Hep A Syringe

Franklin County Health Department Director Angie Hittson says her staff is ahead of the ongoing hepatitis A outbreak in the county, but she does not see an end in sight.

“I just don’t know,” Hittson told The Missourian. “The best case scenario would be to see cases drop because we have vaccinated enough people to stop the spread. The worst case would be that people stop seeking care and we miss diagnoses.”

To declare an official end to the outbreak, she said there must be a period of 100 days, or two incubation periods, with no new cases.

“This outbreak began in Southeast Missouri,” Hittson said. “Right now it is still fairly small, but the state is concerned if it spreads to St. Louis County, it could quickly spread to St. Louis city and then Kansas City and we could have thousand of cases.”

Hittson added there is no doubt in her mind there are additional cases in the county they have missed or that haven’t been reported.

“The number of cases going up isn’t necessarily a bad thing,” she said. “It usually seems like we get one case then it leads to two or three more associated with that person. If more people are diagnosed, that’s more people we can vaccinate and hopefully stop this.”

Still Spreading

With 47 cases now confirmed and total vaccines administered nearing 1,500, the virus continues to spread and has now caused patrons of a second restaurant to be advised to receive vaccinations.

On Wednesday of this week, 40 vaccinations were administered to possible patrons of the restaurant and an additional 40 on Thursday.

On Friday, July 5, the health department identified an employee who handled food at Roadhouse 100 in Gray Summit as being infected by hepatitis A and ordered all employees be vaccinated and urged any customers who had visited the establishment between June 26 and July 5 to attend the health department vaccine clinics that were held Wednesday and Thursday in Union.

Hittson said the health department was notified about the worker’s infection by Mercy Hospital Washington.

“Once a positive test comes back they are required by law to let us know,” Hittson explained. “We then get contact information and reach out to the patient and begin an investigation. We want to know when was the last time they worked and who they may have been in contact with.”

She added in this particular case, the risk to the public is very low and the patient did not serve food while experiencing hepatitis A symptoms.

An additional 600 vaccinations arrived in Franklin County from other parts of the state on Wednesday.

Panic, Rumors

In addition to Roadhouse 100 this week, late last month the Jack in the Box in Union was closed and employees vaccinated after an employee tested positive for the virus.

There have been four other establishments that serve food of some kind where employees have been diagnosed with hepatitis A, but the health department has not released the names and mass vaccinations were not necessary.

“We don’t want people to think we are withholding information they need to know,” Hittson said. “We want the public to trust us.”

Hittson said she has to defer to the DHSS in releasing the information, but added the cases did not meet specific criteria to require action steps.

According to a statement from the DHSS, restaurant exposures where a foodhandler is identified as a hepatitis A case are usually low risk to those that consume food and drink during the times that the case was working.

The factors that go into the decision to recommend postexposure vaccines deal with the hygiene practices of the worker, their symptoms while working, their likely infectious period (when they would have been contagious as defined by symptom onset), and others.

Not all hepatitis A cases in foodhandlers require action steps from the public to protect their health and that of their community, the DHSS says.

When these instances happen, public information is not warranted and would only serve to violate the privacy of the ill person.

“Anyone who would have been exposed at those businesses would have been sick by now and we aren’t seeing that,” Hittson said, “We are not trying to protect any individual business owner, but at this point there is no reason to hurt a business’s reputation just to release a name.”

Hittson added reports in the St. Louis television media have already caused harm to some restaurants in Franklin County which have nothing to do with the outbreak and rumors are making the situation worse.

“We are already at panic levels,” she said. “We have had some businesses shut down voluntarily to get employees vaccinated and because they are closed the rumors have circulated. Every place has done what was required of them.” 


Hittson explained the main source of hepatitis A transmission is through close personal contact and the leading cause is exposure to fecal matter of an infected person.

She added there is some connection between drug and infection, but from what she and other investigators have learned is that even when needles aren’t involved the drugs being taken are often mixed together in the same containers with many hands reaching in.

“Most of our high-risk groups are people with bad hygiene like drug users and homeless,” Hittson said. “Also, most of our high-risk groups are hesitant to report illness or talk to us in fear of retribution, or losing their jobs.” 


As of July 9, the DHSS is reporting 366 cases of hepatitis A spread across 32 counties in the state of Missouri. Of those cases, 193 have resulted in hospitalization and there have been two hepatitis A-related deaths.

With its 47 cases, Franklin County ranks second behind Butler County, which leads the state with 102 confirmed cases. Seventeen of the confirmed cases statewide have been foodservice workers.

Rounding out the top five counties in Missouri are Stoddard with 36; Scott, 35; and Howell, 30. The only other counties with cases in double digits are Carter County with 20 and Dunklin with 13.


As of July 5, the Centers for Disease Control and Prevention (CDC) lists Missouri as eighth in the nation among the 25 states with hepatitis A outbreaks.

There have been a total of 21,000 hepatitis A cases in the United States since 2016 with 12,500 requiring hospitalization and 208 deaths.

The state of Kentucky leads the nation with 4,753 cases; Ohio has 3,130; West Virginia, 2,528; Florida, 1,876; and Indiana has 1,698 confirmed cases.

Neighboring Illinois has 143 cases statewide.

The CDC also lists the states of California (708) and Utah (281) as having declared their hepatitis A outbreaks ended.