A multistate, foodborne outbreak of hepatitis A. National Hepatitis A Investigation Team

N Engl J Med. 1999 Feb 25;340(8):595-602. doi: 10.1056/NEJM199902253400802.


Background: We investigated a large, foodborne outbreak of hepatitis A that occurred in February and March 1997 in Michigan and then extended the investigation to determine whether it was related to sporadic cases reported in other states among persons who had consumed frozen strawberries, the food suspected of causing the outbreak.

Methods: The cases of hepatitis A were serologically confirmed. Epidemiologic studies were conducted in the two states with sufficient numbers of cases, Michigan and Maine. Hepatitis A virus RNA detected in clinical specimens was sequenced to determine the relatedness of the virus from outbreak-related cases and other cases.

Results: A total of 213 cases of hepatitis A were reported from 23 schools in Michigan and 29 cases from 13 schools in Maine, with the median rate of attack ranging from 0.2 to 14 percent. Hepatitis A was associated with the consumption of frozen strawberries in a case-control study (odds ratio for the disease, 8.3; 95 percent confidence interval, 2.1 to 33) and a cohort study (relative risk of infection, 7.5; 95 percent confidence interval, 1.1 to 53) in Michigan and in a case-control study in Maine (odds ratio for infection, 3.4; 95 percent confidence interval, 1.0 to 14). The genetic sequences of viruses from 126 patients in Michigan and Maine were identical to one another and to those from 5 patients in Wisconsin and 7 patients in Arizona, all of whom attended schools where frozen strawberries from the same processor had been served, and to those in 2 patients from Louisiana, both of whom had consumed commercially prepared products containing frozen strawberries from the same processor.

Conclusions: We describe a large outbreak of hepatitis A in Michigan that was associated with the consumption of frozen strawberries. We found apparently sporadic cases in other states that could be linked to the same source by viral genetic analysis.

MeSH terms

  • Adolescent
  • Base Sequence
  • Case-Control Studies
  • Child
  • Disease Outbreaks* / statistics & numerical data
  • Female
  • Frozen Foods / virology*
  • Fruit / virology*
  • Hepatitis A / epidemiology*
  • Hepatitis A / virology
  • Hepatovirus / genetics*
  • Hepatovirus / isolation & purification
  • Humans
  • Maine / epidemiology
  • Male
  • Michigan / epidemiology
  • Odds Ratio
  • RNA, Viral / genetics
  • Sequence Homology, Nucleic Acid
  • Seroepidemiologic Studies
  • United States / epidemiology


  • RNA, Viral