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Public Health Announces Hepatitis A Outbreak in LA County  – Hepatitis A vaccine is the best protection

The Los Angeles County Department of Public Health (Public Health) has declared a local outbreak of hepatitis A (HAV) in Los Angeles County because the most recent new cases appear to be locally acquired.Hepatitis A outbreaks are currently ongoing in San Diego and Santa Cruz counties. The large majority of cases have occurred in persons who are homeless and/or use illicit drugs (injection and non-injection), with several cases also occurring among people who provide services to the homeless.

Public Health has confirmed 10 total cases of hepatitis A among high-risk individuals (those that are homeless or in institutions that serve the homeless) in Los Angeles County. Of the confirmed cases, four had been in San Diego and one had been in Santa Cruz during their exposure period. Three secondary cases occurred in a health care facility in Los Angeles County. The two most recent cases appear to have acquired their infection locally within Los Angeles County.

“Public Health has been proactively preparing for an outbreak for some time and is working diligently to prevent spread in local communities. Our priorities are to keep all our residents both safe and well informed of the situation,” said Jeffrey Gunzenhauser, MD, MPH, Interim Health Officer, Los Angeles County. “Vaccination is the best protection against Hepatitis A. With this in mind, our outreach teams and clinics are offering free vaccine to persons who are homeless, active drug users, and those who provide services and support to those individuals.”

A person can get hepatitis A if they come into contact with an infected person’s feces through contaminated food or objects. The hepatitis A virus can spread when a person does not properly wash their hands after going to the bathroom or changing diapers. Other modes of transmission include certain sexual practices, sharing equipment related to illicit drug use, and consumption of food or water contaminated with the virus. People who are homeless are at higher risk because they face challenges to maintaining good hygiene.

Physicians are required to report HAV cases to Public Health. HAV causes acute liver disease, which may be severe. It is transmitted by contact with feces from a person who is infected – often through contact with food or water or during sex or other close contact. Signs and symptoms of acute HAV include fever, malaise, dark urine, lack of appetite, nausea, and stomach pain, followed by jaundice. Symptoms generally last for less than 2 months although some persons may have prolonged or more severe illness. Infection can be prevented in close contacts of patients by vaccination or administration of immune globulin within 2-weeks following exposure. If you experience these symptoms, contact your physician.

Although Hepatitis A is very contagious, you can take the following steps to prevent Hepatitis A:

  • Get vaccinated for Hepatitis A
  • Don’t have sex with someone who has Hepatitis A infection
  • Use your own towels, toothbrushes and eating utensils
  • Don’t share food, drinks, or smokes with other people
  • Wash hands with soap and water after using the bathroom, changing diapers, and before preparing, serving or eating food.

Public Health continues surveillance for cases and is working closely with healthcare providers and organizations that serve the homeless population to protect the health of patients/clients, staff and the community. Public Health is providing education and vaccination to the homeless and those who work with them, and working with other organizations that provide services for the homeless population to reach this community. Hepatitis A vaccination is available at Public Health clinics or from your health care provider. County residents may call the LA County Information line at 2-1- 1 from any landline or cell phone within the county for referrals to providers offering vaccines at no-cost or a reduced cost. For patients without access to HAV vaccine, Public Health will have vaccine available at its Public Health Centers located throughout the County.

The death toll in an outbreak of hepatitis A in San Diego has reached 16, and 421 people have been sickened with the disease, the county Health and Human Services Agency reported Today. The figures are associated with an outbreak that began last November and has struck the homeless population and users of illicit drugs particularly hard.

Patients who contracted hepatitis A, which attacks the liver, in a manner unrelated to the outbreak aren’t included in the statistics.

The new numbers were released the same day the city of San Diego began a pilot program to keep 14 public restrooms in Balboa Park open 24 hours a day. Under direction from county health, the city on Monday began washing down streets and sidewalks in the East Village with a bleach formula.

Also, around 40 hand-washing stations were set up around the city — concentrated in areas where the homeless congregate — around the beginning of the Labor Day weekend.

County officials, meanwhile, are continuing a program of vaccinations, which are considered to be the best way to prevent hepatitis A. The disease is spread by contact with microscopic amounts of infected feces and via sexual transmission.

More than 7,000 shots have been given to people considered to be at-risk of acquiring the disease, and over 19,000 shots given out in total.

In January’s annual tally of the area’s transient population, 5,619 homeless individuals were counted in the city of San Diego, a 10.3 percent increase from last year. Of those, 3,231 were living on the streets.

Thanks to HepMag.com for a great summary of ongoing hepatitis A outbreaks going on in the US.

California

Public health officials first detected the hepatitis A outbreak in November 2016 and as of July 21, 2017, 251 cases and 5 deaths have been reported in San Diego. Those affected have largely been homeless individuals, which has made public health efforts more challenging to implement, particularly in reaching individuals with vaccinations and improving hygiene practices. Local officials and community organizations have been working to raise awareness of hepatitis A vaccination, distribute “Hepatitis A Prevention Kits” (containing sanitary supplies), and plans are underway to install hand-washing stations in areas frequented by homeless persons to help stop the spread. Since the outbreak began, the county has administered over 4,000 hepatitis A vaccinations, and more work is planned to expand those efforts. With this combined approach, San Diego is hoping to end the outbreak, the largest in California in nearly 20 years.

Colorado

Between January and early July 2017, 43 cases of hepatitis A were reported in Colorado, a significant increase from 2016 where 23 cases were reported for the full year. Half of these cases resulted in hospitalization and one person has died. Unlike many hepatitis A outbreaks, there is no apparent common link to a restaurant or food item. 74% of hepatitis A cases are men and at least half are men who have sex with men (MSM). Local public health agencies are working to battle the epidemic by targeting MSM with outreach and offering vaccination at a variety of sites.

Michigan

Between August 2016 and June 2017 in southeast Michigan, almost 200 people have been diagnosed with hepatitis A infection, 90% of those infected have required hospitalization, and 10 people have died. Public health officials believe the outbreak to be unrelated to water or food contamination, but rather person-to-person spread through use of illicit drugs, sexual contact, and close proximity. Nearly 50% of those infected report a history of substance use disorders and 20% are also infected with hepatitis C.

Oakland County Health Division reports eight new cases of Hepatitis A in the last week associated primarily with the Farmington Hills area. The Health Division has not yet identified a source, but is investigating potential common factors such as contaminated food, sick individuals, travel, and healthcare exposure.

“These new cases serve as a vital reminder of why it is critical to get vaccinated,” said Leigh-Anne Stafford, health officer for Oakland County. “The Health Division urges all residents, food handlers, and healthcare providers to get the Hepatitis A vaccine and to wash hands thoroughly. Ill food workers and health care workers are encouraged to stay home from work, seek medical attention, and report their illness to their employer.”

Dr. Pamela Hackert, medical director for Oakland County Health Division said, “The virus is shed in feces and is most commonly spread from person to person by contaminated hands. In addition to vaccination, good hygiene, proper sanitation of surfaces, and proper food preparation are keys in preventing this contagious disease.”

Hepatitis A is an infection of the liver caused by a virus and is a vaccine-preventable disease. Symptoms of Hepatitis A include sudden abdominal pain, fatigue, diarrhea, nausea, headache, dark urine, and vomiting followed by yellowing of the skin and eyes. Symptoms may appear from two to six weeks after exposure, with the average time being about one month. In rare cases, those with a pre-existing severe illness or a compromised immune system can progress to liver failure. Individuals are advised to contact their doctor if they have a sudden onset of any symptoms.

To reduce the risk of contracting Hepatitis A:

  • Wash hands frequently, especially after using the bathroom, changing diapers, and before preparing and eating food. Rub hands vigorously with soap and warm running water for at least 20 seconds. Handwashing is essential and one of the most effective ways to prevent the spread of infection.
  • Clean and disinfect all surface areas if someone in the household or workplace has symptoms, especially areas such as toilets, sinks, trashcans, doorknobs and faucet handles.
  • Do not prepare food if you have symptoms and refrain from food preparation for at least three days
  • after symptoms have ended, or two weeks after onset of clinical symptoms, whichever is longer.
  • Get the Hepatitis A vaccine.

The Hepatitis A vaccine is available through some health providers, CVS Minute Clinics, Oakland County Health Division offices in Southfield and Pontiac, and many pharmacies. Call ahead to ensure your health care provider or pharmacy has the vaccine available.

Health Division offices are located at the following addresses:

  • North Oakland Health Center, 1200 N. Telegraph Road, Building 34 East, Pontiac
  • South Oakland Health Center, 27725 Greenfield Road, Southfield

Payment options include cash and credit card. There is a $5 fee per visit, per client as well as additional fees for credit card payments. Vaccine fees are charged to individuals who are not eligible for federal and/or state programs that cover vaccination costs. The Vaccines for Children (VFC) Program offers vaccines at no cost for eligible children up to 18-years-old. If you have insurance, check with your health care/insurance provider for possible benefit coverage. No one will be denied access to services due to inability to pay. A discounted/sliding fee schedule is available.

For more information about Hepatitis A, visit www.oakgov.com/health or call Nurse on Call at 800-848-5533, Monday through Friday, 8:30 a.m. – 5:00 p.m.

From August 1, 2016 to March 21, 2017, 107 cases of lab-confirmed hepatitis A have been reported to public health authorities in these jurisdictions. This represents an eightfold increase during the same time last year. Ages of the cases range from 22 to 86 years, with an average age of 45 years. The majority of the cases have been male. Eighty-five percent of the cases have been hospitalized with two deaths reported.  Approximately one-third of the cases have a history of substance abuse, and 16 percent of all cases are co-infected with hepatitis C. No common sources of infection have been identified.

Hepatitis A is a vaccine-preventable disease. While the hepatitis A vaccine is recommended as part of the routine childhood vaccination schedule, most adults have not been vaccinated and may be susceptible to the hepatitis A virus.

Hepatitis A vaccination is recommended for:

  • All children at age 1 year
  • Close personal contacts (e.g., household, sexual) of hepatitis A patients
  • Users of injection and non-injection illegal drugs
  • Men who have sex with men
  • People with chronic (lifelong) liver diseases, such as hepatitis B or hepatitis C. Persons with chronic liver disease have an elevated risk of death from liver failure
  • People who are treated with clotting-factor concentrates
  • Travelers to countries that have high rates of hepatitis A
  • Family members or caregivers of a recent adoptee from countries where hepatitis A is common

Individuals with hepatitis A are infectious for 2 weeks prior to symptom onset. Symptoms of hepatitis A include jaundice (yellowing of the skin), fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, and light-colored stools. Symptoms usually appear over a number of days and last less than 2 months; however, some people can be ill for as long as 6 months. Hepatitis A can sometimes cause liver failure and death.

Risk factors for a hepatitis A infection include living with someone who has hepatitis A, having sexual contact with someone who has hepatitis A, or sharing injection or non-injection illegal drugs with someone who has hepatitis A. The hepatitis A virus can also be transmitted through contaminated food or water.

333 ill, 11 deaths with 232 hospitalized.

Since early 2017, the Public Health Services Division, in the County of San Diego Health and Human Services Agency, has been investigating a local Hepatitis A outbreak. The majority of people who have contracted hepatitis A are homeless and/or illicit drug users, although some cases have been neither.  The outbreak is being spread person-to-person and through contact with a fecally contaminated environment.  No common sources of food, beverage or drugs have been identified that have contributed to this outbreak, though investigation is ongoing.  

Vaccination efforts are being implemented in targeted locations by County staff and in collaboration with health care partners. Health providers are asked to inform the Epidemiology Program if they have a patient suspected to have the hepatitis A infection, before the patient leaves the emergency department or provider’s office.

In a follow-up on the hepatitis A outbreak in San Diego County, CA, the number of cases reported this year has climbed to 312, including 10 fatalities, according to latest health department data.

Of the cases, nearly seven out of 10 patients required hospitalization for their illness (215).

The County of San Diego Health and Human Services Agency says the investigation into the outbreak is ongoing.

It has been challenging because of the long incubation period of the disease (15 to 50 days) and the difficulty experienced to contact many individuals sickened with the illness who are homeless and/or illicit drug users. To date, no common source of food, beverage, or other cause has been identified; as a result, the source of the outbreak remains undetermined.

A comprehensive hepatitis A vaccination program established in Alaska in the 1990s, which became a requirement for school entry in 2001, has virtually wiped out the virus in the native peoples of Alaska, where it had been endemic.

Data from the program is being presented at this year’s World Indigenous Peoples’ Conference on Viral Hepatitis in Anchorage, Alaska, USA (8-9 August) by Stephanie Massay, Epidemiology Specialist with the Alaska Division of Public Health, Section of Epidemiology, Anchorage, AK, USA, and colleagues.

Hepatitis A is an acute (short-term but severe) infection of the liver caused by the hepatitis A virus. Fever, weakness, nausea, aches and pains, and jaundice can be among the symptoms experienced. The hepatitis A virus can survive in the environment on and in food. It is also relatively resistant to detergents but can be inactivated by high temperature (85°C or higher) and by chemicals such as chlorine. Although it occurs worldwide, HAV occurs more commonly in populations with poor sanitation, such as poor populations in developed countries (e.g. Indigenous populations) and also in developing countries more generally.

Alaska experienced epidemics of hepatitis A every 10-15 years during the 1950s to the 1990s, resulting in thousands of cases. Alaska Native (AN) people living in rural communities were disproportionately impacted.

Hepatitis A virus (HAV) vaccines were licensed in 1995 and recommended by the Advisory Committee on Immunization Practice (ACIP) for routine vaccination of US children in populations with high HAV infection rates. Alaska began universal vaccination for children aged 2-14 years in 1996? HAV vaccination became required for school entrance in 2001. In 1997, following ACIP recommendations, this was expanded to include all children age 2 – 18 years, and in 2006 this was further expanded to include children age 1 – 18 years.

The data showed that during 1972-1995, Alaska’s average annual incidence of hepatitis A was 60 per 100,000 population. Rates by race were substantially higher for AN people compared to non-AN people (244 vs 19 per 100,000 respectively, with AN people being 13 times more likely to be infected than non-AN people).

Compared to 1972-1995 (pre-vaccine), 2002-2007 (post­vaccine) statewide hepatitis A incidence fell by 98% (0.9 vs. 60 per 100,000); among AN peoples the incidence fell by 99.9% (0.3 vs. 243.8 per 100,000). During 2008-2016, 23 HAV cases were reported in Alaska? 5 among AN, 11 among non­AN, and 7 among people of unknown race/ethnicity.

The 2008-2016 statewide incidence of hepatitis A was 0.35 cases per 100,000 people? the incidence in children aged <14 years was 0.14 cases per 100,000 children. Of the 17 cases with documentation on travel, 15 (88%) had recent travel outside of Alaska. In 2015, National Immunization Survey data estimated that among children aged 19-35 months, HAV vaccine coverage was similar in Alaska (84%) and all US children (86%).

The authors conclude: “Dramatic declines in the incidence of hepatitis A occurred after HAV vaccine was recommended as a routine childhood vaccine and after it was required for school entry. Prior to routine vaccination, most the reported HAV cases were associated with outbreaks occurring within Alaska. Since 2008 however, 88% of reported hepatitis A cases have been imported, many of which were acquired during travel outside of the United States.”

THE HEPATITIS A VIRUS

Exposure to hepatitis A virus (“HAV”) can cause an acute infection of the liver that is typically mild and resolves on its own.[1] The symptoms and duration of illness vary a great deal, with many persons showing no symptoms at all.[2] Fever and jaundice are two of the symptoms most commonly associated with HAV infection.[3]

Throughout history, hepatitis infections have plagued humans. The “earliest accounts of contagious jaundice are found in ancient China.”[4] According to the CDC:

The first descriptions of hepatitis (epidemic jaundice) are generally attributed to Hippocrates. Outbreaks of jaundice, probably hepatitis A, were reported in the 17th and 18th centuries, particularly in association with military campaigns. Hepatitis A (formerly called infectious hepatitis) was first differentiated epidemiologically from hepatitis B, which has a long incubation period, in the 1940s. Development of serologic tests allowed definitive diagnosis of hepatitis B. In the 1970s, identification of the virus, and development of serologic tests helped differentiate hepatitis A from other types of non-B hepatitis.[5]

Until 2004, HAV was the most frequently reported type of hepatitis in the United States. In the pre-vaccine era, the primary methods used for preventing HAV infections were hygienic measures and passive protection with immune globulin (IG). Hepatitis A vaccines were licensed in 1995 and 1999. These vaccines provide long-term protection against HAV infection.[6

Hepatitis A is the only common vaccine-preventable foodborne disease in the United States.[7] This virus is one of five human hepatitis viruses that primarily infect the human liver and cause human illness.[8] Unlike hepatitis B and C, hepatitis A does not develop into chronic hepatitis or cirrhosis, which are both potentially fatal conditions.[9] Nonetheless, infection with the hepatitis A virus (HAV) can lead to acute liver failure and death.[1

Where does Hepatitis A Come From?

Hepatitis A is a communicable (or contagious) disease that often spreads from person to person.[11] Person-to-person transmission occurs via the “fecal-oral route,” while all other exposure is generally attributable to contaminated food or water.[12] Food-related outbreaks are usually associated with contamination of food during preparation by a HAV-infected food handler.[13] The food handler is generally not ill because the peak time of infectivity—that is, when the most virus is present in the stool of an infected individual—occurs two weeks before illness begins.[14]

Fresh produce contaminated during cultivation, harvesting, processing, and distribution has also been a source of hepatitis A.[15] In 1997, frozen strawberries were the source of a hepatitis A outbreak in five states.[16] Six years later, in 2003, fresh green onions were identified as the source of a HAV outbreak traced to consumption of food at a Pennsylvania restaurant.[17] Other fruits and vegetables, such as blueberries and lettuce, have also been associated with HAV outbreaks in the U.S. as well as in other developed countries.[18] HAV is relatively stable and can survive for several hours on fingertips and hands and up to two months on dry surfaces.[19] The virus can be inactivated by heating to 185°F (85°C) or higher for one minute, or disinfecting surfaces with a 1:100 dilution of household bleach in tap water.[20] HAV can still be spread from cooked food if it is contaminated after cooking.[21]

Although ingestion of contaminated food is a common means of spread for HAV, it may also be spread by household contact among families or roommates, sexual contact, or by direct inoculation from persons sharing illicit drugs.[22] Children are often asymptomatic, or have unrecognized infections, and can pass the virus through ordinary play, unknown to their parents, who may later become infected from contact with their children.[23]

What are the Symptoms of Hepatitis A?

Hepatitis A may cause no symptoms at all when it is contracted, especially in children.[24] Asymptomatic individuals will only know they were infected (and have become immune, given that you can only get hepatitis A once) by getting a blood test later in life.[25] Approximately 10 to 12 days after exposure, HAV is present in blood and is excreted via the biliary system into the feces.[26] Although the virus is present in the blood, its concentration is much higher in feces.[27] HAV excretion begins to decline at the onset of clinical illness, and decreases significantly by 7 to 10 days after onset of symptoms.[28] Most infected persons no longer excrete virus in the feces by the third week of illness. Children may excrete HAV longer than adults.[29]

Seventy percent of HAV infections in children younger than six years of age are asymptomatic; in older children and adults, infection tends to be symptomatic with more than 70% of those infected developing jaundice.[30] Symptoms typically begin about 28 days after contracting HAV, but can begin as early as 15 days or as late as 50 days after exposure.[31] The symptoms include muscle aches, headache, anorexia (loss of appetite), abdominal discomfort, fever, and malaise.[32]

After a few days of typical symptoms, jaundice (also termed “icterus”) sets in.[33] Jaundice is a yellowing of the skin, eyes, and mucous membranes that occurs because bile flows poorly through the liver and backs up into the blood.[34] The urine will also turn dark with bile and the stool light or clay-colored from lack of bile.[35] When jaundice sets in, initial symptoms such as fever and headache begin to subside.[36]

In general, symptoms usually last less than two months, although 10% to 15% of symptomatic persons have prolonged or relapsing disease for up to 6 months.[37] It is not unusual, however, for blood tests to remain abnormal for six months or more.[38] The jaundice so commonly associated with HAV can also linger for a prolonged period in some infected persons, sometimes as long as eight months or more.[39] Additionally, pruritus, or severe “itchiness” of the skin, can persist for several months after the onset of symptoms. These conditions are frequently accompanied by diarrhea, anorexia, and fatigue.[40]

Relapse is possible with hepatitis A, typically within three months of the initial onset of symptoms.[41] Although relapse is more common in children, it does occur with some regularity in adults.[42] The vast majority of persons who are infected with hepatitis A fully recover, and do not develop chronic hepatitis.[43] Persons do not carry HAV long-term as with hepatitis B and C.[44]

Fulminant Hepatitis A

Fulminant hepatitis A, or acute liver failure, is a rare but devastating complication of HAV infection.[45] As many as 50% of individuals with acute liver failure may die or require emergency liver transplantation.[46] Elderly patients and patients with chronic liver disease are at higher risk for fulminant hepatitis A.[47] In parallel with a declining incidence of acute HAV infection in the general population, however, the incidence of fulminant HAV appears to be decreasing.[48]

HAV infects the liver’s parenchymal cells (internal liver cells).[49] Once a cell has been penetrated by the viral particles, the hepatitis A releases its own toxins that cause, in essence, a hostile takeover of the host’s cellular system.[50] The cell then produces new viral components that are released into the bile capillaries or tubes that run between the liver’s parenchymal cells.[51] This process results in the death of liver cells, called hepatic necrosis.[52]

The fulminant form of hepatitis occurs when this necrotic process kills so many liver cells—upwards of three-quarters of the liver’s total cell count—that the liver can no longer perform its job.[53] Aside from the loss of liver function, fulminant hepatic failure can lead to encephalopathy and cerebral edema.[54] Encephalopathy is a brain disorder that causes central nervous system depression and abnormal neuromuscular function.[55] Cerebral edema is a swelling of the brain that can result in dangerous intracranial pressure.[56] Intracranial hypertensions leading to a brain stem death and sepsis with multiple organ failure are the leading causes of death in individuals with fulminant hepatic failure.[57]

Incidence of Hepatitis A Infection

Hepatitis A is much more common in countries with underdeveloped sanitation systems and, thus, is a risk in most of the world.[58] An increased transmission rate is seen in all countries other than the United States, Canada, Japan, Australia, New Zealand, and the countries of Western Europe.[59] Nevertheless, infections continue to occur in the United States, where approximately one-third of the population has been previously infected with HAV.[60]

Each year, approximately 30,000 to 50,000 cases of hepatitis A occur in the United States.[61] Historically, acute hepatitis A rates have varied cyclically, with nationwide increases every 10 to 15 years.[62] The national rate of HAV infections has declined steadily since the last peak in 1995.[63] Although the national incidence—1.0 case per 100,000 population—of hepatitis A was the lowest ever recorded in 2007, it is estimated that asymptomatic infections and underreporting kept the documented incidence-rate lower than it actually is. In fact, it is estimated that there were 25,000 new infections in 2007.[64]

In 2007, the CDC reported a total of 2,979 acute symptomatic cases of HAV.[65] Of these, information about food and water exposure was known for 1,047 cases, leading to an estimate that 6.5% of all infections were caused by exposure to contaminated water or food.[66] In 2,500 of the cases, no known risk factor was identified.[67]

Estimates of the annual costs (direct and indirect) of hepatitis A in the United States have ranged from $300 million to $488.8 million in 1997 dollars.[68] Nationwide, adults who become ill miss an average of 27 workdays per illness, and 11 to 22 percent of those infected are hospitalized.[69] All of these costs are entirely preventable given the effectiveness of a vaccination in providing immunity from infection.[70]

[1]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” in Mandell, Douglas, & Bennett’s PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES, Fifth Edition, Chap. 161, pp. 1920-40 (2000); Mayo Clinic Staff, “Hepatitis A,” (last updated Sept 1, 2011). Articles available online at http://www.mayoclinic.com/health/hepatitis-a/DS00397.

[2]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[3]           Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[4]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[5]           CDC, “Hepatitis A,” in EPIDEMIOLOGY AND PREVENTION OF VACCINE-PREVENTABLE DISEASES (also known as “The Pink Book”), Atkinson W, Wolfe S, Hambrosky J, McIntyre L, editors, 12th edition. Chapter available online at http://www.cdc.gov/vaccines/pubs/pinkbook/hepa.html.

[6]           Id.

[7]           Id.; See also Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” Clinical Infectious Diseases, Vol. 38, 705-715 (March 1, 2004). Full text online at http://www.cdc.gov/hepatitis/PDFs/fiore_ha_transmitted_by_food.pdf.

[8]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[9]           Id.

[10]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[11]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[12]          Id.; See also Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” Emerging Infectious Diseases, Vol. 3, No. 4, pp. 529-39 (October-December 1997). Full text of the article is available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640072/pdf/9366607.pdf

[13]          Fiore, Anthony, supra note 7; CDC, “Hepatitis A,” supra note 5; See also CDC, “Surveillance for Acute Viral Hepatitis – United States, 2007, Morbidity and Mortality Weekly Report, Surveillance Summaries, Vol. 58, No. SS03 (May 22, 2009) at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5803a1.htm.

[14]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[15]          Id.; See also, Wheeler, C, et al., “An Outbreak of Hepatitis A Associated with Green Onions,” New England Journal of Medicine, Vol. 353, 890-97 (2005). Full text of article available at http://www.nejm.org/doi/full/10.1056/NEJMoa050855.

[16]          Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” New England Journal of Medicine, Vol. 340, pp. 595-602 (1999). Full text of article is online at http://nejm.org/doi/full/10.1056/NEJM199902253400802.

[17]          Wheeler, C, et al., “An Outbreak of Hepatitis A Associated with Green Onions,” supra note 15.

[18]          Butot S, et al., “Effects of Sanitation, Freezing and Frozen Storage on Enteric Viruses in Berries and Herbs,” Intentional Journal of Food Microbiology, Vol. 126, No. 4, pp. 233-246 (2003). Full text of article is available at http://www.prograd.uff.br/virologia/sites/default/files/bulot_et_al_2008_inactivation.pdf.; Calder, L, et al., An Outbreak of Hepatitis A Associated with Consumption of Raw Blueberries,” Epidemiology and Infection, Vol. 131, No. 1 745-51 (2003) at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/pdf/12948375.pdf.

[19]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[20]          CDC, “Updated recommendations from Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees,” Morbidity and Mortality Weekly Report, Vol. 58, No. 36,  (Sept. 18, 2006), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5836a4.htm; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations, Morbidity & Mortality Weekly Review, Vol. 55, Report 407, (May 29, 2006) at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm; Todd, Ewan C.D., et al., “Outbreaks Where Food Workers Have Been Implicated in the Spread of Foodborne Disease. Part 6. Transmission and Survival of Pathogens in the Food Processing and Preparation-environment,” Journal of Food Protection, Vol. 72, 202-19 (2009). Full text of the article is available online at http://courses.washington.edu/eh451/articles/Todd_2009_food%20processing.pdf.

[21]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[22]          Id.; See also, Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[23]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Piazza, M, et al., “Safety and Immunogenicity of Hepatitis A Vaccine in Infants: A Candidate for Inclusion in Childhood Vaccination Program,” Vol. 17, pp. 585-588 (1999). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10075165; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” Vaccine, Vol. 10, Suppl. 1, pp. 18-20 (1992). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/1475999.

[24]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7

[25]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[26]          CDC, “Hepatitis A,” supra note 5; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1

[27]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1

[28]          Id.

[29]          Id.; See also Sagliocca, Luciano, et al., “Efficacy of Hepatitis A Vaccine in Prevention of Secondary Hepatitis A Infection: A Randomized Trial,” Lancet, Vol. 353, 1136-39 (1999). Abstract at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)08139-2/abstract.

[30]          CDC, “Hepatitis A,” supra note 5.

[31]          Id.; See also Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[32]          CDC, “Hepatitis A,” supra note 5; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[33]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[34]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[35]          CDC, “Hepatitis A,” supra note 5; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[36]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[37]          Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations,” supra note 20; Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,” Medicine, Vol. 71, No. 1, 14-23 (Jan. 1992). Abstract of article online at http://www.ncbi.nlm.nih.gov/pubmed/1312659.

[38]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[39]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[40]          CDC, “Hepatitis A,” supra note 5; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[41]          Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,” supra note 37.

[42]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,” supra note 37.

[43]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[44]          CDC Summary, “Disease Burden from Viral Hepatitis A, B and C in the United States, 2004-2009, at http://www.cdc.gov/hepatitis/pdfs/disease_burden.pdf; CDC, “Hepatitis A,” supra note 5.

[45]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” World Journal of Gastroenterology, Vol. 12, No. 46 pp. 7405-7412 (Dec. 14, 2006). Full article is available online at http://www.wjgnet.com/1007-9327/12/7405.pdf.

[46]          Taylor, Ryan, et al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” Hepatology, Vol. 44, 1589-1597. Full text http://deepblue.lib.umich.edu/bitstream/2027.42/55879/1/21349_ftp.pdf.

[47]          Id.; See also Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[48]          Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[49]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[50]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” supra note 23.

[51]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45.

[52]          Id.; See also Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[53]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[54]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45.

[55]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[56]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45.

[57]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[58]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” supra note 12.

[59]          CDC, “Update: Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers, Updated ACIP Recommendations,” Morbidity and Mortality Weekly Report, Vol. 56, No. 41, pp. 1080-84 (Oct. 19, 2007), online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm.

[60]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[61]          CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44; CDC, “Hepatitis A,” supra note 5.

[62]          Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” supra note 16.

[63]          CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44; CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13.

[64]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” supra note 23.

[65]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13.

[66]          Id.

[67]          Id.

[68]          CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44.

[69]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; CDC, “Hepatitis A,” supra note 5.

[70]          CDC, “Hepatitis A,” supra note 5; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations,” supra note 20.

According to the San Diego County Health and Human Services Agency, 228 cases of hepatitis A have been reported in 2017, with 161 people hospitalized during the outbreak.  There have been 5 deaths. Public health investigators continue to evaluate cases, but most of those who have become ill are either homeless and/or illicit drug users. Hepatitis A is most commonly spread person-to-person through the fecal-oral route. The disease can be prevented by getting vaccinated. So far, officials said no common food, drink or drug source has been identified as the cause.

In addition, the number of hepatitis A cases over last year in Macomb, Oakland, Wayne and St. Clair counties has increased tenfold, spawning a Michigan Department of Health and Human Services investigation. 190 cases have been reported between August 1, 2016 and June 26, 2017, which has resulted in 10 deaths so far. Officials said it represents a significant health threat, with links to either illicit drug use, sexual activity or close contact among household members.

Symptoms of hepatitis A include jaundice, fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine and light-colored stools. Symptoms usually appear over several days and last less than two months. However, some people can be ill for as long as six months. Hepatitis A can also sometimes cause liver failure and death.

News 12 reports that a Westchester couple says their dream wedding turned into a nightmare as a result of the hepatitis A scare at the Cortlandt Manor venue where they were recently married.

Jay and Jennifer Gorinson had their wedding and reception on June 10 at the Monteverde at Oldstone Restaurant.

The newlyweds have since had to visit the Westchester County Health Department in White Plains for hepatitis A vaccinations. The Gorinsons say they were called about the newly issued Health Department warning while on their honeymoon.

A bartender with hepatitis A worked at the venue while she was infectious, putting the Gorinsons and their 175 wedding guests at risk of contracting the virus.

The virus is transmitted through contaminated food and water, and can be treated with a vaccine. Its symptoms include fever, abdominal pain, dark urine and yellowing of the skin and eyes. It can take from two weeks to two months to develop.

In a previous response, a Monteverde spokesman says the bartender didn’t work the Gorinson wedding, but that some bridal guests did buy drinks from her. Jay Gorinson says the memories of their wedding day are ruined and that the restaurant’s owner and manager have been dodging his calls and emails for nearly a week.

He says he finally received an answer from Monteverde on Tuesday, saying only that they were “unaware” that the bartender was ill.

“It’s embarrassing and sad that the venue has taken no responsibility for this, and we hope it’s something that no one else has to encounter on their wedding day,” says Jay Gorinson.

The Gorinsons say they will have to return to the Westchester County Health Department in six months for further treatment.  In the meantime, they say they’re considering legal action.