FOODBORNEILLNESS

(What you can’t see can harm you)(What you can’t see can harm you)

Anthony Gatt MD, Dip IMC RCS (Ed), MSc, MMCFD

24 November 2014

Directorate of Health Promotion and Disease Prevention

1

Definition

� AKA – foodborne disease; food poisoning

� WHO Definition:� WHO Definition:

� Foodborne illnesses are diseases usually either infectious or toxic in nature, caused by agents that enter the body through the ingestion of food.

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What is foodborne illness?

� Illness resulting from the consumption of contaminated food or water.

� Contamination can be due to unnatural � Contamination can be due to unnatural chemical or natural toxins, or infectious pathogens (bacteria, viruses, parasites).

� Contamination can occur before, during, and after food preparation.

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The Food ChainPOINT of PURCHASEor CONSUMPTION

DelisCafeteriasTake awayRestaurantsGrocery store

4

Agriculture

Transportation ProcessingSlaughterPasteurisationWashing produce Canning

PackagingStorageWarehousingRepackingReprocessing

Consumer

Movement of ingredients and food products across borders

How Many Types Are There?� There are more than 250 knownfoodborne

illnesses types (more likely to exist).

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Types of foodborne pathogens� General: bacterial – viral – parasites –

‘chemical’

� Bacteria:� Campylobacter� Salmonella� Escherichia coli� Shigella� Listeria� Yersinia� Brucellosis� Vibrio cholera

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Other foodborne pathogens� Viruses

� Norovirus� Enteroviruses � Rotavirus� Hepatitis A

� Parasites:� Giardia lamblia; Amoeba histolytica

� Chemical� Exotoxins: Clostridium botulinum; Clostridium perfringens; Staphylococcus

aureus; Bacillus cereus� Natural : scombrotoxic, mushroom poison� Man made: melamine

Prions 7

Most Common causes of Foodborne Illness

� Those caused by the bacteria:� Campylobacter

� Salmonella

� E. coli O157:H7

� Those caused by a group of viruses:� Noroviruses, Enteroviruses

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Symptoms of gastroenteritis� Nausea� Vomiting� Abdominal pain� Diarrhoea� watery� watery� greenish � blood stained

� Myalgia � Arthralgia� Headache� Fever� Rigors� Prostration

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Infectious versus toxic FBI

Infectious FBI

� Incubation period long

e.g. -Campy –1-10 days

-Salm – 6-72 hrs

Toxic FBI

� Short IP – hours

e.g: -Histamine FBI –30mins

-Staph. aureus Toxin – 2-6 hrs-Salm – 6-72 hrs

-Hep A – 21-50 days

� Constitutional symptoms may be severe

� Fever usual & may be high

� Hospitalization likely

� Illness may take days

� Symptoms: D, N, V, ABD pain, H, Rigors, Myalgia/arthralgia

-Staph. aureus Toxin – 2-6 hrs

� Constitutional symptoms not severe

� Fever unlikely

� Hospitalization v. rare

� Short lasting (hours)

� Vomiting or rash the commonest

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Sources� Unsafe food practices (all pathogens)

� Raw meats that have become contaminated with animal waste (all pathogens especially E. coli O157)

� Improperly cooked meats especially poultry (Salm; Campy)

� Undercooked or raw eggs (Salm)

� Food left at improper temperatures for too long (Staph toxin)

� Break in the cold chain

� Cross contamination at any stage of food chain or food preparation

� Infected food handlers (Hep A, Norovirus)

� Poor food handling practices

� Animals, pets & reptiles11

Hotel 2%

Canteen2%

Supermarket

Take away11%

Foodborne outbreaks in Malta according to source in 2012

Number of Foodborne outbreaks in 2012 -28 (yearly mean – 27)

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Household27%

NK28%

School2%

Restaurant26%

Supermarket2%

NB This slide refers to all types of foodborne illness

Antibiotic use for FBI

� Usuallynot necessary

� Most community gastroenteritis is viral

� Most resolve spontaneously within 5-7days or less� Most resolve spontaneously within 5-7days or less

� Rx symptomatically

� Ab* Rx for those who are toxic/hospitalised/those at risk

� E.coli O157: Certainly not indicated- may ↑ risk of HUS**

� Increasing antibiotic resistance

� Antibiogram to guide Rx

13*Ab = Antibiotic **Haemolytic Uraemic Syndrome

People with a higher risk forfoodborne illness include ...

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Infants

15

Pregnant women

16

Children & the elderly

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Immunocompromised persons

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Why surveillance & OB investigationsSURVEILLANCE

� Considerable morbidity & potential mortality

� Follow trends

� Evaluate intervention programmes

OUTBREAKS� Stop outbreak

� Understand what happened and why

� Prevent future outbreaks

� Improve our knowledge

� Improve surveillance and outbreak detection

� Learn epidemiology by doing so

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Surveillance� Campylobacteriosis

� Salmonellosis non-typhoidal

� Salmonellosis typhi

� Giardiasis

� Shigellosis

Reporting to ECDC

� Shigellosis

� Escherichia coli (e.g. E. coli O157)

� Yersiniosis

� Listeriosis

� Hepatitis A

� vCJD

� Botulism

� Brucellosis

� Cholera

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Notifications� Form:

� Snail post

� E-mail� E-mail

� SMS

� Fax

� Phone

� Word of mouth

� Media 21

Maltese law

� Statutory obligations to notify FBI

� Doctors (Public Health Act 2003)� Doctors (Public Health Act 2003)

� Suspected cases including outbreaks

� Confirmed cases including outbreaks

� Laboratories (Medical & Kindred Professions Ordinance)

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Investigation of notified cases� History

� Stool c/s ± viral studies

� OB:� OB:� Epidemiological studies + statistical analysis

� Environmental health and PH lab:� Inspections; risk assessment

� Food/environmental sampling

� Follow up

� Legal action (±)

� Veterinary services investigations

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Who is at risk?� EVERYONE

� Industrialised countries: 30% of the population suffers from FBI/year

� Important cause of preventable morbidity & mortality

� Important public health problem

� Changing epidemiology

� Globalisation 24

International burden of foodborne disease

� In the USA*

� 48 million become ill/year

� 128,000 hospitalized/year

� 3000 die/year

� European Union (2010) [confirmed cases]**

� 99,020 Salmonellosis

� 212,064 Campylobacteriosis

� Malta (2013)� Salmonellosis –85 confirmed cases – estimated 2013 sum = 3230� Campylobacteriosis –245 confirmed cases – estimated 2013 sum = 9310

25* http://www.cdc.gov/foodborneburden/; 2014 reports.

** The European Union Summary Report on Trends and Sources of Zoonoses, Zoonotic Agents and Food-borne Outbreaks in 2010; http://www.efsa.europa.eu/en/efsajournal/pub/2597.htm

Listeriosis

Echinococcosis

Trichinellosis

Brucellosis

TB (M. bovis)

Rabies

Reported zoonotic rates - confirmed human cases in the EU, 2008

4

107

619

670

981

1,381

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0 5 10 15 20 25 30 35 40 45

Campylobacteriosis

Salmonellosis

Yersiniosis

VTEC

Q fever

Listeriosis

Rates/ 100,000 population

1,381

1,594

3,159

8,346

131,468

190,566

Salmonellosis disease burden� It constitutes a major public health burden and

represents a significant cost in many countries (WHO).

� E.g. Denmark: the annual estimated cost of � E.g. Denmark: the annual estimated cost of foodborne salmonellosis is US$ 15.5 million (2001).

� Complications: Reactive Arthritis (rate: 2-15%)

Irritable Bowel Syndrome BacteraemiaOsteomyelitisInfective arthritis

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Campylobacteriosis disease burden

� Campylobacterbacteria are a major cause of foodborne diarrhoeal illness in humans and are the most common bacteria that cause gastroenteritis worldwide (WHO).

� Cost in Europe/ human case estimated at >€69 – >€97

� UK: Total cost estimated at almost €1billion each year

� Complications e.g. Guillain-Barré Syndrome

Reactive arthritis

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Determining scale of disease

Notified

Culture confirmation

Stool specimen

Person seeks care

Person becomes ill

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40

50

60

70

Incid

en

ce rate

/100,0

00 p

op

ula

tion

Incidence rates of Salmonella/Campylobacter in Malta 1990-2012 Campylobacter

Salmonella

30

0

10

20

30

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Incid

en

ce rate

/100,0

00 p

op

ula

tion

Year

50

60

70

80

No

. o

f c

as

es

Salmonella in Malta 2007-2011 distribution with age

20072008200920102011

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0

10

20

30

40

0-5 6-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85 NK

No

. o

f c

as

es

Age groups

Prevention

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Enjoy your food

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