Cases rise despite vaccination effort
By Kay Lazar, Globe Correspondent
December 9, 2004
Months after hepatitis A scares among food handlers at five Massachusetts restaurants grabbed headlines, public health workers across the state are still battling outbreaks of the infectious disease, often among the homeless, substance abusers, and inmates.
At the state’s urging, community health nurses have spent weeks doggedly trooping through shelters, methadone clinics, and rehab centers offering vaccinations and prevention education.
But new infections keep cropping up. And one of the state’s top disease trackers is baffled.

“I’m thinking right after the beginning of the year, we need to regroup and figure out new strategies,” said Dr. Alfred DeMaria, the state’s director of communicable disease control.
As of Nov. 30, the state recorded 927 hepatitis A cases, compared with just 259 for all 2003, DeMaria said. In 2002, the state had just 150. DeMaria said about 60 to 70 percent of the state’s cases this year have been among people with a recent history of homelessness, drug abuse, or incarceration.
In cities north of Boston, public health nurses are in overdrive, hitting soup kitchens, hopping on vans that provide medical care to the homeless, and offering restaurant owners discounted vaccinations for their workers.
“I think we’ve done at least 100 vaccinations [at My Brother’s Table soup kitchen], and I just ordered another 100 doses from the state,” said M. J. Duffy-Alexander, Lynn’s public health nurse.
Duffy-Alexander said Lynn normally has about five hepatitis cases a year, but by December has already notched 30. About a third of the infections were among the homeless and another third among residents who had recently traveled to other countries. But the rest did not fall into the so-called high-risk populations of homeless, drug users, or prisoners, she said.
Hepatitis A, a relatively harmless liver disease that causes fatigue, fever, and nausea, usually spreads when infected people don’t wash their hands after using the toilet and then prepare food. The infection can be much more serious for people with already-damaged livers.
While infections among restaurant workers are rare, officials worry the virus may continue to spill into the general public through eateries, where many unemployed people often enter the workforce.
People living on the streets are particularly vulnerable to infections because they often don’t have access to places where they can wash their hands.
“There aren’t a lot of public restrooms for people who don’t look like a customer,” said Dianne Kuzia Hills, associate director of My Brother’s Table. “You can talk about hand washing all you want, but if someone is going to the bathroom behind a dumpster, they aren’t going to be washing their hands.”
The soup kitchen, which serves dinner to about 200 daily, is handing out tubes of hand sanitizer gels during its Tuesday night clinic where homeless people can receive medical care for free. That’s also when Duffy-Alexander offers hepatitis A vaccinations. She’s hoping to reach an even wider circle by joining street workers from another Lynn nonprofit in their weekly van ride administering health care to the homeless.
In Gloucester, public health nurse Sunny Robinson offered hepatitis A vaccines this fall at the city’s Action shelter and continues to go back regularly to find new residents.
But nurses say the transient nature of homelessness poses a challenge because the hepatitis vaccine is given in two doses, each about six months apart.
“We will do everything we can to track down people who are no longer at the shelter to finish up their immunizations,” Robinson said.
She also has been regularly stopping in at a busy methadone maintenance clinic near Addison Gilbert Hospital.
“Many of the methadone folks come between 5:30 and 7:30 in the morning, so that’s when we do the immunization program,” Robinson said. “You meet the customer where he or she is.”
Gloucester hadn’t had any cases of hepatitis A in the past five years, Robinson said, but recorded two this fall.
In Salisbury, health director Horace Baxter said the virus wasn’t even on his “radar screen” until state health officials called on communities for help this summer after five hepatitis cases among food handlers in Boston, Arlington, and Stoneham.
After that, Baxter said he went to Women in Transition, a small pre-release correctional facility in Salisbury, to make sure the women are wearing gloves in the facility’s kitchen when they prepare food.
But he said his larger concern is his seaside town’s 60 restaurants, many of them seasonal. He said most of the workers come from other countries and go home for the winter.
“We have a lot of Brazilians, Greeks, Italians, two different dialects of Chinese, and a huge Lebanese contingent,” he said.
The problem is, many of the restaurants’ food handlers don’t speak English, he said.
Baxter visited the restaurants before they closed for the season and tried to explain safe food-handling procedures to the owners, including information about wearing gloves and frequent hand washing. But he wasn’t convinced the critical information for stopping spread of the hepatitis A virus reached the people who most needed to understand it — the workers.
So Baxter is determined to spend the winter working on information cards, translated into at least six languages, that will be ready when workers return in the spring.
“If I can accomplish that, in a small community, that’s a huge accomplishment,” he said.