(Note: This guest blog post was written by Barbra Cave, PhD, APRN, Assistant Professor, University of Louisville)
Before SARS-CoV-2, the virus causing COVID-19, was at the forefront of our minds, three other viruses had had the attention of Kentucky’s public health officials and healthcare providers. As important as it is to address COVID-19 and the potential for significant, severe morbidity and mortality, it is also important to remember Kentucky’s other outbreaks.
In 2017, Louisville experienced an outbreak of hepatitis A that eventually spread state-wide that was not associated with contaminated food (Foster et al., 2018). Cases of hepatitis B have been increasing in rural areas, including Kentucky, Tennessee, and West Virginia since 2009 (Harris et al., 2016). Coinciding with the injection drug and hepatitis C epidemics, Kentucky ranked #3 in acute hepatitis B infection (CDC, 2019). With viral hepatitis seeming to flourish across the state, it is important to understand the main differences between the viruses and what we can do to address them.
| Name | Virus Family | Type | Transmission |
| Hepatitis A Virus | Picornaviridae | RNA | Fecal-oral (dirty hands touching things we put our mouth on) and parenteral (sexual contact, injecting drugs with shared equipment) |
| Hepatitis B Virus | Hepadnaviridae | DNA | Parenteral (sexual, mother-to-baby, contaminated tattoos, injecting drugs with shared equipment) |
| Hepatitis C Virus | Falviviridae | RNA | Parenteral (mother-to-baby, contaminated tattoos, injecting drugs with shared equipment, sexual transmission may occur with men who have sex with other men or if someone has HIV) |
Despite similarities in their common names, hepatitis A, B, and C come from distinct genetic backgrounds and virus families. However, each may cause a similar set of symptoms when someone is initially infected. The symptoms of a new viral hepatitis infection may include:
- Fever
- Abdominal pain
- Nausea/vomiting
- Diarrhea
- Loss of appetite
- Light colored stools
- No symptoms at all
The best approach to addressing hepatitis A and B is prevention through vaccination (Nelson et al., 2020). The 2017 hepatitis A outbreak was brought under control through increased hand hygiene access/awareness and mass vaccination efforts targeting key populations: healthcare workers, incarcerated persons, and homeless persons. Food service workers should be routinely vaccinated for hepatitis A. There is no specific treatment or cure for hepatitis A infection. Few people require hospitalization or die from hepatitis A infection; however, the risk for bad outcomes is increased when hepatitis B, C, or alcoholic hepatitis is present. Kentucky’s hepatitis A outbreak ended in July 2019 (KDPH, 2019).
Kentucky began recommending the hepatitis B vaccine at birth in 1991 and testing all pregnant women for hepatitis B infection in 1998 (KCHFS, 2017). Healthcare workers and those with high likelihood of blood exposure are encouraged to receive the vaccine series as part of their employment. Nonetheless, there remains a large number of young and middle-aged adults vulnerable to hepatitis B infection due to lack of vaccination and lack of awareness of how the disease is spread (Harris et al., 2016). If hepatitis B develops into a long-term infection, medications are available to treat the disease. Hepatitis B infections are associated with the development of cirrhosis (advanced liver disease) and hepatocellular carcinoma (liver cancer) (CDC, 2020). Unfortunately, many vulnerable adults do not receive hepatitis B testing and risk continued spread of the disease through sexual transmission and substance use (Harris et al., 2016).
Hepatitis C virus has no vaccine for prevention; however, it can be easily treated and cured with direct-acting antiviral medications. Most hepatitis C infections (80%) are associated with intranasal or injection drug use. The risk of having hepatitis C from substance use exists even if the episode of drug use occurred just once decades ago, or is part of someone’s daily life. Other sources of hepatitis C infection may stem from blood transfusions received prior to 1992, history of military service, or history of incarceration (AASLD, 2018).
As of January 2020, the CDC, USPSTF, and the American Association for the Study of Liver Disease and Infectious Disease Society of America updated hepatitis C testing guidelines to reflect universal testing of all adults at least once, and pregnant women with each pregnancy (AASLD, 2018; Shillie et al., 2020; USPTSF, 2020). It is easy to test for hepatitis C infection. If discovered, patients can be treated across Kentucky from primary care providers, addiction care providers, infectious disease specialists, gastroenterologists, or hepatologists. It is becoming increasingly easy to find someone to treat hepatitis C, and programs are underway in Kentucky to train non-specialists to manage the infection (Patrick, 2019). There are no longer rules preventing someone with ongoing/active substance use disorder from being treated right away.
In summary, Kentucky has endured simultaneous outbreaks of viral hepatitis over the past decade. We appear to have overcome hepatitis A, but remain especially vulnerable to hepatitis B and C propagation. Preventing hepatitis A and B is best through vaccination. When that is not possible or was not completed, screening, diagnosing, and treating viral hepatitis will help lead to case reduction and eventual elimination. Harm reduction strategies such as syringe exchange programs and provision of straight-forward disease transmission education are key to mitigating the spread of viral hepatitis. Although addressing the COVID-19 pandemic is a priority, we cannot forget to address the ongoing battles against hepatitis B and C in the context of the ongoing injection drug epidemic in our region.
References:
AASLD-IDSA HCV Guidance Panel (2018). Hepatitis C guidance 2018 update: AASLD-IDSA recommendations for testing, managing, and treating hepatitis C virus infection. Clinical Infectious Diseases, 67(10), 1477–1492. doi: 10.1093/cid/ciy585
Centers for Disease Control (CDC) (2019). Surveillance for Viral Hepatitis- United States, 2017. Retrieved from https://www.cdc.gov/hepatitis/statistics/2017surveillance/index.htm
Centers for Disease Control (CDC) (2020). Hepatitis B information. Retrieved from https://www.cdc.gov/hepatitis/hbv/index.htm
Foster, M., Ramachandran, S., Myatt, K., Donovan, D., Bohm, S., …& Jorgensen, C. (2018). Hepatitis A virus outbreaks associated with drug use and homelessness – California, Kentucky, Michigan, and Utah, 2017. MMWR. Morbidity and Mortality Weekly Report, 67(43), 1208–1210. doi: 10.15585/mmwr.mm6743a3
Harris, A. M., Iqbal, K., Schillie, S., Britton, J., Kainer, M. A., Tressler, S., & Vellozzi, C. (2016). Increases in acute hepatitis B virus infections – Kentucky, Tennessee, and West Virginia, 2006-2013. MMWR. Morbidity and Mortality Weekly Report, 65(3), 47–50. doi: 10.15585/mmwr.mm6503a2
Kentucky Cabinet for Health and Family Services (KCHFS). (2017). Perinatal hepatitis B. Retrieved from https://chfs.ky.gov/agencies/dph/dehp/idb/Pages/perinatal-hepatitis-b.aspx
Kentucky Department for Public Health (KDPH). (2019). Acute hepatitis A outbreak weekly report. Retrieved from https://chfs.ky.gov/agencies/dph/dehp/idb/HepADocuments/AHAO19W26.pdf
Nelson, N.P., Weng, M.K., Hofmeister, M.G., Moore, K.L., Doshani, … & Harris, A.M. (2020). Prevention of hepatitis A virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(5); 1-38. doi: 10.15585/mmwr.rr6905a1
Patrick, M. (2019, August). Conference speakers call for a more aggressive approach to eliminate hepatitis; Ky leads the nation in both hepatitis A and C. Kentucky Health News. Retrieved from http://ci.uky.edu/kentuckyhealthnews/2019/08/05/conference-speakers-call-for-a-more-aggressive-approach-to-eliminate-hepatitis-ky-leads-the-nation-in-both-hepatitis-a-and-c/
Schillie, S., Wester, C., Osborne, M., Wesolowski, L., & Ryerson, A. B. (2020). CDC Recommendations for Hepatitis C Screening Among Adults – United States, 2020. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports, 69(2), 1–17. https://doi.org/10.15585/mmwr.rr6902a1
US Preventive Services Task Force (USPSTF) (2020). Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force Recommendation Statement. Journal of the American Medical Association, 323(10):970–975. doi:10.1001/jama.2020.1123
