Publisher Platform: It’s time to vaccinate food service workers against hepatitis A

The CDC has been reporting human-to-human outbreaks of hepatitis A for years. Since the outbreak was first detected in 2016, as of October 6, 2023, 37 states have publicly reported the following:

• Cases: 44,915

• Hospitalizations: 27,445 (61%)

• Death toll: 423

Now, the CDC has just reported: Preventable Deaths During Widespread Community Hepatitis A Outbreaks—United States, 2016-2022

Hardly a week goes by without news of a Hepatitis A-positive employee putting co-workers, customers, and the restaurant brand at risk. There were illnesses, deaths, thousands of customers had to wait in long lines to get preventive vaccines, some restaurants closed, and of course there were lawsuits.

All of these are preventable through hepatitis A vaccination—the only foodborne disease that is vaccine-preventable.

Public health authorities are indeed overdue for the same advice. Here’s what I asked the CDC:

ACIP Secretariat
Advisory Committee on Immunization Practices
1600 Clifton Road, NE, Post Office H24-8
Atlanta, Georgia 30329-4027

Re: Letter to CDC Committee on Immunization Practices—It’s Time to Address Hepatitis A and Food Service Workers

Dear ACIP Secretariat:

The Advisory Committee on Immunization Practices (ACIP) provides recommendations and guidance to the CDC Director on the use of vaccines and related preparations to control vaccine-preventable diseases in the U.S. civilian population. Recommendations made by ACIP are reviewed by the CDC Director and, if adopted, are published as official CDC/HHS recommendations in the Morbidity and Mortality Weekly Report (MMWR).

Currently, approximately 5% of hepatitis A outbreaks are associated with infected food handlers.

Here’s what the CDC continues to say about vaccinating food handlers:

If infected food handlers can spread disease during an outbreak, why doesn’t the CDC recommend that all food handlers get vaccinated?

The CDC does not recommend vaccinating all food handlers because doing so will not prevent or stop the ongoing outbreak, which primarily affects individuals who report using or injecting drugs and people experiencing homelessness. Food handlers are not at high risk for hepatitis A because of their occupation. Transmission from food handlers to restaurant patrons is extremely rare during the ongoing outbreak because standard sanitation practices by food handlers help prevent the spread of the virus. Individuals who live in households with infected individuals or engage in the aforementioned risky behaviors are at greater risk of contracting hepatitis A.

CDC is missing the point; of course, food service workers are no longer risk of getting Hepatitis A is because of their occupation, but they are Transmission risk It gives it to customers. Food service positions typically pay lower wages and are likely to be filled by immigrants from countries where hepatitis A may be endemic or by people who have recently experienced homelessness.

Over the past few years, there have been ongoing outbreaks of hepatitis A in the United States. As of February 2, 2023, there were 44,779 cases and a hospitalization rate of 61% (approximately 27,342 hospitalizations). The death toll is 421. Since the outbreak began in 2016, 37 states have reported cases to the CDC.

The CDC recommends to the public that the best way to prevent hepatitis A is to get vaccinated, but the CDC does not explicitly say that food service workers should be vaccinated. While food service workers have not traditionally been considered to be at higher risk for hepatitis A transmission, they are not without risk.

24% of hepatitis A cases are asymptomatic, meaning food handlers carrying the virus could unknowingly spread the disease to consumers. Historically, when outbreaks occur, local health departments begin administering vaccines for free or at a reduced cost. These vaccinations are being funded with taxpayer dollars.

In St. Louis County, Missouri, a mandatory vaccination policy for all food service workers has proven effective in reducing infections and financial burden.

From 1996 to 2003, there were 1,523 confirmed cases of hepatitis A in Clark County, Nevada, which was higher than the national average. Because of these alarming rates, Clark County implemented a mandatory vaccination policy for food service workers. As a result, hepatitis A incidence rates dropped significantly in 2000 and reached an all-time low in 2010. The county lifted its mandatory vaccine mandate in 2012 and is now part of a hepatitis A outbreak.

According to the CDC, vaccinations cost from $30 to $120, with hospital costs running into the thousands, and are 95% effective after the first dose and 95% effective after the second dose 99%. In addition, the vaccine’s efficacy is maintained for 15-20 years.

During an outbreak, if a food service worker is found to be positive for hepatitis A, the local health department will initiate a post-exposure treatment plan, which must be implemented within two weeks to be effective. The financial burden also affects health department personnel and other limited resources. Sometimes, interventions implemented by local health departments may not be effective.

While there have been many examples of point-source outbreaks of hepatitis A across the country over the past few years, a particularly severe outbreak occurred in Roanoke, Virginia, in the early fall of 2021. The health department was notified of the outbreak on September 21, 2021, after the first case was reported at a local hospital. The Roanoke Department of Health investigated the outbreak along with the Virginia Department of Health.

Three different locations of a local restaurant called “Famous Anthony’s” were ultimately linked to the outbreak. The Virginia Department of Health issued a community advisory on September 24, 2021, regarding the outbreak and potential exposure risks.

For investigation purposes, a case is defined as someone with (a) discrete onset of symptoms and (b) jaundice or elevated serum aminotransferase levels and (c) a positive hepatitis A test (IgM anti-HAV positive) in 2021 Frequented any of the three Famous Anthony locations between August 10 and August 27, or had close contact with the index case patient.”

As of November 2021, a total of 49 primary cases (40 confirmed cases and 9 suspected cases) have been found in this epidemic. Two secondary cases were also identified. Cases ranged in age from 30 to 82 years (median age 63 years). Overall, 57% of cases were male. Thirty-one cases were hospitalized and at least four patients died. The onset occurred between August 25 and October 15, 2021.

Ultimately, the outbreak investigation revealed that a chef who also had risk factors related to hepatitis A contracted hepatitis A while working at multiple Famous Anthony’s restaurants. The index case’s mother and adult also tested positive for hepatitis A. After the inspection, the outbreak inspector noted that “due to the etiology of hepatitis A transmission, it is presumed that infectious food handlers did not properly wash their hands or wear gloves” policy. “It has been determined that human-to-human transmission is the most likely mode of transmission of this epidemic. Environmental pollution is also considered a possible mode of transmission.

Overwhelmed by the number of victims seeking legal action, Famous Anthony’s filed for bankruptcy and several locations have closed.

The tragedy of this preventable hepatitis A outbreak cannot be overstated. Four people died. In one family, two members were killed. Most of the victims have been hospitalized. Many people are at risk of acute liver failure. At least one person will need a liver and kidney transplant. The victims’ medical bills totaled more than $6,000,000, including millions of dollars in future costs. All because one employee didn’t receive the $30-$120 Hepatitis A vaccine.

It is possible and necessary to affordably prevent future tragedies like the famous Anthony outbreak. Now is the time to at least recommend that food service workers be vaccinated to reduce the spread of hepatitis A.

Bill Mahler
Representing 31 hepatitis A victims and their families

1 I provided medical summaries of 31 victims privately via email so that the impact of hepatitis A on food consumers at the hands of an unvaccinated food service worker could be clearly assessed.

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