lunes, 22 de septiembre de 2014

Outbreak of hepatitis A in the USA associated with frozen pomegranate arils imported from Turkey: an epidemiological case study : The Lancet Infectious Diseases

The Lancet Infectious Diseases, Volume 14, Issue 10, Pages 976 - 981, October 2014

doi:10.1016/S1473-3099(14)70883-7

Cite or Link Using DOI

This article can be found in the following collections: Infectious Diseases (Infectious diseases-other)

Published Online: 04 September 2014

Outbreak of hepatitis A in the USA associated with frozen pomegranate arils imported from Turkey: an epidemiological case study

Dr Melissa G Collier MD a

, Yury E Khudyakov PhD a, David Selvage MHS d, Meg Adams-Cameron MPH d, Erin Epson MD b e,Alicia Cronquist RN e, Rachel H Jervis MPH e, Katherine Lamba MPH f, Akiko C Kimura MD f, Rick Sowadsky MSPH g, Rashida Hassan MSPH h, Sarah Y Park MD i, Eric Garza MPH j, Aleisha J Elliott MS k l, David S Rotstein DVM k, Jennifer Beal MPH k, Thomas Kuntz MS k, Susan E Lance DVM c k, Rebecca Dreisch MS k, Matthew E Wise PhD c, Noele P Nelson MD a, Anil Suryaprasad MD a,Jan Drobeniuc MD a, Scott D Holmberg MD a, Fujie Xu MD a, for the Hepatitis A Outbreak Investigation Team

Summary

Background

In May, 2013, an outbreak of symptomatic hepatitis A virus infections occurred in the USA. Federal, state, and local public health officials investigated the cause of the outbreak and instituted actions to control its spread. We investigated the source of the outbreak and assessed the public health measures used.

Methods

We interviewed patients, obtained their shopping information, and did genetic analysis of hepatitis A virus recovered from patients' serum and stool samples. We tested products for the virus and traced supply chains.

Findings

Of 165 patients identified from ten states, 69 (42%) were admitted to hospital, two developed fulminant hepatitis, and one needed a liver transplant; none died. Illness onset occurred from March 31 to Aug 12, 2013. The median age of patients was 47 years (IQR 35—58) and 91 (55%) were women. 153 patients (93%) reported consuming product B from retailer A. 40 patients (24%) had product B in their freezers, and 113 (68%) bought it according to data from retailer A. Hepatitis A virus genotype IB, uncommon in the Americas, was recovered from specimens from 117 people with hepatitis A virus illness. Pomegranate arils that were imported from Turkey—where genotype IB is common—were identified in product B. No hepatitis A virus was detected in product B.

Interpretation

Imported frozen pomegranate arils were identified as the vehicle early in the investigation by combining epidemiology—with data from several sources—genetic analysis of patient samples, and product tracing. Product B was removed from store shelves, the public were warned not to eat product B, product recalls took place, and postexposure prophylaxis with both hepatitis A virus vaccine and immunoglobulin was provided. Our findings show that modern public health actions can help rapidly detect and control hepatitis A virus illness caused by imported food. Our findings show that postexposure prophylaxis can successfully prevent hepatitis A illness when a specific product is identified. Imported food products combined with waning immunity in some adult populations might make this type of intervention necessary in the future.