PUBLIC HEALTH
PHYSICIANS CAN HELP CONTROL Louisville’s
Current Hepatitis A Outbreak
Lori Caloia, MD
I
received an interesting welcome to my new
position as medical director for the Louis-
ville Metro Department of Public Health and
Wellness (LMPHW). The day after I started,
the Kentucky Department of Public Health
(KDPH) declared an outbreak of acute hepatitis
A Virus (HAV) in our state. This outbreak has
primarily affected Jefferson County. As of Feb-
ruary 23, we had 99 cases concentrated mostly in the Downtown
and Portland areas, but in other locations as well.
As many of you may recall from medical school days, HAV is
spread through the fecal-oral route, has a 15-50 day incubation
period, and causes acute symptoms of nausea, vomiting, abdominal
pain, dark urine, diarrhea, light stools, fever, fatigue, malaise, loss
of appetite, joint pain and, most notably, jaundice. The diagnosis is
confirmed with HAV IgM antibody testing. It can be deadly, partic-
ularly in those with co-morbid conditions such as other forms of
liver disease. But, there are things we can do to prevent the spread
if we are able to quickly identify and interview cases, notify contacts
of potential exposure, and provide post-exposure prophylaxis in the
form of hepatitis A vaccine or Immunoglobulin (IG).
Initially, my planning/organizing/optimistic brain went right to
work thinking of how we could easily and quickly get this HAV out-
8
LOUISVILLE MEDICINE
break under control. In my previous experience as a flight surgeon
in the US Air Force, my role included public health functions on our
base, such as responding to communicable disease events. Pertussis
and Shigella outbreaks on our base were quickly identified, easily in-
vestigated, and preventive measures and post-exposure prophylaxis
with medication and vaccine were rapidly administered. All of this
was very easy to do when I had a tightly controlled environment
and an incredibly compliant population.
The current HAV outbreak in Jefferson County, however, has
been much more challenging! It has affected people in a broad
area of our city, county and state. It has primarily impacted those
who are homeless or with unstable housing, and people who use
drugs (PWUD). Both of these groups are not only difficult to track
down, but also hard to convince that we intend to provide help by
preventing illness. Many are suspicious when we ask questions
about their possible contacts in order to try to provide post-expo-
sure prophylaxis in a timely manner. They often leave the hospital
against medical advice (AMA) before we interview them to ask
important questions that would help us stop the spread of disease.
It is like trying to keep grains of sand from seeping through your
fingers. You just do the best you can, and only end up with a few
grains remaining despite your best efforts.
In addition to the complexities of our medical population in