Hepatitis in Kentucky: Fifth State for the Outbreak

Highlights:

Cases since 2017: 2159

Deaths since 2017: 14

Case Fatality Rate: <1%

Pandemic Threat Level: 5/10

Hepatitis A has been spreading across the state of Kentucky in recent months, infecting over 2,000 people. Part of a family of viruses, hepatitis A is a liver disease that is easily transmitted from person to person through the fecal-oral route. For those of you who don’t know what the “fecal-oral route” is, it’s essentially how bacteria and viruses can be transferred when a person uses the restroom and does not wash their hands afterwards. The unwashed hands then go on to prepare food, wipe their face, shake YOUR hand where you then wipe your face… you get the picture. Some of the most contagious viruses can be spread this way, such as norovirus (commonly known as the stomach flu).

There are three viruses that make up the Hepatitis family and they are known as A, B and C. All hepatitis subtypes are known for infecting the liver, but each has their own rules for transmission and severity. Hepatitis B, for instance, is transmitted via body fluids (specifically blood or semen) and can cause many flu like symptoms as well as jaundice, abdominal pain, and dark urine. Most of these infections clear up on their own. Sometimes, however, hepatitis B can become recurring and becomes known as a chronic illness. Hepatitis C, on the other hand, is much more serious and is transmitted via blood. Because of this, it most often affects intravenous drug users. For about 70-85% of its victims, hepatitis B becomes chronic and can lead to cirrhosis and liver cancer.

Hepatitis A, the particular viral subtype of this story, is the easiest to transmit of the three viruses, but is also the least serious. In most cases, the disease does not result in a chronic ailment, but it can produce stomach pain, jaundice, fatigue, and low appetite for upwards of two months. As stated earlier, hepatitis A is often passed via the fecal-oral route, but can also be transmitted when contaminated food or water is consumed.

Around this time last year, I was doing an internship at the Kern County Department of Public Health when I heard about a hepatitis A outbreak in San Diego that was being tracked and moving up to Los Angeles. When the strains found in Kentucky were sequenced and compared to the strains found in the outbreak in California, it was determined that the two strains were linked. In other words, the outbreak in Kentucky is part of the same outbreak that had been occurring in California. Hepatitis A has also had epidemics occur in Utah, Florida, and West Virginia- all with the same strain of virus.

In all five states where the outbreak has occurred, hepatitis A has affected primarily the homeless and drug user population. This population is at the highest risk of coming into contact with contaminated food and water, and having limited access to hygienic practices. The transient nature of the homeless population can likely explain how the virus has been able to travel across so many states in a relatively short amount of time.

It is because of these factors that I rated hepatitis A at a 5/10 on the Pandemic Threat Level. However, it did not merit a higher number than 5 due to the nature of the illness. While it is very contagious, simple handwashing practices can help prevent transmission and the virus is vaccine transmittable. In many cases, just supplying adequate sanitation to homeless people and substance abusers has shown to merit some success in preventing the outbreak from spreading.

Cholera on Hispaniola- An Ongoing Story

Highlights

Cases since 2017: 17, 027

Deaths since 2017: 200

Case Fatality Rate: <1%

Pandemic Threat Level: 3/10

Cholera is a waterborne illness known for causing severe, watery diarrhea. In some cases, the symptoms can become so drastic that the body succumbs to dehydration. It can be spread through contaminated water, and sometimes death can come just hours after the first symptoms present themselves.

The outbreak of cholera in Haiti has been continuous since shortly after an earthquake decimated the infrastructure in 2010. In the eight years since its first reporting, cholera has killed at least 10,000 people in the small country, and is still running rampant across the island- even spreading into the Dominican Republic, though not as widespread.

Cholera had not been seen in almost century in Haiti until after 2010, and when it hit, the flooding and poor hygiene that was rampant in the area post-earthquake allowed the disease to spread like wildfire. In fact, throughout history, we have often seen rises of epidemics immediately following a natural disaster. Even more so with waterborne illnesses, since clean water can become hard to come by after earthquakes, floods, hurricanes, and other disasters.

Another contributing factor was the Haitian peoples own immunities. As cholera had not been seen in almost a century, the Haitian people had practically no natural immunities to the disease. Think of the stories of smallpox covered blankets being administered to the American natives. In the same manner, the natives had no immunity and were almost wiped out by smallpox. The Haitian people’s own lack of immunity has only helped to promote this outbreak, and has made it difficult to eradicate.

It wasn’t until years after the disease had already become endemic to Haiti that the source of the outbreak was discovered. In 2016, the United Nations admitted that Nepalese UN peacekeepers had brought cholera into the country with them when they had come to help with earthquake recovery. The disease started near the Nepalese camp, where it was discovered that the peacekeepers had dumped their sewage into local waterways.

Now, in the 8^th year of the outbreak, the disease remains endemic to Haiti, and even if the outbreak is finally brought under control, it is unlikely to be completely eradicated. The introduction of cholera from Nepal to Haiti is a great example of how easily it is in this century for diseases to spread from one location to the next. Historically, civilizations could rely on great mountain ranges and oceans on separating them from their next epidemic, but this isn’t the case anymore. We are all just one flight away from introducing a new disease to a defenseless population.

I gave the Haiti outbreak a Pandemic Threat Level of 3 because of its mode of transmission. Cholera is a waterborne disease and often thrives in locations that do not have water filtration systems. This is why it was so easy to transmit across the island of Hispaniola after the 2010 earthquake. In developed countries that have working water filtration systems, cholera is less likely to be spread. And while cholera is one of the most common diseases seen in developing countries, there are rarely any incidences in the western world.

Cholera can become life threatening in just a matter of hours, but there are ways to prevent its transmission even in endemic regions. Those in infected areas should be sure to wash their hands with warm soap and water and boil any water that could be contaminated before using it for food or washing. But even once infected, modern medicine can do a lot to curb the risk of death. It is also possible to make a homemade solution of water, sugar, salt, baking soda, and fruit to help restore electrolytes of the infected. There is no cure for cholera.