Westchester County Health Department was notified of the first case in what would be identified as the Bartaco hepatitis A outbreak on October 10, 2017. Bartaco is a Mexican restaurant located at 1 Willett Ave, Port Chester, New York.

After learning of a second hepatitis A case with exposure to Bartaco, environmental health investigators conducted facility inspections of the restaurant on October 17 and 19. The Health Departments also provided preventative treatment and timely information to more than 3,000 people who were exposed to the confirmed HAV-infected Bartaco employee.  The inspections found several violations that could have contributed to the spread of hepatitis A to patrons. The Health Departments’ observations included inadequate employee hand washing facilities, and employees handling cooked and prepared foods with bare hands. Additionally, investigators observed that food items were not properly protected during storage and preparation from potential sources of contamination.

The Centers for Disease Control (CDC) performed  genetic analysis of the Hepatitis A strains from the 3 original Westchester residents who ate at Bartaco as well as the HAV-infected employee. The results demonstrated that all the individuals were infected with the same strain of Hepatitis A which was not being seen elsewhere in the United States. Id.

Ultimately, the investigation conducted by the Westchester County Health Department determined that the six laboratory confirmed cases of hepatitis A were associated with the Bartaco hepatitis A outbreak. All six cases had eaten at Bartaco Restaurant between October 12 and 23. It was concluded that the source of the outbreak was an ill employee who worked at the restaurant while infectious. This conclusion was based on (1) one of the initial four primary cases was also a Bartaco employee; (2) none of the primary cases knew each other or ate at the same time; the only commonality among the confirmed cases was their consumption of food and drink from Bartaco from September 7—12, 2017; (3) observations by WCDOH environmental inspectors indicated violations related to bare-hand contact with foods, utensils, and inadequate handwashing facilities for Bartaco staff; (4) subsequent investigation of food sources for the Bartaco brand indicated that all locations are serviced by the same supplier, and no other Bartaco restaurant experienced similar illness; and (5) while no ill employee was ultimately identified from September 2017, 22 employees who worked during that time were unable to be interviewed and investigated as a possible index case.

The conclusions made by the Westchester County Health Department are supported by the plaintiff’s expert witness Kristin Sweet, PhD, MPH. Ms. Sweet has an extensive background in public health, epidemiology, foodborne illness investigations, and viral infections, working specifically as an infectious-disease epidemiologist for viral hepatitis for 13 years.

Specifically, Kristin Sweet, PhD, MPH, concluded:

The only common exposure among the five primary cases of hepatitis A in this outbreak was having eaten at Bartaco in Port Chester, NY. During an inspection of the restaurant, gaps in sanitation practices were identified including bare‑hand contact with ready‑to‑eat foods and lack of handwashing supplies at sinks. Although the epidemiological investigation did not implicate a specific food item or food handler as the source of the infections, the environmental health assessment at the restaurant found food‑handling practices that could have led to contamination.

According to the NEARS Form, the restaurant did not have a salad bar or buffet where customers could more easily contaminate food consumed by other patrons. Employees and customers used separate restrooms and cases occurred both in customers and one employee. While hepatitis A can survive on environmental surfaces for a month or more, the likelihood that a customer contaminated a surface that was touched by multiple patrons on multiple days resulting in infection is low. Despite the fact that the NYDOH reported that no source was identified through their investigations, an ill food handler is still a possible source. These interviews depend on the availability of all employees completing an interview or survey. Even if all employees were interviewed, employees may not be honest or be able to report thoroughly on their symptom history from one or more months prior to interview. In the absence of complete documentation on the employee interviews, either of these scenarios is possible in this instance.

Based on the information provided to me, it is more likely than not that the hepatitis A outbreak at Bartaco was foodborne.

A second expert, Roy E. Costa, RS, MS (MBA), a Public Health Sanitarian and Consultant with over twenty years’ experience reached a similar conclusion, providing the following opinions of the case:

1.     Bartaco was the source of 5 primary HEP A outbreak cases.

2.     There were 2 secondary outbreak cases related to the primary cases.

3.     A HEP A infected Bartaco co-worker was the most likely source of the HEP A virus.

4.     The HEP A Positive employee and 4 other primary cases in October were exposed to an unidentified infected co-worker in September of 2017.

5.     A contaminated food and beverage were the most likely modes of HEP A virus transmission.

6.     The most likely contributing outbreak factors were poor maintenance of hand washing facilities, poor personal hygiene practices, lack of hand washing, bare-hand contact of RTE foods, and poor management surveillance.