Patrons of New York’s Westside Market are lined up for preventative Hepatitis A vaccines yesterday and will for the next few days.  Hopefully the vaccines do the trick and the thousands who were exposed do not get sick.  However, had that employee, who had his or her hands in you fruit, been vaccinated before, those thousands would not be standing in line to get a poke and worrying for the next few weeks if it worked or not.

OK, let’s be honest: as an attorney who makes a substantial portion of his living by filing lawsuits against restaurants, it’s not in my financial interest to have the National Restaurant Association (NRA) change its position on mandatory hepatitis-A vaccinations for food-handlers. That being said, I think the NRA’s position is largely indefensible, especially for the vast majority of independent restaurant operations who are in most cases unable to absorb outbreak-related losses from a single outlet.

The NRA’s position is for the most part based on the fact that, in 1998, the CDC waffled on its recommendations on the prevention of hepatitis-A through immunization. On the one hand, the CDC did not include food handlers among the groups of people it deemed at increased risk for hepatitis A and thus in need of prophylactic vaccinations. On the other hand, it conceded that that “persons who work as food handlers have a critical role in common-source outbreak” and that consideration should be given to whether such vaccinations are “cost-effective”. In short, the CDC left it to state and local health departments to decide what to do. Not surprisingly, most such departments have done nothing.  Here are a few restaurants who likely see if differently – now:

Subway 1999:  In mid-October, 1999, an unusually high number of hepatitis-A cases were reported among individuals residing in Northeast Seattle and Snohomish County. At the same time, the Snohomish Health District reported an increased number of hepatitis-A cases reported among individuals who resided in Snohomish County, but who worked in the Northeast Seattle area.  Because the infected individuals had no other identified risk factor for hepatitis A, health department officials quickly suspected the existence of a hepatitis-A outbreak with a common foodborne source located in Northeast Seattle.

To identify the outbreak’s source, health officials developed an epidemiological survey that included the fast food restaurants and groceries stores prevalent in the North Seattle area.  Health department officials then contacted all persons with hepatitis A in King and Snohomish County since October 15, 1999 and the food survey was completed.  By November 5, 1999, 18 of 21 persons reported with hepatitis A in King County after October 15, 1999, were found to have eaten at one of two Subway Sandwich outlets during the two to six week period prior to the onset of their symptoms. During this same time period, the Snohomish Health District determined that at least six persons with hepatitis A had eaten at one of the two implicated Subway outlets.

Once the likely source of the hepatitis-A outbreak was determined, health department officials performed a case-control study.  The results of the initial case-control demonstrated a strong statistical association between eating at Subway during the identified time period and developing a hepatitis A infection. A subsequent inspection by environmental sanitarians found that neither of the implicated Subway outlets had a written hand washing policy, and that employees were not required to document their knowledge of proper hand washing technique.  In contrast, the vast majority of fast food restaurants in the area have written hand washing policies, intensive training on proper hand washing techniques, and require employees to sign their initials to a check-off sheet that confirms that their hand were washed hourly and all after bathroom use.

Having confirmed that the Subway outlets were, in fact, the outbreak’s common source, health department officials issued a press release that stated, in part, that:

An ongoing investigation by Public Health suggest that many [hepatitis-A] infections are associated with consuming food form one of two Subway Salads and Sandwiches outlets during the month of September. . . .“If you have eaten at these restaurants during September and are ill with symptoms of hepatitis, you should seek prompt medical evaluation,” said Dr. Alonzo Plough, Director of Public Health – Seattle & King County.

It is estimated that over 40 persons became ill as a result of eating contaminated food sold at the two Subway outlets implicated in the September 1999 hepatitis-A outbreak.

Carl’s Jr. 2000:  On February 16, 2000, the Spokane Regional Health District published a “Hepatitis Alert” which read as follows:

The Spokane Regional Health District (SRHD) has received a confirmed report of hepatitis A in a food handler employed at the Carl’s Jr., Restaurant, 707 W 3rd Avenue, Spokane, WA.  The foods with possible risk of transmitting hepatitis A are any sandwiches (including hamburgers) with a vegetable garnish (such as lettuce, tomato, or onion).  The days of possible exposure were:  January 28, January 31, February 2, February 5, February 6, February 8, February 9, and February 10….

Hepatitis A is a viral infection usually spread by eating contaminated food.  After a two-to seven-week incubation period with no symptoms, the infected person presents with symptoms such as:  feeling generally unwell, joint and muscle aches, cramps with belly pain and tenderness, loss of appetite, fever, nausea and diarrhea.

After a few days to a week of these fly-like symptoms, a patient may develop a yellowish tint to the skin and eyes (jaundice); sometimes though, jaundice never appears.  Sometimes urine turns dark brown and bowel movements look pale and gray.  The illness almost always resolves within several weeks to months with out treatment….

D’ Angelo’s Deli 2001:  In October of 2001, the D’Angelo’s corporate office contacted the Massachusetts Department of Public Health (MDPH) to inform MDPH that one of its employees had been diagnosed with hepatitis A, and that he had been working at two different D’Angelo’s delis – at Swansea and Seekonk, during his infectious period.

D’Angelo’s regional and corporate managers assured MDPH that the infected employee, who was ServSafe certified, was fanatical about hand washing and wore gloves when preparing food and touching surfaces.  The corporate office then voluntarily closed the Swansea store, without public notice of the illness.  Thirty doses of immuno globulin (“IG”) were sent to a walk-in clinic in Seekonk to be administered to all employees.

On Saturday, October 27, the Swansea Board of Health (“SBH”) became aware that the store had reopened for business, and inspected that store.  The SBH inspector and town nurse were informed by the D’Angelo’s district manager at the store that the MDPH had authorized the store to reopen if all employees had been given shots and if the sick employee stayed away from work until healthy.  No public notice of the hepatitis A illness of the D’Angelo’s employee, and of the fact that he had worked during at least 15 days of his infectious period, was provided at the time.

On November 20, 2002, the MDPH was notified of seven confirmed hepatitis A cases in the area.  All local boards of health were notified, and an investigation into this hepatitis A outbreak began.

Ultimately, the investigators identified a total of 53 hepatitis A cases meeting the definition of an outbreak-case.  An epidemiological analysis of the case interviews revealed an association between the hepatitis A illness and the consumption of food from D’Angelo’s.  Two of the confirmed cases were food workers employed at Rudy’s Country Store.  Both employees had eaten at the Swansea D’Angelo’s three to four weeks prior to the onset of their respective symptoms.  Both of the Rudy’s employees who tested positive had contact with food served to customers.

On November 27, 2001, a press release and public notice was published notifying the patrons of Rudy’s of their potential exposure to hepatitis A, and recommending that patrons who had eaten food from Rudy’s during the period from November 5 to November 23, 2001 obtain IG shots.  A clinic was held at Charlton Memorial Hospital to provide these treatments on November 29 and 30.  Approximately 1600 persons obtained IG shots there during those two days.  No hepatitis A cases were linked to the consumption of food sold at Rudy’s.

Chi-Chi’s 2003:  Pennsylvania State health officials first learned of a Hepatitis A outbreak when unusually high numbers of hepatitis A cases were reported in late October 2003. All but one of the initial cases had eaten at the Chi Chi’s restaurant at the Beaver Valley Mall, in Monaca, Pennsylvania.

Ultimately, at least 565 cases were confirmed. The victims included at least 13 employees of the Chi Chi’s restaurant, and residents of six other states (identity of the states was not given). Three persons died as a consequence of their hepatitis A illness.  Over 125 were hospitalized.  One man suffered liver failure, which required an emergency transplant.  More than 9,000 persons who had eaten at the restaurant, or who had been exposed to ill persons, were given an injection of immune globulin as prevention against hepatitis A.

Preliminary analysis of a case-control study indicated fresh, green onions were the probable source of this outbreak. Previous hepatitis A outbreaks had been linked to green onions, and had involved patrons of a single restaurant, however this outbreak was unusually large. The FDA issued a statement dated December 9, 2003, reaffirming that this outbreak, as well as others recently, had been associated with eating raw, or undercooked, green onions. The investigation and trace-backs by the state health department, the CDC, and the FDA, confirmed that the green onions had been grown in Mexico.

The viral sequence of the outbreak strain was similar to the viral sequences obtained from persons involved in hepatitis A outbreaks that had occurred in September 2003, in the states of Tennessee, Georgia, and North Carolina. Green onions had also been implicated in these outbreaks.

Friendly’s 2004:  In June of 2004, a food worker at a Friendly’s restaurant in Arlington, Massachusetts was diagnosed with hepatitis A, a virus that can cause acute liver failure.  Health officials estimated that more than 3,800 people were at risk for developing hepatitis A infection after dining at the restaurant.

In mid-June, more than 3,000 people exposed to the hepatitis A virus at Friendly’s lined up at an area clinic to receive immune globulin (“Ig”) shots to prevent hepatitis A infection. When administered within 14 days of exposure to the virus, Ig is effective in preventing – or at least reducing the symptoms of – hepatitis A infection.  Many of the people who lined up for shots were initially turned away and due to a lack of Ig and had to return later.

Quizno’s 2004:  A Boston Quizno’s employee was diagnosed with hepatitis A in June 2004. Upon notification of the potential for a hepatitis A outbreak, the Boston health department advised consumers who had eaten at the Quizno’s Subshop located at 74 Summer Street in Boston to receive Immune globulin shots to prevent infection.

Maple Lawn Dairy 2004:  On November 6, 2004, the Chemung County Health Department issued a hepatitis A news release announcing that four persons had confirmed hepatitis A infections, which were traceable to the Maple Lawn Dairy Family Restaurant in Elmira. The Health Department also advised that persons who had eaten at the defendant’s restaurant between September 26 and October 10, 2004 might have been exposed to the hepatitis A virus. A restaurant employee was diagnosed with the hepatitis A virus on October 10, 2004 and was working at the defendant’s restaurant while infected with the virus. The Department recommended that persons who had potentially been exposed receive injections of immune globulin, an antibody treatment that provides protection from the hepatitis A virus if exposure to the virus has occurred within 14 days prior to the injection.

Houlihan’s 2007:  On or about January 21, 2007 the KCHD, announced that a case of HAV had occurred in a food worker at the Houlihan’s restaurant located at 1332 Commons Drive, Geneva, Illinois. In a notice posted on the KCHD web site health officials warned that people who ate foods at the restaurant between January 8 through January 19 may be at risk of developing HAV.

Officials urged that anyone who ate cold or uncooked foods at the restaurant during that period should contact their health care provider and be administered Immune Globulin shots as soon as possible.  It is estimated that as many as 3000 persons were potentially exposed to HAV at the restaurant in the relevant time frame.

McDonald’s 2009:  On July 13, Rock Island County Health Department officials informed the McDonald’s corporate office that a McDonald’s franchise in Milan, Illinois had an employee infected with hepatitis A.  The employee had been working at that restaurant over the past week.  The next day, health officials went to the Milan McDonald’s and found that employees were washing their hands improperly and should have been wearing gloves when they had cuts, painted nails, or fake nails.  The inspector provided the employees material about proper hand washing and hepatitis A.

On July 15, health officials returned for a full inspection.  The inspection detailed a laundry list of violations, two of them critical, involving “hygienic practices” and “presence of insects/rodents.”  It was also reported that after the first employee was confirmed positive with hepatitis A on June 9, another employee had been confirmed positive with hepatitis A on July 15.  As a result, the Milan McDonald’s was ordered to close until all employees completed health histories, got vaccinated, and completed hand-washing training.

Though it was initially believed that the employee infections were not detected until July 13, evidence later surfaced suggesting otherwise.  The second employee who contracted hepatitis A, Cheryl Schram, had been diagnosed on June 20 and told the restaurant a few days later, once she had been released from the hospital.  Despite the highly contagious nature of her illness, she was permitted to return to work.

During the period when the infected employees had been allowed to work and handle food, it was estimated that as many as 10,000 people ate at that restaurant.  This led to county health officials inoculating more than 5,000 local residents against the disease in order to contain the outbreak.  Unfortunately, the damage had already been done and those infected were beginning to exhibit symptoms.

The Illinois Department of Public Health (IDPH) released a report of its investigation into the Hepatitis A outbreak on October 30, 2009. IDPH reported a final tally of 34 confirmed cases of Hepatitis-A with onsets from June 11 through August 10, 2009.  IDPH concluded that food from the Milan McDonald’s was the source of the outbreak.  IDPH explained:

The restaurant had inspection reports indicating issues with bare hand contact with food, employees reported no use of gloves when preparing foods not later cooked, during hand hygiene education the employees had difficulty in properly washing hands, and the index case in the community, a food handler at McDonalds, had a period of communicability and work history that match with the dates of onset of the majority of the other cases and she handed food that was not later cooked with bare hands.  In addition, the case-control study showed that there was an elevated risk of hepatitis A associated with consuming food from the McDonalds in Milan, Illinois.  Other possible sources in the community were ruled out.

Olive Garden 2001:  In August 2011, the Cumberland County Health Department announced that thousands of diners had potentially been exposed to Hepatitis A after an employee of a Fayetteville, N.C. Olive Garden had tested positive for the virus.  The employee was infected with hepatitis A while working shifts at the restaurant on July 25, 26, 28, 29, and 31, as well as August 1, 2 and 8.  Many people who had dined at the Olive Garden on those dates had to obtain a Hepatitis A vaccinations or Immune globulin (Ig) injections to prevent infection with the potentially deadly hepatitis A virus.  3,000 patrons received shots.

Money well spent:  Estimates of the annual costs (direct and indirect) of hepatitis A in the United States have ranged from $300 million to $488.8 million in 1997 dollars.  In one study conducted in Spokane, Washington, the combined direct and indirect costs for each case of hepatitis A from all sources ranged from $2892 to $3837. In a 2007 Ohio study, each case of HAV infection attributable to contaminated food was estimated to cost at least $10,000, including medical and other non-economic costs. Nationwide, adults who become ill miss an average of 27 workdays per illness, and 11-to-22 percent of those infected are hospitalized. All of these costs are entirely preventable given the effectiveness of a vaccination in providing immunity from infection.  See,