What could be better than dining with friends or family at a popular upscale candlelit restaurant in New York City — a restaurant with an “A” sanitation grade from the city’s Department of Health and Mental Hygiene? While that’s how the story began for many of the people who ate at Alta restaurant in the West Village from March 23 to April 2, it ended with the jolting news that if they had had dessert during that time period, they should get a shot (and another one 6 months later) to protect themselves against hepatitis A. The restaurant’s manager, Manny Solano, told reporters that a pastry chef who had traveled to Mexico discovered she had hepatitis A after going to a doctor because she wasn’t feeling well. It turned out she had contracted the virus during her trip south of the border. Michael Piacente and his wife, who had ice cream sundaes at the restaurant, first learned about it when they got to their room after their wedding. They were surprised indeed to find a message from the city’s health department informing them that they should get hepatitis A shots. (Their names and phone number were on the restaurant’s reservation list.) Michael said they immediately began googling “hepatitis A.” “It wasn’t quite what we had in mind for our wedding night,” he said. They got the shots and also ordered blood tests, and are waiting to get the test results on April 9 as they prepare to go on their honeymoon. “Hopefully, this doesn’t ‘get us’ on our honeymoon,” Michael said. “We’ll be keeping our fingers crossed.” Although he described the food at the restaurant as “awesome,” he said he’d “never go back there.” Another restaurant patron, Rob Fishman, 27, an editor at BuzzFeed, took family and friends to Alta, where they enjoyed some apple and chocolate desserts. He told a reporter from the New York Daily News that although the desserts tasted good at the time, if he had known they were “garnished” with hepatitis A, he wouldn’t have ordered them. Like Piacente, he also said that he doesn’t see himself going back there anytime soon. Fishman is one of 437 people — 52 of them Alta employees — vaccinated against the highly contagious disease on April 6, 7 and 8, according to information emailed to Food Safety News by the city’s Department of Health and Mental Hygiene (DHMH). The city paid for the shots, which cost $21.59 per dose, and won’t be billing the restaurant. The Piacentes, who live in Conneticut, went to a doctor to get their shots and blood tests. What is hepatitis A? Hepatitis A is is a contagious liver disease that results from being infected with the hepatitis A virus, according to the U.S. Centers for Disease Control and Prevention. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months. Hepatitis A is usually spread when a person ingests fecal matter — even in microscopic amounts — after coming into contact with objects, food or drinks contaminated by the feces of an infected person. Unlike hepatitis B and C, which can stay in a person’s body and lead to chronic disease and long-term liver problems, hepatitis A does not become chronic. People with mild cases don’t need to be treated, and most of the people infected with the virus typically don’t suffer permanent liver damage. However, that’s not always the case, as can be seen in this video about a man who had to have a liver transplant after contracting hepatitis A from contaminated green onions in a Chi Chi’s restaurant. By the time doctors discovered that he had the disease, it was too late for him to get a preventive shot. In the case of a restaurant employee, hepatitis A can be spread to food or surfaces — and from there to people dining or working at the restaurant — if the worker doesn’t follow basic hygiene practices, chief among them washing his or her hands after going to the bathroom. “This incident serves as an important reminder to always wash your hands thoroughly to prevent the spread of disease,” New York City Health Commissioner Dr. Thomas Farley said in a statement urging the restaurant’s patrons to get vaccinated as a precautionary measure. The hepatitis A virus is relatively stable and can survive for several hours on fingertips and hands and up to two months on dry surfaces. And although high temperatures will kill the virus, freezing temperatures do not. People who have had possible exposure to the virus and get the necessary shots within 2 weeks of exposure — the sooner the better — will have long-term protection against the virus. The tricky thing about hepatitis A is that people infected with the virus are the most infectious two weeks before they actually become ill. In other words, they can be passing the disease on to other people without even knowing they have it. Symptoms usually appear 2 to 7 weeks after exposure, and may include fever, fatigue, loss of appetite, nausea, vomiting, stomach pain, pale-colored stools and dark urine. A yellowing of the skin and eyes (jaundice), may occur a few days after symptoms appear. Symptoms generally last one to two weeks but can last longer. What’s happening at Alta? Restaurant manager Manny Solano told Food Safety News on April 8 that all of the restaurant’s employees were vaccinated during the recent vaccination clinics held by the health department. Going one step farther, he also said that from now on the restaurant won’t hire anyone who hasn’t been vaccinated against the virus. Christopher Chesnutt, owner of the restaurant, said that the infected employee is no longer on the premises. A prepared statement from the restaurant, emailed to Food Safety News on April 8, said that the restaurant has been certified by the NYC DHMH as being free of any health risks and that “it is completely safe to eat at Alta.” Also, according to the statement, the incident was isolated to one part-time pastry department employee, who worked only 3 days between March 23 to April 2. The department is physically isolated from the other food preparation areas in the restaurant. “As soon as we became aware of the incident, all food items that could have possibly been in contact with the employee were immediately discarded,” says the statement. As of April 9, there were no reports of anyone working or dining at the restaurant contracting the virus. The restaurant was allowed to reopen for dinner on April 5 — without desserts, and was allowed to start serving all courses again on April 6. A city DHMH spokeswoman told Food Safety News that the health department will be offering additional training on hepatitis A for food handlers and that it is “continuously reviewing its regulations to protect the health of New Yorkers.” Anyone needing more information from the city health department is advised to call 311. What about mandatory vaccinations for food workers? Although the number of people getting hepatitis A due to an infected restaurant worker may be low, the number of people who have to receive shots to safeguard themselves from getting the virus should a worker be infected adds up, according to a rundown of cases compiled by Bill Marler, publisher of Food Safety News. For example, in a June 2004 incident in which a food worker at a Friendly’s restaurant in Massachussetts was diagnosed with hepatitis A, more than 3,000 people lined up at an area clinic to receive shots. In an incident involving infected food workers at a McDonald’s restaurant in Milan, Illinois, in 2009, more than 5,000 local residents were inoculated against the disease. Even so, most people do not get sick when someone at a restaurant has hepatitis A, according to the CDC. However, if the food worker is infectious and has poor hygiene, the risk will go up. In an article written for Clinical Infectious Diseases by Anthony E. Fiore of the Division of Viral Hepatitis at CDC in Atlanta, Fiore said that “routine vaccination of all food handlers is not recommended because their profession does not put them at higher risk for infection.” He also pointed out that according to an economic analysis, it would not be economical “from a societal or restaurant owner’s perspective.” Costs in that economic model were driven by the turnover rate of employees and the small percentage of hepatitis A cases attributed to infected food service workers. Even so, the article said that employers concerned about reducing the risk of hepatitis A among employees should focus on providing hepatitis A vaccinations for the people who have risk factors for infection. That would include men who have sex with men, illicit drug users and people planning to travel to developing countries. Yet the article also pointed out that as of 2004 (when the article was written), the source of most reported foodborne hepatitis A outbreaks had involved infected food handlers, such as those in restaurants or those who prepare food for social events such as weddings. “A single hepatitis A-infected food handler can transmit hepatitis A to dozens or even hundreds of persons and cause a substantial economic burden to public health,” says the article. And while most food handlers with hepatitis A do not transmit the virus to fellow workers or restaurant patrons (based on surveillance data), many hundreds of restaurant workers have hepatitis A every year, according to the article. The article concludes by saying that reducing foodborne transmission of the virus can be achieved by improving food production and food handler hygiene and by providing preventive vaccinations to people at risk for infection. In an email to Food Safety News, Dr. David Acheson, former Associate Commissioner of Foods at the U.S. Food and Drug Administration, said although the data in Fiore’s article is not current, “the messages are still appropriate.” Acheson pointed to the economic challenge of the cost of preventing a disease that is not very common. According to the CDC, rates of hepatitis A in the United States are the lowest they have been in 40 years. That’s thanks in large part to a hepatitis A vaccine that was introduced in 1995 and is now routinely administered to all children, travelers to certain countries and people at risk for the disease. New York City DHMH spokeswoman Veronica Lewin told Food Safety News in an email that the incidence of hepatitis A is low in the city and has been declining in recent years. “We believe that the current regulations are sufficient to manage the risk and promote food safety in restaurants,” she said, adding that hepatitis A is now part of the routine childhood vaccination series in New York City. Along those same lines, National Restaurant Association spokeswoman Katie Laning Niebaum told Food Safety News that the CDC reports a 92 percent decline in hepatitis A occurrence in the United States since 1995 and that the rate of hepatitis A is now 1.0/100,000, the lowest rate on record. Responding to questions about whether food workers should be required to be vaccinated against hepatitis A, Joan Rector McGlockton, a food policy official with the Association, said that hepatitis A is “a serious disease and restaurant owners and operators take precautions to prevent exposure to their customers.” “Restaurants operate with good personal hygiene practices and employee-illness controls in order to prevent exposure from a sick worker to a customer,” she said, adding that the FDA requires ‘exclusion practices’ for any employee with symptoms of hepatitis A or anyone confirmed to have the illness. That may be, says food safety attorney Marler, but wouldn’t the money spent on mandatory hepatitis A vaccinations for food workers be well spent? In saying that, he points to estimates of the annual costs (direct and indirect) of hepatitis A in the United States that 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 $2,892 to $3,837. In a 2007 Ohio study, each case of hepatitis A infection attributed 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 work days 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,” Marler said. He also calls the National Restaurant Association’s stand against mandated hepatitis A vaccinations “largely indefensible,” especially for the vast majority of independent restaurant operators who are, in most cases, unable to absorb outbreak-related losses from a single outlet. “Had Alta either paid for or encouraged staff to get shots, none of this adverse publicity would be happening to it,” he said. “How much is that worth?” He also pointed out that in his experience as an attorney, average settlements for people “injured” in hepatitis A outbreaks is higher than in Salmonella cases — “closer to $50,000 at a minimum.” His law firm has filed several class action cases involving people who had to stand in line and get shots. Settlements ranged from $150 per person to $400 per person, depending on whether they had to pay for the shot or if the city, county or state did. Michael Piacente, the Alta diner who learned that he and his wife needed to get shots, said he definitely thinks restaurants should require employees to be vaccinated against the virus. “Why take the risk?” he said. “Why put customers at risk? Why expose people to the possibility of getting hepatitis A?” He also hates to think what could have happened if he and his wife hadn’t left their phone number when they made reservations at the restaurant. “Thank God they called us,” he said. “Otherwise we may never have known and could have gotten sick. I think requiring food workers to be vaccinated against the virus would give restaurant owners peace of mind — especially in New York City where there are so many people working in restaurants.” A county takes a stand In 1999, St. Louis County, Missouri passed an ordinance requiring all foodservice workers to be vaccinated against hepatitis A. Richard Knaup, manager of Communicable Disease Control Services with the St. Louis County Health Department, told Food Safety News in an email that what prompted the county to take this action were three hepatitis A outbreaks between 1993 and 1999, each of which involved a busy food establishment. And while most of the county’s hepatitis A cases during that time did not involve food handlers, these outbreaks comprised the majority of the county’s cases. Knaup said restaurant owners have accepted the ordinance, pointing out that it is their responsibility to assure compliance. Review of immunization records is a standard part of the Department’s inspections. “Compliance has been very good,” he said. And while the county does not provide a discount for hepatitis A immunizations to food service workers, it does offer vaccines for a fairly reasonable price ($37 per immunization including the administration fee). As for whether diners appreciate the ordinance, Knaup said that since its passage, hepatitis A cases have decreased dramatically in the county compared to the early 1990s — from 332 acute cases of the virus in 1993 to only 3 in 2012. (That decline can also be attributed to the hepatitis A vaccine developed in 1995.) The City of St. Louis has a similar ordinance. When it comes to earning recognition for this ordinance, one of county’s epidemiology specialists, Ayesha Iqbal, wrote up the county’s experience with the mandatory hepatitis A immunization requirement for food handlers as a model practice and submitted that to the National Association of City and County Health Officials (NACCHO). Her application was awarded Model Practice status and will be presented at NACCHO’s annual meeting this summer.