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Probable Nipa Palm Wine-Associated Hepatitis A Outbreak after Attending a Funeral Ceremony in Sabah

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  • 1 Sabah State Health Department, Ministry of Health, Kota Kinabalu, Sabah, Malaysia;
  • | 2 Department of Pathobiology and Medical Diagnostics, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia;
  • | 3 Institute of Medical Research, Ministry of Health, Jalan Pahang, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia;
  • | 4 Aimst University, Bedong, Kedah, Malaysia;
  • | 5 Beaufort Health Office, Ministry of Health, Pekan Beaufort, Beaufort, Sabah, Malaysia;
  • | 6 Papar Health Office, Ministry of Health, Bandar Papar, Papar, Sabah, Malaysia;
  • | 7 Borneo Medical and Health Research Centre, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia

ABSTRACT.

Foodborne outbreaks of hepatitis A virus (HAV) are most commonly associated with fresh and frozen produce and with various types of shellfish. Alcoholic beverage-borne outbreaks of hepatitis A are extremely rare. Here, we report an outbreak of hepatitis A associated with the consumption of a traditional wine at a funeral ceremony in the Sabah state of Malaysian Borneo. Confirmed cases were determined by serum anti-HAV immunoglobulin M and/or for fecal HAV by reverse transcription polymerase chain reaction (RT-PCR). The amplicons of RT-PCR were subjected to nucleotide sequencing followed by phylogenetic analysis. We conducted a 1:2 case–control study to identify the possible exposure that led to the outbreak. Sixteen patients met the case definition, they were 18 to 58 years old and 90% of them were males. The case–control study showed that the consumption of nipa palm wine during the ceremony was significantly associated (P = 0.0017) with hepatitis A infection (odds ratio, 5.44; 95% CI, 1.80–16.43). Untreated river water was used to dilute the traditional wine, which was assumed to be the source of the infection. Phylogenetically, these viruses belonged to genotype IA and formed an independent cluster with strains from Taiwan, Japan, and the Philippines. This strain might be an emerging HAV in Asian countries. Environmental assessments were performed and environmental samples were negative for HAV. The incidence of hepatitis A in Sabah was also determined and it was 0.795/100,000 population. Strict monitoring of traditional wine production should be implemented by the local authority to prevent future outbreaks.

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Author Notes

Address correspondence to Kamruddin Ahmed, Department of Pathobiology and Medical Diagnostics, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, 88400 Kota Kinabalu, Sabah, Malaysia. E-mail: ahmed@ums.edu.my

Financial support: The investigation was undertaken within the Ministry of Health activities and supported by Launching Grant for Centre of Excellence from Universiti Malaysia Sabah (Grant Number: AM 18006).

Authors’ addresses: Muhammad Jikal, M. Hafiz Mukhsam, Ismail Ali, and Esther Bernad, Sabah State Health Department, Ministry of Health, Kota Kinabalu, Sabah, Malaysia, E-mails: drmj70@gmail.com, hafizz_mhm@yahoo.com, drismailali@moh.gov.my, and oharaeb@gmail.com. Daisuke Mori and Kamruddin Ahmed, Department of Pathobiology and Medical Diagnostics, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia, E-mails: daisuke.mori.0128@gmail.com and ahmed@ums.edu.my. Ahmad Faudzi Yusoff, Institute of Medical Research, Ministry of Health, Jalan Pahang, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia, E-mail: faudziyusoff@gmail.com. Sarawasthi Bina Rai, Aimst University, Bedong, Kedah, Malaysia, E-mail: binarai@yahoo.com. Liza Abd Latif, Cynthia C. E. Bailon, and Lim Guan Lee, Beaufort Health Office, Ministry of Health, Pekan Beaufort, Beaufort, Sabah, Malaysia, E-mails: liza_emily@yahoo.com, cceb1092@gmail.com, and lglee@moh.gov.my. Alfred A. S. Perianayagam and Vielerian Fredolin, Papar Health Office, Ministry of Health, Bandar Papar, Papar, Sabah, Malaysia, E-mails: draldrin.constantine9@gmail.com and iyanvell23@gmail.com.

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