June 15, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated June 15, 2011

As of June 14, 2011, Germany’s Robert Koch Institute (RKI)* reports 784 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli or STEC infections–and 23 deaths associated with HUS. In the United States, four confirmed cases and one suspect case of STEC O104:H4 infections have been identified. No deaths have been reported. RKI has announced that contaminated raw sprouts were the source of the outbreak. The German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany has been lifted as of June 10.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC).  As of June 14, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 784 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli or STEC infections–and 23 HUS-associated deaths.

In the United States, four confirmed cases and one suspect case of STEC O104:H4 infections have been identified. Of these five cases, four recently traveled to Hamburg, Germany, where they were likely exposed. The bacterial isolates from the three HUS cases reported in Massachusetts, Michigan, and Wisconsin and one case with Shiga toxin-positive diarrheal illness in Michigan have been confirmed as matching the outbreak strain. The Michigan case with Shiga toxin-positive diarrheal illness did not travel to Germany, but is a close contact of the Michigan case with HUS.  Their diarrheal illness developed later and was likely acquired through contact with the HUS case.  The suspect case is currently under investigation.

Among U.S. military personnel and their dependents that are stationed in Germany, there are no confirmed cases at this time. Continuous monitoring has shown no increase in visits due to gastrointestinal illness at U.S. military medical treatment facilities in Europe.

CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany and since April 1, 2011. Additionally, CDC is working with state health departments to learn more about suspect cases and obtain bacterial isolates for further characterization. When a report of STEC infection is investigated, every effort is made to identify ill family members or other close contacts to determine if person-to-person spread has occurred. With this outbreak, only one instance of person-to-person spread has been documented.

RKI, the Federal Institute for Risk Assessment and the Federal Office of Consumer Protection and Food Safety have announced there is substantial epidemiologic and traceback evidence indicating that fresh sprouts produced by a farm in Lower Saxony are responsible for the current outbreak in Germany. German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Trace back investigations of the food chain indicate that no sprouts or other food items from the implicated farm in Lower Saxony have been exported outside Germany. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany has been lifted as of June 10.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

Any person who has recently traveled to Germany or has been in recent contact with an ill person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS, should seek medical care. He or she should tell the medical provider about the outbreak in Germany and the importance of asking the laboratory to test a stool specimen for STEC. 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 go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color of skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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June 7, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated June 7, 2011

As of June 6, 2011, case counts confirmed by Germany’s Robert Koch Institute* includes 642 patients with hemolytic uremic syndrome (HUS) ? a type of kidney failure that is associated with E. coli or STEC infections ? and 15 deaths associated with STEC O104:H4 infection.In the United States, one confirmed and three suspected cases of STEC O104:H4 infections have been identified in persons who recently traveled to Hamburg, Germany, where they were likely exposed.At this time, a specific food has not been confirmed as the source of the infections. German public health authorities advise against eating raw sprouts, tomatoes, cucumbers, and leafy salads from sources in northern Germany until further notice.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC). As of June 6, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 642 patients with hemolytic uremic syndrome (HUS) – a type of kidney failure that is associated with E. coli or STEC infections – and 15 deaths.

In the United States, one confirmed and three suspected cases of STEC O104:H4 infections have been identified in persons who recently traveled to Hamburg, Germany, where they were likely exposed. One case of HUS in Massachusetts has been confirmed as matching the German outbreak strain. Among the three suspected cases, two are cases of HUS, one case each in Michigan and Wisconsin. The third suspected case, a person with Shiga toxin-positive diarrheal illness, is still under investigation.

CDC is working with state health departments to learn more about these suspected cases and obtain bacterial isolates from them for further characterization. In addition, CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany since April 1, 2011.

At this time, a specific food has not been confirmed as the source of the outbreak. Based on German epidemiologic and traceback investigations, several fresh produce items are currently under further investigation. On June 5, the Lower Saxony Ministry of Agriculture reported that the results of an investigation into the distribution chain of a local producer suggest the consumption of sprouts from a single farm may be associated with the outbreak there. Travelers to Germany should be aware that the German public health authorities have advised against eating raw sprouts, tomatoes, cucumbers, and leafy salads from sources in northern Germany until further notice. United States public health and regulatory authorities currently have no indication that any of these foods have been shipped from Europe to the United States.

The U.S. Department of Defense has been notified of this outbreak because of the presence of U.S. military bases in Germany; there are no known confirmed cases among U.S. military personnel or their dependents at this time. However, reports indicate that a small number of U.S service members in Germany with diarrheal illness are currently under investigation. For travel information related to this outbreak, please view the article on CDC Travelers’ Health Website.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

Any person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested for STEC. Symptoms of STEC infection include severe 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 go on to develop HUS?usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color to skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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March 10, 2011: Multistate Outbreak of E. coli O157:H7 Infections Associated with In-shell Hazelnuts

March 10, 2011

Laboratory testing conducted by the Minnesota Department of Agriculture on in-shell hazelnuts recovered from a patient's home has identified Escherichia coli O157:H7 matching patient isolates by DNA analysis.No new cases of persons infected with the outbreak strain of E. coli serotype O157:H7 have been reported since the web announcement on March 5, 2011.

CDC is collaborating with public health officials in California, Michigan, Minnesota, Wisconsin, and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of E. coli O157:H7 infections. Investigators are using DNA analysis of E. coli O157:H7 bacteria obtained through diagnostic testing to identify cases of illness that may be part of this outbreak.

As of March 9, 2011, seven persons infected with the outbreak strain of E. coli serotype O157:H7 have been reported from Michigan (1 case), Minnesota (3 cases), and Wisconsin (3 cases). Reported dates of illness onset range from December 20, 2010 to January 28, 2011. Ill persons range in age from 15 to 78 years, with a median age of 62 years; 86% are male. Among ill persons, 43% reported being hospitalized, and none have reported hemolytic uremic syndrome, a type of kidney failure that is associated with E. coli O157:H7 infections. No deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after February 22, 2011, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 3 weeks. Please see the Timeline for Reporting of E. coli Cases for more details.

Collaborative investigative efforts of local, state, and federal public health and regulatory agencies have associated this outbreak with eating in-shell hazelnuts (also known as filberts). Most of the in-shell hazelnuts were purchased from bulk bins at retail food stores. Source tracing has identified a common distributor for the hazelnuts consumed by ill persons: DeFranco & Sonss in Los Angeles, California. Laboratory testing conducted by the Minnesota Department of Agriculture on in-shell hazelnuts recovered from a patient's home has identified E. coli O157:H7 matching patient isolates by DNA analysis.

DeFranco & Sons of Los Angeles, CA is voluntarily recalling bulk and consumer-packaged in-shell hazelnuts and mixed-nut products containing hazelnuts. These nuts may have been sold by retailers nationwide. The in-shell nuts may have been sold in two-pound and four-pound packages of mixed nuts, one-pound packages containing only hazelnuts, or in open bins of nuts in grocery stores. Consumers are advised to review the DeFranco press release for a list of recalled products.

Most people infected with E. coli O157:H7 develop diarrhea (often bloody) and abdominal cramps 2-8 days (3-4 days, on average) after swallowing the organism, but some illnesses last longer and are more severe. Infection is usually diagnosed by stool sample culture. While most people recover within a week, some develop a severe infection. A type of kidney failure called hemolytic uremic syndrome (HUS) can begin as the diarrhea is improving; this condition can occur among persons of any age but is most common in children under 5 years old and the elderly. Signs and symptoms of HUS may include fever, abdominal pain, pale skin tone, fatigue and irritability, small, unexplained bruises or bleeding from the nose and mouth, decreased urination and swelling of the face, hands, feet, or entire body. Persons who experience these symptoms and believe they are at risk for HUS should seek emergency medical care immediately.

Consumers should not eat any of the recalled products, and restaurants and food service operators should not serve them. Consumers, retailers, and others who have any of the recalled products should dispose of them in a closed plastic bag placed in a sealed trash can. This will prevent people or animals from eating them.

Additional Resources

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with FDA and U.S. Department of Agriculture’s Food Safety and Inspection Service. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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Multistate Outbreak of E. coli O157:H7 Infections Associated with Beef from JBS Swift Beef Company

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

Updated July 1, 2009 (FINAL Update)

Advice to Consumers

Several state health departments, CDC, and the United States Department of Agriculture's Food Safety and Inspection Service (USDA-FSIS) are investigating a multi-state outbreak of Escherichia coli O157:H7 infections. On June 24, FSIS issued a notice about a recall of 41,280 pounds of beef products from JBS Swift Beef Company that may be contaminated with E. coli O157:H7. On June 28, the recall was expanded to include 380,000 pounds of assorted pieces of beef (beef primal products) from the same company. Health officials in several states who were investigating reports of E. coli O157:H7 illnesses found that most ill persons had consumed ground beef, and many reported that it was undercooked. At least some of the illnesses appear to be associated with products subject to these recalls. Samples from unopened packages of ground beef recovered from a patient's home were tested by the Michigan Public Health Laboratory yielded an E. coli O157:H7 isolate that matched the "DNA fingerprint" of the outbreak strain.

Twenty three persons infected with a strain of E. coli O157:H7 with a particular "DNA fingerprint" have been reported from 9 states. Of these, 17 have been confirmed by an advanced DNA test as having the outbreak strain; confirmatory tests are pending on others. The number of ill persons identified in each state is as follows: California (4), Maine (1), Michigan (6), Minnesota (1), New Hampshire (1), New Jersey (2), New Mexico (1), New York (1) and Wisconsin (6).

Most ill persons reported consumption of ground beef, and many reported that it was undercooked. Ground beef with the outbreak strain was obtained from the home of one person infected with that strain. The first reported illness began on April 2, 2009, and the last began on June 13, 2009. Among 17 ill persons for whom hospitalization status is known, 12 (70%) were hospitalized. Two patients developed a type of kidney failure called hemolytic uremic syndrome (HUS). No deaths have been reported. Of patients with available information, 14 (64%) were male and 59% are less than 19 years old (range 2 to 74 years).

Most of the beef packages in the first recall bear the establishment number "Est. 969" inside the USDA mark of inspection and have identifying package dates of "042109" or "042209." Consumers are urged to check their refrigerators and freezers for beef products produced by this firm and purchased on or after April 21, 2009 and discard or return the recalled beef products to the place of purchase for a refund. The pieces of beef (primal beef products) in the expanded recall were produced on April 21, 2009, and were distributed nationally and internationally. Boxes of these pieces of beef bear the establishment number "EST. 969" inside the USDA mark of inspection, the identifying package date of "042109," and a time stamp ranging from "0618" to "1130." These pieces of beef were sold to retail stores nationwide after April 21, 2009, and some was probably cut again or made into ground beef, then re-packaged, so packages purchased by consumers may not have identifying information. Customers with questions about the source of a package of beef should contact the place where they purchased it (e.g., grocery store, club store, or meat market).

More information on the recalled products can be found at:

Eat ground beef or ground beef patties that have been cooked to a safe internal temperature of 160° F.

Use a thermometer to measure the internal temperature?it is the only way to be sure ground beef is cooked to a high enough temperature to kill harmful bacteria.Color is NOT a reliable indicator that ground beef or ground beef patties have been cooked to a temperature high enough to kill harmful bacteria such as E. coli O157:H7.

For more information go to Is It Done Yet? (USDA)*.

Refrigerate raw meat within two hours after purchase or within one hour if temperatures exceed 90° F. Refrigerate cooked meat and poultry within two hours after cooking.

Consumers who have questions about the recalled products can contact USDA-FSIS at "Ask Karen" online at http://www.askkaren.gov/* or call the Meat and Poultry Hotline at 1-888-MPHotline (674-6854). Because any raw ground beef can contain disease-causing germs, CDC and USDA-FSIS encourage consumers to use good food safety practices and to heed the following advice:

To keep food safe, remember to Clean, Separate, Cook, and Chill. For more food safety information visit www.BeFoodSafe.gov*.

* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

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March 5, 2011 [Announcement]: Multistate Outbreak of E. coli O157:H7 Infections Associated with In-shell Hazelnuts

Updated March 5, 2011

Introduction

CDC is collaborating with public health officials in California, Michigan, Minnesota, Wisconsin, and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of E. coli O157:H7 infections. Investigators are using DNA analysis of E. coli O157:H7 bacteria obtained through diagnostic testing to identify cases of illness that may be part of this outbreak.

As of March 4, 2011, seven persons infected with the outbreak strain of E. coli serotype O157:H7 have been reported from Michigan (1 case), Minnesota (3 cases), and Wisconsin (3 cases). Reported dates of illness onset range from December 20, 2010 to January 28, 2011. Ill persons range in age from 15 to 78 years, with a median age of 62 years; 86% are male. Among ill persons, 43% reported being hospitalized, and none have reported hemolytic uremic syndrome, a type of kidney failure that is associated with E. coli O157:H7 infections. No deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after February 17, 2011, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 3 weeks. Please see the Timeline for Reporting of E. coli Cases for more details.

Investigation of the Outbreak

Collaborative investigative efforts of local, state, and federal public health and regulatory agencies have associated this outbreak with eating in-shell hazelnuts (also known as filberts). Most of the in-shell hazelnuts were purchased from bulk bins at retail food stores. Source tracing has identified a common distributor for the hazelnuts consumed by ill persons: DeFranco & Sons in Los Angeles, California.

Recall Information

DeFranco & Sons of Los Angeles, CA is voluntarily recalling bulk and consumer-packaged in-shell hazelnuts and mixed-nut products containing hazelnuts. These nuts may have been sold by retailers nationwide. The in-shell nuts may have been sold in two-pound and four-pound packages of mixed nuts, one-pound packages containing only hazelnuts, or in open bins of nuts in grocery stores. Consumers are advised to review the DeFranco press release for a list of recalled products.

Clinical Features/Signs and Symptoms

Most people infected with E. coli O157:H7 develop diarrhea (often bloody) and abdominal cramps 2-8 days (3-4 days, on average) after swallowing the organism, but some illnesses last longer and are more severe. Infection is usually diagnosed by stool sample culture. While most people recover within a week, some develop a severe infection. A type of kidney failure called hemolytic uremic syndrome (HUS) can begin as the diarrhea is improving; this condition can occur among persons of any age but is most common in children under 5 years old and the elderly. Signs and symptoms of HUS may include fever, abdominal pain, pale skin tone, fatigue and irritability, small, unexplained bruises or bleeding from the nose and mouth, decreased urination and swelling of the face, hands, feet, or entire body. Persons who experience these symptoms and believe they are at risk for HUS should seek emergency medical care immediately.

Advice to Consumers, Retailers and Others

Consumers should not eat any of the recalled products, and restaurants and food service operators should not serve them. Consumers, retailers, and others who have any of the recalled products should dispose of them in a closed plastic bag placed in a sealed trash can. This will prevent people or animals from eating them.

Additional Resources

CDC's Role in Food Safety

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with FDA and U.S. Department of Agriculture’s Food Safety and Inspection Service. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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March 23, 2011: Multistate Outbreak of E. coli O157:H7 Infections Associated with Lebanon Bologna

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

March 23, 2011 (FINAL Update)

CDC is collaborating with public health officials in many states and the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA/FSIS) to investigate a multistate outbreak of Escherichia coli O157:H7 infections. Investigators are using DNA analysis of E. coli O157:H7 bacteria obtained through diagnostic testing to identify cases of illness that may be part of this outbreak.

As of March 22, 2011, 14 persons infected with the outbreak strain of E. coli serotype O157:H7 have been reported from Maryland (3 cases), New Jersey (2 cases), North Carolina (1 case), Ohio (2 cases) and Pennsylvania (6 cases). Reported dates of illness onset range from January 10, 2011 to February 15, 2011. Ill persons range in age from 1 to 70 years, with a median age of 13.5 years. Seventy-nine percent are male. Among 13 ill persons for whom information is known, 3 or 23%, reported being hospitalized, and none have reported hemolytic uremic syndrome (HUS), a type of kidney failure that is associated with E. coli O157:H7 infections. No deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after March 2, 2011, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 3 weeks. Please see the Timeline for Reporting of E. coli Cases for more details.

Collaborative investigative efforts of local, state, federal public health and regulatory agencies have associated this outbreak with eating Lebanon bologna. Lebanon bologna is a fermented, semi-dry sausage. This beef product has an appearance similar to salami. In an epidemiologic study conducted during March 15-18, a total of 13 ill persons answered questions about foods consumed during the days before becoming ill, and investigators compared their responses to those of 21 persons of similar age previously reported to state health departments with other illnesses ("controls"). Ill persons (69%) were significantly more likely than controls (0%) to report eating Lebanon bologna. Additionally, four ill persons have been identified who purchased Seltzer Brand Lebanon bologna at four different grocery store locations in three states before becoming ill.

Palmyra Bologna Company, of Palmyra, PA, is recalling approximately 23,000 pounds of Lebanon bologna products that may be contaminated with E. coli 0157:H7. Consumers are advised to review the USDA's FSIS Recall Press Release for a list of recalled products and images of the product.

Most people infected with E. coli O157:H7 develop diarrhea (often bloody) and abdominal cramps 2-8 days (3-4 days, on average) after swallowing the organism, but some illnesses last longer and are more severe. Infection is usually diagnosed by stool sample culture. While most people recover within a week, some develop a severe infection. A type of kidney failure called hemolytic uremic syndrome (HUS) can begin as the diarrhea is improving; this condition can occur among persons of any age but is most common in children under 5 years old and the elderly. Signs and symptoms of HUS may include fever, abdominal pain, pale skin tone, fatigue and irritability, small, unexplained bruises or bleeding from the nose and mouth, decreased urination and swelling of the face, hands, feet, or entire body. Persons who experience these symptoms and believe they are at risk for HUS should seek emergency medical care immediately.

Consumers should not eat any of the recalled products, and restaurants and food service operators should not serve them. Consumers, retailers, and others who have any of the recalled products should dispose of them in a closed plastic bag placed in a sealed trash can. This will prevent people or animals from eating them.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with FDA and FSIS.  CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with FDA and USDA/FSIS. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

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June 23, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated July 8, 2011 (FINAL Update)

As of July 5, 2011, Germany’s Robert Koch Institute (RKI)* reports 852 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing Escherichia coli, or STEC, infections–and 32 deaths associated with HUS. In the United States, six confirmed cases of STEC O104:H4 infections have been identified. Among these six cases, one death has been reported in an Arizona resident who traveled to Germany before becoming ill.On June 10, 2011, RKI announced that contaminated raw sprouts from one farm in Germany are the likely source of the outbreak. This farm has been closed and the sprouts produced there are no longer in restaurants or store shelves in Germany. Over the past few weeks, the number of cases associated with this outbreak has markedly decreased. On June 24, 2011, France identified a cluster of E. coli O104:H4 infections among attendees of an event in Bordeaux, France; attendees reported consuming sprouts produced locally in Bordeaux.On July 5, 2011, the European Food Safety Authority issued a report identifying a single lot of fenugreek seeds, from an exporter in Egypt, as the most likely source of the sprouts linked with E. coli O104:H4 outbreaks in Germany and France.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC).  As of July 5, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 852 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli, or STEC, infections–and 32 HUS-associated deaths.

In the United States, six confirmed cases of STEC O104:H4 infections have been identified. Of these six cases, five recently traveled to Germany, where they were likely exposed. Bacterial isolates from four HUS cases reported in Arizona (1), Massachusetts (1), Michigan (1) and Wisconsin (1), and two cases with diarrheal illness reported in Michigan (1) and North Carolina (1), have all been confirmed as matching the outbreak strain. One death has been reported in the Arizona resident with HUS who traveled to Germany before becoming ill. The Michigan resident with diarrheal illness did not travel to Germany, but likely acquired this infection through close contact with the Michigan resident with HUS. 

Among U.S. military personnel and their dependents that are stationed in Germany, there are no confirmed cases at this time. Continuous monitoring has shown no increase in visits due to gastrointestinal illness at U.S. military medical treatment facilities in Europe.

CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany and since April 1, 2011. Additionally, CDC is working with state health departments to learn more about suspect cases and obtain bacterial isolates for further characterization. When a report of STEC infection is investigated, every effort is made to identify ill family members or other close contacts to determine if person-to-person spread has occurred. With this outbreak, only one instance of person-to-person spread has been documented in the United States.

RKI, the Federal Institute for Risk Assessment, and the Federal Office of Consumer Protection and Food Safety have found substantial epidemiologic and traceback evidence indicating that fresh sprouts produced by a farm in Lower Saxony are responsible for the current outbreak in Germany. German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Traceback investigations of the food chain indicate that no sprouts or other food items from the implicated farm in Lower Saxony have been exported outside Germany. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany was lifted. On June 10, 2011, RKI announced that contaminated raw sprouts from one farm in Germany are the likely source of the outbreak. This farm has been closed and the sprouts produced there are no longer in restaurants or store shelves in Germany. Over the past few weeks, the number of cases associated with this outbreak has markedly decreased. While some cases may still occur because of the time it takes between when a person becomes ill and when the illness is reported, it is likely that the number of cases will continue to decrease until the outbreak is over.

On June 24, 2011, France reported a cluster of E. coli O104:H4infections among persons who attended an event in Bordeaux, France. Attendees reported eating sprouts served at the event. The sprouts were privately produced in small quantities by the organizer of the event from seeds purchased locally in Bordeaux.

The European Food Safety Authority (EFSA) initiated a comprehensive investigation to identify the source of the two outbreaks. On July 5, 2011, EFSA issued a report of its findings. Comparison of information from the outbreak investigations led to the identification of a single lot of fenugreek seeds, from an exporter in Egypt, as the most likely source of the sprouts linked with the two outbreaks. Given the possible severe health impact of exposure to a small quantity of contaminated material, and in the absence of information regarding the source and means of contamination and possible cross-contamination, all lots of fenugreek seeds from the identified exporter should be considered suspect.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

The STEC O104:H4 responsible for the German outbreak has several genetic factors that contribute to its ability to cause illness. One is its ability to stick to cells in the intestine and another is its ability to make Shiga toxin. These factors are already well known and occur in various strains of E. coli in nature. E. coli, like many other bacteria, exchange genetic material and there is no evidence to think that this strain has been modified intentionally. Because of minimal person-to-person transmission associated with this strain, there is also no evidence to indicate that it will cause a pandemic or spread around the world. More information about the characteristics of the STEC O104:H4 strain can be found in The Lancet (abstract) - “Characterisation of the Escherichia coli strain associated with an outbreak of haemolytic uraemic syndrome in Germany, 2011: a microbiological study” and in The New England Journal of Medicine - "Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany — Preliminary Report".

Any person who has recently traveled to Germany or has been in recent contact with an ill person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS, should seek medical care. He or she should tell the medical provider about the outbreak in Germany and the importance of asking the laboratory to test a stool specimen for STEC. 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 go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color of skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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April 7, 2011: Multistate Outbreak of E. coli O157:H7 Infections Associated with In-shell Hazelnuts

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

April 7, 2011 (FINAL Update)

As of April 1, 2011, eight persons infected with the outbreak strain of E. coli serotype O157:H7 were reported from Michigan (1), Minnesota (3), and Wisconsin (4).Laboratory testing conducted by the Minnesota Department of Agriculture on in-shell hazelnuts recovered from a patient's home identified E. coli O157:H7 matching patient isolates by DNA analysis.

CDC collaborated with public health officials in California, Michigan, Minnesota, Wisconsin, and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of E. coli O157:H7 infections. Investigators used DNA analysis of E. coli O157:H7 bacteria obtained through diagnostic testing to identify cases of illness that may have been part of this outbreak.

As of April 1, 2011, eight persons infected with the outbreak strain of E. coli serotype O157:H7 were reported from Michigan (1), Minnesota (3), and Wisconsin (4). Reported dates of illness onset range from December 20, 2010 to February 16, 2011. Ill persons ranged in age from 15 to 78 years, with a median age of 63 years; 75% were male. Among ill persons, 50% reported being hospitalized, and none reported hemolytic uremic syndrome, which is a type of kidney failure that is associated with E. coli O157:H7 infections. No deaths were reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. This outbreak appears to be over. However, illnesses that occurred after March 17, 2011, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 3 weeks. Please see the Timeline for Reporting of E. coli Cases for more details.

Collaborative investigative efforts of local, state, and federal public health and regulatory agencies associated this outbreak with eating in-shell hazelnuts (also known as filberts). Most of the in-shell hazelnuts were purchased from bulk bins at retail food stores. Source tracing identified a common distributor for the hazelnuts consumed by ill persons: DeFranco & Sons in Los Angeles, California. Laboratory testing conducted by the Minnesota Department of Agriculture on in-shell hazelnuts, the California Department of Public Health on mixed nuts containing in-shell hazelnuts, and the Wisconsin Department of Agriculture, Trade and Consumer Protection and Wisconsin Department of Health Services on mixed nuts containing in-shell hazelnuts identified E. coli O157:H7 matching the outbreak strain by DNA analysis.

DeFranco & Sons of Los Angeles, CA voluntarily recalled bulk and consumer-packaged in-shell hazelnuts and mixed-nut products containing hazelnuts. These nuts may have been sold by retailers nationwide. The in-shell nuts may have been sold in two-pound and four-pound packages of mixed nuts, one-pound packages containing only hazelnuts, or in open bins of nuts in grocery stores. Consumers are advised to review the DeFranco press release for a list of recalled products.

Most people infected with E. coli O157:H7 develop diarrhea (often bloody) and abdominal cramps 2-8 days (3-4 days, on average) after swallowing the organism, but some illnesses last longer and are more severe. Infection is usually diagnosed by stool sample culture. While most people recover within a week, some develop a severe infection. A type of kidney failure called hemolytic uremic syndrome (HUS) can begin as the diarrhea is improving; this condition can occur among persons of any age but is most common in children under 5 years old and the elderly. Signs and symptoms of HUS may include fever, abdominal pain, pale skin tone, fatigue and irritability, small, unexplained bruises or bleeding from the nose and mouth, decreased urination and swelling of the face, hands, feet, or entire body. Persons who experience these symptoms and believe they are at risk for HUS should seek emergency medical care immediately.

Consumers should not eat any of the recalled products, and restaurants and food service operators should not serve them. Consumers, retailers, and others who have any of the recalled products should dispose of them in a closed plastic bag placed in a sealed trash can. This will prevent people or animals from eating them.

Additional Resources

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with FDA and U.S. Department of Agriculture’s Food Safety and Inspection Service. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

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Investigation Announcement: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

June 2, 2011

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC).  As of May 31, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 470 patients with hemolytic uremic syndrome (HUS) – a type of kidney failure that is associated with E. coli or STEC infections – and nine deaths.

Many of these illnesses are in persons who report recent travel to Germany, but reside elsewhere. In the United States, three suspected cases of STEC O104:H4 infections have been identified in persons recently traveled to Hamburg, Germany.

CDC is working with state health departments to learn more about these suspected cases and obtain bacterial isolates from them for further characterization. In addition, CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany since April 1, 2011.

At this time, a specific food has not been confirmed as the source of the infections. Travelers to Germany should be aware that the German public health authorities have recommended against eating raw lettuce, tomatoes, or cucumbers, particularly in the northern states of Germany (Hamburg, Bremen, Lower Saxony, and Schleswig Holstein). United States public health authorities currently have no information that any of these foods have been shipped from Europe to the United States. The U.S. Department of Defense has been notified of this outbreak because of the presence of U.S. military bases in Germany; there are no known cases among U.S. military personnel or their dependents at this time. For the most current information about safe travel, please visit CDC Travelers’ Health Website.

The strain of STEC causing these illnesses, STEC O104:H4 is very rare, and CDC is not aware of any confirmed cases of STEC O104:H4 infection ever reported in the United States. Any person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested for STEC. Symptoms of STEC infection include severe 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 go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color to skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture.  CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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July 8, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated July 8, 2011 (FINAL Update)

As of July 5, 2011, Germany’s Robert Koch Institute (RKI)* reports 852 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing Escherichia coli, or STEC, infections–and 32 deaths associated with HUS. In the United States, six confirmed cases of STEC O104:H4 infections have been identified. Among these six cases, one death has been reported in an Arizona resident who traveled to Germany before becoming ill.On June 10, 2011, RKI announced that contaminated raw sprouts from one farm in Germany are the likely source of the outbreak. This farm has been closed and the sprouts produced there are no longer in restaurants or store shelves in Germany. Over the past few weeks, the number of cases associated with this outbreak has markedly decreased. On June 24, 2011, France identified a cluster of E. coli O104:H4 infections among attendees of an event in Bordeaux, France; attendees reported consuming sprouts produced locally in Bordeaux.On July 5, 2011, the European Food Safety Authority issued a report identifying a single lot of fenugreek seeds, from an exporter in Egypt, as the most likely source of the sprouts linked with E. coli O104:H4 outbreaks in Germany and France.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC).  As of July 5, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 852 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli, or STEC, infections–and 32 HUS-associated deaths.

In the United States, six confirmed cases of STEC O104:H4 infections have been identified. Of these six cases, five recently traveled to Germany, where they were likely exposed. Bacterial isolates from four HUS cases reported in Arizona (1), Massachusetts (1), Michigan (1) and Wisconsin (1), and two cases with diarrheal illness reported in Michigan (1) and North Carolina (1), have all been confirmed as matching the outbreak strain. One death has been reported in the Arizona resident with HUS who traveled to Germany before becoming ill. The Michigan resident with diarrheal illness did not travel to Germany, but likely acquired this infection through close contact with the Michigan resident with HUS. 

Among U.S. military personnel and their dependents that are stationed in Germany, there are no confirmed cases at this time. Continuous monitoring has shown no increase in visits due to gastrointestinal illness at U.S. military medical treatment facilities in Europe.

CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany and since April 1, 2011. Additionally, CDC is working with state health departments to learn more about suspect cases and obtain bacterial isolates for further characterization. When a report of STEC infection is investigated, every effort is made to identify ill family members or other close contacts to determine if person-to-person spread has occurred. With this outbreak, only one instance of person-to-person spread has been documented in the United States.

RKI, the Federal Institute for Risk Assessment, and the Federal Office of Consumer Protection and Food Safety have found substantial epidemiologic and traceback evidence indicating that fresh sprouts produced by a farm in Lower Saxony are responsible for the current outbreak in Germany. German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Traceback investigations of the food chain indicate that no sprouts or other food items from the implicated farm in Lower Saxony have been exported outside Germany. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany was lifted. On June 10, 2011, RKI announced that contaminated raw sprouts from one farm in Germany are the likely source of the outbreak. This farm has been closed and the sprouts produced there are no longer in restaurants or store shelves in Germany. Over the past few weeks, the number of cases associated with this outbreak has markedly decreased. While some cases may still occur because of the time it takes between when a person becomes ill and when the illness is reported, it is likely that the number of cases will continue to decrease until the outbreak is over.

On June 24, 2011, France reported a cluster of E. coli O104:H4infections among persons who attended an event in Bordeaux, France. Attendees reported eating sprouts served at the event. The sprouts were privately produced in small quantities by the organizer of the event from seeds purchased locally in Bordeaux.

The European Food Safety Authority (EFSA) initiated a comprehensive investigation to identify the source of the two outbreaks. On July 5, 2011, EFSA issued a report of its findings. Comparison of information from the outbreak investigations led to the identification of a single lot of fenugreek seeds, from an exporter in Egypt, as the most likely source of the sprouts linked with the two outbreaks. Given the possible severe health impact of exposure to a small quantity of contaminated material, and in the absence of information regarding the source and means of contamination and possible cross-contamination, all lots of fenugreek seeds from the identified exporter should be considered suspect.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

The STEC O104:H4 responsible for the German outbreak has several genetic factors that contribute to its ability to cause illness. One is its ability to stick to cells in the intestine and another is its ability to make Shiga toxin. These factors are already well known and occur in various strains of E. coli in nature. E. coli, like many other bacteria, exchange genetic material and there is no evidence to think that this strain has been modified intentionally. Because of minimal person-to-person transmission associated with this strain, there is also no evidence to indicate that it will cause a pandemic or spread around the world. More information about the characteristics of the STEC O104:H4 strain can be found in The Lancet (abstract) - “Characterisation of the Escherichia coli strain associated with an outbreak of haemolytic uraemic syndrome in Germany, 2011: a microbiological study” and in The New England Journal of Medicine - "Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany — Preliminary Report".

Any person who has recently traveled to Germany or has been in recent contact with an ill person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS, should seek medical care. He or she should tell the medical provider about the outbreak in Germany and the importance of asking the laboratory to test a stool specimen for STEC. 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 go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color of skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

Back to Top

NOTICE: The information on this page is no longer being updated and may have changed. The information is accurate only as of the last page update.

* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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June 3, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated June 3, 2011

As of June 2, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 520 patients with hemolytic uremic syndrome (HUS) – a type of kidney failure that is associated with E. coli or STEC infections – and 11 deaths.In the United States, four suspected cases of STEC O104:H4 infections have been identified in persons who recently traveled to Hamburg, Germany, where they were likely exposed.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC). As of June 2, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 520 patients with hemolytic uremic syndrome (HUS) – a type of kidney failure that is associated with E. coli or STEC infections – and 11 deaths.

In the United States, four suspected cases of STEC O104:H4 infections have been identified in persons who recently traveled to Hamburg, Germany, where they were likely exposed. One case of HUS has been reported in each of three states: Massachusetts, Michigan, and Wisconsin. Additionally, one case of Shiga toxin-positive diarrheal illness is still under investigation. All four cases are pending laboratory confirmation.

CDC is working with state health departments to learn more about these suspected cases and obtain bacterial isolates from them for further characterization. In addition, CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany since April 1, 2011.

At this time, a specific food has not been confirmed as the source of the infections. Travelers to Germany should be aware that the German public health authorities have recommended against eating raw lettuce, tomatoes or cucumbers, particularly in the northern states of Germany (Hamburg, Bremen, Lower Saxony, and Schleswig Holstein). United States public health authorities currently have no information that any of these foods have been shipped from Europe to the United States. The U.S. Department of Defense has been notified of this outbreak because of the presence of U.S. military bases in Germany; there are no known confirmed cases among U.S. military personnel or their dependents at this time. However, reports indicate two U.S. service members in Germany with diarrheal illness are considered suspect cases.  For travel information related to this outbreak, please view the article on CDC Travelers’ Health Website.

The strain of STEC causing these illnesses, STEC O104:H4 is very rare, and CDC is not aware of any confirmed cases of STEC O104:H4 infection ever reported in the United States. Any person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested for STEC. Symptoms of STEC infection include severe 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 go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color to skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture.  CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

Back to Top

* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

View the original article here

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