The number of Hepatitis A outbreak victims in Hawaii has topped 200 and health officials expect that number to continue to increase. As of Wednesday’s weekly update, 206 people have been confirmed in the outbreak, with 51 having had symptoms so severe that they had to be hospitalized, according to the Hawaii Department of Health. In its initial outbreak report July 1, department officials said there were 12 cases. Genki SushiMonday evening, state health officials ordered 11 Genki Sushi locations on two islands to close because of a link between outbreak victims and frozen, imported scallops served raw at the restaurants. The state also embargoed scallops distributed by Koha Foods of Honolulu. The raw, frozen scallops were imported to the U.S. from the Philippines by Sea Port Products Corp., a California business. Now, Hawaii’s health officials are relying on help from the public to continue the investigation into other possible sources. About 70 percent of the victims reported eating at a Genki Sushi restaurant on Oahu or Kauai, state epidemiologist Sarah Park said Tuesday during a news conference. “We are looking for individuals who ate at Genki Sushi after April 23, 2016, and have not been ill with Hepatitis A,” according to the state’s Wednesday outbreak update. “Your assistance is extremely important. We are using this survey to obtain contact information for individuals who would be willing to participate in the study. Selected individuals will be contacted by phone in the next one (to) two weeks and interviewed about particular foods eaten at Genki Sushi.” The survey is voluntary. For those selected for interviews, it should take about 30 minutes. Personal information will be kept confidential and will not be shared outside of the investigative team. Park and other Hawaii health department officials said they expect additional outbreak victims to be confirmed because of the long incubation for Hepatitis A, which usually doesn’t cause symptoms for 15 days after exposure and can take up to 50 days to develop. Of the 206 victims so far, illness onset dates range from June 16 through Aug. 9. Sea Port Products Corp. productsOne of those victims, Oahu resident Brant Mauk, is suing the restaurant chain well as food distributor Koha Foods and importer Sea Port Products Corp. The lawsuit, filed in Hawaii’s 1st Circuit Court, does not specify damages. Mauk developed the flu-like symptoms that typify a Hepatitis A infection in late June, after having eaten at Genki Sushi in previous weeks. Lab work confirmed Hepatitis A on July 5 and he was admitted to a hospital July 7, where he had to stay seven days, according to the lawsuit. His recovery is ongoing. “The scallops’ manufacturing defects and insufficient warnings were the direct, proximate and producing cause of Mauk’s injuries,” according to the complaint filed by Michael F. O’Connor of the firm Ogawa, Lau, Nakamura & Jew, and food safety advocate William D. Marler, managing attorney at Marler Clark LLP in Seattle. More outbreaks predicted Marler, who is publisher of Food Safety News, has been an advocate for the requirement of Hepatitis A vaccination in food service workers for several years. He said this week that he expects more Hepatitis A infections. “The reach and extent of this outbreak is unfortunate, but unsurprising when vaccines aren’t required for food workers,” said Marler. “If policies on vaccination don’t change, this won’t be the last major outbreak we see.” The Hawaii health department’s sanitation branch chief, Peter Oshiro, also predicted more outbreaks, but for a different reason. “We have to go into these things with our eyes open,” Oshiro said during the Tuesday news conference. “These things are going to continue to happen as long as people eat raw food.” Oshiro said he himself enjoys sushi and other raw foods. “It’s the culture, right? It tastes good. I eat it. I like it,” Oshiro said Tuesday. However, he added, the only way to avoid some foodborne pathogens is to eat only throughly cooked foods. He said a new placard system in effect in Hawaii requires notices on menus and certain foods intended to be consumed raw to warn the public of the inherent dangers. Recommendations for the public The Hawaii health department is encouraging people to consider getting vaccinated for Hepatitis A. A list of vaccinating pharmacies is on the department’s website. vaccination list with needleThe two-shot protocol, which must be injected six months apart, has been part of routine childhood vaccinations for a number of years, but adults over 40 likely have not been vaccinated. The vaccine was approved for use in the U.S. in 1995. All 206 victims in the current outbreak have been adults. “Vaccination for Hepatitis A is strongly recommended for certain individuals who are especially at risk  — see here for a CDC list of groups recommended to be vaccinated for Hepatitis A,” health officials said in Wednesday’s outbreak update. “Hawaii residents are also advised that the demand for the vaccine during the outbreak has led to varied supply levels around the state, so it is recommended that they call ahead to assure the vaccine is available at a particular clinic or pharmacy before going there.” While the Hepatitis A virus is frequently transmitted via the fecal-oral route by inadequate hand washing practices, it can survive in frozen food products and in fresh or salt water for months. It primarily infects the liver, causing sudden onset of flu-like symptoms about a month after exposure. The illness usually lasts a few weeks, but recovery can take up to a year. Most people show complete recovery within three to six months. (To sign up for a free subscription to Food Safety News, click here.)