Multi-province hepatitis A outbreak linked to frozen berries (April 23, 2016)

Advisory Alert

April 23, 2016

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Further to the Advisory Alert issued by the Sudbury & District Health Unit on April 18, 2016, the following Advisory Alert provides an update and important information.

Based on the current Public Health Agency of Canada case definition, 11 cases of hepatitis A have been reported in Canada related to this outbreak, 8 of which have been reported in Ontario. One laboratory-confirmed case of hepatitis A has been reported within the Health Unit’s service area. This case reported recent consumption of recalled Costco Nature’s Touch Organic Berry Cherry Blend frozen berries.

Please heighten your index of suspicion of hepatitis A in patients presenting with symptoms suggestive of infection, which may include 1 to 7 days of prodrome followed by abrupt onset of fever, malaise, anorexia, nausea and abdominal pain, often followed by jaundice. Children are often asymptomatic. Infants and the elderly have a greater risk of clinical severity.

Laboratory detection of anti‐HAV IgM, in the absence of recent hepatitis A vaccination, confirms a case of hepatitis A. Serum should be collected in a red top tube and submitted for anti‐HAV IgM (antibody) and anti‐HAV Total (IgG and IgM combined antibody) testing. Treatment is supportive only.

Please refer to the Health Unit anyone who has consumed the recalled berries within the last 50 days and is a food handler, has direct patient care (hospital or long-term care home workers, volunteers or students) or works in a child care setting. The Health Unit will provide employment-specific counseling.

The National Advisory Committee on Immunization (NACI) has recently updated its guidance on the Recommended Use of Hepatitis A vaccine (April 2016). NACI guidelines have been used in the development of Ministry of Health and Long-Term Care recommendations for post-exposure prophylaxis highlighted below:

 If within two weeks of last exposure:

• Everyone 6 months of age and over should be offered hepatitis A vaccine as soon as possible (unless contraindicated, fully immunized in the past or already immune—see below for details).
  • Hepatitis A vaccine is not authorized for children less than 1 year of age; however, NACI has recently recommended its off-label use for children 6 months to 1 year of age.
•  Infants < 6 months of age require no intervention except for careful attention to hygiene when diapering etc. to prevent fecal oral spread. Considerations should be given to offering hepatitis A vaccine to their family members.
  • Immune globulin, which was previously recommended for infants, is generally not recommended, although could be considered on a case-by-case basis in infants less than 6 months of age who are at very high risk for liver complication (e.g. severe liver disease).
•  Individuals with chronic liver disease should be:
  • Offered hepatitis A vaccine if within two weeks of last exposure (unless contraindicated, fully immunized in the past or already immune – see below for details). Ig may be recommended based on risk/benefit analysis. There is a lack of data to support the benefit of serum immune globulin after 14 days from last exposure; any use beyond that time frame should be assessed on a case-by-case basis.
  •  If beyond 14 days of exposure, previously unimmunized individuals with chronic liver conditions should be offered hepatitis A vaccine as per routine recommendations.

Guidance for those who have been previously vaccinated:

• If two previous doses were provided, no additional doses are recommended.
• If one dose was provided less than 6 months ago, no additional doses are recommended until at least 6 months from the last dose.
• If one dose was provided 6 months or more in the past, one additional dose is recommended.

To date, the Health Unit has immunized 190 individuals against hepatitis A at our vaccine clinics. The Sudbury & District Health Unit is holding a free hepatitis A vaccine clinic on Saturday, April 23, 2016, from 10 a.m. 3 p.m. at the main office, 1300 Paris Street, for eligible individuals within its service area who, within the last 14 days, consumed Nature’s Touch Organic Berry Cherry Blend brand frozen berries. Hepatitis A vaccine will also be available during regular clinic times the week of April 25, 2016.

Reporting

Under the Health Protection and Promotion Act, both suspected and confirmed cases of hepatitis A must be reported to the Medical Officer of Health. Laboratory‐confirmed cases should be reported immediately to the Health Unit by phone as soon as identified. Please report to 705.522.9200, ext. 464 (toll-free:1.866.522.9200) or after-hours to 705.688.4366.

For more detailed information on hepatitis A, refer to the MOHLTC Infectious Disease Protocol, Appendix A: Disease‐Specific Chapters, 2015. A full copy can be accessed at: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/infdispro.aspx.

Sincerely,

P. Sutcliffe, MD, MHSc, FRCPC Medical Officer of Health

This item was last modified on September 9, 2016