HUS epidemic 2011

from Wikipedia, the free encyclopedia

The 2011 HUS epidemic (also known as the EHEC epidemic ) is an accumulation and spread of a hitherto unknown, severe form of hemolytic uremic syndrome (HUS) with diarrhea, first observed in Germany in May 2011 . Almost all affected people lived in northern Germany or stayed there at least temporarily in April and May 2011.

The cause was EHEC ( e ntero h ämorrhagische E scherichia c oli ) assumed a pathogenic (disease-causing) strain of the intestinal bacterium Escherichia coli ( " E. coli "). On June 10, 2011, the Federal Institute for Risk Assessment (BfR), the Federal Office for Consumer Protection and Food Safety (BVL) and the Robert Koch Institute (RKI) published the previous warning with reference to studies of various kinds that presumably sprout vegetables are the vector Salad, cucumber and tomatoes are saved. For the authorities and the majority of the scientists concerned with the epidemic, organic fenugreek seeds , which were imported from Egypt to France and to a German organic gardening company , are very likely to be the source of the pathogen; on the other hand, a report by the consumer organization Foodwatch from May 2012 takes the position that the epidemic has not been fully clarified. At the end of July 2011, the Robert Koch Institute declared the epidemic in Germany to be over. A total of 855 people developed HUS and 2,987 gastroenteritis ; 53 people died of the infection.

The bacterium was serologically classified as EHEC strain O104: H4 based on the properties of its surface proteins . The sequencing of the bacterial genome, however, revealed a genetic hybrid of various pathogenic E. coli strains which, in addition to EHEC genetic material, also contains significant proportions of an enteroaggregative Escherichia coli (EAEC). The classification and naming of this new E. coli - strain has not yet occurred. It is currently referred to in the specialist literature as HUSEC (HUS-associated E. coli ) or STEC ( Shigatoxin-producing E. coli ).

Spread

Germany

Course of the HUS infections
(as of June 21, 2011)
Course of the reported EHEC and HUS cases

According to Section 6 of the Infection Protection Act (IfSG), a total of 855 clinically confirmed HUS cases were reported to the RKI nationwide from January 1 to September 2011, including 35 deaths, and according to Section 7 IfSG 2,987 evidence of the new EHEC type in patients, of whom 18 died. With around 75% of the cases, the focus was in the four north-western states of Hamburg, Schleswig-Holstein, Lower Saxony and North Rhine-Westphalia, but cases also occurred with different frequencies in all other federal states. In contrast, for example, the reported incidence of HUS in 2010 was only 65. Due to the temporal and spatial accumulation of cases, the definition of an epidemic is fulfilled.

In Germany, the diseases initially occurred locally and over time as severe and atypical cases of haemolytic-uremic syndrome with diarrhea. In contrast to the previously known courses of HUS due to EHEC, this time the accumulation of cases not in infants and children, but in adults, mostly women, and the particularly severe course were characteristic from the start. On May 19, 2011, ten cases were reported to the Hamburg health department . The increase in the number of cases was reported to the RKI, which began interviewing sick people in Hamburg on May 20, 2011. A food-borne strain of Escherichia coli has been identified as the cause . The cases were almost exclusively concentrated in northern Germany, especially Hamburg and Schleswig-Holstein . Early cases outside of northern Germany could be traced back to recent stays there or were epidemiologically linked to deliveries of vegetables from northern Germany. The analysis of the medical histories after questioning by the RKI showed that the earliest detectable onset of the disease (diarrhea with HUS detected later) was May 1, 2011.

After the first case-control studies by the RKI, fresh vegetables, especially tomatoes , cucumbers and lettuce , were accepted as possible transmission routes. To this end, the eating habits of sick patients were compared with those of a corresponding non-sick control group . In particular when consuming fresh tomatoes, a statistical dose-effect relationship between the amount consumed and the incidence of the disease was demonstrated: According to initial surveys, 92 percent of those infected had eaten raw tomatoes in the days before the disease, compared with only about 60 percent of the healthy people in the control group . However, the pathogen was not detected on tomatoes and lettuce.

In fact, since a major EHEC epidemic in Japan in 1996, sprouts have been considered a possible source of EHEC carriers, as the Federal Institute for Risk Assessment , which had detected EHEC years ago in random samples of sprouts, again pointed out in May 2011. On June 5, 2011, the suspicion that sprouts could be a source of infection in the spread of the outbreak pathogen was justified by the fact that a horticultural company in Bienenbüttel-Steddorf in the district of Uelzen was the common supplier of many sick people. In addition, an employee of the company was sick with EHEC. Laboratory results were not available at this time. As a precaution, the company was initially prohibited from delivering sprouts, and later also other products, but later laboratory tests could not detect any EHEC pathogens in 1000 samples directly from the company.

EHEC pathogens of the type O104: H4 on cucumbers, on the other hand, were found on June 8, 2011 in a bio bin in Magdeburg , which also contained leftovers from a family, three of whom were infected with EHEC. However, it was not possible to establish a connection between the cucumbers and the company in Bienenbüttel, and it remained unclear whether the pathogens were primarily contaminated by these cucumbers or secondarily through contact with other sources.

The RKI announced on June 9, 2011 that the decrease observed in the meantime was possibly due to a “change in the consumption behavior of the population with regard to cucumbers, tomatoes and lettuce”, so it did not mention sprouts in this context.

On June 10, 2011, on the other hand , EHEC pathogens of the type O104: H4 were detected for the first time on sprouts from this company in the waste of a family in the Rhein-Sieg district , two members of which had contracted EHEC in mid-May. However, the pack was already open, so it could not be ruled out that the sprouts had been contaminated by other circumstances.

Also on June 10, 2011, BfR, BVL and RKI published in a joint press conference that there is a high probability that the consumption of sprouts was the cause of the outbreak. The statement is based, among other things, on the findings from a recipe-based restaurant cohort study by the RKI. The previous warning regarding lettuce, cucumber and tomatoes has been lifted.

On June 17, 2011 it was published that 20 of 65 people who had eaten food (not sprouts) from a catering company near Kassel in Göttingen had contracted EHEC O104: H4. An employee of the company later turned out to be sick with EHEC O104: H4. This process was interpreted as an indication of a direct transfer of EHEC O104: H4 from humans to food, or via contaminated objects. Reports of the occurrence of the type O104: H4 pathogen in a stream in Frankfurt am Main turned out to be false alarms.

To date, no cases of transmission in hospitals or other medical facilities have been reported. On the other hand, authorities have repeatedly shown in public that the pathogen of the epidemic could have been transmitted to food through liquid manure . Where manure is not used, that these products are taken into greenhouses especially in the spring of Notice of producers of cucumbers, tomatoes and lettuce, or even, as with sprouts to hydroponics is, as little attention was how to specify a bacteriologist , that colonization of the outbreak strain has so far only been proven in humans, not in ruminants, so that it can be assumed that humans only serve as a reservoir for EHEC O104: H4, which is typical for strains of enteroaggregative E. coli (EAEC) is. Concerning the transmission of the pathogen from person to person corresponds to the fact that some state authorities and health authorities, within the scope of their regional rights of instruction, with reference to § 34, 42 IfSG, have forbidden close contact persons of people who are not infected with EHEC in schools, kindergartens, in the food sector and work in certain medical areas before stool cultures ensure that these contacts are not excretors . Some authorities have banned EHEC sufferers from attending mass events regardless of stool examinations. Other authorities have not issued such bans or have only issued some of them.

At the end of July 2011, the Robert Koch Institute declared the epidemic to be over after the last case of the disease in connection with the germs had been reported three weeks earlier. In Germany, 50 people were killed by the aggressive intestinal germ, while 4321 cases were registered.

category Number of cases (including deaths) Last onset of illness
EHEC
Diseases
Infections with an unsatisfied clinical picture
3,043 (17)
426 (1)
July 17, 2011
June 30, 2011
HUS
Diseases
Suspected cases
732 (28)
120 (4)
July 10, 2011
July 2, 2011
total 4,321 (50)

The last two cases clearly belonging to the outbreak begin on July 4, 2011.
(As of July 25, 2011, 10:00 a.m.)

France

In France, there have been documented cases of a separate outbreak of the epidemic in the region around Bordeaux since June 22, 2011 ; those affected have not been in Germany since May 1, 2011. The same serotype is responsible for the outbreak as in Germany, the bacterial strains are genetically related, which makes a common cause appear very likely. In France, too, it is assumed that sprouts play a role in this.

Europe outside of Germany and France

In the following countries, HUS and STEC cases were reported by June 9, 2011, which according to EU authorities are related to those in Germany: Austria, Czech Republic, Denmark, France, the Netherlands, Norway, Poland, Spain, Sweden, United Kingdom, Greece, Luxembourg and Switzerland. The European Center for Disease Prevention and Control (ECDF) and the European Food Safety Authority (EFSA) jointly issued a health warning on 3 June 2011.

Worldwide cases

Individual cases were reported from Canada and the USA, which are assumed to be related to the cases in Germany.

Pathogen

E. coli colony ( SEM image )

Based on the epidemiology of the outbreak, an immediate spread of an EHEC strain was assumed. The national consultation laboratory for HUS at the University of Münster was able to identify the pathogen strain HUSEC041 of the sequence type ST678 ( serotype O104) on May 26, 2011 based on the serological properties of the isolates . The H-antigens of the fimbriae were assigned to type H04. Pathogens of the serotype O104: H4 have been known for about 10 years, but have been very rarely detected and have not yet been the cause of major epidemics.

A first sequencing of the bacterial genome , carried out in fragments that was not connected , was announced on June 2, 2011 by the BGI in Beijing. The first analysis of the sequence data showed that the newly isolated strain also contains genetic properties of an enteroaggregative E. coli (EAEC) and therefore a genetic mixture of at least two different strains is present. This new genetic property could explain the low rate of pathogen detection in the newly occurring HUS diseases (only around 60%), as the pathogen adheres to intestinal cells much more effectively with the help of the properties of an EAEC and can thus remain in the colon for longer. The new combination of the genome was presumably a result of the naturally occurring mechanism of horizontal gene transfer , in which bacteria from different species can exchange genetic information ( conjugation ).

Like most of the classic EAEC strains, the outbreak strain is also a so-called ESBL generator, i.e. it produces special β-lactam- splitting enzymes ( β-lactamases ), which establish resistance to a large number of antibiotics .

illness

The pathogen is absorbed orally , most likely mainly through contaminated food. It is not inactivated by the acidic environment of the stomach, which means that its disease-causing properties are retained. In order to trigger an illness, an infectious dose of 10 to 100 bacteria is sufficient . After proliferation in the large intestine (colon) and attachment to special structures on the epithelial cells of the intestinal wall, the death and lysis of some bacteria lead to the release of bacterial Shiga toxin (STX2). This initially leads to local damage to the intestinal epithelium ( necrosis ), which means that water can no longer be removed from the digestive pulp and thus watery diarrhea occurs. These are often bloody ( hemorrhagic ) due to the damage to the intestinal wall and the capillary vessels inside . The disease can remain as a mild form in this stage of hemorrhagic colon inflammation and can be ended by eliminating the bacteria through excretion and by the local immune defense . In many cases, however, the bacterial toxins pass into the bloodstream, which apparently occurs more frequently and in higher concentrations in the outbreak strain, which can produce the STX2 toxin in higher quantities than usual EHEC strains.

With the spread of bacterial toxins, the originally localized disease turns into systemic poisoning , in which the STX2 destroys endothelial cells of the blood vessels, especially those of the kidney corpuscles . The destruction of kidney endothelial cells leads to a limitation of the filtration rate and due to the additional inflammatory reactions in the kidney to a limitation of the kidney function up to complete kidney failure . The binding of the STX2 to red blood cells leads to their destruction ( hemolytic anemia ). This destruction is mediated through activation of the complement system . The damage to the cells lining the blood vessels ( endothelial cells ) by the STX2 leads to local inflammation, local clumping of blood platelets (thrombocytes) and, due to the excessive activation of the coagulation system, to a coagulation disorder . This results in a high consumption of platelets with a reduction in their concentration in the blood ( thrombocytopenia ). As a sign of the destruction of the red blood cells, one can find destroyed erythrocytes ( fragmentocytes ) and an increased number of immature erythrocytes ( reticulocytes ) in the blood smear . The hemoglobin released by destroyed erythrocytes also impairs kidney function. Since only the hemoglobin bound in erythrocytes contributes to the transport of oxygen, the supply of other organs may also be restricted. Thrombocytopenia and systemic inflammatory reactions can lead to consumption coagulopathy (clotting disorders).

In addition to damaging the blood vessels, the kidneys and the blood cells, STX2 also has neurotoxic effects, i.e. the central nervous system is impaired and neurological disorders, including epileptic seizures ( grand mal ), can occur, which can last for a long time ( status epilepticus ) and are difficult to break through with common medication.

The severe forms of the disease can lead to death due to multiple organ failure . This leads to irreversible kidney damage ( uremia ), combined with an uncontrollable coagulation disorder with microthrombi in numerous organs.

Laboratory diagnostics

As the test material used swabs of potentially contaminated surfaces or stool samples from patients. In principle, like all E. coli strains, the pathogen can be cultured on blood agar plates. However, the new outbreak pathogen can only be isolated from stool samples on an agar plate in a minority of cases; More sensitive molecular methods ( PCR ) or toxin detection methods are therefore used in diagnostics. When grown on sorbitol McConkey agar plates the new strain is the ability to fermentation of sorbitol . The resistance test on ESBL plates shows the production of ESBL , with sensitivity to ciprofloxacin and aminoglycosides . Serologically the outbreak strain is the E. coli - serogroup O104 with the H-antigen H4 assigned. The differentiation of the outbreak strain HUSEC041, O104: H4 is possible by identifying special gene segments, usually by means of PCR. Here is reflected in the typical genes for EHEC that these for Shiga toxin-1 ( stx1 , negative) stx2 positive intimin ( eae ) negative and iha (iron uptake system) can be positive.

The stx2 produced by the bacterium and also occurring in the stool can also be detected by ELISA tests. This toxin detection can also be carried out as a rapid test procedure and is used in the screening of suspected cases. Serologically, an unspecific detection of anti- LPS IgM antibodies is only indicative if a significant increase in titer between two blood samples taken at a time in connection with the disease is detected. This serological detection of anti-LPS IgM or IgG is of no significance during the outbreak.

The detection of the pathogen or its specific gene segments in stool samples from sick patients is often unsuccessful because the pathogen is not safely and permanently excreted. A negative finding does not rule out an epidemic HUS disease if the clinical symptoms are present according to the case definition .

The national reference laboratory at the BfR tested a specific quantitative real-time PCR for Escherichia coli on food samples and O104: H4 reference strains under the impression of the massive EHEC-O104: H4 outbreak in Germany . This is based on the rapid, quantitative detection of Shiga toxin genes and the wzx gene from Escherichia coli O104: H4. The detection system is suitable for detecting EHEC O104: H4 from enrichment cultures of suspicious foods.

The Department of Clinical Chemistry , Mass Spectrometry and Proteomics at the University Medical Center Hamburg-Eppendorf discovered a biomarker that made it possible to carry out a rapid analysis of suspicious colonies using MALDI-TOF MS .

therapy

The therapy of a classic HUS disease is limited to the symptomatic treatment of anemia, coagulation disorder and kidney failure. At the same time, in the case of severe forms, the aim is to wash out the bacterial toxins. The treatment of the newly emerging severe form is carried out in intensive medicine. The anemia caused by the destruction of the erythrocytes can be balanced out by administering erythrocyte concentrates if the HB value falls below 6.0 g / dl. A plasmapheresis , with the toxins from the bloodstream can be removed should take place at kidney involvement, severe hemolysis and thrombocytopenia (platelets below 100,000 per mm³) or neurological symptoms. Fresh frozen plasma (FFP) from blood donors is used for plasmapheresis . The coagulation disorder is treated by giving heparin . In the most severe cases, especially in pregnant women and children, hemofiltration can also be carried out after plasmapheresis . Suppression of diarrhea and thus prevention of pathogen reduction in the intestine (for example with loperamide ) is contraindicated .

Treatment with antibiotics is not indicated in classic HUS cases , as this can induce toxin synthesis in the bacterium and lead to an increased release of bacterial toxins from destroyed bacteria. The duration of the illness can also be extended by the administration. Since the outbreak strain in 2011, however, properties of EAEC has so firmly to the intestinal epithelial cells in the intestine and he adheres thus been primarily a long persist , could a dose of certain antibiotics is discussed to a permanent toxin production to stop. In certain cases, treatment with carbapenems is considered justifiable by the specialist societies, as is the use of modern macrolides , rifampicin or rifaximin, which only works in the intestine . In principle, these are those antibiotics that inhibit the protein synthesis metabolism of the bacterium and thus could also prevent the production of the toxin. Such an antibiotic treatment to remove the pathogenic bacterium is common with the classic enteroaggregative E. coli , even if they cannot form Shiga toxin 2.

In order to prevent the destruction of the erythrocytes by the stx2 with medication, the use of eculizumab in the most severe cases is also being discussed. This is a monoclonal antibody which , by binding to the complement component C5 , can prevent the activation of the complement system , which is triggered by the binding of the stx2 to erythrocytes.

Prevention

Heating food to a core temperature of over 70 ° C for at least 2 minutes inactivates the bacterium, with meat this is achieved by cooking through. For foods such as vegetables, thorough washing is recommended to reduce the germ count . General hygienic measures to reduce the number of germs are regular washing of hands with soap, the use of disposable paper towels and strict rules of cleanliness when preparing food. To kill pathogens ( disinfection ) on surfaces of objects are bactericidal disinfectants that can lead to disadvantages such as resistance and awareness, however, if used improperly, or sterilization procedures that are not feasible in a normal household.

Economic and political effects of the HUS epidemic

The reporting in the media led to long-term sales losses in the industry (for example also at food stands at street festivals in southern Germany). Even companies that had established expensive laboratory analyzes as part of a strict HACCP concept for self-monitoring before the crisis were severely affected. According to the German Farmers' Association (DBV), the total damage amounted to EUR 75 million.

Temporary warning against the consumption of raw cucumbers, tomatoes and lettuce in Germany

On May 25, 2011 the RKI and the BfR issued a warning against the consumption of raw cucumbers, tomatoes and lettuce by announcing the results of a study by the RKI on EHEC / HUS. The Federal Ministry of Consumers welcomed this warning and for its part issued corresponding warnings, which it renewed several times as a precaution, despite the lack of evidence of the pathogen. As a result, according to surveys, around half of Germans changed their diet and gave up these fresh vegetables. There was an enormous slump in sales in the German vegetable industry; the provider Gemüsering spoke of a decrease of up to 80 percent.

The BfR lifted this warning on June 10, 2011.

De facto import ban on cucumbers from Spain

After EHEC bacteria were detected on Spanish cucumbers on May 26, 2011 (which later turned out to be of a different type than the E. coli associated with the outbreak ), the responsible ministries in North Rhine-Westphalia, Baden-Württemberg and Bavaria issued regulations , who demanded proof of the safety of Spanish cucumbers from the traders, which amounted to a de facto import ban. On June 1, 2011, the EU Commission removed the warning on Spanish cucumbers from the European rapid alert system, referring to the latest research results. North Rhine-Westphalia repealed the decree on June 3, 2011.

The Hamburg authority for health and consumer protection announced in a press conference on May 26, 2011 that EHEC pathogens on cucumber from Spain had been detected during the examination of food samples. This result - according to the statement from the Senator for Health and Consumer Protection at the time - was a real breakthrough in the search for the source of the pathogen that was responsible for the EHEC infection wave. The name of the Spanish company from whose distribution the cucumbers came was also mentioned.

The city-state of Hamburg was sentenced by the Hamburg Regional Court to compensate for the damage caused to Spanish cucumber suppliers. In the appeal proceedings at the Higher Regional Court, the state agreed with the two plaintiffs on the payment of "a mid-six-figure amount". Spanish sources quote amounts of € 400,000 and € 700,000, around half of the amount claimed.

Warning against consumption of products made from fenugreek seeds

Mung bean sprouts

The German Federal Institute for Risk Assessment (BfR) issued a warning on June 6, 2011 against the consumption of sprouts . The RKI followed suit. Although at this point in time there was still no direct evidence of the pathogen, the chain of evidence was so stressful that it was assumed that the outbreak of the epidemic began here. In contrast to the consumption warning for tomatoes, cucumbers and lettuce, which was lifted on June 10, 2011, the consumption warning for sprouts continued until July 21. On June 30, 2011, the BfR announced that fenugreek seeds from Egypt were most likely the cause of the EHEC outbreak. Since it cannot be ruled out that the pathogen is already contained in commercially available seedlings, the consumption of sprouts grown therefrom was not advised. On July 21, 2011, the Robert Koch Institute relaxed the general consumption warning against raw sprouts and seedlings. The warnings against Egyptian fenugreek seeds and sprouts and sprouts grown from them remain. For the EU, there was an import ban on fenugreek and other seeds from Egypt until October 31, 2011.

In a statement dated July 26, 2011, the BfR dealt with the significance of EHEC O104: H4 in fenugreek seeds, which are processed into foods other than sprouts and sprouts. After that, fenugreek seeds are used in foods such as cheese, herbal teas, mustard, curry spices, and dietary supplements. For taste and technological reasons (neutralization of bitter substances), fenugreek seeds are usually heated before being added to food. Food business operators are advised to check whether material from a potentially contaminated batch of fenugreek seeds has been used and whether the operational process procedures are suitable for safely killing the germ in and on the seeds. Consumers are advised to first heat fenugreek seeds vigorously, e.g. B. by roasting in the pan. Herbal teas with fenugreek seeds, like all herbal teas, should be infused with boiling water and steeped for at least 5 minutes. Water from hot water dispensers is not hot enough to safely kill bacteria.

Compensation payments to affected farmers

EU Agriculture Commissioner Dacian Cioloș pledged financial aid to the farmers concerned after a meeting with the European Agriculture Ministers on June 8, 2011. Up to 70% of the sales losses are to be replaced. 210 million euros were available for this. The first payments should be made in July. Of the funds ultimately set aside by the EU Commission as compensation of 227 million euros , only 16 million euros went to the German farmers.

Changes in legislation

From July 1, 2013, new regulations came into force across the EU. This includes, among other things, an authorization requirement for companies that produce sprouts and a new food safety criterion for sprouts within the framework of Regulation (EC) 2073/2005 , which makes regular inspections by the manufacturer mandatory.

Open questions

In February 2012, the German Society for Hospital Hygiene (DGKH) pointed to open questions and hitherto unexplained relationships and stated: “Why one of the largest EHEC outbreaks and the largest HUS outbreak could occur in Germany has so far been unclear consider. ”In May 2012, the consumer organization Foodwatch in its analysis“ Im Bockshorn ”represented the thesis:“ The EHEC outbreak 2011 has not been clarified, there is no convincing explanation for the origin and spread of the pathogen. ”The analysis also complained that the Traceability of delivery routes is inadequate in practice.

See also

literature

  • C. Frank et al .: Large and ongoing outbreak of haemolytic uraemic syndrome, Germany, May 2011 . Eurosurveillance , 16, 21 (May 26, 2011, Rapid Communication, pdf) ( online ; PDF; 158 kB)
  • M. Askar et al .: Update on the ongoing outbreak of haemolytic uraemic syndrome due to Shiga toxin-producing Escherichia coli (STEC) serotype O104, Germany, May 2011 . Eurosurveillance, 16, 22 (June 2, 2011, Rapid Communication) ( online )
  • Preliminary results of the EHEC / HUS study, joint statement by BfR and RKI, May 25, 2011 (pdf) ( online ; PDF; 28 kB)
  • Presentation and evaluation of the previous epidemiological findings in the EHEC / HUS O104: H4 outbreak, May / June 2011, RKI (pdf) ( online )
  • Therapeutic apheresis treatment for EHEC-associated HUS, recommendations of the German Society for Nephrology, as of June 1, 2011 ( online )
  • HUS surveillance and laboratory team of the Infection Epidemiology Department of the Robert Koch Institute : Intensified surveillance during a major EHEC / HUS outbreak in Germany, May - June 2011 . In: Epidemiological Bulletin . No. 25 , 2011, p. 225-229 ( online [PDF]).
  • Bernd Appel, Gaby-Fleur Böl, Matthias Greiner, Monika LahrssenWiederholt and Andreas Hensel (eds.): EHEC outbreak 2011 - Investigation of the outbreak along the food chain Federal Institute for Risk Assessment. BfR Wissenschaft, Berlin 2011, ISBN 3-938163-86-0 . ( online , PDF file)
  • Enteroaggregative E. coli O104 from an outbreak of HUS in Germany 2011, could it happen again? (MA Chattaway et al., 2011, Open Access, Review, J Infect Dev Ctries 2011; 5 (6): 425-436., Doi: 10.3855 / jidc.2166 )

Web links

Individual evidence

  1. ↑ a b Fenugreek seeds highly likely to be responsible for EHEC O104 H4 outbreak. (PDF; 48 kB) In: Federal Institute for Risk Assessment . June 30, 2011, accessed July 1, 2011 .
  2. ↑ King, L. et al. (2012): Outbreak of Shiga Toxin – Producing Escherichia coli O104: H4 Associated With Organic Fenugreek Sprouts, France, June 2011 . Clinical Infectious Diseases 2012, 54 (11): 1588-94. (PDF; 176 kB).
  3. ↑ European Food Safety Authority: Tracing seeds, in particular fenugreek (Trigonella foenum-graecum) seeds, in relation to the Shiga toxin-producing E. coli (STEC) O104: H4 2011 Outbreaks in Germany and France. doi : 10.2903 / sp.efsa.2011.EN-176 .
  4. ^ A b Bernd Appel, Gaby-Fleur Böl, Matthias Greiner, Monika Lahrssen-Wiederholt, Andreas Hensel: EHEC Outbreak 2011. Investigation of the Outbreak Along the Food Chain. Federal Institute for Risk Assessment. (PDF; 6.6 MB).
  5. ↑ Nicolai Kwasniewski: New findings on the 2011 epidemic: The Ehec scandal, which was never cleared up. Spiegel-online, September 20, 2013, accessed on September 20, 2013 .
  6. ↑ Laboratory information on the EHEC outbreak strain (as of June 1, 2011) (PDF; 183 kB)
  7. ↑ M. Askar et al .: Update on the ongoing outbreak of haemolytic uraemic syndrome due to Shiga toxin-producing Escherichia coli (STEC) serotype O104, Germany, May 2011 . Eurosurveillance, 16, 22 (June 2, 2011, Rapid Communication) .
  8. ^ EHEC - a year later dasgastroenterologenportal.de
  9. ↑ Robert Koch Institute : Federal Institute for Risk Assessment: EHEC outbreak 2011 Investigation of the outbreak along the food chain - 6.1.3.1.2 On the risk potential in the current outbreak events. (PDF) Retrieved June 10, 2011 .
  10. ^ Department of Infection Epidemiology of the RKI: On the development of the number of diseases in the current EHEC / HUS outbreak in Germany - update . In: Epidemiological Bulletin . No. 24 , 2011, p. 215–217 ( online [PDF; 126 kB ]).
  11. ↑ RKI notified delayed due to peculiarities of the course
  12. ^ RKI: Information on the EHEC / HUS outbreak events ( memento from August 10, 2014 in the Internet Archive ).
  13. ↑ Kai Gerullis: Experts in Concern: Deadly germs spread furiously , Bergedorfer Zeitung , May 25, 2011
  14. ↑ HUS epidemic curve. (PDF) In: rki.de. Retrieved June 27, 2011 .
  15. ↑ EHEC epidemic in Japan due to contaminated sprouts ( Memento from June 11, 2011 in the Internet Archive )
  16. ↑ High bacterial load in sprouts and ready-to-use salad mixes (PDF; 205 kB) Updated BfR opinion No. 017/2011 of May 9, 2011.
  17. ^ Tagesschau June 5, 2011: New findings in the search for EHEC cause. Sprouts from Lower Saxony suspected. Retrieved June 5, 2011.
  18. ↑ Allgemeine Zeitung Uelzen August 9, 2014: Three years after the epidemic.Retrieved on August 9, 2014.
  19. ↑ Foodwatch 2012: Im Bockshorn Analyze 2012 - The EHEC crisis in early summer 2011. Retrieved on August 9, 2014.
  20. ↑ EHEC type O104: H4 on cucumbers in the garbage of a sick family Spiegel.de: Experts find EHEC pathogens in the garbage .
  21. ↑ RKI information on the EHEC / HUS outbreak, as of June 9, 2011, 9 a.m. ( Memento from August 10, 2014 in the Internet Archive ).
  22. ↑ EHEC suspicion against sprouts from Lower Saxony confirmed  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. , Reuters, June 10, 2011@1@ 2Template: Toter Link / de.reuters.com  
  23. ↑ Dangerous EHEC serotype O 104 found on sprouts in North Rhine-Westphalia - two family members become ill. Accessed June 10, 2011.
  24. ↑ a b c BfR press release 16/2011, June 10, 2011: New findings on the EHEC outbreak. Joint press release from BfR, BVL and RKI. Retrieved June 10, 2011.
  25. ↑ Main echo: But no Ehec pathogen in Erlenbach , Frankfurt , August 13, 2011.
  26. ↑ RKI boss Burger: The reason for the contamination of the vegetables could be faeces from humans or animals .
  27. ↑ Farmer President Sonnleitner: Liquid manure is not used in greenhouses or on field crops .
  28. ↑ Press release University Hospital Münster June 10, 2011: EHEC outbreak strain: Prof. Karch suspects humans as a reservoir .
  29. ↑ EHEC outbreak: The procedure in practice , Deutsches Ärzteblatt of June 17, 2011
  30. ↑ Confusion of information , Deutsches Ärzteblatt from June 17, 2011.
  31. ↑ EHEC / HUS O104: H4 - The outbreak is considered to have ended. Press release of the Robert Koch Institute of July 26, 2011. Accessed July 26, 2011.
  32. ↑ Info-HUS.pdf (application / pdf object). (PDF) (No longer available online.) In: rki.de. Formerly in the original ; Retrieved November 14, 2011 .  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Toter Link / www.rki.de  
  33. ↑ WHO: Outbreaks of E. coli O104: H4 infection: update 28 01-07-2011. ( Memento from December 12, 2012 in the Internet Archive )
  34. ↑ Health warning for the prevention of diarrheal diseases with a special focus on Shiga toxin-producing Escherichia coli (STEC), also known as verotoxin-producing E. coli (VTEC), or enterohaemorrhagic E. coli (EHEC). ( Memento of June 10, 2015 in the Internet Archive ) (PDF; 22 kB) Joint statement by the European Center for Disease Prevention and Control (ECDF) and the European Food Safety Authority (EFSA), June 3, 2011. Retrieved on June 10, 2011
  35. ↑ a b WHO: EHEC outbreak: Update 12 09-06-2011. Retrieved June 10, 2011
  36. ↑ Annex to the press release of May 26, 2011, NKL for HUS (pdf; 86 kB)
  37. ^ BGI Sequences Genome of the Deadly E. coli in Germany and Reveals New Super-Toxic Strain , accessed June 2, 2011
  38. ↑ Notes on diagnostic criteria, KL HUS, Münster, as of June 1, 2011 (PDF; 183 kB)
  39. ↑ Press release: BfR and ANSES develop test system for the identification of EHEC contamination in food, BfR
  40. ↑ Martin Christner, Maria Trusch, Holger Rohde, Marcel Kwiatkowski, Hartmut Schlueter: Rapid MALDI-TOF Mass Spectrometry Strain Typing during a Large Outbreak of Shiga-Toxigenic Escherichia coli . In: PLOS ONE . tape 9 , no. 7 , July 8, 2014, ISSN  1932-6203 , p. e101924 , doi : 10.1371 / journal.pone.0101924 .
  41. ↑ Therapeutic apheresis treatment in EHEC-associated HUS, recommendations of the German Society for Nephrology, as of June 1, 2011 ( Memento from June 9, 2011 in the Internet Archive )
  42. ↑ Position paper of the German Society for Infectious Diseases on the Therapy of the New HUS Cases (pdf from June 1, 2011; 42 kB) ( Memento from August 28, 2013 in the Internet Archive )
  43. ↑ Anne-Laure Lapeyraque, et al .: eculizumab in Severe Shiga toxin-associated HUS. In: New England Journal of Medicine. 364, 2011, pp. 2561-2563, doi: 10.1056 / NEJMc1100859 .
  44. ↑ Protection against infections with EHEC, BfR (pdf; 958 kB)
  45. ↑ Already more than 400 new EHEC cases in 2012 - Only a few food producers have regular laboratory checks carried out
  46. ↑ a b EHEC: Food producers waiting for compensation , August 30, 2011
  47. ↑ Preliminary results of the EHEC / HUS study. As of May 25, 2011, RKI-BfR. Retrieved May 18, 2014
  48. ↑ Survey: 58 percent do not eat vegetables because of EHEC May 28, 2011. Accessed June 5, 2011
  49. ↑ "The market for cucumbers and salads is dead" , Cannstatter Zeitung, June 9, 2011, accessed on May 18, 2014.
  50. ↑ Hamburger Abendblatt: Spanish cucumbers from Malaga are EHEC sources , accessed on May 26, 2011.
  51. ^ "Laboratory test shows: Two cucumbers examined in Hamburg are not the source of the EHEC epidemic" , Hamburg Authority for Health and Consumer Protection, May 31, 2011.
  52. ↑ a b Press release of the NRW Ministry of Consumer Protection from June 3, 2011: NRW Ministry of Consumer Protection cancels the obligation to certify Spanish cucumbers ( Memento from May 18, 2014 in the Internet Archive ). Retrieved May 18, 2014
  53. ^ Ministry of Rural Areas and Consumer Protection: Press Release 121/2011 ( Memento of May 18, 2014 in the Internet Archive ). […] Trade in Spanish cucumbers is only allowed if it has been proven that they are safe […] Retrieved on June 5, 2011
  54. ↑ Bavarian State Office for Health and Food Safety (LGL): Press release No. 11/11 of May 27, 2011. […] Cucumbers of Spanish origin may only be put on the market in Bavaria with proof of harmlessness […]. Retrieved June 5, 2011
  55. ↑ a b Press release of the OLG Hamburg Archived copy ( memento from January 14, 2018 in the Internet Archive ), accessed on January 14, 2018
  56. ↑ Hamburg pays damages [1] accessed on January 14, 2018
  57. ↑ http://www.diariosur.es/economia/agroalimentacion/gerente-frunet-satisfecho-20170826212012-nt.html , accessed on January 14, 2018
  58. ↑ Opinion No. 018/2011 of the BfR of 6 June 2011 (PDF; 38 kB) Retrieved on 7 June 2011
  59. ↑ a b c RKI EHEC infections. (No longer available online.) In: rki.de. Robert Koch Institute , July 21, 2011, archived from the original on July 22, 2011 ; Retrieved July 22, 2011 .
  60. ↑ Opinion No. 031/2011 of the BfR of July 26, 2011 on the significance of EHEC O104: H4 in fenugreek seeds PDF file 122 KB
  61. ↑ Press portal of the EU Commission: EHEC: Rapid help for affected farmers and Dacian Cioloș: Statement on the proposal of compensation for the vegetables sector
  62. ↑ GABOT: Preventing the EHEC epidemic in the future: New regulations , August 15, 2013; accessed on March 20, 2020.
  63. ↑ Statement of the DGKH on open questions in the context of the EHEC outbreak and on future hygiene requirements for sprout processing companies (PDF; 403 kB) February 29, 2012
  64. ↑ In the fenugreek. The EHEC crisis in the early summer of 2011 Foodwatch analysis May 2012