An ongoing hepatitis A outbreak among more than 1,200 people in at least five states, with more than 800 hospitalizations and 40 deaths, has local and state officials struggling to meet vaccination needs.

Many of the victims of the outbreak — described by the California Department of Public Health as the largest person-to-person hepatitis A outbreak in America since a vaccine for the virus became available in the mid-1990s — are homeless people or substance abusers, or both.

Source: CDC
Food Safety News graphic by Kelsey Mackin

However, a third of the 644 confirmed ill people in California and a fourth of the 495 confirmed ill people in Southeast Michigan are neither homeless nor substance abusers. Other states reporting confirmed outbreak cases are Utah, Arizona and Colorado.

City, county and state officials from Ohio to Alabama and back to California are entertaining discussions about how they can decrease the possibility of outbreaks in their communities and how to curb outbreaks already underway.

Those efforts include considering whether to open new public restrooms; raiding areas where substance abusers and homeless people are known to congregate; and closing down food programs for the homeless operated by churches and charitable organizations.

Cases across the country in people of all walks of life have been by laboratory evidence as well as epidemiologic evidence. The outbreak is caused by related strains of the same hepatitis A virus genotype (IB), which is not commonly seen in the United States, according to public health officials.

Federal response
As frantic as local and state officials are, with some posting weekly victim counts and details about vaccination locations, federal officials have been less vocal.

The U.S. Department of Health and Human Services last posted an outbreak update on Aug. 8, saying “Vaccination is safe and an effective approach for hepatitis A prevention so it is a focus of the public health response to several ongoing outbreaks.” The HHS department page did not have current outbreak counts as of Thursday.

The federal Centers for Disease Control and Prevention updated some of its outbreak information as recently as Monday this week, posting Utah’s case count of 57 victims with 30 hospitalizations. However, as of Thursday the CDC outbreak page was still showing Oct. 27 numbers from California.

The CDC has not updated its “Current Vaccine Shortages & Delays” information on hepatitis A vaccine since mid-October, although officials in California and Michigan have been complaining for weeks that supplies are running short of demand.

“In light of ongoing outbreaks of hepatitis A among adults in several U.S. cities, the demand for adult hepatitis A vaccine has increased substantially over the past 6 months and vaccine supply to meet this unexpected demand in the U.S. has become constrained,” according to the CDC website.

Those “constrained” supplies led California Gov. Jerry Brown to declare a state of emergency on Oct. 13 in an effort to secure more of the vaccine. Under the declaration, the state can “purchase additional vaccines directly from manufacturers and coordinate distribution to people at greatest risk in affected areas,” according to the California Department of Public Health.

But the CDC reports the two U.S.-licensed manufacturers of hepatitis A vaccine for adults, GlaxoSmithKline and Merck Vaccines, are having difficulties meeting demand, regardless how it’s being purchased.

“Merck has reported that its adult Hepatitis A vaccine is temporarily unavailable for shipping,” according to the CDC’s mid-October update.

Other details on the vaccine supply were not available this week from the CDC. Questions submitted to the agency Monday morning by Food Safety News had not been answered as of Thursday night.

Other vaccination issues
The ongoing outbreak includes restaurant workers in at least two states, California and Michigan, but officials at all levels say foodservice employees are not the cause of the outbreak. Rather, they are victims themselves of the highly contagious virus.

That assurance does nothing to protect the consumers who ate at restaurants where infected employees were working.

From Champs Rotisserie and Spirits in Grosse Point Woods, MI, to MacKenzie’s Sports Bar and Grille in Sacramento, CA, diners have been advised to seek post-exposure shots to help prevent infection. The post-exposure treatment must be taken within two weeks of exposure to be effective.

However, that window of opportunity can be closed before it even opens because infected foodservice workers may not be diagnosed in time for customers to be treated.

Foodservice workers can spread the hepatitis A virus by working while infected, which often occurs because infected people are contagious before they develop symptoms. That fact, combined with failure to follow proper hygiene and handwashing procedures is a recipe for disaster in any foodservice operation.

One solution would be for all restaurant and other foodservice workers to be vaccinated for hepatitis A. Unlike most children in the U.S., who since 2000 have been routinely vaccinated against the virus, the majority of adults in the United States have not received the vaccine.

“Restaurants can’t require their employees to be vaccinated,” said Seattle food safety attorney Bill Marler. “But they can encourage them to do so and they can pay for the vaccinations. Restaurant owners who don’t are just being stupid, willfully stupid.”

Marler doesn’t believe the government should mandate hepatitis A vaccinations for foodservice workers, though. He sees the situation as one of industry engaging in self-policing.

“I don’t think it’s really a government thing, it’s a self-protection thing for restaurants,” Marler said. “I’ve taken millions of dollars from restaurants in the past 15 years because they had employees who weren’t vaccinated.”

Those millions involved reimbursement for consumers who sought post-exposure treatment. Just paying for the doctor visits, injections and time away from work adds up quickly when tens of thousands of people are involved. Marler said it is much less expensive to pay for employees to be vaccinated than to pay for customers to receive post-exposure treatment.

Restaurant owners can also be on the hook for hepatitis A outbreaks related to food that was contaminated before they took possession of it. Such outbreaks usually have many more illnesses than those associated with an infected employee.

In 2016 an outbreak traced to frozen, raw scallops imported from the Philippines and served at Genki Sushi restaurants in Hawaii sickened 292 people and killed two. Also in 2016, a hepatitis A outbreak traced to frozen strawberries imported from Egypt and served at Tropical Smoothie restaurants sickened 134 people in nine states.

In 2003 an outbreak among patrons of a Chi Chi’s in Beaver County, PA, sickened more than 650 people and killed four. The victims included at least 13 employees of the restaurant, and numerous residents of six other states. The outbreak was traced to fresh green onions.

More than 9,000 people who had eaten at the restaurant during the period of potential exposure, or who had been exposed to ill people, received post-exposure treatment.

“There’s no question that contaminated food can make for bigger outbreaks,” Marler said. “It’s an efficient way to poison people.”

Food safety regulations and testing can help decrease outbreaks traced to contaminated food, but the dozens of outbreaks traced to infected workers each year are completely preventable. The vaccination takes care of the problem before it starts, Marler said. He also said the one positive from hepatitis A scares that cause restaurant goers to seek post-exposure injections is the lasting impact such situations have.

“The success of the post-exposure vaccine can be seen because there are fewer people getting sick over the long run,” Marler said.

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Editor’s note: Bill Marler is publisher of Food Safety News.