At least 1,444 cases of Hepatitis A were reported in 12 European countries in connection with a variety of mixed berry products last year, according to the final outbreak report by the European Food Safety Authority (EFSA). The first signs of the outbreak emerged in May 2013, when Germany reported seven infections in people who had recently traveled to ski resorts in northern Italy. Soon after that, Italy reported a heightened number of Hepatitis A infections at a national level and declared an outbreak. Ultimately, 90 percent of the cases were reported in Italy. Of those 1,444 total reports, 331 were confirmed via laboratory testing in a number of countries, including France, Sweden and the United Kingdom. Hepatitis A is a contagious liver disease caused by the Hepatitis A virus and is usually spread when a person ingests food or water contaminated with infected fecal material. Most illnesses are mild and those sickened recover within a few weeks, but acute illness can persist for months and lead to serious medical complications or even death. EFSA said that no deaths were reported in connection to the outbreak, but it’s impossible to rule out any deaths due to limitations in Hepatitis A surveillance systems. Eighty percent of interviewed victims reported eating mixed berries or berry products during a relevant exposure period. “It is important to note that the exposure to berries may have been underestimated, owing to recall bias caused by the long interval between exposure and onset of symptoms/diagnosis and the fact that berries may be a minor ingredient or used as a decoration in food,” the report states. Health authorities identified 16 Hepatitis-contaminated lots of frozen berries or berry products via subsequent laboratory testing. Officials found dozens of other lots connected to at least one reported illness. All lots of berries considered highly probable to be associated with the outbreak contained blackberries, while the majority also contained red currants. Bulgaria was the most commonly sourced area for blackberries, though not all of the blackberries associated with the outbreak came from Bulgaria. The majority of associated red currants came from Poland, though EFSA noted that Poland has a better infrastructure for tracing data on products compared to many other countries. EFSA’s report concludes with two possible explanations for the outbreak’s origins: 1. There could have been a single point source for the outbreak, but not enough information from berry processors to confirm it. 2. There may be some high-risk practice involved in the process of freezing berries that exposes product to Hepatitis A contamination, or the seasonal workers at multiple production locations are exposed to a higher risk of contamination. In the end, authorities were lacking too much information about berry production methods in various countries and the prevalence of Hepatitis A in those areas. “Further local investigations are necessary to identify whether a single point source or a continuous source of contamination exists,” the report concludes. In 2013, more than 150 people in the U.S. fell ill with Hepatitis A linked to frozen berry mix processed by Townsend Farms and sold at Costco and Harris Teeter stores. The source of that contamination was ultimately traced back to pomegranate seeds from Turkey.