Hepatitis A Is Breaking All The Rules in Northeast Arkansas

Since 2018, there’ve been 363 cases of Hep A across Arkansas—compared with 7 in 2017. Focused primarily in northeast Arkansas, this outbreak is breaking all the rules

FOR MUCH OF its 44 years, Pizza Inn in northeast Arkansas bustled with activity at lunchtime. Customers queued at the salad bar and hot buffet. Staff manned the open kitchen, navigating the sprawling dining room with aluminum pans of bubbling-hot pies. For most patrons of Pizza Inn, or most any restaurant, for that matter, the experience of eating out is somewhat limited, somewhat myopic: When people go out to eat, their experience is limited to what they see in the dining area, but ask the proprietors, and they’ll tell you the requirements for restaurants go much further than what diners observe on any given night.

A salad bar, for instance, with uncooked foods such as lettuce and spinach, has to be strictly controlled because viruses and bacteria aren’t cooked off. The lengths to which the health department enforces food-safety measures might appear overwrought—unnecessarily thorough to the untrained observer—but for Bob Clairday and his family, such measures are practically second nature.

In the decades that Bob’s been a franchisee for Pizza Inn, the business has become more than just a job. With a handful of family members now involved in the day-to-day business dealings, Pizza Inn is a family enterprise. More than that, however, the business has become a part of who they are, a bond firmed up over many years. Then in late 2018, that bond was nearly severed.

On Thursday, Sept. 20, 2018, one of the three Jonesboro Pizza Inn locations learned that one of its staff members had tested positive for hepatitis A. Representatives from the Arkansas Department of Health (ADH) arrived that same day, vaccinating the entire staff and preparing the company for a press release slated to publish that afternoon. The headline read, “Health Department warns of possible hep A exposure to customers of Jonesboro Pizza Inn.” In addition to providing details about the exposure—that people who had eaten at Pizza Inn “from Sept. 4 to Sept. 17 should seek vaccination” and that a free vaccination clinic was scheduled for the coming weekend—the press release also gave a brief epidemiological snapshot.

A highly contagious liver disease caused by the hepatitis virus, hepatitis A—or hep A—is typically acquired either by person-to-person contact, or via contaminated food. Although the disease can range in severity—“from a mild illness lasting a few weeks to a severe illness lasting several months,” as the ADH noted in the press release—when the public believes they could be at risk of a severe illness that can last up to several months, choices tend to change.

As such, even though the ADH press release said the exposure was “possible” and that no confirmed cases had come from food, the public fixated on two terms: “Hep A” and “Pizza Inn.” News reports ran graphics using the word “outbreak,” while showing B-roll footage of the Pizza Inn logo. The restaurant’s business dropped off almost immediately. The staff was reduced. Hours were cut across the entire company.

All because a driver for the company, who never handled food, tested positive for hep A.

“We went from $22,000 a week to $5,000 a week,” Bob says. “Now I don’t put anyone to work for me who’s not had the [vaccine].”

It’s not uncommon for restaurants to experience dips and spikes in business with the ever-changing whims of the public and the ever-tumultuous cycle of current events, but nothing could compare to the alarming consequences of this outbreak of hep A. For the past year and a half, the Clairdays’ experience has been shared by many food-service businesses across northeast Arkansas: In 2018, restaurants on the receiving end of similar press releases included the Corning Taco Bell in February, both the Corning Flash Market/Subway and the Walnut Ridge Doublebee’s gas stop in April, the Jonesboro Steak ‘n’ Shake in June, just to name a few.

But while hep A is often associated with tainted food, it hasn’t been so with this outbreak.

Not even one case has been confirmed to have been contracted through food.

Hep A and the Outbreak

BY THIS POINT in the year, there should be no more than three cases of hep A across the entire state of Arkansas. Since February 2018, there have been 363. Three people have died.

One has to dig pretty deep to find any comparable numbers. In fact, according to figures provided by the Arkansas Department of Health, confirmed cases of hep A haven’t been this bad since the vaccination was introduced in 1996, when the disease was virtually wiped off the map. That year, there were 500 cases in Arkansas. By 1998, the number had dropped to 82. With the exception of a brief spike in 2000—144 cases—those numbers never again left the double digits. Confirmed cases even dropped into the single digits for much of the 2010s. Then came 2018, with 256 cases.

Of course, the first question that arises is, where is the hep A coming from?

This strain of hep A seeped into Arkansas from the Missouri Bootheel, which has seen an even more severe outbreak than Arkansas. However, even Missouri hasn’t seen anything like Kentucky: More than 3,000 cases were confirmed there in 2018, with more than 50 deaths. Reports suggest that Kentucky was hit particularly hard because the state was slow to vaccinate its residents, despite warnings beginning in February 2018.

Arkansas has been anything but slow in administering vaccinations.

The moment any hep A exposure was confirmed at a restaurant, a team was dispatched to the business. Press releases went out to media. Pop-up vaccination clinics were immediately opened in the days and weeks that followed (the vaccine is effective until symptoms set in a few weeks after exposure). Even though Arkansas has seen numbers going through the roof compared to years prior, those numbers could have been far more severe had it not been for the response from the Arkansas Department of Health.

From February 2018 to May 2019, ADH hosted 32 days of hep A mass-vaccination clinics throughout northeast Arkansas. During that same time period, they administered some 26,047 vaccinations (not all of which were done through those clinics). But while hep A is often associated with tainted food—owing, in part, because of the disease’s fecal-oral transmission, and news stories like 2016’s multistate outbreak linked to frozen strawberries—there’s a different reason why the ADH has been painting the area with such a broad brush, epidemiologically speaking:

Those most at risk aren’t customers at restaurants.

Rather, they’re people engaging in high-risk, often stigmatized behaviors—a factor that can make it difficult to get the vaccination to the people who need it most.

“We are balancing the issue of being proactive with the issue of being targeted,” ADH epidemiologist Dr. Dirk Haselow said. “It would be great to say we want to have a clinic for people who are homeless, incarcerated, drug users—come on down, come to our clinic. Unfortunately, that doesn’t work.”

As far as the health department’s outreach in restaurants is concerned, Haselow said that while it might be less efficient than their work in settings with high-risk groups—in jails, prisons, homeless shelters, soup kitchens and so forth—it’s still very important.

“Part of the reason why it’s important is because there have been some studies that show that fast-food workers have a pretty high prevalence of recreational drug use, maybe as high as 25 percent,” he said.

Even though the risk of getting hep A from an infected food worker is low—he made a point of stressing that, again, this outbreak hasn’t been food-related—the health department reaches out anyway “because we know this vaccine is safe and effective and underutilized [in people] from 20 to 60 years of age.”

While there might be some degree of uncertainty with respect to some aspects of the virus—largely because hep A’s incubation period ranges from two weeks to two months, with an average of three to four weeks, making it difficult to pinpoint the virus’s source—the effects of the vaccine are indisputable: It works.

The health department encourages restaurants and restaurant chains to vaccinate all of their employees. In the northeast corner of Arkansas, most of the business owners are listening. Although vaccinations haven’t been mandated—at $50 per treatment, it could create a major financial strain for small restaurants with higher turnover, health officials said—they did share that it was a discussion being looked into. (State Rep. Jack Ladyman of Jonesboro introduced a bill on March 14 calling for food workers to be vaccinated; however, it failed to make it out of committee before the legislative session was adjourned.)

“Different states have different policies,” said Dr. Mike Cima, chief epidemiologist for the ADH. “At this point, we do not have a regulation. We do recommend that a restaurant do it. It’s in their best interest to do so.”

But Cima’s tone shifted as we asked him about the trend of many being skeptical of vaccines. Some people, despite overwhelming scientific evidence, suggest that vaccines even cause health ailments. This has created a resistance by some to using vaccines or vaccinating their children. Despite whether one elects to get vaccinated for hep A, Cima said, vaccines are crucial to human survival.

“Vaccines are among the safest and most studied medicines known to man,” Cima said. “They’ve been lauded in medicine and public health as one of the top-10 discoveries in the past 100 years. They’ve done more to expand our human lifespan than anything, other than clean water, and are associated with increasing our human lifespan by over 10 years. So, yeah.”

Feeling the Pain

AT A RECENT lunch hour at Pizza Inn on Caraway Road in Jonesboro, Greg Clairday, Bob’s son, shifted between working in the kitchen and checking on customers. Even though he said no one in the family has official titles, he might be seen at Pizza Inn locations trimming the grass one day, inspecting kitchens the next and eating with his family at still another. So when the news broke about an exposure at one of his establishments, Greg was as alarmed as anyone.

“When it first came out, I didn’t know anything about it,” he said. “I was concerned, personally for my children, my grandkids—they all eat in the store. I was concerned for my employees; I was really concerned for my customers. We didn’t know anything about it. We met with the health department and said, ‘Do we need to close the store?’ They said ‘No! You wash your hands, and you wear gloves.’ [Those are] the two biggest things in controlling the spread of contagious diseases.”

The efforts have made the food-service industry in northeast Arkansas safer than it has ever been. Nowadays, if you’re a food-service worker, you almost can’t get hired unless you go to the health department and verify that you have your hep A vaccine, Greg said. Despite the absence of a mandate by the ADH—so far—business owners like the Clairdays don’t dare experience a possible exposure again.

But the hep A outbreak came at a steep cost for many businesses, almost all of whom fear doing interviews about the topic because of previous effects of media coverage. For Pizza Inn, those weeks after the news broke were devastating. It took six months before business returned to normal.

“It was traumatic,” Greg said. “It was, yeah. And we have a published office phone number, and we talked to a lot of customers. You could feel that worry, on that end. I’ve seen a few follow up stories, but I think the big takeaway for me is, as an industry, we’re not spreading this disease. We’re not making people sick.” 

Stan Morris is the owner and primary news reporter for NEA Report, a local news outlet based in northeast Arkansas.