E.Coli Outbreaks - Preventable or Fact of Life?

Jul 21, 2011 | HWN Team | Insider
E.Coli Outbreaks - Preventable or Fact of Life?

image by: VeeDunn

Despite advances in medical science, bugs such as E. coli will always be one step ahead of us. Every now and then they will emerge with a vengeance as they spread illness and in extreme cases, death. Always try to find out where your produce comes from and never assume that your food is clean

In the last 15 years, serious E. coli outbreaks have been reported all over the world. Sporadic outbreaks have occurred with loss of life in the past, but have been localized. The 2011 European outbreak is a harsh reminder that the 'global food plate' is here to stay and that no country is immune. In fact, the origin of the European outbreak was eventually traced back to fenugreek seeds from Egypt.

E coli is a natural human enteroflora and more than 700 strains of this species are normally harmless and even beneficial to man. In fact, E. coli is a fecal coliform bacterium species that resides in the intestine of many mammals, including humans, and aids in our digestion and even helps protect us from "bad" bacteria like Salmonella. In some cases, people consuming fecally contaminated food or water may suffer from mild diarrhea that eventually resolves by itself. In the United States the O157:H7 E. coli strain probably sickens close to 100,000 people every year.1

However, our bacterial friends can mutate into a formidable foe.  It is speculated that globalization, ease of travel and the widespread import-export of fresh food products enable bacteria to travel wide distances. Along with the rapid generation time of bacteria, recombination can occur with different strains thereby mutating into forms to which the human body is not adapted or immune to. And this is probably compounded by the overwhelming and at times indiscriminate use of antibiotics in the last 50 to 60 years which in itself has fostered E coli to mutate and develop strong resistance to antibiotics.

These strains of virulent E. coli go by many different names, such as:

  • enterohemorrhagic E. coli (EHEC)
  • Shiga-like toxin-producing E. coli (STEC or SLTEC)
  • Hemolytic uremic syndrome (HUS) – associated enterohemorrhagic E. coli (HUSEC

Symptoms include severe bloody diarrhea which may be followed by hemolytic uremic syndrome (HUS) with serious complications such as kidney failure, bleeding, anemia, paralysis, seizures, coma and death. Treating patients with antibiotics actually aggravates the illness because the bacteria react by releasing the Shiga toxin in large amounts.

The E. coli strain that caused the E. Coli outbreak in Germany was identified as O104:H4 EHEC, a very rare but highly virulent strain which is also highly resistant to antibiotics. Using high-speed DNA sequencing techniques, Chinese researchers identified the pathogen as an exceptionally virulent form of Escherichia coli (E. coli). This EHEC was actually a new strain, a chimera or hybrid strain, genetically closely related to a strain previously identified in the Central African Republic.2,3

The CDC describes the course of the disease as follows: Symptoms of STEC infection include stomach cramps, diarrhea (which is often bloody), and vomiting. If there is fever, it usually is not very high. Most people get better within 5-7 days, but some patients will develop HUS, usually about a week after the diarrhea starts.4

The 2011 'Germany' outbreak claimed 50 lives and affected over 4000 people. It is estimated that over 800 patients required dialysis in the Germany outbreak and many, as a last resort, required exchange transfusions which led to blood shortages at many hospitals. The following chain of events points out that the 'Germany' outbreak was different. Not only was it widespread but it also had devastating consequences both in medical and economic terms.5

May 18 – A patient was admitted to a hospital in Hamburg, a city located in northern Germany with symptoms including severe diarrhea with blood. Later on, severe complications including kidney damage developed. The case was suspicious enough to trigger an alarm of a possible infectious disease.

In the days that followed, hospitals reported cases to the Robert-Koch Institute (RKI), which is the German equivalent of the U.S. Center for Disease Control and Prevention (CDC). Laboratory DNA tests indicated a virulent mutant form of Escherichia coli as the culprit causing the infection, indicating that the infection was food-borne.  The strain was eventually identified as the O104:H4 EHEC.

Several more cases were reported in northern Germany as well as other parts of Europe. Of interest patients outside Germany had recently visited the disease region. German health authorities and food regulators, research institutes and clinics conducted an intensive search for the source of the infection.

The investigation was conducted from different avenues simultaneously, namely:

  • Patients were intensively interviewed regarding their lifestyle and their recent activities, especially in terms of diet.
  • Clinics and research institutes, especially RKI, worked around the clock to identify and characterize the pathogen and figure out possible treatment options.
  • Health authorities inspected the residences of the patients looking for clues.
  • Sentinel surveillance systems were established in emergency departments all over the country.
  • Restaurants where patients ate were inspected, the staff interviewed.

May 25 – A statement was issued by the German Federal Institute for Risk Assessment implicating cucumbers, tomatoes, and lettuce as the possible source of the infection. A warning was issued against consumption of these vegetables. The common denominator among the patients was salad consumption.

May 31 – After analyzing over 4600 vegetable samples, EHEC was isolated from two cucumbers from Spain. Sales of Spanish fresh produce plummeted, leading to protests from farmers all over the EU. The identification turned out to be false positive. It was not the pathogen but a closely related strain. Russia suspended exporting fresh produce from the EU. The number of patients increased to the thousands, with more than 20 fatalities in Germany and one in Sweden.

June 10 – Soya sprouts found in the fridge of an infected family tested positive for O104:H4 EHEC. The sprouts were traced to an organic farm where a worker was also hospitalized for HUS. For the first time, a clear link between product and patients were found. Health authorities issued warning against soya sprouts and declared cucumbers and tomatoes as safe.

June 14 – RKI reports a decreasing trend for HUS hospitalization. The investigation as how the sprouts got infected is still ongoing. Contamination may be from the processing water, from humans, or from the original soya beans themselves. More than 3000 were ill, many seriously, mostly in Germany but also in other parts of Europe. The outbreak so far caused 32 deaths. The latest statement from RKI recommended "not eating uncooked sprouts until this potential source of the contamination has been thoroughly investigated".

Number of HUS and non-HUS STEC cases and associated deaths per EU/EEA Member State as of 15 June 2011 6

EU Member States 
reporting cases
Number of HUS cases (deaths) Number of non-HUS STEC cases (deaths)
Austria 1 (0) 3 (0)
Czech Republic 0 (0) 1 (0)
Denmark 8 (0) 12 (0)
France 0 (0) 2 (0)
Germany 784 (23) 2 470 (13)
Greece 0 (0) 1 (0)
Luxembourg 1 (0) 1 (0)
The Netherlands 4 (0) 4 (0)
Norway 0 (0) 1 (0)
Poland 2 (0) 1 (0)
Spain 1 (0) 1 (0)
Sweden 17 (1) 30 (0)
The United Kingdom 3 (0) 3 (0)
Total 821 (24) 2 530 (13)


July 22 – WHO released the latest numbers – 50 deaths and 4075 total cases.7

The German health authorities were severely criticized as to how they handled the crisis. "During an outbreak like this, weaknesses in the food control system are brutally exposed", said Dr. Patrick Wall, former chief of the European Food Safety Authority (EFSA) at a recent Institute of Food Technologists (IFT) 2011 conference in New Orleans. Conflicting and inaccurate statements led to a lot of confusion, not only in Europe but all over world. The Europe outbreak also caused a major setback... it had a negative impact on consumer trust for 'healthy products' because the source of the infection was fresh produce.8,9

Spanish farmers claimed they lost more than 220 million Euros due to the false accusations by the German health authorities and demanded payment. Organic farms all over Europe were also affected, as media hype suggested that organic produce was more likely to be contaminated than conventional food, because the farmer uses organic fertilizer (manure!).10

In Canada, food inspectors at the Canadian Food Inspection Agency (CFIA) checked fresh vegetables – not only sprouts – coming in through its borders. Of course the focus was only on European imports. According to the CFIA: "Incoming shipments from the European Union will be identified and the CFIA will intensify sampling and testing these products for the presence of Shiga toxin-producing Escherichia coli, the E. coli strain linked to the outbreak in Europe. "If any products are determined to be a health risk, the CFIA will work with importers and distributors to help ensure these products do not reach the Canadian marketplace".11

In the U.S. the U.S. Dept of Agriculture was pressured to expand surveillance - currently primarily focused on E. coli O157:H7 - to other virulent strains including the EHEC O104:H4.

OK, so what needs to be done to avoid a repeat of the 'Germany 'outbreak?

New ways to safeguard the 'global food plate' are required. Irradiation of foods is back on the table. Nuking does eliminate E coli and other food –borne bugs, but is not universal in the food industry due to the' Chernobyl or Fukushima' effect. And new technology is on the way to trace where your food comes from.12

Along the same vein, the Food and Drug Administration is developing new regulations, likely to be issued by 2012, which will take care of the usage of manure, control of livestock, employee hygiene and water quality, among other concerns.

Don't just depend on the food safety agencies or even our usual consumer watchdogs who "fiddled while European food safety burned". Try to find out where your food comes from and become acquainted with some of the other consumer watchdog organizations:

And new treatment options for E. coli outbreaks are needed – fast. Scientists at the Center for Pediatrics and Adolescent Medicine in Heidelberg, Germany may have found a yet untested treatment that saved many of the severely ill, especially children. "…they successfully treated three EHEC-infected children suffering from HUS with a novel approach. They used the monoclonal antibody Eculizumab, which has been on the market since 2007, to treat a rare blood disorder. Eculizumab inhibits a part of the human immune system called the complement system that usually destroys invading cells that have been tagged for destruction by other parts of the immune system".13,14

The Bottom Line

Always clean your food. Remember, those who got sick in the Germany outbreak were the 'healthy eaters'. And, if possible, find out where your fruit, veggies and even meat come from and be selective where you purchase your produce. The 'global food plate' is here to stay.

Published July 21, 2011, updated April 20, 2012


  1. E. coli 0157  in North America, MicrobeWiki
  2. Tribe D,  BGI Sequencing news: German EHEC strain is a chimera created by horizontal gene transfer, Biofortified, 02 June, 2011  
  3. Frank C et al, Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany, N Engl J Med 2011; 365:1771-1780, November 10, 2011
  4. Investigation Update: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany, CDC 08 July 2011
  5. Tracking the Rise of Extreme E.coli Infection, EHEC Bacteria
  6. Outbreak of Shiga toxin-producing E. coli in Germany, European Centre for Disease Prevention and Control (EDEC), 15 June 2011
  7. Outbreaks of E. coli O104:H4 infection: update 30, WHO, JUly 22, 2011
  8. Moore T, Steam & Bean Sprouts: On the Trail of the Killer Bacteria, TimeWorld, June 08, 2011
  9. Goetz G, Germany's E. coli Outbreak: A Global Lesson, Food Safety News, June 28, 2011
  10. E. coli: Germany says worst of illness is over. BBC 8 June 2011
  11. Canadian inspectors testing Europe veggies for E. coli, CTV News, June 03, 2011
  12. O'Brien J, Field to the fork: Tracking produce back to farmers, BBC News, 04 March 2011
  13. Kupferschmidt K, On the Fly, German Doctors Find Treatment for Deadly E. coli Infections, Science Now, 27 May 2011
  14. Lapeyraque AL et al, Complement Blockade in Severe Shiga-Toxin–Associated HUS, N Engl J Med 2011; 364:2561-2563


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