ew07 01 rodriguez-morales

Educational WorkshopEW07: Update in zoonotic infectionsarranged with the ISC Working Group on Zoonoses

Convenor: Georgios Pappas (Ioannina, GR)g pp ( , )

Faculty: Alfonso Rodriguez-Morales (Caracas, VE)Antonio Cascio (Messina, IT)Luciano Nigro (Catania, IT)Christopher Parry (Liverpool, UK)

Rodriguez-Morales - Chagas disease imported in Europe and North America

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Cascio - Leptospirosis

Leptospirosis

Leptospirosis

Antonio Cascio

University of Messina

Italy

• This severely ill 22‐year‐old man had the abrupt onset of headache distressing myalgia shaking chills and rapid collapseheadache, distressing myalgia, shaking chills, and rapid collapse.

• On examination, he was delirious, with a temperature of 40° C.

Blood from this man grew Leptospira icterohemorrhagiae, prompting therapy with high‐dose intravenous penicillin. After a course characterized by renal and hepatic failure, the patient ultimately made a full recovery. He presumably became infected through contact with the urine of rats that infested his home.

• Leptospirosis is a zoonotic disease of global importance.

• It is a potentially fatal disease

• The source of infection in humans is usually either direct or indirect contact with the urine of an infected animal

.

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Adolf Weil Heidelberg

• Ueber eine Eigenthumliche, mit Milztumor, Icterus und Nephritis einhergehende, acute Infectionskrankheit.

• Dtsch. Arch. Klin. Med. 1886; 39:209‐232

0·25 6–25 µ in size.

Leptospires are highly motile Leptospires are highly motile, obligate aerobic spirochetes

Order Spirochaetales, Family Leptospiraceae, Genus Leptospira

• Pathogenic species– L. alexanderi, L. alstonii , L. borgpetersenii, L. inadai, L. interrogans, L. fainei, L. kirschneri, L. li i L hi L i L Llicerasiae, L. noguchi, L. santarosai, L. erpstrae L. weilii, L. wolffii, with more than 260 serovars

• Saprophytic species– L. biflexa, L. meyeri, L.yanagawae, L. kmetyi, L. vanthielii , and L. wolbachii, and contain more than 60 serovars.

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Serovars• The serovar classification of Leptospira is based on the expression of the surface‐exposed epitopes in a mosaic of the lipopolysaccharide antigens.

• The specificity of epitopes depends on their sugar composition and orientation.

EPIDEMIOLOGY• The incidence is significantly higher in warm climate

countries than in temperate regions; this is due mainly to longer survival of leptospires in the environment in warm, humid conditions.

• Most tropical countries are also developing countries, and th t t iti f f th hthere are greater opportunities for exposure of the human population to infected animals, whether livestock, domestic pets, or wild or feral animals.

• The disease is seasonal, with peak incidence occurring in summer or fall in temperate regions, where temperature is the limiting factor in survival of leptospires, and during rainy seasons in warm‐climate regions, where rapid dessication would otherwise prevent survival.

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Andaman Island 500/106 population

North Queensland 288/106 population

Loei Thailand 467/106

Roi Thailand 299/106

Seychelles 432.1/106

Trinidad and Tobago 124/106

Guadeloupe 311/106

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Leptospirosis in Italy 0.7/106

(source: Ministerio della Salute) YEAR NUMBER OF CASES1996 741997 501998 701999 662000 452001 582002 492003 402004 382005 342006 222007 452008 40

TRANSMISSIONFrom soil or fresh waters

contaminated by animal urine

Entrance through abrasions, inhalation of infected particles, drinking infected water

Vertically in pregnancy

Important animal carriers•Rats

•Dogs

•Cows

•Pigs

• Rarely, infection may follow animal bites.

• Direct transmission between humans has been demonstrated rarely. However, excretion of leptospires in human urine months after recovery has been yrecorded. It is thought that the low pH of human urine limits survival of leptospires after excretion.

• Transmission by sexual intercourse during convalescence has been reported .

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Maintenance host• It is a species in which infection is

endemic and is usually transferred from animal to animal by direct contact. Infection is usually acquired at an early age, and the prevalence of chronic excretion in the urine increases with the age of the animal. g

• Animals may be maintenance hosts of some serovars but incidental hosts of others, infection with which may cause severe or fatal disease.

• The most important maintenance hosts are small mammals, which may transfer infection to domestic farm animals, dogs, and humans.

POPULATIONS AT RISK

•Dairy farmers

•Abattoir workers

•Food-industry workers

•Rice farmers

•Sugarcane farmers

•Sewage workers

•Miners

•Adventure travellers

•Military personnel

•Homeless, flood victims, refugees

•Tourists

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Brief aspects of pathogenesis

•Skin penetration

•Invasion of blood stream

•Disruption of cell membrane of small vessel endothelium (toxin effect)

CLINICAL SPECTRUM

•Bacteremia, acute phase

•Possibly renal failure and •Organ hemorrhage & ischemia

•Persistence in anatomically specific sites (renal tubule)

•Immunologic reaction varying

•Both humoral and cellular immunity are required in response

•Possibly renal failure and jaundice

•Remission or evolution to Weil

•2nd phase, immune-mediated

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Clinical manifestations

• Many cases sub-clinical (especially in endemic areas)

•90% of clinical mild, flu-like, self-90% of cl n cal m ld, flu l ke, selfremitting

•5-9% of clinical moderate, hospitalized

•1-5% of clinical severe/ Weil

Clinical manifestations

1st stage- bacteremiaIncubation period 7-12 daysFeverHeadacheHeadache persistent

2nd stage-immune stage2-3 non-symptom daysAseptic meningitisUveitis, chorioretinitis

Conjunctival suffusionConjunctival suffusionConstitutional symptomsMuscle tendernessHepatosplenomegaly

Remission

Severe leptospirosis,Renal failureJaundiceMeningitis

Useful hints for an early suspicion of leptospirosis

•Conjunctival suffusion

•Headache, unusually severe and persistent, frontal, retro-orbital

• Petechiae

•Hypokalemia +/- Renal Tubular Acidosis

•Rhabdomyolysis

•ECG non-specific abnormalities

•Serum Amylase increases in the absence of pancreatitis

•Jarish-Herxheimer reaction upon empirical initiation of antibiotics

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• Any pathogenic species can cause Weil’s

• There are no early predictors for evolution to Weil’s

• Onset of anuria is a poor prognostic sign

• Mortality dependent to healthcare settings, 10-40%

•Recognized in the 1995 Nicaragua epidemic

•Known in India for years

•Varies in severity from blood-streaked sputum to ARDS

•Unknown etiology: host genetic predisposition or

Severe Pulmonary Form of Leptospirosis

•Unknown etiology: host genetic predisposition or virulence factors?

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Diagnosis

Serology-MAT

Gold standard in expert handsD t t tib di i 1st k

Cultures Early from blood and CSFLater from urineRequires specialized media

Dark-field microscopy

Direct visualizationLow sensitivity and specificity (artifacts)

MAT Detects antibodies, so – in 1st weekSeroconversion or X4 fold titer increase or single titer >400

ELISA, dipstick etc

Not proven superior to MAT, maybe practical in certain settings

PCR Early detection, but specialized and costly

Real time PCR

Quantification of leptospiral burden: relation to worse prognosis? (Segura et al, CID 2005)

Treatment

• Antibiotic therapy should be initiated as early in the course of the disease as suspicion allows.

• There have been few randomized or placebo‐controlled trials and these have produced conflicting results.

• Therapeutic benefits of antibiotics may be difficult toTherapeutic benefits of antibiotics may be difficult to demonstrate in populations in which patients present for medical care with late and/or severe disease.

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• A total of 173 patients with severe leptospirosis were randomly assigned to be treated with either intravenous ceftriaxone (1 g daily for 7 days; ) or intravenous sodium penicillin G (1.5 million U every 6 h for 7 days; ).

• The primary outcome was time to fever resolution. Survival analysisThe primary outcome was time to fever resolution. Survival analysis demonstrated that the median duration of fever was 3 days for both groups. Ten patients (5 in each group) died of leptospirosis infection.

• There were no statistically significant differences in the duration of organ dysfunction. Ceftriaxone and sodium penicillin G were equally effective for the treatment of severe leptospirosis.

• Once-daily administration and the extended spectrum of ceftriaxone against bacteria provide additional benefits over intravenous penicillin.

• Results. A total of 264 patients (48.9%) had leptospirosis confirmed by serologic testing or culture. The overall mortality rate was 5%. There were no significant differences between the antibiotics with regard to associated mortality, defervescence, or time to resolution of abnormal findings of laboratory tests either among all study participants orof laboratory tests either among all study participants or among the subgroup of patients with confirmed leptospirosis.

• A total of 132 patients had rickettsial infection diagnosed, and, for these patients, treatment with doxycycline was superior to treatment with penicillin G.

• Conclusions. Doxycycline or cefotaxime is a satisfactory alternative to penicillin G for the treatment of severe leptospirosis.

Supportive therapy • Patients with early renal disease with high‐output renal dysfunction

and hypokalemia should receive aggressive volume repletion and potassium supplementation to avoid severe dehydration and acute tubular necrosis.

• In patients who progress to oliguric renal failure, rapid initiation of h di l i d t lit d i t i ll i d lhemodialysis reduces mortality and is typically required only on a short‐term basis.

• Patients requiring intubation for SPHS have decreased pulmonary compliance and should be managed as cases of ARDS. Protective ventilation strategies involving low tidal volumes (lower than 6 mL/kg) to avoid alveolar injury caused by high ventilation pressures have been shown to improve survival rates in ARDS dramatically.

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Prevention • Avoidance of high‐risk exposures

– immersion in fresh water, as in swimming, and contact with animals and their body fluids.

• Adoption of protective measures– wearing boots, goggles, overalls, and rubber gloves

• Immunization of animals with killed vaccines – the immunity is short‐lived and animals require periodic boosters.

Vaccines do not prevent infection and renal colonization; thus, they have little effect on the maintenance and transmission of the disease

• Human immunization is not widely practiced

• Chemoprophylaxis ‐ weekly doxycycline (200 mg) – effective in military personnel

• Photosensitivity, gastrointestinal side effects, dietary calcium restrictions, and contraindications for pregnant women and children.

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Nigro - Leishmaniasis

Educational Workshop 7Update in zoonotic infections

Leishmaniasis

Luciano NigroUnit of Infectious DiseasesParasitology clinicDepartment of Clinical andMolecular BiomedicineUniversity of Catania

21st European Congress of Clinical Microbiology and Infectious Diseases (ECCMID)27th International Congress of Chemotherapy (ICC)

7 – 10 May 2011 Milano

Leishmaniasis

Representations of skin lesions and facial deformities, typical of cutaneous and mucocutaneous leishmaniasis, have been found on pre-Inca potteries from Ecuador and Perù dating back to the first century AD.

http://www.lshtm.ac.uk/library/archives/leishman.html

LeishmaniasisIncan text from the 15th and 16th century and accounts from Spanish conquistadors noted the presence of skin lesions on agricultural workers returning from the Andes. These ulcers resembled leprosy lesions and were labeled, “white leprosy,” “Andean sickness,” or “valley sickness.” In pAfrica and India , reports in the mid-18 th century describe the disease now known as visceral leishmaniasis, as “kal-azar” or “black fever.”

http://www.lshtm.ac.uk/library/archives/leishman.html

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Leishmaniasis

In 1756, Alexander Russell made an important advance in the discovery of Leishmaniasis after examining a Turkish patient.

"After it is cicatrised it leaves an ugly scar which remains throughAfter it is cicatrised, it leaves an ugly scar, which remains through life, and for many months has a livid colour. When they are not irritated, they seldom give much pain. It affects the natives when they are children, and generally appears in the face, though they also have some lesions on their extremities. In strangers, it commonly appears some months after their arrival in an endemic area; very few escape having lesions, but they seldom affect the same person above once."

Russell called this disease, "Aleppo boil."http://www.lshtm.ac.uk/library/archives/leishman.html

Leishmaniasis

Lieutenant-General Sir William Boog Leishman (1865 -1926) was a Scottish pathologist and British Army medical officer. He attended the University of Glasgow and entered the Royal Army Medical Corps. He served in India, where he studied enteric fevar and kala azar.

In 1901, Leishman identified certain organisms in smears taken from the spleen of a patient who had died from "dum-dum fever". At the time "Dum-dum", a town not far from Calcutta, was considered to be particularly unhealthy.

http://www.lshtm.ac.uk/library/archives/leishman.htmlhttp://it.wikipedia.org/wiki/William_Boog_Leishman

Leishmaniasis

Charles Donovan (1863-1951) was a British surgeon. A surgeon in the Indian Medical Service, He is known mainly for his discovery of the causative organism of kala-azar. In 1905 he discovered the Donovan body, the causative agent of granuloma inguinale.

Initially, these organisms were considered to be trypanosomes, but in 1903 Captain Donovan described them as being new.

http://www.lshtm.ac.uk/library/archives/leishman.htmlhttp://it.wikipedia.org/wiki/Charles_Donovan

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Leishmaniasis

Sir Ronald Ross (1857 – 1932) was a British doctor who received theNobel Prize for Physiology or Medicine in 1902 for his work on malaria. His discovery of the malarial parasite led to the realization that malaria was transmitted by Anopheles, and laid the foundation for combating the disease

The link between these organisms and kala azar was eventually discovered by Ronald Ross, who named them Leishmania donovani. The Leishmania genus had been discovered.

combating the disease.

http://www.lshtm.ac.uk/library/archives/leishman.htmlhttp://it.wikipedia.org/wiki/Ronald_Boog_Ross

Leishmaniasis

Economic and social impact/risk factors

Leishmaniasis is related to enviromental changes such as deforestation, building of dams, new irrigation schemes, urbanization and migration of non-immune people tourbanization and migration of non immune people to endemic areas.

2 million new cases (1.5 million for CL and 500 000 for VL) are considered to occur annually, with an estimated 12 million people presently infected worldwide.88 countries affected by leishmaniasis,

www.who.int/leishmaniasis/burden/.../index.html

Leishmaniasis

Malnutrition is a well-known risk factor in the development of leishmaniasis, and epidemics flourish under conditions of famine, complex emergencies and mass population movements.

In Sudan, for example, a major decade-long epidemic of visceral leishmaniasis occurred from 1984 to 1994. As this was the first epidemic in the area, populations were highly susceptible.

Some studies estimate that the disease caused 100 000 deaths in a population of around 300 000 in the western upper Nile area of the country (1995).

http://www.who.int/tdrold/publications/publications/pdf/pr17/leishmaniasis.pdf

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Leishmaniasis

In 1997, the number of confirmed cases of visceral leishmaniasis in Sudan exploded, showing a 400% increase over the previous year.

Th mi r ti n f n l rk r nd l r p p l ti nThe migration of seasonal workers and large population movements caused by civil unrest carried the epidemic into Eritrea and Ethiopia, 1998.

Brazil has also experienced a sharp increase in the number of cases of visceral leishmaniasis since 1999.

Leishmaniasis

Epidemics of the cutaneous form are of particular concern in Afghanistan, where decades of war and civil unrest have created conditions favouring spread of this disease and making its control especially difficult.making its control especially difficult. Returning refugees and other displaced persons in Kabul are at higher risk of infection (2002)

Distribution of Old World and New World Visceral Leishmaniasis

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Distribution of Old World and New World Cutaneous Leishmaniasis

Visceral leishmaniasis in the mediterranean area

Leishmaniasis

• Phylum: Sarcomastigophorae• Order: Kinetoplastida*• Family: Trypanosomatidae

G L i h i• Genus: Leishmania• Species: divided in groups (complex) on the

basis of bio-chemical and immunological analysis, pathogenicity, geographical distribution, etc.

* Mithocondrial structure with extranuclear DNA“kinetoplast”

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Leishmaniasis

Taxonomy of Leishmania; underlined species are or have been questioned. (Based on the scheme published by the WHO, 1990] with additions from the literature.)

Banuls AL, et al.Adv Parasitol. 2007; 64:1-109

Leishmania

Macrophage

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Genus Sub-genus Complex Species Clinical

diseases

Geographical

Distribution

L. donovaniL. donovani

L infant m

Visceral

Visceral

India, Iran, Ethiopia

Sudan, Kenya, China

Mediterranean basin

Leishmania classification and clinical diseases

Leishmania

Leishmania Leishmania L. donovaniL. major

L. tropicaL.aethiopica

L. infantumL. chagasi

L. infantum L. major

L. tropica L.aethiopica

Visceral

Visceral

Cutaneous

Old World

“

“

Mediterranean basin

Brazil,Venezuela, Colombia, Argentina

Mediterranean basin

Middle East, W. and N. Africa, Kenya

Mediterranean basin Afghanistan

Ethiopia

Genus Sub-genus Complex Species Clinical

diseases

Geographical

Distribution

Leishmania L. mexicana L. mexicanaL. amazonensisL pifanoi

Cutaneaous

New World

“

Central America Amazon basin


Leishmania

Leishmania

Vianna L.braziliensis

L. pifanoi L. garnhamiL.venezuelensis

L. braziliensisL. periuviana

“

“

“

Muco

cutaneaous

Brazil, Peru, Ecuador,

Columbia, Venezuela

Genus Sub-genus Complex Species Clinical diseases Distribution

L. braziliensis L. braziliensisL. Periuviana

Cutaneaous New World

“


Leishmania

Leishmania ViannaL. guyanensis

L. Periuviana

L. guyanensis

L. panamensis

““

Cutaneaous

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Leishmania leishmania spp.

L. l. infantum L. l. donovani L. l. chagasi L l tropica ??

Leishmania

L. l. tropica ??Visceral leishmaniasis

L. l. infontum . L. l. tropica L. l. major L. l. mexicana

Cutaneous leishmaniasis L. l. aethiopicaL. l. amazonensis

Diffuse cutaneous leishmaniasis

Leishmania

Leishmania vianna spp.

L. v. panamensisL. v. guyanensisL v peruvianaL. v. peruviana

Cutaneous leishmaniasis

L. v. braziliensisL. v. panamensis

Muco-Cutaneous leishmaniasis

Vector

The phlebotomine sandfly

The insect vector of leishmaniasis, the phlebotomine sandfly, is found throughout the world's inter-tropical and temperate regions. 6 genera world wide distribution. 500 species. Female haematophagus, male sap feeders

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Parasite Vector Host AreaL. l. dovovani Phl. argentipes

Phl. martinimanman

India

E. Africa

L. l .infantum Phl..perfìliewiPhl. perniciosus

fox, rodentdog

Italia. JugoslaviaW. Mediterraneo

Vector - Host

pPhl. ariasi

Phl. orientalisPhl. longicupisPhl. chinensis

gfox, dogrodent

dogdog

S FranciaSudan

N. AfricaCina

L. l. chagasi Lutzomia longipalpis

dog, fox Brasile

L. l. tropica Phl. sergenti man? Iraq, Arabia

The female sandfly lays its eggs in the burrows of certain rodents, in the bark of old trees, in ruined buildings, in cracks in house walls, in animal shelters and in household rubbish, as it is in such environments that the larvae will find the organic

Vector

environments that the larvae will find the organic matter, heat and humidity which are necessary for their development.

In its search for blood (usually in the evening and at night), the female sandfly covers a radius of a few to several hundred metres around its habitat.

http://www.who.int/leishmaniasis/disease_epidemiology/en/index.html

Vector

Of 500 known phlebotomine species, only some 30 of them have been positively identified as vectors of the disease.

Only the female sandfly transmits the protozoa, infecting itself with the Leishmania parasites contained in the blood it sucks from its human or mammalian host in order to obtain the protein necessary to develop its eggs.

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Vector

During a period of 4 to 25 days, the parasite continues its development inside the sandfly where it undergoes a major transformation.

The infectious female sandfly feeds on a fresh source of blood, its painful sting inoculates its new victim with the parasite, and the transmission cycle is completed. The insect vector of leishmaniasis, the phlebotomine sandfly, is found throughout the world's inter-tropical and temperate regions.

Several species of canids (dogs, foxes, and coyotes), marsupials, and rodents have been incriminated as reservoirs in endemic areas. Dogs play an essential role for maintenance of the disease in endemic

Host

role for maintenance of the disease in endemic areas where they act as domestic reservoir and source of infection for the Phlebotomus and consequently human infections.

http://www.vet.uga.edu/vpp/archives/NSEP/Brazil2002/leishmania/Eng/Leish04.htm

Host

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The main dermatologic signs of visceral leishmaniasis consist of emaciation, keratitis, scaling of skin, seborrhea, onicogripfosis, ulceration, and alopecia, which is often

Host

symmetrical in distribution. Some heavily infected dogs don´t have any clinical signs. Frequently there is also a discrepancy between the intensity of infection and the clinical condition in dogs.


Host

With the visceral form, the disease can be severe, causing clinical signs in many organs. There are: extreme weakness, wasting, diarrhea, epistaxis, lameness, anemia, renal failure, edema of the feet, dermal ulceration, eye inflammation leading to blindness, lymphadenopathy and hepatosplenomegaly.


Leishmania

The leishmaniases are caused by 20 species of protozoa pathogenic for humans belonging to the genus Leishmania,g

The protozoa is transmitted by the bite of the phlebotomine sandfly.

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AMASTIGOTE PROMASTIGOTE

Leishmania

The amastigote forms are characterized as circular, about 5 microns in diameter, having a nucleus, kinetoplast and rudimentary flagellum. It multiplies by binary fission, repeatedly until the host cell is destroyed Inside the gastrointestinal tract of the

Leishmania

destroyed. Inside the gastrointestinal tract of the sandflies, the amastigote transforms into paramastigotes and promastigotes - elongated, flagellated, motile forms, which have a central nucleus and terminal kinetoplast.

In the mammalian host, Leishmania is an obligate i ll l i d i

Leishmania

intracellular parasite and exists in the amastigote form inside cells of the mononuclear phagocytic system

Alexander, J., et al. 1999. J. Cell Sci. 112:2993.

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Life cycle in Phlebotomus

Pathogenesis

Pathogenesis

• Promastigote inoculation by vector bite• Complement activation and C3 opsonization • Adhesion to the macrophage via C3b, mannose/fucose and

fibronectin receptorsfibronectin receptors • Phagocytosis and parasitophorous vacuole maturation • Transformation in amastigote

Dominguez MJ et al. Exp Med. 2002; 18; 195: 451–459. Peter J. Myler, Nicolas Fasel. Leishmania after the genome - 2008 – Science

Courret N. et al. Journal of Cell Science 2002; 115, 2303-2316 Bee A, et al. Parasitology 2001; 122: 521-529

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Immune response to infectionLEISHMANIA

MACROPHAGE IL-1 CD4+

IL-2

Pathogenesis

γ-IFN

KILLING MACROPHAGE

INDUCED BY: •Indipendent CD4+ cytokines(IL-2 , γ-IFN)

•Direct contact with CD4+

Wolday D, et al. Infect Immun. 1999; 67: 5258–5264.

Immune response modulation

Pathogenesis

Due to:

• Antigen presentation

• Expression of MHC class II antigens

• Expansion and activation of different CD4+ subsets

MACROPHAGE

CD4*activator

IL-1CD4*

d

PathogenesisImmune response modulation

activator depressor

IL-2γ-IFN

IL-4

Killing by macrophages

inhibition

TNF IL-3GM - CSF

Ho JL, et al. J Infect Dis 1992;165:344-51

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Life Cycle

Metacyclic promastigote penetration

C3b

Immunology of leishmaniasis

fucose/mannose

fibronectinFcR


Leishmanial antigensLeishmanial antigens

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Macrophage


Immune response

Cytokines and chemokines

IFN-γ TNF- α IL-1 IL-6 IL-8 IL-12 γIL-18

RANTES MIP-1α MIP-1β CCR5


Lysosome and leishmania

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Phagocytosisleisnmania


Macrophage and killing

• Visceral– Fatal (90%

untreated)

• Cutaneous– Generally Self- healing

– Skin

Clinical Disease

– Liver

– Spleen

– Bone marrow

– Mucous membranes

SPECTRUM OF DISEASE

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Clinical features

Actual position

- Asymptomatic

(High endemic area)

Infection 6.5

Visceral leishmaniasis

- Subclinic- Full-blown

•Persistence of leishmania after recover•Reactivation in immunodeficient•Leishmania as opportunistic agent

Disease 1

Incubation

3 - 8 months (10 days - 34 months)

Visceral leishmaniasis

Onset- mild, insidious, acute

Weakness, weight loss, abdomen enlargement,intermittent fever, cough, anemia

Visceral leishmaniasisVisceral leishmaniasis

• Spleen enlargenment

• Anemia (low RBC), leukopenia (low WBC), and thrombocytopenia (low platelets) are common

• Lymphadenopathy may be present

• Most severe form of the disease, may be fatal if left untreated

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Cutaneous LeishmaniasisCutaneous Leishmaniasis

• Most common form

• One or more sores, papules or nodules on the skin

• Sore with a raised edge and central crater

• Usually painless but can become painful if• Usually painless but can become painful if secondarily infected

• Swollen lymph nodes may be present near the sores

Cutaneous LeishmaniasisCutaneous Leishmaniasis

• Sores develop within a few weeks up to months afterthe sandfly bite

• Sores can heal on their own, but this can take hmonths

Mucocutaneous LeishmaniasisMucocutaneous Leishmaniasis

• Cutaneous lesion spreads to involve the mucosal and later bones

• May occur months to years after original skin lesionlesion

• Few parasites are in the lesion

• Lesions can be very disfiguring

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DiagnosisDiagnosis

• Cutaneous Disease– Tissue sample (scraping, aspirate or punch

biopsy) for smear and culture • Sensitivity 75-90%Sensitivity 75 90%• PCR

• Visceral Disease– Bone marrow biopsy or splenic aspirate for

smear and culture– Serology (rk39, various ELISAs)– PCR

DiagnosisDiagnosis

AmBisome amphotericin B

Treatment

antimonials

miltefosine

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Main toxicities of antimonials

• 15-50% ECG abnormalities/arrhythmias • 58-83% myalgias or arthralgias, • 10-28% abdominal pain, nausea or vomiting,

Treatment

• 21% headache, • 10-50% elevated liver transaminases, • 40-100% hyperamylasaemia; 20% pancreatitis.• 8% thrombocytopenia, leukopenia• 5-12% renal impairment

• 0.1% - 1% sudden death

AmBisome is an infusion: need ~20 mg/kg in 2-6 doses

Treatment

AmBisome amphotericin B

Toxicities

Treatment

very little toxicity fever / chillsrenal impairmentvomiting, diarrhea

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MiltefosineI l

Treatment

Is an oral agent for 28 days

Main toxicities of Miltefosine

38% vomiting 20% diarrhoea 25% elevation of liver enzymes

Treatment

anorexia, nausea, abdominal pain 25% increase of urea and creatinine.

contraindicated in pregnancy / breast feeding. need contraception for 3 months after treatment.

Leishmaniasis & HIV

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Overlapping areas of Leishmaniasis / HIV co-infection

IndiaVL: 250.000 cases / yAIDS: 6.500 casesHIV: 1.750.000 cases

Southern EuropeVL: 1.000 cases / yAIDS: 150.000 casesHIV: 600.000 cases

WHO/CTD

Visceral Leishmaniasis Areas

SudanVL 100.000 death / 5 yAIDS: 2000 casesHIV :125.000 casiBrazil

VL: 3.000 cases / yAIDS: 130.000 casesHIV: 550.000

Paris

1996-011990-95

1099318

Leishmaniasis & HIVMediterranean basin

Adults affected25 - 70% HIV+

Madrid

Roma117

P.Dejeux, 2003

335159

Visceral - typical

Visceral - atypicl

C t n

87.6%

6.4%

4 8%

Leishmaniasis & HIVClinical features

Cutaneaus

Other

Mucocutaneus

4.8%

0.7%

0.3%

P.Dejeux, 2003

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Incidence after HAART

4

5

6

0ca

si A

IDS

Leishmaniasis & HIV

Lopez Velez, 2001

0

1

2

3

pre-HAART HAART

Nuo

vi V

L x

100

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Parry - Foodborne zoonoses

Food borne zoonoses

Chris Parry

Department of Clinical Infection, Microbiology and ImmunologyUniversity of Liverpool

Angkor Hospital for Children, Siem Reap, CambodiaMahidol-Oxford Clinical Research Unit, Bangkok, Thailand

Food borne zoonoses

• Introduction• Epidemiology• Burden of disease• Range of pathogens• Antimicrobial resistance• International issues• Prevention

Food borne zoonoses• Zoonoses are diseases and infections that can be

naturally transmitted between vertebrate animals and humans [WHO]

• Vehicle of infection is food or water

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Food borne zoonoses• Each year the average adult in a developed country

drinks more than 500 litres of water and eats over 450 kg of meat and vegetables

• Over 200 microbial, chemical or physical agents that p y gcan cause illness when ingested (Acheson, 1999)

• Trivial inconvenience or an important problem?

Food borne zoonoses• VTEC/STEC (Ecoli O157:H7)

• Outbreak in Scotland 1996– Cross-contamination between cooked and raw meat– 512 cases– 279 confirmed cases– 127 admitted to hospital– 13 required dialysis– 22 died – 17 related to outbreak (All > 69 years of age; 8

attended a church luncheon; 6 residents of a nursing home)

Cowden Epid Infect 2001;126:335

Food borne zoonoses

• Healthy individuals can develop life-threatening illness after eating food– More than just a few uncomfortable days of gastroenteritis– Short and long term consequences

• Epidemiology – Sporadic cases and outbreaks– Transmission routes and sources– International perspective– Multi-disciplinary topic: healthcare professionals,

veterinarians, manufacturers, regulators and consumers

• One world: One health

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Changing Epidemiology• Population growth and shift to an elderly population

• Increase in immunologically compromised individuals

• Intensified farming practices - cheaper food – shift to free-range/organic animal productionto free-range/organic animal production

• Greater global dependency on meat and fish products

• Changing food habits – consumption of raw or lightly cooked food; exotic food such as bush-meat

Newell et al, Int J Food Micro 2010;139:S3

Changing Epidemiology

• Globalisation– Vegetables; meat; fruit; ethnic foods; farm animals – Some countries in this global market lack appropriate

microbiological safety standards– Improved transport logistics and conditions – allows agents

to remain viable on food productsp– Human population carrying its flora world-wide

• Climate change – novel vectors in temperate regions; Temp associated changes in contamination levels

• Microbial adaption

Newell et al, Int J Food Micro 2010;139:S3

Burden of disease• Global burden remains largely unknown• Some industrialised countries conduct surveillance

• Lack f surveillance in the developing world -increasingly producing food for a global marketincreasingly producing food for a global market

• In 2005 1.8 million people died from diarrhoeal disease (WHO) – largely attributed to contaminated food and drinking water

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Burden of disease• USA

• Mead EID 1999;5:607 – 76 million episodes; 325,000 hospitalizations; 5000 deaths

• Scallon EID 2011;17;16– 38.4 million episodes; 71,878 hospitalizations; 1686 deaths– 0.6 episodes of gastroenteritis per person per year in last

decade – could be up to 0.73

– Statistical uncertainty about parameters

Burden of disease

SYMPTOMATIC CASES PRESENTING

LABORATORY CONFIRMED

CASES

‘Tip of the iceberg’Chronic sequelaeFood attribution dataDALY

PREVALENCE OF PATHOGEN IN THE COMMUNITY

PREVALENCE OF ASYMPTOMATIC CASES

PREVALENCE OF SYMPTOMATIC CASES

CASES PRESENTING TO HEALTH CARE

Surveillance• Baseline surveillance data essential• Surveillance data over time also valuable for trends• Variable systems in different countries

– Food Net– EnterNet

MedVetNet– MedVetNet– Global Food Infections Network (WHO)

• Methodology– Microbial agents of intestinal infections still has gaps 50-

60% no pathogen identified– Toxins poorly identified – Molecular epidemiology

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Figure 3. Implicated food vehicles and causative pathogen/ toxin in food borne outbreaks (1992-2009). (EFSA, 2011)

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Common presentations

• Vomiting• Watery diarrhoea• Inflammatory diarrhoea• Non-gastrointestinal

– Bacteraemia– Focal infections– Guillan Barre syndrome– Reactive arthritis– Haemolytic-uraemic syndrome (HUS)– Others

Campylobacter

• Most commonly reported cause of food poisoning in the European Union– In 2008 - 193,814 notified cases– EU 44.1/100,000 population– Czech Republic (193/100,000)p ( , )– UK (91/100,000)

• 92% domestically acquired overall – varies by country

• UK reporting since 1982

Campylobacter infections per year, 1989-2009 (HPA, UK)

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Campylobacter• Isolated species

– C.jejuni 40%– C.coli 3%– Other Campylobacters 9%– Unidentified species 49%

ECDC EU Surveillance 2010

Campylobacter sources

• Baseline survey on Campylobacter colonisation in broiler chickens– 26 EU Member States, Norway, and Switzerland (2008). – 71.2 % in broiler batches (with a variation of 2.0 % to 100.0

% between countries)

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• Diarrhoea (gastroenteritis) • Complications

– Bacteraemia– Focal infection

• Bones and joints• Endovascular infection• Meningitis (very young)

Salmonella

g ( y y g)– Reactive arthritis

• Susceptible patients– Extremes of life (very young, elderly)– Immunocompromised (malignancy, steroids, immunotherapy

agents, DM)– Persons with HIV– Sickle cell disease

Salmonella• Colonise a wide range of hosts

– All the major livestock species– Poultry cattle and pigs

• Regular food-borne outbreaksg– Low infectious dose (especially if delivered in certain

foodstuffs such as chocolate)– Ability to grow in unprocessed food and environment– Amplification and easy recovery from contaminated foods– Habitats that allow adaption and evolution

Salmonella• Salmonella increased in the developed world in 1980s

– S.enterica serovar Enteritidis phage type (PT) 4– Linked to eggs and poultry– Preferentially colonise the avian reproductive tract; persist

in ovary and oviduct; survive in hens eggs

• Culling of flocks and vaccination – first of breeders then of layers– Significant reduction in egg associated infections

• Since 2000 – increase in nonPT4 strains – PT1, PT14b, PT21– Some linked with egg contamination

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Salmonella• 138,469 notified cases in EU

– 29.75/100,000 population– Slovakia, Czech republic and Lithuania the highest rates

• Decrease in notifications over the last three yearsy• High rates in the 0-4 year age group

• Overall 15% imported– Finland, Sweeden, Iceland, Norway over 80%– UK and Ireland over 50%

Salmonella by age group and year (HPA, UK)


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Salmonella• Global estimates• 94 million cases (95% CI 62-132 million)• 155,000 deaths (95% CI 39,000-303,000)• 80 million cases food borne

Majowicz et al CID 2010 50 882Majowicz et al CID 2010 50 882

• Enteritidis 56%• Typhi murium 22%

Salmonella• Continued outbreaks

– Pork, chicken eggs– Fresh fruit juice; goat’s cheese; infant milk formula

• Recent increases in salmonella linked to unusual vehicles including fresh produce– Crops from developing countries where manure is used as a

natural fertilizer– Some Salmonella can attach and colonise vegetables

• Capacity to adapt to new niches

Yersinia spp• Faecal flora of pigs• Ingestion of pigs intestine

• 8200 notified cases in EU in 2008• 2.66/100,000 population• Highest reported cases in Lithuania and Finland

• 96% domestically acquired• 92% Y.enerocolitica

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VTEC/STEC• Ecoli O157:H7• O26; O103; O111; O145

• Grazing herbivores– Ingestion of undercooked ground beef– Venison has also been a sourceVenison has also been a source

• Initial outbreaks in USA in 1982– US estimates 73,000 cases and 250 deaths annually

• Community outbreaks in UK in 1985– Continues to be reported in Europe– In England and Wales 33% estimated to be food borne


VTEC/STEC• In 2008

– 3210 case reported in EU– 0.66/100,000 population– 146 developed HUS in 2008– Children under 5 had the highest notification rate at

4.72/100,000More than 1000 cases from the UK– More than 1000 cases from the UK

• VTEC O157 53% • VTEC O26 5.3%• VTEC O103 2.8%

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VTEC/STEC• Outbreaks continue to occur

– Usually associated with raw beef products and milk– Any food contaminated with ruminant faeces– Vegetables, sprouts, fruits, meat products, and juices

Listeria monocytogenes

• Relatively rare disease – high case fatality rate (20-30%)

• Opportunistic pathogen in the immunocompromised – Immunosuppressive agents; HIV/AIDS

P t – Pregnant women– Unborn or newly delivered infants– Elderly.

• Can grow at refrigeration temperature– Problem in packed ready to eat foods

Number of cases of listeriosis in England and Wales reported to the HPA, UK by patient type, 1990 – 2010

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Listeria monocytogenes• Ingestion of contaminated meat and dairy products

– 1472 cases in 2008– 0.31/100,000 population– Highest notification rates in Scandinavian countries

followed by Belgium and Estonia

• 20.5 % of cases (134/653) with known reported outcome died

• Non-compliant products in 2007 were smoked fish products, meat products and cheeses.

Antimicrobial resistance• Food can be a source of antimicrobial resistant

bacteria and resistance genes

• Antimicrobial resistance in Salmonella, Campylobacter a direct problemp

• Horizontal transfer of resistant genes

• Contact of bacteria with antimicrobial residues in food

Antimicrobial resistance• Salmonella

– Use of antimicrobials at the farm level– Multiple resistance is common in – Typhimurium; Virchow; Derby; Newport; – Typhimurium DT104 still important

R i t t ti i bi l d i i l h b d– Resistance to antimicrobials used in animal husbandry

• Enteritidis– Resistance to nalidixic acid/ decreased susceptibility to

ciprofloxacin

• Emerging extended spectrum cephalosporin resistance

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Nalidixic acid resistance in NTS and foreign travel

Al-Mashhadani EID 2011;17:123

NEJM 2000;342:1242

Antimicrobial resistance• Campylobacter

– Fluoroquinolone resistance– Related to use in animal production– Related to foreign travel

• Ecoli– Source and recipient of resistance genes

• MRSA– MRSA ST398 – pigs and pig farmers– Risks?

• VRE

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Food-borne viral/prion agents• SARS• H5NI avian influenza virus – duck blood• Norovirus, Rotavirus• Enteroviruses• Hepatitis E• Hepatitis E• Nipah virus• Tick-borne encephalitis virus• vCJD

Food-borne viral agents• Viruses do not grow in food

– Transmission via food reflects faecal contamination and persistence of virus on or in the product

• Some are present without faecal contamination– Hepatitis E

Ti k b h li i i– Tick-borne encephalitis virus• Most food- borne viruses are very infectious with

rapid person to person spread – Food may not be recognized as the start of the outbreak

• No systemic surveillance for food-borne viral infections

Food-borne viral agents• Norovirus

– Common cause of diarrhoea– 2001-2007– 10,000 outbreaks– 10% food-borne

2% t b– 2% waterborne– Remainder person to person

Kroenman et al. JCM 2008;46:2959

• Norovirus and Hepatitis A in bivalve molluscs– Molluscs contaminated by sewage

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Food-borne Parasites• Contamianted Water

– Cryptosporidium• Pig intestinal contents

– Ascaris suum• Undercooked infected pork

– Taenia soliumTaenia solium• Undercooked beef, lamb, contaminated goats milk

– Taenia saginata• Fish

– Dihhyllobothrium latum; Clonorchis sinensis; Opisthorchis; Capillaria philipinenesis; Gnathastoma spinigerum

• Contaminated raw vegatables and fruit by fox faeces– Echinococcus multilocularis

Food-borne Parasites• Do not replicate outside the host

• Most not susceptible to antimicrobials that kill bacteria

• Most have an environmental resting stage – Egg, cyst, oocyst – Resistant to desiccation, disinfectants, and other stresses

• Often have low infective dose

• Features that hinder control and prevention

Food-borne Parasites• Burden difficult to estimate• Lack of awareness• Relatively mild or non-specific symptoms• Long incubation periods• Unavailable or inadequate laboratory methods• Unavailable or inadequate laboratory methods

• Information on incidence scarce• Often based on outbreaks

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Toxoplasma gondii• Parasite that can use all warm blooded vertebrates as

hosts

• Cats are the definitive host, shed oocysts in faeces

• Humans infected by ingestion of oocysts, excreted by cats, via contaminated soil, water or food.

• Ingestion of tissue cysts in raw or undercooked meat or meat products from intermediate hosts (sheep, cattle)

Toxoplasma gondii• 1788 notified case in EU in 2008• 0.76/100,000 population• Several countries do not report• Difficult to distinguish congenital cases from all cases

Trichinella• 670 notified case in EU in 2008• 0.13/100,000 population• Four countries (Romania (75%); Bulgaria (10%);

Lithuania (4.7%) and Spain (4%)) account for 94% of total cases

• Preventative measures ensure a low infection rate– Meat of infected swine from backyard farming; horses and

wild boar– Household slaughter of pigs in rural areas of Romania and

Bulgaria in January– Outbreak in Romania in 2008 affected 108 people –

consumed pig meat contaminated with Trichinella

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Malawi Walsh PIDJ 2000 19 312

Salmonella infection in Africa

• Route of transmission

• Food borne?

• But NTS isolated from animals different from those isolated But NTS isolated from animals different from those isolated from humans

• Human – human transmission?

• 7% of human contacts faecal carriage positive• NTS isolates the same as index cases

• Kenya Kariuki et al. J Med Micro 2006 55 585

Salmonella infection in DRCAnimal No sampled No Positive (%) Salmonella serovar

Pig 150 2 (1.3) Typhiumurium (2)

Guinea pig 69 2 (2.9) Paratyphi C (2)

Hens 63 0 (0)

Ducks 22 1 (5) Typhiumurium

Goats 13 0 (0)

Children 265 3 (1.1) Typhiumrium (2)Chandans

Cheesbrough et al (unpublished)

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Prevention• Farm to fork approach

– All sectors of food production chain to improve hygiene and actively incorporate structured approaches to food safety (such as HACCP)pp y

– Aims to make food less contaminated and safer for the ultimate consumer

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Prevention - Farm

• Control the disease in the animal

• Vaccination• Treat worm infections

Cl n f dstuffs nd t• Clean foodstuffs and water• Good housing and husbandry

• What is the economic benefit of preventative measures at this stage

• Cost and quality

Prevention -Farm• Eggs

– Eggs free of droppings; cleaned and date marked

• Milking Cows– Milking machinery clean and hygienic; Disinfected after each

milking; Pipe work and clusters maintained; personal hygieneg p p yg– Milk passed to the bulk tank and chilled rapidly for later

transport and pasteurisation

• Abattoirs– Veterinary inspection pre and post-slaughter– Animals with heavy faecal contamination cleaned or rejected– Rejection of suspect carcasses– Prompt refrigeration of meat and careful cleaning of

carcasses will reduce contamination

Prevention - resistance• Prudent use of antimicrobials in all sectors

– Avoid the use of antimicrobial agents for growth promotion (Banned in the EU in 2006)

• Accurate infection diagnosis and antimicrobial sensitivity testing

• Appropriate antimicrobial and route of administration– Mass treatment of poultry and fish– Prophylaxis minimised– Narrow-spectrum rather than broad spectrum

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Prevention - resistance• Surveillance needed for risk assessment and risk

management and to implement and evaluate interventions

• Regulatory system for approval and licensing of g y y pp gantimicrobial agents

• Disease prevention in animals will reduce the need for antimicrobial use– Animal husbandry and management– Nutrition– Animal welfare– Vaccination

Prevention - Parasites• Prevention

– Strict indoor housing– Pest control– Feed separation and storage– General hygiene

• Outdoor livestock rearing– Close-contact with environment and wildlife– Rick for parasitic infections

• Avoid the use of sewage for irrigation of fruit and vegetables that are eaten raw

Prevention - Retail• Retailing controls

– Disinfection of working tools and areas– Personal and premises hygiene procedures– Source products from assured suppliers– Temperature and environmental monitoring– Separation of cooked and raw productsp p– Tight control of use-by and sell-by dates– Monitoring of refrigerator and freezer plants

• Food Standards Agency– Monitoring safety and standards of all food for consumption– Advising on diet and nutrition– Enforcing the law pertaining to food

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Prevention –Domestic• Common sense!

– Disinfection of surfaces and equipment– Personal hygiene procedures– Correct use of refrigerator– Observing use-by and sell-by dates– Thorough and appropriate cooking; Meat should be cooked

il h j i luntil the juices run clear– Consumer care when eating raw food

• Susceptible groups – compromised immunity– Prevent further spread person-person– Families– Nursing Homes– Schools

Prevention• S.enterica serovar Enteritidis PT4

– Eliminated from breeder and layer flocks of many European countries

– Bio security and vaccination

E l • E.coli O157– Legislation and retailer education– Reduce in cooked meats

• Impact on many diseases unclear• A continuing problem!

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Food borne zoonoses

• Introduction• Epidemiology• Burden of disease• Range of pathogens• Antimicrobial resistance• International issues• Prevention

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