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VOL 1 NO 3 5EPTEMBER 1998
GeneraI outbreaks of infectious intestinaI disease
in EngIand and WaIes: 1995 and 1996
H5 Evans, P Madden, C DougIas, GK Adak, 5j O'Brien, T Djuretic, PG WaII,
R 5tanweII-5nith
Key words:
connunicabIe disease controI
disease outbreaks
epidenioIogy
food poisoning
intestinaI diseases
5unnary: One thousand nine hundred and nineteen general outbreaks of
infectious intestinal disease in England and Wales were reported to the PHLS
Communicable Disease Surveillance Centre (CDSC) between 1 January 1995
and 31 December 1996, compared with 1073 in the previous two years. A
minimum data set was received for 1568 (82%) of the 1919 outbreaks.
Over 40 000 people were affected and about 2% of those who were ill
were admitted to hospital. Seventy-one deaths were reported. The duration of
outbreaks varied between less than one day and 202 days (median six days)
according to the pathogen.
Small round structured virus (SRSV) (43%) and salmonellas (15%) were
the most commonly reported pathogens. In almost a quarter of the outbreaks
(24%) the aetiology was unknown. Over half the outbreaks (64%) were reported
to be transmitted from person to person, most of which were due to SRSV and
occurred in residential homes and hospitals. Twenty-two per cent of outbreaks
were described as mainly foodborne, 51% of which were due to salmonellas.
The number of outbreaks reported in each region ranged from 52 in Wales to
512 in Northern and Yorkshire.
Commun u|s Pu5||c Heo|rh 1998, 1: 165-71.
Methods
CDSC becomes aware of possible general outbreaks of
infectious intestinal disease from several sources,
including consultants in communicable disease control
(CCDCs), environmental health officers (EHOs), the
national laboratory reporting system, microbiologists,
and public health laboratories
4,5
. It responds by sending
a questionnaire covering a minimum set of data to the
appropriate CCDC with the request that it is returned
after the outbreak investigations are completed.
lntroduction
The Committee on the Microbiological Safety of Food
(Richmond Committee) was set up in 1989 by the
Secretary of State for Health, on behalf of the
Uni ted Ki ngdom Heal th and Agri cul ture
Ministers, to investigate questions relating to the
increasing incidence of foodborne infectious disease,
particularly from salmonella, campylobacter, and
listeria
1
. One of the recommendations published in
the commi ttee s report was that the PHLS
Communicable Disease Surveillance Centre (CDSC)
should improve the surveillance of outbreaks,
particularly those occurring in institutions or affecting
the community at large, as opposed to family
outbreaks. CDSC therefore designed a system for the
collection of standardised epidemiological and
mi crobi ol ogi cal data on al l reported general
outbreaks (box) of infectious intestinal disease in
England and Wales, which was introduced at the
beginning of 1992. The system was designed to collect
more reliable and objective data on the distribution,
aetiology, transmission, morbidity, and mortality of
infectious intestinal disease
2
, which could then be
used to inform those responsible for the development
of prevention and control strategies.
BOX Outbreak definitions
Outbreak: an incident in which two or more
people, thought to have a common exposure,
experience a similar illness or proven infection,
at least one of them being ill
3
.
General outbreak: an outbreak that affects
members of more than one household, or residents
of an institution
3
.
Foodborne disease: a disease of infectious or toxic
nature caused or thought to be caused by the
consumption of food or water
4
.
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TABLE 1 Pathogens/toins in generaI outbreaks of infectious intestinaI disease, EngIand and WaIes 1995 and 1996
* Number ot peop|e attected is tbose witb diarrboea and/or vomiting +/- any otber symptoms, not necessari|y |aboratory contirmed
TABLE 2 Nunber of Iaboratory reports that arose fron generaI outbreaks, EngIand and WaIes 1995-1996
month. Outbreaks of viral gastroenteritis reported on
these forms are also incorporated into the general
outbreak surveillance system.
ResuIts
From 1 January 1995 to 31 December 1996, CDSC
received preliminary information about 1919 general
outbreaks of infectious intestinal disease in England
and Wales. A minimum data set was captured for
1568, giving a response rate of 82%.
Pathogens (tabIe 1)
The most commonly reported pathogens were SRSV,
which accounted for 43% (680/1568) of outbreaks,
salmonellas 15% (233), Clostridium difficile 4% (62),
rotavirus 3% (54), and C. perfringens 3% (47). The
Questionnaire data are stored and analysed using
the computer package, Epi-Info
6
. Factors analysed
include: the location of the outbreak; date of outbreak;
pathogen; morbidity and mortality; and foods
suspected to be the vehicles of infection on the basis
of microbiological evidence, a statistical association,
or descriptive epidemiology, as reported by local
investigators.
At the beginning of 1995, a study was introduced
to obtain information from 12 laboratories with
electron microscopy (EM) units. Electron microscopy
is the main method used to identify small round
structured viruses (SRSV). Each of the 12 laboratories
is asked to complete a form when it receives specimens
for identification believed to be part of an outbreak
investigation, and to return the forms to CDSC each
Laboratory contirmed
Tota| number ot intections reported Number ot
Organism |aboratory reports trom genera| outbreaks outbreaks
A|| sa|mone||as 58297 2863 (4.9) 233
So|mone||o enrer|r|o|s PT4 25609 1687 (6.6) 135
S. enrer|r|o|s (otber PTs) 8691 328 (3.8) 34
S. r,ph|mur|um 12285 420 (3.4) 37
S. v|rchow 3307 69 (2.1) 7
otber sa|mone||a serotypes 8405 359 (4.3) 20
SRSV 4803 1923 (40.0) 680
Rotavirus 31229 244 (0.8) 54
Campy|obacter 87213 39 (0.04) 12
Cryptosporidium 9353 900 (9.6) 11
Lscher|ch|o co|| O157 1452 110 (7.6) 19
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1995 1996
Number ot Number ot Number ot Number ot
Organism/toin outbreaks peop|e attected* outbreaks peop|e attected*
SRSV 366 11215 314 11484
A|| sa|mone||as 120 2625 113 2321
So|mone||o enrer|r|o|s PT4 74 1513 61 1354
S. enrer|r|o|s (otber PTs) 12 148 22 439
S. r,ph|mur|um 19 752 18 234
S. v|rchow 6 95 1 4
otber sa|mone||a serotypes 9 117 11 290
C|osrr|o|um o|ff|c||e 32 484 30 357
C. perfr|ngens 25 352 22 441
Rotavirus 23 383 31 483
Lscher|ch|o co|| O157 9 88 10 92
Scombrotoin 9 54 6 23
8oc|||us cereus 8 30 4 118
Campy|obacter 4 140 8 99
Cryptosporidium 6 696 5 278
Astrovirus 1 10 9 218
Sroph,|ococcus oureus 1 7 5 146
8. su5r|||s 3 35 2 4
Sh|ge||o sonne| - - 4 51
Ca|icivirus 2 17 1 6
Otber 9 279 7 101
Unknown 216 4470 163 3267
Tota| 834 20885 734 19489
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TABLE 3 Pathogens/toins in generaI outbreaks of infectious intestinaI disease by node of transnission, 1995 and 1996
cause of 24% (379) of outbreaks was unknown but over
half (215) of these were suspected to be viral.
Fifty-eight per cent of all salmonella outbreaks
(135/233) were due to S. enteritidis phage type (PT) 4,
16% (37) to S. typhimurium, 15% (34) to other phage
types of S. enteritidis, 3% (7) to S. virchow, and 9% (20)
to other salmonella serotypes (three S. heidelberg, three
S. hadar, two S. montevideo, and one each of S. abony,
S. agona, S. derby, S. glostrup, S. indiana, S. goldcoast,
S. saint-paul, S. hvittingfoss, S. senftenberg, S. london,
and two Salmonella spp.).
Laboratory tests (tabIe 2)
In the course of investigating these 1568 outbreaks 21722
people were tested, and a pathogen was identified in
33%, salmonellas being the pathogens most commonly
isolated. Five per cent (200) of the 3825 well people tested
were positive for the pathogen implicated in the
outbreak. The numbers of isolates of each pathogen from
the general outbreaks were compared with the numbers
of laboratory isolates reported to CDSC in 1995 and 1996
5
,
to estimate the proportion of laboratory reports identified
in association with general outbreaks (table 3). This
ranged from 0.04% for campylobacter to 40% for SRSV.
Mode of transnission (tabIe 3)
The mode of transmission was reported to be mainly
from person to person in 64% (1008/1568) of outbreaks,
mainly foodborne in 22% (341), and equal or unknown
proportions of foodborne and person to person spread
in 14% (219). Four outbreaks were due to contact with
farm animals (two were caused by cryptosporidium and
two by S. typhimurium), three of them associated with
farm visits. Two outbreaks of C. difficile infection in
hospitals were attributed to the use of antibiotics.
Fifty-one per cent (174) of the foodborne outbreaks
were due to salmonellas, with S. enteritidis PT4
accounti ng for 30% (102). C. perf ri ngens was
responsible for 11% (36); SRSV for 6% (21); and
scombrotoxin (15), Bacillus cereus (12), and E. coli O157
(12) for 4% each. The aetiology of 12% (42) of the
foodborne outbreaks was unknown.
SRSV accounted for 60% (607/1008) of the outbreaks
associated with person to person spread. Clostridium
difficile for 6% (58), and rotavirus for 5% (51). The
aetiology of 24% (244/1008) of outbreaks transmitted
mainly from person to person was unknown.
Food vehicIes (tabIe 4)
One or more specific foods were suspected to be
vehicles of infection in 80% (273/341) of the foodborne
outbreaks. In addition, 28 outbreaks described as
being due to both foodborne and person to person
transmission identified a food vehicle, giving a total
of 301 outbreaks for which a food vehicle was
identified. The vehicle was confirmed by identifying
the pathogen in a food sample in 20% (62/301) of
these, in 18 of which the association was also
supported by statistical analysis. The vehicle was
confirmed by a statistical association alone in 32%
(100/301). In the rest of the outbreaks, the food vehicle
was implicated by descriptive epidemiology alone.
ggs, mlk, ond dory products
Dishes that contained raw/lightly cooked eggs were
reported as the vehicles of infection in 27% of the
* |nc|udes outbreaks wbicb appear to be due to a miture ot person to person and toodborne spread, outbreaks due to anima|
contact, and outbreaks tor wbicb tbe mode is unknown
Main|y toodborne Main|y person Otber/ Tota| number ot
Organism/toin (inc|. water) to person unknown* outbreaks ()
SRSV 21 607 52 680 (43.4)
A|| sa|mone||as 174 15 44 233 (14.9)
So|mone||o enrer|r|o|s PT4 102 9 24 135 (8.6)
S. enrer|r|o|s (otber PTs) 27 2 5 34 (2.2)
S. r,ph|mur|um 24 2 11 37 (2.4)
S. v|rchow 5 1 1 7 (0.4)
otber sa|mone||a serotypes 16 1 3 20 (1.3)
C|osrr|o|um o|ff|c||e - 58 4 62 (4.0)
C. perfr|ngens 36 5 6 47 (3.0)
Rotavirus - 51 3 54 (3.4)
Lscher|ch|o co|| O157 12 3 4 19 (1.2)
Scombrotoin 15 - - 15 (1.0)
8oc|||us cereus 12 - - 12 (0.8)
Cryptosporidium 5 - 6 11 (0.7)
Campy|obacter 9 1 2 12 (0.8)
8. su5r|||s 4 - 1 5 (0.3)
Ca|icivirus - 3 - 3 (0.2)
Astrovirus 1 8 1 10 (0.6)
Sroph,|ococcus oureus 6 - - 6 (0.4)
Sh|ge||o sonne| - 4 - 4 (0.3)
Otber 4 9 3 16 (1.0)
Unknown 42 244 93 379 (24.2)
Tota| 341 1008 219 1568 (100)
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TABLE 4 Food vehicIes confined by nicrobioIogicaI, statisticaI or descriptive evidence, 1995 and 1996
Number ot
Food vebic|e outbreaks Main patbogen/toins invo|ved (number ot outbreaks)
Lggs (disbes containing raw/|igbt|y 75 So|mone||o enrer|r|o|s PT4 (55), S. enrer|r|o|s (10),
cooked eggs S. r,ph|mur|um (2), C|osrr|o|um perfr|ngens (1), So|mone||o spp (1)
S. v|rchow (1), SRSV (1), Sroph,|ococcus oureus (1)
Pou|try 74 S. enrer|r|o|s PT4 (16), S. r,ph|mur|um (12), C. perfr|ngens (11),
S. enrer|r|o|s (8), Sr. oureus (5), SRSV (3), 8oc|||us cereus (2),
campy|obacter (2), 8. su5r|||s(1), S. ogono (1), S. he|oe|5erg (1),
S. |no|ono (1), S. monrev|oeo (1), S. v|rchow (1)
Red meat/meat products 56 C. perfr|ngens (16), S. enrer|r|o|s PT4 (10), S. r,ph|mur|um (8),
Lscher|ch|o co|| O157 (4), 8. su5r|||s(1), S. oer5, (1),
S. enrer|r|o|s (1), S. v|rchow (1), SRSV (1), S. oureus (1)
8iva|ve sbe||tisb 12 SRSV (4), Astrovirus (1)
Otber sbe||tisb/mied sbe||tisb 12 S. enrer|r|o|s PT4 (3), 8. cereus (2), S. r,ph|mur|um (2), SRSV (1)
Fisb 26 Scombrotoin (15), S. enrer|r|o|s PT4 (5), S. r,ph|mur|um (2),
S. enrer|r|o|s (1)
Rice disbes 23 8. cereus (11), S. enrer|r|o|s PT4 (4), S. enrer|r|o|s (3),
C. perfr|ngens (2), 8. su5r|||s (1), S. r,ph|mur|um (1)
Mi|k/dairy products 13 campy|obacter (2), L. co|| O157 (2), S. r,ph|mur|um (2),
cryptosporidium (1), S. enrer|r|o|s PT4 (1), So|mone||o spp (1),
SRSV (1)
Sa|ads, vegetab|es and truits 23 SRSV (6), C. perfr|ngens (3), S. enrer|r|o|s PT4 (3),
campy|obacter (1), L. co|| O157 (1), S. f|exner| (1)
Water 5 cryptosporidium (4)
Misce||aneous (e.g., sandwicbes, pasta, 48 S. enrer|r|o|s PT4 (16), C. perfr|ngens (4), S. enrer|r|o|s (4),
trit|e) SRSV (4), S. r,ph|mur|um (3), 8. su5r|||s (2),
8. cereus (1), campy|obacter (1), Lnteroaggregative L. co|| (1),
L. co|| O157 (1), S. oureus (1)
87 (1.6) 87 (1.6)
|n addition, two nationa| outbreaks attected severa| regions |n addition, one nationa| outbreak attected severa| regions
258 (3.9)
72 (1.1)
60 (1.2)
86 (1.6)
53 (0.8)
66 (1.0)
126 (1.9)
25 (0.9)
254 (4.0)
38 (0.7)
73 (1.4)
25 (0.4)
63 (0.9) 93 (1.4)
27 (0.9)
46 (0.7)
outbreaks for which a suspect food vehicle was
reported. S. enteritidis PT4 was the predominant
pathogen in these outbreaks.
Milk was implicated in seven outbreaks three
associ ated wi th unpasteuri sed mi l k (two S.
typhi muri um, one campyl obacter), three wi th
pasteuri sed mi l k (two E. col i O157, one
cryptospori di osi s), and one outbreak of
campyl obacter i nfecti on i mpl i cati ng both
unpasteurised milk and pasteurised milk from bottles
pecked open by birds. One of the E. coli O157
outbreaks and the cryptosporidium outbreak involved
pasteurisation failures. The other outbreak of E. coli
O157 infection associated with milk was attributed to
post-pasteurisation contamination of the milk. Six
outbreaks were associated with eating cheese, one due
to S. enteritidis PT4, one due to S. goldcoast, one due to
SRSV, and three of unknown aetiology.
Other [ood vehcles
Poultry and poultry products were implicated in 27%
(74) of the outbreaks, 16 of which were associated with
S. enteritidis PT4 and 12 with S. typhimurium. Red
meat/red meat products were implicated in 21% (56)
FlGURE 1A RegionaI distribution of generaI outbreaks of
infectious intestinaI disease reported in 1995 (rates per 100000
popuIation using nid-1995 popuIation estinates
7
) n=833
FlGURE 1B RegionaI distribution of generaI outbreaks of
infectious intestinaI disease reported in 1996 (rates per 100000
popuIation using nid-1996 popuIation estinates
7
) n=732
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TABLE 5 5ettings of generaI outbreaks of infectious intestinaI disease by node of transnission, 1995 and 1996
* |nc|udes outbreaks tbat appear to bave been due to a miture ot person to person and toodborne spread, outbreaks due to anima|
contacts, and outbreaks wbose modes ot transmission were unknown
FlGURE 2 5easonaI distribution of outbreaks of infectious
intestinaI disease in 1995 and 1996
N
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s
Month
0
20
40
60
80
100
120 All outbreaks
Unknown aetiology
SRSV
Salmonellas
D N O S A J J M A M F J D N O S A J J M A M F J
swimming pool, and one with a paddling pool). The
other outbreak associated with drinking water was of
unknown aetiology.
GeographicaI distribution (figure 1)
Overall, there were 1.6 general outbreaks per 100 000
population in England and Wales in 1995 and 1.4/100000
in 1996. The regional rates varied from 0.8/100000 in
North Thames to 3.9/100 000 in Northern and Yorkshire
in 1995, and from 0.4/100 000 in North Thames to 4.0/
100 000 in Northern and Yorkshire in 1996.
5ettings of outbreaks (tabIe 5)
The commonest settings for outbreaks were hospitals
and residential homes for elderly people, which
accounted for 63% (991) outbreaks. In most of these
outbreaks (865) transmission was from person to
person. Nineteen per cent (293) of outbreaks were
associ ated wi th commerci al cateri ng outl ets
(restaurants, hotels, public houses, canteens, and
caterers), 62% (183) of which were foodborne. Private
dwellings were associated with 52 outbreaks, 45 of
which were foodborne.
5easonaI distribution (figure 2)
A large proportion of the outbreaks occurred in the
winter and spring months. The seasonal peak for
outbreaks of salmonellas occurred in July with a
second smaller peak in December. Outbreaks of SRSV
peaked in the first quarters of both years. Outbreaks
of unknown aetiology reached a peak in March with
two smaller peaks in July and December.
Duration of outbreaks
The dates of onset of the first and last cases were
reported in 86% (1344) outbreaks. The duration of the
outbreaks ranged from less than one day to 202 days,
with a median of six days. The two longest outbreaks,
lasting 202 days and 160 days, were national outbreaks:
an outbreak of S. indiana infection in 1996 affected 120
of the outbreaks, 16 of which were due to C. perfringens
and ten to S. enteritidis PT4. Twenty-four outbreaks
were reported to be due to shellfish, including 12
outbreaks attributed to eating oysters.
Ioctors contrbutng to [oodborne outbreoks
One or more possible contributing factors were
reported in 231 of the 341 foodborne outbreaks.
Cooking or reheating was inadequate in 50% (116/
231), food was stored inappropriately in 45% (104), and
cross contamination was reported in 39% (90). An
infected food handler was identified in 12% (28) of
outbreaks, although it is not known how many food
handlers were symptomatic during or before food
preparation. It was also difficult to establish whether
food handlers were themselves victims of rather than
contributors to the cause of outbreaks.
Waterborne outbreaks
Seven outbreaks of waterborne infectious intestinal
disease were reported, six due to cryptosporidium
(four associated with drinking water, one with a
Main|y toodborne Main|y person Otber/ Tota| number ot
P|ace (inc|. water) to person unknown* outbreaks ()
Hospita| 1 474 43 518 (33.0)
Residentia| bome 26 391 56 473 (30.2)
Hote| 53 48 27 128 (8.2)
Restaurant 80 5 13 98 (6.3)
Scboo|s/co||eges 10 50 22 82 (5.2)
Private dwe||ing 45 - 7 52 (3.3)
Pub/bar 23 1 6 30 (1.9)
Sbop 20 1 5 26 (1.7)
Community 8 6 4 18 (1.1)
Canteen 14 1 5 20 (1.3)
Armed torces 5 5 3 13 (0.8)
Function room 21 1 6 28 (1.8)
Caterer 13 - 4 17 (1.1)
Farm 3 1 3 7 (0.4)
Otber 19 24 15 58 (3.7)
Tota| 341 1008 219 1568 (100)
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TABLE 6 Case fataIity rates in generaI outbreaks of
infectious intestinaI disease, 1995 and 1996
people, and one of S. senftenberg infection in 1995 affected
seven people. The duration varied by pathogen: the
median was four days for S. enteritidis PT 4, five days
for S. typhimurium, seven days for SRSV, nine days for
C. difficile, 10 days for rotavirus and 24 days for
cryptosporidium.
Morbidity and nortaIity
A total of 40374 people were reported ill in the 1568
outbreaks. Five hundred and eighteen outbreaks
occurred in hospitals, affecting 12 158 people. In
addition, 564 hospital admissions were reported in
association with outbreaks that arose elsewhere. Two
hundred and thirty-three outbreaks were associated with
at least one reported admission. Outbreaks due to
salmonellas accounted for 52% (291) of hospital
admissions, SRSV for 11% (64), E. coli O157 for 10% (58),
cryptosporidium for 7% (42), and rotavirus for 6% (32).
Information about mortality was available for 917
outbreaks, from which 71 deaths were reported. Thirty-
six outbreaks were associated with one death, seven
outbreaks with two deaths, two with three, and one with
five. The national outbreak of S. indiana infection in 1996
was associated with 10 deaths. The organisms associated
with deaths were salmonellas (27), E. coli O157 (10), SRSV
(9), C. difficile (8), rotavirus (3), C. perfringens (2), S. sonnei
(1), and one death was reported in an outbreak whose
aetiology was mixed (SRSV and C. perfringens). E. coli
O 157 was associated with the highest case fatality (5.6
%) (table 6). Ten deaths were reported in outbreaks of
unknown aetiology. Forty-five deaths occurred in
residential homes or hospital wards for elderly people.
It is likely that the intestinal infection was a contributory
factor rather than the actual cause of death in a number
of these cases.
Non-responders
SRSV accounted for 46% (161/351) of the outbreaks
about which no further information was available and
a further 32% were of unknown aetiology. Only 7% of
the 351 outbreaks were associated with salmonella
infections. Over half (52%) of the outbreaks about
which minimum data sets were not received occurred
in hospitals and a further 20% in residential homes.
Discussion
Minimum data sets were captured for 1568 of a
possible 1919 outbreaks reported to CDSC during 1995
and 1996, in which 40374 people were reported to be
ill, 564 people were admitted to hospital, and 71 died.
SRSV was the most commonly reported pathogen:
it was associated with more than twice as many
outbreaks in 1995 and 1996 as in 1994 (366, 314, and
156, respectively). The proportion of laboratory
reported cases of SRSV infection reported from
general outbreaks increased from 25% in 1992 to 1994
2
,
to 43% in 1996. The Electron Microscopy Network
study improved the ascertainment of outbreaks of
viral gastroenteritis; thus the large increase in SRSV
may have been due to a change in surveillance, as well
as with a genuine increase in disease activity.
Development of polymerase chain reaction (PCR)
techniques have also improved identification of SRSV
8
.
Laboratory tests for SRSV are usually undertaken only
in outbreaks. While the outbreak surveillance system
is currently the best method of establishing the impact
of SRSV in outbreaks, the population burden of disease
is still considerably underestimated.
The increase in the number of SRSV outbreaks
reduced the proportion of salmonella outbreaks
compared with that in 1994, but the actual numbers of
salmonella outbreaks were about the same as before (113
in 1996 and 120 in 1995 compared with 107 in 1994).
Between 1994 and 1995 S. enteritidis PT4 accounted for
an increasing proportion of all salmonella outbreaks (62%
i n 1995 compared wi th 56% i n 1994), but thi s
proportion fell to 54% in 1996 at the same time as the
proportion of outbreaks due to other phage types of
S. enteritidis, particularly S. enteritidis PT 6, increased.
Sixteen per cent of salmonella outbreaks were due to
S. typhimurium, most of which were definitive type
(DT) 104. This is of particular concern because of the
increase in antibiotic resistance. Most human isolates
of S. typhimurium DT104 are now resistant to one or
more antimicrobial drugs, and more than half are
resistant to ampicillin, chloramphenicol, streptomycin,
sulphonamides, and tetracyclines (R-type ACSSuT)
9
.
Cases associated with general outbreaks continued
to account for a tiny proportion of laboratory reports
of campylobacter infections (0.04%). It is known that
outbreaks of this organism appear to be rare
10
but it is
hoped that the introduction of new typing techniques
will improve their ascertainment
11
. One outbreak was
associated with the consumption of pasteurised milk
from bottles that had been pecked open by birds,
which has previously been described as a vehicle for
transmission of campylobacter
12
.
Although infection was transmitted from person to
person in most of the outbreaks, foodborne transmission
still accounted for 341 outbreaks. Eggs and poultry
remain common vehicles of infection for S. enteritidis PT4,
underlining the importance of reinforcing advice not to
eat raw or undercooked eggs or to use them in dishes
that will not be subject to further cooking, and to ensure
that pasteurised egg is used in commercial catering
13,14
.
Inadequate heating or cooking, inappropriate
storage, and cross contamination were the main factors
responsible for outbreaks of food poisoning. These
highlight the importance of training food handlers in
1995 case tata|ity 1996 case tata|ity
Patbogen/toin rate () rate ()
Lscher|ch|o co|| O157 9.1 2.2
C|osrr|o|um o|ff|c||e 1.2 0.6
C. perfr|ngens 0.6 -
Sa|mone||as 0.3 0.8
Rotavirus 0.3 0.4
SRSV 0.05 0.03
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COMMUNlCABLE Dl5EA5E AND PUBLlC HEALTH
171
VOL 1 NO 3 5EPTEMBER 1998
JM. General outbreaks of infectious intestinal disease in
England and Wales 1992 to 1994. Commun Dis Rep CDR Rev
1996; 6: R57-63.
3. Department of Health. Management of outbreaks of foodborne
illness. London: HMSO, 1994.
4. Grant AD, Eke B. Application of information technology on
the laboratory reporting of communicable disease in England
and Wales. Commun Dis Rep CDR Rev 1993; 3: R75-8.
5. Wall PG, de Louvois J, Gilbert RJ, Rowe B. Food poisoning:
notifications, laboratory reports, and outbreaks - where do the
statistics come from and what do they mean? Commun Dis Rep
CDR Rev 1996; 6: R93-100.
6. Dean AG, Dean JA, Coulombier D, Brendel KA, Smith DC,
Burton AH, et al. Epi Info Version 6: a word processing, database,
and statistics program for epidemiology on microcomputers. Atlanta:
Centers for Disease Control and Prevention, 1994.
7. Office for National Statistics. Monitor Population and Health.
London: HMSO, 1996. (PP1 96/2).
8. Green J, Hale AD, Brown DWG. Recent developments in the
detection and characterisation of small round structured
viruses. PHLS Microbiology Digest 1995; 12: 219-22.
9. Threlfall EJ, Hampton MD, Schofield SL, Ward LR, Frost JA,
Rowe B. Epidemiological application of differentiating
multiresistant Salmonella typhimurium DT104 by plasmid
profile. Commun Dis Rep CDR Rev 1996; 6: R155-9.
10. Pebody RG, Ryan MJ, Wall PG. Outbreaks of campylobacter
infection: rare events for a common pathogen. Commun Dis
Rep CDR Rev 1997; 7: R33-7.
11. CDSC. PHLS Campylobacter Reference Unit extends its
activities. Commun Dis Rep CDR Wkly 1997; 7: 36.
12. Healing TD, Greenwood MH, Pearson AD. Campylobacters
and enteritis. Reviews in Medical Microbiology 1992; 3: 159-67.
13. Department of Health. Raw shell eggs. London: Department
of Health, 1988. (EL/88/136).
14. Department of Health. Expert advice repeated on salmonella
and raw eggs. Press Release 9 April 1998 (98/138).
15. Cowden JM, Wall PG, Adak GK, Evans H, Le Baigue S, Ross
D. Outbreaks of foodborne infectious intestinal disease in
England and Wales: 1992 and 1993. Commun Dis Rep CDR Rev
1995; 5: R109-17.
16. A Working Party of the PHLS Salmonella Committee. The
prevention of human transmission of gastrointestinal
infections, infestations and bacterial intoxications. Commun
Dis Rep CDR Rev 1995; 5: R157-72.
17. Viral Gastroenteritis Sub-committee of the PHLS Virology
Committee. Outbreaks of gastroenteritis associated with
SRSVs. PHLS Microbiology Digest 1993; 10: 2-8.
18. Smith PW, Rusnak RN. APIC guidelines for infection
prevention and control in the long term care facility. Am J Infect
Control 1991; 19: 198-215.
19. Public Health Medicine Environmental Health Group.
Guidelines on the control of infection in residential and nursing
homes. Lewisham: PHMEG, 1995.
20. Department of Health. The Food Standards Agency: A Force for
Change. London: HMSO, 1998.
HS Evans, P Madden, GK Adak, clinical scientists
C Douglas, information assistant
SJ OBrien, PG Wall, R Stanwell-Smith, consultant epidemiologists
T Djuretic, specialist registrar
Epidemiology Division
PHLS Communicable Disease Surveillance Centre
Address for correspondence:
Helen Evans
PHLS Communicable Disease Surveillance Centre
61 Colindale Avenue
London NW9 5EQ
tel: 0181 200 6868
fax: 0181 200 7868
email: hevans@phls.co.uk
good hygiene practices and promoting awareness of
the potential of cross contamination from foods such
as raw eggs, poultry, red meat, and shellfish
15
. Twelve
per cent of the outbreaks reported an infected food
handler as a possible contributing factor. It is
important to stress that food handlers should not work
while they have symptoms of infectious intestinal
disease
16,17
.
The seasonal variation in outbreak reporting was
marked, reflecting the seasonality of SRSV, which
reached a peak early in both years. The regional
distribution of outbreaks followed a similar pattern
to that seen in previous years
2
. Resources available
to EHOs and CCDCs may vary throughout the country,
affecting ascertainment, and reporting of incidents.
Over half of the outbreaks took place in hospitals
and residential homes, and in most of these outbreaks
infection was transmitted from person to person. The
morbidity and mortality are high in these settings
because of the frailty of the patients, as witnessed by
the ten deaths associated with S. indiana infection in
one outbreak. Further evidence of the vulnerability
of elderly people is reflected in the deaths from E. coli
O157 infection: five of the eight deaths associated with
outbreaks of E. coli O157 infection in 1995 occurred in
elderly people living in residential homes.
Outbreaks in hospitals are particularly disruptive
and often lead to ward closures. The association with
person to person transmission demonstrates both the
difficulty of maintaining simple hygiene measures and
the need to promote them continually. Guidelines on
the control of infection in residential and nursing
homes have been issued by the Association for
Practitioners in Infection Control in the United States
and the Public Health Medicine Environmental Group
in the United Kingdom
18,19
.
The outbreak surveillance system continues to
provide useful data on general outbreaks of infectious
intestinal disease. The minimum data set requested
from investigators is sufficient to enable national
trends to be monitored and to highlight areas that may
require more detailed study in the future. The
imminent establishment of a Food Standards Agency
for England and Wales will provide the opportunity
to consult with our reporters on ways of improving
the system to gather more information on means of
control as well as the sources of these outbreaks
20
.
AcknowIedgnents
We thank the CCDCs, public health physicians,
microbiologists, EHOs, infection control nurses, and
the staff of the PHLS and NHS laboratories without
whose work this surveillance system could not
function, and Mrs S Le Baigue and Mrs D Ross who
maintain the database at CDSC.
References
1. Committee on the Microbiological Safety of Food. The
microbiological safety of food: part 1. London : HMSO, 1990.
2. Djuretic T, Wall PG, Ryan MJ, Evans HS, Adak GK, Cowden
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