Five States Experiencing Outbreak of Hepatitis A Due to Frozen Strawberries in Smoothies

The frozen strawberries were imported from Egypt, where previous outbreaks have occurred

Five States Experiencing Outbreak of Hepatitis A Due to Frozen Strawberries in Smoothies
Image: Pixabay
August 31, 2016

An outbreak of Hepatitis A that originated in Virginia has now spread to five states, including North Carolina.

More than 50 people have been confirmed to have the infection, which has been linked to frozen strawberries imported from Egypt that were served to customers at Tropical Smoothie Café locations in Virginia. Egypt is investigating the link.

According to the Virginia Department of Health and the Centers for Disease Control and Prevention (CDC), 44 of the victims live in Virginia. Four live in Maryland, and one each live in North Carolina, Oregon, and Wisconsin.

"CDC, FDA and several states are currently investigating an outbreak of foodborne Hepatitis A linked to frozen strawberries in smoothies served in restaurants," a CDC spokeswoman told Food Safety News (FSN).

"While Tropical Smoothie Café has removed the frozen strawberries from their restaurants and switched to another supplier, we may still see more illnesses due to the long incubation period for Hepatitis A before people start experiencing symptoms. At this time, we do not have information to suggest that there is an ongoing risk of hepatitis A virus infection at Tropical Smoothie Cafés."

Unfortunately, that long incubation period—which ranges from 15 to 50 days—is part of why it is so difficult to investigate outbreaks of Hepatitis A. Health officials in Virginia report dates ranging from May through the end of August for when the current illness broke out; however, it was not until early August that they were able to link the cases in their investigation.

At that time—on August 5 according to company CEO Mike Rotondo—they notified the Tropical Smoothie Café chain, but it was another two weeks before they alerted the public.

Rotondo says that the restaurants removed all frozen strawberries from every location right away, and the company now receives its strawberries from California and Mexico.

While this may have reduced the number of victims, it is possible that even more infections could have been prevented if the Virginia officials had not waited 14 days before notifying the public about the outbreak.

The delay is important because there is a very narrow window of opportunity in which victims can be effectively vaccinated after being exposed to the bacteria. That window is, in fact, 14 days; after this time, vaccination is not effective.

"I think it's important for the Virginia Department of Health and Tropical Smoothie Café to say why they didn't alert the public sooner," said Bill Marler, a food safety attorney based in Seattle who is representing outbreak victims.

"By not coming forward they kept people who had been exposed from having the opportunity to protect themselves and their families from Hepatitis A."

According to an epidemiologist employed by the Virginia health department, the officials delayed so that they could get as much information as they could in order "to determine with enough scientific certainty what the risk to the public was so we could understand the risk and communicate it accurately."

Diane Woolard, director of the health department's division of surveillance and investigation, confirmed this.

"We did not know for sure where the frozen strawberries were distributed, if the risk was associated with one restaurant chain or more general to other potential sources, if it was limited to Virginia or it extended further," she stated. "We wanted more information to feel confident that the source was strawberries and not other fruits, especially since smoothies contain so many ingredients. It is important to have a high level of confidence in the message and accuracy in the assessment of risk when issuing statewide notices about a single product."

The link to the strawberries was made using data from genetic typing and other evidence. The CDC confirmed the link and the outbreak on August 12.

Health officials urge any person who had a smoothie at any restaurant recently to monitor themselves for Hepatitis A symptoms, which will help keep the outbreak contained.

"Approximately 50 percent of the residents, for whom information is available, have been hospitalized for their illness. The 44 ill residents range in age from 15-68. Onsets of illness for the 44 cases range from early May through August," the health department reported Tuesday.

"If illness occurs, seek medical care and take steps to protect others from the infection. Other restaurants, and firms that supply restaurants, may also have received the frozen strawberries imported from Egypt. VDH continues to investigate cases and work with state and federal partners, … to identify additional locations where the product may have been distributed."

Hepatitis A symptoms can include jaundice, fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine and light-colored stools. Transmission of the virus can occur by directly contacting a person who already has it or by ingesting contaminated food or drink.

The spread of the virus can be checked by frequent hand washing using soap and warm water after using the bathroom, changing a diaper, or before fixing food. People experiencing symptoms of Hepatitis A are strongly encouraged to stay home from work, especially if they work in the food service industry.