July 18, 2009News of the outbreak first broke on July 15th, when the Illinois Department of Public Health reported that it was investigating 11 confirmed and 2 suspect cases of hepatitis A among residents of Henry, Mercer and Rock Island counties. As of yesterday evening, the outbreak had grown to include 19 victims, 11 of whom were hospitalized due to the severity of their symptoms. Additional suspect cases are being investigated.
The virus is transmitted when a victim ingests infectious hepatitis viruses that have been deposited on food, or when a victim touches a surface that has been contaminated with live virus particles and then transfers the virus from hand to mouth – as happens when eating finger foods. One infected food handler working at a high turnover restaurant (such as McDonalds) can, through inadequate attention to careful hand-washing and personal hygiene, infect dozens of unsuspecting victims.
This is not the first time that a McDonalds restaurant has been the source of an outbreak of hepatitis. A worker at a Davenport, Iowa McDonalds franchise was diagnosed with hepatitis in 2008. And an infected food handler working at a McDonalds in Calgary (Alberta, Canada) triggered a hepatitis alert in October 2007.
Other restaurant chains also have been the source of hepatitis outbreaks in recent years, including:
- Chipotle in La Mesa (San Diego County) in 2008
- Pizza Ranch in Slayton, MN in 2007
- Quizno's in Boston, MA in 2007
- Chi-Chi's in Beaver County, Pennsylvania in 2003
A very effective vaccine is available against HAV, but the CDC does not recommend routine vaccination for food handlers, saying,
"Although persons who work as food handlers have a critical role in common-source foodborne outbreaks, they are not at increased risk for hepatitis A because of their occupation. Consideration may be given to vaccination of employees who work in areas where community-wide outbreaks are occurring and where state and local health authorities or private employers determine that such vaccination is cost-effective."
This guidance is out of step with the recommendations of CDC's own Advisory Committee on Immunization Practices ( ACIP), which concluded the following in 2006.
"Persons who work as food handlers can contract hepatitis A and potentially transmit HAV to others. One national economic analysis concluded that routine vaccination of all food handlers would not be economical from a societal or restaurant owner's perspective. Nonetheless, to decrease the frequency of evaluations of food handlers with hepatitis A and the need for postexposure prophylaxis of patrons, consideration may be given to vaccination of employees who work in areas where state and local health authorities or private employers determine that such vaccination is appropriate. Food handlers who receive hepatitis A vaccine should be provided with a record of the immunization. Those who do not should be informed of the signs and symptoms of hepatitis A and taught food preparation practices that reduce the risk for fecal contamination."
While the frequency of hepatitis outbreaks has decreased since routine vaccination of all children between one and two years old was introduced in the mid 1990s, individual outbreaks can prove costly – to the victims, to local health agencies, and to restaurant owners. Ten years ago, the average cost per case-patient was estimated at $2,894, including lost wages, which accounted for just over half the cost.
At present, only two counties in the United States mandate vaccination of food handlers and food service workers – Clark County, Nevada and St. Louis County, Missouri (including the city of St. Louis). Los Angeles County, while not requiring that food handlers be vaccinated against hepatitis, recommends that all county residents be immunized, stating,
"The Los Angeles County Department of Public Health recommends that all adults living in the County receive the hepatitis A vaccine, if not already immune, as a preventive measure. Vaccinating all adults will not only protect persons in high-risk groups but others who may be exposed to the virus. In 2006, 35% of the reported hepatitis A cases in Los Angeles County had no known risk factors for infection."
In today's business environment, which supports – even encourages – background checks and drug tests for new employees, it should be simple to require food handlers to show proof of immunity to HAV, or to submit to vaccination as a condition of employment. If one major restaurant chain takes the lead, others may follow.
Is anyone at McDonalds listening?
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They're too busy listening to the ka-ching of their cash registers to care.
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