Kentucky’s hepatitis A outbreak is the nation’s worst, sickening nearly 4,000 and killing 40 by February 2019.
Nikki Boliaux and Michael Clevenger and Chris Kenning, Louisville Courier Journal
Kathy Sanders worried she might lose her job last summer when she told high-ranking government officials that Kentucky’s response to its raging hepatitis A outbreak was “too little, too late.”
But the state’s hepatitis coordinator decided she was willing to take that risk, because too many people were getting sick and dying from the highly infectious virus.
In emails and meetings last summer, Sanders issued a warning to the secretary of the Cabinet for Health and Family Services, the cabinet’s general counsel and the governor’s office: The state must be more aggressive in tackling the outbreak.
She also detailed her concerns about the new public health commissioner, Dr. Jeffrey Howard, saying he lacked experience to handle the crisis. And she described how he rejected the recommendations of a veteran infectious disease chief who urged an aggressive, $10 million vaccination response as the liver disease began sweeping into Appalachia.
But state officials took no action in response to Sanders’ concerns as the virus spread through the Eastern Kentucky mountains, exploding into the nation’s largest outbreak. It ultimately spread to 103 of the state’s 120 counties, with 43 people dead and 4,229 sick.
Read more:Who is the nurse who blew the whistle on Kentucky’s hepatitis A response?
Sanders is angered by the state’s lack of action to her warnings.
“Those are people’s lives,” Sanders told the Courier Journal after resigning Feb. 22 from her job as adult viral hepatitis prevention and control program coordinator. “This hep A. It’s ugly. It’s dirty. But someone’s got to focus on it and handle it. …
“Heads need to be rolling. The people in the commonwealth need to be outraged.”
Our investigation:Kentucky’s ‘too low and too slow’ response to nation’s worst hepatitis A outbreak
‘How many more people are going to die?’
The Courier Journal is investigating the state’s response to the outbreak after it swept through Appalachia starting last spring, spread largely by drug users and the homeless, who are especially vulnerable to severe illness.
A story published Feb. 21 found that Dr. Robert Brawley, former chief of the state health department’s infectious disease branch, recommended in May 2018 an aggressive response to combat the outbreak, including $6 million for vaccines and $4 million for temporary workers in thinly staffed local health departments.
He also called for a public health emergency declaration to help pave the way for federal assistance.
Instead, Howard, acting commissioner of the Department for Public Health at the time, sent $2.2 million in state funds to local health departments. He also declined to declare an emergency.
Story continues below gallery
Kentucky health leaders criticize Courier Journal’s hepatitis A investigation but support agency review
Support our journalism
The Courier Journal interviewed Kentucky health department insiders as well of dozens of public health officials and experts in its investigation into the state’s deadly spread of hepatitis A. It analyzed reams of reports and health statistics, obtained emails and documents and spoke with survivors and families of those who died in the nation’s largest outbreak.
Emails outline Sanders’ concerns
Sanders, 55, worked under Brawley in the health department’s infectious disease branch for seven years. She worked closely with him and mainly dealt with hepatitis C, but offered input and went to meetings on hepatitis A and wrote a federal grant that ended up funding $70,000 worth of hepatitis A vaccine.
Sanders wrote a hepatitis newsletter shared with 4,000 people, including people at the U.S. Centers for Disease Control and Prevention. She volunteers for the Kentucky Rural Health Association as the hepatitis team leader and has spoken about the disease across the country.
Last year, the CDC contacted Sanders and Brawley about highlighting their work on hepatitis B and C. They also were invited by the National Liver Alliance to participate in a multistate collaborative in West Virginia.
Yet, despite her credentials, when Sanders expressed her concerns to Kentucky’s high-ranking state officials, they ignored her warnings.
Sanders emailed Meier on July 1, with a subject line that read: “KY DPH-A story of too little, too late.” Meier had been in the role less than two months and was the third person to hold the position during the outbreak that was declared in November 2017.
In the email, Sanders told Meier she was taking “a great risk in writing this letter, as you may decide to terminate me from my current position.”
She mentioned in the email that she had voted for Bevin and was “excited to see a new administration come in,” but that she was shocked by Howard’s appointment because she said he lacked experience both in public health and as a physician.
Hal Rogers:‘Serious alarm bells were not heeded’ on Kentucky’s hepatitis A outbreak
Howard, 31, received his Kentucky medical license in June 2018.
Brawley, 72, has been a doctor since 1975 and holds specialized degrees in epidemiology and infection control. He resigned in June, and Sanders said in the email that he was “walked out of the building in the middle of an outbreak.”
A letter obtained by the Courier Journal shows that Brawley was told on June 4, 2018, that his services were no longer needed, and that the action was being taken without cause.
Brawley was given the option to resign, and his resignation letter said he was “extremely proud of my more than 12 years of service. …” Brawley confirmed in an interview that he was escorted out of the building.
Before Brawley left, Sanders wrote in her July 1 email to Meier, he shared information from his past experiences dealing with outbreaks and described how San Diego County and Michigan got similar outbreaks under control.
She outlined Brawley’s proposed response, which, among other things, would have given 10 counties enough money for each to buy 10,000 doses of vaccine.
Instead, Howard sent money for 1,000 doses to each of 10 counties in late May. That was the first cash infusion of what ultimately would be more than $2 million in agency funds sent to 48 counties and area development districts.
Brawley’s recommendations were ignored, Sanders said in her email:
“The infectious disease expert at KY DPH with the most experience in public health was walked out of the building. Dangerous. Irresponsible. Too little … too late.”
Sanders forwarded the same email July 17 to Dustin Isaacs, who at the time was an administrative liaison in Bevin’s Office of Constituent Services. Sanders had met with him previously and was following up with the email, but said she got no response.
‘It’s business as usual’
By August 2018, Sanders still wasn’t getting anywhere, she said, and she was willing to reach out to anyone who might listen. She met with Johann Herklotz, general counsel for the cabinet, in early August.
And on Aug. 7, she forwarded an email from Brawley that recounted his recollections of the outbreak response during his tenure, detailed all of his recommendations and said that Howard knew about them.
Herklotz responded, thanking Sanders for the information. He said it would take time to review.
In September, she met with Herklotz and another attorney. They said Howard was qualified, she recalled. She strongly disagreed.
“If anybody in that building, if anyone in this country, knew how to deal with an outbreak, it would be (Brawley). No one else in that building had ever dealt with an outbreak of this magnitude,” she said.
She stressed that there are professional people in the department doing as much as they can, but that they are without adequate support from leadership.
If the state had responded aggressively to her concerns, “we could be looking at a different situation than we are now,” she said. Instead, “it’s business as usual, and ticktock, ticktock, we have a spread of hepatitis A that’s trickling down the whole entire state of Kentucky to every county and then the bordering states.”
Read more:Examination needed of Kentucky’s ‘poor response’ to deadly hepatitis A outbreak, lawmaker says
‘Get the boots on the ground’
Howard, who became the commissioner in June, has defended his decision on state spending.
He said the state used the limited money it had to bolster vaccines in numbers that could feasibly be administered by small staffs in county health departments. He also said he was willing to seek more state funding if needed.
State officials said their strategy was based on best practices — reaching out to and vaccinating drug users and homeless people in places such as syringe services programs and treatment centers.
Howard said he took into account that rural counties had other ways to get vaccine beyond special state money, such as ordering federally funded vaccine through the state or buying shots with nearly $233 million in county health department reserves.
Howard also wrote a letter to legislators taking issue with the Courier Journal investigation, saying it leads readers to draw false conclusions.
He said the articles show the Courier Journal doesn’t understand Kentucky’s public health system, in which both state and local health departments share governance. In most instances, his department “generally cannot require or force a locality to pursue action.”
Opinion:Kentucky must investigate its woeful response to deadly hep A outbreak
Meier emphasized the response, led by the state epidemiologist, was guided by a public health team including epidemiologists, physicians, nurses and scientists. He pointed to county health department reserves and other sources of funding available to help address the outbreak.
Meier has said he stands behind Howard’s decisions, adding that the “challenges Kentucky faced were less financial and more logistical in nature as it related to identifying and engaging the at-risk populations.”
Haeder, the West Virginia professor, said money plays into logistics, since it takes resources to pay for additional public health nurses in rural areas. Those nurses could help not only vaccinate against hepatitis A but also identify other potentially dangerous diseases, or help people get into addiction treatment.
They could help address diseases far more costly to treat than to prevent.
Brawley told the Courier Journal that given all the people Sanders reached out to, “it’s been a great puzzle why there wasn’t more action taken.”
But Howard said in a previous interview that even after Brawley’s departure, the department had experienced staff and the expertise necessary to deal with the crisis.
“We’ve never intentionally run lean during this outbreak,” he said.
On Friday, Kentucky public health leaders held a news conference in Frankfort strongly defending Howard’s decisions and criticizing the Courier Journal’s investigation.
Chris Crum, public health director for the Greenup County Health Department, wrote a letter of support for Howard released at Friday’s press conference:
“Without support from the Commissioner, the necessary resources would not have been allocated to the Greenup County Health Department in a timely manner and the repercussions could have been much more devastating.”
The press conference came the same day that state Sen. Morgan McGarvey, D-Louisville, filed a resolution directing the state agency to review its response to the outbreak, saying he wanted to understand all the factors at play and what could be done better.
“We need to find out what happened, why it happened, and to make sure it doesn’t happen again,” McGarvey said. “I didn’t come here today to bash the media. I wouldn’t be aware of this problem if it weren’t for reporting and putting it on the front page of the paper.”
Sanders said she would like to see Kentucky respond to the outbreak in Appalachia more like San Diego County, which spent more than $12 million on its response. That included nearly quadrupling the vaccines administered seven months into its outbreak.
She said Kentucky needs to take similarly strong action.
“Get the boots on the ground. Now, San Diego, they were aggressive,” she said. “They Cloroxed the street. They engaged. They got their legislators involved. They got money. And it didn’t spread throughout California. If they’d have had the response that we had, it’s hard telling how many millions … would be infected …
“Kentucky needs to be aggressive.”
Related:Hepatitis A is making a deadly sweep across the U.S. Here’s how states are battling it
Laura Ungar: 502-582-7190; [email protected]; Twitter: @laura_ungar; Support strong local journalism by subscribing today: courier-journal.com/laurau. Reporter Chris Kenning contributed to this story.
Read or Share this story: https://www.courier-journal.com/story/news/2019/03/01/hepatitis-outbreak-nurse-told-kentucky-officials-response-too-late/3015982002/