title: Primary and secondary cases in Escherichia coli O157 outbreaks: a statistical analysis.
abstract: BACKGROUND
  Within outbreaks of Escherichia coli O157 (E. coli O157), at least 10-15% of cases are thought to have been acquired by secondary transmission. However, there has been little systematic quantification or characterisation of secondary outbreak cases worldwide. The aim of this study was to characterise secondary outbreak cases, estimate the overall proportion of outbreak cases that were the result of secondary transmission and to analyse the relationships between primary and secondary outbreak cases by mode of transmission, country and median age.
  
  
  METHODS
  Published data was obtained from 90 confirmed Escherichia coli O157 outbreaks in Great Britain, Ireland, Scandinavia, Canada, the United States and Japan, and the outbreaks were described in terms of modes of primary and secondary transmission, country, case numbers and median case age. Outbreaks were tested for statistically significant differences in the number of ill, confirmed, primary and secondary cases (analysis of variance and Kruskal-Wallis) and in the rate of secondary cases between these variables (Generalised Linear Models).
  
  
  RESULTS
  The outbreaks had a median of 13.5 confirmed cases, and mean proportion of 0.195 secondary cases. There were statistically significant differences in the numbers of ill, confirmed, primary and secondary cases between modes of primary transmission (p < 0.021), and in primary and secondary cases between median age categories (p < 0.039) and modes of secondary transmission (p < 0.001).Secondary case rates differed statistically significantly between modes of secondary and primary transmission and median age categories (all p < 0.001), but not between countries (p = 0.23). Statistically significantly higher rates of secondary transmission were found in outbreaks with a median age <6 years and those with secondary transmission via person to person spread in nurseries. No statistically significant interactions were found between country, mode of transmission and age category.
  
  
  CONCLUSIONS
  Our analyses indicated that ~20% of E. coli O157 outbreak cases were the result of secondary spread, and that this spread is significantly influenced by age and modes of primary and secondary transmission, but not country. In particular, the results provide further data emphasising the importance of simple but effective preventive strategies, such as handwashing, that can reduce the risk of secondary spread, particularly amongst young children in nurseries.
authors.affiliation: Department of Population Medicine and Centre for Public Health and Zoonoses, Ontario Veterinary College, University of Guelph, Guelph, Ontario, N1G 2W1, Canada. snedeker@uoguelph.ca
authors.forename: Kate G
authors.initials: KG
authors.lastname: Snedeker
authors.forename: Darren J
authors.initials: DJ
authors.lastname: Shaw
authors.forename: Mary E
authors.initials: ME
authors.lastname: Locking
authors.forename: Robin J
authors.initials: RJ
authors.lastname: Prescott
mesh_terms: D002170:Canada / Q000453:epidemiology; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D004927:Escherichia coli Infections / Q000453:epidemiology* / Q000635:transmission; D019453:Escherichia coli O157; D006801:Humans; D007494:Ireland / Q000453:epidemiology; D007564:Japan / Q000453:epidemiology; D012537:Scandinavian and Nordic Countries / Q000453:epidemiology; D006113:United Kingdom / Q000453:epidemiology; D014481:United States / Q000453:epidemiology