Since November 2017, 4,476 people in Kentucky have contracted hepatitis A virus (HAV), making it the worst outbreak of the virus in the United States. But speaking at a recent gathering at the Kentucky Public Health Association earlier this month, local health officials say they are finally making progress in containing the outbreak, the Courier Journal reports.

The state’s initial response to its hepatitis A outbreak has been criticized for not being aggressive enough. In addition to thousands of infections, 53 people have died as a result of the virus over the past two years—more than in any other state.

However, state health officials are defending their actions amid what they cite as multiple challenges. For example, Kentucky was the first state to experience a primarily rural outbreak of the virus and was unprepared to reach at-risk rural populations. Officials also noted that the reason Kentucky has seen a high number of fatalities is that many drug users with the virus were already living with other illnesses, including hepatitis C virus (HCV). A lack of community health organizations as well as other logistical challenges are also thought to have hamstrung Kentucky’s initial hepatitis A response.

But the state is trying to contain the outbreak. Last week, health officials hired a traveling team of nurses to administer hepatitis A vaccines in rural county jails. Kentucky’s Department for Public Health is also providing more vaccine storage equipment, money and expertise to a handful of hard-hit counties. What’s more, officials now recognize that they must expand harm reduction programs, such as needle exchanges.

Some counties have also discovered new says to reach at-risk populations and are working with local jails, hospitals, syringe exchanges and drug treatment centers; holding vaccine clinics at local convenience stores; and giving vaccine vouchers to people to give to their friends. 

“We could see the trend go back up, so it’s not a time to diminish efforts at all,” said Jeff Howard, MD, Kentucky’s commissioner of public health, who appeared on a panel with other health leaders to discuss the state’s crisis.