Findings that a hepatitis A outbreak was linked to dates allowed action to be taken before the start of Ramadan, likely reducing the number of people affected, according to a study.

Public Health England (PHE) and the Food Standards Agency (FSA) are investigating the hepatitis A virus (HAV) outbreak linked to eating Medjool dates from Jordan. Since the start of this year, 30 people have fallen ill in different parts of England with one person sick in Wales.

Researchers said date consumption was likely to increase because of Ramadan, the ninth month of the Islamic calendar, which began in mid-April and ended in mid-May. Of those sick, 21 described their ethnicity as white British, five as white other and one as Asian. This information is not known for four people, according to the study published in the journal Eurosurveillance.

Dates are a popular food for breaking fast during Ramadan and sales rise during this period. Epidemiological analysis was done rapidly using a case-case method to allow control measures at the start of Ramadan.

No outbreaks in other countries
Scientists said there was concern the public health burden of the outbreak could escalate if there was a contaminated product that continued to be sold. Discussions by public health experts identified that washing fresh dates would not be sufficient to remove HAV contamination.

There are 31 cases with all infections but one /confirm/ied. They have a median age of 60 and range from 6 to 93 years old, and live in England and Wales with symptom onsets beginning Jan. 1. There are slightly more women affected with 17; and 25 patients were hospitalized but no-one has died.

Five secondary cases and 64 contacts of confirmed or probable patients were identified, of whom 10 were older than 60. HAV vaccination was arranged for eligible close contacts of sick people.

The study aimed to flag the possible risk of hepatitis A to those in other countries because of the consumption of contaminated dates because of Ramadan and the incubation period of hepatitis A which is 15 to 50 days.

Information sent via the International Health Regulations focal point and International Food Safety Authorities Network (INFOSAN) emergency contact has not revealed reports of similar outbreaks elsewher.

Food chain traceback
The Food Standards Agency identified two batch numbers and one common product linked to Sainsbury’s in the United Kingdom, from which 25 of 31 patients reported purchasing dates. The retailer had recently received stock from Jordan from a new supplier.

Dates from three patients underwent bacterial and viral contamination testing. Results showed two separate date packages from two different cases were positive for HAV. Both positive products were Taste The Difference Medjool Dates; one package was the only dates said to be consumed by one person, and the second pack was unopened and had been purchased in bulk at the same time as other dates that were consumed by this person.

Three people did not have dates and three reported only consuming dates purchased at other retailers, however for two cases, the dates traced back to the same producer of Taste The Difference Medjool Dates via a different firm who suspended supply.

Sainsbury’s withdrew the product from sale on March 31. After receiving results of the epidemiological investigation, the retailer issued a product recall on April 13. The grower listed on this product is Progressive Agricultural Investment Co.

Marks & Spencer recently recalled Stuffed Medjool Date selecion sold in 350-gram packages with a best-before of July 13. There are no confirmed links between patients and these dates.

Complexity of food supply chains has made it difficult to identify the potential source because most retailers use multiple suppliers, said researchers.

“While the recalled product is related to a large proportion of cases, there are cases who reported consuming dates only from other retailers. This poses a risk that contaminated products from the same grower may still be supplied to other retailers in the UK and internationally, although no other outbreaks have been reported yet,” according to the report.