As she lay in a hospital bed, every part of Crystal Newsome's body ached.
She had yellowish eyes, a fever, and a sore, swollen belly.
“I was so sick,” she said. “I felt like I’d been hit by a truck.”
The 41-year-old recovering drug user from Prestonsburg had been stricken by hepatitis A,
which has infected nearly 4,100 Kentuckians in what has become the nation's largest outbreak of the disease.
Some state health officials contend that it could have been slowed more quickly — before it spread to 103 counties across the state, threatening some of the most impoverished, drug-plagued regions in America.
Before it sent nearly 2,000 people to the hospital.
Before it killed 40 Kentuckians.
This is the story of how the virus broke out of Louisville and swept through counties across Appalachia in the wake of a state response critics say was too little, too late.
The outbreak begins: Fall 2017
Since a vaccine came out in 1995, cases of hepatitis A, a once-common liver disease typically resulting in mild illness, dropped dramatically in the United States.
Until recently, Kentucky saw only about 20 cases a year, often from travelers who ate tainted food in developing countries.
But in August 2017, health officials grew concerned about cases in Louisville, with 19 by late November. By the end of the fall, roughly five new cases appeared every week.
Epidemiologists traced the strain to Utah and California's San Diego County, where a similar outbreak in 2017 sickened 592 and killed 20. Hospitalization rates hovered near 50 percent because it was striking a population with existing medical problems. At its worst, nausea, jaundice, fever and dizziness could morph into liver failure.
Most of those getting sick were homeless or drug users, contracting the virus from needle-sharing or people touching their mouth with something contaminated with infected stool. But one in five people infected were not in risk groups. They were infected because the illness can easily spread through everyday contact.
Gradually, cases appeared on Kentucky’s northeastern border in Boyd, Greenup and Carter counties, where nearly one in five residents lives in poverty and drug abuse is rampant.
To counteract the spread, area health workers held walk-in clinics and worked to vaccinate the at-risk at shelters, jails, needle exchanges and drug rehab facilities.
On Nov. 21, 2017, Kentucky’s health department declared the outbreak had spread to 13 counties. Local health departments worked to vaccinate those who had been in close contact with victims.
But they faced a host of challenges.
People can carry hepatitis A without symptoms for up to two months. Drug users and homeless are far less likely than others to show up at doctors offices or health departments for a shot.
"You can't wait for them to come to you," said Katie Myatt, the state’s lead epidemiologist on the outbreak.
Louisville's health officials spoke with their San Diego County counterparts, who spent more than $12 million fighting their outbreak and bringing it under control by nearly quadrupling the vaccines administered.
Louisville, like San Diego County, had the advantage of being urban. Its large health department with around 220 employees could target concentrated groups in homeless shelters and the metro jail, as well as create partnerships with local groups to expand vaccinations.
They went to homeless camps, underpasses, viaducts and transient hotels, and embedded with social service outreach nonprofits. The city spent at least $170,000 in local funds. In April, Louisville received $250,000 in state vaccine money.
The Louisville Metro Department of Public Health and Wellness ultimately administered 25,000 vaccines to high-risk people as part of more than 100,000 immunizations across Louisville to date.
As in San Diego, an influx of vaccine targeting the right people made the difference.
By: Laura Ungar and Chris Kenning