Re: Europe - 36 dead, 3500+ infected, 800+ severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

[Tonka]

http://www.svd.se/nyheter/inrikes/ehec-kalla-kanske-aldrig-upptacks_6216875.svd

Swedish to English translation

Lettuce source may never be discovered

snip

So far, 18 people died of EHEC infection was the one in Sweden. Scientists can not find the source of infection, and now there is talk of a mutant more aggressive form of the bacterium.
June 3, 2011, at 11:45, Updated: June 3, 2011 at 13:45

[Tonka]

International Case Count - 19 dead, 2000+ infected, 500 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Source: ProMed

http://www.promedmail.org/pls/otn/f?p=2400%3A1001%3A4103571266040841%3A%3ANO%3A%3AF2400_P1001_BACK_PAGE%2CF2400_P1001_PUB_MAIL_ID%3A1000%2C88725

Archive Number 20110603.1692
Published Date 03-JUN-2011
Subject PRO/AH/EDR> E. coli O104 - EU (08) & USA: genetic analysis, more cases
E. COLI O104 - EUROPEAN UNION (08) & USA: GENETIC ANALYSIS, MORE CASES
************************************************** ********************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this posting:
[1] EU report
[2] WHO report
[3] Science Journal: commentary on the organism
[4] Nature Journal: commentary on the organism
[5] Norway (suspected)
[6] Denmark
[7] USA

******
[1] EU report
Date: Thu 2 Jun 2011
Source: Eurosurveillance edition 2011; 16(22) [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19883>


Update on the ongoing outbreak of haemolytic uraemic syndrome due to
Shiga toxin-producing _Escherichia coli_ (STEC) serotype O104,
Germany, May 2011
--------------------------------------------------------------------
[Authors: Askar M, Faber MS, Frank C, et al]

Since early May 2011, a large outbreak of hemolytic uremic syndrome
(HUS) and bloody diarrhea related to infections with Shiga
toxin-producing _E. coli_ (STEC) has been observed in Germany. The
outbreak is focused in the north, but cases have been reported from
all German states and other countries. Since our report last week [26
May 2011], the number of HUS cases has increased to 470 [in Germany]
and STEC serotype O104 has been confirmed in many cases.

Description of the ongoing outbreak
-----------------------------------
Since the beginning of May 2011, 470 cases of hemolytic uremic
syndrome HUS have been notified to the Robert Koch Institute (RKI).
Our initial findings have been presented (1), including background
information on STEC infections and HUS. The clinical and laboratory
case definitions used are available (2). Here we give an update on the
epidemiological characteristics of the outbreak concerning cases of
STEC and HUS notified to the Robert Koch Institute as of 31 May 2011.

Of 470 HUS cases, 273 (58 percent) were clinical cases with
laboratory confirmation of Shiga toxin-producing _E. coli_ (STEC)
infection. The German National Reference Centre for _Salmonella_ and
other Bacterial Enteric Pathogens alone has detected STEC serotype
O104, Shiga toxin 2 (stx2)-positive, intimin (eae)-negative in more
than 60 samples from cases in the outbreak, indicating that this
unusual serotype is the cause of the outbreak.

Geographical distribution of HUS cases
--------------------------------------
Cases of HUS have been notified from all German Federal states. The
highest cumulative incidence of HUS, since 1 May 2011, continues to be
observed in the 5 northern states: Hamburg, Schleswig-Holstein,
Bremen, Mecklenburg-Vorpommern, and Lower Saxony [for table, see
source URL above. - Mod.LL]. A total of 66 percent of HUS cases have
been notified from these states.

Epidemiological development
---------------------------
From 1 to 8 May 2011, the number of new HUS cases was between 1 and 2
cases per day, based on the date of onset of diarrhea (Figure 1) [see
source URL]. From 9 May 2011, we observed an initially steady increase
in the number of cases. This increase gained in intensity over the
following days and reached a maximum of 39 notified HUS cases on 16
May 2011.

Age and sex distribution of HUS cases
-------------------------------------
As reported on 26 May 2011 (1), the age and sex distribution of HUS
cases remain conspicuous: the majority of patients were aged 20 years
or older (88 percent) and female (71 percent). Notably, between 2006
and 2010, the proportion of adults in reported STEC and HUS cases was
only between 1.5 percent and 10 percent, and there were no marked
differences in sex distribution [3]. Figure 2 [see source URL] shows
the age- and sex-specific cumulative incidence of notified cases of
HUS since 1 May 2011.

Fatal cases
-----------
To date, 13 deaths have been notified [now 18 - Mod.LL]: in 9 cases,
the deaths were in connection with HUS; in the remainder, the cases
had had symptomatic STEC infection that was laboratory confirmed. The
cases who died were between 22 and 91 years of age: 5 were aged
between 22 and 40 years and 8 between 75 and 91 years of age.

Foreign cases with connection to the present outbreak
-----------------------------------------------------
Further HUS cases have been communicated from Denmark, UK, France,
Netherlands, Norway, Austria, Spain, Sweden (including 1 death),
Switzerland and the USA. Nearly all of these cases had a travel
history to northern Germany. For some cases, however, detailed
investigations are ongoing. After a stay in northern Germany between 8
and 10 May 2011, 15 members of a Swedish travel group (30 members in
total) developed symptoms of STEC infection and HUS was diagnosed in 5
of these cases.

Evaluation of the situation
---------------------------
The present situation marks one of the largest outbreaks ever
described of HUS worldwide, and the largest outbreak ever reported in
Germany. Because of the delay in notification and reporting of cases,
the current notification data cannot be interpreted as a decrease in
case numbers.

The age and sex distribution of cases in this outbreak is highly
unusual, as is the identified outbreak strain: STEC O104, Shiga toxin
2 (stx2)-positive, intimin (eae)-negative. Serotype STEC O104 has
caused foodborne outbreaks of diarrhea and HUS, or isolated cases of
HUS before (4,5), but is not known to have caused previous outbreaks
in Germany.

Current epidemiological activities
----------------------------------
RKI is currently conducting the following studies to further
investigate the outbreak:

- representative online survey within the German population to
describe the disease burden;
- case/control study in heavily affected hospitals, in Lubeck (in
Schleswig-Holstein) and Hamburg;
- case/control study in hospitals that have observed a recent
increase in cases numbers and had not been previously affected;
- analyses of questionnaires on cases completed by nephrologists
treating the cases;
- investigation of human-to-human transmission (and of information
about purchases made by analysis of till receipts) within the setting
of a special outbreak in a canteen;
- cohort investigations of various groups, in which several members
developed symptoms of STEC infection after dinner in a restaurant (the
members of the groups are questioned about the food products they
consumed);
- exploration of several events and festivities that can be related
to cases.

Furthermore, the RKI is cooperating with colleagues from Sweden and
Denmark, who are performing cohort studies of groups in which several
members developed symptoms of STEC infection.

The Federal Institute for Risk Assessment (BfR) has recommended that
consumers in Germany abstain from eating raw tomatoes, cucumbers, and
leafy salads -- based on results from an epidemiological study,
conducted by the RKI in cooperation with regional and local health
departments from Hamburg (1). As long as the studies outlined above do
not lead to new evidence and as long as the outbreak is still ongoing,
these recommendations concerning goods available in northern Germany
in particular remain in effect.

References
----------
1. Frank C, Faber MS, Askar M, et al: Large and ongoing outbreak of
haemolytic uraemic syndrome, Germany, May 2011. Euro Surveill. 2011;
16(21): pii=19878. Available from
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19878>.
2. Robert Koch Institute (RKI): Case definition for HUS-cases
associated with the outbreak in the spring 2011 in Germany. Available
from
<http://www.rki.de/cln_116/nn_217400/EN/Home/HUS__Case__definition,templateId=raw,property=publ icationFile.pdf/HUS_Case_definition.pdf>.
3. Robert Koch Institute (RKI). SurvStat@RKI. Berlin: RKI. [Accessed
24 May 2011]. German. Available from <http://www3.rki.de/SurvStat>.
4. Bae WK, Lee YK. Cho MS, et al: A case of hemolytic uremic syndrome
caused by _Escherichia coli_ O104:H4. Yonsei Med J. 2006; 47(3):
437-9. [Available from
<http://www.eymj.org/Synapse/Data/PDFData/0069YMJ/ymj-47-437.pdf>].
5. CDC: Outbreak of acute gastroenteritis attributable to
_Escherichia coli_ serotype O104:H21 -- Helena, Montana, 1994. MMWR
Morb Mortal Wkly Rep. 1995; 44(27): 501-3. [Available from
<http://www.cdc.gov/mmwr/preview/mmwrhtml/00038146.htm>].

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[This is the latest report from Eurosurveillance, which covers data
through 31 May 2011. It does not cover issues relating to the genetic
analysis of the organism, which are reported below. - Mod.LL]

******
[2] WHO report
Date: Thu 2 Jun 2011
Source: WHO Outbreak Reports [edited]
<http://www.who.int/csr/don/2011_06_02/en/index.html>


***Overall in Europe, 499 cases of HUS and 1115 cases of EHEC have
been reported, 1614 in total. Cases have now also been notified from:
Austria (HUS 0, EHEC 2), Denmark (7, 7), France (0, 6), Netherlands
(4, 4), Norway (0, 1), Spain (1, 0), Sweden (15, 28), Switzerland (0,
2), and the United Kingdom (2, 1). All these cases except 2 are in
people who had recently visited northern Germany or in 1 case, had
contact with a visitor from northern Germany.***
[Plus 3 suspected cases imported from Germany to the USA -- see [7]
below].


EHEC outbreak: increase in cases in Germany
-------------------------------------------
Cases of hemolytic uremic syndrome (HUS) and enterohemorrhagic _E.
coli_ (EHEC) continue to rise in Germany. 10 countries have now
reported cases to WHO/Europe.

As of 31 May 2011, 9 patients in Germany have died of HUS, and 6 of
EHEC. 1 person in Sweden has also died. There are many hospitalized
patients, several of them requiring intensive care, including
dialysis. The number of patients in Germany presenting with HUS and
bloody diarrhea caused by STEC is 470, which is 97 more than the day
before, and 1064 of EHEC, which is an increase of 268.

Overall in Europe, 499 cases of HUS and 1115 cases of EHEC have been
reported, 1614 in total.

Cases have now also been notified from: Austria (HUS 0, EHEC 2),
Denmark (7, 7), France (0, 6), Netherlands (4, 4), Norway (0, 1),
Spain (1, 0), Sweden (15, 28), Switzerland (0, 2), and the United
Kingdom (2, 1). All these cases except 2 are in people who had
recently visited northern Germany or in 1 case, had contact with a
visitor from northern Germany.

Numerous investigations are continuing into the cause of the
outbreak, which is still unclear.

In accordance with the International Health Regulations (IHR), WHO is
keeping Member States informed about the latest developments and
providing technical guidance on further investigation of the ongoing
outbreak.

WHO does not recommend any trade restrictions related to this
outbreak.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[3] Science Journal: commentary on the organism
Date: Thu 2 Jun 2011
Source: Science Insider, American Association for the Advancement of
Science (AAAS) [edited]
<http://news.sciencemag.org/scienceinsider/2011/06/sequence-yields-clues-to-germany.html?ref=hp>


DNA sequence yields clues to Germany's 'super toxic' _E. coli_
outbreak
-----------------------------------------------------------------------
[Author: M Enserink]

Just from the high number of deaths and severe cases, scientists and
public health experts battling Germany's massive _E. coli_ [O104:H4]
outbreak knew they were up against something unusual. Now, early
results from sequencing projects of the enterohemorrhagic _E. coli_
(EHEC) strain appear to confirm that a never-before-seen hybrid,
combining the worst of several bacterial strains, is causing the
havoc.

The Beijing Genomics Institute (BGI), in Shenzhen, China, which
today, 2 Jun 2011, announced that it has sequenced the microbe's
entire 5.2-million-base-pair genome says that its acquisition of
several virulence genes make this EHEC strain "super toxic."

The outbreak, which has caused mayhem in European trade relations, is
still growing; so far, more than 16 patients have died. The origin of
the microbe remains a riddle; cucumbers from Spain, originally
fingered as the potential source, were acquitted on Tue 1 Jun 2011,
and have not been replaced by other suspects. All researchers know is
that raw vegetables are the most likely carrier.

Scientific results announced in 2 press releases, both also intended
to tout the extraordinary speed of today's sequencing technology,
suggest that within the microbe's DNA lie clues to its aggressive
nature.

The 2nd came from Life Technologies Corporation, which manufactures
so-called 3rd-generation sequencing machines. Today, 2 Jun 2011, the
company announced that sequencing at its lab in Darmstadt, Germany, in
collaboration with the nearby University of Munster, "strongly
suggests that the bacterium is a new hybrid type of pathogenic _E.
coli_ strains." Spokespeople for the company in the USA and Germany
could not provide details. "Further analyses on Ion PGMT", the
company's flagship sequencing machine, "will confirm [the] data," the
press release promised.

BGI, meanwhile, says that the microbe's genome, which it says took
just 3 days to sequence, also using Life Technologies equipment
reveals that it shares 93 percent of its sequence with EAEC 55989 _E.
coli_, a strain isolated in the Central African Republic and known to
cause serious diarrhea. It appears to have acquired several genes that
make it more pathogenic, however, probably in a process called
horizontal gene transfer, by which microbes exchange bits of genetic
information.

In an e-mail to ScienceInsider, Yang Bicheng, director of BGI's
marketing department, wrote that one gene fragment appears to have
come from another foodborne pathogen, _Salmonella enterica_, while
other genes are highly homologous to those found in other,
phylogenetically distinct _E. coli_ strains, including a strain called
O25:H4-ST131.

BGI, which has made the sequence available for researchers to
download, says the analysis also confirmed that the microbe is
resistant to many antibiotics. These include aminoglycosides, the
macrolides, and the beta-lactams "all of which makes antibiotic
treatment extremely difficult," according to the press release.
However, German EHEC patients aren't treated with antibiotics; most
scientists believe they make matters worse, because killing EHEC
results in the release of more toxin.

Yang acknowledged that finding the resistance genes may not be
clinically relevant, but says they may help understand how the strain
arose. "The evolutionary process of this very strange hybrid strain
may be a very interesting scientific story," Yang wrote in his
e-mail.

Microbial genomicist Frederick Blattner of the University of
Wisconsin, Madison who worked for almost 15 years to sequence the 1st
_E. coli_ strain and finished in 1997 says the results have to be
considered preliminary; it's not clear whether BGI assembled the
entire genome from its sequenced pieces, he notes, and usually in such
efforts, a number of stretches need to be resequenced. Still, "they
did this at an amazing speed, and it looks like they found some very
intriguing information," Blattner says.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[This commentary primarily regarding the genetic analysis of the
outbreak organism outlines the unique nature of the pathogen. It is
indeed tempting to speculate on its origin. It is most likely a
'laboratory experiment' under the direction of clearly the world's
most successful bioterrorist, Mother Nature. ProMED-mail awaits more
information about the genetic analyses. - Mod.LL]

******
[4] Nature Journal: commentary on the organism
Date: Thu 2 Jun 2011
Source: Nature News [edited]
<http://www.nature.com/news/2011/110602/full/news.2011.345.html>


German _E. coli_ outbreak caused by previously unknown strain
-------------------------------------------------------------
[Author: M Turner]

The bacterium responsible for the current outbreak of
enterohemorrhagic _E. coli_ (EHEC) infections in Germany is a strain
that has never before been isolated in humans. The discovery,
announced today [2 Jun 2011] by the food safety office of the WHO in
Geneva, Switzerland, means that the infection could prove unusually
difficult to bring under control.

Scientists in Germany are feverishly analysing the genome sequence of
the bacterium, and have found clues as to how this strain, which has
so far infected more than 1500 people and killed 18, is making so many
people ill.

The bacterium is relatively unusual in that it produces
extended-spectrum beta-lactamase enzymes that render the bacteria
resistant to many different antibiotics. Patients with EHEC infections
are not typically treated with antibiotics anyway, because the
bacteria are thought to respond to the medication by increasing
production of the Shiga toxin, which can lead to the life-threatening
complication hemolytic-uremic syndrome (HUS). But antibiotic
resistance might have helped the bacteria to survive and persist in
the environment.

"EHEC outbreaks usually only last around 2 weeks, but this outbreak
has been going on since 1 May 2011 or earlier," says Angelika Fruth, a
microbiologist based in Wernigerode who works for the Robert Koch
Institute, the federal agency responsible for disease control. The
number of new cases is still rising, suggesting that whatever their
source, the bacteria are still infecting people.

Fresh vegetables are still the prime suspect, but Flemming Scheutz,
head of the WHO Collaborative Centre for Reference and Research on
_Escherichia_ and _Klebsiella_ in Copenhagen, suggests that the
bacteria might not have originated in the food chain at all. "This
strain has never been found in any animal, so it is possible that it
could have come from straight from the environment into humans."

Lothar Wieler, a veterinary microbiologist at the Free University of
Berlin, cautiously agrees with this theory. In addition to the
antibiotic-resistance genes, the bacteria contain a gene for
resistance to the mineral tellurite (tellurium dioxide).

Tellurium oxides were used as antimicrobial agents against diseases
such as leprosy and tuberculosis before the development of
antibiotics. Some strains of bacteria may have evolved resistance to
tellurium during its historical medical use, or after its use in the
mining and electronics industries increased its presence in the
environment. According to Wieler, the strain's resistance
characteristics could point towards an environmental source, such as
water or soil.

The ongoing genetic characterization of the strain might also reveal
why the bacterium is mostly infecting adults, and women in particular.
EHEC infections usually occur in children, and affect boys and girls
equally. Initial theories suggested that young adult women are the
people most likely to purchase, handle, and consume salad vegetables.
"This is still our only explanation for this demographic," says
Wieler. But he suspects that the strain might have biological
characteristics that make adults more susceptible to the infection.

A telltale sign is that the strain does not contain the eae gene,
which codes for a protein called intimin, an adhesion protein that
allows the bacteria to attach to cells in the gut. Eae-negative EHEC
have been specifically associated with adult infections before,
although it is still unclear why this particular protein is more
effective in adult guts than in those of children.

Gad Frankel, a microbiologist at Imperial College London, suspects
that the genome of this strain will reveal more information about the
adherence mechanisms of _E. coli_. "Some pathogenic bacteria don't
just stick to cells in our guts, they also have active adherence
mechanisms to stick to some vegetables," says Frankel.

It is possible that the strain has evolved a combination of adhesion
proteins that makes it particularly hard to remove from food, or for
the human body to eliminate. "This outbreak has shown we need to be
prepared to deal with emerging strains with properties that give them
enhanced virulence," says Frankel.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[5] Norway (suspected)
Date: Tue 31 May 2011
Source: Health Canal [edited]
<http://www.healthcanal.com/infections/17562-Patient-Norway-with-possible-connection-EHEC-outbreak-Germany.html>


The Norwegian Institute of Public Health has been notified of a case
of EHEC infection with a possible connection to the current outbreak
in Germany.

The patient is a man in his 40s who was admitted to Sorlandet
Hospital in Kristiansand with bloody diarrhea. It is not yet known if
the bacterial strain is the same as that which is involved in the
German outbreak.

Local health authorities and the Food Safety Authority are following
up the case in co-operation with the Norwegian Institute of Public
Health, and are working to identify the source of infection. The
number of confirmed cases in Europe is increasing so it would be
unsurprising if more cases arise in Norway.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[6] Denmark
Date: Tue 31 May 2011
Source: Crienglish.com, Xinhua News Agency report [edited]
<http://english.cri.cn/6966/2011/05/31/189s640241.htm>


The number of confirmed _E. coli_ [O104] cases has risen to 14 in
Denmark, with at least 26 others suspected of having the intestinal
infection, the National Serum Institute said Mon 30 May 2011; 7 of the
confirmed cases show symptoms of kidney failure, which marks an
advanced stage of the sickness, the institute said.

"Almost all of the 14 infected people have been in northern Germany
recently except just one. There is a 24-year-old man from Jutland, he
has not even been to Germany, so he does not quite fit with the rest
of the pattern," said Kaare Moelbak, chief physician at the institute.
"We do not know yet how he has been so unlucky to get this infection
but we assume that it has been a person-to-person transmission, or
that he has eaten infected vegetables," he added.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[This reports a single case which was not clearly related to travel
to Germany. It is not clearly stated that this case was shown to be
O104, or has been in contact with anyone who was in Germany recently.
- Mod.LL/JW]

******
[7] USA
Date: Thu 2 Jun 2011
Source: msnbc.com [edited]
<http://www.msnbc.msn.com/id/43256788/ns/health-food_safety/>


A 3rd USA resident who recently traveled to Germany has been
hospitalized with an infection that may be linked to the killer
bacterium in Europe, officials from the CDC said Thu 2 Jun 2011.

That person joins 2 other travelers, including someone from
Massachusetts, who are being tested to determine whether they are
victims of a massive food poisoning outbreak that has killed 18
people, sickened more than 1600, and spread to at least 10 European
countries since early May 2011.

But even if they are infected, the USA travelers are unlikely to
spark a spreading outbreak at home, say food safety experts who urge
both common sense and caution.

"These humans aren't going to introduce this strain into the USA and
have it become a permanent, common resident," said Dr Timothy Jones,
an epidemiologist who serves on the FDA's Food Safety committee. The
bacterium can be spread by touch, but it's not like other foodborne
pathogens which can be highly contagious. Good hand hygiene and
careful food preparation can reduce risks.

"The only way it would sort of erupt or explode in this country is if
the original reservoir, whatever's holding it in nature, got infected
and spread it. Unless that happened, it wouldn't really lodge here,"
Jones said.

A spokeswoman for the Massachusetts Department of Public Health
confirmed that the state had reported a case of hemolytic uremic
syndrome, or HUS, a serious side effect of EHEC infection, in a
traveler who'd been to northern Germany. She declined to release
information about the patient's gender, hometown, or condition. No
information about the other 2 travelers, both of whom contracted HUS,
has been released.

USA residents have little to fear from produce imported from Europe
and there's no reason to stop eating fresh fruits and vegetables,
government officials said. The FDA has received no shipments of
tomatoes, cucumbers, or lettuce from countries associated with the
outbreak, said Siobhan DeLancey, an FDA spokeswoman. The USA imports
very little produce during this time of year, she added

[Byline: JoNel Aleccia]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Regarding the speculation in Nature in [4] above about a possible
non-animal origin, it could have evolved in the soil on some unlucky
horticultural farm with tellurite-rich soil, and got from there onto
the vegetable harvest. My bet is it's the lettuce, because cucumbers
& tomatoes easily wash clean -- but unless it is hydroponically
produced, lettuce is pulled up with soil-covered roots, and every cook
knows how difficult it is to wash leafy vegetables. I myself have
found a little slug tucked inside a lettuce that I had rinsed in a
colander under the tap; and who in a food service kitchen is going to
wash lettuce leaf by leaf? - Mod.JW.
]

[see also:
E. coli O104 - EU (07) & USA 20110601.1678
E. coli O104 - EU (06) & USA 20110531.1666
E. coli O104 - EU (05): (Germany) monoclonal antibody trial
20110529.1646
E. coli O104 - EU (04): (Germany) more deaths & HUS cases
20110528.1635
E. coli O104 - EU (03): (Germany, EU ex Germany) alert 20110527.1629
E. coli O104 - EU (02): (Germany, EU ex Germany), alert
20110527.1620
E. coli O104 - EU: (Germany, Denmark, Sweden) Spanish cucumbers
20110526.1611
E. coli VTEC - Germany (04): O104, poss. salad source 20110526.1600
E. coli VTEC - Germany (03): O104, spread South 20110525.1587
E. coli VTEC - Germany (02): increased case burden 20110524.1578
E. coli VTEC - Germany: RFI 20110523.1566
E. coli VTEC non-O157 - Japan: O111, raw beef, alert 20110504.1378
2010
----
E. coli VTEC non-O157 - USA (07): O26, ground beef, alert, recall
20100831.3097
E. coli VTEC non-O157 - USA (06): O145, lettuce 20100528.1777
E. coli VTEC non-O157 - USA (03): O145, lettuce, recall
20100507.1483
E. coli VTEC non-O157 - USA (02): (OH, MI, NY) O145 20100505.1460
E. coli VTEC non-O157 - USA: (MI, OH) 20100427.1358
2008
----
E. coli VTEC non-O157, restaurant - USA (04): (OK), O111
20081201.3779
E. coli VTEC non-O157, restaurant - USA: (OK), O111 20080902.2748
E. coli VTEC non-O157, past. ice cream, 2007 - Belgium: Antwerp
20080218.0655
2007
----
E. coli VTEC non-O157, beef sausage - Denmark 20070602.1784
E. coli VTEC non-O157, 2000-2005 - USA (CT) 20070118.0240
2006
----
E. coli VTEC non-O157, lettuce - USA (UT)(02): background
20060905.2523
E. coli VTEC non-O157, lettuce - USA (UT) 20060904.2521
E. coli VTEC non-O157 - Norway (03) 20060416.1133
E. coli VTEC non-O157 - Norway 20060329.0947
E. coli VTEC non-O157, minced beef - Norway 20060304.0680
2005
----
E. coli O145, fatal - Slovenia 20050916.2739
2003
----
E. coli, VTEC non-O157 - UK (Scotland): correction 20030828.2166
E. coli, VTEC non-O157 - UK (Scotland) 20030825.2144
2001
----
E. coli O26 - South Korea 20010509.0896
1999
----
E. coli O111, diarrhea - USA (Texas) 19990707.1134
1997
----
E. coli, non-0157 - Belgium 19970610.1215]
.................................................s b/ll/mj/jw
*################################################# #########*
************************************************** **********
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************** **********
Donate to ProMED-mail. Details available at:
<http://www.isid.org/ProMEDMail_Donations.shtml>
************************************************** **********
Visit ProMED-mail's web site at <http://www.promedmail.org>.
Send all items for posting to: promed@promedmail.org (NOT to
an individual moderator). If you do not give your full name
name and affiliation, it may not be posted. You may unsub-
scribe at <http://www.isid.org/promedmail/subscribe.lasso>.
For assistance from a human being, send mail to:
<postmaster@promedmail.org>.

[Treyfish]

Re: International Case Count - 19 dead, 2000+ infected, 500 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

The death toll linked to Germany?s E. coli outbreak has risen to 22, the European Centre for Disease Prevention and Control said in an e-mailed statement today. http://www.bloomberg.com/news/2011-0...2-eu-says.html

[tetano]

Re: Europe - 22 dead, 2200+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

The number of aggressive with the intestinal bacterial EHEC-infected people in Schleswig-Holstein in recent days has risen more slowly than before. "We have a great hope on Sunday it has given us a single new infections," said Oliver Grieve, the spokesperson of the University Hospital Schleswig-Holstein (UKSH). A 90-year-old woman died on Friday in the district of Segeberg from the effects of HU-syndrome, as the responsible public health official said. It is the sixth EHEC dead in Schleswig-Holstein.

http://www.ln-online.de/nachrichten/norddeutschland/3138845/Sechste_EHEC-Tote_-_weniger_Neuinfizierte

[tetano]

Re: Europe - 22 dead, 2200+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Robert-Koch-Institut: 22 EHEC deaths in Germany

EHEC pathogens continues: First laboratory samples of shoot vegetables from Lower Saxony fell on Monday were negative. The number of victims increases, meanwhile: 22 dead, the aggressive intestinal germ EHEC now required in Germany.

This was announced by the competent Robert Koch Institute (RKI), the news agency dpa on Monday evening. Accordingly, 15 patients died as a result of hemolytic-uremic syndrome (HUS). In seven other EHEC-infected patients who died this serious complication has not been established according to the information. Most of the dead are there for RKI numbers in Lower Saxony. Six people died there. Five were killed in Schleswig-Holstein, four in North Rhine-Westphalia.

http://www.wz-newsline.de/home/ratgeber/gesundheit-ernaehrung/robert-koch-institut-22-ehec-tote-in-deutschland-1.679257

[tetano]

Re: Europe - 23 dead, 2200+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

First it was the Spanish cucumbers, bean sprouts when, what will it be tomorrow? Nobody
know more.

Meanwhile, 22 people (21 Germans and a Swede) after they were deceased
EHEC-infected with the bacterium. HUS is the counter in Germany at 627. Fifteen
of them are deceased. Yesterday there were 1536 patients with Germany
EHEC bacteria without HUS. Six people have been infected with the deceased.

http://www.healthylives.nl/nieuws/voeding/2011/mei/het-ehec-mysterie

[tetano]

Re: Europe - 23 dead, 2200+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

EHEC: Two more deaths in Lower Saxony

Hanover - The number of EHEC-dead has risen to six in Lower Saxony. Two other women died as a result of severe gastrointestinal illness, said the Health Ministry in Hanover. It was a 88-year-old in a nursing home Celler and a 74-year-old in the district of Stade. Could not be given all-clear yet, said a spokesman of the Ministry. The number of new infections rose, however in less than in the previous week. Nationally, the number of cases and suspected cases climbed to 534th give shortages in the Lower Saxony clinics not it still said Health Minister Ayg?l ?zkan (CDU).

http://www.bild.de/newsticker-meldungen/home/12-ehec-tote-18262496.bild.html

[tetano]

Re: Europe - 25 dead, 2500+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

25 dead - no grounds for complacency

Berlin (dpa) - The EHEC intestinal germ called, according to federal Health Minister Daniel Bahr (FDP) to now 25 deaths in Germany.
It is possible that there were more deaths and new infections, he said Wednesday after a crisis meeting of health and consumer protection minister of federal and state governments together with EU Commissioner for Health, John Dalli in Berlin. It is not the time for complacency.

http://www.welt.de/newsticker/dpa_nt/infoline_nt/thema_nt/article13419314/25-Tote-Keine-Anlass-zur-Entwarnung.html

[tetano]

Re: Europe - 26 dead, 2500+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Berlin - Germany reported two more deaths and 300 more E coli cases on Wednesday, but its health minister insisted that new infections were dropping, giving some hope that the world's deadliest E coli outbreak was abating.

Health Minister Daniel Bahr spoke before an emergency meeting in Berlin with health officials from the European Union, which is getting concerned about Germany's handling of the crisis.

?I cannot yet give an all-clear, but after an analysis of the numbers there's reason for hope,? Bahr told ARD television. ?The numbers are continuously falling - which nonetheless means that there can still be new cases and that one unfortunately has to expect new deaths too - but overall new infections are clearly going down.?

Bahr said the death toll has risen to 26 - 25 in Germany plus one in Sweden.

http://www.iol.co.za/news/world/2-new-e-coli-deaths-reported-1.1080499?showComments=true

[tetano]

Re: Europe - 26 dead, 2500+ infected, 658 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Hannover - In Lower Saxony, another patient died on the intestinal disease. "Today is another EHEC-death case, which confirmed a 72-year-olds from the county Osterholz," said Health Minister Ayg?l ?zkan (CDU). Lower Saxony had a total of seven dead, unfortunately, continue the state in which most victims were complaining of the infection wave. However, it did much of the affected provinces of EHEC in the north and by far the highest population.

http://www.bild.de/news/startseite/news/telegramm-15479348,textId=18284302,tabindex=0.bild.html

[tetano]

Re: Europe - 26 dead, 2700+ infected, 722 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

BERLIN (AP) ? Germany's national disease control center says another person has died in the European E. coli outbreak and 160 more people have been reported ill, but that the rate of new sicknesses is continuing to decline.

The Robert Koch Institute said Thursday that 2,808 people, 722 of whom are suffering from a serious complication that can cause kidney failure, have now been reported sickened in Germany, the country at the epicenter of the E. coli outbreak whose origin has not yet been found.

The World Health Organization says 97 others have fallen sick in 12 other European countries, as well as three in the United States.

A total of 27 people have died ? 26 in Germany and one in Sweden.

Though the number of those sickened is still rising, the Koch institute says the new cases being reported have been dropping for several days.

http://www.ksnt.com/news/world/story/European-E-coli-sicknesses-rise-but-rate-declining/EkA1LaNXMUGVNMDVztR9bQ.cspx

[tetano]

Re: Europe - 27 dead, 2800+ infected, 722 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Three new deaths from EHEC infections
Despite three new deaths from EHEC infections are increasing signs of the slowing of the disease wave. In Hamburg, fewer new infections were reported, also in Lower Saxony is the tendency of decline.



In a laboratory in Krefeld food samples are examined.

Despite three new deaths from EHEC infections are increasing signs of the slowing of the disease wave. 'There is increasing day by day the hope that we have survived the apex really' said Hamburg's Senator for Health Examiner Cornelia Storck (SPD). The number of new infections is increasing, therefore, no longer as strong as before. In Lower Saxony, a man and a woman died from an EHEC infection, Hesse died, another man
In Hamburg, a focus of the epidemic were reported from Wednesday to Thursday, according to health authorities 27 new cases of EHEC. The slight decline in the number of daily new registered cases of disease continued to think so, said Storck's Examiner. Also, the Lower Saxony Ministry of Health said that there was a smaller increase in the tendency of new infections than in the past week.

The number of deaths by EHEC infection but also increased nationwide to at least the 29th In Lower Saxony died, according to the provincial Health Ministry on Wednesday a 68-year-old man and a 20-year-old woman. The government is investigating, according to the Ministry also an EHEC outbreak in G?ttingen, which could be linked with a family party. Both from the district of G?ttingen and from the nearby district of Kassel in Hesse diseases were reported. For the catering at the party, therefore a company from the Kassel district was responsible.

http://www.donaukurier.de/nachrichten/topnews/D-EU-Spanien-Gesundheit-Agrar-Medizin-Verbraucher-Drei-neue-Todesfaelle-durch-EHEC-Infektionen;art154776,2427125

[Tonka]

Re: Europe - 30 dead, 2800+ infected, 722 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Archive Number 20110609.1747
Published Date 09-JUN-2011
Source: ProMed

http://www.promedmail.org/pls/otn/f?p=2400%3A1001%3A784486222932712%3A%3ANO%3A%3AF2400_P1001_BACK_PAGE%2CF2400_P1001_PUB_MAIL_ID%3A1000%2C88802

Subject PRO/AH/EDR> E. coli O104 - EU (14): case update, neurological
E. COLI O104 - EUROPEAN UNION (14): CASE UPDATE, NEUROLOGICAL SYMPTOMS
************************************************** ********************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
[1] Germany: case update
[2] WHO update
[3] A cucumber reprise
[4] Neurological symptoms
[5] Commentary
[6] Poland ex Germany
[7] Switzerland ex Germany
[8] UK ex Germany

******
[1] Case update
Date: Wed 8 Jun 2011
Source: Forbes, Associated Press (AP) [edited]
<http://www.forbes.com/feeds/ap/2011/06/08/general-eu-contaminated-vegetables_8505633.html>


Germany's national disease control center says the number of people
reported sick in a deadly bacterial outbreak is still rising even
though German officials say there is hope the epidemic is abating.

The Robert Koch Institute told The Associated Press on Wed 8 Jun
2011, that another person has died in Germany from the _E. coli_
[O104:H4] infection, raising the toll to 24 in Germany, plus 1 in
Sweden. The number of reported cases is up by more than 300 over the
previous day to 2648, including nearly 700 suffering from a serious
complication that can cause kidney failure [hemolytic uremic
syndrome].

Even though the reported cases are going up, there is often a lag in
the reporting time and German health minister Daniel Bahr says the
number of new infections "are clearly going down."

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[300 more infections are reported which is more than the 94 reported
yesterday (7 Jun 2011).
The absolute numbers reported per day do not necessarily reflect when
the illness began so that new onset cases (reflecting further spread)
can still be decreasing. - Mod.LL]

******
[2] WHO update
Date: Wed 8 Jun 2011
Source: WHO, Regional Office for Europe [edited]
<http://www.euro.who.int/en/what-we-do/health-topics/emergencies/international-health-regulations/news/news/2011/06/ehec-outbreak-update-11>


EHEC outbreak: update 11
------------------------
The outbreak remains primarily centred in Germany, and investigations
continue into the nature of the unusual _E._ coli serotype and its
source.

Hemolytic uremic syndrome (HUS)
-------------------------------
As of 7 Jun 2011 at 15:00 CET, Germany had reported 689 HUS cases
(including 18 fatalities): 47 more cases and 3 additional deaths than
the previous day. 69 percent of cases were in females and 87 percent
in adults aged 20 years or older, with the highest attack rates per
100 000 population in the group aged 20-49 years. Case-onset dates
ranged from 1 May to 4 Jun 2011.

Enterohemorrhagic _E coli_ (EHEC)
---------------------------------
As of 7 Jun 2011 at 15:00 CET, 1959 cases of EHEC infection (without
HUS) had been reported in Germany (6 fatal, as 1 death reported on 7
Jun 2011 had not been confirmed): 276 more than the previous day. 60
percent of cases were in females and 88 percent in adults aged 20
years or older. Case onset dates ranged from 1 May to 4 Jun 2011.

The Robert Koch Institute, in Germany, states that the current HUS
and EHEC notification data, as well as data from the surveillance of
bloody diarrhea in emergency departments, show an overall decreasing
trend in the number of cases. It is uncertain whether this decline is
due to changes in consumption of raw vegetables and/or to the waning
of the source of infection.

Other countries
---------------
As of 7 Jun 2011 at 23:00 CET, 12 other European countries had
reported a total of 33 HUS cases (1 fatal) and 64 EHEC cases (none
fatal). There were 2 more HUS cases and 9 fewer EHEC cases reported
than the previous day. As the revised European Union (EU) case
definition is being applied, a number of cases reported earlier have
been excluded:
Country / HUS / EHEC
Austria / 0 / 2
Czech Republic 0 / 1
Denmark / 8 / 12
France / 0 / 2*
Luxembourg / 0 / 1
Netherlands / 4 / 2
Norway / 0 / 1
Poland / 2 / 0
Spain / 1 / 1
Sweden / 15 / 31
Switzerland / 0 / 3
United Kingdom / 3 / 8
*7 cases of bloody diarrhea have yet to be confirmed.

In addition, the CDC in the USA have published information on 3 HUS
cases (1 confirmed and 2 suspected) and 1 suspected EHEC case (without
HUS) in the USA linked to this outbreak. On 7 Jun 2011, the Public
Health Agency of Canada reported on 1 suspected case of _E. coli_ O104
infection (without HUS), in a person with travel history to northern
Germany and with links to a confirmed case of _E. coli_ O104 infection
in Germany.

All but 1 of the HUS and EHEC cases above were in people who had
traveled to or lived in 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, or more precisely a strain of enteroaggregative
verocytotoxin-producing _E. coli_ (EAggEC VTEC) O104:H4.
Investigations continue into the source of the outbreak.

Note
----
EHEC and HUS have exclusive notification categories, so case numbers
should not overlap. The figures in any rapidly evolving outbreak,
however, are provisional and subject to change for a variety of
reasons. In providing the information above, WHO wishes to recognize
the contribution of its Member States, and technical partners such as
the European Commission, the European Centre for Disease Prevention
and Control and a number of WHO collaborating centers.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[3] A cucumber reprise
Date: Wed 8 Jun 2011
Source: The New York Times [edited]
<http://www.nytimes.com/2011/06/09/world/europe/09ecoli.html>


As Germany's tally of deaths increased in what has become one of the
world's most lethal infections of _E. coli_, new elements of confusion
surfaced Wed 8 Jun 2011, with conflicting signals about whether the
outbreak is abating and what caused it.

Initially, the German authorities blamed cucumbers, tomatoes, and
lettuce from Spain for the infection, which has been spreading since 1
May 2011. Then, last weekend [4-5 Jun 2011], investigators switched
their attention to sprouts grown in northern Germany as a potential
cause.

On Wed 8 Jun 2011, even as the authorities said the sprouts were
still prime suspects, the hunt took a new and apparently baffling turn
when the state authorities in Magdeburg, in eastern Germany, far from
the original epicenter of the infection in northern Germany, said
traces of the pathogen identified in the outbreak had been found on
discarded cucumber leftovers in a garbage can belonging to a family
among those sickened by _E. coli_.

Holger Paech, the state health ministry spokesman in Magdeburg, said
it was unclear how the bacterium got onto the cucumber at the home of
a family where 3 people had sickened, 1 of them with hemolytic-uremic
syndrome whose treatment has strained intensive care units in many
other parts of Germany. The 3 family members had no known contact with
the worst infected areas of northern Germany, he said.

The discarded cucumber had been in the garbage can for a week and a
half, he said, and "there will always be an element of doubt" about
how it had become contaminated.

On a broader scale, differences emerged Wednesday [8 Jun 2011]
between the federal Health Ministry and the Robert Koch Institute over
the status of the outbreak.

Mr Bahr struck a cautiously optimistic tone on Wednesday during an
emergency meeting in Berlin of health officials from Germany and the
European Union. "There is much to suggest that we have put the worst
behind us," he said. While this did not mean the outbreak was fading,
he said, it seemed that fewer people were being diagnosed.

The Robert Koch Institute, however, was far from certain that the
worst was over. "There is a declining trend in new cases but it is not
clear that it is because the outbreak is really waning or whether it
is because the population are being more careful in what they eat," it
said in a statement.

[Byline: Alan Cowell, Judy Dempsey]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[It is not clear if the _E. coli_ isolate from the East German
cucumber is identical to the outbreak strain or not. - Mod.LL]

******
[4] Neurological symptoms
Date: Mon 6 Jun 2011
Source: Science Insider, American Association for the Advancement of
Science (AAAS) [edited]
<http://news.sciencemag.org/scienceinsider/2011/06/sprouts-so-far-innocent-of-e-col.html>


Researchers are now analyzing the genome of the _E. coli_ O104:H7
bacterium to understand its evolutionary history and possibly identify
its source. Closer analysis of the genome might also offer some clues
to how the Shiga toxin made by the bacterium is attacking the brain.
This toxin normally targets the kidney, triggering the sometimes fatal
development of hemolytic-uremic syndrome (HUS). Usually neurological
symptoms are seen in only a few percent of HUS cases, but in the
current outbreak "about half the patients with HUS are developing
neurological symptoms," Christian Gerloff, head of the neurology
department at the University Medical Center Hamburg-Eppendorf, told
ScienceInsider.

Alarm bells started going off when some patients showed problems
finding words or giving the date, Gerloff recalls. It quickly became
clear that a lot of patients were developing problems reading or doing
simple calculations. "Patients were mixing up words and were
disoriented. Later they developed muscle twitching and then
progressing to epileptic fits," Gerloff says.

At the clinic in Hamburg, a team of neurologists now screens all HUS
patients once a day to look for any unusual signs and treats any
patients with neurological symptoms with anticonvulsants to prevent
epileptic fits. But the most surprising thing to Gerloff was that the
bacteria do not appear to cause strokes. "That is what we were
expecting mostly," Gerloff says. But patients with neurological
symptoms showed no signs of structural brain damage when examined with
magnetic resonance imaging. "It is usually assumed that the Shiga
toxin binds to the endothelium and leads to swelling and clotting,
obstructing the vessels," Gerloff says. "So why are we not seeing any
strokes?"

Autopsies of 2 patients could lead to new insights in the next few
days, the neurologist says. But for the time being, it is just one
more perplexing detail of a pathogen that has sprung quite a few
surprises already.

[Byline: Kai Kupferschmidt]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Most of the reports have focused on the renal complication of HUS
with just peripheral mention of neurological complications. Overall,
anywhere up to 50 percent of cases of HUS (with most cases in children
in contradistinction to this series) have had neurological involvement
(1,2). The most common clinical manifestation is seizures, either
generalized or focal. Other manifestations include altered
consciousness without seizures, personality changes, coma, and
transient hemiplegia. Although metabolic alterations or hypertension
occur, these factors are not likely able to explain the disturbances.
Overall, and as seen in the current outbreak, neurological symptoms
seem to suggest a more severe HUS, with higher mortality.

A disease similar to HUS which occurs primarily in adults is
thrombotic thrombocytopenic purpura and is much more likely to be
associated with neurological symptoms rather than the opposite in
HUS.

The higher rate of neurological symptoms in this outbreak may be
related to the amount of toxin produced or other factors related to
the relatively unique organism.

References
----------
1. Sheth KJ, Swick HM, Haworth N: Neurological involvement in
hemolytic-uremic syndrome. Ann Neurol 1986;19(1): 90-3; abstract
available at <http://www.ncbi.nlm.nih.gov/pubmed/3947042>.
2. Eriksson KJ, Boyd SG, Tasker RC: Acute neurology and
neurophysiology in haemolytic-uraemic syndrome. Arch Dis Child 2001;
84(5): 434-5; available at
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718775/pdf/v084p00434.pdf>.
- Mod.LL]

******
[5] Commentary
Date: Wed 8 Jun 2011
Source: Wired.com [edited]
<http://www.wired.com/wiredscience/2011/06/what-know-need/>


The stream of news from the _E. coli_ O104:H4 outbreak in Germany has
been so steady that it's been hard to catch my breath long enough to
post on it. The Robert Koch Institute in Germany said today, 8 Jun
2011, that they think the epidemic curve is cresting, which makes me
unusually late to the party. Nevertheless, since there are likely to
be more cases and more deaths, and a long struggle still to understand
what happened, I thought it would be useful to count the things that
we can say for sure, and those that remain puzzlingly open questions.

First: Is this the largest _E. coli_ outbreak ever? According to
food-safety uber-attorney Bill Marler, this outbreak, more than 2600
victims, 13 countries, 26 deaths, is dwarfed only by a 1996 epidemic
in Japan. If it's not the largest, it is likely to have produced the
largest percentage of serious illness: as of today, 8 Jun 2011, there
are 725 cases of hemolytic uremic syndrome (689 in Germany, 33 in the
rest of Europe, 3 in the United States), according to WHO.

Those case counts pose a 2nd question: Is there something different
about the strain in this outbreak? As Richard Knox of NPR [US National
Public Radio] points out, the outbreak has put about 1 out of every 3
victims in the hospital, compared to 1 in 10 for previously known
toxin-producing strains. That raises 2 possibilities: either the
strain is different, more on that in a moment, or the case-finding has
not turned up the mild cases that would change the denominator and
therefore dilute the percentage back to something more normative.

So, then, 3rd: Is this strain different? In certain key ways, yes,
and we know that thanks to a global, largely volunteer, crowd-sourced
genetic analysis, which by itself is something new. And which is
spread across many blogs and sites, but the best round-ups are
probably at Mike the Mad Biologist
[<http://scienceblogs.com/mikethemadbiologist/2011/06/some_more_thoughts_about_the_g.php>],
who has added some crucial analysis of his own, and The Alignment Gap
[<http://phylogeo.wordpress.com/2011/06/06/some-updates-on-the-crowd-sourcing-around-husec41-genome-analyses/>].
Among the differences noted between this strain and its apparent
recent ancestor, isolated in Germany in 2001, is a change in the gene
for the adhesion protein that makes the bacterium "sticky" in the gut,
prolonging the course of illness.

From my point of view, the most important difference between this
strain, its 2001 ancestor, and just about any previously known
outbreak strain of Shiga toxin-producing _E. coli_ or STEC, including
any of the O157 outbreaks dating back to the 1992-3 Jack-in-the-Box
one that made O157 a household name, is that this one is massively
drug resistant. The Guardian was kind enough to ask me to write a
piece about this on Sunday [5 Jun 2011;
<http://www.guardian.co.uk/commentisfree/2011/jun/05/deadly-ecoli-resistance-antibiotic-misuse>
(which on Monday was named one of The Atlantic's "Five Best Monday
Columns"; thanks, Atlantic!).

It's not fair use or good blogging to quote myself lavishly, so
here's the key point. According to the Koch Institute, the German O104
strain is resistant to at least a dozen antibiotics in 8 different
drug classes: penicillins; streptomycin; tetracycline; the quinolone
nalidixic acid; the sulfa drug combination
trimethoprim-sulfamethoxazole; 3 generations of cephalosporins; and
the combination drugs amoxicillin/clavulanic acid,
piperacillin-sulbactam, and piperacillin-tazobactam. Put all those
together, and what they signal is that O104 possesses what is called
ESBL resistance (for "extended spectrum beta-lactamase"). According to
the Koch Institute's analysis, the strain has acquired 2 genes that
confer that resistance, TEM-1 and CTX-M-15. if this were a strain that
needed to be treated with antibiotics, there are only a few
antibiotics that would work, notably the carbapenems, the drugs of
last resort for Gram negative bacteria.

If there is any good luck in this outbreak story, it is that STECs
are not usually treated with antibiotics, because killing the
organisms causes them to release their toxins, which then starts a
cascade that brings on HUS. So the finding that this strain is
resistant is not clinically relevant. But it's of huge microbiological
significance, because it underlines yet again how resistance DNA is
moving between bacteria in a largely untracked fashion. ESBL
resistance has been spreading through Europe for a decade in hospital
organisms such as _Klebsiella_, but a community outbreak of this size
is surely unprecedented.

Some questions that still need answers:
What's the source? The suspect food has been cucumbers, then sprouts,
then not sprouts, then cucumbers again just today [8 Jun 2011], and
also today, maybe sprouts again. Related question: with so many cases,
and therefore presumably so many interviews of victims going back
several weeks, why hasn't the source been narrowed down?

Where is Europe's traceability system? In the wake of the 2006 US
outbreak of O157 in fresh spinach, a lot of attention was paid to
creating more complete records of chains of custody of produce, so
that a harvest batch could be tracked through the entire distribution
system instead of just from its last stop to its next one. Wasn't
Europe supposed to do this better?

How many steps away from agriculture is this outbreak? As Mark
Bittman emphasized today, sooner or later it all comes back to manure,
because _E. coli_ is a gut bug. Is the source wildlife, as it may have
been in 2006? Sick farm workers, as the German government has
asserted? Can the newly acquired resistance genes throw any light on
its source? CTX-M-15 has been found in _E. coli_ in chickens.

[Byline: Maryn McKenna]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[A concise overview of some of the issues currently being discussed.
- Mod.LL]

******
[6] Poland ex Germany
Date: Tue 7 Jun 2011
Source: Warsaw Business Journal [edited]
<http://www.wbj.pl/article-54886-poland-confirms-first-e-coli-case.html>


Poland's Chief Sanitary Inspectorate has confirmed that a 29-year-old
Polish woman who lives in Germany had contracted _E. coli_ [O104]. The
woman was taken to a hospital in Szczeczin, northwestern Poland.

Authorities are now awaiting test results to confirm 4 additional
suspected cases. These 4 cases are also people who were recently in
Germany, said Jan Bondar, Chief Sanitary Inspectorate spokesperson.

The exact source of the disease has not been identified, and Polish
as well as European authorities expect that further possible cases of
infection will continue to appear.

[Byline: Alice Trudelle]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Another suspected case has also been hospitalized. - Mod.LL]

******
[7] Switzerland ex Germany
Date: Wed 8 Jun 2011
Source: Expatica [edited]
<http://www.expatica.com/de/news/german-news/switzerland-reports-five-e-coli-cases_155164.html>


Swiss health authorities reported new 5 _E. coli_ bacterial
infections on Wed 8 Jun 2011, which they linked to the outbreak that
has killed 25 people, almost exclusively in Germany.

The Federal Office of Public Health said on its website that of
Switzerland's 27 confirmed cases of EHEC _E. coli_ in 2011, including
13 since early May 2011, "5 are of the same bacterial strain as in
northern Germany."

It said the 5 victims, who had travelled to Germany before the
outbreak began, were in stable condition and showed no signs of
complications.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[8] UK ex Germany
Date: Tue 7 Jun 2011
Source: Daily Telegraph [edited]
<http://www.telegraph.co.uk/health/healthnews/8562250/12th-E.coli-case-confirmed-in-UK-as-death-toll-reaches-23.html>


The Health Protection Agency [HPA] announced the 12th confirmed case
in this country as the authorities on the continent continued to
search for the cause of the outbreak.

All of the cases in England have been "related to recent travel to
Germany," where hundreds of people have suffered food poisoning in
recent weeks, and travelers to the country are being reminded not to
eat raw tomatoes, cucumbers, and lettuce.

The HPA said that the new case in England caused by the previously
unseen strain of _E. coli_ O104 bacteria was of "bloody diarrhea",
making it the 3rd with this particular symptom. The other 9 have
developed hemolytic uremic syndrome (HUS).

[Byline: Martin Beckford]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[see also:
E. coli O104 - EU (13): case update, new countries 20110607.1737
E. coli O104 - EU (12): sprout cultures negative so far
20110606.1731
E. coli O104 - EU (11): case update, poss. sprout source
20110605.1720
E. coli O104 - EU (10): USA commentary 20110605.1718
E. coli O104 - EU (09) & USA 20110603.1701
E. coli O104 - EU (08) & USA: genetic analysis, more cases
20110603.1692
E. coli O104 - EU (07) & USA 20110601.1678
E. coli O104 - EU (06) & USA 20110531.1666
E. coli O104 - EU (05): (Germany) monoclonal antibody trial
20110529.1646
E. coli O104 - EU (04): (Germany) more deaths & HUS cases
20110528.1635
E. coli O104 - EU (03): (Germany, EU ex Germany) alert 20110527.1629
E. coli O104 - EU (02): (Germany, EU ex Germany), alert
20110527.1620
E. coli O104 - EU: (Germany, Denmark, Sweden) Spanish cucumbers
20110526.1611
E. coli VTEC - Germany (04): O104, poss. salad source 20110526.1600
E. coli VTEC - Germany (03): O104, spread South 20110525.1587
E. coli VTEC - Germany (02): increased case burden 20110524.1578
E. coli VTEC - Germany: RFI 20110523.1566
E. coli VTEC non-O157 - Japan: O111, raw beef, alert 20110504.1378
2010
----
E. coli VTEC non-O157 - USA (07): O26, ground beef, alert, recall
20100831.3097
E. coli VTEC non-O157 - USA (06): O145, lettuce 20100528.1777
E. coli VTEC non-O157 - USA (03): O145, lettuce, recall
20100507.1483
E. coli VTEC non-O157 - USA (02): (OH, MI, NY) O145 20100505.1460
E. coli VTEC non-O157 - USA: (MI, OH) 20100427.1358
2008
----
E. coli VTEC non-O157, restaurant - USA (04): (OK), O111
20081201.3779
E. coli VTEC non-O157, restaurant - USA: (OK), O111 20080902.2748
E. coli VTEC non-O157, past. ice cream, 2007 - Belgium: Antwerp
20080218.0655
2007
----
E. coli VTEC non-O157, beef sausage - Denmark 20070602.1784
E. coli VTEC non-O157, 2000-2005 - USA (CT) 20070118.0240
2006
----
E. coli VTEC non-O157, lettuce - USA (UT)(02): background
20060905.2523
E. coli VTEC non-O157, lettuce - USA (UT) 20060904.2521
E. coli VTEC non-O157 - Norway (03) 20060416.1133
E. coli VTEC non-O157 - Norway 20060329.0947
E. coli VTEC non-O157, minced beef - Norway 20060304.0680
2005
----
E. coli O145, fatal - Slovenia 20050916.2739
2003
----
E. coli, VTEC non-O157 - UK (Scotland): correction 20030828.2166
E. coli, VTEC non-O157 - UK (Scotland) 20030825.2144
2001
----
E. coli O26 - South Korea 20010509.0896
1999
----
E. coli O111, diarrhea - USA (Texas) 19990707.1134
1997
----
E. coli, non-0157 - Belgium 19970610.1215]
.................................................s b/ll/mj/dk
*################################################# #########*
************************************************** **********
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************** **********
Donate to ProMED-mail. Details available at:
<http://www.isid.org/ProMEDMail_Donations.shtml>
************************************************** **********
Visit ProMED-mail's web site at <http://www.promedmail.org>.
Send all items for posting to: promed@promedmail.org (NOT to
an individual moderator). If you do not give your full name
name and affiliation, it may not be posted. You may unsub-
scribe at <http://www.isid.org/promedmail/subscribe.lasso>.
For assistance from a human being, send mail to:
<postmaster@promedmail.org>.
################################################## ##########

[Emily]

Re: Europe - 30 dead, 2800+ infected, 722 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

Put all those
together, and what they signal is that O104 possesses what is called
ESBL resistance (for "extended spectrum beta-lactamase"). According to
the Koch Institute's analysis, the strain has acquired 2 genes that
confer that resistance, TEM-1 and CTX-M-15.

http://onlinelibrary.wiley.com/doi/1...148.x/abstract

CTX-M-15-type extended-spectrum beta-lactamases-producing Escherichia coli from wild birds in Germany
Environmental Microbiology Reports

Volume 2, Issue 5, pages 641?645, October 2010

http://onlinelibrary.wiley.com/doi/1...7.01851.x/full

Animal reservoirs for extended spectrum β-lactamase producers

A. Carattoli
Clinical Microbiology and Infection
Special Issue: ESBLs, Forever?
Volume 14, Issue Supplement s1, pages 117?123, January 2008

CTX-M-15 E. coli 1 France Poultry

http://vla.defra.gov.uk/news/docs/new_esbl_poultry.pdf

Extended-Spectrum Beta-Lactamases (ESBLs) of the CTX-M
family in E. coli from Poultry.
A meeting to release and discuss the results of recent surveillance
studies on the prevalence of ESBL E. coli in broilers and turkeys.
Tuesday 16 February 2010
Veterinary Laboratories Agency ? Weybridge, UK

[Anne]

Re: Europe - 30 dead, 2800+ infected, 722 severe cases of E-coli - EHEC STEC hemolytic uremic syndrome

http://www.rki.de/cln_160/nn_205760/DE/Home/Info-HUS.html

Stand 06.13.2011, 11:00 clock, data as of 06/12/2011, 15.00

For a few days illness of HUS / EHEC at a much lower level are sent to the RKI.

Since early May 2011 the RKI was provided with 2447 cases of infection with EHEC. Overall, 59% of cases are female, 87% of cases are 20 years or older. A total of 13 submitted EHEC cases have died.
Analogous to infection with EHEC were sent to the Robert Koch Institute since early May 2011 a total of 781 cases with HUS. Overall, 69% of cases are female, 88% of cases are 20 years or older. A total of 22 submitted HUS cases have died. Altogether, 3228 persons are suffering from HUS or EHEC, 35 people died of HUS or EHEC.

In the current events is one of the world's largest so far described outbreaks of EHEC or HUS and the largest outbreak in Germany, whereby in particular the age and gender distribution unusual. As before, especially adults, mostly women, are affected. At other times, mainly children develop this severe clinical picture: In 2010, for example, were the Robert Koch Institute, 65 HUS cases submitted, 6 were affected more than 18 years.