Ahead of Print -Underdiagnosis of Foodborne Hepatitis A, the Netherlands, 2008–20101 - Volume 20, Number 4—April 2014 - Emerging Infectious Disease journal - CDC

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Ahead of Print -Underdiagnosis of Foodborne Hepatitis A, the Netherlands, 2008–20101 - Volume 20, Number 4—April 2014 - Emerging Infectious Disease journal - CDC

Volume 20, Number 4—April 2014

Research

Underdiagnosis of Foodborne Hepatitis A, the Netherlands, 2008–20101

Article Contents

• Methods
• Results
• Discussion
• Acknowledgment
• References
• Table 1
• Table 2
• Table 3
• Table 4
• Suggested Citation

Mariska Petrignani , Linda Verhoef, Harry Vennema, Rianne van Hunen, Dominique Baas, Jim E. van Steenbergen, and Marion P.G. Koopmans

Author affiliations: Municipal Health Service Zoetermeer, Zoetermeer, the Netherlands (M. Petrignani, R. van Hunen);National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands (L. Verhoef, H. Vennema, D. Baas, J.E. van Steenbergen, M.P.G. Koopmans); Erasmus Medical Center, Rotterdam, the Netherlands (M.P.G. Koopmans); Leiden Medical University, Leiden, the Netherlands (J.E. van Steenbergen)

Suggested citation for this article

Abstract

Outbreaks of foodborne hepatitis A are rarely recognized as such. Detection of these infections is challenging because of the infection’s long incubation period and patients’ recall bias. Nevertheless, the complex food market might lead to reemergence of hepatitis A virus outside of disease-endemic areas. To assess the role of food as a source of infection, we combined routine surveillance with real-time strain sequencing in the Netherlands during 2008–2010. Virus RNA from serum of 248 (59%) of 421 reported case-patients could be sequenced. Without typing, foodborne transmission was suspected for only 4% of reported case-patients. With typing, foodborne transmission increased to being the most probable source of infection for 16%. We recommend routine implementation of an enhanced surveillance system that includes prompt forwarding and typing of hepatitis A virus RNA isolated from serum, standard use of questionnaires, data sharing, and centralized interpretation of data.

Hepatitis A virus (HAV) infection is an acute, usually self-limiting, illness; transmission is associated with suboptimal hygiene. Transmission occurs by the oral route, and infected persons can shed high amounts of infectious virus in their feces (1). Over recent decades, the incidence of HAV infections has been declining to a low level of transmission in high-income and middle-income countries. This epidemiologic shift results in a gradual shift in patient age and severity of first infection, from asymptomatic infections in very young children toward more severe illness in older children and adults. The World Health Organization estimates a case-fatality rate ranging from 0.1% for children <15 years of age to 2.1% for adults >40 years of age (2). As incidence of HAV decreases, the proportion of the population vulnerable to infection increases. Thus, paradoxically, hepatitis A virus could reemerge in regions where it is not endemic, affecting mostly adults. Risk for outbreaks with more severe illness becomes greater in countries where such epidemiologic transition has occurred.

In countries with low levels of HAV, the main risk comes from travel, secondary waves of transmission in households and schools, and (ongoing and sometimes epidemic) transmission among men who have sex with men (MSM) (3–11). However, the probable source of infection remains unknown for 20%–30% of cases, possibly because of transmission by persons with subclinical or missed primary cases, but alternatively because of food contamination. Although HAV is listed as the second most common foodborne virus (12), foodborne HAV infections are rarely reported, except when triggered by an unusual outbreak or event. In general, detection of a food source is difficult because the incubation period for hepatitis A is long (average 4 weeks); therefore, responses to food-consumption questionnaires, if administered, might be unreliable because of recall bias. Moreover, the food industry is a complex multinational system, and many high-risk products (shellfish, fresh or frozen fruits and vegetables) are produced in HAV-endemic countries. The common methods used for microbiological quality control of food do not reliably predict presence or absence of virus contamination (13). Virus contamination of high-risk foods is not uncommon; some of these products have a long shelf life as frozen or dried products in which HAV can survive for at least 2–3 months (14,15), and these products can be marketed over a wide geographic region. For these reasons, foodborne HAV infections are difficult to recognize.

These surveillance challenges might discourage physicians from trying to signal foodborne outbreaks. Large outbreaks are detected because of their large numbers. Slow and dispersed clusters can be detected through use of molecular typing, which enables linking of cases that otherwise could not be recognized as a cluster (16,17).

We assessed the role of food as a source of HAV in the Netherlands, a country with low-level endemic circulation of HAV. To do so, we conducted a 2-year study in which we combined detailed epidemiologic investigation with real-time strain sequencing for reported case-patients.

Dr Petrignani is a medical doctor who works as a liaison officer for the Dutch Center of Infectious Disease Control at the Municipal Health Service of Rotterdam. She is also a PhD candidate at the Erasmus Medical Center, Rotterdam. Her research interests are public health and infectious disease control.

Acknowledgment

We greatly appreciate the cooperation of all municipal health services and medical laboratories. In particular, we thank the team of the municipal health service Zoetermeer for their enthusiasm, support, and flexibility during data collection. We also thank Annelies Kroneman for help during startup of the project and Bas van der Veer and Jeroen Cremer for their devoted work on the serum.

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Tables

• Table 1. Hepatitis A virus transmission categories and supplementary public health actions, the Netherlands, 2008–2010
• Table 2. Description of reported patients with hepatitis A virus infection, by age group, the Netherlands, 2008–2010
• Table 3. Hepatitis A transmission modes, the Netherlands, 2008–2010
• Table 4. Hepatitis A virus transmission categories after typing of 42 cases previously assigned to transmission category “unknown,” the Netherlands, 2008–2010

Suggested citation for this article: Petrignani M, Verhoef L, Vennema H, van Hunen R, Baas D, van Steenbergen JE, et al. Underdiagnosis of foodborne hepatitis A, the Netherlands, 2008–2010. Emerg Infect Dis [Internet]. 2014 Apr [date cited]. http://dx.doi.org/10.3201/eid2004.130753

DOI: 10.3201/eid2004.130753

1Preliminary results of this study were presented at the 15th Annual Meeting of the European Society for Clinical Virology; 2012 September 4–7; Madrid, Spain.