When Jeffrey Howard took over as Kentucky commissioner of public health in November 2017, the Eastern Kentucky native quickly came face to face with the state’s emerging health-care crisis: Hepatitis A.

“My first day on the job was November 14, and by November 20, we had declared a statewide Hepatitis A outbreak,” the 30-year-old physician and public health advocate told Rewire.News.

When the outbreak was announced, there were 31 reported cases of the disease, representing a 50 percent increase over previous years. In the 15 months since the outbreak was declared, instances of Hepatitis A have surged, with nearly 4,000 cases reported across 103 of Kentucky’s 120 counties, resulting in almost 2,000 hospitalizations and 40 deaths, primarily affecting Kentucky’s most vulnerable populations.

Hepatitis A is a communicable liver disease that causes symptoms ranging from jaundice and abdominal pain to nausea, diarrhea, and fever. The illness is typically spread through person-to-person contact or fecal contamination, which can occur when people lack access to proper sanitation or don’t take necessary health precautions like hand-washing. The disease frequently occurs within certain at-risk populations, particularly people experiencing homelessness and people using illicit drugs. In Kentucky’s outbreak at least 19 percent of cases reported no known risk factors.

And while Kentucky wasn’t the first state to experience an outbreak—California, Colorado, and Michigan were also affected in 2017—the state’s Hepatitis A outbreak is now, by far, the worst on record across the country.

“We’ve had so many cases, it’s almost an epidemic,” Boyd County Judge-Executive Steve Towler told the Lexington Herald-Leader in July 2018. Boyd County is one of a handful of counties where local officials have passed new laws requiring all food service workers be vaccinated.

The seeming relentlessness of Hepatitis A’s spread across the state can be tracked to the state’s rural-urban divide. When the outbreak was declared, it was concentrated almost exclusively in Louisville—Kentucky’s only metropolis. This meant people in other parts of the state assumed it was a city issue, not something that would reach their smaller, often more isolated communities. This belief still held true even after the Department of Public Health for Indiana—Louisville’s neighbor across the river—issued a warning in April 2018 that anyone traveling to the Kentucky Derby should get vaccinated for the disease.

“I’m from Eastern Kentucky, and there’s some tendency for people from the area to look at Louisville as its own separate entity. There’s a tendency to look at Louisville and say, ‘Well, [Hepatitis A] is there, but it’s not going to come here,’” said Kevin Hall, communications officer for the Lexington-Fayette County Health Department.

The structure of Kentucky’s public health system puts much of the responsibility for community education and awareness on overburdened, understaffed local health departments, not on the state itself.

“Kentucky’s public health structure is a shared governance model, so we’re more of a support organization and [local public health departments] are the real arms and legs of public health, making sure that locals are aware of the issues,” Howard said. “And in Louisville, Lexington, and the Northern Kentucky area, those are actually independent [public health] districts.”

With 120 counties in the state, it’s not difficult to see why preventative steps and public education campaigns vary so widely—and why it took so long for the serious nature of the outbreak to resonate. And while state officials have made efforts to bring public health officers together to share best practices and coordinate efforts in the fight against the spread of Hepatitis A, informal resource-sharing between on-the-ground public health workers has helped the most.

“I’ve seen the informational [Hepatitis A] flyer that our graphic designers created in multiple places,” says Hall. “We’ve told people [in other counties], whether it’s Hepatitis A, a needle exchange or the flu, if there’s a design that you like, we’ll be glad to share it. There’s no point in reinventing the wheel on these things. It’s also a thrill for us to go someplace and see the flyer. They just have to change their logo on it and the phone number!”

“And there are also listservs that [public health] nurse leaders in different counties have, and they communicate with each other,” said Kimberly Harris, a nurse who’s been with the Lexington-Fayette County Health Department formore than ten years. “I’m sure that people are probably using some of those, asking questions, and utilizing things that other counties have done and that have worked well.”

But despite a year’s worth of efforts, it wasn’t until September 2018—ten months after the official declaration of an outbreak—that the public began to react en masse to Hepatitis A, which many had dismissed as a problem that would affect only high-risk populations. The reason? Restaurant workers, from line cooks to fast food workers, were contracting the highly-communicable disease, causing the shutdown of well-trafficked dining establishments for decontamination.

“When we did the press announcement that there was a case where a restaurant worker had Hepatitis A [in September 2018],” says Hall, “that’s when [the public] was like, ‘OK, we’re going to start paying attention.’ There was a mass social media panic, with people saying, ‘I’m not going to eat at restaurants ever again!’”

Facebook meltdowns aside, there have been zero reported instances of Hepatitis A being contracted through contaminated food; experts say a more nuanced, thoughtful look at how the disease is spreading is needed.

“One of the questions we hear from time to time is, ‘Why are we releasing the name of the restaurant?’ Well, because it’s a public health risk,” said Hall, who notes that the health department has worked with more than 20 local restaurants and franchises to vaccinate their workers. “Somebody comes to my house, I know who’s coming into my house, but restaurants don’t have any idea who all is coming in. We have to get the message out so people can be as protected as possible.”

The continuing spread of Hepatitis A throughout the state points to an alarming fissure between public health officials and medical professionals in private practice. Despite the recommendation of those looking to stymie the spread of the outbreak through the most direct and effective means possible—vaccinating everyone in affected counties—doctors are often not offering their patients the same advice on a one-on-one level.

“At the beginning of this, we were sending people to their doctor’s offices to get this vaccine, and they were being told you don’t need it because you don’t have a risk factor,” Harris said. “Well, risk factors are kind of out the window once you hit outbreak status, so it was hard to even get them on board to think differently and just try to protect everybody. Then the restaurant thing happened. Since then, at the [Lexington-Fayette County Health Department] clinic, we’ve added dozens of appointments a day, and they all book up. But that wasn’t happening prior to [the restaurants].”

“It’s coming from medical professionals—still—that you’re not at risk because you don’t have these high-risk factors,” said Lindsey Todd, a nurse with the Lexington-Fayette County Health Department. “You’re not homeless, or you’re not injecting drugs, and some of that has been a barrier. I think it’s just getting them onboard to this new normal.”

The greatest hope for dropping the number of cases down to its pre-2017 levels now rests with Kentucky’s children. Beginning in August 2018, state law required that all public school students had received both doses of the Hepatitis A vaccine. Public health officials think this means the disease will once again become almost obsolete, thanks to preventative measures taken during childhood and the passage of time.

“I don’t work in school health so I can’t specifically speak to what their compliance rates [for getting the Hepatitis A] shot are, but I can tell you that, when I worked as a school nurse in a different county, most children were vaccinated,” says Harris, who notes that the American Academy of Pediatrics has been recommended the Hepatitis A vaccine as part of routine shots for more than a decade. “The fact that that [new state] regulation went in place is just great. I mean, it’s amazing that it was timed so well with this. That’s the one thing that we have not had: We’ve not had a bunch of really sick children.”

Meanwhile, a pair of state senators from Eastern Kentucky introduced legislation last week to allow the Kentucky Fire Commission to pay for Hepatitis A vaccines for older firefighters who may not be able to afford it on their own.

“With the outbreak and recurring spread of Hepatitis A in [Kentucky], firefighters from Harlan County approached me with concerns that some older firefighters have not had the Hepatitis A vaccine,” Democratic state Sen. Johnny Ray Turner told the local NBC affiliate. “Seeing the merit in their concerns, I looked into it and agreed that there was a need to provide the second vaccine. This is a safety and preventive measure.”

As the number of Hepatitis A cases continues to climb, health advocates aim to continue reinforcing through outreach and educational campaigns that public health is a community-wide issue—not something that only affects a certain portion of the population. To stop an outbreak, everyone should play a part.

“I’m hoping that in 2019, we can see a downward trend,” Howard said. “I was raised in [rural] Harlan, Kentucky, so it certainly makes my viewpoint a little different. The fact that outbreaks tend to effect rural Kentucky worse doesn’t surprise me. Lots of places in these communities have had to lessen their clinical staff [due to budget cuts], so they don’t have as many people available to respond to outbreaks. And then in those same places, they’re also already in the middle of a flu season and not well-supplied with workers. But I think, eventually, we can get it back down to under 20 cases a year.”

In Lexington, Hall is cautiously optimistic. “I’m hoping that this time next year, we’re talking about a different issue entirely.”