29 July 2011
Outbreak of Vero cytotoxin-producing E. coli in Germany and France
(This updates the Clinical Update of 1 July 2011)
Beginning in May 2011, Germany experienced an outbreak of Vero cytotoxin-producing Escherichia coli O104:H4 infection. Infection with this organism has resulted in cases of haemolytic uraemic syndrome (HUS) and bloody diarrhoea (also known as enterohaemorrhagic E. coli (EHEC) infection) [1-2].
As of 26 July 2011, a total of 733 probable and confirmed cases of HUS with 28 deaths have been reported in Germany. There have also been 3,052 reported cases of EHEC including 17 deaths. The last reported onset of illness attributed to the outbreak in Germany was 4 July 2011. Although sporadic cases are expected to continue to be reported, the outbreak in Germany has been declared over [1-2].
As of 26 July 2011, a cluster of 15 cases of EHEC infection, (nine with HUS, four with bloody diarrhoea and two with non-bloody diarrhoea), with dates of onset between 11 and 27 June, were reported in Gironde Department, France. Investigations indicate that sprouts served at a recreation centre in Bordeaux were the source of infection. A strain of E. coli O104: H4 that has similar characteristics to the strain identified in the German outbreak was isolated in five cases .
A Joint Rapid Risk Assessment carried out by the European Food Safety Authority (EFSA) and the European Centre for Disease Prevention and Control (ECDC), has concluded that these E. coli O104:H4 outbreaks in Germany and France are the most likely linked to fenugreek seeds imported from Egypt in 2009 and 2010 .
The implicated batches of fenugreek seeds have been withdrawn from sale in the European Union (EU) and there is a temporary ban on the import of fenugreek and certain seeds, beans and sprouts imported from Egypt until 31 October 2011 .
As of 15 July 2011, a total of 26 cases of EHEC infection have been reported, of which 10 were HUS . Almost all the cases were associated with travel to Germany or with contact with individuals who had been infected after travel to Germany [7, 8]
As of 7 July 2011, a total of 17 cases of EHEC (including three cases of HUS) associated with travel to Germany have been reported in the UK .
No further cases of HUS or non-HUS STEC have been reported by other EU Member States in the last two weeks .
Vero cytotoxin-producing E. coli
Vero cytotoxin-producing E. coli (also known as a Shiga toxin and termed VTEC or STEC) can cause a range of clinical syndromes from mild diarrhoea, to bloody diarrhoea and HUS. HUS is a severe and sometimes fatal complication of VTEC infection. It usually presents within a week after onset of diarrhoea, and is characterised by acute renal failure and anaemia. It is estimated that up to 10% of patients with VTEC infection may develop HUS, although in this outbreak there has been a higher percentage. HUS is usually associated with a case-fatality rate of 3% to 5% .
Advice for travellers
VTEC is transmitted via the faecal-oral route. There is no vaccine available for travellers to prevent VTEC infection.
- European Food Safety Authority (EFSA) advice remains in effect that consumers should not grow sprouts for their own consumption and should not eat sprouts or sprouted seeds, unless these products are cooked thoroughly .
Returning travellers with symptoms indicative of VTEC infection (i.e. bloody diarrhoea, cramping abdominal pain) should seek medical assistance as soon as possible and make sure they mention any recent travel history.
1. European Centre for Disease Prevention and Control. Outbreak of shiga toxin-producing E. coli (STEC) in Germany. 27 July 2011. [Accessed 29 July 2011]. Available at: http://ecdc.europa.eu/en/activities/sciadvice/Lists/ECDC%
2. Robert Koch Institut. Informationen zum EHEC/HUS-Ausbruchsgeschehen - Ende des Ausbruchs. [In German] 28 July 2011. [Accessed 29 July 2011]. Available at: http://www.rki.de/cln_162/nn_205760/DE/Home/Info-HUS,templateId=raw,property=publicationFile.pdf/Info-HUS.pdf
3. Institut de Veille Sanitaire. Bilan final sur les cas groupés d’infections à Escherichia coli entéro-hémorragique (EHEC) en Gironde, 26 Juillet 2011 [In French] [Accessed 29 July 2011]. Available at: http://www.invs.sante.fr/Dossiers-thematiques/Maladies-infectieuses/Risques-infectieux-d-origine-alimentaire/Syndrome-hemolytique-et-uremique/Actualites/Bilan-final-sur-les-cas-groupes-d-infections-a-Escherichia-coli-entero-hemorragique-EHEC-en-Gironde-26-juillet-2011
4. European Centre for Disease Prevention and Control. Rapid Risk Assessment Update, 8 July 2011. [Accessed 29 July 2011]. Available at: http://ecdc.europa.eu/en/publications/Publications/
5. European Commission. E. coli outbreak: EU withdraws Egyptian seeds from the market and temporarily bans their import. Press Release. 5 July 2011. [Accessed 29 July 2011]. Available at:
6. The Food Standards Agency. Agency updates advice on E. coli O104. 21 July 2011. [Accessed 29 July 2011]. Available at: http://www.food.gov.uk/news/newsarchive/2011/jul/
7. Statens Serum Institut (SSI), To danskere smittet med VTEC O104 i Danmark. [In Danish] 7 July 2011. [Accessed 29 July 2011]. Available at: http://www.ssi.dk/Aktuelt/Nyheder/2011/2011_07_VTEC-udbrud_070711.aspx
8. Statens Serum Institut (SSI), The Danish Ministry of Health and Prevention. Temaside om udbrud med Escherichia coli VTEC O104. [In Danish] 15 July 2011. [Accessed 29 July 2011]. Available at: http://www.ssi.dk/Aktuelt/Temasider/Udbrud%20med%20
9. Health Protection Agency. Update on E. coli outbreak in Germany. Press releases [online]. [Accessed 29 July 2011]. Available at: http://www.hpa.org.uk/NewsCentre/NationalPressReleases/
10. World Health Organization Regional Office for Europe. Outbreaks of E. coli O104:H4 infection: update 30. 22 July 2011. [Accessed 29 July 2011]. Available at: http://www.euro.who.int/en/what-we-do/health-topics/emergencies/international-health-regulations/news/news/2011/07/outbreaks-of-e.-coli-o104h4-infection-update-30
11. World Health Organization. Factsheet on EHEC [online]. [Accessed 29 July 2011]. Available at: http://www.who.int/mediacentre/factsheets/fs125/en/
12. European Food Safety Authority (EFSA). EFSA publishes report from its Task Force on the E. coli O104:H4 outbreaks in Germany and France in 2011 and makes further recommendations to protect consumers. Press Release. 5 July 2011. [Accessed 29 July 2011]. Available at: http://www.efsa.europa.eu/en/press/news/110705.htm
Health Protection Agency: Haemolytic uraemic syndrome