Since news broke Tuesday about a fast food worker being diagnosed with hepatitis A and customers being encouraged to get vaccinated, the Boyle County Health Department has been flooded with calls.

“I call it ‘the worried well’ — they’re not sick, they’re just trying to understand what to do,” Public Health Director Brent Blevins says. “Or if they need to do anything.”

A worker at Burger King was diagnosed with the viral liver infection, and the health department is urging anyone to get vaccinated who was a customer between Dec. 12, 2018, and Jan. 1, 2019. “We’ve gotten a lot of calls, but it’s a good thing — because we’re able to tell people to get their hep A shot,” he says.

The other positive side, Blevins says, is that more restaurants are now requiring employees to get hep A (or HAV) shots and show proof before they can be hired. “We’ve had at least 10 food places here locally that are doing that. It’s not a law yet, but I think eventually it will be. For me, it’s a good sign when businesses are doing that themselves.”

After all, he says, schools are already requiring the vaccination, since the law was changed, effective last July. All students in kindergarten through 12th grade must now show proof of having received the two doses of HAV vaccine before the new school year begins.

The shots aren’t cheap — for those who come to the health department with no insurance coverage, they are $45 a pop. “It’s not horribly expensive, but it is $90 for the two shots,” Blevins says. The second shot must be administered no sooner or later than six months after the first.

According to the Centers for Disease Prevention and Control, the exact duration of protection after vaccination is unknown. But the anti-HAV has been shown to persist for at least 20 years among those vaccinated with a two-dose schedule.

Blevins says when the health department first started offering the vaccine, it was $70 a shot. But now, pharmaceutical companies are producing more of the medicine, so the price has come down.

“At your regular doctor, insurance usually pays for it. I tell everyone, go to the pharmacy or your doctor, and they can bill your insurance. If you come to the health department, we don’t take insurance, but we can charge based on a sliding scale,” Blevins says, which means based on income.

The CDC says hepatitis A was on a long, downward trend for years — until it saw its first increase in 2012 with 1,562 cases reported, then again in 2013 with 1,781 cases. The CDC says this was due to a large, multi-state outbreak. Cases again increased — this time more than 44 percent — from ‘15-’16, which was linked to two different outbreaks due to imported foods. In 2016, there were 4,000 new hepatitis A infections reported nationally.

“A couple of years ago, in San Diego, their hepatitis A problem got so bad, they washed some of their city streets with bleach water,” Blevins says.

According to a September 2017 report from NPR, the infectious disease had killed at least 15 people in San Diego and infected nearly 400. The outbreak was largely attributed to a shortage of public restrooms in an area where the homeless population congregated.

“In my mind, that’s really out there, that you’d get to that point,” Blevins says. “I don’t see that as happening here, we don’t have that kind of homeless population.”

Most commonly, the outbreaks are attributed locally to drug use being on the rise. The disease is spread fecally and orally. But really, there can be a number of factors affecting the spread, Blevins says.

“It’s hep A now,” Blevins says. “Give it a little bit of time, and it’ll be the next thing …”

Local cases on the rise

Dr. James Duncan says they’ve seen about five cases over the last six months. He’s an internist with KentuckyOne Health Primary Care Associates in Danville.

“We’ve got a lot of patients, in the thousands within the whole practice, but that’s still a fair amount of cases,” Duncan says. He says most of the time, when it’s diagnosed, it’s due to an acute illness — the patient “feels bad, we do some blood work and find out their liver enzymes are elevated.”

Because it’s such a varied illness, Duncan says it’s hard to track it. If children 2 years old or younger get it, it may never be detected.

“Adults can be the same way, they can be mild. But the risk of severe illness increases with age,” he says.

Most of the time, it’s  a “self-limited” illness, he says, meaning there’s no specific treatment other than observation and incubation. Patients cannot be treated with the vaccine once diagnosed.

“As people start to read about it more, they’ll want to be tested. Some want to know if they’ve had it before,” Duncan says. If you’ve had hep A once, you cannot be infected with the virus again. However, you can still be infected with other hepatitis viruses.

In the past, Duncan says the hepatitis A vaccine was primarily recommended for travellers to second- and third-world countries, but all that’s changed.

“I’ve seen two of my own patients, in the last six weeks or so, with it,” says Dr. Brian Ellis with Danville Family Physicians, a primary care group under the Ephraim McDowell Regional Center umbrella. And there’s been more within the practice he hasn’t treated himself who have been diagnosed — probably up to about five cases in the last six weeks.

Ellis says in his 25 years at the practice, he’s never seen this many hep A cases at one time. He also supervises some of the outer clinics of EMRC, which have also reported cases.

The infection spreads easily, Ellis says, because many aren’t very sick at first. “They may have some nausea, don’t feel so great, think they’re coming down with a bug. It may not be a few days until it’s obvious something else is going on,” Ellis says, so it’s not their fault for being out and about, which leads to spreading the infection.

“The theories I’ve heard about why we’re seeing more than we used to — however I’m not sure if anyone truly knows — have been attributed to the rise of the opioid crisis,” Ellis says. “It started there and rose within those ranks, and spilled out over into the general population.”

He says the average incubation period, once a patient knows they are infected is anywhere from 15 to 30 days.

“That’s one reason it’s hard to track down from a public health perspective — we don’t know exactly when a patient is exposed,” Ellis says.

A recent patient was diagnosed because they noticed their urine was dark in color, which is one of the first signs of jaundice. And although it can start out very mildly, once it hits, Ellis says it can take weeks before the person feels better — up to two months, in some cases he’s seen.

“Get your shots — that’s the best thing you can do,” Blevins reiterates.

Symptoms of hep A include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, diarrhea, clay-colored bowel movements, joint pain and jaundice. According to the CDC, symptoms usually last less than two months, although 15 percent will have prolonged or relapsing disease for up to six months.