May 2011

The current EHEC O104:H4, causing a severe outbreak in Germany (May 2011), is microbiologically characterized as follows (1) (27.5.2011; updated 30.5.2011):

Shigatoxin 1: – (negative), Shigatoxin 2 (vtx2a): + (positive), Intimin (eae): – (negative), Enterohemolysin: – (negative)

EaggEC Virulence plasmid:  –   aatA-PCR: + (positive),  –   aggR-PCR: + (positive),  –   aap-PCR: + (positive)

MLST Sequence Type:  ST678 (adk 6, fumC6, gyrB 5, icd 136, mdh 9, purA 7, recA 7). (**)

(**) MLST: kindly provided by Prof. Dr. H. Karch; Konsiliarlaboratorium für Hämolytisch-Urämisches Syndrom (HUS) Institut für Hygiene am Universitätsklinikum Münster Robert-Koch-Str. 41, 48149 Münster

Ampicillin  R

Amoxicillin/Clavulanic acid  R

Piperacillin/Sulbactam  R

Piperacillin/Tazobactam  R*

Cefuroxim  R

Cefuroxim-Axetil  R

Cefoxitin  R

Cefotaxim  R

Cetfazidim  R

Cefpodoxim  R

Imipenem  S

Meropenem  S

Amikacin  S

Gentamicin  S

Kanamycin  S

Tobramycin  S

Streptomycin  R

Nalidixinsäure  R

Ciprofloxacin  S

Norfloxacin  S

Tetracyclin  R

Nitrofurantoin  S

Trimethoprim/Sulfamethoxazol  R

Chloramphenicol  S

Fosfomycin  S

* defined as resistent (AES VITEK)

ESBL: + (CTX-M (Group 1), Other ß-Lactamases: TEM-Type +

Macrorestriction pattern (XbaI) from human E. coli O104:H4 isolates from the current outbreak

Screen shot 2011-05-31 at 8.23.05 PM.png

PFGE according to Prager et al. (2011) IJMM 301:181-191.

Lanes 1 and 5 MW-Standard Salmonella Braenderup H9812. Lane 2: RKI-11-02027 (HUS), Lane 3: RKI-11-02034 (diarrhea), Lane 4: RKI-11-02060 (bloody diarrhea).

1) Source: Nationales Referenzzentrum für Salmonellen und andere bakterielle Enteritiserreger; Robert Koch-Institut; Abteilung 1 Infektionskrankheiten

A well-done and comprehensive article on Der Spiegel online by Veronika Hackenbroch, Samiha Shafy and Frank Thadeusz confirmed a few things but also raised more questions.

By the numbers: This E. coli O104:H4 outbreak is the third largest that I have found (behind Japan’ E. coli O157:H7 outbreak in 1996 and Canada’s E. coli O157:H7 outbreak in 2000). To date, 1,200 are reported ill in Germany, Sweden, Denmark, Britain, Austria and the Netherlands. There have been others reported ill with E. coli infections in both Switzerland and Spain, but as yet not confirmed as part of this larger outbreak. Two U.S. residents who recently traveled in northern Germany appear to be among victims of a massive outbreak, federal health officials confirmed Tuesday.  373 have been confirmed with acute kidney failure (hemolytic uremic syndrome) and there are 16 deaths. Nearly 70% of those sickened have been women. The numbers in this tragedy seem clear, the cause, perhaps less so.

Arion_vulgaris_Orth.jpgEarlier reports from Germany officials linked the outbreak to Spanish cucumbers after the lab at the Hamburg Institute for Hygiene and Environment found “four positive results … on three cucumbers from Spain and one from somewhere else, possibly the Netherlands … Two of the cucumbers were organic … [However, the lab] isn’t sure about the other ones yet.”

Then today Hamburg’s health minister announce that “Spanish cucumbers were probably not the source … [as] the bacteria on two of the four cucumbers did not match” the bacteria in stools of ill patients. However, warnings against eating cucumbers, tomatoes and lettuce have not been lifted.

Speculation has also arisen as to the original method of contamination (assuming it is cucumbers, tomatoes and/or lettuce). Liquid manure, water contamination have been discussed. However, apparently now the lowly slug is being fingered, albeit the Spanish slug, Arion vulgaris.

Whatever the source, this bug is nasty. Mr. E. coli in Germany, Dr. Helge Karch, reported that “the O104:H4 bacteria responsible for the current outbreak are a so-called “chimers” that contains genetic material from various E. coli bacteria. It also contains DNA sequences from plague bacteria which makes it particularly pathogenic.”

I can only imagine what is happening in hospitals throughout Europe (and now in the U.S.). The health and agricultural ministries from the various countries involved are talking past each other and shifting blame when they can. There clearly seems to be some confusion as to the vector of the outbreak, but there should be no confusion that public health comes first.

According to UAE News Reports, the Dubai Court of Appeal stiffened the sentence against the doctor, restaurant cook and supervisor and the restaurant, all of whom were convicted guilty for causing the death of D’Souza’s two children. Five-year-old Nathan D’Souza and his seven-year-old sister, Chelsea, died of food poisoning in 2009. The Appeal Court increased the blood money to Dh400,000 to be paid jointly and stiffened the fine to Dh20,000 to be paid by each convict. According to the arraignment sheet, prosecutors said the cook and the supervisor were charged with violating public health requirements of Dubai Municipality through unhygienic practices in preserving food, which led to bacterial contamination. The doctor was charged with negligence in providing medical care to the children.

In China CNN Reports that China’s highest court has ordered judges nationwide to hand down harsher sentences, including the death penalty, to people convicted of violating food safety regulations. In a directive released by the state-run Xinhua news agency over the weekend, the Supreme People’s Court said in cases where people die from food safety violations, convicted suspects should be given the death sentence, while criminals involved in non-lethal cases should face longer prison terms and larger fines.

The German/European E. coli outbreak death toll is now 16.  And, people in the U.S. do not like trial lawyers and juries.

spaine. coli.jpgVeronika Oleksyn of the Associated Press reports from Germany that the E. coli O104 outbreak has taken its 11th victim. This time a 91-year-old woman (nine of ten deaths are women) from Germany. The number of people contaminated or suspected of having been poisoned has reached 1,200, according to other media reports. The Robert Koch Institute (RKI), Germany’s national disease institute, reported 329 HUS cases in Germany alone. Sweden, Switzerland, Denmark, the United Kingdom and the Netherlands also have reported illness in people who recently visited Germany.

Spanish vegetables, specifically cucumbers, have been suspected as the cause of the outbreak. German officials said even though they know that Spanish cucumbers tainted with E. coli O104 have carried the bacteria, they still have not been able to determine the exact source. “We have found the so-called EHEC pathogens (E. coli O104) on cucumbers, but that does not mean that they are responsible for the whole outbreak,” Andreas Hensel, president of Germany’s Federal Institute for Risk Assessment, said on ZDF television.

Spain, meanwhile, went on the defensive, saying there was no proof that the E. coli outbreak has been caused by Spanish vegetables. “You can’t attribute the origin of this sickness to Spain,” Lopez Garrido told reporters in Brussels. “There is no proof and that’s why we are going to demand accountability from those who have blamed Spain for this matter.”

Let the finger pointing begin as people struggle for their lives and bury the dead.

img_606X341_2605-Deutschlande-Ecoli-Cucumbers-From-Spain.jpgThank goodness for Outbreak Database (www.outbreakdatabase.com) to see the history of bad cucumbers:

European Outbreak Organic Spanish Cucumbers 2011

Assi Market Pickles 2010

Outbreak Associated with Microsporidia, Sweden October 2009

Michigan Banquet Facility Green Salad and Cucumber 2008

Taste of Chicago Pars Cove Booth Hummus Shrazi 2007

Minnesota Banquet Facility Cucumber Salad 2006

Gate Gourmet Salad Vegetables 2004

Screen shot 2011-05-29 at 8.56.31 PM.png

ChicksDucks.JPGCDC is collaborating with public health and agriculture officials in many states and the U.S. Department of Agriculture’s (USDA) National Poultry Improvement Plan (NPIP) to investigate a multistate outbreak of human Salmonella serotype Altona infections. As of May 25, 2011, a total of 25 individuals infected with the outbreak strain of Salmonella Altona have been reported from 11 states. The number of ill persons identified in each state is as follows: Indiana (1), Kentucky (3), Maryland (2), Minnesota (1), North Carolina (4), New York (1), Ohio (7), Pennsylvania (2), Tennessee (2), Virginia (1), and Vermont (1).

Investigators are using the PulseNet system to identify cases of illness that may be part of this outbreak. In PulseNet, the national network of public health and food regulatory agency laboratories coordinated by CDC, DNA is analyzed from bacteria obtained through diagnostic testing of ill people. Findings of multiple traceback investigations of live chicks and ducklings from homes of ill persons have identified a single mail-order hatchery as the source of these chicks and ducklings.

A month ago 90 people fell ill with E. coli O111 after eating raw beef at eateries near Tokyo and on Honshu Island. 23 suffered hemolytic uremic syndrome (HUS) and four died.

We have seen that strain in the United States before. 341 people became ill with E. coli O111:NM during an outbreak traced to Country Cottage Restaurant. Seventy people were hospitalized, 17 with HUS, and one person died as a result of the E. coli infection in what is believed to be the largest community outbreak of diarrheal illness and HUS attributable to E. coli O111:NM ever reported. No specific tainted food item was identified. So, the fresh vegetable industry and the beef industry can say that such an outbreak has not been linked to them – yet!

Screen shot 2011-05-28 at 3.53.57 PM.pngNow throughout Europe (Germany, Britain, Sweden, Denmark, Netherlands, France and Switzerland), 1,000 have been sickened, 300 have developed HUS and 10 have died as a result of E. coli O104:H4 (E. coli O104, stx2 positive and eae negative) – tainted cucumbers from Spain.

We have seen E. coli O104 in the United States before. In 1994 milk from a Montana dairy was implicated in an outbreak of E. coli O104:H21. We have also found it in the testing of retail ground beef that I funded in 2008-2009. In fact, we found an O104:H7, stx2 positive, eae negative, subtilase positive E. coli (see picture above and PowerPoint Presentation). So, the fresh vegetable industry can say E. coli O104 has not been linked to them – yet! The beef industry can say that such an outbreak has not been linked to them – yet, but we certainly found it in a place (hamburger) that it should not be in.

Mr. President, Secretary Vilsack, Secretary Sibelius, FDA, FSIS, what are we doing to avoid a Japanese or European outbreak of E. coli O111 or E. coli O104?

With 1,000 sickened, 300 with Hemolytic Uremic Syndrome and nine deaths, the ongoing E. coli outbreak in Germany (and several other European Countries) will be quickly joining the list of the most severe outbreaks in history. Here is the list since I began litigating E. coli cases in 1993 as of today

  • 12,680 sickened in 1996 in Sakai, Japan from radish sprouts. Fukushima H, Hashizume T, Morita Y, Tanaka J, Azuma K, Mizumoto Y, Kaneno M, Matsuura MO, Konma K, and Kitani T. 1999. Clinical experiences in Sakai City Hospital during the massive outbreak of enterohemorrhagic Escherichia coli O157 infections in Sakai City, 1996. Pediatr Int 41:213–217.
  • 2,300 sickened in 2000 in Walkerton, Canada from drinking water. Hrudey SE, Payment P, Huck PM, Gillham RW, and Hrudey EJ. 2003. A fatal waterborne disease epidemic in Walkerton, Ontario: comparison with other waterborne outbreaks in the developed world. Water Sci Technol 47:7–14.
  • 1,000 sickened in 1999 in New York, USA from well water. Charatan F. 1999. New York outbreak of E. coli poisoning affects 1000 and kills two. Brit Med J 319:873.
  • 788 sickened in 2000 in Wisconsin, USA from raw beef, cross contamination of other foods (Sizzler). Archer, John (personal communication). Epidemiologist, Wisconsin Division of Public Health, Bureau of Communicable Diseases and Preparedness, Communicable Disease Epidemiology Section. http://dhfs.wisconsin.gov/communicable/Communicable/Contacts.htm
  • 700 sickened in 1992–93 in Western USA from hamburger at fast food restaurant (Jack in the Box). Bell BP, Goldoft M, Griffin PM, Davis MA, Gordon DC, Tarr PI, Bartleson CA, Lewis JH, Barrett TJ, Wells JG, and et al. 1994. A multistate outbreak of Escherichia coli O157:H7 associated bloody diarrhea and hemolytic uremic syndrome from hamburgers. The Washington experience. J Am Med Assoc 272:1349–1353.
  • 633 sickened in 1995 in Fife, Scotland from sewage contamination of drinking water. IG and Roworth M. 1996. An outbreak of Escherichia coli O157 and campylobacteriosis associated with contamination of a drinking water supply. Public Health 110:277–282.
  • 512 sickened in 1996–97 in Scotland from meat from one shop. Cowden JM, Ahmed S, Donaghy M, and Riley A. 2001. Epidemiological investigation of the Central Scotland outbreak of Escherichia coli O157 infection, November to December 1996. Epidemiol Infect 126:335–341.
  • 503 sickened in 1996 in Scotland from lunch foods. Pennington H. 1998. Factors involved in recent outbreaks of Escherichia coli O157:H7 in Scotland and recommendations for its control. J Food Safety 18:383–391.
  • 332 sickened in 1997 in UK from restaurant food. Anonymous. 1997. Escherichia coli O157 outbreak in Lincolnshire. CDR Weekly 7:101.

Thanks to Human Illness Caused by E. coli O157:H7 from Food and Non-food Sources.  M. Ellin Doyle, John Archer, Charles W. Kaspar, and Ronald Weiss.