Dr. Robert Tauxe - Public Health Concerns About Resistant Foodborne Infections


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Public Health Concerns About Resistant Foodborne Infections - Dr. Robert Tauxe, Deputy Director, Division of Foodborne, Waterborne and Environmental Infections, Centers for Disease Control and Prevention, from the 2013 NIAA Symposium Bridging the Gap Between Animal Health and Human Health, November 12-14, 2013, Kansas City, MO, USA.

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  • Dr. Robert Tauxe - Public Health Concerns About Resistant Foodborne Infections

    1. 1. Public health concerns about resistant foodborne infections Antibiotics Symposium National Institute for Animal Agriculture Kansas City , Missouri November 12, 2013 Robert Tauxe, MD, MPH Deputy Director, Division of Foodborne, Waterborne, and Environmental Diseases National Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention
    2. 2. Antimicrobial treatments have been critical in human and veterinary medicine for 60+ years Antimicrobial resistance a challenge for almost as long Emerges in settings where antimicrobials are used In a variety of bacteria, viruses, fungi, parasites Sometimes spreads from one bacterial strain to another Central issue for managing infections of all kinds
    3. 3. One Health: The Way Forward A multidisciplinary collaborative effort that focuses on the interconnectedness of a large ecosystem to achieve optimal health of humans, animals, and environments across the world.
    4. 4. CDC report released September 17, 2013 18 pathogens Burden •2,049,000 illnesses •23,000 deaths Foodborne pathogens •4 of the 18 often transmitted through foods •2 with animal reservoirs •2 with human reservoirs http://www.cdc.gov/drugresistance/threat-report-2013
    5. 5. Annual public health burden of resistant foodborne infections  Resistant to principal clinical agents used for treatment Pathogen Percent Resistant # illnesses/ year # deaths/ Year Campylobacter 24% 310,000 28 Non-typhoidal Salmonella 8% 100,000 38 Salmonella Typhi 67% 3,800 <5 Shigella 6% 27,000 <5 441,000 66-70 Total CDC 2013 Antibiotic Resistance Threats
    6. 6. Tracking the public health challenge of foodborne antimicrobial resistance at CDC  1970’s: Periodic surveys of Salmonella and Shigella  1980’s: Outbreaks of resistant infections  1996: National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS), a collaborative effort • USDA/FSIS - animals at slaughter • FDA Center for Veterinary Medicine – retail meats • CDC – human clinical cases • Human, animal strains from all 50 states • Retail food isolates from 14 states • Standard panels of antimicrobial agents (See cdc.gov/NARMS for 2011 Annual Report, testing details)
    7. 7. ? Bacteria tracked in NARMS Humans – CDC Animals - USDA Non-Typhi Salmonella (1996) Non-Typhi Salmonella (1997) E. coli O157:H7 (1996) Campylobacter (1998) Campylobacter (1997) E. coli (2000) Salmonella Typhi (1999) Enterococcus (2003) Shigella (1999) Vibrio other than V. cholerae, (2009) Retail meats – FDA (2002) Non-Typhi Salmonella Campylobacter E. coli Enterococcus
    8. 8. Emergence of drug resistant strains of concern: Salmonella and Campylobacter
    9. 9. Recent multistate outbreaks of resistant Salmonella infections Year Serotype vehicle cases states % hosp resistance 2010 Typhimurium Ground beef 20 7 47 AKSSuFoxCx 2011 Heidelberg Ground turkey 136 34 39 ASSuT 2012 Heidelberg Chicken 134 13 31 Variable* 2013 Heidelberg Chicken 362 21 38 Variable* * Polyclonal outbreak, varied patterns, Some strains had no resistance at all Some strains resistant to clinically important drugs 2013 testing is incomplete
    10. 10. What connects antibiotic use in animals with human health?  Use of antibiotics in food producing animals selects for antibiotic-resistant bacteria (including ones pathogenic to humans) Resistant bacteria can be transmitted from food –producing animals to humans through the food supply Resistant bacterial pathogens can cause illness in humans Infections caused by resistant bacteria can result in adverse health consequences for humans
    11. 11. Why are resistant strains of particular concern?  When treatment is needed, early empiric treatment may fail, and treatment choices will be limited  Increased morbidity and mortality • Longer illnesses • More invasive infections • More likely to be hospitalized • More deaths  When resistance is located on a mobile genetic element, it may be transferred to other bacteria horizontally Mølbak 2005 Clin Infect Dis 41:1613-20
    12. 12. Why are resistant strains of particular concern? (continued) Epidemiological observations, and a well-established animal model  Resistant strains have a selective advantage in individuals who are taking antimicrobial for other reasons  Colonization with a resistant pathogen may convert to overt disease if the individual takes an antibiotic to which it is resistant • Illness in individuals already ill for other reasons • More clinical cases: Proportion of illness attributable to resistance estimated at 3-26% for Salmonella (=58,000 more illnesses) Barza 2002 Clin Infect Dis 34:S123-125, S126-130
    13. 13. FDA withdrew poultry enrofloxacin approval Fluoroquinolones first approved for use in poultry Ciprofloxacin approved for human use Pilot study 0.0%
    14. 14. Non-Typhoidal Salmonella  Resistance to ceftriaxone (2009-2011) • 2.9% of all isolates • 17.9% of Heidelberg isolates  Decreased susceptibility to ciprofloxacin (2009-2011) • 2.7% of all isolates • Approximately half were serotype Enteritidis • Most are travel-associated  Penta-resistance (e.g. ACSSuT) • 8.2% in 2002  4.6% in 2011 all isolates • 23%  21% of Typhimurium • 23%  4% of Newport NARMS 2009-2011 data, 2011 NARMS report
    15. 15. Ceftriaxone resistance in Salmonella serotype Heidelberg, 1996-2012* 32% 3% 0% *2012 human data are preliminary; only 10 ground turkey isolates were tested in 2009 and 11 retail chicken isolates in 2002 and 2011
    16. 16. Salmonella Heidelberg in Québec Ceftiofur resistance – 2003-2008 Cft R S. Heidelberg was common in poultry meat, but was not found in beef or pork 2005-2006: Poultry industry in Québec voluntarily halted use of ceftiofur in eggs Dutil et al. 2010 EID 16: 48-54
    17. 17. Microbiological characterization of non-typhoidal Salmonella strains from food animals, retail meat, and people in US, 2008  Decreased susceptibility to ceftriaxone/ceftiofur (MIC>2μg/L)  blaCMY genes, usually combined with other resistance genes • Human: 4.6% (Newport, Typhimurium, Heidelberg, Agona) • Retail meat: 15.7% (Typhimurium, Heidelberg, Kentucky, Newport) • Animals: 10.6% (Dublin, Kentucky, Newport, Typhimurium)  Conclude: • substantial overlap in strains across sources • same CMY gene is found in all three sources • same CMY gene appearing in several serotypes Karlsson 2013 Microbial Drug Resist 19:191-197
    18. 18. CMY2 genes in Salmonella Heidelberg are plasmid-borne, 2009  The CMY2 gene for ceftiofur/ceftriaxone (Cft/Cx) resistance was first described on a plasmid that easily transferred between Salmonella and E. coli (1998-9)  2009: S Heidelberg that was Cft/Cx-resistant blaCMY + • 47 strains found in NARMS • All 47 were plasmid encoded on plasmids • 41 of the 47 plasmids were Inc type 1, with two closely related sequence types • Same plasmid found in variety of Heidelberg strains • 26 of the 29 animal and meat isolates were from chicken The 2009 increase in Cft/Cx resistance is related to spread of a plasmid among various Heidelberg strains in poultry, rather than to the clonal expansion of one strain Winokur 2001 AAC 45:2716-2722 Folster et al 2012 FPD19:638-645
    19. 19. Salmonella Typhi
    20. 20. Shigella  Ciprofloxacin resistance  2011: resistance to Amp 34%, Tet 41%, TMP-SXT 67%  Reduced susceptibility to azithromycin: • 3.1% in 2011 and 4.3%* in 2012 *preliminary data
    21. 21. Challenges in other parts of the world  Campylobacter in Europe: Cipro resistance in • 52% of strains from humans • 50% of strains from poultry • 80% of strains from international travelers  Salmonella Typhimurium and Enteritidis in eastern Africa • Recurrent outbreaks, sometimes nosocomial • Highly multi-resistant strains • Invasive infections with higher mortality (typhoid-like) Taiwan: Salmonella Choleraesuis: • Increase in human infections in late 1990’s • Resistant, up to 60% cipro R, some to ceftriaxone (CMY2) • Highly invasive, presenting with aortitis, septic shock • Related to epizootic in pigs with same organism WHO Campylobacter Consultation 2013 2013 Kotloff Lancet; 2008 Gordon CID; 2011 Su EID;
    22. 22. Salmonella Kentucky in Africa/Asia/Europe Since 1960, Pasteur Institute tracking Salmonella Kentucky • First: infections in travelers from Tunisia • 1990’s: from Egypt • 2000’s: from India Progressive increase in resistance (since 1990’s) 2008: Appeared in Polish turkey flocks, meat and consumers Since then in turkey flocks and meat in Germany and France One genetic lineage: now R to ASSuTTmpGentCip, and sometimes has CMY2 LeHello 2013 Lancet Infectious Disease 13:652-679 Wasyl 2012 Food Research Int 45:958-961
    23. 23. CDC is addressing the challenge of resistant foodborne infections by Promoting prevention Tracking resistance through NARMS Making that information more available more quickly Refining estimates of the health impact of resistance Making realtime resistance data part of outbreak investigations Refining understanding of sources and mechanisms of • resistance genes • and resistant bacterial strains
    24. 24. Addressing public health concern about resistant infections with Shigella Management of Shigella infections in children has changed Until the 1990’s, often routine to • treat all cases aggressively, no matter how mild • treat exposed family members • prophylaxe other children in the child care center  Rapid increase in resistance to Amp, Tmp-Sxt, Nalidixic acid  In the 1990’s, routine changed to: • reserve treatment for severe illnesses only • provide family members with soap and handwashing advice • Isolate ill children and increase hygiene in child care centers Tuttle et al 1993 Inf Dis Clin Pract 2:55-59
    25. 25. Addressing the public health concern about resistant foodborne zoonotic infections Expertise in animal health and management is vital to Reduce introduction of resistant strains into production • Breeder stock, hatcheries • Animal feed sources • Water, environment, employees, etc.  Consider conditions that foster selection of resistance and spread of resistant organisms • Antimicrobial use that is sub-therapeutic, repeated, widespread, or unnecessary • Management practices that spread illness among animals  Implement prevention measures • Judicious antimicrobial use • Alternate prevention steps • Reduce food contamination
    26. 26. Antimicrobial resistance in foodborne infections in the 21st century  Substantial challenge to human and animal health The burden is substantial, but perhaps not irreversible Non-judicious medical use is being addressed with major efforts Foodborne pathogens resistant to drugs important in human medicine, whether related to human use or agricultural use Limit the emergence of resistance, and prolong effectiveness of current antibiotics • Judicious use for food animals supervised by a veterinarian • Measures that prevent spread and food contamination We all want • Food to be safer • Those who eat it to be healthier • People to have confidence in food supply
    27. 27. Thank you The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention
    28. 28. Our websites Antimicrobial resistance: www.cdc.gov/drugresistance/index.html Our Programs: NARMS: www.cdc.gov/NARMS FoodNet: www.cdc.gov/foodnet PulseNet: www.cdc.gov/pulsenet FoodCORE: www.cdc.gov/ncezid/dfwed/orpb/foodcore/index.html Specific pathogens: E. coli: www.cdc.gov/ecoli Salmonella: www.cdc.gov/salmonella Listeria: www.cdc.gov/listeria Multistate foodborne outbreaks: www.cdc.gov/outbreaknet/outbreaks.html General information about foodborne diseases: www.cdc.gov/foodsafety www.foodsafety.gov
    29. 29. Urban dictionary: “I’m Audi” = to suddenly leave 1987 Audi 5000 Sudden acceleration 700 incidents, 6 deaths First corporate response blamed customers Market response: Loss of $100 million in 1987 US sales dropped 84% by 1991 VW bought Audi Later corporate response: Recalled 5 years of production Retired the A5000 model Re-engineered pedals to be farther apart New interlock required foot on brake to shift from “park”