Editor’s note: This is the companion story of a two-piece news package we are presenting today. The main story describes the ongoing, multi-state outbreak of Hepatitis A and how states are addressing it. Most case counts in both stories are as of April 30. However, some of the main outbreak states have since updated their counts, which are not reflected on accompanying maps.

Food-related outbreaks of Hepatitis A are often associated with contamination of food during preparation. That can happen when a foodservice worker is infected by the highly contagious liver disease.

Person-to-person transmission of Hepatitis A occurs via the “fecal-oral route,” meaning infected food handlers who don’t practice good enough hand-washing techniques can contaminate the foods and beverages they prepare or serve. And, because the peak time of infectivity usually occurs a couple of weeks before symptoms appear, food handlers often don’t even know they are infected and therefore continue to work.

Food handlers include people who stock produce aisles in grocery stores and those who maintain self-serve snack and beverage machines in convenience stores and gas stations.

Hepatitis A symptoms may not occur until several weeks after exposure and may include abdominal discomfort, fever, malaise, muscle aches and a yellowing of the skin called jaundice. In severe cases, Hepatitis A causes liver failure and death.

While the Centers for Disease Control and Prevention recommended in 2006 that all children 1 to 2 years old be vaccinated, the CDC has not recommended Hepatitis A vaccinations for food service workers.

Some local public health officials have hosted vaccination clinics for restaurant workers in recent months as reports of infected foodservice workers, but the vaccination is not required by federal or state laws..

One Hepatitis A-positive foodservice worker can infect large numbers of customers and cause thousands of others to seek preventive vaccines. Illnesses and vaccines can cost thousands if not millions of dollars, and can cost restaurants its viability either by a downturn in customers or civil lawsuits.

All of this is preventable by a vaccine.

Food Safety News contacted health officials in each of the 50 states asking about the incidence of Hepatitis A cases. Not all states provided all of the information requested. Most gave only “preliminary” counts for 2017 and 2018.

Alabama: 23 cases in 2017; three so far this year. The numbers are consistent with previous years. No probable source has been determined and no link found to state with Hep A outbreaks.

Alaska: Zero cases in 2017. That’s normal.

Arizona: 59 cases in 2017; eight so far this year; not unusual. In 2017, the CDC confirmed a 12-person outbreak associated with an Arizona homeless shelter was the same from the strain responsible for the outbreak in San Diego.

Arkansas: 8 cases in 2017; 13 so far this year (*new data 4/30); numbers are a little higher than usual, mostly due to person-to-person spread. The state is investigating but officials say they haven’t found links between Arkansas cases and other outbreaks.

To view a larger version of this map, please click on the image. Graphic by Kelsey Mackin

California: 919 for 2017; numbers are dropping in 2018, but public health officials did not give a number. The number of cases reported in 2017 was substantially higher than in previous years due to widespread infections among homeless and/or substance abusers. The original source for the outbreak has not been identified. However, once introduced, Hepatitis A virus spread very fast in people with limited access to restrooms and hand-washing facilities.

San Diego, Santa Cruz, Monterey and Los Angeles counties have declared local outbreak status, and outbreak-associated cases have been confirmed in other California jurisdictions.

Here’s a county-by-county breakdown for 2017: San Diego 586 cases, with 401 people hospitalized and 20 dead; Santa Cruz 76 cases, 33 hospitalized, 1 dead; Los Angeles 12 cases, 8 hospitalized, none dead; Monterey, 12 cases, 10 hospitalized, none dead; other counties, 17 cases, 8 hospitalized; none dead. Total: 703 cases, 460 hospitalized, 21 dead.

Colorado: 63 cases in 2017; five so far this year; higher than usual, and officials say about a third of the cases were from transmission between men who have sex with men. Twenty cases were identified in this population, which is an increase compared to previous years.

Two cases occurred in persons who were homeless; other cases likely were due to international travel and exposure to household members who were infected. Two cases in 2017 and one in 2018 are linked to outbreaks in homeless populations in other parts of the country.

Several 2017 Colorado cases that occurred in men who reported having sex with men had the same molecular sequence seen in several New York City male cases who reported having sex with men.

Connecticut: 17 cases in 2017; four so far this year; not unusual. Risk factors were normal, and no link was established to outbreaks elsewhere.

Delaware: Six cases in 2017, two so far in 2018; not unusual. Probable source has not been determined. Delaware has one case that was linked to an outbreak in the Baltimore area involving men who have sex with men.

Florida: 275 cases in 2017; 42 so far in 2018. The numbers represent an increase over previous years, but seem to be dropping in 2018. Most cases are defined as sporadic and not linked to other known cases.

Georgia: 24 cases in 2017; seven so far this year; not unusual. Patient interviews are attempted for all cases, but are not always successful in determining source or risk factors. One case involved a Michigan resident who got sick and was diagnosed while visiting Georgia and one case was in a South Carolina resident; neither of those cases is included in Georgia’s count. In previous several years, 25 to 30 percent of patients who were interviewed traveled internationally and were not vaccinated.

Hawaii: Eight cases for 2017, none so far this year. Two were matched to California outbreak. Others were unrelated to outbreak or to each other.

Idaho: Five cases in 2017; three so far this year; lower than usual. One 2017 case and one 2018 case were associated with international travel. It is suspected that one case in 2017 and in 2018 are linked to the multi-state outbreak, which includes Utah.

Indiana: 20 cases in 2017; 71 so far this (*New data May 4); higher than normal. Person-to-person transmission is the likely source for most of these cases, and risk factors include the usual ones. Many of the 2018 cases have been tied to the multi-state outbreak, which includes Kentucky.

Iowa: nine in 2017; one so far this year. No other information was available.

Kansas: Six in 2017; two so far this year. No other information was available.

To view a larger version of this map, please click on the image. Graphic by Kelsey Mackin

Kentucky: 341 in 2017 with 238 hospitalizations and four deaths. Statewide outbreak was declared November 2017. Viral sequencing has linked several cases in Kentucky with the multi-state outbreak. The 10-year average in Kentucky has been about 20 cases per year. In April, public health officials urged people to get vaccinated. The state is requiring that all public school students who are not already vaccinated get the vaccine before the beginning of the 2018-19 school year.

Louisiana: eight cases in 2017. Other information not available.

Maine: Seven cases in 2017, two so far in 2018; not abnormal. No single common point of origin and no link to outbreaks in other states.

Maryland: 29 confirmed cases in 2017; 10 so far this year. In 2017, more than 50 percent of the confirmed cases had no specific source identified; 25 percent reported international travel as a source of infection; some cases were genetically matched to strains circulating in New York and parts of Europe; and other confirmed cases matched to a strain circulating in Colorado; one of those Maryland patients had traveled to—and was potentially infected in one of the outbreak states.

Michigan: 632 in 2017; 112 so far this year. The state had 802 cases from Aug. 1, 2016, to April 4, 2018, with 25 deaths. Between 2011 and 2015, 327 Hepatitis A cases were reported. This is the largest outbreak in the state’s history. Transmission appears to be through direct person-to-person spread.

Minnesota: For 2017, 30 cases; four so far this year; higher than past three years, but within typical range over past 10. Minnesota has determined a source for some but not all of its cases. The most common risk factor is travel outside of the U.S., and public health officials say the cases are not linked to recent outbreaks.

Missouri: 27 in 2017; 73 so far in 2018; higher than normal. Public health officials say the cases are due to an outbreak in Missouri and don’t believe they are associated with outbreak cases elsewhere.

Mississippi: Did not respond.

Montana: three cases in 2017; none so far this year; normal. Foreign travel is most common risk factor. No connection to outbreaks in other states.

Nebraska: Seven cases in 2017, three so far this year; not abnormal. No known connection to outbreak states.

Nevada: Twenty cases in 2017; five so far this year. This represents a slight uptick. None has been linked to outbreaks elsewhere.

New Mexico: zero cases in 2017 and so far this year.

New York: 82 cases in 2017. Numbers for this year were not provided. Numbers exclude New York City. Sequencing analysis available for some cases demonstrated that some are linked to outbreaks in other states.

North Dakota: zero in 2017; two in 2008, 13 in 2009; two in 2016. No other information available.

Ohio: 46 cases in 2017, 31 so far this year; higher than normal. Some cases linked to those in Michigan and Kentucky

Rhode Island: Six cases in 2017; one so far this year; normal. One case was associated with incarceration in San Diego County, as well as food service employment in LA County, and could possibly be linked to the California outbreak.

South Carolina: 21 cases in 2017; one so far this year; not abnormal. Exact source generally not known.

Tennessee: seven cases in 2017; six so far this year; not unusual. One case got the infection in Michigan.

Texas: Information not available.

Utah: 149 cases in 2017; 68 so far this year; state typically sees fewer than 10 each year, and those are usually associated with travel or other risk factors. Several cases have been linked by investigation and/or viral sequencing to national outbreak of Hepatitis A.

Washington: 27 cases in 2017; 10 so far this year; not abnormal; no clusters. A few cases had exposure while visiting outbreak areas. None of the cases were homeless and no evidence of ongoing person-to-person transmission.

Washington D.C.: one in 2017; none this year. Not abnormal. No link to other outbreaks.

West Virginia: Six cases in 2017 and 17 so far this year; slightly higher than normal. Source yet to be determined, but is likely caused by person-to-person spread. Some cases reported visiting a restaurant that employed a reported Hepatitis A-positive food service worker. One case has been confirmed to be genetically linked to the multi-state outbreak occurring in other states.

Wisconsin: 16 cases in 2017; lower than normal. In six of the 2017 cases, the infection was acquired via travel outside the USA; three cases were likely from visits to states where known large outbreaks were. Numbers likely reflect known outbreaks in California, Michigan, Kentucky and Utah, combined with the mobility of the population.

Wyoming: 18 cases in 2017; four so far this year, sigjnificant increase because of an outbreak in Natrona County. Usual occurrence is two cases each year.

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