title: Epidemic profile of Shiga-toxin-producing Escherichia coli O104:H4 outbreak in Germany.
abstract: BACKGROUND
  We describe an outbreak of gastroenteritis and the hemolytic-uremic syndrome caused by Shiga-toxin-producing Escherichia coli in Germany in May, June, and July, 2011. The consumption of sprouts was identified as the most likely vehicle of infection.
  
  
  METHODS
  We analyzed data from reports in Germany of Shiga-toxin-producing E. coli gastroenteritis and the hemolytic-uremic syndrome and clinical information on patients presenting to Hamburg University Medical Center (HUMC). An outbreak case was defined as a reported case of the hemolytic-uremic syndrome or of gastroenteritis in a patient infected by Shiga-toxin-producing E. coli, serogroup O104 or serogroup unknown, with an onset of disease during the period from May 1 through July 4, 2011, in Germany.
  
  
  RESULTS
  A total of 3816 cases (including 54 deaths) were reported in Germany, 845 of which (22%) involved the hemolytic-uremic syndrome. The outbreak was centered in northern Germany and peaked around May 21 to 22. Most of the patients in whom the hemolytic-uremic syndrome developed were adults (88%; median age, 42 years), and women were overrepresented (68%). The estimated median incubation period was 8 days, with a median of 5 days from the onset of diarrhea to the development of the hemolytic-uremic syndrome. Among 59 patients prospectively followed at HUMC, the hemolytic-uremic syndrome developed in 12 (20%), with no significant differences according to sex or reported initial symptoms and signs. The outbreak strain was typed as an enteroaggregative Shiga-toxin-producing E. coli O104:H4, producing extended-spectrum beta-lactamase.
  
  
  CONCLUSIONS
  In this outbreak, caused by an unusual E. coli strain, cases of the hemolytic-uremic syndrome occurred predominantly in adults, with a preponderance of cases occurring in women. The hemolytic-uremic syndrome developed in more than 20% of the identified cases.
authors.affiliation: Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
authors.forename: Christina
authors.initials: C
authors.lastname: Frank
authors.forename: Dirk
authors.initials: D
authors.lastname: Werber
authors.forename: Jakob P
authors.initials: JP
authors.lastname: Cramer
authors.forename: Mona
authors.initials: M
authors.lastname: Askar
authors.forename: Mirko
authors.initials: M
authors.lastname: Faber
authors.forename: Matthias
authors.initials: M
authors.lastname: an der Heiden
authors.forename: Helen
authors.initials: H
authors.lastname: Bernard
authors.forename: Angelika
authors.initials: A
authors.lastname: Fruth
authors.forename: Rita
authors.initials: R
authors.lastname: Prager
authors.forename: Anke
authors.initials: A
authors.lastname: Spode
authors.forename: Maria
authors.initials: M
authors.lastname: Wadl
authors.forename: Alexander
authors.initials: A
authors.lastname: Zoufaly
authors.forename: Sabine
authors.initials: S
authors.lastname: Jordan
authors.forename: Markus J
authors.initials: MJ
authors.lastname: Kemper
authors.forename: Per
authors.initials: P
authors.lastname: Follin
authors.forename: Luise
authors.initials: L
authors.lastname: Müller
authors.forename: Lisa A
authors.initials: LA
authors.lastname: King
authors.forename: Bettina
authors.initials: B
authors.lastname: Rosner
authors.forename: Udo
authors.initials: U
authors.lastname: Buchholz
authors.forename: Klaus
authors.initials: K
authors.lastname: Stark
authors.forename: Gérard
authors.initials: G
authors.lastname: Krause
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003967:Diarrhea / Q000382:microbiology; D004196:Disease Outbreaks; D004927:Escherichia coli Infections / Q000453:epidemiology* / Q000209:etiology; D007887:Fabaceae / Q000382:microbiology; D005260:Female; D005516:Food Microbiology; D005759:Gastroenteritis / Q000453:epidemiology* / Q000382:microbiology; D005858:Germany / Q000453:epidemiology; D006463:Hemolytic-Uremic Syndrome / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D007223:Infant; D008297:Male; D000455:Medicago sativa / Q000382:microbiology; D008875:Middle Aged; D018520:Plant Shoots / Q000382:microbiology*; D012147:Restaurants; D054323:Shiga-Toxigenic Escherichia coli / Q000145:classification