Fecal percutaneous transmission of hepatitis A involving methamphetamine users in Iowa.

An Interview with Patricia Quinlisk, M.D., M.P.H., State Epidemiologist/Medical Director, Iowa Department of Public Health, and Yvan Hutin, M.D., Epidemic Intelligence Service Officer, Centers for Disease Control and Prevention 

Editor's note: One of NEHA's priorities in selecting material to publish in the Journal is to share information with you that is timely, interesting, and relevant. While many of the manuscripts and stories we publish with this priority in mind are submitted to us, we also are proactive in our efforts to obtain them; such is the case with Special Report interviews that we feature from time to time. By conducting interviews with people in the trenches of environmental health - your chosen profession - and publishing them as Special Reports, we intend to provide you with practical insights, as well as with stories that are enjoyable to read.

Introduction

In February 1997, the Iowa Department of Public Health (IDPH) noticed an increase of hepatitis A in four central Iowa counties. The increase was most significant in Polk County, which has the largest population in Iowa, and also is the county where Des Moines is located. In Polk County, the average number of hepatitis A cases ranges from zero to three or four per month. Approximately four cases were reported in Polk County during the month of February 1997; 11 during the month of March; and 21 during the month of June. The number of cases peaked at approximately 44 during the month of August.

Investigators at IDPH suspected that intravenous drug users, specifically methamphetamine users, were playing a major role in the outbreak, because a similar pattern had been detected in outbreaks occurring in other states around the country. Also, the state of Iowa participates in a nationwide viral hepatitis surveillance program, through which additional information was obtained to confirm this suspicion. To determine why methamphetamine users were at higher risk for contracting hepatitis A, Patricia Quinlisk, M.D., M.PH., State Epidemiologist/Medical Director for the Iowa Department of Public Health, requested assistance from the Centers for Disease Control and Prevention (CDC).

CDC, concurring with Dr. Quinlisk that Iowa's hepatitis A outbreak had national implications, sent Yvan Hutin, M.D., Epidemic Intelligence Service Officer, to IDPH to assist with the outbreak investigation. Dr. Hutin's role was to identify infection risk factors and modes of transmission for hepatitis A among methamphetamine users so that, ultimately, IDPH and CDC could issue an effective recommendation for prevention.

JEH: What made you initially suspect that there was a connection between methamphetamine users and this particular hepatitis A outbreak?

Dr. Hutin: In the United States there is a viral hepatitis surveillance program ... in which viral hepatitis cases are investigated [at the state level] with a special questionnaire that contains questions about potential risk factors for hepatitis A, B, or non-A/non-B. This system... is useful for raising hypotheses. One of the questions [on the questionnaire] is whether the case patient has been injecting drugs. Therefore, on a routine basis, if there is a hepatitis A outbreak, by looking at your routine surveillance data you are able to know [if] you have a high proportion of injection users among patients, and that generates the hypothesis .... This work had already been done when I arrived in Iowa, so the main problem had been identified, and we wanted to go further to answer the question, "Why are methamphetamine users at increased risk of [contracting] hepatitis?"

JEH: How did you approach the investigation at that point?

Dr. Hutin: When you try to understand how a disease is transmitted, [there are essentially] two steps: the first ... is hypothesis generating and the second is hypothesis testing. In terms of modes of hepatitis A transmission among methamphetamine users, several hypotheses had been suggested, but none of them had really been studied in an analytic fashion with a controlled study. So the primary objective of this investigation was to find risk factors for hepatitis A among methamphetamine users that would point to specific modes of transmission that would be accessible to prevention. Are you familiar with hepatitis A and B or C?

JEH: Just on a basic level. Could you elaborate about how they are distinguished from each other?

Dr. Hutin: Classically, A is an acute viral hepatitis that is usually self-limited. But complications sometimes occur. There may be prolonged fatigue, relapses or sometimes - quite rarely, but it occurs - fulminant hepatitis. Acute disease usually leads to lifelong immunity, with no chronic effect.

Dr. Quinlisk: Hepatitis A is the one you get over, and then you're done with it.

Dr. Hutin: Yes, and when you are talking about hepatitis with a lifelong burden of chronic infection, then you're talking about B and C. Also, with hepatitis A, the vast majority of cases are transmitted through what we call the fecal-oral route (basically, you ingest something that has been fecally contaminated - either food or water). Hepatitis B and C, however, are mainly transmitted through what we call the percutaneous and, sometimes, sexual route, which is through exposure to blood or body fluids. That is why drug users are usually considered to be at increased risk for hepatitis B and hepatitis C, and why it is less commonly known that illicit drug users are also at increased risk for hepatitis A.

Dr. Quinlisk: Historically, hepatitis A was associated with young children in daycare centers spreading it to mom and dad ... that kind of scenario.

Dr. Hutin: ... yes, and also associated with travel to endemic areas such as Africa or South America.

Dr. Quinlisk: That's why, when we started seeing an association between this outbreak of hepatitis A and drug use, it was ... not a totally new phenomenon, but one that we did not understand.

Dr. Hutin: Although I said that hepatitis A is transmitted primarily through the fecal-oral route, there have been cases in which hepatitis A was acquired through a blood transfusion. If you are incubating hepatitis A, you have virus in your blood. Let's say you donate blood, and it is given to somebody that is susceptible. That person can get hepatitis A.

JEH: So your point is that people can also contract hepatitis A by injecting drugs?

Dr. Hutin: Absolutely. However, some of these drug users did not acquire the disease because of their drug use; they acquired it because their hygiene is not as good as the general population's. They got hepatitis A the way everybody else gets hepatitis A - by eating food or water that was fecally contaminated. Other [investigators] were saying, "Since it can be transmitted through blood transfusions, it's probably from sharing needles that they got hepatitis A." But I was not convinced that this was the only mode of transmission.

JEH: What did you ultimately find out?

Dr. Hutin: We did our entire study among people who reported recent methamphetamine use. It's not like when you study [a typical] outbreak where everybody's eager to cooperate about what they've been eating. In the case of methamphetamine users, when you ask, "What do you use?" and "How?" and "When?", it is a touchy issue. [The subjects of this study were] difficult to contact, and we ended up with a small sample size, so we're careful with the conclusion. But to summarize the data, what we found was that there was probably more than just one mode of transmission, and these modes of transmission included the fecal-oral route. Also, there probably is some percutaneous transmission going on from needle exchange. But one thing that we found, and which had not been suggested so far, is that some of these methamphetamine users acquired hepatitis A through what we decided to call the "fecal-percutaneous" route, which is injection of a drug that has been fecally contaminated.

Just to give you a practical example, if you are a food handler and you don't have good hygiene, you may go to the bathroom without washing your hands; then, if you prepare a salad, you fecally contaminate the salad. Then the person who [eats] the contaminated salad gets hepatitis A. So what may be going on among injecting methamphetamine users is the same thing, except that instead of preparing a salad, they're preparing a dose of methamphetamine that is going to be injected. But it is the dose that has been contaminated that leads to the infection.

Dr. Quinlisk: ... and often they share the drugs, so there is one person preparing a dose that is shared among a small group of people.

JEH: What has been the outcome? Is there a solution?

Dr. Quinlisk: Well, there are a lot of things that we did here in central Iowa ... and this is not a simple problem; it's a very complex problem, with a population that is difficult to get information to, and difficult to intervene [with]. But one of the things we did was provide ... two-pronged education. [The first prong was communicating] to the drug users, "This is what we think is happening. If you're going to use drugs ... you need to wash your hands, etc., to reduce your risk .... "And [the second prong involved] going to the group that was at high risk for transmission, should hepatitis A get in, and that was geared to the restaurants and the daycare centers. We also provided special education to them about how to prevent their establishments from becoming sources of transmission. So education was done in these two different groups.

We also offered a vaccine to the drug-using group (which we offered as well to some other high-risk groups that were identified). Our goal was to get these people vaccinated so they would have a higher level of immunity; we were hoping to reduce transmission.

Plus, we did a lot to promote public awareness. I was just looking through my file, and ... we had the front page of the paper once or twice a week for several weeks, informing people about the problems of hepatitis A .... We even had the media coming to our training sessions for the restaurants .... That really helped us increase awareness.

JEH: As far as the vaccines go, how did you make them available?

Dr. Quinlisk: We had vaccination clinics all over the place. We offered them through the emergency rooms at the hospitals, through drug treatment centers, through the public health department, and we even... offered vaccinations at the casinos because a lot of methamphetamine users often go to places like that when they can't sleep, since those places are open in the middle of the night.

JEH: What has been the public response?

Dr. Quinlisk: Well, really, I was amazed! The response that we got from the groups, not only the public, but the media and the risk groups, as well as the risk-for-transmission groups, was very gratifying to me. Everybody basically said, "Okay, this is a problem in our community; we all have to pull together to get this taken care of." We had private companies offering to make signs saying "Wash Your Hands" for free distribution. We also had people calling in offering to help. I really feel that the community pulled together and did a great job trying to get this thing controlled. Yvan, maybe as an outsider, you might have some insight into that.

Dr. Hutin: Yes, the situation was potentially a difficult one, because we identified the people who were at higher risk of the disease as being people who used methamphetamine - especially people who injected it. Because disease in these people could be prevented by the vaccine, we really wanted to get this message across. This was not an easy one, though, because we wanted the disease prevention message to be well-understood by the public, [but we did not want people to] point to a certain group of the community and say that they were causing the outbreak. That required a lot of attention, so we worked closely with public affairs of IDPH [in developing the best message to release to the press].

Although we always had the concern that there could be some adverse effects, in that some people [might not like the idea of] funding a vaccine for injecting drug users, this did not happen. In fact, nobody complained about the program. And after the message went to the press, there was an increased turnout at the vaccination clinics. Patty, did you want to comment on the impact that the press conference had on the people coming to the vaccination clinics?

Dr. Quinlisk: Well, at the beginning of the outbreak, even though we suspected that drug use might be a risk factor, we were very concerned about that [message] getting out. This was because there was some suggestion that when similar information got out in Sioux City, the drug users stopped coming to the public clinics and getting treatment ... which potentially would make the outbreak worse. So we were concerned because we didn't want to make these people go into hiding.

JEH: You didn't want them to be afraid of being prosecuted as a result of getting vaccinated?

Dr. Quinlisk: Right, or even afraid of being identified to their family and friends as "You've got hepatitis A, so you must be a drug user." It was a fine line that we were walking to get enough information out to people so that [they would] take the right action, but not so much that [other members of the] public would say, "Well gee, I'm not a drug user, so I don't need to wash my hands or be worried about this problem." But because there was such a fine line, we didn't do the press release about the link to drug use until July, I believe it was, even though we were getting lots of publicity in June. Do you remember the exact date that we did [the press conference], Yvan?

Dr. Hutin: The press conference was July 23rd.

Dr. Quinlisk: This was a press conference with Yvan, myself, and Dr. Julius Conner, who is the director of the Polk County Health Department in Des Moines. Basically, the three of us got up there and tried to get the information across that the outbreak was still continuing. [The approach that we took was that] everybody needed to take precautions, but a particular risk group, [intravenous drug users], needed to do things above and beyond what the rest of the public needed to do. And it actually went quite well. We did not get the feeling that these people went into hiding. We did not get the feeling that people were ostracizing that group or pointing fingers at that group, or somehow blaming them for what was happening. Instead, it was taken as "Oh, okay, that group is at higher risk ... they need to do special things, but meanwhile, I Joe-public need to continue washing my hands" and that kind of thing. And I think a lot of that really had to do with the quality of the reporters that we have here. We didn't get a lot of reporters trying to sensationalize the problem. They were very concerned about getting accurate information out, and tried very hard to work with us, to make sure that the proper message got out to the public.

JEH: What made you decide to go public with the link to drug users in July?

Dr. Quinlisk: That was the point at which Yvan's study was showing that the link was not only hypothesized, but that there really truly was a link. That was the point at which we had proof of the link, rather than just thinking it existed.

JEH: Besides Dr. Julius Conner, the director of IDPH, what other local-level environmental health professionals were involved in the outbreak?

Dr. Quinlisk: Well, Bobby Baker and John Bein were the ones that I remember working with the closest. They are the environmental health people here in Polk County, and they did a lot of work - especially with the restaurant group - by putting all the training programs together. They sent things out to, I believe, every single restaurant in central Iowa, not just Des Moines, but central Iowa, telling them of the risk - telling them what the restaurants needed to do to ensure that they weren't going to become sites of transmission. When they went to restaurants and did their inspections, they did some extra things to make sure they had all the information they needed, like signs, and all of that.

JEH: Is the problem resolved now?

Dr. Quinlisk: The numbers went down last fall quite a bit, but now we are almost back up to the numbers we had last summer, and we recently had an outbreak in a school; so unfortunately, no - the problem is not over yet.

JEH: Are you continuing with the education and public awareness then?

Dr. Quinlisk: Yes, and the county health department hired a couple of extra nurses to help out with this.

JEH: Looking back, what about this incident leaves the most significant impression on your mind?

Dr. Hutin: When you have a problem among methamphetamine users, the first reaction that one could have is that "This is going to be a difficult group for me to work with, because they're not going to cooperate, and they're not preoccupied with their health ...." We can say from our experience here that we found a much higher level of cooperation than we anticipated. So in terms of the lessons learned, and future experience, I think that when you deal with a health problem in any type of community, it is important not to assume that you won't have a good response or that it's not going to work. You ought to try it and see what happens. And certainly, at least for the investigation, people were very eager to collaborate and tell us what happened, as well as what their hypotheses were about the modes of transmission. And that is remarkable.

JEH: That's really encouraging.

Dr. Hutin: Yes, and apart from the collaboration with environmental health, it might be useful to mention that this also was a study of the response, in general, to the outbreak .... It was a good example of collaboration [between] a wide variety of people .... Of course, the people from the health departments at the county, state, and federal level were all working really well together, but even the Iowa Division of Narcotics Enforcement was in the loop and kept informed. They really understood that what we were trying to do was to prevent disease, which was a different task than theirs, which was preventing the trafficking of methamphetamine. Also, Charles Larson from the governor's office usually was there [Charles, the "Drug Czar" is Coordinator of the Governor's Alliance on Substance Abuse], as well as people from all the hospitals, the substance abuse programs and the drug abuse centers. And at the county level, we even had interaction with the police. Everybody was working together to get the problem fixed.

Dr. Quinlisk: I don't think there was anybody that we felt should've been involved [who wasn't], or who should've done more but didn't do it. It really was quite amazing .... It was probably the one outbreak that I would say had the most community cohesiveness, and a "We're all going to confront this together," kind of attitude.

The thing that surprised me the most too is that people have retained their sense of humor through this whole thing, even though they have been working very hard. And believe me, there were people who put in evenings and weekends for months during the summertime. But to give you an example, one day I got a photograph sent to me that had a picture of Barney, you know the stuffed pink and purple animal, with a plate of salad on his lap and a sign behind it saying, "Dr. Quinlisk isn't afraid to eat a salad." Things like that happened. People were lighthearted, even though they were tired, and this was an incredible amount of work! That was amazing, because people can burn out pretty fast when you've got something this time-consuming hanging on for so long.

Conclusion

Although Iowa's battle against the outbreak of hepatitis A continues, the dedication of state and county environmental health professionals and nurses to control it remains strong. Community awareness of the problem, and of each person's role in stopping the outbreak, is increasing with the efforts of staff at IDPH, CDC, and other agencies involved in the crisis. Because such awareness is critical to containing the epidemic, public health officials are confident that the number of hepatitis A cases in Iowa soon will decrease to what are normally low levels in the state.

Acknowledgements

NEHA sincerely thanks Dr's. Patricia Quinlisk and Yvan Hutin for volunteering their time for this interview. Thanks are also extended to NEHA member Kevin Anderson, without whose suggestion, this interview never would have been conducted.

Patricia and Yvan wish to thank all of the county nurses involved in the outbreak for the hard work they consistently do, which includes nearly all of the footwork that is involved in following up on cases.