Death Toll in European E. Coli Outbreak Reaches 48, Authorities Now Blame Egyptian Seeds

More than 4,000 cases of E. coli infection in Europe and North America have now been reported in the deadliest outbreak of E. coli in world history.  The infections began to appear May 1, 2011 and continued to mount through late June.  On the heels of the German-centric outbreak, another smaller outbreak occurred in France centered around the French city of Bordeaux.  Both the German and the French outbreak have been linked to sprouted seeds and the deadly E. coli O104:H4. 

Experts from European Centre for Disease Prevention and Control (ECDC) and the European Food Safety Authority (EFSA) said initial investigations suggested that “the consumption of sprouts is the suspected vehicle of infection in both the French cluster and the German outbreak.”  Further, the agencies are now beginning to refine the source of the sprouted seeds: “The tracing back is progressing and has thus far shown that fenugreek seeds imported from Egypt either in 2009 and/or 2010 are implicated in both outbreaks.”

The French E. coli Outbreak Raises Alarms

On Friday June 24, 2011 France reported a cluster of eight patients presenting with bloody diarrhea in and around Bordeaux.  These were determined to be E. coli related.  By June 28, 2011, 15 cases had been identified in this area.  Eleven of them had participated in a single event in the commune of Bègles, in Bordeaux, on June 8, 2011. O f these eleven, eight developed haemolytic uremic syndrome (HUS), a severe complication of E. coli infection.  Seven of the patients are women between 31 and 64 years of age, and four are men, between 34 and 41 years of age.  The date of onset of disease for these 11 patients was between June 15th and 20th.  In three of the patients, infection with E. coli O104:H4 has been clinically confirmed.  The isolated strain evinces characteristics that are similar to that of the strain isolated in the German outbreak with a similar antibiotic resistance profile.

In the French trace-back investigation, authorities concluded that nine of the cases reported having eaten sprouts (fenugreek, mustard and rucola) at the June 8 event (information on the other two is reported to not yet be available).  The ECDC and local French authorities are currently testing left-over seeds from that event.  What they do know is that these suspected sprouts were locally produced, and were not imported from the farm implicated in the German-centered outbreak.  Initial investigations also revealed that the seeds used for the sprouts in France were distributed by a UK-based company.

Another Outbreak in Sweden?  Victims Are All Confirmed Cases of E. Coli 0104:H4

The French outbreak has been overshadowed by the ongoing large outbreak of E. coli O104:H4 in northern Germany.  Now, a case authorities say is unrelated to either the German or French outbreaks has been confirmed in Sweden.  The victim was infected with E. coli 0104:H4.   The victim, a middle aged man, had not recently travelled and preliminary reports state he did not consume sprouts recently.  Nonetheless, he is ill from E. coli 0104:H4 that has been at the center of the deadly German-centric outbreak.

The “German strain” has been described as a mutated strain, and demonstrates characteristics, including the fact that it is antibiotic resistant and combines both toxicity and the ability to remain lodged in the intestines much longer than traditional E. coli strains.  In Germany alone, between May 1, 2011 and June 27, 2011, this highly toxic strain caused 838 HUS cases and 3,063 STEC cases, of which 47 persons died. As of June 28, 2011, at least twelve countries reported cases associated with the outbreak in Germany for a total of 878 HUS and 3,134 non-HUS STEC cases.  A death in Sweden increased the death-toll to 48.   The latest confirmed case of STEC O104 had an onset date of June 12, 2011.  The latest confirmed case of related HUS had an onset date of June 22.

E. coli O104:H4 is a very rare pathotype from humans in Europe, and hence authorities find it highly unlikely that the French outbreak (or the single new case from Sweden) is an isolated event unrelated to the recent German outbreak.  The currently available information on the French cluster is mostly in favor of a link between these two health events:

• The clinical picture of the French HUS cases in Bordeaux is similar to that of the cases reported from Germany;
• The cases are adults, the majority are women, and the majority are presenting with HUS;
• The microbiological characteristics of the isolated strain of E. coli O104:H4 from three of the French HUS patients seem similar to the isolated strain in the German outbreak, including the antibiotic resistance profile; and
• Preliminary investigations in Bordeaux show that all cases with microbiological evidence of E. coli O104:H4 infection attended the same social event on 08 June, consuming sprouts (fenugreek, mustard and rucola) that were grown from imported seeds.

According to the ECDC, the occurrence of the French outbreak has given rise to several initial hypotheses on the cause of the German outbreak:

• The seeds used for sprouting and distributed to local producers or retail outlets contained a level of E. coli O104:H4 contamination;
• Contamination of the seeds could have occurred at any stage in the long and complex supply chain between seed production, transport, packaging and distribution; and
• Other batches of potentially contaminated seeds are still available within the EU and perhaps outside.

Trace-Back Investigation Made Public:  Egyptian Seeds Common Denominator

According to a press release by the ECDC on June 29, 2011, “the consumption of sprouts is the suspected vehicle of infection in both the French cluster and the German outbreak.”  The ECDC also notes “the isolated E. coli O104:H4 strain in human cases in both countries is the same, indicating a potential link between these two public health events.”  Based upon this information, the health experts from the ECDC began to identify commonalities that exist between the sprout production chains linked to the two outbreaks, including: distributors, retail outlets, and suppliers.  The European Food Safety Authority (EFSA) taskforce, established via a request from the European Commission in Germany and France, is engaged in this investigation in order to identify any potentially contaminated batches of sprout seeds so that recall notifications can be employed to remove the vehicle of transmission.

According to the ECDC, preliminary reports of the trace-back investigation have implicated fenugreek seeds imported from Egypt either in 2009 and/or 2010.  “There is still much uncertainty about whether this is truly the common cause of all the infections as there are currently no positive bacteriological results” the ECDCC admitted.  The ECDC report indicates that a particular purchase of a 2009 lot of fenugreek seeds may be liked to the outbreak in France and a purchase of a 2010 lot of fenugreek seeds may be linked to the German outbreak.  The most recent case in Sweden, however, is not linked to the same source.  According to Reuters, who interviewed an EFSA spokeswoman, Lucia de Luca, the EFSA was unwilling to confirm or deny media reports that the seeds had come from Egypt via a single German seed importer. “The investigations are still ongoing,” she told Reuters.

The German importer has been identified as agaSAAT, which confirmed that it distributed seeds to Thomson & Morgan, a British seed trader cited as a possible source for the outbreak in France.  “We’ve sent seeds to Thomson & Morgan in Britain, but the seeds were not contaminated with E. coli,” agaSAAT’s chief executive Werner Arts said. “We put our seeds under microbiological testing and there have been no positive tests for E.coli,” he added. “This has also been confirmed by German health authorities.”  Arts said his firm buys seeds from Egypt because “that’s where a lot come from.  Everyone does it.”

Thompson & Morgan said on Monday it was withdrawing some varieties of seeds from sale and advising people not to eat or grow them. But it said it was not recalling any of its products.