JUSTIN HENDERSON: Welcome and thank you for joining us today as we discuss the hepatitis A
outbreak that's going on in Michigan right now. I'm Justin Henderson I'm an
epidemiologist with the emergency response and enforcement unit in the
Michigan Department of Agriculture and Rural Development's Food and Dairy
Division. With me is Jay Fiedler, he's a Section Manager for Surveillance
Infectious Disease -- THE VIDEO FROZE HERE FOR ABOUT A MINUTE BUT CONTINUES SHORTLY. SORRY, LIVE TV!
JAY FIEDLER: We are live, are we going back to the top Justin? I think we had some technical difficulties.
JUSTIN: Oh, okay. We will re-welcome you and thank you again for joining us today as we discuss the
hepatitis A outbreak that's going on in Michigan so I'm Justin Henderson I'm an
epidemiologist in with Michigan Department of Agriculture and Rural
Development Emergency Response and Enforcement Unit. With me is Jay Fiedler
he's the Section Manager for Surveillance and Infectious Disease
Epidemiology with the Michigan Department of Health and Human Services.
So our departments regularly work together along with our federal and
local health department partners to respond to foodborne illness outbreaks
and diseases that affect the health and well-being of all Michigan residents. So
during this session we're going to present some information on the current
Hepatitis A outbreak that's going on and answer any questions that you might have
for us. As we go through some of the things we want to cover some of the
background information please post any questions that you have to the comments
section there are questions that we can't answer immediately we will get
back to you on those and post those answers in the comment section as soon
as we can. So, for a little background information on the outbreak so we are
currently since August of 2016 experiencing a hepatitis A outbreak in
Michigan. This week the State Emergency Operations Center was activated to
assist state agencies coordinating their response to the outbreak. As far as
current cases and and what the situation currently looks like we last count had
four hundred and eighty six cases of hepatitis A infection as part of the
outbreak about 84 percent of those have been hospitalized so that's over 400
cases and we've also had 18 deaths associated with the outbreak. The area
that's been affected has been growing in recent weeks counties and jurisdictions
include the city of Detroit, Calhoun County, Clare County,
Genesee, Hillsdale, Huron, Ingham, Isabella, Lapeer, Livingston, Macomb, Monroe,
Oakland, Sanilac, St. Clair, Washtenaw, and Wayne. So it's quite a list we have
of affected areas. As that changes, there maybe updates to that list
into those case counts so for the latest information you can go check out
www.michigan.gov/hepatitisAoutbreak. So for some more information on the public
health let's talk to Jay. JAY FIEDLER: Thanks Dustin we have some questions scripted out here
that are pretty good to get us going: first what is hepatitis A? Hepatitis A is
a viral infection that is very easily transmitted from person to person
it is highly infectious, highly contagious: the symptoms of the virus
themselves and I'll read these directly from the information on the CDC website:
fatigue, fever, loss of appetite, nausea, vomiting, abdominal pain, dark colored
urine, clay-colored bowel movements, joint pain, and jaundice. So a lot of those very
nonspecific symptoms but they do really progress once you start to get to
symptoms of jaundice when the virus is affecting your liver. People can protect
themselves from hepatitis A in two main ways number one is vaccination
vaccination for hepatitis A is highly effective in preventing the infection a
very safe and effective vaccine. In addition to that just from a personal
hygiene perspective, like we say with a lot of different things, wash your hands
washing your hands helps prevent the spread from person-to-person because the virus is spread via what's called a fecal oral route. So
contaminated hands from feces can cause spread through food or surface contact
so washing your hands is a great way to prevent the transmission from person to
person. Now when we talk about populations that are most at risk
both traditionally nationwide and in this outbreak again persons with direct
contact with persons who have had hepatitis a any kind of close household
contacts whether that be people that you care for or yourself;
travelers to countries with high or endemic rates of hepatitis A infection;
men who have sex with men and users of injection and non injection drugs are the
primary things that we see nationwide. When it comes to this specific outbreak
in Michigan, there's a few groups that have stood out and those are mostly
reflected in what we see in the national guidelines; homelessness has been a major
risk rector identified with this group as
well as individuals with documented substance abuse. So those are two of the
big populations that we've been targeting and then most recently in the
last couple of weeks we've seen a bump in the number of cases in the MSM
population so in response to that we've been working with local health
departments in Michigan to target education, information and vaccine
towards those groups we're trying to get all of those things out there to try to
get a handle on this and get this outbreak under control. Additionally
we're trying to encourage very prompt Public Health follow-up of new cases so
that when we do identify new folks who may be at high risk of transmitting the
virus to to other people either through their work situation if they look at a
restaurant they work at somewhere else where they've got exposure to the
general public and then also to encourage post exposure prophylaxis
within their household contacts and within their their immediate community
and personal contacts. So we do want to get good follow-up on those cases with
post-exposure prophylaxis is a major step in trying to control this. So I
think that segues into what you want to talk about regarding the food safety
side of this Justin. JUSTIN: Yeah a little bit. So what is the Department of Agriculture
and Rural Development's role in the outbreak? We do our work with other state
and local partners to protect consumers and the food supply in Michigan a lot of
the investigations and and support we provide for food safety and it'll food
worker investigations with our partner agencies is a big part of what we do so
when a new case might be identified, and a food handler or a food worker, we quickly
try and assess what the risk is to further spread via that person's work or
contacts so that's a big part of what we're trying to do to limit the impact
of this outbreak. So speaking of food service establishments: food
establishments in general what can workers there and and other people do to
prevent the spread of hepatitis a there's a few really big things that are
worth mentioning in food not touching ready-to-eat food with bare hands is a
big one so if somebody happens to be sick it's very easy for them to
contaminate food and if that food doesn't then get cooked and the virus
killed then it's it's quite easy to further spread that virus anybody who
who eats that food so in addition to not touching ready-to-eat foods with bare
hands following all of the the general safe
food handling requirements a really big one is hand-washing so even if
somebody's sick if they're properly washing their hands it really reduces
the chance that things are spread though it's certainly still possible it is a
good way to limit the impact of further spread of the virus at that point
another great way as Jay mentioned is getting vaccinated so that is a safe and
effective vaccine that's top of the list of the things that can be done to
prevent further illness so I don't know if we've had a whole lot of questions
come up yet so we had a few other things that we
could hit on one of the things that we have have gotten asked about a few times
is about why the hospitalization rate is so high for this outbreak so we have
over 400 people 84 percent or so of the cases in total that have been
hospitalized so why is it it's a good question I we don't know exactly the
answer to this question something that we're looking into more even as we speak
and it's there are a couple of high profile hepatitis bricks going on in the
United States right now and it's reflected in those other areas too one
of the things that we're looking at is this is a relatively new strain to the
US so is it something about the strain of comte's itself that makes it more
aggressive and results in more hospitalizations is it something about
the population that it's impacting that's causing a higher hospitalization
rate so you know both of those things are things that we're considering and
but that's one of the questions that that we've been asking and we're looking
at more data on how to answer that question yeah so the fact that it's a
newer strain we just don't have a lot of pre-existing information to to go from
in some cases right sure another question that we've gotten is that why
the State Emergency Operations Center was activated in response to this and
the main answer of that is just so we have several state agencies working on
on the response and the activation of the State Emergency Operations Center
just helps coordinate all the different response activities that are going on
across state government so that's why that is an ongoing activation and tell
coordinate all of our efforts sure I mean liquor here you've gotta be HHS and
are working on this jointly you've also got Michigan Department of Corrections
that's very interested in the population of folks that they're working with and
then State Police also brings the resources and coordination so I think
it's a good move absolutely all right so we do have a few
questions one from Margaret what are the symptoms symptoms again very general for
the the initial symptoms of this disease in the onset again fever fatigue loss of
appetite nausea vomiting abdominal pain dark urine clay-colored bowel movements
joint pain and jaundice really the initial presentations you're getting
those those general I don't feel good kind of symptoms that bring people in
sometimes they'll seek health care early on symptoms usually last less than two
months and hepatitis A generally starts to result after the onset of jaundice
folks can remain infectious about a week or so after that period so and so to me
it always occurred jaundice is one of the more unique symptoms of hepatitis
relative to some of the other food possible foodborne pathogens that that
we spend our time working on so you know the yellowing of the skin and ice that
go along with that is pretty unique and often pretty obvious but as Jay said
that sometimes happens later on in the course of the infection yeah one of the
difficult things about hepatitis A is the long incubation period - you know
incubation period can be up to 28 days you may only start to become symptomatic
for the last the second couple weeks we say you're infectious about two weeks
before the onset of symptoms so again that's what makes finding those personal
contacts in you know your food histories and your occupational history is
important when it comes to trying to identify who else might be exposed and
then so it can take a couple two or three weeks for symptoms to develop yeah
and then during that time that person may also may be likely is infectious and
so you may be able to spread the illness around before you even know really that
you've got you know a serious infection so that's a real problem for us another
question see from Nancy how is this spread how is
it spread good one again very well documented in the United States
person-to-person transmission and person-to-person fecal-oral roots so you
have someone with contaminated hands or contaminated surfaces that result in
transmitting either via food or hands to the mouth of another person you ingest
the virus again very infectious and it's very good at spreading via that route
yeah so as a result of that typically when we identify a new case any close
contacts of that case are usually given prophylaxis they're given vaccine or
immune globulin to prevent their illness because we essentially just assume that
they have been exposed just by being in close contact with somebody who's who's
been infected good question one from Joanne is this in the Flint Davison area
so we do know we have added Genesee County to our list of counties in the
outbreak area so I would say you know we can say yes that all Genesee County now
from the public health perspective is being considered part of the outbreak
area and will you know be receiving the same kind of prevention and response
efforts but the rest of the upper area is - yeah and so again just remind his
opportunity remind folks that hepatitis A outbreak comm michigan.gov have to say
outbreak I is where you can get future updates on the numbers both total case
counts and county breakdowns for where we're seeing these infections so
absolutely yeah a good spot to go we have you know information changes
quickly as as everybody's working on this at state local level sure sure
I think we have a question about someone tuned in late and asking about a recap
and would like to remind folks the entire video will be posted on the
Facebook page so it might be hard to do a broader
recap at this point in time but if you've got time to go back and take a
look at the intro material that we provided that'd be great
we'll try to hit on some of those same concepts though as we as we move through
and push your questions push questions while we're going through
and we can we'll keep an eye on those and try to answer them as we
oh yeah another question that we've got where can I get vaccinated again I'm
probably three things number one talk to your to your provider first of all your
provider may have you talked to your local health department there's another
good place where you can be vaccinated and if those two options don't pan out
again go back to the website and for the counties that are impacted we've got a
good list of numbers for the local health department's and then some
information on active outreach in clinics that they may be providing as
well absolutely very good question um let's see what else do we have any other
questions come in yet well so the question is this in epidemic level now
very good question Jay what do you think epidemic outbreak I think it's a fine
line between what you call it I think for in our recent conversations we've
still been calling this an outbreak I think that when we start it hopefully we
don't see this move statewide I think if you see it move statewide then we're
going to be talking about this as a epidemic at that point in time given
that it's it is more localized it is spreading but we've pretty consistently
referred to this as a outbreak at this point in time again
the distinction is pretty right please find mine they're in the same amount of
concern you know and effort goes into it so very good I don't have any new
questions yet to go back to one more time somebody wanted to know the the
counties that were affected so I can list those off again real quick and
again the michigan.gov slash hepatitis A outbreak is a great website that has
will have the latest information on it moving forward so you can always refer
to that but see Detroit Calhoun Claire Genesee Hillsdale here on
Ingham isabelo Lapeer Livingston Macomb Monroe Oakland santé lac st. Clair
Washtenaw in Wayne Counties are those that are currently in the outbreak area
but as we've seen over the last year plus that's expanded yeah a couple of
new questions one regarding us question about someone who's having
surgery and should they be vaccinated I'm not a doctor
talk to your providers you know and raise that question they should be able
to answer that and address any of those concerns and that's really the way to go
when in doubt ask your health care provider it's the best thing to do there
absolutely the other one that I see could this be related to California
produce which is an interesting topic I think in general because it goes back to
hepatitis A and what we typically see with hepatitis A versus what we're
seeing right now and you know a lot of the times when we see him to say
outbreaks we do think about things like produce and foodborne outbreaks we
recently had that contaminated strawberries that we had a lot of
attention about a lot of coordination between our agencies and outreach to the
public there unfortunately you know early on in this outbreak it did start
in Southeast Michigan starting back as Justin said to August of 2016 pretty
elevated slightly elevated but lower levels and we were never able to
identify a common a common food item at a common community exposure that we
could link that back to you so it is a good question in the sense
that we do commonly see this associated with food and on food borne outbreaks
and we respond to those but we haven't been able to identify a source like that
either to connect the Michigan cases back to you nor do I think I've seen
anything like that for what's been going on in San Diego in some other states
right well we don't currently suspect there's some ongoing food exposure that
could be making folks continue to be sick but what we definitely are seeing
is that there's infections in the community and it's continuing to spread
continuing to spread that way more questions have come in from Hanna can
you explain the difference between the different types I can't remember which I
was vaccinated for it does get confusing I totally appreciate that question
there's hepatitis a b c d and beyond yes so it can be confusing so that hepatitis
A is typically an acute viral infection something that we see like we just said
more associated with foodborne outbreaks traditionally in this country because
it's not endemic in Michigan or in the in the US
we do see time to see this as a person-to-person transmission thing in
like I said through contaminated food or person-to-person contact different than
the NC where you're talking about blood-borne infection and more of a
chronic condition so appetite assay tends to be a more of an acute viral
infection we don't see the chronic infections like we do with some of the
other strains right and there are vaccines available both for hepatitis A
and B so you could have been vaccinated for either one of those or both so
that's definitely something to follow up on with your your healthcare provider if
you're interested they may be able to help you figure out which one you were
previously vaccinated for so that you can stay up to date on those vaccines
good question yeah well in the other thing that's
interesting too is the epic anus a vaccine is part of the childhood vaccine
schedule now so a lot of children are or younger bigger people are vaccinated
routinely against hepatitis A as part of your childhood immunization series so
that's a good thing when it comes to the outbreak as a whole we haven't seen a
lot of cases in younger people only one very young individual in fact as part of
this outbreak everyone else is the age 20 or older
so our age ranges been 20 up to 87 I think in the high end of that so in that
vaccines been available since at least the late 90s I believe so a lot of those
folks in the younger age group are more likely to be at receive that vaccine
already so very good question there too
let's see not seeing many other new questions so again if things come up
that you're interested in you may have a few coming yet again we see we got
another question what symptoms that's really quick for us to run down and
again that's also on the website so go there for your source for information
once we're done here two great source of information about the outbreak yeah
fever fatigue loss of appetite nausea abdominal pain dark colored urine
clay-colored bowel movements joint pain jaundice some of those the some of those
symptoms at the end are very classic for hepatitis A and it's very recognizable
about the healthcare community but that's one of the things that we've done
in addition Justin particularly in Southeast Michigan but statewide as well
there has been a lot of messaging out to health care providers to increase
awareness increase awareness with the outbreak so that folks have this on
their differential diagnosis lists so that healthcare providers are looking
this looking for this and making sure to get it get test run and get it diagnosed
as quickly as possible so that we can identify those cases absolutely so I'll
just run through another quick recap of the outbreak J just went over the
symptoms but again why were here talking to you today we are experiencing an
outbreak of hepatitis A virus infection in Southeast Michigan now expanding
beyond what you know many of us would think of as just Southeast Michigan but
that's that is where it started back in August of 2016 now we have 486 cases
that are part of the outbreak over 84 percent of those who have been
hospitalized and we do have 18 deaths that are associated so we've just been
talking a bit about what the Michigan Department Health and Human Services and
the Michigan Department that your culture and rural development have been
working on and trying to bring some of this information to you and answer some
of your questions about about the illness and and what's being done and
what you might be able to do to prevent the illness in yourself sure one of
those things we have a question kinda related to this right now is what is the
vaccine it's a pretty general question but I'll hit on a couple of things we
are pushing vaccine is post exposure prophylaxis and as primary prevention
for the disease itself the vaccines are typically single antigen vaccines that
are delivered here in the United States the vaccine itself is a hepatitis A
vaccine and there are formulations that are hepatitis A and B but you should be
able to find a single antigen hepatitis A vaccine that can be administered for
protection of yourself yep so Michelle has a question is there a blood test to
see if you have it or not well yeah Tennessee infections are commonly
a diagnosed via serology which is a blood test performed by hospital
oratories I know that it's performed by hospital laboratories may be defined by
other people but so that is typically the way that that is diagnosed yeah good
question Michelle another question let's see there was one it is a specific test
as that follow-up question asks there is a specific panel that needs to be
ordered that would include NSA serology yep so if you're wondering if if you if
you think you may need to request a test - - that would be able to detect whether
you've been infected or not it should be as easy as asking your healthcare
provider giving them your concern like I think I may have been exposed to
hepatitis A and I'd like to be tested they should be able to do that without a
whole lot of trouble so the more details you can give them
the better they'll be able to provide you a test it'll answer your question
and I think to piggyback on that if you do think that you've been exposed or
there's an identified exposure in your community say there's a restaurant where
there was a kid infected food worker and that that
notice has been sent out post exposure prophylaxis within 14 days of exposure
is very effective at stopping hepatitis A infection and so all the more reason
to ask those questions of your provider and determine if vaccine is right for
you at that time yeah that 14-day window is really vital in preventing illness
absolutely see there's a question from Ray Canada has has had outbreaks in the
90s could it have gotten in the water and spread to us we live near the border
with st. Clair County so just at first I think you know hepatitis it's possible
for hepatitis A to be transmitted via water we haven't seen a lot of that in
the United States in quite a while since all of our sanitation improvements and
certainly not since the vaccines been out and routinely given to to folks so
that there's a lot of immunity on the population and it doesn't spread so it's
possible to be spread via wire but I would say it's unlikely that it would
have kind of crossed borders that route yeah I think even in the CDC
documentation that I've been reviewing recently there's like spread via water
can happen in in more endemic countries and that's due to issues like you
described a sanitation and other things but not typically a route that we see in
the United States primary route person-to-person transmission yep
absolutely that is a good question
there's no one out there okay I guess that might wrap up what we've got now
again this will be posted to the website after we're done here so that you should
be able to get the repeat repeat performance if you like but in the
meantime please check out this website it's got all the latest information on
it case counts the area that's affected some recommendations for what to do to
protect yourself and others so please use that as your main resource so thanks
again for watching and we appreciate your attention and we will continue to
be updating that website and and doing what we can to limit the effect of this
outbreak on the citizens Michigan thanks dressing thanks Jay
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