2011 Germany E. coli O104:H4 outbreak
A novel strain of Escherichia coli O104:H4 bacteria caused a serious outbreak of foodborne illness focused in northern Germany in May through June 2011. The illness was characterized by bloody diarrhea, with a high frequency of serious complications, including hemolytic-uremic syndrome (HUS), a condition that requires urgent treatment. The outbreak was originally thought to have been caused by an enterohemorrhagic (EHEC) strain of E. coli, but it was later shown to have been caused by an enteroaggregative E. coli (EAEC) strain that had acquired the genes to produce Shiga toxins, present in organic fenugreek sprouts.
|2011 German E. coli O104:H4 outbreak|
|Schistocytes seen in a person with hemolytic-uremic syndrome|
Epidemiological fieldwork suggested fresh vegetables were the source of infection. The agriculture minister of Lower Saxony identified an organic farm in Bienenbüttel, Lower Saxony, Germany, which produces a variety of sprouted foods, as the likely source of the E. coli outbreak. The farm was shut down. Although laboratories in Lower Saxony did not detect the bacterium in produce, a laboratory in North Rhine-Westphalia later found the outbreak strain in a discarded package of sprouts from the suspect farm. A control investigation confirmed the farm as the source of the outbreak. On 30 June 2011, the German Bundesinstitut für Risikobewertung (BfR) (Federal Institute for Risk Assessment), an institute of the German Federal Ministry of Food, Agriculture and Consumer Protection, announced that seeds of organic fenugreek imported from Egypt were likely the source of the outbreak.
In all, 3,950 people were affected and 53 died, 51 of whom were in Germany. 800 people suffered hemolytic uremic syndrome (HUS), which can lead to kidney failure. A handful of cases were reported in several other countries including Switzerland, Poland, the Netherlands, Sweden, Denmark, the UK, Canada and the USA. Essentially all affected people had been in Germany or France shortly before becoming ill.
Initially, German officials made incorrect statements on the likely origin and strain of Escherichia coli. The German health authorities, without results of ongoing tests, incorrectly linked the O104 serotype to cucumbers imported from Spain. Later, they recognised that Spanish greenhouses were not the source of the E. coli and cucumber samples did not contain the specific E. coli variant causing the outbreak. Spain consequently expressed anger about having its produce linked with the deadly E. coli outbreak, which cost Spanish exporters US$200 million per week. Russia banned the import of all fresh vegetables from the European Union from early June until 22 June 2011.
Enterohemorrhagic E. coli has been linked to foodborne outbreaks of bloody diarrhea and hemolytic uremic syndrome around the world since at least the early 1980s. The majority of disease has been attributed to E. coli with the serotype O157:H7; however, over 100 E. coli serotypes have been associated with human diarrheal disease.
In the five years before the outbreak (2006 to 2010) Germany experienced an average of 218 cases of EHEC gastroenteritis and 13 cases of hemolytic uremic syndrome each year. According to the Geman National Reference Centre for Salmonella and Other Enteric Pathogens, the most common serotypes in those years were O157, O26, O103, and O91. Serotype O104 was relatively rare in Europe in the years preceding the outbreak, with just 11 reported cases in the EU and Norway between 2004 and 2009.
Cases began as early as May 1, 2011 with a man in Aachen reporting bloody dirrahea. Cases then rapidly increased, with over 100 cases of EHEC gastroenteritis and/or HUS were being reported each day by May 16th. The outbreak centered on the five northern German states of Hamburg, Schleswig-Holstein, Bremen, Lower Saxony, and Mecklenburg-Western Pomerania. Cases would eventually be reported in all 16 German states; however most cases outside of the northern states were linked to travel in northern Germany. Additionally, a small number of cases were reported from other countries, although most of those ill had previously travelled to Germany. The most substantial outbreak outside of Germany was in Bordeaux, France where 15 cases of EHEC gastroenteritis were associated with the same strain of E. coli which caused the outbreak in Germany. The French cases had not previously travelled to Germany, suggesting they acquired the bacteria from contaminated sprouts grown in France. Cases of EHEC HUS and gastroenteritis peaked on May 21 and 22 respectively. Cases then slowly decreased over the following month, with cases reported throughout the month of June and ending during July 2011. German authorities deemed the outbreak over in early July 2011.
The outbreak disproportionately affected adults and the elderly. 88% of hemolytic-uremic syndrome patients were over 17 years of age, and the median age of hemolytic-uremic syndrome patients was 42 years. The median age of patients who died of gastroenteritis was 82 years, while the median age of patients who died from hemolytic-uremic syndrome was 74 years.
Most or all victims were believed to have become infected in Germany or France. Confirmed cases are listed below according to their location when diagnosed.
|Country||Non-HUS cases||HUS cases||Deaths|
The investigation into the cause of the outbreak officially began with the notification of the Robert Koch Institute on May 19th concerning three cases of HUS in children in Hamburg. On 26 May, German health officials hastily and prematurely announced that cucumbers from Spain were identified as a source of the E. coli outbreak in Germany, when in fact the source were Egyptian sprouts. On 27 May 2011, German officials issued an alert distributed to nearby countries, identifying organic cucumbers from Spain and withdrawing them from the market. The European Commission on 27 May said the two Spanish greenhouses suspected to be the sources had been closed, and were being investigated. The investigation included analyzing soil and water samples from the greenhouses in question, located in the Andalusia region, with results expected by 1 June. Cucumber samples from the Andalusian greenhouses did not show E. coli contamination, but cross-contamination during transport in Germany and distribution in Hamburg are not discounted; in fact, the most probable cause is cross-contamination inside Germany. The Robert Koch Institute advises against eating raw tomatoes, cucumbers, and lettuces in Germany to prevent further cases.
On 31 May, an EU official said the transport chain was so long, the cucumbers from Spain could have been contaminated at any point along the transit route. Spanish officials said before, there was no proof that the outbreak originated in Spain; Spanish Secretary of State for European Affairs Diego López Garrido said, "you can't attribute the origin of this sickness to Spain."
On Tuesday 31 May, lab tests showed two of the four cucumbers examined did contain toxin-producing E. coli strains, most likely because of cross-contamination in Germany according to experts, but not the O104 strain found in patients. The bacteria in the other two cucumbers have not yet been identified.
Genomic sequencing by BGI Shenzhen confirm a 2001 finding that the O104:H4 serotype has some enteroaggregative E. coli (EAEC or EAggEC) properties, presumably acquired by horizontal gene transfer.
On 4 June, German and EU officials had allegedly been examining data that indicated an open catering event at a restaurant in Lübeck, Germany, was a possible starting point of the ongoing deadly E. coli outbreak in Europe. German hospitals were nearly overwhelmed by the number of E. coli victims.
A spokesman for the agriculture ministry in Lower Saxony, warned people on 5 June to stop eating local bean sprouts, as they had become the latest suspected cause of the E. coli outbreak. A farm in Bienenbuettel, Lower Saxony, was announced as the probable source, but on 6 June, officials said this could not be substantiated by tests. Of the 40 samples from the farm that were being examined, 23 had tested negative. But on 10 June, the head of the Robert Koch Institute confirmed the sprouts were the source of the outbreak, and people who ate the sprouts were nine times more likely to have bloody diarrhea. The WHO have confirmed on 10 June this statement on the update 13 of the EHEC outbreak.
According to the head of the national E. coli lab at the German Federal Institute for Risk Assessment, the strain responsible for the outbreak has been circulating in Germany for 10 years, and in humans not cattle. He said it is likely to have gotten into food via human feces.
A joint risk-assessment by EFSA/ECDC, issued 29 June 2011, made a connection between the German outbreak and a HUS outbreak in the Bordeaux area of France, first reported on 24 June, in which infection with E. coli O104:H4 has been confirmed in several patients. The assessment implicated fenugreek seeds imported from Egypt in 2009 and 2010, from which sprouts were grown, as a common source of both outbreaks, but cautioned, "there is still much uncertainty about whether this is truly the common cause of the infections", as tests on the seeds had not yet found any E. coli bacteria of the O104:H4 strain. The potentially contaminated seeds were widely distributed in Europe. Egypt, for its part, steadfastly denied it may have been the source of deadly E. coli strain, with the Minister of Agriculture calling speculations to that effect "sheer lies".
On 22 May, Health Commissioner John Dalli of the European Commission declared the issue to be an 'absolute priority', saying the Commission is working with member states, particularly Germany, to identify the source of the outbreak. Speaking again on 1 June, Commissioner Dalli noted the outbreaks have been limited in origin to the greater Hamburg area and declared any product ban would be disproportionate. He also said he is working with Agriculture Commissioner Dacian Cioloş "to address the hardship faced by this group of our citizens that has also been hit hard by the E. coli outbreak". He also said, "In the future, we need to see how the timing of the alerts can be closer to the actual scientific basis and proof."
By 7 June, EU Ministers held an emergency meeting in Luxembourg to discuss the growing crisis, which had left 23 people dead, and more than 2,000 ill so far. Germany's Federal Agriculture Minister, Ilse Aigner, repeated her warnings to EU consumers to avoid eating any bean sprouts, cucumbers, tomatoes, and salads.
EU member statesEdit
Apart from the German government, which warned against the consumption of all raw cucumbers, tomatoes, and lettuce, several countries implemented restrictions or bans on the import of produce.
Non-EU European nationsEdit
Many other European countries took restrictive actions or lost sales of produce, including Albania, Croatia, and Russia.
The ban on EU vegetables was lifted on 10 June, but stiff safety measures remained in place.
Many countries took restrictive action. Egypt was a focus of the epidemiological investigation because the fenugreek seeds were imported into Germany from Egypt.
Egypt's Minister of Health Ashraf Hatem denied his nation had any patients infected with the new E. coli strain, due to the strict precautions brought in to test overseas tourists entering the country on 2 June.
Responding to claims that Egyptian fenugreek seeds were the cause of the E. coli outbreak, Egyptian Minister of Agriculture Ayman Abu-Hadid told the Egyptian press the problem had nothing to do with Egypt and instead asserted, "Israel is waging a commercial war against Egyptian exports."
Canada and the United States reported cases of E. coli infection that had been acquired in Europe.
On 2 June, Canada brought in stricter anti E. coli-related food inspections, and by 3 June the Public Health Agency of Canada said no Canadians had been reported sick with the strain as of that date. The Canadian government also brought in heavier import and hygiene restrictions on EU cucumbers, lettuces, and tomatoes.
The United States Department of Agriculture and the Food and Drug Administration (FDA) stated that emerging strains of E. coli are a significant problem, but regulatory bodies in the US have concentrated on the more infamous E. coli O157 serotype.
The FDA noted nearly all of America's fresh produce is grown in the US and areas of Central America, and the EU has not been a significant source of fresh produce for the US.
Other countries, including Nigeria, Hong Kong, and Thailand, expressed concern regarding imported produce.
By 1 June, Italian, Austrian, and French cucumber sales had begun to decline sharply, but the Austrian Health Ministry official, Dr. Pamela Rendi-Wagner, claimed Austrian customers were still safe.
On 3 June, the governments of Spain, Portugal, and Germany said they would formally request EU agricultural aid for farmers affected by the outbreak. That day, Russia also set up plans for new imports of cucumbers from Ukraine, Azerbaijan, Egypt, and Turkey.
By 7 June, the EU's farmers had reported they had lost millions of dollars in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying its growers had $256,000,000 in turnover. French, Swiss, Bulgarian, German, Dutch, Belgian, and Portuguese producers have also been similarly affected.
That day, the EU proposed issuing £135,000,000 in agricultural compensation to its farmers. The EU agriculture commissioner said the EU's farmers could get back up to 30% of the cost of vegetables they were unable to sell. The EU's health commissioner, John Dalli, had formally criticised Germany earlier that day for rushing out "premature conclusions" about the source of an outbreak, and only helped to spread alarm among the public and farmers and untimely leading to the damaging the EU's agriculture sector. John Dalli also told the EU parliament in Strasbourg that claims had to be scientifically sound, unbiased, and fool-proof in nature before it was publicised in future.
Spain then rejected a €150,000,000/£135,000,000 the European Commission's compensation deal for their farmers who were hit by the E. coli outbreak, on 8 June, saying it was too small. France, European Union's largest agricultural grower, said it would support the plan to compensate producers hurt by the outbreak, according to the French Agriculture Minister Bruno Le Maire.
Ministers from both EU and Russia were scheduled to meet on 8 June over Russia's earlier decision to ban all its vegetable imports from the EU.
On 8 June, the EU's E. coli O104:H4 outbreak was estimated to have cost $2,840,000,000 in human losses (such as sick leave), regardless of material losses (such as dumped cucumbers).
Consumers across Europe were shunning fruit and vegetables en masse by 8 June, as the German government's edict against eating raw cucumbers, tomatoes, lettuce and sprouts remained on. EU farmers claimed to have losses up to C$417,000,000 a week as ripe vegetables rotted in their fields and warehouses. On 8 June, The EU Farm Commissioner Dacian Ciolos said the EU had increased its offer of compensation to farmers for the losses caused by E. coli outbreak to C$210,000,000.
The outbreak was caused by a strain of E. coli of the serotype O104:H4, that was unusual for having characteristics of both enteroaggregative E. coli and enterohemorrhagic E. coli. The strain has a number of virulence genes typical of enteroaggregative E. coli, including attA, aggR, aap, aggA, and aggC, in addition to the Shiga toxin variant 2. All bacteria isolated from patients in this outbreak were resistant to beta-lactam antibiotics, third-generation cephaloporins, and partially resistant to nalidixic acid, but susceptible to carbapenems and ciprofloxacin.
- "Gärtnerhof Bienenbüttel". Archived from the original on 12 June 2011. Retrieved 13 June 2011.
- "German-grown food named likely culprit in deadly outbreak". CNN. 5 June 2010. Retrieved 5 June 2011.
- "Deadly E. coli found on bean sprouts". thelocal.de. 11 June 2010. Retrieved 11 June 2011.
- "Bundesinstitut bestätigt Sprossen als Ehec-Quelle". sueddeutsche.de. 11 June 2010. Retrieved 13 June 2011.
- King, L. A.; Nogareda, F.; Weill, F.-X.; Mariani-Kurkdjian, P.; Loukiadis, E.; Gault, G.; Jourdan-DaSilva, N.; Bingen, E.; Mace, M.; Thevenot, D.; Ong, N.; Castor, C.; Noel, H.; Van Cauteren, D.; Charron, M.; Vaillant, V.; Aldabe, B.; Goulet, V.; Delmas, G.; Couturier, E.; Le Strat, Y.; Combe, C.; Delmas, Y.; Terrier, F.; Vendrely, B.; Rolland, P.; de Valk, H. (2012). "Outbreak of Shiga Toxin-Producing Escherichia coli O104:H4 Associated With Organic Fenugreek Sprouts, France, June 2011". Clinical Infectious Diseases. 54 (11): 1588–1594. doi:10.1093/cid/cis255. ISSN 1058-4838. PMID 22460976.
- "Samen von Bockshornklee mit hoher Wahrscheinlichkeit für EHEC O104:H4 Ausbruch verantwortlich in English: Fenugreek seeds with high probability for EHEC O104: H4 responsible outbreak" (PDF) (in German). Bundesinstitut für Risikobewertung (BfR) in English: Federal Institute for Risk Assessment. 30 June 2011. Retrieved 17 July 2011. Italic or bold markup not allowed in:
- European Food Safety Authority (11 July 2012). "E.coli: Rapid response in a crisis". Archived from the original on 20 November 2018. Retrieved 2 October 2012.
there were 53 confirmed deaths.
- New insight from whole-genome sequencing of Europe's 2011 E. coli outbreaks, Biotechnology, February 6, 2012.
- "Shiga toxin-producing E. coli (STEC): Update on outbreak in the EU (27 July 2011, 11:00)". ECDC. 27 July 2011. Archived from the original on 4 October 2011. Retrieved 27 August 2011.
- "E. coli cucumber scare: Russia announces import ban". BBC News. 30 May 2011. Archived from the original on 30 May 2011. Retrieved 30 May 2011.
- "E. Two in U.S. infected in German E. coli outbreak". MSNBC Online. 31 May 2011. Retrieved 2 June 2011.
- "/ Europe – Cucumber crisis widens European rift". Financial Times. Archived from the original on 3 June 2011. Retrieved 4 June 2011.
- "EUROPEAN COMMISSION-Audio conference of the STEC OUTBREAK IN GERMANY" (PDF). Archived from the original (PDF) on 3 November 2012. Retrieved 4 June 2011.
- "Notification details - 2011.0703". RASFF Portal. Retrieved 14 March 2018.
- "E. coli outbreak sickens European diplomatic relations". The Periscope Post. Archived from the original on 15 July 2011. Retrieved 4 June 2011.
- "Toll climbs in European E. coli outbreak". Globe and Mail. Toronto, Canada. 30 May 2011. Archived from the original on 31 May 2011. Retrieved 31 May 2011.
- "EUROPEAN COMMISSION – HEALTH AND CONSUMERS DIRECTORATE GENERAL – 2 June 2011" (PDF). Archived from the original (PDF) on 3 November 2012. Retrieved 4 June 2011.
- "Germany now say Spanish cucumbers not source of E. coli". Euskal Irrati Telebista. 31 May 2011. Archived from the original on 2 June 2011. Retrieved 31 May 2011.
- "E. coli cucumber scare: Spain angry at German claims". BBC. 31 May 2011. Archived from the original on 1 June 2011. Retrieved 31 May 2011.
- Chelsom-Pill, Charlotte (22 June 2011). "Russia lifts ban on EU vegetables". Deutsche Welle. Retrieved 26 June 2011.
- Kaper JB, O'Brien AD (2015). "Chapter 1: Overview and Historical Perspectives". In Sperandio V, Hovde CJ (eds.). Enterohemorrhagic Escherichia coli and Other Shiga Toxin-producing E. coli. Microbiology Spectrum. 2. American Society for Microbiology. pp. 3–14. doi:10.1128/microbiolspec.EHEC-0028-2014. ISBN 9781555818784. PMC 4290666. PMID 25590020.
- Hughes JM, Wilson ME, Johnson KE, Thorpe CM, Sears CL (2006). "The Emerging Clinical Importance of Non-O157 Shiga Toxin-Producing Escherichia coli". Clinical Infectious Diseases. 43 (12): 1587–1595. doi:10.1086/509573. PMID 17109294.
- "Final presentation and evaluation of epidemiological findings in the EHEC O104:H4 outbreak - Germany 2011" (PDF). Robert Koch Institut. 2011. Retrieved 12 January 2018.
- Fruth A, Prager R, Tietze E, Rabsch W, Fliger A (2015). "Molecular epidemiological view on Shiga toxin-producing Escherichia coli causing human disease in Germany: Diversity, prevalence and outbreaks". International Journal of Medical Microbiology. 305 (7): 697–704. doi:10.1016/j.ijmm.2015.08.020. PMID 26372529.
- European Food Safety Authority (2011). "Shiga toxin-producing E. coli (STEC) O104:H4 2011 outbreaks in Europe: Taking stock". EFSA Journal. 9 (10): 2390. doi:10.2903/j.efsa.2011.2390.
- Frank, Christina; Werber, Dirk; Cramer, Jakob P.; Askar, Mona; Faber, Mirko; An Der Heiden, Matthias; Bernard, Helen; Fruth, Angelika; Prager, Rita; Spode, Anke; Wadl, Maria; Zoufaly, Alexander; Jordan, Sabine; Kemper, Markus J.; Follin, Per; Müller, Luise; King, Lisa A.; Rosner, Bettina; Buchholz, Udo; Stark, Klaus; Krause, Gérard; HUS Investigation Team (2011). "Epidemic Profile of Shiga-Toxin–Producing Escherichia coliO104:H4 Outbreak in Germany". New England Journal of Medicine. 365 (19): 1771–1780. doi:10.1056/NEJMoa1106483. PMID 21696328.
- "Deadly E. coli found in Spanish cucumbers – The Local". Thelocal.de. Retrieved 5 June 2011.[permanent dead link]
- "Spanish Cucumbers Blamed for Outbreak in Germany". Food Safety News. 27 May 2011. Retrieved 26 January 2016.
- "E. coli cucumber scare: Germany seeks source of outbreak". BBC News. 30 May 2011. Archived from the original on 30 May 2011. Retrieved 30 May 2011.
- Govan, Fiona (30 May 2011). "'Killer cucumbers' row breaks out between Spain and Germany". The Telegraph. London. Archived from the original on 30 May 2011. Retrieved 30 May 2011.
- "Efforts intensify to identify source of 'E. coli outbreak in Germany as final tests clear Spanish cucumbers". Europa (web portal). Retrieved 4 June 2011.
- "Europe lifts cucumber warning". The Irish Times. 1 June 2011. Retrieved 4 June 2011.
- "Ministry of Health Spain". Msps.es. Archived from the original on 20 July 2011. Retrieved 4 June 2011.
- Brown, Jonathan (1 June 2011). "Cucumbers in clear – so what is causing deadly E.coli outbreak?". The Independent. London. Retrieved 4 June 2011.
- "New epidemiological data corroborate existing recommendation on consumption by BfR". Bundesinstitut für Risikobewertung. Retrieved 27 June 2011.
- "Europeans trade blame over E.coli outbreak, Belgium Health". Maktoob News. Archived from the original on 3 June 2011. Retrieved 5 June 2011.
- "BGI Sequences Genome of the Deadly E. coli in Germany and Reveals New Super-Toxic Strain". BGI. 2 June 2011. Archived from the original on 7 July 2011. Retrieved 2 June 2011.
- David Tribe (2 June 2011). "BGI Sequencing news: German EHEC strain is a chimera created by horizontal gene transfer". Biology Fortified. Retrieved 2 June 2011.
- Maev Kennedy and agencies (2 June 2011). "E. coli outbreak: WHO says bacterium is a new strain". The Guardian. London. Archived from the original on 2 June 2011. Retrieved 4 June 2011.
- "A Case of Hemolytic Uremic Syndrome Caused by Escherichia coli O104:H4", Yonsei Medical Journal, Vol. 47, No. 3, pp. 437 – 439, 2006
- "E. coli Outbreak Started from German Restaurant – Sofia News Agency". Novinite.com. 4 June 2011. Retrieved 4 June 2011.
- Marco Krefting (6 June 2011). "Focus shifts to German restaurant in hunt for outbreak source". The Sydney Morning Herald.
- "Germany 'Struggling To Cope' With E.coli". SkyNews. 5 June 2011. Retrieved 14 March 2018.
- "E coli outbreak: German officials identify bean sprouts as likely source | World news | guardian.co.uk". The Guardian. London. 5 June 2011. Retrieved 6 June 2011.
- "German-grown sprouts named likely culprit in deadly outbreak – CNN News International Edition". CNN. 5 June 2011. Retrieved 5 June 2011.
- Connolly, Allison (19 July 2008). "E. coli Outbreak Kills One More Patient as Source Eludes Investigators". Bloomberg. Retrieved 9 June 2011.
- James Gallagher (5 June 2011). "BBC News – E. coli outbreak: First German sprout tests negative". BBC. Retrieved 9 June 2011.
- "Germany says sprouts are most likely source of E.coli". The Jerusalem Post. 10 June 2011. Retrieved 10 June 2011.
- "German tests link bean sprouts to deadly E. coli". BBC News. 10 June 2011. Archived from the original on 10 June 2011. Retrieved 10 June 2011.
- "EHEC outbreak: update 13". WHO News. 10 June 2011. Archived from the original on 11 June 2011. Retrieved 10 June 2011.
- MacKenzie, Debra. "Bean sprouts to blame for 'decade-old' E. coli". New Scientist. Retrieved 11 June 2011.
- EFSA/ECDC joint risk-assessment (29 June 2011). "Cluster of haemolytic uremic syndrome (HUS) in Bordeaux, France". European Centre for Disease Prevention and Control.
- William Neuman; Scott Sayare (29 June 2011). "Egyptian Seeds Are Linked to E. coli in Germany and France". The New York Times. Archived from the original on 1 July 2011. Retrieved 30 June 2011.
- James Gallagher (30 June 2011). "E. coli outbreaks linked to Egypt". BBC News. Archived from the original on 1 July 2011. Retrieved 30 June 2011.
- Maryn McKenna (7 July 2011). "E. coli: A Risk for 3 More Years From Who Knows Where". Wired. Archived from the original on 10 July 2011. Retrieved 12 July 2011.
- "Egypt denies fenugreek-German E coli link". Monsters and Critics. Cairo/Berlin. Deutsche Presse-Agentur. 1 July 2011. Archived from the original on 18 August 2011. Retrieved 2 July 2011.
Egypt on Friday dismissed as untrue European reports that fenugreek seeds from Egypt were a suspected source of a deadly E coli outbreak.
- Escherichia coli outbreak in Germany: Shiga toxin-Producing Escherichia coli (STEC) Archived 4 June 2011 at the Wayback Machine – European Commission
- Statement by Commissioner Dalli on the E. coli outbreak Archived 17 June 2011 at the Wayback Machine – European Commission
- "Germany and Spain talk cucumbers amid E. coli outbreak | Europe | Deutsche Welle | 08.06.2011". Dw-world.de. Retrieved 9 June 2011.
- "EU ministers to meet on E.coli outbreak – Europe". Al Jazeera English. Archived from the original on 7 June 2011. Retrieved 9 June 2011.
- "E-coli cucumber deaths reach 14". Financial Times. 30 May 2011. Archived from the original on 31 May 2011. Retrieved 31 May 2011.
- "Croatian greengrocers complain of drop in sales due to E. coli panic – Business News – Croatian Times Online News – English Newspaper". Croatiantimes.com. Archived from the original on 8 July 2011. Retrieved 5 June 2011.
- Germany blames bean sprouts for E coli, clears cucumbers – Monsters and Critics Archived 13 June 2011 at the Wayback Machine
- "No E. coli bacteria in Egypt: Ministry of Health – Politics – Egypt – Ahram Online". English.ahram.org.eg. Retrieved 5 June 2011.
- "Egypt.com News – Egypt News – No E. coli bacteria in Egypt: Ministry of Health". News.egypt.com. Archived from the original on 10 July 2011. Retrieved 9 June 2011.
- David E. Miller (20 July 2011). "In new Egypt, old conspiracies live on". The Jerusalem Post. Archived from the original on 20 July 2011. Retrieved 20 July 2011.
- "E. coli outbreak sparks beefed up Canadian food import inspections". Healthzone.ca. 2 June 2011. Retrieved 6 June 2011.
- "Canadian inspectors testing Europe veggies for E. coli – CTV News". Ctv.ca. Retrieved 6 June 2011.
- "E. coli O104:H4 responses from the USA". Ecolio104h4.com. 22 February 1999. Archived from the original on 10 July 2011. Retrieved 5 June 2011.
- "William Marler: ''E. coli'' Outbreak: Exporting Bill Marler to Germany or Japan". Huffington Post. 27 May 2011. Retrieved 5 June 2011.
- "FDA STATEMENT ON E. COLI 0104 OUTBREAK IN EUROPE". East County Magazine. Retrieved 9 June 2011.
- "Cucumber sales plummet in Europe". News.xinhuanet.com. 1 June 2011. Retrieved 5 June 2011.
- Stevens, Laura (4 June 2011). "Europe's E. coli Cases Rise". The Wall Street Journal. Retrieved 4 June 2011.
- "Azerbaijan Business Center – Azerbaijan gets chance to increase sharply export of vegetables to Russia". Abc.az. Archived from the original on 3 October 2011. Retrieved 4 June 2011.
- "Russian ban may support Turkish exports – Hurriyet Daily News and Economic Review". Hurriyet Daily News. Turkey. Retrieved 4 June 2011.
- Peter Walker, Adam Gabbatt and agencies (7 June 2011). "E coli: European commissioner suggests £135m payout for farmers | World news". The Guardian. London. Retrieved 9 June 2011.
- Janicek, Karel (29 May 2011). "E. coli cucumbers may be in Austria, Hungary". MSNBC. Retrieved 5 June 2011.
- "Germany criticised by EU health chief over 'premature' E. coli claims". Telegraph. London. 5 June 2011. Retrieved 9 June 2011.
- Driver, Alistair. "Spain rejects €150m E. coli compensation | News". Farmers Guardian. Archived from the original on 23 July 2011. Retrieved 9 June 2011.
- "EU increases E coli compensation offer – RTÉ News". Rte.ie. 20 October 2010. Retrieved 9 June 2011.
- "German E. coli O104:H4 Outbreak – $2.84 Billion in Human Damage : Food Poison Journal : Food Poisoning Lawyer & Attorney : Bill Marler : Marler Clark". Food Poison Journal. 31 May 2011. Retrieved 9 June 2011.
- CTV Edmonton – Cucumbers suspected again in European E. coli outbreak – CTV News