Vero cytotoxin-producing Escherichia coli, particularly serogroup O 157, associated with human infections in the United Kingdom: 1989-91.

This survey reports the results of investigations performed by the Laboratory of Enteric Pathogens (LEP), to identify evidence of human infection with Vero cytotoxin-producing Escherichia coli (VTEC) in the UK during the period 1989-91. Bacterial isolates, faecal specimens and serum samples were received from patients suffering from diarrhoea, bloody diarrhoea and haemolytic uraemic syndrome. Using serotyping, Vero cytotoxin gene probing and an ELISA for serum antibodies to E. coli O 157, evidence of infection was detected in 232, 428 and 615 individuals in 1989, 1990 and 1991 respectively. Of these individuals, 15% were reported as having HUS. Vero cytotoxin-producing E. coli O 157 was the most frequently encountered serogroup, with isolations from a total of 1092 individuals over the 3-year period. The incidence of VTEC infection increased from 0.41/100,000 in 1989 to 1.07/100,000 in 1991. The area with the highest rate of infection in each year was Scotland, increasing from 1.37/100,000 in 1989 to 3.97/100,000 in 1991.     

Vero cytotoxin-producing Escherichia coli O157 gastroenteritis in farm visitors,North Wales

An outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) gastroenteritis in visitors to an open farm in North Wales resulted in 17 primary and 7 secondary cases of illness. E. coli O157 Vero cytotoxin type 2, phage type 2 was isolated from 23 human cases and environmental animal fecal samples. A case-control study of 16 primary case-patients and 36 controls (all children) showed a significant association with attendance on the 2nd day of a festival, eating ice cream or cotton candy (candy floss), and contact with cows or goats. On multivariable analysis, only the association between illness and ice cream (odds ratio [OR]=11.99, 95% confidence interval [CI] 1.04 to 137.76) and cotton candy (OR=51.90, 95% CI 2.77 to 970.67) remained significant. In addition to supervised handwashing, we recommend that foods on open farms only be eaten in dedicated clean areas and that sticky foods be discouraged.     

Vero cytotoxin-producing Escherichia coli O157 outbreaks in England and Wales, 1995: phenotypic methods and genotypic subtyping.

Vero cytotoxin-producing Escherichia coli O157 belonging to four phage types (PTs) caused 11 outbreaks of infection in England and Wales in 1995. Outbreak strains of different PTs were distinguishable by DNA-based methods. Pulsed-field gel electrophoresis best discriminated among strains belonging to the same PT, distinguishing six of the seven PT2 outbreak strains and both PT49 outbreak strains.     

Phage typing of Vero cytotoxin-producing Escherichia coli O 157 isolated in the United Kingdom: 1989-91.

Between 1989 and 1991 a total of 1092 Vero cytotoxin-producing Escherichia coli O 157 isolated in the United Kingdom were phage typed in the Laboratory of Enteric Pathogens (LEP). Twenty-three phage types was identified, the most frequent being types 2 (36.1%), 49 (29.6%), 1 (10.3%) and 4 (8.9%). Although isolations of O 157 VTEC have increased each year from 1 in 1982 to 532 in 1991, the predominant phage types have remained unchanged although the proportion of strains belonging to types 2 and 49 has increased. O 157 VTEC from 17 outbreaks were phage typed during this period with phage type 49 predominating (7 of 17 outbreaks).     

The surveillance of vero cytotoxin-producing Escherichia coli O157 in Wales, 1990 to 1998.

Population-based surveillance for Vero cytotoxin-producing Escherichia coli (VTEC) O157 has been carried out in Wales since 1990. The annual incidence has remained stable during the 9-year period (mean: 1.6 cases per 100,000 population); the rate is highest in children younger than 5 years of age. Blood in the stool is reported in fewer than half the cases, indicating the importance of screening all fecal specimens for VTEC O157.     

Outbreak of Vero cytotoxin-producing Escherichia coli O157 in a child day care facility

In December 1998, an outbreak of Vero cytotoxin-producing Escherichia coli (VTEC) O157 in a crèche affected ten out of 45 children and one out of five staff members. Eight cases were symptomatic and three were asymptomatic. There were two asymptomatic adult family contacts of child cases. All specimens were identified as VTEC O157:H7, phage type 32. None of the cases were seriously ill and none developed haemolytic uraemic syndrome (HUS). One child continued to excrete the organism for 14 weeks. The origin of the outbreak was not found but epidemiological investigation was suggestive of person-to-person spread. All children and staff were screened and excluded from the crèche until microbiological clearance was obtained. An inspection of the crèche revealed overcrowding and inadequacies in cleaning and in the food preparation facilities. These problems were remedied before children were re-admitted to the crèche. This outbreak demonstrates the ease with which VTEC O157 can be transmitted between small children. Two specific features of this outbreak were notable: (1) the mild self-limiting nature of the illness and (2) the prolonged shedding of the bacterium by one child.     

A foodborne outbreak of Vero cytotoxin-producing Escherichia coli O157:H-phage type 8 in hospital.

This paper describes the epidemiological and microbiological aspects of the largest outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infection in a hospital setting in which the route of transmission was foodborne. The outbreak, which was caused by a relatively uncommon phage type of VTEC O157, occurred in four geriatric continuing care wards in May 1997. The total number of people found to be excreting the organism was 37, of whom 16 were inpatients and 11 were staff. Twelve people displayed enteric symptoms. In addition, all but two of 10 cases identified in the local community were thought to be associated with the outbreak. An epidemiological investigation amongst the hospital patients revealed a statistically significant association between VTEC O157 infection and attendance at a concert party on the continuing care wards on 17 May 1997 (relative risk = 3.22;P= 0.006). There was an even stronger relationship between consumption of home-baked cream-filled cakes brought to that party and evidence of infection (relative risk = 19.35;P= 0.00002). Further investigations in the local community, coupled with microbiological evidence, supported the epidemiological finding that homemade cream cakes brought into the hospital were the vehicle of infection for the outbreak. There was no secondary spread within the hospital. The outbreak serves as a reminder of the hazard posed by foodstuffs brought into a hospital from outside.     

Human infections with Shiga toxin-producing Escherichia coli other than serogroup O157 in Germany.

We investigated different types of Shiga toxin-producing Escherichia coli (STEC) not belonging to serogroup O157 for their role as human pathogens. Non-O157 STEC isolated from 89 human patients in Germany were characterized according to serotypes, virulence markers, and association with human illness. EaeA-positive STEC were isolated from 54 (60.7%) of the patients and were frequently associated with severe diarrheal disease, hemolytic uremic syndrome, and young age. EaeA-negative STEC were found in 35 (39.3%) of the patients and were more associated with clinically uncomplicated cases and adult patients. For pediatric patients, a serotype-independent diagnosis of STEC is recommended.     

Properties of Vero cytotoxin-producing Escherichia coli of human and animal origin belonging to serotypes other than O157:H7

Eight non-O157:H7 Vero cytotoxin (VT)-producing Escherichia coli (VTEC) strains isolated from ill persons and nine bovine and lamb strains of serogroups matching the human strains, were characterized for various properties known to be associated with E. coli virulence. Five different serogroups were represented: O5, O55, O103, O111 and O153. The bovine and lamb strains produced VT1, while 3 human strains produced VT1, 3 produced VT2 and 2 were positive for both VT1 and VT2. The strains were non-haemolytic on horse blood agar, did not produce either heat stable toxin A (STA) or heat labile toxin (LT), and were noninvasive. The CVD419 probe which has been proposed to identify enterohaemorrhagic E. coli (EHEC) hybridized with all of the O5 and O103 strains, none of the O55 and O153 strains, and 3 of the 4 O111 strains. The strains carried several different sized plasmids and hybridization of Southern blots with the CVD419 probe identified plasmids ranging in size from 42 x 10(6) to 90 x 10(6). The strains did not hybridize with the enteroadherence factor (EAF) probe derived from an enteropathogenic strain and associated with the ability to give localized adherence to HEp-2 cells. Nevertheless five of the strains adhered in a localized pattern to HEp-2 cells and Intestine 407 cells. Adhesion to either HEp-2 or Intestine 407 cells did not correlate with hybridization with the CVD419 probe or haemagglutinating properties.     

Verotoxin producing Escherichia coli O 157 infections associated with the consumption of yoghurt.

Sixteen cases of verotoxin producing Escherichia coli (VTEC) O 157:H7 Phage Type 49 infection were identified in the North West of England from 1 September to 1 November 1991, eight of whom lived in or around the same large town. Eleven of the cases were aged 10 years or less, and five of the affected children developed haemolytic uraemic syndrome. A case control study demonstrated a strong association between VTEC O 157:H7 PT 49 infection and the consumption of a locally produced live yoghurt. This is the first time that an outbreak of VTEC O 157 infection has been linked to the consumption of yoghurt and this vehicle of infection should be considered when investigating such outbreaks in future.     

The use of sorbitol-MacConkey agar in conjunction with a specific antiserum for the detection of Vero cytotoxin-producing strains of Escherichia coli O 157

Using DNA probes specific for the genes encoding Vero cytotoxins 1 and 2 in hybridization experiments on faecal samples, Vero cytotoxin-producing Escherichia coli (VTEC) of serogroup O 157 were detected in 21 of 63 cases of haemorrhagic colitis, 9 of 31 cases of non-bloody diarrhoea and 14 of 68 cases of haemolytic uraemic syndrome. Compared with these results sorbitol-MacConkey agar in conjunction with a specific O 157 antiserum gave a sensitivity of 62% in haemorrhagic colitis, 56% in non-bloody diarrhoea and 57% in haemolytic uraemic syndrome. The specificity of this method was 100% in all three groups. This demonstrates that sorbitol-MacConkey agar is a useful screening method for the detection of VTEC of serogroup O 157 when used in conjunction with a specific homologous antiserum. However, this method does not detect VTEC belonging to other serogroups and such strains were found, particularly in cases of haemolytic uraemic syndrome.     

An international outbreak of Vero cytotoxin-producing Escherichia coli O157 infection amongst tourists; a challenge for the European infectious disease surveillance network

In March 1997, an outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC) infection occurred amongst holidaymakers returning from Fuerteventura, Canary Islands. For the investigation, a confirmed case was an individual staying in Fuerteventura during March 1997, with either E. coli O157 VTEC isolated in stool, HUS or serological evidence of recent infection; a probable case was an individual with bloody diarrhoea without laboratory confirmation. Local and Europe-wide active case finding was undertaken through national centres, Salm-Net and the European Programme of Intervention Epidemiology, followed by a case-control study. Fourteen confirmed and one probable case were identified from England (7), Finland (5), Wales (1), Sweden (1) and Denmark (1) staying in four hotels. Three of the four hotels were supplied with water from a private well which appeared to be the probable vehicle of transmission. The case-control study showed illness was associated with consumption of raw vegetables (OR 8.4, 95% CI 1-5-48.2) which may have been washed in well water. This investigation shows the importance of international collaboration in the detection and investigation of clusters of enteric infection.     

Escherichia coli O157 infection associated with a petting zoo

A young child was admitted to hospital with haemolytic-uraemic syndrome caused by infection with a Shiga toxin 2-producing strain of Escherichia coli (STEC) O157. Five days before he became ill, the child had visited a small petting zoo. STEC O157 strains were isolated from faecal samples from goats and sheep housed on the farm. The human and the animal isolates were indistinguishable by molecular subtyping. The petting zoo voluntarily closed temporarily to prevent further cases of infection. Two out of 11 other, randomly selected petting zoos (including one deer park) visited subsequently, tested positive. Furthermore, during the study period there was one more notification of STEC O157 infection possibly linked with a farm visit. Although STEC O157 was indeed found in the petting zoo associated with this patient, transmission through animal contact could not be confirmed because the human isolate was not available for subtyping. The case study and the results of the other on-farm investigations highlight the risk of acquiring severe zoonotic infections during visits to petting zoos.     

A cluster of Escherichia coli O157: nonmotile infections associated with recreational exposure to lake water

OBJECTIVES: To identify cases and determine risk factors for an outbreak of Escherichia coli (E. coli) O157: nonmotile (NM) infections in children attending a summer day care program in California. METHODS: The authors conducted a retrospective cohort study; the cohort comprised first and second graders who attended the day care program during the last week in August 1999. Shiga toxin testing and molecular subtyping using pulsed-field gel electrophoresis were performed on isolates. Lake water, lake bottom sediment samples, and waterfowl feces from the lake environs were cultured for E. coli O157. RESULTS: Three cases of Shiga toxin-producing E. coli O157: NM infections with matching pulsed-field gel electrophoresis patterns and four probable cases were found. Children who swallowed more than a mouthful of water had a higher attack rate than those who swallowed less than a mouthful or none at all (43% vs. 10%, relative risk = 4.43, 95% confidence interval 1.12, 17.50). CONCLUSIONS: E. coli O157: NM infections were associated with swallowing water from a freshwater lake. Potential sources of contamination include feces from humans, cattle, or deer. This outbreak illustrates the value in screening patients with diarrhea for E. coli O157, submitting isolates to public health laboratories, and using molecular techniques to identify related cases. Outbreaks associated with contaminated freshwater could be averted by prevention and early detection of contamination.     

Outbreaks of Escherichia coli O157:H7 infections among children associated with farm visits--Pennsylvania and Washington, 2000

During the spring and fall of 2000, outbreaks of Escherichia coli O157:H7 infections among school children in Pennsylvania and Washington resulted in 56 illnesses and 19 hospitalizations. Illness was associated with school and family visits to farms where children came into direct contact with farm animals. This report summarizes the findings of investigations of these outbreaks (Figure 1) and includes strategies to reduce the transmission of enteric pathogens from farm animals to children.     

Properties of strains of Escherichia coli belonging to serogroup O157 with special reference to production of Vero cytotoxins VT1 and VT2

Fifty-four strains of Escherichia coli belonging to serogroup O157 were examined for the production of Vero cytotoxins VT1 and VT2, and for other properties such as plasmid content, resistance to antimicrobial agents and colicin production. Twenty-six strains from cases of diarrhoea, haemorrhagic colitis and haemolytic uraemic syndrome in humans produced VT. By serum neutralization tests and hybridization with DNA probes for VT1 or VT2, three classes were recognized which produced either VT1 alone or VT2 alone or both VT1 and VT2. These strains were of H type 7 or non-motile. The strains producing VT were sensitive to all the antimicrobial agents tested, and all carried at least one plasmid which had a molecular weight of c. 60 X 10(6). Seven strains of porcine origin and 21 strains of human origin did not produce VT or hybridize with either DNA probe. None of these strains was of H type 7. Of the 21 human VT- strains, 17 were of extra-intestinal origin and 18 were of H type 45. Twenty-three of the 28 VT-strains were resistant to at least one antimicrobial agent.     

Multistate outbreak of Escherichia coli O157:H7 infections associated with eating ground beef--United States,June-July 2002

During July 2002, the Colorado Department of Public Health and Environment (CDPHE) identified an outbreak of Escherichia coli O157:H7 infections among Colorado residents. This report summarizes the results of an ongoing epidemiologic and laboratory investigation that has linked 28 illnesses in Colorado and six other states to eating contaminated ground beef products recalled by ConAgra Beef Company on June 30, 2002. To date, seven patients have been hospitalized; five developed hemolytic-uremic syndrome (HUS).     

Escherichia coli O157:H7 infections associated with ground beef from a U.S. military installation--Okinawa, Japan, February 2004

In February 2004, the Okinawa Prefectural Chubu Health Center (OCHC) and the Okinawa Prefectural Institute of Health and Environment (OIHE), Japan, investigated three cases of Escherichia coli O157:H7 infection in a Japanese family associated with eating ground beef. Public health officials from multiple agencies in Japan and the United States collaborated on this investigation, which resulted in a voluntary recall of approximately 90,000 pounds of frozen ground beef in the United States and at U.S. military bases in the Far East. This was the first reported instance in which Japanese public health officials identified contaminated, commercially distributed ground beef that was produced in the United States. This report summarizes epidemiologic and laboratory investigations conducted by OCHC and OIHE. The results underscore the importance of using standardized molecular subtyping methods throughout the world to facilitate international public health communication and intervention.     

Escherichia coli O157 outbreak associated with fresh unpasteurized goats' cheese

A family cluster of three cases of Escherichia coli O157 infection was identified in France. Two cases developed haemolytic-uraemic syndrome. The source was fresh unpasteurized goats' cheese, produced by an independent producer. Three E. coli O157 strains, isolated from one HUS case and faeces of one cow and one goat, were indistinguishable by toxin type and PFGE pattern.