CDC: Investigating Multi-State Outbreak Of Shiga-Toxin Producing E. coli

 

E. coli – Photo Credit CDC

 

# 6380

 

Last year at this time you may recall that much of Europe’s public health system was embroiled in containing a massive outbreak of STEC (Shiga-toxin Producing Escherichia coli) that over a couple of months sickened more than 4,000 people and contributed to the deaths of more than 45 individuals (see Shiga toxin-producing E. coli (STEC): Update on outbreak in the EU (27 July 2011, 11:00)).

 

After more than a month of investigation the European Food Safety Authority (EFSA) zeroed in on a specific lot of imported fenugreek seeds (used for sprouting) imported from Egypt as the source of infection, although some person-to-person transmission was also suspected.

 

STEC (sometimes referred to as verocytotoxic E. coli (VTEC) or enterohemorrhagic E. coli (EHEC)) infections can produce serious illness, particularly among the very young and the elderly.

 

A particularly serious, but fairly rare complication is called HUS (hemolytic uremic syndrome) which is a type of kidney failure.  Not everyone who consumes Shiga-toxin producing strains of E. coli will develop symptoms, however, and far fewer still will go on to experience HUS.

 

 

E. Coli is believed responsible for more than 250,000 illnesses each year in the United States.  The CDC explains about STEC on their E. coli page.

 

 

What are Shiga toxin-producing E. coli?

Some kinds of E. coli cause disease by making a toxin called Shiga toxin. The bacteria that make these toxins are called “Shiga toxin-producing” E. coli, or STEC for short. You might hear them called verocytotoxic E. coli (VTEC) or enterohemorrhagic E. coli (EHEC); these all refer generally to the same group of bacteria. The most commonly identified STEC in North America is E. coli O157:H7 (often shortened to E. coli O157 or even just “O157”). When you hear news reports about outbreaks of “E. coli” infections, they are usually talking about E. coli O157.

 

In addition to E. coli O157, many other kinds (called serogroups) of STEC cause disease. These other kinds are sometimes called “non-O157 STEC.” E. coli serogroups O26, O111, and O103 are the non-O157 serogroups that most often cause illness in people in the United States.

 

Some recent outbreaks that have been investigated by the CDC over the past 18 months include:

 

2012

• Multistate Outbreak of Shiga toxin-producing Escherichia coli O26 Infections Linked to Raw Clover Sprouts at Jimmy John's Restaurants

2011

• Multistate Outbreak of E. coli O157:H7 Infections Linked to Romaine Lettuce
• Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany
• Multistate Outbreak of E. coli O157:H7 Infections Associated with Lebanon Bologna
• Multistate Outbreak of E. coli O157:H7 Infections Associated with In-shell Hazelnuts

 

The CDC is currently investigating a multi-state outbreak of STEC which has sickened 14 people across 6 states.  A common source for the infections has not yet been identified.

 

Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections

Posted June 10, 2012 01:00 AM ET

Highlights

• Read the Advice to Consumers »
• A total of 14 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states.
  • The number of ill persons identified in each state is as follows: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (4), and Tennessee (1).
  • Three ill persons have been hospitalized; one death has been reported in Louisiana.
• Based on interviews conducted to date, a source for these infections has not been identified. If a specific source is identified, public health officials will advise the public and take steps to prevent additional illnesses.
• Dates for patients' onset of illness range from April 15 to May 12, 2012. It has been approximately 4 weeks since the last illness onset among reported cases. Although this indicates that this outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

 

 

Despite our modern technology, foodborne illnesses pose a heavy burden to Americans, with the CDC estimating that 1 in 6 of us (48 million) fall victim to food poisoning each year, and that 128,000 are hospitalized, and as many as 3,000 die.

 

While we await news of the source of this outbreak, the CDC’s advice to consumers is valid and should be heeded 365 days a year, regardless of whether an outbreak of E. coli is being investigated or not:

 

Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections

Advice to Consumers

• No source has been identified for this outbreak, and therefore we do not have specific consumer advice at this time.  Recommendations for protecting against STEC infections are provided below.  If a specific source is identified for this outbreak, public health officials will advise the public and take steps to prevent additional illnesses.
• Practice proper hygiene, especially good hand washing
  • Wash your hands thoroughly after using the bathroom or changing diapers and before preparing or eating food. Wash your hands after contact with animals or their environments (at farms, petting zoos, fairs, even your own backyard).
  • Always wash your hands before preparing and feeding bottles or foods to  your infant, before touching your infant's mouth, and before touching pacifiers or other things that go into your infant's mouth.
  • If soap and water aren't available, use an alcohol-based hand sanitizer. These alcohol-based products can quickly reduce the number of germs on hands in some situations, but they are not a substitute for washing with soap and water.
• It is also important to keep all objects that enter infants' mouths (such as pacifiers and teethers) clean.
• Know your risk for food poisoning.  People at higher-risk for foodborne illness are pregnant women and newborns, children, older adults and those with weak immune systems.
• Cook meats thoroughly. Ground beef and meat that has been needle-tenderized should be cooked to a temperature of at least 160°F/70˚C. It’s best to use a thermometer, as color is not a very reliable indicator of how thoroughly meat has been cooked.
• Avoid consuming raw milk, unpasteurized dairy products, and unpasteurized juices (like fresh apple cider).
• Avoid swallowing water when swimming or playing in lakes, ponds, streams, swimming pools, and backyard “kiddie” pools.
• Prevent cross-contamination in food preparation areas by thoroughly washing hands, counters, cutting boards, and utensils after they touch raw meat. 
• Please see the FoodSafety.gov E.coli web site for information on what you can to  prevent from getting infected with STEC.
• Persons who think they might be ill with STEC should consult their healthcare providers.

The good news is that no new cases have been reported to local health departments since the middle of May, suggesting that this outbreak may all ready be winding down.

 

ECDC: EHEC/STEC Update June 13th

 

 

# 5625

 

Although German authorities are hopeful that the peak of the EHEC or Shiga-Toxin Producing E. Coli outbreak has now passed, the latest ECDC update reports one new fatality since yesterday, and nearly 70 new cases.

 

 

Outbreak of Shiga toxin-producing E. coli in Germany (13 June, 11:00)

13 Jun 2011

 

With an incubation period of up to 2-weeks, it is considered likely that more cases (and perhaps more deaths) will be reported before this outbreak completely burns itself out.

 

Meanwhile, Spiegel Online is reporting that as many as 100 people who developed the life-threatening complication called HUS (Hemolytic Uremic Syndrome) experienced severe enough kidney damage to either need life-long dialysis or a kidney transplant.

 

06/13/2011

Long-Term Impact of E. Coli Outbreak

Expert Warns 100 Patients Will Need New Kidneys or Dialysis

 

 

While the source of the infection has been traced to a specific sprout farm in lower Saxony, exactly how their sprouts came to be contaminated has not been established.    

 

Health authorities warn that sprout seeds may harbor the bacteria, which reproduce rapidly during the sprouting process, and warn that home growers should not consume their produce raw.

 

E.coli warnings over bean sprout seeds

RKI: Sprouts Behind Europe’s EHEC Outbreak

 

 

# 5617

 

 

Although none of the test samples taken from the sprout farm under suspicion in Lower Saxony have come back positive, the epidemiological investigation of cases has convinced investigators at the Robert Koch Institute that locally grown sprouts are behind the ongoing outbreak of E. Coli  (EHEC/STEC) in Europe.

 

The announcement was made by RKI’s president, Reinhard Burger at a press conference this morning, where the warning against eating cucumbers, tomatoes and lettuce was lifted, but the warning regarding sprouts was left in place.

 

The following appears on Monsters & Critics and comes from Deutsche Presse-Agentur. 

 

German all clear for cucumbers, tomatoes, lettuce

Jun 10, 2011, 8:59 GMT

Berlin - Cucumbers, tomatoes and lettuce were given an official all-clear Friday by German authorities, who said the evidence was strong that sprouts grown from beans or peas caused an E coli outbreak that has killed 30 people.

 

'It's the sprouts,' said Reinhard Burger, head of the Robert Koch Institute, the federal infectious-disease laboratory.

(Continue . . .)

 

 

Last night Lisa Schnirring of CIDRAP News wrote about the investigation, and how the trace-back investigation into the outbreak continued to lead to locally grown sprouts.

 

Sprouts data complicate outbreak investigation

Lisa Schnirring Staff Writer

Jun 9, 2011 (CIDRAP News) – An epidemiologic report from German investigators yesterday said the initial case-control study found that just 28% of patients reported they had eaten sprouts, the lead suspect in Europe's Escherichia coli outbreak, pointing up a factor can be difficult to interpret in foodborne illness situations.

 

Though German public officials seem to be zeroing in on sprouts, interviews comparing the food consumption patterns of sick patients and healthy people still suggest that several types of vegetables could be the source, and a third study is under way to focus more on salad ingredients. The full report, posted on the Robert Koch Institute's Web site, appears in German. (CIDRAP News obtained a professionally translated version of the findings.)

(Continue . . . )

 

 

While epidemiological trace-backs often end up being the only method of determining the source of a food borne outbreak, after so many false accusations over the past two weeks, the lack of a `smoking sprout’ will no doubt leave some unconvinced.

 

Criticism of the German response to this outbreak abounds, with legislators, doctors, and public health officials all weighing in.

 

Two days ago, in an AP article appearing in the Detroit Free Press,  CIDRAP’s Director Michael Osterholm is quoted as calling the German response `erratic’ and `a disaster’.

 

 

Experts: E. coli crisis flubbed

June 8th, 2011

 

 

Meanwhile, the outbreak goes on, although German health officials are hopeful that the worst is over. 

 

The most recent ECDC report (June 9th) lists nearly 3,000 victims and 27 deaths.  Other reports have the death toll at at least 30.

 

Germany: Waiting For Test Results

 

 

 

# 5606

 

Although many in the news media have latched firmly onto `organic sprouts’ as the `likely source’ of the E. Coli infection spreading across Europe, test results on the suspect produce have not been released yet.

 

The Associated Press is reporting that these test results are expected later today.

 

Tests to Determine if Sprouts Are to Blame for Killer E. Coli Outbreak

Published June 06, 2011

 

If test results do come back positive, the next step will be to determine exactly how they came to become contaminated. 

 

Fertilizers are not used in the growing of sprouts (essentially all you need is water or steam, the right temperature, darkness, and the seeds).

 

So the `obvious suspects’ would include the water supply, the seed stock, shipping containers, or perhaps accidental introduction of the bacteria by an infected employee.

 

As a home sprouter of mung beans (I have a jar going right now), I’ll be very interested to learn how this contamination – if it is confirmed – came to be.

 

Meanwhile, the ECDC has released their latest figures (June 6th) on cases of HUS and non-HUS STEC cases and associated deaths.

 

ECDC EHEC Update & Collateral Damage

 

 

 

# 5603

 

 

A number of public health agencies (Robert Koch Institute, CDC, WHO Europe, ECDC, etc.) are putting out statements about the ongoing severe outbreak of Shiga-Toxin Producing E. Coli in Germany and Europe.

 

The numbers being reported by these agencies, and in the media, tend to vary. Reuters, for instance, is reporting 19 deaths and 1700 infected, while the ECDC’s numbers sit at 16, and 1605.

 

 

Which simply illustrates that there are delays in the lines of communication, these numbers are constantly changing, and by the time a number is published, it is already likely out of date.

 

So these numbers should be viewed as preliminary.

 

The ECDC has issued an  epidemiological update on this health crisis every day now for a week, which not only provides the most current `official’ data, but a good way to go back and see how this outbreak has progressed.

 

We’ve today’s update, which I will follow with a little more.

 

 

Outbreak of Shiga toxin-producing E. coli in Germany (5 June 2011, 11:00)

05 Jun 2011

Outbreak of Shiga toxin-producing E. coli in Germany
Epidemiological update, 5 June 2011, 11:00

On 22 May, Germany reported a significant increase in the number of patients with haemolytic uremic syndrome (HUS) and bloody diarrhoea caused by Shiga toxin-producing E. coli (STEC).

 

Since 2 May 2011, 658 cases of HUS and 1605 non-HUS STEC cases have been reported from European Union Member States, including 627 HUS cases and 1536 non-HUS STEC cases in Germany. Sixteen of the HUS cases and six non-HUS STEC cases in EU Member states have died. See table below.

 

While HUS, caused by STEC infections, is usually observed in children under 5 years of age, in this outbreak the great majority of cases are adults, with more than two thirds being women.
Laboratory results indicate that STEC serogroup O104:H4 (Stx2-positve, eae-negative, hly-negative, ESBL, aat, aggR, aap) is the causative agent. PFGE results shows indistinguishable pattern of 7 human O104:H4 outbreak strains in Germany and 2 strains of O104:H4 in Denmark.

 

The source of the outbreak is under investigation, but contaminated food seems the most likely vehicle of infection.

 

Most cases are from, or have a history of travel to the North of Germany (mainly Schleswig-Holstein, Lower Saxony, North-Rhine-Westphalia and Hamburg). Within the EU also Denmark, the Netherlands, Poland, Spain, Sweden and the United Kingdom have reported cases of HUS, related to the ongoing outbreak as well as cases of non-HUS STEC cases.

 

Based on the available information, cases are associated with an exposure in Germany (mainly northern parts). The vehicle of the outbreak has not yet been identified and intensive investigations are ongoing.

 

The results of these investigations will determine the assessment of this risk. Rapid identification of potential cases linked to this outbreak, within Germany or among persons who have travelled to Germany since the beginning of May, is essential to prevent the development of severe disease.

 

STEC is a group of pathogenic Escherichia coli (E. coli) strains capable of producing Shiga toxins, with the potential to cause severe enteric and systemic disease in humans.

 

 

With no firm leads on the source of this outbreak, speculation on the origins of this rare pathogen are running rampant.

 

Fresh produce from Spain was first suspected, followed by local meat, a restaurant in Luebeck, and now – according to this Reuters report – even the Biogas industry is being viewed as a potential source.

 

German hospitals swamped with E.coli victims

By Brian Rohan

HAMBURG | Sun Jun 5, 2011 8:10am EDT

(Excerpt)

Scientists are pursuing a number of theories as to where the deadly strain of E.coli originated.

 

Experts told Welt am Sonntag newspaper it could have spread from a biogas plant. During the biogas fermentation process new bacteria often develop.

(Continue . . . )

 

The idea that scientists may have inadvertently brewed up some kind of a `Frankenstein Bacteria’ in biogas fermentation vessels no doubt resonates with a lot of people, particularly among those who are already critics of the industry.  

 

And it might even be true.

 

But a new `prime suspect’ in this outbreak seems to emerge on practically a daily basis. While these theories make for good newspaper fodder, they can also unfairly malign and trample the innocent.

 

Collateral damage may be inevitable in cases like this, but I suspect they will provoke economic and legal repercussions long after this outbreak has concluded.

WHO Europe: EHEC Update & FAQ

 

 

# 5600

 

 

The expanding outbreak of EHEC (or STEC  Shiga-Toxin Producing E. Coli) in Europe has produced an avalanche of news articles and analysis. Most days we are seeing literally scores of updates.

 

Both Crof at Crofsblog and the newshounds at FluTrackers  (see news forum Escherichia coli (E. Coli), Enterohemorrhagic Escherichia Coli (EHEC), Hemolytic-Uremic Syndrome) have been providing outstanding hour-to-hour coverage of this story.

 

Of course, I haven’t been ignoring the crisis.  My coverage, however, has been focused less on the breaking news aspects, and more on research updates (CDC, ECDC, WHO) and background information.

 

Today, an update and a well-done FAQ from WHO Europe.

 

 

EHEC outbreak: Update 6 (04-06-11)

04-06-2011

These are the current figures for the outbreak. Enterohaemorrhagic Escherichia coli (EHEC) and haemolytic uraemic syndrome (HUS) have exclusive notification categories, so case numbers should not overlap. The figures in any rapidly evolving outbreak are provisional, however, and subject to change for a variety of reasons.

• As of 02 June at 15:00 CET, Germany had reported 520 cases of HUS, including 11 fatalalities: 50 more than the previous day. 70% of the cases were in females and 89% in adults aged 20 years or older. 
• As of 02 June 15:00 CET, 1213 cases of EHEC infections (without HUS) had been reported in Germany, 6 of them fatal: 149 more than the previous day. Of those cases, 61% were in females, and 88% in adults aged 20 years or older. Case onset dates for EHEC ranged from 1 to 30 May.
• As of 03 June 18:00 CET, 11 other European countries (see table) had reported a total of 31 HUS (1 fatal) and 70 EHEC cases (0 fatal). 

• In addition, the Centers for Disease Control and Prevention (CDC) in Atlanta, United States of America had previously  published information on two cases of HUS in the United States that were linked to this outbreak.  
• All but 1 of the above HUS and EHEC patients had travelled to or from Germany during the incubation period for infection, typically 3–4 days after exposure (range 2–10 days). An increasing number of cases is laboratory confirmed as EHEC serotype O104:H4.

Since various agencies and news organizations around the world have elected to use different terminology to describe this outbreak, following this story can sometimes be a bit confusing.

 

The World Health Organization has put together a good FAQ (Frequently Asked Questions) file on the outbreak, which may serve to clear up some of the confusion.

 

 

 

Frequently asked questions on the EHEC infection outbreak in Germany

Background

1. What are EHEC and HUS?

Enterohaemorrhagic Escherichia coli (EHEC) is a human pathogenic E. coli bacterium that is able to cause haemorrhagic colitis (bloody diarrhoea), which sometimes develops into haemolytic uraemic syndrome (HUS). HUS is a life-threatening disease that causes kidney damage and is a severe complication of EHEC infection. EHEC is so-called Shigatoxin-producing E. coli (STEC), also known as verocytotoxin-producing E. coli (VTEC). Animals can carry other types of STEC/VTEC in their intestines that are not necessarily pathogenic for humans.

2. Surely E. coli is very common, so why the concern?

Yes, E. coli is a common bacterium that is found in the intestines of humans and warm-blooded animals. Nevertheless, this particular strain, a rare serotype of EHEC (namely E. coli O104:H4), is severe, and has caused much illness and some deaths in Germany. Cases have also occurred in 11 other countries, all of whom had travel links to, or residence in, Germany, except for one case still under investigation. This is a significant outbreak of HUS. It is affecting mostly women and mostly people over 20 years of age, which is unusual. As the source of the outbreak has not been found, it is difficult to say how long it will last.

3. Is this unique?

The serotype of EHEC, O104:H4, isolated from cases in the EHEC infection outbreak in Germany, is a rare one, seen in humans before but never in an EHEC outbreak. This has been confirmed by the WHO Collaborating Centre for Reference and Research on Escherichia and Klebsiella, the Statens Serum Institut in Denmark. The molecular/genetic features of this pathogen are important in helping authorities to identify cases in other countries that could be associated with the outbreak in Germany and to identify the source of the outbreak. While epidemiological and laboratory investigations continue, the source of the outbreak still remains unknown.

4. How would you describe the EHEC outbreak currently happening in Germany?

Germany is experiencing a significant outbreak of EHEC, a highly pathogenic bacterium subgroup of STEC. A minority of cases are presenting complications with HUS, a life-threatening disease characterized by acute kidney failure (uraemia), haemolytic anaemia, and a low platelet count (thrombocytopenia).

5. When was the last EHEC outbreak?

Every year there are EHEC outbreaks in different parts of the world including Europe, sometimes involving HUS and even deaths, but the number of affected people is very much lower than what Germany is now experiencing. In 1996, the world’s biggest recorded outbreak was registered in Japan and included over 10 000 infected cases.

6. How many countries are involved in the current outbreak?

Cases have now been notified from 11 countries in addition to Germany: Austria, the Czech Republic, Denmark, France, the Netherlands, Norway, Spain, Sweden, Switzerland, the United Kingdom and the United States of America. These are typically people who have recently visited northern Germany or, in one case, had contact with a visitor from northern Germany who was an EHEC case.

7. Do people outside Germany need to worry?

Most of the cases are linked to the northern part of Germany, and investigations are taking place to define the exact geographical areas where transmission is occurring. There is no indication so far of confirmed domestic or secondary infection in other countries.