Impact and management of Campylobacter in human medicine--European perspective

In 2001 in Germany, Campylobacter was second to Salmonella as the most frequent foodborne pathogen isolated from humans. This is also true for the major part of the European population with incidence data available, namely Germany, Hungary, Belgium, Denmark, Austria and Spain, with a total population of 154.5 million, and incidence rates for Salmonella and Campylobacter of 81.8/100 000 and 49.0/100 000 respectively. Countries where Campylobacter is predominant are the UK, Switzerland, Sweden, Finland, Norway, and The Netherlands, with a total population of 94.2 million, and incidence rates for Campylobacter and Salmonella of 79.6/100 000 and 33.3/100 000, respectively. Shigella is rarely isolated in Europe (1.9-4.5/100 000). Epidemiologic risk factors for human campylobacteriosis are poultry, untreated milk, and surface water. Travel plays an important role, especially in Scandinavia and the UK. Isolates acquired outside these countries are much more often resistant to fluoroquinolones than are domestic strains. Fluoroquinolone resistance in human Campylobacter isolates is lowest in the UK and Denmark, at 12%. Resistance quotes of around 20-40% are found in Finland, The Netherlands, Norway, Sweden, Austria, and Germany, and peaks in Spain reaching 70-80%. Usually, uncomplicated Campylobacter enteritis is symptomatically treated. If, in severe cases, antimicrobials are indicated, in all European countries except Switzerland, macrolides are used as first-line drugs, followed by fluoroquinolones or doxycycline.

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%).

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.

Incidence trend and risk factors for campylobacter infections in humans in Norway

BACKGROUND

The objectives of the study were to evaluate whether the increase in incidence of campylobacteriosis observed in humans in Norway from 1995 to 2001 was statistically significant and whether different biologically plausible risk factors were associated with the incidence of campylobacteriosis in the different counties in Norway.

METHODS

To model the incidence of domestically acquired campylobacteriosis from 1995 to 2001, a population average random effect poisson model was applied (the trend model). To case data and assumed risk-factor/protective data such as sale of chicken, receiving treated drinking water, density of dogs and grazing animals, occupation of people in the municipalities and climatic factors from 2000 and 2001, an equivalent model accounting for geographical clustering was applied (the ecological model).

RESULTS

The increase in incidence of campylobacteriosis in humans in Norway from 1995 to 2001 was statistically significant from 1998. Treated water was a protective factor against Campylobacter infections in humans with an IRR of 0.78 per percentage increase in people supplied. The two-level modelling technique showed no evidence of clustering of campylobacteriosis in any particular county. Aggregation of data on municipality level makes interpretation of the results at the individual level difficult.

CONCLUSION

The increase in incidence of Campylobacter infections in humans from 1995 to 2001 was statistically significant from 1998. Treated water was a protective factor against Campylobacter infections in humans with an IRR of 0.78 per percentage increase in people supplied. Campylobacter infections did not appear to be clustered in any particular county in Norway.

Temperature-driven Campylobacter seasonality in England and Wales

Campylobacter incidence in England and Wales between 1990 and 1999 was examined in conjunction with weather conditions. Over the 10-year interval, the average annual rate was determined to be 78.4 +/- 15.0 cases per 100,000, with an upward trend. Rates were higher in males than in females, regardless of age, and highest in children less than 5 years old. Major regional differences were detected, with the highest rates in Wales and the southwest and the lowest in the southeast. The disease displayed a seasonal pattern, and increased campylobacter rates were found to be correlated with temperature. The most marked seasonal effect was observed for children under the age of 5. The seasonal pattern of campylobacter infections indicated a linkage with environmental factors rather than food sources. Therefore, public health interventions should not be restricted to food-borne approaches, and the epidemiology of the seasonal peak in human campylobacter infections may best be understood through studies in young children.

Fly transmission of Campylobacter

An annual increase in Campylobacter infection in England and Wales begins in May and reaches a maximum in early June. This increase occurs in all age groups and is seen in all geographic areas. Examination of risk factors that might explain this seasonal increase identifies flies as a potential source of infection. The observed pattern of infection is hypothesized to reflect an annual epidemic caused by direct or indirect contamination of people by small quantities of infected material carried by flies that have been in contact with feces. The local pattern of human illness appears random, while having a defined geographic and temporal distribution that is a function of the growth kinetics of one or more fly species. The hypothesis provides an explanation for the seasonal distribution of Campylobacter infections seen around the world.

Climate variability and campylobacter infection: an international study

Campylobacter is among the most important agents of enteritis in developed countries. We have described the potential environmental determinants of the seasonal pattern of infection with campylobacter in Europe, Canada, Australia and New Zealand. Specifically, we investigated the role of climate variability on laboratory-confirmed cases of campylobacter infection from 15 populations. Regression analysis was used to quantify the associations between timing of seasonal peaks in infection in space and time. The short-term association between weekly weather and cases was also investigated using Poisson regression adapted for time series data. All countries in our study showed a distinct seasonality in campylobacter transmission, with many, but not all, populations showing a peak in spring. Countries with milder winters have peaks of infection earlier in the year. The timing of the peak of infection is weakly associated with high temperatures 3 months previously. Weekly variation in campylobacter infection in one region of the UK appeared to be little affected by short-term changes in weather patterns. The geographical variation in the timing of the seasonal peak suggests that climate may be a contributing factor to campylobacter transmission. The main driver of seasonality of campylobacter remains elusive and underscores the need to identify the major serotypes and routes of transmission for this disease.

Effects of climate on incidence of Campylobacter spp. in humans and prevalence in broiler flocks in Denmark

Campylobacter infections are increasing and pose a serious public health problem in Denmark. Infections in humans and broiler flocks show similar seasonality, suggesting that climate may play a role in infection. We examined the effects of temperature, precipitation, relative humidity, and hours of sunlight on Campylobacter incidence in humans and broiler flocks by using lag dependence functions, locally fitted linear models, and cross validation methods. For humans, the best model included average temperature and sunlight 4 weeks prior to infection; the maximum temperature lagged at 4 weeks was the best single predictor. For broilers, the average and maximum temperatures 3 weeks prior to slaughter gave the best estimate; the average temperature lagged at 3 weeks was the best single predictor. The combined effects of temperature and sunlight or the combined effects of temperature and relative humidity predicted the incidence in humans equally well. For broiler flock incidence these factors explained considerably less. Future research should focus on elements within the broiler environment that may be affected by climate, as well as the interaction of microclimatic factors on and around broiler farms. There is a need to quantify the contribution of broilers as a source of campylobacteriosis in humans and to further examine the effect of temperature on human incidence after this contribution is accounted for. Investigations should be conducted into food consumption and preparation practices and poultry sales that may vary by season.

Campylobacter spp., Giardia spp., Cryptosporidium spp., noroviruses, and indicator organisms in surface water in southwestern Finland, 2000-2001

A total of 139 surface water samples from seven lakes and 15 rivers in southwestern Finland were analyzed during five consecutive seasons from autumn 2000 to autumn 2001 for the presence of various enteropathogens (Campylobacter spp., Giardia spp., Cryptosporidium spp., and noroviruses) and fecal indicators (thermotolerant coliforms, Escherichia coli, Clostridium perfringens, and F-RNA bacteriophages) and for physicochemical parameters (turbidity and temperature); this was the first such systematic study. Altogether, 41.0% (57 of 139) of the samples were positive for at least one of the pathogens; 17.3% were positive for Campylobacter spp. (45.8% of the positive samples contained Campylobacter jejuni, 25.0% contained Campylobacter lari, 4.2% contained Campylobacter coli, and 25.0% contained Campylobacter isolates that were not identified), 13.7% were positive for Giardia spp., 10.1% were positive for Cryptosporidium spp., and 9.4% were positive for noroviruses (23.0% of the positive samples contained genogroup I and 77.0% contained genogroup II). The samples were positive for enteropathogens significantly (P < 0.05) less frequently during the winter season than during the other sampling seasons. No significant differences in the prevalence of enteropathogens were found when rivers and lakes were compared. The presence of thermotolerant coliforms, E. coli, and C. perfringens had significant bivariate nonparametric Spearman's rank order correlation coefficients (P < 0.001) with samples that were positive for one or more of the pathogens analyzed. The absence of these indicators in a logistic regression model was found to have significant predictive value (odds ratios, 1.15 x 10(8), 7.57, and 2.74, respectively; P < 0.05) for a sample that was negative for the pathogens analyzed. There were no significant correlations between counts or count levels for thermotolerant coliforms or E. coli or the presence of F-RNA phages and pathogens in the samples analyzed.

Epidemiological investigation of risk factors for campylobacter colonization in Norwegian broiler flocks

An epidemiological investigation was conducted to identify risk factors related to hygiene and husbandry practices which determine the introduction of Campylobacter spp. into broiler chicken flocks. All 176 broiler farms in an area in southeastern Norway participated in the study. Each farm was represented by one flock selected at random during a one-year period. The flocks were examined for campylobacter colonization at slaughter, and the flock managers were subsequently interviewed about hygiene and husbandry practices. Campylobacter spp. were recovered from 32 (18%) of the flocks. The proportion of colonized flocks varied geographically and seasonally with a peak in the autumn. The following variables were found to be independently associated with an increased risk of campylobacter colonization using logistic regression analysis: (i) feeding the broilers undisinfected water (odds ratio (OR) = 3.42, P = 0.045), (ii) tending other poultry prior to entering the broiler house (OR = 6.43, P = 0.007), (iii) tending pigs before entering the house (OR = 4.86, P = 0.037), (iv) geographic region (Hedmark versus Ostfold county) (OR = 2.91, P = 0.023, (v) season (autumn versus other seasons) (OR = 3.43; P = 0.008). Presence of rats on the farm was associated with an increased risk, but this factor did not reach statistical significance (OR = 3.96, P = 0.083). Preventive measures should include disinfection of drinking water and strict hygienic routines when the farm workers enter the rearing room. The results indicate that disinfection of drinking water is the preventive measure most likely to have the greatest impact on the prevalence of campylobacter among broiler chicken flocks in the study area (population attributable fraction = 0.53).

Serological testing for campylobacteriosis with sera forwarded for Salmonella and Yersinia serology

Single serum specimens forwarded for Salmonella and Yersinia serology, from a total of 250 patients, were tested for anti-C. jejuni antibodies of the IgG class. Anti-Salmonella and anti-Y. enterocolitica O3 antibodies were examined by a microagglutination test and anti-C. jejuni antibodies by ELISA against a C. jejuni ultrasonicate before (ELISA) and after neutralization of antibodies which cross-reacted with Helicobacter pylori antigens (ELISA-Abs). Blood donor sera (n = 50) and sera (n = 40) from patients with various infectious diseases served as controls. A positive test for anti-Salmonella antibodies was recorded in 4/250 (1.6%) of the patients, for anti-Yersinia antibodies in 7/250 (2.8%), and for anti-C. jejuni antibodies in 7/250 (2.8%) in the ELISA; in 25/250 (10%) in the ELISA-Abs. No mixed infection was recorded by the serological testing. The ELISA-Abs showed a diagnostic specificity of 97.7%. Our results support the inference that diagnostic serology for enteropathogenic bacteria should include serology for C. jejuni, preferably by tests which exclude participation by antibodies which cross-react with H. pylori antigens.