Abstract
Non-travel-related hepatitis A is rare in Canada. We describe a hepatitis A outbreak investigation in British Columbia in February to May 2012 in which exposure history was collected from nine confirmed non-travel-related cases. Suspected foods were tested for hepatitis A virus (HAV): a frozen fruit blend was identified as a common exposure for six of the nine cases using supermarket loyalty cards. Consumption of the product was confirmed in each case. Genetic analysis confirmed HAV genotype 1B in the six exposed cases. Of the three non-exposed cases, the virus could not be genotyped for two of them; the virus from the other case was found to be genotype 1A and this case was therefore not considered part of the outbreak. HAV was detected by PCR from pomegranate seeds, a component of the identified frozen fruit blend. Historically low levels of HAV infection in British Columbia triggered early recognition of the outbreak. Loyalty card histories facilitated product identification and a trace-back investigation implicated imported pomegranate seeds.
Highlights
IntroductionIn 2010-2011, 30 out of 45 cases reported in British Columbia (BC), were related to travel to countries where hepatitis A remains endemic [3]
The annual number of reported cases of hepatitis A have consistently decreased in the past decade in British Columbia (BC), Canada, due to improved standards of hygiene and sanitation and provincially funded hepatitis A immunisation for high-risk groups, including people with chronic liver disease, chronic hepatitis B and C, people who inject drugs and men who have sex with men [1] and post-exposure prophylaxis [2]. in 2010-2011, 30 out of 45 cases reported in BC, were related to travel to countries where hepatitis A remains endemic [3].Hepatitis A virus (HAV) is primarily spread by the faecal–oral route, either through direct contact or through ingestion of contaminated food or water
The investigation was triggered during the first week of March 2012, when three non-travel-related hepatitis A cases (Cases 1–3), residing in three different municipalities in BC located in one health authority, were identified within a week, based on laboratory reports to the local public health authority and subsequent public health follow-up (Figure 1)
Summary
In 2010-2011, 30 out of 45 cases reported in BC, were related to travel to countries where hepatitis A remains endemic [3]. Hepatitis A virus (HAV) is primarily spread by the faecal–oral route, either through direct contact or through ingestion of contaminated food or water. Epidemiological evidence (supported by identical molecular sequences among the cases) has implicated a variety of foods in outbreaks, for example, green onions, semi-dried tomatoes, blueberries and frozen strawberries [5,7,8,9,10,11]. Laboratory confirmation of HAV contamination of vegetables and fruit is rare, in part due to low viral loads in many foods [12,13]. Molecular subtyping has improved the ability to detect outbreaks caused by HAV [14]
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