Microsoft PowerPoint 食品安全與溶血性尿毒

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1 E coli O4 談食品安全與溶血性尿毒 Dr. Wong Wing Wai Infectious Diseases, Depart., of Medicine Taipei Veterans General Hospital 人類飲食習慣的改變圖片摘自

2 我國法定傳染病分類類別第一類第二類第三類第四類第五類傳染病名稱天花鼠疫狂犬病炭疽病 H5N 流感 SARS 白喉麻疹德國麻疹流行性腦脊髓膜炎多重抗藥性結核病登革熱瘧疾屈公病西尼羅熱霍亂傷寒副傷寒小兒麻痺症桿菌性痢疾腸道出血性大腸桿菌感染症阿米巴性痢疾急性病毒性 A 型肝炎漢他病毒症候群流行性斑疹傷寒百日咳破傷風日本腦炎結核病 ( 除多重抗藥性結核病外 ) 癩病先天性德國麻疹症候群急性病毒性肝炎 ( 除 A 型外 ) 腮腺炎退伍軍人病侵襲性 b 型嗜血桿菌感染症梅毒淋病新生兒破傷風腸病毒感染併發重症疱疹 B 病毒感染症鉤端螺旋體病類鼻疽 Q 熱地方性斑疹傷寒萊姆病兔熱病恙蟲病貓抓病弓形蟲感染症庫賈氏病肉毒桿菌中毒水痘侵襲性肺炎鏈菌感染症流感併發重症 NDM- 腸道菌感染症裂谷熱馬堡病毒出血熱拉薩熱伊波拉病毒出血熱黃熱病依傳播途徑區分經動物與昆蟲感染狂犬病弓形蟲感染症日本腦炎西尼羅熱裂谷熱鼠疫拉薩熱鉤端螺旋體病萊姆病恙蟲病炭疽病伊波拉病毒出血熱馬堡出血熱漢他病毒症候群疱疹 B 病毒感染症兔熱病 Q 熱地方性斑疹傷寒流行性斑疹傷寒貓抓病鼠咬熱經空氣或飛沫傳染經飲食傳染經血液或皮膚傳染禽流感 Q 熱漢他病毒症候群炭疽病鉤端螺旋體病類鼻疽鸚鵡熱布氏桿菌症阿米巴痢疾腸道出血性大腸感菌感染症新型庫賈氏病肉毒桿菌中毒布氏桿菌症沙門氏菌蛔蟲肝吸蟲廣東住血線蟲胞蟲症旋毛蟲伊波拉病毒出血熱馬堡出血熱鉤端螺旋體病類鼻疽其他庫賈氏病藍色字體標示處 : 非法定傳染病, 但疾管局提供相關檢驗及部分罕見用藥 2

3 98~2 年食品中毒案件病因物質案件數統計 Taiwan FDA 2 年網購三明治沙門氏菌污染事件 3

4 網購三明治沙門氏菌污染事件之規模分局別追蹤件數食用人數生病人數侵襲率第一分局 % 第二分局 % 第三分局 % 第四分局 % 第五分局 % 第六分局 % 總計 % 食用真空包裝豆乾導致肉毒桿菌中毒事件 4

5 27 年至 2 年月肉毒桿菌中毒本土病例趨勢圖名病例中有例曾食用黃豆類製品 ;9 例曾食用真空包裝黃豆類製品 5

6 2 年肉毒桿菌中毒事件 CDC 及 TFDA 利用新聞稿媒體及教育訓練等, 針對民眾與醫護人員進行分眾宣導大溪正真空豆干 2 名病例大溪正真空豆干 TFDA 召開真空包裝黃豆即食食品安全管理業者說明會 TFDA 制定真空包裝即食食品良好衛生規範及真空包裝即食食品標示相關規定大溪正真空豆干 3 名病例大溪仁真空豆干大溪大真空豆干引起集體食物中毒的大腸桿菌 O 2 / 8 月號牛頓 2 年 4 月下旬發生在日本烤肉連鎖店的集體食物中毒的主要禍首就是大腸桿菌 O 至 5 月 3 日止, 仍未能確認被 O 汙染的食物是否就是生牛肉 O 會產生一種稱為 verotoxin 的毒性蛋白質, 引起出血性腹瀉再者, 當 verotoxin 隨著血液流到全身, 也可能會引發重症造成死亡雖然也曾經發生過數起 O 引起食物中毒的事件, 但卻以這次造成重症比率最高 2 年 4 月下旬, 在日本富山縣福井縣和神奈川縣的同一烤肉連鎖店相繼發生用餐者食物中毒的情形根據日本厚生勞働省 ( 相當於衛生署 ) 於 5 月日下午 4 時所公布的資料表示, 具有食物中毒症狀的人有 8 位, 其中重症者達 24 人, 死亡人數 4 人 ( 數字為三縣之合計 ) 日本 NIID 流行病學分析, 與生牛肉料理具有高度關聯性 6

7 Escherichia coli Known as commensal of the large intestine since first described in 885 Enterobacteriaceae, the enteric bacteria, are facultatively anaerobic Gram-negative rods genera within the family are human intestinal pathogens (e.g. Salmonella, Shigella, Yersinia). several others are normal colonists (e.g. Escherichia, Enterobacter, Klebsiella) The entire DNA base sequence genome has been known since 997 Escherichia coli E. coli inhabitant of the human intestinal tract Only a very small proportion of the total bacterial content. The anaerobic Bacteroides species in the bowel outnumber E. coli by at least 2: Can grow in the presence or absence of O 2 Adapt to its intestinal (anaerobic) and its extraintestinal (aerobic or anaerobic) habitats Indicator of fecal pollution and water contamination 7

8 Pathogenesis Over 7 serotypes based on O, H, and K antigens the serotype O57:H7 causing hemolytic uremic syndrome (HUS) an outbreak in the United States of America. EHEC in 982 second to Salmonella as a cause of bacterial diarrhea in NW Pacific Diarrheagenic strains pathogenic E. coli are classified based on their unique virulence factors Enterovirulent E coli, EEC 5 virotypes cause diarrheal diseases: enterotoxigenic E. coli (ETEC) enteroinvasive E. coli (EIEC) enteropathogenic E. coli (EPEC) enterohemorrhagic E. coli (EHEC) enteroaggregative E. coli (EAEC) Each class falls within a serological subgroup and manifests distinct features in pathogenesis. 8

9 Virulence determinants and characteristics Kenneth Todar, PhD Online Textbook of Bacteriology ETEC fimbrial adhesins e.g. CFA I, CFAII, K88, K99 non invasive produce LT and/or ST toxin watery diarrhea in infants and travelers no inflammation, no fever Virulence determinants and characteristics Kenneth Todar, PhD Online Textbook of Bacteriology EIEC nonfimbrial adhesins, possibly outer membrane protein invasive (penetrate and multiply within epithelial cells) does not produce shiga toxin dysentery-like diarrhea (mucous, blood), severe inflammation, fever 9

10 EPEC Virulence determinants and characteristics Kenneth Todar, PhD Online Textbook of Bacteriology non fimbrial adhesin EPEC adherence factor (EAF) enables localized adherence of bacteria to intestinal cells moderately invasive (not as invasive as Shigella or EIEC) does not produce LT or ST; some reports of shiga-like toxin usually infantile diarrhea; watery diarrhea with blood some inflammation, no fever symptoms probably result mainly from invasion rather than toxigenesis EAEC Virulence determinants and characteristics Kenneth Todar, PhD Online Textbook of Bacteriology adhesins not characterized non invasive produce ST-like toxin (EAST) and a hemolysin persistent diarrhea in young children without inflammation or fever

11 Virulence determinants and characteristics Kenneth Todar, PhD Online Textbook of Bacteriology EHEC adhesins not characterized, probably fimbriae moderately invasive does not produce LT or ST but does produce shiga toxin pediatric diarrhea, copious bloody discharge (hemorrhagic colitis) intense inflammatory response may be complicated by hemolytic uremia Reservoir of EEC Mainly cattle, occasionally pork and chicken meat mutton samples have been examined to have E. coli O57:H7 Human being may also be reservoir and caused the transmission among people.

12 Mode of Transmission Intake of contaminated food, most frequently, the improperly prepared beef ( specially mince) and raw milk Through contaminated water supply Food processing by patient contaminated with EEC Clinical Symptom 2~8 days, normally 3~4 days Afebrile, mild diarrhea, acute to dull abd. pain, Initial watery diarrhea, then significant bloody (hemorrhagic) colitis 6-7%, some report as high as 5%, will complicate hemolytic uremic syndrome or brain disease in about 2 weeks renal failure and hemolytic anemia fever and neurologic symptoms, constitutes TTP can have a mortality rate in the elderly as high as 5% 2

13 Microbiologic Diagnosis Isolation of E. coli of serotype O57:H7 or other verotoxin-producing E. coli from diarrheal stools Can t grow at 44~45 C sorbitol-macconkey (SMAC) agar tested for the presence of verotoxin DNA probes to detect genes encoding for the production of verotoxins (VT and VT2) Treatment Supportive No evidence that antibiotics improve outcome Some antibiotics may precipitate kidney complications Antidiarrheal agents, such as loperamide should also be avoided Hemolytic uremic syndrome is life-threatening required blood transfusions and kidney dialysis 3

14 Preventive measure Identify and isolation Meat can become contaminated during slaughter, and organisms can be thoroughly mixed into beef when it is ground Unpasteurized milk and sewagecontaminated water Young children typically shed the organism in their feces for a week or two after their illness resolves Sometimes carry the organism without symptoms 2 Germany E. coli O4:H4 outbreak 4

2 Germany outbreak Serious outbreak of food borne illness focused in northern Germany in May through June 2 Characteristic bloody diarrhea, abd.

days All affected people had been in Germany or France 2 Germany outbreak The agriculture authority incorrectly linked EHEC to cucumbers imported

15 2 Germany outbreak Serious outbreak of food borne illness focused in northern Germany in May through June 2 Characteristic bloody diarrhea, abd. cramp, nausea and with a high frequency of hemolytic-uremic syndrome (HUS) Low febrile Adults with HUS Acute onset, 7- days, some prolong to 2 days All affected people had been in Germany or France 2 Germany outbreak The agriculture authority incorrectly linked EHEC to cucumbers imported from Spain An organic farm in Bienenbüttel, Lower Saxony, which produces a variety of sprouted foods, as the likely source of the E. coli outbreak 5

16 A deadly E. coli contamination were found on sprouts at a farm in Lower Saxony, German It's the sprouts", the president of the Robert Koch Institute (RKI), Reinhard Burger, said 2 Germany outbreak Originally thought to have been caused by an enterohemorrhagic (EHEC) strain of E. coli later shown to have been caused by an enteroaggregative E. coli (EAEC) strain Acquired the genes produce Shiga toxins 6

2 Germany outbreak 說明沒有病例疑似病例確定病例死亡病例標示顏色俄羅斯葡萄牙芬蘭美國加拿大丹麥法國德國瑞典 EHEC Outbreak Number of cases reported as for 2 July 2 Deaths 2 HUS case 3 Non HUS case Austria Canada Czech

17 2 Germany outbreak 說明沒有病例疑似病例確定病例死亡病例標示顏色俄羅斯葡萄牙芬蘭美國加拿大丹麥法國德國瑞典 EHEC Outbreak Number of cases reported as for 2 July 2 Deaths 2 HUS case 3 Non HUS case Austria Canada Czech Republic Denmark France Germany Greece Luxembourg Netherlands Norway Poland Spain Sweden Switzerland United Kingdom United States Total ,67 3 7

18 2 Germany outbreak Origins of the E. coli Strain Causing an Outbreak of Hemolytic Uremic Syndrome in Germany An unusual serotype of Shiga-toxin producing E coli (O4:H4) began in Germany in May 2. As of July 22, a large number of cases of diarrhea caused by Shiga-toxin producing E. coli have been reported. The outbreak strain belonged to an enteroaggregative E. coli lineage that had acquired genes for Shiga toxin 2 and for antibiotic resistance. David A Rasko, et al. N Engl J Med 2; 365:79-77August 25, 2 Holger Rohde, et al. N Engl J Med 2; 365:78-724August 25, 2 2 Germany outbreak 367 without the hemolytic uremic syndrome (6 deaths) and 98 with the hemolytic uremic syndrome (34 deaths), indicating that this strain is notably more virulent than most of the Shiga-toxin producing E. coli strains. Preliminary genetic characterization of the outbreak strain suggested strains should be classified within the enteroaggregative pathotype of E. coli. The enteroaggregative E. coli O4:H4 strains are closely related and form a distinct clade among E. coli and enteroaggregative E. coli strains. The genome of the German outbreak strain can be distinguished from those of other O4:H4 strains because it contains a prophage encoding Shiga toxin 2 and a distinct set of antibiotic-resistance factors. 8

19 Enteroaggregative E. coli O4:H4 Shiga-like toxin-producing E. coli Heat stable at 7 C to 5 C, deactivated over 7 C Destroy gut endothelium cause hemorrhage and bloody stool Circulating toxin combined with endothelial cell membrane of glomerulus, inhibit ADAMTS3 enzyme that induced intravascular coagulopathy and HUS Enteroaggregative E. coli O4:H4 Most diarrheagenic pathogenic E. coli are EHEC EAEC with Shiga-like toxin, SLT O57:H7 cause outbreaks in beef O4:H2 in Montana, USA in a Korean female with HUS had isolated O4:H4 Taiwan first report EHEC hemorrhagic diarrhea from a 6 year old American-born boy in 2 9

20 Diagnosis and Detection of EHEC/EAEC A EU/International standard for the detection of E. coli O57 Food, diary Water Specimen Molecular typing At least 2 methods-german, France Phenotyping, serotyping, antibiotic resistant pattern OMP patterns, LPS patterns, multilocus enzyme electrophresis Genotyping: plasmid analysis, RFLP, ribotyping, PFGE, PCR, RAPD Treatment of EHEC diarrhea and complication Mainly supportive Controversial of antibiotics usage Isolations Source identify Food/diary processing 2

21 Eat health and Thanks for your attention 2

我国小儿四大防治疾病营养性缺铁性贫血婴幼儿腹泻维生素 D 缺乏性佝偻病小儿肺炎

我国小儿四大防治疾病营养性缺铁性贫血婴幼儿腹泻维生素 D 缺乏性佝偻病小儿肺炎第三节小儿腹泻 Infantile Diarrhea 我国小儿四大防治疾病营养性缺铁性贫血婴幼儿腹泻维生素 D 缺乏性佝偻病小儿肺炎来自欧美的研究 : 一个两岁以下的小儿, 如果他平均腹泻超过 5 次, 在他 9~10 岁的时候, 他的身高比平均身高