Hepatitis A in a food worker and subsequent prophylaxis of restaurant patrons.

Introduction

The Centers for Disease Control and Prevention (CDC) have estimated that in 2002 38,000 cases of acute hepatitis A occurred in the United States, with 8,795 acute cases reported (CDC, 2004). Infections among food workers require timely public health assessment and control and entail significant costs. This report outlines the immediate response of a local health department to a hepatitis A case in a food worker with the potential for the infection to spread to restaurant patrons.

A laboratory-confirmed hepatitis A patient was reported to Tri-County Health Department (TCHD) in Colorado on Monday, December 30, 2002. Three household contacts and one sexual partner were provided with immune globulin to prevent illness. In addition, the individual with the case was determined to be an employee of a fast-food restaurant. TCHD conducted an environmental investigation of the restaurant and identified handwashing deficiencies. The restaurant manager reported that the ill employee had worked while infectious, had had frequent and direct contact with ready-to-eat foods without gloves, and had not practiced proper hand hygiene. The onset date of jaundice for this case was December 23. Given the infectious period for hepatitis A, possible exposure through food handled by the ill employee could have occurred on December 10 and December 13 through December 20.

The Clinic

Key TCHD staff representing epidemiology environmental health, and public health nursing met and decided to hold a mass immunoprophylaxis clinic. As is often the case in these situations, the department had less than one day to prepare; therefore, staff immediately began developing plans for the clinic. A news release was issued to notify and advise restaurant patrons to get an immune globulin (IG) shot at the clinic to prevent potential hepatitis A illness. The news release emphasized the location of the restaurant and the days of exposure, based on period of infectiousness and the fact that IG is effective only if given within 14 days of exposure. On the basis of the typical 500-600 transactions per day that the restaurant processes, TCHD planned to accommodate about 900 clients. The Colorado Department of Public Health and Environment (CDPHE) acquired 945 doses of IG to be administered over two clinic days, January 2 and 3, 2003, from 8 a.m. to 5 p.m.

Coordination, implementation, and phone coverage of each clinic day involved the following staff: 12 environmental health staff, 7 public health nurses, 6 administrative support staff, 3 epidemiologists, 1 public information officer, and 1 physician, In addition, the clinic had two Spanish-speaking staff to assist with translation, one CDPHE staff member and one public health nursing staff member (Figure 1). Prior to approving clients for IG, staff greeted them and obtained basic demographic information, information on allergies, and medical consent. Then clients were screened for the appropriate window of exposure, history of hepatitis A disease and vaccine, and any potential symptoms. Eligible individuals were weighed and seen by a public health nurse who administered injections. Fourteen symptomatic people were referred for external medical care.

[FIGURE 1 OMITTED]

A total of 693 people received IG at the TCHD clinic; 289 on January 2 and 404 on January 3. The clinic screened an additional 195 individuals who were determined to be ineligible to receive IG. During the week following the news release, TCHD received 550 calls from the public inquiring about the IG clinic and asking for general information about the hepatitis A virus.

TCHD ensured that all employees of the restaurant either received IG or were removed from the work schedule for the following 50 days. Also, TCHD utilized its Health Alert Network to fax a hepatitis A advisory to physicians informing them of potential exposure dates, symptoms, laboratory tests, and treatment for hepatitis A.

Follow-up inspections of the restaurant were conducted over the next six weeks to assess the health status of employees, handwashing practices, handwashing facilities, and proper glove usage. No additional restaurant employees were ill, and no additional reported cases of hepatitis A were associated with the ill employee.

Conclusions

TCHD decided to offer immunoprophylaxis to restaurant patrons since the ill food worker had been infectious while preparing ready-to-eat foods and had not practiced proper hand hygiene. The Advisory Committee on Immunization Practices (ACIP) recommends considering prophylaxis for people who consume food prepared by an infected person if 1) the food worker has directly handled uncooked food or food after cooking, 2) the food worker has had diarrhea or poor hygiene practices, and 3) patrons can be identified and treated within two weeks of the exposure (CDC, 1999). According to restaurant management, the infected employee had prepared ready-to-eat foods and had poor hygiene practices; however, the employee had denied both of these assertions when interviewed.

Difficulties in the evaluation of food-preparing responsibilities and the risk of transmission have resulted in several food-borne hepatitis A outbreaks (Dalton, Haddix, Hoffman, & Mast, 1996; Hooper et al., 1977; LaPorte et al., 2003; Massoudi et al., 1999; Skala et al., 1993). TCHD's first lesson learned from this incident is that risk assessment should include interviewing the person with the case, as well as interviewing restaurant management and inspecting the facility. In addition, the department learned about the process of setting up an immunoprophylaxis clinic; what were found to be key components of successful planning are given in Table 1. This clinic experience also provided practical emergency preparedness training for the local public health agency.

TCHD has a detailed accounting system, according to which the financial cost of holding this clinic totaled $48,300, or $69.70 per vaccinee; all expenses were recovered from the restaurant corporation. Costs included personnel time (combined total of 900 hours), related benefits, immune globulin, administrative support, and supplies. Despite the considerable cost of the clinic, TCHD took the opportunity to prevent potential illness within the community. The risk of transmission was likely low, as indicated by the lack of identified secondary cases; however, the cost of not providing immunoprophylaxis could have been much higher. A societal cost of over $800,000 was estimated to be associated with a foodborne hepatitis A outbreak in the Denver metropolitan area in 1992 that involved 43 cases and prophylaxis of 16,293 people. The highest single cost was administration of immune globulin (Dalton et al., 1996).

Effective hepatitis A vaccine has been available in the United States since 1995, and substantial reduction in disease incidence has occurred in recent years. Currently, CDC's Advisory Committee on Immunization Practices (ACIP) recommends considering hepatitis A vaccine for food workers who work in areas where state and local health authorities or private employers deem it cost-effective. An economic analysis by Meltzer and co-authors (2001) determined that routine vaccination of restaurant workers was not economical either from the perspective of the restaurant owner or from a societal perspective (2001). Because of the finances and the fact that the vaccine would prevent infection from only one of many enteric agents, it is probably difficult to justify routinely recommending vaccination for food workers. Employers who want to reduce the risk of hepatitis A infection among employees, however, should focus on providing vaccine to people with risk factors for infection, including men who have sex with men, illicit-drug users, and people who travel to developing countries (Fiore, 2004). Ultimately, the most cost-effective means of preventing foodborne illness from any agent is proper food preparation and good hand hygiene.

Acknowledgements: The authors thank the public health nursing and environmental health staff of the Tri-County Health Department who assisted in this effort, particularly Lynn Trefren, R.N., M.S.N., and Bruce Wilson, M.P.A., for their coordination efforts. Thanks also go to the Communicable Disease section at the Colorado Department of Public Health and Environment for their assistance.

Corresponding Author: Jennifer L. Patnaik, Epidemiology Program Coordinator, Tri-County Health Department, 7000 E. Belleview Ave., Suite 301, Greenwood Village, CO 80111. E-mail: [e-mail].

REFERENCES

Centers for Disease Control and Prevention. (1999). Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 1999. Morbidity and Mortality Weekly Report, 48(RR-12), 1-37.

Centers for Disease Control and Prevention. (2004). Hepatitis surveillance (Rep. No. 59). Atlanta, GA: U.S. Department of Health and Human Services.

Dalton, C.B., Haddix, A., Hoffman, R.E., & Mast, E.E. (1996). The cost of a food-borne outbreak of hepatitis A in Denver, Colo. Archives of Internal Medicine, 156, 1013-1016.

Fiore, A. (2004). Hepatitis A transmitted by food. Clinical Infectious Disease, 38, 705-715.

Hooper, R.R., Juels, C.W., Routenberg, J.A., Harrison, W.O., Kilpatrick, M.E., Kendra, S.J., & Dienstag, J.L. (1977). An outbreak of type A viral hepatitis at the Naval Training Center, San Diego: Epidemiologic evaluation. American Journal of Epidemiology, 105(2), 148-155.

LaPorte, T., Heisey-Grove, D., Kludt, P, Matyas, B.T., DeMaria, A., Dicker, R., De, A., Fiore, A., Nainan, O., & Friedman, D.S. (2003). Foodborne transmission of hepatitis A--Massachusetts, 2001. Morbidity and Mortality Weekly Report, 52(24), 565-567.

Massoudi, M.S., Bell, B.P., Paredes, V, Insko, J., Evans, K., & Shapiro, C.N. (1999). An outbreak of hepatitis A associated with an infected food handler. Public Health Reports, 114(2), 157-164.

Meltzer, M.I., Shapiro, C.N., Mast, E.E., & Arcari, C. (2001). The economics of vaccinating restaurant workers against hepatitis A. Vaccine, 19, 2138-2145.

Skala, M., Collier, C., Hinkle, C.J., Donnell, H.D., Schlenker, T., Fessler, K., Hotelling, M., Hopfensperger, D., Schloss, M., & Middaugh, J.P. (1993). Foodborne hepatitis A--Missouri, Wisconsin, and Alaska, 1990-1992. Morbidity and Mortality Weekly Report, 42(27), 526-529.

Jennifer L. Patnaik, M.H.S.

Laura Dippold, M.P.H.

Richard L. Vogt. M.D.

TABLE 1 Key Components in Successful Planning of a Clinic for Mass
Hepatitis A Immunoprophylaxis

Planning
Phase          Component

Pre-clinic
               * Bring together epidemiology/disease control,
                 environmental health, nursing, and public information
                 staff to make key decisions
               * Identify lead roles and staff to fill these roles
               * Inform all agency staff of the situation
               * Estimate adequate amount and locate immune globulin
               * Identify convenient clinic site locations and times
                 (near restaurant)
               * Notify the media promptly and issue news release
               * Notify state and local public health agencies and the
                 medical community
               * Prepare for public phone calls
               * Determine personnel needed at clinic and recruit staff
               * Determine clinic flow process
               * Develop screening questionnaire to document client
                 information
               * Develop hepatitis A and immune globulin fact sheets for
                 the public (English and non-English if necessary)
               * Determine case definition for symptomatic people
               * Thoroughly educate clinic staff on hepatitis A and
                 immune globulin
During clinic
               * Implement incident command system within the clinic
               * Screen clients for exposure, history of vaccine and
                 infection, and symptoms
               * Brief involved staff both before and after each day of
                 the clinic
               * Monitor media activities at the clinic
               * Provide on-site translators for non-English-speaking
                 clients
               * Establish medical-referral locations for potential
                 cases
Post-clinic
               * Debrief with key staff to identify areas of success and
                 challenge
               * Take this opportunity to educate restaurants on
                 foodborne illness
               * Monitor for related cases
               * Continue to implement control measures at the
                 implicated establishment
               * Use clinic outcomes as a tool to improve existing
                 emergency response plans