Attribution of Listeria monocytogenes human infections to food and animal sources in Northern Italy.

Listeriosis is a foodborne illness characterized by a relatively low morbidity, but a large disease burden due to the severity of clinical manifestations and the high case fatality rate. Increased listeriosis notifications have been observed in Europe since the 2000s. However, the reasons for this increase are largely unknown, with the sources of sporadic human listerioris often remaining elusive. Here we inferred the relative contributions of several putative sources of Listeria monocytogenes strains from listerioris patients in Northern Italy (Piedmont and Lombardy regions), using two established source attribution models (i.e. 'Dutch' and 'STRUCTURE') in comparative fashion. We compared the Multi-Locus Sequence Typing and Multi-Virulence-Locus Sequence Typing profiles of strains collected from beef, dairy, fish, game, mixed foods, mixed meat, pork, and poultry. Overall, 634 L. monocytogenes isolates were collected from 2005 to 2016. In total, 40 clonal complexes and 51 virulence types were identified, with 36% of the isolates belonging to possible epidemic clones (i.e. genetically related strains from unrelated outbreaks). Source attribution analysis showed that 50% of human listerioris cases (95% Confidence Interval 44-55%) could be attributed to dairy products, followed by poultry and pork (15% each), and mixed foods (15%). Since the contamination of dairy, poultry and pork products are closely linked to primary production, expanding actions currently limited to ready-to-eat products to the reservoir level may help reducing the risk of cross-contamination at the consumer level.

Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: A multicentre prospective cohort study.

Pressure ulcers lead to discomfort for patients and may have an important impact on a patient's quality of life. Measure the incidence and prevalence of pressure ulcers in a Hospice environment; evaluate the risk factors associated with pressure ulcers; and calculate the incidence of Kennedy Terminal Pressure Ulcers. This multicentre prospective cohort study enrolled 440 cancer patients in advanced phase, consecutively admitted to five hospices of the AUSL della Romagna (Italy), during a period of 1 year. Five hundred more patients were excluded from the study because of inability to sign the consent form or refusal to participate. All patients were adults above 18 years of age. The National Pressure Advisory Panel Classification System was used to evaluate the pressure ulcers. Potential risk predictors were evaluated through the Braden Scale, the Numerical Scale, and the Pain Assessment in Advanced Dementia Scale. Starting in September 2016, 214 (48.6%) females and 226 (51.4%) males were analysed. The incidence of pressure ulcers in the total population was 17.3%. The risk factors that influence the development of pressure ulcers were age, proximity to death, and duration of stay in Hospice. The incidence of Kennedy Terminal Pressure Ulcers was 2.7%. This study demonstrates that 17.3% of all patients admitted to a hospice setting developed a pressure ulcer. The longer the patients stay in hospice and the clinical condition deteriorates, the higher the risk of developing a pressure ulcer.

Isolation of Arcobacter species and other neglected opportunistic agents from aborted bovine and caprine fetuses.

BACKGROUND: Infectious abortion in ruminants is a problem in animal husbandry worldwide. It is important to obtain a diagnosis, to make sure that proper control measures can be instituted, but most abortion cases remain without an etiologic diagnosis. This report describes the presence of Arcobacter species and several neglected opportunistic abortifacient agents in ruminant abortion cases showing or not co-infections among at least one of the major recognized protozoal, fungal, bacterial and viral abortifacient agents. RESULTS: A total of 67 fetuses (55 cattle and 12 goats) and just one placenta (cattle) were considered. Among the most common abortive agents, Neospora caninum (19,4%), followed by Chlamydophila abortus (4,5%), Listeria monocytogenes 1/2a (2,98%), Bovine Viral Diarrhea Virus type 1b (2,98%), Bovine herpesvirus 4 (2,98%), and Aspergillus spp. (2,98%) were detected. The isolated neglected opportunistic bacteria include Escherichia coli, Acinetobacter lwoffii, Staphylococcus spp., Streptococcus spp., Streptococcus uberis, Streptococcus suis, Trueperella pyogenes, Mannheimia haemolytica, Bacillus cereus and Nocardia spp. Other bacterial species, not associated with abortion by literature, but described as causes of diseases occurring sporadically both in humans and animals, were also detected. Three Arcobacter strains, namely two A. skirrowii and one A. cryaerophilus, were isolated from 3 bovine aborted fetuses, and A. butzleri was isolated from the placenta. CONCLUSIONS: A not negligible isolation of Arcobacter species and other neglected abortifacient agents has to be mentioned, with prevalences that seem to be emerging and replacing or co-placing the major infectious players in bovine and caprine reproductive failure due to abortion disease, even if further studies investigating the aetiological power and transmission routes are needed in order to define the role of these microrganisms in ruminant abortion.

Genome-Wide Profiling of Enterotoxigenic Staphylococcus aureus Strains Used for the Production of Naturally Contaminated Cheeses.

Staphylococcus aureus is a major human pathogen and an important cause of livestock infections. More than 20 staphylococcal enterotoxins with emetic activity can be produced by specific strains responsible for staphylococcal food poisoning, one of the most common food-borne diseases. Whole genome sequencing provides a comprehensive view of the genome structure and gene content that have largely been applied in outbreak investigations and genomic comparisons. In this study, six enterotoxigenic S. aureus strains were characterised using a combination of molecular, phenotypical and computational methods. The genomes were analysed for the presence of virulence factors (VFs), where we identified 110 genes and classified them into five categories: adherence (n = 31), exoenzymes (n = 28), genes involved in host immune system evasion (n = 7); iron uptake regulatory system (n = 8); secretion machinery factors and toxins' genes (n = 36), and 39 genes coding for transcriptional regulators related to staphylococcal VFs. Each group of VFs revealed correlations among the six enterotoxigenic strains, and further analysis revealed their accessory genomic content, including mobile genetic elements. The plasmids pLUH02 and pSK67 were detected in the strain ProNaCC1 and ProNaCC7, respectively, carrying out the genes sed, ser, and selj. The genes carried out by prophages were detected in the strain ProNaCC2 (see), ProNaCC4, and ProNaCC7 (both positive for sea). The strain ProNaCC5 resulted positive for the genes seg, sei, sem, sen, seo grouped in an exotoxin gene cluster, and the strain ProNaCC6 resulted positive for seh, a transposon-associated gene. The six strains were used for the production of naturally contaminated cheeses which were tested with the European Screening Method for staphylococcal enterotoxins. The results obtained from the analysis of toxins produced in cheese, combined with the genomic features represent a portrait of the strains that can be used for the production of staphylococcal enterotoxin-positive cheese as reference material.

Arcobacter spp. in raw milk from vending machines in Piedmont and occurrence of virulence genes in isolates.

Arcobacter spp. has been recognized as an emerging foodborne pathogen and a hazard to human health. In the dairy chain, it has been isolated from different sources, nevertheless data on Arcobacter occurrence in raw milk provided by vending machines are few. This study aimed to identify potentially pathogenic Arcobacter spp. in raw milk intended for human consumption sold through vending machines located in Piedmont. In an 8-month period, 37 raw milk samples were collected from 24 dairy farms: 12 (32,4%) were collected directly in farm from bulk tank milk and 25 (67,6%) from vending machines. Eight (21,6%) out of the 37 milk samples and 7 (29,2%) out of the 24 dairy farms were positive for Arcobacter spp. by culture examination. Four (16%) out of the 25 samples from vending machines and 4 (33,3%) out of the 12 samples from bulk tank milk were positive. All 8 isolates were identified as A. butzleri both by MALDI-TOF MS and multiplex end-point PCR. According to the detection of virulence genes, a total of four Patho-types were highlighted: 5 isolates in P-type 1 and only one isolate for each of the P-types 2-3-4. A. butzleri isolates carrying encoding virulence factors genes were isolated from raw milk intended for human consumption: these findings strengthen the compulsory consumption after boiling as required by current legislation and suggest the need of enlarging the analytical investigations to other microorganisms not yet included in the food safety criteria.

Characterization of A Staphylococcal Food Poisoning Outbreak in A Workplace Canteen during the Post-Earthquake Reconstruction of Central Italy.

In summer 2017, a foodborne outbreak occurred in Central Italy, involving 26 workers employed in the post-earthquake reconstruction. After eating a meal provided by a catering service, they manifested gastrointestinal symptoms; 23 of them were hospitalized. The retrospective cohort study indicated the pasta salad as the most likely vehicle of poisoning. Foods, environmental samples, and food handlers' nasal swabs were collected. Bacillus cereus (Bc) and coagulase-positive staphylococci (CPS) including S. aureus, together with their toxins, were the targets of the analysis. CPS, detected in all the leftovers, exceeded 105 CFU/g in the pasta salad, in which we found Staphylococcal Enterotoxins (SEs) (0.033 ng SEA/g; 0.052 ng SED/g). None of the environmental and human swabs showed contamination. We characterized 23 S. aureus from foods. They all belonged to the human biotype, showed the same toxigenic profile (sea, sed, sej, and ser genes), and had the same Pulsed Field Gel Electrophoresis (PFGE) pattern; none of them harbored mecA or mupA genes. We also detected Bc contamination in the pasta salad but none of the isolates harbored the ces gene for the emetic toxin cereulide. The EU Reference Laboratory for CPS confirmed the case as a strong-evidence outbreak caused by the ingestion of SEs produced by a single strain of S. aureus carried by the same human source. This outbreak was successfully investigated despite the emergency situation in which it occurred.

Analysis of Gluten Content in Gluten-Free Pizza from Certified Take-Away Pizza Restaurants.

Currently, a strict gluten-free diet is the only treatment for celiac disease. In Italy, food service establishments and restaurants can be certified for providing gluten-free foods, including pizza restaurants that make both gluten-free pizza and traditional wheat-based pizza. With this study we analyzed the gluten content in samples of gluten-free pizza prepared and purchased at certified restaurants in the Turin metropolitan area. All samples, from 28 pizzas and 28 cooked dough bases, produced results below the test limit of detection, except for one sample of cooked dough, that tested positive for gluten but still below the warning level for celiac consumers (<20 ppm). Gluten-free pizza, as advertised in the restaurants surveyed, can be considered a safe option for gluten-free consumption. Attention to and compliance with good manufacturing practices, a requisite for obtaining gluten-free certification for restaurants, were noted to have a positive effect on the final product.

A Set of Multiplex Polymerase Chain Reactions for Genomic Detection of Nine Edible Insect Species in Foods.

On 1 January 2018, a new regulation on 'Novel Food' has come into application in the EU. Insects and insect-based products are therefore included among the categories of food which constitute novel foods. Insects are nutrient-rich, produce fewer greenhouse gases and ammonia than conventional livestock, and have high feed conversion efficiency. Insects may be an alternative food source in the near future, but consideration of insects as a food requires scrutiny due to the risk of allergens. The aim of the present study was to develop a set of multiplex polymerase chain reaction (PCR) to detect nine edible insect species directly in foods. Four sets of mPCRs were designed to detect Locusta migratoria migratorioides (Reiche & Fairmaire, 1849) (Orthoptera: Acrididae), Tenebrio molitor (Linnaeus, 1758) (Coleoptera: Tenebrionidae) (mPCR-I), Acheta domesticus (Linnaeus, 1758) (Orthoptera: Gryllidae), Bombyx mori (Linnaeus, 1758) (Lepidoptera: Bombycidae (mPCR-II), Alphitobius diaperinus (Panzer, 1797) (Coleoptera: Tenebrionidae), Schistocerca gregaria (Forskål, 1775) (Orthoptera: Acrididae), Zophobas atratus (Fabricius, 1775) (Coleoptera: Tenebrionidae) (mPCR-III), Galleria mellonella (Linnaeus, 1758) (Lepidoptera: Pyralidae), and Gryllodes sigillatus (Walker, 1869) (Orthoptera: Gryllidae) (mPCR-IV). Results demonstrate that the panel of mPCRs allowed a rapid genetic identification of the insect species and has proved to be a sensible and highly discriminatory method. The assay is a potential tool in issues related to the labeling of products and food safety, in case of allergic consumers.

Microbiological Parameters in the Primary Production of Berries: A Pilot Study.

The primary production of fresh soft fruits was considered to be a suspected critical point for the contamination of frozen berries that were responsible for the large 2013⁻2014 Hepatitis A virus (HAV) outbreak in Europe. In this study, an Italian berries’ production area was studied for its agro-technical characteristics, and the fresh fruits were analyzed for the presence of enteric viruses (HAV and Norovirus (NoV) genogroup I and genogroup II (GGI and GGII)), the enumeration of hygienic quality parameters, and the prevalence of bacterial pathogens. A total of 50 producers were sampled, who specialized in the exclusive or shared cultivation of berries. Escherichia coli was detected in two blackberry samples, whereas HAV and Norovirus were not detected. The samples were negative for Salmonella spp., Listeria monocytogenes, and Shiga toxin-producing Escherichia coli (STEC). The farms’ attributes were not associated with positive samples, apart from the presence of E. coli and the aerobic mesophilic bacteria for blackberry that were statistically correlated. In blueberries, the high aerobic mesophilic count could likely be associated with the resistance of the outer layer to handling. However, the two pathogens (Salmonella spp. and STEC) and the targeted viruses (HAV, NoV GGI and GGII) were not detected, highlighting the low risk of foodborne pathogens and viral contamination at the primary production stage of the berry food chain in the area considered in this pilot study.

Outbreak of febrile gastroenteritis caused by Listeria monocytogenes 1/2a in sliced cold beef ham, Italy, May 2016.

In May 2016, two separate clusters of febrile gastroenteritis caused by Listeria monocytogenes were detected by the local health authority in Piedmont, in northern Italy. We carried out epidemiological, microbiological and traceback investigations to identify the source. The people affected were students and staff members from two different schools in two different villages located in the Province of Turin; five of them were hospitalised. The epidemiological investigation identified a cooked beef ham served at the school canteens as the source of the food-borne outbreak. L. monocytogenes was isolated from the food, the stools of the hospitalised pupils and the environment of the factory producing the cooked beef ham. All isolates except one were serotype 1/2a, shared an indistinguishable PFGE pattern and were 100% identical by whole genome sequencing (WGS). By combining a classical epidemiological approach with both molecular subtyping and WGS techniques, we were able to identify and confirm a Listeria gastroenteritis outbreak associated with consumption of sliced cold beef ham.

Draft Genome Sequences of 510 Listeria monocytogenes Strains from Food Isolates and Human Listeriosis Cases from Northern Italy.

Listeriosis outbreaks are frequently multistate/multicountry outbreaks, underlining the importance of molecular typing data for several diverse and well-characterized isolates. Large-scale whole-genome sequencing studies on Listeria monocytogenes isolates from non-U.S. locations have been limited. Herein, we describe the draft genome sequences of 510 L. monocytogenes isolates from northern Italy from different sources.

Insight Into the Distribution of Staphylococci and Their Enterotoxins in Cheeses Under Natural Conditions.

Staphylococcal food poisoning outbreaks are a major cause of food-borne illness in the European Union and their notification has been mandatory since 2005. Criteria for the enumeration of coagulase-positive Staphylococci (CPS) and the detection of staphylococcal enterotoxins (SEs) in cheese have been set down in Commission Regulation EC 2073/2005. Currently, few information are available about the distribution of SEs in naturally contaminated cheeses, including raw-milk and artisanal dairy products. The aim of this study was therefore to investigate at both the CPS enumeration and the succession of the enterotoxigenic Staphylococcus aureus and produced enterotoxins levels on the rind and the core of a raw-milk semi-hard cheese, produced on farm. The study has been conducted in three steps: (I) seven wheels at different time of ripening where tested for the presence of SEs. (II) from each wheel, four portions were subsequently sampled from four different areas (peripheral rind, central rind, peripheral core and central core). (III) two cheese wheels, characterized by the highest and lowest CPS numbers and SEs quantification, based on the second step of the study, were further analyzed. A significant difference has been observed in the distribution of CPS and SEs in the four areas sampled, irrespectively of the batch and the time of ripening. The results of this study provided a set of previously unknown information on the influence of natural conditions on the distribution of CPS and SEs thereof in the cheese matrix, filling a gap in the understanding of SEs biosynthesis process.

Whole-Genome Shotgun Sequence of Salmonella bongori, First Isolated in Northwestern Italy.

This study describes the whole-genome shotgun sequence of Salmonella bongori 48:z35:-, originally isolated from a 1-year-old symptomatic patient in northwest Italy, a typically nonendemic area. The draft genome sequence contained 4.56 Mbp and the G+C content was 51.27%.

Molecular Epidemiology of Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus in the Ovine Dairy Chain and in Farm-Related Humans.

Staphylococcus aureus is a major cause of clinical infections in humans and its enterotoxins cause foodborne disease. In the present study, we tested a total of 51 isolates of S. aureus from small-ruminant dairy farms with artisan dairy facilities, all located in Latium, Italy. The farms have a known history of a high prevalence of methicillin-resistant S. aureus (MRSA). Most of the MRSA isolates (27 of 51) belonged to spa-type t127 (43.1%), followed by t2678 (3.9%), t044 (2%), t1166 (2%), and t1773 (2%). PFGE performed on mecA positive strains identified one cluster (≥ 80% of similarity), comprising 22 MRSA. Nine of twenty-two MRSA isolates were assigned human host origin, and 13 isolates did not belong to a specific host. During the characterization study, one strain isolated from bulk tank milk samples harbored the pvl gene; the strain was not enterotoxigenic with a non-specific host according to the biotyping scheme, highlighting the possible emerging risk of transmission of bacterial virulence factors by foods, the environment, and foodhandlers. These findings stress the importance of hygienic measures at all processing steps of the food production chain and underline that monitoring for the presence of MRSA throughout the food chain is essential for public health.

Draft Genome Sequences of Four Yersinia enterocolitica Strains, Isolated from Wild Ungulate Carcasses.

This study describes the draft genome sequences of four Yersinia enterocolitica strains, originally isolated from ungulate carcasses. These isolates were typed biochemically and two were determined to be highly virulent (biotype 1B). The draft genome sequences had a mean size of 4.77 Mb and a mean G+C content of 47.1%.

Investigation of a Staphylococcal Food Poisoning Outbreak from a Chantilly Cream Dessert, in Umbria (Italy).

On August 28, 2015, a staphylococcal food poisoning outbreak occurred in Umbria, Italy, affecting 24 of the 42 customers who had dinner at a local restaurant. About 3 h after ingesting a variety of foods, the customers manifested gastrointestinal symptoms. Within 24 h of notification from the hospital emergency department, Sanitary Inspectors of the local Public Health Unit performed an epidemiological investigation. A retrospective cohort study was conducted among the customers. Food and environmental samples were collected. Due to the rapid onset of symptoms (vomiting, diarrhea), the food samples were analyzed for the presence of toxigenic bacteria and their toxins; nasopharyngeal swabs were collected from the waiters and cooks. Among the food tested, high levels of coagulase-positive staphylococci (CPS) (3.4 × 108 CFU/g) and staphylococcal enterotoxins (2.12 ng SEA/g) were only detected in the Chantilly cream dessert. CPS were also detected on the surface of a kitchen table (10 CFU/swab), and five food handlers were positive for Staphylococcus aureus. In total, five enterotoxigenic S. aureus isolates were recovered from three food handlers, a kitchen surface, and the Chantilly cream dessert. These isolates were further characterized by biotyping, pulsed-field gel electrophoresis, and multiplex polymerase chain reaction assays for the detection of eleven enterotoxin encoding genes (sea, seb, sec, sed, see, seg, seh, sei, sej, sep, and ser) and three genes involved in antibiotic resistance (mecA, mecC, and mupA). Three sea-positive strains, isolated from the dessert, environment, and one of the cooks, had the same pulsed-field gel electrophoresis profile and belonged to the human biotype, suggesting that the contamination causing the outbreak most likely originated from a food handler. Moreover, improper storage of the dessert, at room temperature for about 5 h, permitted microbial growth and SEA production. This study underlines the importance of both laboratory evidence and epidemiological data for outbreak investigation.

Food Safety and Sustainable Nutrition Workshops: Educational Experiences for Primary School Children in Turin, Italy.

European control and prevention policies are focused to guarantee a high level of protection of consumers' health. Food-borne diseases as obesity, diabetes, food allergy, and food-borne outbreaks are increasing. To prevent food-borne diseases, it is fundamental to involve consumers, in particular children, in educational experiences aimed to learn the proper behaviours to be applied. In this context, we designed and performed 5 educational workshops about food safety, hidden allergens in food and nutrition aimed to involve children attending primary and summer school. These experiences let us collect observations about children knowledge and behaviours. From May to October 2015, a total of 1708 children aged 6 to 11 years joined our workshops. Children were involved in listening activities, laboratory experiments, handling games and sensory experiences. All participants were familiar with food allergy and were interested to know how to behave with allergic people. Children showed great curiosity in discovering that many foods normally contain live bacteria. Less than 25% of children reported to skip breakfast, to have it watching TV or to spend few minutes for it. Many of them (>75%) thought that fruits and vegetables are all year-round available and are not related to a specific period. Very few participants (<25%) knew that freezing is the treatment to be applied to make fresh fish safe from parasites. Children involved in food safety and nutrition educational experiences have the opportunity to increase their awareness about the correct behaviours to prevent food-borne diseases and to improve their own critical thinking about food consumption.

Diversity and persistence of Listeria monocytogenes within the Gorgonzola PDO production chain and comparison with clinical isolates from the same area.

Listeria monocytogenes causes invasive syndromes with high fatality rates in specific population groups. Cheeses have been commonly implicated in outbreaks worldwide. Gorgonzola is a cheese only produced in Northwestern Italy (it is the third Italian cheese in terms of production and export) and L. monocytogenes is frequently isolated from the production chain. The aims of this study were to assess the distribution of L. monocytogenes Virulence Types (VTs) in isolates collected in Gorgonzola processing plants and to determine the presence of Epidemic Clones (ECs). Fifty-Six L. monocytogenes strains collected between 2004 and 2016 from cheese and environmental samples were subtyped with Multi-Virulence-Locus Sequence Typing (MVLST) and compared to previously typed strains. Most isolates (n=50) belonged to two new VTs (VT113 and VT114). The remaining isolates belonged to previously identified VTs: VT14-ECVIII (milk chocolate outbreak, 1994, USA) and VT80 (ricotta salata outbreak, 2012, USA). VT14, VT80 and VT113 were shared with isolates from apparently sporadic human cases in the same geographical area and temporal period (Piedmont and Lombardy, 2005-2016). The overall L. monocytogenes population appears to be homogeneous and may be characteristic of Gorgonzola production. Nevertheless, the detection in cheese and environmental samples of VTs observed in clinical isolates or outbreak related strains (VT80, VT14) contributed to better describe the current scenario and pointed out the need for increased surveillance.

Molecular Typing of Staphylococcus Aureus Isolate Responsible for Staphylococcal Poisoning Incident in Homemade Food.

In October 2012, two persons fell ill with symptoms consistent with staphylococcal food poisoning after eating home-canned tuna fish and tomatoes. Laboratory investigation detected the enterotoxins in the home-canned tuna and molecular analysis of the isolated Staphylococcus aureus confirmed it carried toxin genes. Qualitative enzyme-linked immunosorbent assay and enzime linked fluorescent assay methods and quantitative assay identified the enterotoxins in the food leftovers, specifically staphylococcal enterotoxins type A (SEA) and D (SED), respectively 0.49 and 2.04 ng/g. The laboratory results are discussed considering the relation to the fish in oil, survival and heat resistance of S. aureus, and presumptive microbial contamination due to improper handling during home-canning procedures. This is the first reported cluster of foodborne illnesses due to staphylococcal enterotoxins in tuna in Italy. In this study, we reported cases described and analysed for their spa-type. Showing a high heterogeneity of isolates, spa-type t13252 is correlated in a node of the minimum spanning tree and it has never been reported as responsible for foodborne outbreak. This case underlines the importance of risk communication and dissemination of home-canning guidelines to reduce the incidence of foodborne outbreaks caused by homemade conserves.

Aflatoxin M1 in Cow's Milk: Method Validation for Milk Sampled in Northern Italy.

Aflatoxins (AFs) are mycotoxins produced by some species of Aspergillus. In dairy cows, ingested AFB1 is metabolized into carcinogenic AFM1 which is eliminated through milk, thus posing a risk for consumer health. Here we describe the set, validation, and application of screening (ELISA) and confirmatory (HPLC) tests carried out on milk samples collected through official control of mycotoxin levels in northern Italy over a three-year period (2012-2014). The limit of detection (LOD) was set at 5 ppt and 2 ppt for ELISA and HPLC, respectively, and the limit of quantification (LOQ) was 10 ppt for confirmatory HPLC. A total of 1668 milk samples were analyzed: ELISA identified 36 (2.2%) positive milk samples that were subsequently confirmed by HPLC. The level of AFM1 in the positive samples ranged between 18 ± 2 and 208 ± 27 ppt. Of the total samples, only eight (0.5%) were found non-compliant with the EU regulatory limit (50 ppt; range 74 ± 10 to 208 ± 27 ppt). Use of ELISA and HPLC tests in series allows for high-volume analysis of samples, thus saving time and money while guaranteeing high analytical precision and accuracy.