2011 Germany E. coli O104:H4 outbreak

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2011 German E. coli O104:H4 outbreak
Classification and external resources
Schizocyte smear 2009-12-22.JPG
The 2011 E. coli O104:H4 outbreak.
LEGEND No food restrictions or tests. Food and/or medical tests done. Food sale and/or trade restrictions.
No cases.
  
  
  
Suspected cases
  
  
  
Known non-native cases
  
  
  
Known native cases
  
  
  
Deaths
  
  
  
Exposure to the outbreak start from 21 April 2011 with permanent or temporary stay in Germany, consumption of a food acquired in Germany or close contact with a HUS case.[1]

A novel strain of Escherichia coli O104:H4 bacteria caused a serious outbreak of foodborne illness focused in northern Germany in May through June 2011. The illness was characterized by bloody diarrhea, with a high frequency of serious complications, including hemolytic-uremic syndrome (HUS), a condition that requires urgent treatment. The outbreak was originally thought to have been caused by an enterohemorrhagic (EHEC) strain of E. coli, but it was later shown to have been caused by an enteroaggregative E. coli (EAEC) strain that had acquired the genes to produce Shiga toxins, present in fenugreek beansprouts.

Epidemiological fieldwork suggested fresh vegetables were the source of infection. The agriculture minister of Lower Saxony identified an organic farm[2] in Bienenbüttel, Lower Saxony, Germany, which produces a variety of sprouted foods, as the likely source of the E. coli outbreak.[3] The farm was shut down.[3] Although laboratories in Lower Saxony did not detect the bacterium in produce, a laboratory in North Rhine-Westphalia later found the outbreak strain in a discarded package of sprouts from the suspect farm.[4] A control investigation confirmed the farm as the source of the outbreak.[5] On 30 June 2011 the German Bundesinstitut für Risikobewertung (BfR) (Federal Institute for Risk Assessment), an institute of the German Federal Ministry of Food, Agriculture and Consumer Protection, announced that seeds of fenugreek imported from Egypt were likely the source of the outbreak.[6]

In all, 3,950 people were affected and 53 died, 51 of which were in Germany.[7] A handful of cases were reported in several other countries including Switzerland,[8] Poland,[8] the Netherlands,[8] Sweden,[8] Denmark,[8] the UK,[8][9] Canada[10] and the USA.[10][11] Essentially all affected people had been in Germany or France shortly before becoming ill.

Initially, German officials made incorrect statements on the likely origin and strain of Escherichia coli.[12][13][14][15] The German health authorities, without results of ongoing tests, incorrectly linked the O104 serotype to cucumbers imported from Spain.[16] Later, they recognised that Spanish greenhouses were not the source of the E. coli and cucumber samples did not contain the specific E. coli variant causing the outbreak.[17][18] Spain consequently expressed anger about having its produce linked with the deadly E. coli outbreak, which cost Spanish exporters 200M US$ per week.[19] Russia banned the import of all fresh vegetables from the European Union from early June until 22 June 2011.[20]

Origin[edit]

Beginning 2 May 2011, German health authorities reported the outbreak of bloody diarrhea accompanied by hemolytic-uremic syndrome (HUS).[21] On 22 May 2011, German health authorities said "Clearly, we are faced with an unusual situation", one day after the first death in Germany. Escherichia coli infection is common, infecting 800 to 1200 people a year in Germany, but is usually mild.[22][23] Until 25 May it occurred in northwest Germany mostly.[24]

On 26 May, German health officials announced that cucumbers from Spain were identified as a source of the E. coli outbreak in Germany.[25] On 27 May 2011, German officials issued an alert distributed to nearby countries, identifying organic cucumbers from Spain and withdrawing them from the market.[14] The European Commission on 27 May said that two Spanish greenhouses that were suspected to be sources had been closed, and were being investigated.[26][27] The investigation included analyzing soil and water samples from the greenhouses in question, located in the Andalusia region, with results expected by 1 June.[28] Cucumber samples from the Andalusian greenhouses did not show E. coli contamination,[29][30][31] but a cross-contamination during transport in Germany or distribution in Hamburg are not discounted; in fact, the most probable cause is cross-contamination inside Germany.[32][33] The Robert Koch Institute advises against eating raw tomatoes, cucumbers and lettuces in Germany to prevent further cases.[34]

On 31 May, an EU official said that the transport chain was so long that the cucumbers from Spain could have been contaminated at any point that occurred along the transit route.[35] Spanish officials, said before that there was no proof that the outbreak originated in Spain; Spanish Secretary of State for European Affairs Diego López Garrido said that "you can't attribute the origin of this sickness to Spain."[27]

On Tuesday 31 May, lab tests showed that two of the four cucumbers examined did contain toxin-producing E. coli strains, most likely because of cross-contamination in Germany according to experts,[33] but not the O104 strain that was found in patients. The bacteria in the other two cucumbers have not yet been identified.

Genomic sequencing by BGI Shenzhen confirm a 2001 finding that the O104:H4 serotype has some enteroaggregative E. coli (EAEC or EAggEC) properties, presumably acquired by horizontal gene transfer.[36][37][38]

The only previous documented case of EHEC O104:H4 was in South Korea in 2005 and researchers pointed at contaminated hamburgers as a possible cause.[39]

On 4 June, German and EU officials had allegedly been examining data that indicated that an open catering event at a restaurant in Lübeck, Germany, was a possible starting point of the on-going deadly E. coli outbreak in Europe.[40][41] German hospitals were nearly overwhelmed by the number of E. coli victims.[42]

A spokesman for the agriculture ministry in Lower Saxony, warned people on 5 June to stop eating local bean sprouts as they had become the latest suspected cause of the E. coli outbreak.[43] A farm in Bienenbuettel, Lower Saxony, was announced as the probable source,[44][45] but on 6 June officials said that this could not be substantiated by tests. Of the 40 samples from the farm that were being examined, 23 had tested negative.[46] But on 10 June it was confirmed by the head of the Robert Koch Institute that the bean sprouts were the source of the outbreak, and that people who ate the bean sprouts were nine times more likely to have bloody diarrhea.[47][48] The WHO have confirmed on 10 June this statement on the update 13 of the EHEC outbreak.[49]

According to the head of the national E. coli lab at the German Federal Institute for Risk Assessment, the strain responsible for the outbreak has been circulating in Germany for 10 years, and in humans not cattle. He said it is likely to have got into food via human feces.[50]

A joint risk-assessment by EFSA/ECDC, issued 29 June 2011, made a connection between the German outbreak and a HUS outbreak in the Bordeaux area of France, first reported on 24 June, in which infection with E. coli O104:H4 has been confirmed in several patients.[51] The assessment implicated fenugreek seeds imported from Egypt in 2009 and 2010, from which sprouts were grown, as a common source of both outbreaks, but cautioned that "there is still much uncertainty about whether this is truly the common cause of the infections", as tests on the seeds had not yet found any E. coli bacteria of the O104:H4 strain.[52][53] The potentially contaminated seeds were widely distributed in Europe.[54] Egypt, for its part, steadfastly denied that it may have been the source of deadly E. coli strain, with the Minister of Agriculture calling speculations to that effect "sheer lies."[55]

Affected countries[edit]

Overview[edit]

Most or all victims as of 21 July 2011 were believed to have become infected in Germany or France. Confirmed cases are listed below according to their location when diagnosed.

Number of cases reported to the WHO as for 21 July 2011[10]
Country Deaths HUS cases Non-HUS cases
 Austria 0 1 4
 Canada 0 0 1
 Czech Republic 0 0 1
 Denmark 0 10 15
 France 0 7 10
 Germany 48 857 3078
 Greece 0 0 1
 Luxembourg 0 1 1
 Netherlands 0 4 7
 Norway 0 0 1
 Poland 0 2 1
 Spain 0 1 1
 Sweden 1 18 35
  Switzerland 0 5 0
 United Kingdom 0 3 4
 United States 1 4 2
Total 50 908 3,167

International response[edit]

European Union[edit]

On 22 May, Health Commissioner John Dalli of the European Commission declared the issue to be an 'absolute priority', saying that the Commission is working with member states, particularly Germany, to identify the source of the outbreak.[56] Speaking again on 1 June, Commissioner Dalli noted that the outbreaks have been limited in origin to the Greater Hamburg area and declared that any product ban would be disproportionate. He also said that he is working with Agriculture Commissioner Dacian Cioloş "to address the hardship faced by this group of our citizens that has also been hit hard by the E. coli outbreak".[57] He also said on June that "In future we need to see how the timing of the alerts can be closer to the actual scientific basis and proof."[58]

By 7 June, EU Ministers held an emergency meeting in Luxembourg to discuss the growing crisis, which had left 23 people dead, more than 2,000 ill so far.[58][59] Germany's Federal Agriculture Minister, Ilse Aigner, repeated her warnings to EU consumers to avoid eating any bean sprouts, cucumbers, tomatoes and salads.[59]

The United States Center for Disease Control (CDC) and the United States Department of Agriculture has long been concerned regarding risks involving the E. coli risk in raw bean sprout production.[58]

EU member nations[edit]

Apart from the German government, which warned against the consumption of all raw cucumbers, tomatoes and lettuce,[60] several countries implemented restrictions or bans on the import of produce.

Non-EU European nations[edit]

Many other European countries took restrictive actions or lost sales of produce, including Albania, Croatia,[61] and Russia.

The ban on EU vegetables was lifted on 10 June, but stiff safety measures remained in place.[62]

Middle East[edit]

Many countries took restrictive action. Egypt was a focus of the epidemiological investigation because the fenugreek seeds were imported into Germany from Egypt.

Egypt's Minister of Health Ashraf Hatem denied his nation had any patients infected with the new E. coli strain, due to the strict precautions brought in to test over-seas tourists entering the country on 2 June.[63][64]

Responding to claims that Egyptian fenugreek seeds were the cause of the E. coli outbreak, Egyptian Minister of Agriculture Ayman Abu-Hadid told the Egyptian press the problem had nothing to do with Egypt and instead asserted, "Israel is waging a commercial war against Egyptian exports."[65]

North America[edit]

Canada and the United States reported cases of E. coli infection that had been acquired in Europe.

On 2 June, Canada brought in stricter anti E. coli related food inspections[66] and by 3 June the Public Health Agency of Canada said that no Canadians had been reported sick with the strain as of that date. The Canadian Government also brought in heavier import and hygiene restrictions on EU cucumbers, lettuces and tomatoes.[67]

The United States Department of Agriculture (USDA) and the Food and Drug Administration (FDA) stated that emerging strains of E. coli are a significant problem, but regulatry bodies in the USA have concentrated on the more infamous E. coli O157 serotype.[68][69]

FDA noted that nearly all of America's fresh produce is grown in the U.S. and areas of Central America, and the EU has not been a significant source of fresh produce for the US.[70]

Other countries[edit]

Other countries, including Nigeria, Hong Kong, Thailand expressed concern regarding imported produce.

Economics[edit]

By 1 June, both Italian, Austrian, and French cucumber sales had begun to decline sharply, but the Austrian Health Ministry official Dr. Pamela Rendi-Wagner, claimed Austrian customers were still safe.[71]

On 3 June, the governments of Spain, Portugal and Germany said that they would formally request EU agricultural aid for farmers affected by the outbreak.[72] That day also saw Russia set up plans for new imports of cucumbers from Ukraine, Azerbaijan, Egypt and Turkey.[73][74]

By 7 June, the EU's farmers had reported they had lost millions of dollars in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying its growers had $256,000,000 in turnover.[59] French, Swiss, Bulgarian, German, Dutch, Belgian and Portuguese producers have also been similarly affected.[59]

That day, the EU proposed issuing £135,000,000 in agricultural compensation to its farmers. The EU agriculture commissioner said the EU's farmers could get back up to 30% of the cost of vegetables they were unable to sell.[75] The EU's health commissioner, John Dalli, had formally criticised earlier that day Germany for rushing out "premature conclusions" about the source of an outbreak, and only helped to spread alarm among the public and farmers and untimely leading to the damaging the EU's agriculture sector.[76] John Dalli also told the EU parliament in Strasbourg that claims had to be scientifically sound, unbiased and fool-proof in nature before it was publicised in future.[77]

Spain then rejected a €150,000,000/£135,000,000 the European Commission's compensation deal for there for farmers who were hit by the E. coli outbreak, on 8 June, saying it was too small.[78] France, European Union's largest agricultural grower, said it would support the plan to compensate producers hurt by the outbreak, according to the French Agriculture Minister Bruno Le Maire.[45]

Ministers from both EU and Russian were scheduled to meet on 8 June over Russian's earlier decision to ban all its vegetable imports from the EU.[79]

On 8 June, it was reckoned that the EU's E. coli O104:H4 outbreak cost $2,840,000,000 in human losses (such as sick leave), regardless of material losses (such as dumped cucumbers).[80]

Consumers across Europe were shunning fruit and vegetables en masse by 8 June, as the German government's against eating raw cucumbers, tomatoes, lettuce and sprouts remained on. EU farmers claimed to have losses up to C$417,000,000 ($611,000,000) a week as ripe vegetables produce rotted in their fields and warehouses.[81] On 8 June, The EU Farm Commissioner Dacian Ciolos said that the EU had increased its offer of compensation to farmers for the losses caused by E. coli outbreak to C$210,000,000 ($306,000,000).[81]

Specific countries[edit]

On 8 June, Dacian Cioloş, the European Commissioner for Agriculture & Rural Development, increased the compensation offer to €210 million ($306.2 million) for farmers who lost money due to the outbreak.[82][83]

Several countries reported economic losses, particularly Spain. By 7 June, the EU's Farmers had reported that they had lost millions of dollars in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying its growers had lost $256,000,000m in turnover.[59] Spain rejected the European Commission's €150,000,000/£135,000,000 compensation deal for their farmers who were hit by the E. coli outbreak, on 8 June, saying it was too small.[78]

Other countries reporting losses included Bulgaria,[84] Croatia,[61] and Switzerland,[85][86] Russia requested further Turkish and Azerbaijani cucumber imports to replace banned EU imports.[74][87]

See also[edit]

References[edit]

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