Infected food handlers led to an outbreak of hepatitis A in Ernakulam district, Kerala, Southern India, 2016

Abstract Objective Integrated Disease Surveillance Programme (IDSP) of Ernakulam district of Kerala, India received reports of a cluster of acute jaundice on 26th November 2016 at Panchayath A. We investigated to identify the agent, source and propose recommendations. Method We defined a probable case as acute onset of jaundice with or without malaise, anorexia, fever, dark urine among residents of Panchayath A, Ernakulam district, since 2nd week of November 2016. Result A total of 385 cases (Attack rate: 8/1000) and 3 deaths (Case fatality ratio: 0.8%) were reported from 45th week of 2016 to 1st week of 2017. The attack rate was highest among men (83%) and those aged 16–30 years (61%). The cases were clustered in ward 3 of the Panchayath, where a hotel was situated. Most case-patients interviewed (84%) stated that they dined at that hotel. The index case was a construction worker who resided with hotel staff and subsequently reported illness. We confirmed HAV IgM in all specimens tested. HAV was associated with consumption of lemon juice [OR = 17.1; 95% CI: 3.8–76.7; PAF = 61%] and drinking water [OR: 15.3; 95% CI: 3.7–63.2; PAF = 66%] at the hotel. Conclusion Consumption of lime juice prepared by infected food handlers led to outbreak of hepatitis A. We recommended safe food preparation, drinking boiled water and super-chlorination of wells.