Salmonella Enteritidis outbreak associated with a school-lunch dessert: cross-contamination and a long incubation period, Japan, 2001

Sanitary sewage overflows, boil water advisories, and emergency room and urgent care visits for gastrointestinal illness: a case-crossover study in South Carolina, USA, 2013-2017

BACKGROUND

Sanitary sewage overflows (SSOs) release raw sewage, which may contaminate the drinking water supply. Boil water advisories (BWAs) are issued during low or negative pressure events, alerting customers to potential contamination in the drinking water distribution system.

OBJECTIVE

We evaluated the associations between SSOs and BWAs and diagnoses of gastrointestinal (GI) illness in Columbia, South Carolina, and neighboring communities, 2013-2017.

METHODS

A symmetric bi-directional case-crossover study design was used to assess the role of SSOs and BWAs on Emergency Room and Urgent Care visits with a primary diagnosis of GI illness. Cases were considered exposed if an SSO or BWA occurred 0-4 days, 5-9 days, or 10-14 days prior to the diagnosis, within the same residential zip code. Effect modification was explored via stratification on participant-level factors (e.g., sex, race, age) and season (January-March versus April-December).

RESULTS

There were 830 SSOs, 423 BWAs, and 25,969 cases of GI illness. Highest numbers of SSOs, BWAs and GI cases were observed in a zip code where >80% of residents identified as Black or African-American. SSOs were associated with a 13% increase in the odds of a diagnosis for GI illness during the 0-4 day hazard period, compared to control periods (Odds Ratio: 1.13, 95% Confidence Interval: 1.09, 1.18), while no associations were observed during the other hazard periods. BWAs were not associated with increased or decreased odds of GI illness during all three hazard periods. However, in stratified analyses BWAs issued between January-March were associated with higher odds of GI illness, compared to advisories issued between April-December, in all three hazard periods.

SIGNIFICANCE

SSOs (all months) and BWAs (January-March) were associated with increased odds of a diagnosis of GI illness. Future research should examine sewage contamination of the drinking water distribution system, and mechanisms of sewage intrusion from SSOs.

IMPACT

Sewage contains pathogens, which cause gastrointestinal (GI) illness. In Columbia, South Carolina, USA, between 2013-2017, there were 830 sanitary sewage overflows (SSOs). There were also 423 boil water advisories, which were issued during negative pressure events. Using case-crossover design, SSOs (all months) and boil water advisories (January-March) were associated with increased odds of Emergency Room and Urgent Care diagnoses of GI illness, potentially due to contamination of the drinking water distribution system. Lastly, we identified a community where >80% of residents identified as Black or African-American, which experienced a disproportionate burden of sewage exposure, compared to the rest of Columbia.

Dose response for Salmonella Typhimurium and Enteritidis and other nontyphoid enteric salmonellae

This dose response assessment combines data from 6 human challenge studies and 44 outbreaks to determine infectivity and pathogenicity of several serotypes of nontyphoid Salmonella. Outcomes focus on the major serotypes Salmonella Enteritidis and Typhimurium, showing that Typhimurium is less infectious and has a lower probability of causing acute illness in infected subjects. The dose response relation of Salmonella Enteritidis is less steep than that of Typhimurium, indicating greater heterogeneity in infectivity and pathogenicity. This study revisits an older study with less flexible methods that could not combine the widely different outcomes of challenge studies and outbreaks, and had limited capability for dealing with missing information. Reported outcomes are in a format that allows use in calculations of uncertainty for quantitative risk assessment.

An outbreak of Salmonella Saintpaul in a Scottish childcare facility: the influence of parental under-reporting

BACKGROUND

Salmonella outbreaks in childcare facilities are relatively rare, most often occurring secondary to contaminated food products or poor infection control practices. We report an outbreak of Salmonella Saintpaul at a pre-school facility in Ayrshire, Scotland with atypical clinical and epidemiological features.

METHODS

Following notification of the initial two cases, the multi-disciplinary Incident Management Team initiated enhanced active case finding and two environmental inspections of the site, including food preparation areas. Parent and staff interviews were conducted by the Public Health department covering attendance, symptomatology and risk factors for all probable and confirmed cases. Microbiological testing of stool samples and the facility water tank was conducted. Whole Genome Sequencing (WGS) was performed for positive stool samples at the national reference laboratory. Infection control measures were introduced iteratively due to the atypical progression of the outbreak.

RESULTS

There were 15 confirmed cases and 3 children admitted to hospital during the outbreak. However, 35.7% of cases reported extremely mild symptoms. The attack rate was 15.2%, and age of affected children ranged from 18 to 58 months (mean 35 months). All cases were the same Multilocus Sequence Type (MLST50). Epidemiological investigation strongly suggested person-to-person spread within the facility. Existing infection control practices were found to be of a high standard, but introduction of additional evidence-based control measures was inadequate in halting transmission. Facility staff reported concerns about lack of parental disclosure of gastrointestinal symptoms, particularly where these were mild, with 50.0% of cases having attended while symptomatic against public health advice. Voluntary two-week closure of the facility was implemented to halt transmission, following which there were no new cases. WGS results were unavailable until after the decision was taken to close the facility.

CONCLUSIONS

This is the first reported instance of a Salmonella Saintpaul outbreak at a childcare facility, or where person-to-person transmission is indicated. Clinicians should consider the influence of parental under-reporting on gastrointestinal outbreaks in childcare settings, particularly where perceived severity is low and financial or social pressures to attend work may reduce compliance. WGS cannot yet replace conventional microbiological techniques during short, localised outbreaks due to delays receiving results.

National outbreak of Salmonella Give linked to a local food manufacturer in Malta, October 2016

Salmonella Give is a rare serotype across Europe. In October 2016, a national outbreak of S. Give occurred in Malta. We describe the epidemiological, environmental, microbiological and veterinary investigations. Whole-genome sequencing (WGS) was performed on human, food, environmental and veterinary isolates. Thirty-six human cases were reported between October and November 2016, 10 (28%) of whom required hospitalisation. Twenty-six (72%) cases were linked to four restaurants. S. Give was isolated from ready-to-eat antipasti served by three restaurants which were all supplied by the same local food manufacturer. Food-trace-back investigations identified S. Give in packaged bean dips, ham, pork and an asymptomatic food handler at the manufacturer; inspections found inadequate separation between raw and ready-to-eat food during processing. WGS indicated two genetically distinguishable strains of S. Give with two distinct clusters identified; one cluster linked to the local food manufacturer and a second linked to veterinary samples. Epidemiological, environmental and WGS evidence pointed towards cross-contamination of raw and ready-to-eat foods at the local manufacturer as the likely source of one cluster. Severity of illness indicates a high virulence of this specific serotype. To prevent future cases and outbreaks, adherence to food safety practices at manufacturing level need to be reinforced.

Incubation period for outbreak-associated, non-typhoidal salmonellosis cases, Minnesota, 2000-2015

Incubation period for non-typhoidal Salmonella (NTS) infections is generally reported as 6-72 h despite numerous reports of foodborne NTS outbreaks with median incubation periods >3 days. We summarised 16 years of Minnesota foodborne NTS outbreaks to better estimate the expected range of incubation periods for NTS infections. Of the 1517 NTS outbreak cases, 725 had enough data to calculate a precise incubation period. The median incubation period was 45 h; 77 (11%) cases had incubations ⩽12 h and 211 (29%) cases had incubations >72 h. Incubation period length varied by outbreak vehicle type, Salmonella serotype and outbreak setting. Based on our data, a more accurate description would be that the incubation of NTS infection is usually from 12 to 96 h, that incubations in >96 to 144 h (>4 to 6-day) range are not unusual and that incubations from 7 to 9 days and occasionally longer also occur.

A Multischool Outbreak Due to Salmonella enterica serovar Napoli Associated with Elevated Rates of Hospitalizations and Bacteremia, Milan, Italy, 2014

A multischool outbreak of salmonellosis caused by Salmonella enterica serovar Napoli was investigated in the province of Milan from October to November 2014, following an increase in school absenteeism coinciding with two positive cases. Epidemiological studies detected 47 cases in four primary schools: 46 children and 1 adult woman (51.4% males and 48.6% females, median age 8.9). From these, 14 cases (29.8%) were severe and resulted in hospitalization, including 6 children (12.8%) who developed an invasive salmonellosis. The epidemic curve revealed an abnormally long incubation period, peaking 1 week after the first confirmed case. Twenty-five available isolates were typed by pulsed-field gel electrophoresis showing an identical pattern. The isolate belongs to ST474, an ST composed exclusively of Salmonella Napoli human strains isolated in France and Italy. Antibiotic resistance analysis showed resistance to aminoglycosides, correlating with the presence of the aminoglycoside resistance gene aadA25 in its genome. Trace-back investigations strongly suggested contaminated ham as the most likely food vehicle, which was delivered by a common food center on 21 October. Nevertheless, this ingredient could not be retrospectively investigated since it was no longer available at the repository. This represents the largest Salmonella Napoli outbreak ever reported in Italy and provides a unique scenario for studying the outcome of salmonellosis caused by this emerging and potentially invasive nontyphoidal serotype.

An outbreak of Salmonella serotype Typhimurium infections with an unusually long incubation period

A 1998 investigation of an outbreak of Salmonella serotype Typhimurium infections among children tasting unpasteurized milk during tours of a dairy farm demonstrated a distribution of unusually long incubation periods (median, 8 days; interquartile range [IQR], 6-14 days). Bacterial isolates were highly acid tolerant and contained genes associated with protection against destructive phagocytic reactive oxygen intermediates. We hypothesize that exposure to low-dose oral inoculum of a pathogen with these properties could have contributed to cases of non-typhoidal salmonellosis with the longest incubation period reported to the Centers for Disease Control and Prevention (CDC).

A review of gastrointestinal outbreaks in schools: effective infection control interventions

BACKGROUND

The purpose of this study was to review documented outbreaks of gastrointestinal illness in schools, published in the last 10 years, to identify etiology, mode of transmission, the number of children affected, morbidity and mortality patterns, and interventions for control and prevention.

METHODS

Searches of electronic databases, public health publications, and federal, state, and provincial public health Web sites were completed.

RESULTS

Of the 121 outbreaks that met the inclusion criteria, 51% were bacterial, 40% viral, 7% were from Cryptosporidium, and 2% from multiple organisms. Transmission routes recorded in 101 reports included foodborne (45%), person-to-person (16%), waterborne (12%), and animal contact (11%). Actions to control outbreaks included alerting medical and public health authorities or the community to the outbreak (13%), treating cases (12%), enhancing hand washing (11%), and increased vigilance during food preparation (8%). Recommendations to prevent future outbreaks were compared with previously published studies that demonstrated effectiveness.

CONCLUSIONS

The risk of foodborne illness was reduced when food handlers practiced effective hand washing technique and received food safety training and certification. Student training programs on hand hygiene, enhanced cleaning and disinfection of the school, and hepatitis A vaccination were found effective. Children should be supervised on farm visits, hand washing strictly enforced, and food eaten in an area separated from the animals. Staff and students should have a positive, continuous communication with public health authorities including educational sessions and immediate reporting of possible outbreaks.

A comparison of two PCR-based typing methods with pulsed-field gel electrophoresis in Salmonella enterica serovar Enteritidis

Two novel molecular typing methods, multiple-locus variable-number tandem repeats (VNTR) analysis (MLVA) and multiple amplification of phage loci typing (MAPLT), were compared with pulsed-field gel electrophoresis (PFGE) for the discrimination of 128 Salmonella enterica serovar Enteritidis (S. Enteritidis) isolates. Selected epidemiologically unrelated isolates represented a cross-section of phage types routinely isolated in Australia and included 28 isolates that could not be assigned a phage type. Targeting 5 previously described loci, MLVA generated 61 different profiles with a Simpson index of diversity of DI=0.968. MLVA locus STTR-5 proved to be the most diverse with 11 different alleles detected with a Nei's diversity index value of D=0.769. Using 8 MAPLT primers previously developed for S. Typhimurium produced 36 different profiles with a DI value of 0.948. By contrast, PFGE only generated 13 different pulsed-field patterns, DI=0.873. Within each phage type there was variation in the extent to which either molecular method was able to discriminate the S. Enteritidis isolates. MAPLT provided more discrimination in terms of the number of profiles and DI value for phage type 1 and the untypable strains while MLVA was more discriminatory for phage types 14var and 26. There was a general lack of concordance of either molecular assay to phage type. These results suggest that both MAPLT and MLVA have excellent potential as tools for epidemiological studies of S. Enteritidis.

The role of roof rats ( Rattus rattus) in the spread of Salmonella Enteritidis and S. Infantis contamination in layer farms in eastern Japan

The prevalence of Salmonella in four layer farms in eastern Japan was investigated between 2004 and 2006 to determine the role of roof rats (Rattus rattus) in the epizootology of Salmonella enterica subsp. enterica serovar Enteritidis (S. Enteritidis). Persistent S. Enteritidis and S. Infantis contamination of the environment and pooled egg samples were detected in three out of four layer farms. A total of 113 (13.3%) and 158 (18.6%) out of 851 rats examined were positive for S. Enteritidis and S. Infantis, respectively. By pulsed-field gel electrophoresis, only one indistinguishable pulsed-field pattern was yielded by S. Enteritidis strains from rats, eggs and environmental samples from each of the two contaminated layer farms. Although, a variety of pulsed-field patterns were generated by S. Enteritidis isolates from rats, eggs, and the environment of the other contaminated farms, there are, however, some S. Enteritidis strains that are closely related clones. These results suggest that roof rats are carriers of S. Enteritidis and S. Infantis and that persistent S. Enteritidis and S. Infantis infections in a rat population may play an important role in the spread and maintenance of these pathogens inside the layer premises.

An epidemiological analysis of Salmonella enteritidis contamination in a rat-infested chicken layer farm, an egg processing facility, and liquid egg samples by pulsed-field gel electrophoresis

In order to determine the epidemiological link between the Salmonella Enteritidis contamination in a rat-infested chicken layer farm, an attached egg processing facility and liquid egg samples, several S. Enteritidis isolates were analyzed by pulsed-field gel electrophoresis (PFGE) and bacteriophage typing. A total of 33 S. Enteritidis strains were isolated from a total of 4,081 samples. Similar pulsed-field patterns were generated by S. Enteritidis isolates from liquid eggs, rats and effluent water. Additionally, only two phage types were detected among the S. Enteritidis isolates, PT 1b and PT 6. These results suggest that S. Enteritidis isolates from rats, egg processing facility, and liquid eggs are genetically related. Furthermore, S. Enteritidis infection in rats in layer farms poses a serious public health concern and should be included in future epidemiological studies.

Salmonella outbreaks in restaurants in Minnesota, 1995 through 2003: evaluation of the role of infected foodworkers

The 23 restaurant-associated salmonellosis outbreaks that occurred in Minnesota from 1995 through 2003 were reviewed to characterize the role of infected foodworkers. The median duration of the outbreaks was 21 days (range, 1 to 517 days). The median number of culture-confirmed patron cases per outbreak was seven (range, 1 to 36 cases). The median incubation for patron cases ranged from 9 h to 5.9 days. A specific food vehicle was implicated in four outbreaks and suspected in five. Salmonella of the same serotype and pulsed-field gel electrophoresis subtype as that found in patrons was recovered from foodworkers in 19 outbreaks. Overall, 12% (129 of 1,033) of foodworkers tested positive for Salmonella. Sixty-four (53%) of 121 Salmonella-positive foodworkers reported not having had a recent gastrointestinal illness. Overall, the median duration of Salmonella shedding was 16 days. Among foodworkers who reported gastrointestinal illness, the median shedding duration was 30 days as compared with 3 days for asymptomatic foodworkers. Positive environmental samples were recovered in 4 (33%) of 12 outbreaks. No specific food vehicle was identified in any outbreaks associated with Salmonella-positive environmental samples. The median duration of outbreaks with positive environmental samples (187 days) was significantly longer than the median duration of outbreaks with negative environmental results (26 days, P = 0.03). A higher proportion of Salmonella-positive foodworkers (22 versus 8%) was identified in outbreaks with positive environmental samples. Salmonella outbreaks in restaurants are frequently prolonged yet produce a small number of confirmed patron cases. Prolonged outbreak durations suggest a persistent reservoir of contamination. Infected foodworkers likely serve as an important source for Salmonella transmission. Therefore, assessment of foodworker infection is essential for controlling restaurant outbreaks.

Real-time PCR for the detection of Salmonella spp. in food: An alternative approach to a conventional PCR system suggested by the FOOD-PCR project

A real-time PCR assay using non-patented primers and a TaqMan probe for the detection and quantification of Salmonella spp. is presented. The assay is based on an internationally validated conventional PCR system, which was suggested as a standard method for the detection of Salmonella spp. in the FOOD-PCR project. The assay was sensitive and specific. Consistent detection of 9.5 genome equivalents per PCR reaction was achieved, whereas samples containing an average of 0.95 genome equivalents per reaction were inconsistently positive. The assay performed equally well as a commercially available real-time PCR assay and allowed sensitive detection of Salmonella spp. in artificially contaminated food. After enrichment for 16 h in buffered peptone water (BPW) or universal pre-enrichment broth (UPB) 2.5 CFU/25 g salmon and minced meat, and 5 CFU/25 g chicken meat and 25 ml raw milk were detected. Enrichment in BPW yielded higher numbers of CFU/ml than UPB for all matrices tested. However, the productivity of UPB was sufficient, as all samples were positive with both real-time PCR methods, including those containing less than 300 CFU/ml enrichment broth (enrichment of 5 CFU/25 ml raw milk in UPB).