Middle East Consortium on Infectious Disease Surveillance (MECIDS) Regional network for laboratory-based surveillance of foodborne diseases.

Middle East Consortium on Infectious Disease Surveillance (MECIDS)

Regional network for laboratory-based surveillance of foodborne diseases

Background (1)

• Globalization of food and centralization of its production have important economic advantages

• However, under these circumstances, accidental or deliberate contamination of food can lead to epidemics that can affect large populations.

• Exposure to a high infective dose of enteropathogens may significantly increase complication and fatality rates, especially among young children and aged people.

Background (2)

• Many scientific articles describing naturally occurring epidemics of foodborne diseases including national and even international spread of enteropathogens.

• A few reports on incidents in which intentionally contaminated food caused outbreaks of shigellosis and salmonellosis in the USA

• Two review papers assessed the threat of bioterrorism on the food supply

• Foodborne pathogens were classified by the CDC as a category 2-level candidates for being used as bio-weapons

Background (3)

Solution• To establish enhanced surveillance networks to

provide baseline information against which clusters of disease can be identified.

• To obtain information on the microbial etiology of the disease and on the phenotypic and genotypic characterization of the recovered agents

• To link laboratory data with variables related to the ill subjects

Goal and Rationale (defined by MECIDS members)

• Goal: To establish a regional system of surveillance of foodborne diseases in the Middle East.

• Rationale: In view of the close proximity among the 3 countries and a level of food exchange that hopefully will increase in the near future it was anticipate that the significant upgrading in the methods of surveillance will play an important role in the prevention and control of occurrence and transmission of foodborne diseases in the whole region.

Overall objectives

• To establish or enhance of national laboratory-based surveillance networks for foodborne diseases in Jordan, Israel and the Palestinian Authority

• To use harmonized methodology• To develop a common platform of communication,

data sharing and analysis• To discuss intervention steps when needed.

What happened next ?

• A detailed joint protocol and budget based on these goal and objectives was submitted by the 3 countries to SFCG and NTI.

• Due to paucity of funds, NTI and SFCG committed to support just one year of initial activities in each of the 3 countries that will focus on one of the foodborne pathogen (Salmonella). It was agreed that in this framework each country will outline its specific objectives that will fit the overall goal of the establishment of the regional foodborne

diseases surveillance network.

Middle East Consortium on Infectious Disease Surveillance (MECIDS)

Laboratory-based surveillance of foodborne diseases

Report on activities conducted in Israel (Dec 2004-March 2006)

Objectives for the first year (1)

• Collect Salmonella data at selected sentinel laboratories and improve the transfer of data to the central data analysis unit.

• Improve phenotypic and genotypic characterization of Salmonella, Shigella and other foodborne pathogens.

• Perform a case-control study to identify risk factors of salmonellosis due to infection with Salmonella virchow, which is an emergent Salmonella pathogen in Israel, and potentially in the Middle East as a whole.

• Conduct a nationwide population based survey to estimate the burden of foodborne infections and assess the level of under reporting in Israel.

Objectives for the first year (2)

• Perform a survey among physicians to assess their knowledge and practice (KAP) regarding foodborne diseases.

• Transfer electronically national data on a monthly basis to the regional data depositary unit at CMC Amman.

• Share data and analysis on foodborne diseases among all MECIDS participants.

Structure of the network in Israel

• Sentinel Laboratories: 9 laboratories all over Israel (hospital and community)

• Central Lab: Central MOH Laboratory in Jerusalem and Research Lab at Dept. of Epidemiology, Tel Aviv University

• Data analysis unit : (MOH Israel Center for Disease Control and Dept. of Epidemiology, Tel Aviv University )

Stool cultures performed at the sentinel laboratories (Jan. 05-March 06)

January 05 5372

February 05 4721

March 05 5455

April 05 4171

May 05 6174

June 05 6264

July 05 6244

August 05 6959

September 05 6312

October 05 4943

November 05 5735

December 05 4759

January 06 4244

February 06 4144

March 06 4409

Total 79906

Salmonella isolates (n=824) from stool specimens at the 9 sentinel laboratories from January 2005 to March

2006

0

5

10

15

20

25

30

35

40

45

50

Jan-

05

Feb-

05

Mar-

05

Apr-05 May-

05

Jun-

05

Jul-05 Aug-

05

Sep-

05

Oct-05 Nov-

05

Dec-

05

Jan-

06

Feb-

06

Mar-

06

Month

Nu

mb

er o

f Is

ola

tes

North (C)North (C+H)Central (C)Central 2 (C)

Central (H)Jerusalem (H's)Jerusalem (C)South (C+H)

Salmonella isolates at all the sentinel labs between January 2005 and March 2006

0

10

20

30

40

50

60

70

80

90

100

Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06

Month

Num

ber o

f Iso

late

s

Percentage of Salmonella isolated at the various sentinel labs

(all isolates from January 2005 to March 2006)

North (C)14.9%

North (C+H)5.9%

Central (C)14.9%

Central 2 (C)16.4%

Jerusalem (H's)8.6%

Jerusalem (C)16.7%

South (C+H)20.9%

Central (H)1.6%

Isolation rate of Salmonella at the sentinel labs during the surveillance period

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Jan-05 Feb-05 Mar-05 Apr-05 May -05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov -05 Dec-05 Jan-06 Feb-06 Mar-06

Month

Iso

latio

n R

ate

per

100

Mean isolation rate by sentinel lab (Jan 05-March 06)

0.73 0.68

0.86

0.25

0.74

1.09 1.06

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

North(C+H)

North (C) Central 2(C)

Central (H) Jerusalem(H's)

Jerusalem(C)

South(C+H)

Lab

Iso

latio

n R

ate

per

100

Distribution of Salmonella isolates by age (isolates of the period January- December 2005)

18.7%

37.5%

7.3%4.1%

14.0%

9.5% 8.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

<1 1-4 5-9 10-14 15-44 45-64 >=65

Age Group

Iso

late

Pe

rce

nta

ge

Distribution of Salmonella isolates in the first 5 years of life

Number of isolates

(%)

0 128 (33.2%)

1 140 (36.4%)

2 66 (17.1%)

3 32 (8.3%)

4 19 (4.9%)

Total 385 (100.0%)

Distribution of Salmonella isolates by gender and age group (Jan. 05-Dec. 05)

Age group Females(%) Males(%) Total

1> 62) 18.0%( 66) 19.5%( 128) 18.7%(

1-4 119) 34.5%( 137) 40.5%( 256) 37.5%(

5-9 22) 6.4%( 28) 8.3%( 50) 7.3%(

10-14 13) 3.8%( 15) 4.4%( 28) 4.1%(

15-44 59) 17.1%( 37) 11.0%( 96) 14.1%(

45-64 36) 10.4%( 29) 8.6%( 65) 9.5%(

65<= 34) 9.9%( 26) 7.7%( 60) 8.8%(

Total 345) 100.0%( 338) 100.0%( 683) 100.0%(

Distribution of Salmonella isolates by serogroup

1

160

207

132

233

16 311

43

0

100

200

300

400

500

600

Salmonella A Salmonella B Salmonella C1 Salmonella C2 Salmonella D Salmonella E Salmonella F Salmonella G Salmonella Spp.

Salmonella Serogroup

Nu

mb

er o

f Is

ola

tes

Five most often isolated Salmonella serotypes (Jan 05-Dec05)

Salmonella serotype Number of Isolates (%)

S. Enteritidis 185) 23%(

S. Typhimurium 57) 7%(

S. Virchow 72) 9%(

S. Hadar 48) 6%(

S. Infantis 35) 4%(

Others 392) 51%(

Total 789) 100.0%(

The five most common Salmonella serotypes by age group (Jan 05-Dec05)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Iso

late

s P

erce

nta

ge

<1 1-4 5-9 10-14 15-44 45-64 >=65

Age Group

S. Enteritidis

S. Typhimurium

S. Virchow

S. Hadar

S. Infantis

Phage types of S. Typhimurium in a subsample (n=26) of S. Typhimurium isolates

Group238.5%

R97.7%

Group130.8%

2 (4+)23.1%

Phage types of S. Enteritidis in a subsample (n=65) of S. Enteritidis isolates

F330.8%

B340.0%

C820.0%

F19.2%

Population survey on the burden of diarrheal diseases

• We conducted a nationwide population based survey to estimate the burden of diarrheal diseases among children and adolescents and assess the level of under reporting in Israel.

• A telephone based population survey was conducted during August, September and October 2005.

• 3141 phone number have been selected randomly from all the phone books of Israel.

Flow chart of households selection process

3141Phone calls

6% (189)Business / Fax

12.8% (401)Non-working

phone numbers

56.3% (1769)Households participated

19.9% (626)Refused to participate

4.9% (156)No answer

38.4% (680)Households with al least

one child under 17

61.6% (1089)Households without a

child under 17

7.2% (49)Households with at least one child with diarrhea

92.8% (631)Households without any

child with diarrhea

The chain of events from occurrence of cases of diarrhea in the general population to reporting

Reporting

Positive laboratory cultures

Provided a stool specimen for culture

Asked to provide a stool specimen

Visited a physician 38.8% 38.8%

21.2% 8.2%

100% 8.2%

4.28% 0.35%

0.22%63.5%

Subjects with diarrhea 100% 100%

Rate Cumulative

Factors associated with

Physicians‘ Decision to

Request the Performance of

Stool Cultures

from Patients with Diarrhea

Objectives1. To determine what proportion of physicians

requests in Israel the performance of stool cultures from patients with diarrhea.

2. To determine what patient and physician-related characteristics are associated with a stool culture request.

3. To estimate and characterize biases in morbidity data based on culture-proven cases of foodborne diseases.

Methods• The study was conducted in collaboration

with one of the Health Maintenance Organization (H.M.O.) operating in Israel.

• We performed a survey through questionnaires distributed among pediatric physicians.

Collection of questionnaires from the physicians approached and the level of compliance

444 Questionnaires sent

141 Returned the questionnaire

286 Didn't return the questionnaire

153 Phone connections established

7 Refused to participate

146 Asked again to return the questionnaire

80 Returned the questionnaire

66 Didn't return the questionnaire

17 Left the HMO Maccabi

Proportion of pediatricians determined by the various factors to request a stool culture

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Fever above 30oC

Bloody diarrhea

Abdom

inal pain

Dehydration

Associated w

ith an outbreak

Recent travel to developing country

Diarrhea for >3 days

Repeated com

plaint

Imm

une-comprom

ised

Proxim

ity to the specimen collection site

Age

The relative importance of various factors in the physicians' decision to order a stool culture

Proximity to the specimen

collection site 0%

Fever above 30oC 2%

Age 3%

Bloody diarrhea 71%

Associated with an outbreak 3%

Abdominal pain 1%Dehydration 1%

Recent travel to developing country 3%

Diarrhea for >3 days 9%

Immune-compromised 3%

Repeated complaint 4%

Risk Factors for Enteric Infections Caused by Salmonella Virchow among

young children in Israel

A Matched Case Control Study

Finished, data will be shared shortly