HEALTH NEWS

Apr. 27, 2022

DISEASE OUTBREAK NEWS

Multi-country outbreak of Salmonella Typhimurium linked to chocolate products – Europe and the United States of America

Outbreak at a glance:

On 27 March 2022, the United Kingdom notified WHO of a cluster of cases with monophasic Salmonella Typhimurium sequence type 34 infection.  Investigations linked the outbreak to chocolate produced in Belgium, which have been distributed to at least 113 countries.  A global alert was released by INFOSAN on 10 April, initiating a global product recall.  To date, a total of 151 genetically related cases suspected to be linked to the consumption of the implicated chocolate products have been reported from 11 countries.  The risk of spread in the WHO European region and globally is assessed as moderate until information is available on the full recall of the products.

Outbreak overview

On 27 March 2022, WHO was informed by the IHR National Focal Point of the United Kingdom of Great Britain and Northern Ireland (the United Kingdom) of a widely distributed cluster of Salmonella enterica serovar Typhimurium (S. Typhimurium) with an unidentified source.  Molecular typing confirmed isolation of the bacteria S.

Typhimurium sequence typing (ST) 34 and epidemiological evidence has subsequently linked the outbreak to chocolate products from Belgium, which, as of 25 April 2022, have been found to be distributed to at least 113 countries and territories (list) across all WHO Regions.

Monophasic S. Typhimurium matching the human outbreak cases were identified in buttermilk tanks at the Ferrero Corporate plant in Arlon, Belgium in December 2021 and January 2022.  After implementing hygiene measures and negative Salmonella testing, the implicated products (all Kinder products manufactured at the implicated facility (Arlon) including Kinder Surprise, Kinder Mini Eggs, Kinder Surprise Maxi 100g and Kinder Schoko-Bons) were distributed across Europe and globally.

According to the analyses of the United Kingdom Health Security Agency (UKHSA), the outbreak strain is resistant to six types of antibiotics: penicillins, aminoglycosides (streptomycin, spectinomycin, kanamycin, and gentamycin), phenicols, sulfonamides, trimethoprim, tetracyclines.

As of 25 April 2022, a total of 151 genetically related cases of S. Typhimurium suspected to be linked to the consumption of the implicated chocolate products have been reported from 11 countries (Figure 1): Belgium (26 cases), France (25 cases), Germany (10 cases), Ireland (15 cases), Luxembourg (1 case), the Netherlands (2 cases), Norway (1 case), Spain (1 case), Sweden (4 cases), the United Kingdom (65 cases) and the United States of America (1 case).

Symptom onset dates of cases ranged from 21 December 2021 to 28 March 2022.  Children under 10 years of age (n=134; 89%) were disproportionately affected and females represented 66% (n=99) of reported cases.  Information on reported symptoms and severity were available for 21 cases, and of these, 12 (57%) reported bloody diarrhea and nine (43%) were hospitalized.  As of 25 April 2022, no fatalities associated with the outbreak has been reported.

Epidemiology of Salmonellosis

Salmonellosis is a disease caused by nontyphoidal Salmonella bacteria.  While approximately 2,500 serotypes have been identified, the majority of human infections are caused by two serotypes of Salmonella: Typhimurium and Enteritidis.

Salmonellosis is characterized by acute onset of fever, abdominal pain, nausea, vomiting, and diarrhea that can be bloody as reported in most of the cases in the current outbreak.  The onset of symptoms typically occurs 6–72 hours after ingestion of food or water contaminated with Salmonella, and illness lasts 2–7 days.  Symptoms of salmonellosis are relatively mild and patients will make a recovery without specific treatment in most cases.  However, in some cases, particularly in children and elderly patients, the associated dehydration can become severe and life-threatening.

Salmonella bacteria are widely distributed in domestic and wild animals, such as poultry, pigs, and cattle; and in pets, including cats, dogs, birds, and reptiles such as turtles.  Salmonella can pass through the entire food chain from animal feed, primary production, and all the way to households or food-service establishments and institutions.  Salmonellosis in humans is generally contracted through the consumption of contaminated food of animal origin (mainly eggs, meat, poultry, and milk).  Person-to-person transmission can also occur through the faecal-oral route.

Public health response

  • Food chain investigations were performed by countries where cases were identified and risk management actions were taken, including withdrawal of all product lines produced in the implicated production facility and extensive product recalls, supported by news alerts and advice for consumers.
  • The World Health Organization/Food and Agriculture Organization of the United Nations International Food Safety Authorities Network (INFOSAN) issued a global alert on 10 April notifying Member States of the outbreak and sharing information about implicated products linked to the outbreak to initiate a global recall.  The INFOSAN Secretariat provided distribution details and sought information on risk management measures implemented and further distribution of the implicated products from Member States.
  • WHO Member States were encouraged to report through INFOSAN the identification of distribution of new implicated products not yet reported, and/or the identification of cases possibly linked to the outbreak.
  • The INFOSAN Secretariat will continue to update affected Member States, directly and through the INFOSAN Community Website, as more information becomes available, and continues collaborating closely with various partners (e.g. European Centre for Disease Prevention and Contro (ECDC), European Food Safety Authority (EFSA), European Commission, etc.) at the regional level to complement investigations and facilitate information exchange.

WHO risk assessment

Salmonella infections are typically mild and do not require treatment, however, children and elderly individuals are at greater risk for severe complications related to associated dehydration.  To date, most cases have been in children under 10 years of age which may be due to the implicated product being targeted at children.

While there have been no fatalities associated with the outbreak reported as of 25 April 2022, among the cases with information on symptoms and severity (n=21), a high hospitalization rate (43%; n=9) was observed.  Further information is needed to allow for a more accurate assessment of the severity associated with this event, including data on symptoms.

The outbreak has been epidemiologically and molecularly linked to chocolate produced in Belgium and distributed globally to over 113 countries and territories across all WHO Regions.  While 150 of 151 known cases have been reported in Europe, one case has been reported in the United States of America and there is the likelihood of additional cases being reported from other countries given the broad distribution of the products during the Easter holiday which may lead to increased consumption of the implicated product or transportation of the implicated product to additional locations as a result of holiday-related travel.

Given that the identification of existing cases was through advanced molecular techniques, which are not routinely used in all countries, there is a likelihood that some proportion of cases will go undetected.

The risk of the event spreading within the most affected WHO Region, the WHO European Region, as well as globally is assessed as moderate until information is available on the full recall of the implicated products.  Countries that have reported cases have good capacity for case management; however, information on disease severity associated with this event is still limited.

WHO advice

Prevention of salmonellosis: Prevention requires control measures at all stages of the food chain, from agricultural production, to processing, manufacturing and preparation of foods in both commercial establishments and at home.

General prevention measures for the public also include: handwashing with soap and water in particular after contact with pets or farm animals, or after having been to the toilet; ensuring food is properly cooked; drinking only pasteurized or boiled milk; avoiding ice unless it is made from safe water; washing of fruits and vegetables thoroughly.

WHO recommends the general public to follow the information provided by their national governments to get more information about the outbreak and implicated products.

Surveillance:

  • WHO Member States for which implicated products have been distributed should investigate and report to WHO cases caused or suspected to be caused by the outbreak Salmonella strain.  Enhanced public health surveillance activities are also recommended to be initiated.
  • Member States with insufficient or no Whole Genome Sequence (WGS) capacity should be on the alert for, and investigate, human infections with Salmonella Typhimurium strains that have multi-drug resistance profiles, particularly showing resistance or having resistance markers to kanamycin/gentamicin, trimethoprim or co-trimoxazole (trimethoprim-sulfamethoxazole), and chloramphenicol.
  • Treatment: Routine antimicrobial therapy is not recommended for mild or moderate cases in healthy individuals.  This is because antimicrobials may not completely eliminate the bacteria and may result in resistant strains, which subsequently can lead to the drug becoming ineffective.  Treatment in severe cases is electrolyte replacement (to provide electrolytes, such as sodium, potassium and chloride ions, lost through vomiting and diarrhoea) and rehydration.

Further information

Apr. 27, 2022

WHO Director-General's opening remarks. The role of CSOs in the prevention, detection, and response to sexual exploitation, abuse, and harassment – 26 April 2022

27 April 2022
 

Dear colleagues and friends,

Good afternoon, good morning and good evening, and thank you all for joining us for this very important discussion.

As you know, this issue has been a top priority for me since the reports of sexual exploitation and abuse during the Ebola response in DRC first surfaced in 2020.

I’d like to begin by summarizing the actions we have taken since then to respond to the reported incidents, and to make sure we have much stronger mechanisms in place for preventing sexual exploitation, abuse and harassment, and for responding when it happens.

Our approach has been based on three core principles: transparency, accountability and ownership by leadership.

First, transparency. That is why I chose to appoint an Independent Commission, that in turn selected an independent external investigator, and to make its findings publicly available – the first time this has been done in the UN system - the first-time there is external scrutiny of a UN organization by an external investigator.

The reason we did this is because if you do the same thing again and again, you will get the same result, not a different result, as Albert Einstein said. That’s why from the start, we took it seriously and did it in a different way. And as you will see from the presentation - a summary from me and the details from Gaya - the result has been different and we hope that this will impact our organization significantly, in a positive way, to help us address the challenges we are facing.

The Commission’s report was clear that WHO needed profound reform of its structures, culture and practices.

In response, we prepared a Management Response Plan to address the specific incidents, as well as the systemic issues.

The Independent Expert Oversight Advisory Committee is monitoring progress in implementing the Management Response Plan, and I also meet every week with the relevant directors and senior managers to monitor progress. All staff were invited to participate in the preparation of the management response plan .

To date, 86% of the planned 190 actions of the Management Response Plan are either completed or in process.

WHO has now handed over the investigations into allegations of sexual exploitation and abuse in DRC, as well as cases of possible managerial misconduct, to the UN Office of Internal Oversight Services.

Their investigators are now on the ground in DRC.

We are also continuing to support victims and survivors. So far, we have disbursed about US$ 250 thousand from the Survivor Assistance Fund I set up last year, even in cases where the alleged perpetrator works for another UN agency or partner. As you remember, in the report, there were more than 80 perpetrators, and 23 were from WHO, while the rest were from other agencies and partners.

We will continue to report on the number of investigations related to sexual exploitation, abuse and harassment, and their status, beyond the DRC events.

===

The second core principle is accountability.

We are strengthening our accountability functions, starting with the Investigations Service.

We now have a dedicated, qualified team of 15, mostly women, who manage investigations into all forms of misconduct, with priority given to sexual misconduct.

The team is led by the Head of Investigations, who now reports directly to the Executive Board, and who has the independence to investigate anyone, regardless of rank or grade, and examine every complaint made.

The new team is on track to complete investigations into the backlog of SEAH cases by the World Health Assembly, and has set an ambitious 120-day benchmark for completing all new SEAH investigations. Because as you know, justice delayed is justice denied, so that is why we now have a clear 120-day target to complete investigations.

Trust in the system is growing, as evidenced by an increase in the willingness of our personnel to come forward with complaints of sexual misconduct.

We have a long way to go, but as we increase the speed, effectiveness and standard of investigations, accountability increases, and the perception of impunity decreases.

Of course, increased accountability must be supported by increased capacity.

In January of this year, the Executive Board approved our request for  a core budget of US$ 50 million for this biennium.

WHO’s investment in PRSEAH is now the largest across the United Nations.

We are moving quickly. I have set up a dedicated department reporting directly to me headed by a full-time Director, Dr Gaya Gamhewage;

We are placing senior PRSEAH experts in each Regional Director’s Office;

And we are hiring 12 PRSEAH officers in priority countries.

In the remaining 145 country offices, we are identifying and will train focal points. The personnel in our AFRO Region have already begun coming on board over the last few weeks.

===

The third core principle is ownership by leadership.

While every person who works for WHO has a responsibility to uphold behaviour to prevent, detect and respond to SEAH, leaders have an added responsibility to create the right environment, to take the right measures to prevent and respond to sexual misconduct, and to set the right example.

The Regional Directors and I discuss PRSEAH on a regular basis, to ensure we have an aligned approach across the organization.

Earlier this year, we wrote a joint letter to every member of our workforce, re-affirming our commitment to zero tolerance for SEAH and for inaction against it, and outlining what we expect from each of our personnel, regardless of the type of contract they hold.

All leaders, at all levels, were required to lead discussions with their teams on PRSEAH, using tools developed for the purpose.

Each team was required to select or develop a team objective on PRSEAH, which will be part of their performance evaluation.

This is just a first step on our organization-wide “No Excuse” campaign against SEAH.

We will follow with a series of activities for all personnel, with dedicated activities for all managers and leaders to foster greater ownership.

===

The invasion of Ukraine by the Russian Federation, and the displacement of large numbers of people, creates a high-risk environment for sexual exploitation, abuse and harassment.

While we do not control the situation or the environment, we are committed to taking all possible measures to address the risks proactively.

Some of the actions we have taken so far include:

Recruiting a PRSEAH coordinator based in Poland;

Embedding PRSEAH measures in our Ukraine response, and tracking activities through the Incident Management System;

Screening everyone deployed in the UN ClearCheck database;

Monitoring the proportion of women deployed to the field to identify bottlenecks – so far women make up 30% of deployments to Ukraine;

Requiring each person deployed to complete mandatory training on SEA, and to read and sign the WHO policy directive;

Collaborating with the UN and Interagency Standing Committee  o engage affected populations on preventing, detecting and reporting of SEA;

Ensuring awareness raising materials are available in local languages, and that everyone knows how to raise a complaint;

And working with UNFPA, UNHCR and others to map the services victims can access.

A further challenge, not just in Ukraine but in many countries, is that services for gender-based violence are extremely weak or missing.

The humanitarian response for Ukraine must allocate resources both for SEAH prevention and also for gender-based violence referral services.

Thank you once again to all of you for your engagement, questions, suggestions and guidance.

We have already come a long way, but we still have a long way to go.

We are committed to this path, we are committed to the highest standards, and we are committed to listening and learning.

We want to hear from and engage with all stakeholders, especially civil society organizations, who are closest to the communities we serve.

Thank you once again. We look forward to our discussion today. 

Apr. 27, 2022

Apr. 27, 2022

Multi-country outbreak of Salmonella Typhimurium linked to chocolate products – Europe and the United States of America

Outbreak at a glance:

On 27 March 2022, the United Kingdom notified WHO of a cluster of cases with monophasic Salmonella Typhimurium sequence type 34 infection.  Investigations linked the outbreak to chocolate produced in Belgium, which have been distributed to at least 113 countries.  A global alert was released by INFOSAN on 10 April, initiating a global product recall.  To date, a total of 151 genetically related cases suspected to be linked to the consumption of the implicated chocolate products have been reported from 11 countries.  The risk of spread in the WHO European region and globally is assessed as moderate until information is available on the full recall of the products.

Outbreak overview

On 27 March 2022, WHO was informed by the IHR National Focal Point of the United Kingdom of Great Britain and Northern Ireland (the United Kingdom) of a widely distributed cluster of Salmonella enterica serovar Typhimurium (S. Typhimurium) with an unidentified source.  Molecular typing confirmed isolation of the bacteria S.

Typhimurium sequence typing (ST) 34 and epidemiological evidence has subsequently linked the outbreak to chocolate products from Belgium, which, as of 25 April 2022, have been found to be distributed to at least 113 countries and territories (list) across all WHO Regions.

Monophasic S. Typhimurium matching the human outbreak cases were identified in buttermilk tanks at the Ferrero Corporate plant in Arlon, Belgium in December 2021 and January 2022.  After implementing hygiene measures and negative Salmonella testing, the implicated products (all Kinder products manufactured at the implicated facility (Arlon) including Kinder Surprise, Kinder Mini Eggs, Kinder Surprise Maxi 100g and Kinder Schoko-Bons) were distributed across Europe and globally.

According to the analyses of the United Kingdom Health Security Agency (UKHSA), the outbreak strain is resistant to six types of antibiotics: penicillins, aminoglycosides (streptomycin, spectinomycin, kanamycin, and gentamycin), phenicols, sulfonamides, trimethoprim, tetracyclines.

As of 25 April 2022, a total of 151 genetically related cases of S. Typhimurium suspected to be linked to the consumption of the implicated chocolate products have been reported from 11 countries (Figure 1): Belgium (26 cases), France (25 cases), Germany (10 cases), Ireland (15 cases), Luxembourg (1 case), the Netherlands (2 cases), Norway (1 case), Spain (1 case), Sweden (4 cases), the United Kingdom (65 cases) and the United States of America (1 case).

Symptom onset dates of cases ranged from 21 December 2021 to 28 March 2022.  Children under 10 years of age (n=134; 89%) were disproportionately affected and females represented 66% (n=99) of reported cases.  Information on reported symptoms and severity were available for 21 cases, and of these, 12 (57%) reported bloody diarrhea and nine (43%) were hospitalized.  As of 25 April 2022, no fatalities associated with the outbreak has been reported.

Epidemiology of Salmonellosis

Salmonellosis is a disease caused by nontyphoidal Salmonella bacteria.  While approximately 2,500 serotypes have been identified, the majority of human infections are caused by two serotypes of Salmonella: Typhimurium and Enteritidis.

Salmonellosis is characterized by acute onset of fever, abdominal pain, nausea, vomiting, and diarrhea that can be bloody as reported in most of the cases in the current outbreak.  The onset of symptoms typically occurs 6–72 hours after ingestion of food or water contaminated with Salmonella, and illness lasts 2–7 days.  Symptoms of salmonellosis are relatively mild and patients will make a recovery without specific treatment in most cases.  However, in some cases, particularly in children and elderly patients, the associated dehydration can become severe and life-threatening.

Salmonella bacteria are widely distributed in domestic and wild animals, such as poultry, pigs, and cattle; and in pets, including cats, dogs, birds, and reptiles such as turtles.  Salmonella can pass through the entire food chain from animal feed, primary production, and all the way to households or food-service establishments and institutions.  Salmonellosis in humans is generally contracted through the consumption of contaminated food of animal origin (mainly eggs, meat, poultry, and milk).  Person-to-person transmission can also occur through the faecal-oral route.

Public health response

  • Food chain investigations were performed by countries where cases were identified and risk management actions were taken, including withdrawal of all product lines produced in the implicated production facility and extensive product recalls, supported by news alerts and advice for consumers.
  • The World Health Organization/Food and Agriculture Organization of the United Nations International Food Safety Authorities Network (INFOSAN) issued a global alert on 10 April notifying Member States of the outbreak and sharing information about implicated products linked to the outbreak to initiate a global recall.  The INFOSAN Secretariat provided distribution details and sought information on risk management measures implemented and further distribution of the implicated products from Member States.
  • WHO Member States were encouraged to report through INFOSAN the identification of distribution of new implicated products not yet reported, and/or the identification of cases possibly linked to the outbreak.
  • The INFOSAN Secretariat will continue to update affected Member States, directly and through the INFOSAN Community Website, as more information becomes available, and continues collaborating closely with various partners (e.g. European Centre for Disease Prevention and Contro (ECDC), European Food Safety Authority (EFSA), European Commission, etc.) at the regional level to complement investigations and facilitate information exchange.

WHO risk assessment

Salmonella infections are typically mild and do not require treatment, however, children and elderly individuals are at greater risk for severe complications related to associated dehydration.  To date, most cases have been in children under 10 years of age which may be due to the implicated product being targeted at children.

While there have been no fatalities associated with the outbreak reported as of 25 April 2022, among the cases with information on symptoms and severity (n=21), a high hospitalization rate (43%; n=9) was observed.  Further information is needed to allow for a more accurate assessment of the severity associated with this event, including data on symptoms.

The outbreak has been epidemiologically and molecularly linked to chocolate produced in Belgium and distributed globally to over 113 countries and territories across all WHO Regions.  While 150 of 151 known cases have been reported in Europe, one case has been reported in the United States of America and there is the likelihood of additional cases being reported from other countries given the broad distribution of the products during the Easter holiday which may lead to increased consumption of the implicated product or transportation of the implicated product to additional locations as a result of holiday-related travel.

Given that the identification of existing cases was through advanced molecular techniques, which are not routinely used in all countries, there is a likelihood that some proportion of cases will go undetected.

The risk of the event spreading within the most affected WHO Region, the WHO European Region, as well as globally is assessed as moderate until information is available on the full recall of the implicated products.  Countries that have reported cases have good capacity for case management; however, information on disease severity associated with this event is still limited.

WHO advice

Prevention of salmonellosis: Prevention requires control measures at all stages of the food chain, from agricultural production, to processing, manufacturing and preparation of foods in both commercial establishments and at home.

General prevention measures for the public also include: handwashing with soap and water in particular after contact with pets or farm animals, or after having been to the toilet; ensuring food is properly cooked; drinking only pasteurized or boiled milk; avoiding ice unless it is made from safe water; washing of fruits and vegetables thoroughly.

WHO recommends the general public to follow the information provided by their national governments to get more information about the outbreak and implicated products.

Surveillance:

  • WHO Member States for which implicated products have been distributed should investigate and report to WHO cases caused or suspected to be caused by the outbreak Salmonella strain.  Enhanced public health surveillance activities are also recommended to be initiated.
  • Member States with insufficient or no Whole Genome Sequence (WGS) capacity should be on the alert for, and investigate, human infections with Salmonella Typhimurium strains that have multi-drug resistance profiles, particularly showing resistance or having resistance markers to kanamycin/gentamicin, trimethoprim or co-trimoxazole (trimethoprim-sulfamethoxazole), and chloramphenicol.
  • Treatment: Routine antimicrobial therapy is not recommended for mild or moderate cases in healthy individuals.  This is because antimicrobials may not completely eliminate the bacteria and may result in resistant strains, which subsequently can lead to the drug becoming ineffective.  Treatment in severe cases is electrolyte replacement (to provide electrolytes, such as sodium, potassium and chloride ions, lost through vomiting and diarrhoea) and rehydration.

Further information

Citable reference: World Health Organization (26 April 2022). Disease Outbreak News; Multi-country outbreak of Salmonella Typhimurium linked to chocolate products – Europe and the United States of America. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON369