People who forgot to mention they had eaten sprouts may have thrown disease trackers off the trail as they sought to trace the source of the deadly strain of E. coli that sickened more than 4,300 people and killed at least 50 in Europe this year, according to a study published in the New England Journal of Medicine.

While a definitive genetic link remains elusive, three separate lines of investigation point to sprouts as the means by which the deadly O1O4:H4 strain of the bacteria was spread, researchers led by Udo Buchholz at the Robert Koch Institute in Berlin, Germany’s disease-control agency.

Buchholz and colleagues wrote, “The one dish that frequently exposed guests to sprouts was the side salad, which contained tomatoes, cucumbers, three sorts of leaf salads, and sprouts. Sprouts may have been the ingredient that visitors recalled least in such a mixed salad.”

Buchholz and colleagues conducted three studies in parallel. The first involved asking patients hospitalized with E. coli infection about their recent food consumption, and comparing that with food eaten by uninfected people. It found that “the only significant variable was sprouts.”

The second study identified 10 groups of diners who ate at a restaurant in Luebeck between May 12 and 16. It found that among 115 people who had been served sprouts, 31 fell ill, compared with none of those who had not eaten sprouts.

The third investigation traced 41 clusters of infections to a producer in Lower Saxony, who grew sprouts from seeds that came from a “supplier X,” Buchholz and colleagues wrote, without identifying either the producer or the supplier. A European Commission task force said in July that the sprouts were probably grown from fenugreek seeds imported from Egypt in 2009. The researchers still don’t know whether the seeds were contaminated before, during or after export from Egypt.

In an accompanying editorial, Martin J. Blaser, M.D. from the Departments of Medicine and Microbiology, New York University, writes the chain of transmission appears to have begun in Egypt, with fecal contamination of fenugreek seeds by either humans or farm animals during storage or transportation, perhaps as long ago as 2009. The seeds then went to a European distributor and from there to farms in several countries. During sprout germination, bacteria multiplied and moved from farm to restaurants and consumers, as Buchholz et al. extensively detail in their study. The evidence for such a series of events is compelling, even though the organism was not identified at the earliest steps, since the trail often is cold in point-source outbreaks by the time investigators are able to conduct trace-back investigations.

German outbreak of Escherichia coli O104:H4 associated with sprouts
26.oct.11
The New England Journal of Medicine
Udo Buchholz, M.D., M.P.H., Helen Bernard, M.D., Dirk Werber, D.V.M., Merle M. Böhmer, Cornelius Remschmidt, M.D., Hendrik Wilking, D.V.M., Yvonne Deleré, M.D., Matthias an der Heiden, Ph.D., Cornelia Adlhoch, D.V.M., Johannes Dreesman, Ph.D., Joachim Ehlers, D.V.M., Steen Ethelberg, Ph.D., Mirko Faber, M.D., Christina Frank, Ph.D., Gerd Fricke, Ph.D., Matthias Greiner, D.V.M., Ph.D., Michael Höhle, Ph.D., Sofie Ivarsson, M.Sc., Uwe Jark, D.V.M., Markus Kirchner, M.D., M.P.H., Judith Koch, M.D., Gérard Krause, M.D., Ph.D., Petra Luber, Ph.D., Bettina Rosner, Ph.D., M.P.H., Klaus Stark, M.D., Ph.D., and Michael Kühne, D.V.M., Ph.D.
http://www.nejm.org/doi/full/10.1056/NEJMoa1106482?query=featured_home
Human infection with Shiga-toxin–producing Escherichia coli is a major cause of postdiarrheal hemolytic–uremic syndrome. This life-threatening disorder, which is characterized by acute renal failure, hemolytic anemia, and thrombocytopenia, typically affects children under the age of 5 years. Shiga-toxin–producing E. coli O157 is the serogroup that is most frequently isolated from patients with the hemolytic–uremic syndrome worldwide.1
In May 2011, a large outbreak of the hemolytic–uremic syndrome associated with the rare E. coliserotype O104:H4 occurred in Germany.2-5 The main epidemiologic features were that the peak of the epidemic was reached on May 21 and May 224,5 and that the vast majority of case subjects either resided or had traveled in northern Germany. Almost all patients from other European countries or from North America had recently returned from northern Germany.2,6,7 Of the affected case subjects, 90% were adults, and more than two thirds of case subjects with the hemolytic–uremic syndrome were female.4
Early studies in Hamburg suggested that infections were probably community-acquired and were not related to food consumption in a particular restaurant. A first case–control study that was conducted on May 23 and 24 suggested that raw food items, such as tomatoes, cucumbers, or leaf salad,3 were the source of infection. The consumption of sprouts, which was previously implicated in outbreaks of Shiga-toxin–producing E. coli in the United States8 and Japan,9 was mentioned by only 25% of case subjects in exploratory interviews, so consumption of sprouts was not tested analytically.
This report describes the investigations that were conducted by the federal agencies under the auspices of the German Ministry of Health and the Ministry of Food, Agriculture, and Consumer Protection, as well as by the respective state agencies, to identify the vehicle of infection of this international outbreak.

Fresh from a months-long tour of Europe – or at least one part of Germany – Dr. Chuck Dodd returns to Kansas State to share his experiences from the E. coli O104 outbreak in raw sprouts centered in Germany earlier this year, which killed 53 people and sickened some 4,400.

Dr. Dr. Dodd (DVM, PhD, right, pretty much as shown) is the program manager for veterinary services in the U.S. Army Public Health Command Region – Europe. He will speak at 4 p.m. on Thurs. Oct. 13, 2011 in 407 Trotter Hall, in the College of Veterinary Medicine at Kansas State University. My team will be on-hand to record the talk and, technology willing, throw it up on the web.

 The E. coli O104 outbreak that killed 53 people and sickened over 4,000, primarily in Germany, was apparently caused by – nothing.

While strong epidemiological evidence pointed to raw sprouts grown from fenugreek seeds imported from Egypt and distributed anywhere and everywhere, a European fact-finding commission has, at least according to this story, cleared Egyptian fenugreek seeds as the source.

All tests conducted by a technical team sent by the European Union and the World Health Organisation (WHO) to Egypt last month to probe allegations on the presence of highly-toxic E. coli bacteria in Egyptian fenugreek seed have turned up negative, said Salah Mu`awad, the chief of the Egyptian Agriculture Ministry services and follow up division.

The EU had banned the entry of Egyptian grains after suspecting a batch of Egyptian fenugreek seeds was the source of the E. coli outbreak in Spain and Germany in May.

Egypt has since been repeatedly calling for lifting the ban, saying that its fenugreek imports to Europe do not carry the E.coli microbe and promising to fully cooperate with the EU in investigating the real cause of the outbreak.

As the death toll in the German E. coli O104 sprout outbreak rose to 50 with 4,121 ill including 845 with hemolytic uremic syndrome, Egypt's ministry of agriculture said, don’t blame Egypt.

The head of Egypt's Central Administration of Agricultural Quarantine, Ali Suleiman, said claims by the European Food Safety Authority (EFSA) that Egyptian fenugreek seeds exported in 2009 and 2010 may have been implicated in the outbreak were "completely untrue."



"The presence of this bacteria in Egypt has not been proven at all, and it has not been recorded. He said the Egyptian company that exported the seeds in 2009 has stressed in a letter that it had exported the fenugreek to Holland and not to Germany, Britain or France.



On Wednesday, the EFSA said a "rapid risk assessment" it conducted with the European Centre for Disease Prevention and Control (ECDC), had shown the Egyptian seeds could have been to blame.

The U.K. Food Standards Agency reiterated its advice that sprouted seeds should not be eaten raw, while Bloomberg reports that crudités – fancy French word for raw vegetables -- eaten at a children’s center in Bordeaux are helping doctors in their two-month hunt for the source of the outbreak.

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said, “Fenugreek is showing up clearly in the French outbreak and showing up clearly in the German outbreak.”

The link to fenugreek, a clover-like plant used as both an herb and a spice, was identified after disease investigators found it was served at an event attended by patients in the Bordeaux suburb of Begles.

A cold buffet was served consisting of crudites, or raw vegetables, three dips, industrially produced gazpacho, a choice of two cold soups, pasteurized fruit juices and individual dishes composed of white grapes, tomatoes, sesame seeds, chives, industrially produced soft cheese and fruit, the report said.

The soups were served with fenugreek sprouts, a small amount of which were also placed on the crudite dishes. Mustard and rocket sprouts, still growing on cotton wool, were used to decorate the dishes, the authors said.

The sprouts had been grown from rocket, mustard and fenugreek seeds planted at the center the previous week. The seeds were bought from a branch of a national chain of gardening retailers, having been supplied by a distributor in the U.K., the authors said.

The European agencies advised consumers not to grow sprouts for their own use or to eat sprouts or sprouted seeds unless they have been thoroughly cooked.