When I first started my clinical rotations for my medical technology degree in college, I was required to be up to date on all my immunizations. I had not received the hepatitis B vaccine at the time, so I was given the three-dose series by the university. Once I graduated and started working at a hospital, the infection prevention nurse took a sample of blood and sent it away for testing for antibody levels (titers) for measles, mumps, rubella, hepatitis B and chickenpox. I was also tested for tuberculosis. Because I had received the BCG vaccine in Mexico, the test — a skin tuberculin test — was positive, resulting in yearly chest x-rays to look for tuberculosis.
All of this was part of the process of working in healthcare. With hepatitis B being more infectious than HIV and surviving on surfaces soiled with body fluids for a longer time than HIV, there is a real concern that healthcare workers are at increased risk of contracting hepatitis B. Due to this, 99.9% of healthcare institutions require the hepatitis B vaccine for their employees. Many do it because it is good practice to protect patients and employees from transmission of the disease. Others do it for that reason and because the vaccine requirement is codified into law in several states and cities.
Recently, the United States has been experiencing several outbreaks of hepatitis A. Like hepatitis B, hepatitis A is a viral infection of the liver. It is more acute in its presentation, meaning that the person is sick for a few days and then recovers, although some people do end up having “fulminant” hepatitis A and die of liver failure. (People with chronic liver conditions, like chronic hepatitis B or hepatitis C are at increased risk of fulminant hepatitis A.)
Hepatitis A is primarily transmitted via the fecal-oral route, meaning that someone with the disease will shed the virus in their feces. If they do not practice good hand hygiene, they could transmit it to healthy people by preparing foods or drinks. This may lead to an outbreak of hepatitis A if the food handler prepares food for a large group of people. Other outbreaks have happened when sewage contaminates the water supply. For some recent outbreaks in the United States, there is some evidence that the opiate epidemic is what is fueling the outbreaks.
Like hepatitis B, HIV and other blood borne infections, hepatitis A can be transmitted through the use of contaminated needles. If someone who is using intravenous drugs like heroin, they may become infected if they share a needle with someone who has the disease. They are also at increased risk for hepatitis A and other diseases if they are incarcerated due to the criminalization of their addiction.
Luckily, there is a hepatitis A vaccine with an excellent track record of safety in the United States. In San Diego, California, in 2016, an outbreak of hepatitis A made over 600 people sick and killed 20. Public health authorities deployed thousands of hepatitis A vaccines and worked to resolve the issues of homelessness and drug addition that fueled that outbreak. That outbreak took two years to bring under control.
For some time now, several local jurisdictions have looked at requiring the hepatitis A vaccine for food handlers to reduce the risk of outbreaks associated with food establishments. Just this week, Franklin County, Missouri, issued such a requirement:
“The ordinance requires vaccines for all restaurant workers and anyone involved in food preparation. It covers hospital cafeterias, school kitchens, daycare facilities, nursing homes, catering businesses, and mobile food outlets.
Union City BBQ co-owner Jeffrey Stevenson told local media that he was surprised the ordinance wasn’t adopted “a long time ago.” His employees are already vaccinated.”
Aside from the cost in impacts to human health and life, an outbreak of hepatitis A can be devastating for a food establishment in terms of liability and public relations. A Mexican-style restaurant chain declared bankruptcy and faced a class-action lawsuit after hundreds of patrons became ill with hepatitis A, although the eventual culprit of that outbreak was traced to green onions imported from Mexico. In New York, a fast food restaurant chain was also hit with a lawsuit after an employee at one of its locations was found to have exposed hundreds of people to the disease.
Although the hepatitis A vaccine is recommended for all children born in the United States, not everyone gets it. Some parents refuse it for their children, and some of us are too old to have been included in the recommendations. Still, the vaccine is recommended for adults with an elevated risk of contracting the disease — such as those who are incarcerated, work in healthcare, provide care for people in institutional settings or are intravenous drug users — or with an elevated risk of infecting large groups of people, as food handlers are.
Hopefully, Franklin County is not the last local jurisdiction to mandate hepatitis A vaccine for food handlers. Just like healthcare workers need to be immunized against diseases they might come into contact with and/or transmit to their patients, food handlers need to be protected from being vectors of what can be a serious viral infection that is transmitted easily through food and drink. Perhaps with time enough people will be immunized in high-risk groups to slow down the current outbreaks around the country and prevent more outbreaks from happening.