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.

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 Salmonella 15000 cases Campylobacter 50773 cases E. coli O157 1035 cases

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

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

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 (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

Salmonellosis in England & Wales.

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 samples Number of pooled samples positive Salmonella serotypes and S. Enteritidis phage types UK(Lion Quality) 349 None found UK (not Lion Quality) 274 2 S. Enteritidis PT4, PT6 USA 60 France 45 Spain 468 24 S. Enteritidis PT1, PT5c, PT6, PT6a, PT6d, PT12, PT13a, PT14b, PT58 Not known (not Lion Quality) 200 17 S. Enteritidis PT4, PT6a S. Altona, S.Cerro, S. Infantis, S Livingstone, S. Ohio

Verocytotoxin Producing E. coli O157 ( England & Wales)

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 Dairy Products and other Foods Associated with Transmission of E. coli O157 Vegetables Salad vegetables Mayonnaise Apple cider (USA) Fruit Raw milk “Pasteurised milk” Yoghurt Cheese Cream

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

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

ET in faeces AFLP type A 7 other types 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?”