Escherichia coli O104:H4 outbreak in Germany--clarification of the origin of the epidemic

Precognition of Known And Unknown Biothreats: A Risk-Based Approach

Data mining and artificial intelligence algorithms can estimate the probability of future occurrences with defined precision. Yet, the prediction of infectious disease outbreaks remains a complex and difficult task. This is demonstrated by the limited accuracy and sensitivity of current models in predicting the emergence of previously unknown pathogens such as Zika, Chikungunya, and SARS-CoV-2, and the resurgence of Mpox, along with their impacts on global health, trade, and security. Comprehensive analysis of infectious disease risk profiles, vulnerabilities, and mitigation capacities, along with their spatiotemporal dynamics at the international level, is essential for preventing their transnational propagation. However, annual indexes about the impact of infectious diseases provide a low level of granularity to allow stakeholders to craft better mitigation strategies. A quantitative risk assessment by analytical platforms requires billions of near real-time data points from heterogeneous sources, integrating and analyzing univariable or multivariable data with different levels of complexity and latency that, in most cases, overwhelm human cognitive capabilities. Autonomous biosurveillance can open the possibility for near real-time, risk- and evidence-based policymaking and operational decision support.

Shiga Toxin-Producing Escherichia coli Strains from Romania: A Whole Genome-Based Description

The zoonotic Shiga toxin-producing Escherichia coli (STEC) group is unanimously regarded as exceptionally hazardous for humans. This study aimed to provide a genomic perspective on the STEC recovered sporadically from humans and have a foundation of internationally comparable data. Fifty clinical STEC isolates, representing the culture-confirmed infections reported by the STEC Reference Laboratory between 2016 and 2023, were subjected to whole-genome sequencing (WGS) analysis and sequences were interpreted using both commercial and public free bioinformatics tools. The WGS analysis revealed a genetically diverse population of STEC dominated by non-O157 serogroups commonly reported in human STEC infections in the European Union. The O26:H11 strains of ST21 lineage played a major role in the clinical disease resulting in hospitalisation and cases of paediatric HUS in Romania surpassing the O157:H7 strains. The latter were all clade 7 and mostly ST1804. Notably, among the Romanian isolates was a stx2a-harbouring cryptic clade I strain associated with a HUS case, stx2f- and stx2e-positive strains, and hybrid strains displaying a mixture of intestinal and extraintestinal virulence genes were found. As a clearer picture emerges of the STEC strains responsible for infections in Romania, further surveillance efforts are needed to uncover their prevalence, sources, and reservoirs.

Known and Unknown Transboundary Infectious Diseases as Hybrid Threats

The pathogenicity, transmissibility, environmental stability, and potential for genetic manipulation make microbes hybrid threats that could blur the distinction between peace and war. These agents can fall below the detection, attribution, and response capabilities of a nation and seriously affect their health, trade, and security. A framework that could enhance horizon scanning regarding the potential risk of microbes used as hybrid threats requires not only accurately discriminating known and unknown pathogens but building novel scenarios to deploy mitigation strategies. This demands the transition of analyst-based biosurveillance tracking a narrow set of pathogens toward an autonomous biosurveillance enterprise capable of processing vast data streams beyond human cognitive capabilities. Autonomous surveillance systems must gather, integrate, analyze, and visualize billions of data points from different and unrelated sources. Machine learning and artificial intelligence algorithms can contextualize capability information for different stakeholders at different levels of resolution: strategic and tactical. This document provides a discussion of the use of microorganisms as hybrid threats and considerations to quantitatively estimate their risk to ensure societal awareness, preparedness, mitigation, and resilience.

Analysis of COVID-19 outbreak origin in China in 2019 using differentiation method for unusual epidemiological events

OBJECTIVES

Origin of outbreaks could be natural, accidental, deliberate, and caused by a new or re-emerging bioagent. The aim of this study was the retrospective analysis of whether the COVID-19 outbreak was natural, accidental, deliberate one, or caused by a new or re-emerging bioagent.

METHODS

Analysis was performed according to the Radosavljevic-Belojevic method for outbreak scoring and differentiation. Data for the application of this method were obtained by literature review in the Medline database for the period from 2000 to 2020.

RESULTS

The analysis of the unusual COVID-19 outbreak shows that the present official assumption of its natural origin is questionable and pointed out to a probability that the pathogen could have also been accidentally introduced in the human population.

CONCLUSION

There are no conclusive pieces of evidence about the reservoir of the pathogen or the source of infection. These parameters are essential for the final clarification of the outbreak origin. This study suggests that the COVID-19 outbreak is a consequence of an accidental release of a new COVID-19 virus, probably during the technical accident and/or negligent violation of hygienic norms in the laboratory facility. Further epidemiological, microbiological, and forensic analyses are needed to clarify the COVID-19 outbreak.

Going around in circles: virulence plasmids in enteric pathogens

Plasmids have a major role in the development of disease caused by enteric bacterial pathogens. Virulence plasmids are usually large (>40 kb) low copy elements and encode genes that promote host-pathogen interactions. Although virulence plasmids provide advantages to bacteria in specific conditions, they often impose fitness costs on their host. In this Review, we discuss virulence plasmids in Enterobacteriaceae that are important causes of diarrhoea in humans, Shigella spp., Salmonella spp., Yersinia spp and pathovars of Escherichia coli. We contrast these plasmids with those that are routinely used in the laboratory and outline the mechanisms by which virulence plasmids are maintained in bacterial populations. We highlight examples of virulence plasmids that encode multiple mechanisms for their maintenance (for example, toxin-antitoxin and partitioning systems) and speculate on how these might contribute to their propagation and success.

Efflux pump inhibitors of clinically relevant multidrug resistant bacteria

Bacterial infections are an increasingly serious issue worldwide. The inability of existing therapies to treat multidrug-resistant pathogens has been recognized as an important challenge of the 21st century. Efflux pumps are important in both intrinsic and acquired bacterial resistance and identification of small molecule efflux pump inhibitors (EPIs), capable of restoring the effectiveness of available antibiotics, is an active research field. In the last two decades, much effort has been made to identify novel EPIs. However, none of them has so far been approved for therapeutic use. In this article, we explore different structural families of currently known EPIs for multidrug resistance efflux systems in the most extensively studied pathogens (NorA in Staphylococcus aureus, AcrAB-TolC in Escherichia coli, and MexAB-OprM in Pseudomonas aeruginosa). Both synthetic and natural compounds are described, with structure-activity relationship studies and optimization processes presented systematically for each family individually. In vitro activities against selected test strains are presented in a unifying manner for all the EPIs described, together with the most important toxicity, pharmacokinetic and in vivo efficacy data. A critical evaluation of lead-likeness characteristics and the potential for clinical development of the most promising inhibitors of the three efflux systems is described. This overview of EPIs is a good starting point for the identification of novel effective antibacterial drugs.

An Overview of Zoonotic Disease Outbreaks and its Forensic Management Over Time

Most emerging or re-emerging infections are vector-borne or zoonotic and can be disseminated worldwide by infected humans or animals. They are a major public health problem and cause a great impact on economy. Zoonotic outbreaks began to be characterized in the 90s, after the creation of Europol and the FBI. Such investigations are carried by forensic pathologists and other specialists to determine whether an outbreak is natural or deliberate. This review will discuss ten zoonotic outbreaks nonrelated to wars focusing on forensic management. In conclusion, some points should be highlighted in the management of a zoonotic outbreak: (i) its diagnosis and detection by forensic pathologists and the coordination of efforts between other specialists are key factors; (ii) communication guidelines and an efficient healthcare system are crucial for any emergency response; (iii) biosafety of all specialists involved must be guaranteed.

A Systematic Review of Risk Analysis Tools for Differentiating Unnatural From Natural Epidemics

Introduction: In the era of genetic engineering of pathogens, distinguishing unnatural epidemics from natural ones is a challenge. Successful identification of unnatural infectious disease events can assist in rapid response, which relies on a sensitive risk assessment tool used for the early detection of deliberate attacks (i.e., bioterrorism). Methods: A systematic review was conducted according to the outline of Preferred Reporting Items for Systematic Reviews. Published papers related to the detection of unnatural diseases were searched in MEDLINE (January 1927–April 2016), EMBASE (January 1937–March 2016), and Web of Science (January 1978–March 2016). Full texts were reviewed for the selection of studies on scoring systems specially designed to discern between unnatural and natural outbreaks. Results: A total of 1,753 papers were reviewed, of which we identified the following five scoring systems specifically designed for detecting unnatural outbreaks: (1) the Grunow–Finke epidemiological assessment tool, (2) potential epidemiological clues to a deliberate epidemic, (3) bioterrorism risk assessment scoring, (4) and (5) two modified scoring systems based on (3). Various criteria ranging from the information on perpetrators, type of agents, spatial distribution, and intelligence of deliberate release were involved. Of these systems, the Grunow–Finke assessment tool remains the most widely used, but has low sensitivity for correctly identifying unnatural epidemics when tested against actual historical outbreaks. Others were applied into a few scenarios but provided different perspectives for bioterrorism detection and bio-preparedness. Conclusion: There are few risk assessment tools for differentiating unnatural from natural epidemics. These tools are increasingly necessary and valuable, but improved scoring systems with higher sensitivity, specificity, timeliness, and wider application to biological attacks must be developed.

Primordial and Primary Levels of Biothreat and Bioterrorism Prevention

There is still an abundance of preventive and solving measures against biological attacks that makes confusion and dezorientation among experts and health policy-makers. Our pyramidal model of adversaries, and spherical system of prevention help us to solve this problem. They make clearly to us, which measures should be applied at any of four levels of prevention without robust spending.

Primordial level of prevention should be focused to stop entering perpetrator/source of infection/reservoir of pathogen and biological agent/pathogen on defended territory. This is the first line of biodefense, deeply and multiply linked with the strategies of intelligence and deterrence.

The primary prevention of biological attack is focused on monitoring and surveillance of potential internal sources of biological agents and bioterrorists. We elaborate three types of surveillance: clinical (syndromic), laboratory and environmental.

Both levels of prevention were detailed analyzed, according to the next issues: Perpetrator/source of infection/reservoir of pathogen (Sophistication, Motivation, Intention, Intelligence, Secrecy, Number of perpetrators, Number of sources of infection/reservoirs, Accessibility to sources of agent/pathogen, Accessibility to targets/population at risk), Biological agent/pathogen (A category, B category, C category, Emerging pathogens, Amount of the available agent/pathogen), Means/media of delivery/factors of transmission (Air, Water, Food, Fomites, Vectors, Biological ammunition, Delivery systems, Dispersion systems mechanism of release), Target/susceptible population at risk (Intelligence, Secrecy, Personal control, Control of means/media of delivery/factors of transmission, Physical protection, Protection by chemoprophylaxis, Protection by immunoprophilaxis, Number of people in a target/population at risk, Importance of target/population at risk, Location of target/population, Distribution of people in a target/population at risk), and for each issue a whole spectrum of cheap, simple and effective preventive measures were proposed.

Public Health Research Resulting from One of the World's Largest Outbreaks Caused by Entero-Hemorrhagic Escherichia coli in Germany 2011: A Review

In 2011, Germany experienced one of the largest outbreaks of entero-hemorrhagic Escherichia coli (EHEC) ever reported. Four years thereafter, we systematically searched for scientific publications in PubMed and MEDPILOT relating to this outbreak in order to assess the pattern of respective research activities and to assess the main findings and recommendations in the field of public health. Following PRISMA guidelines, we selected 133 publications, half of which were published within 17 months after outbreak onset. Clinical medicine was covered by 71, microbiology by 60, epidemiology by 46, outbreak reporting by 11, and food safety by 9 papers. Those on the last three topics drew conclusions on methods in surveillance, diagnosis, and outbreak investigation, on resources in public health, as well as on inter-agency collaboration, and public communication. Although the outbreak primarily affected Germany, most publications were conducted by multinational cooperations. Our findings document how soon and in which fields research was conducted with respect to this outbreak.

Analysis of Escherichia Coli O104:H4 Outbreak in Germany in 2011 Using Differentiation Method for Unusual Epidemiological Events

AIM

The aim of the study was to further clarify the origin of Escherichia coli O104:H4 outbreak in Germany in 2011 (German Ec) as the likelihood of a deliberate act has not been excluded in previous analyses.

METHODS

We use an original and the most detailed scoring method so far, with 33 parameters pertaining to the source of infection/reservoir or possible perpetrator, pathogen or biological agent, transmission mechanism/factors or means/media of delivery, and population at risk or target.

RESULTS

Total scores for a deliberate or accidental epidemic indicate that the outbreak was more probably caused unintentionally, presumably due to technical accidents or hygienic shortcomings in the food chain.

CONCLUSIONS

The validity of the present assessment is limited by the lack of data on the reservoir of the pathogen, the source of infection, and the mode of food contamination. Conclusive evidences on these parameters are essential for the final clarification of the outbreak origin.

Long-term survival of the Shiga toxin-producing Escherichia coli O104:H4 outbreak strain on fenugreek seeds

A major outbreak of Shiga toxin-producing Escherichia coli (STEC) O104:H4 occurred in Germany in 2011. The epidemiological investigation revealed that a contaminated batch of fenugreek seeds (Trigonella foenum-graecum) was the most probable source of the pathogen. It was suggested that the most probable point of contamination was prior to leaving the importer, meaning that the seed contamination with STEC O104:H4 should have happened more than one year before the seeds were used for sprout production. Here, we investigated the capacity of STEC O104:H4 and closely related pathogenic as well as non-pathogenic Escherichia coli strains for long-term survival on dry fenugreek seeds. We did not observe a superior survival capacity of STEC O104:H4 on dry seeds. For none of the strains tested cultivatable cells were found without enrichment on contaminated seeds after more than 24 weeks of storage. Our findings suggest that contamination previous to the distribution from the importer may be less likely than previously assumed. We show that seeds contaminated with E. coli in extremely high numbers can be completely sterilized by a short treatment with bleach. This simple and cheap procedure does not affect the germination capacity of the seeds and could significantly improve safety in sprout production.

The ins and outs of RND efflux pumps in Escherichia coli

Infectious diseases remain one of the principal causes of morbidity and mortality in the world. Relevant authorities including the WHO and CDC have expressed serious concern regarding the continued increase in the development of multidrug resistance among bacteria. They have also reaffirmed the urgent need for investment in the discovery and development of new antibiotics and therapeutic approaches to treat multidrug resistant (MDR) bacteria. The extensive use of antimicrobial compounds in diverse environments, including farming and healthcare, has been identified as one of the main causes for the emergence of MDR bacteria. Induced selective pressure has led bacteria to develop new strategies of defense against these chemicals. Bacteria can accomplish this by several mechanisms, including enzymatic inactivation of the target compound; decreased cell permeability; target protection and/or overproduction; altered target site/enzyme and increased efflux due to over-expression of efflux pumps. Efflux pumps can be specific for a single substrate or can confer resistance to multiple antimicrobials by facilitating the extrusion of a broad range of compounds including antibiotics, heavy metals, biocides and others, from the bacterial cell. To overcome antimicrobial resistance caused by active efflux, efforts are required to better understand the fundamentals of drug efflux mechanisms. There is also a need to elucidate how these mechanisms are regulated and how they respond upon exposure to antimicrobials. Understanding these will allow the development of combined therapies using efflux inhibitors together with antibiotics to act on Gram-negative bacteria, such as the emerging globally disseminated MDR pathogen Escherichia coli ST131 (O25:H4). This review will summarize the current knowledge on resistance-nodulation-cell division efflux mechanisms in E. coli, a bacteria responsible for community and hospital-acquired infections, as well as foodborne outbreaks worldwide.

Genomic interplay in bacterial communities: implications for growth promoting practices in animal husbandry

The discovery of antibiotics heralded the start of a “Golden Age” in the history of medicine. Over the years, the use of antibiotics extended beyond medical practice into animal husbandry, aquaculture and agriculture. Now, however, we face the worldwide threat of diseases caused by pathogenic bacteria that are resistant to all existing major classes of antibiotic, reflecting the possibility of an end to the antibiotic era. The seriousness of the threat is underscored by the severely limited production of new classes of antibiotics. Evolution of bacteria resistant to multiple antibiotics results from the inherent genetic capability that bacteria have to adapt rapidly to changing environmental conditions. Consequently, under antibiotic selection pressures, bacteria have acquired resistance to all classes of antibiotics, sometimes very shortly after their introduction. Arguably, the evolution and rapid dissemination of multiple drug resistant genes en-masse across microbial pathogens is one of the most serious threats to human health. In this context, effective surveillance strategies to track the development of resistance to multiple antibiotics are vital to managing global infection control. These surveillance strategies are necessary for not only human health but also for animal health, aquaculture and plant production. Shortfalls in the present surveillance strategies need to be identified. Raising awareness of the genetic events that promote co-selection of resistance to multiple antimicrobials is an important prerequisite to the design and implementation of molecular surveillance strategies. In this review we will discuss how lateral gene transfer (LGT), driven by the use of low-dose antibiotics in animal husbandry, has likely played a significant role in the evolution of multiple drug resistance (MDR) in Gram-negative bacteria and has complicated molecular surveillance strategies adopted for predicting imminent resistance threats.