Hepatitis A: Aftermath Of An Alert

Last week, the Iowa Department of Public Health issued a Hepatitis A Virus exposure alert to patrons of Whitey's Bar and Billiards in Burlington, after an employee of the restaurant was diagnosed with hepatitis A. Anyone who had eaten salad bar items or consumed drinks containing ice or lemon slices was urged to arrange for an injection of hepatitis A vaccine or immunoglobulin.

By July 19th, Whitey's had disinfected the premises and reopened. A Public Health spokesperson interviewed by The Hawk Eye, a local newspaper, advised the public that the restaurant was safe. And no restaurant patrons have shown symptoms of hepatitis A infection (which has an incubation period as long as six weeks) as yet.

An outbreak of hepatitis A appears to have been prevented. The restaurant was cleaned and disinfected and has reopened for business. No harm, no foul? No way!

Business at Whitey's was down by almost 90% immediately after the restaurant reopened, and is recovering very slowly – to about 50% of its pre-hepatitis level. The restaurant, which used to serve more than 100 customers on a Wednesday night, received only 12 customers last Wednesday.

The total cost of running Whiteys, including paying its 25 employees, is approximately $17,000/week, according to the restaurant's owner. In an effort to encourage its customers to return, Whitey's handed out "...a couple thousand dollars worth..." of restaurant coupons worth $3 each to everyone who obtained a hepatitis A vaccine at the County's special clinics.

Let's tally the combined cost – both to the restaurant's owners and to the public – of this non-outbreak of hepatitis.

• Whitey's operating cost for one week with little or no revenue: $17,000
• Value of incentive coupons handed out to restaurant patrons: $2,000
• Cost of precautionary vaccinations (~650 patrons x $30/injection): $19,500

These numbers, which total $38,500, do not include the inconvenience to restaurant patrons, who had to take time out from their schedules to receive precautionary injections. Nor do they take into account Whitey's on-going loss of business – and loss of reputation.

Many people have pointed out that food service-associated hepatitis alerts and outbreaks could be avoided by insisting that all food handlers be vaccinated against hepatitis A virus. Now, only two jurisdictions in the United States mandate this – St. Louis County, Missouri and Clark County, Nevada. But CDC has concluded, based on a study published in 2001, that this approach is not cost-effective, either to restaurant owners or to society in general.

Is CDC correct? It would be interesting to compare the cost and frequency of hepatitis A alerts and restaurant-associated outbreaks in St. Louis and Clark counties against other counties with similar demographics. Perhaps a follow-up study is called for.

Are you listening, CDC?