Listeria monocytogenes and Listeriosis

Panagiotis Skandamis1,3 and Antonia Gounadaki2.3

1
Laboratory of Quality Control and Hygiene of Foods and Beverages. [email protected]
2
Laboratory of Food Microbiology and Biotechnology.
3
Department of Food Science and Technology, Agricultural University of Athens, Iera Odos
75, 118 55, Athens, Greece.

Abstract

In 2003, the Hellenic Food Authority initiated a monitoring program for biological
and chemical hazards in Ready-to-Eat (RTE) food products in Greece. In total, 605
products from diverse catering enterprises and retailers in Athens, Patra, Thessaloniki,
and Crete were examined for the presence of pathogenic and hygiene indicator bacteria
(e.g. coliforms). Detailed inspections of premises were also performed to evaluate the
hygiene level of enterprises offering RTE foods, as well as their compliance to Good
Hygiene Practices. Only 0.7% of analysed samples were found positive for listeria.
Different RTE meat products have been recalled for possible listeria contamination
since that initial study, showing a sharp increase in the number of contaminated
products (i.e., 8.5 tons) in 2005. Five deaths were also been recorded, resulting from
the comsumption of bacon that was presumed contaminated with listeria.

1 Key words: Listeria monocytogenes; listeriosis, Ready-to-Eat foods

2 1 Objectives and learning outcomes

3 (1) Evaluate the potential impact of underestimating the incidence of listeriosis due
4 to under reporting.
5 (2) Assess the contribution of obligatory reporting on the prevention and/or reduction
6 of listeriosis.
7 (3) Examine post-processing contamination points and methods to controlL. mono-
8 cytogenes in Ready-To-Eat products.
9 (4) Understand the survival/growth responses of L. monocytogenes and identify the
10 most significant environmental factors that favor or inhibit growth.
11 (5) Address the necessity for continuous training in Food Safety Management Sys-
12 tems of persons involved in one or more stages of the food chain from “farm-to-
13 fork”.

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 34 Panagiotis Skandamis and Antonia Gounadaki

14 (6) Defend the position that food safety involves everybody along the food chain, in-
15 cluding primary producers (i.e., food, feed, crop), secondary food manufacturers,
16 wholesalers, retailers, and consumers.
17 (7) Convince food producers that compliance with food legislation is not only a typi-
18 cal demand by the authorities, but a crucial ethical aspect for safe food production
19 and protection of public health.

20 2 Introduction
21 Listeria monocytogenes is a pathogen that can cause serious illness in humans. It is
22 Gram-positive, psychrotrophic (i.e., capable of growing at -0.4°C), facultative anaer-
23 obic, a non-sporeforming rod, with minimum reported pH and aw for growth of 4.4
24 and 0.92, respectively. The pathogen is ubiquitous in nature, and normally found in
25 soil, decaying vegetation, animal and human feces, sewage, silage and water.
26 Infections that can be caused by L. monocytogenes have been classified into
27 five categories [Bell and Kyriakides, 1998]: (1) zoonotic infection of skin lesions;
28 (2) Neonatal infection (i.e., usually by infected mothers or cross-infection by other
29 neonates); (3) infection during pregnancy due to consumption of contaminated food;
30 (4) infection of non-pregnant adults, as in (3); (5) food poisoning, which is caused by
31 consumption of food with exceptionally high levels of L. monocytogenes (i.e., >107
32 CFU/g). Symptoms that are associated with listeriosis include abortion, stillbirths,
33 meningitis with or without septicaemia, vomiting or diarrhoea. Despite the low inci-
34 dence of human listeriosis of between 2 to 15 per million inhabitants, the high concern
35 that has been expressed for this pathogens is associated with the high fatality rate (i.e.,
36 approximately 20% for healthy individuals and up to 70% for immunocompromised
37 individuals).
38 It is difficult to control L. monocytogenes, as it is able to persist in agricultural
39 (e.g., soil, water, plants) and food processing environments (e.g., surfaces of industrial
40 equipment), as well as in distribution, retail and home environments [Tompkin, 2002].
41 Meat processing facilities are often the source of contaminated carcasses, and/or boxed
42 beef, poultry, or other meats [Farber and Peterkin, 1991, Tompkin, 2002, Scanga
43 et al., 2000, Gande and Muriana, 2003]. Epidemiological studies have shown that the
44 organism can be transferred through cross-contamination from employees, drains,
45 standing water, residues, floors, and food contact surfaces [Nesbakken et al., 1996,
46 Samelis and Metaxopoulos, 1999, Gande and Muriana, 2003]. It grows in many foods
47 during refrigerated storage and can also tolerate and grow in relatively acidic foods,
48 in foods with relatively low moisture content and in foods with a high salt content
49 (i.e., Ready-To-Eat foods).

50 3 Ready-To-Eat foods
51 Ready-To-Eat (RTE) foods are intended for consumption without further bacterici-
52 dal or viricidal heat treatment or processing with an equivalent effect. Such foods

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 Listeria monocytogenes and Listeriosis 35

53 are regarded as potentially high risk, because they do not receive any treatment that
54 would destroy pathogens before consumption. These products may receive a lethality
55 treatment to eliminate the pathogen but they are likely re-contaminated by exposure to
56 the pathogen after the lethality treatment (e.g., during peeling, slicing, repackaging)
57 This is due to the ability of the microorganism to form persistent biofilms on indus-
58 trial equipment, which can survive common sanitation procedures. In addition, the
59 number of foods that are already prepared from retail establishments, grocery stores
60 and delicatessens are increasing and it is likely that adequate food safety measures
61 may not be applied to control or prevent contamination with L. monocytogenes, thus
62 increasing the risk for consumer exposure to this pathogen. Certain RTE products,
63 such as non-reheated frankfurters and sliced meat products, soft cheeses, and veg-
64 etable salads, pose a greater threat to public health. This was outlined in a report on
65 the L. monocytogenes risk assessment for selected RTE foods [FDA/CFSAN, 2003]
66 RTE foods are frequently implicated in listeriosis outbreaks, due to the aforemen-
67 tioned reasons, and have therefore forced authorities to establish control measures
68 to reduce the risk of consumption of highly contaminated products. In Greece, the
69 institute that deals with surveillance and control of foodborne infections and intoxi-
70 cations is the Center for Serveillance and Intervention (CSI) of the Hellenic Center
71 for Infectious Diseases Control (HCIDC). The Hellenic Food Authority has initiated
72 a survey for the presence and level of certain foodborne hazards, with an emphasis on
73 listeria in various enterprises that are involved in the production, distribution, retail
74 display and serving of RTE products.

75 4 Listeriosis in Greece
76 According to the 7th (i.e., between 1993 and 1998) and 8th (i.e., between 1999
77 and 2000) reports of World Health Organization [BgVV-FAO/WHO, 2000, BfR-
78 FAO/WHO, 2003], the only known cases of listeriosis in Greece were one in 1998,
79 seven in 1999 and six in 2000, whereas the HCIDC reported zero cases of listeriosis
80 for the period 1998-2002 and only one case in 2003. However, it should be noted
81 that data from the HCIDC was obtained from the system of obligatory reporting
82 of illnesses, and thus publicly available reports may have underestimated the actual
83 incidence rates. Despite the existence of the WHO Food Surveillance Programme
84 for the Control of Foodborne Diseases in Europe that was initiated 20 years ago,
85 collection of national epidemiological data is difficult, as official agencies access
86 only 1 to 10% of cases and significant under-reporting is likely [Tirado and Schmidt,
87 2001]. Another reason for under-reporting is the delay between the occurrence of the
88 outbreak and the reporting day.

89 4.1 RTE Products

90 In July 2003, the Hellenic Food Authority iniciated the monitoring of chemical and
91 biological hazards in RTE products. Microbiological analysis was performed by ac-
92 credited microbiological laboratories in Greece, using ISO methods (i.e., ISO 11290-
93 1:1996 and ISO 11290-2:1996 for detection and enumeration, respectively). Of the

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 36 Panagiotis Skandamis and Antonia Gounadaki

94 605 samples tested, four samples (i.e., 0.7%) were found to be contaminated with
95 listeria. The positive samples consisted of composite plates with minced meat or
96 seafood, cold sandwiches and lettuce salad.

97 4.2 Meat products

98 Between March 2003 and April 2005, food authories disposed of approximately 3,500
99 kg of meat products. An outbreak of gastroenteritides occurred in May 25, 2005, at
100 the National Health Institute of Greece, involving 37 employees and 55 patients.
101 Inspectors from the Hellenic Food Authority subsequently destroyed approximately
102 8.5 tonnes of meat products that were characterized unsafe in Thessaloniki on June
103 1, 2005. Five deaths were reported during the following nine days. Initially, deaths
104 were attributed to pathological causes, although the possibility of listeriosis was also
105 considered. The Central Laboratory of Public Health, reported on the detection of
106 listeria in bacon samples, that were used in the National Health Institute to prepare
107 food, on June 13, 2005. However, it remains unclear as to whether the presence of
108 listeria was associated with the manufacturing process or with the storage conditions
109 of the products within the Institute. The processing plant immediately recalled the
110 products of this specific batch and isolated them until disposal.

111 5 Prevention and Control

112 The results of the national survey for pathogens and hygiene indicators (i.e., coliforms)
113 in 605 RTE products indicated promising results with regards to pathogens prevalence
114 and concentration, as opposed to the concerns expressed about the hygienic level (i.e.,
115 due to high coliforms loads) of establishments that prepare cold-composite foods, such
116 as sandwiches with cheese and deli meats (e.g., bacon, ham, frankfurters). The low
117 incidence rates due to under-reporting and the limited surveillance data available so
118 far, showing low frequencies of contamination with pathogens, do not imply zero
119 risk, especially if hygiene conditions in manufacturing, distribution and retail display
120 are not ensured.
121 Tolerable levels of L. monocytogenes in foods and especially in RTE foods, is
122 a matter of great concern at an international level. However, European Community
123 legislation does not provide microbiological standards for L. monocytogenes in all cat-
124 egories of RTE products. Current national legislation requires absence of the pathogen
125 in 25 g of foods, even for fresh meat. However, despite the current “zero tolerance”
126 policy for L. monocytogenes, the complete absence of this pathogen for certain RTE
127 foods is not feasible. Risk assessments that have ben conducted by the United States
128 Department of Agriculture and the World Health Organization over the last 5 years
129 have prompted food safety authorities to discuss the establishment of tolerable levels
130 of L. monocytogenes (i.e., 100 CFU/g) in those RTE foods that do not allow growth of
131 the pathogen until consumption, and in foods that will be heated before consumption.

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 Listeria monocytogenes and Listeriosis 37

132 In addition, risk assessment data are under consideration for setting Appropriate Lev-
133 els of Protection (ALOP) and Food Safety Objectives (FSO) that will ensure tolerable
134 risk until consumption [van Schothorst, 1998].

135 6 Conclusion
136 In order to establish microbiological standards, it is essential to categorize foods
137 based on criteria related to: (1) application of lethality treatment (i.e., mainly heat)
138 during manufacturing; (2) application of post-lethality treatment, that may consists of
139 either the immersion of product into antimicrobial solutions or treatment (e.g., heat,
140 irradiation) of the whole packaging; (3) the possibility of recontamination during dis-
141 tribution or retail display; (4) the ability of food to support the growth of the pathogen
142 (i.e., dependent on the intrinsic properties of the food) during the shelf life, in re-
143 sponse to storage temperature. These considerations may significantly improve the
144 effectiveness of inspections and the safety level of foods. Greek inspection authorities
145 will not be forced to withdraw suspect products without having a scientifically-based
146 criterion, and food manufacturers should target specific performance objectives to
147 ensure safety of final products, while consumers should be aware of proper handling
148 of foods. Other considerations include:
149

150 (1) Rapid and proper reporting of foodborne illnesses to official agencies in order to
151 increase the availability of epidemiological data, and hence enable the effective
152 monitoring of hazards from “farm-to-fork”.
153 (2) Increase training of food manufacturers and those that are involved in RTE food
154 preparation on Good Hygiene Practices.
155 (3) Consideration of research and official surveillance data by the national inspection
156 authorities and the development of risk assessment for different RTE products.
157 (4) Increase number of inspections by the Hellenic Food Authority would enhance
158 the national surveillance programs for foodborne pathogens, provide better mon-
159 itoring of Hygiene in the food industry and finally assist both manufacturers and
160 consumers in better handling of foods.

161 7 Discussion Questions

162 1. To what extent has listeriosis been reported in the last 12 years?
163 2. What is the balance between obligatory reporting and the use of voluntary surveil-
164 lance programs1?
165 3. How variable are diagnostic methods between different Laboratories, such as
166 hospital microbiological laboratories, national reference centers and laboratories
167 of district health authorities, which are significant contributors of surveillance
168 data to the HCIDC?
1
Refer to Tirado and Schmidt [2001]

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 38 Panagiotis Skandamis and Antonia Gounadaki

169 4. Is “zero tolerance” for L. monocytogenes feasible on/in RTE meat and poultry
170 products?
171 5. What measures can be taken to control the potential post-processing contamina-
172 tion of RTE products with L. monocytogenes?
173 6. Which environmental factors affect the survival and growth of L. monocytogenes
174 during distribution and retail display of RTE products?
175 7. Are most people aware of the significance of training in Food Safety principles
176 and especially the current food safety strategy from the “farm-to-fork”1?
177 8. Is compliance with food law a matter of awareness of food safety principles, or is
178 it simply dependent on the frequency of inspection and the severity of punishment
179 in the case of non-compliance? Explain why this is the case.

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