Publisher’s Platform: MAHA my Ass

Hepatitis A is a viral infection of the liver. It is extremely contagious and is spread through feces, often through contaminated food or close person-to-person contact. This can cause sudden liver failure or chronic liver inflammation.

The CDC has received reports of 1,648 new hepatitis A infections in 2023 — the latest available data from the agency — although it estimates new infections are likely closer to 3,300 after accounting for undertesting and underreporting. Most cases involved adults, and at least 85 people died from hepatitis A in the United States that year.

The hepatitis A vaccine became available in the United States in 1995. In 2006, the ACIP recommended that all children be vaccinated against the disease. Cases fell dramatically, by more than 95 percent between 1996 and 2011, after the vaccine was introduced and recommended for children.

Until Monday, the CDC recommended the two-dose series for all children ages 12 to 23 months. Now, most will not be recommended the shot.

Hepatitis A is a vaccine-preventable infection, and it is the only vaccine for foodborne illness that is safe and readily available.

Years ago I wrote this to the CDC.

Subject: Letter to the CDC Committee on Immunization Practices – It’s Time to Address Hepatitis A and Food Service Workers

Dear ACIP Secretariat:

The Advisory Committee on Immunization Practices (ACIP) provides advice and guidance to the Director of the CDC regarding the use of vaccines and related agents to control vaccine-preventable diseases in the civilian population of the United States. Recommendations made by the ACIP are reviewed by the CDC Director and, if adopted, are published as official CDC/HHS recommendations in the Morbidity and Mortality Weekly Report (MMWR).

Currently, about 5% of all hepatitis A outbreaks are linked to people handling infected food.

Here’s what the CDC continues to say about vaccinating food handlers:

Why doesn’t the CDC recommend that all food handlers be vaccinated if an infected food handler can spread the disease during outbreaks?

The CDC does not recommend vaccinating all food handlers because it would not prevent or stop ongoing outbreaks primarily affecting people who report using or injecting drugs and people who are homeless. Food handlers are not at increased risk of hepatitis A due to their occupation. During ongoing outbreaks, transmission from food handlers to restaurant patrons has been extremely rare, as standard sanitation practices by food handlers help prevent the spread of the virus. People who live in a household with an infected person or who participate in the risk behaviors described previously are at greater risk of hepatitis A infection.

The CDC Misses the Point; While food service workers are not at increased risk of contracting hepatitis A because of their occupation, they are at risk of transmitting it to customers. Jobs in the restaurant industry are generally low-paying and are likely to be filled by immigrants from countries where hepatitis A may be endemic or by people who are recently homeless.

In recent years, an epidemic of hepatitis A has occurred in the United States. As of February 2, 2023, there have been a total of 44,779 cases with a hospitalization rate of 61% (approximately 27,342 hospitalizations). The death toll stands at 421. Since the outbreak began in 2016, 37 states have reported cases to the CDC.

The CDC recommends to the public that the best way to prevent hepatitis A is through vaccination, but the CDC has not explicitly stated that food service workers should get vaccinated. Although food service workers are not traditionally designated as being at increased risk for hepatitis A transmission, they are not free of risk.

24% of hepatitis A cases are asymptomatic, meaning a food handler carrying the virus can unknowingly transmit the disease to consumers. Historically, when an outbreak occurs, local health departments begin administering the vaccine for free or at a reduced cost. Funding for these vaccinations comes from taxpayer dollars.

A mandatory vaccination policy for all food service workers has proven effective in reducing infections and economic burden in St. Louis County, Missouri.

From 1996 to 2003, Clark Country, Nevada, had 1,523 confirmed cases of hepatitis A, which was higher than the national average. Due to these alarming rates, Clark County has implemented a mandatory vaccination policy for food service workers. As a result, in 2000, hepatitis A rates dropped significantly and reached historic lows in 2010. The county removed the mandatory vaccination rule in 2012 and is now part of the ongoing hepatitis A epidemic.

According to the CDC, vaccines cost between $30 and $120 to administer, compared to thousands of dollars in hospital bills, and offer an effectiveness rate of 95% after the first dose and 99% after the second dose. Additionally, the vaccine maintains its effectiveness for 15 to 20 years.

During an outbreak, if a food service worker tests positive for hepatitis A, a local health department will initiate post-exposure treatment plans that must be administered within two weeks to be effective. The economic burden also affects the health department in terms of staffing and other limited resources. Sometimes interventions implemented by the local health department may be ineffective.

While there are many examples of one-time hepatitis A outbreaks occurring in recent years across the country, one particularly severe outbreak occurred in early fall 2021 in Roanoke, Virginia. The Ministry of Health was informed of the outbreak on September 21, 2021, after the first case was reported by a local hospital. The Roanoke Health Department, along with the Virginia Department of Health, investigated this outbreak.

Three different locations of a local restaurant, Famous Anthony’s, were ultimately determined to be associated with this outbreak. The Virginia Department of Health issued a community announcement on September 24, 2021 regarding the outbreak and potential exposure risk.

For the purposes of the investigation, a case was defined as a “[p]person with (a) a subtle onset of symptoms and (b) jaundice or elevated serum aminotransferase levels and (c) [who] tested positive for hepatitis A (anti-HAV IgM positive) and attended one of the three Famous Anthony locations, or was a close contact of the index patient, between August 10 and 27, 2021.”

As of November 2021, a total of 49 primary cases (40 confirmed and 9 probable) have been identified in this outbreak. Two secondary cases were also identified. Cases ranged from 30 to 82 years (median age 63 years). In total, 57 percent of cases were men. Thirty-one cases included hospitalizations and at least four patients died. The illness appeared between August 25 and October 15, 2021.

Ultimately, the outbreak investigation revealed that a cook, who also had risk factors associated with hepatitis A, had become infected with hepatitis A while working at several Famous Anthony’s restaurants. The mother and adult son of this index case also tested positive for hepatitis A. Following an inspection, the outbreak inspector noted: “Due to the etiology of hepatitis A transmission, it is presumed that the person handling infectious food did not properly wash their hands or follow the glove policy.” » Person-to-person spread was determined to be the most likely mode of transmission for this outbreak. Environmental contamination has also been considered as a possible mode of transmission.

Overwhelmed by the number of victims who sued for their injuries, Famous Anthony’s filed for bankruptcy and several of its locations were closed.

The tragedy of this preventable hepatitis A epidemic cannot be overstated. Four people died. In one family, two of its members lost their lives. Most of the victims were hospitalized. Many were at risk of acute liver failure. At least one person required a liver and kidney transplant. The victims’ medical bills totaled more than $6,000,000 in acute expenses, with millions of dollars in future expenses. And all because an employee didn’t get a $30 to $120 hepatitis A vaccine.

Affordable prevention of future tragedies such as the famous Anthony outbreak is possible and necessary. Now is the time to at least recommend vaccination for food service workers to reduce the spread of hepatitis A.

And I bet all the victims of this and other outbreaks wish they had gotten the hepatitis A vaccine when they were kids.

Sincerely, Bill Marler On behalf of 31 hepatitis A victims and families