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

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

3. 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.”

4. 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

5. Food Poisoning Annual Corrected Notifications England and Wales 1984-2001

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

7. 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

8. 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

9. 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

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

11. 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

12. 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

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

14. Laboratory Reports of Infections with Campylobacter sp
Laboratory Reports of Infections with Campylobacter sp. England & Wales ( )

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

16. Campylobacter Sentinel Surveillance, UK
22 Health Authorities
12.5 million population
15% of laboratory confirmed cases

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

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

19. Salmonellosis in England & Wales.

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

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

22. 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

24. Verocytotoxin Producing E. coli O157 ( England & Wales)

25. 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

26. 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

27. 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

28. Average Annual Totals of C. perfringens Food Poisoning

29. Place of 176 General Outbreaks of Clostridium perfringens: Food Poisoning 1992-1998
Residential Institution 46 (26%)
Restaurant/Café (19%)
Hotel/Guest House 15 (8.5%)
Pub/Bar (8%)
Hospital (7%)

30. 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

31. 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

32. PCR for C.perfringens alpha-toxin and enterotoxin
Enterotoxin fragment
Alpha toxin fragment
HPA FSML unpublished data

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

34. 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
1 patient detected
6 patients not detected
2 patients not detected
3 patients not tested
2 foods NA
HPA FSML unpublished data

35. Annual Totals of Listeriosis Cases in England and Wales

36. Selected Worldwide Outbreaks of Human Listeriosis
Country Year Food Serovar
UK Pate 4b
Australia Pate 1/2a
Australia Smoked mussels 1/2a
New Zealand Smoked mussels 1/2a
France Pork tongue/aspic 4b
France Pork rillettes 4b
Italy Rice salad 1/2b
USA Chocolate milk 1/2b
Sweden Smoked fish 4b
France Soft cheese 4b
Australia Cooked chicken 1/2
USA Hot dogs/deli meats 4b
France Pork rillettes 4b
France Pork tongue/jelly 4b

37. 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?

38. 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

39. “Does my bum look big in this?”