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Outbreak of shigellosis in Denmark associated with imported baby corn – August 2007

Outbreak of shigellosis in Denmark associated with imported baby corn – August 2007. Hannah Lewis EPIET Fellow, Statens Serum Institut, Copenhagen, Denmark Presented at EpiTrain V, October 26 2007. Background - Shigella spp. Faecal-oral route Low infective dose

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Outbreak of shigellosis in Denmark associated with imported baby corn – August 2007

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  1. Outbreak of shigellosis in Denmark associated with imported baby corn – August 2007 Hannah Lewis EPIET Fellow, Statens Serum Institut, Copenhagen, Denmark Presented at EpiTrain V, October 26 2007

  2. Background - Shigella spp. • Faecal-oral route • Low infective dose • Incubation period: 1 - 3 days • Illness: 4 - 7 days • Diarrhoea, often bloody (dysentery) • Fever and nausea • Sh. sonnei cases in Denmark • Usually travel-related

  3. Lab NotificationsSh. sonnei January 2000 – September 2007Episodes by Month 2000 2001 2002 2003 2004 2005 2006 2007

  4. Thursday 16 Aug - Detection • Call from Medical Officer of Health/Regional Food Authority East • 2cases Shigella sonnei infection • Ate from salad bar in workplace • Both eaten raw “exotic veg” • 2 different companies • “Cateringgruppen” supplied canteens • 206 companies, 4700 employees – Had received complaints

  5. Thursday 16 August • Case Finding • 35 employees with GI symptoms • 5 culture confirmed • Baby corn & sugar snaps • Possibly not restricted to ´Cateringgruppen’ Large and widespread outbreak?

  6. Friday 17 Aug - Control Measures • Product recall - precautionary principle • Baby corn and sugar snaps • One wholesaler, Thailand • Distributed at beginning of August • Press Release • Cook baby corn and sugar snaps • Medical Officers of Health and clinical microbiologists informed • Early Warning Response System alert

  7. Descriptive Epidemiology - Demography • 218 confirmed cases (1/08 – 30/09) • Excluded: 12 travel, 3 secondary, 2 alternative exposures • 201 domestic primary cases • Country-wide • 75% female • Median age 38 years (IQR:18, range: 2-92 years,)

  8. Descriptive Epidemiology - Clinical Of 52 cases interviewed: • 45% dysentery • 13% hospitalised • No deaths

  9. Cases of Sh. sonnei infection in Denmark by day of onset, August 2007 (n=94) Outbreak identified Recall of products EWRS Last onset Cohort & micro results RASSF

  10. Retrospective Cohort study • Large company, 20+ symptomatic cases • Electronic web-based questionnaire • Demographics & symptoms • Ate in canteen on 6-10 August? • Foods eaten on 6th & 7th August? • Case definition: • Employee • Diarrhoea plus nausea or stomach cramps • Ate in the company canteen 6 - 10 August • Excluded travel-related cases

  11. Wednesday 22 Aug - Cohort Results • 103 questionnaires (response rate 61%) • 23 cases • Significant association between baby corn and illness • Multi-variable analysis - no other products

  12. Wed 22 August - Microbiology Results • Baby corn analysis • High levels E. coli (>2000 cfu/g) • Serotypes of Salmonella enterica • No Shigellaspp. New press release & RASFF - Product details

  13. 11 isolates same antibiotic resistance pattern Resistant: tetracycline, ampicillin, sulfonamides, cephalothin, and streptomycin Susceptible: nalidixic acid, ciprofloxacin, chloramphenicol, mecillinam and gentamicin Indistinguishable PFGE profile Sh. sonnei PFGE profiles PulseNet US DB: 20,000 entries Profile - 23 times Pulsenet US, Europe & Asia Molecular Microbiology

  14. Farms 100+ Farms 100+ Packing house A Wholesaler Y (Importer) Trader X (Exporter) Denmark Packing house B Friday 31 August – Visit from Thai Trading Company & Authorities • Complicated production chain • Good records

  15. Friday 31 Aug: Connection Down-Under • Danish Outbreak - Eurosurveillance • Same Antibiotic resistance pattern • 12 cases, onset 9 - 27 August • Concurrent to Danish OB • Acquired infection in Queensland

  16. September: Link between outbreaks • PFGE profile shared • PFGE profile indistinguishable • Trace-back • Common Thai packing house • 3 further countries • WHO INFOSAN Alert • No associated cases

  17. Source of Outbreak? • Thai Authorities conducting investigation • Environment and food handlers swabbed • Probably post-harvest • Washing?

  18. Conclusion • Cohort study, food trace-back and microbiology = strong evidence for baby corn from Thailand • Prevented additional cases of illness • Baby corn – long shelf-life (3 weeks) • Previous large Sh. sonnei outbreak in Denmark • 1998 • Raw baby corn imported from Thailand

  19. Recommendations • Cooking or blanching exotic vegetables • Improved quality standards for imported fresh produce • Sharing information internationally • At early stage • Using all available communication channels (International Health Regulations) Eurosurveillance EWRS RASFF Enternet Pulsenet WHO Infosan

  20. Acknowledgments: Outbreak Team • Department of Epidemiology, Statens Serum Institut, Denmark • S. Ethelberg, C. Kjelsø, L. Vestergaard, K. Qureshi, M. Howitz,K. Mølbak • Department of Bacteriology, Mycology and Parasitology, Statens Serum Institut, Denmark • K.E.P Olsen, E.M Nielsen • Regional Veterinary and Food Control Authority East, Denmark • M. Lisby, S.B. Madsen, P. Rasmussen • OzFoodNet, Australia • M. Kirk, R. Stafford

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