3.3 Verotoxigenic E. coli

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1 3.3 Verotoxigenic E. coli Summry Number of VTEC cses, 215: 73 Crude incidence rte, 215: 15.9/1, Number of VTEC-ssocited HUS, 215: 22 Number of VTEC cses, 214: 77 Introduction For mny yers, Irelnd hs the highest verotoxigenic Escherichi coli (VTEC) notifiction rte in Europe, with the exception of 211 when Germny reported the highest rte due to lrge VTEC O14 outbrek linked with fenugreek seeds. 1-2 In 215, the notifiction rte for confirmed VTEC cses in the Europen Union/Europen Economic Are ws 1.52 per 1, (similr to 214; 1.56/1,) nd the highest country-specific rtes were in Irelnd, Sweden nd the Netherlnds (12.92, 5.65 nd 5.8 per 1, popultion, respectively). 3 The dominnt trnsmission routes reported for VTEC infection in Irelnd hve been person-to-person spred, especilly in childcre fcilities nd mong fmilies with young children, nd wterborne trnsmission ssocited with exposure to wter from untreted or poorly treted privte wter sources. 4-8 Other importnt trnsmission routes identified interntionlly include food (often minced beef products or fresh produce such s lettuce nd spinch), nd contct with infected nimls or contminted 2, 9-1 environments. Mterils nd Methods Infection with verotoxigenic E. coli becme notifible disese in 212; prior to tht VTEC were notifible under the ctegory Enterohemorrhgic E. coli (EHEC) since 24. Enhnced epidemiologicl informtion ws supplied s in previous yers by HSE personnel, nd the VTEC Ntionl Reference Lbortory t the Public Helth Lbortory, Cherry Orchrd Hospitl Dublin (VTEC-NRL t PHL) provided VTEC confirmtion nd typing dt. Dt from ll sources re mintined in the Computerised Infectious Disese Reporting (CIDR) system. Outbreks of VTEC re notifible since 24 nd these dt re reported to CIDR by the eight regionl Deprtments of Public Helth. The dt presented in this report were extrcted from CIDR on 23 rd November 216. Dt from the Centrl Sttistics Office (CSO) 211 census were used to provide denomintors for the clcultion of ntionl, regionl nd ge-specific incidence rtes in 215. Results Incidence In 215, 73 cses of VTEC were notified in Irelnd, equting to crude incidence rte (CIR) of 15.9 per 1, (95% CI ). Compred with 214 there ws 3% increse in the incidence of VTEC (15.4 per 1,); p=.54). Of the 73 VTEC notifictions in 215, 6 (82%) were clssified s confirmed cses (CIR 13.1 per 1,; 95% CI ), 126 s probble cses nd four s possible cses. The criteri under which notified cses were reported in 215 is outlined in Tble 1. As the clssifiction of VTEC cses chnged significntly upon the mendment of the Irish VTEC cse definition in 212, it is not vlid to directly compre the number of notifictions by cse clssifiction before 212. Tble 1. Number of VTEC notifictions by criteri for notifiction, Irelnd, 215 Notifiction criteri Confirmed Probble Possible Totl Lbortory confirmtion by culture Lbortory confirmtion by PCR only b Serodignosis (vlid for HUS only) Reported solely on the bsis of epidemiologicl link Clinicl HUS not meeting lb or epi criteri Totl Symptomtic culture confirmed cses re clssified s confirmed cses, while symptomtic culture confirmed cses re clssified s probble cses b Symptomtic PCR-confirmed cses re clssified s confirmed cses, while symptomtic PCR-confirmed cses re clssified s probble cses HPSC Annul Epidemiologicl Report

2 Of the 73 cses with lbortory evidence of infection, 241 cses (34%) were reported s being infected with E. coli O26 (5.3 per 1,; 95% CI ), 15 cses (21%) with E. coli O157 (3.3 per 1,; 95% CI ), 38 cses (44%) with other VTEC strins, nd 4 cses hd mixed VTEC infections nd were infected with more thn one VTEC strin. Of the 23 probble cses reported on the bsis of n epidemiologicl link to confirmed cse, one ws linked to n E. coli O157 cse, one ws linked to n E. coli O26 cse nd 21 were linked to n outbrek due to mixed VTEC infection. Figure 1 illustrtes the distribution of VTEC cses in Irelnd by serogroup since The downwrd trend in VTEC infections due to E. coli O157 nd the upwrd trend in E. coli O26 observed in recent yers continued in 215. Compred with 214, there ws 16% decrese in O157 infections, 3% increse O26 infections nd 7% increse in other non-o157/non-o26 infections. Severity of illness Of the 73 notified cses in 215, 622 (85%) were symptomtic nd 197 (32%) of the symptomtic cses developed bloody dirrhoe (36% of symptomtic cses when limited to where the bloody dirrhoe vrible is completed). Twenty-two individuls (3%) developed HUS, decrese of 19% on 214 (n=27) nd of 29% on 213 (n=31). In 215, five deths occurred mong VTEC cses, however only one of these five deths ws ttributed to VTEC infection. Where hospitlistion sttus ws reported (n=714), 237 (33%) of these cses were hospitlised (36% of symptomtic cses). Of the 22 HUS cses, seven were infected with E. coli O26, four with E. coli O157, two ungroupble nd one ech with E. coli O13, O145 nd O177 (Tble 2). Of the remining six HUS cses, two were reported s confirmed cses (verotoxin genes detected in stool smples but no isolte ws cultured) nd four were possible cses (i.e. clinicl HUS, without lbortory or epidemiologicl criteri). Although, numbers re smll, 27% (i.e. 3 of 8) E. coli O26 vertotoxin 2 (vt2) developed HUS. HUS cses rnged in ge from 6 months to 74 yers nd 73% (n=16) of the cses were in children under 1 yers of ge. Fifteen of the HUS cses were considered spordic, Number of notifictions Number of notifictions Yer Jn Feb Mr Apr My Jun Jul Aug Sep Oct Nov Dec Month of notifiction Totl O157 non-o men Figure 1. Annul number of confirmed nd probble VTEC cses by serogroup, Irelnd Note: For simplicity in this figure, cses with mixed VTEC O157/other serogroup infections re included in the dt for O157, s re probble cses linked to known E. coli O157 outbreks. Non-O157 dt includes cses with mixed non-o157 infections nd probble cses linked to known O26 outbreks Figure 2. Sesonl distribution of the number of VTEC notifictions in Irelnd, 215 nd the men of Tble 2. Number of VTEC notifictions by serogroup, verotoxin nd HUS sttus, Irelnd, 215 Serogroup Verotoxin HUS non-hus Totl % with HUS HPSC Annul Epidemiologicl Report 215 vt % O26 vt % vt1+vt % Not reported 1 1.% vt1.% O157 vt % vt1+vt % Not reported 1 1.% vt % Other vt % vt1+vt % Not reported 3 3.% No orgnism Unknown % Totl % For simplicity mixed infections were recorded s O157 if t lest one strin ws O157, s O26 if t lest one strin ws O26 but not O157, nd s Other if only non-o157 or non-o26 strins were detected. -69-

3 four were prt of fmily outbreks nd three were prt of generl outbreks (including two cses linked to the sme community outbrek). Sesonl distribution Figure 2 shows the sesonl distribution of notifictions in 215 reltive to the men monthly number of cses in the yers The typicl summer pek normlly seen in July ws not observed in 215; two distinct peks were seen of lmost similr mgnitude, one in April nd the other in September. However, exmining the sesonl distribution by serogroup vritions were observed; O26 nd non-o157/non-o26 (others) hd bimodl distribution (Figure 3). E. coli O26 peked in July nd September nd non-o157/non-o26 (others) peked in My nd September. Although, the numbers of E. coli O157 notifictions peked in September, this pek ws not s pronounced s previous yers nd ws preceded with smller peks in My nd July (Figure 3). Regionl distribution In 215, the highest VTEC incidence rtes were reported in the HSE-W followed by the HSE-M, HSE-MW nd HSE-SE, where the rtes were significntly higher thn the ntionl crude incidence rte (Tble 3). The incidence of VTEC in HSE-E nd HSE-NW were significntly lower thn the ntionl crude incidence rte. The highest incidence of HUS Number of notificitons Jn Feb Mr Apr My Jun Jul Aug Sep Oct Nov Dec Month of notifiction O26 O157 Other Figure 3: Sesonl distribution of VTEC notifictions by serogroup, Irelnd, 215 For simplicity mixed infections were recorded s O157 if t lest one strin ws O157, s O26 if t lest one strin ws O26 but not O157, nd s Other if only non-o157 or non-o26 strins were detected. mongst VTEC cses ws in HSE-M nd HSE-MW (Tble 3). In the eight HSE res, the incidence of E. coli O26 in 215 exceeded or equled tht of E. coli O157 (Figure 3). Other serogroups (i.e. non-o157/non-o26) ccounted for the highest rtes of VTEC infections in five of the eight HSE res (Figure 3) Age-sex distribution As in previous yers, the highest reported ge-specific incidence rte in 215 ws in the -4 yer ge group (81.4 per 1,). Incidence rtes were higher mong femles in ll ge groups 2 yers of ge nd older but were slightly higher in mles in those <15 yers of ge (Figure 5). Lbortory typing In 215, the serogroup nd verotoxin profiles of VTEC isoltes/smples referred to the VTEC-NRL t PHL, Cherry Orchrd Hospitl re presented in Tble 4. The most common serogroup reported ws E. coli O26 (n=241), followed by E. coli O26 (n=15). Among the other serogroups listed by the World Helth Orgnistion s hving the highest ssocition with HUS interntionlly, there were 41 E. coli O145, 15 E. coli O13 cses nd 6 E. coli O111. Although numbers re reltively smll, infections due to O145 continued to increse from 17 cses in 213, to 31 cses in 214 nd 41 cses in 215. As usul mong E. coli O157 cses in Irelnd, isoltes contining the genes for vt2 were more common (78%) thn strins contining genes for both vt1 nd vt2. Among the VTEC O26 strins those contining the genes for both vt1 nd vt2 ccounted for the mjority (64%), followed by vt1 only (32%) nd those contining vt2 mking up the remining 4% of E. coli O26 cses. In contrst, the mjority (85%) of O145 strins were vt2-postive. Furthermore, vt1-contining strins mde up the mjority of O13 strins (87%), while VTEC O111 comprised of vt1 (5%) nd vt1+vt2 (5%) contining strins (Tble 4). Risk fctors Under the enhnced surveillnce system for VTEC, risk fctor informtion is routinely collected on ll notifictions (Tble 5). Exposure to frm nimls or their feces nd exposure to privte well wter were reltively common mong cses in Tble 3. Number nd crude incidence rtes of by serogroup nd HSE re, nd number nd crude incidence rte of VTEC-ssocited HUS by HSE re, Irelnd, 215 HSE-re Number of VTEC cses Crude incidence rte /1, (95% CI) Number HUS cses Incidence of HUS /1, (95% CI) E ( ) 3.2 (.-.4) M ( ) (.-2.3) MW ( ) (.-2.1) NE ( ) 1.2 (.-.7) NW ( ). (.-.) S ( ) 4.6 (.-1.2) SE ( ) 3.6 (.-1.3) W ( ) 4.9 (.-1.8) IE ( ) 22.5 (.3-.7) HPSC Annul Epidemiologicl Report

4 215; 37.9% nd 33% reported these exposures, respectively. According to CSO dt, in the generl popultion, round 1.1% of households re served by privte wells, indicting tht, on ntionl bsis, exposure to privte wells ppers to be more common mong VTEC cses thn mong the generl popultion. Unlike slmonellosis, foreign trvel plys only minor role in VTEC infection in Irelnd, with the mjority of infections cquired indigenously (>97%). Where the informtion ws vilble, just under fifth of VTEC cses in 215 were ttending childcre fcility (CCF). When these nlyses were restricted to notified VTEC under five yers of ge, 43.2% reported ttendnce t childcre fcility. This is similr to the proportion of children in the generl popultion who use non-prentl childcre (42%) s reported by the Centrl Sttistics Office. 11 Outbrek nd environmentl investigtions The outbrek surveillnce system plys key role in our understnding of the trnsmission of VTEC infection in Irelnd. Ninety-one VTEC outbreks were notified in 215, which included 28 of the 73 VTEC notifictions. Forty-one outbreks were due to E. coli O26, 18 to E. coli O157, 16 were mixed E. coli strin outbreks, nd 16 were cused by other VTEC strins. The mjority of outbreks (n=78, 86%) were fmily outbreks, with 13 generl outbreks lso notified. The 73 fmily outbreks resulted in 148 persons becoming ill, n verge of 1.95 (rnge 1-7) persons ill per outbrek. The 13 generl outbreks resulted in 84 persons becoming ill, n verge of 7 (rnge 1-44) persons ill per outbrek. Seventy-four outbreks occurred in privte homes, eight involved extended fmilies, five involved childcre fcilities, three were community outbreks nd one ws in residentil institution. The suspected modes of trnsmission re listed in Tble 6. Person-to-person spred is consistently the most common mode of VTEC trnsmission reported in Irelnd, prticulrly Crude incidence rte per 1, E M MW NE NW S SE W IE HSE-re O157 O26 Other Figure 4: Crude incidence rte VTEC O157, O26 nd other serogroups by HSE re, Irelnd, 215 For simplicity mixed infections were recorded s O157 if t lest one strin ws O157, s O26 if t lest one strin ws O26 but not O157, nd s Other if only non-o157 or non-o26 strins were detected. between young children, nd ws suspected to hve plyed role in 51 (56%) VTEC outbreks in 215 in which 114 persons were reported ill (Tble 6 nd Figure 5). Thirty-four of these outbreks were reported s being solely due to person-toperson trnsmission, including two outbreks which occurred in CCFs. Wterborne trnsmission ws reported to hve contributed to 19 outbreks (21%) with 82 persons ill. Tble 4. Serotype nd verotoxin (vt) profiles for strins ssocited with lbortory confirmed VTEC cses, s determined t the VTEC-NRL t PHL, Cherry Orchrd Hospitl, 215 Serogroup vt1 vt2 vt1 + vt2 Not reported Totl O O O O O O O O O128b O O O O O O O O O O128d O O O O15c O117:H O O O O136:H O O O O O O O O O O O O O OE OE Ungroupble/ unidentifible Mixed Totl HPSC Annul Epidemiologicl Report

5 This is higher thn the number of wterborne VTEC outbreks reported in 214 (n=9) nd 213 (n=8) but similr to the number reported in 212 (n=21) (Figure 6). Of the 19 outbreks with links to wterborne trnsmission, 16 were fmily outbreks with exposure to privte wells reported in 13 of these nd three were generl outbreks. One of the three generl outbreks occurred in the community resulting in 44 people ill nd ws linked to privte group wter scheme. Similr to 214, in 215 niml/environmentl contct ws reported to hve contributed to nine outbreks (9.9%) with 2 persons ill. All occurred in privte houses (Figure 6). One outbrek (fmily outbrek, 2 persons ill) ws reported s foodborne nd linked to unpsteurised cheese while nother fmily outbrek with three persons ill ws reported s food/ wterborne, where the individuls hd been exposure to unpsteurised milk nd wter from privte well. For 31% (n=28) of VTEC outbreks in 215, the trnsmission route ws reported s unknown (Tble 6 nd Figure 6). Summry The number of VTEC notifictions in Irelnd continued to rise (but not significntly) in 215. Within the Europen Union, Irelnd continues to hve the highest incidence rte for VTEC, reporting over seven times the Europen verge in The upwrd trend observed in Irelnd in recent yers of non-o157 notifictions continued in 215 nd reflects the more widespred use by the primry hospitl lbortories, of dignostic methods tht detect broder rnge of E. coli serogroups nd the use of more sensitive moleculr methods tht detect verotoxin genes directly in stool smples 12 Furthermore, ntionl guidnce developed for the lbortory dignosis of humn VTEC in Irelnd provides co-ordinted pproch to VTEC dignosis in Irelnd. 13 Foodborne trnsmission ws the first recognised trnsmission route for VTEC infection historiclly, with minced beef, unpsteurised diry products, nd fresh produce consumed rw ll hving been implicted in outbreks cross the world. Foodborne outbreks typiclly comprise smll percentge of the totl number of VTEC outbreks in Irelnd nd 215 ws not n exception with foodborne outbreks comprising 2.2 % of the VTEC outbreks notified. Trnsmission by person-to-person spred, however, remined the most common trnsmission route reported in VTEC outbreks nd ws involved in 56% of outbreks. As usul, person-to-person spred ws most frequently ssocited with privte house nd childcre fcility outbreks. Hnd-wshing nd exclusion of cses in risk groups from high risk settings remins key prevention mesures for VTEC. 14 In 215, fter person-to person spred, contminted drinking wter ws the second most commonly suspected mode of trnsmission. As in previous yers, the mjority of the drinking-wter ssocited outbreks reported were linked with privte wter supplies nd one outbrek ws Tble 5. Number of cses of VTEC (nd percentge where informtion vilble) for selected risk fctors, Irelnd, 215 (n=73) Risk fctor Yes (% of known) No Unknown or not reported Food suspected 27 (5.4) Exposure to frm nimls or their feces 245 (37.9) Exposure to privte well wter 215 (33.) Trvel-ssocited b 18 (2.7) Attendnce t CCF c 112 (18.8) Attendnce t CCF c (mong <5 yrs) 14 (43.2) Composite vrible recoded from two different wter supply exposure enhnced vribles in CIDR b Inferred from CIDR core vrible Country of Infection c CCF=childcre fcility 16 9 Number of notifictions Rte per 1, popultion Age group (yers) Femle - Cses Mle - Cses Femle - Rte Mle - Rtes Figure 5. Age-sex distribution VTEC notifictions, Irelnd, 215 HPSC Annul Epidemiologicl Report

6 linked to contminted wter from privte group wter scheme. Exposure to wter from contminted untreted or poorly treted privte wter supplies hs historiclly been recognised s strong risk fctor for VTEC infection in Irelnd. 6-8, 15 This hs been prticulrly pronounced following periods of hevy rinfll. Animl/environmentl contct ws reported s the third most common route of trnsmission for VTEC outbreks in 215. This hs long been recognised s risk fctor for VTEC infection 9-1 nd cses due to this trnsmission route re not unexpected in Irelnd given the lrge cttle popultion, the high proportion of rurl dwellers, nd the lrge number of frming fmilies. 8 Fortuntely, none of these niml contct outbreks were ssocited with public venues such s open frms, nd so the numbers of people ffected were smll. Advice is vilble on the HPSC website on how to minimise the risk of gstrointestinl infections following exposure to frm nimls nd environments, nd for the sfe recretionl use of frmlnd. 16 The focus for reducing the incidence of VTEC should be on reducing person-to-person nd wterborne trnsmission. Efforts should focus initilly on publicizing mterils lredy developed in Irelnd, including ntionl guidnce for crèche owners on the mngement of infectious-disese spred in CCFs 17, guidnce for public helth professionls on the mngement of VTEC cses nd outbreks in CCFs 14 nd leflet developed for well owners outlining the infectious disese risks ssocited with drinking wter from privte wells, providing dvice on ctions tht cn be tken nd wht to do in the event the well wter is contminted Number of outbreks Yer of notifiction Person-to-person Foodborne +/- P-P Other Wterborne +/- P-P Animl contct/environmentl +/- P-P Unknown/not specified Figure 6. Number of VTEC outbreks by suspected trnsmission route nd yer, Irelnd, Note: In this figure, reported trnsmission routes were grouped for simplicity. Any outbrek where food contributed ws reported s foodborne, ny outbrek where wter contributed ws reported s wterborne, ny other outbrek where niml contct contributed ws reported s niml contct. Person-to-person outbreks include only those outbreks reported s being due only to person-to-person trnsmission Tble 6. VTEC outbreks by suspected mode of trnsmission, Irelnd, 215 Trnsmission route Number of outbreks Number ill Number of ssocited CIDR events Person-to-person Foodborne Wterborne Person-to-person nd wterborne Foodborne nd wterborne Animl contct Person-to-person nd niml contct Unknown Totl These figures my differ from the number ill, s symptomtic cses identified s result of screening will lso be reported in CIDR HPSC Annul Epidemiologicl Report

7 References 1. ECDC Epidemiologicl updtes on the VTEC O14 outbrek. Pges/epidemiologicl_updtes.spx 2. EFSA Trcing seeds, in prticulr fenugreek (Trigonell foenumgrecum) seeds, in reltion to the Shig toxin-producing E. coli (STEC) O14:H4 211 Outbreks in Germny nd Frnce europ.eu/en/press/news/lists/news/ecdc_dispform.spx?list=32 e43ee8%2de23%2d4424%2d783%2d &id=455&ro otfolder=%2fen%2fpress%2fnews%2flists%2fnews 3. ECDC. Surveillnce Atls of Infectious Diseses. Avilble t tls.ecdc.europ.eu/public/index.spx?instnce=generlatls 4. Grvey, P. et l. 21. Epidemiology of verotoxigenic E. coli in Irelnd, 27. Epi-Insight: 11(9) 5. Locking et l. 21. Escherichi coli O157 Infection nd Secondry Spred, Scotlnd, EID 17(3): content/17/3/pdfs/524.pdf 6. O Sullivn et l. 28. Increse in VTEC cses in the south of Irelnd: link to privte wells? Eurosurveillnce 13(39) eurosurveillnce.org/viewarticle.spx?articleid= HPSC. 28. Press relese. Householders must properly mintin privte wter supplies following increse in contmintion HPSC. MinBody,3127,en.html 8. Óhisedh C, Hynds PD, Fllon UB, O Dwyer J A geosttisticl investigtion of griculturl nd infrstructurl risk fctors ssocited with primry verotoxigenic E. coli (VTEC) infection in the Republic of Irelnd, Epidemiol Infect. 145(1): Locking et l. 21. Risk fctors for spordic cses of Escherichi coli O157 infection: the importnce of contct with niml excret. Epidemiol Infect. 127(2): downlod.php?file=%2fhyg%2fhyg127_2%2fs pdf&code=6ed8f62e7b253791ec5fb14dcd 1. Griffin. 21. Review of the mjor outbrek of E. coli O157 in Surrey, Centrl Sttistics Office. 29. Qurterly Ntionl Household Survey. Childcre. Qurter Accessed t medi/csoie/relesespublictions/documents/lbourmrket/27/ childcreq427.pdf 12. Rice T, Quinn N, Sletor RD, Lucey B Chnging dignostic methods nd decresed detection of verotoxigenic Escherichi coli, Irelnd. Emerg Infect Dis. 22(9); HPSC Guidnce for Lbortory Dignosis of Humn Verotoxigenic E. coli Infection produced by The Lbortory Sub- Group of the VTEC Sub-Committee of the Helth Protection Surveillnce Centre Scientific Advisory Committee, Irelnd. Avilble t ReportoftheHPSCSub-CommitteeonVerotoxigenicEcoli/File,4544,en. pdf 14. HPSC VTEC (Verocytoxigenic E. coli) in Childcre Fcilities: Decision Support Tool for Public Helth. Accessed on October 7 th t ReportoftheHPSCSub-CommitteeonVerotoxigenicEcoli/File,4559,en. pdf 15. Grvey P, Crroll A, McNmr E, McKeown P Verotoxigenic Escherichi coli trnsmission in Irelnd, review of notified outbreks, Epidemiol Infect. 144; HPSC. VTEC Guidnce. Guidnce/ 17. HPSC Preschool nd Childcre Fcility Subcommittee Mngement of Infectious Disese in Childcre Fcilities nd Other Childcre Settings. Accessible t LifeStges/Childcre/ 18. Helth Service Executive Leflet on the Risk of illness from well wter Precutions%2nd%2dvice%2for%2reducing%2risk%2 of%2illness%2from%2well%2wter.pdf HPSC Annul Epidemiologicl Report

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