EHEC importance of hygiene in prevention

Preventive measures to avoid EHEC infections:

Avoidance through animal contact: Particular attention should be paid to measures for. Special recommendations apply to petting zoos or farms with public traffic (Epid. Bull. 1/2005). The essential aspect here is the close supervision of children; fingers should not be put in the mouth after animal or ground contact, but should be thoroughly cleaned with warm water and soap. Food and drink should only be taken away from animal contact areas.

Avoiding human-to-human transmission: Other prevention measures include avoiding human-to-human transmission and safe food handling.

Food handling advice: Raw foods of animal origin and other perishable foods (e.g. meat, mettwurst, cold cuts, milk and milk products, delicatessen salads) should always be stored at refrigerator temperature. When preparing food (especially meat), it should be ensured that the food is well cooked (core temperature at least 70°C for 10 min). In addition, to avoid cross-contamination, meat and other raw foods should not be prepared at the same time as other foods intended for immediate consumption, and in no case should they be prepared using the same utensils and work surfaces unless the latter have been thoroughly cleaned before further use. Hands should also be washed in the meantime.

Milk should not be consumed raw, but only after heat treatment. The supply of raw milk, raw cream or inadequately heated milk to consumers is prohibited by law in mass catering establishments. Although the processing of such milk (e.g. into milk products) is legally permissible in these establishments, it is not recommended for reasons of preventive health protection. Children and the elderly in particular should only eat food of animal origin if it is thoroughly cooked or if another bacteria-killing process has been used. The literature points out that pregnant women and immunosuppressed persons should also adhere to this advice. These persons should refrain from eating foods of animal origin that cannot be heated or subjected to some other bacteria-killing process during manufacture or before consumption, e.g. fresh mettwurst or raw milk cheese (also because of the possibility of other bacterial contaminants). If it is not known whether a particular case involves a raw meat product or a raw milk product, appropriate information should be obtained.

Prevention of further spread - measures for patients, excretors and contact persons

In hospitals, nursing homes and other health care facilities: Measures to prevent the further spread of EHEC are based on four pillars in addition to the observance of food hygiene (see the corresponding information from the Federal Institute for Risk Assessment):

1. Strict adherence to hand hygiene and other standard hygiene measures,
2. isolation of patients,
3. regular disinfection of all hand contact surfaces and the sanitary area,
4. hygienic handling of contaminated linen.

(see also notes at www.rki.de, section Infection Protection, keyword Hospital Hygiene, subdirectory Recommendations of the Commission for Hospital Hygiene).

In the household: The pathogens are excreted with the stool and possibly also with the urine and can lead to an illness even in small numbers. Strict adherence to hygiene measures is necessary to prevent secondary infections. This means that extreme cleanliness is required, especially in the kitchen and sanitary areas. In addition to direct ingestion of contaminated food, bacteria can also be transmitted via the hand or contaminated kitchen utensils. This is particularly significant if the contaminated food is not subsequently heated. Attention should also be paid to the handling of appropriately contaminated bed linen and underwear.

The risk can therefore be reduced if hands and kitchen utensils are washed thoroughly with soap and water and dried carefully before preparing food, especially food that is not subsequently cooked. (The BfR recommendations can be found at: www.bfr.bund.de > A-Z Index > EHEC.) Objects, clothing or surfaces contaminated with faeces or vomit should be washed or cleaned immediately; protective gloves commonly used in the household should be worn when coming into contact with them.

Laundry should be washed at temperatures above 60°C using a heavy-duty detergent. In addition, early physical separation of the ill person from household contacts should be considered. Since transmission from index persons to contacts often occurs very early in the course of the disease, the earlier this measure is taken, the more effective it is.

Transmissions of gastroenteritic infections in the household often affect (siblings of) children. Since they also carry the highest risk of developing HUS, the primary focus of measures to prevent further spread in the household should be on children. In this context, the timeliness of the measures plays a particularly important role.

In schools and other community facilities, including infant homes and kindergartens: According to § 34 www.rki.de, section Infektionsschutz, keyword Krankenhaushygiene, subdirectory Empfehlungen der Kommission für Krankenhaushygienedür Personen, die an EHEC erkrankt oder dessen verdächtig sind, in Gemeinschaftseinrichtungen keine Tätigkeitenüben, bei denen sie zu den dort Betreuigten haben, bzw. als in Gemeinschaftseinrichtungen Betreuigte die Gemeinschaftseinrichtung nicht betreten. This also applies to members of the households of EHEC infected persons and to persons who have contracted EHEC.

Pursuant to Section 34 (7), the authority responsible for the communal facility may, in agreement with the public health authority, permit exceptions to this ban if measures are or have been taken to prevent the transmission of the disease.

It should be taken into account that only stx2-positive EHEC strains are associated with the risk of developing HUS. Persons who are or have been infected with a proven stx2-negative, i.e., non-HUS-associated, strain of EHEC can usually be readmitted to the community setting 48 hours after clinical recovery without stool checks. In contrast, persons with evidence of a stx2-positive, i.e. HUS-associated EHEC or evidence of an EHEC without stx gene differentiation, should only be readmitted after two negative stool controls. The same applies to excretors and contact persons. For further information, see the recommendations of the RKI for re-admission to community facilities in accordance with § 34 IfSG.

The restriction of the activity or the visit to the communal facility applies until a further spread of the disease is no longer to be feared according to medical judgement. The medical judgement can be the judgement of the attending physician or a physician of the responsible public health department. The medical opinion may be given orally. Section 34 of the IfSG does not require a written certificate of the medical opinion, but this may be useful for the protection of all parties involved.

In food establishments and communal catering facilities: According to § 42 IfSG, persons suffering from or suspected of suffering from infectious gastroenteritis, as well as persons who excrete EHEC, may not work or be employed in the production, handling or marketing of certain foodstuffs listed in § 42 Para. 2 if they come into contact with them. This also applies to employees in kitchens of restaurants and other facilities with or for communal catering.

Reference to EU Regulation 852/2004 on the hygiene of foodstuffs: According to Annex 2, Chapter VIII ("Personal Hygiene") No. 2, Sentence 1 of Regulation (EC) No. 852/2004, which lays down general food hygiene rules for food business operators, persons suffering from or carrying a food-borne disease, as well as persons with, for example, infected wounds, skin infections or lesions, or diarrhoea, are generally prohibited from handling food and entering food handling areas if there is a possibility of direct or indirect contamination.

Measures in case of outbreaks: In case of EHEC outbreaks, rapid identification and elimination of the source of infection is required. Therefore, in the case of suspected cases, illness or death, the competent health authority must be informed immediately and notification must be made by the fastest possible means. If infection is suspected from specific food or animals, the health department should immediately inform the relevant food authority and the relevant veterinary office. Conversely, it is necessary that the veterinary and food authorities also inform the public health department without delay if they become aware of illnesses in humans that are associated with food consumption or animal contact or if there are findings from food or animal examinations that give rise to fears of illness in humans.

Legal basis: Obligation to report according to IfSG: According to § 6 Abs. 1 Nr. 1 IfSG, the public health department is notified by name of suspected illness, illness and death from enteropathic haemolytic uraemic syndrome (HUS) and according to § 7 Abs. 1 IfSG of direct or indirect evidence of EHEC, insofar as it indicates an acute infection. Furthermore, according to § 6 Para. 1 No. 2 IfSG, the suspicion of and illness from acute infectious gastroenteritis must be reported if the person concerned handles food or is employed in communal catering facilities (e.g. kitchens, restaurants) (see Measures for Patients and Contacts), or if two or more similar illnesses occur for which an epidemic connection is probable or suspected.

The notifications must be submitted to the public health department no later than 24 hours after they become known. In § 8 IfSG the persons obliged to notify are named (see below https://www.gesetze-im-internet.de/ifsg/__8.html).

Obligation to notify according to IfSG

• In accordance with § 34 Para. 6 IfSG, managers of community facilities must notify the responsible public health department without delay if persons cared for in their facility have contracted EHEC enteritis or are suspected of having contracted it,
• if persons cared for or supervised in their facility excrete EHEC, or
• if, according to medical judgement, an illness with or a suspicion of EHEC enteritis has occurred in the residential communities of the persons looked after or cared for in their institution.

Transmission: In accordance with § 11 Para. 1 IfSG, the public health department only transmits cases of illness or death and evidence of pathogens to the competent state authority that meet the case definition in accordance with § 11 Para. 2 IfSG.

Regarding questions on infection protection and prevention: competent public health department(https://tools.rki.de/plztool/).

Advice on epidemiology: Robert Koch Institute, Division of Infectious Disease Epidemiology, Department 35 - Gastroenterological Infections, Zoonoses and Tropical Infections, Seestraße 10, 13353 Berlin, Tel.: 030 18754 3432.

Consultation for special diagnostics: National Reference Center for Salmonella and other Bacterial Enteritis Pathogens, Robert Koch Institute, Department of Infectious Diseases, Specialty 11 - Bacterial Intestinal Pathogens and Legionella. Burgstraße 37, 38855 Wernigerode. Tel.: 030 18754 4522 / -4206

Further consultation for special diagnostics: Consiliary laboratory for hemolytic-uremic syndrome (HUS). Institute for Hygiene at Münster University Hospital Robert-Koch-Str. 41, 48149 Münster. Tel.: 0251 83 55361

1. Robert Koch Institute: Infektionsepidemiologisches Jahrbuch meldepflichtiger Krankheiten für 2018. Robert Koch Institute, Berlin, 2018.
2. Robert Koch Institute (2004): Risk factors for sporadic STEC(EHEC) illness. Results of a nationwide case-control study. Epid Bull 50:433-436
3. Robert Koch Institute (2005): Risk factors for sporadic STEC illness: recommendations for prevention. Epid Bull 1:1-3
4. Tarr PI et al (2005) Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome. Lancet 365:1073-1086