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A ProMED-mail post <> ProMED-mail is a program of the International Society for Infectious Diseases <>

Date: Mon 29 Apr 2019
Source: Food Safety News [edited] <>

French authorities are investigating an _E. coli_ outbreak linked to cheese after young children developed hemolytic uremic syndrome (HUS). Some Saint-Felicien and Saint Marcellin cheese has been recalled.

The 13 cases of HUS that developed after _E. coli_ O26 infection have occurred in young children since 21 Mar 2019. The patients are from several regions in the country.

HUS is a severe complication of _E. coli_ infection that causes kidney failure and can occur a week or more after the onset of diarrhea.

Notification of Shiga toxin producing _E. coli_ (STEC) [or enterohemorrhagic _E. coli_ (EHEC)] infections is voluntary in France and based on HUS surveillance in children under 15 years old. EHEC identification in stool samples is not routinely performed by medical labs.

French authorities said preliminary investigations found several children ate Saint-Felicien and Saint Marcellin cheeses before onset of their symptoms. Among these, 3 have a possible link with the consumption of Saint Felicien and Saint Marcellin cheese manufactured by Fromagerie Alpine, based in Romans-sur-Isere, a town in the Drome department in Southeastern France in the Auvergne-Rhone-Alpes region. Epidemiological, microbiological and food traceability investigations are continuing to determine the source of infection.

Sante publique France, the national public health agency, and the National Reference Center (CNR) for _E. coli_, _Shigella_ and _Salmonella_ at the Pasteur Institute are continuing enhanced surveillance of HUS to detect possible new cases. The implicated cheeses were distributed across France with different brand names. Saint-Felicien 180-gram and Saint Marcellin 80-gram packages with lot numbers from 032 to 116 have been recalled. Affected brand names are Fromagerie Alpine, Carrefour, Reflet de France, Leclerc, Lidl, Auchan, Rochambeau, Prince des bois, Sonnailles and Prealpin.

General precautionary advice from health authorities is that raw, unpasteurized milk and cheese made from it should not be eaten by young children. Older adults, pregnant women and other people with weakened immune systems, such as cancer patients, are also at high risk of contracting bacterial infections from raw dairy products.

The current situation is the latest in a string of French cheese recalls initiated because of various pathogens that can cause illnesses in people. Since the beginning of March 2019, there have been 14 alerts from the Rapid Alert System for Food and Feed (RASFF) for problems with French cheese, although some of those relate to the same incident.

In another incident, Jacquin recalled Pouligny Saint-Pierre raw goat's milk cheese from more than 10 countries because of _E. coli_ O26. A different raw goat's milk cheese with the brand name "EARL Le Moulin de la Fosse," which was sold from 2-20 Apr 2019 in markets at Chateauroux, was recalled due to potential contamination with _E. coli_ O157.

In March 2019, a company called LHT informed consumers that _E. coli_ O26 was found in a batch of its "Crottin de Chavignol" cheese with the best-before date of 5 Apr 2019. Hardy Affineur also recalled Valencay and Petit Valencay raw goat's milk cheese with best-before dates ranging from 1 to 26 Mar 2019 because of _E. coli_ O157.

[Byline: Joe Whitworth]

Communicated by: ProMED-mail <>

[Unpasteurized dairy products remain a potential risk for a variety of pathogens, including enterohemorrhagic _E. coli_ (EHEC), either the prototypic serotype or one of the other serotypes; in this case, O26. In analyzing the genetic and phenotypic profiles of non-O157 groups of EHEC, it has been found that they belong to their own lineages and have unique profiles of virulence traits different from the prototypic O157 strain (1). The serogroups appearing to be most prominent are O26, O111, O128, and O103 (2), the O26 serotype being the implicated strain in this outbreak.

>From the past reports and this follow-up, many of the cases had HUS (6 out of 14 in the June 2018 posting, plus 2 mentioned above, suggesting 8 out of 16). For so many of the reported cases to be associated with HUS is very unusual; I would suspect that more cases are known, or the particular strain is a hyperproducer of Shiga toxin, or the specific toxin is more potent.

The following was extracted from Lutwick LI. Enterohemorrhagic _E. coli_ infections. In: Confronting emerging zoonoses: the One Health paradigm. Yamada A, Kahn LH, Kaplan B, et al. (editors). Tokyo, Japan: Springer; 2014:77-112:

"Risk factors for the subsequent development of HUS after EHEC include children less than 10 years of age, elevated white blood cell counts, persistent low platelet counts without reversal and the use of either antimicrobial agents or antimotility agents during the diarrhea stage before or after bloody diarrhea develops. Since fever is generally not part of the presentation but significant abdominal pain is, patients with diarrhea, significant abdominal pain and no fever should be considered to have EHEC infection, and antimicrobial or antimotility agents should be avoided. Additionally, certain strains -- for example, the so-called clade 8 and the chimeric organism _E. coli_ O104:H4 -- can be associated with a higher risk of HUS.

HUS itself is a thrombotic illness primarily caused by the effects of the EHEC-produced Shiga toxin acting on the vascular endometrium of organs where the toxin's receptors are expressed, particularly the kidney and brain. The syndrome consists of the combination of prominent low platelet counts (thrombocytopenia), intravascular red blood cell destruction (hemolysis), and diminished kidney function that can require hemodialysis. Neurological involvement occurs mostly in those who develop renal failure and the central nervous system involvement portends much higher mortality. Indeed, most of the acute mortality relates to neurological disease. Most patients will recover, but some, perhaps 10%, remain with renal failure and require chronic hemodialysis."

1. Schmidt H, Geitz C, Tarr PI, et al. Non-O157:H7 pathogenic Shiga-toxin producing _Escherichia coli_: phenotypic and genetic profiling of virulence traits and evidence for clonality. J Infect Dis 1999;179(1):115-23; available at <>.
2. Bettelheim KA. Role of non-O157 VTEC. Symp Ser Soc Appl Microbiol 2000;(29):38S-50S; abstract available at <>.
- Mod.LL

HealthMap/ProMED map available at: France: <>]

[See Also:

E. coli EHEC - France (03): O26, unpasteurized cheese, more cases
E. coli EHEC - Europe: O80:H2, hybrid invasive pathogen, antimicrobial resistance
E. coli EHEC - Sweden: RFI
E. coli EHEC - Norway: O157, RFI
E. coli EHEC - Ireland (02): increased numbers
E. coli EHEC - France (02): O26, unpasteurized cheese, more cases
E. coli EHEC - Ireland: (Ulster) childcare center
E. coli EHEC - France: O26, unpasteurized cheese, alert, recall
E. coli EHEC - Canada: cheese, 2013, 60 day rule
E. coli EHEC - Denmark: O26
E. coli EHEC - UK (02): (England) O157, raw pet food, fatal, 2017
E. coli EHEC - UK: (England) fatal
E. coli EHEC - Ireland (03): (GY) daycare]

Published 29-09-2017 in Focus on , last update 03-05-2019


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