International travel is the principal risk factor for hepatitis A virus (HAV) infection in the U.S., usually acquired by ingestion of contaminated water or uncooked food in a country with medium-to-high HAV endemicity. Since 1996, the CDC has recommended that susceptible persons traveling to such countries receive pre-exposure prophylaxis before departure, regardless of their length of stay or accommodations. In April 2015, the New York City and Rhode Island health departments notified CDC of acute hepatitis A cases among travelers to Tulum, Mexico. We sought to identify additional cases and factors associated with infection.
Acute cases among travelers to Tulum from multiple states were identified after an alert to the CDC foodborne listserv was issued. Health department officials collected information from travelers regarding demographics, travel dates, food history, and lodging.
Twelve U.S. states identified 29 cases of acute hepatitis A among persons who returned from travel to Tulum, Quintana Roo, Mexico that occurred between January 5, 2015 and March 20, 2015. The median age of cases was 34 years (range=21-53), 14 (50%) were female, and all were white, non-Hispanic. The onset of illness of the cases ranged from February 12, 2015 to April 16, 2015, and averaged 27 days (range=20-41) after departure from Mexico. Seventeen (63%) cases reported staying at 9 resorts located within 6 kilometers of each other. Twenty-three cases (79%) reported consuming seafood and 18 (62%) cases reported consuming ceviche, which is raw seafood cured in lime juice. Ten cases (34%) reported consuming seafood at restaurants associated with resorts, 3 had eaten at non-resort restaurants. None of the cases had received hepatitis A vaccination prior to travel.
Adherence to long-standing recommendations for hepatitis A vaccination of travelers to countries endemic for hepatitis A would have prevented this outbreak. It is important to inform travelers to any destination in Mexico or other HAV-endemic locales that the risk for infection is incurred through consumption of contaminated drinking water and uncooked foods, including condiments made with fresh ingredients, particularly raw fruits, vegetables, and shellfish.
K. Spruit-Mcgoff, None
V. Reddy, None
J. Skidmore, None
M. Fonseca-Ford, None
E. Villarino, None