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Abstract
This report describes an outbreak investigation starting with two closely related suspected food-borne clusters of Dutch hepatitis A cases, nine primary cases in total, with an unknown source in the Netherlands. The hepatitis A virus (HAV) genotype IA sequences of both clusters were highly similar (459/460 nt) and were not reported earlier. Food questionnaires and a case-control study revealed an association with consumption of mussels. Analysis of mussel supply chains identified the most likely production area. International enquiries led to identification of a cluster of patients near this production area with identical HAV sequences with onsets predating the first Dutch cluster of cases. The most likely source for this cluster was a case who returned from an endemic area in Central America, and a subsequent household cluster from which treated domestic sewage was discharged into the suspected mussel production area. Notably, mussels from this area were also consumed by a separate case in the United Kingdom sharing an identical strain with the second Dutch cluster. In conclusion, a small number of patients in a non-endemic area led to geographically dispersed hepatitis A outbreaks with food as vehicle. This link would have gone unnoticed without sequence analyses and international collaboration.
Highlights
Hepatitis A virus (HAV) is a faecal-orally transmitted pathogen causing acute self-limiting hepatitis
In this study we describe a thorough outbreak investigation by multiple institutes in two European Union (EU) Member States that yielded evidence for a common source of infection for nine Dutch hepatitis A patients and one patient in the United Kingdom (UK)
Investigations following the traceback of the implicated mussels led to international matching of the nine primary and two secondary Dutch cases to three primary and two secondary cases in the UK with identical HAV sequences within the same time period
Summary
Hepatitis A virus (HAV) is a faecal-orally transmitted pathogen causing acute self-limiting hepatitis. Hepatitis A could re-emerge in regions such as North America or western Europe, where it is not endemic, affecting mostly adults, with more severe course of infection [1]. Cases, including routine demographic and epidemiological data, are reported according to standardised national criteria [3] by regional public health services using Osiris, a national electronic registration system for infectious diseases hosted by the National Institute for Public Health and the Environment (RIVM). Surveillance is intensified for cases with no travel history to endemic countries and an unknown source of infection. For these cases, sequences are actively collected and additional hypothesis-generating (trawler) questionnaires are routinely administered, aiming to identify a potential common (food-borne) source of infection [2,3,4]
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