(CNSNews.com) – Three years after the Obama administration allowed Egyptian strawberry producers access to U.S. markets, imported strawberries from Egypt are "thought to be the source" of an outbreak of hepatitis A that has sickened 44 people in Virginia, according to the Virginia Department of Health (VDH).

“Frozen Egyptian strawberries used at Tropical Smoothie Café are thought to be the source of this outbreak,” VDH reported. The 44 people infected with the hepatitis A virus “reported consuming a smoothie at Tropical Smoothie Café prior to becoming ill.”

“On August 12, the Centers for Disease Control and Prevention notified VDH that genetic testing of multiple ill persons showed the illnesses were caused by a strain of hepatitis A that had been associated with past outbreaks due to frozen strawberries from Egypt,” according to an August 26 VDH press release.

Then-U.S. Ambassador to Egypt Ann Patterson eats a strawberry in a photo accompanying a 2013 press release on the U.S. Embassy in Cairo website. (Screen Capture)

"VDH has not heard of any other restaurant chain affected by this yet," a spokeswoman told CNSNews.com. "Other restaurants, and firms that supply restaurants, may also have received the frozen strawberries imported from Egypt.

"VDH continues to investigate cases and work with state and federal partners, including the Virginia Department of Agriculture and Consumer Services, the U.S. Food and Drug Administration, and the CDC to identify additional locations where the product may have been distributed."

Hepatitis A causes inflammation of the liver. Symptoms include jaundice, pain, fever and nausea. VDH noted that 50 percent of those infected by the virus, who range in age from 15 to 68, had to be hospitalized.

A statement issued by Tropical Smoothie Café on August 19th stated that “our cafes and their food handling practices have not been implicated in any way – the health department believes this is a single product issue (strawberries) sourced from Egypt.

“Egyptian strawberries represent a fraction of our overall strawberries purchased and were predominantly distributed to stores in the Virginia market. Today, our strawberries are primarily sourced from Mexico and California,” the statement continued.

“However, in an abundance of caution, we voluntarily pulled all strawberries sourced from Egypt from every café in our system, not only the Virginia cafes. Our primary concern is for the safety and well-being of our guests and crew members and we will continue to cooperate with health authorities.”

Egypt, which is the world’s fourth largest strawberry producer, exports 40 million tons of fresh and frozen strawberries to 30 countries, including the U.S.

According to Food Safety News, Egypt’s Union of Producers and Exporters of Horticultural Crops issued a statement “casting doubt that the country is the source of the contamination.”

On Feb. 28, 2013, then U.S. ambassador to Egypt Anne Patterson announced that the U.S. would start allowing the importation of Egyptian strawberries.

“We are committed to continuing to work with the Egyptian authorities to increase market opportunities for Egyptian exports,” she said at the time. “Increasing trade between our two countries is a key component of boosting employment and economic growth in Egypt.”

All fruits and vegetables imported into the U.S. must have a permit and be shipped to specific ports, where they are subject to inspection by the U.S. Department of Agriculture (USDA).

On Feb. 27, 2013 the USDA’s Animal and Plant Health Inspection Service posted a notice in the Federal Register “advising the public of our decision to begin issuing permits for the importation into the continental United States of fresh strawberry fruit from Egypt.”

A statement issued by the Egyptian Embassy at the time said that opening the U.S. market to Egyptian strawberries was “a testament to the high quality of Egyptian strawberry exports,” according to a Feb. 3, 2013 article in Daily News Egypt.

However, a June 2015 article in The Lancet reported that in two hepatitis A outbreaks in the European Union, “frozen or fresh strawberries were implicated as the vehicle of infection.

“In the first outbreak in the Nordic countries, the implicated frozen strawberries were found to be imported either from Egypt or Morocco. In the second outbreak, affecting travelers returning from Egypt, the implicated fresh strawberries were most likely locally produced.”