18 months, 25 deaths, and 615 hospitalizations later, state officials are beginning to express hope that a large hepatitis A outbreak is on the cusp of a decline.
Jay Fiedler is with the Michigan Department of Health and Human Services. He says he can definitely see a plateau -- 10 to 15 new cases a week -- and no signs of another uptick.
The state has targeted most of its efforts and funding since the outbreak began on counties with the largest number of cases: Wayne, Oakland, and Macomb counties, with smaller but sizable numbers of cases in St. Clair, Ingham, Washtenaw, Monroe, and Genesee counties.
Hep A cases linked to the outbreak number in the single digits in many other counties in the state.
Fiedler says last week the state turned its attention to counties with no cases or just one case, providing funding to help county health departments focus on primary prevention.
He attributes the "plateau" to three things. First, a public information campaign is getting the word out to at-risk groups that there is an outbreak and that getting vaccinated will protect them. While nearly 40% of those infected have no risk factors, large numbers of cases have occurred among people who abuse drugs, people with no permanent home, men who have sex with men, and people who are in prison.
"And I do think we're getting more vaccine coverage," Fiedler says. "We're almost up to 100,000 doses [in southeast Michigan]. And we're getting better information from cases and we're able to respond more quickly with post-exposure prophylaxis."
County health departments are also increasing their supply of immune globulin, in addition to the hep A vaccine. Immune globulin is considered a better post-exposure treatment for people over the age of 40.
Fiedler says figuring out why this outbreak has resulted in so many hospitalizations will have to wait until the crisis is over. The virus infecting people in Michigan is distinct from the virus infecting people in California, which is experiencing a similarly large outbreak.
The outbreak has only affected adults, for the most part. Only four cases involving children are known. Fiedler says that's because the hep A vaccination rate among Michigan children is about 80%.
But there's still a lot more work to do to increase public awareness, he acknowledges. Eighteen months later, "I still get people asking me, 'what hep A outbreak?'"