How Hepatitis A Is Now An Emergency In Philadelphia

Shown here is the Hepatitis A virus (picornavirus) via transmission electron microscopy. (Photo by: BSIP/Universal Images Group via Getty Images)

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It's certainly not hep, hep, hooray in Philadelphia. The City of Philadelphia has just declared a public health emergency due to a Hepatitis A outbreak.

According to the World Health Organization (WHO), a disease outbreak is "the occurrence of disease cases in excess of normal expectancy." What constitutes a Hepatitis A outbreak in Philadelphia? How about over 25 times the usual number of cases per year? The city typically has two to six reported cases a year. Since January, it has already had 154 reported cases. The "vast majority" (85%) of these cases have occurred since May.

As the following CBS Philly news segment indicates, this surge in cases has prompted Thomas A. Farley, MD, MPH, the Philadelphia Health Commissioner, to make the declaration:

The declaration also described Hepatitis A infection as "a highly contagious liver disease caused by a virus that is transmitted by the fecal-oral route." Fecal-oral is a medical way of saying "poop-to-mouth." I know, I know, you may say that you don't usually eat poop. But you may be doing so if you don't wash your hands frequently and thoroughly enough. Because if you were to take a closer look at many different objects touched by others, poop there it is. You also may be putting poo in you if you eat food or drink beverages (or drink food, if that's what you do) handled by people who don't practice good hand hygiene.

I have written before for Forbes about how hepatitis A can lead to very unpleasant symptoms (e.g., fever, fatigue, loss of appetite, nausea, vomiting, and abdominal pain) as well as more serious complications such as liver failure and death. Death would be considered a highly unpleasant symptom.

The good news is that a Hepatitis A vaccine exists and works quite well. The bad news is that Hepatitis A vaccination rates don't tend to be high. For example, a study in the journal Vaccine found that only 36.6% of adults who were 18 to 49 years of age and were traveling to countries with higher Hepatitis A rates had gotten the vaccine. The percentage was even lower, 12.7%, for those not traveling to such countries. Farley's declaration indicated that at least 12,439 Philadelphian or Philly adults have been vaccinated since the Summer of 2018 and that "the Department has administered 1,775 Hepatitis A vaccinations to at-risk people."

What does "at-risk" mean? Isn't everyone who has a mouth "at-risk" for Hepatitis A? Yes. However, typically, in medical lingo, "at-risk" means having a greater than normal risk to either get infected or have more serious complications. So for Hepatitis A, this includes those who are homeless, use drugs, were recently incarcerated, are men who have sex with men, or have chronic liver disease. But you don't have to be considered "at-risk" to get the vaccine. So why not get it? Unlike many people, the virus and poop do not discriminate.

Philadelphia isn't the only location to declare an emergency. As Bianca Padro Ocasio reported for the Miami Herald, 56 new Hepatitis A cases in Florida this week has prompted Scott Rivkees, MD, the Florida Surgeon General, to declare a statewide public health emergency yesterday.

In fact, Hepatitis A outbreaks are a continuing problem across many states in the U.S. Take a look at this table from the Centers for Disease Control and Prevention (CDC) that lists the totals since 2016 and the states that are having ongoing Hepatitis A outbreaks:

State	Case Total	Hospitalizations n (%)	Deaths	Outbreak Start Date	Data Current Through
Total	22566	13352 (59%)	221
States with an ongoing outbreak
Alabama	98	52 (53%)	NR	9/1/2018	7/17/2019
Arizona	506	390 (77%)	3	11/1/2018	7/25/2019
Arkansas	382	187 (49%)	3	2/7/2018	7/26/2019
Colorado	101	70 (69%)	0	10/1/2018	7/24/2019
Florida	2220	1596 (72%)	28	1/1/2018	6/30/2019
Georgia	527	363 (69%)	3	6/1/2018	7/20/2019
Idaho	28	15 (54%)	0	1/1/2019	7/17/2019
Illinois	145	94 (65%)	1	9/1/2018	7/24/2019
Indiana	1825	996 (55%)	4	11/1/2017	7/26/2019
Kentucky	4793	2311 (48%)	59	8/1/2017	7/13/2019
Louisiana	406	236 (58%)	1	1/1/2018	7/26/2019
Massachusetts	484	387 (80%)	7	4/1/2018	7/19/2019
Michigan	918	737 (80%)	28	8/1/2016	7/17/2019
Missouri	378	206 (54%)	2	9/1/2017	7/23/2019
New Hampshire	158	93 (59%)	1	11/1/2018	7/23/2019
New Jersey	285	201 (71%)	3	12/1/2018	7/20/2019
New Mexico	133	104 (78%)	2	11/8/2018	7/25/2019
North Carolina	87	60 (69%)	1	1/1/2018	7/15/2019
Ohio	3220	1941 (60%)	14	1/1/2018	7/22/2019
South Carolina	225	158 (70%)	1	11/1/2018	7/19/2019
Tennessee	2022	1219 (60%)	10	12/1/2017	7/19/2019
Virginia	108	68 (63%)	0	1/1/2019	7/25/2019
West Virginia	2528	1252 (50%)	23	3/19/2018	7/3/2019

That's a lot of states. Nearly half if you know that there are 50 states. This list of states doesn't include the two states that have declared ends to their outbreaks. California, which had a total of 708 reported cases with 464 hospitalizations and 21 deaths, considered their outbreak over on April 11, 2018. Utah, with tallies of 281, 152, and 8, respectively, called their outbreak done on February 12, 2019.

This ain't a case of liver and let liver. Hepatitis A can be a very serious disease, and it's important to understand what has been driving these outbreaks and how to stop them. Certainly, increased vaccination rates could help. So could a closer look at food safety and how food is being handled. For example, last year I wrote for Forbes about an outbreak that started from a Kentucky Kroger grocery store. As another example, near the end of last year, Bauer’s Candies had a voluntary recall of the Chocolate and Caramel Modjeskas that they had produced between November 16 and 23, 2018. This recall was due to Hepatitis A contamination concerns, according to the U.S. Food and Drug Administration. Indeed, life may be a box of chocolates, but you don't want one of them to have the Hepatitis A virus.

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