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Frozen Berrygate

Dangerous Delights


Wednesday, June 12, 2013

The reason I love my job is its inherent unpredictability. I roll out of bed in the morning wondering what mysterious communicable disease will be thrown at me today. Novel avian virus? Tuberculosis meningitis? Peculiar anthrax specimen? I’ve developed a sort of gut instinct about which potential disease scenarios are real, and which are false alarms. That’s why last Friday, when I was first notified about a potential outbreak of Hepatitis A linked to berries from Costco, I noticed my gut instinct standing at attention.

The details were sketchy at first: frozen berries, hospitalizations, growing number of states – but as the picture solidified and we began receiving confirmation that this was no false alarm, public health sprang into action.

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Courtesy Photo

The contaminated product, it turned out, was the Townsend Farms brand Organic Antioxidant Blend of frozen berries sold at Costco. Eighty-seven cases of acute Hepatitis A Virus infection potentially linked to the frozen berries have now been confirmed across eight states. To date, there have been 38 confirmed cases in California alone and 45% of the patients have been hospitalized. The outbreak grew quickly, as they tend to do, as more members of the public learned about hepatitis symptoms and realized they may have been exposed.

When outbreaks like this unfold, my first job is to stop the bleeding. Within hours of notification, we dispatched inspectors from Environmental Health to Costco to ensure that the product was off the shelves. I quickly issued a provider alert to notify every medical provider in our county to be on high alert for patients with concerning symptoms and a history of eating the frozen berries. Immediately, our Disease Control program began receiving an onslaught of calls from concerned community members and providers. Could they have Hep A? Where could they get the vaccine? What about treatment? What symptoms would show up first?

In a communicable disease outbreak, particularly one where large quantities of tainted food are involved, public health has all hands on deck: Environmental Health does inspections and food quarantine, the Immunization Program coordinates vaccines, the microbiologists in the laboratory ramp up testing, Epidemiology tracks cases, and Disease Control – well, we run the show. We have a team of nerds and geeks (maybe the more appropriate term is experts and scientists) who literally sit around planning for the next outbreak, analyzing how we can do better or act faster. And if you think our team is eclectic, you should meet the Centers for Disease Control (CDC) folks. They picked up on the link between the emerging Hepatitis A cases and the Costco berries way before any of us had a clue. This is what they do best. This is the core of public health.

There are two unfortunate reasons why this Hepatitis A outbreak is particularly worrisome to me, despite our best efforts at containment. First, the unsuspecting folks who purchased the frozen berries probably didn’t eat the whole Costco-sized bag right away. If they are anything like me, they plopped it in their freezer and plan to use handfuls here and there over the coming months, as they make berry shakes or fruit toppings. This means there is a subset of the populations out there who will continue to develop Hepatitis A in the coming months (or year), and for this reason physicians must keep the virus on their radar even after the current media frenzy has subsided.

The second reason for worry in a Hepatitis A outbreak is the virus’s mode of spreading. “Fecal-oral transmission” is a fancy way of saying “poop to mouth,” as in tiny poop particles from one person (carrying the virus) get into the mouth of another person. Sound gross? It happens all the time. In fact, fecal-oral transmission is incredibly common among family members and is the mode of transmission for many other diseases we know and love, such as Giardia, Shigella, and C.diff. The problem with Hepatitis A is that the virus is shed in the stool a full two weeks before any symptoms develop; thus it silently passes among household members. It continues to be present in the stool as long as 10 weeks after symptoms develop, meaning on-going fecal-oral transmission. This is especially problematic in daycare settings where frequent diaper changes increase the chances of transmission, and many of the children aren’t old enough to have been vaccinated against the virus.

In my opinion, there are three take-home lessons from Berrygate.

One: the importance of a large public health infrastructure staffed with hypervigilant epidemiologists and microbiologists who pounced on the early evidence of something amiss in communicable disease-land. Two: Vaccination! Children whose parents follow medical advice and vaccinate against Hepatitis A are protected from the virus, regardless of how many berry shakes they ingest. Adults who choose to get vaccinated are protected as well. And three: the unpredictability of infectious disease outbreaks. For all our planning and strategizing, the truth is that nobody can predict when and where the next one will explode. Maybe that’s why infectious disease work is more of a thrill-seeking profession than most realize. If we can stay one step ahead of the virus (or parasite/ bacteria/ fungus), then we are doing our job. What an adventure it is.

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