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March 19, 2023

Hepatitis A Virus (HAV) infection risk related to recall of frozen organic strawberries

Actions requested

  • Be aware of an outbreak of Hepatitis A virus (HAV) infections associated with frozen organic strawberries and a frozen organic tropical blend distributed in Washington State.
  • Consider HAV infection in patients with compatible symptoms, especially in patients with a history of consuming recalled strawberries in the previous 50 days, including:
    • Fatigue, fever, headache, malaise, joint pain, nausea, abdominal pain, vomiting, diarrhea, jaundice, clay colored stool, or dark urine.
    • Clinical jaundice may be a late sign or may never develop, particularly in children
      • 70% of older children and adults develop symptoms including jaundice
      • 70% of infections in children <6 years of age are asymptomatic
    • Patients with HIV or chronic liver disease, including hepatitis B and C, are at increased risk for severe disease
  • Collect specimens on patients with suspected HAV infection
    • Serum for HAV IgM and liver enzyme levels (ALT, AST)
    • Avoid ordering Total HAV antibody which identifies immunity from prior infection or immunization, not acute infection
    • Consider saving serum or also testing serum for hepatitis B (HBsAg and IgM) and hepatitis C (antibody/EIA) to rule out other causes for acute viral hepatitis
  • Consider post exposure prophylaxis (PEP) in susceptible patients who have had an exposure to HAV (recalled strawberries) within the last 14 days including susceptible close contacts of confirmed HAV cases
    • Susceptible persons include unvaccinated, partially vaccinated, nonresponders to vaccine and never infected.
  • Be aware that the recommended HAV PEP protocol* for susceptible individuals varies by age and health status:
Age Group Health Status Hep A vaccine Immune Globulin (IG)**
<12 months Healthy No 0.1 mL/kg
12 months – 40 years Healthy 1 dose*** None
>40 years Healthy 1 dose*** 0.1 mL/kg
>12 months Immunocompromised or chronic liver disease 1 dose*** 0.1 mL/kg
>12 months Contraindication to vaccine No 0.1 mL/kg

*Vaccine and IG should be administered at different anatomic sites.
**Measles, mumps, and rubella vaccine should not be administered for at least 2 weeks before and 6 months after IG administration.
***Second dose of hepatitis A vaccine is not required as part of PEP but the vaccination series should be completed with a second dose at least 6 months after the first dose.

  • Counsel patients with suspected or confirmed HAV infection on the following:
    • Hepatitis A is highly contagious and spread through the fecal-oral route, typically from person-to-person contact or from consuming contaminated food or drinks
    • People with HAV infection are infectious approximately from 2 weeks prior to symptom onset through one week after onset of jaundice (or 14 days after symptom onset if no jaundice)
    • Patients should maintain diligent hand hygiene practices, using soap and warm water to lather for 20 seconds after bathroom use
    • Patients should not prepare food for others while symptomatic and infectious
  • Advise patients with suspected or confirmed HAV infection not to work or attend sensitive settings including food service, healthcare, and childcare.
    • Persons with hepatitis A are not allowed to work in or attend these settings while infectious and need to be cleared by Public Health.
  • Hepatitis A vaccine is the best way to prevent infections.
  • Immediately report all suspected and confirmed cases to Public Health at 206-296-4774.

Background

On March 17, 2023, Scenic Fruit Company recalled the products frozen Organic Strawberries and Frozen Organic Tropical Fruit Blend after an investigation linked the recalled frozen organic strawberries to at least five cases of HAV infections in Washington state residents. The recalled products were sold in Washington state at Costco, PCC Community Markets, and Trader Joe’s. The product was also sold to Vital Choice Seafood. Consumers are advised to discard these products or return them to stores where they were purchased. Two cases of hepatitis A in King County residents have been linked to the recalled products.

The incubation period for HAV ranges from 14 to 50 days (average 28 days) after exposure. Persons who consumed this product in the prior 14 days may benefit from postexposure prophylaxis. If someone ate the recalled strawberries more than 50 days ago and did not develop HAV infection they are no longer at risk from that exposure.

Resources

This health advisory is also available in PDF format

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