title: Escherichia coli O104:H4 outbreak in Germany--clarification of the origin of the epidemic.
abstract: BACKGROUND
  In 2011, Germany was hit by one of its largest outbreaks of acute gastroenteritis and haemolytic uraemic syndrome caused by a new emerging enterohaemorrhagic Escherichia coli O104:H4 strain. The German Haemolytic Uraemic Syndrome/Enterohaemorrhagic E. coli (GHUSEC) outbreak had unusual microbiological, infectiological and epidemiological features and its origin is still only partially solved. The aim of this article is to contribute to the clarification of the origin of the epidemic.
  
  
  METHODS
  To retrospectively assess whether the GHUSEC outbreak was natural, accidental or a deliberate one, we analysed it according to three published scoring and differentiation models. Data for application of these models were obtained by literature review in the database Medline for the period 2011-13.
  
  
  RESULTS
  The analysis of the unusual GHUSEC outbreak shows that the present official assumption of its natural origin is questionable and pointed out to a probability that the pathogen could have also been introduced accidentally or intentionally in the food chain.
  
  
  CONCLUSIONS
  The possibility of an accidental or deliberate epidemic should not be discarded. Further epidemiological, microbiological and forensic analyses are needed to clarify the GHUSEC outbreak.
authors.affiliation: 1 Military Academy, University of Defense, Belgrade, Serbia 2 Medical Corps Headquarters, Army of Serbia, Belgrade, Serbia.
authors.forename: Vladan
authors.initials: V
authors.lastname: Radosavljevic
authors.affiliation: 3 Senior Scientist, ret., Specialist of Microbiology, Virology and Infection Epidemiology, Munich, Germany.
authors.forename: Ernst-Jürgen
authors.initials: EJ
authors.lastname: Finke
authors.affiliation: 4 Institute of Hygiene and Medical Ecology, Faculty of Medicine, University of Belgrade, Serbia goran.belojevic@hotmail.com.
authors.forename: Goran
authors.initials: G
authors.lastname: Belojevic
mesh_terms: D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D004926:Escherichia coli; D004927:Escherichia coli Infections / Q000453:epidemiology*; D005517:Foodborne Diseases / Q000453:epidemiology*; D005858:Germany / Q000453:epidemiology; D006463:Hemolytic-Uremic Syndrome / Q000453:epidemiology*; D006801:Humans; D012189:Retrospective Studies