Raw milk, farm animals likely cause of new E. coli outbreak among children

This story by Coral Beach first appeared in Food Safety News and is reposted here with permission.

Unpasteurized, raw milk and a visit to an unrelated agricultural animal operation are most likely the causes of an outbreak of E. coli infections among children in Knox County, TN. At least four of the victims are in kidney failure.

Health department spokeswoman Katharine Killen told Food Safety News this afternoon that all of the confirmed illnesses have been caused by the same serotype of E. coli bacteria. During a press conference with local media today, Dr. Joe Childs of East Tennessee Children’s Hospital also reported that all of the cases at that hospital are from one serotype.

Knox County Health Department epidemiologists are working with investigators from the state’s health department and other local and state agencies, including agriculture officials to pinpoint the source of the bacteria.

Childs said the ongoing E. coli outbreak is the largest he has seen in his 30 years at the hospital. Killen said the county averages only about 19 cases on an annual basis. Both said some of the sick children had consumed unpasteurized milk in the days before their symptoms began.

Other victims visited a farm unrelated to the raw milk dairy before becoming ill. Cows and other animals carry E. coli that can cause serious infections in humans. Swimming pools, however — especially public pools — are not a likely source because chemicals used to treat the water are very effective at killing E. coli bacteria, Childs said.

Officials have not specified what kind of agricultural animals victims of the current E. coli outbreak came into contact with before becoming ill. Goats are among the animals that can carry E. coli. Photo illustration

Neither the doctor nor the county spokeswoman would identify the dairy or animal farm. Killen said she wasn’t sure if the dairy was still selling its unpasteurized milk as of this afternoon. A conference call set today could provide more details.

The county started receiving reports about a cluster of E. coli infections among children last week, Killen said. She did not provide the total number of cases or the age range of the patients. However, there are “several” cases and all are children, according to county information.

The East Tennessee Children’s Hospital started hearing about the cluster of E. coli illnesses about 10 days ago, Childs said. He said the hospital is “approaching” 10 cases. Some children who were admitted have recovered enough to go home. Other’s are more seriously ill. Children started being admitted to intensive care units at the hospital about four days ago. Four of the children have developed a life-threatening form of kidney failure called hemolytic uremic syndrome (HUS).

Tennessee is one of the states that allows sales of unpasteurized raw milk. Federal law prohibits the interstate sale of raw milk because of its high risk for causing foodborne illnesses. Young children, elderly people, pregnant women and people with depleted immune systems are at the highest risk of developing life-threatening complications, according to a wide variety of health care providers and other entities.

Among those recommending against consumption of unpasteurized, raw milk are the American Academy of Pediatrics, state health departments, the federal Centers for Disease Control and Prevention, the Food and Drug Administration, and the U.S. Department of Agriculture.

Pasteurization is the process of heating milk to 161 degrees F for 15 seconds. It kills bacteria, viruses and parasites commonly carried by dairy cows. Those pathogens include E. coli, Listeria monocytogenes and Brucella.

Photo illustration

Advice to consumers
Anyone in the Knox County area — including people who consumed raw milk from the area or visited an animal operation — who develops symptoms of E. coli infection should immediately seek medical attention.

People should make sure their doctors know about their possible exposure to the pathogen so the proper diagnostic testing and treatment can be provided, Childs said.

Antibiotics generally should not be used for E. coli infections because the bacteria die off and release even more toxins into the body. This complicates diagnosis because the symptoms of E. coli infections are similar to other illnesses that should be treated with antibiotics.

Symptoms usually begin one to eight days after ingesting the bacteria, according to the U.S. Centers for Disease and Prevention. Symptoms can include diarrhea that can range from mild and watery to severe and bloody; abdominal cramping, pain or tenderness; nausea; and vomiting in some people.

Healthy adults usually recover from E. coli O157:H7 infections within a week. Young children, older adults, pregnant women and people with compromised immune systems have a greater risk of developing a life-threatening form of kidney failure called hemolytic uremic syndrome (HUS).

New Hope for HUS

In one of the first rays of hope for sufferers of hemolytic uremic syndrome (HUS), FDA announced today its approval of Soliris “… to treat patients with atypical Hemolytic Uremic Syndrome (aHUS), a rare and chronic blood disease that can lead to kidney (renal) failure and is also associated with increased risk of death and stroke.”

According to FDA, atypical HUS accounts for 5-10% of all cases of hemolytic uremic syndrome and affects children disproportionately. Soliris is the first drug to be approved in the USA for treating atypical HUS.

Soliris (eculizumab) is a humanized monoclonal antibody that was first approved by FDA in 2007 to treat a rare type of blood disorder (paroxysmal nocturnal hemoglobinuria), and is classified as an orphan drug. It is marketed in the USA by Alexion Pharmaceuticals.

While today’s FDA approval of Soliris is limited to atypical HUS, the agency’s action represents the first hint that a specific treatment for more common forms of hemolytic uremic syndrome may be in the offing. HUS is a life-threatening syndrome that affects a significant percentage of people – especially children – who are infected with E. coli O157:H7 and other shiga-toxin producing strains of E. coli.

More than 900 victims of this summer’s E. coli O104:H4 outbreak developed HUS, and 34 of those people died of the disease. The death toll might have been even higher, had doctors not administered eculizumab (Soliris) to 3 children with severe HUS and central nervous system complications. The children were at risk of permanent neurologic damage and not responding to conventional treatment.

All three children responded to the Soliris treatment, and eventually were discharged from hospital with apparently normal neurological status and little or no residual effects of their illness. Six months later, all three children were “in full remission,” according to a report published in New England Journal of Medicine.

Doctors who want to use Soliris to treat HUS must jump through a few extra hoops, due to the limited nature of its clinical trial. Soliris is available only through a restricted program, according to FDA, and prescribers must enroll in a registration program and provide a medication guide to patients who receive the drug.

Nevertheless, today’s approval is major news for HUS sufferers, so many of whom are children. Parents whose children are suffering from HUS – and physicians who treat HUS patients – should educate themselves about this new treatment possibility.

Germany’s Devastating E. coli Outbreak

The official numbers reported this morning by Germany’s Robert Koch Institut are worthy of a Hollywood thriller. Nine people dead, and 470 notified cases of hemolytic uremic syndrome (HUS) – a life-threatening complication of enterohemorrhagic E. coli infections.

The German outbreak data reported by BBC and others are even worse. Sixteen deaths, including one in Sweden; 1,534 infected with the outbreak strain known as E. coli O104:H4 – 470 of them suffering from HUS.

The outbreak began in Northern Germany; the heaviest concentration of confirmed cases – and of HUS – can be found in the states of Hamburg and Bremen. As of May 26th, thirteen German states had reported 214 cases of HUS – Hamburg (59), Bremen (11), Schleswig-Holstein (21), Mecklenburg-Vorpommern (10), Hesse (31), Saarland (5), Lower Saxony (28), North Rhine-Westphalia (31), Berlin (3), Baden-Württemberg (8), Bavaria (5), Thuringia (1) and Rhineland-Palatinate (1). These numbers already are far out of date, as the total number of cases has more than doubled since that report was issued.

Thanks to the ease of international travel – especially within the European Union, where most borders are invisible and undefended – the outbreak has not been confined to Germany. Eight other countries have reported confirmed or suspect cases of enterohemorrhagic E. coli in German nationals visiting their country or in individuals who reported having traveled to Germany:

Austria: 2 cases
Denmark: 14 cases, 6 with HUS
France: 6 cases
Netherlands: 7 cases, 3 with HUS
Spain: 1 case
Sweden: 41 cases, 15 with HUS and one death
Switzerland: 2 cases
United Kingdom: 3 cases, 2 with HUS

Despite the best efforts of Germany’s epidemiologists, the source of this outbreak is unknown – except that it appears to be associated with consumption of raw tomatoes, cucumber and leaf salad.

For a time, suspicion fell on raw cucumbers imported from Spain – especially after lab analysis of two cucumber samples yielded enterohemorrhagic E. coli. But the cucumber contaminant did not match the outbreak strain.

The most frightening aspect of this outbreak, other than the lack of success in finding its cause, is the unusually high percentage of victims who have developed HUS – more than 30% of victims, as compared to the 5-10% HUS rate experienced in most other outbreaks.

HUS is a life-threatening complication, usually beginning with kidney failure and often progressing to failure of other organs and systems. Some 5-10% of HUS patients die, and most others suffer life-long consequences of their fight for survival – even with treatment. Conventional treatment consists of dialysis and, where necessary, plasma exchange.

The massive and deadly Canadian E. coli O157:H7 outbreak that was centered in Walkerton, Ontario in 2000 spurred Canadian researchers to study ways of preventing HUS – by preventing the bacterial toxins from binding to its target cells in the body. Researchers at the University of Maryland and in Argentina independently explored similar approaches – using monoclonal antibodies against the toxin in order to block its activity.

Just a few days ago, researchers in Canada, France and Germany reported that they used yet another antibody to treat successfully three 3-year-old children who were suffering from severe cases of HUS. But this new development might be too late to help many of the German outbreak victims.

The German outbreak has many unknowns: