Past examples of international foodborne outbreaks

Transcription

1 Past examples of international foodborne outbreaks Ettore Severi European Centre for Disease Prevention and Control Food and waterborne diseases MediEPIET module April 2016, Athens

2 Content Multi-country foodborne hepatitis A outbreak among European tourists returning from Egypt, Nov 2012 to Apr 2013 Multi-country outbreak of Salmonella Stanley infections associated with turkey meat in the EU, Multi-country foodborne outbreak of Salmonella Chester in travellers returning from Morocco, summer 2014 and 2015 Multi-country outbreak of STEC infection associated with haemolytic uraemic syndrome, Romania and Italy 2016

3 Hepatitis A outbreak among European travellers to all-inclusive resorts in Egypt Observations from a multi-state outbreak investigation Jussi Sane, Emily MacDonald, Line Vold, Céline Gossner and Ettore Severi on behalf of the International Outbreak Investigation Team

4 The outbreak April 15, 2013: Norway report in EPIS-FWD* Increase in HAV** infections among tourists returning from Egypt since 1 January 2013 Several cases had an identical HAV RNA sequence Case finding 14 EU-EFTA*** countries reported cases in EPIS replies 107 travellers with HAV infection returning from Egypt International investigation coordinated by ECDC is initiated *Epidemic Intelligence Information System for food- and waterborne diseases (EPIS-FWD) **Hepatitis A virus ***European Free Trade Association

5 International outbreak investigation Form the Outbreak investigation team (teleconference) ECDC, countries affected, Egypt, WHO European outbreak case definition Select EPIET fellow for investigation support Linelist in EPIS to collect info on cases Trawling questionnaire to generate hypothesis Case control study to test hypothesis

6 European outbreak case definition Probable case: a symptomatic person with a laboratory confirmed HAV infection, with onset of symptoms after 1 November 2012 and with travel history to Egypt two to six weeks before onset of symptoms Confirmed case: A probable case infected with HAV RNA sequence matching the outbreak sequence Exclusion criterion: Cases with sequences unlike the outbreak strain were excluded

7 Trawling and case-control study Trawling questionnaire prepared by colleagues in affected countries Aim: hypothesis generation Interviews by colleagues in affected countries Analysis by ECDC Analytical study: case-control study Questionnaire prepared in ECDC with affected countries support Information on demographics, travel, exposures in Egypt Controls were healthy unvaccinated travel companion of cases Cases interviewed by staff from national public health institutes Responses provided to ECDC for combined analysis

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9 Distribution of cases by week of onset and country of origin

10 Distribution of cases by week of onset and case status Number of cases Probable (n=81) Confirmed (n=21) Week of onset 2013

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12 Descriptive analysis

13 Case-control study Transmission likely occurred through contaminated food, strawberries and mango suspected, although the analysis had limited power

14 Actions In Egypt:? Very effective sudden stop in cases in returning travellers In the EU: Reinforce vaccination recommendation prior visiting HAV-endemic areas Emphasize risk to all travellers (including those visiting luxury hotels) Through general practitioners Through travel agencies Enhanced surveillance (epidemiological and laboratory) Increased use of HAV sequencing European harmonised sequencing protocol Endorsement of HAVNET sequence sharing platform

15 Conclusions Large outbreak with few cases in many different countries challenging identification major role of HAV sequencing Common effort of affected countries and ECDC International trawling and case-control study Successful investigation Challenges Exposure out of the EU Information sharing teleconference and EPIS very helpful Participation in analytical study Study power

16 References Multistate foodborne hepatitis a outbreak among european tourists returning from egypt need for reinforced vaccination recommendations, november 2012 to april Outbreak of hepatitis A virus infection in travellers returning from Egypt, 30 April A-virus-infection-travellers-returning-from-Egypt.pdf

17 Multi-country outbreak of Salmonella Stanley infections Céline Gossner, Pete Kinross, Christian Kornschober, Ettore Severi, Johanna Takkinen on behalf of the International Outbreak Investigation Team

18 Initial alert in EPIS-FWD Launch of multistate investigations

19 Timeline of events June: EPIS-FWD message by Belgium 3 and 11 July: Germany and Hungary report cases of S. Stanley 18 July: teleconference with affected countries 27 July: Initial ECDC rapid risk assessment 6 and 22 August: Austria and Czech Republic report cases of S. Stanley 29 August: Update ECDC rapid risk assessment 29 August: Joint database for human, food & animal isolates managed by ECDC 14 September: EC request for joint ECDC-EFSA risk assessment 20 September: Joint ECDC-EFSA risk assessment published

20 Multi-sectorial investigations: Epidemiology Case definition Line listing Trawling questionnaire A confirmed case: a laboratory confirmed case of S. Stanley with PFGE pattern matching the Belgium outbreak strain, with onset of symptoms after August 2011 and without travel history outside the EU in 1-7 days prior the onset of symptoms

21 Multi-sectorial investigations: Microbiology Joint ECDC/EFSA/EURL database for PFGE profiles of human, food, feed, animal and environmental isolates Laboratory testing protocol Objectives: Comparison of baseline genetic diversity Distribution of the outbreak strain over time, country and potential food sources before and during the outbreak period

22 Multi-sectorial investigations: Food safety EFSA - National zoonoses monitoring EFSA - Salmonella baseline survey EC - Rapid Alert System for Food and Feed WHO - International Food Safety Authorities Network MS - Trace-back/trace-forward at the national level

23 Results of the investigations As of 23/01/2013: 684 cases reported by 10 countries Persisting source(s), single clone, widely distributed Turkey meat identified as a possible vehicle of infection Outbreak strain in isolates from the turkey production chain 488 isolates received from 16 countries 357 indistinguishable profiles (70% human-30 % non-human) Strong evidence for turkey meat as vehicle of infection

24 Rates of confirmed and probable cases of Salmonella Stanley by EU Member State, 1/08/2011 to 22/10/2012 (N=498)

25 End of the story?

26 2014 Same strain new outbreak in Austria 2015 Same strain new outbreak in Austria

27 S. Stanley cases by travel history, EU/EEA Jul 2006 Jul 2007 Jul 2008 Jul 2009 Jul 2010 Jul 2011 Jul 2012 Jul 2013 Jul 2014 Jul 2015 Month month moving average S.Stanley cases Source: Jul 2006 Jul 2007 Jul 2008 Jul 2009 Jul 2010 Jul 2011 Jul 2012 Jul 2013 Jul 2014 Jul 2015 Month 12-month moving average S.Stanley cases

28 S. Stanley cases by travel history, EU/EEA No travel out of the EU Jul 2006 Jul 2007 Jul 2008 Jul 2009 Jul 2010 Jul 2011 Jul 2012 Jul 2013 Jul 2014 Jul 2015 Month month moving average S.Stanley cases Source: 40 Travel out of the EU 20 0 Jul 2006 Jul 2007 Jul 2008 Jul 2009 Jul 2010 Jul 2011 Jul 2012 Jul 2013 Jul 2014 Jul 2015 Month 12-month moving average S.Stanley cases

29 ECDC outputs

30 Conclusion and assessment Prolonged investigation with consistent finding over time Only descriptive epidemiology (no analytical study) Strong support from molecular typing The outbreak strain is still circulating additional sporadic or cluster of cases are to be expected ECDC and EFSA recommend that further actions should be taken by risk managers in countries to detect and contain S. Stanley infections in the turkey production chain, thus avoiding the subsequent contamination of turkey meat.

31 References Multidisciplinary Investigation Of A Multicountry Outbreak Of Salmonella Stanley Infections Associated With Turkey Meat In The European Union, August 2011 To January Rapid outbreak assessment: multi-country outbreak of Salmonella Stanley infections-third update, 8/05/ Communicable Disease Threats Report - Week 41, 4-10/10/2015

32 Multi-country Salmonella Chester outbreak associated with travel to Morocco, 2014 L Fonteneau, S Bertrand, W Mattheus, M Torpdahl, CM Gossner, E Severi, L Fabre, N Jourdan Da Silva, S Le Hello, FJ Weill, E Valkanou, B Bouchrif, A El Boulani, I Friesema, S Herrera Leon, C Varela Martínez, M Rehn on behalf of the outbreak investigation team

33 33 Identification of outbreak September 2014: France report in EPIS FWD an increase of S. Chester cases (August and September 2014: 31 cases, 2013: 14) Replies in EPIS FWD Belgium: 18 cases Netherland: 8 cases Spain: 6 cases Denmark: 3 cases Most of the cases had recent travel to Morocco International investigation coordinated by France is initiated

34 34 International investigations Case definition Resident in European Union or European Economic Area Symptoms compatible with salmonellosis Isolate of S. Chester Symptoms onset (or date of isolation if onset date unavailable) between 21 April and 12 October 2014 Microbiological PFGE and WGS comparison

35 35 National epidemiological investigations France only Trawling questionnaire Case-case study Controls: non-typhi salmonella cases with other serotype and recent travel to Morocco Individually matched by age group and week of onset Conditional logistic regression Questionnaire: exposures mentioned by at least 50% of interviewed cases in the trawling questionnaire

36 36 Descriptive analysis Line list (European cases, n=157) 47/54 (87%) had travel history to Morocco Women proportion: 54% Median age < 15 years Trawling questionnaire (French cases, n=16) 15 stayed in Morocco within the 7 days prior to symptoms onset. No common exposure was found (food, city, place visited nor means of transport to Morocco )

37 S. Chester cases by week of isolation and country of residence (N=157),

38 Spatial distribution of cases and controls 38

39 Univariate analysis, France, 2014 POULTRY Exposed Cases (N=14) Exposed controls (N=26) Matched odds ratio 95% CI Chicken sausage 21% 16% 1,3 [ ] Chicken 79% 85% 0.6 [ ] Cachir (Moroccan sausage) 14% 23% 0.6 [ ] Sandwich 25% 24% 1 [ ] Turkey ham 7% 31% 0.2 [ ] FISH AND SEAFOOD Sardine 43% 30% 1.5 [ ] Shrimp 50% 15% 5.6 [1.1-28] Squid 43% 15% 3.3 [ ] PLACE OF EXPOSURE Restaurant attendance 100% 69% 6.2* [ ] Shrimp in restaurant 43% 4% 11.1 [1.3-92] Exposure on the coast 92% 41% 9.3 [1.1-78] *crude odds ratio 39

40 40 Microbiological investigations Whole genome sequencing of 54 S. Chester isolates: 48 human isolates: FR ( ;n=36), BE (2014;n=6), DK (2014;n=6) 6 non-human isolates (2014): 2 from chicken sausages from Morocco 1 from fish meal from Morocco 1 from decanted water from Morocco 1 from turkey meat isolated from Spain 1 from poultry isolated from Belgium 43/54 samples clustered phylogenetically into a tight group (<300 SNPs) = Epidemic strains

41 41 Investigation in Morocco Contact with Moroccan authorities in October 2014: No identified cases No general outbreak No restaurant outbreak Trace back investigation of suspected food items not possible

42 42 In New increase of S. Chester cases in 2015 Since August: - France: 41 cases - Belgium: 34 cases Trawling questionnaire among French cases (n=7) - So far : shrimp (20%), chicken (100%), restaurant (80%), coast (75%) - Hypotheses still valid?

43 43 Conclusions European outbreak associated with travel in Morocco Eating shrimps, eating in a restaurant and visiting the coast in Morocco were associated with S. Chester infection Epidemic strains isolated from chicken sausages, turkey meat, decanted water and fish meal Persistent source in Morocco - Outbreak still ongoing? Actions Continue collaboration and communication at EU level Involve Moroccan FETP in the investigations Inform travelers to Morocco about this outbreak

44 44 Successes EPIS FWD EU collaboration Analytical study (only national) Environmental investigation (EU & Morocco) Challenges Exposure out of the EU Prolonged outbreak Only partially multinational investigation Study power

45 Multi-country outbreak of STEC infection associated with haemolytic uraemic syndrome, Romania and Italy 2016 E Peron, A Zaharia, LC Zota, E Severi, O Mårdh, C Usein, M Bălgrădean, L Espinosa, J Jansa, G Scavia, A Rafila, A Serban, A Pistol On behalf of the outbreak investigation team

46 The outbreak 12/02/ ECDC epidemic intelligence identify a HUS * outbreak in Romania: 12 children reported with HUS after 24 January No aetiology identified 16/02 - Romania report in EPIS FWD No countries report cases suspected to be associated 18/02 Romania request ECDC support ECDC send 2 experts and 1 EPIET fellow 28/02 suspected cheese producer suspends activities 21/03 Italy report 1 HUS associated with the same cheese producer *Haemolytic uraemic syndrome

47 The outbreak investigation Epidemiological investigation Confirm the outbreak Case definition Linelist Descriptive analysis & trawling questionnaire Microbiological investigation Serology (performed in Rome, Italy) PCR (toxin profile and virulence genes) & culture PFGE and WGS Environmental investigation Food inspections

48 HUS outbreak confirmation Notified HUS cases in <5 years-old, Romania No routine non-specific HUS surveillance in RO

49 Final case definition Confirmed case: Epi-link with Romania AND laboratory confirmation for E. coli O26 infection after 15/01/2016 Probable case: Epi-link with Romania AND HUS after 15 January 2016 OR positive for STEC virulence genes: stx1 &/or stx2 and eae by PCR after 15/01/2016 OR positive for a E. coli serogroup other than O26 after 15/01/2016 Epidemiological link with Romania : Travel history to Romania since 15 January Close contact with individuals with travel history to Romania since 15/01/2016 Consumption of dairy products produced in Romania after 15/01/2016 Exclusion criteria Travel history out of the EU in the two weeks before symptoms onset

50 Descriptive analysis 25 cases: 12 confirmed STEC O26 (11 in Romania and 1 in Italy) 13 probable (13 in Romania) Median age Confirmed: 12 months (range 6 38 months) Probable: 12.5 months (range 5 months 33 years) 20 cases <2 years of age 15 were females 19 cases (9 confirmed and 10 probable) with HUS 3 HUS cases died (1 confirmed, 2 probable)

51 Number of cases Distribution of cases by day of onset, outcome and area of residence (n=22; 3 probable cases asymptomatic) D Death Romania_Arges Romania_Bacau Romania_Brasov Romania_Bucarest Romania_Dolj Romania_Ialomita Romania_Sibiu Italy_Florence STEC O26 D D D January February March

52 Outbreak cases by area of residence, RO and IT, Jan to Mar 2016 (n= 24, one RO case missing information)

53 Outbreak cases by area of residence, Romania, Jan to Mar 2016 (n= 23, one case missing information)

54 Results trawling questionnaire (n=16) In Romania Fruits: apple, pear, orange, banana, ʺfruits from the market and backyard ʺ Vegetables: roots, peppers, broccoli, zucchini, spinach, ʺvegetables from the market all cooked Dairy products: cow-milk, joghurt, soft cheeses, ʺfrom the market or home-madeʺ Food-shops: many different chain, but only 2 in the most affected district Brands: several different brands In Italy Consumption of cheese imported by Romania

55 Microbiological investigation STEC O26 confirmed infections: 6 by serology (5 in Romania and 1 in Italy) 6 by slide agglutination (6 in Romania) STEC O157 confirmed infections: 1 by serology (in Romania) 1 by slide agglutination (in Romania) Toxin profiles: Stx1, Stx2, eae: (4 confirmed, 1 probable) Stx1, eae: (1 confirmed, 2 probable) Stx2, eae: (1 confirmed, 2 probable) Different PFGE profiles (in human and food isolate) now in TESSy WGS in near future

56 Environmental investigation Inspection of supermarket pointed by the trawling Inspection of cheese producer pointed by the trawling >500 food and environmental samples taken One milk processing establishment: Dairy product contaminated with O26 Dairy product positive for Stx1, Stx2 and eae Workers positive for Stx1, Stx2 and eae Same establishment exported cheese in Italy (and Belgium, Germany and Spain)

57 Conclusion Foodborne outbreak Persistent common source outbreaks cases infected by the same source over a prolonged period of time Some cases may have had person-to-person transmission Some cases may not be associated with this outbreak Most likely multi-strain outbreak Dairy products contaminated in one establishment Source of infection not identified Limitations/challenges: No analytical study Incomplete communication between the human and the food sector

58 Actions Routine non-specific HUS enhanced surveillance in Romania Enhanced HUS surveillance in the EU Increased STEC testing at national reference laboratory Enhance national surveillance for VTEC in food and animals Food recall in Romania and in the EU Scientific communication in EUROSURVEILLANCE ECDC/EFSA rapid outbreak assessment Success Collaboration between RO, IT, ECDC, EFSA and WHO-EURO

59 References Early findings in outbreak of haemolytic uraemic syndrome among young children caused by Shiga toxin-producing Escherichia coli, Romania, January to February Rapid outbreak assessment: Multi-country outbreak of Shiga toxinproducing Escherichia coli infection associated with haemolytic uraemic syndrome, 5 April O26-Romania-Italy-April2016.pdf

60 Thank you for your attention! 60