Widespread outbreaks of hepatitis A among persons who use illicit drugs (injection and noninjection) have increased in recent years. Hepatitis A is a vaccine-preventable disease.
What is added by this report?
During January 1, 2018–July 31, 2019, hepatitis A–related clinical costs among West Virginia Medicaid beneficiaries ranged from $1.4 million to $5.6 million. Among those with a substance use disorder diagnosis, costs ranged from $1.0 million to $4.4 million.
What are the implications for public health practice?
In addition to insight on preventing illness, hospitalization, and death, the results from this study highlight the potential financial cost jurisdictions might incur when Advisory Committee on Immunization Practices recommendations for hepatitis A vaccination, especially among persons who use illicit drugs, are not followed.
Estimated Medicaid costs associated with hepatitis A outbreak—West Virginia, 2018-2019
Morbidity and Mortality Weekly Report
Samantha J. Batdorf, MPH1; Megan G. Hofmeister, MD2; Tamara C. Surtees, MPH3; Erica D. Thomasson, PhD1,4; Shannon M. McBee, MPH1; Nathan J. Pauly, PhD5
Following outbreaks linked to frozen strawberries in Sweden and Austria in 2018, 65 cases linked to the same hepatitis A virus strain were detected in Germany between October 2018 and January 2020, presenting in two waves.
Two case–control studies and a comparison of cases’ consumption frequencies with purchase data from a large consumer panel provided strong evidence for frozen strawberry cake as the main vehicle of transmission. Of 46 cases interviewed, 27 reported consuming frozen strawberry cake and 25 of these identified cake(s) from brand A spontaneously or in product picture-assisted recall.
Trace back investigations revealed that the Polish producer involved in the previous outbreaks in Sweden and Austria had received frozen strawberries from Egypt via a wholesaler that also delivered frozen strawberries to manufacturer of brand A. Phylogenetic analyses linked the outbreak strain to similar strains formerly isolated from sewage, stool and strawberries in Egypt. Complete trace back and timely recall of products with strong evidence of contamination is important to control an outbreak and prevent later resurgence, particularly for food items with a long shelf life.
Continued molecular surveillance of hepatitis A is needed to identify outbreaks and monitor the success of food safety interventions.
Resurgence of an international hepatitis A outbreak linked to imported frozen strawberries, Germany, 2018 to 2020
Foodborne enteric viruses, in particular HuNoV and HAV, are the most common cause of the berry-linked viral diseases, and outbreaks around the world, and have become an important concern for health authorities. Despite the increased importance of berry fruits as a vehicle for foodborne viruses, there is limited information concerning the fate of foodborne viruses in the berry supply chain from farm to consumer.
A comprehensive understanding of berry-associated viral outbreaks – with a focus on contamination sources, persistence, survival, and the effects of current postharvest and processing interventions and practices – is essential for the development of effective preventative strategies to reduce risk of illness.
The purpose of this paper is twofold; (i) to critically review the published literature on the current state of knowledge regarding berry-associated foodborne viral outbreaks and the efficiency of berry processing practices and (ii) to identify and prioritize research gaps regarding practical and effective mechanism to reduce viral contamination of berries.
The review found that fecally infected food handlers were the predominant source of preharvest and postharvest pathogenic viral contamination. Current industrial practices applied to fresh and frozen berries demonstrated limited efficacy for reducing the viral load. While maintaining best practice personal and environmental hygiene is a key intervention, the optimization of processing parameters (i.e., freezing, frozen storage, and washing) and/or development of alternative processing technologies to induce sufficient viral inactivation in berries along with retaining sensory and nutritional quality, is also an important direction for further research.
Outbreaks, occurrence, and control of norovirus and hepatitis A virus contamination in berries: a review, 03 February 2020
I love the sourness of blackberries. As a child I used to pick baskets full to be made into pies by my aunt. As a grown up in Guelph (that’s in Canada) there was a huge blackberry tree next door and I would pick baskets full and make pies.
Six of the 11 people who’ve been diagnosed have been hospitalized, according to the Food and Drug Administration, which is investigating the outbreak with the Centers for Disease Control and Prevention.
A Nov. 20 notice from the FDA said hepatitis A illnesses in Indiana, Nebraska and Wisconsin are potentially linked to fresh conventionally-grown blackberries. Patients told FDA investigators they bought and consumed the berries from Fresh Thyme Farmers Markets in those three states.
The blackberries came from a distribution center that served 11 states, and the FDA is working with “federal and state partners to obtain additional information during the traceback investigation,” according to the notice.
Fresh Thyme released a statement that there is no indication the berries were contaminated by in-store handling and only conventional blackberries sold from Sept. 9-30 are involved.
Salted clams from China and Korea appear to be the common factor in a spate of hepatitis A cases in various countries.
According to the Korea Biomedical Review, the Korea Centers for Disease Control and Prevention (KCDC) said that it has confirmed that contaminated fermented shellfish was the main culprit behind the hepatitis A outbreak this summer.
The KCDC came to the conclusions after conducting an in-depth epidemiological investigation.
The agency randomly sampled 270 of the 2,178 hepatitis A patients, diagnosed between July 28 and August 24, and surveyed whether they consumed fermented shellfish this summer. It found that 42 percent of the patients had eaten fermented shellfish during the incubation period.
KCDC also found that 80.7 percent of the 26 patients diagnosed with hepatitis A in August also ate fermented shellfish, while discovering Hepatitis A virus genes in 11 batches out of the 18 batches collected after the outbreak.
Notably, five of these genes found in the research showed close relations with the virus detected in hepatitis A patients.
As of now, the disease control agency has confirmed 10 products that have tested positive to the hepatitis A virus. Nine of them were imported from China, and one was made in Korea.
“Out of the total 10 products, weighing 37,094kg, 31,764kg has already been sold to the markets, while the remaining 5,330 kg were recovered and disposed of,” the agency said.
Yesterday, the Australian NSW Food Authority advised that Byul Mi Kim Chi is conducting a recall of Salted clams, due to a possible microbial (Hepatitis A virus) contamination. Further, Koryo Food Co. is conducting a recall of Pickled clams, due to a possible microbial (Hepatitis A virus) contamination.
NSW Food Authority CEO, Lisa Szabo said testing was underway on a number of products but full results may take a number of weeks.
“Although a contamination has not yet been confirmed, we have advised the companies of a potential link to 8 cases of hepatitis A in NSW, and they have both undertaken a recall of the product,” Dr Szabo said.
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  to 1997–2017 [three]; p<0.001), and the 2006 Ground Water Rule and expanded ACIP vaccine recommendations (78% decline from 1971–2006  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.
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
Driving down I-75 from Detroit to Englewood, Florida (starting point was Brantford, Ontario, that’s in Canada) for a couple of weeks became a summer-time routine because gramps was only there in his mobile home in the winter months, and I guess it prepped me for summers in Kansas and Brisbane.
But we never stopped at a Cracker Barrel which littered the Interstate.
Despite its down-home appearance, the food was shit and over-priced.
According to Fox 55the clock is ticking for customers to get vaccinated after a Saginaw County restaurant worker tests positive for Hepatitis A.
The person last worked at the Bridgeport Township Cracker Barrel on Sunday, Aug. 25.
But the Saginaw County Health Department (SCHD) is urging anyone who ate there between Sunday, Aug. 25 and Wednesday, Aug. 28 to get vaccinated right away.
“With an exposure you have up to two weeks to get vaccinated,” explained Health Officer Christina Harrington with the SCHD. “It’s going to prevent you from getting the disease.”
And yes, I own this album (above, left, listen for the reference to I-75 in the version below) and Chapman hates it.
Tommy Tobin of Forbes reports Franklin County, Missouri, joins a handful of jurisdictions across the country with mandatory Hepatitis A vaccine programs aimed at preventing further cases. This development is part of a larger trend aimed at expanding vaccinations for Hepatitis A and addressing future outbreaks of the disease.
The CDC is investigating outbreaks of Hepatitis A across 29 states. According to the CDC, 233 individuals have died from Hepatitis A between 2016 and 2019 out of over 24,000 reported cases. Several states, including Kentucky, Florida, Ohio, and West Virginia, have seen thousands of cases.
In an effort to curb the increase in reported cases of Hepatitis A, many local jurisdictions are considering mandatory Hepatitis A vaccines for food service workers. For example, Missouri has reported 387 cases of Hepatitis A in the past two years. Over 50 of these cases are from Franklin County, which has a population of about 100,000 residents. Franklin County officials have imposed mandatory vaccinations for individuals who handle food. Food establishments, including restaurants, have 90 days to ensure their employees are vaccinated. Nearby St. Louis County, Missouri enacted a mandatory vaccine requirement nearly 20 years ago. Similar ordinances requiring vaccines for food service workers were enacted in Kentucky’s Ashland and Boyd Counties last year.
With the numerous cases across the country of Hepatitis A, the National Restaurant Association recently issued guidance to its member restaurants in an effort to reduce future cases. In this guidance, the Association recommended that restaurant managers and operators encourage employees to get vaccinated, educate restaurant staff about the virus, and monitor for any signs of the disease. (Note: The National Restaurant Association did not respond to requests for comment on this story). Separately, a CDC advisory panel recently recommended expanding the use of the Hepatitis A vaccine to all youth aged 2 to 18.
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