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 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.
Cryptosporidium
Rotavirus
Campylobacters
Salmonellas
Shigellas
50
40
30
20
10
Year
20
01
99
97
95
93
91
89
87
85
83
81
79
0
77
Lab reports (1000's)
60
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
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)
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
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)
(a)
Case consumption (a)GB household consumption (b)Risk per 100 mg
200
6000
3.3
779
3806
110000
3.5
3992
104000
3.8
2012
208000
1.0
3795
122000
3.1
3085
144000
2.1
367
2227
56000
4.0
1569
12000
13.1
334
5000
6.7
181
701
642
3000
21.4
4233
137000
3.1
2216
7000
31.7
3791
193000
2.0
3111
58000
5.4
866
37907
1165000
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
B lood
S T-45
Com plex
P rest on 2000
S T-354
com plex
S T-49
Com plex
human gastro, UK
S T-257
Com plex
S T-658
Com plex
Laboratory reports
Salmonellosis in England & Wales.
35000
S. enteritidis PT4
30000
S. enteritidis (others)
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
samples
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 PT4, PT6
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
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)
1200
1000
800
600
400
200
0
1991
1992
1993
1994
1995
1996
Y ear s
1997
1998
1999
2000
2001
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
“Pasteurised milk”
Yoghurt
Cheese
Cream
• 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
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 alphatoxin 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)
10 patients
1 patient
6 patients
2 patients
3 patients
2 foods
detected
detected
not detected
not detected
not tested
AFLP type A 7 other types
ET gene +
ET gene -
17
0
12
0
5
3
3
0
4
0
9
0
NA
HPA FSML unpublished data
Annual Totals of Listeriosis
Cases in England and Wales
Selected Worldwide Outbreaks
of Human Listeriosis
Country
UK
Australia
Australia
New Zealand
France
France
Italy
USA
Sweden
France
Australia
USA
France
France
Year
1987-9
1990
1991
1992
1992
1993
1993
1994
1994-5
1995
1996
1998-9
2000
2000
Food
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
1/2a
1/2a
1/2a
4b
4b
1/2b
1/2b
4b
4b
1/2
4b
4b
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?”