Editor’s note: This contributed piece is from the thesis of Jamie Ragos, the current holder of The Dave Theno Fellowship for Food Safety.

Thesis: Over the past three years, there has been an ongoing outbreak of Hepatitis A in the United States although it is the only foodborne disease that has a vaccination. Mandating vaccinations to food service workers is essential to reduce the spread of Hepatitis A, especially since outbreaks involving food handlers are in the public eye. 

Background & Analysis: It is estimated that in the United States alone there are 48 million cases of foodborne illness annually. Out of these 48 million, 128,000 are hospitalized and 3,000 people die. The CDC recommends to the general public that the best way to prevent Hepatitis A is through vaccination, but not have explicitly stated that food service workers should be administered the vaccination. While food service workers are not traditionally designated as having an increased risk of Hepatitis A transmission, they are not free from risk. Additionally, 24% of Hepatitis A cases are asymptomatic which means a food-handler carrying the virus can unknowingly transmit the disease to a consumer. Historically, when an outbreak occurs local health departments start administering the vaccine for free or at a reduced cost. The funding from these vaccinations is through taxpayer dollars. 

Talking Points:

  • A mandatory vaccination policy for all food service workers was shown to be effective at reducing infections and economic burden in St. Louis County, Missouri.,  
  • From 1996-2003, Clark Country, Nevada had 1,523 confirmed cases of Hepatitis A, which was higher than the national average. Due to the alarming rates, they implemented a mandatory vaccination policy for food service workers. As a result, in 2000 the Hepatitis A rates significantly dropped and reached historic lows in 2010. The county removed the mandatory vaccine rule in 2012 and are now part of the ongoing Hepatitis A outbreak. 
  • Unvaccinated food service workers may face job insecurity if they contract Hepatitis A as the wages do not pay enough for treatment. 
  • As global food trade increases, the probability of foodborne illness is bound to increase, and Hepatitis A is the only foodborne illness that we have a vaccine against.

Key Facts

  • There has been an increase in Hepatitis A outbreaks since 2016. In a one-year period, there was a 70% increase of cases in the nation.
  • As of November 1, 2019, there has been a total of 27,634 cases with a 60% hospitalization rate (approximately 16,679). The death toll stands at 275. Since the outbreak started in 2016, 30 states have reported cases to the CDC.
  • From 2000 – 2016 there is an average of three foodborne Hepatitis A outbreaks per year nationally. 
  • Approximately 5% of all Hepatitis A outbreaks are linked to food handlers.
  • According to the CDC the vaccinations cost anywhere from $30-$120 to administer compared to $740-$7,000 in hospital bills, and offer a 95% efficacy rate after the first dose and a 99% efficacy after the second dose. Furthermore the vaccine retains its efficacy for 15-20 years.  

Policy Idea

Before you are allowed to work in the healthcare industry, you are required to be up-to-date with your immunizations that follow hospital policy. This policy aims to do the same with food service workers regarding Hepatitis A, requiring restaurateurs and fast food chains to provide their employees Hepatitis A vaccinations, free of charge. It further asks the CDC to list food service workers as individuals who are recommended to get a vaccination. Vaccinating food service workers against Hepatitis A will reduce the number of preventable Hepatitis A cases. 

Policy Analysis

Hepatitis A is commonly spread through the fecal-oral route or if food and water is contaminated. Furthermore, in many cases, infected individuals are asymptomatic. If food service workers are infected, they have the potential of exposing thousands of customers in one day, leading to an outbreak. Additionally, many professional medical organizations recommend that the vaccine be administered.

During the present outbreak, if a food service worker is found to be Hepatitis A positive, a local health department will initiate post-exposure treatment plans that must be administered within a two week period to be effective. The economic burden also affects the health department in terms of personnel and other limited resources. Sometimes the interventions placed by the local health department may be ineffective. These treatment plans use taxpayer dollars that could be going somewhere else. Studies have shown that the epidemiology of Hepatitis A is shifting. Prior outbreaks have been linked to asymptomatic children, but the recent outbreak is currently affecting more adults.

Additionally, the vaccine is more cost-effective than patient treatment. Current prices for the vaccine range anywhere from $30-$120. For acute hepatitis A treatments, healthcare costs were estimated to be $740 for non-hospitalized patients and $7,000 for hospitalized patients in 1997. Healthcare costs have definitely increased over the past 22 years, making vaccination much more cost-effective. 

Furthermore, many studies believe that if we administer the vaccine, Hepatitis A can be eradicated as the only reservoir is humans. Right now, the only disease that has been eradicated is smallpox. Smallpox eradication was achieved in 1980 through vaccination and surveillance. Polio is also very close to being eradicated. Currently, there are three countries that have not stopped the transmission of polio. Immunizations are the only way to eradicate this disease.  Regarding other viruses such as measles and chickenpox, vaccination has shown a significant decrease in the number of cases worldwide. , 

Requiring mandatory vaccinations for food service workers is important for public safety and public health, especially since our global food trade is projected to increase over the years, increasing the probability of foodborne disease outbreaks. Further, implementing a mandatory vaccination policy ensures high uptake, which is required to prevent future outbreaks. Evidence shows that vaccination is the most effective and efficient way to reduce the prevalence of viruses. Furthermore, once individuals are vaccinated, they have permanent immunity. 

Next Steps

  1. Include food service workers as individuals who are recommended to get a vaccine by the CDC. 
  2. Before food service workers are allowed to work, they MUST be vaccinated against Hepatitis A, unless they cannot due to medical or religious reasons. Immunization records must show the Hepatitis A vaccination as proof before employment. If the future employee is not yet vaccinated against Hepatitis A, the employer must provide the vaccination to them free of charge before employment begins.
  3. Current food service workers, who are not vaccinated against Hepatitis A must receive both doses of the Hepatitis A vaccine within a year.
Jamie Ragos

Editor’s note: The Dave Theno Fellowship was established posthumously by colleagues and friends after he died while swimming in Hawaii. Theno was a key expert who helped convince Congress that there should be a law against selling beef that is contaminated with E. coli. That law was created and is credited with saving lives and preventing countless illnesses. He worked for Jack in the Box during the deadly 1993 E. Coli outbreak, helping the company establish controls that spread across the meat industry. Stop Foodborne Illness takes nominations for the year-long fellowship and announces the winner at the annual conference of the International Association for Food Protection.

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