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Published Date: 2008-09-02 17:00:31
Subject: PRO/AH/EDR> E. coli VTEC non-O157, restaurant - USA: (OK), O111
Archive Number: 20080902.2748

E. COLI VTEC NON-O157, RESTAURANT - USA: (OKLAHOMA), O111
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[1] Beginning of outbreak
Date: Wed 27 Aug 2008
Source: NewsOK [edited]
<http://newsok.com/more-in-locust-grove-sickened-by-likely-food-borne-illness/article/3289226/?tm=1219816358>

Hospital and school officials said Tuesday [26 Aug 2008] that children are
among the growing number of victims of an intestinal illness outbreak in
north east Oklahoma.

One person has died, 17 have been hospitalized, and 40 are ill in
connection with the outbreak, according to the state Health Department. The
department says victims have experienced severe and bloody diarrhea, and
most had eaten recently at the Country Cottage buffet restaurant in Locust
Grove, Oklahoma, which is 50 miles east of Tulsa. At least 7 of those
hospitalized are children.

St Francis Hospital in Tulsa reported on Tuesday evening [26 Aug 2008] that
13 children have been admitted, and 4 are in the pediatric intensive care
unit. 3 children, ages 18 months to 12 years, are undergoing dialysis at
Children's Hospital at St Francis, said Dr William Banner, co-director of
the hospital's pediatric intensive care unit. 2 other children were
transferred to Oklahoma City for similar treatment, and a 15 year old may
soon need dialysis in Tulsa, Banner said.

Larry Weatherford, a state Health Department spokesman, said on Tuesday [26
Aug 2008] that state officials became aware of a "suspicious cluster of
illnesses on Friday [22 Aug 2008] but decided not to alert the public until
Monday because "there wasn't information pointing any one direction at that
point."

[byline: John David Sutter]

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ProMED-mail
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[2] Possible water source of _E. coli_
Date: Mon 1 Sep 2008
Source: Chattahbox [edited]
<http://chattahbox.com/health/2008/09/01/source-of-oklahoma-e-coli-outbreak-found-in-water/>

Investigators believe that they may have found the source of the Oklahoma
_E. coli_ outbreak, as it has been traced to water from a restaurant where
many people have gotten sick. Oklahoma state health officials revealed on
Friday [29 Aug 2008] that they have found a trace of _E. coli_ in the water
well of the Country Cottage restaurant in the town of Locust Grove. This is
the same restaurant where many people have fallen ill from the _E. coli_
outbreak.

The outbreak in the state of Oklahoma has already caused the death of a 26
year old, and has also caused 116 other people to become sick. So far, 50
have had to be hospitalized. The push is on to test the water to see if the
strains match.

--
communicated by:
ProMED-mail rapporteur Brent Barrett
<promed@promedmail.org>

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[3] O111 identified
Date: Tue 2 Sep 2008
Source: Oklahoma Department of Health [edited]
<http://www.ok.gov/health/Organization/Office_of_Communications/News_Releases/2008_News_Releases/Situation_Update_No_6_-_Outbreak_of_Severe_Diarrheal_Illness_in_Northeastern_Oklahoma.html>

The Oklahoma State Department of Health (OSDH) reports that at least 176
persons have become ill as a result of the _E. coli_ O111 outbreak in north
eastern Oklahoma. Cases include 128 adults and 48 children. Federal and
state health officials say _E. coli_ 0111 is a rare type not normally
associated with an outbreak this large.

OSDH disease investigators, along with staff from Tulsa Health Department
and area local county health departments, have interviewed more than 450
persons in an effort to identify the source of the outbreak. Interviews
continue this weekend. While the source has not yet been identified, health
officials continue to focus on the Country Cottage restaurant in Locust
Grove, Oklahoma, after interviews with cases indicated most had eaten there
during the time period 15 Aug 2008 through 23 Aug 2008. The restaurant is
closed while the investigation continues. Not all persons who ate at the
restaurant have become ill. No other restaurant or food service outlet in
the area has been linked to the outbreak.

OSDH laboratory analysis of water samples taken from a private well on the
restaurant property is continuing, however, health officials believe it is
unlikely that any well water contamination is the source of the outbreak.

--
communicated by:
Philip Berger, PhD
US Environmental Protection Agency
Washington, DC
<Berger.philip@epa.gov>

[This moderator apologizes to ProMED-mail readers for the delay in posting
the outbreak. The 3 postings here report the initial observation, a
possible (but unproven reservoir), and the identification of the VTEC
(verotoxin-producing _E. coli_) O111.

Although much attention has been paid to O157:H7 strains of _E. coli_ that
(by virtue of toxin production) cause enterohemorrhagic disease with or
without hemolytic-uremic syndrome (HUS), other serotypes of _E. coli_ have
been associated with this illness as well.

_E. coli_ strains can be grouped by the presence of their O (somatic) and H
(flagellar) antigens, hence O157:H7. The toxins produced are generally one
or 2 Shiga toxins (stx1 and stx2) as well as eae, a protein intimin that is
responsible for attachment of the organism and mucosal effacing lesions and
other virulence factors including E-hly, espA, etp, and katP.

Other _E. coli_ serogroups that have been associated with VTEC
(verotoxin-producing _E. coli_) disease include motile ones such as O26:H11
and O104:H21 and non-motile ones such as O111:NM (or H-). Such non-O157
isolates can be obtained from sheep and cattle and although they cause as
many as 30 per cent of outbreaks of VTEC (1), appear to be somewhat less
(or at least more variably) virulent in various in vivo and in vitro assays
(2-4). In analyzing the genetic and phenotypic profiles of non-O157 groups,
it has been found that they belong to their own lineages and have unique
profiles of virulence traits different from O157 (5). The serogroups
appearing to be most prominent are O26, O111, O128, and O103 (6).

If a laboratory is using sorbitol-MacConkey (sMAC) plates to identify VTEC
by virtue of O157's inability to ferment sorbitol, the non-O157 strains
will be missed. In a 3-year pediatric study from the University of
Washington, USA (7), 1851 stool samples were processed for sorbitol
fermentation as well as toxin production by EIA (enzyme immunoassay), and
28 strains of O157 were found along with O103 (4 strains), O118 (2
strains), O111 (2 strains), and 3 other strains.

Clinically, the O157 infections had a higher frequency of bloody stools,
fecal leukocytes, and abdominal pain with shorter symptom duration. 5 (18
per cent) of O157 infections developed HUS; none of the non-O157 strains
did. Since toxin assay did not identify all O157 strains found on sMAC
plates, the investigators did not advocate performing toxin assay alone.
Non-O157 can produce hemolytic-uremic syndrome, as demonstrated by this
outbreak as well as a cluster of O121 cases associated with a lake in
Connecticut, USA (8).

Since toxin assays are not uniformly performed in many areas, and most
cases do not produce HUS, it is likely that cases due to non-O157 strains
are being missed. How frequent this phenomenon will become over time is
unclear.

References
----------
1. Hussain HS, Omaye ST. Introduction to the food safety concerns of
verotoxin-producing _Escherichia coli_. Exp Biol Med 2003; 228: 331-2.
2. Blanco J, Blanco M, Blanco JE, et al. Verotoxin-producing _Escherichia
coli_ in Spain: prevalence, serotypes, and virulence genes of O157:H7 and
non-O157 VTEC in ruminants, raw beef products, and humans. Exp Biol Med
2003; 228: 345-51.
3. Law D, Kelly J. Use of heme and hemoglobin by _Escherichia coli_ O157
and other Shiga-toxin-producing _E. coli_ serogroups. Infect Immun 1995;
63: 700-2.
4. Tzipori S, Wachsmuth KI, Smithers J, Jackson C. Studies in gnotobiotic
piglets on non-O157:H7 _Escherichia coli_ serotypes isolated from patients
with hemorrhagic colitis. Gastroenterology 1988; 94: 590-7.
5. Schmidt H, Geitz C, Tarr PI, et al. Non-O157:H7 pathogenic Shiga-toxin
producing _Escherichia coli_: phenotypic and genetic profiling of virulence
traits and evidence for clonality. J Infect Dis 1999; 179: 115-23.
6. Bettelheim KA. Role of non-O157 VTEC. Symp Ser Soc Appl Microbiol 2000;
(29): 38-50S.
7. Klein EJ, Stapp JR, Calusen CR, et al. Shiga toxin-producing
_Escherichia coli_ in children with diarrhea: a prospective point-of-care
study. J Pediatr 2002; 141: 172-7.
8. McCarthy TA, Barrett NL, Hadler JL, et al. Hemolytic-uremic syndrome and
_Escherichia coli_ O121 at a lake in Connecticut, 1999. Pediatrics 2001;
108: E59.

Locust Grove is located in Mayes county, Oklahoma, and can be found on a
map at <http://en.wikipedia.org/wiki/Locust_Grove,_Oklahoma>. - Mod.LL]

See Also