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Gastrointestinal Infections: Food for Thought! Prof Eric Bolton Regional HPA Laboratory Manchester Medical Microbiology Gastrointestinal Infections: Food for Thought! Prof Eric Bolton Regional HPA Laboratory Manchester Medical Microbiology Partnership Manchester

Topics Included • Background to Food borne Disease • Food Standards Agency (FSA) priorities Topics Included • Background to Food borne Disease • Food Standards Agency (FSA) priorities • HPA contribution to the FSA priorities and new developments • Future activities

Definition of Food Poisoning (Advisory Committee on the Microbiological Safety of Food - 1992) Definition of Food Poisoning (Advisory Committee on the Microbiological Safety of Food - 1992) “Any disease of an infectious or toxic nature caused by or thought to be caused by the consumption of food or water. ”

Foodborne Illness Microbiological Food Poisoning • Foodborne Gastrointestinal infections • Gastrointestinal illness associated with Foodborne Illness Microbiological Food Poisoning • Foodborne Gastrointestinal infections • Gastrointestinal illness associated with toxin producing bacteria • Non Gastrointestinal infections associated with food-borne transmission Intoxication Biological Chemical

Food Poisoning Annual Corrected Notifications England Wales 1984 -2001 Food Poisoning Annual Corrected Notifications England Wales 1984 -2001

Foodborne Disease in England Wales : 1992 - 2000 • 1. 4 million cases Foodborne Disease in England Wales : 1992 - 2000 • 1. 4 million cases in 2000 • >325, 000 general practitioner consultations • 21000 hospital admissions • > 88000 bed days Adak GK, Long SM, O’Brien SJ Trends in Indigenous foodborne disease and deaths, England Wales 1992 – 2000, Gut (In Press)

Food for Thought !! • 1 in 5 members of the population are affected Food for Thought !! • 1 in 5 members of the population are affected by intestinal disease per year • 9. 4 million people in England suffer • The estimated cost to the Nation is at leastthree quarters of a billion pounds !! - 55% to employers - 36% to the NHS - 8% directly to the case

Food Standards Agency: Priorities Established 1 st April 2000 Strategic Themes: – Food-borne illness Food Standards Agency: Priorities Established 1 st April 2000 Strategic Themes: – Food-borne illness – BSE – Chemical Safety of Food – Food Products and Processes – their Licensing and Approval

FSA Strategic Objectives Food-borne Illness (Food Poisoning) • Reduce the incidence of foodborne disease FSA Strategic Objectives Food-borne Illness (Food Poisoning) • Reduce the incidence of foodborne disease by 20% over the next 5 years • Reduce Salmonella contamination of UK produced retail chicken by at least 50% over the next 4 years

Laboratory Reporting of Selected GI Pathogens in England & Wales. Laboratory Reporting of Selected GI Pathogens in England & Wales.

FSA Strategic Objectives Reducing Foodborne disease: Setting the baseline • Baseline set using the FSA Strategic Objectives Reducing Foodborne disease: Setting the baseline • Baseline set using the number of UK acquired food poisoning cases in 2000 • Laboratory reports of five main pathogens will be used to monitor success

Wanted Dead or Alive ( Alive is not an option for Food Safety!!) Public Wanted Dead or Alive ( Alive is not an option for Food Safety!!) Public Enemy No 1 Public Enemy No 2 Public Enemy No 3 Campylobacter 50773 cases Salmonella 15000 cases E. coli O 157 1035 cases

Wanted Dead or Alive !!! Public Enemy No 4 No 5 Clostridium perfringens 166 Wanted Dead or Alive !!! Public Enemy No 4 No 5 Clostridium perfringens 166 cases Listeria monocytogenes 116 cases

Laboratory Reports of Infections with Campylobacter sp. England & Wales (1980 -2002) Laboratory Reports of Infections with Campylobacter sp. England & Wales (1980 -2002)

Campylobacter Sentinel Surveillance • 1 st May 2000 • Population based sentinel surveillance scheme Campylobacter Sentinel Surveillance • 1 st May 2000 • Population based sentinel surveillance scheme for campylobacter infection • Generate new hypothesis for infection • Integrating typing and epidemiological data

Campylobacter Sentinel Surveillance, UK • 22 Health Authorities • 12. 5 million population • Campylobacter Sentinel Surveillance, UK • 22 Health Authorities • 12. 5 million population • 15% of laboratory confirmed cases

Food Exposures (a) Eaten once/more than once (b) mg-1 person-1 week-1; National Food Survey, Food Exposures (a) Eaten once/more than once (b) mg-1 person-1 week-1; National Food Survey, 1999

Distribution of Isolates Among the Clonal Complexes Associated with Human Disease Distribution of Isolates Among the Clonal Complexes Associated with Human Disease

Salmonellosis in England & Wales. Salmonellosis in England & Wales.

FSA – Reducing Salmonella in UK retail chicken • Action plan for addressing bio-security, FSA – Reducing Salmonella in UK retail chicken • Action plan for addressing bio-security, crate washing etc on broiler farms • Survey of current contamination levels

Results of a Public Health Investigation into the use of raw eggs in the Results of a Public Health Investigation into the use of raw eggs in the UK catering industry 2002

Salmonella from Raw Shell Eggs Used in Catering Country of origin Number of pooled Salmonella from Raw Shell Eggs Used in Catering Country of origin Number of pooled samples positive Salmonella serotypes and S. Enteritidis phage types UK(Lion Quality) 349 0 None found UK (not Lion Quality) 274 2 S. Enteritidis PT 4, PT 6 USA 60 0 None found France 45 0 None found Spain 468 24 S. Enteritidis PT 1, PT 5 c, PT 6 a, PT 6 d, PT 12, PT 13 a, PT 14 b, PT 58 Not known (not Lion Quality) 200 17 S. Enteritidis PT 4, PT 6 a S. Altona, S. Cerro, S. Infantis, S Livingstone, S. Ohio

Verocytotoxin Producing E. coli O 157 ( England & Wales) Verocytotoxin Producing E. coli O 157 ( England & Wales)

Meat Products Associated with Transmission of E. coli O 157 • • • Ground Meat Products Associated with Transmission of E. coli O 157 • • • Ground beef products Other red meats Roast beef Dry cured salami Cooked meat products Turkey meat

Dairy Products and other Foods Associated with Transmission of E. coli O 157 • Dairy Products and other Foods Associated with Transmission of E. coli O 157 • Vegetables • • • Raw milk “Pasteurised milk” Yoghurt Cheese Cream • Salad vegetables • Mayonnaise • Apple cider (USA) • Fruit

Verocytotoxin E. coli O 26 • Isolated from human cases in Germany, England, Australia Verocytotoxin E. coli O 26 • Isolated from human cases in Germany, England, Australia and other countries • Now more prevalent in Italy than O 157 • Since June 2003 four strains of O 26 have been isolated from cases in Scotland

Average Annual Totals of C. perfringens Food Poisoning Average Annual Totals of C. perfringens Food Poisoning

Place of 176 General Outbreaks of Clostridium perfringens: Food Poisoning 1992 -1998 • Residential Place of 176 General Outbreaks of Clostridium perfringens: Food Poisoning 1992 -1998 • Residential Institution 46 (26%) • Restaurant/Café 33 (19%) • Hotel/Guest House 15 (8. 5%) • Pub/Bar 14 (8%) • Hospital 13 (7%)

Features of General Outbreaks of Clostridium perfringens: Food Poisoning 1998 -1999 • 66 confirmed Features of General Outbreaks of Clostridium perfringens: Food Poisoning 1998 -1999 • 66 confirmed incidents • Foods associated with outbreaks are meat and poultry. • Accounted for 95% of outbreaks • Over 45 different serotypes detected in confirmed cases

HPA Activities Contributing to FSA Strategic Objectives: Clostridium perfringens When is a cluster of HPA Activities Contributing to FSA Strategic Objectives: Clostridium perfringens When is a cluster of cases a Foodborne outbreak? • Cluster of cases with relevant onset and syptoms • Demonstration of enterotoxin in faeces • Isolation of a common “type” of C. perfringens from patients and food

PCR for C. perfringens alphatoxin and enterotoxin Enterotoxin fragment Alpha toxin fragment HPA FSML PCR for C. perfringens alphatoxin and enterotoxin Enterotoxin fragment Alpha toxin fragment HPA FSML unpublished data

C. perfringens AFLP analysis Mc. Lauchlin et al. Int J Food Microbiol 2000; 56: C. perfringens AFLP analysis Mc. Lauchlin et al. Int J Food Microbiol 2000; 56: 21 -28.

C. perfringens food poisoning ‘outbreak’ : Diarrhoea in >25 patients attending a function No. C. perfringens food poisoning ‘outbreak’ : Diarrhoea in >25 patients attending a function No. cultures ET in faeces (RPLA) 10 patients 1 patient 6 patients 2 patients 3 patients 2 foods detected not tested NA AFLP type A 7 other types ET gene + ET gene 17 0 12 0 5 3 3 0 4 0 9 0

Annual Totals of Listeriosis Cases in England Wales Annual Totals of Listeriosis Cases in England Wales

Selected Worldwide Outbreaks of Human Listeriosis Country UK Australia New Zealand France Italy USA Selected Worldwide Outbreaks of Human Listeriosis Country UK Australia New Zealand France Italy USA Sweden France Australia USA France Year 1987 -9 1990 1991 1992 1993 1994 -5 1996 1998 -9 2000 Food Pate Smoked mussels Pork tongue/aspic Pork rillettes Rice salad Chocolate milk Smoked fish Soft cheese Cooked chicken Hot dogs/deli meats Pork rillettes Pork tongue/jelly Serovar 4 b 1/2 a 4 b 4 b 1/2 b 4 b 4 b 1/2 4 b 4 b 4 b

Quandary for the Food Standards Agency • Target is to reduce food poisoning by Quandary for the Food Standards Agency • Target is to reduce food poisoning by 20% in 5 years • What proportion of reported Gastrointestinal infections are foodborne?

Future Research Activities • Development and study of nucleic acid archive from the Infectious Future Research Activities • Development and study of nucleic acid archive from the Infectious Intestinal Disease (IID) study • GP based sentinel surveillance of GI infections • Campylobacter case-control study • Role of molecular methods for the investigation of potential non-food sources of Campylobacter jejuni infection

“Does my bum look big in this? ” “Does my bum look big in this? ”