German E-Coli outbreak

2011 German E. coli O104:H4 outbreak

2011 German E. coli O104:H4 outbreak
Classification and external resources

Schistocytes seen in a person with hemolytic-uremic syndrome

An Escherichia coli O104:H4 bacterial outbreak began in Germany in May 2011. Certain strains of E. coli are a major cause of foodborne illness. The outbreak started when several people in Germany were infected with enterohemorrhagic E. coli (EHEC) bacteria, leading to hemolytic-uremic syndrome (HUS), a medical emergency that requires urgent treatment.

The agriculture minister of Lower Saxony identified an organic farm in Bienenbüttel, Lower Saxony, Germany, which produces a variety of sprouted foods, as the likely source of the E. coli outbreak. The farm has since been shut down. Although the laboratories in Lower Saxony did not detect the bacterium in produce from the farm, it was later announced that a laboratory in North Rhine-Westphalia had found the deadly strain in a discarded package of sprouts from the suspected farm. A control investigation confirmed the farm as the source of the outbreak. While the threat of EHEC still exists, the number of new cases has been plunging.

In addition to Germany, where 3,792 cases and 42 deaths had been reported as of 22 June, a handful of cases have been reported in several countries including Switzerland, Poland, the Netherlands, Sweden, Denmark, the UK, Canada and the USA. Essentially all affected people had been in Germany shortly before becoming ill.

Initially German officials gave erroneous information of the origin and strain of Escherichia coli. German health authorities, without results of ongoing tests, linked serotype O104 to cucumbers imported from Spain. Later, they recognised that Spanish greenhouses were not the source of E. coli and cucumber samples did not show the specific E. coli variant seen in the outbreak. Spain consequently expressed anger about having its produce linked with the deadly E. coli outbreak, which cost Spanish exporters 200m USD per week. Russia banned the import of all fresh vegetables from the European Union until June 22.


Since 2 May 2011, German health authorities have reported an outbreak in Germany of a severe illness called hemolytic-uremic syndrome (HUS). On 22 May 2011, German health authorities said “Clearly, we are faced with an unusual situation”, one day after the first death in Germany. Escherichia coli infection occurs regularly, infecting 800 to 1200 people a year in Germany, but is usually mild. Until 25 May it occurred in northwest Germany mostly.

On 26 May 2011, German health officials announced that cucumbers from Spain were identified as a source of the E. coli outbreak in Germany. On 27 May 2011, German officials issued an alert distributed to nearby countries, identifying organic cucumbers from Spain and withdrawing them from the market. The European Commission on 27 May said that two Spanish greenhouses that were suspected to be sources had been closed, and were being investigated. The investigation included analyzing soil and water samples from the greenhouses in question, located in the Andalusia region, with results expected by 1 June. Cucumber samples from the Andalusian greenhouses did not show E. coli contamination, but a cross-contamination during transport in Germany or distribution in Hamburg are not discounted; in fact, the most probable cause is cross-contamination inside Germany. The Robert Koch Institute advises against eating raw tomatoes, cucumbers and lettuces in Germany to prevent further cases.

On 31 May 2011, an EU official said that the transport chain was so long that the cucumbers from Spain could have been contaminated at any point that occurred along the transit route. Spanish officials, said before that there was no proof that the outbreak originated in Spain; Spanish Secretary of State for European Affairs Diego López Garrido said that "you can't attribute the origin of this sickness to Spain."

On Tuesday 31 May, lab tests showed that two of the four cucumbers examined did contain toxin-producing E. coli strains, most likely because of cross-contamination in Germany according to experts, but not the O104 strain that was found in patients. The bacteria in the other two cucumbers have not yet been identified.

Genomic sequencing by BGI Shenzhen confirm a 2001 finding that the O104:H4 serotype has some enteroaggregative E. coli (EAEC or EAggEC) properties, presumably acquired by horizontal gene transfer.

The only previous documented case of EHEC O104:H4 was in South Korea in 2005 and researchers pointed at contaminated hamburgers as a possible cause.

On June 4, German and EU officials had allegedly been examining data that indicated that a open catering event at a restaurant in Lübeck, Germany, was a possible starting point of the on-going deadly E. coli outbreak in Europe. German hospitals were nearly overwhelmed by the number of E. coli victims.

A spokesman for the agriculture ministry in Lower Saxony, warned people on June 5 to stop eating local bean sprouts as they had become the latest suspected cause of the E. coli outbreak. A farm in Bienenbuettel, Lower Saxony, was announced as the probable source, but on June 6 officials said that this could not be substantiated by tests. Of the 40 samples from the farm that were being examined, 23 had tested negative. But on June 10 it was confirmed by the head of the Robert Koch Institute that the bean sprouts are the source of the outbreak, and that people who ate the bean sprouts were nine times more likely to have bloody diarrhea. The WHO have confirmed on June 10 this statement on the update 13 of the EHEC outbreak.

According to the head of the national E. coli lab at the German Federal Institute for Risk Assessment, the strain responsible for the outbreak has been circulating in Germany for 10 years, and in humans not cattle. He said it is likely to have got into food via human feces.

A joint risk-assessment by EFSA/ECDC, issued June 29, 2011, made a connection between the German outbreak and a HUS outbreak in the Bordeaux area of France, first reported on June 24, in which infection with E. coli O104:H4 has been confirmed in several patients. The assessment implicated fenugreek seeds imported from Egypt in 2009 and 2010, from which sprouts were grown, as a common source of both outbreaks, but cautioned that "there is still much uncertainty about whether this is truly the common cause of the infections", as tests on the seeds had not yet found any E. coli bacteria of the O104:H4 strain.

Affected countries


Most or all victims as of 8 June 2011 were believed to have become infected in Germany. Confirmed cases are listed below according to their location when diagnosed.

EU member nations


As of 3 June 2011 Germany was the most affected nation, with 18 people reported dead from the disease, and with another about 1,700 infected cases, 520 of them suffering from hemolytic-uremic syndrome (HUS) which can cause kidney failure. It was reported on 26 May that, according to health officials, four cucumbers, three from Spain and the fourth of unknown origin, from a store in Hamburg were found to be contaminated by an enterohemorrhagic E. coli (EHEC). These were at the time suspected to be responsible for the outbreak; in response German authorities began removing Spanish cucumbers from stores that day.

According to German Stern magazine, on 1 June, "Hamburg's Health Senator has rejected criticism for her warning on Spanish cucumbers", that has turned out to be unjustified and for which "Spain is now demanding compensation for the millions of losses caused to farmers."
On 30 May, German health officials convened for a meeting regarding the outbreak, the latter which is reported by European health officials to be the largest ever recorded in Germany.
Twelve of the fatalities have been women. All but one of those deaths were recorded in northern Germany, with Hamburg and its immediate vicinity being hit hardest, but fears that the outbreak was spreading increased when a 91-year-old woman died in the western state of North Rhine-Westphalia. Doctors are pinning their hopes on Eculizumab, a drug that was effective against hemolytic-uremic syndrome.

Around 100 patients with HUS were reported to have suffered significant kidney damage.


The only person in Spain infected is a man in his 40s who had traveled recently to Germany admitted to hospital in San Sebastian. A Spanish athlete who was in Germany on 22 May to run the Hamburg Marathon also became infected. She started to show symptoms during the race and after finishing was accepted to a hospital in Hamburg. She stated that she had not eaten any cucumbers during her stay but other raw fruits and vegetables.


On 31 May the first death from the outbreak in Sweden was reported, a woman in her 50s who died in a hospital in Borås after having been infected during a trip to Germany. Forty-one cases, fifteen serious, were being treated in Swedish hospitals as of 31 May, all of them linked to the German outbreak. On 28 June a patient that fell ill in mid June, was reported by the authorities to have been infected without a known connection to travel to Germany. The day before the Swedish National Food Administration, due to the E. coli outbreak, advised against eating raw sprouts for now.


On 27 May health authorities reported that two German tourists coming by bike from north Germany have been hospitalised in Austria after becoming ill with E.coli.

Czech Republic

The only confirmed case of infection was a female American tourist who had arrived from Germany shortly before.


Officials in Denmark said that, as of 30 May, fourteen cases had been confirmed, with at least 26 more suspected. Seven of those sickened by the disease had already suffered kidney failure, a symptom which occurs in the late stages of infection.

It was reported on 30 May that Denmark's Veterinary and Food Administration (DVFA) started checking Danish cucumbers for infections, while they advised against consuming cucumbers from Spain and cucumbers, lettuce and raw tomatoes from Germany.


Finland’s National Institute for Health and Welfare recorded its first proven case on June 4.


As of 3 June, the Institut de veille sanitaire reports 10 cases, all of which are persons who stayed in Germany at the time of their infection.

On 24 June, the same institute reports 10 cases in Aquitaine region, including 7 connected cases in the city of Bègles, six of which ate sprouts during a festival that took place on 8 June. Two of eight cases (seven of the eight were interviewed) who went to two Bordeaux, France hospitals for treatment, have come down with the hemolytic uremic syndrome (HUS) complication, with the potential for acute renal failure, according to a CNN story on the outbreak.

The strain of the infection on one of the above-mentioned patients presents with similar characteristics as the earlier German outbreak.

The Netherlands

On 6 June RIVM announced a total of six people have a confirmed EHEC infection. Four out of these have the HUS-syndrome while the other two cases have not kidney problems. All of these people have been visiting Germany recently. Other cases are still being investigated.


On 30 May, a woman had been hospitalised in serious condition with E. coli after returning from Hamburg, where at least 467 cases of intestinal infection have been recorded to that date.

United Kingdom

On 28 May it was announced that three people in the UK, all of whom had recently been in Germany, had become infected. On 29 May, the UK's Food Standards Agency issued a statement saying that no cucumbers infected with EHEC had been sold in the country.

Twelve children from the Redfield Edge Primary School, South Gloucestershire who were ill on 20 May and four of their parents who fell ill between then and 2 June, were infected with the known strain E. coli O157, not O104.

Non-EU member states


One case reported, as of 8 June, had recently visited Germany.


On June 5 an undisclosed number of cases were found in Norway.


It had reached Switzerland by 31 May and made one person ill, but no further details were present. A second case was reported to the Swiss Federal Office of Public Health on 1 June. and a third fell ill on 3 June.

United States

All four reported US cases, as of 5 June, had recently visited the Hamburg area.

Suspected cases


By 1 June 2011, Finland's National Institute for Health and Welfare (THL) started examining whether or not a patient who had arrived at Helsinki’s Maria Hospital the preceding weekend was suffering from the enterohemorrhagic Escherichia coli (EHEC) strain.


Luxembourg recorded its first suspected case on June 8th.


On 2 June, Portuguese authorities reported that three Portuguese citizens, one of them from the Portuguese Autonomous Region of Madeira who had returned from Hamburg in Germany are suspected to be infected due to having gastroenteritis. Tests from two of them came back negative for this strain of E. coli.


On June 8, the first suspected case was in Slovakia. the victim was a 25 year old man in the the in Košice, Slovakia.

International response

European Union

On 22 May, Health Commissioner John Dalli of the European Commission declared the issue to be an 'absolute priority', saying that the Commission is working with member states, particularly Germany, to identify the source of the outbreak. Speaking again on 1 June, Commissioner Dalli noted that the outbreaks have been limited in origin to the Greater Hamburg area and declared that any product ban would be disproportionate. He also said that he is working with Agriculture Commissioner Dacian Cioloş "to address the hardship faced by this group of our citizens that has also been hit hard by the E. coli outbreak". He also said on June that "In future we need to see how the timing of the alerts can be closer to the actual scientific basis and proof."

By June 7, EU Ministers held an emergency meeting in Luxembourg to discuss the growing crisis, which had left 23 people dead, more than 2,000 ill so far. Germany's Federal Agriculture Minister, Ilse Aigner, repeated her warnings to EU consumers to avoid eating any bean sprouts, cucumbers, tomatoes and salads.

The United States Center for Disease Control (CDC) and the United States Department of Agriculture has long been concerned regarding risks involving the E. coli risk in raw bean sprout production.

EU member nations

Apart from the German government, which warned against the consumption of all raw cucumbers, tomatoes and lettuce, several countries implemented restrictions or bans on the import of produce.


On May 29 Austria announced that "small amounts" of suspect cucumbers, tomatoes and aubergines, were removed from 33 stores for laboratory testing. On 31 May, Austrian authorities inspected 33 organic supermarkets to make sure Spanish vegetables had been removed. The move came after a German overzealous recall and ban on sales of cucumbers, tomatoes and aubergines that had been imported from Spain and then delivered to Austrian food stores by various German companies. As of June 1 Austria withdrew all Spanish cucumbers from their shops. Customers also expressed concern about imported cucumbers in general.


Belgium banned imports of Spanish cucumbers on 31 May. On May 31 Belgium's had confirmed that some Spanish cucumbers may have still been on sale in Belgium. The Belgian Agriculture Minister, Sabine Laruelle said that no cucumbers have been imported since the previouse winter. The government said to be unhappy with information from Germany.


On May 31, the Bulgarian Minister of Agriculture and Foods, Miroslav Naidenov reiterated that no cucumbers were imported from Spain into Bulgaria.

Czech Republic The Czech Agriculture and said cucumbers from the same batch that went to Austria, the Czech Republic, Hungary and Luxembourg. The Czech Government officials said that their labs had tested a total 120 potentially tainted Spanish cucumbers the 29th as an interim safety measure, but refused to cast blame for the outbreak, which had yet to reach the Czech Republic by that date. On June 1 Czech Republic withdrew all Spanish cucumbers from their shops. As of 3 June, the only cases reported were foreigners.



By 31 May, one of Italy's agriculture lobbies, Coldiretti, had also used the outbreak to urge Italians to support their local growers and avoid imports by 31 May. On June 30 an Italian laboratory issued a report that, as of that date, there was no definitive proof vegetables are behind the outbreak. On June In in response to falling Italian cucumbers sales, Coldiretti carried out an anti-panic campaign, in which it handing out over 10 tons of cucumbers, for free in many of Italy's regions on June 4.



By 31 May, Luxembourg had refused to ban the sale of Spanish and German cucumbers.


By 31 May, The said that investigations made of the business run by the local Dutch cucumber grower and Dutch warehouse did not uncover any traces of the bacteria at that time. The Netherlands had also stopped exporting cucumbers to Germany on 31 May. On June 9, the Dutch authorities recalled that originated in the Netherlands, Germany and Spain were found to be contaminated with a different (and less toxic) strain of E. coli bacteria .


On 30 May, the Spanish government said that it was considering requesting compensation from Germany, claiming that "tremendous damage" had been done to the country's agricultural sector as a result of reduced exports inflicted by Germany's "speculations" on the origin of the outbreak. Since the beginning of the crisis, farms in Andalusia were estimated to have lost up to eight million euros per day. Spanish Health Minister Leire Pajin firmly stated there had been no native cases in Spain by 31 May.


On June 3, Slovenia's Agriculture Minister Dejan Zidan said all Slovene samples food test negative to E. coli. Slovenia’s Prime Minister, Borut Pahor asserted his opinion that Slovenia’s was perfectly safe.

Non-EU European nations


Albania had banned cucumber imports on 30 May, although health minister Petrit Vasili explained that Albanians are in no danger as all cucumbers were produced locally anyway, not imported.


On 30 May, Croatian doctors had increased the nation's medical caution level and were carefully screening people with symptoms which they thought could be corresponding to those of E. coli. By 1 June, Croatian greengrocers complain of drop in sales due to the spreading E. coli panic in Croatia's markets. Croatian scientists have been researching a new antibiotic called Adepantine which could help to cure E. Coli.



On 2 June Russia banned all fresh vegetables from the EU because of the E. coli outbreak. The EU condemned the ban.

The ban on EU vegetables was lifted on June 10, but stiff safety mesures remained in place.

Middle East


Egypt’s Minister of Health Ashraf Hatem denied his nation had any patients infected with the new E. coli strain, due to the strict precautions brought in to test over-seas tourists entering the country on June 2.


Lebanon started a temporarily ban on the importing of fresh vegetables from the EU on June 5.


Qatar began a temporarily ban on the importing of fresh cucumbers, tomatoes and lettuce from both Spain and Germany on June 5.

Saudi Arabia

On June 7, Saudi Arabian health officials banned the import of all fresh and canned vegetables from Europe. The said the ban was to prevent the spread of E. coli into the country.


The United Arab Emirates (UAE) have also blocked the import of Spanish cucumbers as of 1 June. It had banned cucumber imports from Spain, Germany, Denmark and the Netherlands by June 5.

North America


On June 2 Canada brought in stricter anti E. coli related food inspections and by June 3 the Public Health Agency of Canada said that no Canadians had been reported sick with the strain as of that date. The Canadian Government also brought in heavier import and hygiene restrictions on EU cucumbers, lettuces and tomatoes.


Authorities at the USDA as well as the FDA state that emerging strains of the harmful bacteria certainly are a significant problem, yet government bodies in the USA have concentrated mostly on the more infamous E. coli O157 serotype.

CNN reported that the Centres for Disease Control and Prevention's (CDC) Division of Foodborne and Mycobacterial Infectious Diseases has officially confirmed three (there are now reports of a fourth) reported U.S. cases, but each of these individuals had been in the Hamburg, Germany area before they returned and fell ill. The CDC has now recognized that the potential for further U.S. and European cases in the outbreak caused by this strain could now pose a potentially major public health threat. By June 3 the American military community in Europe had started taking additional safety precautions in response to the spreading E. coli outbreak.

On June 8, America's FDA said it was going to remain constantly vigilant and would consistently take steps to increase E. coli monitoring, as it felt appropriate. It said most of America's fresh produce is grown in areas of the U.S. and Central America, while the EU was not a significant source of fresh produce for the country.

Sub-Saharan Africa


The suspect-batches from either the Netherlands and/or Denmark were under investigation on 3 June.

East Asia

Hong Kong

On June 7, Hong Kong's Secretary for Food and Health, York Chow, said that there was a risk of the outbreak of enterohemorrhagic E. coli infection by serogroup O104:H4 infecting Hong Kong nationals either living in Hong Kong or traveling to Germany.


In avocados imported from Europe to Thailand E. coli bacteria were identified, but it was not yet established whether this is the same strain as that in Europe caused the death of 25 people. The Thai government asked the population not to panic stating that there are many variants of the bacterium. Recommended, however, fruits and vegetables be thoroughly washed or cooked. E.coli bacteria was detected in a consignment of avocados come from a European country, which is not specified, according to a statement of the Ministry of Health. Thai government outlined, it will take 3 to 5 days to determine whether it is lethal strain.


By June 1 both Italian, Austrian, and French cucumber sales had begun to decline sharply, but the Austrian Health Ministry official Dr. Pamela Rendi-Wagner, claimed Austrian customers were still safe.

On 3 June, the governments of Spain, Portugal and Germany said that they would formally request EU agricultural aid for farmers affected by the outbreak. That day also saw Russia set up plans for new imports of cucumbers from the Ukraine, Azerbaijan, Egypt and Turkey.

By June 7, the EU’s farmers had reported they had lost millions of dollars in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying it’s growers had $256,000,000 in turnover. French, Swiss, Bulgarian, German, Dutch, Belgian and Portuguese producers have also been similarly affected.

That day, the EU proposed issuing £135,000,000 in agricultural compensation to its farmers. The EU agriculture commissioner said the EU’s farmers could get back up to 30% of the cost of vegetables they were unable to sell. The EU's health commissioner, John Dalli, had formally criticised earlier that day Germany for rushing out "premature conclusions" about the source of an outbreak, and only helped to spread alarm among the public and farmers and untimely leading to the damaging the EU’s agriculture sector. John Dalli also told the EU parliament in Strasbourg that claims had to be scientifically sound, unbiased and fool-proof in nature before it was publicised in future.

Spain then rejected a €150,000,000/£135,000,000 the European Commission’s compensation deal for there for farmers who were hit by the E. coli outbreak, on June 8, saying it was too small. France, European Union’s largest agricultural grower, said it would support the plan to compensate producers hurt by the outbreak, according to the French Agriculture Minister Bruno Le Maire.

Ministers from both EU and Russian were scheduled to meet on June 8 over Russian's earlier decision to ban all its vegetable imports from the EU.

On June 8, it was reckoned that the EU’s E. coli O104:H4 outbreak cost $2,840,000,000 in human losses (such as sick leave), regardless of material losses (such as dumped cucumbers).

Consumers across Europe were shunning fruit and vegetables on mass by June 8, as the German government‘s against eating raw cucumbers, tomatoes, lettuce and sprouts remained on. EU farmers claimed to have losses up to C$417,000,000 ($611,000,000) a week as ripe vegetables produce rotted in their fields and warehouses. On June 8, The EU Farm Commissioner Dacian Ciolos said that the EU had increased its offer of to farmers for the losses caused by E. coli outbreak to C$210,000,000 ($306,000,000).

EU states

On June 8, Dacian Cioloş, the European Commissioner for Agriculture & Rural Development, increased the compensation offer to €210 million ($306.2 million) for farmers who lost money due to the outbreak.


By June 3, Bulgaria had suffered financial losses after some countries, including Russia, banned imports of vegetables from the EU, according to the Minister of Agriculture and Foods, Miroslav Naidenov.


On June 3, the Spanish PM Jose Luis Rodriguez Zapatero said Spain’s Government would demand reparations for any economic losses suffered as a result of Germany's and Russia’s cucumber blockades. By June 7, the EU’s Farmers had reported they had lost millions of $ in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying it’s growers had $256,000,000m in turnover. Spain then rejected a €150,000,000/£135,000,000 the European Commission’s compensation deal for there for farmers who were hit by the E. coli outbreak, on June 8, saying it was too small.

Non EU states


By 1 June, Croatia’s greengrocers had complained of drop in sales due to the spreading E. coli panic in Croatia's markets.


On June 3, Swiss farmers destroyed unsold stocks of cucumbers as a result of the growing fears over the E. coli epidemic that was hitting the EU, despite the fact that all cucumbers have been cleared as the source of the bacteria. According to a Swiss television report on that day, the alone had to destroy 30,000-40,000 of its cucumbers. A further report said another Zurich farmer was due to throw away around 10,000 cucumbers that he could not sell that day. Many farmers have reported seeing their turnover from fresh vegetables drop by up to 50% since the E. coli outbreak had begun.

Turkey Russia requested further Turkish cucumber imports to replace banned EU imports.



Russia requested further Azerbaijani cucumber imports to make up for banned EU imports.

See also



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