title: Outbreak of hepatitis A in the USA associated with frozen pomegranate arils imported from Turkey: an epidemiological case study.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  US Centers for Disease Control and Prevention, US Food and Drug Administration, and US state and local public health departments.
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA. Electronic address: mgcollier@cdc.gov.
authors.forename: Melissa G
authors.initials: MG
authors.lastname: Collier
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Yury E
authors.initials: YE
authors.lastname: Khudyakov
authors.affiliation: New Mexico Department of Health, Santa Fe, NM, USA.
authors.forename: David
authors.initials: D
authors.lastname: Selvage
authors.affiliation: New Mexico Department of Health, Santa Fe, NM, USA.
authors.forename: Meg
authors.initials: M
authors.lastname: Adams-Cameron
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA; Colorado Department of Public Health and Environment, Denver, CO, USA.
authors.forename: Erin
authors.initials: E
authors.lastname: Epson
authors.affiliation: Colorado Department of Public Health and Environment, Denver, CO, USA.
authors.forename: Alicia
authors.initials: A
authors.lastname: Cronquist
authors.affiliation: Colorado Department of Public Health and Environment, Denver, CO, USA.
authors.forename: Rachel H
authors.initials: RH
authors.lastname: Jervis
authors.affiliation: California Department of Public Health, Sacramento, CA, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Lamba
authors.affiliation: California Department of Public Health, Sacramento, CA, USA.
authors.forename: Akiko C
authors.initials: AC
authors.lastname: Kimura
authors.affiliation: Nevada Division of Public and Behavioral Health, Carson City, NV, USA.
authors.forename: Rick
authors.initials: R
authors.lastname: Sowadsky
authors.affiliation: Arizona Department of Health Services, Phoenix, AZ, USA.
authors.forename: Rashida
authors.initials: R
authors.lastname: Hassan
authors.affiliation: Hawaii State Department of Health, Honolulu, HI, USA.
authors.forename: Sarah Y
authors.initials: SY
authors.lastname: Park
authors.affiliation: Texas Department of State Health Services, Austin, TX, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Garza
authors.affiliation: Food and Drug Administration, Silver Spring, MD, USA; Oakridge Institute for Science and Education, Oakridge, TN, USA.
authors.forename: Aleisha J
authors.initials: AJ
authors.lastname: Elliott
authors.affiliation: Food and Drug Administration, Silver Spring, MD, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Rotstein
authors.affiliation: Food and Drug Administration, Silver Spring, MD, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Beal
authors.affiliation: Food and Drug Administration, Silver Spring, MD, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Kuntz
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Food and Drug Administration, Silver Spring, MD, USA.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Lance
authors.affiliation: Food and Drug Administration, Silver Spring, MD, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Dreisch
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Wise
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Noele P
authors.initials: NP
authors.lastname: Nelson
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Anil
authors.initials: A
authors.lastname: Suryaprasad
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Jan
authors.initials: J
authors.lastname: Drobeniuc
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Holmberg
authors.affiliation: Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Fujie
authors.initials: F
authors.lastname: Xu
mesh_terms: D000328:Adult; D018563:Disease Notification; D004196:Disease Outbreaks; D016021:Epidemiologic Studies; D005243:Feces / Q000821:virology; D005260:Female; D005506:Food Contamination; D005638:Fruit / Q000821:virology; D005838:Genotype; D006506:Hepatitis A / Q000453:epidemiology* / Q000517:prevention & control / Q000628:therapy; D017957:Hepatitis A Virus, Human / Q000235:genetics / Q000276:immunology / Q000302:isolation & purification*; D006801:Humans; D007136:Immunoglobulins / Q000008:administration & dosage; D029561:Lythraceae / Q000821:virology*; D008297:Male; D008875:Middle Aged; D010802:Phylogeny; D057051:Product Recalls and Withdrawals; D017422:Sequence Analysis, DNA; D014421:Turkey; D014481:United States / Q000453:epidemiology; D014765:Viral Vaccines / Q000008:administration & dosage*
chemical_list: D007136:Immunoglobulins; D014765:Viral Vaccines