CDC Report - Hepatitis A Cases Among Food Handlers as All Those Infected with Hepatitis A

In a CDC report, investigators looked at the uptick of Hepatitis A in many states across the country.  Those regarded as high risk is where "infections are spreading primarily through close contact among persons who use drugs and persons experiencing homelessness, as well as among men who have sex with men (MSM)"  Of interest in the report was the percentage of food handlers, and overall, the percentage of cases associated with food handlers was low (3.8%).  Looking at food handlers, a high percentage of them were people in the high risk - people use drugs, have unstable housing or are homeless, are active in MSM, or had been incarcerated.

From the report, "Among 22,825 hepatitis A outbreak cases reported from these 26 states during July 1, 2016–September 13, 2019, 871 (3.8%) were among food handlers; 587 (67.4%) hepatitis A–infected food handlers reported one or more risk factors (i.e., drug use, unstable housing or homelessness, MSM, or incarceration) during the 15–50 days before symptom onset. "

https://www.cdc.gov/mmwr/volumes/69/wr/mm6920a4.htm
Notes from the Field: Assessing the Role of Food Handlers in Hepatitis A Virus Transmission — Multiple States, 2016–2019
Weekly / May 22, 2020 / 69(20);636–637
Megan G. Hofmeister, MD1; Monique A. Foster, MD1; Martha P. Montgomery, MD1; Neil Gupta, MD1 (View author affiliations)

Hepatitis A Cases Linked to Fresh Blackberries

A hepatitis A outbreak has been "potentially linked" to blackberries sold by the Fresh Thyme grocery store chain.  To date, there have been 11 cases with 6 hospitalizations in 3 states - Indiana, Nebraska, and Wisconsin.    However, the distributor to Fresh Thyme distributes product in 11 states - Iowa, Illinois, Indiana, Kentucky, Michigan, Missouri, Minnesota, Nebraska, Ohio, Pennsylvania and Wisconsin.  While this product was purchased in the month of September (between September 9 and 30), there is concern that the product may have been frozen by some customers.

One would guess that someone involved in harvesting and/or initial distribution would have had the illness.

https://www.cnn.com/2019/11/21/health/blackberries-hepatitis-a-outbreak-trnd/index.html
Hepatitis A outbreak 'potentially linked' to blackberries from Fresh Thyme stores, officials say
By Harmeet Kaur, CNN
Updated 4:41 PM ET, Thu November 21, 2019

Frozen Berries Recalled After Sample Tested Positive for Hepatitis A

Wawona Frozen Foods is voluntarily recalling packages of frozen raspberries and frozen berry mixes containing raspberries sold at Aldi Grocery Stores and frozen raspberries sold at Raley's Family of Fine Stores because they have the potential to be contaminated with Hepatitis A.  Wawona Frozen Foods is issuing this voluntary recall out of an abundance of caution due to a positive test result taken as part of a government sampling program.  There have been no reported illnesses

https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/wawona-frozen-food-voluntarily-recalls-frozen-raspberries-due-possible-health-risk
Wawona Frozen Food Voluntarily Recalls Frozen Raspberries Due to Possible Health Risk
Summary
Company Announcement Date: October 30, 2019
FDA Publish Date: October 31, 2019
Product Type: Food & Beverages Fruit/Fruit Product
Reason for Announcement: Potential to be contaminated with Hepatitis A
Company Name: Wawona Frozen Foods
Brand Name: Season’s Choice, Raley’s
Product Description: Frozen raspberries, frozen berry mixes

CDC Reports Increasing Number of Hepatitis A Cases Across Country

Hepatitis A viral infection has been on the upswing across the country.  Since March of 2016, there have been 24,280 cases reported with 14525 hospitalizations and 236 deaths.  The numbers have been especially high in those who are homeless/have unstable housing or those using drugs.  Pennsylvania has had 376 of those cases while Ohio has had 3244 cases.

This increased level can put a lot of pressure on the foodservice sector, especially in the larger cities where establishments may be more likely to hire those those considered high risk for contracting the illness or have more interaction.

https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm
Widespread outbreaks of hepatitis A across the United States
Since March 2017, CDC’s Division of Viral Hepatitis (DVH) has been assisting multiple state and local health departments with hepatitis A outbreaks, spread through person-to-person contact.

At a Glance
Since the outbreaks were first identified in 2016, 29 states have publicly reported the following as of August 16, 2019

• Cases: 24,280
• Hospitalizations: 14,525 (60%)
• Deaths: 236

Frozen Blackberries Recalled Due to Potential for Hepatitis A

FDA issued a consumer alert for frozen blackberries potentially contaminated with hepatitis A virus (HAV).    The notice states, "At this time, the FDA and the Centers for Disease Control and Prevention (CDC) are not aware of any cases of hepatitis A linked to the consumption of Kroger Private Selection brand frozen blackberries."  Although nothing was stated, this indicates that someone who handled the product in the up-stream supplier chain had been diagnosed with Hepatitis A.

Kroger issued a recall for the frozen blackberries and the Triple Berry Medley.  The product was sold at Kroger stores.  Costco also recalled product that was shipped to 5 states.

The concern is that if the infected person contaminated the berries when handling the product, even a small amount on the frozen berries could make someone ill.   Of course, many of the berries would be eaten in the raw form.

https://www.fda.gov/food/alerts-advisories-safety-information/public-health-alert-concerning-hepatitis-virus-contamination-kroger-brand-frozen-blackberries
Public Health Alert Concerning Hepatitis A Virus Contamination of Kroger Brand Frozen Blackberries
June 7, 2019

Hepatitis A Case in Philly Grocery Worker Highlights Need for Controls

A Hepatitis A-infected food handler working in a Philadelphia grocery store triggered an alert for those who may have purchased pre-cut RTE fruits and vegetables.  This case is one of an increasing number of Hepatitis A cases seen.   Philadelphia Health Department noted that they are seeing 5 times the number of cases over the 2016 baseline.  While many of these cases are associated with people who are homeless or are drug users, it still increases the risk for food operations in that workers may face increased exposure within the community.

Therefore, it is important for food operations to maintain control including educating workers of the importance of reporting illness or potential exposure. Proper handwashing and glove use are important mitigations against the spread of the disease.

Hepatitis A is a highly infectious virus that is easily spread from an infected person to others through person-to-person contact or person-to-food-to-person.  Once exposed, it takes approximately 6 weeks to see the symptoms, jaundice and fever, but a person can be administered a vaccine within the first two weeks immediately after the exposure event.

Philly.com
https://www.philly.com/health/hepatitis-a-foodborne-illness-acme-philadelphia-health-inspection-reports-20190411.html
After hepatitis A warning at Philly Acme, should you eat precut fruits and veggies?
by Mari A. Schaefer, Updated: April 11, 2019

FDA Issues Alert on Marshmallow-Dipped Candy Products After Worker Diagnosed with Hepatitis A

FDA issued a health alert for Bauer's Candies Modjeska (individually wrapped marshmallow-dipped in chocolate or caramel candies) after a worker tested positive for Hepatitis A.  Although this warning was issued last month, there does not appear to be a recall posted on the FDA website.

Hepatitis A can last for extended periods of time (testing is difficult to determine) on food and food contact surfaces, so it can be expected that if the virus was present on the product it could be transmitted to food.

This example demonstrates the need to have employee health controls in place, including instructing workers to notify management if they have, or have been exposed, to the virus, or have the symptoms.

As a customer, I would be completely ticked off if I had contracted Hepatitis A from chocolate covered marshmallows.  I don't even care for chocolate covered marshmallows which even make it even worse.

From Wikipedia - A Modjeska is a confection consisting of marshmallow dipped in caramel. It was created in the 1880s in Louisville, KY by confectioner Anton Busath to honor Shakespearean actress Helena Modjeska, who was performing there at the time. Other Louisville shops began to make versions of the candy, which continues to be popular in the region today.  Helena Modjeska (October 12, 1840 – April 8, 1909), whose actual Polish surname was Modrzejewska (Polish pronunciation: [mɔdʐɛˈjɛfska]), was a renowned actress who specialized in Shakespearean and tragic roles. (Pic below)

https://www.fda.gov/Food/RecallsOutbreaksEmergencies/SafetyAlertsAdvisories/ucm627841.htm
Public Health Alert Concerning a Possible Hepatitis A Contamination of Bauer’s Candies’ Modjeskas
12/06/2018

Kentucky - Fast Food Worker May Have Exposed Patrons to Hepatitis A

In Kentucky, a fast food worker at a McDonald's restaurant may have worked while infectious with Hepatitis A.  Those patrons who ate at that McDonalds need to now watch for the symptoms as short window for vaccination with immunoglobulin (<2 weeks) has passed.
More on Hepatitis A transmitted by food from CDC.

http://www.madisoncountyhealthdept.org/
Health Department Investigating Hepatitis A Case in a Food Handler

FOR IMMEDIATE RELEASE
Contact: Jim Thacker PIO 859-626-4259
April 12, 2018. Richmond/Berea, KY.

Import Alert Concerning Imported Frozen Tuna Steaks With Hepatitis A

FDA issued an import alert for frozen tuna steaks from Vietnam and Indonesia.   According to the import notice - " FDA believes that Hepatitis A Virus contaminated seafood is a result of insanitary conditions in the production or packing facilities, e.g., poor worker hygiene, inadequate worker sanitation facilities, and/or contaminated water supply."

FDA Import Alert
https://www.accessdata.fda.gov/cms_ia/importalert_1157.html
Import Alert 16-137

Published Date: 12/13/2017
Type: DWPE
Import Alert Name:
DETENTION WITHOUT PHYSICAL EXAMINATION OF SEAFOOD DUE TO HEPATITIS A CONTAMINATION

Three Hepatitis A Issues from Across Country

There are some Hepatitis A outbreak events worth noting.

• First is a case in Alabama where a pizza delivery person has been diagnosed.  People who have purchased pizza from this establishment have been asked to get a vaccine.
• In San Diego, CA, a huge outbreak of Hepatitis A has close to 500 infected but has had a huge impact among the homeless population.  Vaccines have been given at local parks, a place where the homeless my frequent.
• In SE Michigan, more than 300 have become infected, including at least one food worker.

ABC 33 Alabama
http://abc3340.com/news/local/hepatitis-a-virus-found-in-anniston-food-handler
Vaccines recommended after Anniston restaurant worker tests positive for Hepatitis A
by James Franklin| [not the football coach]
Wednesday, October 11th 2017

Frozen Strawberries from Egypt Linked to 134 Hepatitis A Cases

In early September, an outbreak of Hepatitis A linked to frozen strawberries was identified.  As of October 20th, there are 134 cases identified all linked to frozen strawberries served in smoothie drinks (fresh blended fruit and vegetable drinks) served at Tropical Smoothie Cafes.

The frozen strawberries were sourced from Egypt.  FDA issued an import alert for detention without physical inspection of frozen strawberries from Egypt, even though the Egypt Ministry of Climate Change and Environment "claimed Frozen Egyptian strawberries are free from Hepatitis A..".

 

FDA Release

 http://www.fda.gov/food/RecallsOutbreaksEmergencies/Outbreaks/ucm518775.htm

FDA Investigates Outbreak of Hepatitis A Illnesses Linked to Frozen Strawberries

October 20, 2016

Hepatitis A in Frozen Strawberries Infects 89 People

CDC reported that 89 people contracted Hepatitis A from frozen strawberries.  The outbreak was initially reported two weeks by the Virginia Department of Health.  In most all cases, the infections were linked to the strawberries being served in smoothie drinks served by Tropical Smoothie Café.

Smoothies, the blending of fruits and vegetables into a nutritious yet tasty beverage, can be an issue if any of the fruit and vegetable ingredients harbor pathogenic bacteria.  The risk can be made worse if the smoothie product is temperature abused.  The hard part when buying from a commercial smoothie producer is knowing where they source their ingredients.  In the past, had been an issue pomegranate sourced from the middle east.  That too was a source of Hepatitis A.
 

CDC Outbreak
http://www.cdc.gov/hepatitis/outbreaks/2016/hav-strawberries.htm
August 2016 - Multistate outbreak of hepatitis A linked to frozen strawberries
Posted September 8, 2016 10:15 AM ET

At a Glance

Case Count: 89

States: 7

Deaths: 0

Hospitalizations: 39

Hepatitis A Outbreak Link to Frozen Strawberries from Egypt

The VA Department of Health issued a health warning about a cluster of hepatitis A cases and has identified a potential association with frozen strawberries used in smoothies from Tropical Smoothie Cafe restaurants in Virginia.  The frozen strawberries came from Egypt.

This is not the first time that frozen fruit sourced from the Middle East has been a problem for Hepatitis A.   In 2013, frozen pomegranate seeds were linked to a Hepatitis A outbreak  where over 150 were infected.  Smoothies are an issue because there is no elimination step such as heating.  Any contamination on the fruit gets blended into the drink.

Virginia Department of Health News Release
http://www.vdh.virginia.gov/news/public-relations-contacts/news-releases/2016-statewide-news-releases/health-officials-warn-of-increased-hepatitis-a-risk/
Health Officials Warn of Increased Hepatitis A Risk
August 19, 2016

Hepatitis Outbreak in Hawaii Linked to Raw Scallops

Raw sea scallops served at a sushi restaurant in Hawaii are being blamed for over 200 cases of Hepatitis A.  This is one of the largest Hepatitis A cases in the US in the last 20 years.

While sushi grade seafood must be frozen in order to kill parasites, this freezing process will not eliminate bacteria and viruses. 

The scallops are reported to have been sourced from the Philippines.

Hawaii Dept of Health

http://governor.hawaii.gov/newsroom/latest-news/doh-news-release-hawaii-department-of-health-orders-embargo-of-frozen-imported-scallops-and-closure-of-genki-sushi-restaurants-on-oahu-and-kauai/

DOH NEWS RELEASE: Hawaii Department of Health orders embargo of frozen imported scallops and closure of Genki Sushi restaurants on Oahu and Kauai

Hepatitis A Outbreak Linked to Frozen Berries - Canada

An outbreak of Hepatitis A in Canada has been linked to bags of mixed frozen berries.  From the label on the package, it appears that the berries are, at least in part, imported berries.

How does this occur?  Most likely an infected worker handling the fruit, probably at the point of harvest or initial processing, would have contaminated the fruit.  Because the fruit is often used without any further processing, there is no point for reduction of the virus. 

How can it be prevented?  This is a RTE product.  So strategic sourcing is critical.  Have the farms implemented GAP procedures, especially those controls for farm employee health and exclusion of ill employees?  This can be a more difficult issue with Hepatitis A where an employee can be contagious and not yet show signs of illness. 

This has not been the first issue associated with frozen fruit products, so this indicates that there is more work to do with sourcing fruit from farms with good practices.

What is the impact?  Hepatitis A is highly infectious.  There is a period of time, about two weeks, from when a person is exposed where a vaccination can be helpful.  The challenge is getting word out to those who purchased product.  Once infected, the symptoms can vary from fever, low appetite, nausea, vomiting, diarrhea, muscle aches, to jaundice.  Long term liver damage can be a risk for those high risk individuals.
 
The Star (Canada)
 http://www.thestar.com/news/canada/2016/04/19/recalled-costco-frozen-berries-linked-to-13-cases-of-hepatitis-a.html
Recalled Costco frozen berries linked to 13 cases of Hepatitis A
Store is offering vaccinations to those who may have eaten its Nature’s Touch Organic Berry Cherry Blend that was recalled Saturday by the Canadian Food Inspection Agency.

By: The Canadian Press, Published on Tue Apr 19 2016

Fast Food Worker in NY Positive for Hepatitis A

A McDonald's worker in Seneca, NY has been diagnosed with Hepatitis A and may have spread that virus to coworkers and patrons during the time before the diagnosis.

Seneca County NY News Release
http://www.co.seneca.ny.us/
Hepatitis A Confirmed in Seneca County Food Worker

 The Seneca County Health Department has confirmed a case of Hepatitis A in a food service worker employed at the McDonalds located at 2500 Mound Rd. Waterloo, NY. Public health officials are stressing there is a low risk of contracting illness, however, individuals who have not been previously vaccinated for Hepatitis A and who consumed food/drink from McDonalds on the following dates should consider treatment. 

Patrons of SC Fast Food Establishment Exposed to Hepatitis After 2 Employees Test Positive

Thousands of people were potentially exposed to Hepatitis A after eating at one of two Hardees fast food restaurants in South Carolina.  Notification of the potential exposure was broadcast after two employees had tested positive for the virus.

According to reports, some 5000 people had already been vaccinated. There is a window from the time of exposure to about 2 weeks out when a vaccination can prevent the disease. As we know,  Hepatitis A is a highly contagious liver infection caused by the Hepatitis A virus. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months.

A lawsuit has already been filed for those 'who may have been infected".

Food operations, especially those who work with ready-to-eat foods, should institute a Food Workers Health Hygiene Program.  Information is available from FDA as well as many state government websites.

WSPA.com
http://wspa.com/2015/09/18/hepatitis-a-exposure-at-2-spartanburg-co-hardees/
Possible Hepatitis A Exposure at 2 Spartanburg Co. Hardee’s
DHEC Published: September 18, 2015, 5:27 pm Updated: September 20, 2015, 8:45 pm 

For customers and staff who ate at either of these restaurants between Sep. 6 and 15, there is still time to get post-exposure treatment (the vaccine).

This first date will change daily (for e.g., for Monday, it will be Sep. 7 and 15) to reflect the 2 week post-exposure treatment window.

Hepatitis Outbreak in NJ Sends People Running to Get Vaccinated

A Hepatitis A infected kitchen worker at a New Jersey restaurant has caused hundreds to get vaccinated.  However, at this point, the only person to  be diagnosed is that employee.


CBS Philadelphia
http://philadelphia.cbslocal.com/2014/12/04/as-hundreds-try-to-avoid-become-sick-from-exposure-to-hepatitis-a-in-a-popular-nj-restaurant-health-officials-fear-2nd-person-has-the-virus/
Health Officials Rule Out Possible Second Case Of Hepatitis A In Hamilton Township, NJ
December 4, 2014 5:10 PM

By Cleve Bryan

HAMILTON Twp., NJ (CBS) – Fear of contracting hepatitis A drove hundreds of people to a vaccination clinic Thursday after learning a kitchen worker at Rosa’s Restaurant and Catering is severely ill from the virus and may have been contaminating customer’s food for weeks.

Pizza worker diagnosed with Hepatitis A potentially exposes thousands to the virus

A North Carolina Papa John's foodservice worker was diagnosed with Hepatitis A, this after he worked for about 2 weeks.  During that time, some 2,400 orders were placed (at 4 people per pie, and each order was at least one pie, that could potentially mean about 10,000 people have been exposed).

There is a long delay from the time someone who is exposed with Hepatitis A until they see symptoms.  And in this case, it took even longer from the time he had symptoms until the time he was diagnosed.

This worker had traveled overseas and probably contracted the disease during that trip.

It is important for those who have been exposed to get vaccinated, especially those who are more susceptible.

A few interesting notes form the CDC website.

• Hepatitis A is a contagious liver disease that results from infection with the Hepatitis A virus. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months. Hepatitis A is usually spread when a person ingests fecal matter — even in microscopic amounts — from contact with objects, food, or drinks contaminated by the feces, or stool, of an infected person.
• If you were recently exposed to Hepatitis A virus and have not been vaccinated against Hepatitis A, you might benefit from an injection of either immune globulin or Hepatitis A vaccine. However, the vaccine or immune globulin must be given within the first 2 weeks after exposure to be effective.
• The Hepatitis A virus is extremely hearty. It is able to survive the body’s highly acidic digestive tract and can live outside the body for months. High temperatures, such as boiling or cooking food or liquids for at least 1 minute at 185°F (85°C), kill the virus, although freezing temperatures do not.
• Some people get Hepatitis A and have no symptoms of the disease. Adults are more likely to have symptoms than children.   If symptoms occur, they usually appear anywhere from 2 to 6 weeks after exposure.  Symptoms usually develop over a period of several days. Symptoms usually last less than 2 months, although some people can be ill for as long as 6 months.
• Almost all people who get Hepatitis A recover completely and do not have any lasting liver damage, although they may feel sick for months. Hepatitis A can sometimes cause liver failure and death, although this is rare and occurs more commonly in persons 50 years of age or older and persons with other liver diseases, such as Hepatitis B or C.
• There are no special treatments for Hepatitis A. Most people with Hepatitis A will feel sick for a few months before they begin to feel better. A few people will need to be hospitalized. During this time, doctors usually recommend rest, adequate nutrition, and fluids.  Alcohol [unfortunately] should be avoided.
• Anyone traveling to or working in countries with high rates of Hepatitis A should talk to a health professional about getting vaccinated. Hepatitis A vaccine is highly effective in preventing Hepatitis A virus infection. Protection begins approximately 2 to 4 weeks after the first injection. A second injection results in long-term protection.

Charlotte Observer
http://www.charlotteobserver.com/2014/04/10/4832499/officials-papa-johns-worker-contracted.html#.U0fpe6PD99A

Officials: Mecklenburg Papa John’s worker contracted hepatitis A
By Karen Garloch The Charlotte Observer
Posted: Thursday, Apr. 10, 2014
Modified: Thursday, Apr. 10, 2014

Mecklenburg County health officials are urging customers who ate food from a Papa John’s restaurant in the northeast part of the county from March 28 to April 7 to get a hepatitis A vaccine.

A worker at the restaurant, at 8016 Cambridge Commons Drive, became ill March 24 but wasn’t diagnosed until April 7 after he was hospitalized. The Health Department learned of his illness Wednesday, according to Health Director Dr. Marcus Plescia.

155 ill from Hepatitis A in pomegranate used in frozen berry mix

The CDC reports that 155 people in 9 states have become ill from hepatitis A after eating frozen mixed berries with 67 people that had been hospitalized. The source of the Hepatitis A was the pomegranate seeds which were imported from Turkey. 

The outbreak was first reported at the end of May, with cases beginning in April and extending into July. The reason is that symptoms do not occur for 2 to 6 weeks after exposure, and then those symptoms can last 2 to 6 months. Symptoms include fever, fatigue, nausea, vomiting, dark urine, and of course, jaundice . Although most people recover, it can cause liver failure in more susceptible individuals (elderly, people with liver disease) .

The organic frozen berry mix was sold by an Oregon company, Townsend Farms, and distributed through Costco. The blend is produced using fresh fruit and then is bought and used fresh by customers to make smoothies and other fruit drinks. So if Hepatitis A is present on the incoming ingredients, it will not be eliminated by processing (viruses will easily survive freezing), and then end up in product the consumer eats. With the long delay in seeing symptoms, it is easy to see why so many may have become infected.

The strain of Hepatitis A is found primarily in North Africa and the Middle East, and one of the ingredients, pomegranate seeds, is said to come from Turkey.

Food safety is important for ingredients used in products that will be used in RTE (ready-to-eat) applications, This is especially difficult when those ingredients are purchased in international markets. If this company lives up to the promise posted on their website, they should have no problems working back to the source of the issue. Unfortunately, this is not the first time berries have been involved in outbreaks. Earlier this year, there was an outbreak in Europe (71) and another in Canada (8). The Canadian product contained pomegranate. So at this point, if a company is using pomegranate, it may be good to stop using it until the safety can be verified. As a consumer, I would forgo my pomegranate-containing smoothie.



Multistate outbreak of hepatitis A virus infections linked to pomegranate seeds from Turkey
Posted July 30, 2013 9:15 AM ET
http://www.cdc.gov/hepatitis/Outbreaks/2013/A1b-03-31/


CDC is collaborating with public health officials in several states and the US Food and Drug Administration (FDA) to investigate a multistate outbreak of hepatitis A virus infections. Results from the ongoing investigation are highlighted below.

Epidemiologic Investigation:

· As of July 29, 2013, 155 people have been confirmed to have become ill from hepatitis A after eating ‘Townsend Farms Organic Antioxidant Blend’ in 9 states: Arizona (23), California (76), Colorado (27), Hawaii (8), New Hampshire (1), New Mexico (9), Nevada (6), Utah (3), and Wisconsin (2). [Note: The cases reported from Wisconsin resulted from exposure to the product in California, and the cases reported from New Hampshire reported fruit exposure during travel to Nevada.]

o 86 (55%) ill people are women
o Ages range from 1 – 84 years;
  -  87 (56%) of those ill were between 40 – 64 years of age.
  -  11 children age 18 or under were also ill. None were previously vaccinated.
o Illness onset dates range from 3/31/2013 – 7/14/2013
o 67 (43%) ill people (all over 18 years of age) have been hospitalized, and no deaths have been reported
o All ill people who reported eating this product purchased it from Costco markets; however, the product was also sold at Harris Teeter stores. No ill people have been identified that bought the product at Harris Teeter at this time.
 o CDC continues to track hepatitis A cases in all states and test specimens in order to determine if any other cases are related to this outbreak.