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KBIA’s Health & Wealth Desk covers the economy and health of rural and underserved communities in Missouri and beyond. The team produces a weekly radio segment, as well as in-depth features and regular blog posts. The reporting desk is funded by a grant from the University of Missouri, and the Missouri Foundation for Health.Contact the Health & Wealth desk.

HepA Memes? Bootheel Officials Look Beyond Traditional Strategies to Address Outbreak

Rebecca Smith
Many factors have made the hepatitis A outbreak in southeast Missouri hard to mitigate. These include a temporary shortage of vaccine, rural homelessness and drug use.

Poplar Bluff, Missouri, is located deep in the southeastern part of the state, in the area known as the Bootheel. One resident joked to me that if something bad is going to happen in Missouri, “it’s gonna happen here.”

It’s also the location of an on-going hepatitis A outbreak. As of March 4, there have been 266 cases of hepatitis A identified throughout southeast Missouri. Nearly 50 percent of those cases have led to hospitalizations and there has been one associated death. 

I traveled down to Poplar Bluff late last July to meet with Whitney Preslar, the communicable disease nurse for the Butler County Health Department. We had been talking for several weeks about the hepatitis A outbreak that had been going on in her community since late 2017.

She leads weekly meetings at the health department to update staff on the number of active cases and the hospitalization rates, as well as to strategize on how they can further educate and vaccinate people. 

Hepatitis A is similar to its better-known siblings, hepatitis B and C. They are all viruses that cause inflammation of the liver, but the transmission method is different. Hepatitis B and C are transmitted by bodily fluids like blood – think intravenous drug use or shared needles, and hepatitis A is transmitted via the fecal-oral route.

“Hepatitis A is primarily spread through the stool of infected individuals,” said John Bos, the assistant bureau chief for the Bureau of Communicable Disease Control and Prevention with the Missouri Department of Health and Senior Services

Basically, tiny fecal matter particles on someone’s hand get on shared objects and are inadvertently consumed.

When I first visited in July, there had been 97 cases in Butler County and 161 throughout all of southeast Missouri. Preslar said that of those cases, 60 percent identified as drug users and 21 percent as close personal contacts.


“That seems to be the most predominant population that we're seeing it in,” Preslar said, “so again, that's our target population with the vaccine. We're trying to get them in here and get them protected so that we can stop the spread of this and it doesn't spill over into the general population and we go from 97 to 500 cases overnight – because we don't want that.”

Preslar added that of the self-identified drug users, more than 60 percent said they use methamphetamine only, which has led to some confusion as some drug users might think that as long as they aren’t sharing needles, they’re safe.

Another complicating factor is that some members of the at-risk population are without homes, which in a rural area means couch surfing. This can make them hard to find.

So, Preslar said the health department has had to get creative. She works with the health inspectors to set up screening and vaccinations in area restaurants where the at-risk population may work. She created a Facebook page for the health department to can better inform the community. They post weekly updates and use a lot of memes.

Credit Butler County Health Department Facebook Page / Butler County Health Department
Butler County Health Department
The health department uses memes and other references to popular culture to update and educate the community on the hepatitis A outbreak and the hepatitis A vaccine.

They also created a code word of sorts for people who may be scared of perceived legal ramifications if they come in and ask for help.

“Somebody in our group came up with Frank,” Preslar said. “We wanted a code word so somebody could walk into the lobby and just tell our receptionist, ‘Hey, Frank sent me,’ and the receptionist would know exactly what they were talking about. They would just hand them the paperwork and they would directly go back to the nurse and talk to them and answer questions back there.”

The health department has also partnered with behavioral health and treatment centers because they engage with the at-risk population directly. Southeast Missouri Behavioral Health is located in an old bank, and nurse Janna Nicholson said it makes sense for them to talk about vaccination and provide the hepatitis A vaccine to their clients.

“We’re kind of like front line in the war here,” Nicholson said. “One-on-one, as they’re sitting here with me, I can start talking to them about it. Trying to convince them how important it is to get that vaccine.”

Nicholson showed me the temperature-controlled fridge where they store the vaccine and said the Centers for Disease Control and Prevention actually updated their vaccine recommendations to deal with a shortage of hepatitis A vaccine.

According to the CDC, instead of always needing two doses of the vaccine, “concern about loss to follow-up before hep A vaccine series completion should not be a deterrent to initiating the vaccine series in persons experiencing homelessness. One dose of hep A vaccine provides personal protection and can contribute to herd immunity.”

While the vaccine manufacturer has been keeping up with demand since the summer, John Bos said, originally, it was difficult for organizations to get the vaccine.

“Early on with the outbreaks occurring in many states, there was a sudden increase in demand for hepatitis A vaccine, which did result in some concerns over vaccine shortage,” Bos said. 

There were 592 cases in an outbreak in San Diego County, and there’s an active outbreak in Michigan with 913 cases, as of March 6. But those are big areas with large populations.

“We have not seen the numbers of cases maybe reported in some states,” Bos said. “Predominately due to [them being] highly populated areas versus the outbreak in Southeast Missouri is in more of a rural area.”

Bos added that the vaccine manufacturer, the CDC and the Missouri Department of Health and Senior Services are all ‘continuing to watch as we continue to see outbreaks in the United States.”

It’s been months since I first visited the Health Department in Poplar Bluff, and there have only been a few more cases in Butler County – up to 107. But there are now 266 cases throughout 18 counties in Southeast Missouri and one death.

Preslar said Butler County hasn’t seen any new cases since the end of November, “knock on wood.”

She added that while an outbreak could be declared over after give or take 100 days with no new cases, due to the continued presence of hepatitis A in the region – they have no plans to stop vaccination or education efforts anytime soon because, as she put it, “there’s still more work to be done.”

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