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

Updated June 10, 2011

Today's Highlights

  • As of June 9, 2011, case counts confirmed by Germany’s Robert Koch Institute (RKI)* includes 759 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli or STEC infections–and 21 deaths associated with HUS.
  • In the United States, one confirmed and four suspect cases of STEC O104:H4 infections have been identified. No deaths have been reported.
  • RKI has announced that contaminated bean 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.

Introduction

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 9, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 759 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli or STEC infections–and 21 HUS-associated deaths.

In the United States, one confirmed and four suspect cases 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 isolate from one HUS case reported in Massachusetts has been confirmed as matching the outbreak strain. Of the four suspect cases, two have HUS: one reported in Michigan and one reported in Wisconsin. The other two suspect cases are currently under investigation. The first is a person who traveled to Germany and was diagnosed with Shiga toxin-positive diarrheal illness. The second is a family member of the Michigan HUS case; this person did not travel to Germany, but was likely infected by contact with their sick family member and later developed diarrheal illness.

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.

Investigation of the Outbreak

According to a World Health Organization report, 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.

Clinical Features/Signs and Symptoms

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.

Key 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 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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