Northern Ky. Health Dept. declares hepatitis A outbreak over in 4 counties it serves; statewide, it may never be considered 'over'

This story was updated Dec. 16 with comments from Doug Thoroughman, the state epidemiologist. 

With no new cases in the past four months, the Northern Kentucky Health Department has declared the hepatitis A outbreak to be over in the four counties it serves. However, the state Department for Public Health says the outbreak continues statewide, at a much lower level.

“Even though the current outbreak is over, it is still important to get vaccinated against hepatitis A,” NKY Health’s district director of health, Dr. Lynne Saddler, said in a news release. ”Not only will it protect you for the future, but it can also help prevent the future spread of hepatitis A in the community.”

During the region's outbreak, which began in August 2018, there were 319 documented cases of hepatitis A in the four counties served by the health department: Boone, Campbell, Grant and Kenton, including four deaths. In 2017 there were zero cases, says the release.

 Top map shows rate of cases per county since outbreak
began in August 2017. Bottom map shows rate of cases
in November 2019. Both maps are from weekly report.  

State numbers for hepatitis A are also way down. Kentucky saw five new cases between Nov. 17 and 30, according to the state's weekly report. That's compared to 175 at the same time last year.

State Epidemiologist Doug Thoroughman said in an e-mail, "Although our hepatitis A numbers are very low now, Kentucky is still seeing sporadic cases around the state. For the last two months, we have identified between two and four new cases each week across the state. About this time last year we had the peak of our outbreak, with over 100 cases identified statewide each week,"

Health officials in Lexington told Garrett Wymer of  WKYT-TV that the drop is largely due to increased awareness and vaccination, but the statewide outbreak isn't officially over.  Lexington has had no new cases since July.

“In terms of the definition of an outbreak for epidemiologists, this outbreak may never be considered 'over.' In terms of what the state is telling us, it's slowed down,” Kevin Hall of the Lexington-Fayette County Health Department told Wymer. “It's not over, it's not stopped. Definitely though, it's under better control that is has been, and it's definitely under control compared to last year."

As of Nov. 30, more than 4,900 Kentuckians had been sickened by the highly contagious liver disease, and 61 of them had died from it. The primary risk factors for this outbreak have been drug use and homelessness.

Hepatitis A vaccination is now required to attend school in Kentucky, but health officials stress that adults should be vaccinated too. Getting two doses at least six months apart can provide life-long protection.

Conference speakers call for a more aggressive approach to eliminate hepatitis; Ky leads the nation in both hepatitis A and C

By Melissa Patrick
Kentucky Health News

Elimination of the three main types of hepatitis is possible, but will require a more aggressive approach that includes increasing vaccinations for hepatitis A and B and universal screening, non-restricted access to treatment and increased access to harm-reduction programs for those with hepatitis C.

That's been the unwavering message about the liver disease for the the last few years at the Kentucky Rural Health Association's annual Viral Hepatitis Conference, and it was again at the one held July 31 in Lexington.

Meanwhile, Kentucky leads the nation in both acute and chronic cases of hepatitis C and has the largest outbreak of hepatitis A in the nation, and how the state has managed these highly contagious liver diseases has come with both kudos and criticism.

Hepatitis C

Kentucky is often praised for its progressive response to hepatitis C, a chronic disease that is estimated to affect about 43,000 Kentuckian.

But about half of people with hepatitis C don't know they have it, according to Dr. Neil Gupta, chief of the Epidemiology and Surveillance Branch in the federal Centers for Disease Control and Prevention's Division of Viral Hepatitis.

Kentucky is recognized nationwide for its embrace of syringe-exchange programs, which allow drug users to swap dirty needles for clean ones to thwart the spread of HIV and hepatitis C, as well as offering other "harm reduction" services. Most new hepatitis C cases result from drug users sharing needles.

As of June 2, Kentucky had 62 operating syringe exchanges in 55 counties, with four more approved but not yet operational.

Mike Selick, with the national Harm Reduction Coalition, pointed to other ways Kentucky leads the nation in harm reduction, including its Good Samaritan law, its standing order for a drug that is used to reverse opioid and heroin overdoses called naloxone, and its efforts to increase access to medication-assisted therapies (MAT) such as buprenorphine.

That said, he also offered examples of how Kentucky could improve its harm-reduction programs, such as increasing the days and hours that syringe exchanges operate; getting rid of any requirements that the exchanges be one-for-one; increasing access to naloxone and MAT in rural areas; and getting rid of any prior-authorization insurance requirements for MAT.

Kentucky got a "B" on the report card, "Hepatitis C: State of Medicaid Access," largely because it provides "moderate access" to treatment. The report, and several speakers at the conference, called for removal of specialist restrictions in treating hepatitis C and for managed-care organizations, which care for most Medicaid patients, to follow the Medicaid fee-for-service guidelines and not impose any restrictions for liver damage or sobriety for people seeking treatment for the first time.

Selick stressed that hepatitis treatment is safe and effective for people who inject drugs, pointing to research that shows reinfections rates in this population are low. Further, he said treating this population early in their infection becomes "treatment as prevention," because it would decrease the spread of the disease.

Jon Zibbell, senior public health scientist for RTI International, an independent, nonprofit research institute, noted that people who inject drugs present the largest population of new hepatitis infections, and that only 1 to 2 percent of them are being treated each year.

"This population needs to be treated if we are to stop incident infections and achieve hepatitis C elimination," Zibell said. "We cannot achieve hepatitis C elimination if we don't massively treat people who are . . . injecting drugs, and a lot of the pay restrictions are getting in the way of that."

The state health department has launched a statewide hepatitis C elimination project to create a comprehensive and statewide strategic plan to eliminate the disease. It met for the first time July 29.

In 2018, Kentucky was the first state to pass a law to require all pregnant women to be tested for hepatitis C. The law also requires that the information be recorded in both the mother's and the infant's records, and that the child be tested at 24 months for the disease. One in 63 Kentucky births are to mothers who test positive for hepatitis C.

Gupta told the group that subject to change after public and peer-review comment, the CDC would be changing its guidance on hepatitis C screening next year to recommend it for all pregnant women, at least once in a lifetime for all adults, and periodic testing for people with risk factors.

The Kentucky Rural Health Association has started a nationally recognized provider training program called  the Kentucky Hepatitis Academic Mentorship Program, or KHAMP, which so far has trained over 100 providers to treat hepatitis C.

Hep C treatment comes at a cost

One of the challenges to treating hepatitis C is the cost, though an argument can be made that it is more expensive to care for these patients when they progress to late-stage liver damage, liver cancer or need a liver transplant.

Dr. Bennett Cecil, medical director of Hepatitis C Treatment Centers in Louisville and Russell Springs, told the group that the cost for a treatment has dropped to upwards of $30,000, down from about $80,000 several years ago.

Kathleen Winter, as assistant professor in the division of epidemiology at the University of Kentucky College of Public Health, offered some numbers to show the scope of the problem.

Her slides showed that in 2017 Kentucky screened 70,270 people on Medicaid for hepatitis C, and 21,322 of them, or 30 percent, were diagnosed with chronic hepatitis. Only 499 were treated. In 2018, when the state loosened its treatment restrictions, Medicaid screened 79,647 people, 22,342 of them were diagnosed with a chronic infection, and 1,924 were treated.

Winter also showed cost data from the Kentucky All-Payer Hospitalization Claims database that found in 2018 there were 2,973 hospital admissions for patients who had both hepatitis C and liver disease or liver cancer, and that these patients incurred more than $181 million in patient pre-negotiated charges. Adjusted, she said, that would be upwards of $90 million a year to treat chronic, late-stage hepatitis C.

It also found 68 admissions related to liver transplants associated with hepatitis C, which had $4.8 million in associated cost. She said most of these patients were either on Medicare or Medicaid.

While most of these patients were older, Winters pointed out that the largest burden of the disease is with younger adults, who are largely in the early stages of the disease process, and who if not treated will present a tremendous cost-burden to the health-care system in years to come.

Winter also presented her research on pregnant women on Medicaid with hepatitis C, which found that many of them could not correctly identify their hepatitis C status, even though they had been tested; many did not understand how the virus was transmitted; many knew it could be treated, but didn't know what that treatment entailed; many knew treatment was important, but had widespread misunderstandings about what Medicaid would cover -- which Winter said was also a widespread problem among medical professionals.

Hepatitis A

Kentucky has made great progress in decreasing its number of new hepatitis A cases, but not without criticism for what some say was a slow response to the nation's largest outbreak of the disease.

Since August 2017, there have been 4,793 cases of hepatitis A in Kentucky, with more than half of them hospitalized (2,311) and 59 dead from it, according to a weekly surveillance report. The primary risk factors for hepatitis A are drug use and homelessness.

Andy Beshear addressed the conference.

Attorney General Andy Beshear, the second speaker of the day, was quick to criticize Gov. Matt Bevin's administration for its slow response to the hepatitis A outbreak. Beshear is running against Bevin in the Nov. 5 gubernatorial election. 

To a room full of applause, Beshear first thanked Dr. Robert Brawley, the state's former infectious-disease chief, for his "courage in doing what is right," even though it cost him his job. Brawley is a volunteer with KRHA and was a co-moderator of the event.

Beshear was referring to Brawley's request that the state have a more aggressive response to the outbreak, including $6 million to buy more vaccines and $4 million for temporary health workers to help administer them. Brawley also called for the state to declare a public-health emergency as a way to get more federal funds, the Louisville Courier Journal reported.

Health Commissioner Jeffrey Howard didn't declare an emergency but sent local health departments $2.2 million and committed to seek more funding if needed. Howard and other state officials have defended their actions, citing that logistical challenges were greater than the need for more money as the outbreak spread to rural Kentucky.

Brawley, who was allowed to resign in lieu of being fired on June 4, 2018, has maintained his position that the state has not acted aggressively enough.

Beshear said, "I think when you also look at hepatitis, we see an absolute failure by the Bevin administration that cost people their lives. They had the information, they had the ability to respond in a real way for only about $10 million, but they didn't listen. Instead they had people inexperienced and incompetent in really important positions."

The health cabinet stood by its decisions, stating in an e-mail that their response to the outbreak "followed protocol and procedures guided by the CDC and informed by an entire DPH team."

"While hindsight might provide more context for some things now, in retrospect there's not a single decision that I'm aware of that has been made in real time, with the information available at the time, that I would change," Health Secretary Adam Meier said in the e-mail.

Howard, a physician, recently resigned as commissioner to pursue a fellowship in Washington, a spokeswoman from the cabinet told the Courier Journal.

Maria Hardy, the public health director at Ashland-Boyd County Health Department, painted a pretty grim picture of the financial cost associated with the outbreak. Boyd County has been one of the counties hardest hit by the outbreak, with an incident rate of 362.7 cases per 100,000 people.

Because many of the people testing positive for hepatitis A in Boyd County kept showing up in the food-service industry, at the health department's recommendation the county passed an ordinance requiring all food workers be immunized against hepatitis A.

Hardy said her health department's hepatitis A costs have been "devastating to budget." From January 2018 to June 2018, the agency spent $718,902, including the cost of salaries, vaccines and certified mailings. She added that the department got $183,520 from the state to buy more vaccine.

Looking to the future

To applause, Zibbell suggested that it was time to turn syringe-exchange programs into medical homes for people who use drugs, largely because of the stigma in traditional health-care settings against this population.

Dr. Daniel Moore, of the emergency-medicine department at UK HealthCare, said emergency departments must play a significant role in eliminating hepatitis C because they see the "downstream" effects of the disease and are the only places that most drug users interact with the health-care system.

Moore is conducting a grant-funded pilot study that allows him to screen every patient in the UK emergency department for hepatitis C. He said research shows that risk based screening would miss about 25% of people who would test positive for hepatitis c.

Between July 2018 and July 2019, he said the ED had done about 23,000 tests, with about 11% of them testing positive for ever having been exposed to hepatitis C and more than 50% of that group testing positive for an active virus. He added that 443 of these patients had been linked to care.

He said the next step toward elimination of this disease will be to bring drug treatment and hepatitis C interventions to the point of contact in the ED, just like they already do for patients who have had a stroke or a heart attack.

"This is a disease that has a cure," he said. "The patients are in front of me and there is a cure."

State health department is sending nurses to jails, treatment centers, homeless shelters, other sites to give hepatitis A shots

Nurses administered vaccinations at the Fayette County
Detention Center. (Cabinet for Health and Family Services photo)

The state Department for Public Health has sent a team of nurses to give hepatitis A vaccinations at county jails, state probation-and-parole offices, homeless shelters, treatment centers and drug stores, the Cabinet for Health and Family Services announced in a press release.

"Since April, the team has provided more than 2,100 vaccines at 40 different sites," the release says. "The state is collaborating with local partners on harm-reduction programs, aimed at reaching those who are most at risk. At least 18 additional vaccination events are scheduled through August."

“We have found it particularly challenging to reach the at-risk population in rural Kentucky,” said Dr. Jeffrey Howard, commissioner of the department. “One reason is the stigma associated with substance-use disorder. In some of our rural communities, more than 80 percent of hepatitis A cases have occurred in those with SUD. Due to the stigma surrounding SUD, the at-risk population is often hesitant to seek preventative care.”

The department identified the outbreak in November 2017, and has been criticized for not reacting more robustly to it. It has identified 4,700 cases, almost half of them requiring hospitalization, and 58 deaths have been linked to the outbreak.

"Kentucky was the first state to experience a large, rural spread of the disease," the press release says. "Similar to outbreaks in other states, the primary risk factors have been illicit drug use and homelessness. A contaminated food source has not been identified, and transmission of the virus is believed to have occurred through person-to-person contact. Hepatitis A is a highly contagious liver infection."

Infection-control activist calls for timely outbreak notifications, comprehensive tracking, aggressive containment and vaccines

OPINION By Dr. Kevin Kavanagh

I live in Kentucky, a state with the nation’s largest hepatitis A outbreak, an emerging measles outbreak and a governor who said he exposed his children to chickenpox rather than get them vaccinated. In the past year, two heads of infection control in Kentucky’s Department of Health have left the position. The first one was asked to leave after he expressed the need for an urgent increase in infection control funding.

Dr. Kevin Kavanagh

I am a firm believer that we must learn from history or be doomed to repeat it. Unfortunately, the United States and many other nations appear not to have learned this lesson with regard to public health and are heading down a dangerous path.

The recent book The Pandemic Century by Mark Honigsbaum examines a number of major disease outbreaks around the world and draws lessons about how some of them were mismanaged. But one can see many disturbing parallels in the handling of today’s epidemic of drug-resistant bacteria and viruses.

One of the most important is that when infections spiral out of control, governments worry too much about avoiding accountability, often downplaying the severity of an outbreak until it is too late. In the severe acute respiratory syndrome epidemic of 2002 and 2003, for example, the Chinese government initially withheld information about an outbreak in Guangzhou, which delayed the discovery that the infection was not caused by the flu, but by a more dangerous pathogen.

In the ebola epidemic of 2014, the government of Guinea, a country with very limited health resources, initially insisted that only laboratory-confirmed cases be counted, this led to a drop in reported cases and a false sense of security, delaying the mobilization of resources and fueling the spread of the virus.

And as the 2015 Zika epidemic was taking hold, resulting in the births of babies with the neurological condition microcephaly, the Brazilian Ministry of Health changed the definition of microcephaly from a head circumference of 33 centimeters to 32 centimeters, effectively reducing the numbers of cases.

The United States also falls victim to the practice of mathematical case reduction. Several years ago the Centers for Disease Control and Prevention doubled the amount of bacteria required to be present before a urinary infection must be reported to health officials. Bladder infections associated with a catheter and caused by any type of yeast are no longer reported, which technically includes the deadly superbug Candida auris.

The definition of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections has been changed from patients who developed an infection after two days of hospitalization to after three days. And the number of “community-acquired” infections occurring in the first three days of hospitalizations are not released to the public.

And instead of fixing a requirement that hospitals keep logs of infectious disease cases, in 2012 the U.S. eliminated this requirement and used our current spotty federal tracking system as justification.

In past epidemics, the cause and mechanism of the spread of infection and even vaccines were desperately sought after, but academic pride and competition often impeded science. No better example was the Spanish flu epidemic, which killed more soldiers in World War I than the war itself. Academic pride perpetuated the myth that the primary cause was a bacteria and not a virus. In the past few decades, other powerful factors, industrial profits and conflicts of interest, have emerged.

Finally, local beliefs, lack of education and mistrust create the breeding ground for pandemics. This was evident in the 2014 ebola outbreak, when the general population believed that the infection was a government plot and that health-care workers were purposely spreading the infection. In addition, they firmly embraced social customs and burial practices that were fueling the epidemic.

In some respects, this type of misinformation and paranoia is held by many who refuse to vaccinate their children. Often standing behind a shield of “religious freedom” or “personal belief,” such parents are allowing their children to act as reservoirs to spread dangerous pathogens. I have a niece who had a heart transplant and is immuno-compromised, and it terrifies me that the anti-vaxxers could jeopardize her life.

Americans over 65 still remember the ravages of epidemics and how vaccines were transformative. I still vividly recall being deathly sick with measles as a young child. I would not wish this on anyone. When the vaccines came out, there was a public rush to get them, and we all stood in long lines. But as memories faded, a suspicion of vaccines grew and dangerous pathogens re-emerged.

The public needs timely notification of infectious disease outbreaks, and epidemics need to be comprehensively tracked and aggressively confronted. All states should mandate vaccinations and eliminate religious exemptions. Our collective health depends on having public policy fully aligned with good science.

Physician Kevin Kavanagh of Somerset is founder and chairman of Health Watch USA, a nonprofit patient-advocacy and health-care policy research organization. Kavanagh wrote this opinion piece for the Los Angeles Times.

Hepatitis outbreak is declining in Ky., but we are still finding more in a week than we once got in a year; 57 have died from it in state

The good news about hepatitis in Kentucky is that the number of hepatitis A cases is dropping. The bad news is that there are still as many cases each week as were once seen in a year's time, and the state is by the far the leader in deaths from the liver disease.

According to the state's weekly report, the number of hepatitis A cases in Kentucky has dropped to around 20 per week for several weeks, a huge improvement from the height of the outbreak in the last months of 2018, when more than 100 new cases were being reported every week. But before the outbreak, which was declared in November 2017, the state averaged about 20 cases a year.

Since August 2017, the report shows that 4,621 Kentuckians have been diagnosed with hepatitis A and 2,233, or 48% of them, have been hospitalized. The primary risk factors for getting this highly contagious disease remains illicit drug use and homelessness.

The 57 deaths reported in Kentucky account for about one-third of the 170 deaths reported to the Centers for Disease Control and Prevention since 2016 in 22 states. "West Virginia and California, by comparison, each has had 21 deaths in their outbreaks. Michigan has had 28, and Indiana 4," Chris Kenning reports for the Louisville Courier Journal.

Four Kentuckians died from the disease in the week ending May 4, says the latest state report. It notes that deaths are identified through periodic reviews of death records and includes anyone who dies with documentation of hepatitis A as a contributing factor to the death -- even if it wasn't the primary cause of death, which is often the case among drug users.

Hepatitis A has been diagnosed in 108 of the state's 120 counties, with 15 reporting new cases in the week ending May 4.

The state's initial response to the outbreak has been criticized for not being aggressive enough.

Kenning notes that a Courier Journal investigation found that the state's former infectious-diseases chief, Dr. Robert Brawley, "recommended $6 million for vaccines and $4 million for temporary workers to help thinly staffed local health departments deliver vaccines to hard-to-reach drug users. He also called for a public health emergency declaration to help pave the way for federal assistance. Instead, Department for Public Health Commissioner Dr. Jeffrey Howard, citing limited funding and the local reserves that some health departments had, sent $2.2 million in state funds to local health departments and declined to seek an emergency declaration."

Howard and other state officials have defended their actions, citing that logistical challenges were greater than a need for more money as the outbreak spread to rural Kentucky.

Brawley, who was allowed to resign in lieu of being fired on June 4, 2018, has maintained his position that the state has not acted aggressively enough. (Since Brawley left, the state has fired Dr. John Bennett, who had been the state's infectious-disease manager since last fall.)

"The Kentucky public should be outraged about the slow-motion public health response that has caused the hepatitis A outbreak to continue into 2019," Brawley told Kenning on May 14. "I am saddened that 57 Kentuckians have died after developing acute hepatitis A and where hepatitis A was a risk factor for their deaths."

In late March, a legislative measure directing the state to review its response to Kentucky's outbreak failed to pass. The Cabinet for Health and Family Services has said it plans to review its response.

Meanwhile, the state has hired a roving team of nurses to administer vaccines in rural county jails and the state is providing more vaccine storage equipment, money and expertise to a handful of currently hard-hit counties, Kenning reports.

Specifically, Kenning reports that the Pulaski County Jail has been vaccinating its jailers, and that the state health department has awarded $46,000 to Jessamine, Bell and Christian counties, which had requested extra support; and that a roving team of nurses will soon be in the Lake Cumberland area.

"The department is continuing to coordinate with local health officials to ensure that resources are available and prevention efforts continue," Howard said in a statement to the Courier Journal on Tuesday. "We want to reiterate that though cases are declining, this is not a time to be complacent. Rather, we must continue to promote prevention including appropriate hygiene practices and vaccination."

Brawley said, "While the number of reported cases has fallen in recent weeks, I expect that the Kentucky hepatitis A outbreak will continue for at least six more months and will have a total of more than 5,000 cases before the outbreak is declared over."

For second time during big outbreak of hepatitis A, state health officials fire the manager of their Infectious Disease Branch

For the second time during the nation's worst outbreak of hepatitis A, state health officials have fired their top infectious-disease leader.

Hepatitis A is a liver disease.

"Dr. John Bennett, the state's Infectious Disease Branch manager since last fall, told the Courier Journal on Monday that he was dismissed last Friday," Chris Kenning reports for the Louisville newspaper. Bennett told Kenning that he wasn't given a specific reason for his dismissal. That is typical in such cases. He "said he had no information to suggest it was related to the state's recently criticized response to its hepatitis A outbreak," Kenning reports.

"First declared in November 2017, the outbreak later exploded in rural Kentucky, mainly among drug users, and grew into the nation's deadliest," Kenning notes. "The outbreak has since sickened 4,419 and killed 52, according to the latest state report released Monday. Kentucky has had more deaths than any of the other 17 states with similar hepatitis A outbreaks."

Bennett was hired last September to replace Dr. Robert Brawley, who was allowed to resign in lieu of fired on June 4, 2018. Brawley had "lobbied for a more aggressive state response to the outbreak," Kenning notes. "He recommended $6 million for vaccines and $4 million for temporary workers in thinly staffed local health departments and also called for a public health emergency declaration to help pave the way for federal assistance." Instead, "The Department for Public Health sent $2.2 million in state funds to local health departments and declined to declare an emergency."

The department's commissioner, Dr. Jeffrey Howard, "has told the Courier Journal that he was willing to seek more funding if needed."

Resolution to require study of response to hepatitis A outbreak, and recommendations to avoid a repeat, failed in the legislature

Hepatitis A vaccine (USA Today photo by Nikki Boliaux)

The state Cabinet for Health and Family Services won't have to conduct a study of its response to the hepatitis A outbreak that has killed at least 52 in the state and is the nation's worst outbreak of the liver disease. It also won't have to make recommendations to the General Assembly "to ensure that future responses to outbreaks are more effective," as a legislative resolution would have directed.

The Senate-passed resolution directing the study and recommendations wasn't brought up for a vote in the House on the last day of the session, "despite broad bipartisan support," reports Deborah Yetter of the Louisville Courier Journal.

The sponsor of the resolution, Senate Democratic Leader Morgan McGarvey of Louisville, told Yetter that he didn't think it failed because of any opposition to the measure. "Rather, he said, he thinks it got caught in the crush of last-minute legislation that kept members of the House wrangling over other, more controversial bills almost till midnight," he said.

McGarvey said he will "demand answers" about how state officials responded to the outbreak, and Rep. Joni Jenkins, D-Shively, "said she expects lawmakers will pursue the matter with the cabinet," Yetter reports. Jenkins said, "It is a national embarrassment that we've handled it so poorly."

"The Courier Journal reported in February that a slow response over the past year by state public health officials to an outbreak of the contagious liver disease appeared to contribute to what became the the nation's largest and deadliest outbreak," Yetter notes.

Health departments scramble to fight hepatitis A outbreak

Peyton Manning had hepatitis C but didn't know about hepatitis
A or the outbreak until it hit him. (Michael Clevenger, Courier Journal)

The nation's largest outbreak of hepatitis A has slacked off somewhat in Kentucky, but remains a threat and local health departments are dipping into their reserves and taking unusual steps to get people vaccinated for the liver disease, which has killed 44 Kentuckians during the outbreak.

The medical director of the Lake Cumberland District Health Department doesn't usually give vaccinations, but each of her counties only had one or two nurses to do that, so Dr. Christine Weyman started giving shots, too, Laura Ungar and Chris Kenning report for the Louisville Courier Journal.

"She has gone out to vaccinate drug users who largely were spreading the virus," they report. "She once went so far as to chase two men down a street to persuade them to get the shot. (They weren't interested.) She also went to the crowded Pulaski County Detention Center, realizing the 213-bed jail with more than 400 inmates could be an excellent incubator for the virus. Right outside the jailer's office door, her health department placed a refrigerator for the sole purpose of storing vaccines."

"In many ways," Ungar and Kenning wrote, the Somerset-based department "is a microcosm of rural Kentucky's continuing struggle with hepatitis A. What's happening there reflects how Kentucky's communities with limited resources are quietly battling the nation’s largest and deadliest outbreak — learning as they go and altering their strategies to meet the many challenges they face."

The state has averaged 76 hepatitis A cases per week this year, "sometimes reaching more than 90 a week, compared with 151 a week at its peak in early November," the CJ reports, but "Kathleen Winter, an epidemiologist at the University of Kentucky, said a recent downward curve in the outbreak doesn't necessarily mean it's waning."

"We still need robust intervention," Winter told the newspaper. "It's still too early to say whether it’s really winding down. We still have individuals getting sick, being hospitalized and dying."

The story's first example was Peyton Manning, 27, "who was sleeping behind a Walmart in Lexington and spending his days shooting meth and heroin. Late last year, he admitted himself to The Healing Place in Campbellsville. Then a virus hit him. He couldn’t sleep. He couldn't keep any food down." He went to the UK hospital and recovered at his mother's home.

Manning already had hepatitis C, but said he didn't know about hepatitis A or the outbreak. "didn’t even know it was a thing," he told the CJ. "I started to watch the news. It was like, damn, I didn’t know it was that bad."

Health departments are responding "with a mix of resources," the paper reports. "In addition to using state funding, local health departments can also order federally funded vaccine through the state or buy shots using money from $233 million in county health department reserves," which "vary greatly across counties and area development districts. They're in the negative numbers in some places and reach into the millions of dollars in others."

The Lake Cumberland agency had unrestricted reserves of about $5 million when the outbreak hit in 2017, but was "trying to avoid using this as much as possible to help with the pension crisis," said Ron Cimala, its administrative director. Many health departments have said they will have to close unless the legislature keeps giving them relief from the state's new requirement for funding their employees' pensions.

Ranges of health department reserves that could be used to pay Kentucky Employees Retirement System obligations. About half of the counties are in district departments; others are independent.

State officials defend handling of hepatitis A outbreak as an additional warning is revealed and legislators voice concern

By Melissa Patrick
Kentucky Health News

State Cabinet for Health and Family Services Secretary Adam Meier called a news conference on March 1 to discuss the state's hepatitis A outbreak, and spent most of the time criticizing news-media coverage, mainly the Louisville Courier Journal's investigation that revealed state health officials had rejected expert advice to mount a stronger response.

Since the outbreak started in August 2017, more than 4,200 Kentuckians have been diagnosed with  hepatitis A, a highly contagious liver disease; more than 2,000 have been hospitalized because of it; and 43 people have died from it. The primary risk factors remain illicit drug use and homelessness.

Health Secretary Adam Meier (center) led a March 1 news
conference on hepatitis A. Sen. Ralph Alvarado (left) and
Sen. Morgan McGarvey (right) have want to examine the
state's response to the outbreak. (Facebook Live image)

As part of a series of articles about hepatitis A, Courier Journal reporters Laura Ungar and Chris Kenning reported that Dr. Robert Brawley, then chief of the state Department for Public Health's infectious-disease unit, called for an aggressive response to the outbreak, including $6 million for vaccines and $4 million for temporary workers, plus declaration of a public-health emergency as a way to get more federal assistance.

Instead, Dr. Jeffrey Howard, commissioner of the department, sent $2.2 million to local health departments and did not declare an emergency. He told the Courier Journal that "he was willing to seek more funding if needed," the paper reported. It also quoted Meier's support of Howard's decisions.

Howard told the newspaper, "I wish I would've been more bold and said, 'Let's move into Eastern Kentucky,' as opposed to waiting." He sent all state legislators a letter Feb. 28 to, as he wrote, "provide accurate context for a situation that certainly deserves attention, but has been badly misrepresented."

At the news conference, Meier said the Courier Journal didn't report positive comments it received about the state's handling of the outbreak because they did not line up with a narrative the newspaper had chosen. He said the paper implied, by saying Howard is 31, that he was not competent.

Local health directors defend their commissioner

Meier read comments from several local health-department directors praising Howard's response to the outbreak. Some said they had given the paper positive comments about the state's response that weren't used. The letters dealt mainly with help the state gave them, not the state's overall response.

Scott Lockard, public-health director for Kentucky River District Health Department, which serves seven Eastern Kentucky counties, a region that has been hard-hit by the outbreak, said he was among those who made such comments that weren't included.

Lockard wrote, "It is easy to try to place blame on Commissioner Howard for a response that has been less than what some people would ... like to have seen. However, I believe Dr. Howard has shown model leadership during this time. The breakdown in the system is a result of many years of underfunding, increasing pension costs, and the erroneous belief that the Affordable Care Act would address our public-health concerns."

In an article about the state's complaints, Courier Journal Editor Rick Green said the paper had conducted an extensive investigation into the crisis and "had numerous conversations with state officials, and we’ve gone to great lengths to share their opinions and insights."

"I am proud of our coverage and pledge to continue our investigation," Green wrote. "Kentuckians count on us to do that. The Courier Journal’s reporting has been fair, comprehensive, balanced and most important, accurate. We stand by our stories.”

Hours after the news conference, the CJ published another article reporting that the nurse who ran the state's hepatitis program had urged Meier, the cabinet's general counsel and the office of Gov. Matt Bevin to "be more aggressive in tackling the outbreak." She recently quit. The story also reported that the official who gave the first warning, Dr. Robert Brawley, was fired but allowed to resign.

Lawmakers voice concern

Then the paper reported that U.S. Reps. Hal Rogers of Somerset and John Yarmuth of Louisville voiced concerns about the state's response.

Rogers (Courier Journal photo)

"I am disappointed by reports that clear warning signs and serious alarm bells were not heeded sooner," said Rogers, a Republican who represents the 5th District, which "is being pummeled by the nation's largest outbreak of hepatitis A," reporter Ungar wrote.

Yarmuth, a Democrat from the 3rd District, said "I'm grateful for the Courier Journal's work to help shine light on this situation, and I hope state officials will take ownership in getting to the bottom of what went wrong to ensure additional lives are not put at risk."

Two state senators, Republican Ralph Alvarado of Winchester and Democrat Morgan McGarvey of Louisville, filed a resolution to examine the state's response to the outbreak and appeared at the news conference with Meier. Alvarado is Bevin's running mate for lieutenant governor.

"We need to find out what happened, why it happened, and to make sure it doesn’t happen again," said McGarvey, who has a journalism degree. "I didn't come here today to bash the media. I do know I wouldn't be aware of this problem if it weren't for reporting and putting it on the front page of the paper."

Broader issues

Amid the questioning and finger pointing, health officials seized the opportunity to call attention to the importance of public health and prevention, noting that drastic funding cuts since 2008 have resulted in staff reductions that impact how they are able to respond to public health threats.

They also said that if the state's pension crisis is not resolved, the resulting payments required from local health departments have potential to force half of them to close in the next two years.

Lockard said, "If there are lessons to be learned from this hepatitis A outbreak, we must invest in prevention to prevent something like this from impacting us again."

Ky. officials rejected infectious-disease chief's plea to move faster against hepatitis A outbreak, now nation's largest and deadliest

As part of a package of stories about Kentucky's hepatitis A outbreak, which is the "worst this century, sickening nearly 4,100 and killing 40," Laura Ungar and Chris Kenning of the Courier Journal write that the "state could have done more to control it."

In an April 2018 e-mail obtained by the Louisville newspaper, Dr. Robert Brawley, the state's infectious-disease chief at the time, wrote to his health department colleagues: "Need to move faster. The virus is moving faster than we and [local health departments] are … immunizing persons.”

"Brawley argued that a powerful state response was needed: $10 million, including $6 million for a fusillade of 150,000 vaccines and $4 million for temporary health workers to help administer them. In an email, he also lobbied for a public health emergency declaration to bolster the case for more federal money," Ungar and Kenning report. "His urgent pleas went nowhere. And in the months that followed, Kentucky’s outbreak metastasized into the nation's largest and deadliest."

The Courier Journal found that Brawley's "aggressive recommendations" were rejected by his boss, 31-year-old acting Health Commissioner Dr. Jeffrey Howard. Now Kentucky's death toll from this outbreak is the highest in the nation.

"Amid limited state budgets, county staffing constraints and the availability of more than $220 million in local health-department reserve funds — he stuck instead to a $3 million state response," the CJ reports. "The state ultimately sent $2.2 million to local departments and declined to declare an emergency. In addition, county health departments added little to no staff to increase efforts to find and vaccinate drug users and homeless people."

Ungar and Kenning report that Kentucky "never tried strategies used successfully by some of the other 15 states who fought outbreaks with limited budgets," like seeking money from the state legislature, deploying "strike teams" of state health workers to counties, and immediately deploying state funds for the epidemic.

The article details the decision-making process of Howard, who stood by his decisions, though he did acknowledge that in retrospect he could have done some things differently.

"I wish I would've been more bold and said, 'Let's move into Eastern Kentucky,' as opposed to waiting, as we did," said Howard, who grew up in Appalachia. "As an Eastern Kentucky guy, it's heartbreaking to see this disease spread out in rural Kentucky. And I knew the struggles that they'd have once it started."

Adam Meier, secretary of the Cabinet for Health and Family Services, told the reporters that he stood by Howard's choices, saying in a statement that the "challenges Kentucky faced were less financial and more logistical in nature as it related to identifying and engaging the at-risk populations. While hindsight might provide more context for some things now, in retrospect there’s not a single decision that I’m aware of that was made in real time, with the information available at the time, that I would change."

But Brawley, who resigned in June, told the Courier Journal that much greater resources were needed to battle Kentucky's spread of hepatitis A and called the state's response "too low and too slow" for what has become "the worst hepatitis A outbreak in the United States in the 21st century."

He added, "Had the state hastened its vaccination efforts, it may have more quickly reduced the risk of the disease's spread and prevented acute cases, hospitalizations for about 50 percent of those cases, deaths and avoided millions of dollars in healthcare expenses for emergency department visits and hospitalizations."

Ungar and Kenning reported that several others in the health department agreed with Brawley's recommendations, including nurse Margaret Jones, manager of the state's immunization program. "We should have done more sooner," said Jones, who retired last summer. "If we had been able to get the vaccines out early, we may not have near as many cases or near as many hospitalizations. … He knew what to do. I think his advice should have been heeded."

Now, state health officials are hopeful the hepatitis A outbreak has crested. The number of new cases each week is down from 150 in early November 2018, averaging 87 a week this year. Officials said their plans in 2019 include "working to help local departments vaccinate more regularly at jails, increase vaccinations generally, enlist more federally qualified health centers to administer vaccines, and continue to push out federally funded vaccine to counties," the CJ reports.

The newspaper published four other articles on this topic on the same day.

Ungar tells the story of an Eastern Kentucky woman who learned she had hepatitis A, along with her existing hepatitis C, while getting treatment for her heroin and methamphetamine addiction. Another story covers how other states have responded to the outbreaks of the disease, reporting that since 2017, 16 states have had outbreaks, infecting more than 13,000 people. Another details how hepatitis A spread across Kentucky.

The final story, written by Kenning, chronicles the story of an Appalachian woman with a heroin addiction who said she didn't know about the highly contagious virus, and even if she had, she wouldn't have cared. "People who are addicted like myself, I really didn't care if I lived or died. So I (wouldn't have) really cared if I was infected with it," she said.

Ky.'s hepatitis A outbreak is over 3,000 cases. It may be slacking off, but it's done that before. Advice: wash hands, get vaccinated.

Chart by WKYT-TV, based on data from Kentucky Department for Public Health, adapted by Kentucky Health News

Kentucky Health News

Kentucky's hepatitis A outbreak appears to have hit a plateau or even be slacking off, but it has made such moves before, and then resurged. And the state continues to record about 60 new cases a week. The state Department for Public Health has logged 3,122 cases from September 2017, the start of the outbreak, through the first week of December 2018.

That being said, the department's most recent weekly report showed the largest one-week drop in reported cases since the outbreak began, to levels that haven't been that low in five months. The biggest single week was in late October.

The outbreak has been blamed for the deaths of 19 Kentuckians, "and 82 percent of Kentucky's 120 counties have reported at least one case," Lexington's WKYT-TV reports. "More than half of the cases have led to patients being hospitalized. . . . Carter County has the highest incident rate per capita."

Hepatitis A is transmitted by oral contact with fecal matter, and there is no cure, so authorities urge hand washing and vaccinations. The disease attacks the liver and causes symptoms including abdominal pain, nausea, diarrhea, fever and yellowing of the skin.

Hepatitis found among three more Lexington-area food workers

Lexington Herald-Leader graphic

Three more restaurant workers in the Lexington area have been found to have hepatitis A, but the state still has no food-borne cases of the disease more than 15 months into a statewide outbreak of then liver disease, health officials said.

"Anyone who ate in November at the Hardee’s at 2990 Richmond Road in Lexington, the Waffle House at 2347 Buena Vista Road in Lexington or the Waffle House at 4 Carol Road in Winchester may have been affected," Morgan Eads of the Lexington Herald-Leader reports, based on information from the Lexington-Fayette County Health Department.

The department said in a news release, “While it is relatively uncommon for restaurant customers to become infected with the hepatitis A virus due to an infected food handler, anyone who consumed food or drink at these locations during the stated time period is advised to get a hepatitis A vaccination.” It said the three employees won't return to work until they are medically cleared.

Hepatitis A can be transmitted from person to person by food or water contaminated by fecal material. Symptoms include fatigue, stomach pain, nausea, darkened urine and yellowed skin. The health department recommends getting vaccinated for the disease and carefully washing hands with warm water and soap after using the bathroom, and before making food and drinks.

Through Nov. 17, the outbreak had affected 2,769 Kentuckians, hospitalized 1,438 and killed 17, according to the state Cabinet for Health and Family Services.

Food-service employee at UK hospital diagnosed with hepatitis A; if you ate at Pavilion A cafeteria Oct.11-30, get vaccinated

A food service employee at the Albert B. Chandler Hospital at the University of Kentucky has been diagnosed with hepatitis A, a highly contagious liver disease, the hospital announced.

The employee prepared food at the Pavilion A cafeteria, but was not involved in any food preparation for hospital patients. The hospital advises anyone who ate at the cafeteria between Oct. 11 and 30 to get a hepatitis A vaccination, which requires two shots, six months apart.

All food-service workers at UK HealthCare will now be required to get the vaccine, and the hospital will set up "vaccination stations" for that.

The Lexington-Fayette County Health Department and UK HealthCare have recommended that all Lexington residents get vaccinated as the number of cases continues to climb. Kentucky schoolchildren were required to have the vaccination at the beginning of the school year.

In the current outbreak, there have been no confirmed cases of hepatitis A being transmitted by food-service workers in Kentucky. The primary risk factors continue to be illicit drug use and homelessness.

Since August 2017, 2,410 cases of acute hepatitis A have been reported in 94 of the state's 120 counties, resulting in 1,267 hospitalizations and 16 deaths, according to the state Department of Public Health. The agency's weekly report has county-by-county figures.

Last week, two people died in Franklin County from the virus and an employee at Frisch's Big Boy on Harrodsburg Road was diagnosed with it -- the first time a restaurant worker had been diagnosed with the disease in Lexington since the outbreak, the Lexington Herald-Leader reported.

Hepatitis A is a contagious liver disease that is usually spread when a person unknowingly eats or drinks something contaminated with by small amounts of fecal material from an infected person. Washing your hands for about 20 seconds with soap and water after using the bathroom or changing a diaper, or before preparing food and drinks can help stop the spread of hepatitis A. It is important to note that hand gels are not an alternative because they do not kill the virus that causes hepatitis A.

Symptoms of hepatitis A are fatigue, decreased appetite, stomach pain, nausea, darkened urine, pale stools and yellowing of the skin and eyes (jaundice). Not everyone with the virus has symptoms and a person with the virus is contagious for up to two weeks before showing symptoms. People can become ill 15 days to 50 days after being exposed to the virus. Anyone experiencing symptoms should seek medical attention.

2 more deaths linked to hepatitis A, making outbreak toll 16; some restaurant workers had it, but no food-borne transmission found

Hepatitis A has been blamed for two more deaths, both in Franklin County, bringing to 16 the statewide toll in the outbreak of the contagious liver disease, which has lasted more than a year.

None of the deaths have been connected to food-service workers, but concern about transmission by them remains a concern. Officials in Franklin and Fayette counties confirmed the disease in two more food-service workers and urged residents to get vaccinated for hepatitis A.

"Since August 2017, more than 2,275 outbreak-associated cases of acute hepatitis A have been reported in 94 of the state’s 120 counties," Chanda Veno reports for The State Journal in Frankfort.

Franklin County Health Director Judy Mattingly "couldn’t give the victims’ age or sex, but she did explain that both cases fit within the statewide profile of those afflicted by hepatitis A, whose mean age is 37.7 years old," Veno reports. Mattingly told her, “As with all Kentucky cases in this outbreak, it is believed that transmission occurred through person-to-person contact — when an infected individual did not thoroughly wash their hands, thereby passing microscopic fecal matter on to another person who unknowingly ingests the virus.”

Friday, Mattingly announced that one of the latest Franklin County residents diagnosed with hepatitis A worked at a Frankfort restaurant Oct. 22-25 while ill. "While rare for restaurant customers to become infected, patrons who ate at the restaurant during that four-day span have until Thursday to receive vaccination to further protect themselves from illness," Veno reports.

The restaurant is KFC, 1229 South U.S. 127. It "voluntarily closed for a thorough cleaning and sanitizing after being notified of the case on Thursday," Veno reports.

Mattingly said a “remote chance” exists that the worker could have been contagious as early as Oct. 8 before experiencing any symptoms. "Those who ate at the restaurant from that date through Oct. 25 are being asked to monitor their health for any hepatitis A symptoms for 50 days after any potential exposure, wash their hands frequently with warm water and soap and stay at home and contact a health-care provider immediately if symptoms develop," Veno reports, noting signs and symptoms of hepatitis A: jaundice (yellowing of the skin or eyes), dark-colored urine, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, fever and gray-colored stools.

In Lexington, an employee of Frisch’s Big Boy on Harrodsburg Road was diagnosed with hepatitis A, marking the first time a restaurant employee was diagnosed with the disease during this outbreak," and worked several days while ill, Mike Stunson and Karla Ward report for the Lexington Herald-Leader.

“If they had improper hand washing at any point in time they could’ve possibly transmitted the virus by not washing their hands and touching either food or any of the door handles or any of the restaurant’s plates and dishes and anything,” said Jessica Cobb, a community health officer for the Lexington-Fayette County Health Department, which advises anyone who ate at the restaurant Oct. 10-28 to get a hepatitis A vaccination. "The employee is not currently working at the restaurant and will remain off work until cleared to return," the Herald-Leader reports.

The health department "said it is relatively uncommon for restaurant customers to become infected with hepatitis A due to an infected food handler, but the health department does recommended the vaccination," the Herald-Leader reports. "In September, the Lexington health department recommended that all Fayette County residents get their hepatitis A vaccinations when the number of cases in the region began to surge."

Fayette Health Commissioner of Health Dr. Kraig Humbaugh said in September, “The vaccine is effective and has an excellent track record. However, most adults have not yet been immunized since the vaccine was not given routinely as part of their childhood schedule of shots.”

Cobb said Frisch’s has been cleaned with an EPA-approved sanitizer, and “they’re also working with us to make sure that their employees get vaccinated.”

Local outbreak of hepatitis A declared in Madison County, calling for vaccinations; heavy demand for vaccine in Whitley County

Madison County health officials have declared a local outbreak of hepatitis A and called on all local residents to get vaccinated for the liver disease that lives on poor hygiene.

"There are now 24 hepatitis A cases in Madison County related to the statewide outbreak that produced more than 2,050 across Kentucky," reports Mike Stunson of the Lexington Herald-Leader, citing the county health department. "It reported 13 cases on Oct. 6."

The department recommended hepatitis A vaccinations for all residents.

In Whitley County, where 99 cases have been reported, "Pharmacies are struggling to keep up with the demand for vaccines," reports Phil Pendleton of Lexington's WKYT and Hazard's WYMT.

"Rick Loudermelt at Whitley Pharmacy in Williamsburg says they have given out numerous vaccines since May of this year," Pendleton reports. "He says it's been hard to keep up with the demand, administering between 15 and 20 a week."

Madison County Public Health Director Nancy Crewe said vaccinations “should have a mitigating effect on the severity of the outbreak. We certainly don’t think there is any need for panic, but it is important that we get the word out to our citizens and encourage them to get the vaccine.”

The state Department for Public Health says more than 1,100 people have been hospitalized, and 14 died, in the statewide outbreak since November 2017.

Hepatitis A is usually spread when someone eats or drinks something contaminated by small amounts of stool from an infected person, according to the health department.

Symptoms include fever, fatigue, loss of appetite, nausea, abdominal discomfort, dark urine and yellowing of the skin and eyes. People can become ill 15 to 50 days after being exposed to the virus.

"Aside from the vaccination, good hand-washing is also recommended to help control the spread of hepatitis A," Stunson notes.

Frankfort fast-food restaurant closes for cleaning after one employee is found to have hepatitis A

A Frankfort fast-food restaurant closed for cleanup after one of its employees was found to have the liver disease hepatitis A, usually caused by ingestion of fecal material.

“The risk of infection from this food-service worker is very low due to hand-hygiene requirements at Hardee’s and all eating establishments,” Franklin County Health Department Director Judy Mattingly said in a news release.

Top of health department news release

The restaurant, at 1248 South US 127, "voluntarily closed . . . for a thorough cleaning and sanitizing after being notified," and ensured that all employees received a hepatitis A vaccination immediately, said the release, posted on the department's Facebook page.

The department later posted, "Prior to Oct. 4 the food service worker was in roles wearing gloves, or roles where there was no contact with food. So, the minimal risk of exposure occurred on Oct. 4. Any concerned community member should get a hepatitis A vaccine before Oct. 18."

"It’s the 22nd case of the virus in Franklin County during the ongoing outbreak in Kentucky — called the worst in the nation," Josh Bergeron of The State Journal reports. "From Aug. 1, 2017, to Sept. 22, 2018, the latest available numbers, the hepatitis A outbreak in Kentucky numbered 1,851 cases, with 1,029 hospitalizations and 14 deaths. In Franklin County, there had been 21 total cases reported as of Sept. 22. A majority of the reported cases in Kentucky have been linked to illicit drug use." 

Hepatitis A can cause fatigue, loss of appetite, nausea, fever, stomach pain, brown urine, light-colored stools, and yellowing of the eyes or skin or eyes. People may have some of these symptoms or none of them; a person can transmit the disease without showing symptoms, and can become ill from the virus up to seven weeks after being exposed to it.

The disease "usually spreads when a person unknowingly ingests the virus from objects, food or drinks contaminated by small, undetected amounts of stool from an infected person," the news release said. "The virus spreads when an infected person does not wash his/her hands adequately after using the toilet, or engages in behaviors that increase risk of infection."

The federal Centers for Disease Control and Prevention recommends the hepatitis A vaccination for the following groups:
• All children at age 1
• Travelers to countries that have high rates of hepatitis A
• Family members and caregivers of recent adoptees from countries where hepatitis A is common
• Men who have sexual contact with other men
• People who use injection and non-injection illegal drugs

• People with chronic (lifelong) liver diseases, such as hepatitis B or hepatitis C

Lexington has 100+ restaurants on probation for health violations; hepatitis A raises concern, but no cases have been related to food

Amid a nearly statewide outbreak of hepatitis A, the Lexington-Fayette County Health Department is monitoring more than 100 restaurants that it has placed on probation for violation of public-health standards, Janet Patton reports for the Lexington Herald-Leader.

"Spoiled food. Soiled equipment. Dirty floors, dirty walls. Live roaches and flies inside kitchens. Dead ducks hanging outside. Lexington’s restaurant inspectors have seen it all," Patton writes. "Since 2015, they’ve compiled a list of restaurants and other food service providers to target for heightened scrutiny."

The cleanliness of restaurants has taken on fresh importance since the hepatitis A outbreak started in about a year ago. The Lexington health department recently recommended that everyone in Fayette County be vaccinated against the liver disease because some food service workers had tested positive for the virus. No Kentucky cases of the disease have been attributed to food service.

A restaurant goes on probation if it has an inspection score below 85 or a critical violation that can’t be corrected immediately, including "employee hygiene practices such as a lack of hand washing, cold food being too hot or hot food being too cold, dishwashers not sanitizing properly, or evidence of rodents or insects," Patton reports. The most common violation is incompletely cleaned dishes and utensils, "either because the dishwasher isn’t dispensing sanitizer or the water isn’t hot enough to kill germs."

Kitchens at two Lexington hospitals are on probation. The one that serves patients and the cafeteria at UK Good Samaritan Hospital, went on probation when a May inspection "found live flies throughout the kitchen, and dirty walls, ceiling and equipment," Patton reports. UK spokeswoman Kristi Willett said the kitchen scored 98 in a follow-up inspection May 30. She said the hospital "has passed all other health department inspections in the past five years with a score of 98 or above.”

The cafeteria at St. Joseph Hospital "has been on probation since June, when an inspection found live roaches in the kitchen in the reach-in cooler, as well as unclean floors, walls, soda and juice dispensers," Patton writes. Kentucky One Health spokeswoman Mary Branham said the inspection was “not reflective of the scores our food service typically receives,” and the follow-up score was 99.

Patton reports that several "high profile" restaurant operators said the label "probation" is misleading. “People don’t understand … that upon reinspection the score was good,” said Rob Ramsey, who operates several restaurants with his family name in Lexington. “As far as I’m aware of we’ve never had a food-safety hazard that has been passed to the public.”

About 100 Anderson Co. students out of school until they get hepatitis A vaccine; state sees 'overall good compliance' in Ky.

Nearly 100 students had to stay home from school in Anderson County this week because they were not compliant with the state's new hepatitis A vaccination requirement, Ben Carlson reports for The Anderson News.

Since August 2017, Anderson County has had seven reported cases of the highly contagious liver disease, according to a weekly Department of Public Health report. One of them was a student at Anderson County High School.

Carlson reports that the health department said that as of Tuesday, Sept. 11, the high school and Anderson County Middle School had the highest number of non-compliant students, with 48 and 35, respectively, and the rest scattered in elementary schools and an early-childhood center.

County Health Director Tim Wright told Carlson that there was no reason for students to have shown up to school in early August without being in compliance. “We started advertising this in July of 2017,” he said. “The requirement was for August of 2018, so we advertised it for 13 months.”

Lexington's WKYT-TV reported on Sept. 6 that School Supt. Sheila Mitchell said students and their families had been well informed about the new requirement and the Sept. 7 deadline, adding that they had worked closely with the the Anderson County Health Department and Cumberland Family Medical to provide two clinic days at school for all students to get vaccinated or seek exemptions.

Wright told Carlson he was "disappointed" that schools let non-compliant students in on Monday, Sept. 10, even though they had been told not to come if they hadn't been vaccinated for hepatitis A. He was also frustrated that the school district still couldn't tell him how many of the 350 people who could have been exposed to the student who tested positive for the disease had had their vaccine.

Carlson reports that Supt. Mittchell did not respond when asked why non-compliant students were allowed to attend on Monday, nor could she answer why the school's Cumberland Family Medical nurse left Monday in the middle of sorting through which students remained non-compliant. Cumberland Family Medical also refused to comment on why the nurse left.

Despite his many frustrations, Wright told Carlson: "The positive thing is, we don’t have any more confirmed cases. Hopefully we won’t have an outbreak but, as of today, those not in compliance are not in school.”

State Public Health Commissioner Dr. Jeffrey Howard told Kentucky Health News in an e-mail that the state health department has received "sparse reports" from across the state of only a few students being held out of school for not being vaccinated for hepatitis A.

"However, when our team investigated the case of a student with HAV [hepatitis A] in Anderson County, they discovered many students were not in compliance with vaccination recommendations," he said. "Having 100 students without the appropriate vaccination at a single school [district] is an extreme exception to what has been overall good compliance."

Fayette County becomes 11th Kentucky county to recommend that all its residents be vaccinated for hepatitis A

As the number of hepatitis A cases continues to climb in Kentucky, health officials in Fayette County are recommending all Lexington residents get vaccinated, Mike Stunson and Karla Ward report for the Lexington Herald-Leader.

“The best way to prevent hepatitis A is to get vaccinated,” said Dr. Kraig Humbaugh, the Fayette County health commissioner. “The vaccine is effective and has an excellent track record. However, most adults have not yet been immunized, since the vaccine was not given routinely as part of their childhood schedule of shots.” The state recently required all students to prove that they have had the two-dose hepatitis A vaccine.

As of Sept. 1, there have been 1,628 cases of hepatitis A in the state since November. That number includes 919 hospitalizations and 13 deaths, according to the state Department of Public Health. The weekly report also offers county level data. Since August, 86 of the state's 120 counties have reported an "outbreak-associated case."

The Lexington-Fayette County Health Department has reported 12 cases since Aug. 1, 2017, with half of those cases being reported since July, including three this month.

"Humbaugh said a significant percentage of those who have contracted the disease statewide were not part of an at-risk population," the Herald-Leader reports. He said, “We wanted to wait until we thought there was a concern about transmission to the wider community.”

In April, the state health department urged citizens of six counties, including Jefferson, Bullitt, Hardin, Greenup, Carter and Boyd, to get vaccinated for hepatitis A. The Northern Kentucky Health Department urged residents of its Boone, Grant, Kenton and Campbell counties to do the same in August.

The primary risk factors in Kentucky continue to be illicit drug use and homelessness, and so far the state has had no reported transmissions of hepatitis A involving food-service workers.

Dr. Jeffrey Howard, the state health commissioner, told Kentucky Health News that the state health department gets a lot of calls from people who are worried about eating out and said his advice is: "You are OK to go out to eat in your local restaurants. The risk of getting hepatitis A from an infected food worker as long as they are adhering to normal precautions is very minimal."

Howard added that he expects the epidemic to last another eight to 12 months in Kentucky.

Symptoms of hepatitis A include fever, fatigue, loss of appetite, nausea, abdominal discomfort, dark urine and yellowing of the skin and eyes (jaundice). Not everyone with the virus has symptoms and a person with the virus is contagious for up to two weeks before showing symptoms. People can become ill 15 days to 50 days after being exposed to the virus, the health department said.

The disease is “usually spread when a person unknowingly eats or drinks something contaminated by small amounts of stool from an infected person,” according to the health department.

Besides vaccination, thorough hand washing for about 20 seconds with soap and water after using the bathroom, before eating and when returning home from being out in the public is also an important way to decrease the risk of transmission. It's also important to note that hand gels are not an alternative because they do not kill the virus that causes hepatitis A.