Exposure to the 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. Since 2006, hepatitis A vaccination has been recommended for all U.S. children, and in 2019 the CDC’s Advisory Committee on Immunization Practices recommended vaccination of people experiencing homelessness in response to the outbreaks (CDC/ACIP).[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 can lead to acute liver failure and death.[10]

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. Since 2016, person-to-person spread has in fact become the predominant mode of hepatitis A transmission in the United States: large community outbreaks affecting 37 states and roughly 44,900 reported cases have occurred primarily among people who use drugs and people experiencing homelessness, with more than half of patients hospitalized and over 400 associated deaths (CDC, 2016–2023).[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 an HAV outbreak traced to the 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. More recently, imported frozen and fresh produce has repeatedly been implicated, including a 2016 outbreak linked to frozen strawberries and multistate outbreaks in 2022 and 2023 linked to organic strawberries (CDC).[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 by 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 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 the onset of symptoms.[28] Most infected persons no longer excrete the virus in their 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, 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 will be 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] 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, loss of appetite, 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, 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 hypertension leading to 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] Reported cases fell steadily after the last peak in 1995 and reached historic lows around 2015 (roughly 1,390 reported cases nationwide).[63]Beginning in late 2016, the person-to-person outbreaks reversed that decline, driving reported cases sharply higher through 2019 before they fell again; by 2023 the CDC reported 1,648 acute cases and 85 hepatitis A–related deaths. Because many infections are asymptomatic or otherwise go unreported, the true number of infections is considerably higher than the reported count.[64]

    For historical comparison, 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]

    Prevention of Hepatitis A

    Because there is no specific antiviral treatment for hepatitis A, the most effective way to reduce the burden of the disease is to prevent infection in the first place.[68] Hepatitis A is one of the few foodborne illnesses that is vaccine-preventable, and prevention today rests on two complementary strategies: immunization—both active (vaccination) and passive (immune globulin)—and basic measures of hygiene, sanitation, and food safety.[69]

    The hepatitis A vaccine is the single most effective tool for preventing infection.[70] Two inactivated single-antigen vaccines—Havrix and Vaqta—are licensed in the United States, along with Twinrix, a combination vaccine that protects against both hepatitis A and hepatitis B.[71] The single-antigen vaccines are given as a two-dose series six months apart, while Twinrix is ordinarily administered as a three-dose series over six months.[72] The vaccine is both safe and highly effective: nearly all healthy recipients develop protective levels of antibody, and immunity appears to last at least twenty years and probably much longer.[73] Since routine childhood vaccination began in the mid-1990s, the reported incidence of hepatitis A in the United States has fallen by more than ninety percent.[74]

    The CDC’s Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all children beginning at twelve to twenty-three months of age, catch-up vaccination for children and adolescents aged two through eighteen years who were not vaccinated earlier, and vaccination of adults at increased risk of infection or of severe disease.[75] Groups at increased risk include international travelers to countries where the disease is common, men who have sex with men, people who use injection or non-injection drugs, people experiencing homelessness, persons with chronic liver disease or HIV, and close contacts of international adoptees.[76] These recommendations were expanded incrementally over time—from certain at-risk groups in 1996, to all children nationwide in 2006, to people experiencing homelessness in 2019, and to all previously unvaccinated children and adolescents and persons with HIV in 2020.[77]

    For individuals who have been exposed to the virus but never vaccinated, prompt post-exposure prophylaxis can prevent illness if it is administered within two weeks of exposure.[78] Under current ACIP guidance, a single dose of single-antigen hepatitis A vaccine is preferred for healthy persons twelve months of age and older, while immune globulin may be given in addition to, or instead of, the vaccine for infants under twelve months, adults older than forty, and persons who are immunocompromised or have chronic liver disease, depending on the clinician’s assessment.[79]Immune globulin—a preparation of antibodies that confers immediate but short-lived passive protection—may also be used before anticipated exposure for those who cannot or elect not to receive the vaccine.[80]

    Because hepatitis A spreads primarily by the fecal-oral route, simple hygiene remains a cornerstone of prevention.[81] Thorough handwashing with soap and warm running water—particularly after using the toilet, changing a diaper, or before preparing or eating food—substantially reduces transmission.[82] In the food industry, scrupulous personal hygiene by food handlers and the exclusion of ill workers are essential, and the virus itself can be inactivated by heating food to 185°F (85°C) for at least one minute or by disinfecting surfaces with a 1:100 dilution of household bleach in tap water.[83] Notably, the CDC does not recommend routine vaccination of food handlers purely as an occupational matter, because documented transmission from an infected food handler to restaurant patrons is uncommon; nonetheless, a single infected handler can expose large numbers of people, which is why hygiene, illness-reporting policies, and—in many establishments—voluntary vaccination remain important safeguards.[84]

    Finally, travelers headed to regions where hepatitis A is endemic should be vaccinated well in advance of departure; for healthy persons between twelve months and forty years of age, a single dose given at least two weeks before travel provides reliable protection, with the series completed on the normal schedule.[85] Combined with careful attention to safe food and water while abroad, vaccination has made hepatitis A an almost entirely preventable disease.[86]

    [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]         Centers for Disease Control and Prevention, “Clinical Overview of Hepatitis A,” available at https://www.cdc.gov/hepatitis-a/hcp/clinical-care/index.html (last visited July 2026).

    [69]         Nelson NP, Weng MK, Hofmeister MG, et al., “Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020,” Morbidity and Mortality Weekly Report, Recommendations and Reports, Vol. 69, No. RR-5, pp. 1–38 (July 3, 2020), available at https://www.cdc.gov/mmwr/volumes/69/rr/rr6905a1.htm.

    [70]         Centers for Disease Control and Prevention, “Hepatitis A Vaccine Administration,” available at https://www.cdc.gov/hepatitis-a/hcp/vaccine-administration/index.html.

    [71]         CDC, “Hepatitis A,” in EPIDEMIOLOGY AND PREVENTION OF VACCINE-PREVENTABLE DISEASES (“The Pink Book”), supra note 5.

    [72]         Id.

    [73]         CDC, “Clinical Overview of Hepatitis A,” supra note 68; CDC, “Hepatitis A,” Pink Book, supra note 5.

    [74]         Nelson NP, et al., supra note 69.

    [75]         Nelson NP, et al., supra note 69.

    [76]         Id.

    [77]         CDC, “Hepatitis A,” Pink Book, supra note 5; Nelson NP, et al., supra note 69.

    [78]         CDC, “Clinical Overview of Hepatitis A,” supra note 68.

    [79]         Nelson NP, et al., supra note 69; CDC, “Clinical Overview of Hepatitis A,” supra note 68.

    [80]         CDC, “Clinical Overview of Hepatitis A,” supra note 68.

    [81]         CDC, “Hepatitis A,” Pink Book, supra note 5.

    [82]         CDC, “Clinical Overview of Hepatitis A,” supra note 68.

    [83]         Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7; Fiore, Anthony, et al., ACIP, “Prevention of Hepatitis A Through Active or Passive Immunization,” supra note 20.

    [84]         CDC, “Hepatitis A,” Pink Book, supra note 5.

    [85]         CDC, “Clinical Overview of Hepatitis A,” supra note 68; Nelson NP, et al., supra note 69.

    [86]         Nelson NP, et al., supra note 69.

    Vancouver Coastal Health is notifying people who consumed food from a second location on the Sunshine Coast — Pepper Creek Pizza & Pasta (4330 Sunshine Coast Hwy., Sechelt) — about a possible exposure to hepatitis A between July 31-Aug. 14; and Aug. 23-29, if they consumed salads from this location. People who consumed cooked foods like pizza, sandwiches and pasta are not at risk of exposure.

    Getting immunized with one dose of  hepatitis A vaccine  vaccine can help to prevent infection if given within two weeks of exposure.  Therefore, VCH recommends anyone who ate salads between Aug. 23 to 29 inclusive receive a hepatitis A vaccine as soon as possible.   

    This notification is in addition to one issued yesterday for Sea Monkey Coffee — located onsite at Sunday Cider in Gibsons (1632 Sunshine Coast Hwy.) — for people who ate food between Aug. 1- 25. For that location, vaccine is also recommended for people still within two weeks of exposure, between Aug. 15 to 25. 

     Although the risk of transmission to the public is low, VCH Public Health advises anyone who consumed food from either of these locations during the noted dates to monitor themselves for symptoms of hepatitis A, which can take two to seven weeks to develop after exposure and last for about two months. 

     Symptoms of hepatitis A include: 

    • Feeling very tired
    • Feeling sick to your stomach and not feeling hungry
    • Losing weight without trying
    • Pain on the right side of the belly, under the rib cage (where your liver is)
    • Fever
    • Sore muscles
    • Yellow skin and eyes (jaundice), dark urine, and clay-coloured stools 

    If you have early symptoms of hepatitis A it is very important to see your health care provider. In most cases, the infection goes away on its own and does not lead to long-term liver problems. In rare cases, it can be more serious. 

    A free dose of hepatitis A vaccine is available for those who are eligible at clinics and pharmacies throughout the VCH region. A current list of locations — as well as information about causes, tests, treatments and prevention —can be found at https://www.vch.ca/en/health-topics/hepatitis-a

    Those who are outside the VCH region should check with a local pharmacy about vaccine availability or contact their local Public Health unit. 

    Those who have previously been infected with hepatitis A or those who received two doses of hepatitis A vaccine prior to the exposure event are considered protected. 

    Individuals who are concerned they may have been exposed and have questions can call 811 or speak to their primary care provider.  

    The Massachusetts Department of Public Health (DPH), Barnstable County Department of Health and Environment, and the Provincetown Board of Health are alerting anyone who dined at The Red Inn at 15 Commercial Street in Provincetown between April 30 and May 15 that they may have been exposed to hepatitis A and should contact their healthcare provider.

    A food service employee of the restaurant who worked during those dates has a confirmed infection with hepatitis A virus. Customers who could have been exposed to the virus are being advised to contact their health care provider and receive appropriate medical treatment for a possible exposure to hepatitis A. Preventive measures such as hepatitis A vaccine and hepatitis A immune globulin are generally only effective at preventing hepatitis A infection if given within two weeks of exposure, prior to symptom onset.

    The early signs and symptoms of hepatitis A are fever, fatigue, loss of appetite, nausea, vomiting, diarrhea, and jaundice (dark urine, yellowing of the skin or the whites of the eyes). The illness varies in severity, with mild cases lasting two weeks or less and more severe cases lasting four to six weeks or longer. Some individuals, especially children, may not develop jaundice and may have an illness so mild that it can go unnoticed. However, even mildly ill persons can still be highly infectious. People with illness suggestive of hepatitis should consult a health care provider even if symptoms are mild.

    Hepatitis A virus is spread as a result of fecal contamination (fecal-oral route) and may be spread from person-to-person through close contact or through food handling. The virus can be spread by contaminated food and beverages.

    Customers who dined at The Red Inn between April 30 and May 15 are urged to be particularly thorough in handwashing after toileting and prior to food preparation to avoid any potential further spread of disease. Handwashing should include vigorous soaping of the hands, including the back of the hands, wrists, between fingers and under fingernails. Hands should be thoroughly rinsed.

    Hepatitis A vaccine has been recommended as part of childhood immunizations since 1991, so people 34 years and younger may have been previously vaccinated. Those who dined at the restaurant between April 30 and May 15 are urged to confirm their vaccination status with their provider.

    Boulder County Public Health (BCPH) has identified a potential exposure to Hepatitis A associated with beverages containing fresh juice at the Rio Grande Mexican Restaurant (1101 Walnut St) in Boulder on Dec. 30, 2024, and Jan. 5, 2025. 

    BCPH has established that there is no ongoing risk to the public due to quick collaboration with the restaurant to ensure the safety of staff and patrons. No other locations were affected.

    Anyone who drank one or more of the following beverages at the restaurant on Sunday, Jan. 5, 2025, and is not up to date on their Hepatitis A vaccination should obtain a vaccine before Jan. 19, 2025.

    Anyone who consumed at least one of the following beverages on Dec. 30, 2024, should monitor for symptoms for the next four weeks, as too much time has passed for a vaccine to prevent disease from possible exposure.

    • Plain fresh squeezed OJ
    • Mimosa with fresh squeezed OJ
    • Michelada with fresh lime juice
    • Mimosarita with fresh squeezed OJ
    • Big Tex margarita with fresh lemon and lime juice
    • Barrel-Aged Big Tex margarita with fresh lemon and lime juice
    • Special reserve coin margarita with fresh lime juice
    • Silver coin margarita with fresh lime juice
    • Fresh jalapeño margarita with fresh lime juice
    • Skinny margarita with fresh lime juice
    • Kendall’s skinny margarita with fresh lime juice
    • Agave martini with fresh lemon and lime juice
    • Mezcal margarita with lemon and lime juice

    It is important to note that only beverages containing fresh juice, consumed on Dec. 30, 2024, or Jan. 5, 2025, pose a risk of exposure to Hepatitis A. Beverages consumed at the restaurant on other days, or that did not contain freshly squeezed juice, are not considered a potential risk.

    Hepatitis A is a highly contagious virus that infects the liver and mainly spreads when germs from feces (poop) contaminate something that enters the mouth. This may occur through:

    • Contaminated food or drinks (i.e., tiny, unseen amounts of feces from an infected person).
    • Close contact with someone who is infected (e.g., a member of the household or caregiver).
    • Sexual contact with an infected person.

    Symptoms usually appear two to six weeks after exposure and may last from a few weeks to several months. Symptoms include: 

    • Yellow skin or eyes (jaundice)
    • Dark urine or clay-colored stools
    • Diarrhea
    • Feeling tired
    • Fever
    • Joint pain
    • Loss of appetite
    • Nausea, stomach pain and/or vomiting

    Older adults and people with existing health conditions are more likely to have severe illnesses or complications. Anyone experiencing symptoms and thinks they have been exposed, should contact their health care provider right away. 

    Prompt vaccination within two weeks of a potential exposure can be effective in preventing disease. While there are no specific treatments for Hepatitis A, vaccination is a safe and effective way to prevent the virus. Adults who haven’t been fully vaccinated with two doses, or who haven’t had Hepatitis A, can receive the vaccine, including pregnant women. The Hepatitis A vaccine is not recommended for children under one-year-old.

    If you are unable to receive the Hepatitis A vaccine, you may be able to receive an injection of immune globulin (IG) within 14 days after exposure.

    BCPH will be providing vaccinations at no cost for anyone who is not up to date on Hepatitis A vaccine and who consumed potentially contaminated beverages. No appointments are necessary. Clinics will be held in the Sundquist building (3482 Broadway, Boulder) on:

    • Wednesday Jan. 15 from 9 a.m.-7 p.m.
    • Thursday Jan. 16 from 3-7 p.m.
    • Friday Jan. 17 from 3-7 p.m.

    Other local public health agencies in Colorado may be able to provide Hepatitis A vaccine in association with this event. Individuals with private insurance are encouraged contact their health care provider to receive vaccination if needed.

    University of Colorado students can access medical services at Wardenburg Health Center.

    Colorado residents may be able to check their vaccination status directly at copublicportal.state.co.us.

    For more information, contact the Colorado Health Emergency Line for the Public at 1-877-462-2911 or 303-398-1687.

    The Los Angeles County Department of Public Health is investigating a report of hepatitis A virus infection in an employee of Buffalo Wild Wings in Monterey Park (4000 Market Place, Monterey Park, CA 91754).

    No additional cases have been identified at this time. The investigation is ongoing.

    Based on the employee’s job duties and symptoms while at work, Public Health is recommending that patrons who consumed food or beverages from Buffalo Wild Wings in Monterey Park between November 13, 2024, and November 22, 2024, receive hepatitis A vaccine if they are not already immune to it and to monitor for the symptoms listed below. Patrons who develop symptoms should call their provider and ask for a hepatitis A test.

    People who have not received the hepatitis A vaccine or had a previous hepatitis A infection may not be protected from the virus. Vaccination is not necessary for people who previously completed the hepatitis A vaccine series or are known to have a previous infection.

    Receiving the vaccination as soon as possible after exposure (ideally within 14 days) could help reduce the risk of developing hepatitis A infection. Residents should contact their local pharmacy or medical provider for the vaccine. Public Health is working with the restaurant to ensure employees that are not immune receive vaccination.

    About Hepatitis A

    Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. It can range from a mild illness lasting a few weeks to a severe illness lasting several months. Symptoms of hepatitis A include fever, weakness, fatigue, nausea, loss of appetite, jaundice (yellowing of the skin or eyes), stomach pain, vomiting, dark urine, pale stools, and diarrhea. 

    Although rare, hepatitis A can cause death in some people. Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person.

    There is no specific antiviral treatment for hepatitis A. While prompt vaccination is likely to prevent infection, infection may occur in those who receive vaccination too late. Patrons who develop symptoms should call their provider and ask for a Hepatitis A test.

    Vaccination is the best way to prevent disease. Infection can be prevented by vaccination after a known exposure to a person with infectious hepatitis A. Older adults and people with weakened immune systems might benefit from receiving immune globulin (IG) in addition to hepatitis A vaccination for prevention after an exposure. For any questions about hepatitis A or the need for immune globulin, Public Health recommends that you speak to your primary care provider.

    Public Health will continue monitoring all known individuals who may have been exposed to individuals ill with hepatitis A.

    For questions or to find a nearby clinic or doctor, call the Public Health InfoLine at 1-833-540-0473, open every day from 8 a.m. to 8 p.m.

    The Hawai‘i Department of Health (DOH) has confirmed a case of hepatitis A infection in a food service employee at Hana Koa Brewing Company, located at 962 Kawaiaha‘o St., in Honolulu.

    Anyone who has consumed any food or drink products from this establishment from Aug. 3-16, 2024, may have been exposed to the disease. Individuals who have not been vaccinated against hepatitis A should contact their health care provider if they develop symptoms and should mention their potential exposure to the disease. Early diagnosis guides appropriate care and can help stop further spread of the disease. Post-exposure prophylaxis can be offered to close contacts of infected individuals and is most effective when administered within two weeks of exposure to hepatitis A.

    It is important to note that Hana Koa Brewing Company had no food safety violation that resulted in this case, but was merely a place where the infected employee was working. The likelihood that patrons of this food establishment will become infected is very low, but to prevent possible additional cases, the DOH Disease Outbreak Control Division is notifying the public so they may seek advice and help from their health care providers. The establishment has cooperated with the DOH to exclude ill and exposed food handlers and does not pose any ongoing risk for disease transmission associated with this case.

    Symptoms of hepatitis A infection include fever, fatigue, loss of appetite, abdominal discomfort, dark urine, diarrhea and yellow skin and eyes. Individuals, including food service employees, exhibiting symptoms of hepatitis A should stay home and contact their health care provider. There are no specific treatments for hepatitis A, other than to rest and take care of yourself. Your body will clear the virus on its own.

    Hepatitis A is usually spread through close person-to-person contact or by consuming contaminated food or drink. Since 2006, the hepatitis A vaccine has been routinely recommended for all children ages 12-23 months old, and all youth ages 2-18 years old who have not been previously vaccinated. The hepatitis A vaccine is also recommended for other groups at higher risk. Vaccination is highly effective at preventing infection and provides long-lasting protection (boosters are not routinely recommended).

    While vaccination provides the best protection, individuals can also prevent the spread of hepatitis A through safe cooking practices, as well as frequent handwashing with soap and warm water after using the restroom, after changing a diaper and before preparing food.

    Additional information about hepatitis A can be found on the DOH website at: https://health.hawaii.gov/docd/disease_listing/hepatitis-a/

    For a list of vaccinating pharmacies, visit: https://health.hawaii.gov/docd/vaccines-immunizations/vaccine-locators/

    Screenshot 2024-05-17 at 7.12.55 PM

    The Los Angeles County Department of Public Health is investigating a report of hepatitis A virus infection in an employee of Whole Foods Market in Beverly Hills (239 N. Crescent Drive, Beverly Hills, CA 90210).

    No additional cases have been identified at this time. The investigation is ongoing.

    Based on the employee’s job duties and symptoms while at work, Public Health is recommending that anyone who purchased products from the seafood counter section of the store between April 20th and May 13th receive hepatitis A vaccine if they are not already immune. People who have not received the hepatitis A vaccine or had a previous hepatitis A infection may not be protected from the virus.

    Receiving vaccination as soon as possible after exposure could help reduce the risk of developing hepatitis A infection. Residents should contact their local pharmacy or medical provider for the vaccine. Public Health is working with the company to ensure employees that are not immune are referred for vaccination.

    Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. It can range from a mild illness lasting a few weeks to a severe illness lasting several months. Although rare, hepatitis A can cause death in some people. Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person.

    There is no specific antiviral treatment for hepatitis A. While prompt vaccination is likely to prevent infection, infection may occur in those who receive vaccination too late. Patrons who develop symptoms should call their provider and ask for a hepatitis A test.

    Vaccination is the best way to prevent disease. Infection can be prevented by vaccination after a known exposure to a person with infectious hepatitis A. Older adults and people with weakened immune systems might benefit from receiving immune globulin (IG) in addition to hepatitis A vaccination for prevention after an exposure. For any questions about hepatitis A or the need for immune globulin, Public Health recommends that you speak to your primary care provider. If you do not have a regular provider, call 2-1-1 for assistance.

    Public Health will continue monitoring all known individuals who may have been exposed to individuals ill with hepatitis A.

    People who ate at the Main Deck restaurant (301 Lake Street, Penn Yan, NY) between March 27 and April 12 were potentially exposed to the hepatitis A virus. Most people do not get sick when an employee at a restaurant has hepatitis A, but there is still a risk. People who may have been exposed should receive treatment to prevent infection.

    “While the risk of hepatitis A infection is low, we must act carefully to prevent the spread of this very contagious disease,” said Doug Sinclair, Yates County Public Health Director. “Anyone who may have eaten at this restaurant during this timeframe should check their immunization status and if not already vaccinated against hepatitis A, come to our free clinic or visit their healthcare provider if they are experiencing symptoms.”

    The hepatitis A vaccine is only effective within two weeks of exposure to the virus. Yates County Public Health is advising anyone who ate food from the Main Deck restaurant between April 4 and April 12 to receive a free hepatitis A vaccine on April 18, 2024, from 1:00 PM to 7:00 PM at the Yates County Office Building located at 417 Liberty Street in Penn Yan. To register for an appointment, visit www.yatescountypublichealth.org. If you need assistance with scheduling an appointment or are unable to attend our clinic, call our office at (315) 536-5160.   

    Those who ate at Main Deck between March 27 and April 3 may have been exposed, but receiving the hepatitis A vaccine now will not prevent infection from this exposure. These persons are encouraged to monitor themselves and their families for symptoms for 50 days after consuming the food. Symptoms may include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark-colored urine, clay-colored stools, joint pain, or jaundice. If you have any symptoms, contact your healthcare provider and be sure to tell them that you may have been exposed to hepatitis A.

    The owner and staff at Main Deck have been very cooperative and have complied with all recommendations from the state and local health departments. New York State Health Department staff conducted a thorough inspection of the restaurant and has cleared it to open.  

    If you have questions, call Yates County Public Health at (315) 536-5160. For more information on hepatitis A, visit the New York State Department of Health website at https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_a/, or the Centers for Disease Control and Prevention at https://www.cdc.gov/hepatitis/hav/afaq.htm. 

    Erie County Health Department has identified a case of Hepatitis A in a restaurant worker, it announced Friday. The employee works at Cracker Barrel, which is located at 7810 Interstate Dr. in Summit Township. The health department said the risk of infection is low, but customers who ate or drank at the restaurant or ordered or delivered take-out Jan. 30 through Feb. 21 are asked to watch for symptoms of hepatitis A. Symptoms can take two to seven weeks after exposure before they start to appear. They include fatigue (tiredness), loss of appetite, nausea, stomach pain, diarrhea, dark urine, joint pain or jaundice (yellowing of the skin or eyes). The symptoms can last from a few weeks to several months. If they appear, health officials urge you to seek medical attention. The health department advises dine-in and take-out customers from Feb. 10 to 21 to get the vaccine for hepatitis A as soon as possible because they may have potentially been exposed. The restaurant is following cleaning and employee health guidelines provided by corporate and the health department, according to officials. The contagious liver disease spreads through person-to-person contact or by eating contaminated food or drinks. Anyone with questions can call the Erie County Health Department at 814-451-6707 or, if outside the county, Pennsylvania Department of Health at 1-877-724-3258. Restaurant staff is asked to contact management for guidance.

    Hepatitis-b-d-c-Jaundice-ppt

    According to the Gloucester County Health Department a food handler at an Olive Garden restaurant in Gloucester County tested positive for Hepatitis A.

    The employee at the Olive Garden at 1500 Almonesson Road in Deptford worked while infected between Dec. 26 and 30, according to the announcement.

    Hepatitis A is a viral illness with symptoms including abdominal pain, nausea, vomiting, tiredness, poor appetite, jaundice and dark urine, county officials advised. Symptoms usually appear within two to seven weeks after exposure.

    Anyone who previously received a Hepatitis A vaccine is not at risk, the county said. Those who are unvaccinated face a low risk, but the risk may be lowered further by getting vaccinated within two weeks of exposure, officials said.

    Those who are unvaccinated and believe they may have been exposed are encouraged to contact their health care provider.

    The county is working with the restaurant to vaccinate potentially exposed co-workers, officials said.

    “Gloucester County Department of Health is working closely with the New Jersey Department of Health and the restaurant facility to protect the public and prevent further spread of disease,” officials stated.