H5N1

US: CDC investigation update of E. coli 0157 H7 infections now linked to romaine lettuce

CDC has published CDC Investigation Update of E. coli 0157 H7 Infections Now Linked to Romaine Lettuce. Excerpt:

A CDC investigation notice of a multistate outbreak of E. coli 0157:H7 infections has been posted: https://www.cdc.gov/ecoli/2019/o157h7-11-19/index.html  

What is new: 

• Consumers should not eat and retailers and restaurants should not sell or serve any romaine lettuce harvested from the Salinas, Calif. growing region. 

• This advice includes all types of romaine lettuce harvested from Salinas, such as whole heads of romaine, hearts of romaine, and packages of precut lettuce and salad mixes that contain romaine, including baby romaine, spring mix, Caesar salad, and organic romaine. 

• If you have romaine lettuce at your home or restaurant and the label says “Salinas” (whether alone or with the name of another location). don’t eat it. Throw it away. If you don’t know if the lettuce is romaine or whether a salad mix contains romaine, don’t eat it or serve it. Throw it away. 

• Most romaine lettuce products are labeled with a harvest location showing where they were grown. Do not eat, serve, or sell any lettuce labeled as grown in Salinas, regardless of any other location on the label. 

• Restaurants and retailers should check the label on bags or boxes of romaine lettuce or ask their suppliers about the source of their romaine lettuce. 

Latest outbreak information:  

• A total of 40 people infected with the outbreak strain of coli 0157:H7 have been reported from 16 states. 

• A total of 27 hospitalizations have been reported. Five people have developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported. 

• Epidemiologic and laboratory evidence and interviews with ill people indicate that romaine lettuce from the Salinas, Calif., growing region may be contaminated with coli O157:H7 and is making people sick. 

• FDA is tracing the romaine lettuce eaten by ill people in this outbreak. Preliminary information collected indicates that the lettuce eaten by some of the ill people was grown in Salinas, Calif. No common grower, supplier, distributor, or brand of romaine lettuce has been identified. 

• The USDA has recalled several products containing romaine lettuce due to possible coli contamination. 

• Laboratory data confirmed this outbreak is caused by the same strain of coli O157:H7 that caused previous outbreaks linked to leafy greens in 2017 and romaine lettuce in 2018. 

• This investigation is ongoing and CDC will provide updates when more information becomes available. 

About Shiga toxin-producing E. coli:  

• People get sick from Shiga toxin-producing E. coli an average of 3 to 4 days after swallowing the germ. 

• Most people get diarrhea (often bloody), severe stomach cramps, and vomiting. 

• Most people recover within a week, but some illnesses can last longer and be more severe. 

• Antibiotics are not recommended for patients with suspected E. coli infections until diagnostic testing can be performed and E. coli infection is ruled out.

See also this Washington Post report.

ECDC: Surveillance of antimicrobial resistance in Europe 2018

ECDC has published Surveillance of antimicrobial resistance in Europe 2018. Excerpt from the executive summary: 

As in previous years, the AMR situation in Europe displays wide variations depending on bacterial species, antimicrobial group and geographical region. For several bacterial species–antimicrobial group combinations, a north-to-south and west-to-east gradient is evident. In general, lower resistance percentages were reported by countries in the north while higher percentages were reported in the south and east of Europe. The high variability in AMR across EU/EEA countries reinforces the scope for significant reductions through investments to strengthen current best practice.   

In 2018, more than half of the Escherichia  coli isolates reported to EARS-Net and more than a third of the Klebsiella pneumoniae isolates were resistant to at least one antimicrobial group under regular surveillance, and combined resistance to several antimicrobial groups was frequent. Resistance percentages were generally higher in K. pneumoniae than in E. coli. While carbapenem resistance remained rare in E. coli, several countries reported carbapenem resistance percentages above 10% for K. pneumoniae. 

Carbapenem resistance was also common in Pseudomonas  aeruginosa and Acinetobacter species, and at higher percentages compared with K. pneumoniae. For all four gram-negative bacteria, the countries reporting the highest carbapenem resistance percentages were also among the countries reporting the highest resistance percentages for other antimicrobial groups. For most gram-negative bacterial species–antimicrobial group combinations, changes in resistance percentages between 2015 and 2018 were moderate, and resistance remained at previously reported high levels.  

For Streptococcus pneumoniae, the resistance situation appeared stable, but with large inter-country variations. For Staphylococcus aureus, the decline in the percentage of methicillin-resistant (i.e. MRSA) isolates reported in previous years continued in 2018. Nevertheless, MRSA remains an important pathogen in the EU/EEA, as the levels of MRSA were still high in several countries, and combined resistance to other antimicrobial groups was common. 

Population-level surveillance of antibiotic resistance in Escherichia coli through sewage analysis

Today my wife and I had the pleasure of a quick tour of ECDC's headquarters in Solna. The previous HQ, an old building on the campus of the Karolinska, had a lot of charm but wasn't up to the needs of a modern health agency.

Credit: ECDC

 

ECDC moved into its new digs about a year and a half ago, farther out in Solna, a Stockholm suburb. The building features offices and meeting rooms built around a six-storey atrium; the view from the cafeteria on the top floor is a panorama of Stockholm.

Credit: ECDC

 

Most impressive was the Emergency Operations Centre, where ECDC's Epidemic Intelligence Division works and everyone gathers at 11:30 a.m. for an update on the current situation—dominated, of course, by Ebola (one of the clocks on the wall is set to Kinshasa time).

Credit: ECDC

 

ECDC also publishes Eurosurveillance, a weekly journal of studies into current and potential threats to European public health. Here's an example from today's issue: Population-level surveillance of antibiotic resistance in Escherichia coli through sewage analysis. The abstract:

Introduction 

The occurrence of antibiotic resistance in faecal bacteria in sewage is likely to reflect the current local clinical resistance situation. Aim This observational study investigated the relationship between Escherichia coli resistance rates in sewage and clinical samples representing the same human populations. 

Methods 

E. coli were isolated from eight hospital (n = 721 isolates) and six municipal (n = 531 isolates) sewage samples, over 1 year in Gothenburg, Sweden. An inexpensive broth screening method was validated against disk diffusion and applied to determine resistance against 11 antibiotics in sewage isolates. Resistance data on E. coli isolated from clinical samples from corresponding local hospital and primary care patients were collected during the same year and compared with those of the sewage isolates by linear regression. 

Results 

E. coli resistance rates derived from hospital sewage and hospital patients strongly correlated (r2 = 0.95 for urine and 0.89 for blood samples), as did resistance rates in E. coli from municipal sewage and primary care urine samples (r2 = 0.82). Resistance rates in hospital sewage isolates were close to those in hospital clinical isolates while resistance rates in municipal sewage isolates were about half of those measured in primary care isolates. Resistance rates in municipal sewage isolates were more stable between sampling occasions than those from hospital sewage. 

Conclusion 

Our findings provide support for development of a low-cost, sewage-based surveillance system for antibiotic resistance in E. coli, which could complement current monitoring systems and provide clinically relevant antibiotic resistance data for countries and regions where surveillance is lacking.

Toddler dies from E. coli linked to contact with animals at San Diego County Fair

Via The New York Times: Toddler Dies From E. coli Linked to Contact With Animals at San Diego County Fair. Excerpt:

A 2-year-old boy died from complications of E. coli and three other children were sickened in cases that officials said were linked to contact with animals at the San Diego County Fair in June. 

Four children, ages 2 to 13, visited the fair from June 8 to 15 and exhibited symptoms of Shiga toxin-producing E. coli from June 10 to 16, the County of San Diego Health and Human Services Agency said in a news release on Friday.  

The 2-year-old died on June 24 from complications of the bacteria; the other three children who were sickened were not hospitalized. Their conditions were not immediately available on Sunday. 

The fair features more than 2,900 animals and numerous activities, including pig races and livestock shows with calves, rabbits, pigeons and goats. The fair shut public access to animals on Saturday, and on Sunday it began removing them from the fairgrounds.

Symptoms of E. coli infection include severe abdominal cramps, watery or bloody diarrhea and vomiting, the agency said. Symptoms may occur with or without fever.  

Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in Manhattan, said the most common form of transmission was the fecal-oral route. In that route, children touch surfaces or animals contaminated with E. coli and then put their hands in their mouths.

“Young children at these zoos come in contact with feces of the animals,” he said on Sunday. “Certainly the animals clean themselves, and obviously contact by virtue of petting is common. We’re looking at calves, cows, goats, sheep as well as deer.” 

Dr. Glatter emphasized the importance of hand washing after coming in contact with animals, calling it “paramount.”

'We're holding up a floodgate': BC fights off superbugs brought home by medical tourists

Via CBC News: 'We're holding up a floodgate': B.C. fights off superbugs brought home by medical tourists. Excerpt:

The risks involved in medical tourism aren't just personal. Having surgery abroad could also mean bringing back a drug-resistant superbug and putting people in this country at risk, B.C. officials warn. 

That alert comes after the recent discovery that two patients at New Westminster's Royal Columbian Hospital had been colonized with the multidrug-resistant yeast Candida auris. Though neither patient is infected with the bug, the two join just a handful of cases that have been identified in B.C. since 2017.  

Dr. Linda Hoang, medical co-director for the Provincial Infection Control Network (PICNet), said most of these cases have come from travellers who have had treatment overseas, including medical tourists. 

It means patients need to do serious research on the facilities they're considering for surgeries or other treatments abroad, including looking for objective information about the presence of any drug-resistant microorganisms.  

"It's not only a problem in India or Southeast Asia. It is endemic in parts of the U.S. and parts of Europe," Hoang told CBC News.  

"It [antibiotic-resistant superbugs] is a global problem, and the only way to to be aware of them is to make sure that health-care professionals are informed and our residents are informed when they're seeking health care outside of British Columbia." 

It's a sobering reminder for those who travel abroad for medical treatments, whether it's to skip the surgery wait list in B.C., access therapies that aren't approved in Canada or save money on cosmetic therapy. Some of the top destinations for medical tourists from around the world include India, Mexico, Southeast Asia, Brazil and Turkey, according to the Medical Tourism Association.  

But facilities in other countries can sometimes take a more haphazard approach to prescribing antibiotics, and overuse can trigger the evolution of resistance to these crucial drugs.  

India a major source of bug 

The two colonized patients at Royal Columbian were isolated after the bug was discovered, and the hospital has been aggressively cleaning all areas they had visited, using UV light for disinfection, according to Fraser Health. 

C. auris was first identified in Japan in 2009, but it has popped up since then in countries around the world. 

It acts much like any other yeast species, causing infections in wounds, the bloodstream and the ears, but the real problem is how to treat it. 

"The only real reason why we're concerned or interested in monitoring Candida auris is because of that potential resistance profile, making it difficult to treat with the anti-fungal agent that we have," Hoang said. 

The biggest risk of infection right now seems to come from Indian facilities, Hoang said.

The bug was confirmed for the first time in B.C. in July 2017 in a patient who'd been treated in India. As it turned out, that traveller also came back with infections from multiple other drug-resistant organisms. 

B.C. doesn't track whether infected people travelled abroad as medical tourists or simply required medical treatment because of an emergency during their voyages. 

But patients who have had medical treatment outside B.C. for any reason are a major source of these superbugs, she said.

They include so-called CPOs — carbapenemase-producing organisms like Klebsiella, E. coli and Pseudomonas that have become resistant to broad-spectrum antibiotics, which Hoang describes as the "last resort" for treatment. 

In 2017-2018, PICNet recorded more CPO cases than ever before, and more than half of them were from people who had accessed health care overseas, Hoang said.

Only romaine lettuce from central and northern California is unsafe, FDA says

Via The New York Times: Only Romaine Lettuce From Central and Northern California Is Unsafe, F.D.A. Says. Excerpt:

It’s O.K. to eat romaine lettuce again, federal health officials said on Monday — as long as you’re sure it wasn’t grown on California’s north and central coast. 

The Food and Drug Administration and the Centers for Disease Control and Prevention said investigators had traced the romaine lettuce associated with an outbreak of E. coli that has sickened 65 people in 12 states and Canada to “end of summer” romaine lettuce harvested from that region.  

With the growing and harvesting season over there, according to the F.D.A., people may eat romaine lettuce that has been hydroponically or greenhouse grown, or has been harvested from the winter growing desert regions of the United States, and is labeled such.

“If it does not have this information,” the agency said in a statement posted on its website, “you should not eat or use it.” 

 Dr. Scott Gottlieb, the F.D.A. commissioner, said that, to protect consumers, the industry had agreed to label romaine lettuce with the harvest date and region.  

“The F.D.A. also has commitments from the romaine lettuce industry that such labeling will continue into the future and become standard for their products,” Dr. Gottlieb said. The labels may be extended to other leafy greens, he said.

Romaine and Ebola

Via the website of CBC Radio's excellent current-affairs program: The Current for November 22, 2018. Click or tap through to hear the items:

• After a warning that romaine lettuce could be contaminated with E. coli, we weigh the pros and cons of leafy greens, and ask: is it time to give up on salad?

• Efforts to contain an Ebola outbreak in the Democratic Republic of Congo are being complicated by an armed conflict in the area. We hear from aid workers about the challenges of fighting a deadly disease, in deadly circumstances.

Public Health Notice - Outbreak of E. coli infections linked to romaine lettuce

Via the Public Health Agency of Canada: Public Health Notice - Outbreak of E. coli infections linked to romaine lettuce. Excerpt and then a comment:

The Public Health Agency of Canada is collaborating with provincial public health partners, the Canadian Food Inspection Agency, Health Canada, as well as the United States Centers for Disease Control and Prevention (U.S. CDC) and the United States Food and Drug Administration (U.S. FDA), to investigate an outbreak of E. coli infections in Ontario and Quebec, and several U.S. states. 

In Canada, based on the investigation findings to date, exposure to romaine lettuce has been identified as a source of the outbreak, but the cause of contamination has not been identified. Laboratory analysis indicates that the illnesses reported in this outbreak are genetically related to illnesses reported in a previous E. coli outbreak from December 2017 that affected consumers in both Canada and the U.S. 

This tells us that the same strain of E. coli is causing illness in Canada and the US as was seen in 2017 and it suggests there may be a reoccurring source of contamination. Investigators are using evidence collected in both outbreaks to help identify the possible cause of the contamination in these events.  

The current outbreak appears to be ongoing as illnesses linked to romaine lettuce continue to be reported. These recent illnesses indicate that contaminated romaine lettuce may still be on the market, including in restaurants, grocery stores and any establishments that serve food. At this time, the investigation evidence in Ontario and Quebec suggests that there is a risk of E. coli infections associated with eating romaine lettuce. 

As the risk is ongoing, the Public Health Agency of Canada is advising individuals in Ontario and Quebec to avoid eating romaine lettuce and salad mixes containing romaine lettuce until more is known about the outbreak and the cause of contamination. Currently, there is no evidence to suggest that residents in other parts of Canada are affected by this outbreak. 

The U.S. CDC has also issued communications with similar advice for U.S individuals in affected states. The outbreak investigation is ongoing, and this public health notice will be updated as the Canadian investigation evolves.

We eat a lot of romaine, but a quick check in the fridge confirms that ours in grown in Canada. So we'll continue until PHAC advises British Columbians to ditch it also.

UK: Two children from same family die after contracting E coli

Via The Guardian: Two children from same family die after contracting E coli. Excerpt:

Two children from the same family have died after contracting E coli, Public Health England (PHE) has said. 

The health body has not confirmed the ages of the children or where they are from, but said PHE East Midlands had been working closely with environmental health colleagues from Charnwood borough council following the confirmation of two cases of haemolytic uraemic syndrome (HUS) in two siblings.  

Dr Lauren Ahyow, a consultant in communicable disease control at PHE East Midlands, said: “E coli is an infection that causes a spectrum of illness ranging from mild through to severe bloody diarrhoea, mostly without fever.  

“Sometimes the infection can cause a condition called haemolytic uraemic syndrome (HUS), which affects the kidneys and can be very serious. Young children and elderly people are more prone to development of complications associated with E coli. 

“E coli can be acquired through a number of routes including contaminated food, contact with farm animals and infected water. PHE are working with partners to investigate further to try and determine a source of infection.”

Climate change and antibiotic resistance

Via bioRxiv: Rates of increase of antibiotic resistance and ambient temperature in Europe: a cross-national analysis of 28 countries between 2000-2016. The abstract:

Background. 

Widely recognized as a major public health threat globally, the rapid increase of antibiotic resistance in bacteria could soon render our most effective method to combat infections obsolete. Factors influencing the burden of resistance in human populations remain poorly described, though temperature is known to play an important role in mechanisms at the bacterial level. 

Methods. 

We performed an ecologic analysis of country level antibiotic resistance prevalence in 3 common bacterial pathogens across 28 countries in Europe, and used multivariable models to evaluate associations with minimum temperature and other predictors over a 17-year period (2000-2016). We quantified the effects of minimum temperature, population density, and antibiotic consumption on the rate of change of antibiotic resistance across geographies. Findings. 

For three common bacterial pathogens and four classes of antibiotics, we found evidence of a long-term effect of ambient minimum temperature on rates of increase of antibiotic resistance across 28 countries in Europe between 2000-2016. 

Specifically, we show that across all antibiotic classes for the pathogens E. coli and K. pneumoniae, European countries with 10°C warmer ambient temperatures have experienced more rapid increases in antibiotic resistance over the 17-year period, ranging between 0.33%/year (95% CI 0.2, 0.5) and 1.2%/year (0.4, 1.9), even after accounting for recognized drivers of resistance including antibiotic consumption and population density. 

We found a decreasing relationship for S. aureus and methicillin of -0.4%/year (95% CI -0.7, 0.0), reflecting widespread declines in MRSA across Europe over the study period. 

Interpretation. 

Ambient temperature may be an important modulator of the rate of change of antibiotic resistance. Our findings suggest that rising temperatures globally may hasten the spread of resistance and complicate efforts to mitigate it.