After several years of decreasing trend, foodborne hepatitis A virus (HAV) infection has re-emerged as a public health problem in EU/EEA since 2011. Several consecutive multi-country foodborne HAV outbreaks were experienced in Europe 2012-2014.

1. Recurring hepatitis A outbreaks
in the EU/EEA: summary of the
recommendations
Johanna Takkinen, EPIET alumnus 1999 (cohort 5)
European Centre for Disease Prevention and Control
ESCAIDE, Stockholm, 12 November 2015

2. Hepatitis A – acute illness and virus
characteristics
 Faecal-oral transmission
 Relapses in about 15% of patients =>
prolonged disease course up to 6-9
months
 Asymptomatic or subclinical infection
mostly in children < 5 years
 Case-fatality low, < 0.5%
"HAV Infection" by GrahamColm at English Wikipedia.
Licensed under CC BY-SA 3.0 via Commons -
https://commons.wikimedia.org/wiki/File:HAV_Infection.png#
/media/File:HAV_Infection.png
 RNA virus in the family Picornaviridae
 High environmental persistence
 One serotype, genotypes I, II and III
of human origin
 Highly conserved => slow replication
pace
 High genetic diversity

3. ECDC 1st Annual Epidemiological Report,
covering data for 1995 - 2005
EU/EEA trend in 1995 – 2004:
Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/annual_epidemiological_report/Pages/2007_epi_report.aspx

4. Hepatitis A notifications in EU/EEA,
2010 – 2014*
*Unpublished data for 2014
Main risk groups:
- Intravenous drug users
- Homeless people
- Men having sex with men
- Travelling communities
Average EU/EEA notification rate
2.7 / 100 000 in 2010-2014

5. ”Cluster” of alerts in Epidemic Intelligence
Information System (EPIS) in 2013
Norway, 17 April 2013:
Germany, 8 May 2013:
Denmark, 1 March 2013:

6. Hepatitis A (IB, two strains) in Denmark, Finland,
Norway and Sweden, October 2012 – June 2013
(N=103)
Severi et al .The Lancet Infectious Diseases 2015
15, 632-634DOI: (10.1016/S1473-3099(15)00021-
3)
Vehicles of infection from
Egypt or Morocco:
EPIS & EWRS
ECDC-EFSA ROA*
*ROA = Rapid Outbreak Assessment

7. Hepatitis A (IB) in travellers returning
from Egypt, November 2012 – April 2013
(N=107, 14 countries)
mOR 10.1
(95%CI 1.1-93)
mOR 21
(95%CI 1.1-409)
fresh, in smoothies, pastries and fruit sauce
Vehicles of infection:
EPIS & EWRS
week 16
RRA*
week 17
*RRA = Rapid Risk Assessment
No vaccination in travellers!

8. Multi-state hepatitis A (IA) outbreak,
due to contaminated berries and travel to IT,
January 2013 – June 2014 (9 countries, finally 13 countries)
Source: EFSA report, Tracing food items in connection to hepatitis A, 2014
Vehicles of infection:
Mixed frozen berries
EPIS & EWRS
ECDC-EFSA ROA
1st update of ECDC-EFSA ROA
2nd update of
ECDC-EFSA ROA

9. Hepatitis A: seroprevalence in EU/EEA
1975 – 2014*
*ECDC: Hepatitis A virus in the EU/EEA, 1975-2014: a systematic review of seroprevalence and incidence comprising European Surveillance data and
national vaccination recommendations, expected publication in early 2016
1975 - 1989 1990 - 1999 2000 - 2013
WHO classification1:
I = Intermediate
L = Low
VL = Very low
1World Health Organization. WHO position paper on hepatitis A vaccine-June 2012. WER 2012; 28-29:
261-276. Available at: http://www.who.int/wer/2012/wer8728_29.pdf?ua=1
24 countries in EU/EEA have
very low seroprevalence profiles
(based on seroprevalence estimates at 15 and 30 years)

10. Hepatitis A: susceptibility profiles
in EU/EEA 2000 – 2014*
*ECDC: Hepatitis A virus in the EU/EEA, 1975-2014: a systematic review of seroprevalence and incidence comprising European Surveillance data and
national vaccination recommendations, expected publication in early 2016

11. Conclusions
 Sequencing of HAV strains crucial for outbreak detection and
investigation
 Centralised collection of sequences essential for hypothesis generation
 HAV sequencing practices vary by countries => comparison difficult
 Population at risk shifted from risk groups to EU general population
– Large variations in susceptibility by countries and regions
– Vaccine recommended for risk groups (e.g. travellers)
 Lack of vaccination in European travellers => risk perception low when
staying in luxury hotels even in endemic countries
 Collaboration worked well between national food safety and public health
authorities
 EFSA-ECDC (risk assessors) and Commission (risk manager) worked too
much in silos
– Delay in the start of an EU-wide trace-back investigation
 Invaluable support to all investigations received from EPIET/EUPHEM
fellows in the field
– EPIET/EUPHEM vision fulfilled; a network of
epidemiologists/microbiologists using common language and tools

12. Recommendations and
actions (to be) taken
 A common sequencing protocol prepared in RIVM by
HAVNET
 Promotion of centralised sequence data collection is needed
=>HAVNET is a recommended centralised database for
HAV sequences in Europe
 A review of seroprevalence and susceptibility of EU
populations by countries is needed to assist countries in
their assessment on appropriateness of vaccination
practices
=>Prepared by ECDC and expert panel, report to be
published in early 2016
 Increasing importance of berries as vehicle of HAV infection
 EU-wide trace-back investigation should be initiated faster
=> Regular communication between Commission and
ECDC-EFSA is needed in a multi-state foodborne outbreak
event

13. Acknowledgements
Ettore
Severi
Jussi Sane
Julita Gil
Cuesta
Emily
MacDonal
d
Sofie
Gillesberg
Lassen
Pieter
Smit
Max
Gertler
Anneke
Steens
Michael
Edelstein
Line Vold
Bernardo
Guzman-
Herrador
Bolette
Søborg
Ruska
Rimhanen
-Finne
Martina
Escher
Margot
Einöder-
Moreno
Heidi
Lange
Margaret
Fitzgerald
Justina
Rogalska
Rita da
Sousa
• Jussi Sane (EPIET) and Rita de Sousa
(EUPHEM)
• All epidemiologists and virologists
in affected countries that
participated in investigations
• Harry Vennema /HAVNET/RIVM
• ECDC staff
• Ettore Severi
• Lara Tavoschi
• Celine Gossner
• Pier Luigi Lopalco
• Paloma Carrillo-Santisteve
• Marion Muehlen
• Aftab Jasir
• Yvan Huitin
• Denis Coloumbier
• EFSA staff
• Jane Richardson
• Olaf Mosbach-Schulz
• Pia Mäkelä
• Commission
• Klaus Kostenzer
19 fellows involved!

14. Multi-state hepatitis A outbreak
due to contaminated berries and travel to IT,
January 2013 – June 2014 (9 countries, finally 13 countries)
Source: EFSA report, Tracing food items in connection to hepatitis A, 2014
Vehicles of infection:
Mixed frozen berries
EPIS & EWRS
ECDC-EFSA ROA
1st update of ECDC-EFSA ROA
2nd update of
ECDC-EFSA ROA
ECDC-EFSA-MS-EC TC

15. Thank you for your attention!
Contact ECDC FWD team: fwd@ecdc.europa.eu
ECDC website: www.ecdc.europa.eu