Have you ever felt ill with nausea, lethargy, aching joints, loss of appetite, abdominal pain or fever? The symptoms could have resulted from many different ailments. One is hepatitis E, a largely hidden and inadequately diagnosed disease caused by the hepatitis E virus (HEV). It is usually self-limiting, in that it will disappear without treatment (there is generally none available in acute cases) after several weeks. However, far more serious outcomes can also occur, particularly in people with weakened immune systems, such as the elderly, some cancer patients, HIV patients, organ transplant patients and pregnant women.

There are four types of HEV, two of which can be transmitted between animals (primarily pigs but also others such as deer, rabbits and rats) and humans. Unlike its effect on many humans, HEV does not make the animals ill. [1] Although avian strains exist, they are not known to be transmitted to humans. [2]

Genotypes 1 and 2 are limited to humans and are generally found in countries with poor sanitation systems. Genotype 1 is common in Asia, Africa, and Latin America, while genotype 2 is more common in sub-Saharan Africa and Mexico. [3]

Genotypes 3 and 4 are the forms that can infect humans and animals. [3] Genotype 3 has been found in all developed countries where its presence has been investigated, while genotype 4 is mainly found in China, Southeast Asia, some pockets of Europe and Japan (although it does not appear to be the dominant form in that country). [4] [5]

Accordingly, genotype 3 is the key form of the virus responsible for infections within developed nations.

Like all forms of hepatitis, HEV involves swelling or inflammation of the liver. In addition to the symptoms mentioned earlier, jaundice is common, with yellowing of the skin and eyeballs, while other symptoms can include tingling, numbness and weakness in the arms and legs, general itching, darkened urine, and mild flu-like symptoms. [1] The virus can sometimes cause acute liver failure, which can lead to death. [6]

Serious outcomes that are not related to the liver can include: (a) neurological conditions such as Guillain–Barré syndrome, brachial neuritis, transverse myelitis, Bell’s palsy (with paralysis of facial nerves) and vestibular neuritis; (b) haematological conditions such as thrombocytopenia, lymphopenia and monoclonal immunoglobulin; and (c) other conditions such as acute pancreatitis, arthritis and autoimmune thyroiditis. [4]

HEV in Britain

In a paper published in the medical journal, The Lancet, researchers estimated there were likely to have been 80,000 – 100,000 acute HEV infections in England during 2013. The findings were based on retrospective screening of 225,000 individual blood donations. After allowing for the duration of a detectable virus in the blood, the results were extrapolated across the country’s population. [7]

In comparison, only 846 cases were reported in England and Wales combined that year, indicating the extent to which the disease is insufficiently recognised by healthcare professionals and patients. [8] One reason may be that there are sometimes no symptoms, particularly in children (although the carriers can still spread the virus to others). [6] [22] Nevertheless, the number of reported cases more than tripled from 2010 to 2015, from 368 to 1,213 (with a further increase to 1,244 in 2016). [8] [22]

The Sunday Times in London recently reported that more than 60,000 Britons per year are being infected with HEV by consuming pig meat imported from France, Holland, Germany and Denmark, often consumed in the form of bacon, saus­ages, pork pies and salami. [9]

British farms may also be a source, with a 2013 study of abattoirs finding that 92.8 per cent of pigs tested had antibodies for HEV, which indicates they had previously been exposed to the virus. 5.8 per cent were found to have HEV in their blood and were therefore likely to be infectious at the time of slaughter. [10][11] [Footnote]

However, a study led by Sylvia Grierson of the Department of Virology at the Animal and Plant Health Agency, published in 2015, indicated that imported products were likely to be the dominant source. [12]

Although the Sunday Times report indicated that 10 per cent of sausages in the UK were affected, the nation’s Food Standards Agency has said that that particular finding needs to be “interpreted with caution as the sample size was small and not representative of the UK market and the majority of the HEV positive sausages were from the same batch”. [11]

HEV in Australia

HEV was first detected in Australian pigs in 1999, with a study reporting positive findings in 17 per cent of tested wild-caught pigs and more than 90 per cent of tested commercial piglets aged up to 16 weeks (which is close to the age at which piglets are generally slaughtered).

Writing in the Medical Journal of Australia in April 2016, Yapa et al. noted that there appear to have been no subsequent studies investigating the virus within Australia’s pig population, possibly leading to (as in Britain) inadequate recognition of the problem among clinicians and laboratories, in turn possibly leading to under-diagnosis. [13]

The first outbreak of locally acquired HEV in Australia’s human population occurred in New South Wales in 2013, when a number of people were infected after eating Australian produced pork livers or products made from them, such as pork liver sausages or pork pâté. The outbreak lasted nine months, and according to Dr Joseph Doyle of St Vincent’s Hospital and Dr Alexander Thompson of the University of Melbourne, shows that transmission of the virus should be considered an ongoing risk in Australia. [14]

In mid-2016, the Australian Red Cross Blood Service commenced a study with the aim of understanding how common the virus is in Australia, thereby assisting in determining appropriate blood safety measures. [20] The results are awaited.

Blood serum tests have found a higher incidence of the virus among pig veterinarians, pig farmers and abattoir workers than in the general population, which is consistent with overseas findings. [5] [13]

Australian Pork Limited (APL), which describes itself as “the producer owned organisation supporting and promoting the Australian pork industry”, has reported that around two-thirds of Australia’s processed pork (ham, bacon and smallgoods) is imported. [27] Around 45 per cent of imported product comes from Denmark and the Netherlands (Holland), two of the countries allegedly responsible for HEV in Britain. [28]

However, Australia’s import regulations distinguish between cooked, uncooked and cured meat. [33] Only Spain and Italy are permitted to export cured meat to Australia (that is meat preserved by salting, drying or smoking), with the product range limited to Iberian ham, Iberian shoulder ham or Serrano ham from Spain and dry-cured Culatta and Parma ham from Italy. (Product from those countries may also be responsible for some cases of HEV in Britain.)

All uncooked pig meat entering Australia is required to undergo heat processing at a facility operating under a compliance agreement with the Department of Agriculture, Fisheries and Forestry and managed by the entry management national coordination centre in Adelaide.

Other foods can be affected

In addition to pig meat and venison (deer), other products found to carry HEV are strawberries, green leafy vegetables and shellfish. [17] [18] [19] Contaminated irrigation water was a suspected cause in studies examining the first two products. Similarly, human sewage and runoff from a pig slaughterhouse were suspected in the case of shellfish. The fact that shellfish are generally eaten raw means there is no opportunity to inactivate the virus through cooking.

The relevant papers also noted that the products can be contaminated through various other means, including: raw manure; compost; wildlife intrusion; and handling during harvesting or post-harvest activities. Two of the papers noted the robust nature of HEV and other viruses in the environment.

Given the risk of contamination, the practice of spraying pig waste on fields, supposedly as fertiliser rather than sewage, must be brought into question. [32]

A key mitigation measure in relation to other foods such as those mentioned here would be to reduce our reliance on animal-based food products, thereby reducing the contamination risk.

Prevention and treatment

The virus is passed on through faeces and contaminated food or water, so personal hygiene is an important factor in prevention. The British Liver Trust (BLT) has reported that, unlike some other forms of hepatitis, there is no evidence of HEV being transmitted through sharing needles, bodily fluids or sexual contact. [1] (NSW Health does refer to sexual contact as a risk factor, but notes that direct person-to-person transmission is uncommon.) [6]

BLT recommends that the following actions be avoided when traveling to high risk areas: drinking tap water (drink bottled water where possible); having ice cubes in drinks; cleaning teeth with tap water; drinking unpasteurised milk; eating uncooked meat and shellfish; eating unpeeled fruit and uncooked vegetables, including salads, that you have not been prepared yourself. [1]

To reduce the risk of becoming infected in developed countries (relevant to genotypes 3 and 4 ), all meat, especially pork, should be thoroughly cooked before eating. (Please see further comments below.) Hands should also be washed after touching uncooked meat or meat products and after contact with any animals that may be infected.

People who suffer from a long-standing liver disease, are pregnant or have a suppressed immune system for other reasons, should be particularly careful with raw meats, shellfish and pork products. Dr Harry Dalton, a gastroenterologist at Exeter University and Royal Cornwall Hospital, was quoted in the Sunday Times article as recommending that pregnant women and transplant patients avoid pork products altogether (with that view likely to also apply to anyone with liver disease or a suppressed immune system).

In terms of genotypes 3 and 4, it seems the most effective prevention measure would be for others to also avoid pig meat. Such an approach would also reduce an individual’s risk in terms of cancer, diabetes and cardio-vascular disease (noting that medical researchers generally consider pig meat to be a form of red meat). [25] [26]

There is no specific treatment for acute (non-chronic) hepatitis E infection. Some patients with chronic liver problems have been treated successfully with anti-viral therapy using the drug ribavirin. [23]

A vaccine was approved in China in 2012 but is not available in other countries. Researchers from the University Hospital Hamburg say it is unclear whether or not the vaccine prevents infections with HEV genotype 3, thereby questioning its value in most industrialised nations. [23] However, Zhang, et al, while acknowledging that the vaccine’s efficacy against genotypes 1 – 3 is yet to be investigated, argue that all HEV genotypes are recognised as belonging to the same serotype and that one hepatitis E vaccine can protect against infection with any HEV genotype. [24]

Because of various uncertainties regarding the vaccine, the World Health Organization has recommended against its use in children aged under 16 years, pregnant women, people with chronic liver disease, people on organ transplant waiting lists, and travellers. [29]

To what extent should meat be cooked?

Although it appears the virus can be inactivated by cooking, there is some uncertainty about the extent required. In any event, much of the pig meat consumed is cured rather than cooked, potentially providing no opportunity to inactivate the virus if it is present.

For pig meat that is cooked, the Food Safety Authority of Ireland (FSAI) has said the required extent would depend, in part, on the number of infectious virus particles present and the composition of the food. [15]

In one study, the researchers reported that it was necessary to heat infected pig liver to 71oC for twenty minutes. [16] The FSAI has also referred to other studies indicating that 71oC for 10 minutes or 70oC for 5 minutes would be sufficient.

On balance, its opinion is that it is sufficient to cook pork and products containing pork (e.g. sausages) to a minimum temperature of 75oC at the centre of the thickest segment. It has not specified the duration, but stated: “Normal grilling or frying of sausages until they are well browned and firm inside with no traces of pink meat, usually results in centre temperatures in excess of 85oC.”

It says that visual cues should not be relied upon in isolation, and recommends that a meat thermometer be used to check the temperature of cooked meat and meat products before consuming them.

In Australia, NSW Health recommends the same approach, but specifies a minimum 2 minute time period. [6]

The UK Food Standards Agency is more general, recommending all whole cuts of pork, pork products and offal be thoroughly cooked until steaming hot throughout, with the meat no longer pink, and the juices running clear. [11]

HEV during pregnancy

The immune response in pregnant women is lower than normal, causing them to be more vulnerable to infection, including from HEV. There has been a high rate of mortality among pregnant women in developing nations after infection with HEV genotype 1.

Researchers led by Dr Harry Dalton (referred to earlier) have stated: “In contrast to HEV genotype 1, excess mortality in pregnant women is not seen with genotype 3, and the few women who have been described in the literature have all survived.” [2] Nevertheless, as mentioned, Dr Dalton argues that pregnant women should not eat pork products.

Researchers at the Johns Hopkins Bloomberg School of Public Health in Baltimore, who also perceive genotype 1 as the key area for concern, have cautiously stated, “the potential of genotypes 2–4 to cause adverse outcomes in pregnant women, given exposure, remains uncertain”. [30]

An increased risk of miscarriage, stillbirth and death and disease in newborn children has also been reported. [21]

Curiously, the Victorian State Government’s “Better Health” page dealing with pregnancy and diet mentions listeria and salmonella, but says nothing about HEV. It also includes pork in its “healthy eating” recommendations, although it does recommend against eating ham, salami, pate and certain other products in relation to salmonella. [31]

Product labelling

How many people know the extent of risk involved in consuming pig meat products? Product labelling laws may currently be inadequate to warn people of those dangers, particularly for those in the most vulnerable categories. Consumers have a right to be adequately informed regarding products they consider purchasing, particularly in what can literally be life and death situations. It is essential that regulators respond to the extent that current labelling laws are failing.

Conclusion

There appears to have been a general lack of awareness of hepatitis E risk among health care professionals and the wider community. However, preventative guidelines are available from numerous authoritative sources for anyone who is concerned.

As with so many ailments facing our planet and its human and non-human populations, a simple, effective and potentially critical mitigation measure, which is not widely communicated, is to avoid certain products. In this case, food products derived from pigs are the primary concern, and can easily be replaced by nutritious plant-based alternatives. It is time for the community to embrace such choices.

Author

Paul Mahony

Footnote

There is a slight discrepancy between the two sources in the figures indicating the prevalence of HEV in British abattoirs. The Food Standards Agency reported figures of 93 per cent and 5.7 per cent, compared to figures of 92.8 per cent and 5.8 per cent used in the article, which it also contributed to.

References

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[2] Shrestha, A. C., Faddy, H. M., Flower, R. L. P., Seed, C. R., & Keller, A. J. (2015). Hepatitis E virus: do locally acquired infections in Australia necessitate laboratory testing in acute hepatitis patients with no overseas travel history? Pathology, 47(2), 97–100. http://doi.org/10.1097/PAT.0000000000000229, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4341517/

[3] Chaudhry SA, Verma N, Koren G. “Hepatitis E infection during pregnancy”, Canadian Family Physician. 2015;61(7):607-608, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501603 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501603/pdf/0610607.pdf

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[6] NSW Health, Hepatitis E Fact Sheet, 17 September 2014, http://www.health.nsw.gov.au/Infectious/factsheets/Factsheets/hepatitis-e.pdf

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[10] Animal Health and Veterinary Laboratory Agencies, Department for Environment Food and Rural Affairs, Food Standards Agency, Biomedical Physics & Engineering Express (BPEX), Public Health England, Veterinary Medicines Directorate, “Study of Salmonella, Toxoplasma, Hepatitis E virus, Yersinia, Porcine Reproductive and Respiratory Syndrome virus, antimicrobial resistance in Campylobacter coli and extended spectrum beta lactamase E. coli in UK pigs at slaughter”, March 2014, http://webarchive.nationalarchives.gov.uk/20140707135733/http://www.defra.gov.uk/ahvla-en/files/pig-survey-key-findings.pdf

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[12] Grierson, S., Heaney, J., Cheney, T., Morgan, D., Wyllie, S., Powell, L., Smith, D., Ijaz, S., Steinbach, F., Choudhury, B., and Tedder, R.S., “Prevalence of Hepatitis E Virus Infection in Pigs at the Time of Slaughter, United Kingdom, 2013”, Emerging Infectious Diseases. 2015;21(8):1396-1401. doi:10.3201/eid2108.141995, Aug 2015, https://wwwnc.cdc.gov/eid/article/21/8/14-1995_article

[13] Chaturangi M Yapa, Catriona Furlong, Alexander Rosewell, Kate A Ward, Sheena Adamson, Craig Shadbolt, Jen Kok, Samantha L Tracy, Scott Bowden, Elizabeth J Smedley, Mark J Ferson, Vicky Sheppeard and Jeremy M McAnulty, “First reported outbreak of locally acquired hepatitis E virus infection in Australia”, Med J Aust 2016; 204 (7): 274, doi: 10.5694/mja15.00955, 18 Apr 2016, https://www.mja.com.au/journal/2016/204/7/first-reported-outbreak-locally-acquired-hepatitis-e-virus-infection-australia

[14] Doyle, J.S., and Thompson, A.J.V., “Local transmission of hepatitis E virus in Australia: implications for clinicians and public health”, Med J Aust 2016; 204 (7): 274, doi: 10.5694/mja16.00167, 18 Apr 2016, https://www.mja.com.au/journal/2016/204/7/local-transmission-hepatitis-e-virus-australia-implications-clinicians-and-public

[15] Food Safety Authority of Ireland, “Hepatitis E Virus and Food”, 14 Jan 2016, https://www.fsai.ie/faq/hepatitis_E.html

[16] Barnaud, E., Rogee, S., Garry, P., Rose, N., Pavio, N., 2012. Thermal Inactivation of Infectious Hepatitis E Virus in Experimentally Contaminated Food. Appl. Environ. Microbiol. 78, 5153–5159, http://aem.asm.org/content/78/15/5153.full.pdf+html and http://aem.asm.org/content/78/15/5153.full

[17] Brassard J, Gagné MJ, Généreux M, Côté C, “Detection of Human Food-Borne and Zoonotic Viruses on Irrigated, Field-Grown Strawberries”, Appl Environ Microbiol. 2012 May;78(10):3763-6. doi: 10.1128/AEM.00251-12. Epub 16 Mar 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3346374/

[18] Kokkinos P, Kozyra I, Lazic S, Bouwknegt M, Rutjes S, Willems K, Moloney R, de Roda Husman AM, Kaupke A, Legaki E, D’Agostino M, Cook N, Rzeżutka A, Petrovic T, Vantarakis A., “Harmonised investigation of the occurrence of human enteric viruses in the leafy green vegetable supply chain in three European countries.”, Food Environ Virol. 2012 Dec;4(4):179-91. doi: 10.1007/s12560-012-9087-8. Epub 21 Sep 2012, https://www.ncbi.nlm.nih.gov/pubmed/23412890 and http://tinyurl.com/ya2zc7mo

[19] Crossan, C., Baker, P.J., Craft, J., Yasu Takeuchi, Dalton, H.R., and Scobie, L., “Hepatitis E Virus Genotype 3 in Shellfish, United Kingdom”, Emerging Infectious Diseases. 2012;18(12):2085-2087. doi:10.3201/eid1812.120924, Dec 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557861/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557861/pdf/12-0924.pdf

[20] Australian Red Cross Blood Service, “Hepatitis E study kicks off”, 20 July 2016, https://www.transfusion.com.au/BSIB_July2016_8

[21] Price-Hayward, M. and Hartnell, R., Centre for Environment, Fisheries & Aquaculture Science, “Summary Report of Joint Scientific Workshop on Foodborne Viruses” (Commissioned by Food Standards Agency and European Food Safety Authority), 20 Oct 2016, https://www.food.gov.uk/news-updates/news/2016/15612/key-priorities-established-for-research-on-foodborne-viruses, http://www.efsa.europa.eu/en/supporting/pub/1103e and http://onlinelibrary.wiley.com/doi/10.2903/sp.efsa.2016.EN-1103/pdf

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[27] Australian Pork Limited, “Get the facts on your pork industry”, April 2015, http://australianpork.com.au/wp-content/uploads/2013/09/1113329_AustralianPork_Final-Cover_1-2_AustralianPork_Inner_1-2_Page-PDF-LoRes.pdf

[28] Australian Pork Limited, “Import, Export and Domestic Production Report”, Graph 4.3 Australian Import Volume Share by Country – Financial Year Comparison, March 2017, http://australianpork.com.au/wp-content/uploads/2017/05/ImportsExportsDom-Prod-March-Report-2017.pdf

[29] World Health Organization, Media Centre, Hepatitis E Fact Sheet, July 2016, http://www.who.int/mediacentre/factsheets/fs280/en/

[30] Krain LJ, Atwell JE, Nelson KE, Labrique AB. Fetal and Neonatal Health Consequences of Vertically Transmitted Hepatitis E Virus Infection. The American Journal of Tropical Medicine and Hygiene. 2014;90(2):365-370. doi:10.4269/ajtmh.13-0265, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919250/

[31] Victorian State Government, Better Health Channel, “Pregnancy and diet”, https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-and-diet

[32] Strassmann, M., CBS News, “North Carolina hog farms accused of putrid pollution”, 4th July 2016, http://www.cbsnews.com/news/north-carolina-hog-farms-accused-of-putrid-pollution/

[33] Department of Agriculture, Fisheries and Forestry, “The effectiveness of controls for imported uncooked, cooked and cured pig meat – Interim inspector-general of biosecurity audit report”, June 2013, http://apfa.com.au/wp-content/uploads/2017/03/IGB-report-imported-pig-2013.pdf

Image

Photographee.eu | Closeup of woman dishing out grilled sausage | Shutterstock | Photo ID 283801919

Update

29th May 2017: Additional comments and reference added in relation to Australian pig meat imports, along with additional comments in relation to the Victorian Government’s “Better Health” page.

Disclaimer

No information in this article is intended to represent medical, health, nutritional, dietary or similar advice, and should not be relied upon as such. Please consult a medical professional if you have any queries or concerns about the issues referred to in the article.