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 • HPA contribution to the FSA priorities and new developments • Future activities

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 toxin producing bacteria • Non Gastrointestinal infections associated with food-borne transmission

Intoxication Biological Chemical

Food Poisoning Annual Corrected Notifications England and Wales 1984-2001

Foodborne Disease in England and 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 and Wales 1992 – 2000, Gut (In Press)

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 least three 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 – 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 food borne 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.

60 50 40 30 Cryptosporidium Rotavirus Campylobacters Salmonellas Shigellas 20 10 0 77 79 81 83 85 87 89 Year 91 93 95 97 99 2001

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 Enemy No 1 Public Enemy No 2 Public Enemy No 3 Campylobacter 50773 cases Salmonella 15000 cases

E. coli

O157 1035 cases

Wanted Dead or Alive !!!

Public Enemy No 4 Public Enemy No 5 Clostridium perfringens 166 cases Listeria monocytogenes 116 cases

Laboratory Reports of Infections with Campylobacter sp. England & Wales (1980-2002) 60000 50000 40000 30000 20000 10000 0 1980 1983 1986 1989 1992 1995 1998 2001

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 • 15% of laboratory confirmed cases

Food Exposures

(a)

Food

Baby food Barbecued food Beef (incl roast, mince, steak) Cheese Poultry Cold meats (pre-cooked) Fish & shellfish Halal Lamb Meat pies Offal Organic meat Organic veg Pate Pork, ham or bacon Pre packed sandwiches Salad Sausages Vegetarian food Total (of foods reported)

Case consumption (a) GB household consumption (b)

200 6000 3.3

779 3806 3992 2012 110000 104000 208000 3.5

3.8

1.0

3795 3085 367 2227 1569 334 181 701 642 122000 144000 56000 12000 5000 3000 3.1

2.1

4.0

13.1

6.7

21.4

4233 2216 3791 3111 866 37907 137000 7000 193000 58000 1165000 3.1

31.7

2.0

5.4

3.3

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

40 35 30 25

p

20 15 10 5 0 S T-21 Com plex S T-206 Com plex S T-45 Com plex S T-354 com plex S T-49 Com plex B lood P rest on 2000 human gastro, UK S T-257 Com plex S T-658 Com plex

Salmonellosis in England & Wales.

35000 30000 25000 20000 S. enteritidis PT4 S. enteritidis (others) S. typhimurium Other serotypes 15000 10000 5000 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 Source: PHLS Salmonella dataset Year

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 UK catering industry 2002

Salmonella from Raw Shell Eggs Used in Catering

Country of origin

UK(Lion Quality) UK (not Lion Quality) USA France Spain Not known (not Lion Quality)

Number of pooled samples

349

Number of pooled samples positive

0

Salmonella

serotypes and S. Enteritidis phage types

None found 274 2 S. Enteritidis PT4, PT6 60 45 468 200 0 0 24 17 None found None found S. Enteritidis PT1, PT5c, PT6, PT6a, PT6d, PT12, PT13a, PT14b, PT58 S. Enteritidis PT4, PT6a S. Altona, S.Cerro, S. Infantis, S Livingstone, S. Ohio

Verocytotoxin Producing E. coli O157 ( England & Wales)

1 2 0 0 1 0 0 0 8 0 0 6 0 0 4 0 0 2 0 0 0 1 9 9 1 1 9 9 2 1 9 9 3 1 9 9 4 1 9 9 5 1 9 9 6

Y e a r s

1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1

Meat Products Associated with Transmission of E. coli O157

• 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 O157

• Raw milk • “Pasteurised milk” • Yoghurt • Cheese • Cream •Vegetables • Salad vegetables • Mayonnaise • Apple cider (USA) • Fruit

Verocytotoxin E. coli O26

•Isolated from human cases in Germany, England, Australia and other countries •Now more prevalent in Italy than O157 •Since June 2003 four strains of O26 have been isolated from cases in Scotland

Average Annual Totals of C. perfringens Food Poisoning

60 50 40 30 20 10 0 1980-84 1985-89 1990-94 C.perfringens

B.species

S. aureus 1995-99

Place of 176 General Outbreaks of Clostridium perfringens: Food Poisoning 1992-1998

•Residential Institution •Restaurant/Café •Hotel/Guest House •Pub/Bar •Hospital 46 (26%) 33 (19%) 15 (8.5%) 14 (8%) 13 (7%)

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 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 alpha toxin and enterotoxin

Enterotoxin fragment Alpha toxin fragment HPA FSML unpublished data

C.perfringens AFLP analysis

McLauchlin

et al

. Int J Food Microbiol 2000;56:21-28.

C.perfringens food poisoning

‘outbreak’ : Diarrhoea in >25 patients attending a function

No. cultures

ET in faeces (RPLA) AFLP type A 7 other types ET gene + ET gene 10 patients 1 patient 6 patients 2 patients 3 patients detected detected not detected not detected not tested 17 0 12 0 5 2 foods NA

HPA FSML unpublished data

9 3 3 0 4 0 0

Annual Totals of Listeriosis Cases in England and Wales

Selected Worldwide Outbreaks of Human Listeriosis Country Year Food UK Australia Australia New Zealand France France Italy USA Sweden France Australia USA France France 1987-9 1990 1991 1992 1992 1993 1993 1994 1994-5 1995 1996 1998-9 2000 2000 Pate Pate Smoked mussels 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 4b 4b 1/2 4b 4b 4b 4b 1/2a 1/2a 1/2a 4b 4b 1/2b 1/2b

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 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?”