An introduction to two important cases of SFPO occurred in Italy in 2014

1. Lucia Decastelli & Guerrino Macori
lucia.decastelli@izsto.it; nrlstafilococo@izsto.itNational Reference Laboratory for Coagulase Positive Staphylococci including S.aureus – Torino
SC Controllo Alimenti e Igiene delle Produzioni
Food Control Laboratory and Hygiene of the Production
SFPO Cases in Italy 2014:
a prison outbreak and “The SUSHI case”
28 - 29 May 2015
ANSES Laboratory for Food Safety, Maisons-Alfort, France
Laboratorio Nazionale di Riferimento
per gli Stafilococchi Coagulasi Positivi
incluso S.aureus
9th workshop of the NRLs for Coagulase Positive Staphylococci

2. Outline
1. Introduction
2. SFPO 1: Outbreak among prisoners;
3. SFPO 2: Associated with the consumption of SUSHI;
4. Investigation and discussion;
Recent SFPOs Session
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gli Stafilococchi Coagulasi Positivi
incluso S.aureus
9th workshop of the NRLs for Coagulase Positive Staphylococci

3. 9th workshop of the NRLs for Coagulase Positive Staphylococci
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4. FIRST OUTBREAK
6 June 2014: local city prison in Terni (center of Italy)
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Laboratorio Nazionale di Riferimento per
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5. This is the last report compiled by the commission of observers that studied the situation of prisons in
Italy - Terni is an important prisons in terms of type of prisoners: system of rigorous imprisonment and
maximum isolation site and an excess in number.
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK

6. 9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK
In recent years have been recorded several critical situations, e.g manifestations of the prisoners for
the internal conditions and attacks

7. Epidemiological research:
80 cases
Patients results with Symptoms
nausea, abdominal cramps, vomit and diarrhea after few hours from
the breakfast.
medical care outside the prison not possible
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK

8. On the basis of symptoms and the food involved a FBO due to
ESs was suspected
Regional Health Service collected samples of
-Remaining milk in thermos
Samples were sent to Food Control Laboratory of
Terni (IZS) – a lab of Italian net
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK

9. Milk sample
Enumeration of
coagulase-positive staphylococci
and identification of S.aureus
ISO 6888-2: 1999/Amd1:2003
Staphylococcal enterotoxin
VIDAS
ESM v5
5 Isolates typing
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incluso S.aureus
FIRST OUTBREAK

10. Results
Sample CPS Enterotoxin
milk 3,6 x 10^8 ufc/g POS
Isolate Characterization
•mPCR targeting sea-e, seg-j, ser and sep (Kerouanton et al. 2007)
•mecA, mecALga251 and Panton Valentine Leucocidin (pvl) genes (Larsen et al. 2000).
•SPA-typing
•Biotyping Number
Analysis
mPCR ESs genes Biotyping Spa-type
Strain/1 sea, sed, ser e sej Human t104
Strain/2 sea, sed, ser e sej Human t104
Strain/3 sea, sed, ser e sej Human t104
Strain/4 sea, sed, ser e sej Human t104
Strain/5 sea, sed, ser e sej Human t104
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK

11. was sent to…
EU-RL for Coagulase Positive
Staphylococci, including S.aureus Insufficient volume
Moreover...
Additionalsampling
Necessary, in order to confirm the source of the contamination.
9th workshop of the NRLs for Coagulase Positive Staphylococci
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gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK

12. Additionalsampling
Two days after
•Environmental swabs of table surfaces and inside the thermos flasks containing
the suspected milk;
•Nasal and hands swabs were not collected from the food handlers involved in the
preparation and distribution of the breakfast, due to the prisoners’ resistance
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
gli Stafilococchi Coagulasi Positivi
incluso S.aureus
FIRST OUTBREAK

13. Results
Number
Analyses
mPCR ESs genes Biotyping Spa-type
1 sea, sed, ser e sej Human t104
2 sea, sed, ser e sej Human t104
3 sea, sed, ser e sej Human t104
4 sea, sed, ser e sej Human t104
5 sea, sed, ser e sej Human t104
6 sea, sed, ser e sej Human t104
7 neg NHS3 t84
8 neg NHS3 t84
9 neg NHS3 t84
10 neg NHS3 t84
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
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incluso S.aureus
FIRST OUTBREAK

14. SECOND OUTBREAK
October 2014 during international food exhibition in Rome
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2nd OUTBREAK

15. Trade show at the New Fair of Rome and..
many stalls for the Consumption in site, especially orientals
Different types of sushi and other food preparations, were purchased
and consumed at a desk stand within the Fair.
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2nd OUTBREAK

16. On October 6, several people went to the emergency room
Patients interview:
abdominal pain, nausea, vomiting and diarrhea
after 2-2.5 hours after administration of sushi at the stall.
Few hours later various hospitals in Rome and Province alarmed:
admitted 30 people who accused the similar symptoms after eating sushi at the same counter.
9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
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2nd OUTBREAK

17. Regional Health Service collected samples of:
•(S1) Samples of various types of sushi taken to counter stand
• Rol with shrimp tempura
• canadian rol
• hosomaki salmon
• onigiri
•(S2) Sample of smoked salmon taken in the restaurant
Samples were sent to Food Control Laboratory of Rome (IZS) –
a lab of Italian net
2nd OUTBREAK
9th workshop of the NRLs for Coagulase Positive Staphylococci
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incluso S.aureus

18. 2nd OUTBREAK
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19. • (S1) for all the samples
• (S2) Negative
2nd OUTBREAK
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20. 4 isolates from
patients
in this case biological sampling -
S.aureus isolates and biological samples:
Nasal swab from preparing
and handling food:
• 1 isolate in 1 cook
5 isolates from onigiri
2nd OUTBREAK
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incluso S.aureus

21. 2nd OUTBREAK
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22. Number
Analyses
mPCR ESs genes Biotyping
Patient 1 sea, seb, seh Human
Patient 2 sea, seb, seh Human
Patient 3 sea, seb, seh Human
Patient 4 sea, seb, seh Human
Cook 1 sea, seb, seh Human
Onigiri Strain 1 sea, seb, seh Human
Onigiri Strain 2 sea, seb, seh Human
Onigiri Strain 3 sea, seb, seh
Human
Onigiri Strain 4 sea, seb, seh
Human
2nd OUTBREAK
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Ice-storage only for few minutes….

23. 2nd OUTBREAK
9th workshop of the NRLs for Coagulase Positive Staphylococci
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Ice-storage only for few minutes….
…but the day was really warm, so they decide to use the ice for refreshing drinks

24. S.aureus typing
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gli Stafilococchi Coagulasi Positivi
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25. 9th workshop of the NRLs for Coagulase Positive Staphylococci
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incluso S.aureus

26. 9th workshop of the NRLs for Coagulase Positive Staphylococci
Laboratorio Nazionale di Riferimento per
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27. 9th workshop of the NRLs for Coagulase Positive Staphylococci

28. However, the epidemiological investigation remains the weak
point… several professionals, interdisciplinary collaboration and
speed in interviewing communication deficits at-side
(interdisciplinary approach)
IT: low No. of notified SFPO compared to EU
mild/self-limiting disease, no mandatory reporting system in place
situation of SFPO presumably underestimated in Italy
9th workshop of the NRLs for Coagulase Positive Staphylococci
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Focus on
S.aureus typing and epidemiological interviews

29. Thanks for the attention
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