Friday, November 07, 2003

By Christopher Snowbeck, Post-Gazette Staff Writer

The first five patients who showed up last week with signs of hepatitis A infection piqued Dr. Marcus Eubanks' curiosity. But it was only when the sixth patient arrived on Friday that someone -- the patient's wife -- uttered the magic word: Chi-Chi's.

	Related article Hepatitis outbreak in Beaver County reaches 130

The woman told Eubanks, an emergency physician at The Medical Center Beaver, that three of the couple's friends had come down with the disease that week and that the friends had shared a meal in October at the restaurant's Beaver Valley Mall location.

"He said to me, 'Oh, my God, we've got to call the Health Department,' " recalled the woman, Tammy Flaminio, who is also a critical care nurse at the hospital. "We realized, 'Holy Cow, this is an outbreak.' "

Dr. Andre Weltman, public health physician with the state Department of Health, got the message at 7 a.m. Saturday, and by the end of the day, inspectors from the state Department of Agriculture had visited the restaurant and learned that several workers were also sick. That spurred an investigation that has looked at everything from seafood nachos to green onions as possible causes of the outbreak.

Hepatitis A was the last thing on Eubanks' mind on Oct. 28, when he treated a man so beset with flu symptoms that "he looked like he'd been hit by a truck." While the man received anti-nausea medicines and intravenous fluids in the emergency room, Eubanks sent a blood specimen to the lab for testing.

The results showed an elevated level of liver enzymes, meaning he likely had some form of hepatitis.

That was odd because there are few cases of hepatitis A in this country, thanks to good public sanitation systems, Eubanks said. Two other forms of hepatitis, B and C, can be spread by drug use and risky sexual behavior, but those are risk factors that didn't apply to the patient. Nor was the patient a drinker, which also can lead to liver damage.

Eubanks sent away an additional blood sample for a definitive test to determine the form of hepatitis and sent the patient home. Two hours later, a woman showed up in the emergency room who also lacked risk factors but tested positive for hepatitis.

"I thought to myself, 'Wow, that's really interesting, two in one day,' " Eubanks said. "But it's not completely unheard of. In emergency medicine, you can see statistical blips."

But the blips kept coming.

The next day, Eubanks overheard a colleague dictating notes about a third hepatitis case. Eubanks was off Thursday, but when he arrived at work last Friday he learned that two other hepatitis cases had appeared that day. Late in the day, Eubanks treated Wayne Flaminio. It was his wife who suggested the Chi-Chi's connection.

Eubanks wasn't sure what to do, since at that point only one test confirming hepatitis A had come back from the lab. But when he returned to the hospital Saturday morning, two more hepatitis patients appeared and neither had any apparent connection to the Flaminios.

"That was the tipping point," said Weltman, the Department of Health physician who fielded the call in Harrisburg.

Weltman started talking with investigators in the Pittsburgh area, who quickly found in their records a recent hepatitis A case with no known cause. Employing what Weltman called "detective story" techniques, the interviewers asked whether the patient had eaten in a series of restaurants. When they mentioned Chi-Chi's, the patient said "yes."

Next came information about sick workers from the Department of Agriculture, more evidence that the sickness wasn't confined to the Flaminios' social contacts.

The Flaminios and two other couples had eaten at Chi-Chi's on Oct. 4 following a dog show in Aliquippa. The four who got sick all shared a seafood nacho appetizer, which Tammy Flaminio didn't touch because of a seafood allergy. Another woman in the group did share the food but didn't get sick. She had been vaccinated for hepatitis.

While that might have suggested a food-based problem, investigators from the health department learned during the weekend that other patrons and restaurant workers who had gotten sick hadn't eaten nachos, Weltman said.

Many had consumed green onions, which were the root of a hepatitis A outbreak in three states earlier this year. But investigators determined those onions came from a different source than the ones at the Chi-Chi's, Weltman said. Besides, no cases were cropping up from other Chi-Chi's.

While the number of probable and confirmed cases of hepatitis A grew throughout the weekend, the department couldn't go public with the information until it had completed plans to set up a clinic in the area. One of the sticking points was buying enough immune globulin, which can provide temporary immunity to hepatitis A but isn't readily stocked in doctors offices or even many hospitals, Weltman said.

On Monday, the department issued a news release about the problem and, by Wednesday, as some 3,000 people were getting immune globulin shots, the evidence suggested that worker hygiene was the probable cause.

"I continue to keep an open mind, because not all the data are in," Weltman said. But the evidence now in hand "pushes me toward a hygiene issue -- one person makes a mistake a few times and it explodes."

"The way you get hepatitis A is the fecal-oral route," he said. "No one likes to think about it, but someone with hepatitis uses the toilet and doesn't wash their hands."

The end result has been shocking to Flaminio, whose husband was admitted to the hospital for five days and has lost 20 pounds in two weeks of illness. Another member of the dog-show group spent three days in the hospital, she said, and a third spent a night in the emergency room.

Hepatitis A infection typically causes a flu-like illness with yellowing of the skin, nausea, and vomiting, fatigue and diarrhea. Most patients recover with no serious long-term health problems, but you wouldn't know that by looking at the patients Flaminio has seen.

"I've never seen patients this ill that aren't on a ventilator and on life support," she said.

E-mail this story   Print this story