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Addressing a Hepatitis A Outbreak - Collaborative Community Response
Bill Ridella
Director/Health Officer
Bill.Ridella@macombgov.org
586-469-5110
Mount Clemens
Michigan
48048
Your summary must address all the questions below:
Macomb County Health Department (MCHD) protects and promotes the health and well-being of those who live, work, and play in Macomb County. Macomb County is the third largest county in the state, with an estimated population of 871,375 (US Census, 2017). Macomb County is composed of both suburban and rural communities, with the majority of the population residing in the southern portion of the county. Three of these communities are among the largest in Michigan: Warren (3rd), Sterling Heights (5th), and Clinton Township (10th).
In August 2016, Michigan Department of Health and Human Services (MDHHS) confirmed a hepatitis A outbreak in Southeast Michigan. Macomb County had the highest number of confirmed hepatitis A cases, with a total of 223 cases (25% of total) from August 1, 2016 to December 5, 2018. In a typical year, MCHD identifies approximately 5-10 hepatitis A cases. To counter this unprecedented increase in hepatitis A cases, innovative and wide-ranging interventions were needed.
In collaboration with state and local partners, MCHD identified that by September 30, 2018 the department would increase understanding of the hepatitis A outbreak through epidemiological study, and increase pre and post exposure vaccination among identified at-risk populations to control further spread of disease and increase understanding of the risk of hepatitis A. The objectives of this project were as follows:
Objective 1 – Increase the epidemiological study of the outbreak.
Objective 2 – Increase vaccination among identified at-risk populations.
Objective 3 – Launch a public information campaign to increase awareness and action among at-risk populations to obtain hepatitis A vaccination.
Objective 4 – Increase collaboration with agencies that serve those at highest risk of hepatitis A.
Epidemiological data identified the following high risk populations:
MCHD collaborated with Macomb County Office of Substance Abuse (MCOSA), Macomb County Homeless Coalition, Macomb County Jail, first responders, and substance abuse centers to discuss the outbreak, strategies on how to increase/encourage vaccination, and how best to educate their high risk clientele. MCOSA generated a list of agencies in Macomb County that educated, counseled and treated individuals with substance use disorders. Identified agencies were contacted by phone and email to educate them on the status of the outbreak, how clients could protect themselves against the disease, and to offer an onsite vaccine clinics. Presentations were provided at staff meetings at these locations in order to educate providers, who could then educate their clientele and encourage vaccination.
In addition to the engagement with substance abuse service providers, the MCHD Healthy Communities team disseminated educational materials to businesses and provided in-person education to employees in communities with the highest case counts. Furthermore, the team identified upcoming events during the summer months to provide outreach materials and education for residents when hepatitis A cases were expected to increase at large events such as fairs and festivals through improper hand washing.
Environmentalists from the Environmental Health Division provided hepatitis A information and hand washing signs at routine and follow-up inspections of food service establishments.
Indoor and exterior bus ads were designed and purchased to help reach at risk populations. The ads promoted hepatitis A vaccination and hand washing, and discouraged sharing of items such as drinks, utensils, toothbrushes, smokes and the like.
Based on feedback from MDHHS, MCHD was consistently on target, week-after-week, in meeting their established work plan activities.
MCHD’s Communicable Disease Program’s ability to promptly contact hepatitis A cases and gather epidemiologic and qualitative data about their circumstances, contributed to comprehensive data collection, helping to craft targeted interventions. However, during the outbreak, 80% of cases were hospitalized. Through established relationships with Infection Preventionists at local hospitals, new cases were quickly referred to the Communicable Disease staff, and who promptly followed up with hospitalized cases.
Prompt connection with hospitalized cases was important in obtaining information on the circumstances regarding their possible infection route, and to offer post exposure prophylaxis to potential contacts to reduce secondary transmission.
The materials and updates regarding the hepatitis A outbreak can be found on the Macomb County Health Department website: Health.Macombgov.org
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.)
Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
From August 2016- December 2018, MDHHS confirmed 908 cases of hepatitis A in the State of Michigan, with the largest number of these cases coming from Macomb County (223 cases or 25% of statewide total).
Individuals at highest risk for contracting hepatitis A during this outbreak included persons with a history of substance abuse, persons experiencing homelessness/transient living, men who have sex with men (MSM), persons with cirrhosis, hepatitis B or hepatitis C, food workers, healthcare workers, and persons who work with the high risk populations listed.
Utilizing CDC recommendations and lessons learned from previous hepatitis A outbreaks, MCHD established an effective response to the outbreak, and witnessed a decrease in outbreak cases.
Many of the populations at highest risk during the outbreak were less likely to seek out recommended preventative vaccinations or post exposure prophylactic vaccination for hepatitis A. MCHD worked in partnership with the Macomb County Jail, Macomb County Office of Substance Abuse (MCOSA) and Macomb County Homeless Coalition to develop strategies designed to engage our hard to reach at risk groups. Their expertise with at-risk clients helped craft the community and partner agency onsite hepatitis A vaccination clinics.
To better prepare for clinic and outreach requests, MCHD created a hepatitis A outreach team, or “Strike Force Team” that was flexible, and best suited to work with the diverse populations identified at highest risk during the outbreak. The Strike Force Team was assembled across programs within the department including Immunizations (responsible for vaccination and education), Communicable Disease (data collection and risk factors) and Environmental Health (logistics). The Strike Force Team had access to hepatitis A outreach “go packs” – personal hygiene kits provided to clients to help reduce their risk of acquiring hepatitis A and efficiently packaged supplies with a smaller footprint than typical clinic outreach supplies to enable the team to respond to clinic requests in a shorter time frame.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
In collaboration with MDHHS, MCHD identified that by September 30, 2018 the Department would increase understanding of the hepatitis A outbreak through epidemiological study, and increase pre and post exposure vaccination among identified at-risk populations to control further spread of disease. The objectives of this project were as follows:
Objective 1 – Increase the epidemiological study of the outbreak.
Objective 2 – Increase vaccination among identified at-risk populations.
Objective 3 – Conduct communications activities to increase awareness and action among at-risk populations to obtain hepatitis A vaccination.
Objective 4 – Increase collaboration with agencies that serve those at highest risk of hepatitis A.
Using epidemiological data in which at risk populations were identified, MCHD, MDHHS and local partners including the Macomb County Office of Substance Abuse (MCOSA), Macomb County Jail, and Macomb County Homeless Coalition, developed targeted interventions.
To reach persons with substance abuse disorders, MCHD, MCOSA, and its local substance use disorder partners implemented the following community outreach interventions:
Data indicated that a high percentage of incarcerated persons have a history of substance abuse, and to reach this population in their current setting, MCHD worked with the Macomb County Jail and Correct Care Solutions, the Jail medical provider, to administer hepatitis A vaccine at the time of the inmate’s history and physical. Newly incarcerated persons were vaccinated during the booking and intake process at the jail. In addition, MCHD provided oversight to the County Jail staff and CorrectCare Solutions staff, to ensure appropriate vaccine handling and storage, including the procurement of storage and temperature monitoring units. In addition, vaccine administration documentation was monitored to ensure vaccines were being administered in accordance with local and state immunization protocols.
MCHD worked with the Macomb County Homeless Coalition, community kitchens and homeless shelters to provide onsite monthly vaccination clinics to reach the homeless and transient housing populations that were at risk.
To reach the men who have sex with men (MSM) population, MCHD embedded an immunization nurse in our STD/HIV clinic to provide education and vaccination at the time of STD and HIV testing and counseling.
Continuous two-way communication with partners helped adapt the outreach efforts when epidemiological data changed over the course of the outbreak, and when outreach efforts were not reaching the intended populations.
To fund outbreak activities, MCHD received a grant totaling $216,000 from MDHHS. MCHD provided in-kind funding through staff hours to supplement grant funding and to strengthen outreach and vaccine clinics in the community.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
The outbreak protocol is still in effect and activities are ongoing. Reviewing the data, MCHD and its community partners provided 358 outreach clinics and 11,627 doses of hepatitis A vaccine through September 2018. Clientele outbreak data was collected by Communicable Disease staff and entered into the Michigan Data Surveillance System (MDSS). MCHD received weekly MDSS updates weekly during the worst part of the outbreak. A significant decline in cases (162) was noted between the second half of 2017 and the end of the first half of 2018 (22).
MCHD provided weekly situation reports and updates on activities to the state early on in the outbreak. Now that hepatitis A cases have significantly decreased, reporting occurs monthly. By reviewing the risk factors of the outbreak cases, up-to-date at risk clientele were identified and targeted for pre and post exposure vaccination and educational outreach.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
MCHD learned, or reaffirmed, several lessons through the outbreak response.
As the outbreak has plateaued, MCHD has continued to focus on high risk populations including those with substance use disorders, Macomb County Jail inmates or homelessness. In addition, MCHD has continued to promote routine hepatitis A vaccination with all clients at in-house immunization clinics. MCHD has continued its relationship with three in-patient residential treatment centers located in the county, and with the Macomb County Jail to assess high risk clients and provide preventative and prophylactic vaccination as needed.
To continue these outreach and vaccination activities, funding has been secured from the County general fund, a $5,000 stipend has been allocated from the state, and the MDHHS is supplying MCHD with additional hepatitis A vaccine. MDHHS is also contributing In-kind epidemiological support and analysis.
2014 Model Practice
