Hazards of healthy living: bottled water and salad vegetables as risk factors for campylobacter infection.Campylobacter Campylobacter
Genus of gram-negative spiral-shaped bacteria infecting mammals. Many species, especially C. fetus, cause miscarriage in sheep and cattle. C. jejuni is a common cause of food poisoning. Sources include meats (particularly chicken) and unpasteurized milk. is the most common cause of bacterial gastroenteritis
Bacterial gastroenteritis is an inflammation of the stomach and intestines caused by bacteria or bacterial toxins. worldwide, yet the etiology of this infection remains only partly explained. In a retrospective cohort study A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design.
In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute , we compared 213 sporadic campylobacter case-patients with 1,144 patients with negative fecal fecal /fe·cal/ (fe´k'l) pertaining to or of the nature of feces.
Relating to or composed of feces.
pertaining to or of the nature of feces. samples. Information was obtained on food history, animal contact, foreign travel, leisure activities, medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. , and medication use. Eating chicken, eating food from a fried chicken Fried chicken is chicken which is dipped in a breading mixture and then deep fried, pan fried or pressure fried. The breading seals in the juices but also absorbs the fat of the fryer, which is sometimes seen as unhealthy. outlet, eating salad vegetables, drinking bottled water, and direct contact with cows or calves were all independently associated with infection. The population-attributable fractions for these risk factors explained nearly 70% of sporadic campylobacter infections. Eating chicken is a well-established risk factor, but consuming salad and bottled water are not. The association with salad may be explained by cross-contamination of food within the home, but the possibility that natural mineral water is a risk factor for campylobacter infection could have wide public health implications.
Campylobacter is the most commonly reported bacterial cause of foodborne infection in the Western world and affects more than 2 million people in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. each year (1). In England and Wales England and Wales are both constituent countries of the United Kingdom, that together share a single legal system: English law. Legislatively, England and Wales are treated as a single unit (see State (law)) for the conflict of laws. , over 50,000 campylobacter cases are reported each year and show no signs of a decline in incidence (2). For every case reported to laboratory surveillance, another seven cases are estimated to occur in the community, suggesting that from 0.5% to 1.0% of the United Kingdom's population is infected annually (3). Although the infection usually causes a mild, self-limiting illness, serious sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention , including Guillain-Barreo syndrome and death, occur in approximately 1 in 1,000 and 1 in 20,000 infections, respectively (1). Many national food safety agencies, such as the Food Standards Agency The Food Standards Agency is a non-ministerial government department of the Government of the United Kingdom. It is responsible for protecting public health in relation to food throughout the United Kingdom and is led by an appointed board that is intended to act in the public in the United Kingdom, have set goals of reducing food poisoning food poisoning, acute illness following the eating of foods contaminated by bacteria, bacterial toxins, natural poisons, or harmful chemical substances. It was once customary to classify all such illnesses as "ptomaine poisoning," but it was later discovered that . To achieve these goals, a much clearer understanding of the etiology of campylobacter infection will be necessary.
In spite of the frequency of campylobacter infections, the cause has proved elusive. Recognized outbreaks are rare and are usually caused by contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object. water, milk, or poultry (4,5). However, these food products explain only a small proportion of sporadic cases, and the source of infection is unaccounted for An inclusive term (not a casualty status) applicable to personnel whose person or remains are not recovered or otherwise accounted for following hostile action. Commonly used when referring to personnel who are killed in action and whose bodies are not recovered. in >60% of U.K. campylobacter cases (6,7). Several case-control studies case-control study,
n an investigation employing an epidemiologic approach in which previously existing incidents of a medical condition are used in lieu of gathering new information from a randomized population. of risk factors for sporadic campylobacter infection have been performed in the United Kingdom (6-10), but many unanswered questions remain. We conducted a retrospective cohort study that involved mailing a questionnaire to the patient at the time the fecal specimen was received by the laboratory to investigate the cause of sporadic campylobacter infection in the community.
The study population included all persons living in the Cardiff area who consulted their general practitioner general practitioner
n. Abbr. GP
A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. for gastrointestinal symptoms and subsequently submitted a diagnostic fecal sample for microbiologic testing from January 1 through December 31, 2001. Cardiff Public Health Laboratory is the sole laboratory providing a diagnostic microbiology service for the area. All specimens were cultured for Campylobacter spp., Salmonella spp, Shigella shigella
Any of the rod-shaped bacteria that make up the genus Shigella, which are normal inhabitants of the human intestinal tract and can cause dysentery, or shigellosis. Shigellae are gram-negative (see gram stain), non-spore-forming, stationary bacteria. S. spp., and Escherichia coli Escherichia coli (ĕsh'ərĭk`ēə kō`lī), common bacterium that normally inhabits the intestinal tracts of humans and animals, but can cause infection in other parts of the body, especially the urinary tract. O157 and examined for ova ova (o´vah) plural of ovum.
Mentioned in: Stool O & P Test
plural of ovum. and parasites, by standard methods. Follow-up specimens from the same patient (<4 weeks after the previous specimen submission date); specimens received from hospital wards and other sites were excluded from study. The study was approved by the local research ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of committee.
Immediately upon receipt of the specimen at the laboratory (next working day), a questionnaire, together with an explanatory letter and a postage-paid envelope, was mailed to the patient. Patients who had not responded within 1 week were sent a reminder letter and provided with another questionnaire on request. The questionnaire asked about basic personal details personal details npl (on form etc) → coordonnées fpl
personal details person npl → Personalien pl
personal details , including age, sex, employment status, occupation, details of illness, and details of household contacts. It included sections on foreign travel, food and drink eaten, animal contact (pets and farm animals), outdoor leisure activities (gardening, walking, visits to parks or farms, fishing, swimming, and sports), and questions on specific medical conditions and medication (antacids Antacids Definition
Antacids are medicines that neutralize stomach acid.
Antacids are used to relieve acid indigestion, upset stomach, sour stomach, and heartburn. , H2 antagonists antagonists,
n muscles that counterbalance agonists during specific movements.
opioid Neurology A pain-attenuating peptide that occurs naturally in the brain, which induces analgesia by mimicking endogenous opioids at opioid , and antibiotics). The food history covered meat and fish, poultry and eggs, vegetables (raw vegetables, leaf vegetables [e.g., lettuce], salad vegetables [e.g., tomato], and prepared salads [e.g., coleslaw cole·slaw also cole slaw
A salad of finely shredded raw cabbage and sometimes shredded carrots, dressed with mayonnaise or a vinaigrette. ]), fruit, milk and dairy products dairy products dairy npl → produits laitier
dairy products dairy npl → Milchprodukte pl, Molkereiprodukte pl , drinking water drinking water
supply of water available to animals for drinking supplied via nipples, in troughs, dams, ponds and larger natural water sources; an insufficient supply leads to dehydration; it can be the source of infection, e.g. leptospirosis, salmonellosis, or of poisoning, e.g. (tap water, bottled water, and other sources), and eating out (type of restaurant or takeaway). Participants were asked to respond yes or no and, to the question of exposure for tap water, to indicate the number of glasses drunk per day. All questions related to exposure in the 7 days before the onset of symptoms, except for those on antibiotics, which concerned the month before illness onset.
Case-patients were defined as any patient, not associated with an outbreak, who submitted a fecal sample that was positive for Campylobacter spp. on microbiologic culture. Case-patients were compared with patients whose samples were negative on culture and microscopic examination. Patients with an alternative microbiologic diagnosis were excluded (unless they had dual infection with campylobacter).
Initial univariate analysis was performed with Epi Info Epi Info is a public domain statistical software for epidemiology developed by Centers for Disease Control and Prevention.
Developed by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA), Epi Info has been in existence for over 20 years and is software (v. 6.04; Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. ) to calculate maximum likelihood estimates for Mantel-Haenzel odds ratios (OR) with exact 95% mid-p confidence limits. Continuous variables were analyzed using the t test or Mann-Whitney U test Mann-Whitney U test,
n.pr See test, Mann-Whitney U. , as appropriate. All reported p values are two sided. Multiple logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. models were constructed with Stata software (v. 6, Stata Corporation, College Station, TX). Risk factors were selected a priori a priori
In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. on biologic grounds and grouped into four exposure categories: food and drink consumption; animal contact; leisure activities, including foreign travel; and medical history. Logistic regression models were first constructed for risk factors within each exposure category (adjustment A). We then fitted a model that combined all the independent risk factors (for which the Wald test The Wald test is a statistical test, typically used to test whether an effect exists or not. In other words, it tests whether an independent variable has a statistically significant relationship with a dependent variable. p value for the adjusted OR was <0.10) from the four exposure categories (adjustment B). Finally, to detect any residual confounding confounding
when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies.
confounding factor , we fitted all personal factors with a p value of <0.10 (age group, presence of a child <5 years of age in the household, and employment status). Of these, only age group interacted significantly with the other terms as tested by goodness of fit Goodness of fit means how well a statistical model fits a set of observations. Measures of goodness of fit typically summarize the discrepancy between observed values and the values expected under the model in question. Such measures can be used in statistical hypothesis testing, e. and was therefore included in the final model (adjustment C). The population-attributable fraction for each risk factor associated with campylobacter infection was calculated by using methods described by Greenland and Drescher (11).
Questionnaires were sent to 2,694 eligible patients; fecal samples from 346 (12.8%) were positive for Campylobacter spp. (including 4 dual infections: 3 with salmonella infection, I with giardiasis giardiasis (jēärdī`əsĭs, järdī`əsĭs), infection of the small intestine by a protozoan, Giardia lamblia. Giardia, which was named after Alfred M. ). No campylobacter outbreak occurred during the study period. Ninety-one patients (3.4%) were positive for other organisms (42 Salmonella spp., 20 Giardia lamblia Giardia lamblia
or G. intestinalis
Single-celled protozoan parasite. Pear- or beet-shaped, the cells have two nuclei and eight flagella and attach with a sucking organ to human intestinal mucous membranes. They cause the disease giardiasis. , 12 Cryptosporidium cryptosporidium (krĭp'tōspərĭd`ēəm), genus of protozoans having at least four species; they are waterborne parasites that cause the disease cryptosporidiosis. sp., 7 Clostridium difficile Clostridium difficile A common cause of bacterial colitis; it is the causative agent in 99% of pseudomembranous colitis, and 20-30% of antibiotic-associated diarrhea , 2 Shigella sp., 2 E. coli E. coli: see Escherichia coli.
in full Escherichia coli
Species of bacterium that inhabits the stomach and intestines. E. coli can be transmitted by water, milk, food, or flies and other insects. O157, 1 amoebic dysentery amoebic dysentery
Variant of amebic dysentery.
Noun 1. amoebic dysentery - inflammation of the intestines caused by Endamoeba histolytica; usually acquired by ingesting food or water contaminated with feces; characterized , and 5 other parasites); these were excluded from further analysis. Responses were received from 213 (61.6%) of 346 persons with campylobacter infection and 1,144 (50.7%) of 2,257 persons with negative specimen results. Median delay in response (from date questionnaire sent to date questionnaire returned) was 6 days (range 2-73 days) for case-patients and 7 days (range 1-77 days) for non-case-patients (Kruskal-Wallis H 1.8l, p=0.18).
Personal Factors and Symptoms
Case-patients (median 43 years of age, range 0-80 years of age) were significantly older than non-case-patients (median 36 years of age, range 0-100 years of age) (Kruskal-Wallis H 5.31, p=0.02) (Table 1). Non-case-patients were also more likely to come from a household that included a child <5 years of age (even after adjusting for the age of the respondent), although not more likely to report prior diarrheal illness in a household contact. Case-patients were more likely to report symptoms than non-case-patients, particularly fever (OR 3.19; 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] 2.36 to 4.31), muscle aches (OR 3.13; 95% CI 2.32 to 4.22), and abdominal pain Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem. (OR 3.40; 95% CI 2.32 to 5.12. Nearly all case-patients and most non-case-patients had diarrhea, but case-patients (18.3%) were more likely than non-case-patients (11.8%) to report blood in the stool (OR 1.67; 95% CI 1.12 to 2.46).
Food and Drink Consumed
Case-patients were more likely to report eating meat, including beet beet, biennial or annual root vegetable of the family Chenopodiaceae (goosefoot family). The beet (Beta vulgaris) has been cultivated since pre-Christian times. , pork, and ham; poultry products, including chicken and eggs; and a variety of uncooked vegetables and fruit, including lettuce, other salad vegetables (cucumber cucumber, fruit of Cucumis sativus, a species of gourd whose many varieties are descended from a plant native to Asia and Africa. Cucumber is classified in the division Magnoliophyta, class Magnoliopsida, order Violales, family Curcurbitaceae. , tomatoes, etc.), preprepared salad (coleslaw', etc.), and fresh or frozen berries. An association existed with drinking bottled water (OR 1.98; 95% CI 1.48 to 2.67) and between infection and drinking cold tap water (OR 1.51; 95% CI 1.06 to 2.18) but not with drinking cold milk. Neither tap water nor milk consumption showed a dose response relationship. Case-patients were more likely to have eaten out in the 7 days before illness onset, particularly at a tried chicken outlet, sandwich bar, or other unspecified restaurant.
Animal Contact, Leisure Activities, and Medical History
Case-patients were no more likely than non-case-patients to report pet ownership or contact with other people's pets. Non-case-patients were more likely to own a pet rabbit, though this association was weaker after adjusting for age. Case-patients were more likely to have gone walking, to have visited a farm, or to report contact with cows or calves in the 7 days before illness, though the number of persons exposed to cows was very small. No difference existed in history of recent foreign travel. In respect to medical history, case-patients were no more likely than non-case-patients to suffer from diabetes or indigestion indigestion or dyspepsia, discomfort during or after eating caused by some interference with the normal digestive process. Symptoms include nausea, heartburn, abdominal pain, gas distress, and a feeling of abdominal distention. , or to be taking antacid antacid, any one of several basic substances that counteract stomach acidity (see stomach). Antacids are used by physicians to treat hyperchlorhydria, i.e., the excessive production of hydrochloric acid by the parietal cells lining the stomach. or ulcer medicines but were less likely to report preexisting pre·ex·ist or pre-ex·ist
v. pre·ex·ist·ed, pre·ex·ist·ing, pre·ex·ists
To exist before (something); precede: Dinosaurs preexisted humans.
v.intr. bowel disease or to have taken antibiotics in the month before onset of illness.
Multivariate Analysis multivariate analysis,
n a statistical approach used to evaluate multiple variables.
n a set of techniques used when variation in several variables has to be studied simultaneously.
After adjustment for other variables within each of the four exposure groups (adjustment A), several independent risk factors were identified (Table 2). After combining all these variables (adjustment B), eating frozen fish, eggs, or berries; having milk delivered to the home; eating out at a Chinese restaurant See:
Our study identified five risk factors for campylobacter infection that, if taken together, could account for most sporadic cases. Most important was eating chicken in the 7 days before onset of illness. Two other risk factors, not previously described, could also potentially account for a sizeable proportion of case-patients: eating salad vegetables such as tomatoes or cucumber and drinking bottled water.
The study used a retrospective cohort design that included all patients submitting fecal specimens through their general practitioner to a single laboratory. This design controls for patient characteristics associated with physician-consulting behavior and may also minimize recall bias associated with using healthy controls. Use of a laboratory study population does, however, have several disadvantages. Non-case-patients probably represent a group whose illnesses have disparate cause. Many may have had viral gastroenteritis viral gastroenteritis Intestinal flu Infectious disease A generic term for GE induced by viruses Clinical presentations 1. Epidemic VGE, most often caused by the Norwalk agent or Norwalk-like viruses Clinical N&V, diarrhea, abdominal pain, anorexia, since this is known to be common in the community and is not detectable by routine laboratory testing. This fact would explain why symptoms reported by non-case-patients were milder. Non-case-patients were also significantly more likely than case-patients to report a history of lower bowel problems, suggesting that some had pre-existing disease that might predispose pre·dis·pose
To make susceptible, as to a disease. to non-infectious diarrhea. Antibiotic use in the month before onset of illness was also more common in non-case-patients, and symptoms in these persons may therefore be a side effect of antibiotic treatment. Persons with pre-existing bowel problems may have atypical dietary habits, but neither a history of bowel problems nor of antibiotic use should affect the accuracy of food histories. The multivariate analysis controlled for both these variables.
The most consistent finding in studies of campylobacter infection etiology has been an association with eating chicken. This finding has been described in three previous U.K. studies (6,7,9), and in studies from the United States (12 16), Scandinavia (17-19), the Netherlands (20), Switzerland (21), and New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. (22,23). However, the relationship with chicken is sometimes only seen for eating undercooked chicken (12,22,23) or eating chicken away from home (8,15,22,23). Recent microbiologic studies of raw poultry in the United Kingdom indicate continuing high levels of campylobacter contamination in chicken and the occurrence of identical subtypes in both chicken and human isolates (24). Our finding of an association between illness and eating chicken or eating from a fried chicken outlet highlights the fact that chicken remains a major risk factor for campylobacter in the United Kingdom and that measures are needed both in the food industry and at home to promote thorough cooking of chicken and to reduce the risk for cross-contamination.
Neither eating salad vegetables nor drinking bottled water has previously been recognized as a risk factor. In our study, both these associations made a significant contribution to the final logistic regression model and could explain a substantial number of campylobacter infections. Both are also biologically plausible. Salad vegetables could be contaminated with campylobacter either before or after the point of sale. Contamination at the source could occur through contaminated soil or contaminated water during harvesting. Salad vegetables are often imported from abroad, and changes in the sourcing of such items could introduce new vehicles of campylobacter infection into the U.K. food chain. For example, contaminated imported lettuce has been identified as a vehicle of infection in recent salmonella and shigella outbreaks in the United Kingdom (25). However, recent extensive sampling of organic fruit and vegetables and ready-to-eat prepackaged pre·pack·age
tr.v. pre·pack·aged, pre·pack·ag·ing, pre·pack·ag·es
To wrap or package (a product) before marketing.
Adj. 1. salads in the United Kingdom found no pathogens such as Campylobacter, Salmonella, or E. coli O157, suggesting that contamination of such items is either rare or intermittent (26). Two reports on campylobacter outbreaks associated with salad have been published. Both of these involved contamination in the kitchen. The first was a 3-month long outbreak from cucumber served at a salad bar; the outbreak resolved after changes were made in food preparation and storage procedures (27). The second involved salad prepared by a food-handler who exhibited symptoms of campylobacter infection (28). In a recent review of outbreaks in England and Wales (including five from campylobacter) linked with salad vegetables and fruit, cross-contamination was also the most frequently identified contributory con·trib·u·to·ry
1. Of, relating to, or involving contribution.
2. Helping to bring about a result.
3. Subject to an impost or levy.
n. pl. factor (25). The association we observed was specific to items such as tomatoes and cucumber that require extensive handling during preparation and often the use of a chopping board, rather than with lettuce or with salads bought preprepared. This finding suggests that salad most likely gets cross-contaminated during food preparation.
Natural mineral water is usually obtained from springs and occasionally from borehole bore·hole
A hole that is drilled into the earth, as in exploratory well drilling or in building construction. sources. In Europe, legislation requires that mineral water be free from parasites and pathogenic path·o·gen·ic or path·o·ge·net·ic
1. Having the capability to cause disease.
2. Producing disease.
3. Relating to pathogenesis. organisms but, unlike tap water, it may not be treated in any way that might alter its chemical composition (29). A variety of organisms, including coliforms, can be found in mineral water and will survive for a considerable length of time, particularly in uncarbonated water supplied in plastic bottles or bottled by hand (30). To our knowledge, campylobacter has not been identified in mineral water, but this may simply be because testing for campylobacter is rarely undertaken. Mineral water has, however, been identified in the past as a vehicle of transmission during a cholera epidemic (31) and as a potential source of typhoid fever typhoid fever acute, generalized infection caused by Salmonella typhi. The main sources of infection are contaminated water or milk and, especially in urban communities, food handlers who are carriers. in travelers (32). More recently, a study of diarrhea in HIV-infected persons found symptoms were significantly associated with drinking bottled or filtered water, whereas drinking tap water was protective (33). Drinking bottled water has also recently been identified as a possible risk factor for campylobacter infection acquired abroad (34), and for Campylobacter coli infection (35). These findings suggest that bottled water could, given the right circumstances, provide a vehicle of transmission for campylobacter.
A small proportion of cases were explained by contact of personswith cows or calves. This occurred exclusively within the context of a farm visit and probably reflects the urban context of our study. This association, though apparently uncommon, is entirely plausible. Occupational contact with animal feces feces
or excrement or stools
Solid bodily waste discharged from the colon through the anus during defecation. Normal feces are 75% water. The rest is about 30% dead bacteria, 30% indigestible food matter, 10–20% cholesterol and other fats, (8), living on a farm (16,19), and contact with cattle (16,23) have all been previously described as risk factors for campylobacter infection. Healthy beef and dairy cattle both excrete excrete /ex·crete/ (eks-kret´) to throw off or eliminate by a normal discharge, such as waste matter.
To eliminate waste material from the body. campylobacter (36,37), and molecular evidence suggests a rink between campylobacter in the farm environment with those causing disease in the community (38).
Our study confirms that eating chicken still plays an important role in the cause of campylobacter infection. It also identifies two potentially important new risk factors that merit further investigation: salad vegetables (and the associated risks of cross-contamination in the home) and bottled natural mineral water. Cross-contamination in the domestic kitchen is potentially preventable, but we need to know how it happens and what interventions are most effective at reducing the risk. Bottled water is a $35 billion worldwide industry (39). In the United States, 1.7 billion gallons of natural mineral water were consumed in 2000 (39). Consumption is also increasing dramatically in the United Kingdom (by approximately 10% each year), and approximately 300 million gallons of bottled water are now consumed annually (40). Consequently, increased illness from contamination of bottled water could be considerable. More studies of the microbiologic quality of natural mineral waters are required, and these should include testing for Campylobacter spp.
Table 1. Comparison of personal and household factors in campylobacter case-patients and non-patients Case-patients (n=213) Variable No. (%) Female 99 (46.5) Age group 0-14 y 26 (12.2) 15-44 y 84 (39.4) 45-64 y 72 (33.8) [greater than or equal to] 65 y 30 (14.1) Employment status Employed 92 (43.2) Full-time student 27 (12.7) Caring for home and family 15 (7.0) Other 45 (21.1) Unemployed 10 (4.7) Long-term illness 16 (7.5) Mean no. of other people in household (median, range) 3.0 (3) (1-12) Child <5 y of age in the household 28 (13.1) Mean no. of children <5 y of age in household (median, range) 0.21 (0) (0-5) Other ill person in the household 15 (7.0) Mean no. of other ill people in household (median, range) 0.09 (0) (0-3) Child caregiver 3 (1.4) Food handler 8 (3.8) Non-case-patients (n=1,144) Variable No. (%) Female 504 (44.1) Age group 0-14 y 328 (28.7) 15-44 y 323 (28.2) 45-64 y 231 (20.2) [greater than or equal to] 65 y 255 (22.3) Employment status Employed 352 (30.8) Full-time student 82 (7.2) Caring for home and family 84 (7.3) Other 453 (39.6) Unemployed 31 (2.7) Long-term illness 84 (7.3) Mean no. of other people in household (median, range) 3.2 (3) (1-36) Child <5 y ofage in the household 326 (28.5) Mean no. of children <5 y of age in household (median, range) 0.41 (0) (0-5) Other ill person in the household 112 (9.8) Mean no. of other ill people in household (median, range) 0.15 (0) (0-6) Child caregiver 25 (2.2) Food handler 61 (5.3) Variable OR (95% CI) (a) Female 1.10 (0.82 to 1.48) Age group 0-14 y Reference 15-44 y 3.28 (2.06 to 5.23) 45-64 y 3.93 (2.44 to 6.35) [greater than or equal to] 65 y 1.48 (0.86 to 2.57) Employment status Employed Reference Full-time student 1.26 (0.77 to 2.06) Caring for home and family 0.68 (0.38 to 1.23) Other 0.38 (0.26 to 0.56) Unemployed 1.23 (0.58 to 2.61) Long-term illness 0.53 (0.24 to 1.14) Mean no. of other people in household (median, range) Child <5 y ofage in the household 0.38 (0.25 to 0.57) Mean no. of children <5 y of age in household (median, range) Other ill person in the household 0.70 (0.39 to 1.20) Mean no. of other ill people in household (median, range) Child caregiver 0.64 (0.15 to 1.94) Food handler 0.69 (0.31 to 1.41) Variable p value Female 0.56 Age group 0-14 y 15-44 y <0.001 45-64 y <0.001 [greater than or equal to] 65 y 0.16 Employment status Employed Full-time student 0.36 Caring for home and family 0.21 Other <0.001 Unemployed 0.58 Long-term illness 0.29 Mean no. of other people in household (median, range) 0.98 (b) Child <5 y ofage in the household <0.0001 Mean no. of children <5 y of age in household (median, range) <0.0001 (b) Other ill person in the household 0.26 Mean no. of other ill people in household (median, range) 0.20 (b) Child caregiver 0.61 (c) Food handler 0.43 (a) OR, odds ratio: CI, confidence interval. (b) Mann-Whitney U test. (c) Fisher exact test. Table 2. Frequency of food exposure, animal contact, leisure activities and medical history in campylobacter infected case-patients and non- case-patients Case- Non-case patients (%) -patients (%) Exposure (n=213) (n=1,144) Food and drink Lamb 47 (22.1) 282 (24.7) Frozen fish 53 (24.9) 341 (29.8) Chicken 177 (83.1) 777 (67.9) Eggs 141 (66.2) 606 (53.0) Salad vegetables 159 (74.6) 635 (55.5) Fresh or frozen berries 51 (23.9) 173 (15.1) Milk delivered to the doorstep 29 (13.6) 215 (18.8) Bottled water 114 (53.5) 420 (36.7) Ate at a fried chicken outlet 22 (10.3) 51 (4.5) Ate at a Chinese restaurant 23 (10.8) 114 (10.0) Animal contact Own a pet rabbit 7 (3.3) 89 (7.8) Had contact with cows or calves 5 (2.3) 6 (0.5) Leisure activities Walking (>15 min) 162 (76.0) 712 (62.2) Medical history History of lower bowel problems 21 (9.9) 197 (17.2) Antibiotic in month before illness 11 (5.2) 160 (14.0) Crude OR (a) Exposure (95% CI) Food and drink Lamb 0.87 (0.61 to 1.22) Frozen fish 0.78 (0.55 to 1.09) Chicken 2.32 (1.6 to 3.43) Eggs 1.74 (1.28 to 2.37) Salad vegetables 2.36 (1.7 to 3.30) Fresh or frozen berries 1.77 (1.23 to 2.51) Milk delivered to the doorstep 0.68 (0.44 to 1.03) Bottled water 1.98 (1.48 to 2.67) Ate at a fried chicken outlet 2.47 (1.44 to 4.13) Ate at a Chinese restaurant 1.09 (0.67 to 1.74) Animal contact Own a pet rabbit 0.40 (0.17 to 84) Had contact with cows or calves 4.55 (1.27 to 15.74) Leisure activities Walking (>15 min) 1.93 (1.38 to 2.72) Medical history History of lower bowel problems 0.53 (1.32 to 0.83) Antibiotic in month before illness 0.34 (0.17 to 0.61) Adjusted OR Exposure (95% CI) p value Food and drink Lamb 0.67 (0.45 to 0.99) 0.046 Frozen fish 0.64 (0.45 to 0.93) 0.020 Chicken 1.61 (1.03 to 2.50) 0.036 Eggs 1.35 (0.95 to 1.92) 0.096 Salad vegetables 1.73 (1.09 to 2.74) 0.019 Fresh or frozen berries 1.43 (0.95 to 2.13) 0.086 Milk delivered to the doorstep 0.60 (0.38 to 0.94) 0.026 Bottled water 1.39 (0.98 to 1.96) 0.062 Ate at a fried chicken outlet 1.82 (1.00 to 3.30) 0.050 Ate at a Chinese restaurant 0.58 (0.33 to 0.99) 0.048 Animal contact Own a pet rabbit 0.46 (0.20 to 1.05) 0.066 Had contact with cows or calves 5.44 (1.05 to 28.1) 0.043 Leisure activities Walking (>15 min) 1.92 (1.34 to 2.73) <0.001 Medical history History of lower bowel problems 0.55 (0.34 to 0.90) 0.018 Antibiotic in month before illness 0.34 (0.18 to 0.65) 0.001 (a) Adjusted for potential confounders within each exposure group; OR, odds ratio; CI, confidence interval. Table 3. Multiple logistic regression analysis showing independently associated variables in campylobacter case-patients and non-case- patients (a) Adjustment A (b) Variable Odds ratio (95% CI) p value Lamb 0.67 (0.46 to 0.99) 0.05 Chicken 1.61 (1.03 to 2.50) 0.04 Salad vegetables 1.73 (1.09 to 2.73) 0.02 Bottled water 1.39 (0.98 to 1.96) 0.06 Ate at a fried chicken outlet 1.82 (1.00 to 3.30) 0.05 Had contact with cows or calves 5.44 (1.05 to 28.10) 0.04 Own a pet rabbit 0.46 (0.210 to 1.05) 0.07 History of lower bowel 0.55 (0.34 to 0.90) 0.02 problems Had antibiotic in month before 0.34 (0.18 to 0.65 0.001 illness Adjustment B (c) Variable Odds ratio (95% CI) p value Lamb 0.69 (0.48 to 1.00) 0.05 Chicken 2.01 (1.35 to 3.00) 0.001 Salad vegetables 1.99 (1.40 to 2.82) <0.001 Bottled water 1.57 (1.15 to 2.14) 0.005 Ate at a fried chicken outlet 2.08 (1.20 to 3.62) 0.01 Had contact with cows or calves 3.98 (1.08 to 14.65) 0.04 Own a pet rabbit 0.36 (0.16 to 0.81) 0.01 History of lower bowel 0.48 (0.29 to 0.79) 0.004 problems Had antibiotic in month before 0.41 (0.21 to 0.78) 0.006 illness Adjustment C (d) Variable OR (95% CI) p value Lamb 0.68 (0.47 to 0.98) 0.04 Chicken 1.79 (1.19 to 2.69) 0.005 Salad vegetables 1.53 (1.06 to 2.21) 0.02 Bottled water 1.41 (1.02 to 1.95) 0.04 Ate at a fried chicken outlet 1.94 (1.10 to 3.42) 0.02 Had contact with cows or calves 5.07 (1.30 to 19.74) 0.02 Own a pet rabbit 0.37 (0.16 to 0.83) 0.02 History of lower bowel 0.45 (0.27 to 0.73) 0.015 problems Had antibiotic in month before 0.40 (0.21 to 0.77) 0.006 illness Attributable fraction (%) Variable (95% CI) Lamb Chicken 31 (9 to 48) Salad vegetables 21 (2 to 36) Bottled water 12 (0 to 23) Ate at a fried chicken outlet 4 (0 to 7) Had contact with cows or calves 1 (0 to 3) Own a pet rabbit History of lower bowel problems Had antibiotic in month before illness (a) OR: odds ratio; CI, confidence interval. (b) Adjustment A, adjusted for potential confounders within each group. (c) Adjustment B, adjusted for other significant variables from all four exposure groups. (d) Adjustment C, adjusted for age group.
We thank clerical staff at the Public Health Laboratory Service Communicable Disease communicable disease
A disease that is transmitted through direct contact with an infected individual or indirectly through a vector. Also called contagious disease. Surveillance Centre (Wales Wales, Welsh Cymru, western peninsula and political division (principality) of Great Britain (1991 pop. 2,798,200), 8,016 sq mi (20,761 sq km), west of England; politically united with England since 1536. The capital is Cardiff. ) and the Cardiff Public Health Laboratory for their assistance with the study, and all the patients who participated.
This work was funded by a grant from the Public Health Laboratory Service Small Scientific Initiative Fund, grant no. 2001042.
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Meirion R. Evans, * C. Donald Ribeiro, ([dagger]) and Roland L. Salmon ([dagger])([dagger])
* University of Wales College of Medicine The University of Wales College of Medicine was a medical school based in the University Hospital of Wales, Cardiff, that formed a part of the University of Wales. It was also known as UWCM and by its Welsh name Coleg Meddygaeth Prifysgol Cymru. , Cardiff, United Kingdom; ([dagger]) Cardiff Public Health Laboratory, Cardiff, United Kingdom; and ([dagger][dagger])Public Health Laboratory Service Communicable Disease Surveillance Centre (Wales), Cardiff, United Kingdom
Dr. Evans is a regional epidemiologist working with the Public Health Laboratory Service Communicable Disease Surveillance Centre (Wales). After training as a public health physician, he worked for many years as a field epidemiologist. His current research interests include the epidemiology of food-borne disease and traveler's diarrhea Traveler's Diarrhea Definition
The occurrence of multiple loose bowel movements in someone traveling to an area outside their usual surroundings (usually from temperate industrialized regions to tropical areas), is known as Traveler's diarrhea (TD). , hepatitis C Hepatitis C Definition
Hepatitis C is a form of liver inflammation that causes primarily a long-lasting (chronic) disease. Acute (newly developed) hepatitis C is rarely observed as the early disease is generally quite mild. , and sexually transmitted infections.
Address for correspondence: MR. Evans, Department of Epidemiology, Statistics and Public Health, University of Wales College of Medicine, Cardiff CFI CFI
cost, freight, and insurance 4 4XN. UK; fax: +44 2920 521987; email: meirion.evans @phls.wales.nhs.uk