Salmonella Infections 1

Running Head: SALMONELLA INFECTIONS

FPUK-0714-61536364
SALMONELLA INFECTIONS IN UK
I ntroduction
Salmonella generally lives in the gut of animals, including birds. Salmonella is usually
transmitted to humans by eating foods contaminated with animal feces. These contaminated
foods are typically from animal origin such as beef, poultry, milk or eggs but all foods, including
vegetables, may be contaminated. The bacteria are commonly found in raw eggs and
undercooked chicken and eggs. Person-to-person spread is possible in close contact, usually
during the acute diarrheal phase of the illness

Epidemiology of Salmonella Enteritidis in the United Kingdom
Epidemiologic investigations of outbreaks and sporadic cases repeatedly showed
that Salmonella Enteritidis PT4 infection in humans was frequently associated with consumption
of poultry meat and hens' eggs on both sides of the Atlantic [2531]. In nearly 2500 food borne
disease outbreaks reported to the UK Health Protection Agency between 1992 and 2008,
Salmonella species accounted for 47% of all outbreaks, 46% of cases, 70% of hospital
admissions, and 76% of deaths. Salmonella Enteritidis PT4 was the causative organism in 51%
of all the Salmonella outbreaks throughout the surveillance period but the percentage of
outbreaks caused by Salmonella Enteritidis PT4 declined from the late 1990s onward. At least
one food vehicle was identified in 75% of outbreaks reported, and poultry meat was the vehicle
most often implicated (19% of outbreaks). Desserts were also implicated commonly (11% of
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outbreaks), and raw shell eggs were used as an ingredient in 70% of these desserts. Eggs were
implicated separately in an additional 6% of outbreaks. Analysis of outbreak data also showed
that nearly 50% of food borne Salmonella outbreaks occurred in the food service/catering sector.
Salmonella Gallinarum and Salmonella Pullorum had been the dominant Salmonella servers in
UK poultry until the early 1970s. These strains both caused clinical disease in the birds and were
virtually eradicated by a combination of slaughtering of seropositive hens and vaccination.
However, the ecological niche left by these 2 servers was filled by Salmonella Enteritidis.
Complete genome sequencing of a host-promiscuous Salmonella Enteritidis PT4 isolate and a
chicken-restricted Salmonella Gallinarum isolate has indicated that Salmonella Gallinarum is a
recently evolved descendent of Salmonella Enteritidis. Importantly, Salmonella Enteritidis
infects poultry without causing overt disease, which probably facilitated its rapid spread
internationally. Another key feature of Salmonella Enteritidis is colonization of the reproductive
tissues leading to the production of eggs with Salmonella-positive contents and, in some eggs;
the numbers of organisms can be very high.
Disease Prevention
The EU Animal Health Strategy, Prevention is better than cure, outlines both prevention and
control measures to be implemented during a disease outbreak. Some of these measures, such as
vaccines and antimicrobials, can be used for both prevention and control.
Surveillance
Surveillance provides early warning and prompt detection of livestock disease threats, together
with analysis of the way diseases spread. Surveillance within the UK depends on disease
identification and reporting by livestock keepers and veterinarians and enables disease patterns to
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be monitored. Monitoring of international disease at Defra was intensified in the wake of the
2001 Foot and Mouth Disease (FMD) outbreak, to identify new threats to UK livestock. Defra
uses official disease reports from the OIE , EU, Foreign and Commonwealth Office, UK
laboratories and research articles to monitor disease risk and trends in new and emerging
diseases. It produces monthly reports outlining the main exotic disease threats and monthly and
quarterly reports on the domestic disease situation.
Control at Source
Livestock disease is a global problem. Emerging diseases, changing patterns of disease and
increasing globalization mean that global disease threats also put the UK at risk. Control, and
ultimately eradication, of diseases elsewhere in the world have the potential to protect animals in
the UK. For instance Rinderpest, a disease of cattle, is on schedule to be eradicated worldwide
by. However, the extent to which other diseases can be tackled in this way is uncertain.
Bio security
Good bio security means ensuring good hygiene practices are in place. It is a vital part of
keeping disease away from livestock, preventing any spread between livestock and, for
zoonoses, minimizing the transfer to humans. Bio security measures address isolation of new and
diseased animals; movement of people, animals and equipment; and procedures for cleaning and
disinfecting facilities and vehicles. Bio security must be maintained in farms, markets, during
transport and at slaughter.


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Traceability
Being able to trace livestock movements enables disease spread to be monitored. Currently,
individual identification can be achieved, for example in cattle, using a paper-based system of
animal passports and holding registers combined with national identification databases. The EU
is implementing a system across member states requiring all sheep 12 months or older to be
electronically tagged. The introduction of affordable electronic identification could improve
efficiency and lead to an integrated EU electronic system. However, other livestock such as
poultry are not currently covered by such arrangements.
Import/Trade controls
Legal and illegal imports of live animals and animal products are potential sources of disease
risk. Non-animal products can also be potential. For instance imported car tyres can harbour
mosquito larvae.
Wildlife Control/Management
Seventy two percent of diseases transferred between livestock and humans are also present in
wildlife.
Vaccination and culling of wildlife can be used to prevent the spread from wildlife to livestock.
For instance, various trials have shown that culling badgers reduces bovine TB incidence where
the culling occurs, but can also increase bovine TB in the surrounding area. Defra is consulting
on whether to licence badger culling in two different locations; culling has been opposed by
some animal welfare and conservation groups.

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Vaccination
Vaccines stimulate an immune response to protect animals against later infection with a specific
disease. They are widely and routinely used to control endemic diseases such as Salmonella in
poultry. Vaccines could potentially be used to prevent diseases such as bovine TB, although no
effective cattle vaccine is currently available for this disease.
Husbandry/Production System
Animals that are cared for appropriately and in accordance with existing welfare standards are
less likely to contract or spread disease and tend to be healthier. Additionally, different
production systems are associated with differing disease risks. For example, intensive, indoor
systems can significantly reduce contact with certain diseases. However, stress associated with
intensive production may increase susceptibility to disease and its subsequent spread.
Conversely, animals housed in extensive systems might be more likely to come into contact with
disease, but the risk of contracting and spreading it may be lower.
Genetic Modification and Cloning
Genetic modification (GM) could be used to introduce novel genes that confer resistance to
infection. For instance in 2011, scientists at the Roslin Institute used GM to prevent chickens
transmitting Avian Influenza. Animal cloning is used to generate an individual that has the same
DNA as another individual. Scientists have already cloned animals to extend their breeding and
production potential, and may in future be able to clone animals with reduced susceptibility to
disease. Some consumer groups have expressed safety concerns about GM and cloned animals,
whereas other groups oppose such procedures on animal welfare grounds. Food from cloned
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animals must be authorised under the EU Novel Foods Regulation before it can be sold.
However, there have been no applications in the EU to date. In November 2010, the Advisory
Committee on Novel Foods and Processes concluded that meat and milk from cloned cattle and
their offspring were unlikely to present a food safety risk, but noted that consumers may wish to
see effective labelling. EU negotiations on amendments to the novel foods regulations broke
down in March 2011. The Commission is likely to propose new legislation specifically on
cloning but the timing is unclear.
Disease Control
Following a disease outbreak, additional measures can be implemented to control its spread. For
some notifiable diseases, the European Commission prohibits export of animals and animal
products from the affected species until disease-free status has been achieved.
Antimicrobials
Antimicrobials (or antibiotics) destroy or inhibit the growth of bacteria. They may be used both
to treat disease in infected animals and to prevent disease in those at risk or known to be
susceptible. All livestock medicines are subject to strict regulation. While the controlled use of
antimicrobials by veterinarians is necessary to limit infections in animals, excessive or
inappropriate use may contribute to the development of antimicrobial resistant organisms. There
is concern that the irresponsible use of antimicrobials in animals might compromise the
effectiveness of related medicines in humans.


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Culling of Livestock
Another control measure is to slaughter and dispose of infected animals, and animals that have
been in contact with them or in their vicinity. Accurate surveillance information about the
geographical location of disease and its spread can be used to construct models to inform culling
policy.
Emergency vaccination
Vaccination can be used to control an outbreak of disease once it has been detected. For
example, it was successfully used to control a UK Bluetongue outbreak in 2007, and Defra is
currently trialling a badger vaccine as a control measure for bovine TB. However, vaccination
has its drawbacks. For instance, few vaccines give 100% protection and vaccines have not yet
been developed for all diseases. For some diseases, use of vaccination during an outbreak can
make it difficult to distinguish between animals that have been vaccinated and those that are
infected. This makes it hard to ascertain when the disease has been eliminated and disease-free
status has been achieved. The development of DIVA (Differentiating Infected and Vaccinated
Animals) tests is ongoing and is likely to make vaccination a more attractive option.
Animal Movement Controls
During an outbreak of a contagious notifiable disease, preventing the movement of animals
between farms, markets and slaughterhouses can limit disease spread.
Critical evaluation of current legislation Salmonella concerning UK
Compelling evidence that the decline in Salmonella is real is derived from 3 sources. The first
comprises 2 population-based prospective cohort studies of infectious intestinal disease (IID) in
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the community conducted more than a decade apart. The primary outcome measures in both
studies were estimates of the incidence of IID in the community, presenting to primary
healthcare and reported to national surveillance. They were conducted using identical study
designs and case definitions and employed similar microbiological methods, the exception being
that molecular microbiological techniques were used alongside traditional microbiology in the
second study of infectious intestinal disease (IID2). In the first study of infectious intestinal
disease (IID1) in 19931996, the incidence of non-typhoidal Salmonella in the community in
England was 2.2 cases per 1000 person-years (95% confidence interval [CI], 1.14.3) but by
20082009 this had fallen to 0.7 cases per 1000 person-years (95% CI, .23.0). For non-
typhoidal Salmonella cases presenting to primary care in England, the incidence rate had fallen
from 1.6 cases per 1000 person-years (95% CI, 1.22.1) in IID1 to 0.2 cases per 1000 person-
years (95% CI, .1.5) in IID2. The decline in incidence in the community was not statistically
significant because in IID2 the study power was insufficient to detect statistically significant
changes in organism-specific incidenceto do this would have required >100 000 person-years
of follow-up, based on incidence rates in IID1. Nevertheless, the reduction in presentations to
primary healthcare was statistically significant.
Second, there has been a substantial fall in laboratory-confirmed Salmonella cases reported to
national surveillance Phage typing of Salmonella Enteritidis was implemented from 1981 as an
addition to the centralized, national service already in existence for confirmation and further
typing, and all clinical diagnostic laboratories have continued to refer all Salmonella isolates to
the national reference laboratories since that date. At the beginning of 1992, 2 separate
national Salmonella databases were merged to form a single national dataset, which became
patient-based rather than isolate-based, thus eliminating potential duplication if people were
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tested more than once. Laboratory testing methods have remained constant since then and
reporting algorithms have not changed, suggesting that the reduction in Salmonella is real.
When Salmonella Enteritidis PT4 peaked in 1993 in the United Kingdom, >18 000 laboratory-
confirmed cases of illness were recorded in national surveillance statistics, yet by 2010 PT4
isolations had fallen to just 459 [24]. Thus, the decline in non-typhoidal Salmonellosis witnessed
in the United Kingdom in recent years reflects this major contraction in reports
of Salmonella Enteritidis PT4.
Finally, outbreaks of Salmonellosis have declined. Standardized reporting of outbreaks of
gastrointestinal infection was introduced in 1992 in England and Wales and in 1996 in Scotland
partly in response to the increase in non-typhoidal Salmonellosis. A food borne outbreak is
defined in European legislation as an incidence, observed under given circumstances, of two of
more human cases of the same disease and/or infection, or a situation in which the observed
number of human cases exceeds the expected number and where the cases are linked, or are
probably linked, to the same source. Between 1992 and 2008, food borne Salmonella outbreaks
reported to national surveillance fell from nearly 150 per year to just over 20 annually, and the
pattern of decline closely mirrors that of laboratory-confirmed case.
Ethical I ssues with Management of Salmonella
These organisms cause enteric fever and paratyphoid fever respectively, which is a severe illness
that can be fatal in the absence of medical treatment. It is known to be easy to pass on and there
may be prolonged, intermittent excretion of bacteria after symptoms stop. It is most common in
less developed countries and so in food businesses will most likely be associated with people
who have travelled abroad or who have come to work in the UK. Anyone who suspects they are
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suffering from this illness or has had it in the past, or who has a lot of contact with someone who
has it should be excluded from food handling and food handling areas until cleared to return to
work by a medical professional. The investigation and management of their case should be
referred to the local authority and health professionals who should seek advice from the Health
Protection Agency. If the person is confirmed as being infected or is a carrier of the bacteria, the
exclusion period could be lengthy, three months or more, to allow for treatment and confirmation
of clearance of infection through faecal testing.
Conclusion
The nature of public health interventions often means that evaluating their impact is complex as
they are often implemented in combination and/or simultaneously. It is interesting to reflect on
the fact that the various legislative measures in the United Kingdom in the late 1980s and early
1990s appear to have slowed down the increase in Salmonella Enteritidis PT4, whereas the
decrease in laboratory-confirmed human cases coincides quite closely with the introduction of
vaccination programs in broiler-breeder and laying flocks and prior to much of the EU legislation
being implemented. It is probable that no single measure contributed to the decline
in Salmonella Enteritidis PT4 and that the combination of measures was successful, but the
temporal relationship between vaccination programs and the reduction in human disease is
compelling and suggests that these programs have made a major contribution to improving
public health.
There has also been a reduction in reported human Salmonellosis cases across the EU (on
average 12% per year between 2005 and 2009). The European Commission and European Food
Safety Authority are attributing this, at least in part, to successful control of Salmonella in
broiler, laying, and breeding hen flocks and eggs.
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If success in public health is defined by illnesses averted, then the story of Salmonella Enteritidis
PT4 in the United Kingdom; which has come down and stayed down is good news. However,
history teaches us that something else may come along to take its place. Robust surveillance,
incorporating state-of-the-art microbiological, epidemiological, and bio statistical methods, and
maintaining a prompt and comprehensive response to outbreaks is just as important now as it
ever was.