Monthly Newsletter of National Centre for Disease ControlDirectorate - PDF document

1 Alert Monthly Newsletter of National Centre for Disease Control,Directorate General of Health Services, Government of India 2 due to Norwalk-like virus in 2002.2. Chemical Food poisoningToxic compounds like lectins and glycoalkaloidscompounds like pesticides, heavy metals andtonnes in 2004, and rampant use of thesechemicals has lead to several short-term andlong-term effects. The first report of pesticideover 100 people died after consuming food madefrom wheat flour contaminated with parathion. In1997, a food-borne outbreak ofcontaminated with pesticide residues in India.CLASSIFICATION OF FOOD-BORNE - caused bywith bacteria, viruses, or parasites. TheseInvading and multiplying in the lining ofconsuming foods or beverages alreadycontaminated with a toxin. Sources ofMycotoxins of importance in India includea real threat to human health. An outbreak ofUnder the Integrated Disease Surveillancereported from all over India in 2009 increased tomore than double as compared to the previousreporting. Etiological diagnosis was not made inIn one outbreak, groundnuts were reported asactual n

umber of outbreaks may be much higher,reported.INFECTIONS VERSUS INTOXICATIONS INFECTIONSINTOXICATIONSBacteria / Viruses /T Invade and / or multiplyNo invasion or Hours to daysMinutes to hoursDiarrhoeaNausea /Vomiting, Nausea,nalDiarrhoeacramps± FeverDouble vision TransmissionCan spread fromNot communicable via the faeco-oral routeInadequate cookingInadequate cookingto foodCroos-contaminatiohygienetemperaturesPATHOGENESIS 3 TYPES OF BACTERIAL FOOD POISONING IllnessStool M/EWateryNo faecalETEC, EAggEC, (enterotoxin)smalldiarrhoeal Colon /Dysentery /PMN faecalShigella, Salmonella, (invasion /inflammatorylCl. difficile, E. histolytica Salmonella typhi, Y. enterocolitica,Campylobacter fetus caused by contaminants like heavy metals,E. coli on the other – 10PATHOGENS AND TOXINSfrom animal or human faeces. Animalsanimals. During slaughter, meat and poultryare exposed to small amounts of intestinalin infected lesions and normal nasal florafood-handler to ready-to-eat foods.insufficient cooking bacteria can multiply 4 SOME IMPORTANT FOOD-BORNE PATHOGENS, TOXINS AND CHEMICALSPATHOGENS Ent

ero Toxigenic Salmonella (non Typhi) sps (EPEC)Shigella Brucella sppEntero-Haemorrhagic Campylobacter sppEntero-Invasive E. coli Clostridium botulinumListeria monocytogenesVibrio parahaemolyticus ngensSalmonella typhi S. paratyphiYersinia enterocolitica Viruses Hepatitis A virusNorovirusRotavirus Hepatitis E virusPoliovirus Entamoeba histolyticaT sGiardia lamblia Trematodes Fasciolopsis buskiOpisthorchis vive Fasciola hepaticaOpisthorchis felineus Cestodes Diphyllobothrium sppEchinococcus sppHymenolepis nana Taenia solium / saginata Nematodes Ascaris lumbricoidesTrichinella spiralisTrichuris trichiura BACTERIAL FOOD POISONING I.P.CauseSymptomsNausea, Vomiting,Ham, poultry, potato / egg salad, Nausea, Vomiting,Fried rice Abdominal cramps,Beef, poultry, legumes, graviesWatery diarrhoeaShell-fishWatery diarrhoeaSalad,Bloody diarrhoeaBeef, salami, raw milk / vegetables, appleBeef, poultry, eggs, diary productsPoultry, raw milkDysenteryPotato / egg salad, lettuce, raw eggsV. parahaemolyticusDysenteryMolluscs, crustaceans 5 Marine biotoxinsTMushroom toxinsPhytohaemagglutinin (red kid

ney Shellfish toxins (paralytic,Mycotoxins (e.g. amnesic)Scombroid poisoning/Plant toxicants histamine RadionuclidesNitrites (food preservatives) Toxic metals (cadmium, copper, lead, mercury, tin)Polychlorinated biphenylsZincMonosodium glutamateevaluation and management of these cases. Duringor antibiotic use, as well as presence of blood orcan provide valuable clues to the aetiology.During the clinical examination, special attentiondehydration and abdominal examination. In an Indiana fatal outcome. Presence of fever, systemicINVESTIGATIONThe investigation and control of food-bornedisease outbreaks require multi-disciplinary skillsin the areas of clinical medicine, epidemiology,chemistry, food safety and food control, besidesSteps of Outbreak Investigation1.Establishing the existence of an outbreakInformation about the person(s) reporting theSpecific symptoms experiencedTotal number of persons exposed / notSpecific food item or drink consumed,meals or activities 6 MAJOR FOOD-BORNE HAZARDS: CLINICAL FEATURES & SAMPLESPredominant symptomsAssociatedSamples fromorganism or toxincases

(and food-handlers) Upper gastrointestinal tract symptoms (nausea, vomiting) occur first or predominate hourNausea, vomiting, unusual taste, burning of mouth.Metallic saltsVomit, urine, blood, stool1–2 hoursNausea, vomiting, cyanosis, headache, dizziness, dyspnoea,Nitrites 1–6 (mean 2–4)Nausea, vomiting, retching, diarrhoea, abdominal pain,Stool, vomit, (swabs from and its enterotoxinsnostril, skin lesions)8–16 hoursVomiting, abdominal cramps, diarrhoea, nausea Mycotoxins (Amanita sp.Urine, blood (SGOT, 12–48 (medianNausea, vomiting, NorovirusS 36 hours) Abdominal cramps, diarrhoea (putrefactive diarrhoea hours- 6…96 hoursFever, abdominal cramps, diarrhoea, vomiting, headache 6 hours to 5 daysAbdominal cramps, diarrhoea, vomiting, fever, malaise,(O1 andStoolV. vulnificus,mucoid diarrhoea, cutaneous lesions associated withV. fluvialis, Vibrio vulnificus)V. parahaemolyticus1-10 (median 3-4)Diarrhoea (often daysvomiting, malaise, fever (uncommon with Fever, vomiting, watery non-inflammatory diarrhoeaRotavirus, astrovirus, Fever, diarrhoea, abdomYersinia enterocolitica Mucoid diarrh

oea (fatty stools) abdominal pain, flatulence, eeksAbdominal pain, diarrhoea, constipation, headache, 3-6 monthsNervousness, insomnia, hunger pains, anorexia, weightTaenia saginata, T. 7 Predominant symptomsAssociatedSamples fromorganism or toxincases (and food-handlers) Neurological symptoms (visual disturbances, vertigo, tingling, paralysis) Less than 1 Neurological and/or gastrointestinal symptomsGastroenteritis, nervousness, blurred vision, chest pain,Or Muscaria-typeV 1…6 hoursTingling, numbness, gastroenteritis (GE), temperatureCi pupils, blurred vision, paralysisNausea, vomiting, tingling, dizziness, weakness, anorexia,Chlori weight loss, confusion(insecticides, pesticides)w2 hours to 6 days,Vertigo, double / blurred vision, loss of light reflex, difficultyusually 12…36 hoursin swallowing, speaking & breathing, dry mouth, weaknessand its neurotoxinsw � 72 hoursNumbness, weakness of legs, spastic paralysis, impairmentO Allergic symptoms (facial flushing, itching)Less than 1 hourHeadache, dizziness, nausea, vomiting, peppery taste inHistamine (scombroid)Vomit Peri-ora

l numbness, tingling sensation, flushing, dizziness,Monosodium glutamate headache, nauseaFlushing, itching, abdominal pain, puffing of face and kneesNicotinic acid (additive / preservative) Generalized infection symptoms (fever, chills, malaise, prostration, aches, swollen lymph nodes)4…28 (mean 9) daysGastroenteritis, fever, oedema around eyes, perspiration,Trichinella spiralis Malaise, headache, fever, Varying periodsFever, chills, headache, C. jejuni, B. anthracis,(depends on specifics Fr. tularensis,P. multocida 2.Coordination with key personnelfood inspectors, microbiologists and healthcare3.Collection and transport of clinicalstool samples have to be collectedas Enteric fever, Listeriosis or viral hepatitis,although, serology has a limited role for mostStool sample collection should be encouragedwhenever a person is experiencing or haspossible, collection of stool samples should beginTesting of all ill individuals is neither usefulfew randomly selected patients is usuallysufficient to confirm the diagnosis in outbreakto shed the pathogen in their stool even aconfirmation, p

ositive results, or definitivediagnosis, pathogens may still be implicatedand public health measures may bethe outbreak investigation.4.Implementation of control and preventive5.Definition of cases, population at risk andThe case definition in the setting of anclassified appropriately. Good case. Good casethree or more loose stools in a 24-hourperiod] with vomiting or nausea). Thepopulation at risk provides the denominator6.Description of epidemiology (in time,Tools that may be used to organize and depictthe outbreak by time, place, and personinclude epidemic curves, maps and frequency7.Development of possible hypotheses 9 8.Planning and conducting anthose affected and not affected by the9.Analysis of the data collected andfinalize the data include the following:In a retrospective cohort study, calculatestudy, calculate the odds ratios10.Reporting the findings of the outbreakinvestigation. A written report provides aof the outbreak for potential medico-legalbackground, methods, results,LABORATORY The main objectives of laboratory analysis during(1)Confirm the clinical diagnosis by

isolation of(2)Ensure proper identification of the disease,(3)Determine if the same causative agent isprofile, pulsed field gel electrophoresis, PCR,Most food-borne infections are diagnosedcollected from infected persons. Vomitus has alsoconfirm the aetiology. Blood samples areVomitus / gastric aspirate can also be testedcontainer, such as a screw-capped bottle (or aask the patient to vomit in a clean container, bowlor plastic bag and transfer the vomitus to thescrew-capped container with a clean spoon.the lid with tape.Microbiological analysis of food supports theepidemiological investigation of a food-borne 10 investigation should be treated as official samplesthe food as it was prepared, served, or used inStir or shake the liquid food item and pourproof container.- name and type of product, brand of product,number, collected by, date, time, and placeof collection, and establishment’s name.in a zip-lock bag and sealed. Cold chain shouldbe maintained during transport by sendingsample in vaccine carrier with ice packs, avoidoutbreak investigation does not have medico-Prevention o

f Food Adulteration Act, 1954.TREATMENTpoisoning should focus on assessment andSpecific treatment in case of pesticide poisoningof sodium with a total osmolarity of 311 mOsm/l.Because of the improved effectiveness ofand UNICEF now recommend that countries use LINICAL APPROACH TO OOD OISONING CASESFP*(adapted from Harrison's Principles of Internal Medicine, 17 edition, 2008) Assess duration (if� 1day)and (if high)severity Continued illness Non-inflammatory(No WBCs)- Symptomatic treatment - Further evaluation if no resolution Inflammatory(WBCs and/or RBCs)- Culture -Salmonella, Shigella, Campylobacter, toxin Cl. difficile Parasites(parasites seen) specific (anti-parasitic)treatment Stop YesIf more than �10 daysSamples that cannot be shipped in theiritem should be taken from the geometric 11 REDUCED OSMOLARITY ORS FORMULATIONSodium chloride2.6Glucose, anhydrous13.5Potassium chloride1.5Trisodium citrate, dihydrate2.9CCEPTABLESodium75Chloride65Glucose, anhydrous75= Na but 111Potassium20Citrate10Total Osmolarity245200-310 mmol/lHazard Analysis and Critical Con

trol Pointand biological hazards as a means of preventionsystem is used in the food industry at all stagesPRINCIPLES OF HAZARD ANALYSIS AND CRITICAL CONTROL POINT (HACCP)1.Analyse hazards - Potential hazards associated with a food and measures to control thosehazards (biological, e.g. a microbe; chemical, e.g. a toxin; or physical, e.g. ground glass or2.Identify critical control points - These are points in a food’s production - from its raw state3.Establish preventive measures with critical limits for each control point - For a cookedfood, for example, this might include setting the minimum cooking temperature and time required4.Establish procedures to monitor the critical control points - 5.Establish corrective actions when monitoring shows that a critical limit has not been - For example, reprocessing or disposing of food if the minimum cooking temperature is6.Establish procedures to verify that the system is working properly - For example,testing time-and-temperature recording devices to verify that a cooking unit is working properly.7.Establish effective record keeping for do

cumentation - 12 ...about CD AlertChief Editor:Dr. R. K. SrivastavaEditorial Board:Dr. R. L. Ichhpujani, Dr. Shashi Khare, Dr. A. K. HaritGuest Editor (Authors):Dr Anuj Sharma, Dr. Sampath Krishnan, Dr D.Chattopadhya, Mr. Ramesh Aggarwal, Dr Arti BahlPublisher:Director, National Centre for Disease Control, 22 Shamnath Marg, Delhi 110 054Tel: 011-23971272, 23971060 Fax : 011-23922677 dirnicd@bol.net.in and dirnicd@gmail.com Ww.nicd.nic.inPrinted at IMAGE, 6, Gandhi Market, Minto Road, New Delhi-110 002, Phones : 23238226, 98111168411.Keep CleanWash your hands before handling food and often during food preparationWash your hands after going to the toiletWash and sanitize all surfaces and equipment used for food preparation2.Separate raw and cooked foodStore food in containers to avoid contact between raw and prepared foods3.Cook thoroughlyCook food thoroughly, especially meat, poultry, eggs and seafood4.Keep food at safe temperaturesUse safe water or treat it to make it safeChoose foods processed for safety, such as pasteurized milkWash fruits and vegetables, especially if eaten