Christopher Larime goes out to lunch most days, often with co-workers from the General Motors Tech Center in Warren.
The father of three said he ate in March at the Buffalo Wild Wings across Mound Road from his office. It’s the same restaurant where a food worker was later found to have hepatitis A.
Larime is one of 837 people sickened with the virus in Michigan since August 2016. It has killed 27 people in the state, which remains in the throes of the biggest hepatitis A outbreak in the country.
As of May 23, hardest hit are Macomb County, with 220 cases; the City of Detroit, with 170; Wayne County, with 144, and Oakland County, with 114 cases.
The virus is highly contagious and can be spread through food or water contaminated by the feces of an infected person, through close contact or sex with a person who has hepatitis A or by touching a surface contaminated by the virus and then touching your mouth. It causes liver inflammation — and liver failure in extreme cases — and can be prevented through vaccination and hand washing.
The outbreak has led to alerts from county health departments about several restaurants in metro Detroit where as many as 35 workers were found to have the virus and who may have spread it unknowingly to diners. The virus is contagious weeks before a person begins to exhibit symptoms, which makes it extremely challenging for public health officials to manage.
The Wayne County Health Department and the City of Detroit’s Health Department now recommend all restaurant employees and food handlers get the vaccine. Oakland County’s Health Division also urges restaurant employees to consider vaccination.
Last month, the State of Indiana’s Department of Health issued a travel alert warning Hoosiers planning to visit Michigan to get vaccinated before they come.
Though Larime, 46, of Grosse Pointe Park can’t be certain he contracted the virus at Buffalo Wild Wings and not at another restaurant or in some other way, that’s how he suspects he was sickened.
“I could take a rough guess,” he said. “If I look back now, there was fever, stomach pain, shortness of breath, and probably the biggest thing was just you know, I felt like eating very little, it was loss of appetite.”
Those symptoms led him to the emergency room at Beaumont Hospital in Grosse Pointe, where he was hospitalized for nearly a week.
“The reason I eventually went to the ER was because it was so persistent,” he said. “I had acute hepatitis, so my liver enzymes were way out of whack.”
The strain of hepatitis A that has spread through metro Detroit the last two years has a higher rate of hospitalization than past outbreaks, said Jay Fielder, an epidemiologist who is section manager for surveillance and infectious disease epidemiology with the Michigan Department of Health and Human Services. Of the 837 people who have contracted the virus since August 2016, 80% — or 671 — have been hospitalized and 3.2% have died.
That’s a far higher rate of hospitalization and death than is normally seen with the hepatitis A virus, said Dr. Nicholas Gilpin, chief medical officer of Beaumont Hospital, Grosse Pointe, and medical director of infection control/epidemiology.
“For the average person, hepatitis A is more of a nuisance,” he said of an ordinary outbreak. “There’s a very, very slim chance that a hepatits A infection would lead to serious complications. … About 1% of cases will go on to liver failure, which means you would require a transplant. In the majority of cases, you feel sick for a period of time and then you get better.”
But since August 2016, people who have been sickened in Michigan and in outbreaks in San Diego and Utah, haven’t fared as well, Fielder said.
“In all three of those jurisdictions, which have been most heavily impacted by these ongoing hepatitis outbreaks, the hospitalization rates have all been very high,” Fielder said. “In our case, it’s up around 80%. In those other locations, I believe it’s been up between 70-80%. So, we’re seeing something in Michigan that’s been very similar to what we’re seeing in other places around the country.
“Something is different and we’re trying to figure out what it is. It’s going to take a little while.”
Fielder said the U.S. Centers for Disease Control and Prevention is investigating, but what he’s noticed in this spate of infections is that it has most impacted an older population with other illnesses that make them more vulnerable to more complications with hepatitis A.
Among those who have died in Michigan as part of the outbreak, most of them are 50 or older, Fielder said, and they died of liver failure, septic shock or other organ failure.
MORE: Michigan health departments get money to fight hepatitis A
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“Generally, it’s been people who are more sick or people who have less access to health care,” Fielder said. “You know, we’ve also seen a homeless component to this. We’re seeing this driven by a substance use disorder risk group. You know, folks that are harder to reach and might not seek health care quite as much. So we think those really are risk factors that play into this.”
People who use illegal drugs account for about half of outbreak-related cases, “and when we see cases moving to new areas, it’s often in this population,” he said. “They seem to be the people who are driving it to new areas and are kind of continuing to propagate this outbreak at this point in time.
“It’s a very hard group to reach, and it’s a very hard group to get public health messaging to. There’s a lot of trust issues with government entities in general. So there’s a lot of outreach going out from local public health to … people they do trust in the community.”
Still, the state Department of Health and Human Services does not recommend that everyone in Michigan get the vaccine. Rather, it suggests continued routine vaccination for all children starting at the age of 1, and for adults who:
- Are homeless
- Are incarcerated
- Use injection or non-injection illegal drugs
- Work with the high-risk people listed above
- Have contact with, care for or live with someone with hepatitis A
- Have sex with someone who has hepatitis A
- Are men who have sex with men
- Travel to countries with high or medium rates of hepatitis A
- Have chronic liver disease such as cirrhosis, hepatitis B or hepatitis C
- Have clotting-factor disorders
Vaccination also is recommended for anyone who may have been exposed to a person with the virus. So long as people who have been exposed to hepatitis A are vaccinated within 14 days (and often given a boost of immune globulin), the risk of contracting it is greatly reduced.
“I think that people need to evaluate their risk,” Fielder said. “This is something that I can’t make a blanket statement that everyone should be vaccinated for hepatitis A. … I think they should evaluate their personal risk factors and have a discussion with their physician or their local health department about whether to get vaccinated.”
MDHHS spokeswoman Lynn Suftin said the Indiana health advisory recommending its residents get vaccinated for hepatitis A before traveling to Michigan is overstated.
“That recommendation doesn’t match what we’ve worked on with the CDC or the CDC recommendations,” she said. “Those high-risk populations definitely should consider getting vaccinated, but there is not any kind of travel advisory within the United States for hepatitis A at this point.”
Now stretching almost two years, the outbreak in Michigan has showed some signs of slowing in the first part of 2018.
However, health officials are bracing for another upward swing in cases that often comes with the summer months.
“Typically, winter and spring tend to be lower incident times. We see a little more hepatitis A in the summer,” Fielder said.
“We are still seeing cases at a rate that very much exceeds what we would typically expect in Michigan at this time of year.
“We’re seeing about six cases a week. In Michigan, we typically see about 60 cases a year — so at this rate, in 10 weeks, we’re seeing our yearly expected total of hepatitis A.”
Though adults typically get two doses of the vaccine spaced six months apart, the CDC recommends just one dose right now, as it has a limited supply of the vaccine.
“Right now, in the situation we’re in with a constrained vaccine supply, the current recommendation is that we’re trying to get one dose in as many people as we can because one dose is highly efficient at preventing hepatitis A infections,” Fielder said.
“Here in Michigan, we’re expecting to be dealing with this outbreak for months still, and I know there’s currently outbreaks in Indiana, Kentucky, Ohio and West Virginia. Missouri is starting to see an increase in cases. Given what I know about the regional activity, I think that CDC is going to be in a constrained status for a while for the vaccine.”
Food handlers, in general, fall into a much lower priority/risk group across the state and are not MDHHS’ focus for vaccination, Suftin said.
However, she noted that “in areas of high-case density, such as Oakland, Macomb and Wayne counties and the City of Detroit, the recommendations are slightly different and outreach to food handlers is appropriate.”
Fielder said that while hepatitis A is a public health risk to be taken seriously, “when you look at the epidemiology of this outbreak over the course of almost a year and a half now, we’ve identified 35 food workers as part of this cluster. Very few of those have been in a position — I’d say maybe half of those — have been in a position where it required public notification and post-exposure prophylaxis as part of the response.
“I don’t think that anyone needs to be more worried about hepatitis A when they’re eating out than they would be about anything else. Of course, I work in communicable disease. I work in public health, I have a pretty good idea of what happens behind the scenes in a restaurant. I would worry more about Norovirus or about E. coli or many other things before I would worry about hepatitis A from a restaurant situation.
“We see a lot more food-borne transmission of communicable disease — in other viruses and bacteria than we do from Hep A.
“There’s all kinds of things we should be scared of that we don’t even know about, and you don’t want to know.”
WHAT IS HEPATITIS A?
Hepatitis A is a very contagious virus that causes liver inflammation that can be deadly. It is spread when people come into contact with the feces of people with the virus by eating contaminated food or water, during sex, or just by living with an infected person. People can spread the virus weeks before they become symptomatic, which makes it so easy to pass to others.
WHAT ARE THE SYMPTOMS?
Not all people with hepatitis A exhibit symptoms, but most people experience one or more of the following:
- nausea and vomiting
- belly pain
- feeling tired
- loss of appetite
- yellowing of the skin and eyes
- dark urine
- pale-colored feces (poop)
- joint pain
HOW CAN I PREVENT HEPATITIS A?
Children born after 1999 have been routinely vaccinated against hepatitis A. For adults, two doses of the vaccine spaced six months apart will provide lifelong protection from the virus.
Health officials also recommend hand washing after using the bathroom and before preparing meals. Do not share towels, toothbrushes, food, cigarettes or eating utensils with other people and do not have sex with someone who has a hepatitis A infection.
If you’ve been exposed to someone with the virus, a vaccination within 14 days of exposure (potentially with an immune globulin injection) has been shown to be effective in preventing infection.
HOW TO LEARN MORE
The Michigan Department of Health and Human Services has updated information about the outbreak on its website, https://bit.ly/2s9E4Hz.
SOURCE: Michigan Department of Health and Human Services
WHERE TO GET VACCINATED
The Detroit Health Department along with the Wayne, Oakland and Macomb county health departments all are offering hepatitis A vaccines. Costs range from $25-$65, although they offer vaccinations at reduced cost or free to people without insurance or who don’t have an ability to pay.
Detroit: Samaritan Center, 5555 Conner, Detroit: 8 a.m.-5 p.m. Mon., Tues., Thurs., Fri.; 9 a.m.-6 p.m. Wed.; 10 a.m.-4 p.m. Sat. 313-410-8142
Wayne County: Health Department, 33030 Van Born Road, Wayne: 8 a.m.-11 a.m. and 12:30 p.m.-4 p.m. Mon., Tues., Thurs., Fri.; or 11 a.m.-2 p.m. and 3:30-7 p.m. Wed. 734-727-7100.
Macomb County: Three service centers offer vaccinations.
- The Central Health Service Center, 43525 Elizabeth St., Mt. Clemens: 8:30 a.m.-4:30 p.m. Mon. and Thurs.; 8:30 a.m.-6:30 p.m. Wed., and 11:30 a.m.-4:30 p.m. the third Friday of each month. 586-469-5372
- The Southwest Service Center, 27690 VanDyke, Warren: 8:30 a.m.-4:30 p.m. Tues., Wed. and Fri.; 8:30 a.m.-6:30 p.m. Thurs., and 11:30 a.m.-4:30 p.m. the third Friday of each month. 586-465-8537
- Southeast Service Center, 25401 Harper Ave., St. Clair Shores: 8:30 a.m.-6:30 p.m. Mon.; 8:30 a.m.-4:30 p.m. Tues. and Fri. except for the third Friday of each month, when the office is closed. 586-466-6800.
Oakland County: Two service centers offer vaccinations noon-8 p.m. Mon., and 8:30 a.m.-5 p.m. Tues.-Fri. They are
- North Oakland Health Center, 1200 N. Telegraph Road, Building 34 East, Pontiac. 248-858-1280.
- South Oakland Health Center, 27725 Greenfield Road, Southfield. 248-424-7000.
Statewide: This link shows upcoming vaccinations around the state: https://teamup.com/ksoh9ax9sgr1simjeg