As of May 31, 2022, a total of 18 outbreak-associated cases of hepatitis A have been reported from 3 states – California (16), Minnesota (1), and North Dakota (1). Illnesses started on dates ranging from March 28, 2022, to May 6, 2022. Ill people range in age from 9 to 73 years, with a median age of 57.5 years. Sixty-seven percent of ill people are female. Of 18 people with available information, 13 (72%) have been hospitalized. No deaths have been reported.
Epidemiologic and traceback evidence indicate that fresh organic strawberries imported from Baja California, Mexico, are the likely source of this outbreak. The potentially affected FreshKampo and HEB products are past shelf life and no longer available for purchase in the United States. People who purchased FreshKampo or HEB fresh organic strawberries from March 5, 2022, through April 15, 2022, and then froze those strawberries for later consumption should not eat them. These products may have been sold at the following retailers, including, but not limited to: HEB, Kroger, Safeway, Sprouts Farmers Market, Trader Joe’s, Walmart, Weis Markets, and WinCo Foods. One downstream recall from a company that may have used strawberries linked to this outbreak to make a product has been initiated. The recall is for Urban Remedy Organic Revitalizing Tea Tonic Strawberry Hibiscus Rose. People should not drink recalled tea.
In Canada, As of June 2, 2022, there are 10 laboratory-confirmed cases of hepatitis A illness being investigated in two provinces: Alberta (4) and Saskatchewan (6). Individuals became ill between early and mid-April 2022. Individuals who became ill are between 10 to 75 years of age. Four individuals have been hospitalized. No deaths have been reported.
The CFIA is conducting a food safety investigation into the FreshKampo brand of fresh organic strawberries purchased between March 5 and 9, 2022, at Co-op stores in Alberta and Saskatchewan. Currently, there are no food recall warnings associated with this outbreak.
The U.S. CDC and FDA are also investigating an outbreak of hepatitis A infections potentially linked to fresh organic strawberries. Investigators in Canada and the U.S. continue to collaborate to exchange information and identify commonalities in the outbreak information that may identify additional sources of illness or help to identify the cause of contamination in the fresh organic strawberries.
Hepatitis A is much more common in countries with underdeveloped sanitation systems and, thus, is a risk in most of the world.[1] 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.[2] Nevertheless, infections continue to occur in the United States, where approximately one-third of the population has been previously infected with HAV.[3]
Each year, approximately 30,000 to 50,000 cases of hepatitis A occur in the United States.[4] Historically, acute hepatitis A rates have varied cyclically, with nationwide increases every 10 to 15 years.[5] The national rate of HAV infections has declined steadily since the last peak in 1995.[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.[7]
In 2007, the CDC reported a total of 2,979 acute symptomatic cases of HAV.[8] 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.[9] In 2,500 of the cases, no known risk factor was identified.[10]
Hepatitis A outbreaks associated with fresh, frozen, and minimally processed produce worldwide from 1983 to 2016—adapted and expanded from Sivapalasingam et al., 2004 and Fiore, 2004. Italics indicate instances where the food was locally sourced with respect to the cases. The implicated foods were raw unless listed otherwise.
| Year | # Cases | Implicated food | Location of cases | Source of implicated food | Suspected cause of contamination | Reference |
| 1983 | 24 | Raspberries (frozen) | Scotland | Scotland | Infected pickers or packers | Reid et al., 1987[11] |
| 1987 | 5 | Raspberries (frozen) | Scotland | Tayside, Scotland | Infected pickers | Ramsay and Upton, 1989[12] |
| 1988 | 202 | Iceberg lettuce | Kentucky | Unknown, suspected to be from Mexico | Believed to have occurred prior to distribution, since multiple restaurants involved | Rosenblum et al., 1990[13] |
| 1990 | 35 | Strawberries (frozen) | Montana, Georgia | California | Suspect an infected picker at farm | Sivapalasingam et al., 2004;[14]Niu et al., 1992[15] |
| 1996 | 30 | Salad ingredients | Finland | Imported salad ingredients | Unknown | Pebody et al., 1998[16] |
| 1997 | 256 | Strawberries (frozen) | Michigan, Maine, Wisconsin, Arizona, Louisiana, Tennessee | Grown in Mexico,processed and frozen at a single California facility a year before consumption | Inconclusive due to time between harvest and consumption, suspect barehanded contact with berries at harvesting, coupled with few latrines and handwashing facilities on site | Hutin et al., 1999[17] |
| 1998 | 43 | Green onions | Ohio | One of two Mexican farms or a farm in California | Believed to be contaminated before arrival at restaurant | Dentinger et al., 2001[18] |
| 2000 | 31 | Green onions or tomatoes | Kentucky, Florida | Green onions: California or MexicoTomatoes: Unknown | Unknown | Wheeler et al., 2005[19]; Datta et al., 2001[20]; Fiore, 2004[21] |
| 2002 | 81 | Blueberries | New Zealand | New Zealand, one orchard | Inadequate bathroom facilities in fields, workers had barehanded contact with product, polluted groundwater from nearby latrines a possibility | Calder et al., 2003[22] |
| 2003 | 601 | Green onions | Pennsylvania, Tennessee, Georgia, North Carolina | Mexico, two farms | Contaminated during or before packing at farm | CDC, 2003[23]; Wheeler et al., 2005[24] |
| 2009 | 562 | Tomatoes (semidried) | Australia | Unknown; imported and domestic product involved | Product suspected to be imported due to concurrent outbreaks elsewhere at the time, source of contamination unknown | Donnan et al., 2012[25] |
| 2009 | 13 | Tomatoes (semidried) | Netherlands | Unknown; imported product suspected | Identical strain to the 2009 Australian outbreak | Petrignani et al., 2010[26] |
| 2010 | 59 | Tomatoes (semidried) | France | Likely Turkey, single batch of product | Unable to determine when and where contamination occurred. Virus was slightly different from one in the 2009 Australian and Dutch outbreaks. | Gallot et al., 2011[27] |
| 2012 | 9 | Pomegranate seeds (frozen) | Canada | Egypt | Suspect product contamination before export. Some history of travel to endemic areas among workers at Canadian processing facility, but less likely as only one product was associated with illness. | CDC 2013[28]; Swinkels et al., 2014[29] |
| 2013 | 103 | Strawberries (frozen)Other frozen berries may have been involved | Denmark, Finland, Norway, Sweden | Suspected Egypt and Morocco based on virus strain and import history | Unknown, some cases matched the strain of the larger 2013 European outbreak (see below) | Nordic Outbreak Investigation Team, 2013[30] |
| 2013 | 1589 | Berries (frozen) | Italy (90% of cases), Austria, Bulgaria, Denmark, England, Finland, France, Germany, Ireland, the Netherlands, Norway, Poland, Sweden | Multiple food items containing frozen mixed berries (cakes, smoothies); Bulgarian blackberries and Polish redcurrants were the most common ingredients in the implicated lots | Unknown, no single source found. Some cases also related to travel to Italy. | Severi et al., 2015[31]; EFSA 2014[32]; Chiapponi et al., 2014[33]; Rizzo et al., 2013[34]; Guzman-Herrador et al., 2014[35]; Fitzgerald et al., 2014[36] |
| 2013 | 165 | Pomegranate arils (frozen) | Arizona, California, Colorado, Hawaii, New Hampshire, New Jersey, New Mexico, Nevada, Utah, Wisconsin | Turkey | Unknown | Collier et al., 2014[37]; CDC 2013[38] |
| 2016 | 143 | Strawberries (frozen) | Arkansas, California, Maryland, New York, North Carolina, Oregon, Virginia, West Virginia, Wisconsin | Egypt | Unknown | CDC 2016[39] |
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.[40] In one study conducted in Spokane, Washington, the combined direct and indirect costs for each case of hepatitis A from all sources ranged from $2,892 to $3,837.[41] 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.[42] Nationwide, adults who become ill miss an average of 27 workdays per illness, and 11 to 22 percent of those infected are hospitalized.[43] All of these costs are entirely preventable, given the effectiveness of vaccination in providing immunity from infection.[44]
[1] Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” supra note 12.
[2] 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.
[3] CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.
[4] CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44; CDC, “Hepatitis A,” supra note 5.
[5] Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” supra note 16.
[6] CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44; CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13.
[7] CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” supra note 23.
[8] CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13.
[9] Id.
[10] Id.
[11] Reid, T., Robinson, H. (1987). Frozen raspberries and hepatitis A. Epidemiol Infect, 98: 109–112.
[12] Ramsay, C. N. and Upton, P. A. (1989). Hepatitis A and frozen raspberries. Lancet, 1: 43–44.
[13] Rosenblum, L. S., Mirkin, I. R., Allen, D. T., Safford, S., Hadler, S. C. (1990). A multifocal outbreak of hepatitis A traced to commercially distributed lettuce. American Journal of Public Health, 80(9): 1075-1079.
[14] Sivapalasingam, S., Friedman, C. R., Cohen, L., Taube, R. V. (2004). Fresh produce: a growing cause of outbreaks of foodborne illness in the United States, 1973 through 1997. J Food Prot, 67: 2342-2353.
[15] Niu, M. T., Polish, L. B., Robertson, B. H. (1992). Multistate outbreak of hepatitis A associated with frozen strawberries. J Infect Dis 166: 518-524.
[16] Pebody, R. G., Leino, T., Ruutu, P., Kinnunen, L., Davidkin, I., Nohynek, H., & Leinikki, P. (1998). Foodborne outbreaks of hepatitis A in a low endemic country: an emerging problem? Epidemiology and infection, 120(1): 55-59.
[17] Hutin, Y. J., Pool, V., Cramer, E. H., Nainan, O. V., Weth, J., Williams, I. T. et al. (1999). A multistate, foodborne outbreak of hepatitis A. New England Journal of Medicine, 340(8): 595-602.
[18] Dentinger, C. M., Bower, W. A., Nainan, O. V., Cotter, S. M., Myers, G., Dubusky, L. M., Fowler, S., Salehi, E. D. P., and Bell, B. P. (2001). An outbreak of hepatitis A associated with green onions. J Infect Dis, 183: 1273-1276.
[19] Wheeler, C., Vogt, T. M., Armstrong, G. L., Vaughan, G., Weltman, A., Nainan, O. V. et al. (2005). An outbreak of hepatitis A associated with green onions. New England Journal of Medicine, 353(9): 890-897.
[20] Datta, S. D., Traeger, M. S., & Nainan, O. V. (2001). Identification of a multi-state outbreak of hepatitis A associated with green onions using a novel molecular epidemiologic technique [abstract 896]. In Program and abstracts of the 39th Annual Meeting of the Infectious Diseases Society of America. Alexandra, VA: Infectious Diseases Society of America (Vol. 192).
[21] Fiore, A. E. (2004). Hepatitis A transmitted by food. Clinical Infectious Diseases, 38(5): 705-715.
[22] Calder, L. , Simmons, G., Thornley, G. (2003). An outbreak of hepatitis A associated with consumption of raw blueberries. Epidemiol Infect,131: 745-751
[23] Centers for Disease Control and Prevention (CDC). (2003). Hepatitis A outbreak associated with green onions at a restaurant–Monaca, Pennsylvania, 2003. MMWR, 52(47): 1155-1157. Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a5.htm
[24] Wheeler, C., Vogt, T. M., Armstrong, G. L., Vaughan, G., Weltman, A., Nainan, O. V. et al. (2005). An outbreak of hepatitis A associated with green onions. New England Journal of Medicine, 353(9): 890-897.
[25] Donnan, E. J., Fielding, J. E., Gregory, J. E., et al. (2012). A multistate outbreak of hepatitis A associated with semidried tomatoes in Australia, 2009. Clin Infect Dis, 54: 775–781.
[26] Petrignani, M., Harms, M., Verhoef, L. (2010). Update: a food-borne outbreak of hepatitis A in The Netherlands related to semi-dried tomatoes in oil, January-February 2010. Euro Surveillance, 15(20): 19572.
[27] Gallot, C., Grout, L., Roque-Afonso, A., Couturier, E., Carrillo-Santisteve, P., Pouey, J. et al. (2011). Hepatitis A Associated with Semidried Tomatoes, France, 2010. Emerging Infectious Diseases, 17(3): 566-567.
[28] Centers for Disease Control and Prevention (CDC). (2013). Multistate outbreak of hepatitis A virus infections linked to pomegranate seeds from Turkey (Final Update). Available at: https://www.cdc.gov/hepatitis/outbreaks/2013/a1b-03-31/
[29] Swinkels, H. M., Kuo, M., Embree, G., Andonov, A., Henry, B., Buxton, J. A. (2014). Hepatitis A outbreak in British Columbia, Canada: the roles of established surveillance, consumer loyalty cards and collaboration, February to May 2012. Euro Surveillance, 19: 20792.
[30] Nordic Outbreak Investigation Team C (2013). Joint analysis by the Nordic countries of a hepatitis A outbreak, October 2012 to June 2013: frozen strawberries suspected. Euro Surveillance, 18(27): 20520.
[31] Severi, E., Verhoef, L., Thornton, L., Guzman-Herrador, B. R., Faber, M., Sundqvist, L. et al. (2015). Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014. Euro Surveillance, 20(29): 1-9.
[32] European Food Safety Authority (EFSA). (2014). Tracing of food items in connection to a multinational hepatitis A virus outbreak in Europe. EFSA Journal, 12(9): 3821-4007. Available at http:// www.efsa.europa.eu/en/efsajournal/pub/3821.htm
[33] Chiapponi, C., Pavoni, E., Bertasi, B., Baioni, L., Scaltriti, E., Chiesa, E., et al. (2014). Isolation and genomic sequence of hepatitis A virus from mixed frozen berries in Italy. Food Environ Virol, 6(3): 202-206.
[34] Rizzo, C., Alfonsi, V., Bruni, R., Busani, L., Ciccaglione, A., De Medici, D., et al. (2013). Ongoing outbreak of hepatitis A in Italy: preliminary report as of 31 May 2013. Euro Surveillance, 18(27): 20518.
[35] Guzman-Herrador, B., Jensvoll, L., Einoder-Moreno, M., Lange, H., Myking, S., Nygard, K., et al. (2014). Ongoing hepatitis A outbreak in Europe 2013 to 2014: imported berry mix cake suspected to be the source of infection in Norway. Euro Surveillance, 19(15): 20775.
[36] Fitzgerald, M., Thornton, L., O’Gorman, J., O Connor, L., Garvey, P., Boland, M., et al. (2014). Outbreak of hepatitis A infection associated with the consumption of frozen berries, Ireland, 2013 – linked to an international outbreak. Euro Surveillance: European communicable disease bulletin, 19(43).
[37] Collier, M. G., Khudyakov, Y. E., Selvage, D., Adams-Cameron, M., Chiepson, E., Cronquist, A., et al. (2014). Outbreak of hepatitis A in the USA associated with frozen pomegranate arils imported from Turkey: an epidemiological case study. Lancet Infectious Diseases, 14(10): 976-981.
[38] Centers for Disease Control and Prevention (CDC). (2013) – Multistate outbreak of hepatitis A virus infections linked to pomegranate seeds from Turkey (Final Update), supra note 85.
[39] Centers for Disease Control and Prevention (CDC). (2016). 2016 – Multistate outbreak of hepatitis A linked to frozen strawberries (Final Update). Available at https://www.cdc.gov/hepatitis/outbreaks/2016/hav-strawberries.htm
[40] CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44.
[41] 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. 233-46 (2003). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/12856793; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations,” supra note 20.
[42] Scharff, RL, et al., “Economic Cost of Foodborne Illness in Ohio,” Journal of Food Protection, Vol. 72, No. 1, pp. 128-36 (2009). Abstract available online at http://www.ingentaconnect.com/content/iafp/jfp/2009/00000072/00000001/art00018.
[43] CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; CDC, “Hepatitis A,” supra note 5.
[44] CDC, “Hepatitis A,” supra note 5; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations,” supra note 20.