Shiga toxin-producing Escherichia coli (STEC) infection
Queensland Health Guidelines for Public Health Units
Revision History
Version | Date | Changes |
1.0 | June 2013 | Full revision of guideline. |
2.0 | July 2014 | Full revision of guideline. |
3.0 | December 2024 | Full revision of guideline. |
- Infectious Agent
- Case definitions and notification criteria
- Notification Procedure
- Objectives of surveillance
- Public Health Significance and Occurrence
- Clinical Features
- Reservoir
- Mode of Transmission
- Incubation Period
- Period of Communicability
- Susceptibility
- Management
- Preventive Measures
- References
- Flowcharts
Infectious Agent
Shiga toxin-producing Escherichia coli (STEC) are defined as strains of E. coli that produce Shiga toxins (stx). Stx are cytotoxic to Vero cells, and this is the basis for an alternative nomenclature, verotoxins (VT) and verotoxigenic E. coli (VTEC). Strains of STEC that cause haemorrhagic colitis are commonly referred to as enterohaemorrhagic E. coli (EHEC).
STEC can cause diarrhoea, which is often bloody and can trigger thrombotic microangiopathy that leads to haemolytic uraemic syndrome (HUS). Although a range of microbial pathogens can precipitate HUS, STEC are responsible for most cases in children worldwide (1).
There are many different E. coli serogroups; most are non-pathogenic. The most common STEC serogroup reported in Australia between 2007 and 2016 was Escherichia coli O157 (56%), followed by O26 (11%) and O111 (7%) (2). Local unpublished Queensland data from 2014 to 2023 showed O157 to be the most common serogroup, followed by O26 and O128, though there were a significant number of samples where typing was not available.
Several virulence factors have been implicated in the pathogenicity of STEC organisms. Production of Shiga toxin 2a (Stx2a) and intimin (encoded by the eae gene) have been established as the primary organism factors involved in HUS development. Other factors such as the presence of plasmid-encoded enterohaemolysin (ehxA) have also been implicated (3). Analysis of recent Queensland data from 2014 to 2023 supports this virulence profile, with presence of stx2 independently associated with increased risk of severe disease (bloody diarrhoea, hospitalization, HUS and death). Stx1 in combination with eaeA and ehxA is also associated with severe disease (unpublished).
Case definitions and notification Criteria
Report confirmed cases only
Note: Where STEC is isolated in the context of haemolytic uraemic syndrome (HUS), it should be notified as both STEC and HUS.
Confirmed Case
A confirmed case requires Laboratory definitive evidence only
Laboratory definitive evidence
- Isolation of Shiga toxin-producing E. coli from faeces
OR - Detection of the gene(s) encoding the Shiga toxins (stx1 and/or stx2) in faeces or from a clinical isolate of Escherichia coli
Note: Where STEC is isolated or detected in the context of haemolytic uraemic syndrome (HUS), it should be notified as STEC and HUS (4).
Community Outbreak Criteria
Two or more associated cases involving more than one household.
Notification Procedure
Pathology Laboratories
To notify on laboratory confirmation, by usual means.
Attending Medical Practitioners/Medical Superintendents (or Delegates)
Notify two or more possibly linked cases of gastroenteritis by telephone, email or facsimile.
Objectives of surveillance
- To identify outbreaks of STEC and HUS promptly, so as to enable rapid public health response.
- To monitor the epidemiology of STEC infections.
- To identify cases with propensity to severe disease in high-risk groups so as to implement public health action to prevent further spread.
Public Health Significance and Occurrence
Most Shiga toxin producing E. coli cases notified in Australia are sporadic infections. Infected individuals usually present with bloody diarrhoea, and some may experience kidney failure due to HUS. HUS may occur in 5-10% of individuals during STEC outbreaks and is more likely to occur among children or the elderly (5). HUS carries a 12% risk of death or end stage renal disease with 25% of survivors suffering long-term renal consequences (6). Therefore, considerable effort is made by public health authorities to investigate and control the spread of STEC infection. In Australia between 2012 and 2022 there were an average of 16 cases (range 7 to 21) of HUS notified annually to NNDSS. This is very similar to the previous 10-year period. In Queensland, an annual average of three HUS cases (range 1 to 5) were notified over the same period.
Notable outbreaks
- There were six community STEC outbreaks reported in Queensland between 2001 and 2013. Two outbreaks were caused through zoonotic transmission (both petting zoos), two outbreaks involved person-to-person transmission and one outbreak was associated with contaminated tank water. No source or mode of transmission was identified in the other outbreak.
- Australia’s largest outbreak of STEC infection occurred in Queensland during August 2013 associated with a petting zoo at the RNA (Ekka). There were 57 notified cases of E. coli O157:H- infection including 55 primary infections and 2 secondary infections acquired through transmission from a primary case in the same household. The median age of cases was 9 years (65% cases were children). Bloody diarrhoea was reported among 41% cases but there were no reports of HUS. The median incubation period among primary cases was 4 days (range 1 to 11 days) (7).
- A large outbreak of E. coli O111 infection occurred in Australia in 1995 associated with the consumption of contaminated mettwurst (8).
- A large international outbreak of E. coli O104:H4, associated with more than 3000 cases of infection, over 800 cases of HUS and 53 deaths, occurred predominantly in Germany in May and June 2011 (9). Sprouts grown from fenugreek seeds were implicated as the source of infection on the basis of traceback investigation (10).
Risk factors for STEC infection
- A case control study covering six Australian jurisdictions over the period 2003-2007 found risk factors for sporadic infection with E. coli O157 to include consuming hamburgers, eating at restaurants, occupational exposure to raw red meat by the case or a member of their household. Risk factors for sporadic infection with non O157 serotypes included occupational exposure to animals, consumption of sliced processed chicken meat, consumption of sliced corned beef, bush camping in Australia and eating at catered events (11).
- The most common cause of sporadic infection and outbreaks of E. coli O157:H7 in the United States has been the consumption of undercooked minced beef (12). Other documented causes of infection include consumption of contaminated alfalfa sprouts, salads (lettuce, coleslaw), fermented meat, unpasteurised milk, apple cider and drinking water (13).
- An international meta-analysis reviewing 31 publications from four continents calculated the population attributable fraction (PAF) for individual risk factors. It was found the risk factor with the greatest PAF was consumption of undercooked/raw meat (19%), followed by person-to-person transmission (15%), contact with animals (14%) and visiting farms (12%) (14).
Clinical Features
STEC causes a wide range of illness. Infection may be asymptomatic. Symptomatic infection can vary from mild non-bloody diarrhoea to haemorrhagic colitis. HUS is typically reported among cases with bloody diarrhoea, though it can also develop in patients with non-bloody diarrhoea. Illness in patients with non-bloody diarrhoea is usually less severe, and these individuals are less likely to develop systemic sequelae. Haemorrhagic colitis is marked by an acute onset of severe abdominal cramps followed by a progression from watery to bloody diarrhoea that lasts for 4-10 days. Stools are usually free of white blood cells. Nausea and vomiting may occur. Fever is comparatively mild, even absent. The infection is normally self-limiting with most patients recovering within 7-10 days of onset. However, in some instances, Shiga toxins are absorbed from the gut and damage vascular endothelial cells in target organs such as the gut and kidney.
The development of fever and leukocytosis may herald complications, which include HUS (more commonly in children), thrombotic thrombocytopenic purpura (more commonly in the aged), and death. HUS usually develops between 2 and 14 days after the onset of diarrhoea (15). By the time HUS develops the STEC organism may no longer be detectable in the stool.
Reservoir
The lower intestinal tract of ruminants, particularly healthy adult cattle (both beef and dairy) and sheep are the principal reservoirs of STEC. STEC can also colonise birds, dogs and cats. Some strains of STEC cause diarrhoea in young calves. STEC can survive for months in the environment including animal faeces, soil and water. Humans may also serve as a reservoir for person-to-person transmission.
Mode of Transmission
Transmission occurs via the faecal-oral route. Ingestion of bacteria may occur through:
- Consumption of contaminated food or water: Most human infections are probably foodborne. Transmission occurs primarily by ingestion of faecally contaminated food, most often inadequately cooked beef, especially minced beef, dried, fermented or ready to eat meat products (e.g., salami), fresh produce (including melons, lettuce, coleslaw, cider and alfalfa sprouts) and also unpasteurised milk and milk products. Waterborne transmission can also occur from contaminated drinking and recreational waters.
- Direct contact with infected animals or their faeces.
- Cross contamination from fomites (e.g., contaminated bathroom surfaces).
- Person-to-person contact with someone who is infectious (particularly in families, childcare settings and residential care facilities).
- In large outbreaks the risk of secondary transmission of STEC O157 is estimated to be 7-11% (16). A study in Wales calculated the household transmission rate for sporadic STEC O157 infection to be between 4 and 15% (17), while a Scottish study of both sporadic and outbreak cases over a 10-year period calculated the secondary transmission rate for E. coli O157 to be 11% (18). This estimate was based on the testing of symptomatic secondary cases only and is therefore likely to be an underestimate. Most secondary cases occurred in the same household as the index case.
- Child-to-child transmission accounts for the majority of secondary transmission within households.
- The Welsh study found that presence of a sibling (risk ratio, 3.8; 95% confidence interval, 0.99–14.6) and young age (<5 years) of the primary case patient (risk ratio, 2.03; 95% confidence interval, 0.99–41.6) were independent predictors for households in which secondary cases occurred (17).
- The Scottish study reported that child-to-child transmission accounted for 72% of secondary cases, child-to-adult for 19%, and adult-to-adult for 9% (18).
Incubation Period
Incubation period is usually 2 to 10 days (with a median of 3-4 days), though may be as long as 14 days. The median incubation period among primary cases from the RNA (EKKA) outbreak in 2013 was 4 days (range 1 to 11 days).
Period of Communicability
Duration of excretion of the pathogen is usually a week or less in adults and up to 3 weeks in children (19) although excretion can extend up to 14 weeks (20). Based on date of onset of diarrhoea and date of last positive stool sample, the median duration of excretion among primary cases from the RNA (EKKA) outbreak in 2013 was 19 days (range 2 to 52 days). For children aged <5 years, the median duration of excretion was 29 days (range 5 to 37 days) (7).
Susceptibility
The infectious dose is reported to be very low (15, 21). STEC can cause human infection after ingestion of fewer than 50 organisms (21). Little is known about differences in susceptibility and immunity. Children less than 5 years of age are at greatest risk of developing HUS (22). Old age also appears to be a risk factor for developing HUS (15).
Management
Management of cases and contacts is determined by whether they are symptomatic and their risk category. See Table 1 for groups at higher risk of transmitting infection.
Cases (Figure 1)
Investigation
A case report form should be completed for all priority cases for investigation to enable a detailed history to be obtained for the 10 days prior to illness onset.
Priority cases for investigation include:
- Cases with red flags:
- Possible higher-risk STEC strain identified (detection of stx2, or stx1 in combination with eaeA and ehxA, or detection of STEC O157, O111 or O26. See Table 2)
- Evidence of severe disease (including HUS, hospitalisation or bloody diarrhoea)
- Any case aged 5 years old or younger
- STEC case clusters
Follow up should be commenced within one business day. Attempt to identify the food vehicle or source of infection, such as ingestion of suspect foods, especially raw or undercooked meat, fermented meats, sprouts, unpasteurised milk and their products, exposure to petting zoos or farms with ruminants, drinking or contact with untreated water, and recent overseas travel. Identify if the case is in a high-risk group (Table 1) and whether they attended childcare or worked as a food handler or child carer or health care worker during their exposure and/or infectious period.
Public health actions should target cases infected with higher-risk STEC strains, cases who are hospitalised and cases of STEC-associated HUS (Tables 2-3,). Microbiological evidence of clearance should be obtained from cases in high-risk groups if a higher-risk STEC strain is identified (Table 3). This consists of 2 successive negative stool samples obtained at least 24 hours apart and not sooner than 48 hours after the last dose of antimicrobials (if administered). The first clearance sample should not be taken until at least 48 hours after symptoms have ceased.
Table 1: High risk groups for case and contact management
Risk group | Description | Additional comments |
---|---|---|
Group A | Any person who is unable to perform adequate personal hygiene due to their lack of capacity or ability to comply, or lack of access to hygiene facilities | Risk assessment should consider availability or access to toilets, handwashing and hand drying facilities in the work or educational setting, or use an alcohol-based hand sanitizer that contains at least 60% alcohol |
Group B | All children aged 5 years old or under (up to sixth birthday) who attend school, pre-school, childcare, home daycare, or minding groups | For children aged 5 years and under who do not attend school, risk assessment for clearance purposes should explore potential for transmission within other settings, for example, household or attendance at parties |
Group C | People whose work involves preparing or serving unwrapped ready to eat food (including drink) | Consider non vocational food handlers, for example, someone who helps to prepare food for charity or community events |
Group D | Healthcare workers involved in direct patient care, carers of children below primary school age, carers of the elderly and others working with vulnerable groups, particularly if activities increase the risk of transferring infection via the faecal oral route.. | Risk assessments should consider activities such as helping with feeding or handling objects that could be transferred to the mouth |
Source: Adapted from Public health operational guidance for Shiga-toxin producing Escherichia coli (STEC) including STEC O157 and non-O157 infections (publishing.service.gov.uk) (23)
Table 2: Virulence profiles of higher-risk STEC strains
Stage of STEC testing | Virulence profile | Description | |||
---|---|---|---|---|---|
Initial results received | stx1 | stx2 | eaeA | ehxA | |
(+/-) | (+) | (+/-) | (+/-) | Possible higher-risk | |
(+) | (-) | (+) | (+) | Possible higher-risk | |
(+) | (-) | (-) | (-) | Lower-risk |
Stage of STEC testing | Virulence profile | Description | |||
---|---|---|---|---|---|
Further testing undertaken at Public Health Reference Laboratory |
stx1 subtypes |
stx2 subtypes | eaeA | ehxA | |
(+/-) |
stx2a or stx2d | (+/-) | (+/-) | Confirmed higher-risk | |
(+) | (-) | (+) | (-) | Lower-risk | |
(+) | (-) | (-) | (+) | Lower-risk | |
(+/-) |
stx2b, stx2c, stx2e, stx2f, or stx2g | (+/-) | (+/-) | Lower-risk |
* Higher-risk STEC strains comprise:
- STEC strains expressing stx2 subtypes associated with severe disease and HUS (including stx2a and stx2d) together with other virulence factors (eaeA and ehxA).
- STEC O157, O111 and O26. Serogroup PCR testing can be undertaken if stx1 only is detected.
Source: Adapted from: Public health operational guidance for Shiga-toxin producing Escherichia coli (STEC) including STEC O157 and non-O157 infections (publishing.service.gov.uk) (23)
Restriction
Exclusion and microbiological evidence of clearance are recommended if red flags are present (as defined below) and the case is in a high-risk group (See Figure 1, Tables 1–3).
Red flags include:
- Initial or further testing results indicate higher-risk STEC strain identified (Table 2)
- Evidence of severe disease (including HUS, hospitalisation, and bloody diarrhoea)
If red flags are absent, the case does not require microbiological evidence of clearance. Their contacts do not require screening. The following actions are recommended for these cases:
- Careful attention to personal hygiene
- Exclusion until 48 hours symptom-free
Table 3: Exclusion and microbiological clearance procedures for cases with higher-risk STEC strains or evidence of severe disease (HUS, hospitalisation or bloody diarrhoea) (ie for cases with red flags)
Risk group | Symptomatic | Recovered or asymptomatic for ≥48 hours |
---|---|---|
Case not in a risk group | Provide personal hygiene advice. Exclude until 48 hours symptom free. No microbiological clearance required. Arrange screening for high-risk contacts (Table 4) | No exclusion or microbiological clearance required for case Arrange screening for high-risk contacts (Table 4) |
Case in risk group A, C or D | Provide personal hygiene advice. Exclude until microbiological clearance completed Arrange screening for high-risk contacts (Table 4) | Provide personal hygiene advice Exclude and arrange microbiological clearance Review risk assessment to determine whether restriction or redeployment may be appropriate whilst awaiting results of microbiological testing. If not appropriate, exclude case until microbiological clearance completed. Arrange screening for high-risk contacts (Table 4) |
Case in risk group B* | Provide personal hygiene advice Exclude until microbiological clearance completed Arrange screening for high-risk contacts (Table 4) | Provide personal hygiene advice Exclude until microbiological clearance completed Arrange screening for high-risk contacts (Table 4) |
* Stx2a / stx2d profile has the highest risk of HUS. Thus, for cases with stx2a/stx2d, it is advisable to continue exclusion and await clearance. For other strains, provided the child did not have HUS, it may be possible to allow early supervised return at 4 weeks, provided the risk assessment supports this.
Source: Adapted from Public health operational guidance for Shiga-toxin producing Escherichia coli (STEC) including STEC O157 and non-O157 infections (publishing.service.gov.uk) (23)
In cases of persistent excretion, consider referral to an infectious diseases physician. Those in high-risk occupations may be allowed to return to work in non-high-risk roles.
Treatment
While the use of antibiotics has been described both in treatment of cases early in their infection, and in eliminating carriage in asymptomatic individuals (24, 25), the role of antibiotics in the management of STEC is controversial and there is concern that they may increase the risk of HUS. A meta-analysis found that antibiotic administration to individuals with STEC infection was associated with an odds ratio of 2.24 (95% CI 1.45 – 3.46, I2 = 0%) of developing HUS, after excluding studies with a high risk of bias (26).
Where prolonged STEC carriage is causing a significant social or psychological burden, antibiotics may be considered in consultation with an infectious diseases physician, microbiologist and/ or paediatrician on a case by case basis.
Counselling
The case/carers of case should be advised of the nature of the infection, its mode of transmission and the low infectious dose. The importance of good hygiene should be emphasised. Educate about hygiene practices, in particular the importance of washing hands with soap and water for at least 20 seconds, or use an alcohol-based hand sanitizer that contains at least 60% alcohol (unless visibly soiled) after using the toilet, prior to handling food, or caring for children or patients. Cases should be made aware of the concerns around use of antibiotics in the management of STEC.
Contacts
Contact Tracing
Yes
Definition
Contacts include (i) people exposed to the suspected or identified source(s) of infection and (ii) people who are believed to have had significant risk of direct or indirect exposure to the excreta of an infectious person. This includes but is not limited to household members, people who physically care for or are cared by the case, and childcare contacts.
Investigation
Investigation of contacts should be prioritised for symptomatic contacts, and household contacts of cases of higher risk STEC strains (Table 4).
Restriction
Asymptomatic contacts
Lower-risk STEC strains and no other red flags
Where lower-risk STEC strains have been identified, microbiological evidence of clearance is not required for asymptomatic contacts, regardless of risk group.
Associated case had red flag(s)
Where higher-risk STEC strains have been identified, or the associated case had evidence of severe disease, household contacts in high-risk groups (as defined in Table 1) should be excluded from childcare, school or work settings (e.g. food businesses, healthcare facilities, residential aged care facilities) until 2 negative consecutive stool specimens collected ≥24 hours apart are obtained (Table 4). Where the associated case has a higher-risk strain or severe disease, asymptomatic household contacts who are not in a high-risk group do not need to be tested or excluded.
Follow up of non-household contacts
Asymptomatic non-household contacts who are in a high-risk group should be assessed on a case-by-case basis regarding exclusion from work/school/childcare while being screened.
Asymptomatic non-household contacts who are not in a high-risk group do not need to be tested or excluded.
Symptomatic contacts
All contacts with diarrhoea should be excluded from work/school/childcare whilst symptomatic. Stool samples should be obtained for testing. The contact should be managed as a probable case, pending results. Contacts with confirmed STEC should be managed as cases.
Symptomatic contacts (and those who become confirmed STEC cases) who are not in high-risk groups can return to work 48 hours following resolution of symptoms (Table 4).
Table 4: Exclusion and microbiological screening for contacts of STEC cases with higher risk STEC strains or evidence of severe disease (including HUS, hospitalisation or bloody diarrhoea) (ie cases with red flags)
Contact type | Symptomatic (including contacts who have recovered from recent gastrointestinal illness and are symptom-free for >48 hours) | Asymptomatic contacts |
---|---|---|
Contact not in a risk group | Provide personal hygiene advice Test and manage as a probable case, pending results | Provide STEC factsheet Not excluded |
Contact in a high-risk group (as defined in Table 1) | Provide personal hygiene advice Test and manage as a probable case, pending results | Provide personal hygiene advice Household contacts: Exclude and undertake microbiological screening for STEC infection (2 consecutive stool samples taken ≥24 hours apart) Non-household contact: Undertake microbiological screening for STEC infection. Risk assess to determine if exclusion necessary. |
Household contacts of HUS cases | In addition to the above risk group considerations, all household contacts of a case of HUS should be offered screening to identify and characterise the organism and guide public health management. Any contacts who test positive for STEC should be managed as cases. |
Source: Adapted from Public health operational guidance for Shiga-toxin producing Escherichia coli (STEC) including STEC O157 and non-O157 infections (publishing.service.gov.uk) (23)
Counselling
Contacts should be advised of the nature of the infection, its mode of transmission and the low infectious dose. The importance of good hygiene should be emphasised. Educate about hygiene practices, in particular the importance of washing hands with soap and water for at least 20 seconds, after using the toilet, prior to handling food or caring for children or patients. This should be supervised for young children in childcare and similar settings.
Other control measures
Consider informing adjacent public health units of outbreaks. Depending on Public Health risks identified, interstate notifications may be required.
Special situations
Multiple cases among children in childcare
If two or more cases are identified in the same childcare setting, form an outbreak control team. Undertake a situation specific risk assessment to inform appropriate public health management. The risk assessment should involve a visit to the childcare centre. Points to consider in assessing risk include:
- the likely source of infection for the cases (i.e., from childcare or elsewhere)
- the potential for transmission in that setting, which may include whether the case was continent and symptomatic during their infectious period at childcare, and nappy changing and food preparation practices
The OCT should call together an expert advisory group if needed. Temporary closure of the facility (or part of the facility in which the cases attended) and a full clean may need to be considered in some circumstances.
Whenever a case occurs in a childcare setting, special attention should be paid to personal hygiene practices and cleaning within the setting.
Community outbreaks/epidemics
- Establish an IMT
- Determine spread of outbreak (OzFoodNet to monitor for interstate cases)
- Consider the need for enhanced surveillance (including HUS) through hospitals and diagnostic pathology laboratories
- Look for common source of infection and the vehicle of transmission
- If the outbreak is suspected to be foodborne, refer to the Queensland Health Guidelines for the investigation and management of suspected foodborne illness outbreaks, 2018 and notify Food Safety Standards & Regulation Team, Health Protection Branch.
Preventive Measures
- Minimise person-to-person transmission by instructing cases and contacts on the importance of washing hands with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer that contains at least 60% alcohol (unless visibly and drying thoroughly, prior to handling food and after using the toilet)
- Educate the public that all beef should be thoroughly cooked. Minced beef should be cooked until all pink colour is gone
- Encourage good food hygiene practices, such as washing cutting boards, knives and hands after preparing raw meat; using separate cutting boards for foods of animal origin and other foods; not returning cooked meat to the same plate that was used for raw meat; and not using marinade or sauces used on raw meat on cooked meat
- Educate the public on the risks associated with consuming unpasteurised milk or untreated water
- Ensure adequate hygiene in childcare centres, especially frequent supervised hand washing with soap and water and cleaning of toys, surfaces
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