Hepatitis A is usually not a problem to recover from. But in Michigan, 27 people died since this outbreak began.

WARREN, Mich.— Michigan is in the throes of the largest hepatitis A outbreak in the USA, a flareup that began in August 2016 and has killed 27 people, state health officials say.

The hepatitis A virus, which attacks the liver, is highly contagious. Just ask Christopher Larime ,46, of Grosse Pointe Park, who goes out to lunch most days with co-workers from the General Motors Tech Center here.

The father of three said he ate in March at the Buffalo Wild Wings across the road from his office. It's the same restaurant where a food worker later was found to have hepatitis A. 

Though he only suspects the source of his infection, Larime now is one of 837 people who have been sickened with the virus in the state. Last month, Indiana's Department of Health issued a travel alert warning Hoosiers planning to visit Michigan to get vaccinated before they come. 

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"If I look back now, there was fever, stomach pain, shortness of breath and probably the biggest thing was just, you know, I felt like eating very little," he said of his symptoms. "It was loss of appetite."

The symptoms' persistence led him to the emergency room at Beaumont Hospital, Grosse Pointe, where he was hospitalized for nearly a week.

"I had acute hepatitis, so my liver enzymes were way out of whack," Larime said.

The virus can be spread through food or water contaminated with the feces of an infected person, close contact or sex with a person who has hepatitis A or touching a surface contaminated by the virus and then touching your mouth. It causes liver inflammation — and liver failure in extreme cases.

It's also easily preventable through vaccination and hand washing.  

As of Wednesday before Memorial Day, the hardest hit areas are Macomb County, north of Detroit, with 220 cases; Detroit itself with 170; elsewhere in Wayne County, where Detroit is located, with 144; and Oakland County, to the west of Macomb County where Pontiac is located, with 114 cases, according to the Michigan Department of Health & Human Services. 

Part of the problem: As many as 35 restaurant workers in the Detroit area were found to have the virus and may have spread it unknowingly to diners. The virus is contagious weeks before a person begins to exhibit symptoms, which makes it extremely challenging for public health officials to manage.

Both the Wayne County Health Department and Detroit's Health Department now recommend all restaurant employees and food handlers get the vaccine. Oakland County's Health Division also urges restaurant employees to consider vaccination.  

The strain of hepatitis A that has spread through metro Detroit the past two years has a higher rate of hospitalization than past outbreaks, said Jay Fielder, an epidemiologist with the state Department of Health & Human Services. Of the 837 people who have contracted the virus since August 2016, 80% — or 671 — have been hospitalized, and 3.2% have died. 

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"For the average person, hepatitis A is more of a nuisance," said Dr. Nicholas Gilpin, chief medical officer of Beaumont Hospital, Grosse Pointe. "There’s a very, very slim chance that a hepatits A infection would lead to serious complications. ...

"About 1% of cases will go on to liver failure, which means you would require a transplant," he said. "In the majority of cases, you feel sick for a period of time and then you get better."

But since August 2016, people sickened in Michigan and in outbreaks in San Diego and Utah, haven't fared as well, Fielder said.

"Something is different, and we’re trying to figure out what it is," he said. "It’s going to take a little while."

Fielder said the federal Centers for Disease Control and Prevention is investigating, but what he's noticed is that many patients are older with other illnesses that make them more vulnerable to hepatitis A complications. 

Most of those who have died in Michigan in this outbreak are 50 or older, Fielder said. And they died of liver failure, septic shock or other organ failure.

"Generally, it's been people who are more sick or people who have less access to health care," Fielder said. "You know, we’ve also seen a homeless component to this. We’re seeing this driven by a substance use disorder risk group."

People who use illegal drugs account for about half of outbreak-related cases.. 

"It’s a very hard group to reach, and it’s a very hard group to get public health messaging to. There’s a lot of trust issues with government entities in general. So there’s a lot of outreach going out from local public health to ... people they do trust in the community."

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Now stretching almost two years, Michigan's outbreak showed some signs of slowing in the first part of 2018. However, health officials are bracing for another upward swing in cases that often comes with the summer months. 

"We are still seeing cases at a rate that very much exceeds what we would typically expect in Michigan at this time of year," about six cases a week, Fielder said. "In Michigan, we typically see about 60 cases a year — so at this rate, in 10 weeks, we're seeing our yearly expected total of hepatitis A."

Though adults typically get two doses of the vaccine spaced six months apart, the CDC recommends just one dose right now because of a limited supply of the vaccine. 

"Here in Michigan, we're expecting to be dealing with this outbreak for months still, and I know there's currently outbreaks in Indiana, Kentucky, Ohio and West Virginia. Missouri is starting to see an increase in cases," Fielder said. "Given what I know about the regional activity, I think that CDC is going to be in a constrained status for a while for the vaccine."

Restaurant workers account for a little more than 4% of the reported cases. Maybe half of those cases have required notification to the public and follow-through with vaccinations, he said.

Still want to worry about eating in a restaurant? Concern yourself with possible norovirus or E. coli contamination, Fielder said.

If you have diarrhea, nausea, vomiting or other stomach pain, norovirus is often the cause, the CDC said. It's the most common cause of gastroenteritis.

E. coli is a bacterium that can be transmitted through food. Most recently this infection has been in the news because of contamination of romaine lettuce harvested in Yuma, Ariz., in which 172 people in 32 states were sickened; one person died.

"We see a lot more food-borne transmission of communicable disease in other viruses and bacteria than we do from hep A," Fielder said.

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How to prevent hepatitis A

• Wash your hands. The best defense against transmitting hepatitis A is washing your hands after using the bathroom and before preparing meals, health officials say.

• Be selfish. Don't share towels, toothbrushes, food, cigarettes or eating utensils with other people as a safeguard. And do not have sex with someone who has a hepatitis A infection.

• Get vaccinated. Children born after 1999 have been routinely vaccinated against hepatitis A. For adults, two doses of the vaccine spaced six months apart will provide lifelong protection.

If you've been exposed to someone with the virus, a vaccination within 14 days of exposure, potentially with an immune globulin injection, has been shown to be effective in preventing the liver infection.