. You develop this network,” he said.
That’s much harder to do for drug users, both securely housed and otherwise, who now dominate the hepatitis A rolls. Among people with hepatitis A who admit to drug use, 18 percent say they never use injection drugs, 44 percent say they only use injection drugs and 39 percent use both (percentages rounded). And most resist any overture from a stranger offering vaccination. Kern and his wife travel with an outreach group to an abandoned building where residents may have been exposed to hepatitis A. But no one accepts a shot until the couple makes a second visit accompanied by someone familiar to building residents.
Epidemiologist Zhao says drug use also complicates data gathering — an essential component in tracking and fighting the disease. “Some individuals do not care. They’ll tell me everything,” Zhao says. “Some flat out lie to me and it’s like, I have your tox (toxicology) screen. I know you do drugs, but you’re still going to tell me you don’t do drugs?” Others grow angry, taking inquiries like accusations as Zhao runs through the list of questions he asks every hepatitis A patient. “And sometimes they falsely blame other individuals,” Zhao says. He worries that naming homelessness and drug addiction as risk factors further burdens an already ostracized population. “People want to say (addiction) is a choice,” Zhao says, “but it’s not a choice. Did they have choice when doctors prescribed them opiates? Did they have choice when all these opiates were put on the market, and we were told they were clinical, safe and non-addictive?
“The things that happened in the ’90s are having repercussions now and will have repercussions for years.”
It’s an issue that troubles Moyer. “Why is it hard to reach (drug users)?” she says. “Because we jail people with substance-abuse disease. We don’t jail people with diabetes. Eighty-five percent of people in corrections have substance-abuse disorder.” If society treated substance abuse like any other chronic disease, Moyer says, the hepatitis A outbreak would be that much easier to fight. “We have to change the language around substance-abuse disorder.”
Weeks 25 and 26, Feb. 18-March 3:
34 new cases. Total: 127
During the hepatitis-A briefing on Feb. 23, Zhao reports a new potential source of hepatitis A infections: sex workers. He realized it during a patient interview. He conducts each interview using a questionnaire adapted by the state for this outbreak. Over the months, he has tacked on additional questions as he learns the particulars of the Louisville outbreak. Now he has a new one about sex work.
He added it when a young woman told him women in her neighborhood “were hopping into cars, trading sex for drugs or houses or food.” Until that moment, no one was thinking about sex work as a possible mode of hep A transmission. “We know that (trading sex) happens among the homeless and housing-insecure individuals. We know that it happens with drugs and other disease,” Zhao says. “But it wasn’t really identified here for hepatitis A.” And no one is conducting hep A outreach to sex workers.
Paul Kern expands his search. He needs vaccination sites that might be welcoming to sex workers. He needs connections with people these women and men would trust. “Given the sensitivity of all this, it’s one of those things you don’t just barge into,” he says. “That would probably stifle a lot of opportunities.”
Week 27, March 4-10:
Nine new cases. Total: 136
March brings unwelcome news. A produce worker at a Kroger on Dixie Highway (of the two Krogers on Dixie, this one is closest to Interstate 264) is diagnosed with hepatitis A. An employee at Denny’s on Dutchmans Lane comes down with the virus. There is no proven transmission from either site, but it adds a complication to Zhao’s attempt to track the virus. Now, when he asks new hepatitis A patients whether anyone they know uses drugs, or whether they have other risk factors, many blame their hepatitis on Kroger or Denny’s, frequently mentioning the wrong Kroger location or a different Denny’s. It’s another barrier to pinpointing the real source of infection, another way the virus slips away.
The city also sees its first hepatitis A death. Due to privacy concerns, the health department releases little information about the individual, except to indicate he or she had severe pre-existing health problems. Louisville has been lucky when it comes to hepatitis A mortality. The San Diego outbreak led to 20 deaths, and the Michigan outbreak has racked up 25 deaths among its 894 hepatitis A patients since the epidemic started in August 2016. Kentucky head epidemiologist Ballard says the high mortality rate in San Diego may reflect an older and sicker homeless population. “It hit a vulnerable population, people with chronic liver disease. A lot already had hepatitis C,” he says. “It’s interesting that most people contracting it in Kentucky are younger and healthier.”
The average age of Louisville hepatitis A patients is consistently about 37. No patient has been younger than 18, and the oldest patient by March is 69. (By mid-April, this will rise to 75.) The age range tells two stories, Ballard says. The simplest story is that drug users and homeless people are generally younger adults. But it also suggests something about the history of the disease in the last 50 or so years.
Before 2000, hepatitis A outbreaks were common. In 1971, just after development of a blood test for hepatitis A, there were 59,606 confirmed cases in the United States. Even as recently as the 1980s and ’90s, U.S. physicians reported an average of 26,000 cases annually. But the introduction of a hep A vaccine in the mid-’90s changed everything. By 1999, infection rates plummeted as many states mandated childhood hepatitis A vaccination — something Kentucky introduced this year for school-age children. By 2010, hepatitis A was so rare, only 1,670 cases were reported nationwide. It’s a good news-bad news thing: Now far fewer people contend with a disease that can take them out of circulation for two weeks or longer. At the same time, far fewer people are protected against it when it rears up. More bad news, if you were alive when hepatitis A was endemic in the United States: You probably don’t know if you were ever exposed. Children infected with hepatitis A rarely have symptoms.
Weeks 28 and 29, March 11-24:
36 new cases. Total: 172
Connie Mendel, sanitation unit supervisor during the outbreak, works with one eye trained to the calendar. It’s March 13. Thunder Over Louisville is April 21 — 40 days away. The Kentucky Derby is May 5, 53 days away. But the dates she’s tracking are two weeks earlier, April 8 and April 20. People vaccinated before April 8 would have adequate protection against hepatitis A in time for Thunder and would be, therefore, less likely to be a hepatitis A carrier. Anyone vaccinated by April 20 will be protected in time for the Kentucky Derby. Studies show that people produce protective levels of hepatitis A antibodies within two weeks of the initial shot. Although the vaccine is actually a two-dose regimen, that first shot is more than 90 percent protective. It’s enough.
In a normal year, Mendel’s unit, which handles restaurant inspections, is also responsible for examining every food vendor at every festival, even going up and down the route of the Pegasus Parade. “We, unfortunately, quarantine a lot of food that day,” Mendel says. But this year’s epidemic has heightened those normal concerns. She’s talking to Kentucky Derby Festival event coordinators about handwashing stations and portable toilets (called “Thunder Pots” for Thunder, of course). Will it be a problem, she wonders, when handwashing stations at Thunder run out of water and there’s no way to resupply them through the crowds? And what about vaccinating the food and beverage workers? Many of the Thunder vendors are from out of town, but as many as 25 are from Louisville. How to best reach them? And what about the 4,000 mostly local people hired to work the crowds at Derby each year?
It hasn’t been easy getting the attention of restaurants. When the epidemic started, Mendel says, the health department notified restaurants through listservs, encouraging vaccination for all food-service employees and repeating the handwashing gospel. But the initial announcement was only so much background chatter. No restaurants followed up. On March 13, Mendel is about to send another notice, this one announcing reduced-cost vaccines for restaurant employees through the U of L Global Health Initiative. Perhaps recent cases at Kroger and Denny’s will incite other food operations to take preventive measures, even if just to protect reputations.
Food inspectors already visit any restaurant hepatitis A patients say they frequent. The inspectors let the businesses know about the outbreak, check if anyone on staff has been sick and look for other hepatitis A risk factors. For a few venues, the risk factors are onsite drug use, Mendel says. “They’ve seen it in their parking lot. They’ve seen it in their restaurant. One said they had someone OD in their drive-thru lane,” she says. A Portland fast-food outlet removes all its electric outlets from the dining area to keep people from hanging out, charging phones and — they suspect — using drugs in the restaurant.
As the March 13 health department briefing wraps up, a half-dozen people remain at the table to talk Derby. Right now, it’s mostly questions: How will they reach hotel employees? What about sex workers? How about all those barbecue and sandwich businesses that pop up in the neighborhoods around the Downs on Derby Day? “Do we have people go literally house-to-house?” Caloia asks. Will there be enough vaccines, not just the CDC-supplied inoculations for the at-risk groups, but vaccines for everyone else who could spread hepatitis?
The following week, Zhao shows the team the latest epidemiological map. The neighborhoods off Taylor Boulevard near Churchill Downs now appear to be one of the city’s major hepatitis A clusters. The Kentucky Derby is 43 days away.
Week 30, March 25-31:
27 new cases. Total 199
The number of hepatitis cases has risen steadily in March. In January, there were 28 new cases. In February, 48. By the end of March, there will be 72. Forty-nine cases come in during the final two weeks of March, overwhelming the people charged with investigating every case. It takes 45 minutes to an hour to interview each new patient. Several of the people who conduct these interviews have other outbreak-related duties, and all have non-outbreak duties. Keeping up is near impossible.
As the month closes, Jefferson County Public Schools has a hep A scare. An employee for a food-preparation company shows evidence of hepatitis A. But follow-up genetic sequencing — the gold standard for diagnosis — reveals the individual is a false positive. The Portland Kroger isn’t so lucky: An employee tests positive for hepatitis A. So does a worker at the new restaurant Sarino on Goss Avenue. Frightened residents flood the health department with calls. Zhao’s office is among several inundated by the phone queries. “The calls are really disruptive,” he says. Many callers are upset. Some don’t understand why they can’t get the free vaccine, which is earmarked for people without insurance and anyone in a high-risk group. The department turns to Metro United Way 211, providing it with information about which calls to forward to which office and scripts to cover general outbreak information.
Everyone is busy. By the end of the month, the department will have administered more than 8,400 vaccines since the epidemic began. Vaccination events fill the calendar as nurses and others head to drug-treatment centers, shelters and halfway houses. They go to Family Health Center Portland, the Franciscan Kitchen on South Preston Street, the Lord’s Kitchen on Standard Avenue, the Cathedral of the Assumption on South Fifth Street, Hotel Louisville on West Broadway, the House of Grace, Wayside Christian Mission, Portland Presbyterian, the Healing Place, Gratitude House, Community Transitional Services and others. The Kerns continue their outreach with an organization called My Dog Eats First. About 150 people line up early in front of the former Boys and Girls Club on Portland Avenue to collect dog food and other needed supplies. Many live in the neighborhood; some live on the streets. Several bring their dogs to the old school gym, patiently waiting in a line that snakes out the door. Just before visitors wander back into the mild evening air, they pass the table where the Kerns are working. None of the student nurses who usually assist Nancy could make it tonight, so by herself, she vaccinates 25 people. No one complains as they wait.
During the March 27 briefing, Mendel says the Louisville Downtown Partnership has agreed to champion vaccinations to workers at all downtown hotels. But there’s still no plan to vaccinate the 4,000 temporary Derby workers, nor a plan for the food purveyors coming to Thunder. There’s talk of offering vaccinations to Derby workers at orientation and training sessions, but is it even worth the effort? How many temp workers will fit the high-risk definition required to receive the CDC-issued vaccine? The Substance Abuse and Mental Health Service Administration reports drug abuse and addiction rates of 20 percent in the accommodations and food-service industries — the highest of any industry, according to data from 2008 to 2012. (Across all industries, the average is 10 percent.) For a moment, the health department briefing group decides to drop the notion of vaccinating the temp employees. They’ll make due with informational fliers, posters and repeated admonitions to wash your hands.
Kathy Harrison Turner, the communications director, leans forward. “So if we have so many food-service workers in our high-risk population, tell me again why we wouldn’t want to do vaccinations at orientation?”
Director Moyer chimes in. The CDC-supplied vaccine will be gone soon anyway, she says. The health department will have to buy its own supply at $33 per dose. If the health department buys the vaccine, it can distribute it to anybody. “I think it’s worth it,” Moyer says. Suddenly, vaccinations are a go. Now all they need to to do is arrange a mass vaccination event for 4,000 people.
Weeks 31-32, April 1-14:
41 new cases. Total: 240
Mendel, the sanitation supervisor, feels like the subject of a weird physics experiment demonstrating the vagaries of time and space. Although the people from Levy Restaurants — the national firm that operates food and beverage service at Churchill Downs — were amenable to vaccinating their employees the first time she spoke to them in March, they had to talk to corporate. Then time slowed to a crawl. “For us, this is an immediate, urgent event,” Mendel says. “I think I’m getting a slow response from some of these people — I hope I’m not badgering them — but it’s because we’re moving so fast.”
In truth, it’s remarkable how rapidly things finally come together. On April 12, the Kentucky Nurses Association and medical students are in a room behind PBR Louisville at Fourth Street Live, vaccinating a steady stream of employees from the surrounding restaurants and bars. The Cordish Companies, which owns the entertainment district, is paying for its employee inoculations. On Saturday, April 14, Ken Luther, a nurse and an administrator head to Waterfront Park during a food truck and craft beer festival and vaccinate food-truck operators. From there, they to go Fourth Street Live, where the Louisville Taco Festival is in full swing, and vaccinate several more food-truck operators.
The following week, the nurse association and medical students set up shop at Whiskey Row, where employers are helping pay for employee vaccinations. Plans are underway to stage another event for NuLu employees. The Louisville Downtown Partnership continues to cheerlead vaccination of hotel employees. In addition, Anthem and Aetna chip in $35,000 toward vaccination. That donation allows the health department to lower the price of vaccines to $25 for food-service workers. Kroger also donates vaccines not used by their employees. By mid-April, the health department has spent nearly $600,000 on vaccines, although the state picked up a significant portion of the total.
On April 17, state health officials issue a recommendation that everybody in Jefferson County should receive a hepatitis A vaccination. The public learns that another restaurant employee, this one at an Applebee’s on Dixie Highway, tested positive for hep A. On April 18 and 19, just before the pre-Derby vaccination window slams shut, a mass vaccination event takes place during mandatory training for the 4,000 temporary employees at Churchill Downs. “I think the biggest thing about Derby is people are coming here and some let their guard down, doing things they might not normally do,” Caloia, the medical director, says. “We don’t want to be infamous for spreading hepatitis A.”
