The hepatitis A virus causes liver infection. Cases are on the rise in North Carolina. Centers for Disease Control.

Overshadowed by the novel coronavirus pandemic, North Carolina health departments struggle to combat a smaller, yet still deadly outbreak: hepatitis A.

According to the national Centers for Disease Control and Prevention, an outbreak in North Carolina began on Jan. 1, 2018, resulting in 855 cases. Nearly two-thirds of those resulted in hospitalizations, with 13 deaths reported.

The viral disease affects the liver and may cause abdominal pain, fatigue, nausea, and jaundice, according to the CDC.

Case numbers vary wildly across the state.

Cumberland County reported only one case, a rate of 0.3 per 100,000 population. At the other end of the spectrum, Burke County reported 59 cases, a rate of 65.2 cases per 100,000 population.

Most cases are in the Piedmont and western part of the state.

While food- and water-related outbreaks can and do occur, in the United States individuals transmit most cases to one another.

In Catawba County, 67 reported cases have occurred since the outbreak started, a rate of 42 per 100,000 population.

“Cases of hepatitis A are not unique to Catawba County, and there is an uptick both nationwide and statewide in hepatitis A cases,” said Emily Killian, community engagement specialist for Catawba County Public Health.

“Statewide, this broad uptick has been associated with person-to-person transmission, especially among three groups at increased risk: people who use drugs; people who are experiencing homelessness; and men who have sex with men,” she said.

“In Catawba County, people experiencing homelessness and people who use drugs are at the highest risk and account for the majority of our cases. However, these are not the only individuals who have been affected.”

Causes of the increase

Some counties saw numbers climb in 2020 and 2021.

“Since COVID, Burke County has seen an increase in drug use, as well,” said Ashley Jarrett, a communicable disease nurse at the Burke County Health Department. Jarrett cited a possible “correlation between the two, but we just noticed that trend.”

In Catawba, just more than half of the 67 cases reported since April 2018 occurred last year alone.

“Catawba County experienced a dramatic increase in cases in 2020,” Killian said. “In 2018 and 2019, we received one report of acute hepatitis A each year; in 2020, we received 34 reports.”

Gaston County also saw a spike, with 33 reported cases in the county from 2018-20. 

As of June 9, Gaston had a total of 78 cases (a rate of 34.7 per 100,000) since 2018, according to state data.

“We’ve really never seen anything like this,” Ellen Wright, communicable disease supervisor for the Gaston County Health Department, said in a press release from the county in May.

“The case numbers are the highest we’ve seen and continue to climb. While our homeless population, incarcerated individuals and those using drugs are the most impacted right now, it only takes one person working in a restaurant or other public-facing industry to cause a large-scale community outbreak. We have to do everything we can to get high-risk individuals vaccinated so we can prevent the spread.”

In Caldwell County, there had been another four cases as of July 1, bringing the numbers to 42 since April 1, 2018, according to Anna Martin, public health director for the Caldwell County Health Department. The county rate was at least 46 per 100,000 population.

“The majority of our hepatitis cases involve individuals involved in substance abuse, specifically methamphetamines,” Martin said Thursday.

“We find that many of our positive cases are hesitant to discuss circumstances of exposure and potential contacts to this illness, which delays or prevents vaccine prophylaxis.”

The problem isn’t just limited to North Carolina.

As of Friday, 26 states are experiencing outbreaks, according to the CDC. Another nine had a “declared end” to the outbreak; reported end dates ranged from April 11, 2018, through as recently as Feb. 1 of this year.

All 35 states have seen a total of 39,903 reported cases since the official start of the outbreaks, which vary by state, with 24,305 hospitalizations and 376 cases ending in death.

Fighting back

Individuals who fall into high-risk groups for the disease can often receive free vaccinations.

“The state has allocated free hep A vaccinations,” Jarrett said.

“It’s one vaccine that provides 95% protection against hepatitis A virus for those who have not already contracted the hepatitis A virus and meet either drug use (can be either injection or noninjection), is experiencing forms of homelessness or unstable living situation, men who have sex with men, or they’re in a contact with a confirmed hep A exposure.”

In Burke, the health department offered a vaccine as well as other forms of prevention. It works with other organizations to help distribute the vaccine.

“And then anytime we are going out, we’re bringing all of our education on who’s at risk, who qualifies (for the free vaccine) and what you can do to prevent (hepatitis A),” Jarrett said.

“And then, in the sense of homelessness, we are going to go to the shelters and offer the free vaccines there and also talk to them, particularly about hygiene and how to prevent it.”

Jarrett said she has noticed what seems to be a hesitancy from some individuals to approach health care providers with problems.

Health department officials have to meet possible patients where they are, she said.

In May, Burke had a rate of 63 per 100,000 population, according to Jarrett. The rate was 65.2 as of June 9.

With vaccines now widely available for COVID-19, Jarrett hopes Burke can focus more on hepatitis A.

“COVID took a lot of our resources for a long time,” Jarrett said.

“Unfortunately, we did not have a tremendous amount of manpower to address vaccinating heavily in the community. We still offered (it to) anyone who wanted to come in and get vaccinated.”

In Caldwell, the county has also reached out to the community through local partnerships.

“Caldwell County has provided hepatitis A vaccine clinics at Leo’s Place (homeless shelter in Lenoir), Caldwell House (Substance Abuse Recovery Facility), and our Lenoir Soup Kitchen,” Martin said via email.

In Catawba, Killian said part of the increase may be due to greater detection.

“Catawba County’s increased rate is multifactoral,” Killian said via email.

“A few factors that could be in play include enhanced testing, as Catawba County has a robust drug user health program, and clusters that are based on group dynamics within at-risk populations. In response, we have encouraged people in these increased-risk groups to receive hepatitis A vaccinations, which are offered at no charge to individuals in these groups.”

Catawba used partnerships to reach marginalized communities.

“Our strategy has been to collaborate with and work through community organizations and individuals who are trusted in these sometimes hard-to-reach communities,” Killian said.

The department also “convened a local hepatitis coalition that includes infectious disease providers, substance use treatment providers, syringe exchange and other key stakeholders to address rising hepatitis case numbers,” Killian said. 

“Our adult health clinic screens individuals for increased risk and refers them for vaccination if needed,” Killian added.

“We have also taken an extra precaution of sharing information with child care providers who change diapers because this is also a way hepatitis A can spread in a community.”

Recognizing the signs

While the reported rate of infection climbed in North Carolina, it is impossible to know how many cases of hepatitis A are never reported.

“Most of the hepatitis A cases I have investigated complain of nausea, vomiting and severe right upper quadrant abdominal pain,” said Martin, the public health director in Caldwell.

While some individuals may need hospitalization, she said, most recover at home, making tracking the virus more difficult.

Since the symptoms can be similar to those of many other illnesses, Jarrett said, some may not seek treatment if they confuse their illness with the flu or a stomach bug.

For those who are at risk, prevention is key.

While the vaccine offers strong protection, outreach is one of the key tools in slowing the outbreak, Jarrett said.

“I have noticed … that going out into the community and becoming approachable and showing your face and building rapport with those who are at risk has definitely relieved some of that barrier for them to reach out to us,” she said.

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Imari Scarbrough is a contributing writer to Carolina Public Press. Email her at