National Outbreak of Hepatitis A Linked to Frozen Strawberries – Product was Distributed in Alaska
Alaska Public Health Advisory November 4, 2016
This advisory alerts Alaska health care providers and the public of a nationwide recall of frozen strawberries that have been linked to cases of hepatitis A. A recall notice was issued on October 25 for frozen strawberries, and Alaska Department of Environmental Conservation (DEC) food safety officials are working to confirm the precise food service establishments where the product may have been sent. Persons who consumed the implicated strawberries and were not already immune to the hepatitis A virus (HAV) may be at risk for developing hepatitis A. While we are not aware of any hepatitis A cases related to this outbreak in Alaska at this time, the product (sold in 15-50 pound bags) was distributed to some restaurants and other food service facilities in Alaska.
Investigation of an outbreak of hepatitis A that began in May 2016 in the eastern United States revealed that frozen strawberries from Egypt were the source of infection. The firm that sourced the frozen strawberries issued a recall of all product distributed in the U.S. since January 2016. Most of the approximately 140 HAV cases to date have been in the eastern U.S.; however, because the entire downstream path of food distribution has not been fully traced at this time, it is difficult to quantify the risk to the entire nation. Therefore, out of an abundance of caution, anyone who might have consumed frozen strawberries in restaurants and other food service facilities is considered to have potentially been exposed.
Detailed information about the outbreak can be found on the following websites:
RecallsOutbreaksEmergencies/ Outbreaks/ucm518775.htm# Recalled
Frozen strawberries were reportedly distributed in Alaska; however, information about the distribution chain is actively being investigated. An evolving list of restaurants and other food service facilities where frozen strawberries were served in the past 2 weeks will be posted on-line and updated with new information as it becomes available; see http://dhss.alaska.gov/dph/
Guidance for the Public
- Persons who consumed frozen strawberries from restaurants or other food service facilities in the past 15-50 days and who are experiencing symptoms of HAV (e.g., jaundice, abdominal pain, diarrhea, pale stools, and dark urine) should contact their health care provider immediately for medical evaluation.
- The Centers for Disease Control and Prevention (CDC) is recommending that persons who consumed frozen strawberries in restaurants and other food service facilities within the past 14 days AND who are not already immune to HAV should contact their health care provider as soon as possible to get post-exposure prophylaxis (PEP).
- PEP consists of:
- Hepatitis A vaccine for people between the ages of 1 and 40 years.
- Hepatitis A virus-specific immunoglobulin (IG) for people outside of this age range, but the hepatitis A vaccine can be substituted if IG is not available.
- Those with evidence of previous vaccination or prior infection do not require PEP.
- NOTE: The implicated frozen strawberries were not sold to individual consumers in retail grocery stores, so the strawberries in people’s freezers at home are not implicated in this outbreak.
- Persons who do not need PEP include those who:
- Are immune to HAV, i.e., those who have received at least one dose of single-antigen HAV vaccine, those who have had previous HAV infection, and those who are HAV IgG positive;
- Ate fresh strawberries or frozen strawberries they bought in a retail store; or
- Ate frozen strawberries in restaurants and other food service facilities more than 14 days ago, as PEP has limited effectiveness after this timeframe.
- Hepatitis A virus is killed during cooking to 185 degrees.
- A Hepatitis A fact sheet is available at: http://dhss.alaska.gov/dph/
Epi/id/SiteAssets/Pages/ hepatitis/HepatitisA_ FactSheet.pdf
Guidance and Resources for Health Care Providers
- Health care providers should be aware of the possibility of patients requesting PEP for recent exposures to frozen strawberries. PEP consists of dosing with HAV vaccine or immunoglobulin (IG) depending on the patient’s age and pre-existing conditions.
- Persons who recently (<14 days) have been exposed to HAV and who previously have not received hepatitis A vaccine should be administered a single dose of single-antigen hepatitis A vaccine or immune globulin (IG) (0.02 mL/kg) as soon as possible.
- For healthy persons aged 12 months–40 years, single antigen hepatitis A vaccine at the age-appropriate dose is preferred.
- For persons aged >40 years, IG is preferred, but the vaccine can be used if IG cannot be obtained.
- Because the effectiveness is greatest the sooner PEP is administered after exposure, it is not recommended to perform immunologic laboratory screening prior to making decisions about administering PEP.
- IG should be used for children aged <12 months, immunocompromised persons, persons who have had chronic liver disease diagnosed, and persons for whom vaccine is contraindicated.
- Advisory Committee on Immunization Practices (ACIP) guidelines for PEP can be read here: http://www.cdc.gov/mmwr/
- HAV vaccine has been routinely recommended for children since 1999 and part of the Alaska school and childcare vaccine requirements since 2001.
- Health care providers should also be aware that patients who had exposure to frozen strawberries in the past 15-50 days might present with symptoms of HAV (e.g., jaundice, abdominal pain, diarrhea, pale stools, and dark urine).
- Serum specimens should be obtained and can be sent to the Alaska State Public Health Laboratory (ASPHL; note that the patient is symptomatic) or a commercial laboratory for antibody testing. See ASPHL webpage for information on specimen collection and handling: http://www.dhss.alaska.gov/
- Cases of HAV are reportable to the Alaska Section of Epidemiology; call 907-269-8000 or 800-478-0084 after hours to report suspected or confirmed cases.