Hepatitis A has the potential to become the next E. coli 0157:H7, salmonella or listeria monocytogenes -- causing illness in customers, bad press and the scrutiny of an official investigation.
Yet the very nature of the virus has kept it from making national headlines, since it seems exclusive to certain regions of the country. Similarly, reports are often publicized during the outbreak phase, after food has been consumed, and well beyond the time period when pre-sale recalls are effective.
As recently as September, an outbreak of hepatitis A linked to food consumption made headlines in Baltimore; a month earlier, two Subway Sandwich franchises in Seattle were forced to settle a hepatitis A-related lawsuit filed by 29 people to the tune of $1.06 million. Yet, among its higher-profile rivals, the virus continues to attract little attention. "Hepatitis seems to be one of those things that will only gain attention in this industry if there is another major outbreak," said Matt Prentice, president of Unique Restaurant Corp., Binghman Farms, Mich., referring to a Detroit-area incident involving the virus that nearly put several of his competitors out of business and caused one death more than two years ago.
According to the latest statistics from the Hepatitis Foundation International, Cedar Grove, N.J., an estimated 152,000 Americans are infected with hepatitis A annually, and approximately 100 people in the United States die each year from contracting it. While "foodborne hepatitis A outbreaks are relatively uncommon in the United States," according to the Centers for Disease Control and Prevention, Atlanta, the agency's Web site does add that "when they occur, intensive public health efforts are required for their control."
The CDC estimates that only 83,000 U.S. cases of hepatitis A occur each year (lower than HFI's number), and that 5% of those cases are related to foodborne transmission. In 1999, more than 10,000 people were hospitalized with hepatitis A infections, and 83 people died, according to the CDC.
Though it maintains that foodborne hepatitis A outbreaks are somewhat uncommon in the United States, the CDC said the frequency of outbreaks associated with food that has been contaminated before reaching a food-service establishment has been increasing in recent years, particularly with shellfish and some raw produce. Because hepatitis A can survive for up to 10 months in water, such products are more susceptible to the virus, especially those harvested from areas prone to contamination with raw sewage.
An outbreak of hepatitis A in 1997, in which 213 cases were reported in 23 schools in Michigan, was linked to frozen strawberries shipped from the same processing plant. Research showed the strawberries were contaminated before they were distributed.
According to a published CDC report, "The vehicles of transmission in foodborne outbreaks are most often uncooked foods or foods touched by human hands after cooking, but outbreaks have been reported in association with foods contaminated before wholesale distribution."
Dr. Jill Hollingsworth, vice president of food safety programs at the Food Marketing Institute, Washington, noted that her organization works very closely with the CDC in advising retailers how to prevent hepatitis A incidents, and feels that the industry shows appropriate concern toward the issue.
She noted that good sanitary procedures are the best way to prevent the virus from showing up. FMI educates retailers on the proper sanitary measures, such as the use of gloves and utensils when handling food, and the need for proper hygiene like hand washing.
"We feel it is still more of a community problem as opposed to a foodborne problem," said Hollingsworth, referring to the regional tendencies of most hepatitis A outbreaks. For example, in 1998, Arizona and Michigan reported more hepatitis A cases than any other states in the country, she said.
She added that immunizing children is another practice that should be high on the list of preventative measures. Hollingsworth pointed out that a large percentage of the adult population is already naturally immune to hepatitis A, making the younger generation a main target for vaccination efforts.
"Food-service retail workers are not seen as a high-risk category," she said, noting that many workers are already adults or at least old enough to have developed resistance to the virus. "The retail environment is not seen as an area of great concern as far as this disease goes."
Nevertheless, negative publicity stemming from a foodborne illness outbreak can be especially damaging when children are affected. The most recent headlines detailing a hepatitis A outbreak noted that, of 24 people in Baltimore stricken by a hepatitis A outbreak linked to three local restaurants, five victims were elementary school students.
In that case, it was ultimately discovered that an employee at one of the restaurants had tested positive for the virus only weeks earlier. In Matt Prentice's restaurants, this would not have happened.
In the past year, his company mandated and enacted a policy to vaccinate all present and new employees for the hepatitis A virus. Prentice likens it to a security blanket.
SN reported that Prentice was making vaccinations for hepatitis A mandatory for all employees, at a considerable cost and for a variety of reasons [see "Food Chain To Require Hepatitis A Vaccinations," SN, Jan. 31, 2000]. Now, nearly a year later, Prentice remains proud of his company's safety program, pleased with the comfort it has brought, and not surprised by the lack of copycat policies across the country. "I think the industry is looking at it from a more immediate perspective than I am, and has put more time and money into the more obvious pathogens," said Prentice. "But you do what you feel needs to be done."
The restaurateur spent more than $30,000 to vaccinate some 250 employees, and the practice remains mandatory for any new employees to begin working at any of his restaurants.
Prentice, who was stricken by the disease as a youth, is in no rush to see another hepatitis A outbreak anytime soon, no matter how protected his own business appears to be.
"If [another outbreak] happened, I'm sure our program here would become a very hot topic and we'd be swamped with all the attention," he said. "But we're very happy to be low on the radar, because that means hepatitis is too."
Prentice's precautionary measures, based upon the past outbreaks in the Detroit area, could prove to be cost effective, according to Hepatitis Foundation International. The organization estimated that hepatitis A causes an average of 30 missed days of work per case, results in approximately $2,600 in lost wages, and can run up medical costs of nearly $2,800 per hospitalized individual.
Another of Prentice's major focuses in keeping hepatitis A out of his restaurants, and one the most vital aspects of preventing the spread of the disease, is the strict sanitary policies he maintains in all locations. He posts signs at the restaurants emphasizing thorough hand washing by all employees several times over the course of a day.
Periodic outbreaks of the disease have been attributed to contamination spread by inadequate hand washing, and Prentice enforces his policies very seriously while encouraging all retailers and food-handling agencies or businesses to do the same.
A recent study by the American Society for Microbiology, Washington, surveyed 1,000 people across the United States concerning their hand-washing habits, with 95% claiming they always cleaned their hands after using the bathroom. But upon further observation of public restrooms in several major cities, scientists for the organization discovered only about 33.3% of the people were doing so.
This lack of hygiene is not limited to the general public, either. According to Dr. William Jarvis, chief of the CDC hospital infection's program's investigation and prevention unit, only 40% of health care workers wash their hands, even at times when it is recommended.
Regardless of what methods associations and retailers take to battle the spread of hepatitis A in the food industry, it remains a constant threat, just as E. coli 0157:H7, salmonella and listeria monocytogenes crept into the foodborne picture years ago. Whether proactive or reactive, insiders agree that keeping it out of the food customers buy is of great importance to both business and consumer health.