Recent European outbreaks: lessons learned

Transcription

1 Recent European outbreaks: lessons learned Andrea Ammon, Deputy to the Director European Centre for Disease Prevention and Control ILSI Annual Meeting, Phoenix, 23 January 2012

2 Disclosure All data presented have been funded by European Centre for Disease Prevention and Control (ECDC) European Food Safety Authority (EFSA) The public health authorities of the EU Member States

3 Overview How do we get information about foodborne illness and outbreaks? Surveillance for human disease Communication tools Collaboration Surveillance of foodborne outbreaks Some recent outbreaks and lessons learned

4 Role of ECDC (European Centre for Disease Prevention and Control) Identify, assess & communicate current & emerging health threats to human health from communicable diseases Role of EFSA (European Food Safety Authority) Assess and communicate on all risks associated with the food chain.

5 TESSy: One-Stop-Shop MS MS MSs Data users MS National institutes MS MS MS MS MS MS MS MS MS Data upload and access TESSy The European Surveillance System Data access Disease experts General public AF members MB members WHO EU Agencies EFSA Others MS

6 X 1000 Scope of European food- and waterborne diseases and zoonoses surveillance Anthrax /49 diseases (41%) Confirmed cases of 49 communicable diseases by ECDC disease specific programmes (excluding HCAI*), AER 2007, N = FWD HIV/STI TB VPD INF EVD *HCAI = health care associated infection ECDC disease specific programme Botulism Brucellosis Campylobacteriosis Cholera Variant Creutzfeldt-Jakob disease Cryptosporidiosis Echinococcosis Giardiasis Hepatitis A Listeriosis Leptospirosis Salmonellosis Shigellosis STEC/VTEC infection Toxoplasmosis Trichinosis Tularaemia Typhoid/paratyphoid fever Yersiniosis

7 EU-notification rates human cases of foodborne and zoonotic diseases, 2009 Campylobacteriosis Salmonellosis Yersiniosis VTEC infections Toxoplasmosis Q-fever Listeriosis Echinococcosis Trichinellosis Brucellosis TB due to M. bovis Cases per 100,000 pop

8 Why is S Enteritidis decreasing? S Enteritidis most common in egg and egg products Compulsory Salmonella control programs in laying hen flocks since 2008 Salmonella reduction targets per MS set up by the commission (often solved by vaccination of laying hen flocks) Since 2008, illegal to put Salmonella positive table eggs on the market

9 FWD (Urgent Inquiry) network in EPIS EPIS platform Index country Urgent inquiry Monthly summaries Country replies ECDC comments FWD network Multinational outbreak investigations

10 Source of exposure (2009) Petting farm Pet reptiles Aquatic frogs Sun dried tomatoes Roasted pistacchios Peanut butter crackers Sugar peas Alfalfa sprouts Hamburger or hot dog Minced meat, steak tartare or dried sausage Pork products Travel related No source Number of urgent inquiries

11 Integrated approach in animal-human health and food safety Collaborations Member States European Food Safety Authority (EFSA) European Commission Rapid Alert System for Food and Feed (RASFF) WHO (Infosan) Source:

12 Reporting scheme EU-FORS Outbreak No Food-borne? Do not report Yes No Suspected food vehicle? Report limited dataset Yes Strength of evidence implicating food vehicle Strong Report detailed dataset Weak Report limited dataset

13 Information from the EU Summary Report 2009, on food-borne outbreaks; published in March 2011 Interesting results from a substantial dataset at EU level

14 Food-borne outbreaks in EU, 2009, EUSR Unknown Salmonella Viruses Bacterial toxins Campylobacter Other causative agents Escherichia coli, pathogenic Verified outbreaks Possible outbreaks Parasites Other bacterial agents Number of outbreaks 5,550 food-borne outbreaks (977, 17.6%, verified); 48,964 human cases, 4,356 hospitalisations and 46 deaths in Main causes Salmonella (31%), viruses (19%), bacterial toxins (10%),

15 Possible and verified FBOs, 2009, EUSR Austria Belgium Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom Norway Switzerland Verified outbreaks Possible outbreaks Number of outbreaks Distribution quite similar to 2007 and MSs + 2 non-mss reported outbreaks

16 Trends in outbreaks Unknown Salmonella Viruses Bacterial toxins Campylobacter Other causative agents Escherichia coli, pathogenic Parasites Other bacterial agents Number of outbreaks Salmonella outbreaks declined, virus and bacterial toxins outbreaks increased

17 Food vehicles in verified FBOs, 2009, EUSR Fruit, berries and juices and other products thereof, 2.3% Vegetables and juices and other products thereof, 2.1% Unknown, 22.1% Eggs and egg products, 17.3% N=977 Bovine meat and products thereof, 2.5% Other foods, 14.2% Other or mixed meat and products thereof, 3.4% Cheese, 3.4% Crustaceans, shellfish, molluscs and products Broiler meat (Gallus thereof, 3.6% gallus) and products thereof, 3.6% Bakery products, 4.3% Fish and fish products, 5.4% Mixed or buffet meals, 8.1% Pig meat and products thereof, 7.8%

18 Settings in verified FBOs, 2009, EUSR Temporary mass catering (fairs, festivals), 2.8% Unknown, 15.0% N=977 Hospital or medical care facility, 4.8% Household, 36.4% Canteen or workplace catering, 4.9% School, kindergarten, 5.5% Other setting, 9.9% Restaurant, café, pub, bar, hotel, 20.6%

19 Food-borne outbreaks, 2009, EUSR Egg and egg products outbreaks 97% caused by Salmonella Pig meat outbreaks Trichinella 40%, Clostridium 22%, Salmonella 16%, others Mixed and buffet meals outbreaks Salmonella 23%, Bacillus 20%, Clostridium 20%, Staphylococcus 17%, others Fish outbreaks 65% histamine, others Fruit and vegetables outbreaks 65% viruses, others

20 Foodborne outbreaks Local Diffuse Primary production Processing Primary production Processing Contamination Distribution Distribution Final preparation Final preparation Contamination Point source type outbreak Local food cross-contamination Restricted spread via food Diffuse widespread outbreak Contamination at production or processing level Number of cases higher than expected Detection by lab-based subtype surveillance Complex multistate investigation Adapted by courtesy of Alexandra Fetsch, BfR, Germany

21 STEC O104:H4 outbreak what do we know and is there less or more to learn? Johanna Takkinen, Carlijn Bogaardt, Lara Payne-Hällström European Centre for Disease Prevention and Control

22 Size of the outbreak Totally 3979 cases 3967 (99,7%) in EU/EEA, 12 (0,3%) outside EU/EEA 3842 cases* In Germany 125 cases In 12 EU/EEA countries 12 cases* In 3 non-eu countries (CA, CH, US) 2987 non-hus STEC 855 HUS 76 non-hus STEC 49 HUS 8 non-hus STEC 4 HUS 18 deaths (0.6%) 35 deaths (4.1%) No deaths 1 death No deaths 1 death Incubation period: -Median 8 days (25% 6 d, 75% 10 d) Time between diarrhoea and HUS: - Median 5 days (25% 4d, 75% 7 d) Of HUS cases - 68% women - Median age 42 years (0-91 years) - Bloody diarrhoea in 79% *Source: Robert Koch Institute. Report: Final presentation and evaluation of epidemiological findings in the EHEC O104:H4 outbreak, Germany Berlin 2011.

23 Age-specific notification of HUS, EU/EEA Confirmed HUS cases Other serotypes Age group

24 First questions: -How common is serotype STEC O104:H4 in humans? -How common is serotype STEC O104:H4 in animals/food? TESSy human data from 2009: - No cases of STEC O104:H4 reported Scheutz/Enter-net data: - Two cases in Germany in One case in France in 2004 ECDC-EFSA joint report 9 June: - One case in Finnish traveller in 2010 (Egypt) - No animal/food isolates reported - Literature; one case in Korea in 2005 Additional info from CDC, US: -Strains isolated from two patients during an unconfirmed outbreak of HUS in the Republic of Georgia in 2009

25 German epidemiological studies in May-June 6 case-control studies 7 cohort studies 3 explorative questionnaires 2 on-line questionnaires Recipe-based restaurant cohort study - Independent relative risk for sprouts 14,2 (95% CI 2,40 infinite) => Exhaustive number of epidemiological studies within a short time period *Source: Robert Koch Institute. Report: Final presentation and evaluation of epidemiological findings in the EHEC O104:H4 outbreak, Germany Berlin 2011 and presentation by Gerard Krause at MB on 9 Nov 2011.

26 STEC O104:H4 outbreak France 24 June 2011 France reported: 16 STEC cases (8 bloody diarrhoea, 8 HUS) In 4 cases STEC O104:H4 confirmed, identical to German strain 11 attended a private event 6 of those remembered having eaten sprouts

27 EU imports of fenugreek seeds from third countries in 2010 Malaysia Barbados Lebanon Syria Jordan Israel Pakistan Brazil Singapore China Sri Lanka Australia Morocco Thailand Turkey Egypt India kg Source: EFSA technical report: Tracing seeds, in particular fenugreek (Trigonella foenum-graecum) seeds, in relation to the Shiga toxinproducing E. coli (STEC) O104:H Outbreaks in Germany and France

28 Delivery channels of fenugreek seeds explain German and French STEC O104:H4 outbreak Date: 12 th July 2011 horticultural farm in Lower Saxony retail in France seed producer intermediaries (colours: european states) outbreak clusters sprout delivery seed delivery Source: Task Force EHEC; 2011, BfR, 2011; EFSA, 2011, by courtesy of Alexandra Fetsch, BfR, Germany

29 Food Supply supply Chain: chain Established established Links links A tool developed for food backward and forward tracing by EFSA Germany other countries > 1000 kg > 100 kg > 10 kg > 1 kg 1 kg Importer Exporter Retail France Sprout producer, Germany Representation of the delivery quantities and routes of all examined seeds (six varieties including fenugreek).. By courtesy of Olaf Mosbach-Schulz, EFSA. From:Weiser A et al. (2011). EHEC O104:H4 outbreak 2011 in Europe: a new tool to support the outbreak investigations on governmental side. Poster at the Medical. Poster on Biodefense Conference, Munich 25th-28th October 2011

30 Shigella spp. increase import to EU? Outbreak due to imported vegetables in 2009: Example of routes of snow peas to Denmark* Kenya Ethiopia Guatemala Farmer 1 Farmer 2 37 farmers 4 farmers Exporter A Exporter B Exporter C Exporter D Insert picture here Importer A MS Importer B MS *Kindly provided by Tenna Jensen, Danish Veterinary and Food Administration Denmark

31 Lessons learned Efforts to increase speed of notification, all over Europe Define in advance basic epi indicators that need to be monitored throughout the outbreak, e.g. (epicurve (by date of onset), age group - gender tabulation Strengthen diarrhoeagenic HUS surveillance Collaboration between clinicians, public health (epi and lab) and veterinary/food safety authorities at all levels from the beginning is key Enhance laboratory capacity Harmonise methods Using the experience of the back tracing of sprout seeds in Europe, appropriate tools for the generic methodology of trace back should be developed and validated at the EU level

32 Acknowledgements Johanna Takkinen Pia Mäkäla Colleagues in the Member States at national, regional and local level

33 Thank you for your attention!

34 Example of multinational outbreak investigation: Salmonella Goldcoast

35 Multinational Salmonella Goldcoast outbreak - ongoing Uncommon serotype in the EU Large human outbreaks reported from various EU countries in relation to pork products October, 2009: Urgent Inquiry issued by Hungary regarding unusual increase in human cases 11 Member States with no increase, 5 others with potentially linked cases Nationwide outbreaks detected in Italy and Hungary Working hypothesis source of infections various pork meat/pork products

36 Identified S. Goldcoast cases by month of disease onset for all countries responding to the urgent inquiry in 2009 (N =149).

37 Animal Health Situation in the EU EFSA Salmonella baseline survey report: Positive for S. Goldcoast serotype in 2008: 39 pig production holdings in 10 EU countries 3 breeding holdings in 3 countries Highest proportions of positive breeding and pig production holdings by country: the Netherlands (9,5% and 11,9%) the United Kingdom (8,6% and 3,6%) Spain (4,2% and 9,9%) Both production holdings and breeding holdings could be a continuous source of contamination in the food chain Transport of pigs and pork meat is complex in the EU

38 Example: Importation of live pigs to Hungary in 2007 and 2008, source: Eurostat trade data Imported live pigs X 100 kg DE CZ IT SK PL NL

39 Conclusions from current investigations 1. There is an unusual increase of S. Goldcoast in humans in several countries in the EU, occurring since Epidemiological data suggest that there is a continuous source of exposure 3. Pork containing products confirmed as a likely source in Italy - Supports the working hypothesis - Previous outbreaks raw fermented sausage

40 Questions and steps forward Complete case control studies in Hungary and Italy Is it the EU pig populations that are mainly infected with this particular serotype of Salmonella? Animal health authorities engaged in the EU Comparison of PFGE profiles from animal and food isolates to human isolates is ongoing

41 Use of typing methods in EU laboratories PulseNet Europe survey September 2009 (38 labs in 24 countries): PFGE MLVA Other sequence-based method Salmonella VTEC Listeria EFSA survey in food laboratories in 2009 (26 MSs): PFGE/ PulseNet Europe protocol MLVA Other typing methods Salmonella VTEC Listeria 13-5 ECDC survey in reference labs in 2009: 23/26 perform PFGE for Salmonella

42 Multinational studies Project: Seroepidemiology as a tool to assess incidence of Salmonella and Campylobacter infections ; Antibody response in infected but asymptomatic cases Protocol for countries to perform seroepidemiological burden of Salmonella and Campylobacter infections Multinational seroepidemiological study studies to assess Joint Listeria typing study with EFSA planned pilot a joint molecular typing exercise between ECDC and EFSA support the development of molecular typing surveillance system for listeriosis at the EU level provide useful information for food safety and public health authorities on potential links between identified high risk food types and human infections. Participating countries ( ): Sweden, Norway, Lithuania, Hungary, Denmark, Luxembourg, UK, Czech Republic, France, Finland, and Slovenia

43 Most common Salmonella serotypes in humans, 2010* S. Agona 0.5% S. Mbandaka 0.5% S. Virchow 0.7% S. Derby 0.7% S. Kentucky 0.8% S. Typhimurium, monophasic S. Newport 1,4,[5],12:i:- 0.9% 1.5% Other 25.3% S. Typhimurium 22.4% S. Enteritidis 45.0% S. Infantis 1.8% 2/3 of human Salmonella infections caused by S. Enteritidis and S. Typhimurium *Preliminary data from the European Surveillance System, TESSy

44 Outbreak investigation support Project: Practical toolbox for investigations of FWD threats that have an EU dimension ; Case definitions EU trawling questionnaire Database with questions Automated data analysis Guidance for microbiology and environmental investigations Guidance for analytical investigations

45 Organisms associated with UI s, Salmonella spp Shigella spp. 1 3 STEC/VTEC (shigatoxin- /verotoxin producing E. coli) 1 6 Hepatitis A 0 1 Cyclospora 0 1

46 Salmonella spp. Urgent Inquiries 2009 S. Saintpaul S. Oranienburg S. Ohio S. Hadar S. Goldcoast S. Carrau S. Bovismorbificans S. Newport, S. Montevideo, S. Senftenberg, S. Larochelle S. Enteritidis S. Typhimurium Number of Urgent Inquiries

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