The apparent international rise in foodborne virus outbreaks attributed to fresh produce and the increasing importance of fresh produce in the Australian diet has led to the requirement to gather information to inform the development of risk management strategies.
A prevalence survey for norovirus (NoV) and hepatitis A virus (HAV) in fresh Australian produce (leafy greens, strawberries and blueberries) at retail was undertaken during 2013–2014 and data used to develop a risk profile. The prevalence of HAV in berries and leafy greens was estimated to be <2%, with no virus detected in produce during the yearlong survey. The prevalence of NoV in fresh strawberries and blueberries was also estimated to be <2% with no virus detected in berries, whilst for leafy greens the NoV prevalence was 2.2%.
Prevalence of a bacterial hygiene indicator, Escherichia coli, was also investigated and found to range from <1% in berries to 10.7% in leafy greens. None of the NoV positive leafy green samples tested positive for E. coli, indicating it is a poor indicator for viral risk.
The risk was evaluated using standard codex procedures and the Risk Ranger tool. Taking all data into account, including the hazard dose and severity, probability of exposure, probability of infective dose and available epidemiological data, the risk of HAV and NoV foodborne illness associated with fresh Australian berries (strawberries and blueberries) sold as packaged product was deemed to be low. The risk of foodborne illness from HAV associated with leafy greens was also deemed to be low, but higher than that for fresh berries, due mainly to the potential for recontamination post-processing if sold loose. The risk of foodborne illness from NoV associated with leafy greens was deemed to be low/moderate. Despite the prevalence of NoV in leafy greens being low and the inability to discriminate between infective and non-infective virus using PCR based methodologies, the fact that NoV was detected resulted in a higher risk associated with this pathogen-product pairing; compounded by the higher prevalence of NoV within the community compared to HAV, and the potential for leafy greens to become contaminated following processing if sold loose.
Estimating risk associated with human norovirus and hepatitis A virus in fresh Australian leafy greens and berries at retail 26 August 2019
The hepatitis A vaccine is the best way to prevent HAV infection.
The following groups are at highest risk for acquiring HAV infection or developing serious complications from HAV infection in these outbreaks and should be offered the hepatitis A vaccine in order to prevent or control an outbreak:
People who use drugs (injection or non-injection)
People experiencing unstable housing or homelessness
Men who have sex with men (MSM)
People who are currently or were recently incarcerated
People with chronic liver disease, including cirrhosis, hepatitis B, or hepatitis C
One dose of single-antigen hepatitis A vaccine has been shown to control outbreaks of hepatitis A and provides up to 95% seroprotection in healthy individuals for up to 11 years.1,2
Pre-vaccination serologic testing is not required to administer hepatitis A vaccine. Vaccinations should not be postponed if vaccination history cannot be obtained or records are unavailable.
“Outbreak-associated” status is currently determined at the state level in accordance with each state’s respective outbreak case definition.
Outbreak-related hepatitis A deaths are defined at the state level in accordance with each state’s respective hepatitis A-related death definition. Some states are reviewing death certificates on a regular basis to actively find hepatitis A-related deaths, while other states are utilizing passive surveillance.
Outbreak start date is defined at the state level and may represent the earliest onset date of an outbreak case (AR, AZ, UT), the left censor date for which cases are considered part of the outbreak based on the state outbreak case definition (AL, CA, CO, FL, GA, ID, IL, IN, KY, LA, MA, MI, MO, NC, NH, OH, SC, TN, VA), or when a state declared a hepatitis A outbreak (NM, WV).
CDC’s Response
In response to all hepatitis outbreaks, CDC provides ongoing epidemiology and laboratory support as well as support on vaccine supply and vaccine policy development. When requested, CDC sends “disease detectives” to affected areas to evaluate and assist in an outbreak response. CDC alerts other public health jurisdictions of any increases in disease. All jurisdictions are encouraged to be watchful for increases in hepatitis A cases. CDC also works with state and local health officials to ensure hepatitis A vaccine is targeted to the correct at-risk populations and that supply is adequate.
Postexposure Prophylaxis
Postexposure prophylaxis (PEP) is recommended for unvaccinated people who have been exposed to hepatitis A virus (HAV) in the last 2 weeks; those with evidence of previous vaccination do not require PEP.
NOTE: CDC recommends that all children be vaccinated against hepatitis A at age 1 year. Parents or caregivers who are unsure if a child has been vaccinated should consult the child’s health-care provider to confirm vaccination status.
HAV Specimen Requests
State health departments wanting to submit specimens must contact CDC at hepaoutbreaklab@cdc.gov for approval before shipping specimens to CDC. Only specimens that that have tested positive for anti-hepatitis A IgM and meet any of the following criteria will be considered.
Specimen from a case patient in a county that has not yet reported a hepatitis A case in an at-risk population;
Specimen from a case patient who doesn’t report any known risk factors or contact with at-risk populations (e.g., household or sexual contact, volunteering at a homeless shelter);
Specimen from a case patient suspected to be associated with foodborne transmission;
Archived/stored specimen from a patient who has died, and whose classification as an outbreak-related death requires nucleic acid testing beyond anti-HAV IgM-positivity; or
Other patient specimens not meeting the above criteria that require nucleic acid testing or molecular characterization (to be discussed on a case-by-case basis).
CDC is developing educational materials to support the outbreak at the state and local levels. Most materials include an area where local information can be inserted. Your organization’s contact information can be typed into the blue colored rectangle. To upload your logo, click on the white space below the blue colored rectangle. In the pop-up box, select browse and upload a PDF version of your logo.
Fact Sheets
One page visual fact sheets encouraging vaccination for:
Two page visual fact sheet pdf icon[PDF – 615 KB] that includes information on hepatitis A prevention, transmission, symptoms and encourages multiple populations to get vaccinated
Printing Instructions: These cards should be printed double-sided on 4.25” x 5.5” perforated postcard templates that print four double-sided cards per page. The print settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment of the two sides of the cards.
Pocket Card Printing Instructions: These cards should be printed double-sided on business card templates that print six double-sided cards per page. The print settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment of the two sides of the cards.
The U.S. Centers for Disease Control reports that Hepatitis A is a vaccine-preventable viral infection of the liver that is primarily transmitted through consumption of microscopic amounts of feces.
During 2016–2018, reports of hepatitis A infections in the United States increased by 294% compared with 2013–2015, related to outbreaks associated with contaminated food items, among men who have sex with men, and primarily, among persons who report drug use or homelessness.
What are the implications for public health practice?
Increasing vaccination among groups at risk for hepatitis A infection might halt ongoing outbreaks and prevent future outbreaks.
Hepatitis A virus (HAV) is primarily transmitted fecal-orally after close contact with an infected person (1); it is the most common cause of viral hepatitis worldwide, typically causing acute and self-limited symptoms, although rarely liver failure and death can occur (1). Rates of hepatitis A had declined by approximately 95% during 1996–2011; however, during 2016–2018, CDC received approximately 15,000 reports of HAV infections from U.S. states and territories, indicating a recent increase in transmission (2,3). Since 2017, the vast majority of these reports were related to multiple outbreaks of infections among persons reporting drug use or homelessness (4). In addition, increases of HAV infections have also occurred among men who have sex with men (MSM) and, to a much lesser degree, in association with consumption of imported HAV-contaminated food (5,6). Overall, reports of hepatitis A cases increased 294% during 2016–2018 compared with 2013–2015. During 2016–2018, CDC tested 4,282 specimens, of which 3,877 (91%) had detectable HAV RNA; 565 (15%), 3,255 (84%), and 57 (<1%) of these specimens were genotype IA, IB, or IIIA, respectively. Adherence to the Advisory Committee on Immunization Practices (ACIP) recommendations to vaccinate populations at risk can help control the current increases and prevent future outbreaks of hepatitis A in the United States (7).
Hepatitis A infections among persons who meet the Council of State and Territorial Epidemiologists (CSTE) hepatitis A case definition (https://wwwn.cdc.gov/nndss/conditions/hepatitis-a-acute/) are notified to CDC through the National Notifiable Diseases Surveillance System (NNDSS). Cases reported to CDC through NNDSS during 2013–2018 were used to calculate percent change (2013–2015 versus 2016–2018) by state and mapped using RStudio software (version 1.2.1335; RStudio, Inc.). Serum specimens from CSTE confirmed cases submitted to the CDC laboratory were tested for HAV RNA by polymerase chain reaction, and isolated virus was amplified to characterize a 315–base-pair fragment of the VP1/P2B region, which defines the genotype of the virus.
Overall, reports of hepatitis A cases increased 294% during 2016–2018 compared with 2013–2015 (Figure). Eighteen states had lower case counts during 2016–2018 compared with 2013–2015. Nine states and Washington, DC had an increase of approximately 500%. During 2013–2018, 4,508 HAV anti-immunoglobulin M–positive specimens underwent additional testing at CDC. During 2013–2015, 226 specimens underwent additional testing, of which 197 (87%) had detectable HAV RNA; of the RNA-positive specimens, 76 (39%), 121 (61%), and 0 (0%) tested positive for a genotype IA, IB, or IIIA viral strain, respectively. In comparison, 4,282 specimens were tested by CDC during 2016–2018, of which 3,877 (91%) had detectable HAV RNA; 565 (15%), 3,255 (84%), and 57 (<1%) of these specimens were genotype IA, IB, or IIIA, respectively.
The number of hepatitis A infections reported to CDC increased during 2016–2018, along with the number of specimens from infected persons submitted to CDC for additional testing. In the past, outbreaks of hepatitis A virus infections occurred every 10–15 years and were associated with asymptomatic children (8). With the widespread adoption of universal childhood vaccination recommendations (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm), asymptomatic children are no longer the main drivers of hepatitis A outbreaks (3,9). Although the overall incidence rate of HAV infections has decreased within all age groups, a large population of susceptible, unvaccinated adults who were not infected by being exposed to the virus during childhood remain vulnerable to infection by contaminated foods (typically imported from countries with endemic HAV transmission) and recently, on a much larger scale, through behaviors that increase risk for infection in certain vulnerable populations, such as drug use (3).
Increasingly, molecular epidemiology is employed by public health laboratories to better characterize hepatitis A transmission patterns. When combined with reliable epidemiologic data, these laboratory data can be used to identify transmission networks and confirm the source of exposure during common-source outbreaks, facilitating prompt and effective public health response. Historically, genotype IA has been the most common genotype circulating in North and South America. During 2013–2018, HAV genotype IB predominated in the United States. Increasing numbers of genotype IIIA were seen, a genotype that is considered rare in the United States.
Decreasing new infections from hepatitis A virus can be achieved and sustained by maintaining a high level of population immunity through vaccination. There is no universal vaccination recommendation for adults in the United States; however, ACIP does recommend vaccination for adults who plan travel to HAV-endemic countries, MSM, persons who use drugs, persons with chronic liver disease, and recently, persons experiencing homelessness (7). Continued efforts to increase hepatitis A vaccination coverage among the ACIP-recommended risk groups is vital to halting the current hepatitis A outbreaks and reducing overall hepatitis A incidence in the United States.
Members of the Division of Viral Hepatitis Laboratory, Division of Viral Hepatitis HAV Incident Management Team, Food and Drug Administration CORE Signals Teams; state and local health departments; medical and mental health partners; corrections partners; syringe service providers.
Outbreak News Today reports the Sweden Public Health Authority, or Folkhälsomyndigheten are reporting an outbreak of hepatitis A where the suspected source of infection is fresh dates from Iran.
Of the nine cases reported since late February, eight of the cases are confirmed and have the same type of hepatitis A virus (genotype IIIA) and one case is suspected.
The cases are between the ages of 28 and 73, five are men and four are women. The cases are from seven different counties (Örebro, Stockholm, Uppsala, Skåne, Södermanland, Kalmar and Halland). The latest case fell on April 16. Common to the cases is that they regularly eat fresh dates.
In the eight confirmed cases, four different strains with genotype IIIA have been detected. Two of these are similar to the tribes that caused an outbreak in Denmark in 2018 linked to dates from Iran. In that outbreak, several variants of genotype IIIA strains could be detected in the cases. One of these outbreak strains could also be detected in dates.
Health officials continue the investigation to identify the source of the outbreak.
There are so many Hepatitis A outbreaks going on in the U.S., we can’t begin to report them all, and many of the outbreaks have nothing to do with food.
But when it involves at a Disney worker at the Hoop-Dee-Doo Musical Revue dinner show, it’s sorta tempting.
Hepatitis A vaccinations have now been offered to other workers at the resort
Disney has not closed the resort but insists it has been thoroughly sanitized
A Disney restaurant employee at the Fort Wilderness Resort has been diagnosed with the highly contagious infection Hepatitis A, sparking health fears at the Orlando resort.
The unnamed employee worked at the Hoop-Dee-Doo Musical Revue where diners can eat while watching a show.
Disney has not closed the facility despite the scare but insists it has been thoroughly sanitized.
The worker has not yet returned to the restaurant and will not be allowed to until they have been cleared of the virus, the company said.
The employee has not worked since they were diagnosed with Hepatitis A and the park remains open
The case was reported to Florida’s Department of Health on January 24.
In a statement, Disney said that all of its employees had been offered vaccinations for the virus but it remains unclear if they all took them.
‘Nothing is more important to us than safety. Upon learning this news, we immediately began working with the Florida Department of Health in Orange County.
‘The impacted cast member has not worked since being diagnosed and will not return until officially cleared by the Department of Health.
‘We are not aware of anyone else becoming ill and continue to be engaged with the Department of Health to ensure we have all of the right processes in place to protect our cast members and guests,’ a spokesman told DailyMail.com.
The individual worked at the restaurant between Oct. 4 and Oct. 20, an investigation found.
Anyone who frequented the restaurant within the time period and has not previously received a hepatitis A vaccination is advised to do so as soon as possible. Those who have previously had a hepatitis A vaccination do not need to take any additional action.
A 24-hour hotline has also been set up for people who have questions about hepatitis A. It can be reached at 813-307-8004.
Doctor’s offices, pharmacies and state and local health departments offer hepatitis A vaccinations. Find out more at vaccines.gov.
And I would urge Hepatitis A shots for all food service employees.
For the first time, a U.S. advisory committee is recommending a routine vaccination for homeless people, voting Wednesday to urge hepatitis A shots to prevent future outbreaks of the contagious liver disease.
Carla Johnson of ABC News reports the Advisory Committee on Immunization Practices made the recommendation at a meeting in Atlanta. The Centers for Disease Control and Prevention is expected to adopt it and send guidance to health care providers.
Homeless encampments can contribute to disease through unsanitary conditions. Hepatitis A spreads person to person through contaminated food or dirty needles used for injection drugs. The virus also can spread from sexual contact with an infected person.
The recommendation would make it easier for shelters, emergency rooms and clinics that serve the homeless to offer hepatitis A shots along with other services.
Hepatitis A vaccinations already are recommended for children at age 1 and for others in danger of infection, such as drug users, some international travelers and men who have sex with men.
The committee of health experts voted unanimously to add homeless people to those groups. The panel is charged with developing recommendations for the CDC on the use of vaccines in the United States.
Health experts have seen an increase in hepatitis A outbreaks and suspected exposures, caused in part by homelessness and drug use.
Twelve states have reported more than 7,500 hepatitis A infections from January 2017 to October 2018, according to the CDC. There were more than 4,300 hospitalizations and about 74 deaths.
Homeless people have made up a large percentage of the cases in San Diego and Utah. Michigan, Kentucky, West Virginia and Tennessee have also reported cases among homeless people.
With even low rates of routine vaccination, the spread of hepatitis A can be slowed, Dr. Noele Nelson of the CDC told the committee before the vote. The recommendation is for a two-dose series of shots, but even one dose can provide immunity for 11 years, Nelson said.
At $28 per dose, a price available through the public health system, the cost of routine vaccination could be in the millions of dollars, Nelson said, but fighting a prolonged outbreak can be even more expensive and disruptive to the health care system.
Hepatitis A virus is an important cause of food-borne diseases and has been associated with several European outbreaks linked to berries [1–4]. Here, we describe an ongoing outbreak of hepatitis A virus (HAV) in Sweden and Austria and the confirmation of frozen strawberries imported from Poland as the source of infection. The aims are to highlight the importance of sequencing in outbreak investigations and, due to the long shelf-life of the food vehicle, to increase awareness and warnings towards HAV infections related to frozen strawberries in Europe.
According to a report by the scientific journal Eurosurveillance, 20 cases of hepatitis A were reported in six districts of Sweden between June and September 2018, of which 17 were confirmed and three were likely. “In combined epidemiological and microbiological studies, imported frozen strawberries produced in Poland were identified as the source of the outbreak,” the journal said. Also in Austria hepatitis A diseases have been associated with strawberries from the same manufacturer. Swedish and Austrian researchers have identified strawberries as a source of infection for many hepatitis A diseases in their countries. “Examinations and interviews with kitchen staff showed that the strawberries had never been sufficiently heated before serving. Strawberries were the only food that was common to all cases, “says the Swedish experts.
The best protection against hepatitis A is vaccination, which is available for children 12 months and older.
Hepatitis A outbreak linked to imported frozen strawberries by sequencing, Sweden and Austria, June to September 2018
Hepatitis A virus is an important cause of food-borne diseases and has been associated with several European outbreaks linked to berries [1–4]. Here, we describe an ongoing outbreak of hepatitis A virus (HAV) in Sweden and Austria and the confirmation of frozen strawberries imported from Poland as the source of infection. The aims are to highlight the importance of sequencing in outbreak investigations and, due to the long shelf-life of the food vehicle, to increase awareness and warnings towards HAV infections related to frozen strawberries in Europe.
Hepatitis A outbreak linked to imported frozen strawberries by sequencing, Sweden and Austria, June to September 2018
Theresa Enkirch, Ronnie Eriksson, Sofia Persson, Daniela Schmid, Stephan W. Aberle, et al
A prevalence survey for norovirus (NoV) and hepatitis A virus (HAV) in fresh Australian produce (leafy greens, strawberries and blueberries) at retail was undertaken during 2013–2014 and data used to develop a risk profile. The prevalence of HAV in berries and leafy greens was estimated to be <2%, with no virus detected in produce during the yearlong survey. The prevalence of NoV in fresh strawberries and blueberries was also estimated to be <2% with no virus detected in berries, whilst for leafy greens the NoV prevalence was 2.2%.
Prevalence of a bacterial hygiene indicator, Escherichia coli, was also investigated and found to range from <1% in berries to 10.7% in leafy greens. None of the NoV positive leafy green samples tested positive for E. coli, indicating it is a poor indicator for viral risk.
