Multistate foodborne hepatitis A outbreak among European tourists returning from Egypt– need for reinforced vaccination recommendations, November 2012 to April 2013

A multistate outbreak of hepatitis A virus (HAV) among European travellers returning from Egypt occurred between November 2012 and April 2013. A total of 14 European Union (EU)-European Free Trade Association (EFTA) countries reported 107 cases. Twenty-one cases from six countries were affected by strains of sub-genotype IB harbouring identical RNA sequences, suggesting a common source outbreak. An international outbreak investigation team interviewed a number of cases with a trawling questionnaire to generate hypotheses on potential exposures. Some of these exposures were further tested in a case-control study based on a more specific questionnaire. Both trawling and case-control questionnaires aimed to collect cases' vaccination details as well as epidemiological information. Most cases participating in either questionnaire (35/43) had been staying in all-inclusive hotels located along the Red Sea. The case-control study found cases associated with exposure to strawberries or mango (multivariable analysis p value: 0.04). None of the 43 cases interviewed in any of the two questionnaires had been vaccinated. The most common reasons for non-vaccination was unawareness that HAV vaccination was recommended (23/43, 53%) and perceiving low infection risk in all-inclusive luxury resorts (19/43, 44%). Vaccination had not been recommended to five of the six cases who sought travel medical advice before travelling. Public health authorities should strongly reinforce measures to remind travellers, travel agencies and healthcare providers of the importance of vaccination before visiting HAV-endemic areas, including Egypt. .