A second case of cholera??

A diarrhoeal epidemic (which appears to be fading) now 2 cases of cholera? What's happening?

Anything to do with the faecal contamination of waters off Pasir Ris?

The great diarrhoea mystery

So the diarrhoea cases continue to baffle us all. For four weeks running it has reared its head above the epidemic threshold. And yet the Ministry of Health maintains its stony silence as if nothing is happening. Salmonellosis remains high (29 cases) but not high enough apparently to explain the diarrhoea epidemic.

Curiouser and curiouser, to say the least.

Salmonellosis and diarrhoea epidemic in Singapore

The diarrhoea epidemic continues. I am told the polyclinics have been somewhat overloaded with diarrhoeal cases. I am assuming that this has been salmonellosis because that's what the MOH stats appear to suggest.

But MOH and AVA have persisted in their silence and one wonders what's going on.

Meanwhile, the latest 'hot-off-the-press' nationwide recall in US because of salmonella are chocolate covered nuts made by Kilwin's. I wonder if any of these chocolate products have made their way into Singapore.

See http://www.fda.gov/Safety/Recalls/ucm182067.htm

Salmonellosis epidemic in Singapore - strange silence from MOH and AVA

I posted about the spike in diarrhoeal disease 2 days ago, not knowing a report was coming out in Straits Times the very next day. Technically the numbers being seen at polyclinics indicate an 'epidemic' in Singapore. Yet MOH and AVA has been strangely silent about this. Is this food poisoning? Where are the clusters? What's happening? We are all in the dark!

Dr Paul Ananth posted a comment refering to the recent recall of some salmonella contaminated product. In 2007, there was a similar recall of Peter Pan peanut butter in Singapore for salmonella contamination.

So what's happening, AVA? Is this some contaminated food that we should be aware of?

Spike in diarrhoeal diseases? What's happening?

Unbeknownst to many, and almost slipping under the radar screen, is this spike in diarrhoeal diseases over the last 2 weeks. I wonder what's going on?
The MOH report just indicates salmonellosis as the bug; 26 over the last week. No new reports of specific food poisoning outbreaks in the media. But we've crossed the epidemic threshold for 2 weeks already.

Someone tell us something!!

The problem with organic foods - need for objectivity

The Straits Times has followed up on this controversy by publishing an editorial comment about it.

The problem that plagues controversies such as these is that one is often unsure about the credibility of the scientific data out there. Nowadays we cannot even put our full confidence in academic studies because these studies can be funded by commercial interests. Sometimes these interests are reported, but often they are not revealed. The possible involvement of the agri-food industry is also highlighted in the ST editorial.

But my previous post references comments made by the UK FSA (Food Safety Agency). The FSA is "an independent Government department set up by an Act of Parliament in 2000 to protect the public's health and consumer interests in relation to food". One hopes that their governance allows them to be objective about the issue.

Thinking about the FSA also triggered some thinking on my part about our own food agency, the AVA (Agri-Food & Veterinary Authority). Unlike the FSA, the AVA's mission is to "..ensure a resilient supply of safe food, safeguard the health of animals and plants and facilitate agri-trade for Singapore". Like many of our regulatory agencies in Singapore, the AVA's mission carries some inherent conflict of interests. It does not just regulate food safety, but must also ensure food supply and promote agri-trade. How do they do they manage this conflicted mission?

One other thing I've also wondered about is why the separation between food safety, environment safety and pharmaceutical safety? Whether they deal with pesticides, environmental pollutants or pharmaceutical safety, these are all different parts of the same spectrum of safety concerns. Should they not reside in the same regulatory agency? Can environmental toxicology be artificially separated from health and medical toxicology?

Indian rojak mass poisoning timeline...

Well, some light is starting to be shed on the sequence of events related to the Indian Rojak Mass Poisoning incident.

What I have pieced together thus far is as follows......

Poisoning began about Thursday. Symptoms appeared Thursday evening and patients start to appear at GP clinics and CGH in the evening. MOH was informed and investigations begin. Stall was shut down on Saturday morning.

I think MOH/NEA did as well as they could....The question is...'Was it enough?'

What troubles me is that in the sequence of events, there was almost 48 hours between first exposure to the poisoning and eventual shut down and isolation of the stall. There was actually one full day (Friday) of unnecessary exposure allowed after the poisoning was first recognized before the stall was shut down. It is 'fortunate' that this was just a food poisoning (albeit affecting 154 people and causing 2 deaths). Perhaps not so fortunate for at least the one lady who died because she was poisoned on Friday.

I am not an expert of the management of mass poisonings or bio-terrorism, but it seems to my little mole brain, that there might have been too long a lag between the start of the poisoning and definitive action taken to isolate and contain the poison. It was a good thing it wasn't a very infectious incident. If it had been an actual bio-terrorist event, I wonder if this amount of time delay would actually be considered acceptable.

I think MOH/NEA need to go back and relook their proceures and timelines. All those exercises and drills for events like this might not be very indicative of our national preparedness, when we take so long to respond to a real mass poisoning situation like this.

Geylang Serai food poisoning - time to review our food safety procedures?

Just want to highlight a coincidental publication of a report about US Centers for Disease Control and Prevention comments on food safety.

"EFFORTS to improve food safety in the United States have 'plateaued,' exposing the need for an overhaul of the nation's food safety system, government health officials said on Thursday.

Despite work to improve food safety in recent years, the number of foodborne infections remained steady, with little change in the past few years, suggesting fundamental problems are not being solved.

'Progress has plateaued. This indicates to us that further measures are needed to prevent more foodborne illness,' Dr Robert Tauxe of the US Centers for Disease Control and Prevention told reporters in a telephone briefing."

The findings were outlined Thursday in a new CDC report on foodborne illness.

Following excerpt from CNN report.

"The FDA is working to keep consumers informed of the latest food recalls and food safety initiatives, and is hiring more scientists, investigators and inspectors as part of a wide-reaching effort to protect the food supply, the agency said. The report underscores the need for modernization of the system, an FDA official said.

"The FDA is embarking on an aggressive and proactive approach in protecting and enforcing the safety of the U.S. food supply," said Dr. David Acheson, associate commissioner for foods. "The FoodNet data indicates a need for a different approach to safeguard the food supply, and the FDA is committed to make the necessary changes to keep unsafe products out of the marketplace before they reach consumers."

Florida, California, North Carolina, Minnesota, Michigan and Massachusetts are working on a pilot program in which teams work with the FDA to react more quickly to potential threats to the food supply, Acheson said. Three additional states are expected to join the program this year.

The report also found that none of the Healthy People 2010 targets, set by the Department of Health and Human Services in 2000 to reduce foodborne illness and death by 2010, had been met last year.

"Lack of progress in reaching Healthy People 2010 goals for foodborne pathogens is not acceptable," said Nancy Donley, president of Safe Tables Our Priority (STOP). Her 6-year-old son Alex died after eating contaminated hamburger in 1993.

"It is clear that current food safety regulatory programs are not effective in reducing the toll of foodborne illness," she said. "We need the setting of strict microbial standards and improved government oversight and inspection of our food supply to ensure that other lives are not cut short and other families will not have to suffer as mine has."

So what now, MOH and NEA?

Geylang Serai food poisoning - the poor rats...

Well .... typically as in other kinds of hysteria, some irrationality creeps into the picture. Here my poor relatives (not that close, by the way - they are from the Muroidea family while us moles are from the Talpidae family) have become the scapegoats for everything tragic and negligent about the food poisoning. *sigh*

Fact is - rats usually carry disease related to salmonella and leptospirosis. They are just a convenient visible icon of a dirty environment. Killing rats without cleaning the environment will not save us. Cleaning the environment will make sure rats do not flourish. So this hysterical mass killing of rats is nothing more than a massive public relation exercise to demonstrate how much effort is going into cleaning the environment. Poor rats. Where is the SPCA when you need them?

Fact is the causative organism - Vibrio parahaemolyticus is a rather fragile thing that lives best in salty water. Hence it is carried in raw shellfish/seafood. It tends to be rather heat sensitive so a little bit of cooking (even just high warming above about 60C) will pretty much kill it. It does however produce a toxin that is more heat resistant.

This spate of food poison is caused by ingestion of lots of bacteria and toxin. Those who succumbed almost immediately after consumption of the rojak, suffered effects due to the toxin. Those who developed fever and other delayed symptoms of bacterial infection, clearly ingested lots of live bacteria.

How the contamination of food occured here remains a mystery. Sure...there must have been contamination of the rojak gravy by a raw seafood source. But how? The only seafood in Indian rojak are the deep fried prawn fritters. Not a likely source of poisoning I think.

The poor Pa'chik must be going through hell at the moment. What I fear is that he, like the rats, will become the scapegoat for this whole episode. This will create another unnecessary tragedy.

It now behoves the MOH and NEA to do a serious evaluation of their procedures and work quality. How much of this was due to systemic problems that created an environment where something like this was just waiting to happen. It is just far too easy and convenient to blame the last person holding the parcel when the bomb goes off.

What also puzzles me also is how come our management of food safety straddles 2 ministries? Do these ministries talk to each other or not? In the management of this mass food poisoning, how does reporting occur? Do people know how to report? And to which agency? Does the MOH tell the NEA when it receives reports? How quickly does this occur?

The examination of the response times between first symptoms and notification, and then notification and response is an extremely important indicator of how effective the 2 ministries have been. This is not a trivial matter to be swept under the carpet, but an vitally important consideration if we want to make sure of our national preparedness against biological or chemical terrorism.

Geylang Serai food poisoning - Vibrio parahaemolyticus

Big tragic wayang here.

For the scale of the epidemic and severity of infection, this is not just eating one or two infected shellfish, or contaminated food from a server with dirty hands. This is an infection resulting from a massive dose of live bacteria and toxins.

To my mind the only plausible source is the rojak gravy that functions primarily as a bacterial broth because it sits there on a warming stove for pretty much the whole day. Very happy bugs!

Question is how did the bugs get into the rojak gravy in the first place since it does not contain any kind of raw sea food products e.g. prawns or other shellfish? This is not a problem about dirty hands, or rats running in the longkangs. This is substantial contamination from raw seafood occuring after the rojak sauce has been initially cooked, and then incubated before serving.

How? Some things don't add up.

Can we eat shit and get away with it? Coprophagy is normal.

Talking about gut fermentation and ruminants got me thinking the physiology of eating faeces. Animals like rabbits have to do it because their fermentation chamber is sited quite far down their alimentary tract. If they don't eat their own faeces, the fermentation products and nutrients have little chance of being absorbed. And rabbits don't die from eating their own shit.

We are actually more like rabbits than cows where our gut is concerned. While we do not have a large caecal fermentation chamber, scientists have documented considerable digestion occuring in the colon and have suggested that as much as 10% of our nutritional needs may be contributed by what happens in our colons. So why don't we eat our own shit... can we do it and get away with it?

Many animal species in fact do engage in coprophagy. Our closest primate relatives do it regularly. But we don't ... and in fact regard it as an abnormal activity reserved for mad people.

Actually from a biological perspective, there is really no problem in eating our own shit. Mad people do it and they do not fall sick, or die. Our gut is full of bacteria, and our shit is teeming with bugs. But in reality, most of them are friendly creatures. Reswallowing them should really not cause any problems.

The problems with coprophagy is when we are sick and carry some abnormal, pathogenic bacteria in our gut, as when we have salmonellosis, or a pathogenic coliform bacteria, or the dreaded norovirus... then eating shit becomes a problem...not so much for ourselves because if we are already infected, eating more of it is not really going to make much of a difference. The problem is when other people eat our infected shit. Then the infection spreads across the community.

For this reason the practice of eating shit or shit contaminated materials is not recommended. Public health people look for evidences of such contamination by counting the number of Escherichia coli present in food. These otherwise friendly bugs who live happily in our colon, generally do not cause problems unless they have a chance to attack other organs They generally do not live long outside our bodies so their presence in food generally indicates fresh faecal contamination.

So the long and short of it is that eating shit is fine. I wouldn't recommend it though, because I don't think it will be a pleasant experience. But whatever you do, try not to eat other people's shit...

Bon appétit