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					        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 1st 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
                                  Cryptosporidium
                        50        Rotavirus
 Lab reports (1000's)




                                  Campylobacters
                        40
                                  Salmonellas
                        30        Shigellas

                        20

                        10

                        0
                        77

                             79

                                  81

                                       83

                                            85

                                                 87

                                                      89

                                                           91

                                                                93

                                                                     95

                                                                          97

                                                                               99

                                                                                      01
                                                                                    20
                                                       Year
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    Public Enemy   Public Enemy
      No 1            No 2           No 3




                  Salmonella
  Campylobacter                     E. coli O157
  50773 cases     15000 cases       1035 cases
Wanted Dead or Alive !!!


  Public Enemy        Public Enemy

     No 4                  No 5




  Clostridium         Listeria
  perfringens         monocytogenes
  166 cases           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


 • 1st 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

      Food                                                                             Risk per 100 mg
                                        Case consumption (a)GB household consumption (b)
      Baby food                         200                 6000                       3.3
      Barbecued food                    779                 -                          -
      Beef (incl roast, mince, steak)   3806                110000                     3.5
      Cheese                            3992                104000                     3.8
      Poultry                           2012                208000                     1.0
      Cold meats (pre-cooked)           3795                122000                     3.1
      Fish & shellfish                  3085                144000                     2.1
      Halal                             367                 -                          -
      Lamb                              2227                56000                      4.0
      Meat pies                         1569                12000                      13.1
      Offal                             334                 5000                       6.7
      Organic meat                      181                 -                          -
      Organic veg                       701                 -                          -
      Pate                              642                 3000                       21.4
      Pork, ham or bacon                4233                137000                     3.1
      Pre packed sandwiches             2216                7000                       31.7
      Salad                             3791                193000                     2.0
      Sausages                          3111                58000                      5.4
      Vegetarian food                   866                 -                          -
      Total (of foods reported)         37907               1165000                    3.3

(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
    40

    35

    30

    25

p   20

    15

    10

     5

     0
          S T-21     S T-206      S T-45         S T-354     S T-49     S T-257    S T-658
         Com plex   Com plex     Com plex       com plex    Com plex   Com plex   Com plex

                      B lood   P rest on 2000   human gastro, UK
Salmonellosis in England & Wales.

                      35000   S. enteritidis PT4
                      30000   S. enteritidis (others)
 Laboratory reports




                      25000   S. typhimurium

                      20000   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   Number of pooled   Number of pooled   Salmonella serotypes
                      samples            samples positive   and S. Enteritidis phage
                                                            types

  UK(Lion Quality)    349                0                  None found


  UK (not Lion        274                2                  S. Enteritidis PT4, PT6
  Quality)

  USA                 60                 0                  None found


  France              45                 0                  None found


  Spain               468                24                 S. Enteritidis PT1,
                                                            PT5c, PT6, PT6a,
                                                            PT6d, PT12, PT13a,
                                                            PT14b, PT58

  Not known (not      200                17                 S. Enteritidis PT4,
  Lion Quality)                                             PT6a S. Altona,
                                                            S.Cerro, S. Infantis, S
                                                            Livingstone, S. Ohio
Verocytotoxin Producing
E. coli O157 ( England & Wales)
  1200




  1000




   800




   600




   400




   200




     0

         1991   1992   1993   1994   1995     1996    1997   1998   1999   2000   2001


                                            Y ear s
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

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

                                        C.perfringens
   60
                                        B.species
   50
                                        S. aureus
   40
   30
   20
   10
    0
        1980-84   1985-89   1990-94   1995-99
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 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     AFLP type A 7 other types
                (RPLA)         ET gene +     ET gene -

10 patients     detected          17            3
1 patient       detected           0            3
6 patients     not detected       12            0
2 patients     not detected        0            4
3 patients      not tested         5            0

2 foods              NA               9         0

          HPA FSML unpublished data
Annual Totals of Listeriosis
Cases in England and Wales
   Selected Worldwide Outbreaks
   of Human Listeriosis
Country                Year           Food          Serovar

UK            1987-9          Pate                  4b
Australia     1990            Pate                  1/2a
Australia     1991            Smoked mussels        1/2a
New Zealand   1992            Smoked mussels        1/2a
France        1992            Pork tongue/aspic     4b
France        1993            Pork rillettes        4b
Italy         1993            Rice salad            1/2b
USA           1994            Chocolate milk        1/2b
Sweden        1994-5          Smoked fish           4b
France        1995            Soft cheese           4b
Australia     1996            Cooked chicken        1/2
USA           1998-9          Hot dogs/deli meats   4b
France        2000            Pork rillettes        4b
France        2000            Pork tongue/jelly     4b
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?”

				
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