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Hep Express Issue 11

(1 of 8)
November 26, 2003
The Centers for Disease Control and Prevention (CDC) published "Hepatitis A Outbreak Associated with Green Onions at a Restaurant--Monaca, Pennsylvania, 2003" in the November 28 issue of "Morbidity and Mortality Weekly Report" (MMWR). The article is reprinted below in its entirety, excluding references and one figure.
The Pennsylvania Department of Health and CDC are investigating an outbreak of hepatitis A outbreak among patrons of a restaurant (Restaurant A) in Monaca, Pennsylvania. As of November 20, approximately 555 persons with hepatitis A have been identified, including at least 13 Restaurant A food service workers and 75 residents of six other states who dined at Restaurant A. Three persons have died. Preliminary sequence analysis of a 340 nucleotide region of viral RNA obtained from three patrons who had hepatitis A indicated that all three virus sequences were identical. Preliminary analysis of a case-control study implicated green onions as the source of the outbreak.
Among 207 persons with hepatitis A who were interviewed and who ate at Restaurant A only once during the 2-6 weeks (i.e., the typical incubation period for hepatitis A) before illness, dates of illness onset were between October 14 and November 12. These 207 patrons reported eating food prepared in Restaurant A during September 14-October 17; a total of 181 (87%) persons reported eating at Restaurant A during October 3-6. All infected Restaurant A food service workers became ill after October 26, suggesting that a food service worker could not have been the source of the outbreak. However, during late October-early November, these ill food service workers were working in Restaurant A when they could have been infectious. For this reason, immune globulin has been provided to approximately 9,000 persons who ate food from Restaurant A during this time or had exposures to ill persons involved in the outbreak. The restaurant has been closed.
A case-control study was conducted to identify menu item(s) or ingredient(s) associated with illness. A case-patient was defined as a person who had illness onset during October 14-November 12, had laboratory confirmation of acute hepatitis A virus (HAV) infection (i.e., positive IgM anti-HAV), reported eating food prepared at Restaurant A during  October 3-6, and had eaten only once at Restaurant A during the 2-6 weeks before illness onset. Controls included persons without hepatitis A who either had dined with case-patients at Restaurant A or were identified through credit card receipts as having dined at Restaurant A during October 3-6. Controls with a previous history of hepatitis A, hepatitis A vaccination, or receipt of immune globulin within 2 weeks after eating Restaurant A food were excluded. Enrolled case-patients and controls were asked about Restaurant A food that they had eaten.
The median age of the 181 case-patients in the study was 34 years (range: 4-73 years), and that of the 83 controls was 28 years (range: 2-81, p greater than 0.05). Of 133 menu items, only chili con queso and mild salsa were associated significantly with illness. Mild salsa was eaten by 94% of case-patients, compared with 39% of controls (odds ratio [OR] = 24.2; 95% confidence interval [CI] = 11.4-51.4). Chili con queso was eaten by 15% of case-patients, compared with 3% of controls (OR = 5.2, 95% CI = 1.5-17.8). Both menu items associated with illness contained uncooked or minimally heated fresh green onions. Among 11 case-patients who reported not eating mild salsa, seven ate at least one of the other 52 menu items that contained green onions. Of 103 ingredients used at the restaurant, 12 were associated with illness in a univariate analysis. Of these, 10 had been consumed by fewer than 50% of case-patients. Eating a menu item containing green onions was reported by 98% of case-patients, compared with 69% of controls (OR = 20.2, 95%CI = 6.8-59.9). Eating a menu item containing white onions also was associated with illness. However, among the 176 case-patients who reported eating white onions, 174 (99%) also ate green onions. Among the four case-patients and 28 controls who reported not eating green onions, white onions were not associated with illness (OR = 2.5, 95% 0.3-20.9).
During interviews conducted at Restaurant A, food service workers described green onion storage, washing, and preparation practices. Green onions were shipped in 8.5-lb. boxes containing multiple small bundles (6-8 green onions per bundle). Each box was unpacked, and bundles were stored upright (root side down) and refrigerated in a bucket with ice included in the shipment. Green onions were stored 5 or fewer days before processing, which consisted of rinsing intact onion bundles, cutting the roots off, and removing the rubber bands. Green onions from each box were chopped by machine to yield approximately 8 qts. Chopped green onions were refrigerated for approximately 2 days.
Periodically (i.e., every 1-3 days), salsas were prepared in batches of 40-80 qts. Mild salsa included chopped fresh green onions; hot salsa did not. Salsas were refrigerated in 8-quart containers with a shelf life of 3 days. Mild and hot salsa were ladled into bowls and provided free with tortilla chips upon seating at Restaurant A.
The Food and Drug Administration (FDA), CDC, and the state health departments are investigating the source of the green onions associated with this outbreak and how they became contaminated with HAV. Preliminary traceback information indicates that green onions supplied to Restaurant A were grown in Mexico.
Editorial Note:
This report describes a large hepatitis A outbreak associated with eating a food item containing green onions at a single restaurant. The majority of ill patrons interviewed as of November 21 were exposed during a 3-day period in early October. No ill food service worker identified could have been the source of the outbreak. The green onions likely were contaminated with HAV in the distribution system or during growing, harvest, packing, or cooling. Traceback investigations completed to date have determined that the green onion source is one or more farms in Mexico.
Both green onions and white onions were associated with illness in the univariate analysis. However, white onions were not associated with illness among those who did not eat green onions. This association with white onions observed in the univariate analysis might not remain when multivariate modeling is completed. Restaurant A purchases previously chopped white onions and adds them to several menu items, including hot and mild salsa. Mild salsa, which contains both green onions and white onions, was associated with illness; however, hot salsa, which contains only white onions, was not associated with illness.
The genetic sequence of the outbreak strain is very similar to viral sequences obtained from persons involved in hepatitis A outbreaks in Tennessee, Georgia, and North Carolina during September 2003 that were linked epidemiologically to green onions. These sequences also were identical or very similar to sequences observed among persons with hepatitis A living along the United States-Mexico border and travelers returning from Mexico, consistent with a source in Mexico (CDC, unpublished data, 2003). Raw green onions from three firms in Mexico have been implicated in the Tennessee and Georgia outbreaks. FDA is still reviewing records to determine if additional firms are involved. The Mexican government is assisting with the traceback investigation in Mexico and the investigation to determine the source of the contamination.
Previous hepatitis A outbreaks linked to green onions have been reported and have involved patrons of a single restaurant. However, the outbreak at Restaurant A was unusually large. Several characteristics of the way food was prepared and served in Restaurant A could have contributed to the outbreak's size, including 1) multiple opportunities for intermingling of uncontaminated and contaminated green onions in a common bucket for 5 days with the ice in which they were shipped and 2) serving contaminated items with a relatively long shelf life (e.g., mild salsa) to a large proportion of patrons over several days.
HAV is transmitted by the fecal-oral route. Green onions require extensive handling during harvesting and preparation for packing. Contamination of green onions could occur 1) by contact with HAV-infected workers, especially children, working in the field during harvesting and preparation and 2) by contact with HAV-contaminated water during irrigation, rinsing, processing, cooling, and icing of the product. Green onions and other selected produce items (e.g., strawberries) might be more vulnerable to contamination because plant surfaces are particularly complex or adherent to viral or fecal particles. Outbreaks of other enteric pathogens linked to green onions have been reported.
On November 15, FDA issued an alert to consumers about the recent hepatitis A outbreaks associated with green onions  (available at http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01262.html . FDA advised consumers concerned about the possibility of getting hepatitis A from green onions to cook green onions thoroughly before eating and to ask about use of green onions in prepared foods. Unless directed otherwise by public health officials, persons who have recently eaten green onions do not need postexposure prophylaxis (i.e., immune globulin).
CDC is working with state health departments to identify other hepatitis A outbreaks associated with green onions. As of November 21, no other hepatitis A outbreaks have been identified. To identify other cases related to these outbreaks, state and local health officials should interview persons with hepatitis A with onset after October 1. Persons without typical risk factors for hepatitis A should be asked about food and restaurant exposures during their incubation period. Because molecular epidemiologic techniques have been useful for identifying related cases of foodborne hepatitis A in previous outbreaks, health departments might consider obtaining serum specimens for cases of interest.
An increasing proportion of reported foodborne outbreaks have been linked to fresh produce. This increase might be attributed to increased consumption of fresh produce or better surveillance techniques. HAV contamination of fresh produce can be reduced by using approaches such as the application of Good Agricultural Practices/Good Manufacturing Practices recommended by FDA. Recommended control measures include providing sanitary facilities for field workers, ensuring appropriate water quality, use of properly treated manure or biosolids, and ensuring worker health. Reducing HAV transmission in areas where produce is grown and discouraging the presence of children in areas where food is harvested also will reduce opportunities for HAV contamination. Further investigation of this and other hepatitis A outbreaks linked to green onions, including observation of cultivation and harvesting practices, can guide additional specific critical control measures.
To access a web-text (HTML) version of the article online, go to:
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
To receive a FREE electronic subscription to MMWR (which includes new ACIP statements), go to:

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(2 of 8)
November 26, 2003

The hard copy of the November 2003 issue of "VACCINATE ADULTS!" was just mailed to nearly 150,000 adult medicine specialists and health departments. You can access the entire issue or selected articles from the website of the Immunization Action Coalition (IAC). Immunization and hepatitis experts at the federal Centers for Disease Control and Prevention (CDC) have reviewed each article and education piece in the issue for accuracy (with the exception of editorials).
You can download the entire issue from the Web or view selected articles from the table of contents.
To view the table of contents with links to individual articles, go to:
Please note: The PDF file of the entire November 2003 issue, linked below, is large at 353,640 bytes. Some printers cannot print such a large file. For tips on downloading and printing PDF files, go to: http://www.immunize.org/nslt.d/tips.htm
To download the entire PDF version of the November 2003 issue, go to:

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(3 of 8)
November 26, 2003
The November 5, 2003, issue of "SIGNpost," the electronic newsletter of the Safe Injection Global Network (SIGN), includes an article titled "Jail Contractor to Treat Hepatitis C."
On November 10, the state's three-year, $142 million contract with Prison Health Services took effect. According to Ronald Cavanaugh, director of treatment for the Alabama Department of Corrections, it will be the first time state prisons will offer HCV treatment and have a protocol for prevention and education. The new HCV treatment and prevention program alone will cost the department $3 million to $8 million.
Charles Edwards, community resource officer for Pardons and Paroles, said he welcomes the improved care. Parolees with HCV regularly report to his office; because the disease creates a greater susceptibility to illness, they "have a hard time holding jobs."
Cavanaugh estimated that a couple hundred prisoners initially may be identified as candidates for treatment.
"SIGNpost" is a free weekly electronic forum about safe and appropriate use of injections. To subscribe, go to:
To visit the SIGN Alliance website, go to:

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(4 of 8)
November 26, 2003
[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 11/17/03.]
The Wisconsin State Legislature passed legislation requiring public and private post-secondary educational institutions to give all enrolled students information about meningococcal and hepatitis B diseases and vaccines. In addition, students residing in a residence hall or dormitory are required to provide documentation if they have received immunization against the two diseases. The governor approved the legislation October 16; it goes into effect January 1, 2004.
The Immunization Action Coalition (IAC) has compiled information about all states that have meningococcal and hepatitis B prevention mandates for colleges and universities.
To access information on meningococcal mandates for colleges and universities, go to:
This information is also depicted visually on a map of the United States. To access the map, go to:
To access information on hepatitis B mandates for colleges and universities, go to:
This information is also depicted visually on a map of the United States. To access the map, go to:

For information about state mandates for other vaccines, including vaccines for adults, go to:
We depend on our readers to help us stay informed and ensure our website contains the most current and accurate information available. Please let us know when any changes occur in your state by emailing us at admin@immunize.org

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(5 of 8)
November 26, 2003
[The following is cross posted from the National Network for Immunization Information's "Immunization Newsbriefs" electronic newsletter, 11/19/03.]
A pilot study testing Chiron's experimental hepatitis C vaccine on humans will soon begin at Saint Louis University. No vaccine currently exists for hepatitis C, which is a major health problem throughout the world. The university is the only site conducting the testing, and the clinical trial, sponsored by Chiron and the National Institutes of Health, is the first trial to test a potential hepatitis C vaccine in humans.

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(6 of 8)
November 26, 2003

The following recent journal articles present research related to viral hepatitis prevention or treatment.

"An Economic Assessment of Pre-Vaccination Screening for Hepatitis A and B"
Authors: Jacobs RJ, Saab S, Meyerhoff AS, Koff RS
Source: Public Health Reports, November-December 2003, Vol. 118(6):550-8
Click here for abstract

"Women's Drug Injection Practices in East Harlem: An Event Analysis in a High-Risk Community"
Authors: Tortu S, McMahon JM, Hamid R, Neaigus A
Source: AIDS and Behavior, September 2003, Vol. 7(3):317-328
Click here for abstract

"Hepatitis A and B Vaccination in a Sexually Transmitted Disease Clinic for Men Who Have Sex with Men"
Authors: Sansom S, Rudy E, Strine T, Douglas W
Source: Sexually Transmitted Diseases, September 2003, Vol. 30(9):685-8
Click here for abstract

"Costs of a Hepatitis A Outbreak Affecting Homosexual Men: Franklin County, Ohio, 1999"
Authors: Sansom SL, Cotter SM, Smith F, et al
Source: American Journal of Preventive Medicine, November 2003, Vol. 25(4):343-6
Click here for abstract

"The Cost Effectiveness of Hepatitis Immunization for US College Students"
Authors: Jacobs RJ, Saab S, Meyerhoff AS
Source: Journal of American College Health, May 2003, Vol. 51(6):227-236
Click here for abstract

"Human Immunodeficiency Syndrome and Hepatitis B and C Infections Among Homeless Adolescents"
Authors: Beech BM, Myers L, Beech DJ, Kernick NS
Source: Seminars in Pediatric Infectious Diseases, January 2003, Vol. 14(1):12-19
Click here for abstract

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(7 of 8)
November 26, 2003
The HIV Vaccine Awareness Communications Campaign recently released a request for proposals for its Community Education and Outreach Partnership Program (CEOPP). This one-time funding opportunity aims to increase the capacity of nonprofit organizations to stress the importance of HIV vaccine research to their clients, particularly among hard-to-reach populations, including Blacks/African Americans, Hispanics/Latinos, and men who have sex with men, where the greatest misinformation and misconceptions about HIV vaccines exist.
Interested organizations are requested to submit a letter of intent by 4:00 PM EST, on December 1, 2003. Proposals must be submitted by mail by 4:00 PM EST, on December 19, 2003.
The complete request for proposals can be accessed at

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(8 of 8)
November 26, 2003
The Immunization Action Coalition recently posted five Vaccine Information Statements (VISs) in Hindi on its website. The VISs are for the following vaccines: varicella, hepatitis A, hepatitis B, measles-mumps-rubella (MMR), and pneumococcal conjugate (PCV7). IAC gratefully acknowledges the California Department of Health Services for providing the Hindi translations.
To access the VIS for hepatitis A vaccine, go to:
To access the VIS for hepatitis B vaccine, go to:
For information about the use of VISs, and for VISs in a total of 30 languages, go to: http://www.immunize.org/vis

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