Academic journal article Journal of Environmental Health

Fecal Percutaneous Transmission of Hepatitis A Involving Methamphetamine Users in Iowa

Academic journal article Journal of Environmental Health

Fecal Percutaneous Transmission of Hepatitis A Involving Methamphetamine Users in Iowa

Article excerpt

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.


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. …

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