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Tuesday Jun 12, 2018

Outbreak Brings Patients Running for Vaccinations

I have a reputation for being a risk-taker when it comes to food safety. I once ate a pineapple upside-down cake that a woman at church had dropped on her foot.

[employees must wash hands sign]

I was notorious during residency for carrying food in my white coat and eating it regardless of how long it had been in my pocket.

I ignore expiration dates. I eat food my patients make for me. And I have paid the price a few times with impressive gastrointestinal distress.

Some of my recklessness comes from a need to stay hydrated. I get kidney stones, so I drink as much water as I can get my hands on to prevent them. Sometimes I drink water in places I probably shouldn't, including other countries.

But here I am, carrying on, not changing my ways. And lately, I've had the chance to use my lack of fear to prove a media-induced health hysteria to be overblown by eating at restaurants where cases of hepatitis A involving employees have been reported.

Recently in West Virginia and Kentucky, we have had an interesting change in our hepatitis patterns. We have long been national leaders in producing acute hepatitis B and C cases, and that has not changed.(dhhr.wv.gov) But hepatitis A had been a rarity in the region until March. Kentucky had an increase in incidence of hepatitis A cases before West Virginia, but it wasn't long before our own food service workers were making headlines.

Those headlines have provided a great example of fear of the unknown. The statistics about influenza in the fall were far more frightening, with higher mortality rates than this hepatitis A outbreak. Flu also is far easier to catch, but it didn't sway my patients from their deep-rooted thoughts about flu shots. When it comes to influenza vaccine, my patients either line up as soon as we have it in stock, or they argue with me and ultimately refuse the shot despite all the data available.

Now people are coming in, calling, begging for hepatitis A vaccinations. Some of the patients coming in for hepatitis A shots are the same people who have repeatedly (because we try at every visit) refused influenza, pneumococcal, shingles, hepatitis B, MMR, HPV and Tdap vaccines.

As I've written before, West Virginia has mandatory vaccinations for school-aged children, so aside from HPV and influenza -- which are not mandated -- I don't often have discussions with parents about refusing vaccines. So, what has intrigued me about this hepatitis A situation is that although the infection is something I would want to avoid (and yes, I had my vaccine series years ago), it isn't likely to kill me or provide any long-lasting effects, yet people are demanding we give them the vaccine even if they have no exposure, extremely low likelihood of exposure or have already been vaccinated.

Many of these same patients absolutely refuse to give their children the HPV vaccine, which provides much more significant benefits than hepatitis A vaccination for the individual patient in the long run. Hepatitis A will most likely cause you to miss work and whatever social engagements you may have planned, and it may even land you in the hospital for IV fluids, but the mortality risk in the absence of significant liver disease is low. If I had to pick one, I would definitely choose getting hepatitis A over cervical cancer.

It feels like half my recent visits start with a patient saying they are afraid to go out to eat (because of the way the media has portrayed the outbreak), and they want my opinion about getting the hepatitis A shot. I explain that I recommend it just as I do all vaccines. My favorite tag line to explain this outbreak is that it is "poop in your food" and that simple handwashing is the most effective means of preventing transmission.

Kitchen staff should wash their hands after any possible contact with body fluids, particularly stool because it has far higher viral levels than other body fluids, such as urine or blood. Restaurant patrons should wash their hands before eating because there is potential to have touched contaminated surfaces. The virus can live outside the body for months if given the right circumstances.

There is nothing novel about this. We have all been taught that handwashing is important for preventing disease transmission, particularly when it comes to diarrheal illnesses in the setting of food preparation, handling and ingestion.

I also explain that I don't see any increased urgency in our rural county related to hepatitis A compared to, say, pertussis or hepatitis B, both of which I have had cases of within the past year. But yes, I do indeed support the decision to get the hepatitis A shot, along with all the other vaccines patients should receive.

At this point, 150 cases into the outbreak, there have been zero cases of hepatitis A transmission from an infected restaurant employee to a customer. Only six of the reported cases have been in food service workers. Yet the media has published maps of restaurants that have reported infected staff, and they highlight each new case that comes up in a food service worker. The reporting created paranoia about restaurants, which thus far is not warranted. More than 90 percent of the cases have been in individuals who admitted to drug use. Granted, even those cases are still mostly likely being transmitted via fecal-oral contamination pathways because they are occurring in settings with poor hygiene. Each case is investigated by the local health department, and in the six restaurant cases, no food handling violations have been found.

Although I disagree with how it has been portrayed, because the risk of transmission to the general public is much lower than the media have led patients to believe, I'm optimistic that the fallout from this hepatitis A outbreak will result in higher vaccination rates for other diseases and continued support for our state's mandatory childhood vaccine policy. Parents have been relieved when I tell them their kids are already protected. I have every intention of mentioning a patient's recent hep A vaccine at their next appointment as a discussion starter for the other vaccine boosters they need.  

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 01:34PM Jun 12, 2018 by Kimberly Becher, M.D.

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