Hepatitis A virus (HAV) causes acute inflammatory hepatic infections in humans. Transmission occurs primarily via the faecal-oral route through contaminated food or water or person-to-person spread [1]. While the disease is often asymptomatic or mild in younger children, it can cause debilitating symptoms and fulminant hepatitis in adults. After an abrupt onset with fever, malaise and abdominal discomfort, jaundice is the predominant symptom. The average incubation period is 28 to 30 days (range: 15–50) with maximum infectivity during the latter half of the incubation period, i.e. while being asymptomatic [1]. HAV retains infectivity after freezing and can persist in the environment, being able to withstand food-production processes routinely used to inactivate bacterial pathogens [2].
Direct or indirect detection of HAV infection in humans is notifiable in Germany to local public health authorities (LPHA), which transmit case reports electronically via the state level to the national public health institute (Robert Koch Institute, RKI). The case definition of hepatitis A in place for surveillance purposes in Germany is: a symptomatic disease (defined as one or more of the following: fever, abdominal discomfort, increase of serum transaminases, jaundice), plus laboratory confirmation (i.e. detection of HAV nucleic acid or HAV-specific IgM or a distinct increase of HAV-IgG concentrations). Symptomatic cases with an epidemiological link to a laboratory-confirmed hepatitis A case also fulfil the case definition. Forwarding of HAV-reactive serum or stool samples from diagnosing laboratories to the National Consultant Laboratory for HAV for sequencing is voluntary, and is intensified during outbreaks.
In 2016, the European Union/European Economic Area (EU/EEA) incidence of hepatitis A was 2.4 cases per 100,000 population; the highest incidences were in eastern EU countries, while HAV infections in other EU/EAA regions were mostly associated with infections acquired abroad [3]. Like most high-income countries, Germany is a low-incidence country with a median hepatitis A incidence of 1.02 per 100,000 inhabitants between 2010 and 2018. The median hepatitis A incidence in Berlin, Germany is slightly higher (1.79/100,000 in 2010–2018). European outbreaks of hepatitis A among men who have sex with men caused higher case numbers in Berlin and the EU/EEA in 2017 [4,5]. Recently, several hepatitis A outbreaks associated with frozen berries have been described in Europe [6,7].
This HAV subgenotype IB strain has previously caused outbreaks in Sweden (June–July 2018) and Austria (July–September 2018) [8], comprising a total of 34 reported cases. Combined epidemiological and microbiological outbreak investigations identified imported frozen strawberries produced in Poland as the vehicle. In Sweden, the HAV outbreak strain was detected in frozen strawberries and the contaminated batch was withdrawn from the Swedish market. Trace-back investigations from both Sweden and Austria identified Polish producer Y as the source for the implicated frozen strawberries.
Shortly after outbreak control in both countries, cases with the identical virus sequence started to appear in Germany in October 2018. The Federal Office of Consumer Protection and Food Safety (BVL) and all federal public health authorities were informed about this by the RKI and sequencing of samples of autochthonous hepatitis A cases was intensified.
Here we describe the results of the epidemiological investigation of an outbreak of hepatitis A in Germany presenting in two waves, one in 2018 and another in 2019.
