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Publisher’s Platform: Salmonella Import Problem

Collaborative investigation efforts of state, local, and federal public health agencies indicate that a frozen raw yellowfin tuna product imported from India, known as Nakaochi Scrape, from Moon Marine USA Corporation is the likely source of this Salmonella Bareilly and Salmonella Nchanga outbreak.

plateofsushi-406.jpgAccording to the CDC, 190 persons infected with the outbreak strain of Salmonella Bareilly have been reported from 21 states and the District of Columbia. The number of ill persons with the outbreak strain of Salmonella Bareilly identified in each state is as follows: Alabama (2), Arkansas (1), Connecticut (8), District of Columbia (2), Florida (1), Georgia (9), Illinois (15), Louisiana (3), Maryland (20), Massachusetts (24), Mississippi (2), Missouri (4), New Jersey (18), New York (33), North Carolina (3), Pennsylvania (7), Rhode Island (6), South Carolina (3), Texas (4), Virginia (9), Vermont (1), and Wisconsin (15).  10 persons infected with the outbreak strain of Salmonella Nchanga have been reported from 5 states. The number of ill persons with the outbreak strain of Salmonella Nchanga identified in each state is as follows: Georgia (2), New Jersey (1), New York (5), Virginia (1), and Wisconsin (1).  28 ill persons have been hospitalized, and no deaths have been reported.

Past tuna Salmonella outbreaks in United States

Twenty-three were sickened in 2010 with Salmonella Paratyphi B linked to the consumption of imported, raw, ahi tuna at various locations on the island of Oahu, Hawaii. The product was said to have originated from Asia, and was previously frozen. Concurrent cases of Salmonella Paratyphi B were reported in five other U.S. states, California, Maryland, Pennsylvania, Massachusetts, and New York. It was not stated whether these cases were also linked to the consumption of raw ahi tuna.

Four were sickened in 2008 linked to an outbreak of Salmonella Barranquilla among people who had eaten raw tuna or bass fish at a restaurant in Massachusetts.

Forty-four were sickened in 2007 with Salmonella Paratyphi B after the consumption of previously frozen, raw, ahi tuna on the island of Oahu, Hawaii. Additional cases were identified in Colorado and California. The tuna had been sent from Indonesia to a U.S. mainland importer.

Are there 5,860 sickened?

The CDC’s recent estimates that for every case counted, 29.3 cases go unreported and therefore uncounted. See Table 2 in this citation: Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson M-A, Roy SL, et al. Foodborne illness acquired in the United States–major pathogens. Emerg Infect Dis [serial on the Internet]. 2011 Jan.

That would mean this outbreak has sickened as many as 5,860 people. If applying a previous CDC estimated ratio of non-reported salmonellosis cases to reported cases (38.6), one would arrive at an estimated 7,720 illnesses from this outbreak. Voetsch, et al. (2004-04-15). “FoodNet Estimate of the Burden of Illness Caused by Nontyphoidal Salmonella Infections in the United States”. Clinical Infectious Diseases, 2004; 38:S3.

What are Salmonella complications?

The CDC estimates that over 1 million cases occur annually in the United States, according to a 2011 report. Of these cases, approximately 20,000 result in hospitalization and 378 result in death. This means that Salmonella accounts for almost 30 percent of foodborne illness-related deaths each year.

Irritable Bowel Syndrome

A recently published study surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first described over five decades ago. The Walkerton Health Study further notes that:

Between 5% and 30% of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms despite clearance of the inciting pathogens.

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.” The WHS also identified risk factors for subsequent IBS, including: younger age; female sex; and four features of the acute enteric illness–diarrhea for > 7days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds. Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain. In one recent study, over one-third of IBS sufferers had had IBS for more than ten years, with their symptoms remaining fairly constant over time. IBS sufferers typically experienced symptoms for an average of 8.1 days per month.

As would be expected from a chronic disorder, IBS sufferers required more time off work, spent more days in bed, and more often cut down on usual activities, when compared with non-IBS sufferers. And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms. IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation. Finally, while a patient’s psychological state may influence the way in which he or she copes with illness, and responds to treatment, there is no evidence that supports the theory that psychological disturbances in facts cause IBS or its symptoms.

Reiter’s Syndrome

A variety of other medical problems may derive from Salmonella infections in any given case. Within several months of infection, a certain percentage of ill individuals will develop an arthritic condition known as reactive arthritis, or “Reiter’s Syndrome,” which results from an immune response to the Salmonella bacteria in the body where the immune system attacks the cartilaginous tissues in the joints. The condition frequently resolves within several months, but it can become chronic, even permanent.

Reiter’s Syndrome, which includes, and is sometimes referred to as reactive arthritis, is an uncommon, but debilitating, possible result of a Salmonella infection. Reiter’s Syndrome is a disorder that causes at least two of three seemingly unrelated symptoms:

“Reactive” arthritis, eye irritation, and urinary tract infection. The reactive arthritis associated with Reiter’s develops when a person eats food that has been tainted with bacteria. Reactive arthritis is characterized by the inflammation of one or more joints, following an infection localized in another portion of the body, commonly the gastrointestinal tract. The symptoms of Reiter’s Syndrome usually occur between one and three weeks after the infection.

The three most common symptoms of Reiter’s Syndrome are arthritis, eye irritation, and urinary tract symptoms. The arthritis associated with Reiter’s Syndrome typically affects the knees, ankles, and feet, causing pain and swelling. Wrists, finger
s and other joints can be affected, though with less frequency. Patients with Reiter’s Syndrome commonly develop inflammation where the tendon attaches to the bone, a condition called enthesopathy. Some patients with Reiter’s Syndrome also develop heel spurs, bony growths in the heel that cause chronic or long-lasting foot pain. Arthritis from Reiter’s Syndrome can also affect the joints of the back and cause spondylitis, inflammation of the vertebrae in the spinal column. The duration of reactive arthritis symptoms can vary greatly. Most of the literature suggests that the majority of patients recover within a year. The condition, can, however, be permanent. One study found nearly 50% of patients with postdysenteric reactive arthritis continued to have symptoms roughly one year after onset.

The involvement of the eye in Reiter’s Syndrome is most commonly manifested as conjunctivitis, inflammation of the mucous membrane that covers the eyeball, or uveitis, an inflammation of the inner eye. Conjunctivitis and uveitis can cause redness of the eyes, eye pain and irritation, and blurred vision.

The third situs for Reiter’s Syndrome symptoms is the urogenital tract. This includes the prostate, urethra, and penis in men and the fallopian tubes, uterus, and vagina in women. Men may notice an increased need to urinate, a burning sensation when urinating, and a discharge from the penis. Some men also develop prostatitis. Symptoms of prostatitis include fever, chills, increased need to urinate, and a burning sensation when urinating.

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