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Bureaucracy in (non) action: lessons learned from the 2011 outbreak of E. coli O104:H4 in sprouted seeds

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Considering the outrageous scale of the E. coli O104 outbreak in sprouts, the lessons learned are incredibly banal.

The Commission of the European Communities writes in a new report that from May to July 2011, a major outbreak occurred in the European Union due to contamination of sprouted seeds by Shiga toxin-producing Escherichia coli (STEC) O104:H4 with clusters in the North of Germany and in the Bordeaux region in France.

Based on the date of onset, the outbreak started in Germany at the beginning of May and reached a peak on 22 May 2011. On 22 June 2012, an increase of hemolytic-uremic syndrome (HUS) and bloody diarrhea cases was also reported in the Bordeaux region of France. A few days later the strain was identified as the same as in German outbreak.

As soon as the outbreak was notified, the German and Länder health services were mobilized, launching of alert systems at all levels (local, national, EU and international) and all parties involved collaborated intensively. The German Robert Koch Instituted reported 855 cases of HUS and 2987 cases of bloody diarrhoea (without HUS), including 53 fatalities in Germany in its final presentation and evaluation on the outbreak. An additional 54 HUS (incl. 2 deaths) and 83 diarrhoea cases were reported through the European Centre for Disease Prevention and Control (ECDC) as linked to the German cluster in other countries of Europe, Canada and the United States. The Bordeaux cluster counted for 24 cases, including 7 HUS.

The losses for farmers in the fruit & vegetable sector were estimated at least 812 Million (Mio) € in the first 2 weeks. In addition a temporary export ban of vegetables to Russia occurred, constituting an annual value of 600 Mio €.

The objective of this document is to indicate possible actions from the EU to prevent similar outbreaks or to limit their scale and to be better prepared for food-borne outbreaks in general. Actions are also needed to strengthen coordination between the health and food safety authorities in line with the "One Health" principle.

And these are the big lessons learned:

• strengthen EU capacities to ensure protection of citizens against cross border health threats;
• awareness of the need for improvement of hygiene in food of non-animal origin including primary production and import by better enforcement of existing hygiene provisions;
• enhanced preparedness through regular practical exercises involving all key players in an outbreak;
• respect of responsibilities and involvement of all partners in outbreak management;
• better co-ordinated and clear communication;
• improve tools of market intervention and product promotion to reduce reaction time to crises outbreak and thereby limit the negative economic impact on the EU sector; and,
• strengthen public-private initiatives linking producers (incl. processing, retail and trade) and citizen/consumers to increase awareness and enhance communication and knowledge.

None of these would have presented the outbreak, although may limited things. And nowhere is the probable cause addressed: that sprout seeds themselves can become contaminated.

Reform falters in Europe after 53 deaths from E. coli O104 in sprouts

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In May, 2011, the delayed reporting of cases between agencies due to a decentralized government and its agencies was a contributing factor in the Germany-based E. coli O104 outbreak that led to 53 deaths and over 4,000 sick people. The E. coli strain responsible for the outbreak was unusually virulent, with high mortality and hemolytic uremic syndrome (HUS) rates observed in healthy adults.

A year later, Marian Turner writes in Nature that governments have made little progress towards improving the monitoring and reporting systems that allowed the crisis to drag on for weeks.

Although the panic has sparked some proposed policy changes, these have become mired in political debate at both German and European levels.

Under Germany’s current system, it can take up to 18 days for local and state health departments to relay case reports to the Berlin-based Robert Koch Institute (RKI), the German federal agency for disease surveillance. Legislators have proposed a law to bring the country’s disease-reporting schedule into line with the World Health Organization’s International Health Regulations. The law would require local health authorities to report cases of notifiable diseases to state authorities on the next working day; the states would then have another day to relay the information to the RKI. “We’ve been waiting almost a decade for this,” says Alexander Kekulé, a microbiologist at the Martin Luther University of Halle-Wittenberg in Halle, Germany.

The draft law has been passed by Germany’s federal parliament but is stuck in negotiations at the legislative council that represents Germany’s 16 states. For scientists, though, this change would still not be enough. “What really delayed the detection of this outbreak was the irregularity with which patients were referred for microbiological follow-up,” says Gérard Krause, an epidemiologist at the RKI. Like many European countries, Germany does not require that a patient with bloody diarrhoea or haemolytic uraemic syndrome (a life-threatening complication of some E. coli infections) be tested for the causative bacterial strain. The same is true of the United States.

After the outbreak, German diagnostic laboratories were provided with kits to test samples for genes belonging to certain pathogenic strains of bacteria, such as those expressing particular toxins, or proteins involved in adhesion or invasion.

But physicians are responsible for requesting the tests, and the cost is not covered by German health-insurance companies. “The problem is mostly getting the money to use these kits,” says Angelika Fruth, a microbiologist at the RKI, “and that situation is just the same as before the outbreak.”

In the wake of the outbreak, the European Food Safety Authority concluded that sprouted seeds pose a particular food-safety concern, and recommended that a standardized test for sprouts be developed and adopted across the European Union (EU). But EU member countries are still discussing the proposal, and scientists have yet to develop reliable methods to isolate pathogenic bacteria from seeds or sprouts.

Foodborne Clostridium botulinum intoxication from mass produced foodstuffs in Europe

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It’s botulism week at Eurosurveillance as the on-line journal summarizes three different and recent Europe-based botulism outbreaks, which represents an alarming increase over previous years.

In an overview editorial, Cowden notes the incidence of botulism in the European Union (EU) is described elsewhere, but that from 2006 and 2008, 477 confirmed cases were notified: an average of 119 cases per year, with a range of 104 to 132, and no discernable trend.

The surveillance of cases of botulism in the EU includes the three main forms of the disease but does not distinguish between them.

Food-borne botulism is caused by the ingestion of toxin produced by organisms in an anaerobic environment. It usually results from inadequately sterilised domestically canned or bottled foods.

Intestinal botulism is caused by the production in the gut of toxin by organisms which have been ingested and have proliferated. This form predominantly affects infants under a year old, often associated with the consumption of honey.

Wound botulism is caused by the production of toxin by organisms introduced into wounds. This is often associated with dirty wounds, including those following injecting drug use.

Since 2009, Eurosurveillance has published only four reports of outbreaks of food-borne botulism in Europe and only three resulted from consumption of widely distributed, commercially produced foods.

Despite only one of the four outbreaks being due to domestically prepared food, home-preserved food is generally acknowledged to be the major cause of botulism in those EU countries that have had most cases in recent years and outbreaks resulting from mass produced foods are rare.

Against this background, from September to November 2011, there were three outbreaks in three different countries in Europe. In the outbreaks which feature in this issue of Eurosurveillance, the vehicles of intoxication were demonstrated, on the basis of strong toxicological and descriptive epidemiological evidence, to have been widely distributed, commercially produced foods.

These three outbreaks present intriguing differences and similarities.

In two outbreaks, the Finnish and the Scottish, cases were confined to single households. In France cases occurred in two household clusters.

In the French and Finnish outbreaks the vehicles included olives: olive tapenades in the French outbreak, and almond-stuffed olives in the Finnish. In the Scottish outbreak, the vehicle was korma sauce.

In all three outbreaks the vehicle of intoxication was marketed in glass jars with screw-top lids.

In the French and the Scottish outbreaks the food was produced and distributed within the country of origin. In the Finnish outbreak, the food was distributed internationally from another country, Italy.

In the Finnish and the Scottish outbreaks the food was produced in industrialized units. In the French outbreak the producer was described as an “artisanal producer” although the tapenade was commercially produced and widely distributed.

In the French and the Scottish outbreaks the toxin was type A. In the Finnish outbreak it was type B.

In two outbreaks, the Finnish and the French, defects potentially explaining the contamination were identified. In the Finnish outbreak, seals in other jars from the same batch were found to have defects, although none was found to be contaminated. In the French outbreak an improper sterilization process was identified. In the Scottish outbreak the food originated from a state-of-the-art food-production facility where intensive investigation has yet to find any shortcomings, and no post-production event has been identified which could explain the contamination.

The number of cases in all three outbreaks was surprisingly low if a production fault is assumed to have affected the production of at least a whole batch of jars.

This is particularly true of the Scottish outbreak where only one household was affected, and which could be explained by the contamination of a single jar from a batch of 1,836 jars. Likewise, the Finnish outbreak affected a single household, and could be explained by only one contaminated jar of stuffed olives, despite the batch being part of a lot of 900 imported into Finland, and the product having been exported to many countries in Europe and beyond.

Only in the French outbreak does the contamination of more than one jar need to be hypothesized to explain the cases – and even here, contamination of only two jars could explain the cases. The size of the batch in the French outbreak was approximately 60 pots.

The other 3 outbreak write-ups are available at the urls below, and full-text, as always, on bites-l.

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20035

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20034

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20036

EU gives thumbs up to Egyptian fenugreek sprout seed

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 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.

Cheetos or norovirus? Raw oyster risk

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Proving again that risk comparisons are risky and that maybe raw oysters are as dangerous as Cheetos, Eurosurveillance today reports on the fourth norovirus-related outbreak linked to raw oysters in recent memory – and there’s a bunch of them.

Since January 2010, 334 cases in 65 clusters were reported from five European countries: the United Kingdom, Norway, France, Sweden and Denmark. The article describes the available epidemiological and microbiological evidence of these outbreaks.

?Oysters are grown in coastal waters of several countries and are considered a delicacy in most parts of the world. Like all bivalve molluscs, they feed by filtering large amounts of water through their gills. In situ studies with bioaccumulation of a virus indicator in oysters have shown that oysters can concentrate viruses up to 99 times compared to the surrounding water [1]. In water contaminated with norovirus, this leads to the accumulation of the virus within the flesh and gut of the oyster.

Norovirus has been detected in 5 to 55% of oysters from Europe and the United States (US) by random sampling at market places and oyster farms [2-4]. The detection of norovirus in oysters follows the same seasonal trend as the norovirus epidemiology in the general population, i.e. norovirus in oysters is generally detected between October and February [1, 12].

Seventy-eight percent of shellfish-related illness from noroviruses in the US between 1991 and 1998 were associated with the consumption of oysters harvested between the months of November and January [1]. Contamination of oyster beds with noroviruses can occur after heavy rains cause flooding, which results in combined sewer overflow or hydraulic overload in sewage treatment plants [5, 13]. There are also examples of oyster harvesters disposing sewage into oyster-bed waters causing multi-state outbreaks of norovirus in the US [6]. Noroviruses are difficult to remove from oysters through cleansing and also stay infectious [7]. Oysters are often eaten raw, creating the potential for foodborne enteric virus infections.

From January to March 2010, the European Centre for Disease Prevention and Control (ECDC) was informed through its Food- and Waterborne Diseases and Zoonoses (FWD) surveillance network about norovirus outbreaks linked to consumption of oysters in five EU/EEA countries: the United Kingdom (UK), Norway, France, Sweden and Denmark. In total 65 small clusters involving 334 cases were reported. Most cases had eaten oysters in restaurants. …

??In conclusion, an increased number of norovirus outbreaks related to the consumption of oysters have been observed at EU level in the last three months. … consuming raw oysters involves potential exposure to norovirus and is particularly hazardous for immunocompromised or chronically ill persons. Therefore, countries might consider informing the public about the risks linked with consuming raw oysters.

Or Cheetos.

As James Wesson, oyster scientist with the Virginia Marine Resource Commission, told the Daily Press the other day,

"More people die each year from eating Cheetos than from eating oysters.”

No data was provided.