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Publisher’s Platform: CDC punts on recommending food service worker vaccinations – CDC, low risk perhaps, but at times, at a very high cost

Yesterday it was reported that a food handler at the White Steamer diner in Washington, Indiana who worked last week has been diagnosed with Hepatitis A.
The Daviess County Health Department says while it is rare for restaurant patrons to get contract the disease due to an infected food handler, anyone who consumed food or drink at the White Steamer from May 12 to May 15 is recommended to get a vaccination within 14 days of exposure.
A free clinic will be held at the Washington National Guard Armory from 9 a.m. to 3 p.m. on Wednesday May 27. Face coverings will be required for entry into the clinic and you must stay in your car upon arrival. Those who cannot attend that clinic should contact their doctor or the Daviess County Health Department at 812-254-8666.
Having a hepatitis A positive worker has been (to the extent they are reported – and many are not) weekly occurrence.  Generally speaking that one ill employee causes thousands of exposed customers to seek preventative vaccination.  The vast majority of those vaccination are usually given by departments of public health at taxpayer expense – thousands of people exposed and hundreds of thousands spent in prevention – post risk of infection.
Ironically, the CDC weighed in on MMWR and punted on the recommendation of vaccinating food service employees because it would “be ineffective at mitigating the current risk for person-to-person outbreaks.” That outbreak to date has sickened 32,541, hospitalized 19,885 and killed 324.  Here is the full CDC article on the recent study:
The United States is experiencing person-to-person outbreaks of hepatitis A in unprecedented numbers during the vaccine era (1). As of May 2020, 33 states had reported hepatitis A outbreaks involving approximately 32,500 cases, 19,800 (61%) hospitalizations, and 320 deaths since 2016 (1). These infections are spreading primarily through close contact among persons who use drugs and persons experiencing homelessness, as well as among men who have sex with men (MSM) (2).
During these outbreaks, hepatitis A infections occurring among food handlers have raised public alarm and resulted in calls for vaccinating all food handlers, often prompting health departments to divert limited resources away from populations at risk. However, the risk for secondary transmission from hepatitis A–infected food handlers to food establishment patrons is not well understood. To characterize this risk, a novel, structured survey was developed and conducted using Research Electronic Data Capture (REDCap) (version 9.5.13; Vanderbilt University); among 30 state health departments reporting person-to-person hepatitis A outbreaks during July 1, 2016–September 13, 2019, 29 states responded (3,4).
Twenty-six states (89.7%) submitted complete information regarding secondary transmission events associated with food handlers. Among 22,825 hepatitis A outbreak cases reported from these 26 states during July 1, 2016–September 13, 2019, 871 (3.8%) were among food handlers; 587 (67.4%) hepatitis A–infected food handlers reported one or more risk factors (i.e., drug use, unstable housing or homelessness, MSM, or incarceration) during the 15–50 days before symptom onset. Associated with these 871 hepatitis A–infected food handlers were eight (0.9%) secondary transmission events (Table), which resulted in 57 secondary cases.
Eighteen of 29 states (62.1%) submitted complete information for public health response activities related to hepatitis A–infected food handlers. Among 275 cases in food handlers from these 18 states, 271 (98.5%) investigations and 63 (22.9%) public notifications took place.
Ongoing hepatitis A outbreaks have been prolonged and costly to control (5). These study findings indicate that the risk for secondary infection from hepatitis A–infected food handlers to food establishment patrons in these outbreaks is low (<1.0%). Therefore, public health efforts to preemptively vaccinate all food handlers would be ineffective at mitigating the current risk for person-to-person outbreaks. To optimize resources, health departments should assess the risk for secondary transmission of hepatitis A from infected food handlers on a case-by-case basis and prioritize vaccination efforts in situations where secondary transmission risk is deemed high (6).
Approximately two thirds of the hepatitis A–infected food handlers in this survey reported risk factors commonly associated with the current person-to-person outbreaks. This underscores the importance of vaccination strategies targeting the populations at highest risk (i.e., persons who use drugs, persons experiencing unstable housing or homelessness, MSM, and persons who are or were recently incarcerated) as the cornerstone of an effective public health response.
Here is full CDC article –  https://www.cdc.gov/mmwr/volumes/69/wr/mm6920a4.htm?s_cid=mm6920a4_w
I get it that focusing on vaccinating food service workers – some of the most lowest paid and vulnerable workers – makes sense when the risk of person to person spread in “persons who use drugs, persons experiencing unstable housing or homelessness, MSM, and persons who are or were recently incarcerated” is likely higher.  However, common sense and low wages likely mean that there is certainly crossover between food service workers and “persons who use drugs, persons experiencing unstable housing or homelessness, MSM, and persons who are or were recently incarcerated.”  On top of that, although the risk might be low of transmitting hepatitis A (a human fecal pathogen) between food service worker and customer, the cost of thousands of people having to stand in line for shots paid for by the public, is not unsubstantial. And, those customers then wait weeks to see if the received the vaccine in time to prevent the disease.  Finally, I have seen the illnesses and deaths attributed to a hepatitis A positive food serves worker infecting customers.  I have represented hundreds over the years who became ill for weeks or months due to a hepatitis A infection, and yes, I have represented people who became so ill that a life-saving liver transplant was necessary, and, yes, I have represented people who died due to the exposures.
CDC, low risk perhaps, but at times, at a very high cost.

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