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:
- persons with history of injection and non-injection drug use
- persons experiencing homelessness or transient housing
- incarcerated population
- men who have sex with men (MSM).
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