“I was shivering. I was achy. I felt like something was wrong, but I didn’t know what,” recalls Smith, 51, one of four people who contracted the dangerous liver disease last year at the now-defunct New Hawaii Sea restaurant in the Bronx.
“Then my wife looked at me and said: The whites of your eyes are becoming yellow.”
Smith, like most American diners, didn’t know that the hepatitis A virus is highly contagious and spread when people use the toilet and then fail to properly wash their hands. And he didn’t know that in most places across the U.S., there’s no requirement that kitchen workers receive the vaccination that can prevent infection in the first place.
“I couldn’t believe it,” said Smith, whose wife and mother-in-law also contracted the virus. “If you work in a kitchen and you have exposure to food and you’re handling raw food, it makes sense that, you know, you’re going to get your people vaccinated.”
The question of whether hepatitis A inoculations should be mandatory for food workers — or whether the cost to business isn’t worth the wider benefit — is gaining renewed attention from federal regulators, health officials and ordinary consumers amid a spate of new restaurant warnings.
Just this month, nearly 2,000 people who went out for Italian food at La Fontana restaurant in Nyack, N.Y., and a Papa John’s pizza place in Charlotte, N.C., wound up getting immunoglobulin shots to prevent hepatitis A after food handlers tested positive.
There was another scare in Hilton Head, S.C., in February, when patrons of Hudson’s Seafood House on the Docks warned patrons they’d been exposed by an employee. In that case, nearly 100 people got shots, health officials said.
In the New Hawaii Sea outbreak, more than 3,000 people received jabs, health officials said.
As many as 17,000 people a year are sickened by hepatitis A, according to 2010 estimates from the Centers for Disease Control and Prevention, and about 95 people die. That’s only a fraction of the 48 million people in the U.S. who are sickened by food poisoning each year, but hepatitis A is the only foodborne bug for which an effective vaccine actually exists.
The hepatitis A virus causes acute liver infection that can trigger lingering illness and even liver failure or death, though that’s rare. It’s spread when a person ingests fecal material from an infected person and causes symptoms that include, fever, chills, nausea, dark-colored urine and jaundice, a yellowing of the skin or eyes.
For years, CDC officials have said that food handlers didn’t need hepatitis A vaccinations because outbreaks are rare and food workers aren’t at increased risk of infection because of their jobs. They pointed to plummeting rates of hepatitis A infections since the introduction in 1996 of a safe and effective vaccine.
But that could change, said Dr. Trudy Murphy, a medical epidemiologist in the agency’s viral hepatitis division. Hepatitis A used to be more common among children in the U.S. and not adults, because they were exposed as kids. In 2006, experts began recommending universal hepatitis A vaccines for kids starting at age 1, changing the pool of potential infections.
“There was a very rapid transition in the U.S. over the last half decade,” Murphy said. “We have this gap of adults who are not protected in their 20s, 30s, 40s and 50s.”
In other words, the people most vulnerable to hepatitis A are those most likely to work — and eat — in restaurants.
In 2003, CDC data showed that about 8 percent of adults in the U.S. who got hepatitis A were food handlers, indicating that “thousands of food handlers have hepatitis A each year,” officials wrote. On average, about 10 restaurants a year reported exposures. But those may have increased, Murphy said.
“I think we need to collect some additional information to see whether that would be something we need to look at,” she said.
It’s about time, said Bill Marler, a Seattle food safety lawyer who has lobbied for mandatory vaccination for food handlers since a hepatitis A outbreak tied to two Subway sandwich shops sickened 40 people in 1999.
“It was a horrible outbreak. We represented a bunch of people including a little boy who lost his liver at 8 years old and required a transplant,” he said.
But restaurant industry officials — and some health officials — note that such outbreaks and consequences, though regrettable, are rare.
“Hepatitis A is a serious disease and we take it very seriously,” said Catherine Adams Hutt, a food safety expert and consultant to the National Restaurant Association. “We’re not chasing a pandemic, we’re not chasing an epidemic. What is the appropriate reaction? For most businesses today, the reaction is reactive.”
Mandating vaccination for food handlers would be difficult, said Adams Hutt, has worked for leading firms including McDonald’s Corp., the Campbell Soup Company and H.J. Heinz. Two doses of vaccine are required, months apart, for full immunity.
There are personal privacy issues to consider and there’s the cost, which could amount to $150 to $200 per worker, she said. In addition, there are strict regulations that already govern food safety operations and reporting of infectious disease.
“The controls are in place,” she said. “We need to make sure that they are religiously in practice.”
That makes sense, even to William Pilkington, the public health officer in Cabarrus County, N.C., where residents were last week warned about the infected Papa John's. He figures taxpayers in two counties will foot a bill totaling more than $20,000 for the recent round of about 1,600 shots to protect against hepatitis A, but Pilkington said it would be even more expensive to vaccinate in the long run.
“I’ve been the public health director here for 33 years and we’ve had two of these,” he said.
There are places in the U.S., however, where health officials have decided that the cost of vaccination is worth the benefit. The city of St. Louis requires food handlers to be vaccinated.
So does St. Louis County, Mo., where three large hepatitis A outbreaks tied to food handlers in the mid-to–late 1990s strained local resources. County officials passed an ordinance requiring all restaurant workers to be vaccinated. Since then, the number of cases dropped from 110 a year to virtually none, said Dr. Dolores Gunn, the county health director.
“We still have our traditional E. coli foodborne illness like everybody else, but not hep A,” she said.
The cost savings go beyond the price of the shots, she said.
“There is a huge economic cost, hospital cost, reputation cost, lost employee time,” she said. “It’s not just a cost savings in terms of medical or life or healthiness, but an economic cost savings in your community.”
That makes sense to Luther Smith, a government lobbyist who took weeks to fully recover. His two children needed hepatitis A shots, the family had to notify the kids' school and day care, and his wife and mother-in-law still fell seriously ill, all in the middle of the holiday season.
Whatever the cost to businesses, it can’t compare to the fallout from even a single infection, he said.
“C’mon. New Hawaii Sea was a very large restaurant. I can’t believe that whatever they’re going to pay via their insurance and their reputation. I can’t imagine that that’s cheaper.”
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