A multistate outbreak of hepatitis A caused by the consumption of raw oysters

Global outbreaks of foodborne hepatitis A: Systematic review and meta-analysis

Hepatitis A Virus (HAV) is a significant threat in terms of food safety. A systematic literature search with the research question "What are the clinical outcomes of foodborne Hepatitis A virus infections?" was conducted. The pooled estimate of the outcomes-mortality, hospitalization, and severity rates, along with a 95% confidence interval (CI), was estimated. After screening, 33 studies were included for the data extraction and meta-analysis. The pooled prevalence of hospitalization among the HAV-positive patients was estimated to be 32% (95% CI 21-44), with high heterogeneity (I2 = 98%, p < 0.01). Australia had the highest hospitalization rate, with 82%, followed by Europe (42%). The hospitalization rate showed a significantly increasing trend (beta = 0.015, p=0.002) over the period. The pooled prevalence of mortality among the HAV-positive patients was estimated to be <1%, with low heterogeneity (I2 = 5%, p = 0.39). A wide range of food products were linked with the HAV outbreaks.

Microplastics as potential carriers of viruses could prolong virus survival and infectivity

Microplastics are emerging contaminants in various aquatic environments, leading to human and environmental health concerns. Viruses have also been ubiquitously detected in aquatic environments, and there is an unknown risk of microplastics-mediated virus migration through adsorption. This study applied polystyrene microplastics as the carrier and the T4 bacteriophage (or phage) as the virus model, and a violet side scatter/green fluorescence double-gated flow cytometry approach to investigate the adsorption capacity of viruses on microplastics. Our results show that up to 98.6±0.2% of the dosed viruses can be adsorbed by microplastics, and such adsorptions are dependent on size and surface functional groups. Both Fourier-transform infrared spectroscopy and fluorescence-labelled confocal microscopy confirmed that the virus can successfully adsorb onto microplastics. Zeta potential characterisation revealed that the electrostatic interaction is the primary adsorption mechanism associated with the adsorption of viruses. UV-aging was found to enhance the adsorption capacities of viruses on microplastics. Both pristine and UV-aged microplastics were found to significantly prolong the infectivity of the adsorbed viruses, even under elevated temperatures. Collectively, our findings highlight that microplastics are associated with the biological risks of water-borne viral transmission through virus adsorption.

Efficient capturing and sensitive detection of hepatitis A virus from solid foods (green onion, strawberry, and mussel) using protamine-coated iron oxide (Fe3O4) magnetic nanoparticles and real-time RT-PCR

Hepatitis A virus (HAV) continues to be a public health concern and has caused large foodborne outbreaks and economic losses worldwide. Rapid detection of HAV in foods can help to confirm the source of outbreaks in a timely manner and prevent more people getting infected. In order to efficiently detect HAV at low levels of contamination in foods, rapid and easy-to-use techniques are required to separate and concentrate viral particles to a small volume. In the current study, HAV particles were eluted from green onion, strawberry, and mussel using glycine buffer (0.05 M glycine, 0.14 M NaCl, 0.2% (v/v) Tween 20, pH 9.0) and suspended viral particles were captured using protamine-coated magnetic nanoparticles (PMNPs). This process caused a selective concentration of the viral particles, which could be followed by quantitative real-time RT-PCR analysis. Results showed that pH, NaCl concentration, and PMNP amount used for the capturing had significant effects on the recovery efficiency of HAV (P < 0.05). The highest recovery rate was obtained at pH 9.0, 0.14 M NaCl, and 50 μL of PMNPs. The optimized PMNP capturing method enabled the rapid capture and concentration of HAV. A sensitive real-time RT-PCR test was developed with detection limits of 8.3 × 10⁰ PFU/15 g, 8.3 × 10¹ PFU/50 g, and 8.3 × 10⁰ PFU/5 g of HAV in green onion, strawberry, and mussel, respectively. In conclusion, the PMNP method is rapid and convenient in capturing HAV from complex solid food samples and can generate concentrated HAV sample solutions suitable for high-sensitivity real time RT-PCR detection of the virus.

Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020

HEPATITIS A IS A VACCINE-PREVENTABLE, COMMUNICABLE DISEASE OF THE LIVER CAUSED BY THE HEPATITIS A VIRUS (HAV). THE INFECTION IS TRANSMITTED VIA THE FECAL-ORAL ROUTE, USUALLY FROM DIRECT PERSON-TO-PERSON CONTACT OR CONSUMPTION OF CONTAMINATED FOOD OR WATER. HEPATITIS A IS AN ACUTE, SELF-LIMITED DISEASE THAT DOES NOT RESULT IN CHRONIC INFECTION. HAV ANTIBODIES (IMMUNOGLOBULIN G [IGG] ANTI-HAV) PRODUCED IN RESPONSE TO HAV INFECTION PERSIST FOR LIFE AND PROTECT AGAINST REINFECTION; IGG ANTI-HAV PRODUCED AFTER VACCINATION CONFER LONG-TERM IMMUNITY. THIS REPORT SUPPLANTS AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) REGARDING THE PREVENTION OF HAV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS ROUTINE VACCINATION OF CHILDREN AGED 12-23 MONTHS AND CATCH-UP VACCINATION FOR CHILDREN AND ADOLESCENTS AGED 2-18 YEARS WHO HAVE NOT PREVIOUSLY RECEIVED HEPATITIS A (HEPA) VACCINE AT ANY AGE. ACIP RECOMMENDS HEPA VACCINATION FOR ADULTS AT RISK FOR HAV INFECTION OR SEVERE DISEASE FROM HAV INFECTION AND FOR ADULTS REQUESTING PROTECTION AGAINST HAV WITHOUT ACKNOWLEDGMENT OF A RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE GUIDANCE FOR VACCINATION BEFORE TRAVEL, FOR POSTEXPOSURE PROPHYLAXIS, IN SETTINGS PROVIDING SERVICES TO ADULTS, AND DURING OUTBREAKS.

A new pattern in hepatitis A virus infection in an urban population

INTRODUCTION

hepatitis A virus (HAV) infection is a common cause of acute hepatitis worldwide. Since the generalization of vaccination, its incidence had markedly declined. Nevertheless, several HAV-outbreaks have been described in the last decade, mainly related to contaminated alimentary products. In recent years, a new pattern of acute HAV infection has been described with changes in the demographic profile of the infected population, which is more common in healthy young men.

PATIENTS AND METHODS

a retrospective case series study was performed to evaluate this possible change in the pattern of HAV infection. The case series included all patients with a diagnosis of HAV acute infection in our hospital between January 2005 and May 2017.

RESULTS

a total of 196 cases were diagnosed which were comprised of two probable outbreaks: one starting in November 2008 of 26 cases and one starting in 2016 with 69 cases at the time of data collection. The two outbreak populations were comparable. While the sporadic cases group was predominantly formed by pediatric and third-age patients with a slight male tendency, the outbreak related cases showed a clear predominance for young males (proportion of males: 63.2% vs 85.3%, p < 0.001). A possible chronological relationship with the national gay festivity celebrated in Madrid was observed. Outbreak related cases had higher bilirubin, alanine aminotransferase and longer APPT at diagnosis as well as a lower albumin concentration. The clinical relevance was minimal with a similar hospitalization rate and clinical outcome in both groups. There were no related deaths, acute liver failure or need for liver transplantation in our cohort.

CONCLUSION

these epidemiological findings emphasize the importance of implementing preventive measures as well as social awareness campaigns.

An outbreak of hepatitis A in Canada: The use of a control bank to conduct a case-control study

An outbreak of 18 cases of hepatitis A virus infection across five Canadian provinces was investigated. Case onsets occurred between October 2017 and May 2018. A retrospective matched case-control study was conducted to identify the likely source of the outbreak. Three matched controls were recruited for each case using a previously established control bank, supplemented by landline and cell phone call lists. Univariate and multivariate matched analyses were conducted to identify a potential outbreak source. Seventy-two per cent of controls were recruited through the control bank, and required on average 25.5 calls per recruited control; 20% of controls were recruited through a landline sample and 8% of controls were recruited through a cell phone sample, requiring an average of 847.3 and 331.7 calls per recruited control, respectively. Results of the analysis pointed to shrimp/prawns (odds ratio (OR) 15.75, p = 0.01) and blackberries (OR 7.21, p = 0.02) as foods of interest, however, an outbreak source could not be confirmed. The control bank proved to be a more efficient method for control recruitment than random call lists. Expanding the control bank size and using alternative methods, such as online surveys, may prove beneficial for increasing the timeliness of a case-control study during an outbreak investigation.

Hepatitis A Outbreak in the General Population due to a MSM-Associated HAV Genotype Linked to a Food Handler, November 2017-February 2018, Germany

Hepatitis A (HAV) is a viral infection causing a range of symptoms, sudden onset of fever, malaise, diarrhea, and jaundice. It is mostly transmitted fecal-oral through contaminated food, with immediate household and sexual contacts having a higher risk of infection. Since 2016 an increased number of HAV infections, mostly affecting men who have sex with men (MSM) have been noticed worldwide, with three main genotypes circulating. We report here on the first spillover outbreak of the MSM-associated HAV genotype RIVM-HAV16-090 in the German general population in November 2017-February 2018. In total, twelve cases could be attributed to the outbreak with the index case and a coworker in a butchers shop being the most probable source of the outbreak. The identical HAV genotype was detected in two environmental samples in the premises of the butchers shop and in nine cases. Outbreak control measures included detailed contact tracing and stool examinations, several environmental investigations, thorough cleaning, and disinfection of the premises of the butchers shop. Post-exposure vaccination was recommended to all unprotected contacts during the investigation. Furthermore, although hand-washing facilities were in accordance with the required law, additional installment of soap and disinfectant dispensers and contactless faucets has been recommended.

Alteration of host-pathogen interactions in the wake of climate change - Increasing risk for shellfish associated infections?

The potential for climate-related spread of infectious diseases through marine systems has been highlighted in several reports. With this review we want to draw attention to less recognized mechanisms behind vector-borne transmission pathways to humans. We have focused on how the immune systems of edible marine shellfish, the blue mussels and Norway lobsters, are affected by climate related environmental stressors. Future ocean acidification (OA) and warming due to climate change constitute a gradually increasing persistent stress with negative trade-off for many organisms. In addition, the stress of recurrent hypoxia, inducing high levels of bioavailable manganese (Mn) is likely to increase in line with climate change. We summarized that OA, hypoxia and elevated levels of Mn did have an overall negative effect on immunity, in some cases also with synergistic effects. On the other hand, moderate increase in temperature seems to have a stimulating effect on antimicrobial activity and may in a future warming scenario counteract the negative effects. However, rising sea surface temperature and climate events causing high land run-off promote the abundance of naturally occurring pathogenic Vibrio and will in addition, bring enteric pathogens which are circulating in society into coastal waters. Moreover, the observed impairments of the immune defense enhance the persistence and occurrence of pathogens in shellfish. This may increase the risk for direct transmission of pathogens to consumers. It is thus essential that in the wake of climate change, sanitary control of coastal waters and seafood must recognize and adapt to the expected alteration of host-pathogen interactions.

Shellfish-Associated Enteric Virus Illness: Virus Localization, Disease Outbreaks and Prevention

Numerous outbreaks of shellfish-borne enteric virus illness have been reported worldwide. Most notable among the outbreaks are those caused by NoV and HAV. Lessons learned from outbreak investigations indicate that most outbreaks are preventable. Anthropogenic sources of contamination will continue to invade shellfish growing waters. Shellfish, by their very nature, will continue to bioconcentrate these contaminants, including enteric viruses. There is no quick fix for enteric virus contamination of shellfish; however, vigilance on behalf of the industry, regulatory agencies, and the consumer could substantially reduce the incidence of illness. Enhanced monitoring in all areas of shellfish production, harvesting, distribution, and processing would help to reduce viral illnesses. Pollution abatement and improved hygienic practices on behalf of the industry and consumers are needed. Improved analytical techniques for the detection of enteric viruses in shellfish will lead to enhanced shellfish safety and better protection for the consumer and the industry. Better reporting and epidemiological follow-up of outbreaks are keys to reducing the transmission of foodborne viral infections. It is anticipated that recent advances in analytical techniques, particularly for NoV, will lead to better monitoring capabilities for food and water and a reduction in the incidence of enteric virus illness among shellfish consumers.

Efficacy of domestic cooking inactivation of human hepatitis A virus in experimentally infected manila clams (Ruditapes philippinarum)

AIM

The aim of this work was to evaluate the efficacy of domestic cooking in inactivating Manila clams experimentally infected with human hepatitis A virus (HAV).

METHODS AND RESULTS

Electronic temperature probes were positioned to measure the internal temperature of Manila clams during domestic cooking. Two batches were infected with 10(7) and 10(5) TCID50  ml(-1) of HAV. The infected whole-in-shell clams were divided into three replicates and cooked on a conventional stove both singularly and in group and removed from the pan at fixed intervals. Pools of three digestive glands were examined by virus isolation for three blind passages and cell culture supernatant tested with real-time PCR.

CONCLUSION

Results showed that 2-min cooking by a traditional domestic method at a temperature close to 100°C, after the opening up of the valves of all the clams, can completely devitalize the HAV in high viral load-infected clams.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first study on inactivation of HAV in experimentally infected Manila clams subjected to domestic cooking. At present, labelling all lagoon products as 'requiring cooking before consumption' is highly recommended, but no specifications are given on how long and at what temperature they should be cooked. Considering the high commercial value of Manila clams, our results can provide both the producers and the consumer with useful indications on how to cook clams to prevent the risk of HAV foodborne illness.

Clinical Factors and Viral Load Influencing Severity of Acute Hepatitis A

Background and Aims

Clinical manifestations of hepatitis A virus (HAV) infection vary from mild to fulminant hepatic failure (FHF) in adults. We investigated the relationship between laboratory findings, including viral load, and clinical outcomes in patients with acute hepatitis A (AHA) and evaluated predictive factors for severe acute hepatitis (s-AH).

Methods

We analyzed the clinical manifestations of AHA in 770 patients. Patients with a prothrombin time (PT) of less than 40% of normal were classified as s-AH and included 4 patients with FHF, 11 patients with acute renal failure, and 3 patients with prolonged jaundice (n = 128). Other patients were defined as mild acute hepatitis (m-AH) (n = 642). Serum samples were obtained from 48 patients with acute hepatitis A. Among them, 20 with s-AH, and 28 with m-AH, were tested for HAV RNA titer.

Results

In a multivariate analysis, age (HR = 1.042, P = 0.041), peak creatinine (HR = 4.014, P = 0.001), bilirubin (HR = 1.153, P = 0.003), alanine aminotransferase (ALT) (HR = 1.001, P<0.001), initial lactate dehydrogenase (LDH) (HR = 1.000, P = 0.045) and total cholesterol (HR = 0.978, P<0.001) were independent factors for s-AH. Serum HAV RNA was detected in 20/20 (100%) patients with s-AH and 22/28 (78.6%) patients with m-AH. In a multivariate analysis of the 48 patients who were tested for HAV RNA, peak ALT (HR = 1.001, P = 0.004) and HAV RNA titer (HR = 2.076, P = 0.012) were independent factors for s-AH.

Conclusions

Clinical factors including age, peak creatinine, bilirubin, ALT, initial LDH and total cholesterol were independent factors for s-AH in a multivariate analysis. In particular, HAV load strongly correlated with the severity of hepatitis A.

Detection of hepatitis A virus in seeded oyster digestive tissue by ricin A-linked magnetic separation combined with reverse transcription PCR

Outbreaks of hepatitis A virus (HAV) infections are most frequently associated with the consumption of contaminated oysters. A rapid and selective concentration method is necessary for the recovery of HAV from contaminated oysters prior to detection using PCR. In this study, ricin extracted from castor beans (Ricinus communis) was tested as an alternative to antibody used in immunomagnetic separation while concentrating HAV prior to its detection using reverse transcription PCR. Initially, the extracted proteins from castor beans were fractionated into 13 fractions by gel filtration chromatography. Pretreatment of different protein fractions showed a variation in binding of HAV viral protein (VP) 1 to oyster digestive tissue in the range of 25.9 to 63.9%. The protein fraction, which caused the highest reduction in binding of VP1 to the tissue, was identified as ricin A by quadrupole time-of-flight mass spectrometry. Ricin A could significantly inhibit binding of VP1 to the tissue with a 50% inhibitory concentration of 4.5 μg/ml and a maximal inhibitory concentration of 105.2%. The result showed that the rate of inhibition of HAV binding to tissue was higher compared to the rate of ricin itself binding to HAV (slope: 0.0029 versus 0.00059). However, ricin A concentration showed a higher correlation to the relative binding of ricin itself to HAV than the inhibition of binding of HAV to the tissue (coefficient of determination, R(2): 0.9739 versus 0.6804). In conclusion, ricin A-linked magnetic bead separation combined with reverse transcription PCR can successfully detect HAV in artificially seeded oyster digestive tissue up to a 10(-4) dilution of the virus stock (titer: 10(4) 50% tissue culture infective dose per ml).

Source identification through social networks in an epidemiological investigation of a hepatitis A outbreak at an elementary school in Anhui province, China

In May 2011, the Center for Disease Control and Prevention of a Chinese county found a rapid increase in the number of hepatitis A case notification; these were traced to an outbreak in an elementary school. Twenty-eight cases aged between 7 and 13 years with onset between 7 May and 8 June were serologically confirmed. Network method was conducted to reconstruct an outbreak network and to quantify the relative importance of those involved in the outbreak. A case-control study was used to study the association between the outbreak and putative risk factors. The network analysis suggested this was a disseminated outbreak originating from a 4-year-old boy with propagated spread. Evidence from the case-control study supported consumption of well water as a potential risk factor; however, this was unable to be established through field investigation. Outbreak networks can be used to identify the possible source of infectious disease outbreak, especially when the environmental investigation information is negative or not available.

Humanized HLA-DR4 mice fed with the protozoan pathogen of oysters Perkinsus marinus (Dermo) do not develop noticeable pathology but elicit systemic immunity

Perkinsus marinus (Phylum Perkinsozoa) is a marine protozoan parasite responsible for “Dermo” disease in oysters, which has caused extensive damage to the shellfish industry and estuarine environment. The infection prevalence has been estimated in some areas to be as high as 100%, often causing death of infected oysters within 1–2 years post-infection. Human consumption of the parasites via infected oysters is thus likely to occur, but to our knowledge the effect of oral consumption of P. marinus has not been investigated in humans or other mammals. To address the question we used humanized mice expressing HLA-DR4 molecules and lacking expression of mouse MHC-class II molecules (DR4.EA⁰) in such a way that CD4 T cell responses are solely restricted by the human HLA-DR4 molecule. The DR4.EA⁰ mice did not develop diarrhea or any detectable pathology in the gastrointestinal tract or lungs following single or repeated feedings with live P. marinus parasites. Furthermore, lymphocyte populations in the gut associated lymphoid tissue and spleen were unaltered in the parasite-fed mice ruling out local or systemic inflammation. Notably, naïve DR4.EA⁰ mice had antibodies (IgM and IgG) reacting against P. marinus parasites whereas parasite specific T cell responses were undetectable. Feeding with P. marinus boosted the antibody responses and stimulated specific cellular (IFNγ) immunity to the oyster parasite. Our data indicate the ability of P. marinus parasites to induce systemic immunity in DR4.EA⁰ mice without causing noticeable pathology, and support rationale grounds for using genetically engineered P. marinus as a new oral vaccine platform to induce systemic immunity against infectious agents.

Shellfish-borne viral outbreaks: a systematic review

Investigations of disease outbreaks linked to shellfish consumption have been reported in the scientific literature; however, only few countries systematically collate and report such data through a disease surveillance system. We conducted a systematic review to investigate shellfish-borne viral outbreaks and to explore their distribution in different countries, and to determine if different types of shellfish and viruses are implicated. Six databases (Medline, Embase, Scopus, PubMed, Eurosurveillance Journal and Spingerlink electronic Journal) and a global electronic reporting system (ProMED) were searched from 1980 to July 2012. About 359 shellfish-borne viral outbreaks, alongside with nine ProMED reports, involving shellfish consumption, were identified. The majority of the reported outbreaks were located in East Asia, followed by Europe, America, Oceania, Australia and Africa. More than half of the outbreaks (63.6 %) were reported from Japan. The most common viral pathogens involved were norovirus (83.7 %) and hepatitis A virus (12.8 %). The most frequent type of consumed shellfish which was involved in outbreaks was oysters (58.4 %). Outbreaks following shellfish consumption were often attributed to water contamination by sewage and/or undercooking. Differences in reporting of outbreaks were seen between the scientific literature and ProMED. Consumption of contaminated shellfish represents a risk to public health in both developed and developing countries, but impact will be disproportionate and likely to compound existing health disparities.

Quantitative approach of risk management strategies for hepatitis a virus-contaminated oyster production areas

It is not yet known whether using the new molecular tools to monitor hepatitis A virus (HAV) in shellfish production areas could be useful for improving food safety. HAV contamination can be acute in coastal areas, such as Brittany, France, where outbreaks of hepatitis A have already occurred and have been linked to the consumption of raw shellfish. A quantitative probabilistic approach was carried out to estimate the mean annual risk of hepatitis A in an adult population of raw oyster consumers. Two hypothetical scenarios of contamination were considered, the first for a rare and brief event and the second for regular and prolonged episodes of contamination. Fourteen monitoring and management strategies were simulated. Their effects were assessed by the relative risk reduction in mean annual risk. The duration of closure after abnormal detection in the shellfish area was also considered. Among the strategies tested, results show that monthly molecular reverse transcription PCR monitoring of HAV is more useful than bacterial surveys. In terms of management measures, early closure of the shellfish area without waiting for confirmatory analysis was shown to be the most efficient strategy. When contamination is very short-lived and homogeneous in the shellfish production area, waiting for three negative results before reopening the area for harvest is time wasting. When contamination is not well identified or if contamination is heterogeneous, it can be harmful not to wait for three negative results. In addition, any preventive measures, such as improving sewage treatment or producing shellfish in safer areas, that can reduce contamination by at least 2 log units are more efficient and less costly. Finally we show that controlling and managing transferred shellfish are useful and can play an important role in preventing cases. Qualitative results from HAV monitoring can advantageously supplement other measures that improve the safety of shellfish products in exposed areas.

Space–time pattern of hepatitis A in Spain, 1997–2007

In Spain hepatitis A is a compulsory notifiable disease and individual cases are reported to the national epidemiological surveillance network. Incidence rates show variations in different regions. The aim of this study was to analyse the space–time pattern of hepatitis A risk at municipal level in Spain and at global and local levels during the period 1997–2007. At global level we used two estimates of risk: the standardized incidence ratio (SIR) and the posterior probability that the smoothed relative risk is >1 (PP). At local level we used the scan statistic method to analyse the space–time clusters. The SIR and significant PP (>0·8) showed the highest risk concentrated in areas of the Mediterranean coast. The most likely cluster gave a relative risk of 53·530. These spatial statistics methodologies can be complementary tools in the epidemiological surveillance of infectious diseases.

Drosophila Nora virus capsid proteins differ from those of other picorna-like viruses

The recently discovered Nora virus from Drosophila melanogaster is a single-stranded RNA virus. Its published genomic sequence encodes a typical picorna-like cassette of replicative enzymes, but no capsid proteins similar to those in other picorna-like viruses. We have now done additional sequencing at the termini of the viral genome, extending it by 455 nucleotides at the 5' end, but no more coding sequence was found. The completeness of the final 12,333-nucleotide sequence was verified by the production of infectious virus from the cloned genome. To identify the capsid proteins, we purified Nora virus particles and analyzed their proteins by mass spectrometry. Our results show that the capsid is built from three major proteins, VP4A, B and C, encoded in the fourth open reading frame of the viral genome. The viral particles also contain traces of a protein from the third open reading frame, VP3. VP4A and B are not closely related to other picorna-like virus capsid proteins in sequence, but may form similar jelly roll folds. VP4C differs from the others and is predicted to have an essentially α-helical conformation. In a related virus, identified from EST database sequences from Nasonia parasitoid wasps, VP4C is encoded in a separate open reading frame, separated from VP4A and B by a frame-shift. This opens a possibility that VP4C is produced in non-equimolar quantities. Altogether, our results suggest that the Nora virus capsid has a different protein organization compared to the order Picornavirales.

Epidemiology of seafood-associated infections in the United States

Seafood is part of a healthful diet, but seafood consumption is not risk-free. Seafood is responsible for an important proportion of food-borne illnesses and outbreaks in the United States. Seafood-associated infections are caused by a variety of bacteria, viruses, and parasites; this diverse group of pathogens results in a wide variety of clinical syndromes, each with its own epidemiology. Some seafood commodities are inherently more risky than others, owing to many factors, including the nature of the environment from which they come, their mode of feeding, the season during which they are harvested, and how they are prepared and served. Prevention of seafood-associated infections requires an understanding not only of the etiologic agents and seafood commodities associated with illness but also of the mechanisms of contamination that are amenable to control. Defining these problem areas, which relies on surveillance of seafood-associated infections through outbreak and case reporting, can lead to targeted research and help to guide control efforts. Coordinated efforts are necessary to further reduce the risk of seafood-associated illnesses. Continued surveillance will be important to assess the effectiveness of current and future prevention strategies.

Culture as an explanation in population health

In the last two decades, culture has emerged in population health as a common explanation for health outcomes and disparities. This paper systematically reviews such cultural accounts, focusing on a historical sample of articles from prominent population health journals (1930-2008, n=100) and a contemporary sample of articles in the American Journal of Public Health (2008, n=95). The review reveals that references to culture rarely (1) specify the precise pathways by which culture influences health or (2) assess the plausibility of these pathways. Despite these weaknesses, a few studies have begun to clarify, measure, and assess how culture can influence health outcomes, and these articles reflect promising new avenues for understanding how cultural factors influence variation in health and well-being.

An outbreak of hepatitis A in recently vaccinated students from ice snacks made from contaminated well water

On 30 May 2006, township S in Sichuan Province, China, reported an outbreak of hepatitis A (HA) in students who had recently received HA vaccine. The concern was raised that the vaccine had caused the outbreak. We attempted to identify the source of infection and mode of transmission. A HA case was defined as onset of jaundice or anorexia since 1 April 2006 with a twofold elevation of alanine aminotransferase (ALT) and anti-HA virus-IgM in a resident of or visitor to the township. Exposures to vaccine and snacks of 90 case-students to those of 107 control-students were compared. Thirty-four per cent of cases ate ice slush compared to 4.7% of controls (OR 4.1), and 51% of cases ate snow cones compared to 17% of controls (OR 8.3). The ice snacks were made with well water. HA virus RNA was detected by reverse transcription-polymerase chain reaction from patients' blood and well water. Untreated well water poses important dangers to the public in areas where piped, potable water is available.

Results of field investigations into the impact of intermittent sewage discharges on the microbiological quality of wild mussels (Mytilus edulis) in a tidal estuary

Field surveys were designed to examine the effects of sewage contamination from storm overflow effluent on faecal coliform and Escherichia coli concentrations in the flesh of wild mussels (Mytilus edulis). Bags containing 30 mussels each were fixed at known inter-tidal locations and retrieved at intervals following discharge from a nearby combined sewer overflow (CSO). Concentrations of faecal coliform bacteria and E. coli were measured in the shellfish flesh and in samples of overlying water prior to collection of the mussel samples. Faecal coliform and E. coli concentrations in shellfish increased rapidly after CSO discharge. E. coli concentrations exceeded the European shellfish hygiene class C limit of 46,000 100g(-1), and decayed during subsequent CSO discharge-free periods. The concentration and depuration response was independent of the magnitude of CSO spill volume. First-order exponential decay functions were fitted to the data. Decay rates were lower than those found in corresponding microcosm experiments. This relates to the repeated pattern of inundation and exposure associated with the tidal cycles in the estuary. Relationships between E. coli and faecal coliform concentrations in the shellfish and overlying water samples were relatively weak (r<0.60), a pattern often seen with data from uncontrolled environmental experiments.

Does mutation of hepatitis A virus exist in North India?

BACKGROUND

Human hepatitis A, a widespread infectious disease that is hyperendemic in vast areas of the world, results in the infection of the liver. Different human HAV strains of diverse geographic origin are remarkably closely related. HAV exploits all known mechanisms of genetic variation to ensure survival, including mutation and genetic recombination.

OBJECTIVES

The aim of the study was to undertake an in-depth analysis of the mutation in three groups: (i) mild acute hepatitis (m-AH), (ii) severe acute hepatitis (s-AH), and (iii) fulminant hepatitis (FHF) A patients, who were tested positive for HAV RNA.

MATERIALS AND METHODS

A total of 500 patients of acute viral hepatitis (AVH) were screened for HAV-IgM positivity from January 2003 to December 2004. HAV RNA positivity was subject to reverse transcription of RNA followed by polymerase chain reaction (RT-PCR) for the detection of HAV RNA. The HAV RNA positive cases were subject to single-stranded conformational polymorphism (SSCP).

RESULTS

Out of 500 acute cases of hepatitis, 80 (16%) were positive for HAV-IgM. HAV RNA was detected in 34 (42.5%) cases by RT-PCR. Twenty-four (70.5%) were m-AH, seven (20.5%) were s-AH, and three (8.8%) were FHF. All the positive samples were subject to SSCP. No mobility shift was observed with respect to any screened samples by PCR-SSCP. Four (m-AHI-54, m-AHI-80, s-AHI-341 and FHFI-195 suspected cases were directly sequenced to prove that there was no point mutation.

CONCLUSION

SSCP demonstrates no mobility shift in the VP1/P2A region of the HAV genome. No point mutation was observed in the four suspected cases by sequencing. However a large study from different geographical locations is needed to achieve a logical conclusion about the existence of HAV mutation in the Indian population.

Performance indicators for response to selected infectious disease outbreaks: a review of the published record

The purpose of this study was to determine whether published reports of infectious disease outbreaks could serve as a source of evidence for public health practice, particularly in responding to bioterrorism. Such performance indicators are measures of practice and process that lead to optimal health outcomes. We collected data from 116 individual articles that described 59 outbreaks of eight different pathogens with potential for bioterrorist use. Analysis of these reports determined whether they addressed 12 process indicators and four outcome indicators--each generally recognized as a component of effective outbreak response. The results showed that outbreak reports typically included information about these process and outcome indicators, thus validating their practical importance. However, few reports had been written with specificity to document the chronology of outbreak response, or the dissemination of information to protect healthcare workers, or the communication with law enforcement and emergency operations that are important in response to bioterrorism. We conclude that the published record of infectious disease outbreaks can, in the future, be used as a source for practice-based evidence if agreed-upon measures for effective performance become standard components of outbreak reports.

Use of Molecular Epidemiology to Confirm a Multistate Outbreak of Hepatitis a Caused by Consumption of Oysters

The 39 oyster consumption-related cases of hepatitis A reported in 2005 represent the first large outbreak of hepatitis A associated with shellfish consumption in the United States in >15 years. This is the first outbreak investigation in which an identical hepatitis A virus sequence was obtained from both the implicated food product and case patients.

Molecular confirmation of oysters as the vector for hepatitis A in a 2005 multistate outbreak

Numerous hepatitis A outbreaks were linked to the consumption of raw molluscan shellfish in the United States between 1960 and 1989. However, there had been no major molluscan shellfish-associated hepatitis A outbreaks reported in the United States for more than a decade (1989 to 2004). Beginning in late August 2005, at least 10 clusters of hepatitis A illnesses, totaling 39 persons, occurred in four states among restaurant patrons who ate oysters. Epidemiologic data indicated that oysters were the source of the outbreak. Traceback information showed that the implicated oysters were harvested from specific Gulf Coast areas. A voluntary recall of oysters was initiated in September. Hepatitis A virus (HAV) was detected in multiple 25-g portions in one of two recalled samples, indicating that as many as 1 of every 15 oysters from this source was contaminated. Comparing 315 nucleotides within the HAV VPl-2B region, 100% homology was found among four amplicons recovered from a total of six independent experiments of the implicated oysters, and an identical HAV sequence was detected in sera from all 28 patient serum specimens tested. Ten percent heterogeneity over 315 nucleotides (31 variants) was observed between the outbreak strain (subgenotype 1A) and an HM-175 strain (subgenotype 1B) used in the laboratory where the oysters were processed. To our knowledge, this investigation is the first in the United States to identify an HAV-identical strain in persons with hepatitis A as well as in the food that was implicated as the source of their infections.

Comparative evaluation of new TaqMan real-time assays for the detection of hepatitis A virus

Three novel real-time TaqMan RT-PCR assays targeting the 5'-UTR, the viral protease and the viral polymerase regions of the hepatitis A virus (HAV) were developed, evaluated and compared against a new published 5'-UTR TaqMan assay (JN) and a widely used conventional RT-PCR assay (HAVc). All conventional RT-PCR (HAV, SH-Prot and SH-Poly systems) and TaqMan (SH-Prot, SH-Poly, JN and SH-5U systems) assays evaluated were consistent for the detection of the three different HAV strains (HM-175, HAS-15 and LSH/S) used and reproducible for both RNA duplicates with the exception of two reproducibility discrepancies observed with both 5'-UTR real-time systems (JN and SH-5U). Limits of detection for conventional HAV, SH-Prot and SH-Poly RT-PCR systems were found to be equivalent when tested with serially diluted suspensions of the HM-175 strain. Although the four real-time RT-PCR TaqMan assays evaluated herein produced similar and consistent quantification data down to the level of one genomic equivalent copy with their respectively cloned amplicons, significant and important differences were observed for the detection of HAV genomic RNA. Results showed that the new real-time TaqMan SH-Poly and SH-Prot primer and probe systems were more consistent and sensitive by 5 logs as compared to both 5'-UTR designs (JN and SH-5U) used for the detection of HAV genomic RNA as well as for the detection in cell culture by cytopathic effect. Considering their higher analytical sensitivity, the proposed SH-Poly and SH-Prot amplification systems could therefore represent valuable tools for the detection of HAV in clinical, environmental and food samples.

Oceans and human health: Emerging public health risks in the marine environment

There has been an increasing recognition of the inter-relationship between human health and the oceans. Traditionally, the focus of research and concern has been on the impact of human activities on the oceans, particularly through anthropogenic pollution and the exploitation of marine resources. More recently, there has been recognition of the potential direct impact of the oceans on human health, both detrimental and beneficial. Areas identified include: global change, harmful algal blooms (HABs), microbial and chemical contamination of marine waters and seafood, and marine models and natural products from the seas. It is hoped that through the recognition of the inter-dependence of the health of both humans and the oceans, efforts will be made to restore and preserve the oceans.

Diagnosis of hepatitis a virus infection: a molecular approach

Current serologic tests provide the foundation for diagnosis of hepatitis A and hepatitis A virus (HAV) infection. Recent advances in methods to identify and characterize nucleic acid markers of viral infections have provided the foundation for the field of molecular epidemiology and increased our knowledge of the molecular biology and epidemiology of HAV. Although HAV is primarily shed in feces, there is a strong viremic phase during infection which has allowed easy access to virus isolates and the use of molecular markers to determine their genetic relatedness. Molecular epidemiologic studies have provided new information on the types and extent of HAV infection and transmission in the United States. In addition, these new diagnostic methods have provided tools for the rapid detection of food-borne HAV transmission and identification of the potential source of the food contamination.

Identification and sequence analysis of hepatitis A virus detected in market and environmental bivalve molluscs

In Italy in 1998, hepatitis A virus (HAV) was responsible for an infectious disease transmitted by contaminated bivalve molluscs. To determine the presence of HAV in the bivalves collected during a 1-year follow-up study, hepatitis A RNA was extracted and amplified by a nested reverse transcriptase-PCR method overlapping the VP1/2A region. The HAV genome was detected in 24 (14.1%) of 170 samples: 19 clams (Tapes decussates and Tapes semidecussatus), 1 oyster (Crossostea gigas), and 4 mussels (Mytillus galloprovincialis). Eleven positive samples were collected from marketing areas, and 13 positive samples were collected from growing areas. Seventeen of the 24 positive samples had been taken from domestic products, and 7 had been imported. Sequence analysis showed the presence of genotypes IA and IB. Our results suggest significant presence of HAV in bivalves from both marketing (public consumption) and environmental (growing) areas.

Diagnosis of hepatitis a virus infection: a molecular approach

Current serologic tests provide the foundation for diagnosis of hepatitis A and hepatitis A virus (HAV) infection. Recent advances in methods to identify and characterize nucleic acid markers of viral infections have provided the foundation for the field of molecular epidemiology and increased our knowledge of the molecular biology and epidemiology of HAV. Although HAV is primarily shed in feces, there is a strong viremic phase during infection which has allowed easy access to virus isolates and the use of molecular markers to determine their genetic relatedness. Molecular epidemiologic studies have provided new information on the types and extent of HAV infection and transmission in the United States. In addition, these new diagnostic methods have provided tools for the rapid detection of food-borne HAV transmission and identification of the potential source of the food contamination.

Multiple norovirus genotypes characterised from an oyster-associated outbreak of gastroenteritis

The diversity of norovirus (NV) genotypes was investigated in persons who were ill with acute gastroenteritis associated with the consumption of oysters. Initial results from a commercial enzyme immunoassay (EIA) indicated a mixed NV genogroup I (GI) and II (GII) outbreak. A reverse-transcriptase (RT)-PCR for NVs was applied to nucleic acid extracted from faecal specimens collected from symptomatic cases. Using primers that amplified contiguous sequences in the ORF1/2 region of the NV genome and a hemi-nested PCR derived from this assay, three different GII and two GI NV genotypes were detected and the strains were characterised by DNA sequencing. Using this approach a recombinant NV genotype, rGII-3a (recombinant Harrow/Mexico) the predominant strain identified in several symptomatic cases from the outbreak, was detected and characterised. No other gastroenteric viruses, including rotavirus, astrovirus, sapovirus and adenovirus 40/41 were detected by RT-PCR and PCR.

Development and evaluation of a broadly reactive TaqMan assay for rapid detection of hepatitis A virus

Primers and a TaqMan probe for the 5'-untranslated region (UTR) of the hepatitis A virus (HAV) genome were designed and evaluated. The assay detected 0.5 infectious units of HAV and 40 copies of a synthetic transcript and provides an important screening tool for rapid quantitative HAV detection in clinical or environmental samples.

Hepatitis A virus attachment to agri-food surfaces using immunological, virological and thermodynamic assays

AIMS

This study was designed to investigate the ability of hepatitis A virus (HAV) to attach to various food contact surfaces.

METHODS AND RESULTS

HAV attachment was demonstrated after elution of attached viruses from solid surfaces by an immunofluorescent method using anti-HAV-specific antibodies and confocal microscopy. Attachment and survival of HAV on stainless steel, copper, polythene and polyvinyl chloride (PVC) at 20 and 4 degrees C after 2 and 4 h were quantified by plaque assay. HAV was shown to attach almost instantaneously to all four surfaces tested. Attachment of HAV depended on initial viral concentration and was slightly greater at 4 degrees C. The total surface energy (gammaTOT), nonpolar Lifshitz-Van der Waals (gammaLW) and polar short range (gammaSR) hydrogen-bonding components for HAV and each surface as well as total free energy of the system were determined by contact angle measurements using an extended Young equation [Young (1805) Philosophical Transactions of The Royal Society (London) 95, 65-87). The calculation of these parameters predicted the favourable conditions for attachment of HAV to all four surfaces tested.

CONCLUSION

HAV particles attach to stainless steel, copper, polythene and PVC at 20 and 4 degrees C and the total free energy of the interaction is optimal for this attachment.

SIGNIFICANCE AND IMPACT OF THE STUDY

Comprehension of viral attachment to the solid surfaces will permit to successfully disinfect these surfaces and to establish a better surveillance programme for control of viral food-borne illnesses.

Infection of a Japanese patient by genotype 4 hepatitis e virus while traveling in Vietnam

Cases of imported hepatitis E in industrialized countries infected with a genotype 1 hepatitis E virus (HEV) have been identified. We report a 56-year-old Japanese man who acquired infection with a genotype 4 HEV with 98.8% identity to a Vietnamese isolate after ingestion of uncooked shellfish while traveling in Vietnam.

Hepatitis A Transmitted by Food

Hepatitis A is caused by hepatitis A virus (HAV). Transmission occurs by the fecal-oral route, either by direct contact with an HAV-infected person or by ingestion of HAV-contaminated food or water. Foodborne or waterborne hepatitis A outbreaks are relatively uncommon in the United States. However, food handlers with hepatitis A are frequently identified, and evaluation of the need for immunoprophylaxis and implementation of control measures are a considerable burden on public health resources. In addition, HAV-contaminated food may be the source of hepatitis A for an unknown proportion of persons whose source of infection is not identified.

Time course of hepatitis A viremia and viral load in the blood of human hepatitis A patients

The hepatitis A virus (HAV) is the most common etiological cause of acute hepatitis infections in humans in industrialized countries. Investigations into the viral load during HAV viremia, however, are rare. Therefore, correlation studies between viral load, biochemical, and specific serological markers have been undertaken. The group of sera comprised a series of multiple consecutive blood samples drawn from 11 patients at different times after onset of the disease. During the period up to 70 days after the onset of icterus, the individual range was at 1 x 10(3) to 3 x 10(4) HAV genome equivalents/ml. From day 75 until 120 after onset of the disease, the levels traced were at 10(3). In one case, it was possible to trace 1.25 x 10(4) genome equivalents/ml up to 180 days after onset of icterus and in two cases even up to 408 and 490 days viral load levels of 5 x 10(3) and 4 x 10(4) were detected, respectively. The same sera were used to measure IgM class antibodies to hepatitis A virus and the total anti-HAV. The results demonstrate that a direct correlation to peak levels of viral load exists with peak serum transaminase levels, but neither with peak anti-HAV IgM levels nor with total anti-HAV. Decreasing amounts of anti-HAV IgM tend to occur with decreasing amounts of HAV genome equivalents; and, vice versa, increasing amounts of total anti-HAV are accompanied by decreasing amounts of HAV genome equivalents. The longest duration of viremia was found in patients infected with HAV genotype IA.

Comparative analysis of viral pathogens and potential indicators in shellfish

Shellfish can be responsible of outbreaks of infectious diseases and current health measures do not guarantee the absence of viral pathogens in this product. Here we examine the presence of pathogenic viruses and potential indicators in shellfish in a comparative analysis.Sixty shellfish samples collected in three areas with different levels of faecal contamination were analysed for Escherichia coli, total coliforms, Clostridium perfringens, somatic coliphages, F-specific phages of RNA (F-RNA), bacteriophages infecting Bacteroides fragilis RYC2056, human adenovirus, enterovirus and hepatitis A virus (HAV). Viruses were eluted in a glycine buffer at pH 10. The overall percentage of viral pathogens detected was 47% for human adenoviruses, 19% for enteroviruses and 24% for HAV. Since all the samples positive for enterovirus and HAV were also positives for human adenovirus, the latter may be considered useful as a molecular index of viral contamination in shellfish. No significant differences in the bioaccumulation of bacteria and bacteriophages for oysters or mussels were observed. It was found that the probability of detection of any of the pathogenic virus decreases as the temperature of shellfish growing waters increases. However, the probability of detecting viruses increases when phages of B. fragilis are found. Although more data are needed in order to fulfil the need of viral indicators for controlling the presence of human viruses in shellfish, the obtained results indicate that phages infecting B. fragilis RYC2056 could be a suitable group of bacteriophages to be used as an indicator of the presence of viruses in shellfish.

Evaluation of potential indicators of viral contamination in shellfish and their applicability to diverse geographical areas

The distribution of the concentration of potential indicators of fecal viral pollution in shellfish was analyzed under diverse conditions over 18 months in diverse geographical areas. These microorganisms have been evaluated in relation to contamination by human viral pathogens detected in parallel in the analyzed shellfish samples. Thus, significant shellfish-growing areas from diverse countries in the north and south of Europe (Greece, Spain, Sweden, and the United Kingdom) were defined and studied by analyzing different physicochemical parameters in the water and the levels of Escherichia coli, F-specific RNA bacteriophages, and phages infecting Bacteroides fragilis strain RYC2056 in the shellfish produced, before and after depuration treatments. A total of 475 shellfish samples were studied, and the results were statistically analyzed. According to statistical analysis, the presence of human viruses seems to be related to the presence of all potential indicators in the heavily contaminated areas, where E. coli would probably be suitable as a fecal indicator. The F-RNA phages, which are present in higher numbers in Northern Europe, seem to be significantly related to the presence of viral contamination in shellfish, with a very weak predictive value for hepatitis A virus, human adenovirus, and enterovirus and a stronger one for Norwalk-like virus. However, it is important to note that shellfish produced in A or clean B areas can sporadically contain human viruses even in the absence of E. coli or F-RNA phages. The data presented here will be useful in defining microbiological parameters for improving the sanitary control of shellfish consumed raw or barely cooked.

Distribution of human virus contamination in shellfish from different growing areas in Greece, Spain, Sweden, and the United Kingdom

Viral pollution in shellfish has been analyzed simultaneously across a wide range of geographical regions, with emphasis on the concomitant variations in physicochemical characteristics and social features. The methods for sample treatment and for the detection of human enteric viruses were optimized by the participating laboratories. The second part of this study involves the selection of a protocol for virus detection, which was validated by analyzing the distribution and concentration of human viral pathogens under diverse conditions during an 18-month period in four European countries. Shellfish-growing areas from diverse countries in the north and south of Europe were defined and studied, and the microbiological quality of the shellfish was analyzed. Human adenovirus, Norwalk-like virus, and enterovirus were identified as contaminants of shellfish in all the participating countries. Hepatitis A virus was also isolated in all areas except Sweden. The seasonal distribution of viral contamination was also described. Norwalk-like virus appeared to be the only group of viruses that demonstrated seasonal variation, with lower concentrations occurring during warm months. The depuration treatments currently applied were shown to be adequate for reducing Escherichia coli levels but ineffective for the elimination of viral particles. The human adenoviruses detected by PCR correlate with the presence of other human viruses and could be useful as a molecular index of viral contamination in shellfish.

Depuration dynamics of viruses in shellfish

The consumption of shellfish has been associated with viral infections even in cases where shellfish complied with the current regulation, which is based on bacterial analysis. In this study, depuration rates of potential indicators and human viruses have been analysed in order to study the use of complementary parameters for evaluating the microbiological quality of depurated shellfish. Depuration of naturally highly polluted mussels has been evaluated and analyses for Escherichia coli, Clostridium perfringens, somatic coliphages, F-RNA phages and bacteriophages infecting Bacteroides fragilis RYC2056 and HSP40, human adenovirus, enterovirus have been done. Seawater of the depuration tank was disinfected by UV irradiation, ozone and passed through a skimmer and a biological filter. The correct functioning of the depuration tank was monitored by the quantification of total organic carbon (TOC), NH4+ and total aerobic bacteria in the seawater. To study the relation between the bacteriophages and the human viruses analysed, a logistic regression model was applied. F-RNA phages are significantly related to human adenoviruses and enteroviruses. Thus, they can be used as a complementary parameter for evaluating the efficiency of the depuration treatment. Somatic coliphages are also significantly associated with enteroviruses. Bacteriophages infecting B. fragilis HSP40 were analysed by the double-agar-layer (DAL) method, which quantifies infectious viruses, and by nested PCR, which detects the presence of the genome of these phages. The highest sensitivity of the molecular techniques was demonstrated and the results obtained are an indicator of a close relation between positive results by PCR and the presence of infectious viral particles in shellfish. All shellfish samples were negative for human viruses by PCR after 5 days of depuration treatment and the results obtained applying a regression model also showed negative results or nearly for F-RNA phages and bacteriophages infecting B. fragilis RYC2056. Thus, in this specific depuration treatment, 5 days may be necessary to assess the sanitary quality of shellfish.