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The investigation of Georgia's hepatitis A outbreak --- which struck about 250 people with the viral liver disease in September and October --- has focused on three restaurants: J. Alexander's in Norcross and two O'Charley's in Macon and Centerville, south of Macon.
Health officials say patrons of at least a dozen restaurants in Georgia became ill, but the other establishments have not yet been included in the probe.
The restaurants are not to blame and are cooperating with the investigation, the health officials say. The green onions that caused the problem were contaminated before arriving at the restaurants --- probably at a farm in California or in another country. A supplier shipped the produce to a distributor at the Atlanta State Farmers Market in Forest Park who sold the green onions to the restaurants.
Though infection peaked in mid-August and the outbreak subsided by mid-October, health officials say a few illnesses spread by the original cases have been reported recently. The officials are reminding restaurants and the general public that a vaccine, given in two injections of about $50 each, can prevent the disease.
"For people who eat foods at risk for carrying hepatitis A --- raw vegetables, raw fruits and shellfish --- it would be a good thing for them to consider getting the vaccine if they are able," said Richard Quartarone, spokesman for the Georgia Division of Public Health.
The state's investigation began in late September, after an unusual number of hepatitis A cases were reported in the Macon and Atlanta areas. Interviews with patients revealed a link to J. Alexander's and the two O'Charley's, among other restaurants.
According to state investigation documents, the food items most associated with illness at J. Alexander's were pico de gallo salsa, cilantro shrimp and orzo and wild rice. Each contains green onions. Details are not available for the dishes connected to illness at O'Charley's.
Health officials in Tennessee linked green onions to a simultaneous hepatitis A outbreak among 70 diners at an O'Charley's in Knoxville. The Atlanta-based Centers for Disease Control and Prevention believes the outbreaks are related, despite a scientific puzzle: Georgia's patients have had a slightly different genetic sequence of the virus than the Knoxville patients.
During the same period, about a dozen people contracted hepatitis A in Asheville, N.C., many of them at a Doc Chey's Noodle House. They have the same viral sequence as the Georgia patients, so that outbreak is considered to be linked.
The green onions from the three Georgia restaurants were traced to the unidentified distributor at the farmers market in Forest Park, said Dr. Paul Blake, state epidemiologist. The distributor had obtained the produce from three suppliers in California. By comparing lot numbers, the state tied the contaminated produce to one supplier, which the Food and Drug Administration is investigating, Blake said.
The state hopes to compare a list of Georgia restaurants that received the supplier's green onions with the list of other restaurants where hepatitis patients reported eating, Blake said. That could draw more of the restaurants into the investigation.
Contaminated workers or water could have tainted the green onions at the supplier's headquarters or at a farm in California, Mexico or another country, Blake said. The contamination could have occurred during the planting, irrigation, harvesting, processing or shipping of the green onions, he said. At least three farm workers routinely handle green onions during harvesting --- peeling them, tying them into bundles and cutting off their roots.
If the virus burrows deep into the sleeves of the green onions, restaurants "could wash them all day and not be affecting what's between those sleeves," Blake said. "The only way to make the green onions totally safe would be to cook them thoroughly. That, of course, makes them lose their appeal."
Officials with J. Alexander's and O'Charley's --- chains both based in Nashville --- say the companies have cooperated with the investigation. No employees at J. Alexander's became ill, and the restaurant did not see any reason to vaccinate its workers, said company spokesman Tom Lawrence. Meg Bayless of O'Charley's said the company would not comment further, referring calls to the Division of Public Health.
While health officials regularly inform restaurants and the public about the hepatitis A vaccine, the CDC formally recommends it only for certain groups: gay men; illegal drug users; travelers to countries with high rates of the disease; children in states with high rates (mostly in the West); workers in research labs that keep the virus or animals infected with it; people with chronic liver disease and people with clotting-factor disorders.
The CDC does not recommend vaccination for food service workers. That is because food-borne transmission accounts for only 10 percent of hepatitis A cases, and food handlers account for only 7 percent of cases, said Dr. Anthony Fiore, a CDC infectious disease specialist. The disease is spread more frequently among drug users and children and from children to adults, he said. And food service workers frequently shift jobs, making vaccination less effective and more costly, Fiore said.
Recommendations also can trigger an expectation that public health funds help pay for some vaccinations.
No states require hepatitis A vaccination for food handlers, according to Fiore and other authorities. Clark County, Nev., which surrounds Las Vegas, requires the vaccine for food handlers, at the employees' expense. St. Louis has the same requirement, letting the employer decide who pays. Oklahoma offers tax breaks to restaurant owners if they vaccinate employees.
For the general public, the 8-year-old vaccine is an option for people concerned about getting the disease, Fiore said. About three in 100,000 people contract hepatitis A every year, with about 10,600 cases reported nationally in 2001. About 70 percent of infected adults become ill, and about 70 percent of infected children don't. The vaccine, which offers long-term protection, is one of the safest, with very few side effects, Fiore said.
The DeKalb County Board of Health, like other departments, offers the hepatitis A vaccine at its five health centers. The vaccine is also available through the county's community flu shots clinics this fall.
"Some people get it, but it's not recommended across the board," said Dr. Stuart Brown, DeKalb's medical director for personal health services.
Bruce Barfield of Alpharetta wishes he had received the shots. He ate at J. Alexander's on Aug. 16, sharing pico de gallo salsa with a friend. Both men became ill a few weeks later with hepatitis A, and Barfield is one of three Georgians who have retained a Seattle attorney to review his case. Lawsuits have been filed against O'Charley's in the Knoxville outbreak.
A 44-year-old computer software salesman who frequently travels for work, Barfield was ill for three weeks. "I was completely shut down," he said. "It's debilitating."
Barfield said he didn't know there was a vaccine. "I guess I've been [naturally] vaccinated now," he said.
Copyright 2003 The Atlanta Journal-Constitution