Multi-State Hepatitis A
Outbreak Suspected

From Patricia Doyle, PhD

Hepatitis A is especially deadly for people with HCV. Given the widespread infection of HCV as well as HBV, and HIV a multistate outbreak is very serious.
Patricia Doyle
A ProMED-mail post ProMED-mail is a program of the International Society for Infectious Diseases
[1] Date: Tue 30 Sep 2003 From: ProMED-mail <> Source: Asheville Citizen Times, Mon 29 Sep 2003 [edited]
North Carolina: Hepatitis Scare May Be Part of Multistate Outbreak --------------------------------------------------
State and federal health officials are concerned the cases of hepatitis A virus infection in Buncombe County could be part of a multistate outbreak. Dr. Jeff Ingle, head of the Communicable Disease Control Program for the North Carolina Division of Public Health, said hepatitis outbreaks also have occurred in Tennessee (see [2] below) and Georgia (see [3] below), and officials are investigating whether affected restaurants had common food suppliers.
"The other connection could be with these multi-day camp-out rock festivals," Ingle said. "Food preparation is largely unregulated and the sanitation can be less than ideal." The Centers for Disease Control and Prevention have issued a warning about the outdoor festivals featuring various "jam bands." Information on the CDC Web site says 26 cases of hepatitis A virus infection have been reported among residents of 10 states.
Officials also are concerned about diners who don't live in the area and may not know they've been exposed. Alerts have gone out to every state department of health, Ingle said, but it's impossible to reach everyone. Dwight Butner, owner of Vincenzo's in downtown Asheville, and President of the Asheville Independent Restaurant Association, hopes the outbreak won't affect tourism as foliage season approaches. "But the main concern here is the health of our workers and patrons," he said. "Whether people stay away is certainly a concern for business, but that will pass as soon as the outbreak is over. All we can do is make sure we're all extremely vigilant about hygiene and food handling issues and hope this is the end of it."
Dr. Susan Mims, medical director of the Buncombe County Health Center, is concerned with containing the outbreak here. So far, 10 cases have been recorded in Buncombe County, all related to food handlers at Doc Chey's Noodle House and Laughing Seed Cafe. People who ate at either of those restaurants between 16 and 21 Sep 2003 are urged to go to the health center for free immune globulin shots. So far, the health center has administered more than 3000 shots.
Immune globulin only works to prevent hepatitis A virus infection for 2 weeks after exposure, so anyone exposed before 16 Sep 2003 who has not had a shot should watch for symptoms - fever and chills, fatigue, nausea, vomiting, diarrhea, and jaundice (yellowing of the skin and eyes). Symptoms can appear any time between 15 and 50 days after exposure. "The best prevention is hand-washing," Mims said. "Frequent and thorough hand-washing. I can't emphasize that enough."
However, once the virus is in food, hand-washing won't help, Ingle said. Cooking will deactivate the virus, but there's still danger in salads, and raw shellfish can carry the virus no matter how clean the food handler is. The only way to get permanent protection is with the hepatitis A vaccine, which is administered in 2 doses 6 months apart. Ingle said inoculating everyone who works in a restaurant isn't feasible because the rate of employee turnover is so high. "It's a fairly transient population," he said. "There's been talk of requiring all food handlers to be inoculated for a long time, and we asked Duke University to do a feasibility study in the mid-1990s. That study found it just wasn't economically sound." However, some restaurants and catering businesses do offer to pay for hepatitis A vaccine shots for their workers. Eventually, Ingle said he expects the hepatitis A vaccine to become a common childhood inoculation.
More information on hepatitis A virus infection is also available from the Centers for Disease Control and Prevention at <>
[Byline: Leslie Boyd]
****** [2] Date: Tue 30 Sep 2003 From: ProMED-mail <> Source: Tennessee Department of Health, Thu 18 Sep 2003 [edited] <>
Tennessee: Cluster of Hepatitis A Cases - Free Medication Offered --------------------------------------------------
A cluster of hepatitis A cases has been confirmed among workers at O'Charley's Restaurant, located in the Turkey Creek retail development in West Knoxville. People who ate uncooked foods at this restaurant may be at risk for developing hepatitis A. Specifically, persons who ate salads and other uncooked food items, or who drank iced drinks may have been exposed to the virus.
Medication called immune globulin may prevent infection or diminish the severity of the illness, but only if it is given within 2 weeks of exposure. Persons who ate high-risk food items should receive an injection of immune serum globulin if their exposure occurred between 5 Sep and 14 Sep 2003. Investigators have determined that there was no exposure in the restaurant after 14 Sep 2003.
Because there was a University of Tennessee football game in Knoxville on 6 Sep 2003, a large number of people from outside the Knoxville area may have eaten at the restaurant and will need to be treated. Individuals potentially exposed on 5 Sep 2003 must receive immune globulin by Fri 19 Sep 2003 in order for the medication to be potentially effective; those exposed on 6 Sep 2003 must receive immune globulin by Sat 20 Sep 2003.
The Knox County Health Department is offering free shots of immune globulin for people who live in the Knoxville/East Tennessee area, and the Tennessee Department of Health will offer shots for individuals who ate at the restaurant but who live in other areas of the state. The medication is free of charge.
****** [3] Date: Tue 30 Sep 2003 From: ProMED-mail <> Source: Atlanta Journal Constitution, Sat 27 Sep 2003 [edited] <;COXnetJSessionID=
Georgia: Hepatitis A Outbreak Sparks Inquiry
Health officials are investigating a hepatitis A outbreak in Georgia, to see whether the cases have a common link. At least 116 cases of the liver disease have been reported since 1 Aug 2003, more than double the number in August and September of 2002.
In an average year, Georgia records about 400 cases of the disease, usually spread by eating food contaminated with infected stool. Restaurants and food distributors are potential sources. An outbreak in Knoxville this month was traced to a restaurant. A food handler at a restaurant in Asheville, North Carolina (see [1] above), recently acquired hepatitis A, prompting hundreds of patrons to get shots to prevent the disease. Georgia's cases could be connected to those outbreaks, officials say.
The Centers for Disease Control and Prevention is looking into the cases in Georgia, North Carolina, and Tennessee, spokesman Dave Daigle said. The CDC did not provide further details. One possibility is a phenomenon the CDC reported in other states this summer: clusters of young attendees of outdoor "jam band" concerts contracting the disease, possibly from poor sanitary conditions.
No cause has been identified for the Georgia outbreak, and the cases appear to be spread around the state, Richard Quartarone, spokesman for the Georgia Division of Public Health, said on Fri 26 Sep 2003. "We're starting to do some very aggressive investigating to see what in the world may be going on. We're trying to focus on combinations of geography and behavior." Georgia health officials are asking patients where and what they have eaten and whether they have been to any large events. Since people don't become ill until about a month after they are infected, investigations are difficult.
Health officials also are working with organizers of this weekend's Blue Ridge HarvestFest in LaFayette, a jam and folk music gathering just south of Chattanooga, to encourage frequent hand washing, Quartarone said. No specific problem has been identified with the festival or the music groups involved.
Byline: David Wahlberg
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From Patricia Doyle, PhD
Hello, Jeff - It is about time researchers looked into HCV spread via saliva. We discussed this many years ago when you brought up that question. Think of all the people who have contracted HCV over those years. Of course, HCV spreads more easily then previously thought. Just look at the numbers of infected. They certainly all aren't doing IV drugs or having illicit sex.
Hepatitis C is a flavivirus. Flaviviruses are by nature, vectored viruses. I am wondering how long it will take before we hear that HCV can, in some cases, be spread via mosquitos.




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