Hepatitis A in the Foodservice Industry

Steven F. Grover and Judith G. Dausch

Foodservice operations are becoming known for the quality and diversity of food. While meeting the constant demand for healthful and tasty food, operations are also paying strict attention to personal hygiene and clean food-preparation practices. Maintaining standard food safety practices is especially important in these times of heightened consumer awareness of foodborne disease outbreaks, such as hepatitis A, despite the fact that the rate of hepatitis A has fallen to its lowest level in more than 30 years, foodservice operators should consider several critical factors in the decision to vaccinate their employees.

Every operator knows the importance of a good reputation. The average foodborne outbreak costs an operation upwards of $100,000. This includes medical charges, lost wages, lost business and lawyers’ fees. For the small operator, one incident almost certainly means going out of business. Small operations can’t withstand a 30% reduction in sales, which can
easily occur with a loss of customer trust. Even a large operation suffers from an outbreak in terms of potential for growth and negative public perception.
With the recent decline of hepatitis A cases and improvements in personal hygiene and environmental sanitation, the need for public notification of an incident at an operation may also be diminished. As such, if a food handler is found to be infected with hepatitis A, many local health regulators may evaluate the effectiveness of an operation’s sanitation and hygiene program and determine that the risk of transmission to the public is minimal. This means that a policy of routinely publicizing all reports of infected food handlers in operations, regardless of the sanitation, hygiene or risk of transmission to customers, should be reevaluated.

Depending on the infection rate of a particular area, control measures to prevent incidents of hepatitis A may vary. For example, in communities where the rate of hepatitis A infection is high, an operator may view the cost of vaccinating employees against hepatitis A as insurance against the potential costs of public notification. Whether to vaccinate food workers against hepatitis A is a business decision that should be made by each operator. Based on the unique circumstances of each operation, each operator must determine the risk and benefit of providing their employees with immunity to the disease.

The Federal government has recently addressed the issue of how to best prevent hepatitis A transmission in the general population. A report on the prevention of hepatitis A through immunization was published last fall by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP). The Committee’s key finding is that “routine vaccination of children”—and not targeted vaccination of high-risk groups”—is the most effective way to reduce hepatitis A incidence nationwide over time.” This recommendation represents a fundamental shift in the strategy to combat this disease from one targeting certain groups, to one in which routine immunization of the general population is the key. This finding represents an important piece of evidence that local lawmakers should consider when addressing proposals to mandate hepatitis A vaccinations for food handlers and other groups.

The ACIP’s 1996 recommendations on preventing hepatitis A focused on “vaccinating persons in groups shown to be at high risk for infection.” The groups cited in 1996 do not include food handlers. ACIP notes that its review of data indicates that vaccinating these high-risk groups would only have a limited impact on the disease, and that therefore “a shift is needed from the present immunization strategy to one that achieves widespread routine vaccination of children to prevent infection...”

It is important to note that ACIP does not include food handlers among the six groups at increased risk for hepatitis A. As for food handlers, ACIP states that “although persons who work as food handlers have a critical role in common-source foodborne HAV transmission, they are not at increased risk for hepatitis A because of their occupations.” This statement is key because it shows that while food handlers may be a critical control point for transmitting hepatitis A, their risk of contracting the disease—which mandatory hepatitis A vaccinations are meant to combat—is similar to that of the general population.
ACIP states that “consideration may be given” to vaccinating food handlers “who work in areas where state and local health authorities or private employers determine that such vaccination is cost-effective.” The first point to note is that ACIP does not recommend vaccination in such cases; rather, it states that “consideration may be given” to doing so—certainly not a strong endorsement of the practice. Secondly, ACIP advises such consideration in cases where it is determined to be cost-effective. Note that the committee does not advise that such consideration be given on any basis other than cost-effectiveness.

The key recommendation contained in this report—of routine vaccination as the most effective way to reduce hepatitis A incidence nationwide over time—is based on a two-year review by the CDC’s ACIP. It represents the most authoritative recommendation made to date on this subject. To base public health policy decisions on anything less than this information is clearly not in the best interest of the public. Therefore, operators and local health departments should consider the above information in addressing proposals to mandate hepatitis A vaccinations for food handlers.

Effective hepatitis A control is best addressed through wide-ranging recommendations, as evidenced by the CDC recommendations. The foodservice industry has made great strides in containing or preventing outbreaks of hepatitis A, although there is always room for improvement. It is our view that the downward trend of hepatitis A incidents is inextricably linked to voluntary preventive measures of each operator. This strategy allows each operator to make an appropriate business decision, and is highly preferable to mandatory vaccination programs. Thus, as experience in the food industry has taught, successful management and prevention of hepatitis A incidents in the establishment should be based on careful evaluation of critical factors and combated on a case-by-case basis.

Steven F. Grover and Judith G. Dausch are with the Health and Safety Regulatory Affairs of the National Restaurant Association.