Bettina Rosner

Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany

BACKGROUND We describe an outbreak of gastroenteritis and the hemolytic-uremic syndrome caused by Shiga-toxin-producing Escherichia coli in Germany in May, June, and July, 2011. The consumption of sprouts was identified as the most likely vehicle of infection. METHODS We analyzed data from reports in Germany of Shiga-toxin-producing E. coli gastroenteritis and the hemolytic-uremic syndrome and clinical information on patients presenting to Hamburg University Medical Center (HUMC). An outbreak case was defined as a reported case of the hemolytic-uremic syndrome or of gastroenteritis in a patient infected by Shiga-toxin-producing E. coli, serogroup O104 or serogroup unknown, with an onset of disease during the period from May 1 through July 4, 2011, in Germany. RESULTS A total of 3816 cases (including 54 deaths) were reported in Germany, 845 of which (22%) involved the hemolytic-uremic syndrome. The outbreak was centered in northern Germany and peaked around May 21 to 22. Most of the patients in whom the hemolytic-uremic syndrome developed were adults (88%; median age, 42 years), and women were overrepresented (68%). The estimated median incubation period was 8 days, with a median of 5 days from the onset of diarrhea to the development of the hemolytic-uremic syndrome. Among 59 patients prospectively followed at HUMC, the hemolytic-uremic syndrome developed in 12 (20%), with no significant differences according to sex or reported initial symptoms and signs. The outbreak strain was typed as an enteroaggregative Shiga-toxin-producing E. coli O104:H4, producing extended-spectrum beta-lactamase. CONCLUSIONS In this outbreak, caused by an unusual E. coli strain, cases of the hemolytic-uremic syndrome occurred predominantly in adults, with a preponderance of cases occurring in women. The hemolytic-uremic syndrome developed in more than 20% of the identified cases.

Epidemiology of reported Yersinia enterocolitica infections in Germany, 2001-2008

BackgroundYersiniosis is the third most common zoonotic bacterial disease in Germany and the European Union. Sequelae of Yersinia enterocolitica infections, such as reactive arthritis, have been reported. Consumption of pork and its products, especially eaten raw or undercooked, is an important risk factor of yersiniosis. Infection with Y. enterocolitica is notifiable through the national surveillance system for infectious diseases in Germany and several thousands of cases are being reported each year. We present recent data on the epidemiology of reported yersiniosis in Germany.MethodsSurveillance data on yersiniosis, accessed through the national level database (SurvNet), were analyzed with regard to time trends, demographical and geographical distribution, serotypes, and hospitalization, for the time period 2001-2008.ResultsA total of 47,627 cases of yersiniosis were reported. The mean annual incidence of yersiniosis was 7.2/100,000 population. A downward trend in the number of reportable cases has occurred since 2002. Almost all Y. enterocolitica infections were reported as single cases, i.e., with no apparent links to other cases. The number of reported infections showed substantially less seasonal variation than in other zoonotic enteric diseases. The incidence was highest in children under five years (58/100,000 population), in particular in one-year-old children (108/100,000 population). Almost 97% of infections were acquired domestically. High incidences occurred in the eastern German federal states Thuringia, Saxony, and Saxony-Anhalt. Differences in incidences across federal states were driven primarily by incidence differences in children under five years. Hospitalization was reported for 17% of cases, the proportion being highest among teenagers. Almost 90% of Y. enterocolitica strains were diagnosed as serotype O:3, which is the serotype most frequently isolated from pigs.ConclusionsYersiniosis is a zoonotic foodborne disease of relevance to public health in Germany because of its high incidence and risk for sequelae. The incidence of reported yersiniosis in Germany varies markedly from state to state, mainly due to incidence difference among young children. More research efforts should be directed towards the elucidation of risk factors of yersiniosis in this age group.

A multi-country outbreak of Salmonella Newport gastroenteritis in Europe associated with watermelon from Brazil, confirmed by whole genome sequencing: October 2011 to January 2012

In November 2011, the presence of Salmonella Newport in a ready-to-eat watermelon slice was confirmed as part of a local food survey in England. In late December 2011, cases of S. Newport were reported in England, Wales, Northern Ireland, Scotland, Ireland and Germany. During the outbreak, 63 confirmed cases of S. Newport were reported across all six countries with isolates indistinguishable by pulsed-field gel electrophoresis from the watermelon isolate.A subset of outbreak isolates were whole-genome sequenced and were identical to, or one single nucleotide polymorphism different from the watermelon isolate.In total, 46 confirmed cases were interviewed of which 27 reported watermelon consumption. Further investigations confirmed the outbreak was linked to the consumption of watermelon imported from Brazil.Although numerous Salmonella outbreaks associated with melons have been reported in the United States and elsewhere, this is the first of its kind in Europe.Expansion of the melon import market from Brazil represents a potential threat for future outbreaks. Whole genome sequencing is rapidly becoming more accessible and can provide a compelling level of evidence of linkage between human cases and sources of infection,to support public health interventions in global food markets.

Relevance of Campylobacter to public health—The need for a One Health approach

Campylobacter species belong to the most important foodborne bacteria which cause gastroenteritis in humans in both developed and developing countries. With increasing reporting rates, the public awareness towards Campylobacter infections is growing continuously. This strengthens the necessity to establish intervention measures for prevention and control of thermophilic Campylobacter spp. along the food chain, as in particular poultry and poultry meat represent a major source of human infections. An interdisciplinary One Health approach and a combined effort of all stakeholders are necessary to ultimately reduce the burden of campylobacteriosis cases in humans. Numerous studies point out, however, that at present a complete elimination of Campylobacter in the food chain is not feasible. The present aim should therefore be to establish control measures and intervention strategies to minimize the occurrence of Campylobacter spp. in livestock (e.g. poultry flocks) and to reduce the quantitative Campylobacter burden in animals and foods. To this end, a combination of intervention methods at different stages of the food chain appears most promising. That has to be accompanied by targeted consumer advice and education campaigns to raise the awareness towards Campylobacter infections.

An outbreak of Salmonella Newport associated with mung bean sprouts in Germany and the Netherlands, October to November 2011.

The largest Salmonella enterica serovar Newport outbreak (n=106) ever reported in Germany occurred in October and November 2011. Twenty associated cases were reported in the Netherlands. The outbreak investigation included an analytical epidemiological study, molecular typing of human and food isolates and food traceback investigations. Unspecified Salmonella had been detected in samples of mung bean sprouts at a sprout producer (producer A) in the Netherlands and mung bean sprouts contaminated with S. Newport had been found during routine sampling at a sprout distributor in Germany. Therefore, we tested the hypothesis of sprouts being the infection vehicle. In a case-control study, we compared 50 notified adult S. Newport cases with 45 Salmonella enterica serovar Enteritidis cases regarding their food consumption in the three days before illness. In multivariable logistic regression analysis, only sprout consumption was significantly associated with S. Newport infection (odds ratio: 18.4; 95% confidence interval: 2.2-150.2). Molecular typing patterns of human isolates were indistinguishable from a mung bean sprouts isolate. Traceback of sprouts led to distributors and producer A in the Netherlands. Since sprouts are frequently contaminated with microorganisms, consumers need to be aware that consumption of raw or insufficiently cooked sprouts may pose a health risk.

Risk factors for sporadic Yersinia enterocolitica infections, Germany 2009-2010

Yersinia enterocolitica is an important cause of acute gastrointestinal disease and post-infectious complications. In Germany, incidence of reported yersiniosis is relatively high compared with other countries of the European Union. Children aged <5 years are most frequently affected. The aim of our study was to identify risk factors for sporadic yersiniosis in Germany. A population-based case-control study was conducted in five federal states of Germany from April 2009 to June 2010. Cases exhibiting gastrointestinal symptoms were notified to the local health department with a Yersinia enterocolitica infection culture-confirmed from stool. Controls were selected from population registries and frequency-matched on age group and state of residency. Cases and controls received a questionnaire on possible risk factors by mail. Multivariable logistic regression modelling was used to identify risk factors and to calculate adjusted odds ratios (aORs). Population attributable fractions (PAFs) were estimated for exposures associated with yersiniosis. We analysed data on 571 case patients and 1798 controls. Consumption of raw minced pork, a dish frequently consumed even by young children in Germany, was the main risk factor for disease (aOR 4·7, 95% confidence interval (CI) 3·5-6·3, PAF 30%). This association varied by age group and, unexpectedly, was strongest for children aged <2 years (aOR 17·5, 95% CI 6·0-51·2). Other independent risk factors included recent preparation of minced pork in the household (aOR 1·4, 95% CI 1·1-1·9, PAF 21%), playing in a sandbox (aOR 1·7, 95% CI 1·3-2·4, PAF 17%), and contact with birds (aOR 1·7, 95% CI 1·1-2·6, PAF 4%). Prevention efforts should specifically target parents and caregivers of young children and focus on the high infection risk associated with consumption of raw minced pork.

Clinical aspects and self-reported symptoms of sequelae of Yersinia enterocolitica infections in a population-based study, Germany 2009–2010

BackgroundFoodborne Yersinia enterocolitica infections continue to be a public health problem in many countries. Consumption of raw or undercooked pork is the main risk factor for yersiniosis in Germany. Small children are most frequently affected by yersiniosis. In older children and young adults, symptoms of disease may resemble those of appendicitis and may lead to hospitalization and potentially unnecessary appendectomies. Y. enterocolitica infections may also cause sequelae such as reactive arthritis (ReA), erythema nodosum (EN), and conjunctivitis.MethodsWe studied clinical aspects of yersiniosis, antimicrobial use, and self-reported occurrence of appendectomies, reactive arthritis, erythema nodosum and conjunctivitis. To assess post-infectious sequelae participants of a large population-based case–control study on laboratory-confirmed Y. enterocolitica infections conducted in Germany in 2009–2010 were followed for 4 weeks.ResultsDiarrhea occurred most frequently in children ≤4 years (95%); abdominal pain in the lower right quadrant was most common in children 5–14 years of age (63%). Twenty-seven per cent of patients were hospitalized, 37% were treated with antimicrobials. In 6% of yersiniosis patients ≥5 years of age, appendectomies were performed. Self-reported symptoms consistent with ReA were reported by 12% of yersiniosis patients compared to 5% in a reference group not exposed to yersiniosis. Symptoms consistent with EN were reported by 3% of yersiniosis patients compared to 0.1% in the reference group. Symptoms of conjunctivitis occurred with the same frequency in yersiniosis patients and the reference group.ConclusionsAcute Y. enterocolitica infections cause considerable burden of illness with symptoms lasting for about 10 days and hospitalizations in more than a quarter of patients. The proportion of yersiniosis patients treated with antimicrobial drugs appears to be relatively high despite guidelines recommending their use only in severe cases. Appendectomies and post-infectious complications (ReA and EN) are more frequently reported in yersiniosis patients than in the reference group suggesting that they can be attributed to infections with Y. enterocolitica. Physicians should keep recent Y. enterocolitica infection in mind in patients with symptoms resembling appendicitis as well as in patients with symptoms of unclear arthritis.

Associations of Age and Sex With the Clinical Outcome and Incubation Period of Shiga toxin–producing Escherichia coli O104:H4 Infections, 2011

We pooled data on adults who reported diarrhea or developed life-threatening hemolytic uremic syndrome (HUS) in any of 6 closed cohorts from 4 countries (1 cohort each in Denmark, France, and Sweden and 3 in Germany) that were investigated during a large outbreak of Shiga toxin-producing Escherichia coli (STEC) O104:H4 infection in 2011. Logistic regression and Weibull regression for interval censored data were used to assess the relation of age and sex with clinical outcome and with incubation period. Information on the latter was used in a nonparametric back-projection context to estimate when adult cases reported in Germany were exposed to STEC O104:H4. Overall, data from 119 persons (median age, 49 years; 80 women) were analyzed. Bloody diarrhea and HUS were recorded as the most severe outcome for 44 and 26 individuals, respectively. Older age was significantly associated with bloody diarrhea but not with HUS. Woman had nonsignificantly higher odds for bloody diarrhea (odds ratio = 1.81) and developing HUS (odds ratio = 1.83) than did men. Older participants had a statistically significantly reduced incubation period. The shortest interval that included 75% of exposures in adults spanned only 12 days and preceded outbreak detection. In conclusion, the frequency of bloody diarrhea but not of HUS and the length of the incubation period depended on the age of individuals infected with STEC O104:H4. A large number of people were exposed to STEC O104:H4 for a short period of time.

Hormonal contraceptive use among adolescent girls in Germany in relation to health behavior and biological cardiovascular risk factors.

PURPOSE To determine the association between hormonal contraceptive (HC) use, and behavior-related and biological cardiovascular risk factors among teenage girls in Germany. METHODS HC use was assessed among 2,285 girls aged 13-17 years who participated in the health survey for children and adolescents (German Health Interview and Examination Survey for Children and Adolescents, KiGGS), between years 2003 and 2006. Prevalence of HC use was determined according to sociodemographic variables, behavior-related health risks, and overweight status. We compared HC users and nonusers with respect to biological cardiovascular risk factors, including systolic and diastolic blood pressure, and serum concentrations of lipids, lipoproteins, high sensitivity C-reactive protein (hs-CRP), and homocysteine. RESULTS HC users were more likely than nonusers to combine several behavior-related health risks, independent of sociodemographic factors. In particular, HC use was strongly associated with current smoking (odds ratio: 3.4, 95% confidence interval: 2.7-4.3). HC use and behavioral factors showed an additive effect on biological cardiovascular risk factors, explaining between 6% and 30% of the population variance. Relative contributions of HC use ranged from <1% for systolic and diastolic blood pressure to 12% for hs-CRP. CONCLUSIONS HC use among 13-17-year-old girls in Germany is significantly correlated with a more unfavorable cardiovascular risk profile, which is partly explained by a clustering of behavioral risk factors among HC users. When prescribing HC to teenagers, physicians should systematically assess avoidable behavioral cardiovascular risk factors and provide counseling tailored to the risk profile of the individual patient.

Erratum to: Ergebnisbericht der Task Force EHEC zur Aufklärung des EHEC O104:H4 Krankheitsausbruchs in Deutschland

Im Folgenden wird uber die Ergebnisse der Arbeit der Task Force EHEC bei der lebensmittelseitigen Aufklarung des EHEC O104:H4 Krankheitsausbruchs in Deutschland berichtet. In der ersten Phase der Ausbruchsaufklarung ging es darum, das mit EHEC O104:H4 behaftete Lebensmittel zu identifizieren. Hierbei wurden von der Task Force parallel zwei Strategien verfolgt. Zum einen wurde fur funf ausgewahlte Ausbruchsorte mit mehreren Erkrankten eine detaillierte Ruckverfolgung fur dort abgegebene Salatbestandteile und rohes Gemuse durchgefuhrt, um Gemeinsamkeiten von Lebensmitteln und Lieferketten aufzudecken. Zum anderen wurden Sprossenlieferungen eines Gartenbaubetriebes in Niedersachsen verfolgt um zu ermitteln, ob Ausbruchsorte mit diesen beliefert wurden. Beide strategische Ansatze haben zur Erkenntnis gefuhrt, dass mit EHEC O104:H4 kontaminierte Sprossen aus einem Gartenbaubetrieb in Niedersachsen mit hoher Wahrscheinlichkeit den Krankheitsausbruch verursacht haben. In der zweiten Phase der Ausbruchsaufklarung wurde die Quelle des Ausbruchserregers gesucht. Die Task Force EHEC formulierte Empfehlungen zum Eliminieren der Ausbruchsquelle und wertete epidemiologische Informationen zur Eingrenzung des Zeitraums, in welchem die Quelle aktiv war, aus. Weiterhin wurde die Ruckverfolgung von verdachtigen Samenarten, die bei der Sprossenproduktion im niedersachsischen Gartenbaubetrieb eingesetzt wurden, initiiert. Diese Ermittlungsergebnisse flossen als Grundlage in die von der Europaischen Behorde fur Lebensmittelsicherheit koordinierte Ruckverfolgung von Sprossensamen im Rahmen der Ausbruchsaufklarung in Frankreich und Deutschland ein, welche aus Agypten importierte Bockshornkleesamen als vermutliche gemeinsame Ursache der Ausbruche identifizierte. Die von der Task Force EHEC entwickelte neue Strategie fur die Ausbruchsaufklarung mit der engen Zusammenarbeit von Bundes- und Landesbehorden und zwischen Gesundheitsbehorden, Lebensmitteluberwachungsbehorden und Wissenschaftlern ist ein Erfolgsmodell mit Zukunft.