Surveillance

  • Posted: August 23rd, 2012 - 9:35pm by Doug Powell

    There was this one time, Chapman came to Manhattan (Kansas) and lasted one quarter of a Kansas State football game before rushing home with explosive diarrhea.

    My whiny kid didn’t help either.

    He spent the rest of the visit holed up downstairs, sucking back Gatorade and sitting on the toilet.

    When he got back to North Carolina he had the wherewithal to donate a stool sample, and eventually found out he was part of a state-wide antibiotic-resistant campylobacter outbreak.

    In light of the German-based E. coli O104 outbreak in raw sprouts last year, researchers in Germany and Sweden are now calling for all stool samples from patients with diarrhea to be tested for enteropathic E. coli.

    Writing in Eurosurveillance, the authors state:

    Following an outbreak of enterohaemorrhagic Escherichia coli (EHEC) in Germany 2011, we observed increases in EHEC and non-EHEC E. coli cases in Bavaria. We compared the demographic, clinical and laboratory features of the cases reported during the outbreak period, but not related to the outbreak, to the cases reported before and after. The number of EHEC and non-EHEC E. coli cases notified per week during the outbreak was fivefold and twofold higher respectively, compared to previous years. EHEC cases notified during the outbreak were more often reported with bloody diarrhoea, and less often with unspecified diarrhoea, compared to the other periods. They were more often hospitalised during the outbreak and the following period compared to the period before. Their median age (26.5 years, range: 0–90) was higher compared to before (14.5 years, range: 0–94) and after (5 years, range: 0–81). The median age of non-EHEC E. coli cases notified during the outbreak period (18 years, range 0–88) was also higher than before and after (2 years, p<0.001). The surveillance system likely underestimates the incidence of both EHEC and non-EHEC E. coli cases, especially among adults, and overestimates the proportion of severe EHEC cases. Testing all stool samples from patients with diarrhoea for enteropathic E. coli should be considered.

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  • Posted: July 30th, 2012 - 6:00pm by Doug Powell

    Only Washington-types could take a story about recent successes and failures in foodborne illness rates and surveillance – 18 fascinating papers -- and turn it into a whine about how lobbyists were excluded from access, ahead of mere mortals.

    The Washington Post reports that unlike last year, the U.S. Centers for Disease Control released the data without reaching out to consumer groups and other key stakeholders who typically are notified in advance. Instead, the charts and graphs were quietly posted online Friday.

    I’m not sure who these key stakeholders are, and how many of them are self-proclaimed. The solution is for CDC to publish a press release summarizing the findings, note their existence, and releasing it to everyone at the same time.

    And only in Washington would people whine that delayed passage of the Food Safety Modernization Act is leading to increases in foodborne illness.

    “Everyone was hoping that this new food safety law would be in place and we’d start seeing improvements by now,” said Erik Olson, a director at the Pew Health Group. “What these CDC numbers show is that unless new protections are put into place, millions of Americans are going to continue to get sick from contaminated food.”

    I’m immediately suspicious of people who speak on behalf of everyone (and people who say trust me). I have yet to see a credible, detailed analysis that shows FSMA will lower rates of foodborne illness.

    But that’s the bizness of Washington. They don’t seem good at it.

    Four years ago, the CDC numbers yielded the same story – rates were stagnant, but still way too many sick people. There is no evidence educational campaigns do anything except make people feel like they are doing something, there is no evidence legislation does much, yet that’s always the punchline: we need more laws, we need more education.

    Doesn’t work.

    We need new messages using new media to really create a culture that values microbiologically safe food.

    That’s what I said four years ago, it could have been 20 years ago. Same as it ever was.
    The most recent figures from the Centers for Disease Control and Prevention show that the rates of infections linked to four out of five key pathogens it tracks — salmonella, vibrio, campylobacter and listeria — remained relatively steady or increased from 2007 through 2011. The exception is a strain of E. coli, which has been tied to fewer illnesses in the same time frame.

    The CDC found that the most frequent cause of infection in 2011 was salmonella, followed by campylobacter.

    Below are actual excerpts from the CDC summary report. All 18 abstracts will appear on bites-l as soon as I complete a long plane ride, custom(s) probing, and return to the land of unlimited Internet.

    Foodborne disease is an important public health problem in the United States, with an estimated 9.4 million domestically acquired illnesses and 1351 deaths from known pathogens each year. The Foodborne Diseases Active Surveillance Network (FoodNet) tracks important foodborne illnesses, generating information that provides a foundation for food safety policy and prevention efforts. FoodNet has provided information that contributes to food safety efforts by estimating numbers of foodborne illnesses, monitoring trends in incidence of specific foodborne illnesses over time, attributing illnesses to specific foods and settings, and disseminating information. Since it started in 1996, FoodNet has been an excellent example of partnership among federal and state agencies. This Clinical Infectious Diseases supplement contains a variety of articles that provide new information on current issues; together, they highlight FoodNet’s central role in U.S. surveillance and investigation of foodborne disease.

    FoodNet’s core work is ongoing active, population-based surveillance for laboratory-confirmed infections caused by 9 pathogens transmitted commonly through food, as well as for hemolytic uremic syndrome. Several articles in this supplement report on these core data, examining trends and providing regulatory and public health agencies, industry, and consumer groups with data needed to prioritize and evaluate food safety interventions and monitor progress toward national health objectives. For example, Ong et al report the dramatic decline in Yersinia enterocolitica infections since 1996, particularly among young black children. Not all the news is good, however; Newton et al [analyze data from FoodNet and the Cholera and Other Vibrio Illness Surveillance System (COVIS), showing that Vibrio infections have increased nationally. Two articles in this supplement examine FoodNet surveillance data on invasive listeriosis. The article by Silk et al summarizes trends in surveillance data from 2004 to 2009, whereas Pouillot et al use FoodNet surveillance data to estimate the relative risk of listeriosis by age, pregnancy, and ethnicity, providing new insights into variations in risk across the population. Together, these articles emphasize that to substantially decrease the incidence of listeriosis, prevention measures should target higher-risk groups, particularly pregnant women, especially Hispanics, and older adults. Hall et al examine trends in Cyclospora infection, showing that outbreaks and international travel play an unusually large role in the epidemiology of these infections and suggesting that prevention efforts would most effectively focus on foods from and travel to endemic areas.

    FoodNet continuously works to improve the quality of its surveillance data and methods for analysis. In this supplement, Henao et al describe the methods and rationale surrounding the introduction, in 2011, of a measure of overall change in the incidence of infection over time using surveillance data on infections caused by 6 bacterial pathogens. This measure, which provides a comprehensive picture of changes in incidence of foodborne infections, documents a 23% decline overall in incidence for these pathogens in 2010 compared with the first 3 years of surveillance (1996–1998). Although it does not replace pathogen-specific trend data, this summary measure can help inform the development and assessment of policies and interventions to prevent foodborne illness. Another article, by Manikonda et al, reports on a study to validate the reporting of deaths in FoodNet surveillance, an important issue because deaths, although rare, are disproportionately responsible for the economic and human costs of foodborne disease. Finally, Ong et al examine the impact of case ascertainment strategies and case definitions on surveillance for pediatric hemolytic uremic syndrome in FoodNet.

    Several articles in the supplement elucidate aspects of the “surveillance steps” that are necessary for a case of infection to be ascertained by FoodNet surveillance. FoodNet and many other surveillance systems for bacterial enteric infections are based on culture-confirmed infections, so FoodNet surveillance data must be interpreted in the context of the “surveillance steps” that lead to culture confirmation: the ill person must seek medical care, a stool specimen must be submitted, and the clinical laboratory must test for and identify the pathogen. In particular, the recent and ongoing shift among clinical laboratories toward culture-independent methods for detecting enteric pathogens is of great importance.

    In 2011, the CDC released new estimates of the number of foodborne illnesses in the United States, the Food Safety Modernization Act was signed into law, and new national health objectives for foodborne illness were set as part of the Healthy People 2020 goals. All of these initiatives, as well as continued concern about food safety on the part of the public and policy makers, emphasize the need for precise and accurate information about foodborne disease. Regulators and other public health officials, consumer advocates, industry, and others need information on trends, high-risk populations, and the foods causing illness so that interventions can be targeted most efficiently and effectively. FoodNet provides the articles in this supplement as part of its efforts to disseminate the results of its surveillance and analytic work. Although FoodNet surveillance is conducted in a geographic area that covers only 15% of the US population, the data it generates are a valuable resource for the entire United States. The FoodNet program shows the impact that high-quality, nationally coordinated surveillance can have on public health and policy.

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  • Posted: July 17th, 2012 - 5:34am by Doug Powell

    Mike Doyle, Regents Professor and director of the Center for Food Safety, University of Georgia, writes in China Daily today:

    “The food-borne disease surveillance system in the United States has become so robust that it has detected hundreds of outbreaks in the past six years that previously would likely have gone unrecognized.

    “This has resulted in many foods being newly identified as vehicles of illnesses. This increased awareness of weaknesses in the U.S. food safety net has by and large led to the Food Safety Modernization Act, which will raise the level of attention that food producers, processors, distributors and importers must give to ensuring their products are safe for human and animal consumption.

    These new regulations will have direct relevance to the Chinese food industry, especially if foods or ingredients from China are exported to the U.S.. Also, many of the new rules, if applied in China, could enhance the overall safety of its food supply. …

    “Although federal oversight of food processors is important, there is a fundamental principle that must be adopted by the entire food industry for a food safety net to be robust and effective. Everyone involved in the food continuum must be focused foremost on providing consumers with safe foods. Producers who are more motivated by economics and consider food safety to be secondary can undermine public confidence and the integrity of a country's entire food system.

    The approaches to enhancing the safety of the U.S. food supply are largely the result of decades of experience by food safety regulatory agencies and the food industry in mitigating the risk of food contamination.

    With a national food safety program under development in China, the Chinese food industry and regulatory agencies could readily benefit from the U.S. experience in improving the safety of their foods by adopting and implementing similar practices and policies.

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  • Posted: May 31st, 2012 - 8:50pm by Doug Powell

    In May, 2011, the delayed reporting of cases between agencies due to a decentralized government and its agencies was a contributing factor in the Germany-based E. coli O104 outbreak that led to 53 deaths and over 4,000 sick people. The E. coli strain responsible for the outbreak was unusually virulent, with high mortality and hemolytic uremic syndrome (HUS) rates observed in healthy adults.

    A year later, Marian Turner writes in Nature that governments have made little progress towards improving the monitoring and reporting systems that allowed the crisis to drag on for weeks.

    Although the panic has sparked some proposed policy changes, these have become mired in political debate at both German and European levels.

    Under Germany’s current system, it can take up to 18 days for local and state health departments to relay case reports to the Berlin-based Robert Koch Institute (RKI), the German federal agency for disease surveillance. Legislators have proposed a law to bring the country’s disease-reporting schedule into line with the World Health Organization’s International Health Regulations. The law would require local health authorities to report cases of notifiable diseases to state authorities on the next working day; the states would then have another day to relay the information to the RKI. “We’ve been waiting almost a decade for this,” says Alexander Kekulé, a microbiologist at the Martin Luther University of Halle-Wittenberg in Halle, Germany.

    The draft law has been passed by Germany’s federal parliament but is stuck in negotiations at the legislative council that represents Germany’s 16 states. For scientists, though, this change would still not be enough. “What really delayed the detection of this outbreak was the irregularity with which patients were referred for microbiological follow-up,” says Gérard Krause, an epidemiologist at the RKI. Like many European countries, Germany does not require that a patient with bloody diarrhoea or haemolytic uraemic syndrome (a life-threatening complication of some E. coli infections) be tested for the causative bacterial strain. The same is true of the United States.

    After the outbreak, German diagnostic laboratories were provided with kits to test samples for genes belonging to certain pathogenic strains of bacteria, such as those expressing particular toxins, or proteins involved in adhesion or invasion.

    But physicians are responsible for requesting the tests, and the cost is not covered by German health-insurance companies. “The problem is mostly getting the money to use these kits,” says Angelika Fruth, a microbiologist at the RKI, “and that situation is just the same as before the outbreak.”

    In the wake of the outbreak, the European Food Safety Authority concluded that sprouted seeds pose a particular food-safety concern, and recommended that a standardized test for sprouts be developed and adopted across the European Union (EU). But EU member countries are still discussing the proposal, and scientists have yet to develop reliable methods to isolate pathogenic bacteria from seeds or sprouts.

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  • Posted: May 11th, 2012 - 3:15pm by Doug Powell

    The French published their own series of detailed foodborne disease surveillance papers, and did it the day before the Americans.

    A special issue of the Bulletin épidémiologique hebdomadaire (BEH) and the Bulletin épidémiologique Anses-DGAL, May 2012, number 50, Microbiological hazards in food products of animal origin: monitoring and evaluation contains 13 research papers.

    In an editorial, the author writes foodborne illness surveillance is an important and complex issue. Important because tens of thousands of cases of foodborne outbreaks are still reported each year, complicated by the difficulty in assessing and controlling the risk throughout the supply chain -- from the farm to the fork.

    Thanks to Albert Amgar for passing along the information and some translation.

    The abstracts are available at http://www.anses.fr/bulletin-epidemiologique/Documents/BEP-mg-BE50.pdf and are available in English. They are also available in the daily bites-l listserv and at bites.ksu.edu.

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  • Posted: May 11th, 2012 - 12:46am by Doug Powell

    surveillance.jpg

     Based on numerous media interviews today, the take-home message will be, foodborne illness has declined by 23 per cent over 14 years.

    Nope.

    Instead, what the U.S. Centers for Disease Control has done is publish 18 papers today that provide a glimpse into the intricacies, problems and potential of foodborne illness surveillance. There are many caveats, there will be many criticisms, but the approach is consistent with a risk analysis approach to problems: this is what we know, these are the assumptions we made, this is what we think it means, let’s discuss how to make it better.

    And bring evidence to the table.

    The papers also highlight the complexities of food-pathogen interactions while reinforcing that food safety happens in lots of places in lots of ways, from farm-to-fork. The next time someone says food safety is simple, roll your eyes, walk away, respond with derision, whatever your preference.

    But bring some data to the table. This issue of Clinical Infectious Disease will help with that.

    Below are the urls for the 18 abstracts:

    http://cid.oxfordjournals.org/content/54/suppl_5/S381.extract
    http://cid.oxfordjournals.org/content/54/suppl_5/S385.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S396.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S405.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S411.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S421.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S424.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S432.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S440.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S446.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S453.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S458.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S464.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S472.abstract
    http://cid.oxfordjournals.org/content/54/suppl_5/S480.abstract http://cid.oxfordjournals.org/content/54/suppl_5/S498.abstract

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  • Posted: April 30th, 2012 - 11:09am by Doug Powell

    On March 23, 2010, the national food surveillance system in Denmark reported a steady occurrence of positive isolates of S. Typhimurium, of unknown phage type and resistant to ampicillin, streptomycin and sulphamethoxazole, in samples from mainly pork meat and products.

    Researchers from Denmark and Sweden report in Epidemiology and Infection that several isolates originated from a specific pig slaughterhouse A or a closely associated cutting plant. At this point, although no human cases had yet been identified, an investigation was initiated with the focus on food contamination. On 20 April, a total of 14 human cases with the outbreak type had been confirmed.

    A case-control study was undertaken to confirm an association between illness in a subgroup of patients and consumption of teewurst or tea sausage, a spreadable sausage made from fresh salted and smoked pork and beef which is fermented but not heat-treated. The producer of the teewurst had received pork from slaughterhouse A during the period that the outbreak strain had been isolated.

    Herds delivering pigs to slaughterhouse A were identified by a unique herd identification number given to all animal herds in Denmark.

    From March 2010 and onwards, the outbreak strain was identified in a total of 113 samples; four environmental samples from slaughterhouse A and 109 meat
    samples, mainly pork, of which 96 were sampled directly at slaughterhouse A or could be traced back there. Positive meat types included mainly minced pork, pork belly, pork loin and loin back ribs.

    Investigation of slaughterhouse A showed positive discovery of the outbreak strain in swabs from equipment and meat samples, even after closing down production for thorough cleaning and disinfection. It was concluded that the establishment was most likely contaminated. Repeated cleaning and disinfection was performed and alterations in equipment and procedures were implemented, From the beginning of July, no further positive samples of the outbreak strain were found at slaughterhouse A.

    On 8 July, a press statement was issued jointly by the DVFA and SSI, notifying the public about the salmonellosis outbreak and the link to consumption of pork meat from slaughterhouse A. In addition to describing the outbreak investigation and the action taken to control the outbreak, the statement also contained detailed guidelines on how to prevent infection with Salmonella.

    A total of 172 cases of S. Typhimurium U323 were reported between March and September 2010 in Denmark demonstrating how a combination of typing Salmonella isolates from farm-to-fork and from the human population can provide early warning of a salmonellosis outbreak. It also highlights the importance of national Salmonella surveillance which allowed identification of the slaughterhouse contamination and provided the COMG with valuable information to initiate investigative measures. In spite of the existence of these systems, tracing pork meat that has entered the production chain still poses a significant challenge. If feasible, adoption of a standardized automated system across the EU, with detailed product and distribution information, for tracing products might prove worthwhile.

    Currently, this is not possible in the EU and such systems are only as good as the data provided by the operators. At present, by the time enough evidence has been gathered to issue a product recall, products with a short shelf-life (such as fresh meat) are most likely to have been consumed.

    In this outbreak, early warnings from the Salmonella surveillance system were not sufficient to prevent the outbreak from lasting almost 7 months.

    State-of-the-art surveillance, typing, epidemiology and food traceback allowed us to firmly establish the source of the outbreak and, in essence, solve it almost before it became evident; however, legislative measures and some delays in traceback did not allow for sufficient control, resulting in one of the longest lasting Salmonella outbreaks in Denmark.

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  • Posted: April 20th, 2012 - 3:15pm by Doug Powell

    The latest report from Canada’s National Integrated Enteric Pathogen Surveillance System has hit the Intertubes. Think of it as FoodNet, 15 years late.

    Only bureaucrats could have written this.

    In 2010, campylobacteriosis, salmonellosis and giardiasis (beaver fever? Oh, it’s Canada) were the most common enteric diseases in C-EnterNet’s sentinel sites, with rates of 29.5/100,000, 26.0/100,000 and 14.2/100,000, respectively. Overall, the number of endemic, travel- and outbreak-related cases reported in SS1 in 2010 were higher than that reported in 2009. In SS1, the incidence rate of campylobacteriosis, especially travel-associated infections, was higher in 2010 than 2009. The incidence rate of endemic salmonellosis has increased in both sentinel sites over the last couple of years, with SS2 steadily increasing since 2006.

    Travel continues to be an important factor in the burden of enteric disease. In 2010, 30% and 23% of all cases of enteric disease were associated with travel outside of Canada, in SS1 and SS2 respectively. In both sentinel sites, the travel-related proportion of cases, compared with endemic cases, was highest for cyclosporiasis (100% in both SS1 and SS2), shigellosis (83% (SS1) and 33% (SS2)) and cryptosporidosis (43% (SS1) and 60% (SS2)).

    C-EnterNet is an integrated enteric pathogen surveillance system based on a sentinel site surveillance model collecting information on both cases of infectious gastrointestinal illness and sources of exposure within defined communities. C-EnterNet’s primary objectives are to detect changes in trends in human enteric disease and levels of pathogen exposure from food, animal and water sources in a defined population; and to strengthen source attribution efforts in Canada by determining statistically significant risk factors for enteric illness.

    In 2010, C-EnterNet implemented a second sentinel site in part of the Fraser Valley in the lower mainland of British Columbia, in partnership with the Fraser Health Authority (FHA). The communities of Burnaby, Abbotsford and Chilliwack comprise the sentinel site within the Fraser Health Region. In this region, active surveillance of enteric pathogens is performed in the retail sampling of bagged leafy greens, and enhanced human disease surveillance is performed in collaboration with FHA and the BCCDC Public Health Microbiology and Reference Laboratory. In the first sentinel site, C-EnterNet continues its strong partnership with the Region of Waterloo Public Health within the Regional Municipality of Waterloo, Ontario and the Ontario Agency for Health Protection and Promotion’s Toronto Public Health Laboratory where enhanced surveillance of human cases of enteric disease in the community is performed. In parallel, active surveillance of enteric pathogens is performed in water, food and on farms.

    The purpose of this report is to present the preliminary findings from the 2010 surveillance year in both sentinel sites. Note that C-EnterNet data need to be considered in the context of two sentinel sites, thus major conclusions cannot yet be extrapolated nationally.1 This report will be followed by the Long Report, which will include more extensive analyses of temporal trends and subtyping information for an integrated perspective on enteric disease from exposure to illness for 2010.

    For further information about the C-EnterNet program or sampling methodologies, please refer to our website (http://www.phac-aspc.gc.ca/c-enternet/index-eng.php).

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  • Posted: March 15th, 2012 - 12:12am by Doug Powell

    Foodborne disease outbreaks caused by imported food appeared to rise in 2009 and 2010, and nearly half of the outbreaks implicated foods imported from areas which previously had not been associated with outbreaks, according to research from the U.S. Centers for Disease Control and Prevention, presented today at the International Conference on Emerging Infectious Diseases in Atlanta.

    “It's too early to say if the recent numbers represent a trend, but CDC officials are analyzing information from 2011 and will continue to monitor for these outbreaks in the future,” said Hannah Gould, Ph.D., an epidemiologist in CDC’s Division of Foodborne, Waterborne and Environmental Diseases and the lead author.

    CDC experts reviewed outbreaks reported to CDC’s Foodborne Disease Outbreak Surveillance System from 2005-2010 for implicated foods that were imported into the United States. During that five-year period, 39 outbreaks and 2,348 illnesses were linked to imported food from 15 countries. Of those outbreaks, nearly half (17) occurred in 2009 and 2010. Overall, fish (17 outbreaks) were the most common source of implicated imported foodborne disease outbreaks, followed by spices (six outbreaks including five from fresh or dried peppers). Nearly 45 percent of the imported foods causing outbreaks came from Asia.

    “As our food supply becomes more global, people are eating foods from all over the world, potentially exposing them to germs from all corners of the world, too,” Gould said. “We saw an increased number of outbreaks due to imported foods during recent years, and more types of foods from more countries causing outbreaks.”

    According to a report by the Department of Agriculture's Economic Research Service (ERS), U.S. food imports grew from $41 billion in 1998 to $78 billion in 2007. Much of that growth has occurred in fruit and vegetables, seafood and processed food products. The report estimated that as much as 85 percent of the seafood eaten in the United States is imported, and depending on the time of the year, up to 60 percent of fresh produce is imported. ERS also estimated that about 16 percent of all food eaten in the United States is imported. The types of food causing the outbreaks in this analysis aligned closely with the types of food that were most commonly imported.

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  • Posted: March 8th, 2012 - 7:01am by Doug Powell

    The European Food Safety Authority (EFSA) and the European Centre for Disease Prevention and Control (ECDC) have published their annual report on zoonoses and foodborne outbreaks in the European Union for 2010. The report shows that Salmonella cases in humans fell by almost 9% in 2010, marking a decrease for the sixth consecutive year. Salmonella prevalence in poultry is also clearly declining at the EU level.

    Campylobacteriosis remains the most reported zoonotic infection in humans since 2005 and the number of cases has been increasing over the last five years. This report supports the European Commission and EU Member States in their consideration of possible measures to protect consumers from risks related to zoonoses.

    According to the report, the likely main reasons for the decrease in human salmonellosis cases are the successful EU Salmonella control programmes for reducing the prevalence of the bacteria in poultry populations, particularly in laying hens[

    The report also gives an overview of other food-borne diseases. Human cases of Shiga toxin/verotoxin -producing Escherichia coli (STEC/VTEC) have been increasing since 2008 and amounted to 4,000 reported cases in 2010.

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