Outbreak oof calicivirus gastroenteritis associated with eating frozen raspberries

Sources and contamination routes of microbial pathogens to fresh produce during field cultivation: A review

Foodborne illness resulting from the consumption of contaminated fresh produce is a common phenomenon and has severe effects on human health together with severe economic and social impacts. The implications of foodborne diseases associated with fresh produce have urged research into the numerous ways and mechanisms through which pathogens may gain access to produce, thereby compromising microbiological safety. This review provides a background on the various sources and pathways through which pathogenic bacteria contaminate fresh produce; the survival and proliferation of pathogens on fresh produce while growing and potential methods to reduce microbial contamination before harvest. Some of the established bacterial contamination sources include contaminated manure, irrigation water, soil, livestock/ wildlife, and numerous factors influence the incidence, fate, transport, survival and proliferation of pathogens in the wide variety of sources where they are found. Once pathogenic bacteria have been introduced into the growing environment, they can colonize and persist on fresh produce using a variety of mechanisms. Overall, microbiological hazards are significant; therefore, ways to reduce sources of contamination and a deeper understanding of pathogen survival and growth on fresh produce in the field are required to reduce risk to human health and the associated economic consequences.

Microbiological Parameters in the Primary Production of Berries: A Pilot Study

The primary production of fresh soft fruits was considered to be a suspected critical point for the contamination of frozen berries that were responsible for the large 2013⁻2014 Hepatitis A virus (HAV) outbreak in Europe. In this study, an Italian berries’ production area was studied for its agro-technical characteristics, and the fresh fruits were analyzed for the presence of enteric viruses (HAV and Norovirus (NoV) genogroup I and genogroup II (GGI and GGII)), the enumeration of hygienic quality parameters, and the prevalence of bacterial pathogens. A total of 50 producers were sampled, who specialized in the exclusive or shared cultivation of berries. Escherichia coli was detected in two blackberry samples, whereas HAV and Norovirus were not detected. The samples were negative for Salmonella spp., Listeria monocytogenes, and Shiga toxin-producing Escherichia coli (STEC). The farms’ attributes were not associated with positive samples, apart from the presence of E. coli and the aerobic mesophilic bacteria for blackberry that were statistically correlated. In blueberries, the high aerobic mesophilic count could likely be associated with the resistance of the outer layer to handling. However, the two pathogens (Salmonella spp. and STEC) and the targeted viruses (HAV, NoV GGI and GGII) were not detected, highlighting the low risk of foodborne pathogens and viral contamination at the primary production stage of the berry food chain in the area considered in this pilot study.

Microbial pollution and food safety

Microbial pollution is a serious food safety issue because it can lead to a wide range of foodborne diseases. A great number of foodborne diseases and outbreaks are reported in which contamination of fresh produce and animal products occurs from polluted sources with pathogenic bacteria, viruses and protozoa and such outbreaks are reviewed and the sources are revealed. Investigations of foodborne outbreaks involved meat production and fresh produce, namely, that occurred at the early stages of the food chain have shown certain sources of contamination. Domesticated food animals, as well as wild animals, flies and rodents can serve as a source of contamination of nearby produce-growing fields and can lead to human infection through direct contact at farms and, mostly, mail order hatcheries. The most of the fresh produce associated outbreaks have followed wildlife intrusion into growing fields or fecal contamination from nearly animal production facilities that likely led to produce contamination, polluted water used for irrigation and improper manure. Preventive measures, as part of implemented good agricultural practice systems are described. Controlling and minimizing pre-harvest contamination may be one of the key aspects of food safety.

Evidence of the internalization of animal caliciviruses via the roots of growing strawberry plants and dissemination to the fruit

Human norovirus (NoV) is the leading cause of foodborne disease in the United States, and epidemiological studies have shown that fresh produce is one of the major vehicles for the transmission of human NoV. However, the mechanisms of norovirus contamination and persistence in fresh produce are poorly understood. The objective of this study is to determine whether human NoV surrogates, murine norovirus (MNV-1) and Tulane virus (TV), can attach and become internalized and disseminated in strawberries grown in soil. The soil of growing strawberry plants was inoculated with MNV-1 and TV at a level of 10(8) PFU/plant. Leaves and berries were harvested over a 14-day period, and the viral titer was determined by plaque assay. Over the course of the study, 31.6% of the strawberries contained internalized MNV-1, with an average titer of 0.81 ± 0.33 log10 PFU/g. In comparison, 37.5% of strawberries were positive for infectious TV, with an average titer of 1.83 ± 0.22 log10 PFU/g. A higher percentage (78.7%) of strawberries were positive for TV RNA, with an average titer of 3.15 ± 0.51 log10 RNA copies/g as determined by real-time reverse transcriptase quantitative PCR (RT-qPCR). In contrast, no or little virus internalization and dissemination were detected when TV was inoculated into bell peppers grown in soil. Collectively, these data demonstrate (i) virally contaminated soils can lead to the internalization of virus via plant roots and subsequent dissemination to the leaf and fruit portions of growing strawberry plants and (ii) the magnitude of internalization is dependent on the type of virus and plant.

A food-borne outbreak of gastroenteritis caused by norovirus GII in a university located in Xiamen City, China

OBJECTIVES

We investigated a diarrhea outbreak that occurred at a university in China to identify the etiological agent of the outbreak, source of infection, mode of transmission, and risk factors.

METHODS

In this case-control study, we compared the food sources and examined the food and water items consumed between the probable and confirmed cases and the asymptomatic control students, who were selected randomly and frequency-matched by class and age at a ratio of 1:2.

RESULTS

Out of 7141 students (excluding teachers), 87 (1.2%) developed an illness. Thirty-three of 44 (75%) cases and 11 of 88 (13%) control students had consumed bread products supplied by an unlicensed small bakery (odds ratio 21, 95% confidence interval 8-60). Norovirus GII was detected in seven patients and in a food handler at the bread workshop and his 8-month-old son.

CONCLUSIONS

The outbreak of gastroenteritis was caused mainly by bread products contaminated with norovirus GII. A food handler with an asymptomatic norovirus GII infection was the possible source of infection.

Foodborne norovirus outbreak: the role of an asymptomatic food handler

Background

In July 2005 an outbreak of acute gastroenteritis occurred on a residential summer camp in the province of Barcelona (northeast of Spain). Forty-four people were affected among residents and employees. All of them had in common a meal at lunch time on 13 July (paella, round of beef and fruit). The aim of this study was to investigate a foodborne norovirus outbreak that occurred in the residential summer camp and in which the implication of a food handler was demonstrated by laboratory tests.

Methods

A retrospective cohort study was designed. Personal or telephone interview was carried out to collect demographic, clinical and microbiological data of the exposed people, as well as food consumption in the suspected lunch. Food handlers of the mentioned summer camp were interviewed.

Ten stool samples were requested from symptomatic exposed residents and the three food handlers that prepared the suspected food. Stools were tested for bacteries and noroviruses. Norovirus was detected using RT-PCR and sequence analysis.

Attack rate, relative risks (RR) and its 95% confidence intervals (CI) were calculated to assess the association between food consumption and disease.

Results

The global attack rate of the outbreak was 55%. The main symptoms were abdominal pain (90%), nausea (85%), vomiting (70%) and diarrhoea (42.5%). The disease remitted in 24-48 hours. Norovirus was detected in seven faecal samples, one of them was from an asymptomatic food handler who had not eaten the suspected food (round of beef), but cooked and served the lunch. Analysis of the two suspected foods isolated no pathogenic bacteria and detected no viruses. Molecular analysis showed that the viral strain was the same in ill patients and in the asymptomatic food handler (genotype GII.2 Melksham-like).

Conclusions

In outbreaks of foodborne disease, the search for viruses in affected patients and all food handlers, even in those that are asymptomatic, is essential. Health education of food handlers with respect to hand washing should be promoted.

Enhanced reverse transcription-PCR assay for detection of norovirus genogroup I

We have developed a one-tube reverse transcription (RT)-PCR method using the real-time TaqMan PCR system for the detection of norovirus genogroup I (NV GGI). By introduction of a novel probe based on locked nucleic acid technology, we enhanced the sensitivity of the assay compared to those of conventional TaqMan probes. The sensitivity of the NV GGI RT-PCR was determined by probit analysis with defined RNA standards and quantified norovirus isolates to 711 copies/ml (95% detection limit). In order to detect PCR inhibition, we included a heterologous internal control (IC) system based on phage MS2. This internally controlled RT-PCR was tested on different real-time PCR platforms, LightCycler, Rotorgene, Mastercycler EP realplex, and ABI Prism. Compared to the assay without an IC, the duplex RT-PCR exhibited no reduction in sensitivity in clinical samples. In combination with an established NV GGII real-time RT-PCR, we used the novel assay in a routine assay for diagnosis of clinical and food-borne norovirus infection. We applied this novel assay to analyze outbreaks of nonbacterial acute gastroenteritis. Norovirus of GGI was detected in these outbreaks. Sequence and similarity plot analysis of open reading frame 1 (ORF1) and ORF2 showed two genotypes, GGI/2 and GGI/4, in semiclosed communities.

Broadly reactive nested reverse transcription-PCR using an internal RNA standard control for detection of noroviruses in stool samples

We developed a nested reverse transcription-PCR (nRT-PCR) for the detection of noroviruses in stools, using random primers for RT, the JV12/JV13 primer pair in the first round of nPCR, and a set of nine inner primers for the second, comprising the reverse sequences of primers SR46, SR48, SR50, and SR52, and five novel oligonucleotide sequences (113-1, 113-2, 115-1, 115-2, and 115-3). The specificity of the nRT-PCR was confirmed by testing 61 stools containing enteric viruses other than noroviruses. In comparative assays on either stools or RNA dilutions from two genogroup I and three genogroup II (GII) norovirus-positive samples, nRT-PCR was always at least as sensitive as RT-PCR and Southern hybridization. With some of the samples tested, the increase in sensitivity was 10-fold or higher. For GII viruses, the detectable range of nRT-PCR was estimated to be 8.4 x 10(4) to 2 RNA viral particles. When used on 85 stools from pediatric patients with acute gastroenteritis negative for viruses by electron microscopy and cell culture, the nRT-PCR detected norovirus in 19 samples (22.3%), while it failed to detect one reference RT-PCR-positive sample containing a Desert Shield strain. Sixteen of the 19 nRT-PCR-positive samples gave concordant results with reference RT-PCR and Southern hybridization, and all with sequence analysis. Partial sequencing of the polymerase region revealed that from January to April 2000 all GII strains except two (Rotterdam- and Leeds-like viruses) formed a tight cluster related to Hawaii virus. The nRT-PCR described could prove suitable for large epidemiological studies and for specialized clinical laboratories performing routine molecular testing.

Norovirus and foodborne disease, United States, 1991-2000

Analysis of foodborne outbreaks shows how advances in viral diagnostics are clarifying the causes of foodborne outbreaks and determining the high impact of norovirus infections.

Efforts to prevent foodborne illness target bacterial pathogens, yet noroviruses (NoV) are suspected to be the most common cause of gastroenteritis. New molecular assays allow for better estimation of the role of NoV in foodborne illness. We analyzed 8,271 foodborne outbreaks reported to the Centers for Disease Control and Prevention from 1991 to 2000 and additional data from 6 states. The proportion of NoV-confirmed outbreaks increased from 1% in 1991 to 12% in 2000. However, from 1998 to 2000, 76% of NoV outbreaks were reported by only 11 states. In 2000, an estimated 50% of foodborne outbreaks in 6 states were attributable to NoV. NoV outbreaks were larger than bacterial outbreaks (median persons affected: 25 versus 15), and 10% of affected persons sought medical care; 1% were hospitalized. More widespread use of molecular assays will permit better estimates of the role of NoV illness and help direct efforts to control foodborne illness.

International collaborative study to compare reverse transcriptase PCR assays for detection and genotyping of noroviruses

To allow more rapid and internationally standardized assessment of the spread of noroviruses (previously called Norwalk-like viruses [NLVs]) as important food-borne pathogens, harmonization of methods for their detection is needed. Diagnosis of NLVs in clinical diagnostic laboratories is usually performed by reverse transciptase PCR (RT-PCR) assays. In the present study, the performance of five different RT-PCR assays for the detection of NLVs was evaluated in an international collaborative study by five laboratories in five countries with a coded panel of 91 fecal specimens. The assays were tested for their sensitivity, detection limit, and ease of standardization. In total, NLVs could be detected by at least one RT-PCR assay in 69 (84%) of the samples that originally tested positive. Sensitivity ranged from 52 to 73% overall and from 54 to 100% and 58 to 85% for genogroup I and II viruses, respectively. In all, 64% of the false-negative results were obtained with a set of diluted stools (n = 20) that may have lost quality upon storage. Sensitivity was improved when these samples were excluded from analysis. No one single assay stood out as the best, although the p1 assay demonstrated the most satisfactory overall performance. To promote comparability of data, this assay will be recommended for newly starting groups in future collaborative studies.

Foodborne viruses

Foodborne and waterborne viral infections are increasingly recognized as causes of illness in humans. This increase is partly explained by changes in food processing and consumption patterns that lead to the worldwide availability of high-risk food. As a result, vast outbreaks may occur due to contamination of food by a single foodhandler or at a single source. Although there are numerous fecal-orally transmitted viruses, most reports of foodborne transmission describe infections with Norwalk-like caliciviruses (NLV) and hepatitis A virus (HAV), suggesting that these viruses are associated with the greatest risk of foodborne transmission. NLV and HAV can be transmitted from person to person, or indirectly via food, water, or fomites contaminated with virus-containing feces or vomit. People can be infected without showing symptoms. The high frequency of secondary cases of NLV illness and - to a lesser extent - of hepatitis A following a foodborne outbreak results in amplification of the problem. The burden of illness is highest in the elderly, and therefore is likely to increase due to the aging population. For HAV, the burden of illness may increase following hygienic control measures, due to a decreasing population of naturally immune individuals and a concurrent increase in the population at risk. Recent advances in the research of NLV and HAV have led to the development of molecular methods which can be used for molecular tracing of virus strains. These methods can be and have been used for the detection of common source outbreaks. While traditionally certain foods have been implicated in virus outbreaks, it is clear that almost any food item can be involved, provided it has been handled by an infected person. There are no established methods for detection of viruses in foods other than shellfish. Little information is available on disinfection and preventive measures specifically for these viruses. Studies addressing this issue are hampered by the lack of culture systems. As currently available routine monitoring systems exclusively focus on bacterial pathogens, efforts should be made to combine epidemiological and virological information for a combined laboratory-based rapid detection system for foodborne viruses. With better surveillance, including typing information, outbreaks of foodborne infections could be reported faster to prevent further spread.

Ecological factors influencing survival and growth of human pathogens on raw fruits and vegetables

Outbreaks of human infections associated with consumption of raw fruits and vegetables have occurred with increased frequency during the past decade. Factors contributing to this increase may include changes in agronomic and processing practices, an increase in per capita consumption of raw or minimally processed fruits and vegetables, increased international trade and distribution, and an increase in the number of immuno-compromised consumers. A general lack of efficacy of sanitizers in removing or killing pathogens on raw fruits and vegetables has been attributed, in part, to their inaccessibility to locations within structures and tissues that may harbor pathogens. Understanding the ecology of pathogens and naturally occurring microorganisms is essential before interventions for elimination or control of growth can be devised.

The survival of hepatitis A virus in fresh produce

Fresh produce has been repeatedly implicated as the source of human viral infections, including infection with hepatitis A virus (HAV). The objective of the present study was to evaluate the HAV adsorption capacity of the surface of various fresh vegetables that are generally eaten raw and the persistence of the HAV. To this end, the authors experimentally contaminated samples of lettuce, fennel, and carrot by immersing them in sterile distilled water supplemented with an HAV suspension until reaching a concentration of 5 log tissue culture infectious dose (TCID50)/ml. After contamination, the samples were stored at 4 degrees C and analysed at 0, 2, 4, 7, and 9 days. To detect the HAV, RT-nested-PCR was used; positive samples were subjected to the quantitative determination using cell cultures. The three vegetables differed in terms of their adsorption capacity. The highest quantity of virus was consistently detected for lettuce, for which only a slight decrease was observed over time (HAV titre = 4.44 +/- 0.22 log TCID50/ml at day 0 vs. 2.46 +/- 0.17 log TCID50/ml at day 9, before washing). The virus remained vital through the last day of storage. For the other two vegetables, a greater decrease was observed, and complete inactivation had occurred at day 4 for carrot and at day 7 for fennel. For all three vegetables, washing does not guarantee a substantial reduction in the viral contamination.

Gastrointestinal infections

Advances in public health have reduced the risk of contracting certain enteric diseases, but many remain, and new pathogens have emerged and/or recently have been discovered. The pathogenic agents are varied and consist of a variety of bacteria and select viruses and parasites. Selected use of microbiologic assays to detect these pathogens is encouraged. When tests are ordered non-judiciously, costs rapidly accrue. The age of the patient, time of year, travel history, and clinical presentation all provide clues to the etiologic agent. Microbiologic assays should be used judiciously to confirm or exclude the likely infectious agents.

Foodborne outbreaks in Canada linked to produce

Examples of foodborne outbreaks traced to fresh fruits and vegetables can be found worldwide. The quantity of produce eaten per capita has been increasing steadily over the past two decades, creating a heightened potential for produce-related foodborne disease. A number of outbreaks identified during this time period were reviewed, with particular emphasis placed on incidents that have occurred in Canada. The collective information highlights the diversity of infectious agents and produce items involved, with a view to the prevention of fresh produce-related foodborne disease in the future.

Efficacy of commonly used disinfectants for the inactivation of calicivirus on strawberry, lettuce, and a food-contact surface

Norwalk and Norwalk-like viruses (NLVs) are important causes of foodborne gastroenteritis in restaurant-related outbreaks. Efficacy of common disinfection methods against these viruses on food-contact surfaces and fresh produce is not known partially because of their nonculturability. Seven commercial disinfectants for food-contact surfaces and three sanitizers for fruits and vegetables were tested against cultivable feline calicivirus (FCV). Disks of stainless steel, strawberry, and lettuce were contaminated with known amounts of FCV. The disinfectants were applied at one, two, and four times the manufacturer's recommended concentrations for contact times of 1 and 10 min. The action of disinfectant was stopped by dilution, and the number of surviving FCVs was determined by titration in cell cultures. An agent was considered effective if it reduced the virus titer by at least 3 log10 from an initial level of 10(7) 50% tissue culture infective dose. None of the disinfectants was effective when used at the manufacturer's recommended concentration for 10 min. Phenolic compounds, when used at two to four times the recommended concentration, completely inactivated FCV on contact surfaces. A combination of quaternary ammonium compound and sodium carbonate was effective on contact surfaces at twice the recommended concentration. Rinsing of produce with water alone reduced virus titer by 2 log10. On artificially contaminated strawberry and lettuce, peroxyacetic acid and hydrogen peroxide was the only effective formulation when used at four times the manufacturers' recommended concentration for 10 min. These findings suggest that FCV and perhaps NLVs are very resistant to commercial disinfectants. However, phenolic compounds at two to four times their recommended concentrations appear to be effective at decontaminating environmental surfaces and may help control foodborne outbreaks of calicivirus in restaurants.

Diagnosis of foodborne viral infections in patients

A significant global problem is the microbiological contamination of foods and water. The microorganisms associated with about half of the foodborne disease outbreaks still go unrecognized, primarily as a result of inadequate diagnostic methods and sampling. A significant amount of food- and waterborne diseases are associated with viruses, information that has been obtained only in recent years. Improved diagnostic methods have established that caliciviruses are the most important non-bacterial pathogens associated with food- and waterborne outbreaks, and are the major cause of seafood-associated gastroenteritis.

Epidemiology of calicivirus infections in Sweden, 1994-1998

Outbreaks of acute gastroenteritis are frequently caused by caliciviruses. Electron microscopy was used to search for these viruses in fecal samples from patients with acute gastroenteritis. Of 5800 samples collected and analyzed from November 1994 to June 1998, 3700 were associated with outbreaks. A total of 676 outbreaks were analyzed, and viruses were found in 67%. Caliciviruses, usually Norwalk-like viruses (NLVs), were found in 407 (89%) of 455 outbreaks, while Sapporo-like viruses were identified in nine outbreaks, including six that were suspected to include foodborne transmission. Sixty percent of the 1041 patients with calicivirus infections were between 70 and 90 years of age. Food- and waterborne infections were associated with 66 calicivirus outbreaks. Virus-positive outbreaks were documented mainly during winter and spring. The longitudinal survey showed that caliciviruses, and especially the NLVs, cause most nosocomial and community-associated outbreaks in Sweden.

The epidemiology of enteric caliciviruses from humans: a reassessment using new diagnostics

In the United States, acute gastroenteritis is one of the most commonly noted illnesses on hospital discharge records and death certificates, yet few of these cases have an etiologic diagnosis. The application of new molecular diagnostic methods has shown caliciviruses (previously referred to as the Norwalk family of viruses or small round structured viruses) to be the most common cause of acute gastroenteritis (AGE) outbreaks in the United States, and they may emerge as a common cause of sporadic cases of AGE among both children and adults. Novel molecular methods have permitted outbreak strains to be traced back to their common source and have led to the first identification of virus in implicated vehicles of infection-water, shellfish, and foods contaminated both at their source and by food handlers. The broad application of these methods to routine diagnosis in hospitals and public health laboratories is advancing our appreciation of the full burden of calicivirus-associated diarrhea, and it is opening new avenues for its prevention and control.