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Food Poison Journal Food Poisoning Outbreaks and Litigation: Surveillance and Analysis

Foodborne Illness Outbreaks

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E. coli Flour Outbreak – more ill, more strains, more hospitalized

big-map-7-25-16The CDC reports that as of July 25, 2016, 46 people infected with the outbreak strains of STEC O121 (45 people) or STEC O26 (1 person) have been reported from 21 states.  Illnesses started on dates ranging from December 21, 2015 to June 25, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Eighty percent of ill people are female. Thirteen ill people have been hospitalized. One person developed hemolytic uremic syndrome, a type of kidney failure.

In July 2016, laboratory testing by General Mills and FDA isolated STEC O26 from a sample of General Mills flour. Whole genome sequencing (WGS) showed that the STEC O26 isolated from the flour sample was closely related genetically to isolates from an ill person. The flour tested was not included in the earlier General Mills recalls.

On July 25, 2016, General Mills expanded its recall to include more production dates. CDC recommends that consumers, restaurants, and retailers do not use, serve, or sell the recalled flours.

Prior Recalls and Test Results:

In June 2016, laboratory testing by the U.S. Food and Drug Administration (FDA) isolated STEC O121 from samples of General Mills flour collected from the home of an ill person in Oklahoma. The STEC O121 isolated from the flour sample has the same PFGE pattern, or DNA fingerprint, as the outbreak strain. The flour collected in Oklahoma was not included in the initial General Mills recall

In the same month, FDA identified STEC O121 in an open sample of General Mills flour collected from the homes of ill people in Colorado and Arizona. Whole genome sequencing (WGS) showed that the STEC O121 isolates from the flour samples were closely related genetically to the STEC O121 isolates from ill people. The flour sample that was tested came from lots of flour included in the initial recall announced by General Mills.

On July 1, 2016, General Mills expanded the recall to include some flours sold under the same brand names included in the initial recall: Gold Medal Flour, Gold Medal Wondra Flour, and Signature Kitchens Flour. CDC recommends that consumers, restaurants, and retailers do not use, serve, or sell the recalled flours.

On May 31, 2016, General Mills recalled several sizes and varieties of Gold Medal Flour, Gold Medal Wondra Flour, and Signature Kitchens Flour due to possible E. coli contamination. The recalled flours were produced in the Kansas City facility during a time frame identified by traceback and sold nationwide.

General Mills announces more sick with E. coli in expanded recall

From a press release from General Mills:

Due to four new confirmed illnesses, General Mills is adding additional flour production dates to the previously announced U.S. retail flour recall that was originally announced on May 31, 2016. The illnesses reported to health officials continue to be connected with consumers reporting that they ate or handled uncooked dough or ate uncooked batter made with raw flour. 

The addition of new flour production dates is the result of General Mills conducting proactive flour testing and new information from health officials who are using new whole genome sequencing techniques to trace illnesses. E. coli (several sub-types) has been detected in a small number of General Mills flour samples and some have been linked to new patient illnesses that fell outside of the previously recalled dates.  Recall Announcement.

At this time, it is unknown if we are experiencing a higher prevalence of E. coli in flour than normal, if this is an issue isolated to General Mills’ flour, or if this is an issue across the flour industry. The newer detection and genome sequencing tools are also possibly making a connection to flour that may have always existed at these levels.

According to the CDC:

As of June 28, 2016, 42 people infected with the outbreak strain of STEC O121 have been reported from 21 states. 

Illnesses started on dates ranging from December 21, 2015 to June 8, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Eighty-one percent of ill people are female. Eleven ill people have been hospitalized. No one has developed hemolytic uremic syndrome, a type of kidney failure, and no deaths have been reported.

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.

How to prevent Hepatitis A Lawsuits – Vaccines, Handwashing and Gloves

Hepatitis A is totally and completely preventable.

Each year, approximately 30,000 to 50,000 cases of hepatitis A occur in the United States.  And, yes, that includes Hawaii where a mystery 74 person hepatitis A outbreak is occurring.  Two of those 74 individuals that separately work at a Taco Bell and a Baskin-Robbins have compounded to risk and fear of a continuing and spreading problem on Oahu when they worked when unknowingly contagious.

UnknownhepaAlthough outbreaks continue to occur in the United States, no one should ever get infected if preventive measures are taken.  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. 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.  In addition, 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 people not vaccinated by two years of age be vaccinated subsequently.

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.  Nationwide, adults who become ill miss an average of 27 work-days per illness, and 11-to-22 percent of those infected are hospitalized. Fulminant hepatitis A (Acute Liver Failure) is a rare but devastating complication of HAV infection. As many as 50% of individuals with acute liver failure may die or require emergency liver transplantation. Elderly patients and patients with chronic liver disease are at higher risk for fulminant hepatitis A.

And, vaccines, gloves and handwashing does prevent litigation as well:

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 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.

A History of Hamburger E. coli Outbreaks 1993 to the Present

ground-beef-300x224The 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.

In 2002, I wrote an Op-ed for the Denver Post entitled: “Put me out of business. Please.”

For this trial lawyer, E. coli has been a successful practice – and a heart-breaking one. I’m tired of visiting with horribly sick kids who did not have to be sick in the first place. I’m outraged with a food industry that allows E. coli and other poisons to reach consumers, and a federal regulatory system that does nothing about it….

… And, with a little luck, it will force one damn trial lawyer to find another line of work.

From the Jack in the Box E. coli outbreak of 1993 until the 2002 ConAgra E. coli outbreak, at least 95% of Marler Clark revenue was E. coli cases linked to hamburger.  Today, it is nearly zero.  That is success.  To the beef industry – thank you for meeting the challenge.  The millions spent on interventions, and the countless hours of food safety professionals, made the difference.

That all being said, there is still much the industry can do.  Shiga-toxin producing E. coli will always be an issue.  Listeria and antibiotic resistant Salmonella and Campylobacter, and other bad bugs we do not even know about, lurk around the corner.  The industry cannot let up.  Even with the success there still have been isolated tragedies like Stephanie Smith and Abby Fenstermaker who remind you the battle will likely always have to be fought.

A history of E. coli Litigation:

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.

Chicago Carbon Mexican Grill E. coli toll tops 67

The number of people sickened in an E. coli outbreak traced to a suburban Chicago restaurant continues to increase, with 67 now confirmed. Twenty of the victims’ symptoms were so severe they were admitted to hospitals.

Public health officials have not yet determined the root cause of the outbreak, which was traced to the Carbón Live Fire Mexican Grill location on 26th Street in the suburb of Bridgeport. The restaurant remains closed, according to Matt Smith, a spokesman for the Chicago Department of Public Health.

logo Carbon Live Fire Mexican Grill“As part of our comprehensive investigation, we have taken and tested numerous samples from the restaurant and have tested staff,” Smith said Thursday. He did not say whether the department had the test results yet.

It remains unknown when exactly the health department became aware of the outbreak. The department posted a news release about the outbreak July 1, but has not posted an update since then.

The restaurant’s owners voluntarily closed the Carbón Live Fire Mexican Grill, according to the July 1 news release. A second Carbón Live Fire Mexican Grill on North Marshfield was also voluntarily closed, but the health department cleared it and the owners reopened.

Oahu Hawaii Hepatitis A Outbreak Spikes to 74 – Source Still A Mystery

UnknownHHThe Hawaii Department of Health (HDOH) is investigating a cluster of hepatitis A infections on Oahu.  HDOH staff are conducting interviews with the cases in an effort to identify the source of infection.

Identifying the source of infection continues to be a challenge because of the long incubation period of the disease and the difficulty patients have in accurately recalling the foods consumed and locations visited during the period when infection could have taken place.

Healthcare providers have been informed and are asked to notify HDOH immediately if they have a patient they suspect may be infected.

Individuals who are interested in being vaccinated should contact their healthcare providers.

As of July 20, 2016:

Since the last update, HDOH has identified 22 new cases of hepatitis A.  All cases have been in adults, 26 have required hospitalization.

All of the cases are residents of Oahu with the exception of two individuals who now live on the islands of Hawaii and Maui, respectively, but were on Oahu during their exposure period.

CONFIRMED CASES OF HEPATITIS A  74

Onset of illness has ranged between 6/12/16 – 7/14/16.

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.

Salmonella Strikes Kapowsin Pork Twice?

lightning_strikeSeattle/King County Department of Public Health is investigating an outbreak of salmonellosis (caused by Salmonella bacteria) associated with a Good Vibe Tribe Luau held on 7/3/16 from 6:00-11:00 PM at Golden Gardens Park in Seattle. A number of different foods were eaten, and the cause has not been determined.

A total of 11 people that appear to have gotten sick at the luau event. Six cases have been confirmed with Salmonella, and five additional people who responded to the survey report eating at the event and later developing an illness consistent with salmonellosis, but did not get tested. None of them were hospitalized.

The pork served at the luau was supplied by Kapowsin Meats, and everyone who got sick after the luau had eaten the pork that was served there.  The genetic fingerprints of cases in this outbreak match the fingerprint of the Salmonella outbreak cases from last year when 192 people (30 hospitalized) in 5 states were sickened according to the CDC. However, there were many other foods served at the event. The Department of Public Health is still investigating food source and preparation procedures for all items to confirm which item might have made people ill.

Salmonellosis is a bacterial infection that is often spread through the fecal-oral route, through contaminated food and water, or through contact with animals and their environments. Symptoms of salmonellosis include nausea, vomiting, diarrhea, headache, fever, chills, and abdominal cramping. Illness typically lasts several days and people can spread infection to others even after symptoms resolve. To prevent Salmonella infection:

– Wash hands with soap and water after going to the bathroom, changing diapers, touching animals, and before eating or preparing food.

– Cook all meats thoroughly, especially poultry.

– Wash cutting boards and counters used for meat or poultry preparation immediately after use to avoid cross contaminating other foods.

Good Vibe Tribe Luau Leads to Salmonella

Public Health is investigating an outbreak of salmonellosis (caused by Salmonella bacteria) associated with attendance at the Good Vibe Tribe Luau held on 7/3/16 from 6:00-11:00PM at Golden Gardens Park, 8498 Seaview Pl NW, Seattle, WA 98117. As of 7/15/16, at least four people have become ill after eating at the event; no one has required hospitalization for their illness.

Public Health received Salmonella case reports on 7/11/16, 7/12/16, and 7/15/16 (two reports), and the common event exposure was identified during a case interview on 7/13/16. Investigation is in progress to determine what food or foods might have caused illness. Foods served at the event included: rotisserie roasted pig, parilla (barbecued beef), congri (black beans and rice), tropical fruit salad, Hawaiian salad (pineapple cole slaw), Hawaiian sweet bread, and corn on the cob. The event organizers are working cooperatively with Public Health.

Food for the event was catered by Mojito, 7545 Lake City Way NE, Seattle. Environmental Health inspectors visited the catering facility on 7/13/16 to inquire about food sources and preparation methods.  Understanding where food came from and how it was prepared allows health officials to determine how food might have made people ill and, if necessary, to trace back to the food’s point of origin if specific food items are suspected.
If you or a family member attended this event, even if you did not get ill, please take a few minutes to complete the following survey. Comparing food histories between those who became ill and those who did not can help us determine what might have caused illness and prevent others from becoming sick. Access the survey.

If you are currently ill (i.e. experiencing blood in your stool, vomiting, or diarrhea lasting more than three days) please contact your health care provider to discuss testing and treatment options. Submitting a stool sample can help confirm if you have salmonellosis. The typical incubation period (time between exposure to the bacteria and symptom onset) for Salmonella is 1-5 days, so if you attended the event and have not yet developed symptoms, it is unlikely you will become ill.

About salmonellosis:

Salmonellosis is a bacterial infection that is often spread through the fecal-oral route, through contaminated food and water, or through contact with animals and their environments. Symptoms of salmonellosis include nausea, vomiting, diarrhea, headache, fever, chills, and abdominal cramping. Illness typically lasts several days and people can spread infection to others even after symptoms resolve.

To prevent Salmonella infection:

Wash hands with soap and water after going to the bathroom, changing diapers, touching animals, and before eating or preparing food.
Cook all meats thoroughly, especially poultry.
Wash cutting boards and counters used for meat or poultry preparation immediately after use to avoid cross contaminating other foods.

Oahu Hawaii Hepatitis A Outbreak Updated to 52 – Still No Source

hep_a_banner

The Hawaii Department of Health (HDOH) is investigating a cluster of hepatitis A infections on Oahu.  HDOH staff are conducting interviews with the cases in an effort to identify the source of infection.

Identifying the source of infection continues to be a challenge because of the long incubation period of the disease and the difficulty patients have in accurately recalling the foods consumed and locations visited during the period when infection could have taken place.

Healthcare providers have been informed and are asked to notify HDOH immediately if they have a patient they suspect may be infected.

Individuals who are interested in being vaccinated should contact their healthcare providers.

As of July 12, 2016*: Since the last update, HDOH has identified 21 new cases of hepatitis A.  All cases have been in adults on Oahu, 16 have required hospitalization.

CONFIRMED CASES OF HEPATITIS A 52

Onset of illness has ranged between 6/12/16 – 7/3/16.

CONTACTS OF CASES

Unvaccinated contacts of cases should talk to their healthcare providers about the possibility of receiving hepatitis A vaccine or immune globulin, which may provide some protection against the disease if administered within the first two weeks after exposure.

A contact is defined as:

  • All unvaccinated household members
  • All unvaccinated sexual contacts
  • Anyone sharing illicit drugs with a case
  • Anyone sharing food or eating or drinking utensils with a case
  • Anyone consuming ready-to-eat foods prepared by an infectious food handler with diarrhea or poor hygiene
    Note: A food handler is any person who directly prepares, serves, or handles food

PLACES OF INTEREST

An employee of the following food service business(es) has been diagnosed with hepatitis A. This list does notindicate these businesses are sources of this outbreak; at this time, no infections have been linked to exposure to these businesses. The likelihood that patrons of these businesses will become infected is very low. However, 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 — Waikele Center — June 17, 18, 19, 21, 22, 25, 27, 30, and July 1 and 3, 2016

Taco Bell — Waipio (94-790 Ukee Street) — June 16, 17, 20, 21, 24, 25, 28, 29, 30, and July 1, 3, 4, 6, 7, and 11, 2016

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.

What you need to know during Hawaii Hepatitis A Outbreak

As 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.

References.

1.         Bialek, Stephanie, et al., “Hepatitis A Incidence and Hepatitis A Vaccination among American Indians and Alaska Natives, 1990–2001,” American Journal of Public Health.Vol. 94, No. 6, pp. 996-1001 (2004). Full text of article is available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448379/pdf/0940996.pdf.

2.         Bownds, Lynne, et al., “Economic Impact of a Hepatitis A Epidemic in a Mid-Sized Urban Community: The Case of Spokane, Washington,” Journal of Community Health, Vol. 28, No. 4, pp. 233-246 (2003). Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/12856793

3.         Butot S, et al., “Effects of Sanitation, Freezing and Frozen Storage on Enteric Viruses in Berries and Herbs,” International Journal of Food Microbiology, Vol. 126, pp. 30-35 (2008). Full text of article is available at http://www.prograd.uff.br/virologia/sites/default/files/bulot_et_al_2008_inactivation.pdf

4.         Calder, L, et al., “An Outbreak of Hepatitis A Associated with Consumption of Raw Blueberries,” Epidemiology and Infection, Vol. 131, No. 1, 745-751 (2003) at  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/pdf/12948375.pdf

5.         CDC Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States, 2004-2009, at http://www.cdc.gov/hepatitis/pdfs/disease_burden.pdf

6.         CDC, “Surveillance for Acute Viral Hepatitis — United States, 2007, Morbidity and Mortality Weekly Report, Surveillance Summaries, Vol. 58, No. SS03 (May 22, 2009) at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5803a1.htm

7.         CDC, “Hepatitis A,” in EPIDEMIOLOGY AND PREVENTION OF VACCINE-PREVENTABLE DISEASES (also known as “The Pink Book”), Atkinson W, Wolfe S, Hamborsky J, McIntyre L, editors, 12th edition. Chapter available online at http://www.cdc.gov/vaccines/pubs/pinkbook/hepa.html

8.         CDC, “Updated recommendations from Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees,” Morbidity and Mortality Weekly Report, Vol. 58, No. 36, (Sept. 18, 2009), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5836a4.htm

9.         CDC, “Update: Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers, Updated ACIP Recommendations,” Morbidity and Mortality Weekly Report, Vol. 56, No. 41, pp. 1080-84 (Oct. 19, 2007), online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm.

10.       Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure:  Pathophysiology and Management,” World Journal of Gastroenterology, Vol. 12, No. 46, pp. 7405-7412 (Dec. 14, 2006). Full article is available online at http://www.wjgnet.com/1007-9327/12/7405.pdf

11.       Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” in Mandell, Douglas, & Bennett’s PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES, Fifth Edition, Chap. 161, pp. 1920-40 (2000).

12.       Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” Clinical Infectious Diseases, Vol. 38, 705-715 (March 1, 2004). Full text online at http://www.cdc.gov/hepatitis/PDFs/fiore_ha_transmitted_by_food.pdf

13.       Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations, Morbidity & Mortality Weekly Review, Vol. 55, Report 407, (May 19, 2006) at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm

14.       Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,”  Medicine, Vol. 71, No. 1, 14-23 ( Jan. 1992). Abstract of article online at http://www.ncbi.nlm.nih.gov/pubmed/1312659

15.       Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” New England Journal of Medincine, Vol. 340, pp. 595–602 (1999). Full text of article is online at http://www.nejm.org/doi/full/10.1056/NEJM199902253400802

16.       Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” Emerging Infectious Diseases, Vol. 3, No. 4, pp. 529-39 (October-December 1997). Full text of the article is available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640072/pdf/9366607.pdf

17.       Mayo Clinic Staff, “Hepatitis A,” (last updated Sept. 1, 2011). Articles available online at http://www.mayoclinic.com/health/hepatitis-a/DS00397 .

18.       Piazza, M, et al., “Safety and Immunogenicity of Hepatitis A Vaccine in Infants: A Candidate for Inclusion in Childhood Vaccination Program,” Vaccine. Vol. 17, pp. 585-588 (1999). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10075165

19.       Rawls, R.A. and Vega, K.J., “Viral Hepatitis in Minority America,” Journal of Clinical Gastroenterology, Vol. 39, No. 2, pp. 144–151 (Feb. 2005). Abstract is at  http://www.ncbi.nlm.nih.gov/pubmed/15681912

20.       Sagliocca, Luciano, et al., “Efficacy of Hepatitis A Vaccine in Prevention of Secondary Hepatitis A Infection: A Randomized Trial,” Lancet, Vol. 353, 1136-39 (1999). Abstract at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)08139-2/abstract

21.       Scharff, RL, et al., “Economic Cost of Foodborne Illness in Ohio,” Journal of Food Protection, Vol. 72, No. 1, pp. 128-136 (2009). Abstract available online at http://www.ingentaconnect.com/content/iafp/jfp/2009/00000072/00000001/art00018

22.       Schiff, E.R., “Atypical Manifestations of hepatitis-A,” Vaccine, Vol. 10, Suppl. 1, pp. 18-20 (1992). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/1475999

23.       Taylor, Ryan, et al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” Hepatology, Vol. 44, 1589-1597 (2006). Full text http://deepblue.lib.umich.edu/bitstream/2027.42/55879/1/21439_ftp.pdf

24.       Todd, Ewan C. D., et al., “Outbreaks Where Food Workers Have Been Implicated in the Spread of Foodborne Disease. Part 6. Transmission and Survival of Pathogens in the Food Processing and Preparation-environment,” Journal of Food Protection, Vol. 72, 202-219 (2009). Full text of the article is available online at http://courses.washington.edu/eh451/articles/Todd_2009_food%20processing.pdf

25.       Wheeler, C, et al., “An Outbreak of Hepatitis A Associated with Green Onions,” New England Journal of Medicine, Vol. 353, 890-897 (2005). Full text of article available at http://www.nejm.org/doi/full/10.1056/NEJMoa050855

26.       Willner, IR, et al., “Serious Hepatitis A: An Analysis of Patients Hospitalized During an Urban Epidemic in the United States,” Annals of Internal Medicine, Vol. 128, No. 2, pp. 111-114 (Jan. 15, 1998). Full text of the article is available at http://www.annals.org/content/128/2/111.full.pdf+html

27.       CDC. “Prevention of Hepatitis A through Active or Passive Immunization:  Recommendations of the Advisory Committee on Immunization Practices (ACIP),”  Morbidity and Mortality Weekly Report, Vol. 55, (RR07), pp. 1-23 (May 29, 2006) online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm.