An outbreak with at least 240 confirmed cases of the Hepatitis A virus originally thought to be confined to Italy is making a much larger footprint in Europe. There have been 240 cases of individuals who have not visited Italy associated with the outbreak in France, Germany, Ireland, Norway, the Netherlands, Sweden and the United Kingdom. Overall, there have been 1,315 Hepatitis A cases since Jan. 1, 2013, in the 11 European Union countries with cases. The likely source of the Hepatitis A outbreak was originally thought to be frozen berries, according to the European Food Safety Authority (EFSA). More recently, however, attention has focused on the potential for cross-contamination in food production equipment or even the possibility that the now-widespread strain was previously undetected. EFSA is leading the trace-back investigation in cooperation with EU countries, the European Center for Disease Prevention and Control, the European Commission and the Federal Institute for Risk Assessment. All 1,315 Hepatitis A cases could be part of the outbreak. The 240 confirmed cases share the same strain sequence and viral genome junction. The pathogen has a long incubation period – the time between exposure and the onset of illness – and EFSA says whatever food vehicle is involved has a long shelf life and a complex processing and distribution chain. This combination makes it likely that additional cases will be reported and the number of countries with cases may also expand. The investigation is using the EU’s Rapid Alert System for Food and Feed. The risk to human health and the geographic spread of ongoing transmission are both seen as increasing. Heat treatment of frozen berries and HAV vaccinations for those who work with them are among the recommendations EU health officials are making at this time. “A whole genome sequencing approach needs to be considered to examine viral isolates from different points in time during the outbreak in order to confirm the hypothesis of a single outbreak,” EFSA reports. A new risk assessment is expected to follow soon.