Campylobacteriosis in New Zealand: results of a case-control study

Marked campylobacteriosis decline after interventions aimed at poultry, New Zealand

Beginning in the 1980s, New Zealand experienced rising annual rates of campylobacteriosis that peaked in 2006. We analyzed notification, hospitalization, and other data to explore the 2007-2008 drop in campylobacteriosis incidence. Source attribution techniques based on genotyping of Campylobacter jejuni isolates from patients and environmental sources were also used to examine the decline. In 2008, the annual campylobacteriosis notification rate was 161.5/100,000 population, representing a 54% decline compared with the average annual rate of 353.8/100,000 for 2002-2006. A similar decline was seen for hospitalizations. Source attribution findings demonstrated a 74% (95% credible interval 49%-94%) reduction in the number of cases attributed to poultry. These reductions coincided with the introduction of a range of voluntary and regulatory interventions to reduce Campylobacter spp. contamination of poultry. The apparent success of these interventions may inform approaches other countries could consider to help control foodborne campylobacteriosis.

The spatial and temporal determinants of campylobacteriosis notifications in New Zealand, 2001–2007

Despite recent improvements, New Zealand still has one of the highest per-capita incidence rates of campylobacteriosis in the world. To reduce the incidence, a thorough understanding of the epidemiology of infection is needed. This retrospective analysis of 36 000 notified human cases during a high-risk period between 2001 and 2007 explored the spatial and temporal determinants of Campylobacter notifications at a fine spatial scale in order to improve understanding of the complex epidemiology. Social deprivation was associated with a decreased risk of notification, whereas urban residence was associated with an increased risk. However, for young children rural residence was a risk factor. High dairy cattle density was associated with an increased risk of notification in two of the three regions investigated. Campylobacter notification patterns exhibit large temporal variations; however, few factors were associated with periods of increased risk, in particular temperature did not appear to drive the seasonality in campylobacteriosis.

Campylobacter spp. as a Foodborne Pathogen: A Review

Campylobacter is well recognized as the leading cause of bacterial foodborne diarrheal disease worldwide. Symptoms can range from mild to serious infections of the children and the elderly and permanent neurological symptoms. The organism is a cytochrome oxidase positive, microaerophilic, curved Gram-negative rod exhibiting corkscrew motility and is carried in the intestine of many wild and domestic animals, particularly avian species including poultry. Intestinal colonization results in healthy animals as carriers. In contrast with the most recent published reviews that cover specific aspects of Campylobacter/campylobacteriosis, this broad review aims at elucidating and discussing the (i) genus Campylobacter, growth and survival characteristics; (ii) detection, isolation and confirmation of Campylobacter; (iii) campylobacteriosis and presence of virulence factors; and (iv) colonization of poultry and control strategies.

The integration of molecular tools into veterinary and spatial epidemiology

At the interface of molecular biology and epidemiology, the emerging discipline of molecular epidemiology offers unique opportunities to advance the study of diseases through the investigation of infectious agents at the molecular level. Molecular tools can increase our understanding of the factors that shape the spatial and temporal distribution of pathogens and disease. Both spatial and molecular aspects have always been important to the field of infectious disease epidemiology, but recently news tools have been developed which increase our ability to consider both elements within a common framework. This enables the epidemiologist to make inferences about disease patterns in space and time. This paper introduces some basic concepts of molecular epidemiology in a veterinary context and illustrates the application of molecular tools at a range of spatio-temporal scales. Case studies - a multi-state outbreak of Serratia mastitis, a national control program for campylobacteriosis, and evolution of foot-and-mouth-disease viruses - are used to demonstrate the importance of considering molecular aspects in modern epidemiological studies. The discipline of molecular epidemiology is in its infancy and our contribution aims to promote awareness, understanding and uptake of molecular epidemiology in veterinary science.

Marked campylobacteriosis decline after interventions aimed at poultry, New Zealand

Beginning in the 1980s, New Zealand experienced rising annual rates of campylobacteriosis that peaked in 2006. We analyzed notification, hospitalization, and other data to explore the 2007-2008 drop in campylobacteriosis incidence. Source attribution techniques based on genotyping of Campylobacter jejuni isolates from patients and environmental sources were also used to examine the decline. In 2008, the annual campylobacteriosis notification rate was 161.5/100,000 population, representing a 54% decline compared with the average annual rate of 353.8/100,000 for 2002-2006. A similar decline was seen for hospitalizations. Source attribution findings demonstrated a 74% (95% credible interval 49%-94%) reduction in the number of cases attributed to poultry. These reductions coincided with the introduction of a range of voluntary and regulatory interventions to reduce Campylobacter spp. contamination of poultry. The apparent success of these interventions may inform approaches other countries could consider to help control foodborne campylobacteriosis.

Microbiological quality of roof-harvested rainwater and health risks: a review

Roof-harvested rainwater (RHRW) has been considered an effective alternative water source for drinking and various nonpotable uses in a number of countries throughout the world. The most significant issue in relation to using untreated RHRW for drinking or other potable uses, however, is the potential public health risks associated with microbial pathogens. This paper reviews the available research reporting on the microbial quality of RHRW and provides insight on the capacity of fecal indicator bacteria to monitor health risks and disease outbreaks associated with the consumption of untreated RHRW. Several zoonotic bacterial and protozoan pathogens were detected in individual and communal rainwater systems. The majority of the studies reported in the literature assessed the quality of rainwater on the basis of the presence or absence of specific pathogens, with little information available regarding the actual numbers of such pathogens. In addition, no information is available concerning the ongoing prevalence of different pathogens in RHRW over time. The published data suggest that the microbial quality of RHRW should be considered less than that expected for potable water and that the commonly used indicators may not be suitable to indicate the presence of pathogens in RHRW. Several case control studies established potential links between gastroenteritis and consumption of untreated RHRW. Therefore, health risks assessment models, such as those using Quantitative Microbial Risk Assessment, should be used to manage and mitigate health risks associated with drinking and nonpotable uses of RHRW.

Risk factors for sporadic Campylobacter jejuni infections in children in a Greek region

A case-control study was conducted in the urban area of Attica, Greece to investigate risk factors for sporadic Campylobacter jejuni infections in children aged <15 years. Over a 2-year period, 205 cases and 205 controls, matched by age group (<1, 1-4, 5-9, 10-14 years) and gender, were selected from the registries of the paediatric hospitals of this area. In conditional multivariate logistic regression analysis, ethnicity [odds ratio (OR) 5·06, 95% confidence interval (CI) 2·49-10·28], consumption of chicken the week prior to disease onset (OR 1·97, 95% CI 1·10-3·55) and playing in the garden (OR 1·83, 95% CI 1·05-3·19) were independently associated with disease occurrence; consumption of raw vegetables was a 'protective' factor (OR 0·48, 95% CI 0·27-0·85).

The impact of domestic travel on estimating regional rates of human campylobacteriosis

Residential locations of cases are often used as proxy measures for the likely place of exposure and this assumption may result in biases affecting both surveillance and epidemiological studies. This study aimed to describe the importance of domestic travel in cases of human campylobacteriosis reported during routine surveillance in Iceland from 2001 to 2005. Various measures of disease frequency were calculated based upon the cases' region of residence, adjusting location of domestic travel cases to their travel region, as well as separate estimations for travellers and non-travellers. Of the 376 cases included in the analysis, 37% had travelled domestically during their incubation period. Five of the eight regions were identified as high-risk when considering domestic travel whereas there were no high-risk regions when considering only region of residence. The change in regional representation of disease occurrence indicates the importance of collecting domestic travel information in ongoing surveillance activities.

Population-based surveillance study of Campylobacter infections in Finland

The annual incidence in 14,361 campylobacteriosis cases reported in Finland in 2002-2005 varied between 61 and 76/100,000 population. The mean incidence was highest (148/100,000) in the 25-29 years age group and lowest (range 21-24/100,000) in children aged 5-14 years and patients aged ≥75 years. The number of domestic cases was low in winter and peaked in summer. A total of 622 strains isolated from domestic infections and 785 foreign travel-related strains were serotyped. Serotypes Pen 3 and Pen 37 had the strongest association with travel-related infections (96%, P<0·001), and Pen 6,7, Pen 12 and Pen 27 were significantly associated with domestic infections (>70% domestic within each serotype, P<0·001). Pen 2 and Pen 1,44 were less common in older than in younger patients. Of domestic strains, a higher proportion of Pen 2 strains was isolated in winter (18%) compared to the other serotypes (0-10%).

Risk factors for indigenousCampylobacter jejuniandCampylobacter coliinfections in The Netherlands: a case-control study

A case-control study comprising 1315Campylobacter jejunicases, 121Campylobacter colicases and 3409 frequency-matched controls was conducted in The Netherlands in 2002–2003. Risk factors for bothC. jejuniandC. colienteritis were consumption of undercooked meat and barbecued meat, ownership of cats and use of proton pump inhibitors. Consumption of chicken was a predominant risk factor forC. jejunienteritis, but many additional risk factors were identified. Unique risk factors forC. coliinfections were consumption of game and tripe, and swimming. Contact with farm animals and persons with gastroenteritis were predominant risk factors forC. jejunienteritis in young children (0–4 years). Important risk factors for the elderly (⩾60 years) were eating in a restaurant, use of proton pump inhibitors and having a chronic intestinal illness. Consumption of chicken in spring, steak tartare in autumn and winter and barbecued meat in rural areas showed strong associations withC. jejuniinfections. This study illustrates that important differences in risk factors exist for differentCampylobacterspp. and these may differ dependent on age, season or degree of urbanization.

Molecular epidemiology of Campylobacter jejuni in a geographically isolated country with a uniquely structured poultry industry

In New Zealand the number of campylobacteriosis notifications increased markedly between 2000 and 2007. Notably, this country's poultry supply is different than that of many developed countries as the fresh and frozen poultry available at retail are exclusively of domestic origin. To examine the possible link between human cases and poultry, a sentinel surveillance site was established to study the molecular epidemiology of Campylobacter jejuni over a 3-year period from 2005 to 2008 using multilocus sequence typing. Studies showed that 60.1 to 81.4% of retail poultry carcasses from the major suppliers were contaminated with C. jejuni. Differences were detected in the probability and level of contamination and the relative frequency of genotypes for individual poultry suppliers and humans. Some carcasses were contaminated with isolates belonging to more than one sequence type (ST), and there was evidence of both ubiquitous and supplier-associated strains, an epidemiological pattern not recognized yet in other countries. The common poultry STs were also common in human clinical cases, providing evidence that poultry is a major contributor to human infection. Both internationally rare genotypes, such as ST-3069 and ST-474, and common genotypes, such as ST-45 and ST-48, were identified in this study. The dominant human sequence type in New Zealand, ST-474, was found almost exclusively in isolates from one poultry supplier, which provided evidence that C. jejuni has a distinctive molecular epidemiology in this country. These results may be due in part to New Zealand's geographical isolation and its uniquely structured poultry industry.

The spatial distribution of campylobacteriosis in New Zealand, 1997-2005

In New Zealand Campylobacter infection rates have increased steadily since 1980, reaching a peak in 2003 (396/100,000 population). Compared to other nations, disease rates are unfavourably high (e.g. Australia 117/100,000 population, UK 85/100,000 population, USA 13/100,000 population). This ecological study investigated spatial variations in Campylobacter infection rates across New Zealand's Territorial Local Authorities (TLAs, n=73) for the period 1997-2005. Applying multiple linear regression, we examined whether geographical factors such as socio-demographic characteristics, climate, land use, water and the food environment were associated with local differences in the occurrence of Campylobacter infection rates. The results suggested significant variations in campylobacteriosis across TLAs (average annual rates ranging from 97 to 526/100,000 population), with higher rates in the South Island. Disease rates were associated with lower socio-economic deprivation (P<0.01), the proportion of the population aged 25-44 years (P<0.01) and fresh food outlet density (P<0.76). The results underline the role of area-level characteristics in explaining the spatial distribution of campylobacteriosis in New Zealand. In particular, the findings draw attention to the relatively unexplored role of fresh food outlets as a potential risk factor for increased Campylobacter notifications.

Campylobacter excreted into the environment by animal sources: prevalence, concentration shed, and host association

An intensive study of 443 isolates of Campylobacter jejuni and Campylobacter coli from 2031 fecal samples excreted by animal sources including cattle, sheep, and pigs, a range of wild and domesticated avian species and pets is described. The prevalence found in the majority of animal sources ranged from 22% to 28% with poultry being highest at 41% and cats and dogs lowest (<5%). The average count excreted for each animal source was found not to be significantly different ranging from approximately 10(2) to 10(5) cfu/g. Multilocus sequence typing (MLST) identified phylogenies that exhibited host specificity. A number of clonal complexes (CCs) and sequence types (STs) were characteristic of particular hosts (e.g., CC-179, ST-637, and ST-1341 found only in pigeons and gulls). Analysis of genetic distance demonstrated numerous significant differences in the distribution of MLST types (CC, ST, and allele) between animal sources. Host association was quantified using structure that correctly assigned the nine animal sources with accuracies of 28%, 24%, and 55% at the CC, ST, and allele levels, respectively. This is substantially higher than would be expected by random allocation (11%) but farmyard poultry had the lowest assignment accuracy (13%, 13%, and 21%) suggesting that isolates were shared with a wide range of other animals. This study demonstrates the link between MLST type and host and provides data that can be used in risk assessment and food attribution models. Further, it demonstrates the applicability of MLST to characterize Campylobacter strains from a broad range of environmental sources.

Description and sources of contamination by Campylobacter spp. of river water destined for human consumption in Brittany, France

Presence or absence of Campylobacter spp. in water of five rivers upstream from an intake point for drinking water production was investigated, and isolates genetically compared with human, pig and poultry isolates in order to determine their source. River water and drinking water obtained from these rivers were sampled one time per month, over a period of one year, and tested for Campylobacter. Isolates were typed by PFGE. Campylobacter was not detected in treated drinking water, but 50% of the river samples were contaminated. Contamination was observed on the four seasons. In total, 297 Campylobacter isolates were collected and generated 46 PFGE profiles. Campylobacter jejuni was the most frequently detected species in samples (74.1% of the isolates), followed by Campylobacter coli (17.8%) and Campylobacter lari (8.1%). Forty-two of the 46 PFGE profiles were unique. Only one genotype was detected three times in a river during the year and four genotypes in two different rivers. When compared to animal and human Campylobacter PFGE profiles, 14, 11 and one Campylobacter genotypes from water were genetically closed to human, poultry, and pig Campylobacter genotypes, respectively. The Campylobacter population displayed a high level of genetic diversity, suggesting that contamination originated from various origins. Human, poultry and pig were sources of contamination of the river by Campylobacter. Finally, no Campylobacter were detected in drinking water, indicating that the risk of outbreaks due to consumption of drinking water is low.

Patient-reported complications associated with Campylobacter jejuni infection

This study aimed to investigate the occurrence of complications, especially musculoskeletal symptoms, after sporadic Campylobacter jejuni enteritis of domestic origin in Finland. This multi-centre cross-sectional study was conducted during a seasonal peak in 2002. Questionnaires were sent to Campylobacter-positive patients, representing different geographical areas, 2 months after collection of positive stool samples. Medical records were viewed in several cases. Besides antimicrobial susceptibility testing C. jejuni isolates were serotyped. A total of 235 patients (58%) returned the questionnaire and 201 C. jejuni-positive patients were finally included in the study. Musculoskeletal symptoms associated with C. jejuni enteritis were frequent (39%); joint pain was most commonly reported (81%). The incidence of reactive arthritis was 4% and that of Achilles enthesopathy and/or heel pain was 9%. Stomach ache during enteritis was associated with the later development of joint pain. Antimicrobial treatment was common but did not prevent complications.

Assigning the source of human campylobacteriosis in New Zealand: a comparative genetic and epidemiological approach

Integrated surveillance of infectious multi-source diseases using a combination of epidemiology, ecology, genetics and evolution can provide a valuable risk-based approach for the control of important human pathogens. This includes a better understanding of transmission routes and the impact of human activities on the emergence of zoonoses. Until recently New Zealand had extraordinarily high and increasing rates of notified human campylobacteriosis, and our limited understanding of the source of these infections was hindering efforts to control this disease. Genetic and epidemiological modeling of a 3-year dataset comprising multilocus sequence typed isolates from human clinical cases, coupled with concurrent data on food and environmental sources, enabled us to estimate the relative importance of different sources of human disease. Our studies provided evidence that poultry was the leading cause of human campylobacteriosis in New Zealand, causing an estimated 58-76% of cases with widely varying contributions by individual poultry suppliers. These findings influenced national policy and, after the implementation of poultry industry-specific interventions, a dramatic decline in human notified cases was observed in 2008. The comparative-modeling and molecular sentinel surveillance approach proposed in this study provides new opportunities for the management of zoonotic diseases.

Treatment of Escherichia coli O157:H7 with lactic acid, neutralized electrolyzed oxidizing water and chlorine dioxide followed by growth under sub-optimal conditions of temperature, pH and modified atmosphere

The utilization of sub-lethal decontamination treatments gains more and more interest due to the increased consumers' demand for fresh, minimally processed and convenient food products. These products rely on cold chain and hurdle (combination) technology to provide microbiological safety and quality during their shelf life. To investigate the ability of surviving cells to resuscitate and grow in a food simulating environment, sub-lethal decontamination treatments were coupled with subsequent storage under sub-optimal growth conditions. For this purpose chlorine dioxide (ClO2) and neutralized electrolyzed oxidizing water (NEW)-treated cultures of Escherichia coli O157:H7 were inoculated in TSB-YE of pH 5.8 and aw 0.99, and stored at 10 degrees C, 12.5 degrees C and 15 degrees C, under four different atmospheres (0%, 30% and 60% CO2 balanced with N2, and air). Due to the severity of injury, lactic acid-treated cells were inoculated in TSB-YE pH 7.0. Data obtained reveal that the fraction of sub-lethally injured E. coli O157:H7 undergoes an additional inhibitory effect during the storage period under of sub-optimal conditions. Observed extension in the lag growth phase was a direct consequence prior sub-lethal injury. The effects of liquid ClO2 and NEW were less pronounced in comparison to lactic acid. The current study signifies the potential utilization of appropriate combination of different extrinsic and intrinsic factors in the elimination or growth inhibition of food-borne pathogens.

Chicken consumption and use of acid-suppressing medications as risk factors for Campylobacter enteritis, England

In a case-control study of Campylobacter spp. risk factors in England during 2005-2006, we identified recent consumption of commercially prepared chicken as an important risk factor. The risk for illness associated with recent chicken consumption was much lower for persons who regularly ate chicken than in those who did not, which suggests that partial immunologic protection may follow regular chicken preparation or consumption. Chicken-related risk factors accounted for 41% of cases; acid-suppressing medication, for 10%; self-reported past Campylobacter enteritis, 2%; and recent acquisition of a pet dog, 1%. Understanding the risks associated with chicken from different sources will benefit strategies to reduce Campylobacter infections. Better characterization of immune correlates for Campylobacter infection is necessary to assess the relative importance of immunity and behavioral factors in determining risk.

Immunity to Campylobacter: its role in risk assessment and epidemiology

Acquired immunity is an important factor in the epidemiology of campylobacteriosis in the developing world, apparently limiting symptomatic infection to children of less than two years. However, also in developed countries the highest incidence is observed in children under five years and the majority of Campylobacter infections are asymptomatic, which may be related to the effects of immunity and/or the ingested doses. Not accounting for immunity in epidemiological studies may lead to biased results due to the misclassification of Campylobacter-exposed but apparently healthy persons as unexposed. In risk assessment studies, health risks may be overestimated when immunity is neglected.

Novel clonal complexes with an unknown animal reservoir dominate Campylobacter jejuni isolates from river water in New Zealand

Campylobacter jejuni is widely distributed in the environment, and river water has been shown to carry high levels of the organism. In this study, 244 C. jejuni isolates from three river catchment areas in New Zealand were characterized using multilocus sequence typing. Forty-nine of the 88 sequence types identified were new. The most common sequence types identified were ST-2381 (30 isolates), ST-45 (25 isolates), and ST-1225 (23 isolates). The majority of the sequence types identified in the river water could be attributed to wild bird fecal contamination. Two novel clonal complexes (CC) were identified, namely, CC ST-2381 (11 sequence types, 46 isolates) and CC ST-3640 (6 sequence types, 12 isolates), in which all of the sequence types were new. CC ST-2381 was the largest complex identified among the isolates and was present in two of the three rivers. None of the sequence types associated with the novel complexes has been identified among human isolates. The ST-2381 complex is not related to complexes associated with cattle, sheep, or poultry. The source of the novel complexes has yet to be identified.

Source attribution of food-borne zoonoses in New Zealand: a modified Hald model

A Bayesian approach was developed by Hald et al.((1)) to estimate the contribution of different food sources to the burden of human salmonellosis in Denmark. This article describes the development of several modifications that can be used to adapt the model to different countries and pathogens. Our modified Hald model has several advantages over the original approach, which include the introduction of uncertainty in the estimates of source prevalence and an improved strategy for identifiability. We have applied our modified model to the two major food-borne zoonoses in New Zealand, namely, campylobacteriosis and salmonellosis. Major challenges were the data quality for salmonellosis and the inclusion of environmental sources of campylobacteriosis. We conclude that by modifying the Hald model we have improved its identifiability, made it more applicable to countries with less intensive surveillance, and feasible for other pathogens, in particular with respect to the inclusion of nonfood sources. The wider application and better understanding of this approach is of particular importance due to the value of the model for decision making and risk management.

Risk factors for campylobacteriosis: an epidemiological surveillance study of patients and retail poultry

Isolates from Campylobacter jejuni-infected patients were collected and fresh poultry meat from retail sources was sampled during the same time period and within the same geographical area. The patients were interviewed about exposure to known risk factors, and a significant correlation between the presence of a poultry subtype in patients and the consumption of fresh poultry meat was observed.

Environmental determinants of campylobacteriosis risk in Philadelphia from 1994 to 2007

Campylobacter species infections are a common cause of acute gastroenteritis, and may uncommonly be complicated by renal, neurological, and rheumatologic sequelae. Although excess summertime campylobacteriosis has been observed, environmental mechanisms driving disease seasonality are poorly understood. We sought to evaluate the relationship between environmental factors and campylobacteriosis risk in a major North American metropolitan area. We evaluated 1532 cases of campylobacteriosis reported in Philadelphia between 1994 and 2007. We constructed Poisson regression models with oscillatory smoothers, and also used case-crossover design, to evaluate the associations between environmental exposures and disease risk on weekly and daily time scales. Both methods control for confounding by seasonally oscillating environmental factors. Incidence was greatest in June and July, with annual periodicity. Weekly incidence was associated with increasing relative humidity, (incidence rate ratio (IRR) per % 1.017, 95% CI 1.008-1.025), temperature (IRR per degrees C 1.041, 95% CI 1.011-1.072), and decreasing Delaware River temperature during the same week (IRR per degrees C 0.922, 95% CI 0.883-0.962), and at 4-week lags (IRR per degrees C 0.953, 95% CI 0.919-0.990). No acute associations were identified in case-crossover analyses. Our findings affirm the summertime seasonality of campylobacteriosis in Philadelphia, and the link between warm, humid weather and disease risk. However, the link between low river temperatures and enhanced campylobacteriosis risk in humans described here is novel, consistent with known links between watershed temperature and Campylobacter survival, and implicates local watersheds as epidemiologically important reservoirs for foodborne pathogens.

Demographic determinants for Campylobacter infection in England and Wales: implications for future epidemiological studies

Despite a significant public health burden the epidemiology of human Campylobacter infection remains blurred. The identification of demographic determinants for Campylobacter infection is therefore essential for identifying potential areas for intervention. Demographic data from an active, population-based sentinel surveillance system for Campylobacter infection (from 2000 until 2003, n=15 907) were compared with appropriate denominator data from the 2001 United Kingdom Census. Incidence was higher in males from birth until the late teens and in females from 20 to 36 years. Age- and gender-specific differences in Campylobacter incidence were observed in different ethnic and socioeconomic groups and hence are all major drivers for Campylobacter infection. Epidemiological studies on Campylobacter infection need to take these factors into consideration during design and analysis. The collation of detailed epidemiological data and its comparison with appropriate denominator data provides a valuable epidemiological tool for studying infection.

Molecular epidemiology of Campylobacter jejuni isolates from wild-bird fecal material in children's playgrounds

In many countries relatively high notification rates of campylobacteriosis are observed in children under 5 years of age. Few studies have considered the role that environmental exposure plays in the epidemiology of these cases. Wild birds inhabit parks and playgrounds and are recognized carriers of Campylobacter, and young children are at greater risk of ingesting infective material due to their frequent hand-mouth contact. We investigated wild-bird fecal contamination in playgrounds in parks in a New Zealand city. A total of 192 samples of fresh and dried fecal material were cultured to determine the presence of Campylobacter spp. Campylobacter jejuni isolates were also characterized by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST), and the profiles obtained were compared with those of human isolates. C. jejuni was isolated from 12.5% of the samples. MLST identified members of clonal complexes ST-45, ST-682, and ST-177; all of these complexes have been recovered from wild birds in Europe. PFGE of ST-45 isolates resulted in profiles indistinguishable from those of isolated obtained from human cases in New Zealand. Members of the ST-177 and ST-682 complexes have been found in starlings (Sturnus vulgaris) in the United Kingdom, and these birds were common in playgrounds investigated in New Zealand in this study. We suggest that feces from wild birds in playgrounds could contribute to the occurrence of campylobacteriosis in preschool children. Further, the C. jejuni isolates obtained in this study belonged to clonal complexes associated with wild-bird populations in the northern hemisphere and could have been introduced into New Zealand in imported wild garden birds in the 19th century.

The transmission of thermotolerant Campylobacter spp. to people living or working on dairy farms in New Zealand

New Zealand has one of the highest rates of campylobacteriosis in the developed world with an incidence rate of 383.5 cases per 100,000 in 2006. Dairy farming has been suggested as a potential source of campylobacteriosis. To explore this connection, seven farm investigations were undertaken at dairy farms on which a campylobacteriosis case had been notified. Campylobacter spp. were isolated from a range of sources on the farm (including 66% of bovine faecal samples) and genotypes compared with that of the clinical isolate of the index case. In depth, epidemiological questionnaires were also administered to determine exposure risks from a wide range of possible sources. Contact with dairy cow faeces was the most likely source of infection in four of the seven cases investigated, and occurred exclusively in new farm workers and children. In one of the cases investigated, infection was likely to have been acquired from non-dairy related sources, and in two cases the source could not be determined. The relative risk of dairy farm worker being notified with campylobacteriosis was estimated to be 1.88 (95% confidence interval=1.6-2.2).

Case-case analysis of enteric diseases with routine surveillance data: Potential use and example results

BACKGROUND

Case-control studies and outbreak investigations are the major epidemiological tools for providing detailed information on enteric disease sources and risk factors, but these investigations can be constrained by cost and logistics.

METHODS

We explored the advantages and disadvantages of comparing risk factors for enteric diseases using the case-case method. The main issues are illustrated with an analysis of routine notification data on enteric diseases for 2006 collected by New Zealand's national surveillance system.

RESULTS

Our analyses of aggregated New Zealand surveillance data found that the associations (crude odds ratios) for risk factors of enteric disease were fairly consistent with findings from local case-control studies and outbreak investigations, adding support for the use of the case-case analytical approach. Despite various inherent limitations, such an approach has the potential to contribute to the monitoring of risk factor trends for enteric diseases. Nevertheless, using the case-case method for analysis of routine surveillance data may need to be accompanied by: (i) reduction of potential selection and information biases by improving the quality of the surveillance data; and (ii) reduction of confounding by conducting more sophisticated analyses based on individual-level data.

CONCLUSION

Case-case analyses of enteric diseases using routine surveillance data might be a useful low-cost means to study trends in enteric disease sources and inform control measures. If used, it should probably supplement rather than replace outbreak investigations and case-control studies. Furthermore, it could be enhanced by utilising high quality individual-level data provided by nationally-representative sentinel sites for enteric disease surveillance.

Weather and notified Campylobacter infections in temperate and sub-tropical regions of Australia: an ecological study

BACKGROUND

The relationship between weather and food-borne diseases has been of great concern recently. However, the impact of weather variations on food-borne disease may vary in different areas with various geographic, weather and demographic characteristics. This study was designed to quantify the relationship between weather variables and Campylobacter infections in two Australian cities with different local climatic conditions.

METHODS

An ecological-epidemiological study was conducted, using weekly disease surveillance data and meteorological data, over the period 1990-2005, to quantify the relationship between maximum and minimum temperatures, rainfall, relative humidity and notifications of Campylobacter infections in Adelaide, with a temperate Mediterranean climate, and Brisbane, with a sub-tropical climate. Spearman correlation and time-series adjusted Poisson regression analyses were performed taking into account seasonality, lag effects and long-term trends.

RESULTS

The results indicate that weekly maximum and minimum temperatures were inversely associated with the weekly number of cases in Adelaide, but positively correlated with the number of cases in Brisbane, with relevant lagged effects. The effects of rainfall and relative humidity on Campylobacter infection rates varied in the two cities.

CONCLUSION

Weather might have different effect on Campylobacter infections in different cities. Further studies are needed for a better understanding of these relationships for they may indicate epidemiologic factors important for control of these infections.

Assessment of microbiological quality of drinking water from household tanks in Bermuda

Bermuda residents collect rainwater from rooftops to fulfil their freshwater needs. The objective of this study was to assess the microbiological quality of drinking water in household tanks throughout Bermuda. The tanks surveyed were selected randomly from the electoral register. Governmental officers visited the selected household (n = 102) to collect water samples and administer a short questionnaire about the tank characteristics, the residents' habits in terms of water use, and general information on the water collecting system and its maintenance. At the same time, water samples were collected for analysis and total coliforms and Escherichia coli were determined by 2 methods (membrane filtration and culture on chromogenic media, Colilert kit). Results from the 2 methods were highly correlated and showed that approximately 90% of the samples analysed were contaminated with total coliforms in concentrations exceeding 10 CFU/100 mL, and approximately 66% of samples showed contamination with E. coli. Tank cleaning in the year prior to sampling seems to protect against water contamination. If rainwater collection from roofs is the most efficient mean for providing freshwater to Bermudians, it must not be considered a source of high quality drinking water because of the high levels of microbial contamination.

Comparison of Campylobacter jejuni genotypes from dairy cattle and human sources from the Matamata-Piako District of New Zealand

AIMS

To identify the prevalence and types of Campylobacter jejuni carried by dairy cattle and the extent of overlap of these types with those causing disease in humans.

METHODS AND RESULTS

Faecal samples from 410 dairy cattle were collected from 36 farms in the Matamata-Piako district in New Zealand. Campylobacter jejuni was isolated on all 36 farms, with a prevalence of 51% (95% CI 45-57) in dairy cattle and 65% (95% CI 58-72) in calves. Eighty-nine of these isolates were typed using Penner serotyping and pulsed field gel electrophoresis and were compared with 58 human C. jejuni isolates from people resident within this study area.

CONCLUSIONS

Campylobacter jejuni were found in the faeces of over half of the dairy cows and calves examined. Twenty-one per cent of the bovine isolates and 43% of the human isolates formed indistinguishable clusters of at least one bovine and one human isolate.

SIGNIFICANCE AND IMPACT OF THE STUDY

While a direct link between bovine isolates and human cases was not demonstrated, the finding of indistinguishable genotypes among C. jejuni isolates from bovine and human sources confirms that dairy cows and calves are a potential source of human campylobacteriosis. Barriers to separate bovine faecal material from the general public are therefore important public health measures.

Population-attributable risk estimates for risk factors associated with Campylobacter infection, australia

One-sentence summary: Each year, an estimated 50,500 cases in persons >5 years of age can be directly attributed to consumption of chicken.

In 2001–2002, a multicenter, prospective case-control study involving 1,714 participants >5 years of age was conducted in Australia to identify risk factors for Campylobacter infection. Adjusted population-attributable risks (PARs) were derived for each independent risk factor contained within the final multivariable logistic regression model. Estimated PARs were combined with adjusted (for the >5 years of age eligibility criterion) notifiable disease surveillance data to estimate annual Australian Campylobacter case numbers attributable to each risk factor. Simulated distributions of “credible values” were then generated to model the uncertainty associated with each case number estimate. Among foodborne risk factors, an estimated 50,500 (95% credible interval 10,000–105,500) cases of Campylobacter infection in persons >5 years of age could be directly attributed each year to consumption of chicken in Australia. Our statistical technique could be applied more widely to other communicable diseases that are subject to routine surveillance.

Real-time PCR detection of pathogenic microorganisms in roof-harvested rainwater in Southeast Queensland, Australia

In this study, the microbiological quality of roof-harvested rainwater was assessed by monitoring the concentrations of Escherichia coli, enterococci, Clostridium perfringens, and Bacteroides spp. in rainwater obtained from tanks in Southeast Queensland, Australia. Samples were also tested using real-time PCR (with SYBR Green I dye) for the presence of potential pathogenic microorganisms. Of the 27 rainwater samples tested, 17 (63%), 21 (78%), 13 (48%), and 24 (89%) were positive for E. coli, enterococci, C. perfringens, and Bacteroides spp., respectively. Of the 27 samples, 11 (41%), 7 (26%), 4 (15%), 3 (11%), and 1 (4%) were PCR positive for the Campylobacter coli ceuE gene, the Legionella pneumophila mip gene, the Aeromonas hydrophila lip gene, the Salmonella invA gene, and the Campylobacter jejuni mapA gene. Of the 21 samples tested, 4 (19%) were positive for the Giardia lamblia beta-giardin gene. The binary logistic regression model indicated a positive correlation (P < 0.02) between the presence/absence of enterococci and A. hydrophila. In contrast, the presence/absence of the remaining potential pathogens did not correlate with traditional fecal indicators. The poor correlation between fecal indicators and potential pathogens suggested that fecal indicators may not be adequate to assess the microbiological quality of rainwater and consequent health risk.

Statistical comparison of Campylobacter jejuni subtypes from human cases and environmental sources

AIM

To analyse Campylobacter jejuni typing data to define statistically which potential reservoirs and transmission sources contain isolates that are most similar to one another and to isolates from human infections.

METHODS AND RESULTS

Serotyping and SmaI macrorestriction profiling data for C. jejuni isolates from human campylobacteriosis cases, chicken carcass rinses, duck, sheep, dairy and beef cattle faeces, river water, and sheep, beef and pork offal obtained from a defined rural area of New Zealand were compared using the Czekanowski proportional similarity index. Subtypes of isolates from ruminant animals, whether derived from their faeces or offals, were generally similar to one another. The spectrum of isolate subtypes from human cases was more similar to that from ruminant faeces than the other matrices considered. Isolate subtypes from chicken rinses, pork offal, water and duck faeces were not highly similar to those from other matrices.

CONCLUSIONS

Results from a combination of phenotypic and genotypic approaches suggest that, for this rural population, exposures associated with a rural lifestyle may be significant sources of human campylobacteriosis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The Czekanowski index was applied to subtyping data and supported the greater importance of contact with livestock in campylobacteriosis cases associated with a rural setting, in comparison with urban studies that have identified poultry-related factors.

Economics of reducing Campylobacter at different levels within the Belgian poultry meat chain

Campylobacter infections pose a serious public health problem in Belgium. Poultry meat is most likely responsible for 40% of human campylobacteriosis cases in Belgium. On a yearly basis, consumption of poultry meat causes at least 22,000 campylobacteriosis cases, with a cost of illness of Euro 10.9 million. Several intervention measures have been proposed in literature, aiming to reduce the contamination of poultry meat and thus lead to significant reductions of human campylobacteriosis cases. This study aimed to evaluate the cost-benefit ratio, i.e., the ratio of reduced costs of illness on intervention costs of various intervention measures. These measures were selected by representatives from the poultry meat sector and experts in the field of poultry science. The selection comprised measures at the farm level (phage therapy), at the processing plant (spraying of carcasses with lactic acid or electrolyzed oxidizing water, crust freezing, or irradiation), and at the consumer level (improving kitchen hygiene and application of home freezing). Among these measures, the decontamination of carcasses with electrolyzed oxidizing water applied in the processing plant was the most efficient (17.66), followed by the use of lactic acid (4.06). In addition, phage therapy generated a positive cost-benefit ratio (2.54). Irradiation indicated the highest efficacy, but its cost-benefit ratio was rather low (0.31). There seems to be less gain by trying to improve food handling in the kitchen. The cost to reach consumers is large, while only a very limited fraction of the consumers is willing to change its behavior. The outcome of this study poses valuable information for future risk-management decisions in Belgium.

How effective is good domestic kitchen hygiene at reducing diarrhoeal disease in developed countries? A systematic review and reanalysis of the UK IID study

Background

To assess whether domestic kitchen hygiene is an important contributor to the development of diarrhoea in the developed world.

Methods

Electronic searches were carried out in October 2006 in EMBASE, MEDLINE, Web of Knowledge, Cochrane central register of clinical trials and CINAHL. All publications, irrespective of study design, assessing food hygiene practices with an outcome measure of diarrhoea were included in the review. All included studies underwent data extraction and the data was subsequently analysed. The analysis was conducted by qualitative synthesis of the results. Given the substantial heterogeneity in study design and outcome measures meta-analysis was not done. In addition the existing dataset of the UK IID study was reanalysed to investigate possible associations between self-reported diarrhoea and variables indicative of poor domestic kitchen hygiene

Results

Some 14 studies were finally included in subsequent analyses. Of the 14 studies included in this systematic review, 11 were case-control studies, 2 cross-sectional surveys, and 1 RCT. Very few studies identified any significant association with good environmental kitchen hygiene. Although some of the variables in the reanalysis of the UK IID study were statistically significant no obvious trend was seen.

Conclusion

The balance of the available evidence does not support the hypothesis that poor domestic kitchen hygiene practices are important risk factors for diarrhoeal disease in developed countries.

Wide geographical distribution of internationally rare Campylobacter clones within New Zealand

During the southern hemisphere winter of 2006 New Zealand experienced a significant increase in the number of reported cases of Campylobacter infection. In total, 112 Campylobacter isolates from eight district health boards (DHBs) located across New Zealand were submitted for PFGE, MLST and Penner serotyping analysis. Distinct clusters of Campylobacter isolates were identified, several of which were composed of isolates from up to five different DHBs located on both the North and South islands of New Zealand. One sequence type, ST-474, was identified in 32 of the 112 isolates and may represent an endemic sequence type present in New Zealand. The spatial pattern of genotypes, combined with the generalized increase in notifications throughout the country is consistent with a common source epidemic, most likely from a source contaminated with the dominant sequence types ST-474 and ST-190 and may also represent widely distributed stable clones present in New Zealand.

Explaining unexplained diarrhea and associating risks and infections

Gastrointestinal illnesses are common afflictions. However, knowledge of their etiology is often lacking. Moreover, most cases of infections with reportable enteric pathogens (Campylobacter jejuni, Escherichia coli O157:H7, Salmonella, Shigella, Yersinia, Cryptosporidia and Giardia) have sporadic modes of acquisition, yet control measures are often biased towards mitigation of risks discerned by outbreak analysis. To determine the etiology of unexplained diarrhea it is important to study populations that can be matched to appropriate controls and to couple thorough classic microbiologic evaluation on receipt of specimens with archiving and outgrowth capabilities. Research evaluations should address the potential roles of a broad panel of candidate bacterial pathogens including diarrheagenic E. coli, Listeria monocytogenes, Helicobacters and jejuni Campylobacters, and also apply novel massively parallel sequencing and nucleic acid detection technologies that allow the detection of viral pathogens. To fill voids in our knowledge regarding sources of known enteric pathogens it will be critical to extend case-control studies to assess risk factors and exposures to patients with non-epidemic illnesses and to appropriate controls. By filling these gaps in our knowledge it should be possible to formulate rational prevention mechanisms for human gastrointestinal illnesses.

Epidemiology, relative invasive ability, molecular characterization, and competitive performance of Campylobacter jejuni strains in the chicken gut

One hundred forty-one Campylobacter jejuni isolates from humans with diarrhea and 100 isolates from retailed poultry meat were differentiated by flaA typing. The bacteria were isolated in a specific geographical area (Dunedin) in New Zealand over a common time period. Twenty nine flaA types were detected, one of which (flaA restriction fragment length polymorphism type 15 [flaA-15]) predominated among isolates from humans ( approximately 30% of isolates). This strain was of low prevalence (5% of isolates) among poultry isolates. flaA-15 strains were five to six times more invasive of HEp2 cells in an in vitro assay than a flaA type (flaA-3) that was commonly encountered on poultry meat (23% of isolates) but was seldom associated with human illness (5%). Competitive-exclusion experiments with chickens, utilizing real-time quantitative PCR to measure the population sizes of specific strains representing flaA-15 (T1016) and flaA-3 (Pstau) in digesta, were carried out. These experiments showed that T1016 always outcompeted Pstau in the chicken intestine. Genomic comparisons of T1016 and Pstau were made using DNA microarrays representing the genome of C. jejuni NCTC 11168. These comparisons revealed differences between the strains in the gene content of the Cj1417c-to-Cj1442c region of the genome, which is associated with the formation of capsular polysaccharide. The strains differed in Penner type (T1016, O42; Pstau, O53). It was concluded that poultry meat was at least one source of human infection with C. jejuni, that some Campylobacter strains detected in poultry meat are of higher virulence for humans than others, and that bacterial attributes affecting strain virulence and commensal colonization ability may be linked.