Farm visits and undercooked hamburgers as major risk factors for sporadic Escherichia coli O157:H7 infection: data from a case-control study in 5 FoodNet sites

Risk Factors for Non-O157 Shiga Toxin-Producing Escherichia coli Infections, United States

Shiga toxin-producing Escherichia coli (STEC) causes acute diarrheal illness. To determine risk factors for non-O157 STEC infection, we enrolled 939 patients and 2,464 healthy controls in a case-control study conducted in 10 US sites. The highest population-attributable fractions for domestically acquired infections were for eating lettuce (39%), tomatoes (21%), or at a fast-food restaurant (23%). Exposures with 10%-19% population attributable fractions included eating at a table service restaurant, eating watermelon, eating chicken, pork, beef, or iceberg lettuce prepared in a restaurant, eating exotic fruit, taking acid-reducing medication, and living or working on or visiting a farm. Significant exposures with high individual-level risk (odds ratio >10) among those >1 year of age who did not travel internationally were all from farm animal environments. To markedly decrease the number of STEC-related illnesses, prevention measures should focus on decreasing contamination of produce and improving the safety of foods prepared in restaurants.

Seropositivity to Shiga toxin 2 among Argentinian urban and rural residents. Association with sociodemographic and exposure factors

BACKGROUND

Shiga toxin-producing Escherichia coli (STEC) are enteric pathogens that cause hemolytic-uremic syndrome (HUS). Ruminants, especially cattle, are their main reservoir. This study describes the seroepidemiology of STEC in rural and urban populations in Argentina, a country with a high HUS incidence.

METHODS

A cross-sectional study was performed in patients without gastrointestinal symptoms. IgG antibodies against Stx2 were detected by western blotting.

RESULTS

Anti-Stx2 antibodies were detected in 14.56% of serum samples, more frequently in rural (19.38%) than urban residents (12%). Seropositivity was associated with lower socioeconomic status (SES). Among the other variables considered, thawing homemade hamburgers before cooking them, and the lack of knowledge about HUS were also associated with seropositivity. A multivariate logistic regression analysis performed with the variables that were statistically significant showed that only the SES index remained significant. As SES was measured based on several variables, we further analyzed each one of them and found that the lack of a high education level was statistically associated with seropositivity.

CONCLUSIONS

The present findings have implications for STEC prevention efforts, highlighting the importance of considering SES and risks factors linked to different SES levels when targeting consumer-level public health interventions.

Situated food safety behavior

Previous studies indicate that many consumers eat rare hamburgers and that information about microbiological hazards related to undercooked meat does not necessarily lead to changed behavior. With this study we aim to investigate whether consumers' willingness to eat hamburgers, both risky and safe, depends on the situation where they are confronted with the food. A representative sample of 1046 Norwegian consumers participated in a web experiment. Participants were randomly divided into four groups. Each group was told to imagine a specific eating situation (at their friend's place, at home, at a restaurant abroad, at a domestic restaurant). Four pictures of hamburgers (rare, medium rare, medium, well-done) were presented in randomized order, and participants rated their intentions to eat each hamburger. Situated risk perception was measured as the stated likelihood of food poisoning from consuming hamburgers in eight different situations. The results show that both risk perception and risk taking vary depending on the situation. In general, participants perceive their own home to be the safest place to consume a hamburger, but they are significantly more likely to consume an undercooked hamburger when at a friend's place. These findings indicate that situations play an important role for consumers' likelihood of eating unsafe food, and that risk taking does not always follow risk perception. That risk taking is elevated in situations that may have social consequences should be taken into consideration when developing food safety strategies.

Associating sporadic, foodborne illness caused by Shiga toxin-producing Escherichia coli with specific foods: a systematic review and meta-analysis of case-control studies

Shiga toxin-producing Escherichia coli (STEC) infections are a significant public health issue, with foodborne transmission causing >1 million illnesses worldwide each year. We conducted a systematic review and meta-analysis (PROSPERO registry # CRD42017074239), to determine the relative association of different food types with sporadic illnesses caused by STEC. Searches were conducted from 01 August to 30 September 2017, using bibliographic and grey literature databases, websites and expert consultation. We identified 22 case-control studies of sporadic STEC infection in humans, from 10 countries within four World Health Organization subregions, from 1985 to 2012. We extracted data from 21 studies, for 237 individual measures in 11 food categories and across three status types (raw or undercooked, not raw and unknown). Beef was the most significant food item associated with STEC illness in the Americas and Europe, but in the Western Pacific region, chicken was most significant. These findings were not significantly moderated by the raw or cooked status of the food item, nor the publication year of the study. Data from the African, South-East Asian and Eastern Mediterranean subregions were lacking and it is unclear whether our results are relevant to these regions.

The effect of transportation and lairage on faecal shedding and carcass contamination with Escherichia coli O157 and O26 in very young calves in New Zealand

The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4-7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal-oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.

2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea

These guidelines are intended for use by healthcare professionals who care for children and adults with suspected or confirmed infectious diarrhea. They are not intended to replace physician judgement regarding specific patients or clinical or public health situations. This document does not provide detailed recommendations on infection prevention and control aspects related to infectious diarrhea.

Attribution of human infections with Shiga toxin-producing Escherichia coli (STEC) to livestock sources and identification of source-specific risk factors, The Netherlands (2010-2014)

Shiga toxin-producing Escherichia coli (STEC) is a zoonotic pathogen of public health concern whose sources and transmission routes are difficult to trace. Using a combined source attribution and case-control analysis, we determined the relative contributions of four putative livestock sources (cattle, small ruminants, pigs, poultry) to human STEC infections and their associated dietary, animal contact, temporal and socio-econo-demographic risk factors in the Netherlands in 2010/2011-2014. Dutch source data were supplemented with those from other European countries with similar STEC epidemiology. Human STEC infections were attributed to sources using both the modified Dutch model (mDM) and the modified Hald model (mHM) supplied with the same O-serotyping data. Cattle accounted for 48.6% (mDM) and 53.1% (mHM) of the 1,183 human cases attributed, followed by small ruminants (mDM: 23.5%; mHM: 25.4%), pigs (mDM: 12.5%; mHM: 5.7%) and poultry (mDM: 2.7%; mHM: 3.1%), whereas the sources of the remaining 12.8% of cases could not be attributed. Of the top five O-serotypes infecting humans, O157, O26, O91 and O103 were mainly attributed to cattle (61%-75%) and O146 to small ruminants (71%-77%). Significant risk factors for human STEC infection as a whole were the consumption of beef, raw/undercooked meat or cured meat/cold cuts. For cattle-attributed STEC infections, specific risk factors were consuming raw meat spreads and beef. Consuming raw/undercooked or minced meat were risk factors for STEC infections attributed to small ruminants. For STEC infections attributed to pigs, only consuming raw/undercooked meat was significant. Consuming minced meat, raw/undercooked meat or cured meat/cold cuts were associated with poultry-attributed STEC infections. Consuming raw vegetables was protective for all STEC infections. We concluded that domestic ruminants account for approximately three-quarters of reported human STEC infections, whereas pigs and poultry play a minor role and that risk factors for human STEC infection vary according to the attributed source.

Preharvest Food Safety Challenges in Beef and Dairy Production

Foods of animal origin, including beef and dairy products, are nutritious and important to global food security. However, there are important risks to human health from hazards that are introduced to beef and dairy products on the farm. Food safety hazards may be chemical, biological, or physical in nature. Considerations about protecting the safety of beef and dairy products must begin prior to harvest because some potential food safety hazards introduced at the farm (e.g., chemical residues) cannot be mitigated by subsequent postharvest food processing steps. Also, some people have preferences for consuming food that has not been through postharvest processing even though those foods may be unsafe because of microbiological hazards originating from the farm. Because of human fallibility and complex microbial ecologies, many of the preharvest hazards associated with beef and dairy products cannot entirely be eliminated, but the risk for most can be reduced through systematic interventions taken on the farm. Beef and dairy farms differ widely in production practices because of differences in natural, human, and capital resources. Therefore, the actions necessary to minimize on-farm food safety hazards must be farm-specific and they must address scientific, political, economic, and practical aspects. Notable successes in controlling and preventing on-farm hazards to food safety have occurred through a combination of voluntary and regulatory efforts.

Factors associated with recovery of meat products following recalls due to Shiga toxin-producing Escherichia coli

Food-product recall data for recalls due to Shiga toxin-producing Escherichia coli (STEC) from 2000 to 2012 were obtained for establishments regulated by the United States Department of Agriculture, Food Safety and Inspection Service (FSIS). Statistical tests were used to assess the factors associated with recovery of product following STEC recalls along with the relationship between cluster detection and jurisdictions. Our results indicated that the percentage of recalled product recovered following a recall action due to STEC was dependent on the complexity of distribution, type of distribution, amount of time between production and recall dates, and the number of pounds of product recalled. Illness-related STEC recalls were associated with a lower percentage of product recovery which was probably impacted by larger amounts of product recalled, broader production scope, and delays from epidemiological and traceback investigations. Further, detection of illnesses related to STEC recalls seemed to be enhanced in states with additional resources and a history of successful foodborne investigations. This makes an argument for additional resources dedicated to public health agencies specifically for the surveillance of foodborne illnesses.

Bacterial Enteric Infections Among Older Adults in the United States: Foodborne Diseases Active Surveillance Network, 1996-2012

BACKGROUND

A growing segment of the population-adults aged ≥65 years-is more susceptible than younger adults to certain enteric (including foodborne) infections and experience more severe disease.

MATERIALS AND METHODS

Using data on laboratory-confirmed infections from the Foodborne Diseases Active Surveillance Network (FoodNet), we describe trends in the incidence of Campylobacter spp., Escherichia coli O157, Listeria monocytogenes, and nontyphoidal Salmonella infections in adults aged ≥65 years over time and by age group and sex. We used data from FoodNet and other sources to estimate the total number of illnesses, hospitalizations, and deaths in the United States caused by these infections each year using a statistical model to adjust for underdiagnosis (taking into account medical care-seeking, stool sample submission, laboratory practices, and test sensitivity).

RESULTS

From 1996 to 2012, 4 pathogens caused 21,405 laboratory-confirmed infections among older adults residing in the FoodNet surveillance area; 49.3% were hospitalized, and 2.6% died. The average annual rate of infection was highest for Salmonella (12.8/100,000) and Campylobacter (12.1/100,000). Salmonella and Listeria led as causes of death. Among older adults, rates of laboratory-confirmed infection and the percentage of patients who were hospitalized and who died generally increased with age. A notable exception was the rate of Campylobacter infections, which decreased with increasing age. Adjusting for underdiagnosis, we estimated that these pathogens caused about 226,000 illnesses (≈600/100,000) annually among U.S. adults aged ≥65 years, resulting in ≈9700 hospitalizations and ≈500 deaths.

CONCLUSIONS

Campylobacter, E. coli O157, Listeria, and Salmonella are major contributors to illness in older adults, highlighting the value of effective and targeted intervention.

Verotoxigenic Escherichia coli transmission in Ireland: a review of notified outbreaks, 2004-2012

Verotoxigenic Escherichia coli (VTEC) are significant for their low infectious dose, their potential clinical severity and the frequency with which they generate outbreaks. To describe the relative importance of different outbreak transmission routes for VTEC infection in Ireland, we reviewed outbreak notification data for the period 2004-2012, describing the burden and characteristics of foodborne, waterborne, animal contact and person-to-person outbreaks. Outbreaks where person-to-person spread was reported as the sole transmission route accounted for more than half of all outbreaks and outbreaks cases, most notably in childcare facilities. The next most significant transmission route was waterborne spread from untreated or poorly treated private water supplies. The focus for reducing incidence of VTEC should be on reducing waterborne and person-to-person transmission, by publicizing Health Service Executive materials developed for consumers on private well management, and for childcare facility managers and public health professionals on prevention of person-to-person spread.

Shiga toxin-producing Escherichia coli O157, O26 and O111 in cattle faeces and hides in Italy

INTRODUCTION

Ruminants are regarded as the natural reservoir for Shiga toxin-producing Escherichia coli (STEC), especially of serogroup O157.

MATERIALS AND METHODS

During 2011 and 2012, 320 samples (160 faecal samples from the rectum and 160 hide samples from the brisket area) were collected from 160 cattle at slaughter in Northern Italy during warm months (May to October). Cattle were reared in different farms and their age at slaughter ranged between nine months and 15 years, most of them being culled cattle (median age: six years; average age: 4.6 years). Samples were tested by immunomagnetic-separation technique for E coli O157 and O26 and by a screening PCR for stx genes followed by cultural detection of STEC. The virulence genes stx1, stx2, eae, and e-hlyA were detected and among stx2-positive isolates the presence of the stx2a and stx2c variants was investigated.

RESULTS

Twenty-one of 160 cattle (13.1 per cent; 95 per cent CI 8.3 to 19.4 per cent) were found to be faecal carriers of STEC. STEC O157 was found in 10 (6.3 per cent) samples, STEC O26 in six (3.8 per cent) and STEC O111 in one (0.6 per cent). Four isolates (2.5 per cent) were O not determined (OND). Six out of 160 (3.8 per cent; 95 per cent CI 1.4 to 8.0 per cent) hide samples were positive for STEC; four hides (2.5 per cent) were contaminated by STEC O157 and two (1.3 per cent) by STEC O26. In three cattle (1.9 per cent) STEC from both faeces and hides were detected. Among STEC O157, 87.5 per cent of them carried the stx2c gene and 12.5 per cent carried both stx1 and stx2c genes. No O157 isolate harboured stx2a variant. STEC O26 and O111 carried the stx1 gene only. One OND strain carried both the stx2a and stx2c genes.

CONCLUSIONS

This study shows that STEC O157 from cattle can harbour the stx2c variant, which is associated with haemolytic uraemic syndrome in humans, and that cattle hides may be a source of human pathogenic STEC O157 and O26 in the slaughterhouse environment.

Clinical Studies of Escherichia coli O157:H7 Conjugate Vaccines in Adults and Young Children

Pediatric immunization has been the most effective measure to prevent and reduce the burden of infectious diseases in children. The recent inclusion of pneumococcal and meningococcal polysaccharide conjugates in infant immunization further reinforces their importance. Currently there is no human vaccine against enterohemorrhagic Escherichia coli (EHEC) infections. This review focuses on the human EHEC vaccine that has been studied clinically, in particular, the polysaccharide conjugate against E. coli O157. The surface polysaccharide antigen, O-specific polysaccharide, was linked to rEPA, recombinant exotoxin A of Pseudomonas aeruginosa. In adults and children 2 to 5 years old, O157-rEPA conjugates, shown to be safe, induced high levels of antilipopolysaccharide immunoglobulin G with bactericidal activities against E. coli O157, a functional bioassay that mimics the killing of inoculum in vivo. A similar construct using the B subunit of Shiga toxin (Stx) 1 as the carrier protein elicited both bactericidal and toxin-neutralizing antibodies in mice. So far there is no clinical study of Stx-based human vaccine. Passive immunization of Stx-specific antibodies with humanized, chimeric, or human monoclonal antibodies, produced in transgenic mice, showed promising data in animal models and offered high prospects. Demonstrations of their safety and effectiveness in treating hemolytic-uremic syndrome or patients with EHEC infections are under way, and results are much anticipated. For future development, other virulence factors such as the nontoxic Stx B subunit or intimin should be included, either as carrier protein in conjugates or as independent components. The additional antigens from O157 may provide broader coverage to non-O157 Stx-producing E. coli and facilitate both preventive and therapeutic treatment.

Vaccination of Cattle against Escherichia coli O157:H7

Human infection with Shiga toxin-producing Escherichia coli O157:H7 (STEC O157) is relatively rare, but the consequences can be serious, especially in the very young and the elderly. Efforts to control the flow of STEC O157 during beef processing have meaningfully reduced the incidence of human STEC O157 infection, particularly prior to 2005. Unfortunately, despite early progress, the incidence of STEC O157 infection has not changed meaningfully or statistically in recent years, suggesting that additional actions, for example, targeting the cattle reservoir, are necessary to further reduce STEC O157 illness. Ideally, preharvest interventions against STEC O157 should reduce the likelihood that cattle carry the organism, have practical application within the beef production system, and add sufficient value to the cattle to offset the cost of the intervention. A number of STEC O157 antigens are being investigated as potential vaccine targets. Some vaccine products have demonstrated efficacy to reduce the prevalence of cattle carrying STEC O157 by making the gut unfavorable to colonization. However, in conditions of natural exposure, efficacy afforded by vaccination depends on how the products are used to control environmental transmission within groups of cattle and throughout the production system. Although cattle vaccines against STEC O157 have gained either full or preliminary regulatory approval in Canada and the United States, widespread use by cattle feeders is unlikely until there is an economic signal to indicate that cattle vaccinated against STEC O157 are valued over other cattle.

Risk factors for sporadic Shiga toxin-producing Escherichia coli O157 and non-O157 illness in The Netherlands, 2008-2012, using periodically surveyed controls

Shiga toxin-producing Escherichia coli (STEC) infections have been associated with severe illness. Ruminants are seen as the main reservoir and the major transmission route is considered to be foodborne. In The Netherlands, a case-control study was conducted, using data collected during 2008-2012. Patients were interviewed and controls completed a self-administered questionnaire. Patients travelling abroad were excluded from the analyses. STEC O157 and non-O157 were examined separately and differentiated into two age groups (<10 years, ⩾10 years). We included 130 O157 cases, 78 non-O157 cases and 1563 controls. In both age groups of O157 patients, raw spreadable sausage was the main risk factor for infection. For STEC non-O157 cases aged <10 years, contact with farm animals was the main risk factor and in non-O157 cases aged ⩾10 years, consumption of beef was the main risk factor. During 2008-2012, risk factors for STEC infections in the Dutch population differed between age groups and serogroup categories, and were related to eating meat and contact with farm animals. Advising the public about the risks of consuming raw or undercooked meat (products) and hygiene habits in case of contact with farm animals, could help in the prevention of STEC infections.

Raw milk consumption among patients with non-outbreak-related enteric infections, Minnesota, USA, 2001-2010

Raw milk has frequently been identified as the source of foodborne illness outbreaks; however, the number of illnesses ascertained as part of documented outbreaks likely represents a small proportion of the actual number of illnesses associated with this food product. Analysis of routine surveillance data involving illnesses caused by enteric pathogens that were reportable in Minnesota during 2001-2010 revealed that 3.7% of patients with sporadic, domestically acquired enteric infections had reported raw milk consumption during their exposure period. Children were disproportionately affected, and 76% of those <5 years of age were served raw milk from their own or a relative's farm. Severe illness was noted, including hemolytic uremic syndrome among 21% of Escherichia coli O157-infected patients reporting raw milk consumption, and 1 death was reported. Raw milk consumers, potential consumers, and policy makers who might consider relaxing regulations regarding raw milk sales should be educated regarding illnesses associated with raw milk consumption.

Escherichia coli O157: Insights into the adaptive stress physiology and the influence of stressors on epidemiology and ecology of this human pathogen

Escherichia coli O157, a foodborne pathogen of major concern for public health, has been associated with numerous outbreaks of haemorrhagic colitis and hemolytic uremic syndrome worldwide. Human infection with E. coli O157 has been primarily associated with the food-chain transmission route. This transmission route commonly elicits a multi-faceted adaptive stress response of E. coli O157 for an extended period of time prior to human infection. Several recent research articles have indicated that E. coli O157:H7 has evolved unique survival characteristics which can affect the epidemiology and ecology of this zoonotic pathogen. This review article summarizes the recent knowledge of the molecular responses of E. coli O157 to the most common stressors found within the human food chain, and further emphasizes the influence of these stressors on the epidemiology and ecology of E. coli O157.

Cattle Production Systems: Ecology of Existing and Emerging Escherichia coli Types Related to Foodborne Illness

Shiga toxin–producing Escherichia coli (STEC), particularly STEC O157, cause rare but potentially serious human infections. Infection with STEC occurs by fecal-oral transmission, most commonly through food. Cattle are the most important reservoir for human STEC exposure, and efforts to control the flow of STEC through beef processing have reduced rates of human illness. However, further reduction in human incidence of STEC may require control of the pathogen in cattle populations. The ecology of STEC in cattle production systems is complex and explained by factors that favor (a) colonization in the gut, (b) survival in the environment, and (c) ingestion by another cattle host. Although nature creates seasonal environmental conditions that do not favor STEC transmission in cattle, human efforts to control STEC by environmental manipulation have not succeeded. Vaccines and direct-fed microbial products have reduced the carriage of STEC by cattle, and other interventions are under investigation.

Case-control studies of sporadic enteric infections: a review and discussion of studies conducted internationally from 1990 to 2009

Epidemiologists have used case-control studies to investigate enteric disease outbreaks for many decades. Increasingly, case-control studies are also used to investigate risk factors for sporadic (not outbreak-associated) disease. While the same basic approach is used, there are important differences between outbreak and sporadic disease settings that need to be considered in the design and implementation of the case-control study for sporadic disease. Through the International Collaboration on Enteric Disease "Burden of Illness" Studies (the International Collaboration), we reviewed 79 case-control studies of sporadic enteric infections caused by nine pathogens that were conducted in 22 countries and published from 1990 through to 2009. We highlight important methodological and study design issues (including case definition, control selection, and exposure assessment) and discuss how approaches to the study of sporadic enteric disease have changed over the last 20 years (e.g., making use of more sensitive case definitions, databases of controls, and computer-assisted interviewing). As our understanding of sporadic enteric infections grows, methods and topics for case-control studies are expected to continue to evolve; for example, advances in understanding of the role of immunity can be used to improve control selection, the apparent protective effects of certain foods can be further explored, and case-control studies can be used to provide population-based measures of the burden of disease.

Ground beef handling and cooking practices in restaurants in eight States

Eating in table-service restaurants has been implicated as a risk factor for Escherichia coli O157:H7 infection. To explore this association and learn about the prevalence of risky ground beef preparation practices in restaurants, the Environmental Health Specialists Network (EHS-Net) assessed ground beef handling policies and practices in restaurants in California, Colorado, Connecticut, Georgia, Minnesota, New York, Oregon, and Tennessee. Eligible restaurants prepared and served hamburgers. EHS-Net specialists interviewed a restaurant employee with authority over the kitchen (defined as the manager) using a standard questionnaire about food safety policies, hamburger preparation policies, and use of irradiated ground beef. Interviews were followed by observations of ground beef preparation. Data from 385 restaurants were analyzed: 67% of the restaurants were independently owned and 33% were chain restaurants; 75% of the restaurants were sit down, 19% were quick service or fast food, and 6% were cafeteria or buffet restaurants. Eighty-one percent of restaurants reported determining doneness of hamburgers by one or more subjective measures, and 49% reported that they never measure the final cook temperatures of hamburgers. At least two risky ground beef handling practices were observed in 53% of restaurants. Only 1% of restaurants reported purchasing irradiated ground beef, and 29% were unfamiliar with irradiated ground beef. Differences in risky ground beef handling policies and practices were noted for type of restaurant ownership (independently owned versus chain) and type of food service style (sit down versus quick service or fast food). This study revealed the pervasiveness of risky ground beef handling policies and practices in restaurants and the need for educational campaigns targeting food workers and managers. These results highlight the importance of continued efforts to reduce the prevalence of E. coli O157:H7 in ground beef.

A prospective case-control and molecular epidemiological study of human cases of Shiga toxin-producing Escherichia coli in New Zealand

Background

Shiga toxin-producing Escherichia coli (STEC) O157:H7 and related non-O157 STEC strains are enteric pathogens of public health concern worldwide, causing life-threatening diseases. Cattle are considered the principal hosts and have been shown to be a source of infection for both foodborne and environmental outbreaks in humans. The aims of this study were to investigate risk factors associated with sporadic STEC infections in humans in New Zealand and to provide epidemiological information about the source and exposure pathways.

Methods

During a national prospective case–control study from July 2011 to July 2012, any confirmed case of STEC infection notified to regional public health units, together with a random selection of controls intended to be representative of the national demography, were interviewed for risk factor evaluation. Isolates from each case were genotyped using pulsed-field gel electrophoresis (PFGE) and Shiga toxin-encoding bacteriophage insertion (SBI) typing.

Results

Questionnaire data from 113 eligible cases and 506 controls were analysed using multivariate logistic regression. Statistically significant animal and environmental risk factors for human STEC infections were identified, notably 'Cattle livestock present in meshblock’ (the smallest geographical unit) (odds ratio 1.89, 95% CI 1.04–3.42), 'Contact with animal manure’ (OR 2.09, 95% CI 1.12–3.90), and 'Contact with recreational waters’ (OR 2.95, 95% CI 1.30–6.70). No food-associated risk factors were identified as sources of STEC infection. E. coli O157:H7 caused 100/113 (88.5%) of clinical STEC infections in this study, and 97/100 isolates were available for molecular analysis. PFGE profiles of isolates revealed three distinctive clusters of genotypes, and these were strongly correlated with SBI type. The variable 'Island of residence’ (North or South Island of New Zealand) was significantly associated with PFGE genotype (p = 0.012).

Conclusions

Our findings implicate environmental and animal contact, but not food, as significant exposure pathways for sporadic STEC infections in humans in New Zealand. Risk factors associated with beef and dairy cattle suggest that ruminants are the most important sources of STEC infection. Notably, outbreaks of STEC infections are rare in New Zealand and this further suggests that food is not a significant exposure pathway.

Attributing sporadic and outbreak-associated infections to sources: blending epidemiological data

Common sources of shiga toxin-producing Escherichia coli (STEC) O157 infection have been identified by investigating outbreaks and by case-control studies of sporadic infections. We conducted an analysis to attribute STEC O157 infections ascertained in 1996 and 1999 by the Foodborne Diseases Active Surveillance Network (FoodNet) to sources. Multivariable models from two case-control studies conducted in FoodNet and outbreak investigations that occurred during the study years were used to calculate the annual number of infections attributable to six sources. Using the results of the outbreak investigations alone, 27% and 15% of infections were attributed to a source in 1996 and 1999, respectively. Combining information from both data sources, 65% of infections in 1996 and 34% of infections in 1999 were attributed. The results suggest that methods to incorporate data from multiple surveillance systems and over several years are needed to improve estimation of the number of illnesses attributable to exposure sources.

The physiologic state of Escherichia coli O157:H7 does not affect its detection in two commercial real-time PCR-based tests

Multiplex real-time PCR detection of Escherichia coli O157:H7 is an efficient molecular tool with high sensitivity and specificity for meat safety assurance. The Biocontrol GDS(®) and DuPont Qualicon BAX(®)-RT rapid detection systems are two commercial tests based on real-time PCR amplification with potential applications for quantification of specific E. coli O157:H7 gene targets in enriched meat samples. However, there are arguments surrounding the use of these tests to predict pre-enrichment concentrations of E. coli O157:H7, as well as arguments pertaining to the influence of non-viable cells causing false positive results. The present study attempts to illustrate the effects of different bacterial physiologic states and the presence of non-viable cells on the ability of these systems to accurately measure contamination levels of E. coli O157:H7 in ground beef. While the PCR threshold cycle (C(T)) values of these assays showed a direct correlation with the number of bacteria present in pure cultures, this was not the case for ground beef samples spiked with various levels of injured or healthy cells. Furthermore, comparison of post-enrichment cell densities of bacteria did not correlate with injured or healthy cell numbers inoculated before enrichment process. Ground beef samples spiked with injured or healthy cells at different doses could not be distinguished by C(T) values from either assay. In addition, the contribution of nonviable cells in generating positive real-time PCR signals was investigated using both assays on pre-enriched and post-enriched beef samples, but only if inoculated at levels of 10(6) cells/sample or higher, which are levels not typically seen in ground beef.

Biofilm formation by Shiga toxin-producing Escherichia coli O157:H7 and Non-O157 strains and their tolerance to sanitizers commonly used in the food processing environment

Shiga toxin-producing Escherichia coli (STEC) strains are important foodborne pathogens. Among these, E. coli O157:H7 is the most frequently isolated STEC serotype responsible for foodborne diseases. However, the non-O157 serotypes have been associated with serious outbreaks and sporadic diseases as well. It has been shown that various STEC serotypes are capable of forming biofilms on different food or food contact surfaces that, when detached, may lead to cross-contamination. Bacterial cells at biofilm stage also are more tolerant to sanitizers compared with their planktonic counterparts, which makes STEC biofilms a serious food safety concern. In the present study, we evaluated the potency of biofilm formation by a variety of STEC strains from serotypes O157:H7, O26:H11, and O111:H8; we also compared biofilm tolerance with two types of common sanitizers, a quaternary ammonium chloride-based sanitizer and chlorine. Our results demonstrated that biofilm formation by various STEC serotypes on a polystyrene surface was highly strain-dependent, whereas the two non-O157 serotypes showed a higher potency of pellicle formation at air-liquid interfaces on a glass surface compared with serotype O157:H7. Significant reductions of viable biofilm cells were achieved with sanitizer treatments. STEC biofilm tolerance to sanitization was strain-dependent regardless of the serotypes. Curli expression appeared to play a critical role in STEC biofilm formation and tolerance to sanitizers. Our data indicated that multiple factors, including bacterial serotype and strain, surface materials, and other environmental conditions, could significantly affect STEC biofilm formation. The high potential for biofilm formation by various STEC serotypes, especially the strong potency of pellicle formation by the curli-positive non-O157 strains with high sanitization tolerance, might contribute to bacterial colonization on food contact surfaces, which may result in downstream product contamination.

Ranking the disease burden of 14 pathogens in food sources in the United States using attribution data from outbreak investigations and expert elicitation

Understanding the relative public health impact of major microbiological hazards across the food supply is critical for a risk-based national food safety system. This study was conducted to estimate the U.S. health burden of 14 major pathogens in 12 broad categories of food and to then rank the resulting 168 pathogen-food combinations. These pathogens examined were Campylobacter, Clostridium perfringens, Escherichia coli O157:H7, Listeria monocytogenes, norovirus, Salmonella enterica, Toxoplasma gondii, and all other FoodNet pathogens. The health burden associated with each pathogen was measured using new estimates of the cost of illness and loss of quality-adjusted life years (QALYs) from acute and chronic illness and mortality. A new method for attributing illness to foods was developed that relies on both outbreak data and expert elicitation. This method assumes that empirical data are generally preferable to expert judgment; thus, outbreak data were used for attribution except where evidence suggests that these data are considered not representative of food attribution. Based on evaluation of outbreak data, expert elicitation, and published scientific literature, outbreak-based attribution estimates for Campylobacter, Toxoplasma, Cryptosporidium, and Yersinia were determined not representative; therefore, expert-based attribution were included for these four pathogens. Sensitivity analyses were conducted to assess the effect of attribution data assumptions on rankings. Disease burden was concentrated among a relatively small number of pathogen-food combinations. The top 10 pairs were responsible for losses of over $8 billion and 36,000 QALYs, or more than 50 % of the total across all pairs. Across all 14 pathogens, poultry, pork, produce, and complex foods were responsible for nearly 60 % of the total cost of illness and loss of QALYs.

Seasonality in human zoonotic enteric diseases: a systematic review

Background

Although seasonality is a defining characteristic of many infectious diseases, few studies have described and compared seasonal patterns across diseases globally, impeding our understanding of putative mechanisms. Here, we review seasonal patterns across five enteric zoonotic diseases: campylobacteriosis, salmonellosis, vero-cytotoxigenic Escherichia coli (VTEC), cryptosporidiosis and giardiasis in the context of two primary drivers of seasonality: (i) environmental effects on pathogen occurrence and pathogen-host associations and (ii) population characteristics/behaviour.

Methodology/Principal Findings

We systematically reviewed published literature from 1960–2010, resulting in the review of 86 studies across the five diseases. The Gini coefficient compared temporal variations in incidence across diseases and the monthly seasonality index characterised timing of seasonal peaks. Consistent seasonal patterns across transnational boundaries, albeit with regional variations was observed. The bacterial diseases all had a distinct summer peak, with identical Gini values for campylobacteriosis and salmonellosis (0.22) and a higher index for VTEC (Gini = 0.36). Cryptosporidiosis displayed a bi-modal peak with spring and summer highs and the most marked temporal variation (Gini = 0.39). Giardiasis showed a relatively small summer increase and was the least variable (Gini = 0.18).

Conclusions/Significance

Seasonal variation in enteric zoonotic diseases is ubiquitous, with regional variations highlighting complex environment-pathogen-host interactions. Results suggest that proximal environmental influences and host population dynamics, together with distal, longer-term climatic variability could have important direct and indirect consequences for future enteric disease risk. Additional understanding of the concerted influence of these factors on disease patterns may improve assessment and prediction of enteric disease burden in temperate, developed countries.

Ground beef consumption patterns in the United States, FoodNet, 2006 through 2007

Infection resulting from foodborne pathogens, including Escherichia coli O157:H7, is often associated with consumption of raw or undercooked ground beef. However, little is known about the frequency of ground beef consumption in the general population. The objective of this study was to describe patterns of self-reported ground beef and pink ground beef consumption using data from the 2006 through 2007 FoodNet Population Survey. From 1 July 2006 until 30 June 2007, residents of 10 FoodNet sites were contacted by telephone and asked about foods consumed within the previous week. The survey included questions regarding consumption of ground beef patties both inside and outside the home, the consumption of pink ground beef patties and other types of ground beef inside the home, and consumption of ground beef outside the home. Of 8,543 survey respondents, 75.3% reported consuming some type of ground beef in the home. Of respondents who ate ground beef patties in the home, 18.0% reported consuming pink ground beef. Consumption of ground beef was reported most frequently among men, persons with incomes from $40,000 to $75,000 per year, and persons with a high school or college education. Ground beef consumption was least often reported in adults ≥65 years of age. Men and persons with a graduate level education most commonly reported eating pink ground beef in the home. Reported consumption of ground beef and pink ground beef did not differ by season. Ground beef is a frequently consumed food item in the United States, and rates of consumption of pink ground beef have changed little since previous studies. The high rate of consumption of beef that has not been cooked sufficiently to kill pathogens makes pasteurization of ground beef an important consideration, especially for those individuals at high risk of complications from foodborne illnesses such as hemolytic uremic syndrome.

Epidemiology of Shiga toxin producing Escherichia coli in Australia, 2000-2010

BACKGROUND

Shiga toxin-producing Escherichia coli (STEC) are an important cause of gastroenteritis in Australia and worldwide and can also result in serious sequelae such as haemolytic uraemic syndrome (HUS). In this paper we describe the epidemiology of STEC in Australia using the latest available data.

METHODS

National and state notifications data, as well as data on serotypes, hospitalizations, mortality and outbreaks were examined.

RESULTS

For the 11 year period 2000 to 2010, the overall annual Australian rate of all notified STEC illness was 0.4 cases per 100,000 per year. In total, there were 822 STEC infections notified in Australia over this period, with a low of 1 notification in the Australian Capital Territory (corresponding to a rate of 0.03 cases per 100,000/year) and a high of 413 notifications in South Australia (corresponding to a rate of 2.4 cases per 100,000/year), the state with the most comprehensive surveillance for STEC infection in the country. Nationally, 71.2% (504/708) of STEC infections underwent serotype testing between 2001 and 2009, and of these, 58.0% (225/388) were found to be O157 strains, with O111 (13.7%) and O26 (11.1%) strains also commonly associated with STEC infections. The notification rate for STEC O157 infections Australia wide between 2001-2009 was 0.12 cases per 100,000 per year. Over the same 9 year period there were 11 outbreaks caused by STEC, with these outbreaks generally being small in size and caused by a variety of serogroups. The overall annual rate of notified HUS in Australia between 2000 and 2010 was 0.07 cases per 100,000 per year. Both STEC infections and HUS cases showed a similar seasonal distribution, with a larger proportion of reported cases occurring in the summer months of December to February.

CONCLUSIONS

STEC infections in Australia have remained fairly steady over the past 11 years. Overall, the incidence and burden of disease due to STEC and HUS in Australia appears comparable or lower than similar developed countries.

Direct healthcare costs of selected diseases primarily or partially transmitted by water

Despite US sanitation advancements, millions of waterborne disease cases occur annually, although the precise burden of disease is not well quantified. Estimating the direct healthcare cost of specific infections would be useful in prioritizing waterborne disease prevention activities. Hospitalization and outpatient visit costs per case and total US hospitalization costs for ten waterborne diseases were calculated using large healthcare claims and hospital discharge databases. The five primarily waterborne diseases in this analysis (giardiasis, cryptosporidiosis, Legionnaires' disease, otitis externa, and non-tuberculous mycobacterial infection) were responsible for over 40 000 hospitalizations at a cost of $970 million per year, including at least $430 million in hospitalization costs for Medicaid and Medicare patients. An additional 50 000 hospitalizations for campylobacteriosis, salmonellosis, shigellosis, haemolytic uraemic syndrome, and toxoplasmosis cost $860 million annually ($390 million in payments for Medicaid and Medicare patients), a portion of which can be assumed to be due to waterborne transmission.

Dynamics of Escherichia coli O157:H7 outbreak detection and investigation, Minnesota 2000-2008

We determined characteristics of Escherichia coli O157:H7 pulsed-field gel electrophoresis clusters that predict their being solved (i.e. that result in identification of a confirmed outbreak). Clusters were investigated by the Minnesota Department of Health (MDH) using a dynamic iterative model. During 2000-2008, 19 (23%) of 84 clusters were solved. Clusters of ≥3 isolates were more likely to be solved than clusters of two isolates. Clusters in which the first two case isolates were received at MDH on the same day were more likely to be solved than were clusters in which the first two case isolates were received over ≥8 days. Investigation of clusters of ≥3 E. coli O157:H7 cases increased the success of cluster investigations.

Large outbreak of verocytotoxin-producing Escherichia coli O157 infection in visitors to a petting farm in South East England, 2009

In the summer of 2009, an outbreak of verocytotoxigenic Escherichia coli O157 (VTEC O157) was identified in visitors to a large petting farm in South East England. The peak attack rate was 6/1000 visitors, and highest in those aged <2 years (16/1000). We conducted a case-control study with associated microbiological investigations, on human, animal and environmental samples. We identified 93 cases; 65 primary, 13 secondary and 15 asymptomatic. Cases were more likely to have visited a specific barn, stayed for prolonged periods and be infrequent farm visitors. The causative organism was identified as VTEC O157 PT21/28 with the same VNTR profile as that isolated in faecal specimens from farm animals and the physical environment, mostly in the same barn. Contact with farm livestock, especially ruminants, should be urgently reviewed at the earliest suspicion of a farm-related VTEC O157 outbreak and appropriate risk management procedures implemented without delay.

Ten-year trends and risk factors for non-O157 Shiga toxin-producing Escherichia coli found through Shiga toxin testing, Connecticut, 2000-2009

BACKGROUND

The epidemiology over time of non-O157 Shiga toxin-producing Escherichia coli (STEC) is unknown. Since 1999, increasing numbers of laboratories in Connecticut have been testing for ST rather than culturing for O157, enabling identification of non-O157 STEC.

METHODS

Beginning in 2000, Connecticut laboratories were required to submit ST-positive broths to the State Laboratory for isolation and typing of STEC. The ratio of non-O157:O157 from laboratories conducting ST testing was used to determine state-level estimates for non-O157 STEC. Patients with STEC were interviewed for exposure factors in the 7 days preceding illness. Incidence trends, clinical features, and epidemiology of non-O157 and O157 STEC infections were compared.

RESULTS

From 1 January 2000 through 31 December 2009, ST testing detected 392 (59%) of 663 reported STEC infections; 229 (58%) of the isolates were non-O157. The estimated incidence of STEC infection decreased by 34%. O157 and the top 4 non-O157 serogroups, O111, O103, O26, and O45, were a stable percentage of all STEC isolates over the 10-year period. Bloody diarrhea, hospitalization, and hemolytic uremic syndrome were more common in patients with O157 STEC than in patients with non-O157 STEC infection. Exposure risks of patients with non-O157 STEC infection differed from those of patients with O157 STEC infection primarily in international travel (15.3% vs 2.5%; P < .01). Non-O157 types differed from each other with respect to several epidemiologic and exposure features.

CONCLUSIONS

Both O157 and non-O157 STEC infection incidence decreased from 2000 through 2009. Although infection due to O157 is the most common and clinically severe STEC infection, it accounts for a minority of all clinically significant STEC infections. STEC appear to be a diverse group of organisms that have some differences as well as many epidemiologic and exposure features in common.

Epidemic cholera in a crowded urban environment, Port-au-Prince, Haiti

We conducted a case-control study to investigate factors associated with epidemic cholera. Water treatment and handwashing may have been protective, highlighting the need for personal hygiene for cholera prevention in contaminated urban environments. We also found a diverse diet, a possible proxy for improved nutrition, was protective against cholera.

Combining risk assessment and epidemiological risk factors to elucidate the sources of humanE. coliO157 infection

E. coliO157 can be transmitted to humans by three primary (foodborne, environmental, waterborne) and one secondary (person-to-person transmission) pathways. A regression model and quantitative microbiological risk assessments (QMRAs) were applied to determine the relative importance of the primary transmission pathways in NE Scotland. Both approaches indicated that waterborne infection was the least important but it was unclear whether food or the environment was the main source of infection. The QMRAs over-predicted the number of cases by a factor of 30 and this could be because allE. coliO157 strains may not be equally infective and/or the level of infectivity in the dose–response model was too high. The efficacy of potential risk mitigation strategies to reduce human exposure toE. coliO157 using QMRAs was simulated. Risk mitigation strategies focusing on food and environment are likely to have the biggest impact on infection figures.

Seasonal variation of HUS occurrence and VTEC infection in children with acute diarrhoea from Argentina

In order to study the seasonality of haemolytic uraemic syndrome (HUS) and verotoxigenic Escherichia coli (VTEC) infection in children, 437 patients under 6 years of age with acute diarrhoea were studied, 8% of whom progressed to HUS. VTEC was found in 10% of all of the stool samples analysed and seasonal occurrence of HUS (p < 0.01) was confirmed. VTEC infection was more prevalent in warm months, although the differences were not statistically significant. Moreover, a significant difference in the detection of O157:H7 serotype and in the vt profile between cold and warm months (autumn and winter; spring and summer, respectively) was established. The O157:H7 serotype was isolated more frequently during warm months. Moreover, a predominance of vt (2) was noted, which was partially replaced by the combination of vt (1) with vt (2) in the cold season. The results of this study indicate the seasonal variation of the disease and the presence of serotype O157:H7 and the vt types. They also reinforce the need to develop prevention programmes considering the seasonal pattern of the disease, which would generate an impact on public health. Control strategies of the pathogen in cattle in the most risky season of the year would also be of benefit.

Eliciting expert opinion on the effectiveness and practicality of interventions in the farm and rural environment to reduce human exposure to Escherichia coli O157

Few hard data are available on emergent diseases. However, the need to mitigate and manage emergent diseases has prompted the use of various expert consultation and opinion elicitation methods. We adapted best-worst scaling (BWS) to elicit experts' assessment of the relative practicality and effectiveness of measures to reduce human exposure to E. coli O157. Cattle vaccination was considered the most effective and hand-washing was considered the most practical measure. BWS proved a powerful tool for expert elicitation as it breaks down a cognitively burdensome process into simple, repeated, tasks. In addition, statistical analysis of the resulting data provides a scaled set of scores for the measures, rather than just a ranking. The use of two criteria (practicality and effectiveness) within the BWS process allows the identification of subsets of measures judged as potentially performing well on both criteria, and conversely those judged to be neither effective nor practical.

High stability of Stx2 phage in food and under food-processing conditions

Bacteriophages (phages) carrying Shiga toxin genes constitute a major virulence attribute in enterohemorrhagic Escherichia coli (EHEC). Several EHEC outbreaks have been linked to food. The survival of such strains in different foods has received much attention, while the fate of the mobile Shiga toxin-converting phages (Stx phages) has been less studied. We have investigated the stability of an Stx phage in several food products and examined how storage, food processing, and disinfection influence the infectivity of phage particles. The study involved a recombinant Stx phage (Δstx::cat) of an E. coli O103:H25 strain from a Norwegian outbreak in 2006. Temperature, matrix, and time were factors of major importance for the stability of phage particles. Phages stored at cooling temperatures (4°C) showed a dramatic reduction in stability compared to those stored at room temperature. The importance of the matrix was evident at higher temperatures (60°C). Phages in ground beef were below the detection level when heated to 60°C for more than 10 min, while phages in broth exposed to the same heating conditions showed a 5-log-higher stability. The phages tolerated desiccation poorly but were infective for a substantial period of time in solutions. Under moist conditions, they also had a high ability to tolerate exposure to several disinfectants. In a dry-fermented sausage model, phages were shown to infect E. coli in situ. The results show that Stx phage particles can maintain their infectivity in foods and under food-processing conditions.