Division of Disease Control and Health Protection

Date: April 19, 2000

From: Hepatitis Branch

Division of Viral and Rickettsial Diseases, NCID

Subject: Hepatitis A associated with consumption of frozen strawberries

To: State and Territorial Epidemiologists

State and Territorial Public Health Laboratory Directors

SENT BY FAX and E-MAIL

There has been a recent cluster of cases of hepatitis A in Massachusetts linked to the consumption of commercially processed frozen strawberries. Information on the harvesting, processing and distribution of the potentially contaminated frozen strawberry products is currently being investigated by the Food and Drug Administration, and will be provided in a separate communication when available.

The Boston Communicable Disease Control Division and the Massachusetts Department of Public Health are investigating 7 cases of acute hepatitis A among persons who attended an ice cream party at a hospital cafeteria on February 11 and 12, 2000. Foods served at the event included commercially prepared ice cream, and a variety of toppings including frozen strawberries, whipped cream, candies, nuts, and cherries. All 7 persons with hepatitis A became ill between March 7 and March 21, 2000. No ill food handlers have been identified, and all are negative for IgM antibodies to hepatitis A virus.

A case control study that included all cases and 38 well controls who ate at the ice cream party indicated that eating frozen strawberries was the only food associated with illness (OR 36.4, 95% CI 3.8-infinity). All cases ate frozen strawberries at the party.

Because no known food handlers have evidence of infection, and because the event reportedly involved little hand contact with the food served, contamination of the frozen strawberries likely occurred at some point during harvest, processing or distribution.

This investigation is ongoing and these findings should be considered preliminary. We are requesting that state and local health departments look at their hepatitis A reporting and be on the lookout for recent hepatitis A clusters or unexplained increases in cases that could be associated with the consumption of frozen strawberries. In such instances, recently identified cases of hepatitis A should be asked about frozen strawberry consumption, including frozen strawberries consumed in commercial or institutional settings. Serum specimens from persons with hepatitis A during the acute phase of their illness (e.g., the first diagnostic specimen) who report frozen strawberry consumption should be saved (frozen) for possible viral sequencing studies. Please contact Dr. Stephanie Bialek of the Hepatitis Branch at CDC (404 371 5910), SBialek@CDC.gov, for additional information and assistance.

Anthony Fiore, M.D., M.P.H.

Medical Epidemiologist, Hepatitis Branch

Mailstop G37

Centers for Disease Control and Prevention

Atlanta, GA 30333

Cases of serogroup W-135 in association with the Haj in Saudi Arabia have been reported throughout Europe, including the United Kingdom, France, and Germany, with a total so far of 24 cases. These reports are of cases of W-135 among pilgrims returning from the Haj or their close contacts. Saudi Arabia requires meningococcal vaccine for all entering pilgrims, but the vaccine varies by country. Since the quadrivalent A/C/Y/W-135 vaccine is the only vaccine licensed in the U.S., most U.S. pilgrims probably have received this vaccine and therefore are protected. Most other countries use a bivalent A/C meningococcal vaccine which would not protect vaccinees. It is possible that some U.S. pilgrims were vaccinated in other countries with a bivalent vaccine and the vaccine is not 100% protected. Further, since the polysaccharide vaccine does not provide protection against carriage, close contacts of returning Hajjis may still be at risk. CDC is very interested in hearing about any cases of W-135, which is typically rare in the U.S, or any cases of illness consistent with meningococcal disease among returning Hajjis or their close contacts. Also, CDC would be very interested in molecular subtyping of the isolates so please save any isolates that are related to their cases.

On April 12th, the Meningitis Special Pathogens Branch, NCID, CDC notified the EIN regarding meningococcal illness due to serogroup W135 in travelers to Saudi Arabia for the Haj, the annual pilgrimmage to Mecca. The number of reported cases has risen from 24 to 38 (including 21 known family contacts) from the United Kingdom, France, Germany, Pakistan, and the Netherlands. All occurred since March 21, 2000. There have been at least 7 fatalities.

Two recent cases of group W135 meningococcal disease have been identified by the New York City Department of Health, Communicable Disease Program (212-788-9830); one is a returning pilgrim, and the second is a close family contact of a returning pilgrim. These represent the first known American cases associated with this outbreak. We appreciate the participation so far from EIN members for this.

While all pilgrims to Mecca are required to be vaccinated against Neisseria meningitis, bivalent vaccines administered overseas do not cover group W135 strains, and no vaccine eliminates carriage and transmission of the bacterium to household contacts.

Please:

1) Notify your state and local health department of all cases of meningococcal disease

2) Report any case of meningococcal disease in a person returning from Saudi Arabia to the Meningitis and Special Pathogens Branch, NCID, CDC by phone (404-639-3158) or fax (404-639-3059).

3) Report any case of meningococcal disease in a person who is a close contact of someone returning from Saudi Arabia

4) Report any cases of serogroup W-135 meningococcal disease that might

be related to recent travel to the Middle East or Africa.

5) Save and send Neisseria meningitidis isolates from the types of cases

described above.

6) Inform colleagues treating travelers from Saudi Arabia about the

possibility of meningococcal meningitis in their patients.

Thank You,

Meningitis and Special Pathogens Branch

National Center for Infectious Diseases, CDC

Long in advance of the second Sunday in each May, the florists, the telegraph companies and the greeting card concerns all tell us that it will soon be mother’s day. We see advertisements in papers and magazines, in shop windows and other prominent places, admonishing us to "Remember Mother." Accompanying these advertisements, there usually is a picture of a nice, comfortable-looking mother, verging on middle age. But the picture and the slogan rarely bring to mind the picture of mothers, especially young mothers, struggling to bring forth a new life into this world; mothers dying because they do not know the simplest hygienic measures of pregnancy; mothers who become invalids for life because they have borne a child; mothers who bring forth diseased and sickly children – no we do not think of these as we see the sweet, gray-haired women of the magazine advertisements…

The real tragedy in maternal deaths is that so many of them are not necessary; that just a little knowledge might have saved a life…. We as public health nurses, by persistent teaching, can do much to reduce maternal mortality. This must involve not only the teaching of the prospective mothers themselves – and fathers, too - and the imparting of concrete information, but must also include appreciation of what constitutes good medical and nursing care.

Would you believe that the poorest and most illiterate man in the swamps and backwoods of Florida can be taught to made his home a habitable place in which to live? That his wife can be taught the meaning of cleanliness and the care of herself and family before and after her children are born? That [because] the materials [are] near at hand and theirs for the taking, their home can be transformed from a hovel into a palace to them out of a few discarded boxes, a little paint, a few nails and some effort? That they can be taught that the health and comfort of their children and themselves is paramount to their happiness?

It is said that people are more eye-minded that ear-minded …With this is mind the Florida State Board of Health has available for lending to Directors of County Health Units and public Health Nurses, various types of equipment with which to demonstrate the many articles that can be made with the resources at hand…

Would you believe that a baby’s slat bed can be made out of discarded boxes, short lengths of lumber, (many times given away as too small to sell ), five cents’ worth of small nails, two sets of screws costing five cents and two metal strips to hold the mosquito netting for twenty-five cents and the paint for ten cents, making a total of forty-five cents?

Would you believe that the fluff from "Cattails" found growing in almost every county in Florida could be used for making a baby’s mattress after it had been baked in a warm oven to kill insects? By the way, this cattail fluff is much like kapok.

Would you believe that Florida moss when cured makes a comfortable mattress, using flour sacking for ticking? That a homemade bed-bath stand can be made of discarded wooden boxes and scrap lumber? That and improvised bed pan (12 "x 17") can be made from a biscuit pan, costing from ten to fifteen cents, and a section of prune box with a little paint? An ordinary bed pan when purchased costs about two dollars and a half.

Would you believe that baby’s improvised potty can be made from a cigar box and an empty coffee can, and that mothers are being taught to begin to teach their children to use the potty when just a few weeks old?

Flour sacks have become an important factor in the homes of many Florida families and the thin ones are used for babies' dresses and petticoats. Even if you paid a dollar a yard for it you could not get anything softer for a new baby’s delicate skin. Burlap sacks (feed sacks) can be made into expensive looking coat suits and sport dresses. The uses to which these crude articles can be put are being taught to many people of our State by showing them a finished article and explaining the way in which it is made. To see and touch the original of the article to be made has been found the simplest method of teaching most people.

It is known that Florida has the unenviable reputation of leading every State but one in its high maternity death rate. The care of the mother before the birth of her child and the care of her baby is being particularly stressed. The significance of proper lighting, cleanliness and sanitation is taught to mothers through demonstrations with miniature model houses and articles.

Cattle are dipped for ticks – hogs are treated for cholera – what is your county doing to reduce the maternal and infant death rate?