We’re all hosts on a viral planet and vaccines still work: Hep A outbreaks related to drinking water

The U.S. Centers for Disease Control reports that waterborne hepatitis A outbreaks have been reported to CDC. Person-to-person transmission of hepatitis A has increased in recent years.

Reported drinking water–associated hepatitis A outbreaks have declined since introduction of universal childhood vaccination recommendations and public drinking water regulations. However, unvaccinated persons who use water from untreated private wells remain at risk.

Public health officials should raise awareness of risks associated with untreated ground water among users of private wells and of options for private well testing and treatment. Water testing and treatment are important considerations to protect persons who use these unregulated systems from HAV infection.

Hepatitis A virus (HAV) is an RNA virus primarily transmitted via the fecal-oral route and, in rare cases, causes liver failure and death in infected persons. Although drinking water–associated hepatitis A outbreaks in the United States are rarely reported (1), HAV was the most commonly reported etiology for outbreaks associated with untreated ground water during 1971–2008 (2), and HAV can remain infectious in water for months (3). This report analyzes drinking water–associated hepatitis A outbreaks reported to the Waterborne Disease and Outbreak Surveillance System (WBDOSS) during 1971–2017. During that period, 32 outbreaks resulting in 857 cases were reported, all before 2010. Untreated ground water was associated with 23 (72%) outbreaks, resulting in 585 (68.3%) reported cases. Reported outbreaks significantly decreased after introduction of Advisory Committee on Immunization Practices (ACIP) hepatitis A vaccination recommendations* and U.S. Environmental Protection Agency’s (USEPA) public ground water system regulations.† Individual water systems, which are not required to meet national drinking water standards,§ were the only contaminated drinking water systems to cause the last four reported hepatitis A outbreaks during 1995–2009. No waterborne outbreaks were reported during 2009–2017. Water testing and treatment are important considerations to protect persons who use these unregulated systems from HAV infection.

U.S. states and territories have voluntarily reported waterborne disease outbreaks to WBDOSS since 1971.¶ Waterborne hepatitis A outbreaks (1971–2017) reported as of March 13, 2018, were reviewed. An outbreak of hepatitis A was defined as two or more cases of HAV infection epidemiologically linked by time and location of water exposure. To compare occurrence with other waterborne exposure pathways, outbreaks reviewed included those caused by drinking, recreational, environmental (i.e., nondrinking, nonrecreational water), or undetermined water exposures.** As described previously (1), data reviewed included location; date of first illness; estimated number of primary cases, hospitalizations, and deaths; water system type according to USEPA Safe Drinking Water Act definitions (i.e., community, noncommunity, and individual); setting of exposure; drinking water sources (i.e., ground water, surface water, and unknown); and water system characteristics.†† Community and noncommunity water systems are public water systems that have 15 or more service connections or serve an average of 25 or more residents for ≥60 days per year.§§ A community water system serves year-round residents of a community, subdivision, or mobile home park. A noncommunity water system serves an institution, industry, camp, park, hotel, or business. Individual water systems are small systems (e.g., private wells and springs) not owned or operated by a water utility that have fewer than 15 connections or serve fewer than 25 persons. The number of outbreaks before and after public health interventions were compared; chi-squared tests were used to identify significant (p-value<0.05) differences. Data were analyzed using SAS software (version 9.4; SAS Institute) and visualized in ArcGIS (version 10.6.1; Environmental Systems Research Institute).

Thirty-two drinking water–associated hepatitis A outbreaks were reported to CDC during 1971–2017; the last one occurred in 2009 (Table). These drinking water–associated outbreaks accounted for 857 cases (range = 2–50), with no reported deaths. Data on number of deaths were unavailable for three outbreaks. Data on hospitalizations were unavailable for all outbreaks. Outbreaks occurred in 18 states, all in the lower continental United States (Figure 1). One environmental outbreak (1975) and one recreational water outbreak (1989) were reported during this period, but were excluded from this analysis.

The most commonly reported water system type associated with an outbreak was individual, accounting for 13 of 32 (41%) outbreaks and 257 of 857 (30.0%) cases, followed by community (10 [31%] outbreaks; 241 [28.1%] cases) and noncommunity (9 [28%] outbreaks; 359 [41.9%] cases). All individual water systems with outbreaks were supplied by private wells or springs. The majority of all drinking water outbreaks and cases were associated with systems supplied by ground water (30 [94%] outbreaks; 804 [93.8%] cases) and with an absence of water treatment (23 [72%] outbreaks; 585 [68.3%] cases).

The incidence of reported drinking water–associated hepatitis A outbreaks significantly decreased after introduction of the 1989 USEPA Total Coliform and Surface Water Treatment Rules (77% decline from 1971–1989 [24 outbreaks] to 1990–2017 [eight]; p = 0.003), the 1996 ACIP hepatitis A vaccination recommendations (87% decline from 1971–1996 [29] to 1997–2017 [three]; p<0.001), and the 2006 Ground Water Rule and expanded ACIP vaccine recommendations (78% decline from 1971–2006 [30] to 2007–2017 [two]; p = 0.038) (Figure 2). From 1995 through 2009, all four hepatitis A drinking water–associated outbreaks, resulting in 35 cases, were attributed to individual water systems using untreated ground water sources. No water-associated hepatitis A outbreaks have been reported since July 2009.

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Discussion

Reported drinking water–associated hepatitis A outbreaks have declined since reporting began in 1971, and none have been reported since 2009, mirroring the overall decline in U.S. cases (4,5). Vaccination for hepatitis A, combined with USEPA regulations that require testing and, where necessary, corrective actions or treatment for drinking water supplies, likely played a role in reducing reported hepatitis A drinking water–associated outbreaks.

Vaccination efforts have led to significant changes in hepatitis A epidemiology (4,6,7). HAV infection rates in the United States have decreased since the introduction of hepatitis A vaccine in 1995 (4,5). Vaccine recommendations were originally targeted to children in communities with high rates of hepatitis A infections west of the Mississippi and other groups at risk (e.g., international travelers, men who have sex with men, illicit drug users, persons with clotting factor disorders, and persons with occupational risk). By 2006, routine hepatitis A vaccination was recommended for all children aged ≥l year regardless of geographic area of residence (5). Although vaccination was never recommended for users of individual ground water systems, this group likely benefited from the recommendations targeting children and other groups at risk. Incidence of HAV infection is now lowest among persons aged 0–19 years (4). However, the proportion of HAV-associated hospitalizations steadily increased during 1999–2011, likely because of more severe disease in older adults, with persons aged ≥80 years experiencing the highest rates of infection (6). The number of hepatitis A cases in the United States reported to CDC increased by 294% during 2016–2018, compared with the period 2013–2015 (8), primarily because of community-wide outbreaks in persons reporting homelessness or drug use (7). ACIP recommends vaccination to persons who use drugs and recently expanded recommendations to persons experiencing homelessness.¶¶

Reported drinking water–associated hepatitis A outbreaks were most commonly linked to individual water systems that used wells with untreated ground water. Recreational and environmental outbreaks were only reported twice, suggesting that drinking water is a more common waterborne exposure pathway for hepatitis A. Nearly 43 million U.S. residents, or 13% of the population, are served by individual water systems, primarily from ground water sources (https://pubs.er.usgs.gov/publication/cir1441external icon). Untreated ground water sources were associated with 30% of all drinking water–associated outbreaks reported to CDC during 1971–2008 (1). The USEPA Total Coliform and Surface Water Treatment Rules of 1989 and Ground Water Rule of 2006 provide enhanced safety measures for public water systems using ground water sources and might have contributed to the absence of reported hepatitis A outbreaks linked to community water sources since 1990. However, federal regulations do not apply to individual water systems, which often have inadequate or no water treatment (9). Private wells or springs were the only contaminated drinking water systems to cause the last four reported hepatitis A outbreaks during 1995–2009. CDC recommends that owners of private wells test their water annually for indicators of fecal contamination (https://www.cdc.gov/healthywater/drinking/private/wells/testing.html). Factors contributing to fecal contamination of ground water include nearby septic systems or sewage, weather patterns (e.g., heavy rainfall), improper well construction and maintenance, surface water seepage, and hydrogeologic formations (e.g., karst limestone) that allow for rapid pathogen transport (2,9).

The findings in this report are subject to at least three limitations. First, waterborne hepatitis A outbreak reporting is through a passive, voluntary surveillance system; health departments have varying capacity to detect, investigate, and report outbreaks, which might result in incomplete data on outbreak occurrence and characteristics within and across jurisdictions. Thus, outbreak surveillance data might underestimate the actual number of drinking water–associated hepatitis A outbreaks and might underreport information regarding health outcomes such as cases of illness. Second, attributing the source of an outbreak to individual water systems can be particularly difficult because hepatitis A can also be spread through person-to-person transmission within a household. Finally, outbreak data before 2009 did not include case-specific information; thus, demographic factors, including age, could not be assessed.

Drinking water–associated hepatitis A outbreaks have declined and essentially stopped, likely in large part because of the introduction of an efficacious vaccine as part of the routine childhood immunization program and microbial drinking water regulations for public water systems. The degree to which these interventions have contributed to the decline in outbreaks is uncertain. However, waterborne outbreak surveillance data is not yet finalized for 2018, and the recent increase in person-to-person transmission of hepatitis A (7,8) has the potential to cause a resurgence in waterborne outbreaks through increased fecal HAV contamination of private ground water supplies. Outbreak data suggest that individual water systems, primarily those systems drawing untreated ground water from wells, pose the highest risk for causing drinking water–associated hepatitis A outbreaks. These systems are not regulated by USEPA; CDC recommends that owners evaluate their well water quality at least yearly. If indicators of fecal contamination are detected, remediation and treatment of private well water is recommended. Guidance on private well testing and treatment solutions for microbial contamination is provided by USEPA (https://www.epa.gov/privatewells/protect-your-homes-waterexternal icon) and CDC (https://www.cdc.gov/healthywater/drinking/private/wells/index.html). Although the current nationwide outbreak of hepatitis A is not water-associated, considering ground water as a possible transmission route is warranted during community-wide outbreaks of hepatitis A. Ground water can be contaminated with HAV during community transmission of hepatitis A, increasing the risk for persons using untreated water. Public health education about the risks associated with drinking untreated ground water from individual systems, as well as relevant safety measures (i.e., water testing, water treatment, and vaccination), is needed to prevent future drinking water–associated hepatitis A outbreaks.

US: Impact of public health interventions on drinking water-associated outbreaks of hepatitis A-United States, 1971-2017

6.sep.19

CDC

Catherine E. Barrett, Bryn J. Pape, et al

https://www.cdc.gov/mmwr/volumes/68/wr/mm6835a4.htm?s_cid=mm6835a4_e&deliveryName=USCDC_921-DM8344

Salmonella in cake mix: It’s the raw eggs and flour

The U.S. Centers for Disease Control reports in August 2018, two Oregon patients with diagnosed Salmonella infection were interviewed using a standard enteric illness questionnaire; both patients reported having eaten raw cake mix.

Standardized interview questionnaire data collected from 207 Oregon patients with salmonellosis in 2017 indicated a 5% rate of consumption of raw “cake mix or cornbread mix” (Oregon Health Authority, unpublished data, 2017). The binomial probability that both 2018 patients were exposed to raw cake mix by chance was determined to be 0.003, prompting the Oregon Health Authority (OHA) to collect and test the contents of 43 boxes of unopened cake mix of various brands from six retail locations. OHA sent samples to the Institute for Environmental Health Laboratories in Lake Forest Park, Washington, for pathogen testing. Salmonella Agbeni was isolated from an unopened box of white cake mix from manufacturer A, and whole genome sequencing (WGS) data describing the isolate were uploaded to the U.S. National Library of Medicine’s National Center for Biotechnology Information (NCBI) website (https://www.ncbi.nlm.nih.gov/pathogensexternal icon). OHA used the NCBI database to compare sequence data with the cake mix isolate (PNUSAS056022) and then consulted CDC’s System for Enteric Disease Response, Investigation, and Coordination (SEDRIC), a web-based, outbreak investigation tool designed for collaborative, multistate investigations of enteric disease outbreaks.* On October 19, OHA determined that clinical isolates from four patients from Maryland, Ohio, and Wisconsin, with specimen isolation dates ranging from June to September 2018, were genetically related to the Salmonella Agbeni isolate from the unopened box of white cake mix, within four single nucleotide polymorphisms (SNPs).

On October 22, 2018, OHA notified state public health counterparts in the three states of this finding and inquired about raw cake mix exposures among their patients. The Wisconsin patient reported having consumed an entire box of raw white cake mix over several days during the likely exposure period. In addition, WGS analysis indicated that this clinical isolate was closely related genetically (within one SNP) to the isolate cultured from the Oregon white cake mix. On October 25, CDC requested officials in Maryland, Ohio, and Wisconsin to interview patients using a questionnaire with specific questions about baking exposures.

On October 31, the Food and Drug Administration (FDA) initiated an investigation of manufacturer A with regard to the Salmonella-positive white cake mix. In addition to the investigation and document collection, FDA collected samples including an ingredient (flour), finished cake mix, and environmental samples. All collected samples tested negative for Salmonella. On November 5, a voluntary recall of manufacturer A’s classic white, classic butter golden, signature confetti, and classic yellow cake mixes was announced because they might be contaminated with Salmonella bacteria.

On January 14, 2019, CDC declared this outbreak, which totaled seven cases in five states,† to be over (1). This is the first time that OHA used WGS data on the publicly available NCBI website to detect a multistate outbreak associated with a widely distributed consumer product, which resulted in product action. WGS of food and environmental isolates and subsequent analysis on the NCBI and SEDRIC platforms are emerging as useful tools in identifying outbreaks associated with widely distributed products with long shelf lives and low background rates of consumption, such as raw cake mix. Detection of these outbreaks is typically difficult and relies mainly upon epidemiologic evidence from investigation of a larger number of cases (2–4). These efforts also highlight the value of collaboration between public health epidemiologists and laboratorians as well as the use of new technological tools for outbreak detection. During outbreak or cluster investigations, food and environmental samples should be collected as quickly as possible whenever practical, particularly when epidemiologic data suggest an association. WGS, in conjunction with the NCBI website and SEDRIC, can be used to identify genetically related isolates quickly.

US: Notes from the field: Multistate outbreak of salmonella Agbeni associated with consumption of raw cake mix – five states, 2018

30.aug.19

CDC

Stephen G Ladd-Wilson, Karim Morey, et al

https://www.cdc.gov/mmwr/volumes/68/wr/mm6834a5.htm

7 sick with Listeria in Canada linked to Rosemount brand cooked diced chicken: 2 dead 22 sick in US possibly related

As of August 23 2019, there have been seven confirmed cases of Listeria monocytogenes illness in three Canadian provinces: British Columbia (1), Manitoba (1) and Ontario (5) linked to cooked Rosemount brand cooked diced chicken.

The Public Health Agency of Canada notes Rosemount cooked diced chicken was supplied to institutions (including cafeterias, hospitals and nursing homes) where many of the individuals who became sick resided, or visited, before becoming ill.

Individuals became sick between November 2017 and June 2019. Six individuals have been hospitalized. Individuals who became ill are between 51 and 97 years of age. The majority of cases (86%) are female.

The collaborative outbreak investigation was initiated because of an increase of Listeria illnesses that were reported in June 2019. Through the use of a laboratory method called whole genome sequencing, two Listeria illnesses from November 2017 were identified to have the same genetic strain as the illnesses that occurred between April and June 2019. It is possible that more recent illnesses may be reported in the outbreak because of the period of time it takes between when a person becomes ill and when the illness is reported to public health officials. In national Listeria monocytogenes outbreak investigations, the reporting time period is usually between four and six weeks.

The U.S. CDC is also investigating an outbreak  of Listeria illnesses occurring in several states. The type of Listeria identified in the U.S. is closely related genetically (by whole genome sequencing) to the Listeria making people sick in Canada. Canada and U.S. public health and food safety partners are collaborating on these ongoing Listeria investigations.

CDC is not recommending that consumers avoid any particular food at this time. Restaurants and retailers are not advised to avoid serving or selling any particular food. We will update our advice if a source is identified.

Latest Outbreak Information

At A Glance

Reported Cases: 24

States: 13

Hospitalizations: 22

Deaths: 2

24 people infected with the outbreak strain of Listeria monocytogeneshave been reported from 13 states.

Of 23 ill people with information available, 22 hospitalizations have been reported.

Two deaths have been reported.

Good year for Cyclospora bad year for humans: 205 sick linked to Mexican basil in latest outbreak

The U.S. Centers for Disease Control (CDC), public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of Cyclospora infections linked to fresh basil from Siga Logistics de RL de CV of Morelos, Mexico.

CDC is advising that consumers do not eat or serve any fresh basil from Siga Logistics de RL de CV of Morelos, Mexico. This investigation is ongoing and the advice will be updated when more information is available.

Consumers who have fresh basil from Siga Logistics de RL de CV of Morelos, Mexico, in their homes should not eat it. Throw the basil away, even if some has been eaten and no one has gotten sick.

Do not eat salads or other dishes that include fresh basil from Siga Logistics de RL de CV of Morelos, Mexico. This includes dishes garnished or prepared with fresh basil from Siga Logistics de RL de CV of Morelos, Mexico, such as salads or fresh pesto.

If you aren’t sure the fresh basil you bought is from Siga Logistics de RL de CV of Morelos, Mexico, you can ask the place of purchase. When in doubt, don’t eat the fresh basil. Throw it out.

Wash and sanitize places where fresh basil was stored: countertops and refrigerator drawers or shelves.

The FDA strongly advises importers, suppliers, and distributors, as well as restaurants, retailers, and other food service providers to not sell, serve or distribute fresh basil imported from Siga Logistics de RL de CV located in Morelos, Mexico. If you are uncertain of the source, do not sell, serve or distribute the fresh imported basil.

Two hundred and five people with laboratory-confirmed Cyclosporainfections and who reported eating fresh basil have been reported from 11 states; exposures occurred at restaurants in 5 states (Florida, Minnesota, New York, Ohio, and Wisconsin).

Illnesses started on dates ranging from June 10, 2019 to July 18, 2019.

Five people have been hospitalized. No deaths attributed to Cyclospora have been reported in this outbreak.

Epidemiologic evidence and early product distribution information indicate that fresh basil from Siga Logistics de RL de CV of Morelos, Mexico is a likely source of this outbreak.

2019 Outbreak of Cyclospora infections linked to fresh basil from Mexico

15.aug.19

CDC

https://www.cdc.gov/parasites/cyclosporiasis/outbreaks/2019/weekly/index.html

Outbreak investigation of Cyclospora illness linked to imported fresh basil, July 2019

16.aug.19

FDA

https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-cyclospora-illnesses-linked-imported-fresh-basil-july-2019

FDA investigating contaminated pig ear treats connected to Salmonella

One of daughter Sorenne’s chores is to feed our two cats every night, with their special anti-neurotic food.

And every night I say, wash your hands.

Same with Ted the Wonder Dog and treats.

With the recent announcements of the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) investigating contaminated Pig Ear Treats connecting to Salmonella, Pet Supplies Plus is advising consumers it is recalling bulk pig ear product supplied to all locations by several different vendors due to the potential of Salmonella contamination. Salmonella can affect animals eating the products and there is risk to humans from handling contaminated pet products, especially if they have not thoroughly washed their hands after having contact with the products or any surfaces exposed to these products.

Testing by the Michigan Department of Agriculture and Rural Development revealed that aging bulk pig ear product in one of our stores tested positive for Salmonella. We have pulled bulk pig ear product from the shelves at all of our stores and have stopped shipping bulk pig ears from our Distribution Center. We are working with the FDA as they continue their investigation as to what caused the reported Salmonella related illnesses.

Don’t swallow pool water: Cryptosporidiosis outbreaks – United States, 2009-2017

The U.S. Centers for Disease Control reports that Cryptosporidium is the leading cause of outbreaks of diarrhea linked to water and the third leading cause of diarrhea associated with animal contact in the United States.

During 2009–2017, 444 cryptosporidiosis outbreaks, resulting in 7,465 cases were reported by 40 states and Puerto Rico. The number of reported outbreaks has increased an average of approximately 13% per year. Leading causes include swallowing contaminated water in pools or water playgrounds, contact with infected cattle, and contact with infected persons in child care settings.

What are the implications for public health practice?

To prevent cryptosporidiosis outbreaks, CDC recommends not swimming or attending child care if ill with diarrhea and recommends hand washing after contact with animals.

Vaccines work: Widespread outbreaks of Hepatitis A across the U.S.

Since March 2017, the U.S. Centers for Disease Control Division of Viral Hepatitis (DVH) has been assisting multiple state and local health departments with hepatitis A outbreaks, spread through person-to-person contact.

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.

CDC has provided outbreak-specific considerations for hepatitis A vaccine administration.

At A Glance

Since the outbreaks were first identified in 2016, 24 states have publicly reported the following as of June 21, 2019

Cases: 20,512

Hospitalizations: 11,776 (57%)

Deaths: 194

State-Reported Hepatitis A Outbreak Cases as of June 21, 2019

State-Reported Hepatitis A Cases and Clinical Outcomes
State Case Total Hospitalizations
n (%)
Deaths Outbreak
Start Date
Data Current
Through
Total 20512 11776 (57%) 194
States with an ongoing outbreak
Alabamaexternal icon 84 NR (NR) NR 9/1/2018 6/19/2019
Arizonaexternal icon 396 309 (78%) 2 11/1/2018 6/20/2019
Arkansasexternal icon 343 NR (NR) NR 2/7/2018 6/7/2019
Coloradoexternal icon 74 47 (64%) 0 10/1/2018 6/19/2019
Floridaexternal icon 1876 1353 (72%) 21 1/1/2018 5/31/2019
Georgiaexternal icon 437 292 (67%) 1 6/1/2018 6/14/2019
Idahoexternal icon 26 14(54%) 1 1/1/2019 6/20/2019
Illinois external icon 126 75(60%) 0 9/1/2018 6/19/2019
Indianaexternal icon 1581 851 (54%) 4 11/1/2017 6/21/2019
Kentuckyexternal icon 4715 2277 (48%) 58 8/1/2017 6/8/2019
Louisiana external icon 302 178 (59%) 1 1/1/2018 6/21/2019
Massachusettsexternal icon 363 298 (82%) 5 4/1/2018 6/14/2019
Michiganexternal icon 916 735 (80%) 28 8/1/2016 6/19/2019
Missouriexternal icon 323 163(50%) 2 9/1/2017 6/19/2019
New Hampshireexternal icon 138 83 (60%) 1 11/1/2018 6/18/2019
New Mexicoexternal icon 126 100 (79%) 2 11/8/2018 6/20/2019
North Carolinaexternal icon 85 60 (71%) 1 1/1/2018 6/17/2019
Ohioexternal icon 3070 1841 (60%) 10 1/1/2018 6/17/2019
South Carolinaexternal icon 147 108 (73%) 1 11/1/2018 6/14/2019
Tennesseeexternal icon 1791 1085 (60%) 10 12/1/2017 6/21/2019
Virginiaexternal icon 71 45 (63%) 0 1/1/2019 6/20/2019
West Virginiaexternal icon 2533 1249 (49%) 23 3/19/2018 6/21/2019
States with a declared end to their outbreak
Californiaexternal icon 708 464 (66%) 21 11/1/2016 4/11/2018
Utahexternal icon 281 152 (54%) 3 5/8/2017 2/12/2019

NR: not publicly reported

“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.

PEP consists of:

Hepatitis A vaccine for people aged ≥12 months

Hepatitis A virus-specific immunoglobulin (IG) for specific populations

PEP Recommendations:

ACIP Recommendations for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel

Supplement 1. Provider Guidance on Risk Assessment and Clinical Decision-making for Hepatitis A Postexposure Prophylaxis

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).

Dear Colleague Letter pdf icon[PDF – 6 MB] from CDC Division of Viral Hepatitis Director regarding Submission of Patient Specimens to CDC for Hepatitis A Testing.

Additional Vaccination Information

Outbreak-specific considerations for hepatitis A vaccine administration

MMWR – The dose of GamaSTAN™ S/D has recently been changed

Current Vaccine Shortages & Delays – Information on Vaccine Supply

For Immunization Managers – Information on Vaccines Purchased with 317 Funds

Professional Resources

Medscape Commentary: Hepatitis A: Breaking Out All Overexternal icon

Archived webinar: Preventing and Controlling Hepatitis A in Jails and Prisons from the National Institute of Corrections, BOP and CDCexternal icon

HAN: Update: Widespread Outbreaks of Hepatitis A among People Who Use Drugs and People Experiencing Homelessness across the United States – March 2019

COCA Call On-Demand Webinar for Clinicians: Hepatitis A Outbreaks in Multiple States – CDC Recommendations and Guidance – Nov. 2018

HAN: Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness– June 2018

MMWR: Hepatitis A Virus Outbreaks Associated with Drug Use and Homelessness — California, Kentucky, Michigan, and Utah, 2017

Posters on how to clean up and disinfect to help prevent spread of hepatitis A virusexternal icon from Water Quality & Health Council

Updated CSTE clinical case definition for acute viral hepatitis A

CDC guidance on viral hepatitis surveillance and case management

CDC training on hepatitis A serology 

Hepatitis A general FAQs for Health Professionals

Educational Resources

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:

people who use drugs pdf icon[PDF – 244 KB]

gay and bisexual men pdf icon[PDF – 332 KB]

people experiencing unstable housing or homelessness pdf icon[PDF – 282 KB]

people who are or were recently in jail or prison pdf icon[PDF – 282 KB]

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

Pocket Cards

Outbreak of hepatitis A Pocket Card pdf icon[PDF – 786 KB] to localize with organization information and outlines who should get vaccinated and the symptoms of hepatitis A

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.

Get Vaccinated Pocket Card pdf icon[PDF – 455 KB] to localize with information where to go to get the vaccine and who should get vaccinated

If You’re Sick Pocket Card pdf icon[PDF – 470 KB] to localize with information on where to go for medical care and the symptoms of hepatitis A

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.

279 sick: Salmonella infections again linked to backyard poultry

People, seriously, stop kissing your chicks.

The U.S. Centers for Disease Control reports that since the last update on May 16, 2019, illnesses in an additional 227 people and 20 states have been added to this investigation. Four Salmonella serotypes have also been added.

A total of 279 people infected with the outbreak strains of Salmonella have been reported from 41 states.

40 (26%) people have been hospitalized and no deaths have been reported.

70 (30%) people are children younger than 5 years.

Epidemiologic and laboratory evidence indicate that contact with backyard poultry, such as chicks and ducklings, from multiple hatcheries is the likely source of these outbreaks.

In interviews, 118 (77%) of 153 ill people reported contact with chicks or ducklings.

People reported obtaining chicks and ducklings from several sources, including agricultural stores, websites, and hatcheries.

One of the outbreak strains making people sick has been identified in samples collected from backyard poultry in Ohio.

People can get sick with Salmonella infections from touching backyard poultry or their environment. Backyard poultry can carry Salmonella bacteria but appear healthy and clean and show no signs of illness.

Follow these tips to stay healthy with your backyard flock:

Always wash your hands with soap and water right after touching backyard poultry or anything in the area where they live and roam.

Adults should supervise handwashing by young children.

Use hand sanitizer if soap and water are not readily available.

Don’t let backyard poultry inside the house, especially in areas where food or drink is prepared, served, or stored.

Set aside a pair of shoes to wear while taking care of poultry and keep those shoes outside of the house.

 

Damn you, hedgehogs: 27 now sick from Salmonella

The U.S. Centers for Disease Control reports that since the last update on March 29, 2019, illnesses in an additional 10 people and six states have been added to this investigation.

Twenty-seven people infected with the outbreak strain of Salmonella Typhimurium have been reported from 17 states.

Two people were hospitalized. No deaths have been reported.

Forty-two percent are children aged 12 or younger.

Epidemiologic and laboratory evidence indicate that contact with pet hedgehogs is the likely source of this outbreak.

Don’t kiss or snuggle hedgehogs, because this can spread Salmonella germs to your face and mouth and make you sick.

Don’t let hedgehogs roam freely in areas where food is prepared or stored, such as kitchens.

Clean habitats, toys, and supplies outside the house when possible. Avoid cleaning these items in the kitchen or any other location where food is prepared, served, or stored.

They are not cute and funny. They are Salmonella factories.

Tangled up in blue: Finding food safety purpose

I used to write up the U.S. Centers of Disease Control with the enthusiasm of a teenage going on a date.

It was current, it was confident and it was cool.

Now, not so much.

Maybe it’s just me, but I’m tired of watching Salmonella and other foodborne illnesses flatline, even if a Senator brings a day-old bucket of KFC into a hearing to make some sort of metaphorical point.

I’ll say the same thing I say every year: the numbers aren’t changing because the interventions are in the wrong place.

When national organizations go agenst the World Health Organization and don’t mention on-farm food safety, then they’re missing the source.

According to Food Business News, illness was more prevalent in 2018, according to preliminary surveillance data from the Centers for Disease Control (C.D.C.) and Prevention. Incidents of Campylobacter, Salmonella and Cyclospora infections increased last year, according to FoodNet 2018 preliminary data released by the C.D.C. The increases were due, in part, to more infections being diagnosed using culture-independent diagnostic tests (C.I.D.T.s), but the C.D.C. noted the possibility that the number of infections actually is increasing.

Campylobacter infections were the commonly identified infection in FoodNet sites since 2013 with poultry being the major source of infection.  More infections are being diagnosed, the C.D.C. said, because more laboratories use C.I.D.T.s to detect Campylobacterand other pathogens. C.I.D.T.s detect the presence of a specific genetic sequence of an organism. The tests produce results more rapidly because they do not require isolation and identification of living organisms.

Reducing Campylobacter infections will require more knowledge of how case patients are becoming infected, the C.D.C. said. The pathogen can contaminate raw chicken or poultry juices, and cross-contamination can impact hands, other foods or kitchen equipment.

“Focusing on interventions throughout the food production chain that reduce Campylobacter bacteria in chicken could lead to fewer illnesses in people,” the C.D.C. said. “Whole genome sequencing might help us figure out the contribution of various sources and help target interventions.”

Salmonella infections, the second most common infection, also appear to be increasing, according to the preliminary report. The most common Salmonella serotypes were Enteritidis, Newport and Typhimurium. Additionally, Enteritidis infections are not decreasing despite regulatory programs aimed at reducing Salmonella in poultry and eggs.