The Other Hepatitis

There are plenty of types of hepatitis: C likely being the most familiar and capable of setting off the loudest alarm bells in workplace settings.

But other forms of the infectious liver disease include A, B, D and even E– all of which have different symptoms and modes of transmission; different means for prevention and control, notes the Canadian Centre for Occupational Health and Safety (CCOHS) in Hamilton, Ontario.

And it is through these forms of transmission and control that work and the public domain can become an unhealthy twosome. Hepatitis A “can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months,” reports Rachel Powell, a spokesperson for the National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases and Tuberculosis Prevention in Atlanta, part of the Centers for Disease Control and Prevention.

Symptoms — which include fever, loss of appetite, diarrhea, nausea, abdominal discomfort and jaundice — may appear two to seven weeks following exposure, but usually surface after four weeks, says information from York Region Community and Health Services (YRCHS). Most people recover without complications after several weeks.

Talk of Hepatitis A recently surfaced following separate incidents involving two Tim Hortons employees at the centre of a two-stage scare north of Toronto. The workers returned to their jobs in late April after tests deemed the risk for public exposure was low.

Nick Javor, vice-president of corporate affairs for Tim Hortons in Oakville, Ontario, reported at the time that both workers were “feeling good.” One employee in question was a supervisor; the other handled food directly.

Concerns were raised on April 21, after YRCHS received notification of a case of Hepatitis A infection in an employee (the supervisor) at the restaurant in Newmarket, Ontario, about 45 kilometres north of Toronto.

Upon receipt of the report, YRCHS spokesperson Jennifer Mitchell-Emmerson says, investigators found “this particular case had an epi-link [epidemiologic link] to a confirmed case within another health unit jurisdiction.” Laboratory testing was carried out and the results confirmed that the individual was infected with the Hepatitis A virus (HAV), Mitchell-Emmerson notes.

Following an investigation, however, it was “determined that the risk to customers was very low based on the nature of the work of the [supervisor] and the results of the inspection of the food-handling process,” says a YRCHS statement.

Dr. Karim Kurji, medical officer of health for York Region, reports that the supervisor followed excellent hand hygiene practices — improper hand hygiene is the most common way in which HAV is spread — but contracted the virus from a “close contact” elsewhere.

STAY OR GO

David Morelli, director of public affairs for Tim Hortons, says that following the supervisor incident — and in conjunction with the recent focus on the H1N1 (swine flu) virus — the company re-emphasized the importance of hand hygiene “with a reinforced sick policy, which encourages staff to stay home if they are not well.”

The national restaurant chain already enforces a program “with all levels of employees to avoid bare-hand contact with food wherever possible,” Morelli reports. Tim Hortons, in fact, held a managers’ training symposium (one focus of which was diligence in hand hygiene practices) a short time before the incident, he says.

Still, several days after the initial health concerns were raised, a second employee — identified as a higher risk because of food-handling duties — began experiencing symptoms associated with Hepatitis A, says Mitchell-Emmerson.

Javor notes that the restaurant location in question was shut down for almost two hours while the company performed a high-level disinfection of the premises. A sign was posted outdoors to inform customers of the situation.

By April 27, the exposure risk was lowered after test results on the second worker “confirmed that the symptoms experienced were not caused by Hepatitis A and foods prepared by this individual did not potentially expose customers to Hepatitis A,” the region’s statement notes.

There were no other reports of worker infection at the restaurant, Dr. Kurji adds.

“A” POSSIBLE CONCERN

Hepatitis A is a disease typically spread when a person ingests fecal matter, “even in microscopic amounts,” says Powell. This ingestion may occur as a result of contact with objects, food or drinks contaminated by the feces of an infected person, she explains.

Powell points out that HAV may be spread through person- to-person contact, for instance, when an infected person does not wash his or her hands properly after using the bathroom and then touches other objects or food, or when either a parent or a caregiver does not properly wash his or her hands after changing diapers or cleaning up the stool of an infected individual.

It is important to note that three of every four people infected with Hepatitis A will have symptoms, the CCOHS re- ports. But for those who don’t, they can still spread the virus.

The good news is that, unlike some other forms of viral hepatitis, the A version does not cause chronic damage and is usually not fatal, the centre notes.

The CCOHS information adds there is little evidence of risk for Hepatitis A infection on the job: health care workers who follow standard infection control procedures do not seem to be at increased risk; sewage workers may be at increased risk during community outbreaks.

Still, the way in which Hepatitis A is transmitted is precisely why proper hand hygiene techniques — such as scrubbing hands with soapy, warm water for at least 15 seconds — is critically important, says Dr. Mark Swain, a professor of medicine at the University of Calgary.

“Fecal contamination of the hands” can spread the virus from a worker to the public, says Dr. Swain. “Someone at Tim Hortons, if they are preparing a cold meat sandwich or they are touching stuff that is definitely not going to be cooked, like lettuce, that’s where the big risk is,” he advises.

The CCOHS recommends that workers be informed of appropriate protective clothing, the need to remove that clothing at the end of a shift, and the importance of avoiding nail biting.

Powell says that Hepatitis A can also be spread by eating or drinking contaminated food or water, usually fruits, vegetables, shellfish, ice or water. This is a more likely scenario, however, “in countries where Hepatitis A is common and in areas where there are poor sanitary conditions or poor personal hygiene.”

Dr. Swain agrees, adding that HAV is “relatively uncommon in more developed countries.” Nonetheless, he points out that if there are contaminated vegetables that come from an area where Hepatitis A is endemic, “then that’s a potential source.”

Although the U. S. witnessed an estimated 25,000 new cases in 2007, says Powell, “the official number of reported Hepatitis A cases is lower (almost 3,000) since many people who are infected never have symptoms and are never reported to public health officials.”

Jason Contant is editor of CANADIAN OCCUPATIONAL HEALTH & SAFETY NEWS.

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“…this particular case had an epi-link to a confirmed case within another health unit jurisdiction.”

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…unlike other forms of viral hepatitis, the A version does not cause chronic damage.