Twenty years ago this week, Marcus Eubanks reported to work as an emergency room physician at what was then The Medical Center Beaver.
On Tuesday, Oct. 28, 2003, a patient who came in complaining of vomiting and diarrhea had blood test results consistent with hepatitis, followed hours later by another patient with similar symptoms and a similar test result. By Friday, there were a total of six patients with hepatitis.
“There’s all sorts of hepatitis,” said Dr. Eubanks, now the chief of emergency services at UPMC East in Monroeville. “One is nothing remarkable, two in a day is like, ‘Oh, that’s interesting.’ But the next day, there’s another one or two — that’s something.”
Later that Friday, Dr. Eubanks realized that one of the hepatitis patients was married to a critical care nurse at The Medical Center. His conversation with that nurse would prompt a frantic late- night phone call to the state health department.
“I know a bunch of people who have this and those guys all ate at Chi-Chi’s,” he recalls her telling him. “These guys were all at lunch at the same time together.”
Ultimately, 660 people would become infected with Hepatitis A after eating at the Beaver County Mall Chi-Chi’s in what is still the largest food-borne Hepatitis A outbreak in U.S. history. Four people died and nearly 10,000 received immune globulin shots in a mass inoculation campaign that prevented many secondary infections. The outbreak would play a part in changing federal law and increasing childhood vaccinations.
After receiving the call from Dr. Eubanks, state workers went out that Saturday to inspect the busy Chi-Chi’s at the mall in Monaca. Several employees there also were sick with hepatitis-like symptoms, prompting the restaurant to close voluntarily the next day and for the state to issue a public health advisory.
By Monday, Nov. 3, the day after the state issued its advisory, 34 people who ate at Chi-Chi's had shown signs of hepatitis. The next day, that number jumped to 84. By Thursday, it was 185 and one of those patients, 38-year-old Jeffrey Cook, died of liver failure.
“Every day I remember we would hear case counts from the public health officials and it was rising rapidly,” said David Ernst, a Portland, Ore.-based lawyer who represented Chi-Chi’s. “This was a very serious situation. These weren’t just minor injuries.”
Hepatitis A is a highly contagious viral disease affecting the liver, spread via fecal-oral transmission. The disease has a relatively long incubation period of two to six weeks and in some instances of an outbreak, it can be difficult to trace a common place where infected people ate multiple weeks prior.
In this case, however, the site seemed clear: “You’re making some assumptions, but if they all said they ate at Chi-Chi’s, this is not rocket science,” said Joel Hersh, who now is retired but was then the director of the bureau of epidemiology for the state health department.
Much more difficult was determining the cause of the outbreak, requiring weeks of what Mr. Hersh called “shoe-leather epidemiology.”
Hepatitis A outbreaks at restaurants generally occur in one of two ways: A restaurant worker who is already infected with the disease doesn’t wash his or her hands after going to the bathroom or food is already contaminated, often in the growing or harvesting process.
At Chi-Chi’s, signs eventually pointed to the latter scenario. Restaurant workers seemed to have gotten sick at the same time as customers. Inspectors didn’t find issues with the restaurant’s sanitation practices, and as cases grew, epidemiologists doubted that one employee’s poor hygiene could sicken so many people.
Focusing then on contaminated food, the health department began a massive effort to figure out exactly what those sickened had eaten.
In addition to interviewing those who were sick, investigators were able to find uninfected customers by pulling restaurant credit card records and working with the credit card companies for contact information.
The investigation began with entrees, which were sometimes difficult to remember and identify from Chi-Chi’s huge menu, Mr. Hersh said. And initially, there didn’t seem to be that many entrees in common among sick patrons. One infected group had shared seafood nachos, for example, but others had eaten something completely different.
To this day, Richard Miller can’t remember what entree he ordered Oct. 12, 2003, when he and his wife, Linda, wanted to use a Chi-Chi’s coupon for lunch after church. When they got to the mall and found out that the coupon wasn’t valid on Sundays, they almost left. But they figured the coupon wouldn’t save that much money anyway.
Three weeks later, Ms. Miller had flu-like symptoms, including a stabbing pain in her back. The next day, Mr. Miller started to feel sick, too. “We had never even heard of hepatitis,” said Ms. Miller, sitting in their living room in Beaver this week.
Mr. Miller, then 57, felt so sick that his wife drove him to The Medical Center on Nov. 3. Doctors gave him fluids, tested his blood and asked whether he’d eaten at Chi-Chi’s. The state was about to release information about an outbreak, they told him.
Charles Vukotich Jr., who was not involved in the outbreak investigation but authored a case study for the University of Pittsburgh about it, recalled hearing about one couple who had contracted Hepatitis A at Chi-Chi’s but had only ordered Mexican fried ice cream.
“You can’t get Hepatitis A from fried ice cream,” he said, “but wait a minute, they serve chips and salsa when you sit down.”
Investigators realized that not only had the vast majority of those infected with Hepatitis A eaten the salsa, but that they’d eaten the mild salsa, which contained raw green onions added on site. People who ate only the hot salsa, which didn’t have green onions, were less likely to be sick.
The prevalence of the salsa also helped to explain the scale of the outbreak, which reached 555 cases by the time the Centers for Disease Control and Prevention announced Nov. 21 that green onions were the likely cause.
“I ate at Chi-Chis all the time and I love Chi-Chis for this — you walked into Chi-Chi’s and you got salsa and chips for free,” said Mr. Vukotich. “That’s the key to why this was so big.”
The state health department’s scientific approach to identifying green onions was later published in the New England Journal of Medicine.
At Chi-Chi’s, the green onions were chopped up and used in more than 50 different menu items, according to the NEJM article. In the four days of the outbreak’s peak exposure period, more than 2,000 people ate at the Beaver County Mall Chi-Chi’s.
The mild salsa was made into 40-quart batches and refrigerated for up to three days, meaning that contaminated onions could reach hundreds of people just through salsa. The article also notes that because different bundles of green onions were at times stored together, there was a possibility of cross contamination.
Mr. Miller, who had indeed eaten the mild salsa served with chips, felt better after going to the emergency room and was discharged. A few days later, however, he got worse -—so much so that he couldn’t get out of bed. His wife called an ambulance, which took him back to The Medical Center, which is now Heritage Valley Beaver, and then to UPMC Presbyterian.
Ms. Miller, still sick herself, was told that her husband was in liver failure and would need a transplant to survive. That night, a liver became available from a young man who died in Philadelphia and by 6 a.m. the next morning, Ms. Miller and their three children were at the hospital in time for the transplant.
Mr. Miller was hospitalized for a month and was never able to return to his job as a railroad engineer. He and hundreds of others sued Chi-Chi’s. The restaurant chain, which had filed for bankruptcy just weeks before the outbreak, ending up paying claims totaling more than $40 million, some of which it recovered by suing its suppliers.
Although it took years for Mr. Miller to recover physically — amid concerns about brain damage and loss of mobility — he now is in relatively good health at age 77. He considers himself fortunate — at least one of the deaths from the outbreak came while the person was awaiting a liver transplant.
“The Lord’s blessed us, that’s all we can say,” he said this week. “When I heard about the other people who got it and perished, it’s very sad.”
As tales of deaths, sickness and serious liver complications reached the public in 2003, fear began to spread. Clearly there was an issue at the Beaver County Mall Chi-Chi’s, but had whatever was making people sick there also been served elsewhere?
“Restaurant chains often have some common suppliers,” said Mr. Ernst, then the lawyer for Chi-Chi’s. “Was this going to be a situation where we were going to have many Chi-Chi’s or many restaurants in Pennsylvania or many on the East Coast affected? We didn’t know.”
Politicians made a show of eating sandwiches at the Beaver County Mall to reassure the public that it was safe to eat out.
Media attention was intense — Mr. Hersh did more than 100 interviews in the first four days before switching to a daily press conference. A television station showed up on Dr. Eubanks’ South Side doorstep. Mr. Miller was put under fake names in the hospital so reporters couldn’t find him.
As health officials dealt with managing the outbreak, they also scrambled to protect the public from new infections passed on by the hundreds of people who were now possibly contagious.
Anyone who had eaten at Chi-Chi’s or been in close contact with someone with Hepatitis A was advised to receive a shot of immune globulin that could prevent infection if administered shortly after exposure. Lines of people snaked around the Beaver County Community College dome, with ultimately about 9,400 receiving the inoculation, including more than 8,500 in the first five days.
The program moved so fast that there was no precedent for even purchasing the shots – Mr. Hersh paid for them by charging about $100,000 to his state-issued credit card (eventually, he said, the state sued Chi-Chi’s and won $98,000 in reimbursements).
Despite the hundreds who were infected, the outbreak did not continue to spread. “The immunizations worked and we prevented a bigger disaster,” said Mr. Hersh.
Once the epidemiologists identified green onions as the source, the U.S. Food and Drug Administration investigated how the onions became contaminated. They traced the onions back to a few farms in Mexico, alleging that they could have been contaminated because of inadequate sanitation or handwashing facilities, poor hygiene among workers or irrigation of the crops with untreated water.
Once Hepatitis A gets onto food, it can be killed in the cooking process but not always by freezing or washing raw produce, especially produce with a rough and layered surface such as green onions, said Lee Harrison, a professor of epidemiology at Pitt.
Even 20 years later, Ms. Miller said she thinks about the outbreak every time she sees a green onion. She prefers to eat them only if grown in her garden, but she will sometimes buy them if they are grown in the U.S. She still can’t bring herself to eat salsa in a restaurant.
In public policy, as well as Ms. Miller’s kitchen, the outbreak has had lasting effects. A Hepatitis A vaccine was introduced in 1996, but was used only in limited cases in populations deemed high risk. In 2006, following the Chi-Chi’s outbreak, the CDC recommended that all children receive it.
“That has totally changed the epidemiology,” said Dr. Harrison. “If you look at the recommendation that was made in 2006, they actually cite this and other outbreaks. Just focusing on those who were high risk was not very effective.”
The outbreak was also a factor in federal food safety legislation in 2010.
“It was part of a wave of significant food borne illness cases that . . . ultimately became the impetus for the Food Safety and Modernization Act,” said Bill Marler, a lawyer who represented 78 Chi-Chi’s victims and lobbied for the legislation. “I remember talking to congressmen and senators about Chi-Chi’s – it was really just a terrible outbreak and tragedy.”
Anya Sostek: asostek@post-gazette.com.
First Published: November 2, 2023, 9:30 a.m.
Updated: November 3, 2023, 1:23 p.m.