Volume 1, Number 4
Hepatitis A rate per 100,000 1966-1995 |
vaccination for food handlers
The U.S. restaurant industry is considering whether to use hepatitis A vaccine to reduce its hepatitis A problems in outbreak areas. A few companies have already begun limited vaccination of food handlers. Others are considering future programs targeted at high-incidence areas.
ACIP recommendation rests on cost effectiveness
The Advisory Committee on Immunization Practice (ACIP) statement on the vaccination of food handlers against hepatitis A, published on December 27, 1996, makes no definitive recommendation. Instead, the committee said the decision should be made by health departments and the food service industry based on cost effectiveness.
The statement notes: "Persons who work as food handlers can contract hepatitis A and potentially transmit HAV to others. To decrease the frequency of evaluations of food handlers with hepatitis A and the need for postexposure prophylaxis of patrons, consideration may be given to vaccination of employees who work in areas where state and local health authorities or private employers determine that such vaccination is cost effective."
The statement acknowledges that "the frequency of evaluations of food handlers with hepatitis A and the need for postexposure prophylaxis of patrons" can be a problem for local and state health departments and for private employers. But it also reflects the reality that hepatitis A-infected food handlers do not contribute significantly to the national caseload. In 1993, only 2.2% of all hepatitis A cases reported to CDCs Viral Hepatitis Surveillance Program (VHSP) were asso-ciated with a suspected food- or waterborne outbreak (CDC Hepatitis Surveillance Report No. 56., 1996). Outbreaks of hepatitis A traced to food are reported uncommonly, numbering only 7 to 12 outbreaks per year in the U.S. Only about half of those occur in restaurants, delicatessens or cafeterias (Surveillance for foodborne-disease outbreaks - United States, 1988-1992. CDC Surveillance Summaries, October 26, 1996).
Public health authorities cite resource drain
During consideration of the ACIP statement in late 1995, a few state and local health department officials pushed for a more definitive statement on food handler vaccination, arguing that infected food handlers cause a significant drain on department resources during outbreaks. The drain, they said, is measured in public health nurses' and epidemiologists time devoted to evaluating infected food handlers, and in the costs and time involved in administering immune globulin to restaurant patrons. Resources expended on the evaluation of infected food handlers can be significant. During the recent epidemic in Memphis (see stories in HCR, April 1996 and Summer 1996), 107 of 1,538 hepatitis A cases reported during the year 1995, about 7%, were employed as food handlers. Similarly, during a large outbreak in Washington State in 1987-88, 277 of 5,259 cases (5.3%) were food handlers (Sharp TW, unpublished report). Most food handler cases trigger an evaluation by the health department to determine whether mass administration of immune globulin to patrons is indicated under CDC guidelines. This evaluation usually entails an on-site interview of restaurant workers by health department personnel, plus supervised immune globulin shots for other food handlers at the same restaurant. In a proportion of cases (13% in the Sharp study), the initial evaluation leads to a public warning through news media, and a recommendation for patrons of the restaurant to receive immune globulin. While actual foodborne transmission is uncommon, it is very expensive for health departments when it occurs. Dalton and colleagues calculated disease control costs of $689,314 for one outbreak in Denver, which included health department personnel time ($105,699), serologic studies and physician fees ($133,218), and immune globulin injections ($450,397) (Arch Intern Med 1996; 158:1013-1016). In the outbreak, 43 cases were attributed to foodborne transmission and more than 16,000 persons received injections of immune globulin.
Restaurants wary of costs and logistics
Restaurant companies are aware of hepatitis A vaccine, but so far, they have been hesitant to embark on vaccination programs. An adult dose of hepatitis A vaccine on the private market starts at around $45, plus the costs of administration, transportation, record-keeping, and lost work time (pediatric doses are less costly and can be used for some younger employees). With the industry's personnel turnover rates of 100% to 300% per year, a restaurant could expend a lot of money in purchasing first doses. For employees who remain working at a restaurant for 6 to 12 months, the second dose would be an additional cost.
Restaurant companies are also concerned about the potential public relations downside of a vaccination program. A company that began vaccinations in an epidemic area could receive bad publicity if the vaccinations were misinterpreted by customers as a food contamination problem. During the Memphis outbreak, one restaurant suffered substantial revenue losses when it vaccinated food handlers. A local television station ran news of the vaccination program adjacent to a story about another restaurant's hepatitis A contamination problem. Viewers were unable to separate desirable vaccination from undesirable contamination. Despite these concerns, a few restaurant chains are seriously considering vaccination programs in areas of highest incidence. Managers from major chains say that annual national revenue losses caused by public announcements and outbreaks are at least $15 million, and probably much higher. Because restaurant employees acquire their infections in the community outside the restaurant, hepatitis A vaccination is the only practical step that a restaurant can take to avoid infected food handlers. Handwashing programs and other hygienic measures in the restaurant do help prevent outbreaks (and also prevent public announcements), but they do not prevent the occurrence of infected food handlers. Because of the vaccine's price and the industry's high employee turnover, vaccination of a company's entire food-handling workforce would be prohibitively expensive. Vaccinations must be targeted to geographic areas of highest risk. Important questions are: how cost-effective would vaccination be when it is aimed at geographic areas of highest risk, and where a public announcement is most probable? Additionally, can vaccination be successfully portrayed to the restaurant-going public as a positive event?
To make matters worse for the industry, some health departments have adopted a policy of publicly announcing all reported infected food handlers, regardless of whether immunoglobulin prophylaxis of patrons is indicated under CDC criteria. These departments say that exposed patrons have a right to know of their exposure, even if immune globulin cannot be offered. They also believe that secondary cases can be prevented more easily if symptoms of hepatitis A in exposed patrons are recognized early. During outbreaks in these jurisdictions, restaurants face a relatively high probability of business losses prompted by public announcements.
Losses can be severe
Food safety managers cite losses of 40% to 80% of revenues for restaurants named in public announcements. These losses may last for as little as a few weeks, or as long as 12 to 18 months. In some cases, revenues remain depressed indefinitely as patrons switch to unaffected restaurants selling different types of food (for example, hamburgers to pizza).
Losses may also extend beyond the affected restaurant to other company restaurants in the same media market. For a company with 50 restaurants in the same media market, losses can quickly extend into the seven-figure range.
Case study: Midwest tourist Mecca
One local health department in an outbreak area has decided to vaccinate all food handlers through a voluntary program. Branson, Missouri is one of America's top tourist spots, with 60,000 tourists arriving daily to visit country music shows and other attractions. Southwest Missouri, where Branson is located, experienced a 400% increase in hepatitis A incidence last year (637 in 1996, 137 in 1995) due to a communitywide outbreak based in young adults.
The director of the Branson health department, Linn Smith, recognized that a single infected food handler requiring patron notification could cause a costly downturn in tourist volume due to adverse publicity. With the support of local restaurants and the medical community, she began vaccinating. By mid-March, she had vaccinated 900 of an estimated 4,000 food handlers in the city. The city's McDonald's and Burger King franchises vaccinated all their employees.
No jurisdiction in the U.S. has yet required the vaccination of food handlers, but the city of St. Louis recently passed an ordinance establishing a voluntary food handler vaccination program. Vaccine will be purchased by restaurants through the city health department, which will administer the vaccinations. St. Louis has experienced vigorous communitywide outbreaks over the past few years. A few months ago, an infected food handler was identified at a popular local restaurant. Many patrons, including players on the St. Louis Cardinals baseball team, received injections of immune globulin.
In the end, each restaurant company will have to calculate for itself the benefits versus the costs of vaccination based on its own hepatitis A experience. Companies with small hepatitis A-related risks will choose not to vaccinate. Companies with larger risks may adopt vaccination strategies aimed at the highest-incidence areas, especially at areas where health departments routinely announce to the news media all infected food handlers.