Hepatitis A after eating out

Jennifer Seavers was 14 years old when she went out for Mexican food to celebrate her friend Eve's birthday. Although Jennifer wasn't particularly crazy about Mexican food, she didn't want to miss the party. So, in October 2003, Jennifer and a dozen girls from Ambridge High School sat down to plates of nachos, fajitas and tacos at a Chi-Chi's restaurant in Beaver, Pennsylvania, 25 miles northwest of Pittsburgh.

Within a few weeks, one of Jennifer's friends developed fever, stomachaches, muscle pain, weakness, nausea and vomiting. Then her urine turned dark brown, her skin turned yellow, and she couldn't breathe without feeling like she was being stabbed in her abdomen, just below her rib cage. Frantic, the girl's parents took her to the doctor where a blood test revealed the diagnosis: hepatitis A virus.

About hepatitis A

Hepatitis A virus is one of the most common causes of infectious hepatitis in the world. The virus enters the body through the mouth and spreads quickly from the intestine to the liver, where it destroys liver cells. The virus then enters the gall bladder, travels back to the intestine, and is excreted in large quantities in the stool. Some people, such as young children, never develop any symptoms when they are infected. Others, such as adults older than 40, become seriously ill. Before the hepatitis A vaccine became available in 1995, every year in the United States about 200,000 people were infected with hepatitis A and 100 died from the disease. In Asia, Africa and Latin America, where there is an inadequate separation of sewage from drinking water, almost everyone is infected. Around the world, millions are infected and thousands die every year.

Hepatitis A outbreak

Jennifer Seavers knew that she had dodged a bullet. "I feel really lucky that I didn't get sick," she said. "But I know a lot of people did." Jennifer's friend was one of many. The first case of hepatitis occurred on October 2, 2003. During the next few weeks, several more people got sick. By November 3, local health officials confirmed that there was an outbreak of hepatitis and told Chi-Chi's to shut its doors. Health officials also knew that the incubation period (the time from exposure to the virus to the first symptoms) could be as long as seven weeks, so everyone who had eaten at the restaurant from September through November was at risk.  The Chi-Chi's in Beaver Valley, Pennsylvania, had served 11,000 meals during that time.

By Tuesday, November 4, 34 people who had eaten at the Chi-Chi's were sick with hepatitis. By Wednesday, November 5, the number rose to 84; by November 6 to 130; and by November 7 to 185. Also on November 7, Jeffrey Cook, a 38-year-old auto-body restorer from Aliquippa, Pennsylvania, died of liver failure soon after receiving a liver transplant in a desperate attempt to save his life.

Health officials were convinced that the outbreak was caused by a restaurant employee with hepatitis. During their investigations they found 12 employees that were infected with the virus. However, all were infected at the same time as the customers, not before. The timing wasn't right. The virus was coming from somewhere else.

By Monday, November 10, the number of people with hepatitis rose to 240. The outbreak had now surpassed a previous outbreak that occurred in 1990, when 230 people that had eaten at a sandwich shop in Missouri developed hepatitis.

By Tuesday, November 11, the number rose to 300, and two more people were in critical condition.

By Wednesday, November 12, the number of cases rose to 340 and investigators finally closed in on the likely source of the infection. Earlier that year, state and federal public health officials had interviewed thousands of people during outbreaks of hepatitis A in Georgia, Tennessee and North Carolina that sickened 250. They asked people who got sick and those who didn't what they had eaten; then they carefully checked the ingredients of each of those foods. One item kept appearing on the list of those infected with hepatitis A — green onions (scallions). Investigators found that the restaurants involved had imported all of their green onions from Mexico, a country with a very high rate of hepatitis A infection.

Richard Quartarone, a spokesman for the Georgia State Health Department, said, "Because they're multi-layered, green onions are very difficult to clean. The only way to be 100 percent sure that you killed the hepatitis in the green onions is to cook them. But they're often used as a garnish; so you don't cook them." Chi-Chi's immediately pulled green onions from the menus of their 99 other restaurants from the mid-Atlantic to Minnesota.

By Thursday, November 13, the number of cases rose to 410 and the outbreak claimed its second victim, Dineen Wieczorek, a 52-year-old customer service representative for Ikea, who died while waiting for a liver transplant. She had eaten at Chi-Chi's on October 6 to celebrate her 32nd wedding anniversary. Her daughter, Darleen Tronzo recalled, "One meal. One meal, that's all it took. And people eat out every day. I eat out every day. And you never think something like this could come of it."

By Friday, November 14, the number of cases rose to 490 and the outbreak claimed its third victim, John Spratt, an employee at a payroll processing company. Spratt had eaten at Chi-Chi's with his 17-year-old daughter, Jacqueline. They both ordered the chicken fajitas. But Spratt, not his daughter, chose to eat the condiments that came with the meal — a choice that killed him. Joseph Spratt remembered his visit to the hospital during the final days of his brother's life: "We were told that he could hear us. And if you talked to him there'd be a little flutter of the eyebrow or a soft squeeze of the hand. But that was about it."

By Saturday, November 15, the number rose to 510. Thousands of people were now showing up at health clinics throughout Western Pennsylvania to receive protective shots of gamma globulin. And, because hepatitis A virus is present briefly in blood before infecting the liver, the Central Blood Bank and local branch of the American Red Cross discarded blood from people who had eaten at Chi-Chi's.

When it was over, the hepatitis A virus outbreak at Chi-Chi's infected 660 people and killed four. It was one of the largest single-source outbreaks of an infectious disease in United States history. But it wasn't the largest hepatitis A outbreak in the world. In 1989 in Shanghai, hepatitis A virus in uncooked, polluted clams from the East China Sea infected more than 300,000 people and killed 47. Clams, like mussels and oysters, can filter as much as 10 gallons of water an hour. If hepatitis A virus is present in water, clams can concentrate the virus 100-fold.

In 1995, the U.S. Food and Drug Administration licensed the hepatitis A vaccine which is recommended in two doses for all children between 12 and 23 months of age.

Learn more about hepatitis A and the vaccine that prevents it.