Yesterday, I posted a blog that tried to summarize some of William Balistreri’s talk on Global Health. He gave a 2nd Excellent Lecture on Food Safety at the Georgia AAP Nutrition Symposium. One audience member suggested that this lecture was well-paired with the previous lecture as the awareness of food-borne illnesses might deter gluttony.
This lecture was packed with information regarding food safety; he highlighted the extensive and frequent food-borne illnesses.
The problem of food-borne illness was put under a spotlight by Upton Sinclair in The Jungle (1906) which led to reforms in meat packing industry. However, more work is needed
FSMA -Food Safety Modernization Act was signed into law in 2011; it’s aim is to create a proactive rather than reactive approach, Historic opportunity to increase food safety
Food-borne illnesses: 1 in 10 persons worldwide will be sick every year & leads to 1/2 million deaths worldwide each year. 125,000 deaths in children
Food-borne illnesses: 48 million cases in U.S. each year (CDC estimates) and 3000 deaths (MMWR 64:2, 2015)
Besides significant mortality rates for food-borne illnesses, they also contribute to post-infectious irritable bowel syndrome (~13% of all cases) and these illnesses can be indefinite
Social media, including “IwasPoisoned.com” and Yelp, will likely help identify outbreaks more quickly. Newer molecular technologies during food processing has the potential to improve food safety.
For those who want to keep up food-borne illnesses, Dr. Balistreri recommended food safety news, which provides daily emails. Link to subscribe: Food Safety News
Two books that were recommended: The Poison Squad by Deborah Blum and Outbreak by Timothy Lytton
On October 13, 2017, Governor Jerry Brown of California declared a state of emergency in response to a hepatitis A outbreak that began in the homeless population in San Diego. In the past year, more than 649 people throughout California have been infected, 417 have been hospitalized, and 21 have died from hepatitis A, making this the largest outbreak in the United States in the past 20 years. The vast majority of those affected have been homeless. Like two thirds of people who experience homelessness in California, most were unsheltered.
The environmental conditions associated with homelessness — overcrowding in encampments and emergency shelters, exposure to the elements, and limited access to facilities for hygiene and food preparation and storage — facilitate infectious-disease transmission..Infectious diseases are one of many health threats faced by homeless people. Poorly controlled chronic diseases, complications of substance use disorders and smoking, and unintentional injuries and violence are prevalent, difficult to manage, and often severe among homeless adults.
Despite the excitement regarding Hepatitis C, Hepatitis A and Hepatitis B remain important challenges. Here’s the latest:
1. Collier MG, et al. “Hepatitis A Hospitalizations in United States, 2002-2011” Hepatology 2015; 61: 481-85. The authors examined the changes in demographics and frequency of HAV hospitalization during the study period. Key findings:
Rates of hospitalization dropped from 0.72/100,000 to 0.29/100,000.
Average age of hospitalized patient increased from 37.6 years to 45.5 years and more comorbidities were noted.
No changes were noted in length-of-stay or in-hospital deaths
2. DiBisceglie AM et al. “Recent US Food and Drug Administration Warnings on Hepatitis B Reactivation with Immune-Suppressing and Anticancer Drugs: Just the Tip of the Iceberg?” Hepatology 2015; 61: 703-11. Key recommendation: “There is good evidence to support routine screening of all patients for hepatitis B prior to undergoing chemotherapy or immunosuppressive treatment; use of prompt antiviral treatment appears to diminish the risk of severe or fatal reactivation of hepatitis B. Different organizations suggest disparate screening recommendations (Table 4). AASLD suggests HBsAg, and anti-HBc. CDC suggests adding anti-HBs.
3. Reddy KR, et al. Gastroenterology 2015; 148: 215-19, technical review 221-44. AGA Guideline on the Prevention and Treatment of HBV Reactivation During Immunosuppressive Therapy.Key Recommendations:
Screen patients with HBsAg and anti-HBc, followed by a sensitive HBV DNA test if positive
Treat at-risk patients with antivirals with high barrier to resistance for at least 6 months after discontinuation of immunosuppressive therapy (except in patients taking B cell depleting agents who it is recommended to treat for at least 12 months afterwards)
High risk of reactivation (>10%): B cell depleting agents (eg. rituximab, ofatumumab), anthracycline derivatives (eg. doxorubicin, epirubicin), and daily moderate to high dose steroids (>10 mg) for at least 4 weeks.
Moderate risk of reactivation (1-10%): anti-TNF therapy, integrin inhibitors (eg. ustekinimab, vedolizumab), tyrosine kinase inhibitors, low-dose steroids daily (<10 mg/day) for at least 4 weeks (if HBsAg-positive but not if only anti-HBc-positive)
Low risk of reactivation (<1%): azathiopurine, 6-mercaptopurine, methotrexate. No antiviral prophylaxis required.
4. Corsa AC et al. “No Resistance to Tenofovir Disoproxil Fumarate Through 96 Weeks of Treatment in Patients with Lamivudine-Resistant Chronic Hepatitis B. Clin Gastroenterol Hepatol 2014; 12: 2106-12. This study followed 280 patients–no resistance to tenofovir was observed.
Despite the availability of a safe and effective vaccine, immunization rates in the U.S. remain poor (Pediatrics 2012; 129: 213-221).
In this study which included data from the 2009 National Immunization Survey-Teen, hepatitis A virus (HAV) vaccination coverage was examined in adolescents 13-17 years of age. The national coverage for at least 1 dose was 42%; 70% of these vaccinees completed the 2-dose series. For Georgia, the rates were similar to national data: the 1-dose receipt % was 42.5% and the 2-dose receipt % was 26.3%; 62% completion of 2 doses.
More specific breakdown of coverage rates:
74.3% from 11 states that recommended universal HAV vaccination since 1999
54% from 6 states that recommended consideration of HAV vaccination since 1999 & universal coverage since 2006
27.8% for 33 states that recommended universal vaccination since 2006
While acute HAV rates have been declining, in 2009 there were 1987 reported cases; the CDC estimates that the total number of cases was 21,000 (due to underreporting and asymptomatic cases). The highest rates of disease were in young adults between 20-29 years of age.
This data is disappointing. Yet, extrapolation from this data indicates that national coverage in seven years, when all states will have had 10 years to implement universal vaccination to young children, could be markedly better.
-NEJM 2007; 357: 1685. HAV vaccine effective in preventing cases of HAV after exposure (as good as IVIG). Low rates of HAV c postexposure prophylaxis c HAV vaccine (4.4%) or immune globulin (3.3%). n=1090.
-MMWR 2007; 56: 1080-84. Updated recs for IVIG -use only for exposures in infants <12months, immunocompromised persons, persons with chronic liver disease, or persons w contraindications to HAV vaccine.
-Pediatrics 2007; 120: 189. Recs from AAP. Recs for vaccine — all children at 1 year of age in US w 2-dose regimen; w/in 1 mo of 1st dose 97% of children & 95% of adults develop protective antibody. VAERS (adverse rxns) 800-822-7967 for forms.
-Pediatrics 2007; 119; e12, e22. HAV vaccine is cost-effective.
-MMWR 2007; 56: No. SS-3. drop in new infections by 80% compared to previous nadir; HAV 1.5/100,000 & HBV 1.8/100,000
-Hepatology 2006; 44: 1589. Decreasing incidence of fulminant HAV ; between 1988-2005, decrease of HAV in UNOS database from 0.7% to 0.1%. Risk factors for severe disease: creatinine >2, ALT <2600, intubation, pressors.
-J Pediatr 2004; 144: 327. Maternal antibody decrease HAV vaccine response when administered at 2, 4 & 6 months.
-Am J Gastroent 2002; 97: 721-8. ? cost-effective to vaccinate HCV pts; however, ~35% FHF risk if secondarily infected.