Salmonella
Praveen
Rao, Sophia W. Riccardi, Danielle Birrer
Seminar
in Nucleic Acids-Spring 2004
Prof.
Zubay
Salmonella
- Overview
- History
and Epidemiology
- Molecular
Biology
- Clinical
- Weaponization
Overview
- Salmonella
is a rod-shaped, gram-negative, facultative anaerobe in the family Enterobacteriaceae
Salmonella
Taxonomy
- The
genus Salmonella is divided into two species, S. enterica and S. bongori
(CDC).
- Over
2000 strains are grouped into S. enterica. This species is further
divided into six subgroups based on host range specificity, which also
involves immunoreactivity of three surface antigens, O, H and
Vi.
- All
strains that are pathogenic to humans are in species S. enterica, subgroup
1 (also called enterica).
-
For example, the correct taxonomic name for the organism that causes
typhoid fever is Salmonella enterica ssp. enterica, serovar typhi.
The simplified version: Salmonella typhi.
- Taxonomy
has been revised several times, due to the degree of DNA similarity
between genomes.
-
For example, In the U.S., another legitimate species name for enterica
is choleraesuis.
Other
Facts
- Bacterium
of 2501 identified strains, as of 2001. Many different diseases
are caused by more than 1,400 serotypes of this bacteria genus.
- “Salmonella”
derived from Dr. Salmon, a U.S. veterinary surgeon, who discovered and
isolated the strain enterica or choleraesuis
from the intestine of a pig in 1885.
- They
are ingested orally by contaminated food or water. Refrigeration prevents
growth but does not kill bacteria. Heating at 57-60°C
or 134-140°F has shown to be effective
in killing the bacteria.
-
Optimal growth: 37°C or 98.6°F
Disease-associated
facts
- “Salmonellosis”:
Any of several bacterial infections caused by species of Salmonella,
ranging from mild to serious infections.
-
Two main kinds in humans: enteric fever (typhoid and paratyphoid) and
gastroenteritis (non-typhoidal).
- The
main feature for S. diseases is the Type III Secretion System, a needle-like
multi-protein complex that is associated with transferring toxic proteins
to host cells.
Principal
habitats in different types of Salmonella
- Their
principal habitat is the intestinal tracts and bloodstream of humans,
and in the intestinal tracts of a wide variety of animals.
- The
WHO groups Salmonella into 3 types:
-
- Typhoidal (enteric) Salmonella
- (example:
S. typhi)
-
٠causes typhoid and paratyphoid fever
-
٠restricted to growth in human hosts
-
٠principal habitat is in intestinal tracts and the
bloodstream
- Nontyphoidal
Salmonella (example: S. enteritidis, S. typhimurium)
٠prevalent
in gastrointestinal tracts of a broad range of animals, including mammals,
reptiles, birds and insects.
٠cause
a whole range of diseases in animals and humans, mainly gastroenteritis.
٠usually
transferred animal-to-person, through certain food products: fresh meat,
poultry, eggs and milk
- fruits, vegetables, seafood
٠house
and exotic pets, contamination through contact with their feces
- Salmonella mostly restricted to certain animals, such
as cattle and pigs;
infrequently in humans; if these
strains do cause disease
in humans, it is often
invasive and life-threatening.
Salmonella
- Overview
- History
and Epidemiology
- Molecular
Biology
- Clinical
- Weaponization
History
of Salmonella
-
Some historical figures are believed to have been killed by
-
Salmonella:
-
Alexander the Great died mysteriously in 323 B.C. In
2001, a group of doctors at the University of Maryland suggested that
S. was the cause of death, based on a description of Alexander’s
symptoms written by the Greek author Arrian of Nicomedia.
-
Prince Albert, the consort of Queen Victoria, died of a Salmonella infection
in 1861. During the Victorian era, an estimated 50,000 cases per
year occurred in England.
History
- Scholars
working on the history of Jamestown, Virginia, believe that a typhoid
outbreak was responsible for deaths of over 6000 settlers between 1607
and 1624.
- Typhoid
Epidemic in the Spanish-American War (1898)
- In all, 20,738 recruits contracted the disease (82% of all sick
soldiers), 1,590 died (yielding a mortality rate of 7.7%)
- It accounted for 87% of the total deaths from disease.
- A significant number of these deaths actually occurred at training
areas in the southeastern United States.
History
- Typhoid
outbreak in British camps during the South African War (1899-1902)
- more soldiers suffered from typhoid fever than from battle wounds.
- British troops lost 13,000 men to typhoid,
as compared to 8,000 battle deaths.
- outbreak was largely due to unsanitary towns and farms throughout
Africa, and polluted soil was washed into the network of streams and
rivers during the rainy season.
- Epidemic
potential during a war prominent because of the disposal problems of
men’s discharges.
History
- Similar
problems of sanitation occurred in urban areas. Many historic
documents report about typhoid outbreaks in England:
- Most
outbreaks that were reported could be traced back to unsanitary
water supplies or polluted milk supplies.
- Dr. William
Budd (1811-1880): documented his observations, published them in the
Lancet; It was known then that polluted water can spread the disease.
Budd urged for more disinfection and water treatment
- reports
show that in the nineteenth century, population seemed powerless against
this disease even though they knew it was perfectly preventable.
- with the
introduction of piped and filtered water supplies in most urban areas,
its prominence as a cause of death had diminished.
Salmonella
vaccine
- First
preventive measure against Salmonella was discovered in 1896, as an
antityphoid vaccine was developed by the British surgeon Almroth Wright.
- Vaccine
consisted of heat-denatured, rudimentary killed whole-cell bacteria;
said to be highly effective.
- Early
wars: -Immunization known, but new
British War Office authorized it on a voluntary basis only;
most soldiers refused to be immunized because of
violent reaction following injection; possible contraction
- Urban
outbreaks: opposition to any type of vaccination; a way around
the problem of sanitation and cleanliness. It was seen as
a disease of “defective civilization …due
to defective sanitation”.
- Between
1904-1914, the vaccine had become respectable, in the scientific as
well as military world.
- Vaccine
was successfully used during World War I to reduce the number of soldiers
who died of enteric fever (S. typhi).
Salmonella
vaccine
First typhoid
inoculation, 1909 United States Army Medical School
Bottling
typhoid vaccine, 1944
Division of
Biologic Products, U.S. Army of Medical Department Professional Service
Schools
History
in the U.S.
- “Typhoid Mary”
Mallon was the first famous carrier of typhoid fever in the U.S.
- Some
individuals have natural immunity to Salmonella. Known as “chronic
carriers”, they contract only
mild or asymptomatic disease, but still carry the bacteria in their
body for a long time. These cases serve as natural reservoir for
the disease.
- Approximately
3% of persons infected with S. typhi and 0.1% of those infected with
non-typhoidal salmonellae become chronic carriers which may last for
a few weeks to years.
- One
such case was Mary Mallon, who was hired as a cook at several private
homes in the new York area in the early 1900’s.
History:
Mary Mallon
- Mary
Mallon caused several typhoid outbreaks, moving from household to household,
always disappearing before an epidemic could be traced back to the particular
household Mary was working in. All together, she had worked for
7 families, with 22 cases of typhoid and one death.
- She
was finally overtaken by the authorities in 1907 and committed to an
isolation center on North Brother Island, NY. There she stayed
until she was released in 1910, on the condition that she never accept
employment involving food handling.
- But:
She was found to work as a cook and to cause typhoid outbreaks again.
She was admitted back to North Brother Island, where she lived until
her death in 1938.
Recent outbreaks
- More
recently reported outbreaks in the U.S. involve different kinds of Salmonella
strains, predominantly S. enteritidis and S. typhimurium.
- In
1985, a salmonellosis (S. typhimurium) outbreak involving 16,000 confirmed
cases in 6 states by low fat milk and whole milk from one Chicago dairy.
Largest outbreak of food-borne salmonellosis in the U.S. Investigations
discovered that raw and pasteurized milk had been accidentally mixed.
Oregon:
Intentional Contamination
of Restaurant Salad Bars
In September
of 1984, 10 area restaurants in The Dalles, Oregon, were involved with
outbreaks of S. typhimurium
Outbreaks
- January
2000: infant aged 1 month visited a clinic with fever and diarrhea.
A stool specimen yielded Salmonella serotype Tennessee. One week
before illness onset, the infant's family moved into a household that
contained a bearded dragon (i.e., Pogona vitticeps).
- During
June 2002, a child aged 21 months was admitted to a hospital with fever,
abdominal cramps, and bloody diarrhea. Blood and stool cultures yielded
Salmonella serotype Poona (from pet Iguana).
Foodborne
diseases
- WHO:
in 2000 that globally about 2.1 million people died of foodborne illness
- in
industrialized countries, about 30% of people suffer from foodborne
diseases each year; around 76 million cases occur each year, of which
325,000 result in hospitalization and 5,000 in death.
(WHO, 2002)
Why
do foodborne diseases emerge ?
- Globalization
of food supply: for example, multistate outbreaks of S. Poona infections
associated with eating Cantaloupe from Mexico (2000-2002)
- Unavoidable
introduction of pathogens into new geographic areas: for example,
vibrio cholerae introduced into waters off the coast of southern U.S.
by cargo ship (1991).
- Travelers,
refugees and immigrants exposed to unfamiliar foodborne hazards.
- Changes
in microorganisms: evolution of new pathogens, development of
antibiotic resistance, changes in the ability to survive in adverse
environmental conditions.
Why
do foodborne diseases emerge ?
- Changes
in human population: population of highly susceptible people is expanding;
more likely to succumb to bacterial infections.
- Changes
in lifestyle: Great amount of people eat prepared meals.
In many countries, the boom in food service establishments is not matched
by effective food safety education and control.
Relative
Frequency of the disease in the U.S.
- Estimate:
2 to 4 million cases of salmonellosis occur in the U.S. annually (reported
and unreported). Salmonella accounts for the majority of food
poisoning cases in the U.S
In 2002, a total of 32,308 cases were reported from health laboratories
in 50 states.
The national rate of reported isolates was 11.5 per 100,000 population.
Shows decrease of 7% compared to 1992, slight increase of 2% from 2001.
Epidemiology
- The
most commonly reported serotypes, in history and present:
- S. typhi
- S. enteritides and S. typhimurium
- The “top
20” serotypes accounted
for 80% of all isolates reported in the U.S. in 2001.
Top
15 Salmonella Serotype list in the U.S., 2001
1.1
343
Typhi
15
1.2
370
Agona
14
1.2
388
Braenderup
13
1.4
440
Infantis
12
1.5
466
Paratyphi B
tartrate positive
11
1.5
469
Saintpaul
10
1.6
514
Thompson
9
1.8
583
Muenchen
8
1.9
595
Oranienburg
7
2
626
Montevideo
6
3.4
1,067
Javiana
5
5.9
1,884
Heidelberg
4
10
3,158
Newport
3
17.7
5,614
Enteridites
2
22.1
6,999
Typhimurium
1
31,675
U.S.A., Centers of Disease Control, Control
and Prevention-FDDB Epi, 2001, Human
% of Total
Serotyped
Count
Serotype
Rank
Total
Serot
ped
Country, Institution, Biological origin
Epidemiology
S. typhi (typhoidal Samonella)
- Have
no known hosts other than humans.
- Transmission
through close contact with infected or chronic carriers. While
direct person-to-person transmission through the fecal-oral route is
rare, most cases of disease result from digestion of contaminated food
or water.
- Since
improvements in food handling, piped and filtered water supplies as
well as water/sewage treatment have been made, enteric fever has become
relatively rare in developed countries.
- However,
typhoid fever is still a big health-problem in developing countries.
- The
WHO estimates that there are worldwide about 16 million of clinical
cases annually, of which about 600,000 result in death. In comparison,
about 400 cases occur each year in the U.S., and 70% of these cases
are acquired while traveling internationally.
Salmonella
typhi in developing countries
- Contaminated
water is a common cause in the spread of typhoid fever. At the
time of rain, the contaminated surface water further contaminates water
supplies.
- Severity,
Morbidity and complication rate is much higher than in Europe and North
America due to lack of antibiotics supply, water filtration and treatment,
sterilization of water and sanitation.
S.
Typhi in the U.S.
- Almost
30% of reported cases in the U.S. are domestically acquired.
- Although
most cases are sporadic, large outbreaks do occur.
For example, outbreak linked to contaminated orange juice
in N. Y., caused by a previously unknown chronic carrier (1991).
recent trend toward an increased incidence of multi-drug resistant S.
typhi in developing countries is reflected by increase in the proportion
of U.S. cases: 0.6% in 1985-1989 to 1.2% in 1990-1994.
Epidemiology
- S.
enteriditis and typhimurium (non-typhoidal S.):
- are
the 2 top serotypes in the U.S. since 1980’s
- cause
gastroenteritis following ingestion of the
bacteria on or in food or on fingers and other objects
- cause
the majority of cases of zoonotic salmonellosis in many countries.
Salmonella
Enteritidis
- transmitted
to humans by contaminated foods of animal origin, predominantly eggs.
Raw eaten or undercooked eggs that have been infected in the hen’s
ovaries can cause gastroenteritis
Humpty
Dumpty
by R. Wayne Edwards January 1999
Humpty
Dumpty lay on the ground
A crushed and broken fella.
No one wanted to put him together
'Cause he had salmonella.
Salmonella
Enteritidis Infections, United States, 1985–1999
- During
the 1980s, illness related to contaminated eggs occurred most frequently
in the northeastern United States, but now it is increasing in other
parts of the country as well.
- CDC,
2002: In the Northeast, approximately one in 10,000 eggs may be internally
contaminated; one in 50 average consumers could be exposed to a contaminated
egg each year.
- In
1995: high of 3.9 per 100,000 population,
In 1999: 1.98 per 100,000, rate still decreasing due to prevention and
control efforts by the government.
S.
typhimurium
- has
been reported increasingly frequently as the cause of human and animal
salmonellosis since 1990, due to antibiotic resistance
- Predominant
multi-drug resistant strain DT 104, which initially emerged in cattle
in England, 1988
- In
1997, the WHO stated that some countries in Europe had a staggering
20-fold increase in incidences between 1980 and 1997, and a 5-fold increase
in the U.S. between 1974 and 1994, due to antibiotic resistant strains
- intensive
animal maintenance.
Epidemic
measures
- Salmonellosis
is a reportable disease.
An intensive search should be conducted for the source of an infection
and for the means (food or water) by which the infection was transmitted.
- Samples
of blood can be taken immediately for confirmation and for testing for
antibiotic sensitivity.
Samples of stool or urine may be taken after one week of onset for effective
confirmation.
- Food
and water samples should be taken from suspected sources of the outbreak.
It is recommended to organize temporary water purification and sanitation
facilities until longer term measures can be implemented.
Cost
Estimates
- The
cost per reported case of human salmonellosis range from US $100 to
$1300 in North America and Europe.
- The
costs associated with individual outbreaks in North America and Europe
range from around
$60,000 to more than $20 Million.
- The
total annual cost in the U.S. is estimated a total of almost $400 Million.
Salmonella
- Overview
- History
and Epidemiology
- Molecular
Biology
- Clinical
- Weaponization
Salmonella
Microbiology
Classification
- Enterobacteria
- Gram-negative
- Facultative
anaerobes
- Straight,
rod
- 2-3
µm in length
- Flagellated
- Many
serovars
- Typhi
- Typhimurium
- Enteriditis
LPS
on Surface
- Lipopolysaccharide
- Protective
outer layer of most strains
- (not
S. typhi)
- Coded
for by rfb locus on chromosome
- Lipid
core of LPS highly conserved across serovars, but polysaccharide side
chains are highly polymorphic (nature of rfb gene)
LPS
(cont.)
- Memory
immune response and antibodies directed against LPS
- Polymorphic
nature of side chains is advantageous for bacteria
- Since
Typhi has outer capsule, this infection is worse.
Infection
- Ingestion
of contaminated food or water
- Passes
through mucosa of intestine to epithelial cells
- Causes
membrane ruffling
- Releases
effector proteins through Type III Secretion system
- Endocytosis
Salmonella
Entry
Membrane
Ruffling
Virulence
Factors
- Genes
for virulence factors cluster in pathogenicity islands (PI)
- Genes
acquired through lateral transfer
- Bacteriophage
and transposon insertion sequences flank PI
- Maybe
vehicles for transfer of PI to Salmonella at one time
- Acquisition
of PI enhances virulence of bacteria
Horizontal
Transfer
- Transformation
- Uptake
of naked DNA
- Mediates
exchange of any part of DNA
- Conjugation
- F+
to F-
- Requires
cell to cell contact – conjugation bridge
- Transduction
- Transfer
of DNA by a phage
- New
phage: viral coat with bacterial DNA
Salmonella
Pathogenicity Islands
- Salmonella
Pathogenicity Island 1 (SPI-1)
- entry
into intestinal epithelium
- Enables
pathogen to exploit host intestinal environment
- Salmonella
Pathogenicity Island 2 (SPI-2)
- intracellular
bacterial replication and initiation of systemic infection
- Do
not influence enteropathogenesis to any great extent
Type
III Secretion System (TTSS)
- Main
way Salmonella delivers virulence factors to host
- Made
up of 20 proteins
- Assemble
in step-wise order
- PrgI
is a needle structure extended by protein base, forms a channel to host
PrgI
Salmonella-host
Interaction
- Two
forms of TTSS
- One
encoded on SPI-1, other on SPI-2
- SPI-1
TTSS probably causes initial interaction
- Starts
bacteria-mediated endocytosis
- Entry
activates SPI-2 TTSS to cause thorough infection
Membrane
Ruffling
- Cytoskeleton-associated
proteins relocate to site of bacterial entry
- Bacterial
effector proteins trigger cytoskeleton rearrangements
- Apical
membrane surface undergoes structural changes, resembling ruffling
- This
triggers endocytosis into vesicles
- Slightly
different from receptor-mediated endocytosis
Salmonella
Containing Vesicle
- After
ingestion, Salmonella enters a SCV through bacteria-mediated endocytosis
- Lives
and multiplies in SCV
- Very
little known about SCV or how bacteria exist inside
- A
method to avoid host immune response
- Phagosome:
maturing SCV
SPI-1
Effector Proteins
- SipA
- Binds
actin and stabilizes filaments
- Allows
actin to polymerize more easily
- Maximizes
efficiency of Salmonella invasion
- SipC
- Aides
in entry of other SPI-1 effector proteins
- Activtes
G-actin to form F-actin, then polymerize
- Aides
in cytoskeleton rearrangements in membrane ruffling
SopB
- Main
virulence factor
- Encoded
by SPI-5
- An
enterotoxin associated with SPI-1 TTSS
- Induces
an increase in concentration of cellular inositol polyphosphate
- Increased
chloride secretion into lumen
- Na+
follows to balance charge
- Water
follow to balance osmolarity
diarrhea
SPI-2
TTSS
- Activated
once bacteria enters cell
- Necessary
for systemic infection
- SPI-2
TTSS secretes effector proteins from phagosome into cytosol
- Interfere
with maturation of phagosome
- No
fusion with lysosome
- How
Salmonella avoids degredation in cell
Flagella
- Another
antigen
- Host
cytotoxic T-cell response directed against flagellar epitopes
- N-
and C- termini are highly conserved
- Middle
of flagellum is variable
Phase
I / II Flagella
- Operon
encoding Phase I flagella also encodes for a protein that represses
trascription of Phase II
- The
switch mediated by an enzyme that inhibits Phase I, allowing Phase II
- May
help Salmonella avoid cell-mediated immune response
Tumor
Necrosis Factor-α
- Flagella
from S. Typhimurium induces expression of TNF-α through cell-mediated
reponse
- Phase
II flagella are less-potent inducers
- Switching
mechanism may provide bacteria with a way to down-regulate inflammatory
response within host
Immune
Response
- White
blood cells recognize – trigger T cells, B
cells
- Two
types of B cells: one to attack now, one for memory
- Macrophages
and neutrophils attack bacteria, secrete interleukins, causing cell-mediated
response by T-cells
- Antibodies
from B cells attach to bacteria, allowing cytotoxic T cells, macrophages,
and neutrophils to kill the organism
Inside
Macrophages
- SPI-2
TTSS works in macrophages as well
- Bacterium
produces enzymes that inactivte toxic macrophage compounds
- Homocysteine
(Nitric Oxide antagonist)
- Superoxide
dismutase (inactivates reactive peroxides)
- Salmonella
must produce additional factors to survive limited nutrient base
- Allows
bacteria to travel throughout body, causing systemic infection (only
in S. typhi)
Septicemia
- Invasion
of bloodstream
- spv
genes causes detachment of cells to ECM and apoptosis
- Spreads
infection
- Bacteria
can enter bloodstream and lymphatic system
- Main
cause of death by Salmonella
How
do we respond?
Salmonella
Vaccine Strategy
- Delete
chromosomal regions that code for independent and essential functions.
This results in:
-
low probability of acquiring both traits
-
both traits:
* aro genes: aromatic compound biosynthesis
* pur genes: purine metabolism biosynthesis
-
can be grown on complete medium in lab
-
in vivo, growth is reduced
-
only a low level of infection is established
-
immune system can mount a response
- Vaccine
suitable for humans and mice, chickens, sheep, cattle
DNA
adenine methylase (Dam)
- Enzyme
that methylates specific adenine residues in Salmonella genome
- Disrupts
regulation of DNA replication and repair
- Regulates
expression of about 20 bacterial genes active during infection
- Dam
(-) mutants are not virulent
- Good
antimicrobial potential
- Current “hot
topic” of research
Antibiotics
- Antibiotics
are selective poisons
- Target
different aspects of bacteria, such as ability to synthesize cell wall,
or metabolism
- MIC:
Minimum Inhibitory Concentration
- the
minimum amount of agent needed to inhibit the growth of an organism
Antibiotic
Resistance
- Bacteria
can counteract antibiotics by:
- Preventing
antibiotic from getting to target
- Changing
the target
- Destroy
the antibiotic
- Bacteria
can acquire resistance
- Horizontal
transfer from another bacteria
- Vertical
transfer due to natural selection
Salmonella
- Overview
- History
and Epidemiology
- Molecular
Biology
- Clinical
- Weaponization
How
Do You Catch Salmonella?
- Food
borne
- Transmitted
via improperly prepared, previously contaminated food or water
- Meat:
poultry, wild birds, pork
-
Dairy: eggs
How
does Salmonella affect the body?
- Three
clinical forms of salmonellosis
- -
Gastroenteritis (S. typhimurium)
- -
Septicemia (S. Choleraesius)
- -
Enteric Fevers (i.e. S. typhi – Typhoid Fever)
Who
Can Be Infected?
- Everyone
- Especially:
the elderly, infants, immunocompromised patients (AIDS, sickle cell
anemia)
Factors
Increasing Susceptibility
Identification
I
- Laboratory
identification of genus Salmonella: biochemical + serological tests
- HOW?
-
stool or blood specimens are plated on agar media (bismuth sulfite,
green agars, MacConkey)
- Suspect
colonies further analyzed by triple sugar iron agar/ or lysine-iron
agar
-
confirmed by antigenic analysis of O (somatic) and H (flagellar) antigens
Test for antigens:
Identification
II
- testing for lactic acid production
- if negative, diagnose (presence of red spots surrounded by a bright
red zone)
Salmonella
typhimurium
Nontyphoidal
Salmonella
- General
Incubation: 6 hrs-10 days; Duration: 2-7 days
- Infective
Dose = usually millions to billions of cells
- Transmission
occurs via contaminated food and water
- Reservoir:
c)
fresh produce and exotic pets are also a source of contamination (>
90% of reptile stool contain salmonella bacterium); small turtles
ban.
- General
Symptoms: diarrhea with fever, abdominal cramps, nausea and sometimes
vomiting
Nontyphoidal
Salmonella
- Caused
by S. typhimurium and S. enteritidis
- Rainy
season of tropical climates; Warm season of temperate climates
- Growing
rapidly in the U.S.: five-fold increase between 1974-1994
- Centralization
of food processing makes nontyphoidal salmonellosis particularly prevalent
in developing countries
- Resistance
is a concern, especially with multi-drug resistant S. Typhimurium
known as Definitive Type 104 (DT 104)
Nontyphoidal
Salmonella:
Gastroenteritis
- Incubation:
8-48 hrs ; Duration: 3-7 days for diarrhea & 72 hrs. for fever
- Inoculum:
large
- Limited
to GI tract
- Symptoms
include: diarrhea, nausea, abdominal cramps and fevers of 100.5-102.2ºF.
Also accompanied by loose, bloody stool; Pseudoappendicitis (rare)
- Stool
culture will remain positive for 4-5 weeks
- <
1% will become carriers
Nontyphoidal
Salmonella:
Bacteremia and Endovascular Infections
- 5%
develop septicemia; 5-10% of septicemia patients develop localized infections
- Endocarditis:
Salmonella often infect vascular sites; preexisting heart valve
disease risk factor
- Arteritis:
Elderly patients with a history of back/chest + prolonged fever or abdominal
pain proceeding gastroenteritis are particularly at risk.
-
Both are rare, but can cause complications that may lead
to
death
Septicemia
- Serotype
S. choleraesius causes septicemia:
-
prolonged state of fever, chills, anorexia, and anemia
-
lesions in other tissues
-
septic chock, death
Incidence
of S. Enteritidis
Nontyphoidal
Salmonellosis:
Localized Infections
- INTRAABDOMINAL
INFECTIONS:
- Rare,
usually manifested as liver or spleen abscesses
- Risk
factors: hepatobiliary, abdominal abnormalities, sickle cell disease
- Treatment:
surgery to correct anatomic damages and drain abscesses
- CENTRAL
NERVOUS SYSTEM INFECTIONS:
- Usually
meningitis (in neonates, present with severe symptoms e.g. seizures,
hydrocephalous, mental retardation, paralysis) or cerebral abscesses
- PULMONARY
INFECTIONS:
- Usually
lobar pneumonia
- Risk
factors: preexisting lung abnormalities, sickle cell disease, glucocorticoid
usage
Typhoidal
Salmonellosis: Enteric Fever
- Incubation:
7-14 days after ingestion; Duration: several days
- Infective
Dose = 105 organisms
- Symptoms:
a)
1st week: slowly increasing fever, headache, malaise, bronchitis
b)
2nd week: Apathy, Anorexia, confusion, stupor
c)
3rd week: rose spots (1-2 mm diameter on the skin): duration:
2-5 days, variable GI symptoms, such as abdominal tenderness (majority),
abdominal pain (20-40% of cases) and diarrhea; enlargement of the spleen/liver,
nose bleeds, and bradycardia
- neuropsychiatric
symptoms: delirium and mental confusion
- Long
term effects: arthritis
Typhoidal
Salmonellosis
- Late
stage complications include intestinal perforation and gastrointestinal
hemorrhage
- Immediate
care such as increase antibacterial medications or surgical resection
of bowel
- Other
rare complications include inflammation of the pancreas, endocardium,
perocardium, myocardium, testes, liver, meninges, kidneys, joints, bones,
lungs and parotid gland and hepatic/splenic abscesses
- In
general, symptoms of paratyphoid fever are similar to typhoid fever,
but milder with a lower mortality rate
- Majority
of bacteria gone from stool in 8 weeks; However, 1-5% become asymptomatic
chronic carriers: gallbladder is the primary source of bacterium
Typhoidal
Salmonella
Chest PA view
shows pleural effusion, left lower pulmonary lobe atelectasis, medial
and downward shift
of bowel gas,
and an increase in the air-fluid level in the abdomen
Pictures
(A) In sub-acute
infections, multiple white to yellow foci occur in the liver, spleen
is enlarged, and
mesenteric
lymph nodes may be enlarged
(B) Histopathological
examination may reveal necrotizing splenitis and hepatitis, with necrotic
foci often
accompanied by colonies of bacteria (arrow in right photo).
(A)
(B)
Treatment
of Typhoidal Salmonellosis
- Third
generation cephalosporins or quinolones is the current treatment
- IV
or IM ceftriaxone (1-2g) is also prescribed; usually 10-14 days (5-7
days for uncomplicated cases)
- Multi
Drug Resistant (MDR) strains of S. typhi: quinolones are the
only effective oral treatment
- Nalidixic
acid resistant S. typhi (NARST) must be tested for sensitivity
to determine course of treatment
- Sever
typhoid fever (altered consciousness, septic shock): dexamethasone treatment
- Chronic
carriers: 6 weeks of treatment with either oral amoxicillin, ciprofloxacin,
norfloxacin
- Surgical
intervention to remove damaged cells
Prevention
- Generally treated with antibiotics
- vaccinations available; the CDC currently recommends vaccination for
persons traveling to developing countries
- Education of general public, especially in developing countries; identification
of all carriers and sources of contamination of water supplies
- avoid risky foods & drinks:
buy bottled water or boil water for at least 1 minute;
COOK and CLEAN food thoroughly, avoid raw vegetables and fruits
- WASH
YOUR HANDS WITH SOAP AND WATER!!!
Preventive
measures for non-typhoidal S.
- pasteurization
of milk-products; Eggs from known infected commercial flocks will be
pasteurized instead of being sold as grade A shell eggs.
- tracebacks,
on-farm testing, quality assurance programs, regulations regarding refrigeration,
educational messages for safe handling and cooking of eggs
- Cross-contamination:
uncooked contaminated foods kept separate from cooked, ready-to-eat
foods.
Salmonella
Vaccines I
- Poultry
vaccine: Megan™Vac 1
-
applied to baby chicks via drinking water and cattle. It stimulates
immunity in the chickens, preventing Salmonella infection during the
growing period which may result in contamination and subsequent food
borne infection of humans
-
targets S. Enteritidis
-
Salmonella infection is stopped at lower levels of the food chain will
mean increased productivity for the farmer and a break in the cycle
of Salmonella transmission from animals à humans
Salmonella
Vaccines II
- Today,
three types of Typhoid Vaccines are available:
(1)
inactivated whole-cell vaccine: 2 doses/ 4wks. Apart; single booster
dose recommended every 3 years
(2)
Ty21a: a live, attenuated S. typhi vaccine. Administered orally (4 doses).
Efficacy: 7 years
(3)
Vi polysaccharide vaccine: from purified Vi polysaccharide from S.
typhi. Administered subcutaneously or intramuscularly. To
maintain protection, revaccination recommended every 3 years.
- These
vaccines have been shown be 70-90% effective.
Salmonella
- Overview
- History
and Epidemiology
- Molecular
Biology
- Clinical
- Weaponization
Salmonella
as A Bioweapon?
CDC
classification
- Category
B agent: includes microorganisms that are moderately easy to disseminate,
have moderate morbidity (i.e., ability to cause disease) and low mortality,
but require enhanced disease surveillance.
- Biosafety
Level 2
- Risk
Level 2: associated with human disease that is rarely serious and prophylactic
intervention is often available.
- 9
different species: Salmonella arizonae, cholerasuis, enteritidis,
gallinarum-pullorum, meleagridis, paratyphi (Type A,B,C), spp.,
typhi, and typhimurium
- Salmonella
typhi is the only species that requires import and/or export permit
from CDC and/or Department of Commerce; has
high droplet or aerosol production potential
WHO
Global Salm Surv (GSS)
- GSS
is an international Salmonella surveillance program initiated in January
2002. It collects annual summary data from member institutions
all over the world.
- The
goal is to enhance the quality of Salmonella surveillance, serotyping
and antimicrobial resistance testing and leading local interventions
that reduce the human health burden of Salmonella.
- A
total of 138 laboratories were enrolled in the GSS in September 2003.
Salmonella
as a Bioterrorist Weapon: What
states are most at risk?
- The
states most vulnerable to terrorist attack on the agricultural sector
are those with several or most of the following attributes:
- High
density, large agricultural area
- heavy
reliance on monoculture of a restricted range of genotypes
- major
agricultural exporter, or heavily dependent on a few domestic agricultural
products
- suffering
serious domestic unrest, or the target of international terrorism, or
unfriendly neighbor of states likely to be developing BW programs
First
Use of Salmonella as a Bioterrorist Weapon
- From
1932-1945, Japan conducted biological warfare experiments in Manchuria
- At
Unit 731, a biological warfare research facility, prisoners were infected
with Salmonella typhosa among other biological agents
- Additionally,
a number of Chinese cities were attacked. The Japanese contaminated
water supplies and food items with Salmonella.
Cultures were also tossed into homes and sprayed from aircraft
- Due
to inadequate preparation, training, and/or lack of proper equipment,
the Chekiang Campaign in 1942 led to about 10,000 biological casualties
and 1,700 deaths among the Japanese troops.
Oregon 1984:
a religious cult known as the Rajneeshees, a Buddhist cult sought to
run
the whole country
by wining the local election in 1984 using salmonella bacteria. They
brewed a "salsa"
of salmonella and sprinkled it on the town's restaurant salad bars.
Ten
restaurants
were hit and more than 700 people got sick.
-
First large scale bioterrorism attack on American soil
-
A communitywide outbreak of salmonellosis resulted; at least 751 cases
were
documented
in a county that typically reports fewer than five cases per year.
-
Health officials soon pinned down salmonella as the cause of the sudden
outbreak, but
put the blame
on food handlers. In 1984, who could have imagined bioterrorism?
-
caused by S. typhimurium as this type
- Wide
distribution of food: contaminated food produced in one country
can cause illness in other countries
- Traceability
- Antimicrobial
resistance: strains of
Salmonella
are being found that have
multiple drug
resistance
- Capacity
building: Salm-gene project
used to enhance
outbreak detection by
routinely sub-typing
certain salmonellas
using molecular
methods
Salmonella
as a Bioterrorist Weapon
Salmonella
as a Bioterrorist Weapon
- Contaminating
unguarded food supplies
- Some
terrorist acts may be designed purely to spread panic: contaminating
the food supply could bring economic and agricultural production to
a standstill
EX.
If numerous food-borne outbreaks occurred across the country, people
would soon fear their meals
- Unfortunately,
people have reason to worry: all these contaminations have occurred
naturally every year. If Mother Nature can do this repeatedly, then
a terrorist should have no problem recreating these outbreaks over and
over in any number of American cities.
Salmonella
as a Bioterrorist Weapon
- readily
accessible and easy to grow or make
- Centralized
food production: largely unmonitored food supply; food that is tampered
with can be widely + quickly distributed
- Terrorist
groups could use infectious disease agents to confuse public health
officials into believing that outbreaks are naturally occurring: it
is estimated that 1.4 million salmonella infections occur each year,
but the CDC gets reports of only about 38,000 annually
- According
to the Centers for Disease Control (CDC), only 32% of the reported outbreaks
have a known etiology.
Salmonella
as a Bioterrorist Weapon
- No
food product is safe: vegetables and fruits are the easiest to contaminate.
Fresh-produce wholesalers and distributors are notorious for employing
illegal immigrants and not checking their background information.
- Even
processed foods aren’t safe: Terrorists
could use heat-stable toxins that would survive the packaging process.
- As
more of our food becomes imported, especially hard-to-clean off-season
fruits and vegetables, bioterrorists don’t even have to be inside
the United States to do damage
Salmonella
as a Bioterrorist Weapon: Who
might be tempted to initiate an attack on the agricultural sector?
- Terrorist
groups might be interested in agricultural bioweapons for a variety
of reasons:
1.
international terrorist organizations: cause harm/injury to enemy states
or peoples
-
in an ideologically-motivated terrorist attack there would be willing
assumption of responsibility by the perpetrator OR an attempt
to disguise the outbreak as natural.
2.
Extreme activist groups:
-
EX. anti-GMO groups for their potential value in deterring farmers from
the use of genetically engineered crops or animals
Salmonella
as a Bioterrorist Weapon: What
goals might an attack on the agricultural sector serve?
- Food
attack by a terrorist group: initiate point-source
epidemics using available Salmonella strains
- Destabilize
a government by initiating food shortages/unemployment: the
potential for immense economic damage due to contamination of the food
supply
- Alter
supply and demand patterns for a commodity: an outbreak can trigger
the imposition of trade restrictions. This is turn would open up or
close markets for others.
Salmonella
as a Bioterrorist Weapon: What
are the special features of an attack on the agricultural sector?
- Salmonella
is not hazardous to perpetrators:
easy to produce, stockpile, and disseminate
- Few
technical obstacles to weaponization:
it would not be difficult to obtain Salmonella strains on the open market.
- Low
security of vulnerable targets:
Fields, supermarkets, restaurants have essentially no security at all.
- Point
source to mimic natural introduction:
Because of the high incidence of naturally-occurring diseases, a deliberately
instigated outbreak could be mistaken for a natural one
- Multiple
point source outbreaks can be initiated by contaminating imported feed
or fertilizer, without even entering the country:
allows the possibility of initiating multiple outbreaks over a large
geographic area, in a way that mimics a natural event
Salmonella
Dilemma
- Dissemination
of genomic knowledge of salmonella can facilitate bio-weapons development:
- Alternative
1: Restrict dissemination of genomic knowledge
-
short term: hinders development of a “super-Salmonella”
terror weapon
-
long run: leaves us at the mercy of multi-drug resistant salmonella
strains ranging from incapacitating to lethal
- Alternative
2: Disseminate genomic knowledge, but support development of salmonella
specific-drugs
-
knowledge may provide a terrorist org. with the ability to develop “super-Salmonella”
terror weapons, but it provides us with the opportunity to defend against
all salmonella infection.
Combating
Salmonella Bioterrorism
- Establish
a national disease surveillance system that could not only help uncover
a terrorist attack but also recognize naturally occurring outbreaks
that now go undetected
- New
technology: creating a diagnostic gene chip covering all major diseases
could give the health care provider instant diagnoses. Similar gene
chips could monitor the health of livestock, poultry, and crops. Chips
could be used during various steps of food processing to ensure quality
control and food safety.
Lines
of Defense
- Food
processors should limit access to their production, storage and packaging
areas: rerouting traffic, installing locks
- Randomized
safety checkpoints: will increase fear of detection
- COSTS:
- Increase
work force
- Sampling
and test costs
- Record
keeping
Government
Action
- CDC
monitors the frequency of Salmonella infections in the country and assists
the local and State Health Departments to investigate outbreaks and
devise control measures
- FDA
inspects imported foods, milk pasteurization plants, promotes better
food preparation techniques in restaurants and food processing plants,
and regulates the sale of turtles and it also regulates the use of specific
antibiotics as growth promotants in food animals
- USDA
monitors the health of food animals, inspects egg pasteurization plants,
and is responsible for the quality of slaughtered and processed meat.
- EPA
regulates and monitors the safety of our drinking water supplies.
Biological
Weapon Prevention
- BTWC
(Biological and Toxin Weapons Convention): drafted in 1972
-
intended to prevent the development, production and stockpiling of biological
weapons
-
pathogens or toxins in quantities that have no justification for protective
or peaceful services are to be eliminated
-
today, 159 countries have signed the convention and 141 have ratified
it
-
however, more can be done: “ Factories in the former
Eastern Europe supply viruses that cause fatal diseases, such as E-Coli
and Salmonella, without checking the identities of the purchasers” (from the trials of
the largest fundamentalist org. in Egypt, Abu-al-Dahab)
Acknowledgements
- Dr.
Geoffrey Zubay
- Salwa
Touma
- Kathleen
Kehoe