title: Outbreak of uncommon O4 non-agglutinating Salmonella typhimurium linked to minced pork, Saxony-Anhalt, Germany, January to April 2013.
abstract: BACKGROUND
  In January 2013, the National Reference Centre for Salmonella (NRC) detected a salmonellosis cluster in Saxony-Anhalt, Germany, caused by uncommon O4 non-agglutinating, monophasic Salmonella (S.) Typhimurium DT193. Circulating predominant monophasic S. Typhimurium DT193 clones typically display resistance phenotype ASSuT. We investigated common exposures to control the outbreak, and conducted microbiological investigations to assess the strains' phenotype.
  
  
  METHODS
  We conducted a case-control study defining cases as persons living or working in Saxony-Anhalt diagnosed with the O4 non-agglutinating strain between January and March 2013. We selected two controls contemporarily reported with norovirus infection, frequency-matched on residence and age group, per case. We interviewed regarding food consumption, especially pork and its place of purchase. We calculated odds ratios (ORs) with 95% confidence intervals (95% CI) using logistic regression. The NRC investigated human and food isolates by PCR, SDS-PAGE, MLST, PFGE, MLVA and susceptibility testing.
  
  
  RESULTS
  Altogether, 68 O4 non-agglutinating human isolates were confirmed between January and April 2013. Of those, 61 were assigned to the outbreak (median age 57 years, 44% female); 83% cases ≥ 60 years were hospitalized. Eating raw minced pork from butcheries within 3 days was associated with disease (31 cases, 28 controls; OR adjusted for sex: 3.6; 95% CI: 1.0-13). Phage type DT193 and MLST ST34 were assigned, and isolates' lipopolysaccharide (LPS) matched control strains. Isolates linked to Saxony-Anhalt exhibited PFGE type 5. ASSuT- and ACSSuT phenotype proportions were 34 and 39% respectively; 54% were resistant to chloramphenicol. Three pork isolates matched the outbreak strain.
  
  
  CONCLUSIONS
  Raw minced pork was the most likely infection vehicle in this first reported outbreak caused by O4 non-agglutinating, mostly chloramphenicol-resistant S. Typhimurium DT193. High hospitalization proportions demand awareness on the risk of consumption of raw pork among elderly. LPS analysis indicated O4 expression; therefore, testing with antisera from different lots is recommendable in unexpected agglutination reactions.
authors.affiliation: Department for Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany.
authors.forename: Katja
authors.initials: K
authors.lastname: Alt
authors.affiliation: National Reference Centre for Salmonella and other Bacterial Enterics, Robert Koch-Institute, Wernigerode, Saxony-Anhalt, Germany.
authors.forename: Sandra
authors.initials: S
authors.lastname: Simon
authors.affiliation: State Agency for Consumer Protection of Saxony-Anhalt, Magdeburg, Saxony-Anhalt, Germany.
authors.forename: Carina
authors.initials: C
authors.lastname: Helmeke
authors.affiliation: State Agency for Consumer Protection of Saxony-Anhalt, Magdeburg, Saxony-Anhalt, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Kohlstock
authors.affiliation: National Reference Centre for Salmonella and other Bacterial Enterics, Robert Koch-Institute, Wernigerode, Saxony-Anhalt, Germany.
authors.forename: Rita
authors.initials: R
authors.lastname: Prager
authors.affiliation: National Reference Centre for Salmonella and other Bacterial Enterics, Robert Koch-Institute, Wernigerode, Saxony-Anhalt, Germany.
authors.forename: Erhard
authors.initials: E
authors.lastname: Tietze
authors.affiliation: National Reference Centre for Salmonella and other Bacterial Enterics, Robert Koch-Institute, Wernigerode, Saxony-Anhalt, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Rabsch
authors.affiliation: Department for Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Karagiannis
authors.affiliation: Department for Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Werber
authors.affiliation: Department for Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany.
authors.forename: Christina
authors.initials: C
authors.lastname: Frank
authors.affiliation: National Reference Centre for Salmonella and other Bacterial Enterics, Robert Koch-Institute, Wernigerode, Saxony-Anhalt, Germany.
authors.forename: Angelika
authors.initials: A
authors.lastname: Fruth
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D004196:Disease Outbreaks; D005511:Food Handling; D059022:Food Safety; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010641:Phenotype; D000069466:Red Meat / Q000382:microbiology*; D012478:Salmonella Food Poisoning / Q000453:epidemiology* / Q000382:microbiology; D012486:Salmonella typhimurium / Q000302:isolation & purification / Q000502:physiology*; D055815:Young Adult