Multidisciplinary response to the E. coli O104 outbreak in Europe

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.

Most German E. coli-in-sprouts patients have recovered well, except for the 50 who died

 Maybe something was lost in translation, but Prof. Christian Gerloff, Head of Neurology at the Hamburg-Eppendorf University Hospital (UKE), told the annual congress of the German Society for Neurology in Wiesbade on Sept. 28, 2011, that despite their life-threatening infection, most E. coli O104-in-raw-sprouts patients have recovered well from the summer’s epidemic.

The professor described how the wave of illness, caused by contaminated bean sprouts, was new territory for neurology. The neurology department had to help "in the crisis management of an epidemic for the first time."

According to the Robert Koch Institute, almost 3,500 EHEC cases were registered in Germany between May and July 2011. 50 patients, who were infected with the aggressive intestinal germ, died of the disease.

Gerloff stated that, of the around 100 patients who were treated for the most intense course of the disease, only three are still displaying symptoms, such as paralysis or lalopathy. He explained that everyone else has recovered very well.

In each case, the illness began with diarrhea. However, every third patient was also hit by a life-threatening kidney failure –hemolytic-uremic syndrome (HUS). In addition, every sixth patient developed acute neurological disorders; in some cases seizures, in other cases epileptic fits, said Gerloff. "Patients fell into a coma within a few days."

Gerloff also reported that some EHEC cases resulted in neurological disorders without HUS. As such, the disorders do not always relate to the kidney failure.

Babies and bearded dragons don’t mix: outbreak of reptile-associated Salmonella Tennessee, Germany 2008

 In early 2008, eight cases of Salmonella Tennessee were reported in infants in Germany; normally there is about one case per year.

Using a case–control study to identify the source of infection, German researchers report in the current issue of Vector-Borne and Zoonotic Diseases they identified 18 cases less than 3-years-old. Ten children were male; median age was 3 months (1–32 months). In 8 of 16 case households reptiles were kept. Although direct contact between child and reptile was denied, other forms of reptile contact were reported in some cases. Identical Salmonella Tennessee strains of child and reptile kept in the same household could be shown in 2 cases.

The researchers conclude that indirect contact between infants and reptiles seems to be sufficient to cause infection and should therefore be avoided.

EU to lift ban on Egyptian sprout seeds after E. coli scare devastation, no safety evidence provided

Why are outbreaks of foodborne illness, like when 53 are killed and 4,400 sickened from eating sprouts produced in Germany from Egyptian seeds, referred to in media reports as ‘scares.’

This wasn’t a scare, it was a sprout shitstorm. Neither the first nor last.

Afrique en ligne reports the European Union will soon lift a ban on Egyptian sprout seeds after an EU delegation, which just wrapped up a visit to Egypt, produces a report in about 10 days.

Egypt’s Agriculture Export Council chairman, Sherif Al-Beltaguy stated that the national reports from agricultural and health authorities on seeds in Egypt were good and that the EU delegation found them acceptable.

Egypt had denied responsibility for the E.coli outbreak, saying the suspected batch dated back to November 2009 and contained dried seeds, arguing the bacteria could not have survived for so long.

I look forward to some sort of data, especially E. coli testing of germinated seeds.
 

Germany’s E. coli nightmare: Too often, politics trumps safety

The Aug/Sept. issue of Food Quality magazine contains a package of articles about lessons learned from this year’s E. coli O104 outbreak in Germany linked to raw sprouts grown from seeds produced in Egypt.

My own contribution was an attempt, at the editor’s request, to capture the uncertainty and vagaries that characterize outbreaks of food- or waterborne illness.

My friend Jim called on a Friday afternoon. Jim is a dairy farmer located on the edge of a town in Ontario, Canada, called Walkerton, and he said a lot of people were getting sick. The community knew there was a problem several days before health types went public.

On Sunday, May 21, 2000, at 1:30 p.m., the Grey Bruce Health Unit in Owen Sound, Ontario posted a notice on its website to hospitals and physicians to make them aware of a boil water advisory and inform them that a suspected agent in the increase of diarrheal cases was E. coli O157:H7.

There had been a marked increase in illness in the town of about 5,000 people, and many were already saying the water was suspect. But because the first public announcement was also the Sunday of the Victoria Day long weekend, it received scant media coverage.

It wasn’t until Monday evening that local television and radio began reporting illnesses, stating that at least 300 people in Walkerton were ill.

At 11 a.m. on Tuesday, May 23, the Walkerton hospital held a media conference jointly with the health unit to inform the public of the outbreak, to make people aware of the potential complications of the E. coli O157:H7 infection, and to warn them to take the necessary precautions. This generated a print report in the local paper the next day, which was picked up by the national wire service Tuesday evening, and subsequently appeared in papers across Canada on May 24.

These public outreach efforts were neither speedy nor sufficient. Ultimately, 2,300 people were sickened and seven died—in a town of 5,000. All the gory details and mistakes and steps for improvement were outlined in the report of the Walkerton inquiry
(www.attorneygeneral.jus.gov.on.ca/english/about/pubs/walkerton).

The E. coli O157:H7 was thought to have originated on a farm owned by a veterinarian and his family at the edge of town, someone my friend Jim knew well, a cow-calf operation that was the poster farm for Environmental Farm Plans. Heavy rains washed cattle manure into a long abandoned well-head, which was apparently still connected to the municipal system. The brothers in charge of the municipal water system for Walkerton, who were found to have been adding chlorine based on smell rather than something minimally scientific like test strips, were criminally convicted.

But the government-mandated reports don’t capture the day-to-day drama and stress that people like my friend experienced. Jim and his family knew many of the sick and dead. This was a small community. News organizations from around the province descended on Walkerton for weeks. They had their own helicopters, but the worst was the medical helicopters flying patients with hemolytic uremic syndrome to the hospital in London. Every time Jim saw one of those, he wondered if it was someone he knew.

I’m not an epidemiologist, but as a scientist and journalist with 20 years of contacts, I usually find out when something is going on in the world of foodborne outbreaks.

The uncertainties in any outbreak are enormous, and the pressures to get it right when going public are tremendous.

The public health folks in Walkerton may have been slow by a couple of days while piecing together the puzzle; what happened in Germany this summer in the sprout-related outbreak of E. coli O104, a relative of O157, was a travesty.
Worse, bureaucrats seemed more concerned about the fate of farmers than that of citizens. By at least one count, 53 have died, and more than 4,200 have been sickened.

Raw sprouts are one of the few foods I won’t eat, and as many epidemiologists have pointed out, sprouts top the list of any investigation involving foodborne illness.

We at bites count at least 55 outbreaks related to raw sprouts beginning in the U.K. in 1988, sickening thousands.

The first consumer warning about sprouts was issued by the U.S. Centers for Disease Control and Prevention (CDC) in 1997. By July 9, 1999, the U.S. Food and Drug Administration (FDA) had advised all Americans to be aware of the risks associated with eating raw sprouts. Consumers were informed that the best way to control the risk was to not eat raw sprouts. The FDA stated that it would monitor the situation and take any further actions required to protect consumers.

At the time, several Canadian media accounts depicted the U.S. response as panic, quoting Health Canada officials as saying that, while perhaps some were at risk, sprouts were generally a low-risk product.

That attitude changed in late 2005, as I was flying back to reunite with a girl I had met in Kansas and 750 people in Ontario became sick from eating raw bean sprouts.

Unfortunately, what food safety types think passes for common knowledge—don’t eat raw sprouts—barely registers as public knowledge. It’s hard to compete against food porn.

Sprouts present a special food safety challenge because the way they are grown, with high moisture at high temperature, also happens to be an ideal environment for bacterial growth.

Because of continued outbreaks, the sprout industry, regulatory agencies, and the academic community in the U.S. pooled their efforts in the late 1990s to improve the safety of the product, implementing good manufacturing practices, establishing guidelines for safe sprout production, and beginning chemical disinfection of seeds prior to sprouting.

But are such guidelines being followed? And is anyone checking?

Doubtful.

This was demonstrated by two sprout-related outbreaks earlier this year linked to sandwiches served by Jimmy John’s, a chain of gourmet sandwich shops based in Champaign, Ill.

Sprouts served on Jimmy John’s sandwiches supplied by a farm called Tiny Greens sickened 140 people with Salmonella, primarily in Indiana. In January, Jimmy John’s owner Jimmy John Liautaud said his restaurants would replace alfalfa sprouts, effective immediately, with allegedly easier-to-clean clover sprouts. This was one week after a separate outbreak of Salmonella sickened eight people in the U.S. Northwest who had eaten at a Jimmy John’s that used clover sprouts.

If the head of a national franchise is that clueless about food safety, can we really expect more from others?

Sprout grower Bill Bagby, who owns Tiny Greens Sprout Farm, said in the context of the German outbreak that, for many like him, the nutritional benefits outweigh the risk:

“Sprouts are kind of a magical thing. That’s why I would advise people to only buy sprouts from someone who has a (food safety) program in place (that includes outside auditors). We did not have (independent auditors) for about one year, and that was the time the problems happened. The FDA determined that unsanitary conditions could have been a potential source of cross-contamination and so we have made a lot of changes since then.”

Independent auditors? Like the ones who said everything was cool, everything was OK, at Peanut Corporation of America (nine dead, 700 sick in 2008-09) and Wright County Egg (2,000 sick in 2010)?

Like the Walkerton E. coli O157:H7 outbreak in 2000, too many are using the filters of their politics to advance their own causes and saying too many dumb things in light of the sprout outbreak of 2011.

It’s really about biology and paying attention to food safety basics—no matter how much that interferes with personal politics.

I wouldn’t: Germany says it’s OK to eat sprouts

Amy e-mailed me from Australia last night – or during the day for her what with a 15-hour time difference – to tell me she had a sandwich and didn’t notice until the last bite that it was stacked with sprouts, and to remind her of this if she got sick in a couple of days.

So after 53 deaths and some 4,300 illnesses, Germany has decided it’s OK to eat raw sprouts again –just not the ones from fenugreek seeds from Egypt. How would a consumer eating a sandwich know where the sprout seeds originate, when it appears most sprouters don’t know where their seeds originate.

A table of sprout-related outbreaks is available at http://bites.ksu.edu/sprouts-associated-outbreaks.
 

German E. coli farm reopens, but is risk contained

The farm at the epicenter of the German sprout storm that has killed 53 and sickened over 4,000 from E. coli O104 is sparkling clean to reopen after testing and removal of all fenugreek seeds.

But as science-types have pointed out, the farm may function with the clarity and cleanliness of Marie Antoinette’s but that won’t prevent future outbreaks if the seeds themselves are contaminated.

As reported by the European Food Safety Authority (EFSA), despite the epidemic curve’s trending down, the outbreak can’t be considered over. The ultimate source — the contaminated seeds from which salad sprouts were grown — has been so widely distributed that no one really knows where they have gone or for how long they might remain for sale. One prediction, based on the probable package labeling, is that they could remain on shelves for 3 more years.

Wired magazine reported the first wave of cases, in Germany in May, arose from a firm that grew and sold sprouts at wholesale. The sprouts from that farm would subsequently be linked to 41 separate clusters of cases; all of them could be traced back to that facility’s sprouts, re-sold as a produce item somewhere in Europe.

A second wave, in France in June, initially confounded investigators. Out of those 16 cases, 11 had attended the same event. They did eat sprouts there — but not sprouts from the German farm. Instead, the sprouts had been grown by the event’s catering firm, from seeds the company had bought at an everyday garden center.

That shifted the focus from the German farm’s practices to the seeds that both the farm and the caterer used. The German farm sold two blends of grown sprouts, spicy (grown from fenugreek and radish seeds and black and brown lentils) and mild (fenugreek and alfalfa seeds, adzuki beans and lentils). The French caterer had used three seed types: fenugreek, mustard and rocket (or roquette; what Americans call arugula). The only type in common with both companies and all the mixtures was fenugreek.

That discovery sent EU investigators in pursuit of fenugreek seeds back down the European food chain, in a rapid-fire search that deployed personnel from eight countries’ food agencies as well as the ECDC, World Health Organization and the Food and Agriculture Organization of the United Nations. They drafted a detailed 4-page questionnaire that fed data into Excel spreadsheets and a relational database. They crunched (and crunched and crunched) the numbers, and this is what emerged:

All of the seeds came from a single shipment that left a port in Egypt almost 2 years earlier, on Nov. 24, 2009.

The seeds took a tortuous path. That initial shipment — which was immense, 15,000 kg (33,000 lbs) — was containerized at the port of Damietta in Egypt, shipped by boat to Antwerp in Belgium, went by barge to Rotterdam in the Netherlands where it passed customs, and then was trucked to Germany. There, an importer broke up the shipment:
10,500 kg to a single German distributor;
3,550 kg to nine other German companies;
375 kg to a Spanish company;
250 kg to an Austrian distributor that sold the entire lot to a single Austrian company;
and 400 kg to a company in England.

The German importer broke up the 10,500-kg shipment into multiple lots. Only 75 kg ended up at the German farm that sparked the first wave of illness. The rest went to 16 other companies. One of those 16 broke its shipment up further, selling the seeds on to 70 additional companies: 54 in Germany, 16 in 11 other countries within the EU.

A new report details the complexities of the E. coli O104 outbreak investigation. Thanks to Albert Amgar in France for sending it along.

Source food from safe sources; including seeds and other inputs.

Cook sprouts: Egyptian seeds most likely source of deadly E. coli

A single shipment of fenugreek seeds from Egypt is the most likely source of a highly toxic E. coli epidemic in Germany which has killed 49 people and of a smaller outbreak in France, European investigators said on Tuesday.

The European Food Safety Authority urged the European Commission to make "all efforts" to prevent any further consumer exposure to suspect seeds and advised consumers not to eat sprouts or sprouted seeds unless they are thoroughly cooked.

Reuters reports more than 4,100 people in Europe and in North America have been infected in two outbreaks of E. coli infection — one centred in northern Germany and one focused around the French city of Bordeaux.

Almost all of those affected in the first outbreak — the deadliest on record — lived in Germany or had recently travelled there. The infection has killed 48 people in Germany and one person in Sweden so far.

"The analysis of information from the French and German outbreaks leads to the conclusion that an imported lot of fenugreek seeds which was used to grow sprouts imported from Egypt by a German importer is the most common likely link," the EFSA said in a statement.

A consignment of fenugreek seeds, from the batch believed to be the source of the EHEC infection in Germany and France, has been tracked to Sweden, according to the Swedish National Food Administration.

The seeds have been recalled but 25 kilos have already arrived in Sweden. The National Food Administration has contacted the company Econova in Norrköping, who in their turn have stopped the sales and recalled already delivered bags of seeds.

Egypt denies its seeds caused E.coli 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.
 

Sprouts must be cooked to avoid E.coli: EU food agency

European Union food safety and disease prevention agencies joined a mounting chorus today and said, don’t eat raw sprouts, as clues emerged about the origin of seeds.

AFP reports the two bodies conducted a study and said that they "strongly recommend to advise consumers not to grow sprouts for their own consumption and not to eat sprouts or sprouted seeds unless they have been cooked thoroughly."

The report by the European Food Safety Authority in Italy and the European Centre for Disease Prevention and Control in Sweden said sprouts are often sold as mixes and "during re-packaging cross-contamination cannot be excluded."

Meanwhile CIDRAP reports new trace-back investigations in German and French E. coli outbreaks are pointing to two lots of fenugreek seeds that were imported from Egypt, according to the latest threat assessment from European officials.

Sprouts from Egyptian fenugreek seeds are suspected in both a cluster of French E coli O104:H4 illnesses and the large outbreak in Germany involving the same strain, the European Centre for Disease Prevention and Control (ECDC) and the European Food Safety Authority (EFSA) said in a risk assessment today. But the agencies cautioned that there is no lab evidence yet tying the seeds to the outbreaks.

The ECDC and the EFSA said they have urgently requested that the German-based company that imported the seeds help them track other customers who received fenugreek seeds from the two lots.

Officials suspect that Egyptian fenugreek seeds imported in 2009 are linked to the French E coli cluster and that a batch from 2010 is linked to the German outbreak. The ECDC identified the seed importer as AGA SAAT GMBH, based in Dusseldorf, Germany. It said a UK company that reportedly supplied the sprout seeds linked to the French cluster obtained the seeds from AGA SAAT GMBH.