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2016 - Multistate outbreak of hepatitis A linked to frozen strawberries (Final Update)

Posted December 16, 2016 2:30 PM ET

This particular outbreak appears to be over. However, Viral Hepatitis is still an important cause of human illness in the United States. More information about Viral Hepatitis, and steps people can take to reduce their risk of infection, can be found on the CDC Viral Hepatitis website.

Highlights

  • Read the Advice to Retailers, Public Health Officials, and Consumers >>
  • Several states, CDC, and the U.S. Food and Drug Administration (FDA) have completed investigation of a multistate outbreak of foodborne hepatitis A. Hepatitis A is a contagious liver disease that results from infection with the hepatitis A virus.  It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months.  Although rare, people have died from infection with hepatitis A. Symptoms appear between 15 and 50 days after infection and can include yellow eyes or skin, abdominal pain, or pale stools.
  • Epidemiologic and traceback evidence indicate frozen strawberries imported from Egypt were the likely source of this outbreak.
    • In interviews, nearly all ill people interviewed reported drinking smoothies containing strawberries at Tropical Smoothie Café locations prior to August 8 in a limited geographical area, including Maryland, North Carolina, Virginia, and West Virginia, but there have been a small number of cases outside of that geographic area with no Tropical Smoothie Café exposure.
  • Information available at this time does not indicate an ongoing risk of acquiring hepatitis A virus infection at Tropical Smoothie Café’s, as the contaminated food product has been removed as of August 8. As of December 13, 2016:
    • 143 people with hepatitis A have been reported from nine states: Arkansas (1), California (1), Maryland (12), New York (5), North Carolina (4), Oregon (1), Virginia (109), West Virginia (7), and Wisconsin (3).
  • 129 of these cases reported eating a smoothie from Tropical Smoothie Café. There have been no cases reporting illness from this same exposure since September 23, 2016.
    • 14 cases had no direct exposure to Tropical smoothie café. The latest illness onset date among these cases was October 25, 2016.
    • 56 ill people were hospitalized. No deaths were reported.
  • FDA traceback information indicated that the frozen strawberries served in the Tropical Smoothie Café locations were from the International Company for Agricultural Production & Processing (ICAPP), imported from Egypt. On August 8, 2016, Tropical Smoothie Café reported that they removed the Egyptian frozen strawberries from their restaurants in Maryland, North Carolina, Virginia, and West Virginia and switched to another supplier out of an abundance of caution. Information available at this time does not indicate an ongoing risk of hepatitis A virus infection at Tropical Smoothie Cafes.
  • On October 30, 2016, the International Company for Agricultural Production & Processing (ICAPP) recalled all of its frozen strawberries that were imported into the U.S. since January 1, 2016. The recalled products were distributed for sale to and use in food service establishments nationwide.
    • The FDA reports that hepatitis A virus contamination was found in multiple samples of ICAPP frozen strawberries.
  • This investigation is considered complete.

Initial Announcement - September 1, 2016

Introduction

CDC is collaborating with public health officials in several states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of foodborne hepatitis A.

The investigation began in early August when the Virginia Department of Health (VDH) identified an outbreak of hepatitis A cases potentially linked to smoothies from Tropical Smoothie Café restaurants in that state.

Since then, 70 people infected with hepatitis A linked to this outbreak have been reported from seven states: Maryland (6), New York (1), North Carolina (1), Oregon (1), Virginia (55), West Virginia (5), and Wisconsin (1).  Among people with available information, 32 people have been hospitalized.

People with hepatitis A may not have symptoms until 15 to 50 days after consuming a contaminated food or drink. We expect to see more ill people reported in this outbreak because of this long incubation period.

Investigation of the Outbreak

Epidemiologic and traceback evidence available at this time indicate that frozen strawberries imported from Egypt are the likely source of this outbreak.

In interviews, ill people answered questions about the foods they ate and other exposures in the month before they became ill. Of the 70 ill people, 68 (97%) reported drinking a smoothie from Tropical Smoothie Café in the month before illness started. Of the 54 ill people who were interviewed about the type of smoothie, all (100%) reported drinking a smoothie containing strawberries. These ill people purchased smoothies at cafés located in a limited geographical area, including Virginia and neighboring states. The ill person in Oregon traveled to Virginia and while there, had purchased smoothies containing frozen strawberries from a Tropical Smoothie Café location.

Federal, state, and local officials are performing traceback investigations from the Tropical Smoothie Café locations where ill people reported drinking smoothies with frozen strawberries. The investigations currently indicate that the strawberries served in those locations were imported from Egypt. Investigators are working to determine which specific lots may have been contaminated with hepatitis A virus and to find out if the frozen strawberries were distributed to other U.S. customers. Frozen strawberries used at Tropical Smoothie Café locations were collected for testing. The FDA’s analysis is ongoing.

On August 8, 2016, Tropical Smoothie Café reported that they removed the Egyptian frozen strawberries from restaurants in Maryland, North Carolina, Virginia, and West Virginia and switched to another supplier. Out of an abundance of caution, Tropical Smoothie Café has since switched to another supplier for all restaurants nationwide. At this time, we do not have information to suggest that there is an ongoing risk of hepatitis A virus infection at Tropical Smoothie Cafes. We are not yet aware of any other restaurants or retailers that may have received frozen strawberries linked to this outbreak. If this information changes, CDC will update the public immediately.

This investigation is ongoing. CDC and state and local public health partners are continuing to work to identify additional ill people and to interview those people about foods they ate before they got sick.

Frozen Strawberry Recall

  • On October 30, 2016, ICAPP announced that it had notified its distributors that frozen strawberries were being recalled due to a potential contamination with hepatitis A.  See http://www.fda.gov/Safety/Recalls/ucm527273.htm
  • ICAPP Distributors are required to notify facilities/retailers that have received the frozen strawberries
    • Recalled products were distributed for sale to and use in in facilities (nursing homes, schools, etc)  nationwide.
    • Notification is ongoing.
  • Facilities and retailers should not sell or serve recalled frozen strawberries.

Advice to Facilities who have received notification from ICAPP Distributors

  • If the facility has served any of the recalled frozen strawberries in the last 2 weeks since the notification , contact their local health department for further instructions and consideration of post exposure prophylaxis (PEP)
  • If the facility has received any of the recalled frozen strawberries but has not served them to anyone, any remaining product should be discarded and no further action is needed.

Advice to Public Health Officials

  • Because hepatitis A can have serious health consequences, CDC recommends providing post exposure prophylaxis (PEP) for unvaccinated people who have eaten recalled strawberries in the last 2 weeks. 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. If immunoglobulin is not available, hepatitis A vaccine can be substituted
    • Those with evidence of previous vaccination do not require PEP

NOTE: CDC recommends that all children be vaccinated against hepatitis A at age 1.  Any parent or caregiver who is unsure if a child has been vaccinated should consult their health care provider and confirm vaccination status.

Advice to Consumers

Information available at this time does not indicate an ongoing risk of hepatitis A virus infection at Tropical Smoothie Cafes.

  • It is possible that you might be contacted by an institution (i.e., school, nursing home) and told that you or a family member was exposed to recalled frozen strawberries. 
  • If you are unsure if you have been vaccinated against hepatitis A, contact your health professional to check your immunization records.  If you have been vaccinated, no further action is needed.  If you have never received the hepatitis A vaccine, getting a single dose within two weeks of exposure can protect against illness.  Because hepatitis A can have serious health consequences, CDC recommends post exposure prophylaxis (PEP) for unvaccinated people who have eaten recalled strawberries in the last 2 weeks. 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 do not require PEP
  • Symptoms can occur anywhere from 15 to 50 days after exposure, but not everyone will experience symptoms from a hepatitis A virus infection. Some people may experience mild flu-like symptoms. Other symptoms of hepatitis A virus infection include:
    • Yellow eyes or skin
    • Abdominal pain
    • Pale stools
    • Dark urine

General Hepatitis A Prevention

Cases of hepatitis A have decreased dramatically over the last decade in large part due to successful vaccination programs and policies. Most new cases of hepatitis A are now related to international travel, and occasional foodborne outbreaks. Once a person becomes ill from hepatitis A, the virus can be easily transmitted to household or sexual partners. Thorough hand washing can help minimize transmission among close contacts.

The hepatitis A vaccine is recommended as part of routine childhood vaccinations and for adults at high risk. CDC recommends the following groups be vaccinated against hepatitis A:

  • All children at age 1 year
  • Travelers to countries that have high rates of hepatitis A
  • Family members and caregivers of recent adoptees from countries where hepatitis A is common
  • Men who have sexual contact with other men
  • Users of injection and non-injection illegal drugs
  • People with chronic liver disease
  • People who are treated with clotting-factor concentrates
  • People who work with hepatitis A infected animals or in a hepatitis A research laboratory
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