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The Epidemiology of Listeriosis in Pregnant Jeffs et al. BMC Public Health (2020) 20:116 https://doi.org/10.1186/s12889-020-8221-z RESEARCH ARTICLE Open Access The epidemiology of listeriosis in pregnant women and children in New Zealand from 1997 to 2016: an observational study Emma Jeffs1, Jonathan Williman2, Cheryl Brunton2, Joanna Gullam3 and Tony Walls1* Abstract Background: Listeria monocytogenes causes the foodborne infection listeriosis. Pregnant women, infants and immunocompromised children are at increased risk for infection. The aim of this study was to describe the trends in the epidemiology of disease notifications and hospital admissions due to listeriosis in pregnant women aged 15 to 45 years and children aged less than 15 years in New Zealand (NZ) from 1997 to 2016. Methods: In this population-based descriptive study, listeriosis notification and hospitalization rates from 1997 to 2016 were analyzed. Notification data were extracted from the Institute of Environmental Science and Research (ESR) Notifiable Diseases Database (EpiSurv) and hospitalization data were extracted from the National Minimum Dataset (NMDS). Pregnant women aged 15 to 45 years and children less than 15 years of age were included. Subgroup analysis was conducted for age and ethnicity. Outcomes of infection were described. Results: In the 20-year period considered, there were 147 pregnancy-associated cases of listeriosis either notified to ESR (n = 106) and/or coded in the NMDS (n = 99), giving a crude incidence rate of 12.3 (95% CI 10.4, 14.4) per 100, 000 births. In addition, there were 22 cases in children aged 28 days to < 15 years (incidence =0.12, 95% CI 0.08 to 0.19 per 100,000). There were no trends observed over time in the incidence of pregnancy-associated listeriosis. Incidence rates of pregnancy-associated and childhood listeriosis were highest in people of Pacific and Asian ethnicity. Conclusions: NZ has a low incidence of listeriosis in pregnant women and children, however, the consequences of infection are frequently severe. Those of Pacific and Asian ethnicity have the highest rates of disease and future messaging around food safety should target these groups. This study provides important insights into the epidemiology of listeriosis in pregnant women and children in NZ. Keywords: Listeria monocytogenes, Listeriosis, Pregnant, Pregnancy, Neonate, Infant, Child Background [3–6]. In developed countries, L. monocytogenes has the Listeria monocytogenes, a facultative rod-shaped Gram highest case-fatality rate of any foodborne pathogen [7]. positive bacteria, causes listeriosis, a serious and poten- L. monocytogenes has a predilection to infect pregnant tially life-threatening infection that is principally transmit- women, neonates, those who are immunocompromised ted by the consumption of contaminated food [1]. The and the elderly. Pregnant women, in particular, are at genus Listeria is composed of 17 species, of which Listeria approximately 18 times greater risk for infection than monocytogenes is an opportunistic foodborne pathogen of the general population owing to the natural immunosup- humans and animals [2]. Both sporadic episodes and large pression of pregnancy [8]. While maternal illness is usu- outbreaks of disease have been attributed to this pathogen ally mild, neonatal illness is frequently severe and potentially fatal [1, 9]. Neonatal listeriosis may occur by vertical transmission of L. monocytogenes from mother to foetus, either by inhalation of infected amniotic fluid, * Correspondence: [email protected] 1Department of Paediatrics, University of Otago, PO Box 4345, Christchurch trans-placentally from the maternal circulation, or by as- Mail Centre, Christchurch 8140, New Zealand cending colonization during birth [10]. Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Jeffs et al. BMC Public Health (2020) 20:116 Page 2 of 8 Clinical outcomes are influenced by the gestation at rates of listeriosis for the total NZ population are which infection occurs. Listeriosis most commonly pre- known, listeriosis rates in pregnant women and children sents in the third trimester of pregnancy (from 28 weeks) have not been systematically studied. The aim of this and is rarely fatal in the mother, particularly in the ab- study was to describe the trends in the epidemiology of sence of coexisting medical conditions [11, 12]. Later in- disease notifications and hospital admissions due to lis- fection, particularly that within the third trimester, is teriosis in pregnant women aged 15 to 45 years and chil- typically associated with more favourable foetal out- dren aged less than 15 years in NZ from 1997 to 2016. comes than earlier infection [13]. If transmission to the foetus does occur, infection can lead to miscarriage, pre- Methods term delivery or stillbirth. In a recent study of 107 cases Data sources of pregnancy-related listeriosis in France, the transmis- Case data were sourced from two databases of routinely sion of infection from the mother to the foetus occurred collected information for this population-based descriptive in 96% of cases, and major foetal or neonatal complica- study: the national notifiable disease surveillance database tions were observed in 83% of infants of infected (EpiSurv) operated by The Centre for Environmental Sci- mothers [7]. ence and Research Ltd. (ESR) and The National Minimum Neonatal listeriosis typically manifests within the first Dataset (NMDS) held by the NZ MoH. 24 to 72 h of life and can present as bacteremia, respira- EpiSurv contains data on notifiable diseases and tory distress, meningitis and, less frequently, pneumonia should, theoretically, contain all cases of notifiable dis- [14]. Late-onset listeriosis, that presenting in infants ease resulting in hospital admission, as well as cases aged one to 4 weeks, is most often associated with men- managed in the community without hospitalization. ESR ingitis [15]. About half the infants who are infected with commenced standardized on-line reporting in 1997 and L. monocytogenes have no apparent immunocompromis- therefore 1997 was elected as the start point for data ing condition [16]. Neonatal listeriosis is associated with analysis. Laboratory definitive evidence for a confirmed an overall case fatality rate of 50% [17], with severe case of listeriosis requires identification of L. monocyto- neurological and developmental sequalae observed in genes from a normally sterile site, including the foetal 40% of surviving neonates [18]. Due to the severity of gastrointestinal tract, by either isolation (culture) of L. the illness, in New Zealand (NZ) all neonates with sus- monocytogenes or detection of L. monocytogenes nucleic pected infection are treated with amoxicillin which tar- acid [24]. Only invasive disease is notifiable. Where ill- gets L. monocytogenes, as well as other infections [19]. In ness has occurred in a pregnant woman, foetus or infant children who are immunocompetent, listeriosis is most aged ≤28 days, the mother is notified as the case and the likely to present as an influenza-like illness or, if the in- disease is recorded as pregnancy-associated. fection is significant, gastroenteritis. However, in chil- The NMDS is a national dataset of public and private dren who are immunocompromised, infection can hospital discharge information that describes clinical data present as several clinical syndromes, of which meningi- for inpatients and day patients, and is coded according to tis and bacteraemia are the most common [1]. international standards, including the International Classi- In NZ, the Ministry of Health (MoH), the principal ad- fication of Diseases – Clinical Modification 9 (ICD-9- visor to the NZ government on health and disability, CM). The original NMDS was implemented in 1993 and supports public health messages aimed at reducing the back-loaded with public hospital discharge information risk for infection of listeriosis in pregnancy. The Minis- from 1988. The NMDS (hospital events) dataset used in try for Primary Industries, the ministry charged with this study contains information on the number of episodes overseeing NZ’s primary industries (e.g. farming) and of disease resulting in hospital admission. food safety, publishes food safety in pregnancy guidelines Data were requested from both databases for all listeri- which are available on-line and as a printed booklet [20]. osis cases (ICD-9-CM code 027.0) from 1 January 1997 Listeriosis has been a notifiable disease in NZ since to 31 December 2016 for all women of childbearing age, 1983, requiring notification of laboratory-diagnosed defined as 15 to 45 years (inclusive), and all children < cases to the local public health service, and food safety 15 years of age. Children < 15 years were included as this guidelines have been available since at least 1997. is the New Zealand cut off for pediatric hospital admis- L. monocytogenes infection is rare in NZ. In 2018, sions. Data were
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