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Biological Hazard – Public Health Alert | Fatal E. coli EHEC strain Outbreak: (Update) Southwest Utah, and Arizona USA

2017/07/27

E. COLI EHEC – USA (18): (UTAH, ARIZONA) O157, FATALITIES
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Published Date: 2017-07-27 10:02:37
Subject: PRO/AH/EDR> E. coli EHEC – USA (18): (UT, AZ) O157, fatalities
Archive Number: 20170727.5206988

Date: Tue 25 Jul 2017
Source: Food Poisoning Journal [edited]

Public health officials have ruled out ground beef as the likely source of an _E. coli_ [O157] outbreak in southwest Utah, but they have not been able to pinpoint the source of the bacteria, which has already killed 2 children. “While the investigation continues into a source for this _E. coli_ outbreak, we have determined ground beef is not a likely cause,” according to the latest update from the Southwest Utah Public Health Department. “The advisory not to consume previously purchased ground beef is discontinued.”

Unpasteurized, raw milk is still being considered as a possible source for the _E. coli_ and the health department’s recommendation to avoid consuming it remains in place. One additional person has been confirmed in the outbreak, bringing the total to 12 victims.

Mohave County epidemiologist Anna Scherzer said this past week that confirmed cases in the outbreak are mostly children, including 2 who died. The 1st victim was a 3-year-old boy who died in June 2017. He and the other fatality, a 6-year-old girl, were not related but they lived in the same multi-family dwelling in Hildale, UT.

[Byline; Bill Marler]

Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

[At least 1 case of the cluster has apparently occurred across the Utah border in Arizona.

The case fatality rate for EHEC is usually below 10 percent. There is significant evidence that the administration of most antimicrobial agents early in EHEC disease may increase the risk of hemolytic uremic syndrome (HUS). Most fatalities are in individuals who develop central nervous system complications in HUS.

Since CS Wong and colleagues reported a relative risk of the development of HUS in _E. coli_ O157 infection of 17.3 (95 percent confidence interval 2.2 to 137) (1), it has generally been thought that antimicrobial agents increase HUS risk. In this study, trimethoprim-sulfamethoxazole and beta-lactam drugs were those most linked to HUS. Whether other antimicrobial agents would likewise be linked to HUS; whether the same effect would occur in adults; whether non-O157 strains would behave similarly; and what the mechanism of the effect is, are not clearly known. Overall, trimethoprim-sulfamethoxazole (also referred to as cotrimoxazole) and fluoroquinolones seemed to be the prime offenders, both not uncommonly used empirically for perceived bacterial enteritis.

As discussed in Kimmitt’s paper in Emerging Infectious Diseases, the Shiga toxin genes reside on a lambda-like bacteriophage genome integrated into the bacterial chromosome (2). Different EHEC strains contain various numbers of these phages displaying much diversity and some being defective (3). In particular, fluoroquinolones induce high-level expression of previously silent bacteriophage genes with coexpression of the toxin genes.

A number of studies have addressed Shiga toxin production and/or release using a variety of antimicrobial agents at subinhibitory and/or suprainhibitory concentrations using a variety of markers for toxin. These include direct immunologic measurement, cytotoxicity assays, and enzyme reporters. It appears that imipenem (4) and rifaximin (5) do not induce toxin production or phage-mediated cell lysis, suggesting that these agents may not increase the risk of HUS and might be useful in management. TJ Ochoa and colleagues found that fluoroquinolones induced Shiga toxin induction much more commonly in O157 than non-O157 strains (5), but Lee and Stein did not (6).

References:
1. Wong CS, Jelacic S, Habeeb RL, Watkins SL and Tarr PI. The risk of the hemolytic-uremic syndrome after antibiotic treatment of _Escherichia coli_ O157:H7 infections. N Engl J Med. 2000; 342(26):1930-6; available at
http://www.nejm.org/doi/full/10.1056/NEJM200006293422601#t=articleTop.
2. Kimmitt PT, Harwood CR and Barer MR. Toxin gene expression by Shiga toxin-producing _Escherichia coli_: the role of antibiotics and the bacterial SOS response. Emerg Infect Dis. 2000; 6(5):458-65.; available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2627954/pdf/10998375.pdf.
3. Hayashi T, Makino K, Ohnishi M, et al. Complete genome of sequence of enterohemorrhagic _Escherichia coli_ O157:H7 and genomic comparison with a laboratory strain K-12. DNA Res. 2001; 8(1): 11-22; available at
http://dnaresearch.oxfordjournals.org/content/8/1/11.long.
4. Takahashi K, Narita K, Kato Y, et al. Low-level release of Shiga-like toxin (verocytotoxin) and endotoxin from enterohemorrhagic _Escherichia coli_ treated with imipenem. Antimicrob Agents Chemother. 1997; 41(10): 2295-6; available at
http://aac.asm.org/cgi/reprint/41/10/2295?view=long&pmid=9333067.
5. Ochoa TJ, Chen J, Walker CM, Gonzales E and Cleary TG. Rifaximin does not induce toxin production or phage-mediated lysis of Shiga toxin-producing _Escherichia coli_. Antimicrob Agents Chemother. 2007; 51(8): 2837-41; available at
http://aac.asm.org/cgi/content/full/51/8/2837?view=long&pmid=17526759.
6. Lee JH and Stein BD. Antimicrobials effective for inhibition of enterohemorrhagic _Escherichia coli_ strains O26, O111, and O157 and their effects on Shiga toxin releases. J Microbiol Biotechnol 2009; 19(10): 1238-43; available at
http://www.jmb.or.kr/journal/download.php?Filedir=../submission/Journal/019/&num=3456

Hildale is a city in Washington County, in extreme southwest Utah, United States https://en.wikipedia.org/wiki/Hildale,_Utah. Hildale is a twin city to the better-known Colorado City, Arizona, which together straddle the border between Utah and Arizona. Hildale is the headquarters of the Fundamentalist Church of Jesus Christ of Latter Day Saints. A map showing its location can be found at the above URL. – Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/34818.]

See Also

E. coli EHEC – USA (17): (OH) summer camp, RFI 20170724.5198725
E. coli EHEC – USA (16) : (MN) fatality 20170721.5195217
E. coli EHEC – USA (15): (UT) O157, fatalities 20170711.5167176
E. coli EHEC – USA (14): (UT) O157, fatalities 20170705.5152059
E. coli EHEC – USA (13): (UT) fatalities, susp EHEC, RFI 20170703.5147181
E. coli EHEC – USA (12): (TX) 20170621.5121066
E. coli EHEC – USA (11): O157, deer droppings, water exposure, 2016 20170511.5028649
E. coli EHEC – USA (10): O157, soynut butter 20170505.5014128
E. coli EHEC – USA (09): (AR) fatality, unrelated cases 20170422.4988037
E. coli EHEC – USA (08): (AR) fatality, RFI 20170421.4984124.
E. coli EHEC – USA (07): (MA) O157, restaurant chain, RFI 20170414.4970974
E. coli EHEC – USA (06): O157, soynut butter 20170405.4949992
E. coli EHEC – USA (05): O157, soynut butter, CDC update 20170401.4941247
E. coli EHEC – USA (04): (OR) O157, soynut butter, preschool 20170315.4902827
E. coli EHEC – USA (03): O157, soynut butter, more cases, recall 20170308.4887992
E. coli EHEC – USA (02): O157, soynut butter 20170307.4883675
E. coli EHEC – USA 20170302.4875298

2016
—-
E. coli EHEC – USA (35): (KS) 0157, cider festival, RFI 20161105.4608827
E. coli EHEC – USA (34): O157, ground beef, alert, recall 20160927.4517488
E. coli EHEC – USA (33): (WA) O157, restaurant, separate strain 20160915.4490622
E. coli EHEC – USA (32): O157, foodborne 20160913.4484871
E. coli EHEC – USA (31): (WA) restaurant 20160911.4480793
E. coli EHEC – USA (30): (MO) school children, RFI 20160908.4472898
E. coli EHEC – USA (29): (MI) unpasteurized milk 20160827.4445879
E. coli EHEC – USA (27): (MT) O157, town celebration, RFI 20160807.4396767
E. coli EHEC – USA (26): (MI) cheese, alert, recall 20160807.4396765
E. coli EHEC – USA (25): O121, O26, flour, alert, expanded recall 20160726.4371012
E. coli EHEC – USA (24): (NH) 20160725.4367732
E. coli EHEC – USA (23): (WA) RFI 20160721.4360070
E. coli EHEC – USA (22): (IL) restaurant 20160715.4345845
E. coli EHEC – USA (21): (OH) ex Cote d’Ivoire 20160709.4333423
E. coli EHEC – USA (20): (OH) ex Cote d’Ivoire 20160707.4330781
E. coli EHEC – USA (19): (IL) restaurant 20160703.4323887
E. coli EHEC – USA (18): (CO) O157, restaurant 20160614.428461
E. coli EHEC – USA (17): (WA) RFI 20160611.4279449
E. coli EHEC – USA (16): O121, flour, alert, recall 20160602.4261085
E. coli EHEC – USA (15): (CA) possible creek water exposure 20160601.4258822
E. coli EHEC – USA (14) : O121, flour, alert, recall 20160601.4259202
E. coli EHEC – USA (13): (CT) O157, goat farm exposure, RFI 20160408.4146994
E. coli EHEC – USA (12): (CT) O157, goat farm exposure 20160401.4133414
E. coli EHEC – USA (11): O157, goat farm exposure 20160328.4123767
E. coli EHEC – USA (10): O157, goat farm exposure 20160327.4121606
E. coli EHEC – USA (09): goat farm exposure 20160325.4118888
E. coli EHEC – USA (08): O157, dough susp 20160318.4102909
E. coli EHEC – USA (07): (MN,KS) O157, pizza dough susp 20160316.4096967
E. coli EHEC – USA (06): (MN,WI) sprouts 20160224.4047813
E. coli EHEC – USA (05): (CA) O157, unpasteurized milk, alert, recall 20160224.4047551
E. coli EHEC – USA (04): (CA) O157, unpasteurized milk, alert, recall 20160213.4018874
E. coli EHEC – USA (03): (CA) O157, unpasteurized milk, alert, recall 20160210.4006446
E. coli EHEC – USA (02): (TN) O157, ground beef, alert, recall 20160124.39542000
E. coli EHEC – USA 20170302.4875298
………………………………………….sb/ll/ao

Source:
A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases


Note: Category C bioterrorism agents are the third highest priority organisms/biological agents, and are emerging pathogens that might be engineered for mass dissemination because of their availability, ease of production and dissemination, high mortality rate, or the ability to cause a major health impact

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