From 2009 through 2017, the Georgia Department of Public Health (DPH) reported zero hepatitis A cases in Bartow County. A single case was confirmed in the community in 2018; one year later, the number of confirmed cases in Bartow increased to 76.
“Historically, hep A has been linked to international travel or contaminated food products,” said DPH public information officer and risk coordinator Logan Boss. “But most of the recent infections we’ve seen in Georgia — including northwest Georgia since our hepatitis outbreak began in June 2018 — have been among people who are living homeless or use drugs, and people who are close contacts of these people.”
“Tennessee began having a serious hepatitis A outbreak in late 2017, and what we saw was the hep A outbreak move southward,” Boss said. “In fact, in northwest Georgia, our epidemiologists could actually trace the movement of the disease through two of our primary transportation corridors — those being U.S. 27 and I-75.”
A similar situation occurred in south Georgia, Boss added, as the outbreak quickly spread northward from Florida.
As with all types of hepatitis, hep A primarily affects the liver. While hepatitis A complications are generally less severe than hepatitis B and C, in extreme cases the disease can be fatal.
Indeed, Boss said DPH data indicates “more than one but less than five” hepatitis A fatalities were reported in Bartow last year.
“Usually the virus doesn’t cause any long-term problems or complications, but a few people with hepatitis A will have symptoms that last a long time or come back over a six-to-nine month period,” he said. “It’s rare, but some people may get liver failure or need a transplant.”
Although hepatitis A can be prevented through a vaccine, it remains highly contagious.
“It gets in the body through the mouth after someone touches an object — food or a drink — that’s contaminated with the virus,” Boss said. “If an infected person doesn’t wash their hands well, especially after using the toilet or changing a baby’s diaper, for example, undetectable amounts of the virus can spread from the hands of that person to other objects, surfaces and foods.”
Common hepatitis A symptoms run the gamut from lethargy to abdominal pain to nausea to low-grade fevers. Other potential indicators of the disease include clay-colored bowel movements and dark urine.
Jaundice is another commonly reported hepatitis A symptom — a yellowy discoloration of the whites of the eyes and skin. Yet in some cases, Boss noted that an infected individual may display no symptoms at all.
In the 10-county northwest Georgia DPH region, which includes Bartow, Boss said one of the leading causes of the hepatitis A uptick remains environmental factors — i.e., substandard living conditions.
“Our epidemiological follow-up in hep A cases shows most of ours in northwest Georgia are related to drug use,” he said. "That includes injection as well as non-injection drugs — it’s not the drugs themselves that cause it, it’s the lifestyle.”
THE AT-RISK GROUPS
Data from the DPH indicates that in Bartow, about 70% of the confirmed hepatitis A caseload are males. Roughly 75% are white, with blacks and Hispanics making up 10% and 5% of the confirmed caseloads, respectively. About 60% of the county’s hepatitis cases involve individuals between the ages of 30-49.
“In northwest Georgia, those most at risk of hep A are illicit drug users — injection and non-injection — people who have a history of incarceration in jail or prison and men who have sex with men,” Boss said. “If you have a friend or family member who has hep A, you are at risk, so we try to encourage those people to also get vaccinated.”
Monitoring and providing services to those most at risk, Boss said, can be challenging.
“Our folks from the health departments, including in Bartow, have worked with your local public safety people to go into the jails and provide free hep A vaccines, because that is part of that transient and sometimes homeless population,” he said. “In some communities where we can identify a homeless camp, we’ll enlist the aid of local public safety to accompany some of our nurses to those locations to provide hep A vaccination.”
Particularly difficult, Boss said, is getting public health messages to those most likely to contract hepatitis A. Traditional media outlets and outdoor advertising might be a good way of communicating information to the general public, but Boss said those methods may not be as effective at reaching the populations most susceptible to hep A.
Social media messaging, he said, poses an entirely different set of challenges. Boss recounted the DPH creating several public service ads targeting individuals with substance use disorders — only for Facebook to ultimately reject them for, in Boss’ words, “disparaging a part of their audience.”
Unlike hepatitis C, hepatitis A can be prevented. And if one has already recovered from hep A, Boss said he or she has lifelong immunity against the disease.
“And since hep A vaccination is required for school-aged children born after Jan. 1, 2006, these individuals may not need vaccination,” he added.
Still, Boss noted that many individuals in northwest Georgia at risk for contracting hepatitis A may not have adequate access to health care. Compounded by a lack of resources to basic hygienic care, environmental exposures and potentially other health-related problems associated with substance use, in the most severe cases the outcomes of what would normally be a totally preventable disease can turn deadly.
“If they don’t fit into one of those risk-factor categories, adult risk is so low that getting vaccinated is really a matter of personal preference,” Boss said. “And if someone is not sure whether they should get the hep A vaccine, they can talk to their doctor about their specific concerns.”
So far in 2020, Boss said the DPH has confirmed seven hepatitis A cases in Bartow. However, he said it may be too early to begin celebrating the apparent decrease in reported hep A figures in the community.
“While it’s easy to say that’s a reduction of cases — and it certainly is a reduction in confirmed hep A cases in Bartow — but there are a lot of potential reasons for that,” he said. “But we don’t have definitive evidence of the reasons for this drop.”
On the optimistic side, Boss said there is a likelihood that recent DPH efforts have helped reduce the spread of hep A in the region.
“We did aggressive promotion of the hep A vaccine throughout northwest Georgia in 2019,” he said. “We especially concentrated on Bartow because of some incidents we had there — two, I believe, were involving restaurants.”
Coincidentally, preventative measures taken in the wake of the coronavirus outbreak may also be playing a role in Bartow’s seeming hepatitis A downturn.
“Another factor could be the peripheral impacts of COVID-19,” he said. “Physical distancing measures might mean fewer opportunities for transmission.”
But as Boss noted, that could be a double-edged sword, so to speak.
“Alternatively, fewer people might be seeking medical care for symptoms of hepatitis A infection out of concern about COVID-19 exposure in a medical setting,” he said. “And unfortunately, we’ve seen that with a lot of other health issues, as well.”
In most cases, Boss said there are no long-term health problems associated with hepatitis A. Whatever damage is done to the liver, he said, typically heals in about two months; he noted that the Bartow County Health Department, at 100 Zena Drive in Cartersville, does provide free hepatitis A vaccinations.
Even in the midst of the COVID-19 crisis, Boss said the DPH’s “aggressive” efforts to address the hep A outbreak continue.
“Our resources are currently spread thin, but we are still aggressively promoting hep A vaccination, and will continue to do so as long as we have evidence that the disease is still spreading in our communities,” he said. “If it continues unabated — concealed or hidden at the moment within an overriding context of the COVID-19 pandemic — we’re going to continue to see more hepatitis A cases.”