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Outbreak Notice
Shiga toxin-producing E. coli O104:H4 infections in Germany

This information is current as of today, June 27, 2011 at 00:48 EDT

Updated: June 23, 2011

Current Situation

German health authorities have reported an outbreak of a severe illness called hemolytic uremic syndrome (HUS) in Germany since May 1, 2011. In this outbreak, HUS is being caused by an infection with Escherichia coli O104:H4, a Shiga toxin-producing E. coli (STEC) bacteria. This strain of E. coli causes an illness similar to infection with E. coli O157:H7. Many people have been hospitalized, several requiring intensive care, and some people have died. New cases are still being reported. For case counts and updated situation information, please see Investigation Update: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Most infections have been reported in people in northern Germany (mainly Bremen, Hamburg, Lower Saxony, and Schleswig-Holstein) or in people who have recently traveled to these areas. Cases in travelers to northern Germany have been reported in a number of European countries and in the United States.

Although outbreak investigations continue, Germany's Robert Koch Institute (RKI) has announced that contaminated raw sprouts are the most likely source of the outbreak. 

Advice for US Travelers to Germany

The German public health authorities recommend that people in Germany not eat raw sprouts of any origin. Travelers should also follow regular food safety measures when handling fruits and vegetables. The recommendation not to eat cucumbers, tomatoes, and leafy salads in northern Germany has been lifted as of June 10.

If you have traveled to Germany and have bloody diarrhea and stomach cramps or symptoms of HUS (see below), go to a doctor right away. Tell your doctor about your recent travel and the importance of asking the laboratory to test a stool specimen for STEC.

More Disease Information

STEC infections can cause different gastrointestinal symptoms, which often include severe stomach cramps, diarrhea (often bloody), and vomiting. If there is fever, it usually is not very high (less than 101°F [38.3°C]). Most people get better within 5–7 days, but some patients develop HUS—usually about a week after the diarrhea starts. HUS is a disorder that can occur when an infection in the digestive system (such as STEC) produces toxic substances that destroy red blood cells and cause kidney injury. Early symptoms of HUS include decreased frequency or volume of urination, feeling very tired, and losing pink color in the cheeks and inside the lower eyelids due to anemia. Diarrhea or bloody stools may no longer be present when HUS develops.

Advice for Clinicians

If you care for a patient with bloody diarrhea or HUS who has recently been in Germany or has been in contact with someone recently returned from Germany, it is important to test for STEC O104:H4. Complete testing for STEC O104:H4 includes simultaneous culture of stool for E. coli O157 and assay of the stool for non-O157 STEC with a test that detects Shiga toxin. Clinicians and clinical laboratories should send E. coli O157 isolates and Shiga toxin-positive samples to public health laboratories as soon as possible for additional characterization. Any suspected STEC O104:H4 and HUS cases should be reported to health departments. For more information, see the CDC Health Alert Network (HAN) Health Advisory: Notice to Health Care Providers — Shiga Toxin-producing E. coli O104 (STEC O104:H4) Infections in U.S. Travelers Returning from Germany.

Helpful Links

For more information about STEC and HUS, visit:

For more information about the outbreak in Germany, visit the following websites:


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