CDC: Food Service Workers is a low, but not a no risk of Hepatitis A infection

According to the CDC, the hepatitis a virus (HAV) is transmitted via the fecal-oral route, usually from direct person-to-person contact or consumption of contaminated food or water (33). Children were a key source of HAV transmission before HepA vaccination was available and recommended routinely for children because the majority of children infected with HAV have asymptomatic or unrecognized infections and can shed the virus in their feces for months (34,35). Transmission currently occurs primarily among susceptible adults.

Common-source outbreaks and sporadic cases also occur from exposure to food or water with fecal contamination. Uncooked foods have been recognized as a source of outbreaks (36). Cooked foods also can transmit HAV if the heat level used in preparation is inadequate to inactivate the virus or if food is contaminated after cooking, which can occur during outbreaks associated with infected food handlers (36). Waterborne outbreaks of hepatitis A are infrequent in developed countries with well-maintained sanitation and water supplies (37). Depending on conditions, HAV can be stable in the environment for months (33,38). HAV also is stable when frozen (10,39–41). Heating foods at temperatures >185°F (>85°C) for 1 minute or disinfecting surfaces with a 1:100 dilution of sodium hypochlorite (i.e., household bleach) in tap water inactivates HAV (42).

HAV vaccination is not specifically recommended for persons who handle food in the absence of other risk factors. Foodborne hepatitis A outbreaks occur relatively infrequently in the United States; however, recent outbreaks of hepatitis A related to pomegranate arils (the fruit-coated seeds) imported from Turkey, frozen scallops imported from the Philippines, and frozen strawberries imported from Egypt demonstrated the risk for outbreaks related to foods imported from HAV-endemic areas (10,11,169). Contamination of food with HAV can happen at any point: growing, harvesting, processing, handling, or after cooking. Food handlers are not at increased risk for hepatitis A because of their occupation (36). Transmission of HAV from infected food handlers to susceptible consumers or restaurant patrons in the workplace is rare (36,170,171). Transmission among food handlers has not been common since the adoption of the universal childhood HepA vaccination recommendation in 2006, despite costly and resource-intensive investigations of HAV infections among food handlers. One study found that in >90% of case investigations of infected food handlers, only the food handler was infected, with no secondary cases (172). A survey of state health departments experiencing person-to-person hepatitis A outbreaks during 2016–2019 demonstrated that among almost 23,000 hepatitis A outbreak cases reported from states, <4% occurred among food handlers; secondary infections among patrons accounted for 0.2% of outbreak cases (173). The risk for secondary infection from hepatitis A–infected food handlers to food establishment patrons in these person-to-person hepatitis A outbreaks was <1% (173).

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11. Viray MA, Hofmeister MG, Johnston DI, et al. Public health investigation and response to a hepatitis A outbreak from imported scallops consumed raw—Hawaii, 2016. Epidemiol Infect 2018;147:1–8.

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38. McCaustland KA, Bond WW, Bradley DW, Ebert JW, Maynard JE. Survival of hepatitis A virus in feces after drying and storage for 1 month. J Clin Microbiol 1982;16:957–8. CrossRefexternal icon PubMedexternal icon

39. Niu MT, Polish LB, Robertson BH, et al. Multistate outbreak of hepatitis A associated with frozen strawberries. J Infect Dis 1992;166:518–24. CrossRefexternal icon PubMedexternal icon

40. Nordic Outbreak Investigation Team. Joint analysis by the Nordic countries of a hepatitis A outbreak, October 2012 to June 2013: frozen strawberries suspected. Euro Surveill 2013;18:20520. CrossRefexternal icon PubMedexternal icon

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42. Favero MSBW. Disinfection and sterilization. In: Zuckerman AJ TH, ed. Viral hepatitis, scientific basis and clinical management. New York: Churchill Livingstone; 1993. pp. 565–75.

169. CDC. 2016—Multistate outbreak of hepatitis A linked to frozen strawberries (final update). Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/hepatitis/outbreaks/2016/hav-strawberries.htm

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172. Morey RJ, Collier MG, Nelson NP. The financial burden of public health responses to hepatitis A cases among food handlers, 2012–2014. Public Health Rep 2017;132:443–7. CrossRefexternal icon PubMedexternal icon

173. Hofmeister MG, Foster MA, Montgomery MP, Gupta N. Notes from the field: assessing the role of food handlers in hepatitis A virus transmission—multiple states, 2016–2019. MMWR Morb Mortal Wkly Rep 2020;69:636–7. CrossRefexternal icon PubMedexternal icon

Republished with permission from Bill Marler and Marler Clark. Copyright (c) Marler Clark LLP, PS. All rights reserved.