Multistate foodborne hepatitis A outbreak among European tourists returning from Egypt--need for reinforced vaccination recommendations, November 2012 to April 2013

Global outbreaks of foodborne hepatitis A: Systematic review and meta-analysis

Hepatitis A Virus (HAV) is a significant threat in terms of food safety. A systematic literature search with the research question "What are the clinical outcomes of foodborne Hepatitis A virus infections?" was conducted. The pooled estimate of the outcomes-mortality, hospitalization, and severity rates, along with a 95% confidence interval (CI), was estimated. After screening, 33 studies were included for the data extraction and meta-analysis. The pooled prevalence of hospitalization among the HAV-positive patients was estimated to be 32% (95% CI 21-44), with high heterogeneity (I2 = 98%, p < 0.01). Australia had the highest hospitalization rate, with 82%, followed by Europe (42%). The hospitalization rate showed a significantly increasing trend (beta = 0.015, p=0.002) over the period. The pooled prevalence of mortality among the HAV-positive patients was estimated to be <1%, with low heterogeneity (I2 = 5%, p = 0.39). A wide range of food products were linked with the HAV outbreaks.

Travel vaccines-priorities determined by incidence and impact

BACKGROUND

Infectious disease epidemiology is continuously shifting. While travel has been disrupted by the COVID-19 pandemic and travel-related epidemiological research experienced a pause, further shifts in vaccine-preventable diseases (VPDs) relevant for travellers have occurred.

METHODS

We conducted a literature search on the epidemiology of travel-related VPD and synthesized data for each disease with a focus on symptomatic cases and on the impact of the respective infection among travellers, considering the hospitalization rate, disease sequela and case fatality rate. We present new data and revised best estimates on the burden of VPD relevant for decisions on priorities in travel vaccines.

RESULTS

COVID-19 has emerged to be a top travel-related risk and influenza remains high in the ranking with an estimated incidence at 1% per month of travel. Dengue is another commonly encountered infection among international travellers with estimated monthly incidence of 0.5-0.8% among non-immune exposed travellers; the hospitalized proportion was 10 and 22%, respectively, according to two recent publications. With recent yellow fever outbreaks particularly in Brazil, its estimated monthly incidence has risen to >0.1%. Meanwhile, improvements in hygiene and sanitation have led to some decrease in foodborne illnesses; however, hepatitis A monthly incidence remains substantial in most developing regions (0.001-0.01%) and typhoid remains particularly high in South Asia (>0.01%). Mpox, a newly emerged disease that demonstrated worldwide spread through mass gathering and travel, cannot be quantified regarding its travel-related risk.

CONCLUSION

The data summarized may provide a tool for travel health professionals to prioritize preventive strategies for their clients against VPD. Updated assessments on incidence and impact are ever more important since new vaccines with travel indications (e.g. dengue) have been licensed or are undergoing regulatory review.

Hepatitis A notifications in the EU/EEA, 2010-2019: what can we learn from case reporting to the European Surveillance System?

BackgroundEuropean Union/European Economic Area (EU/EEA) countries annually report hepatitis A (HepA) notifications to The European Surveillance System (TESSy).AimTo describe EU/EEA HepA notifications from 2010 to 2019 and identify infection drivers and surveillance improvements.MethodsWe analysed demographic, clinical and transmission information of HepA confirmed cases from TESSy. We stratified countries by population susceptibility profile and performed time-series analysis to describe trends in notification rates, sex distribution and travel history.ResultsTwenty-nine EU/EEA countries reported 139,793 HepA cases. Six eastern EU countries reported > 60% of these cases. EU/EEA notification rate during the study period was 3.2 cases per 100,000 population (range 2.7-5.6). Notifications peaked in 2014 and 2017, with marked differences in case demographic characteristics. Notification trends varied across different country susceptibility groups. In 2017, the proportion of males (74%) and case median age (31 years) increased steeply, while no changes occurred in 2014. Travel history showed seasonal case peaks following the summer. More than 47,000 hospitalisations were reported. Annual case fatality was < 0.2% for all years. Information on travel history, hospitalisation, death and mode of transmission was suboptimal.DiscussionApart from some countries in its east, the EU/EEA is characterised by low HepA incidence baseline and susceptible to recurrent large cross-border outbreaks. Analysis of European surveillance data highlighted the need for stronger prevention policies for eastern EU countries, men who have sex with men and travellers. Improving surveillance data-quality will enhance knowledge on food-borne, and travel-related exposures to inform more effective and tailored regional prevention policies.

Severity of the clinical presentation of hepatitis A in five European countries from 1995 to 2014

OBJECTIVES

We analysed hepatitis A (HepA) notifications and hospitalisations in Italy, the Netherlands, Norway, Spain, and Sweden for available periods between 1995 and 2014. We aimed to investigate whether decreasing HepA incidence is associated with increasing age at infection and worsening HepA presentation and to identify groups at risk of severe disease.

METHODS

We performed a retrospective cohort study including 36 734 notified and 36 849 hospitalised patients. We used negative binomial regressions to identify over time: i) trends in hospitalisation and notification rates; ii) proportion of hospitalised and notified patients aged ≥40 years; iii) proportion of "severe hospitalisations"; and iv) risk factors for severe hospitalisation.

RESULTS

During the study period both HepA notifications and hospitalisations decreased, with notification rates decreasing faster, patients aged ≥40 years increased, however, the proportion of severe HepA hospitalisations remained stable. Older patients and patients with comorbidities, particularly liver diseases, were more likely to experience severe disease.

CONCLUSIONS

We used digitalised health information to confirm decreasing trends in HepA hospitalisations and notifications, and the increasing age of patients with HepA in Europe. We did not identify an increase in the severity of the clinical presentation of patients with HepA. Older patients with liver diseases are at increased risk of severe disease and should be prioritised for vaccination.

Prevalence of Anti-Hav IgG Antibodies in the Population of the Łódź Macroregion by Age Group

Over the last several decades, a gradual decrease in the incidence of hepatitis A and an increase in the population of non-immune people, especially in the group of young people have been observed in Poland. The aim of this study was to assess of the presence of specific anti-hepatitis A virus IgG class antibodies (anti-HAV IgG) in relation to age among non-vaccinated hepatitis A patients. There were statistically significantly more patients up to 45 years of age with anti-HAV IgG negative results than those over 45 years of age, and the Fi-square correlation coefficient (Φ2) was 0.263 between the analyzed variables. The data analysis shows that the number of people with specific IgG antibodies against hepatitis A increases with age. The risk of hepatitis A infection in people under 45 is high due to widespread seronegativity in this age group.

The global trends and regional differences in incidence and mortality of hepatitis A from 1990 to 2019 and implications for its prevention

Background and purpose

Despite decades of improved sanitation and hygiene measures and vaccine introduction, hepatitis A has been spread through numerous outbreaks globally. We used data from the Global Burden of Disease (GBD) study to quantify hepatitis A burden at the global, regional and national levels.

Methods

Annual incident cases, deaths, age-standardized incidence rates (ASIRs), and age-standardized mortality rates (ASMRs) of hepatitis A between 1990 and 2019 were derived from the GBD study 2019. Percentage changes of cases and deaths, and estimated annual percentage changes (EAPCs) of ASIRs and ASMRs were calculated to quantify their temporal trends.

Results

Global hepatitis A incident cases increased by 13.90% from 139.54 million in 1990 to 158.94 million in 2019. ASIR of hepatitis A remained stable (EAPC = 0.00, 95% CI −0.01 to 0.01), whereas ASMR decreased (EAPC = −4.63, 95% CI −4.94 to −4.32) between 1990 and 2019. ASIR increased in low (EAPC = 0.09, 95% CI 0.04 to 0.14) and low-middle (EAPC = 0.04, 95% CI 0.03 to 0.06) socio-demographic index (SDI) regions. For GBD regions, the most significant increases of ASIR were detected in high-income Asia Pacific (EAPC = 0.53, 95% CI 0.41 to 0.66), Oceania (EAPC = 0.31, 95% CI 0.25 to 0.36), and Australasia (EAPC = 0.28, 95% CI 0.13 to 0.44). EAPC of ASIR was positively associated with SDI value in countries and territories with SDI value ≥ 0.7 (ρ = −0.310, p < 0.001).

Conclusion

There is an unfavorable trend that hepatitis A is still pending in hyperendemic regions and is emerging in low endemic regions. These highlight the need of targeted and specific strategies to eliminate hepatitis A, such as sanitation measures and a comprehensive plan for surveillance and vaccination against hepatitis A.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10232-4.

Foodborne transmission of hepatitis A and hepatitis E viruses: A literature review

Foodborne viruses have been recognized as a growing concern to the food industry and a serious public health problem. Hepatitis A virus (HAV) is responsible for the majority of viral outbreaks of food origin worldwide, while hepatitis E virus (HEV) has also been gaining prominence as a foodborne viral agent in the last years, due to its zoonotic transmission through the consumption of uncooked or undercooked infected meat or derivatives. However, there is a lack of scientific reports that gather all the updated information about HAV and HEV as foodborne viruses. A search of all scientific articles about HAV and HEV in food until March 2020 was carried out, using the keywords "HAV", "HEV", "foodborne", "outbreak" and "detection in food". Foodborne outbreaks due to HAV have been reported since 1956, mainly in the USA, and in Europe in recent years, where the number of outbreaks has been increasing throughout time, and nowadays it has become the continent with the highest foodborne HAV outbreak report. Investigation and detection of HAV in food is more recent, and the first detections were performed in the 1990s decade, most of them carried out on seafood, first, and frozen food, later. On the other hand, HEV has been mainly looked for and detected in food derived from reservoir animals, such as meat, sausages and pate of pigs and wild boars. For this virus, only isolated cases and small outbreaks of foodborne transmission have been recorded, most of them in industrialized countries, due to HEV genotype 3 or 4. Virus detection in food matrices requires special processing of the food matrix, followed by RNA detection by molecular techniques. For HAV, a real-time PCR has been agreed as the standard method for virus detection in food; in the case of HEV, a consensus assay for its detection in food has not been reached yet. Our investigation shows that there is still little data about HAV and HEV prevalence and frequency of contamination in food, prevalent viral strains, and sources of contamination, mainly in developing countries, where there is no research and legislation in this regard. Studies on these issues are needed to get a better understanding of foodborne viruses, their maintenance and their potential to cause diseases.

Involvement of Egyptian Foods in Foodborne Viral Illnesses: The Burden on Public Health and Related Environmental Risk Factors: An Overview

Foodborne viral diseases are a major public health threat and pose a huge burden on the economies of both developed and developing countries. Enteric viruses are the causative agents of most foodborne illnesses and outbreaks. Egypt is classified by WHO among the regions with intermediate to high endemicity for various enteric viruses. This is manifested by the high prevalence rates of different enteric virus infections among Egyptian population such as Hepatitis A and E viruses, human rotaviruses, human noroviruses, human astroviruses, and human adenovirus. Recently, a number of foodborne gastroenteritis and acute hepatitis outbreaks have occurred in the US, Canada, Australia, and the European Union countries. Some of these outbreaks were attributed to the consumption of minimally processed foods imported from Egypt indicating the possibility that Egyptian foods may also be partially responsible for high prevalence of enteric virus infections among Egyptian population. In the absence of official foodborne-pathogen surveillance systems, evaluating the virological safety of Egyptian foods is a difficult task. In this review, we aim to provide a preliminary evaluation of the virological safety of Egyptian foods. A comprehensive review of prevalence studies on enteric virus infections shows hyperendemicity of several enteric viruses in Egypt and provides strong evidence of implication of Egyptian foods in these infections. We also address possible environmental risk factors that may lead to the contamination of Egyptian foods with enteric viruses. In addition, we describe potential obstacles to any plan that might be considered for improving the virological safety of Egyptian foods.

Hepatitis A outbreak linked to imported frozen strawberries by sequencing, Sweden and Austria, June to September 2018

Between June–September 2018, 20 hepatitis A cases were notified in six counties in Sweden. Combined epidemiological and microbiological investigations identified imported frozen strawberries produced in Poland as the source of the outbreak. Sequence analysis confirmed the outbreak strain IB in the strawberries with 100 % identity and the respective batch was withdrawn. Sharing the sequence information internationally led to the identification of 14 additional cases in Austria, linked to strawberries from the same producer.

Travel-associated hepatitis A in Europe, 2009 to 2015

Travel to countries with high or intermediate hepatitis A virus (HAV) endemicity is a risk factor for infection in residents of countries with low HAV endemicity. Aim: The objective of this study was to estimate the risk for hepatitis A among European travellers using surveillance and travel denominator data. Methods: We retrieved hepatitis A surveillance data from 13 European Union (EU)/ European Economic Area (EEA) countries with comprehensive surveillance systems and travel denominator data from the Statistical Office of the European Union. A travel-associated case of hepatitis A was defined as any case reported as imported. Results: From 2009 to 2015, the 13 countries reported 18,839 confirmed cases of hepatitis A, of which 5,233 (27.8%) were travel-associated. Of these, 39.8% were among children younger than 15 years. The overall risk associated with travel abroad decreased over the period at an annual rate of 3.7% (95% confidence interval (CI): 0.7–2.7) from 0.70 cases per million nights in 2009 to 0.51 in 2015. The highest risk was observed in travellers to Africa (2.11 cases per million nights). Cases more likely to be reported as travel-associated were male and of younger age (< 25 years). Conclusion: Travel is still a major risk factor for HAV infection in the EU/EEA, although the risk of infection may have slightly decreased in recent years. Children younger than 15 years accounted for a large proportion of cases and should be prioritised for vaccination.

Improving preparedness to respond to cross-border hepatitis A outbreaks in the European Union/European Economic Area: towards comparable sequencing of hepatitis A virus

IntroductionSequence-based typing of hepatitis A virus (HAV) is important for outbreak detection, investigation and surveillance. In 2013, sequencing was central to resolving a large European Union (EU)-wide outbreak related to frozen berries. However, as the sequenced HAV genome regions were only partly comparable between countries, results were not always conclusive.AimThe objective was to gather information on HAV surveillance and sequencing in EU/European Economic Area (EEA) countries to find ways to harmonise their procedures, for improvement of cross-border outbreak responses.MethodsIn 2014, the European Centre for Disease Prevention and Control (ECDC) conducted a survey on HAV surveillance practices in EU/EEA countries. The survey enquired whether a referral system for confirming primary diagnostics of hepatitis A existed as well as a central collection/storage of hepatitis A cases' samples for typing. Questions on HAV sequencing procedures were also asked. Based on the results, an expert consultation proposed harmonised procedures for cross-border outbreak response, in particular regarding sequencing. In 2016, a follow-up survey assessed uptake of suggested methods.ResultsOf 31 EU/EEA countries, 23 (2014) and 27 (2016) participated. Numbers of countries with central collection and storage of HAV positive samples and of those performing sequencing increased from 12 to 15 and 12 to 14 respectively in 2016, with all countries typing an overlapping fragment of 218 nt. However, variation existed in the sequenced genomic regions and their lengths.ConclusionsWhile HAV sequences in EU/EEA countries are comparable for surveillance, collaboration in sharing and comparing these can be further strengthened.

Declining seroprevalence of hepatitis A in Vojvodina, Serbia

To assess the current hepatitis A virus (HAV) endemicity in the Autonomous Province of Vojvodina, Serbia, we examined the seroprevalence and susceptibility profiles of the general population. A serum bank of 3466 residual samples, collected in 2015-16 as per the specifications of the European Sero-Epidemiology Network 2 project (ESEN2), was tested for anti-HAV antibodies with an enzyme immunoassay. Relationships between anti-HAV positivity and demographic features of respondents were examined by univariable and multivariable analyses. Present-day HAV seroprevalence was compared with that obtained in 1978-79. Surveillance data for hepatitis A recorded between 2008 and 2017 were also analyzed. Age was the only demographic variable found to be independently associated with a HAV seropositive status. Seropositivity (17% overall vs. 79% in 1978-79) increased with age to a maximum of 90% in the elderly ≥60 years. Only 5% of subjects <30 years were seropositive, unlike the 44% of seropositives ≥30 years. The estimated age at midpoint of population immunity (AMPI) increased markedly from 14 years in the late 70s to 55 years in 2015-16. Meanwhile, disease incidence decreased noticeably in recent years (from 11 in 2008 to 2 per 100,000 population in 2017). In the ongoing pre-vaccine era, natural infection provides immunity for merely a third (31%) and two thirds (57%) of people in their 40s and 50s, respectively. Hence, the majority of people ≤40 years (94%) and middle-aged adults 40-49 years (69%) are susceptible to HAV. Older susceptible individuals, particularly those ≥50 years (24%), are prone to severe symptoms. Taken together, these changes reflect the epidemiological transition of Vojvodina and Serbia from high to very low HAV endemicity, thereby supporting the current national policy of immunization of only high-risk groups.

Hepatitis A Outbreak in the General Population due to a MSM-Associated HAV Genotype Linked to a Food Handler, November 2017-February 2018, Germany

Hepatitis A (HAV) is a viral infection causing a range of symptoms, sudden onset of fever, malaise, diarrhea, and jaundice. It is mostly transmitted fecal-oral through contaminated food, with immediate household and sexual contacts having a higher risk of infection. Since 2016 an increased number of HAV infections, mostly affecting men who have sex with men (MSM) have been noticed worldwide, with three main genotypes circulating. We report here on the first spillover outbreak of the MSM-associated HAV genotype RIVM-HAV16-090 in the German general population in November 2017-February 2018. In total, twelve cases could be attributed to the outbreak with the index case and a coworker in a butchers shop being the most probable source of the outbreak. The identical HAV genotype was detected in two environmental samples in the premises of the butchers shop and in nine cases. Outbreak control measures included detailed contact tracing and stool examinations, several environmental investigations, thorough cleaning, and disinfection of the premises of the butchers shop. Post-exposure vaccination was recommended to all unprotected contacts during the investigation. Furthermore, although hand-washing facilities were in accordance with the required law, additional installment of soap and disinfectant dispensers and contactless faucets has been recommended.

Successful Use of Advertisement Pictures to Assist Recall in a Food-Borne Hepatitis A Outbreak in The Netherlands, 2017

This study describes an outbreak investigation of 14 hepatitis A cases in the Netherlands. The hepatitis A virus (HAV) genotype IB sequences in cases were highly similar (459/460 nt). The origin of strains could be narrowed to Bulgaria based on information from EPIS-FWD. As an association with consumption of soft fruit was suspected, a case-control study was initiated using a questionnaire and a list of pictures of soft fruit available at the supermarket chain involved. Twelve out of 13 cases consumed a specific frozen raspberry/blueberry product shown on the list (OR 46.0, 95% CI 5.0-27). In multivariable regression analysis this product was the only risk factor (aOR 26.6, 95% CI 2.0-263). Laboratory analyses could not demonstrate HAV-RNA in batches that had been on the market in the incubation period of patients. Trace back of frozen fruit showed that raspberries had been traded by a producer in Bulgaria. After withdrawal of the product from the supermarket no new cases were reported. Use of advertisement pictures of consumed food was helpful in this investigation. Suspicion of the source was strengthened by data from molecular typing and food trace back activities, underlining the importance of good (inter)national cooperation between public health and food safety organisations.

Two concurrent outbreaks of hepatitis A highlight the risk of infection for non-immune travellers to Morocco, January to June 2018

From January to June 2018, two ongoing hepatitis A outbreaks affected travellers returning from Morocco and cases in Europe without travel history, resulting in 163 patients in eight European countries. Most interviewed travel-related cases were unaware of the hepatitis A risk in Morocco. Molecular analysis revealed two distinct hepatitis A virus (HAV) strains (subgenotype IA DK2018_231; subgenotype IB V18-16428). Vaccination recommendations should be emphasised to increase awareness among non-immune travellers to Morocco and HAV-endemic countries.

German travelers' preferences for travel vaccines assessed by a discrete choice experiment

BACKGROUND

Many travelers to regions with endemic infectious diseases do not follow health authorities' recommendations regarding vaccination against vaccine-preventable infectious diseases, before traveling. The determinants of individual travelers' decisions to vaccinate before traveling are largely unknown. This study aimed to provide this information using a discrete choice experiment (DCE) administered to four types of German travelers: (1) business travelers; (2) travelers visiting friends and relatives (VFR); (3) leisure travelers; and (4) backpackers.

METHODS

A DCE survey was developed, pretested and administered online. It included a series of choice questions in which respondents chose between two hypothetical vaccines, each characterized by four disease attributes with varying levels describing the of risk, health impact, curability and transmissibility of the disease they would prevent (described with four disease attributes with varying levels of risk, health impact, curability and transmissibility), and varying levels of four vaccine attributes (duration of protection, number of doses required, time required for vaccination, and vaccine cost). A random-parameters logit model was used to estimate the importance weights each traveler type placed on the various attribute levels. These weights were used to calculate mean monetary equivalents (MMEs) of changes in each attribute (holding all others constant) and of hypothetical disease-vaccine combinations.

RESULTS

All traveler types' choices indicated that they attached the greatest importance to the risk and health impact of disease and to the vaccine cost whereas the other disease and vaccine attributes were less important for their decisions about travel vaccines. An option of not choosing any of the vaccine-pairs presented was rarely selected indicating that travelers' generally prefer to be vaccinated rather than not. The MMEs of changes in vaccine attributes indicated a very high variability between the individual travelers within each type.

CONCLUSIONS

The travelers' responses indicated strong preferences for selecting vaccination rather than opting out of vaccination, and disease risk, health impact and vaccine cost were the most important features for vaccine choice.

Multi-country outbreak of Salmonella enteritidis infection linked to the international ice hockey tournament

In April 2015, Finnish public health authorities alerted European Union member states of a possible multi-country Salmonella enteritidis outbreak linked to an international youth ice-hockey tournament in Latvia. The European Centre for Disease Prevention and Control (ECDC), Finnish and Latvian authorities initiated an outbreak investigation to identify the source. The investigation included a description of the outbreak, retrospective cohort study, microbiological investigation and trace-back. We identified 154 suspected and 96 confirmed cases from seven countries. Consuming Bolognese sauce and salad at a specific event arena significantly increased the risk of illness. Isolates from Finnish, Swedish and Norwegian cases had an identical multiple-locus variable-number of tandem repeats analysis-profile (3-10-6-4-1). Breaches in hygiene and food storing practices in the specific arena's kitchen allowing for cross-contamination were identified. Riga Cup participants were recommended to follow good hand hygiene and consume only freshly cooked foods. This investigation demonstrated that the use of ECDC's Epidemic Intelligence Information System for Food- and Waterborne Diseases and Zoonoses platform was essential to progress the investigation by facilitating information exchange between countries. Cross-border data sharing to perform whole genome sequencing gave relevant information regarding the source of the outbreak.

Detection and characterization of hepatitis A virus circulating in Egypt

Hepatitis A virus (HAV) still poses a considerable problem worldwide. In the current study, hepatitis A virus was recovered from wastewater samples collected from three wastewater treatment plants over one year. Using RT-PCR, HAV was detected in 43 out of 68 samples (63.2%) representing both inlet and outlet. Eleven positive samples were subjected to sequencing targeting the VP1-2A junction region. Phylogenetic analysis revealed that all samples belonged to subgenotype IB with few substitutions at the amino acid level. The complete sequence of one isolate (HAV/Egy/BI-11/2015) showed that the similarity at the amino acid level was not reflected at the nucleotide level. However, the deduced amino acid sequence derived from the complete nucleotide sequence showed distinct substitutions in the 2B, 2C, and 3A regions. Recombination analysis revealed a recombination event between X75215 (subgenotype IA) and AF268396 (subgenotype IB) involving a portion of the 2B nonstructural protein coding region (nucleotides 3757-3868) assuming the herein characterized sequence an actual recombinant. Despite the role of recombination in picornaviruses evolution, its involvement in HAV evolution has rarely been reported, and this may be due to the limited available complete HAV sequences. To our knowledge, this represents the first characterized complete sequence of an Egyptian isolate and the described recombination event provides an important update on the circulating HAV strains in Egypt.

Foodborne Disease in the Middle East

Food safety is a concern worldwide and according to the World Health Organization, developing countries are probably more at risk of foodborne illness because many of these, including those in the Middle East, have limited disease surveillance and prevention and control strategies. Specifically, the Middle East and North Africa (MENA) region has the third highest estimated burden of foodborne diseases per population, after the African and South-East Asia regions. However, it is difficult to determine what the burden is since little is published in peer-reviewed journals or government reports for public access. This chapter reviews 16 autonomous nations, namely, Afghanistan, Bahrain, Egypt, Iran, Iraq, Israel, Palestine, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia (KSA), Syrian Arab Republic (Syria), United Arab Emirates (UAE) and Yemen. Countries range in size from Bahrain with 1.8 million inhabitants to Pakistan with a population of 184 million. Agriculture and local food production is much influenced by water availability for irrigation. Water shortages are most severe in the Gulf countries which rely on aquifers, desalination, and recycled waste water for most of their water supplies. This means that most food is imported which is expensive if not subsidized through petrodollars. This impacts food security which is a particular concern in countries under conflict, particularly, Syria, Yemen and Iraq. Gastrointestinal infections are frequent in this region from Salmonella Typhi and other Salmonella spp., Shigella spp., Campylobacter jejuni and C. coli, rotavirus, hepatitis A virus, parasites, and more rarely from Aeromonas, Yersinia enterocolitica, Brucella spp., and Middle East Respiratory Syndrome coronavirus (MERS-CoV). Reports indicate that children are the most susceptible and that many isolates are multidrug resistant. Chemical contamination of water supplies and crops are probably more of a concern than published reports indicate, because of widespread indiscriminate use of fertilizers, antibiotics, and pesticides, coupled with increased industrial pollution affecting the water supplies. Like many other parts of the developing world, foodborne disease surveillance is limited and outbreaks are most often reported through the Press but with insufficient detail to determine the etiological agents and the factors contributing to the outbreaks, leading to speculation to the cause by those interested or responsible for food prevention and control. However, there are some well investigated outbreaks in the region that have those details, and reveal where the shortcomings of both the establishments and the inspection systems have been. Where the causative agents are known, the kinds of pathogens are generally similar to those found in the West, e.g., Salmonella, but many outbreaks seem to have short incubation periods that point to a toxin of some kind of chemical or biological origin, but these are almost never identified. Because of sectarian warfare, residents and refugees have been given food that has made them sick and solders? have been deliberately poisoned. Research has been focused on microbial contamination of locally-sold foodstuffs and manager and employee knowledge of food safety and hygienic conditions in food preparation establishments. An innovative pilot project in Qatar is to use seawater and sunlight for raising crops through the Sahara Forest Project. All countries have some kind of food establishment inspection system, but they tend to be punitive if faults are found in management or employees on the premises rather than being used for their education for improving food safety. Restaurants may be closed down and owners and employees fined for often unspecified infringements. However, some food control agents are moving towards employee training through seminars and courses before problems occur, which is a good disease prevention strategy. Unfortunately, many of the food handlers are from Asian countries with languages other than Arabic and English, which makes effective food safety communication and training difficult. Tourists visiting popular resorts in Turkey and Egypt have suffered from foodborne illnesses, usually of unknown origin but poor hygienic conditions are blamed with law suits following, and the adverse publicity affects the long-term viability of some of these resorts. Food exports, important for local economies, have occasionally been contaminated resulting in recalls and sometimes illnesses and deaths, notably fenugreek seeds from Egypt (E. coli O104:H4), pomegranate arils from Turkey (hepatitis A virus), and tahini from Lebanon (Salmonella). Overall, in recent decades, the Middle East has made strides towards improving food safety for both residents and foreign visitors or ex-pat workers. However, within the countries there are large discrepancies in the extent of effective public health oversight including food safety and food security. Currently, almost all of the countries are involved to a greater or lesser extent in the civil wars in Syria and Yemen, or are affected through political tensions and strife in Egypt, Iraq, Iran, Israel, Palestine, Lebanon and Turkey. In addition, the current overproduction of oil on a world-wide scale has led to a rapid decrease in revenues to most Gulf states. All this points to a severe setback, and an uncertain foreseeable future for improvements in obtaining both sufficient and safe food for residents in this region.

'Holiday sickness'-reported exploratory outcome of over 500 United Kingdom holidaymakers with travellers' diarrhoea

AIMS

To ascertain any predictors of potential food poisoning pathogens and development of post-infective irritable bowel syndrome (IBS) in UK travellers. An analysis was undertaken on prospectively collected data on 527 patients reporting symptoms of suspected food poisoning between June 2012 and June 2015.

MAIN OUTCOME MEASURES

Positive stool sample indicative of food poisoning pathogens and diagnosis of post-infective IBS.

RESULTS

Data on 527 patients were examined. The large majority of patients did not provide a stool sample on return from holiday (n = 430, 81.6%) as few visited a Doctor locally or in the UK. Only 18 patients (18.6%, 95% confidence interval [CI] 11.4-27.7) who provided a stool sample were positive for microbiological food poisoning pathogens. Univariate analysis indicated a significant relationship between a positive stool sample and whether the individual sought any medical assistance at the resort (odds ratio [OR] 0.24, 95% CI 0.08-0.70) and whether they took any treatment (including self-medicated), (OR 0.21, 95% CI 0.06-0.67). Of the 527 patients only 30 (5.7%, 95% CI 3.9-8.1) experienced post-infective IBS. Univariate regression indicated a significant relationship between experiencing Per Rectal (PR) bleeding and a diagnosis of post-infective IBS (OR 3.64, 95% CI 1.00-10.49). Univariate regression also indicated an increase in the risk of developing post-infective IBS with increasing duration of symptoms (OR 1.04, 95% CI 1.02-1.05). No significant relationship was found between a positive stool sample and developing post-infective IBS (P = 0.307).

CONCLUSIONS

Very few patients provide a stool sample after experiencing holiday sickness abroad. Of those that do, only a small proportion have a positive stool sample indicative of a food poisoning microorganism. Around 6% of individuals were diagnosed with post-infective IBS. Those individuals with PR bleeding and symptoms persisting for longer durations were significantly more at risk of developing post-infective IBS, whilst medical aid and treatment abroad was found to reduce the odds of a positive stool sample.

Underreporting of hepatitis A in non-endemic countries: a systematic review and meta-analysis

BACKGROUND

Information on reporting completeness of passive surveillance systems can improve the quality of and public health response to surveillance data and better inform public health planning. As a result, we systematically reviewed available literature on reporting completeness of hepatitis A in non-endemic countries.

METHODS

We searched Medline, EMBASE and grey literature sources, restricting to studies published in English between 1997 and 21 May 2015. Primary studies on hepatitis A surveillance and underreporting in non-endemic countries were included, and assessed for risk of bias. A pooled proportion of reporting completeness was estimated using a DerSimonian-Laird random-effects model.

RESULTS

Diagnosed hepatitis A cases identified through positive laboratory tests, physician visits, and inpatient hospital discharges were underreported to public health in all eight included studies. Reporting completeness ranged from 4 to 97 % (pooled proportion 59 %, 95 % confidence interval = 32 %, 84 %). Substantial heterogeneity was observed, which may be explained by differences in the referent data sources used to identify diagnosed cases and in case reporting mechanisms and/or staffing infrastructure. Completeness was improved in settings where case reporting was automated or where dedicated staff had clear reporting responsibilities.

CONCLUSIONS

Future studies that evaluate reporting completeness should describe the context, components, and operations of the surveillance system being evaluated in order to identify modifiable characteristics that improve system sensitivity and utility. Additionally, reporting completeness should be assessed across high risk groups to inform equitable allocation of public health resources and evaluate the effectiveness of targeted interventions.

Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

Changing hepatitis A epidemiology in the European Union: new challenges and opportunities

Binary file ES_Abstracts_Final_ECDC.txt matches