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Brief Description of Outbreak: In November 2017, the Kentucky Department for Public Health (DPH) identified an outbreak of acute hepatitis A. The increase in cases observed in Kentucky was well over the 10-year average of reported hepatitis A cases, and several cases have been infected with hepatitis A virus (HAV) strains genetically linked to outbreaks in California, Utah, and Michigan. Similar to hepatitis A outbreaks in other states, the primary risk factors have been illicit drug use and homelessness. A contaminated food source has not been identified, and HAV transmission is believed to have occurred through person-to-person contact. Below is a weekly and cumulative update on the outbreak. Please note that all data is preliminary and subject to change as additional reports are received. In accordance with 902 KAR 2:020, cases of acute hepatitis A should be reported within 24 hours. The case definition used for outbreak-associated acute hepatitis A cases is available upon request. Unless otherwise noted, all data are reported by date of specimen collection.

Table 1: Summary of Outbreak-Associated Acute Hepatitis A Cases*

* Cases are reported based on date of specimen collection.

^ Cases are generally confirmed weeks after submission for testing, so will only be reflected in total case counts.

† Deaths are defined as any outbreak-associated acute hepatitis A case with documentation of hepatitis A as a contributing

factor to the individual’s death. #

One of the deaths being reported this week was identified through periodic death record review. Weekly death counts may

appear artificially high due to delays in death certification.

Update for Week 39: Total Case Counts: 8/1/2017 – 9/28/2019:

Number of new cases (n=2):

Confirmed^ - 0

Probable - 1 Suspected - 1

Total number of cases (n=4943):

Confirmed^ - 841

Probable - 2749 Suspected - 1353

Number of counties with new cases:

2

Total number of counties with cases:

114 (95% of KY counties)

Number of individuals with specimens submitted for genotyping where results are available:

0

Number of individuals with specimens submitted for genotyping where results are available:

885 (18%)

Number of cases with genotype IB among those with genotype testing:

0 Total number of cases with genotype IB among those with genotype testing:

824 (93% of those tested)

Number of Hospitalizations:

2 Total Number of Hospitalizations:

2381 (48%)

Number of deaths

Reported†:

0 Total number of deaths

reported†:

61 (1.2%)

Kentucky Department for Public Health KY17-089 - Acute Hepatitis A Outbreak Weekly Report

Morbidity and Mortality Weekly Report (MMWR) Week 39, 2019 September 22, 2019 – September 28, 2019

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Table 2: Cumulative Distribution of Cases by County

KY17-089 Distribution Of Outbreak-Associated Acute Hepatitis A Cases,

by County, August 1, 2017 – September 28, 2019*^#

County Total number of

cases reported

Number of

confirmed

cases

Number of

probable

cases

Number of

suspected

cases

Incident Rate

per 100,000

population

Adair 4 0 3 1 20.5

Allen 46 8 28 10 219.7

Anderson 25 0 18 7 110.9

Ballard 12 4 5 3 149.3

Barren 16 1 15 0 36.5

Bath 37 3 13 21 298.9

Bell 70 18 31 21 260.3

Boone 65 8 34 23 49.7

Bourbon 13 0 10 3 64.9

Boyd 176 104 44 28 366.8

Boyle 31 0 18 13 103.6

Bracken 6 0 4 2 72.6

Breathitt 30 1 22 7 231.7

Bullitt 64 32 23 9 79.8

Butler 11 2 5 4 85.7

Calloway 1 0 0 1 2.6

Campbell 69 3 56 10 74.6

Carlisle 1 0 1 0 20.6

Carroll 13 2 7 4 121.3

Carter 127 46 60 21 467.9

Casey 14 1 9 4 88.9

Christian 81 27 47 7 115.0

Clark 93 0 57 36 258.0

Clay 82 1 37 44 402.6

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KY17-089 Distribution Of Outbreak-Associated Acute Hepatitis A Cases,

by County, August 1, 2017 – September 28, 2019*^#

County Total number of

cases reported

Number of

confirmed

cases

Number of

probable

cases

Number of

suspected

cases

Incident Rate

per 100,000

population

Clinton 13 2 9 2 126.5

Crittenden 2 0 1 1 22.0

Cumberland 2 0 2 0 29.8

Daviess 4 0 2 2 4.0

Edmonson 1 0 1 0 8.2

Elliott 24 4 4 16 319.0

Estill 26 1 20 5 182.1

Fayette 205 5 149 51 63.7

Fleming 4 0 0 4 27.7

Floyd 146 5 78 63 402.5

Franklin 58 1 43 14 114.9

Gallatin 9 3 4 2 102.6

Garrard 20 0 13 7 114.1

Grant 43 3 34 6 172.1

Graves 1 0 0 1 2.7

Grayson 30 2 25 3 113.8

Green 3 0 3 0 27.1

Greenup 62 31 19 12 174.6

Hardin 41 10 10 21 37.9

Harlan 42 17 15 10 157.2

Harrison 28 0 17 11 149.1

Hart 2 0 2 0 10.7

Henderson^ 1 1 0 0 2.2

Henry 13 3 8 2 81.2

Hickman 1 0 0 1 22.1

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KY17-089 Distribution Of Outbreak-Associated Acute Hepatitis A Cases,

by County, August 1, 2017 – September 28, 2019*^#

County Total number of

cases reported

Number of

confirmed

cases

Number of

probable

cases

Number of

suspected

cases

Incident Rate

per 100,000

population

Hopkins 64 32 17 15 140.5

Jackson 22 1 11 10 163.8

Jefferson 661 312 235 114 85.7

Jessamine 62 0 40 22 116.2

Johnson 81 1 45 35 358.5

Kenton 124 14 90 20 75.0

Knott 38 2 24 12 248.5

Knox 108 7 66 35 345.9

Larue 3 0 1 2 21.1

Laurel 224 5 164 55 372.3

Lawrence 35 4 20 11 222.7

Lee 36 3 31 2 547.9

Leslie 38 1 32 5 367.7

Letcher 21 5 13 3 94.0

Lewis 26 0 15 11 194.9

Lincoln 38 2 24 12 155.4

Livingston 2 0 0 2 21.6

Logan 2 0 2 0 7.4

Madison 148 3 99 46 162.2

Magoffin 54 1 32 21 430.7

Marion 23 1 17 5 118.6

Marshall 3 0 1 2 9.6

Martin 41 0 29 12 358.0

Mason 26 0 17 9 151.4

McCracken 15 4 6 5 22.9

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KY17-089 Distribution Of Outbreak-Associated Acute Hepatitis A Cases,

by County, August 1, 2017 – September 28, 2019*^#

County Total number of

cases reported

Number of

confirmed

cases

Number of

probable

cases

Number of

suspected

cases

Incident Rate

per 100,000

population

McCreary 29 1 19 9 166.0

Meade 12 1 1 10 42.6

Menifee 18 1 11 6 278.9

Mercer 41 1 25 15 190.5

Metcalfe 2 0 1 1 19.8

Monroe 2 1 0 1 18.8

Montgomery 94 9 62 23 336.6

Morgan 23 1 18 4 174.4

Muhlenberg 4 2 0 2 13.0

Nelson 19 4 6 9 41.6

Nicholas 2 0 0 2 28.1

Ohio 7 0 4 3 28.9

Oldham 18 4 9 5 27.1

Owen 13 0 11 2 120.8

Owsley 12 0 9 3 270.6

Pendleton 29 3 18 8 199.0

Perry 89 3 63 23 335.2

Pike 84 3 60 21 142.7

Powell 51 2 30 19 412.2

Pulaski 95 0 62 33 147.4

Robertson 1 0 1 0 46.9

Rockcastle 26 0 16 10 155.7

Rowan 49 5 28 16 199.9

Russell 3 0 2 1 16.9

Scott 31 0 20 11 56.5

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KY17-089 Distribution Of Outbreak-Associated Acute Hepatitis A Cases,

by County, August 1, 2017 –September 28, 2019*^#

County Total number of

cases reported

Number of

confirmed

cases

Number of

probable

cases

Number of

suspected

cases

Incident Rate

per 100,000

population

Shelby 27 10 14 3 56.9

Simpson 10 3 6 1 55.2

Spencer 8 3 4 1 43.2

Taylor 50 2 35 13 196.3

Todd 1 1 0 0 8.2

Trigg 4 2 2 0 27.7

Trimble 3 2 0 1 35.0

Union 2 0 1 1 13.6

Warren 44 10 25 9 34.1

Washington 9 0 6 3 74.2

Wayne 21 1 10 10 101.4

Webster 6 4 2 0 46.1

Whitley 201 15 103 83 555.0

Wolfe 26 0 18 8 357.9

Woodford 14 0 10 4 53.1

Total Number of Cases: 4943 841 2749 1353 111.0

* Cases are reported based on date of specimen collection.

^ Denotes a county where cases have not been previously identified.

# As genotyping results become available, cases may be excluded if they do not meet the outbreak case definition. Cases in

the following counties have been excluded from the outbreak case count this week: Jefferson.

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Figure 1: Hepatitis A Vaccine Doses Administered, Public Health Versus All Other Providers, as Reported to the Kentucky

Immunization Registry

0

5000

10000

15000

20000

25000

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35000

40000

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KY17-089 Adult Hepatitis A Vaccine Administered by Local Health Department Versus All Other Providers as Reported to KYIR, November 1, 2017 - September 28, 2019

Local Health Dept All Other Providers

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Figure 2: Geographic Distribution of Outbreak-Associated Cases by County

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Figure 3: Incidence of Outbreak-Associated Cases by County

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Figure 4: Incidence and Distribution of Outbreak-Associated Cases in the Last 30 Days, by County

*Case count for the last 30 days is displayed beside county name. Statewide outbreak-associated case count over the last 30 days is 23.

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Figure 5: Outbreak-Associated Cases by Age

*The mean age of cases is 37.6 years, and the median age is 36.0 years.

Table 3: Frequent Risk Factors of Outbreak-associated Cases

KY17-089 Risk Factors of Outbreak-Associated Acute

Hepatitis A Cases, August 1, 2017 – September 28, 2019#^

Risk Factor

Number of Cases

Reporting Risk Factor

(n=3967)*

Homelessness + No/Unk Illicit Drug Use 57 (1.4%)

Illicit Drug Use + No/Unk Homelessness 2851 (72%)

Homelessness + Illicit drug use 304 (7.7%)

No Outbreak-Related Risk Factors 755 (19%)

* Risk factor information is unavailable for 976 (19.7%) of all outbreak-associated cases.

# The percentages in the table may add up to greater than 100 percent due to rounding.

^ 38 MSM cases have been reported. Of those, 12 have reported no other risk factors. MSM is not considered an

outbreak-related risk factor.

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Age Range (years)*

KY17-089 Outbreak-Associated Cases of Acute Hepatitis A in Kentucky, by Age, August 1, 2017 - September 28, 2019

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Figure 6: Epidemic-curve (Epi-Curve) of Outbreak-Associated Cases, by Week of Specimen Collection

1 1 1 1 2 2 4 2 3 5 3 5 5 4 5 5 6 4 4

8

3

128

109

22

24

18

29

29

53

43

47

59

57

46

69

57

54

83

67

68

66

78

60

64

58

58

68

89

72

78

79

85

80

91

105

114

114

110

120

153

112

123

109

130

93

131

97

112 109

108

79

95

83 95

62

61

46

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53

41

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40

41

25

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27

23

15

24

11

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21

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20

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12

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64

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60

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120

140

160

180

Au

g 0

6 -

Aug 1

2 (

32)

Au

g 2

0 -

Aug 2

6 (

34)

Se

p 0

3 -

Sep 0

9 (

36)

Se

p 1

7 -

Sep 2

3 (

38)

Oct 01 -

Oct 07 (

40)

Oct 15 -

Oct 21 (

42)

Oct 29 -

Nov 0

4 (

44)

Nov 1

2 -

Nov 1

8 (

46)

Nov 2

6 -

Dec 0

2 (

48)

Dec 1

0 -

Dec 1

6 (

50)

Dec 2

4 -

Dec 3

0 (

52)

Jan

07 -

Jan 1

3 (

02)

Jan

21 -

Jan 2

7 (

04)

Fe

b 0

4 -

Fe

b 1

0 (

06)

Fe

b 1

8 -

Fe

b 2

4 (

08)

Ma

r 4 -

Mar

10 (

10)

Ma

r 18

- M

ar

24 (

12)

Ap

r 01 -

Apr

07 (

14)

Ap

r 15 -

Apr

21 (

16)

Ap

r 29 -

May 0

5 (

18)

Ma

y 1

3 -

Ma

y 1

9 (

20

)

Ma

y 2

7 -

Jun 0

2 (

22)

Jun

10 -

Jun 1

6 (

24)

Jun

24 -

Jun 3

0 (

26)

Jul 08 -

Jul 14 (

28)

Jul 22 -

Jul 28 (

30)

Au

g 0

5 -

Aug 1

1 (

32)

Au

g 1

9 -

Aug 2

5 (

34)

Se

p 0

2 -

Sep 0

8 (

36)

Se

p 1

6 -

Sep 2

2 (

38)

Se

p 3

0 -

Oct 06 (

40)

Oct 14 -

Oct 20 (

42)

Oct 28 -

Nov 0

3 (

44)

Nov 1

1 -

Nov 1

7 (

46)

Nov 2

5 -

Dec 0

1 (

48)

Dec 0

9 -

Dec 1

5 (

50)

Dec 2

3 -

Dec 2

9 (

52)

Jan

06 -

Jan 1

2 (

02)

Jan

20 -

Jan 2

6 (

04)

Fe

b 0

3 -

Fe

b 0

9 (

06)

Fe

b 1

7 -

Fe

b 2

3 (

08)

Ma

r 03

- M

ar

09 (

10)

Ma

r 17

- M

ar

23 (

12)

Ma

r 31

- A

pr

6 (

14)

Ap

r 14 -

Apr

20 (

16)

Ap

r 28 -

May 0

4 (

18)

Ma

y 1

2 -

Ma

y 1

8 (

20

)

Ma

y 2

6 -

Jun 0

1 (

22)

Jun

09 -

Jun 1

5 (

24)

Jun

23 -

Jun 2

9 (

26)

Jul 07 -

Jul 13 (

28)

Jul 21 -

Jul 27 (

30)

Au

g 0

4 -

Aug 1

0 (

32)

Au

g 1

8 -

Aug 2

4 (

34)

Se

p 0

1 -

Sep 0

7 (

36)

Se

p 1

5 -

Sep 2

1 (

38)

Se

p 2

9 -

Oct 05 (

40)

Oct 13 -

Oct 19 (

42)

Nu

mb

er

of

Cas

es

MMWR Week*

KY17-089 Epi-Curve of Outbreak-Associated Cases by MMWR Week, August 1, 2017 - September 28, 2019

13

Figure 7*: Epidemic-curve (Epi-Curve) of Outbreak-Associated Cases, by Month of Specimen Collection

*Note: As of the report ending July 6, 2019, this figure will be based on date of specimen collection rather than date of onset to be consistent with other figures.

0

100

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400

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600

Jun

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Jul 17

Au

g 1

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Se

p 1

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Oct 17

Nov 1

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7

Jan

18

Fe

b 1

8

Ma

r 18

Ap

r 18

Ma

y 1

8

Jun

18

Jul 18

Au

g 1

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Se

p 1

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Oct 18

Nov 1

8

Dec 1

8

Jan

19

Fe

b 1

9

Ma

r 19

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r 19

Ma

y 1

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Jul 19

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g 1

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Oct 19

Nov 1

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mb

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of

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es

Month of Specimen Collection*

KY17-089 Epi-Curve of Outbreak-Associated Cases by Month of Specimen Collection, August 1, 2017 -September 28, 2019 (Current month shown in gold - case counts are not complete)

14

Figure 8: Case Count Comparison of Acute Hepatitis A cases, Jefferson County versus Non-Jefferson Counties

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20

40

60

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120

140

160

Jul 2

9 - A

ug 0

5 (3

1)

Au

g 2

0 - A

ug

26

(34)

Se

p 1

0 - S

ep

16

(37)

Oct 0

1 - O

ct 0

7 (4

0)

Oct 2

2 - O

ct 2

8 (4

3)

No

v 1

2 - N

ov 1

8 (4

6)

De

c 0

3 - D

ec 0

9 (4

9)

De

c 2

4 - D

ec 3

0 (5

2)

Jan

14

- Ja

n 2

0 (0

3)

Fe

b 0

4 - F

eb 1

0 (0

6)

Fe

b 2

5 - M

ar 3

(09

)

Ma

r 18 - M

ar 2

4 (1

2)

Ap

r 08

- Apr 1

4 (1

5)

Ap

r 29

- Ma

y 0

5 (1

8)

Ma

y 2

0 - M

ay 2

6 (2

1)

Jun

10

- Ju

n 1

6 (2

4)

Jul 0

1 - J

ul 0

7 (2

7)

Jul 2

2 - J

ul 2

8 (3

0)

Au

g 1

2 - A

ug

18

(33)

Se

p 0

2 - S

ep

08

(36)

Se

p 2

3 - S

ep

29

(39)

Oct 1

4 - O

ct 2

0 (4

2)

No

v 0

4 - N

ov 1

0 (4

5)

No

v 2

5 - D

ec 0

1 (4

8)

De

c 1

6 - D

ec 2

2 (5

1)

Jan

06

- Ja

n 1

2 (0

2)

Jan

27

- Feb

02 (0

5)

Fe

b 1

7 - F

eb 2

3 (0

8)

Ma

r 10 - M

ar 1

6 (1

1)

Ma

r 31 - A

pr 0

6 (1

4)

Ap

r 21

- Apr 2

7 (1

7)

Ma

y 1

2 - M

ay 1

8 (2

0)

Jun

02

- Ju

n 0

8 (2

3)

Jun

23

- Ju

n 2

9 (2

6)

Jul 1

4 - J

ul 2

0 (2

9)

Au

g 0

4 - A

ug

10

(32)

Au

g 2

5 - A

ug

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(35)

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p 1

5 - S

ep

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(38)

Oct 0

6 -O

ct 1

2 (4

1)

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MMWR Week

KY17-089 Outbreak-Associated Acute Hepatitis A Cases, by Date of Specimen Collection, August 1, 2017 to September 28, 2019

Jefferson

Non-Jefferson

15

Figure 9: Epidemic-Curve (Epi-Curve) of Outbreak-Associated Cases in County with at least Five Reported Cases in the Last 30

days, by Month of Specimen Collection (Hopkins County)

0

2

4

6

8

10

12

14

16

18

Jul 17

Au

g 1

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r 18

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Jun

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Jul 18

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Oct 19

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Month of Specimen Collection*

KY17-089 Epi-Curve of Outbreak-Associated Cases by Month of Specimen Collection, Hopkins

County, August 1, 2017 - September 28, 2019