WHO Surveillance Programme for Control of Foodborne Infections and Intoxications in Europe FRANCE (FRA) Population: 60.2 million Area: 547 026 km 2 The designations and the presentation of material on this map of the Member States of the WHO European Region (as at 31 July 1997) do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines represent approximate border lines for which there may not yet be full agreement. 1. General information In France, foodborne diseases surveillance relies on 3 surveillance systems (figure 1): 1. Mandatory notification of foodborne outbreaks, botulism, brucellosis and listeriosis 2. Surveillance data from National Reference laboratories (CNR): salmonellosis, listeriosis 3. National hospital network: Haemolytic Uraemic Syndrome (HUS). 1.1 Mandatory notification of foodborne outbreaks An outbreak is defined as the occurrence of at least two cases of a similar illness, usually gastro-intestinal, due to the consumption of a common food product. Botulism and listeriosis are notifiable even for a single case. Notifications are done by general practitioners, hospital physicians, medical laboratories. Foodborne outbreaks can also be notified by the head of the establishment (schools, restaurants, etc.) or the head of the family where the cases occur. Outbreaks are investigated by the local public health authorities (DDASS = Direction Départementale des Affaires Sanitaires et Sociales) and Veterinary officers (DSV = Services Vétérinaires Départementaux). Standardized reports are sent to the French Public Health Institute (Institut de Veille Sanitaire) and Department of Agriculture. Theses reports are pooled and analyzed on an annual basis after checking for double notifications. The results are annually published in the Bulletin Epidémiologique Hebdomadaire.
Notifications, investigations of outbreaks and collaboration between local Public Heath Authorities and Veterinarian Services have been strengthened in 1987 by the implementation of the following measures: - An information was sent to 100 000 physicians to improve the notification, - Guidelines dealing with methodology of investigations and control measures were provided to local Health and Veterinarian Services, - An epidemiological software TIAC was developed to encourage case control studies and facilitate data analysis in foodborne outbreak management. 1.2 Contribution of National Reference Centres Contribution of National Reference Centres in foodborne diseases surveillance consists in: - microbiological expertise (typing) of strains sent by medical laboratories - epidemiological surveillance - early warning - technical advisory function For example, the National Reference Centre for Salmonella and Shigella receives: Strains of Salmonella from medical laboratories Epidemiological informations about Salmonella strains isolated in laboratories performing serotyping. Data analysis according to serotype and place (department) and date of isolation allows to detect an unusual increase of a serotype which may be due to the consumption of a commercialized contaminated product. For foodborne infections, bacteria under surveillance by National Reference Centres are: Salmonella, Shigella, Yersinia, Campylobacter, Vibrio, anaerobic bacteria (Clostridium perfringens and Clostridium botulinum), Listeria. - 2 -
Figure FR 1 Surveillance of foodborne diseases Laboratories Physicians Head of establishments Cases Mandatory Notification Isolates DDASS DSV Epidemiological studies Microbiological analyses (cases, food) Study of food chain Identification : -microorganism - Food - contributing factors - lots - supply Control measures CNR InVS Ministry of Agriculture Trend analysis Establishing of alert thresholds Data Analysis 1.3 National hospital network Since 1996, a surveillance system based on a national network of pediatric nephrology departments has been established for the monitoring of HUS in children under 15 years and is ruled by the InVS. - 3 -
2. Notified cases of foodborne diseases (mandatory notification + laboratories and hospital networks) Table FR 1 Notified cases of foodborne diseases FRANCE 1993 1998 Disease 1993 1994 1995 1996 1997 1998 Salmonellosis* 17705 17152 19174 16523 Incidence rate** 32.1 31.1 34.7 29.9 Listeriosis 451 336 301 220 228 230 Incidence rate 0.8 0.6 0.5 0.4 0.4 0.4 SHU E.coli O157+other serogroups/not O157 58 94 94 68/19 90 56/28 100 38/41 79 27/2 Trichinellosis 17 7 10 550 Brucellosis* 100 71 91 - * Source of data: EU Zoonoses Reports 1996-98 ** per 100 000 2.1 Mandatory notification 2.1.1 Botulism Botulism is notifiable whether it occurs as single case or if more than one person is involved. The incidents are reported by the DDASS and the National Reference Centre for anaerobic microorganisms at the Institut Pasteur. The number of episodes of botulism is given in Table FR 2. Table FR 2 Botulism incidents reported in mandatory notification framework. FRANCE 1993 1997 1993 1994 1995 1996 1997 1998 Total No. of episodes 10 13 7 5 8 16 59 N of cases 18 29 15 10 17 22 111 2.2 Foodborne outbreaks The following results include foodborne outbreaks notified in the framework of mandatory notification on one hand and the outbreaks of salmonellosis and shigellosis, reported by the National Reference Centre (CNR) on the other hand. Data collected from mandatory notification and data collected from the CNR can't be pooled for two main reasons: - there is actually no way to identify common notifications between the two systems; - the CNR provides data only for salmonellosis and shigellosis outbreaks. The foodborne origin of these outbreaks is not confirmed. - 4 -
Salmonellosis outbreaks notified by the CNR are used to assess the exhaustivity of the mandatory notification framework for salmonellosis outbreaks. In 1995, the exhaustivity of the mandatory notification system for salmonellosis outbreaks has been estimated to 20%. Because of previously discussed reasons, epidemiological characteristics of outbreaks are presented only for foodborne outbreaks reported in the mandatory notification framework. 3. Epidemiological characteristics of outbreaks The total number of reported outbreaks from 1988 to 1997, including mandatory notifications on one hand and CNR notifications on the other hand is shown in figure FR 2 and table FR 3. Figure FR 2 Foodborne Diseases Outbreaks Reported in Mandatory Notification Framework and by CNR France 1988-1997 1200 1000 800 600 400 200 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Mandatory notifications of foodborne outbreaks Outbreaks of salmonellosis or shigellosis reported by the CNR BgVV; FAO/WHO Centre, Berlin Table FR 3 Foodborne outbreaks reported in the mandatory notification system and number of cases involved FRANCE 1988-1997 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Outbreaks 164 330 326 384 446 369 533 395 414 478 Cases 5622 10085 7968 7192 10967 8643 9532 7349 7858 7817-5 -
3.1 Causative agents Table FR 4 Confirmed causative agents in foodborne outbreaks reported in the mandatory notification system FRANCE 1993-1997 1993 1994 1995 1996 1997 Total No. % Salmonella 200 267 185 162 201 1015 71.1 Clostridium perfringens 32 29 10 15 13 99 6.9 Staphylococcus aureus 37 60 32 34 32 195 13.6 Histamine 12 8 5 9 4 38 2.7 Bacillus cereus 3 4 2 2 1 12 0.8 Shigella 6 6 0 3 3 18 1.3 Others 6 18 4 4 11 43 3 DSP 0 0 3 1 1 5 0.3 Trichinella 1 0 2 - - 3 0.2 Hepatitis A - - - - - - 0.0 Clembuterol - - - - - - 0.0 Total agent identified 297 392 243 230 266 1428 65.2 Agent not identified 72 141 152 184 212 761 34.8 Total 369 533 395 414 478 2189 100.0 Figure FR 3 Foodborne Disease Outbreaks Confirmed Causative Agents France 1993-1997 Salmonella spp. 88,7% Cl.perfring.1,9% Agent not identified 34,8% Agent identified 65,2% Staph.aureus 3,7% Others 5,7% Total outbreaks agent identified: 1428 Total outbreaks agent not identified: 761 BgVV; FAO / WHO Centre, Berlin - 6 -
Table FR 5 Salmonella serotypes in foodborne outbreaks reported in the mandatory notification system. FRANCE 1993 1997 1993 1994 1995 1996 1997 Total No. % Enteritidis 125 175 113 106 118 637 62.8 Typhimurium 27 38 29 24 41 159 15.7 Heidelberg 1 2 1 4 3 11 1.1 Virchow 2 6 4 3 0 15 1.5 Hadar 1 0 4 1 2 8 0.8 Others serotypes 8 14 5 5 11 43 4.2 Total serotypes identified 164 235 156 143 175 873 86.1 Non identified serotypes 36 32 29 19 26 141 13.9 Total Salmonella 200 267 185 162 201 1015 100.0 Figure FR 4 Foodborne Disease Outbreaks Salmonella Serotypes France 1993 and 1997 1993 1997 S.Enteritidis 62,5% S.Enteritidis 58,7% Unknown 18,0% Unknown 12,9% S.Typhimurium 13,5% Other 6,0% S.Typhimurium 20,4% Other 8,0% BgVV; FAO / WHO Centre, Berlin - 7 -
3.2 Incriminated food Table FR 6 Food S. Enteritidis Foodborne outbreaks by incriminated foods and confirmed or suspected causative agents (Outbreaks reported to D.D.A.S.S. or D.S.V.) FRANCE 1993-1997 Salmonella S. Typhimuriu m Other Serotypes Not serotyped Causative agent Cl. Staph. perfr. aureus Other agents Unknown Total No. % Milk/milk products 15 5 0 4 1 65 7 19 116 5.3 Eggs/egg products 463 73 19 81 2 23 5 51 717 32.7 Meat 22 23 10 9 54 37 14 72 241 11 Poultry 8 11 22 8 11 10 5 22 97 4.4 Fish/shellfish 15 6 4 10 6 9 72 84 206 9.4 Other foods 36 5 6 15 46 53 32 94 287 13.1 Unknown 78 36 16 37 20 51 32 255 525 23.9 Total 637 159 77 164 140 248 167 597 2189 100 Figure FR 5 Foodborne Disease Outbreaks Incriminated Foods France 1993-1997 Poultry 4,4% Fish and fish prod. 9,4% Milk and milk prod. 5,3% Eggs/-prod. 32,8% Meat and meat prod. 11,0% Other 13,1% Total outbreaks: 2189 Unknown 24,0% BgVV; FAO/WHO Centre, Berlin - 8 -
3.3 Place where food was acquired or eaten Table FR 7 a Foodborne outbreaks by place where food was acquired or eaten FRANCE 1993-1997 Place Year Total 1993 1994 1995 1996 1997 1993-1997 No. No. % Private Home 139 235 166 137 190 866 39.6 Total collectives 225 298 215 276 287 1301 59.4 School 57 99 50 86 73 365 16.7 Social/Medical Institutions * 26 41 36 24 34 161 7.4 Canteen (restaurant in a work establishment) 17 25 17 27 29 115 5.2 Restaurant 61 62 46 76 79 324 14.8 Other communities ** 55 56 54 56 68 289 13.2 Community wide *** 9 15 12 7 4 47 2.1 Unknown 5 0 14 1 1 21 0.9 TOTAL 369 533 395 414 478 2189 100 * hospitals, homes for elderly people, kindergarten etc. ** holiday resorts, prisons, gatherings *** Several establishments or families with the same source of contamination - 9 -
Table FR 7b Total foodborne outbreaks by confirmed or suspected causative agents and place where food was eaten FRANCE 1993 1997 Place Causative agent Salmonella Cl. Perfr. B. cereus Staph. aureus other agents Histamine Unknown Total S. Enteritidis S. Typhimurium Other Serotypes Not serotyped Schools 40 9 7 18 43 8 59 4 16 161 365 Canteen 9 3 1 3 24 5 12 14 10 34 115 Social/Medical Institutions * 37 10 7 8 27 0 10 0 12 49 161 Restaurants 83 20 7 30 12 4 44 16 11 97 324 Other Communities* 56 20 6 17 27 2 44 5 16 96 289 * Private home 392 87 46 85 5 2 70 7 24 149 867 Community wide *** 15 7 3 3 0 1 7 2 4 5 47 Unknown 5 3 0 0 2 0 2 0 3 6 21 TOTAL 637 159 77 164 140 23 248 48 96 597 2189 * hospitals, homes for elderly people, kindergarten etc. ** holiday resorts, prisons, gatherings *** Several establishments or families with the same source of contamination Figure FR 6 Foodborne Disease Outbreaks Place where Food was Eaten France 1993-1997 School/kindergarten 16,7% Canteen 5,3% Other community 13,2% Restaurant,hotel 14,8% Medical care fac. 7,4% Unknown 1,0% Community wide 2,1% Private home 39,6% BgVV; FAO/WHO Centre, Berlin Total outbreaks: 2189-10 -
While most of the total number of outbreaks from 1993-1997 were reported to occur in various places outside from home, the majority of the salmonellosis outbreaks were reported to occur in private homes (see Figure FR7). This different frequency distribution reflects the efficacy of the control measures that have been implemented to reduce salmonellosis hazards in the restauration/public sector. In private homes, education programmes (e.g. storage and cooking) may, therefore, be needed as complementary measures to limit the transmission of salmonellosis. Figure FR 7 Salmonella Outbreaks by Place where Food was Eaten France 1993-1997 Other community 9,5% Medical care fac. 6,0% School/kindergarten 7,1% Canteen 1,5% Restaurant,hotel 13,5% Unknown 0,8% Community wide 2,7% Private home 58,8% BgVV; FAO/WHO Centre, Berlin Total Salmonella outbreaks: 1037-11 -
3.4 Contributing factors Table FR 8 Foodborne disease outbreaks by contributing factors FRANCE 1995-1997 Figure FR 9 Contributing Factor 1995 1996 1997 Total Outbreaks No. No. * % Contaminated raw material 57 80 88 225 16.3 Environmental contamination - personnel 46 45 49 140 10.1 - equipment 70 92 85 247 17.9 Faults in processing 71 90 101 262 19.0 Temperature misuse - preparation too far in advance 49 61 73 183 13.3 - inadequate heating 19 28 43 90 6.5 - inadequate cooling 63 77 94 234 16.9 Total 375 473 533 1381 100 * More than one factor is mentioned in some outbreaks Foodborne Disease Outbreaks Contributing Factors France 1993-1998 BgVV; FAO/WHO Centre, Berlin 4. Additional Information The French National Institute for Public Health Surveillance (Institut de Veille Sanitaire) publishes a weekly electronic epidemiological bulletin (B.E.H) that can be found at: http://www.invs.sante.fr/. For further reference on national and international data on foodborne diseases please visit the web page http://www.who.it/docs/fdsaf/fddata.htm. - 12 -