Food & Water Borne

Infections (Selected
Enterics)
Prof. Marohren C. Tobias-Altura
College of Public Health
University of the Philippines Manila

Notifiable Diseases
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Acute bloody diarrhea

Acute hemorrhagic fever
Acute lower respiratory
tract infection &
pneumonia
Acute watery diarrhea
Cholera
Diphtheria
Filariasis
Leprosy
Leptospirosis
Malaria
Measles

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Meningococcal infection
Neonatal tetanus
Non-neonatal tetanus
Paralytic shellfish
poisoning
Rabies (human)
Schistosomiasis
Typhoid & paratyphoid
fever
Viral encephalitis
Viral hepatitis
Viral meningitis
Whooping cough

National Epidemic Sentinel Surveillance

System - NEC (NESSS) of the DOH

TEN LEADING CAUSES OF MORBIDITY

No. & Rate/100,000 Population
PHILIPPINES, 2004
CAUSE

MALE

FEMALE

Rate**

Rate**

BOTH SEXES
Number

Rate*

1. Acute Lower RTI and

Pneumonia

888.8

868 776,562

929.4

2. Bronchitis/Bronchiolitis

651.8

817.1 719,982

861.6

3. Diarrheas

668.5

651.5 577,118

690.7

4. Influenza

400.7

444.6 379,910

454.7

5. Hypertension

338.2

442.1 342,284

409.6

93.9 103,214

123.5

6. TB Respiratory
7. Chickenpox

137.7
51.5

8. Diseases of the Heart

56.2

46,779

56

38.5

45.1

37,092

44.4

24

20

19,894

23.8

17.8

17.1

15,838

19

9. Malaria
10. Dengue fever

Source: 2003 FHSIS Annual Report

** rate/100,000 of sex-specific pop.
* Total population of regions with reports only

TEN LEADING CAUSES OF MORBIDITY

No. & Rate/100,000 Population
PHILIPPINES, 2010
CAUSE

MALE

FEMALE

Rate**

Rate**

BOTH SEXES
Number

Rate*

1. Acute Respiratory Infection

888.8

868 776,562

929.4

2. Acute Lower RTI and

Pneumonia

651.8

817.1 719,982

861.6

3. Bronchitis/Bronchiolitis

668.5

651.5 577,118

690.7

4. Hypertension

400.7

444.6 379,910

454.7

5. Acute watery
diarrhea

338.2

442.1 326,551

347.6

93.9 103,214

123.5

6. Influenza
7. UTI

137.7
51.5

8. TB Respiratory
9. Injuries Source: 2003 FHSIS Annual Report

56.2

46,779

56

38.5

45.1

37,092

44.4

24

20

19,894

23.8

** rate/100,000 of sex-specific pop.

* Total population of regions with reports only

Acute Bloody Diarrhea morbidity

rate by region (Philippines, 2005)
Lacking data or
underreported

Acute watery diarrhea morbidity

rate by year, 1992-2005

Acute watery diarrhea morbidity

rate by region (Philippines, 2005)

Cholera morbidity rate by year

Philippines, 1999 - 2005
Outbreak in Sultan Kudarat

Cholera morbidity rate by region

Philippines, 2005

Typhoid & Paratyphoid Fever morbidity rate

by year (Philippines, 1992 2005)

Outbreak in Laguna

Typhoid & Paratyphoid Fever morbidity rate

by region (Philippines, 2005)

TEN LEADING CAUSES OF MORBIDITY

No. & Rate/100,000 Population
PHILIPPINES, 2003
CAUSE

MALE

FEMALE

Rate**

Rate**

BOTH SEXES
Number

Rate*

1. Acute Lower RTI and

Pneumonia

770.9

748.2

674,386

861.2

2. Diarrheas

695.0

655.0

615,692

786.2

3. Bronchitis/Bronchiolitis

639.6

677.0

604,107

771.4

2003

# 2

455.4

503.1

431,216

550.6

5. Hypertension2002

# 2

325.4

420.7

325,390

415.5

126.4

84.0

92,079

117.9

28.8

29.2

30,398

38.8

41.1

30.4

28,549

36.5

9. Chickenpox

30.3

30.4

26,137

33.4

10. Measles

30.2

30.4

25,535

32.6

4. Influenza

6. TB Respiratory

2001

# 1

2000

# 1

7. Heart Diseases
8. Malaria

Source: 2003 FHSIS Annual Report

** rate/100,000 of sex-specific pop.
* Total population of regions with reports only

TEN LEADING CAUSES OF MORTALITY

By Sex No. & Rate/100,000 Population, Phils, 2003
CAUSE

MALE

FEMALE

BOTH SEXES

1. Heart Diseases

38,677

29,019

Number
67,696

2. Vascular System Diseases

29,054

22,814

51,868

64.0

13.1

3. Malignant Neoplasm

20,634

18,664

39,298

48.5

9.9

4. Accidents

27,720

6,246

33,966

41.9

8.6

5. Pneumonia

15,831

16,224

32,055

39.5

8.1

6. TB, all forms

18,367

8,404

26,771

33.0

6.8

Rate*
83.5 Percent
17.1

10,740 10,623
21,363
26.3
5.4
7. Symptoms, signs and

unsafe
water,
along
with
food,
is
implicated
in
3
million
deaths
abnormal clinical, laboratory
findings, NEC

about 2.4 billion episodes of illness per year

-WHO

12,998

5,907

18,905

23.3

4.8

9. Diabetes Mellitus

6,823

7,373

14,196

17.5

3.6

10. Certain conditions

originating in the perinatal
period

8,397

5,725

14,122

17.4

3.6

8. Chronic lower respiratory

diseases

Source: The2003 Philippine Health Statistics

*percent share from total deaths, all causes, Philippines

Diarrhea & gastroenteritis of presumed infectious

origin as CAUSE of DEATHS among infants,
under 5, children 5-9 ; PHILIPPINES, 2000

Infants 0-12
months old
0.7 rate per 1,000
live births

Children 1-4 years

#8
#1 is pneumonia
#2 bacterial sepsis

#3
#1 pneumonia,
#2 accidents

16.14 rate per

100,000 children

Children 5-9 years

2.19 rate per
100,000 children

#5
#1 accidents
#2 pneumonia

Food & Waterborne diseases

Bacterial Infections
Bacterial Food Poisoning
Viral Gastroenteritis
Prevention and Control

Outline
Bacterial Infections

Cholera
Shigellosis
Typhoid fever
Salmonellosis
Diseases caused
by E. coli

Enterobacteriaceae
Often referred as enterics
General Characteristics
Gram(-) bacilli/coccobacilli
Facultative anaerobes
Glucose fermenters
Oxidase-negative
Reduce nitrates to nitrites

Virulence and Antigenic Factors

Ability to colonize, adhere, produce various toxins and
invade tissues
Some possess plasmids that may mediate resistance to
antibiotics
Many enterics possess antigens that can be used to
identify groups:
O antigen somatic, heat-stable antigen located in the cell
wall
H antigen flagellar, heat labile antigen
K antigen capsular, heat-labile antigen

Antigenic Structure
O antigen:
Lipopolysaccharide
K antigen: Capsular
H antigen: Flagellar

Shigella

Shigella
S. dysenteriae -Group A
S. flexneri -GroupB
S. boydii -Group C
S. sonnei -Group D
gram-negative rods
cannot ferment lactose, no capsule
non-motile

Shigella - natural reservoir &

transmission
man only "reservoir"
mostly young children
fecal to oral contact
children to adults
transmitted by adult food handlers
unwashed hands

Shigella
Diseases--Shigellosis
Symptoms start 1-3 days after exposure
with profuse watery diarrhea. Disease can stop
here.

Can progress to dysentery,

which is an intestinal inflammation with abdominal
pain, intense diarrhea,
relatively scant stool
with blood, mucous, and white blood cells (pus)

Symptoms usually resolve on their own in 1

week
Rarely, an infected person becomes a carrier

Shigella
Diseases--Shigellosis
More severe form of this disease is
produced by S. dysenteriae type1A.
This species produces a toxin-called
Shiga toxin

Shigella-Pathogenic factors
Ipa (invasive plasmid antigen) A,B,C,
and D proteins are secreted into host
cells intracellular growth of Shigella
1st, bacteria invade intestinal cells by
endocytosis
2nd, escape from endocytotic vesicles
and multiply inside the cells.
3rd, directly invade adjacent cells
4th, host cells die and mucosal abscess
forms

Shiga toxin
classic A/B toxin
B subunit binds to cells and
gets A inside the cell.
A inhibits protein synthesis
lysing 28S rRNA

cytotoxic for intestinal cells

Treating shigellosis
manage dehydration
use of antibiotics, controversial if
case is not severe
patients respond to antibiotics
disease duration diminished

fluoroquinolone

Salmonella

Salmonella
>2000 antigenic O and H serotypes
genetically single species-maybe?
S. enterica, choleraesuis

disease category
S. typhi
S. paratyphi

Salmonella
Natural reservoir: not humans, but many
other animals, including birds, reptiles,
many others and vegetation. Eggs are also
a risk.
Transmission is by ingestion of
contaminated food products, especially
poultry or dairy products. Some
transmission by person to person can
occur in children, health care, or food
preparation if proper sanitation is not
observed.

Salmonella typhi & paratyphi

Natural reservoir: only infected humans
Transmission: person to person by the
oral-fecal route and by ingestion of water
or food contaminated with human feces.

Salmonellosis
Gastroenteritis
nausea
vomiting
non-bloody stool mostly, sometimes bloody
with fecal leukocytes
sometimes fever, abdominal cramps,
malaise
self-limiting (2 - 7 days)
40,000 reported cases; 1.4 million total

Salmonellosis
Gastroenteritis
identification- usually not cultured unless
symptoms last a long time. Stool cultures
treatment is just fluid and salt
replacement
antibiotics not recommended, with
exceptions for very young, very old,
immunocompromised, debilitated.

Typhoid fever
enteric fever
severest salmonella disease
Salmonella typhi
S. paratyphi causes milder form of enteric fever

endemic areas -Latin America, Philippines,

Indian subcontinent
epidemics
third world
Europe(historical)

Typhoid -Therapy
Antibiotics
essential
cephalosporin like ceftriaxone
fluoroquinolone
treatment must long lasting to
eliminate carrier state

vaccine for visitors to endemic

areas

Escherichia coli

Epidemiology & Diseases

Strain

Diseases

ETEC

Travelers diarrhea, infant diarrhea

in 3rd World. Watery diarrhea with
cramps, nausea, sometimes
vomiting.
Self-limiting in 5 days.

EPEC

Major cause of infant diarrhea in

3rd World.

Epidemiology & Diseases

Strain

Diseases

EIEC

Mild shigella-like dysentery

Common in Third World.

EAEC

Infant and child diarrhea in

3rd World
Persistent watery diarrhea that
generally last >14 days
Often the cause of chronic
diarrhea in immunocompromised
patients

Epidemiology & Diseases

Strain
EHEC

Diseases
After 3-4 days, watery, non-bloody
diarrhea. 25% get a bloody
diarrhea with cramps and maybe
vomiting after 2-3 days. 5-10%
develop hemolytic uremic
syndrome
Often, O157:H7 serotype

Virulence factors and pathogenicity

Strain

Virulence Factors

ETEC

1 to 4 enterotoxins,
enterotoxins plasmid-mediated

EPEC

Variety of proteins that lead to

attachment & effacing/destruction
(A/E Lesions)
Lesions of microvilli.
Plasmid-mediated.

Enterotoxigenic E. coli
Heat labile toxin (LT)
like choleragen
Adenyl cyclase activated
cyclic AMP
secretion water/ions
Heat stable toxin (ST)
Guanylate cyclase activated
cyclic GMP
uptake water/ions

Enteropathogenic E. coli
destruction of surface microvilli
fever
diarrhea
vomiting
nausea
non-bloody stools

Virulence factors and pathogenicity

Strain

Virulence Factors

EIEC

Variety of factors very similar to

those of shigella (shiga-like toxin).
toxin
Plasmid-mediated

EAEC

Fimbriae which attach to intestinal

cells

Enteroinvasive E. coli (EIEC )

Dysentery
- resembles shigellosis

Virulence factors and pathogenicity

Strain

Virulence Factors

EHEC

Stx-1 and Stx-2 toxins which are

very similar to toxins of shigella.
Toxin genes are on a lysogenic
phage. Hemolysins.

Enterohemorrhagic E. coli
Vero toxin
shiga-like
Hemolysins
Many strains are unable to ferment
sorbitol, whereas most other E. coli do
ferment sorbitol.

Vibrio species

Vibrio cholerae

Common characteristics
Gram-negative
short, curved, rod-shaped
rapidly motile due to single polar
flagellum
facultative anaerobes
growth of many vibrio strains requires
or is stimulated by NaCl

Common characteristics
growth of many vibrio strains requires
or is stimulated by NaCl
culture on blood or MacConkey agar

Pathogenesis
V. cholerae is transmitted by
contaminated water and food. There
are no known animal reservoirs, nor
animal or arthropod vectors.
Outbreaks of V. cholerae infection
have been associated with raw or
undercooked seafood harvested from
contaminated waters.

Pathogenesis
Following ingestion, V. cholerae
infects the small intestine. Adhesion
factors are important for colonization
& virulence. The organism is noninvasive, and causes disease through
the action of an enterotoxin (cholera
toxin) that causes the activation of
adenylate cyclase by ADPribosylation. This initiates an
outpouring of fluid into the intestine.

Treatment
Replacement of fluids & electrolytes is
crucial in preventing shock, & does
not require bacteriologic diagnosis
Antibiotics such as doxycycline can
shorten the duration of diarrhea and
excretion of the organism

Prevention
Public health measures that reduce
fecal contamination of:
water supplies and food
adequate cooking of foods
can minimize transmission