Hepatitis A Outbreak in Michigan Schools Release No. 0100.97 Backgrounder Hepatitis A Outbreak in Michigan Schools U.S. Department of Agriculture & U.S. Department of Health and Human Services April 2, 1997 Actions Taken by Food Safety and Public Health Agencies Centers for Disease Control and Prevention (CDC) has conducted two studies of the hepatitis A outbreak in Michigan and has found a strong association between illness and consumption of food items containing frozen strawberries. U.S. Department of Agriculture (USDA) has instructed the six states known to have received the implicated product (Michigan, Arizona, southern California, Georgia, Iowa and Tennessee) to suspend the use and distribution of the strawberries until further notice. As an additional precautionary measure, USDA has informed ten other states (Florida, Illinois, Indiana, Maine, New Jersey, New York, North Carolina, North Dakota, Washington, D.C. and Wisconsin) not to use strawberries from the California-based company until more information is available. The Food and Drug Administration (FDA) is investigating the packer/processor of these berries, and has inspected the facility and its production records. FDA is continuing to work closely with CDC, USDA and the processor/packer of the strawberries to determine whether any implicated product is still in distribution. CDC has alerted state epidemiologists about this association and has asked them to work with school officials to identify any students that might benefit from immune globulin. CDC and FDA have identified the quantities of immune globulin and hepatitis A vaccine currently available, and CDC will be working with state health departments to analyze their needs and help them get the needed doses. Summary Since the beginning of March, approximately 130 cases of hepatitis A have been identified in Calhoun County, Michigan. Nearly all patients are students or staff of three different school districts. Two epidemiological studies by the Centers for Disease Control found a strong association between illness and the consumption of food items containing frozen strawberries. The strawberries associated with the illness were imported from Mexico and were processed, packed and frozen for institutional use by a company in southern California. Thirteen lots of strawberries produced on three dates in April and May 1996 are implicated in the Michigan outbreak. These frozen strawberries were distributed by three vendors to U.S. Department of Agriculture (USDA) sponsored school lunch programs in six states: Michigan, Arizona, southern California, Georgia, Iowa and Tennessee. USDA purchases only U.S. grown commodities for the school meals programs, and all suppliers must certify in writing that the product is in fact domestic. In addition to this requirement placed upon the vendors, USDA regularly conducts compliance audits, regarding the origin of the product. A false statement to Federal officials concerning the origin of a product is a criminal offense, punishable by up to five years in prison and significant fines. Civil penalties, including debarment from Federal contracting, and the loss of a license to sell perishable agricultural commodities may also be assessed. State and Federal authorities working on this outbreak have not been able to determine if transmission was limited to only some of the 13 lots, so all 13 implicated lots are being recalled. The Food and Drug Administration, which is responsible for the safety of processed packaged food, is working closely with CDC, USDA, and the processor/packer of the strawberries to determine whether any frozen strawberries, or products made from the strawberries, are still in distribution. To date, Michigan is the only state that has reported a cluster of hepatitis A cases. CDC has notified State epidemiologists of the association between frozen strawberries and hepatitis A in Michigan and has asked officials in other states that have received the implicated lots to be on the lookout for hepatitis A cases. Chronology March 24, 1997: Public health authorities in the State of Michigan invite epidemiologists from CDC to investigate a hepatitis A outbreak. March 27, 1997: FDA and USDA are informed of the outbreak and its possible link to frozen strawberries provided to school lunch programs in Michigan. FDA officials contact the processor/packer in California and begin an investigation of the facility and its production and distribution records. USDA instructs states that may have received the possibly implicated product to suspend the use and distribution of the frozen strawberries until further notice. USDA's Food, Nutrition and Consumer Services works with states to notify individual schools not to server these strawberries. Late afternoon, March 28, 1997: CDC concludes that the outbreak is associated with the consumption of frozen strawberries served in school lunch programs. March 29, 1997: CDC notifies state epidemiologists in those states that had received the suspect product of the association with hepatitis A in Michigan and asks them to work with school officials to identify any students that might benefit from immune globulin. April 1, 1997: Southern California officials announce that school children in the L.A. School District were served frozen strawberries from the implicated lots within the past week and may be at risk for contracting hepatitis A. Hepatitis A Hepatitis A is a virus that causes fever, malaise, loss of appetite, nausea, abdominal pain, and jaundice. It is transmitted through the fecal/oral route or by consuming food or water contaminated by an infected food handler. Hepatitis A infection is usually a mild and self-limiting illness. It is rarely fatal (less than one percent of all cases) and can be prevented through post-exposure immune globulin or by vaccination. Immune Globulin Many products made from blood plasma, including immune globulin, are frequently in short supply. It is therefore important for parents, health professionals, and state officials to carefully define and identify those patients who can benefit from immune globulin -- patients who were exposed within the last 14 days. CDC and FDA are aware of the quantities of immune globulin that are currently available and will be working with state and local health departments to analyze their needs and help them get an adequate supply. # NOTE: USDA news releases and media advisories are available on the Internet. Access the USDA Home Page on the World Wide Web at http://www.usda.gov