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Hawaii Should Mandate Hepatitis A Vaccines for Food Service Workers

My bet is Baskins-Robbins, Sushi Shiono and Taco Bell would agree.

According to the Hawaii Department of Health, an employee of each of the following food service businesses has been diagnosed with hepatitis A.  These restaurants are not the source of the 93 people sickened – the three employees are part of the 93 sickened.  Persons who have consumed food or drink products from these businesses during the identified dates of service should contact their healthcare provider for advice and possible preventive care.

Baskin-Robbins, Oahu, Waikele Center – Exposure Risk Dates:  June 17, 18, 19, 21, 22, 25, 27, 30, and July 1 and 3, 2016

Sushi Shiono, Hawaii, Waikoloa Beach Resort, Queen’s MarketPlace – Exposure Risk Dates:  July 5-8, 11-15, and 18-21, 2016

Taco Bell, Oahu, Waipio – Exposure Risk Dates:  June 16, 17, 20, 21, 24, 25, 28, 29, 30, and July 1, 3, 4, 6, 7, and 11, 2016

Hardly a month passes without a warning from a health department somewhere that an infected food handler is the source of yet another potential hepatitis A outbreak. Absent vaccinations of food handlers, combined with an effective and rigorous hand-washing policy, there will continue to be more hepatitis A outbreaks.

It is time for health departments across the country to require vaccinations of food-service workers, especially those who serve the very young and the elderly.

Hepatitis A is a communicable disease that spreads from person-to-person. It is spread almost exclusively through fecal-oral contact, generally from person-to-person, or via contaminated food or water. Hepatitis A is the only foodborne illness that is vaccine-preventable. According to the U.S. Centers for Disease Control and Prevention (CDC), since the inception of the vaccine, rates of infection have declined 92 percent.

CDC estimate that 83,000 cases of hepatitis A occur in the United States every year, and that many of these cases are related to food-borne transmission. In 1999, more than 10,000 people were hospitalized due to hepatitis A infections, and 83 people died. In 2003, 650 people became sickened, four died, and nearly 10,000 people got IG (immunoglobulin) shots after eating at a Pennsylvania restaurant. Not only do customers get sick, but also businesses lose customers or some simply go out of business.

Although CDC has not yet called for mandatory vaccination of food-service workers, it has repeatedly pointed out that the consumption of worker-contaminated food is a major cause of foodborne illness in the U.S.

Hepatitis A continues to be one of the most frequently reported, vaccine-preventable diseases in the U.S., despite FDA approval of hepatitis A vaccine in 1995. Widespread vaccination of appropriate susceptible populations would substantially lower disease incidence and potentially eliminate indigenous transmission of hepatitis A infections. Vaccinations cost about $50. The major economic reason that these preventive shots have not been used is because of the high turnover rate of food-service employees. Eating out becomes a whole lot less of a gamble if all food-service workers faced the same requirement.

According to CDC, the costs associated with hepatitis A are substantial. Between 11 percent and 22 percent of persons who have hepatitis A are hospitalized. Adults who become ill lose an average of 27 days of work. Health departments incur substantial costs in providing post-exposure prophylaxis to an average of 11 contacts per case. Average costs (direct and indirect) of hepatitis A range from $1,817 to $2,459 per case for adults and from $433 to $1,492 per case for children younger than 18. In 1989, the estimated annual direct and indirect costs of hepatitis A in the U.S. were more than $200 million, equivalent to more than $300 million in 1997 dollars.  A new CDC report shows that, in 2010, slightly more than 10 percent of people between the ages of 19 and 49 got a hepatitis A shot.

Vaccinating employees make sense – especially in a state so dependent on tourism.

It is moral to protect customers from an illness that can cause serious illness and death. Vaccines also protect the business from the multi-million-dollar fallout that can come if people become ill or if thousands are forced to stand in line to be vaccinated to prevent a more serious problem.

Hepatitis A:  Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Hepatitis A outbreaks. The Hepatitis A lawyers of Marler Clark have represented thousands of victims of Hepatitis A and other foodborne illness outbreaks and have recovered over $600 million for clients.  Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our Hepatitis A lawyers have litigated Hepatitis A cases stemming from outbreaks traced to a variety of sources, such as green onions, lettuce and restaurant food.  The law firm has brought Hepatitis A lawsuits against such companies as Subway, McDonald’s, Chipotle, Quiznos and Carl’s Jr.

If you or a family member became ill with a Hepatitis A infection after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Hepatitis A attorneys for a free case evaluation.

A Baker’s Dozen of E. coli Cases in New Hampshire

No announcement of where illnesses are located or what the source of the E. coli infections are as of today.

AP reports the as the investigation of an outbreak of E. coli bacteria associated with ground beef continues in New Hampshire, the Health Department says a 13th person has gotten sick since June.

Investigations started last week to determine the source of the ground beef. The safety of ground beef in the United States is regulated by the United States Department of Agriculture, which is assisting the state with the investigation.

The people who became ill ate ground beef at a number of different locations in the state.

New Hampshire E. coli Outbreak Linked to Ground Beef Sickens 12

UnknowneThe New Hampshire Department of Health and Human Services (DHHS), Division of Public Health Services (DPHS) is investigating an outbreak of Escherichia coli O157:H7 (E. coli) associated with ground beef. Since June, 12 people have been infected with the same strain of E. coli after eating ground beef. Investigations are underway to determine the source of the ground beef. The safety of ground beef in the United States is regulated by the United States Department of Agriculture (USDA), which is assisting DPHS with the investigation.

“The Division of Public Health Services is working with our federal partners to investigate the source of the ground beef that is causing people in New Hampshire to become ill,” said Marcella Bobinsky, Acting Director of DPHS. “Ground beef is a known source of E. coli and it is important for people to avoid eating under-cooked ground beef whether at home or at a restaurant. Young children and the elderly are especially vulnerable to severe illness with this infection.”

The people who became ill ate ground beef at a number of different locations. DPHS and USDA are actively working to identify the specific source of the ground beef and will provide updates as they become available. This outbreak does not present a risk to New Hampshire residents as long as they strictly follow food safety best practices. Ground beef should be cooked to a temperature of at least 160°F or 70˚C. It is best to use a thermometer, since color is not a very reliable indicator of ‘doneness.’ People should also prevent cross contamination in food preparation areas by thoroughly washing hands, counters, cutting boards, and utensils after they touch raw meat.

Escherichia coli O157:H7 is bacteria that causes severe stomach cramps, diarrhea (often bloody), and vomiting. If there is fever, it usually is not very high. Most people get better within 5–7 days. Some infections are very mild, but others are severe or even life-threatening. Very young children and the elderly are more likely to develop a potentially life-threatening complication known as hemolytic uremic syndrome (HUS). Antibiotics should not be used to treat this infection because they may increase the risk of HUS.

For further information visit the CDC website at http://www.cdc.gov/ecoli/general/index.html, or to report a suspected case contact the DPHS Bureau of Infectious Disease Control at 603-271-4496.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of E. coli outbreaks and hemolytic uremic syndrome (HUS). The E. coli lawyers of Marler Clark have represented thousands of victims of E. coli and other foodborne illness infections and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our E. coli lawyers have litigated E. coli and HUS cases stemming from outbreaks traced to ground beef, raw milk, lettuce, spinach, sprouts, and other food products.  The law firm has brought E. coli lawsuits against such companies as Jack in the Box, Dole, ConAgra, Cargill, and Jimmy John’s.  We have proudly represented such victims as Brianne Kiner, Stephanie Smith and Linda Rivera.

If you or a family member became ill with an E. coli infection or HUS after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark E. coli attorneys for a free case evaluation.

FSIS Warns about Salmonella Pork but with NO Recall

The U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) is issuing a public health alert today due to concerns about illnesses caused by Salmonella I 4,[5],12:i:- that may be associated with use and consumption of whole hog roasters prepared for barbeque.

On July 13, FSIS was notified of an illness investigation in Washington. The Washington State Department of Health notified FSIS on July 19 of confirmed case patients involved in an illness outbreak of Salmonella I 4,[5],12:i-. Working in conjunction with the Washington State Department of Health and local health departments, and the Centers for Disease Control and Prevention (CDC), FSIS determined that there is a possible link between the roaster hogs for barbeque from Kapowsin Meats and this illness cluster. Based on epidemiological investigation, three Salmonella I 4,[5],12:i:- case-patients have been identified with illness onset dates ranging from July 5, 2016 to July 7, 2016. Traceback investigation indicated that three case-patients consumed whole hog roasters for barbeque from Kapowsin Meats. It is not known at this time if this outbreak strain has any drug resistance; results are pending.

This investigation is ongoing. FSIS continues to work with public health partners at the Washington State Department of Health, local health agencies and the CDC on this investigation. Updated information will be provided as it becomes available. FSIS moved forward with a Public Health Alert because company representatives were not available to participate in a recall committee conference earlier in the day. FSIS is working with the company to identify specific products to be removed from commerce. In the meantime, FSIS recommends the following guidance associated with roasting pigs.

Roasting a pig is a complex undertaking with numerous potential food handling issues. FSIS urges consumers to keep the four food safety steps in mind: Clean, Separate, Cook, and Chill.

  • CLEAN: Obtain your pig from a reputable supplier. Have the supplier wrap it in plastic, or a large plastic bag to contain the juices. Keep the pig cold until it is time to cook it. If you can’t keep it under refrigeration or on ice, consider picking it up just before you are ready to cook it.
  • SEPARATE: Anything that comes into contact with whole pig should be washed with hot soapy water afterwards. This includes hands and utensils.
  • COOK: FSIS recommends that all pork products are cooked to a minimum internal temperature of 145º F with a three minute rest time. Make sure to check the internal temperature with a food thermometer in numerous places, including near the bone. Check the temperature frequently and replenish wood or coals to make sure the fire stays hot. Remove only enough meat from the carcass as you can serve within 1-2 hours.
  • CHILL: Once the meat is cooked, transfer to clean serving dishes. Pack leftovers in shallow containers and refrigerate within 1-2 hours. It is not necessary to cool before you refrigerate it.

FSIS advises all consumers to safely prepare their raw meat products, including fresh and frozen, and only consume pork and whole hogs for barbeque that have been cooked to a minimum internal temperature of 145° F with a three minute rest time. The only way to confirm that whole hogs for barbeque are cooked to a temperature high enough to kill harmful bacteria is to use a food thermometer that measures internal temperature,

Listeria Recall: Bar-S Foods Company

Screen Shot 2016-07-19 at 7.15.24 PMBar-S Foods Company, an Altus, Okla. establishment, is recalling approximately 372,684 pounds of chicken and pork hot dog and corn dog products that may be adulterated with Listeria monocytogenes, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today. The ready-to-eat, chicken and pork hot dog and corn dog items were produced on July 10, 11, 12, and 13, 2016. The following products are subject to recall: [View Labels (PDF Only)]

  • 16-oz/1-lb. packages of “BAR-S Classic BUN LENGTH Franks MADE WITH CHICKEN, PORK ADDED” with “Use By” date of 10/11/2016 and case code 209.
  • 12-oz. packages of “BAR-S CLASSIC Franks MADE WITH CHICKEN, PORK ADDED” with package code 6338, “Use By” date of 10/10/2016 and case code 6405.
  • 24-oz./1.5-lb. cartons of “SIGNATURE Pick 5 CORNDOGS – 8 Honey Batter Dipped Franks On A Stick” with a “Use By” date of 4/6/2017 and case code 6071.
  • 42.72-oz./2.67-lb. cartons of “BAR-S CLASSIC CORN DOGS – 16 Honey Batter Dipped Franks On A Stick” with “Use By” dates of 4/7/2017 and 4/8/2017 and case code 6396.
  • 48-oz./3-lb. cartons of “BAR-S CLASSIC CORN DOGS – 16 Honey Batter Dipped Franks On A Stick” with package code 14054, “Use By” dates of 4/6/2017 and 4/9/2017, and case code 14038.

The products subject to recall bear establishment number “EST. P-81A” inside the USDA mark of inspection. These items were shipped to retail locations nationwide.

What you need to know during Chicago Carbon E. coli Outbreak

Up to 65 sick with 25 hospitalized.

We are representing 37 people sickened in the Carbón Live Fire Mexican Grill E. col Outbreak and Lawsuit.

What is E. coli?

E. coli O157:H7 was identified for the first time at the CDC in 1975, but it was not until seven years later, in 1982, that E. coli O157:H7 was conclusively determined to be a cause of enteric disease. Following outbreaks of foodborne illness that involved several cases of bloody diarrhea, E. coli O157:H7 was firmly associated with hemorrhagic colitis.

The Centers for Disease Control and Prevention (CDC) estimated in 1999 that 73,000 cases of E. coli O157:H7 occur each year in the United States. Approximately 2,000 people are hospitalized, and 60 people die as a direct result of E. coli O157:H7 infections and complications. The majority of infections are thought to be foodborne-related, although E.coli O157:H7 accounts for less than 1% of all foodborne illness.

E. coli O157:H7 bacteria are believed to mostly live in the intestines of cattle but have also been found in the intestines of chickens, deer, sheep, goats, and pigs. E. coli O157:H7 does not make the animals that carry it ill; the animals are merely the reservoir for the bacteria.

While the majority of foodborne illness outbreaks associated with E. coli O157:H7 have involved ground beef, such outbreaks have also involved unpasteurized apple and orange juice, unpasteurized milk, alfalfa sprouts, and water. An outbreak can also be caused by person-to-person transmission of the bacteria in homes and in settings like daycare centers, hospitals, and nursing homes.

Symptoms of an E. coli O157:H7 Infection

E. coli O157:H7 infection is characterized by the sudden onset of abdominal pain and severe cramps, followed within 24 hours by diarrhea. As the disease progresses, the diarrhea becomes watery and then may become grossly bloody – bloody to naked eye. Vomiting can also occur, but there is usually no fever. The incubation period for the disease (the period from ingestion of the bacteria to the start of symptoms) is typically 3 to 9 days, although shorter and longer periods are not that unusual. An incubation period of less than 24 hours would be unusual, however. In most infected individuals, the intestinal illness lasts about a week and resolves without any long-term problems.

Detection and treatment of E. coli O157:H7

Infection with E. coli O157:H7 is usually confirmed by detecting the bacteria in the stool of the infected individual. Antibiotics do not improve the illness, and some medical researchers believe that medications can increase the risk of complications. Therefore, apart from good supportive care, such as close attention to hydration and nutrition, there is no specific therapy for E. coli O157:H7 infection. The recent finding that a toxin produced by E. coli O157:H7 initially greatly speeds up blood coagulation may lead to medical therapies in the future that could forestall the most serious consequences. Most individuals recover within two weeks.

Preventing an E. coli O157:H7 Infection

Eating undercooked ground beef is the most important risk factor for acquiring E. coli O157:H7. Cook all ground beef and hamburger thoroughly. Because ground beef can turn brown before disease causing bacteria are killed, use a digital instant read meat thermometer to ensure thorough cooking. Hamburgers should be cooked until a thermometer inserted into several parts of the patty, including the thickest part, reads at least 160? F. Persons who cook ground beef without using a thermometer can decrease their risk of illness by not eating ground beef patties that are still pink in the middle. If you are served an undercooked hamburger or other ground beef product in a restaurant, send it back for further cooking.

Avoid spreading harmful bacteria in your kitchen. Keep raw meat separate from ready-to-eat foods. Wash hands, counters, and utensils with hot soapy water after they touch raw meat. Never place cooked hamburgers or ground beef on the unwashed plate that held raw patties. Wash meat thermometers in between tests of patties that require further cooking.

Drink only pasteurized milk, juice, or cider. Commercial juice with an extended shelf life that is sold at room temperature (such as juice in cardboard boxes or vacuum-sealed juice in glass containers) has been pasteurized, although this is generally not indicated on the label. Most juice concentrates are also heated sufficiently to kill pathogens.

Wash fruits and vegetables thoroughly, especially those that will not be cooked. Children younger than 5 years of age, immunocompromised persons, and the elderly should avoid eating alfalfa sprouts until their safety can be assured. Methods to decontaminate alfalfa seeds and sprouts are being investigated.

Drink municipal water that has been treated with chlorine or other effective disinfectants, or bottled water that has be sterilized with ozone or reverse osmosis (almost all major brands use one or the other method).

Avoid swallowing lake or pool water while swimming, especially pool water in public swimming facilities.

Avoid petting zoos and other animal exhibits unless there are good hand washing facilities available and other sanitation measures have been taken. Wash your hands and your children’s hands after handling animals.

Make sure that persons with diarrhea, especially children, wash their hands carefully with soap after bowel movements to reduce the risk of spreading infection, and that persons wash hands after changing soiled diapers. Anyone with a diarrheal illness should avoid swimming in public pools or lakes, sharing baths with others, and preparing food for others.

What is Hemolytic Uremic Syndrome?

Hemolytic Uremic Syndrome (HUS) is a severe, life-threatening complication of an E. coli O157:H7 bacterial infection. Although most people recover from an E. coli O157:H7 infection, about 5-10% of infected individuals goes on to develop HUS. E. coli O157:H7 is responsible for over 90% of the cases of HUS that develop in North America. Some organs appear more susceptible than others to the damage caused by these toxins, possibly due to the presence of increased numbers of toxin-receptors. These organs include the kidney, pancreas, and brain. Visit the Marler Clark sponsored Web site about Hemolytic Uremic Syndrome for more information.

What are the Symptoms associated with Hemolytic Uremic Syndrome?

About ten percent of individuals with E. coli O157:H7 infections (mostly young children) goes on to develop Hemolytic Uremic Syndrome, a severe, potentially life-threatening complication. HUS is an extremely complex process that researchers are still trying to fully explain.

Its three central features describe the essence of Hemolytic Uremic Syndrome: destruction of red blood cells (hemolytic anemia), destruction of platelets (those blood cells responsible for clotting, resulting in low platelet counts, or thrombocytopenia), and acute renal failure. In HUS, renal failure is caused when the nephrons, or filtering units, become occluded (blocked) by micro-thrombi, which are tiny blood clots. In almost all cases, the filtering ability of the kidneys recovers as the body of the patient slowly dissolves the micro-thrombi within the microvessels.

A typical person is born with about one million filtering units, called nephrons, in each kidney. The core of the nephron is a bundle of tiny blood vessels, called a glomerulus, where osmotic exchange allows for the filtration of wastes that eventually collect in the urine and are excreted. During Hemolytic Uremic Syndrome, the lack of blood flow to the nephrons can cause them to die or be damaged, just as heart muscle can die as the result of coronary vessel occlusion during a heart attack. Dead nephrons do not regenerate.

In general, the longer a patient suffers kidney failure, the greater the loss of filtering units as a result. At some point, the damage to the kidneys’ filtering units can be so severe that the patient will, over a period of years, lose kidney function and suffer end-stage renal disease (ESRD), which requires chronic dialysis or transplantation.

HUS can also cause transient or permanent damage to other organs, which include the pancreas, liver, brain, and heart. The essential pathogenic process is the same regardless of the organ affected: microthrombi inhibit necessary blood flow and cause tissue death or damage. During the acute stage of Hemolytic Uremic Syndrome, patients must be carefully monitored for these extra-renal complications. It is very difficult to predict the severity and course of HUS once it initiates.

The active stage of Hemolytic Uremic Syndrome may be defined as that period of time during which there is evidence of hemolysis and the platelet count is less than 100,000. In HUS, the active stage usually lasts an average of six days (range, 2-16 days). It is during the active stage that the complications of HUS per se usually occur.

For more information visit www.about-ecoli.com and www.about-hus.com.

Bill-color-headshotMarler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of E. coli outbreaks and hemolytic uremic syndrome (HUS). The E. coli lawyers of Marler Clark have represented thousands of victims of E. coli and other foodborne illness infections and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our E. coli lawyers have litigated E. coli and HUS cases stemming from outbreaks traced to ground beef, raw milk, lettuce, spinach, sprouts, and other food products.  The law firm has brought E. coli lawsuits against such companies as Jack in the Box, Dole, ConAgra, Cargill, and Jimmy John’s.  We have proudly represented such victims as Brianne KinerStephanie Smith and Linda Rivera.


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  63. Samadpour, M., V. Beskhlebnaya, and W. Marler. “Prevalence of non-O157 enterohaemmorrhagic Escherichia coli in retail ground beef in the United States.” 7th International Symposium on Shiga Toxin (Verocytoxin)-producing Escherichia coli Infections. Buenos Aires, Argentina. (2009) available at http://www.marlerblog.com/uploads/file/PREVALENCE%20OF%20NON.pdf
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Hawaii State Department of Health Continues Hepatitis A Investigation

Additional cases of hepatitis A infection have been reported to the Hawaii State Department of Health (DOH), increasing the number of confirmed cases to 31. DOH staff worked through the holiday weekend to conduct interviews with the newly identified cases in an effort to identify the cause of infection.

“Identifying the source of infection is a challenge,” said State Epidemiologist Dr. Sarah Park. “Hepatitis A has a long incubation period lasting anywhere from two weeks to as long as 50 days. Accurately recalling all of the foods consumed and locations visited during the period when infection could have taken place is challenging for many, especially those who are still feeling ill.”

Patients infected with hepatitis A virus are most contagious during the week before the symptoms start until at least one week after the start of the first symptoms. “Since people are contagious before they feel ill, we are very concerned about the disease unknowingly being spreading to others,” said Health Director Dr. Virginia Pressler.

The virus is found in the stool of people with hepatitis A infection and is usually spread by eating contaminated food or drinking water, and can be spread through close personal or sexual contact. A person who has hepatitis A can easily pass the disease to

others within the same household. For this reason, DOH investigators are currently reaching out to individuals who were in contact with those who have or had hepatitis A.

Hepatitis A vaccine or immune globulin (a substance made from human blood plasma that contains antibodies to protect the body against diseases) administered within the first two weeks after exposure may provide some protection against the disease. Unvaccinated individuals recently exposed to the disease are encouraged to talk to their healthcare providers about these preventive measures.

DOH continues to encourage the public to review their immunization record and talk to their healthcare provider about vaccination. For a list of vaccinating pharmacies, visit http://health.hawaii.gov/docd/files/2013/07/IMM_Adult_Resource_List.pdf or call the Aloha United Way information and referral line at 2-1-1.

While vaccination provides the best protection, frequent handwashing with soap and warm water after using the bathroom, changing a diaper, or before preparing food can help prevent the spread of Hepatitis A. Appropriately cooking and preparing foods can also help prevent infection.

Additional information about hepatitis A can be found on the DOH website at http://health.hawaii.gov/docd/dib/disease/hepatitis-a/.

General Mills Recalls Beyond Meat Vegetarian Indian Curry with Beyond Chicken for Listeria

General Mills today announced a voluntary recall of a limited quantity of frozen Beyond Meat Vegetarian Indian Curry with Beyond Chicken, produced over seven days in April 2016. This product is available exclusively at Whole Foods. The recall is being issued as a precaution after the producer of frozen peas used as an ingredient in this product issued a national recall for the potential presence of Listeria monocytogenes.

General Mills has not received any reported consumer illnesses related to this issue. General Mills produces and distributes this product under license from Beyond Meat.

This voluntary recall is limited to only one variety of frozen Beyond Meat product — Vegetarian Indian Curry with Beyond Chicken — and only with the following “Better if Used By” dates printed on the package:

10NOV2016 NL 16NOV2016 NL 25NOV2016 NL
12NOV2016 NL 20NOV2016 NL
15NOV2016 NL 24NOV2016 NL

General Mills Flour Recalled Due to E. coli Risk

1422618_630x354General Mills Inc. recalled two flavors of Betty Crocker cake mix sold in the U.S. and one flavor sold in Canada because they used flour that was recalled earlier because it could contain E. coli.

The flavors include Betty Crocker Delights Super Moist Party Rainbow Chip Cake Mix, which is called Betty Crocker Super Moist Rainbow Bit Cake Mix in Canada.

In the U.S, the mix carried a Package UPC 000-16000-40997 and “better if used by dates” including 25MAR2017, 28MAR2017, 27APR2017, 28APR2017, 23MAY2017, 24MAY2017, and 25MAY2017.

The U.S. recall also included Betty Crocker Delights Super Moist Carrot Cake Mix with UPC 000-16000-40987 and “better if used by dates” including 12APR2017, 13APR2017, 14APR2017, 28May2017, 29May2017, 30MAY2017, 07JUL2017 and 08JUL2017.

In Canada, the Super Moist Rainbow Bit Cake Mix has a Package UPC of 000-65633-46589 and “better if used by dates” of 27AL2017, 08JN2017 and 09JN2017.

A General Mills supplier used General Mills Wondra flour implicated in a July 1, 2016, recall to make the flavor chips used in the recalled cake mix flavors.

No illnesses reported to date have been connected to cake mix.

A full list of products included in the flour recall can be found here.

What to know about Hepatitis A during the Oahu Hawaii Outbreak

hepatitisa11As many as 53 sickens, 13 hospitalized with 1 likely liver transplant.

An Introduction to Hepatitis A

Exposure to the hepatitis A virus can cause an acute infection of the liver that is typically mild and resolves on its own. [11, 17] The symptoms and duration of illness vary a great deal, with many persons showing no symptoms at all. [11] Fever and jaundice are two of the symptoms most commonly associated with a hepatitis A infection. [17]

It has been written that the “earliest accounts of contagious jaundice are found in ancient China.” [11] According to the CDC:

The first descriptions of hepatitis (epidemic jaundice) are generally attributed to Hippocrates. Outbreaks of jaundice, probably hepatitis A, were reported in the 17th and 18th centuries, particularly in association with military campaigns. Hepatitis A (formerly called infectious hepatitis) was first differentiated epidemiologically from hepatitis B, which has a long incubation period, in the 1940s. Development of serologic tests allowed definitive diagnosis of hepatitis B. In the 1970s, identification of the virus, and development of serologic tests helped differentiate hepatitis A from other types of non-B hepatitis.

Until 2004, hepatitis A was the most frequently reported type of hepatitis in the United States. In the pre-vaccine era, the primary methods used for preventing hepatitis A were hygienic measures and passive protection with immune globulin (IG). Hepatitis A vaccines were licensed in 1995 and 1996. These vaccines provide long-term protection against hepatitis A virus (HAV) infection. [7]

Consequently, hepatitis A is the only common vaccine-preventable foodborne disease in the United States. [7, 12]  This virus is one of five human hepatitis viruses that primarily infect the human liver and cause human illness. [11] Unlike hepatitis B and C, hepatitis A does not develop into chronic hepatitis or cirrhosis, which are both potentially fatal conditions, [7, 11, 17] Nonetheless, infection with the hepatitis A virus (HAV) can lead to acute liver failure and death. [12, 17]

The Incidence of Hepatitis A Infections

Hepatitis A is much more common in countries with underdeveloped sanitation systems and, thus, is a risk in most of the world. [11, 16]  An increased transmission rate is seen in all countries other than the United States, Canada, Japan, Australia, New Zealand, and the countries of Western Europe. [9] Nevertheless, infections continue to occur in the United States, where approximately one-third of the population has been previously infected with HAV. [6, 12]

Each year, approximately 30,000 to 50,000 cases of hepatitis A occur in the United States. [5, 7] Historically, acute hepatitis A rates have varied cyclically, with nationwide increases every 10 to 15 years. [13] The national rate of HAV infections has declined steadily since the last peak in 1995. [5, 6] Although the national incidence—1.0 cases per 100,000 population—of hepatitis A was the lowest ever recorded in 2007, it is estimated that asymptomatic infections and underreporting kept the documented incidence-rate lower than it actually is. In fact, it is estimated that there were 25,000 new infections in 2007. [6, 22]

Although the rates of HAV infection have declined over the years, rates are twice as high among American Indians and Alaskan Natives. [1] Hispanics are also twice as likely to be infected compared to non-Hispanic Whites in the United States. [19]. Rates among American Indians and Alaskan Natives have decreased dramatically, largely as a result of increased vaccination of children in both urban and rural communities. [1]

In 2007, the CDC reported a total of 2,979 acute symptomatic cases of hepatitis A. [6] Of these, information about food and water exposure was known for 1,047 cases, leading to an estimate that 6.5% of all infections were caused by exposure to contaminated water or food. [6] In 2,500 of the cases, no known risk factor was identified. [6]

Estimates of the annual costs (direct and indirect) of hepatitis A in the United States have ranged from $300 million to $488.8 million in 1997 dollars. [5] In one study conducted in Spokane, Washington, the combined direct and indirect costs for each case of hepatitis A from all sources ranged from $2892 to $3837. [2, 13] In a 2007 Ohio study, each case of HAV infection attributable to contaminated food was estimated to cost at least $10,000, including medical and other non-economic costs. [21] Nationwide, adults who become ill miss an average of 27 workdays per illness, and 11-to-22 percent of those infected are hospitalized. [6, 7] All of these costs are entirely preventable given the effectiveness of a vaccination in providing immunity from infection. [7, 13]

 How is Hepatitis A Transmitted?

Hepatitis A is a communicable (or contagious) disease that often spreads from person to person. [11] Person-to-person transmission occurs via the “fecal-oral route,” while all other exposure is generally attributable to contaminated food or water. [11, 16] Food-related outbreaks are usually associated with contamination of food during preparation by a HAV-infected food handler. [6, 7, 12]  The food handler is generally not ill because the peak time of infectivity—that is, when the most virus is present in the stool of an infected individual—occurs two weeks before illness begins. [12]

Fresh produce contaminated during cultivation, harvesting, processing, and distribution has also been a source of hepatitis A. [12, 25] In 1997, frozen strawberries were the source of a hepatitis A outbreak in five states. [15] Six years later, in 2003, fresh green onions were identified as the source of a hepatitis A outbreak traced to consumption of food at a Pennsylvania restaurant. [25] Other produce, such as blueberries and lettuce, has been associated with hepatitis A outbreaks in the U.S. as well as other developed countries. [3, 4]

HAV is relatively stable and can survive for several hours on fingertips and hands and up to two months on dry surfaces. [11, 17] The virus can be inactivated by heating to 185°F (85°C) or higher for one minute, or disinfecting surfaces with a 1:100 dilution of sodium hypochlorite (household bleach) in tap water. [8, 13, 24]  It must be noted, however, that HAV can still be spread from cooked food if it is contaminated after cooking. [12]

Although ingestion of contaminated food is a common means of spread for hepatitis A, it may also be spread by household contact among families or roommates, sexual contact, or by direct inoculation from persons sharing illicit drugs. [12, 17] Children are often asymptomatic, or have unrecognized infections, and can pass the virus through ordinary play, unknown to their parents, who may later become infected from contact with their children. [11, 18, 22]

Symptoms of a Hepatitis A Infection

Hepatitis A may cause no symptoms at all when it is contracted, especially in children. [12] Asymptomatic individuals will only know they were infected (and have become immune, given that you can only get hepatitis A once) by getting a blood test later in life. [17] Approximately 10 to 12 days after exposure, HAV is present in blood and is excreted via the biliary system into the feces. [7, 11]  Although the virus is present in the blood, its concentration is much higher in feces. [11] HAV excretion begins to decline at the onset of clinical illness, and decreases significantly by 7 to 10 days after onset of symptoms. [11] Most infected persons no longer excrete virus in the feces by the third week of illness; children may excrete HAV longer than adults. [11, 20]

Seventy percent of hepatitis A infections in children younger than six years of age are asymptomatic; in older children and adults, infection tends to be symptomatic with more than 70% of those infected developing jaundice. [7] Symptoms typically begin about 28 days after contracting HAV, but can begin as early as 15 days or as late as 50 days after exposure. [7, 11, 12] The symptoms include muscle aches, headache, anorexia (loss of appetite), abdominal discomfort, fever, and malaise. [[7, 11, 17]

After a few days of typical symptoms, jaundice (also termed “icterus”) sets in. [11, 17] Jaundice is a yellowing of the skin, eyes and mucous membranes that occurs because bile flows poorly through the liver and backs up into the blood. [17] The urine will also turn dark with bile and the stool light or clay-colored from lack of bile. [7, 11, 17] When jaundice sets in, initial symptoms such as fever and headache begin to subside. [17]

In general, symptoms usually last less than 2 months, although 10% to 15% of symptomatic persons have prolonged or relapsing disease for up to 6 months. [13, 14] It is not unusual, however, for blood tests to remain abnormal for six months or more. [11] The jaundice so commonly associated with hepatitis A can also linger for a prolonged period in some infected persons—sometimes as long as eight months or more. [11, 17] Additionally, pruritus, or severe “itchiness” of the skin, can persist for several months after the onset of symptoms. These conditions are frequently accompanied by diarrhea, anorexia, and fatigue. [7, 17]

Relapse is possible with hepatitis A, typically within three months of the initial onset of symptoms. [14] Although relapse is more common in children, it does occur with some regularity in adults. [11, 14] The vast majority of persons who are infected with hepatitis A fully recover, and do not develop chronic hepatitis. [17] Persons do not carry hepatitis A long-term as with hepatitis B and C. [5, 7]

Fulminant Hepatitis A

Fulminant hepatitis A is a rare but devastating complication of HAV infection. [10] As many as 50% of individuals with acute liver failure may die or require emergency liver transplantation. [23] Elderly patients and patients with chronic liver disease are at higher risk for fulminant hepatitis A. [11, 23] In parallel with a declining incidence of acute HAV infection in the general population, however, the incidence of fulminant HAV appears to be decreasing. [23]

HAV infects the liver’s parenchymal cells (internal liver cells). [10, 11] Once a cell has been penetrated by the viral particles, the hepatitis A virus releases its own toxins that cause, in essence, a hostile takeover of the host’s cellular system. [11, 22] The cell then produces new viral components that are released into the bile capillaries or tubes that run between the liver’s parenchymal cells. [11] This process results in the death of liver cells, called hepatic necrosis. [11, 23]

The fulminant form of hepatitis occurs when this necrotic process kills so many liver cells—upwards of three-quarters of the liver’s total cell count—that the liver can no longer perform its job. [10, 23] Aside from the loss of liver function, fulminant hepatic failure can lead to encephalopathy and cerebral edema. [10] Encephalopathy is a brain disorder that causes central nervous system depression and abnormal neuromuscular function. [10, 11] Cerebral edema is a swelling of the brain that can result in dangerous intracranial pressure. [10] Intracranial hypertensions leading to brain stem death and sepsis with multiple organ failure are the leading causes of death in individuals with fulminant hepatic failure. [10, 23]

How is a Hepatitis A Infection Diagnosed?

The various human hepatitis viruses cause very similar illnesses. [11] Therefore, neither the individual nor the healthcare provider can tell by symptoms or signs if a given individual is suffering from hepatitis A unless laboratory tests are performed. [7, 17]

Fortunately, blood tests are widely available to accurately diagnose hepatitis A, including tests for antibodies, or the affected person’s immune response to hepatitis A proteins. [7] This immune response is conclusively demonstrated by the presence of Immunoglobulin M (IgM) antibodies, indicating acute disease, and immunoglobulin G (IgG), indicating a past infection. [11, 13] The IgG antibodies are present for life, indicating immunity. [13] Following is some guidance for the interpretation of the test results:

  • IgM negative / IgG negative: Most persons with these results have never contracted hepatitis A. Antibodies of the IgM variety develop five to ten days prior to the onset of symptoms.
  • IgM positive / IgG negative: This result indicates acute hepatitis A.
  • IgM positive / IgG positive: This result indicates that acute hepatitis A occurred within the last six months. By six months, the IgM reverts to negative.
  • IgM negative / IgG positive: Persons with this result are immune to hepatitis A. They have either been infected with the virus months or years in the past (with or without symptoms), or they have been vaccinated for hepatitis A. However, if they are currently ill, it is not likely to be due to hepatitis A.

Treatment for Acute Hepatitis A Infections

Once a clinical infection is established, there is no specific treatment for hepatitis A.  Affected individuals generally suffer from loss of appetite, so the main concern is ensuring a patient receives adequate nutrition and avoids permanent liver damage. [7, 17] An individual’s perception of the severity of fatigue or malaise is the best determinant of the need for rest. [17]

Treatment of those suffering from fulminant hepatic failure depends largely on the affected person’s status.  [23, 26] Those who have not become encephalopathic generally undergo an intense course of supportive treatment.  [10, 23] But for those whose liver failure is so complete that it has lead to encephalopathy or cerebral edema, timely liver transplantation is often the only option. [10, 14] Unfortunately, many individuals with irreversible liver failure do not receive a transplant because of contraindications or the unavailability of donor livers. [11, 23]

Real Life Impacts

The number of acute hepatitis A infections in the U.S. drastically fell in the first part of the 21stCentury, largely in part because hepatitis A vaccination was recommended for persons in groups shown to be at high risk for infection and children living in communities with high rates of disease beginning in 1996.   By 2006, hepatitis A vaccine had been incorporated into the Advisory Committee on Immunization Practices’ recommended childhood vaccination schedule. [27]

Despite a decrease in the number of hepatitis A cases reported annually, anyone who has not been vaccinated is at increased risk for contracting hepatitis A infection.  Persons over the age of 50, those with chronic liver disease, and immunocompromised individuals who have not been vaccinated against hepatitis A remain most at risk for developing fulminant hepatitis, a rare but devastating complication of a hepatitis A infection that can lead to the need for a liver transplant, or death.

How to Prevent Hepatitis A

Hepatitis A is totally and completely preventable. [12] Although outbreaks continue to occur in the United States, no one should ever get infected if preventive measures are taken. [7, 12] For example, food handlers must always wash their hands with soap and water after using the bathroom, changing a diaper, and certainly before preparing food. [12, 24] Food handlers should always wear gloves when handling or preparing ready-to-eat foods, although gloves are not a substitute for good hand washing. Ill food-handlers should be excluded from work. [14, 24]

After exposure, immune globulin (IG) is 80% to 90% effective in preventing clinical hepatitis A when administered within 2 weeks of last exposure. [9] Although efficacy is greatest when IG is administered early in the incubation period, when administered later, IG is still likely to make the symptoms less severe. [9, 11] Given the lack of appropriately designed studies comparing the postexposure efficacy of vaccine with that of IG, the Advisory Committee on Immunization Practices (ACIP) recommends IG exclusively for post-exposure. [9] Hepatitis A vaccine, if recommended for other reasons, could be given at the same time. [9, 13]

In 2006, the ACIP recommended routine hepatitis A vaccination for all children ages 12-23 months, that hepatitis A vaccination be integrated into the routine childhood vaccination schedule, and that children not vaccinated by two years of age be vaccinated subsequently. [9, 13] The vaccine is recommended for the following persons:

  • Travelers to areas with increased rates of hepatitis A
  • Men who have sex with men
  • Injecting and non-injecting drug users
  • Persons with clotting factor disorders (e.g. hemophilia)
  • Persons with chronic liver disease
  • Persons with occupational risk of infection (e.g. those who work with hepatitis A-infected primates or with hepatitis A virus in a laboratory setting)
  • Children living in regions of the U.S. with increased rates of hepatitis A
  • Household members and other close personal contacts (such as regular babysitters) of adopted children newly arriving from countries with high or intermediate rates of hepatitis A. [9]

The vaccine may also help protect household contacts of those persons infected with hepatitis A. [9, 20] Although generally not a legal requirement at this time, vaccination of food handlers would be expected to substantially diminish the incidence of hepatitis A outbreaks. [12] Persons traveling to a high-risk area less than four weeks after receiving the initial dose of hepatitis A vaccine, or travelers who choose not to be vaccinated against hepatitis A should receive a single dose of Immune Globulin, which provides protection against hepatitis A infection for up to three months. [9, 11, 18]

For more information visit www.about-hepatitis.com.

We have been contacted by victims of the Oahu Hawaii Hepatitis A Investigation.

Bill-color-headshotMarler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Hepatitis A outbreaks. The Hepatitis A lawyers of Marler Clark have represented thousands of victims of Hepatitis A and other foodborne illness outbreaks and have recovered over $600 million for clients.  Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our Hepatitis A lawyers have litigated Hepatitis A cases stemming from outbreaks traced to a variety of sources, such as green onions, lettuce and restaurant food.  The law firm has brought Hepatitis A lawsuits against such companies as Costco, Subway, McDonald’s, Red Robin, Chipotle, Quiznos and Carl’s Jr.  We proudly represented the family of Donald Rockwell, who died after consuming hepatitis A tainted food and Richard Miller, wo required a liver transplant after eating food at a Chi-Chi’s restaurant.

If you or a family member became ill with a Hepatitis A infection after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Hepatitis A attorneys for a free case evaluation.

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