In just the last two weeks, one restaurant in Tampa Bay has shut down and another closed temporarily after outbreaks of hepatitis A. Health officials in Hillsborough and Pinellas counties say reports of the virus are way up, and they worry that more are likely to come.
The cases are among a growing number of infections nationally, the largest outbreak since the hepatitis A vaccine was developed nearly 20 years ago.
So why is this happening now?
"The spread is intimately linked to the opioid crisis," said Jill Roberts, a professor of microbiology and environmental health at the University of South Florida. "The biggest factors to this spread are IV drug use and homelessness. And now we're seeing this spill over into restaurants."
The owners of a Hamburger Mary's franchise in Ybor City announced this week that the restaurant would not reopen after being closed temporarily when a worker there tested positive for hepatitis A. An announcement on its Facebook page lamented, "The latest challenge over the last couple of weeks has proven too much to overcome."
In response, the Hillsborough health department received 400 calls and administered 620 free hepatitis A vaccines to restaurant patrons.
And on Monday, the Toasted Monkey Beach Bar & Grille on St. Pete Beach temporarily closed when one of its workers also tested positive for the virus.
"We alerted the public because of the number of patrons who could have been exposed to the virus while the person was on duty at the restaurant," said Maggie Hall, a spokeswoman with the Pinellas health department.
Hepatitis A is spread person-to-person through feces contaminated with the virus, so practicing proper hygiene is essential, health officials say. Symptoms include fever, dark urine, yellow-tinged skin or eyes, fatigue and gastric issues. It can cause damage to the liver, especially among those who already have liver disease.
At least 58 cases of the virus have been reported in Pinellas this year, including a jump of 10 cases from September to October. Last year, the county reported zero cases. In 2016, there were just two, and in 2015, just four.
Hillsborough County, meanwhile, has reported at least 36 cases of hepatitis A so far this year, compared to 10 all of last year and five in 2015 and 2016.
Generally, fewer than 3,000 cases of hepatitis A are reported nationwide each year, according to the Centers for Disease Control and Prevention. But that hasn't been the case recently. More than 7,000 outbreak-associated cases have been reported from 12 states this year, said Dr. Monique Foster, an epidemiologist at the CDC.
"In the previous decade, most large outbreaks of hepatitis A were attributed to contaminated commercial food products. During 2017, however, most reports were primarily among people reporting drug use or experiencing homelessness," she said. "Our most recent national data shows states experiencing outbreaks are facing unique challenges to reach people who are at greatest risk for infection."
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California Gov. Jerry Brown declared a state of emergency last year over an outbreak of hepatitis A cases that began in San Diego and spread to the Los Angeles, Monterey and Santa Cruz areas. The state has been battling a rise for years, but in 2017 it reported more than 700 active cases with more than half of those patients needing to be hospitalized. All told, 21 people have died.
Getting the outbreak under control was a costly endeavor — California bleached the streets in San Diego, set up mobile vaccination units and hosted hundreds of vaccination events, opening dozens of public hand-washing stations.
Public health experts say the majority of the cases come from white men in their young adult years to middle age. Most are from transient populations with limited access to sanitation methods and are more commonly drug users.
"We're a little late to the game, in that we should have remembered the lessons we learned from other diseases, like the spread of HIV," said Roberts, the USF professor. "The major factor is using dirty needles in unclean conditions. Restaurants are particularly susceptible to this population because they offer generally low-paying jobs, and there is a lot of turnover in employees. If someone who has active hepatitis A is handling food in a restaurant, all of those customers are at risk."
There is no requirement for food handlers to be vaccinated against hepatitis A, said Dr. Kartik Cherabuddi, a physician with UF Health that specializes in infectious diseases.
"We predominantly don't see many outbreaks in restaurants because generally, food handlers are trained well in this country," he said.
But health inspections by the Florida Department of Business and Professional Regulation show that the two local restaurants with positive cases had a recent history of sanitation issues. Reports from earlier this year show that food service workers at both Hambuger Mary's and the Toasted Monkey lacked knowledge of food-borne illnesses and employees were handling food without washing their hands or wearing gloves.
The Florida Restaurant and Lodging Association is keeping an eye on the situation and alerting its members to do the same, said spokeswoman Amanda Handley.
"The food code has very clear, effective policies regarding employee illness, and all who work in food service are required to have training to help keep everyone safe and healthy," she said. "We have scheduled some social media posts to go out reminding members to ensure all employees are trained and directing them to our SafeStaff Food Handler training. Additionally, we have drafted messaging to include in our monthly newsletter."
Consumers should also be aware of the outbreaks in their communities, as some may be at higher risk to contracting the virus than others, such as people who previously have been in jail or traveled internationally. All 1-year-old children, transient people, users of recreational drugs and gay men are encouraged to be vaccinated as soon as possible.
"The older you are, the higher the risk," Roberts said. "In Florida, the vaccine has been on the schedule for 20 years. If you are older than that, there's a good chance you never got vaccinated."
People who catch hepatitis A are the most infectious during the two weeks before they experience symptoms, Foster said.
"Many who are infected do not have symptoms that require medical care, some may unknowingly infect others before they know that they are infected," she said. "This makes it difficult to find cases and provide timely vaccine to prevent people who were exposed to the virus from becoming infected."
In addition to the vaccine, washing hands after a bathroom visit and after changing diapers lessens the chance that contamination will spread. But vaccination is the best protection against the virus.
Contact Justine Griffin at firstname.lastname@example.org or (727) 893-8467. Follow @SunBizGriffin.