Hepatitis A and the Restaurant Industry

What is Hepatitis?

Hepatitis is simply inflammation of the liver. Most commonly it is associated with a viral infection of the liver although many other disease states will produce disease states causing inflammation and injury to the liver, a common example being alcoholic hepatitis. Other disease like cancer and lupus can also cause hepatitis.

Drugs such as Ecstasy, Tylenol and others can also damage the liver causing hepatitis. Even some species of toxic mushrooms attack the liver.

Most viral hepatitis infections are from Hepatitis A, B, C, D, and E; Epstein Barr Virus (that causes "mono"), and Cytomegalovirus.

What is Hepatitis A?

Hepatitis A is a virus that will cause infectious inflammation of the liver. It is common in developing countries and transmitted through contaminated food and water.

Many people will have mild symptoms including nausea, vomiting and diarrhea. Active Hepatic disease may last up to 90 days. Some people may become jaundiced and rarely is it a cause of death more notably in older travelers. Infection with Hepatitis A has recently been suggested to be a risk factor for Arteriosclerosis. People, who have grown up in developing countries where Hepatitis A was present, may already have an immunity built up to it. If a person has had Hepatitis A at any time in their life, they are felt to be immune to it. If there is any doubt whether a previous infection was actually Hepatitis A or not, a blood test can be done to determine this.

Hepatitis A may infect food and water. Uncooked shellfish (especially oysters) may cause Hepatitis A. Hepatitis A also affects children and a vaccination is recommended for children 1 year and over. Risk is estimated to be 3-6 per 1000 per month to 20 per 1000 per month in higher risk travelers. Individuals who are at high risk include: ethnic populations, homosexual or bisexual men, IV drug users, military personnel, individuals with liver disease, lab workers, primate handlers or people who routinely receive blood products.

One dose of the Hepatitis A vaccine will provide protection for up to twelve month. A booster can be given between 6 - 12 months after the initial shot. The second shot will boost the response for at least 10 years. Hepatitis A vaccine is also recommended and considered safe for pregnant women who plan to travel. Pregnant women are more likely to become very sick from a Hepatitis Some don't get sick.

People who do get sick from hepatitis A may have no symptoms or minimal elevations in their liver function enzymes (which reflect some of the damage that has occurred to the liver. It is rare for the very young to become ill but severe illness is more common with advancing age. Young adults may have clinical jaundice and acute illness causing ~22% to be hospitalized. The incidence if death increases in those afflicted above 40 years of age. Recently, expanded indications for vaccination include: fast food workers, all children, daycare workers, and medical people. It is recommended for all non-immunes going to developing countries. Although the vaccine provides protection against Hepatitis A caution should still be taken when infectious agents may be present in both food and water, because of the other infections or pollutants that may be present as well.

Common symptoms of Hepatitis A include liver pain, jaundice (as bile becomes backed up), and fever.

How do you get Hepatitis A?

Hepatitis A virus is transmitted through contact with contaminated food or water. This commonly occurs when hands are not washed adequately by people carrying the virus. Not everyone is sick immediately so the infection may be transmitted silently and seemingly mysteriously because some of the carriers do not get ill.

Outbreaks are linked with exposures from travelers to areas of high risk, sewage workers, daycare personnel, illicit drug users, health care workers and food handlers. Of all the above groups it is typically that those in the food industry are more frequently blamed for outbreaks.

In order for hepatitis A to spread the person must be susceptible and the virus must be present. If the virus only encounters immune people then transmissions cannot be sustained.

Immunity is acquired either naturally through previous infection (these people are thought to be immune for life) or artificially through immunization. One dose of the Hepatitis A vaccine gives 12 months protection. A second dose given after at least 6 months gives at least protection for 10-20 years although some medical reports suggest 40 years.

A third form of temporary immunity is given through gamma globulin injections which is made of pooled blood from people who have already had Hepatitis A in the past. Gamma globulin gives a temporary immunity as these borrowed antibodies stay in the body for 3-6 months.

Hepatitis A outbreaks are rare in food handlers but when they do occur make the headlines, as there is lots of media attention. Usually there is a stigma attached to the restaurant or food company forgetting that it was individuals who transmitted the illness not businesses. The main focus remains what can be done to prevent outbreaks in the future that affect human health and the restaurant industry.

Ways to Prevent Hepatitis A

Firstly meticulous hygiene should always be practiced. This includes the day to day handling of foodstuffs as well as the training of new staff.

In Manitoba a restaurant is required to have on shift an employee who has the Food Handler Certificate . But not all employees are even required to have this basic accreditation. The question remains if this is adequate to ensure optimal sanitation and safe dining?

Hand washing is of course needed as many pathogens that cause diseases can be kept down.

Hepatitis A is a virus that should be prevented by good hygiene but outbreaks periodically occur in the restaurant industry.

One solution is to have employees immunized to prevent them from passing this virus on to patrons.

Immunization for Hepatitis A

Immunization with Hepatitis A vaccine is safe and effective. One dose is good for 12 months and a booster after 6 months will give immunity for 10-20 years. There are no significant side effects or allergies other than a sore arm and low grade self limited fever. The immunization does not contain live virus and will not give anyone hepatitis A. It gives immunity without giving the disease.

Reasons For Visits To Consider Hepatitis A Vaccines For Employees

Can be seen as a business expense that will enhance employee's health and decrease potential sick days. As a paid benefit Hep A immunization can be seen as desirable for employees who plan to go on vacations to where Hep A coverage is needed and desirable (examples Mexico, Caribbean, Cuba and many worldwide locations). An at work Hepatitis A program can be implemented in much the same way as at work flu shots where a skilled health team goes to the workplace and gives immunizations without disrupting the regular business.

The perception of preventative hygiene measures is greatly appreciated by patrons worrying about unsafe dining.

Common Reasons to reject Hepatitis A Programs

•  Immunization requires s a needle and some people hate needle and this may additionally cause a sore arm, low-grade fever, and aches. These minor irritations may last 1-2 days but may be minimized with immediate pressure and ice packs.

•  Expensive for employer to do if high turnover of employees. This is true as each vaccine alone costs at our clinic $50 per dose. We therefore recommend that restaurateurs consider if this would be a worthwhile expenditure even if tax deductible. We suggest Hepatitis A immunity programs for those restaurants where identifiable brand protection is essential.

•  Booster needed only once after 6 months. As mentioned above one-dose gives a year protection but a second dose after at least 6 months has passed will boost this to over 10-20 years. If immunizing employees we suggest a reminder follow-up after 6 months

•  Is elective and employees choice so not everyone may want immunization. We strongly encourage only willing employees to the Office Hepatitis A program and many employees may choose not to be immunized for philosophical reasons. We strongly believe that personal choice is important. Immunizing less than 100% of a group is still essential to controlling Hepatitis A.

Why should a restaurant Owner care about Hepatitis A?

•  Risk of an actual outbreak is small

•  Real value is in public perception of safety and cleanliness

•  Outbreak can ruin a restaurant's reputation at an individual location or the Name of chain of restaurants

•  i.e. Jack in the Box US outbreak of E coli

Having a Hepatitis A outbreak associated with a restaurant

•  Media looks for a good story

•  Public as a Long memory for Disasters

•  Good news more common than bad news yet isn' t advertised

What are other Areas doing?

•  Health Districts in US starting to vaccinate unaffected restaurants

•  Mixed results

•  Some restaurants have embraced idea

•  Others have found it not cost effective

•  Lawsuits are rarer in Canada and much less likely than in US climate and I believe culpability of a restaurant is not an issue in Winnipeg. One case of litigation in BC

Our Immunization Program

•  We specialize in vaccines for a variety of people

•  Travelers

•  Children

•  Health Care Workers

•  Expeditions

•  We can help you if you decide to start an Employee Immunization Program

•  Similar to Present Flu clinics we do

•  Our Costs (effective until Mar 2004)

•  Regular Doctors Visit ($40$+ Hep A ($50) Vaccine=$90

•  Our Visit fee for Hepatitis A alone ($20)+ Hepatitis A ($50) Vaccine=$70

•  If we do a clinic of several employees on site or at our office the visit fee will be only $10 for groups of 6 or more + cost of Vaccine ($50)

•  All our drugs are pre-bought from the manufacturer and there is no GST or PST on Physicians services. These should be cheaper than through a pharmacy since there is no dispensing fee

•  The drug information number is also given so that insurance plans can reimburse for cost

Some clients who have used us for immunization services:

•  Royal Winnipeg Ballet

•  Manitoba Hydro

•  Cangene Corporation

•  Red River College Nursing Program'

•  University of Manitoba Faculties of Medicine, Nursing and Occupational Rehab

•  University Of Winnipeg International Development

Summary

•  We would like you to consider this information and decide what would be best for your company now or at a later date

•  More resources and links at our Website:

•  www.skylarkmedicalclinic.com

•  Or for more specific information read our handout material

•  Feel free to call:

Our Office Manager Candace;

Clinical Travel Nurse Gail;

or myself 453-9107  

Appendix Explaining the other Hepatitis Diseases

Hepatitis B

Hepatitis B is a virus that infects the liver causing infectious Hepatitis, which may lead to liver disease and liver cancer. Hepatitis B is transmitted through blood products, IV drug use and sexual contact with infected partners.

Less commonly it can be transmitted through unclean medical and dental procedures as well as living closely with a person who has been infected. Children playing together with cuts and scrapes may also transmit this. Athletes have been known to transmit Hepatitis B through cuts in a game. Hepatitis B virus is more common and easier to transmit than AIDS. It also kills more people yearly.

Fortunately there is a vaccine available for people who are at potential risk. It is recommended that travelers have the Hepatitis B vaccine if they are traveling to a country where it is common or if a traveler is planning to spend three months or more in a certain area. People involved with medical centers, sanitation and sewage projects, or day care positions should consider being immunized. Although travelers often deny planning risky sexual behavior on vacation it is well known that many do so and therefore they should consider immunization be very serious. Conversely all individuals with any liver disease should consider vaccination for both Hepatitis A and B.

Hepatitis B should be considered for travelers when:

•  To cover accidents requiring medical intervention

•  Exposed to non-sterile medical equipment and unscreened blood or blood products

•  Cosmetic practices (body piercing) and tattoos

•  Casual sexual liaisons

•  Exposure to poor food, hygiene and sanitation

•  Estimated rate of infection of Hepatitis B in travelers .8-2.4/1000 per month Risk is dependant on exposure, destination and duration. In general people spending more than 6 months in or repeated visits to developing countries should consider vaccination.

Other information on the Hepatitis B vaccine:

General: Hepatitis B is a viral liver infection that is spread from person to person by blood and body fluids. To be immunized against it you will need a series of three injections.

Side effects:

These are reactions you may or may not experience after the injection. These generally last for 24-48 hours. At the injection site: swelling, redness, and tenderness.

Other: There is no proof that this causes autism, diabetes, multiple sclerosis or other autoimmune diseases. A recent study showed the incidence of multiple sclerosis less in people vaccinated with Hepatitis B.

Muscular activity increases these side effects; avoid strenuous activities for 24-48 hours after injection. No other change in normal activity is needed. Wash site as usual.

Treatment for side effects:

-Tylenol, as directed on label.

Hepatitis C

Hepatitis C is another virus that is similar to Hepatitis B in its transmission. At present there is no available vaccination for Hepatitis C since the virus frequently mutates. Travelers going to areas where Hepatitis C is common are advised to be careful when coming in contact with blood and other body fluids.

Hepatitis D

Hepatitis D is a plant virus that can infect only people who are positive with Hepatitis B. The Hepatitis D infection will make their liver disease much worse. There is currently no vaccine for this type of Hepatitis.