By Hans-Edzard Busemann and Brian Rohan
HAMBURG, Germany (Reuters) - Even if Germany finds the source of the E.coli outbreak that has infected thousands of people since early May, it may be too late for Erika.
The 66-year-old chain smokes in the grounds of a Hamburg hospital as she waits to learn if an apparently healthy salad has given her a rare and deadly disease.
"I had prepared a salad with cucumbers and tomatoes," recalls Erika, whose husband died late last year and who asked not to be identified by her full name because the symptoms she has developed are embarrassing. "I peeled the cucumbers but I did not wash them first."
She fell ill on May 19 with bloody diarrhea. A few days later she heard about the outbreak on the radio and went to see a specialist. By then she was suffering from stomach cramps too.
Erika was sent to the university clinic for tests which showed she is one of 2,300 people infected by the outbreak of E.coli. Soon she will learn if she is one of more than 660 to develop haemolytic uraemic syndrome (HUS) where the bacteria attacks the kidneys and nervous system, gives its victims fits and often forces them onto dialysis.
The deadliest outbreak of its type on record has so far killed 23 people -- 22 in Germany and one in Sweden. Striking suddenly in the middle of a hot and sunny May, the crisis has doctors struggling to explain the outbreak and public health authorities in one of Europe's most famously organised countries stumped as to how to manage it and how to stop it happening again. As the outbreak enters its second month, plenty of questions remain, not least of which is this: If the Germans can't manage an outbreak, who can?
"They can't rule out HUS yet," Erika says, drawing deeply on yet another cigarette. "It makes you think."
BLAME THE SPROUTS
The first case in Germany's E.coli outbreak was reported on May 1. Soon an average of nine cases a day were being reported, rising to 122 cases on May 23 alone.
At first, German officials blamed cucumbers -- specifically, Spanish cucumbers. Within days, though, investigators had ruled out the vegetable and started looking closer to home for the cause. Chancellor Angela Merkel was forced to explain Germany's actions to an irate Spanish prime minister and Spanish farmers later said they might sue for damages.
Germany's main center for disease control, the Robert Koch Institute (RKI), deployed 10 teams to outbreak hotspots such as restaurants and canteens and to ask patients exactly what they ate for each course. To double check the data, customers of these establishments who did not fall ill have been interviewed too. Officials have also sifted through the contents of rubbish bins and fridges and sent some of their contents for analysis.
Specialists working around the clock at RKI headquarters in Berlin cross-check the data looking for what the institute's president, Reinhard Burger, called a "common denominator". So far that's pointed the finger of blame at raw vegetables.
After a few days the search took scientists to the Kartoffelkeller (Potato Cellar) restaurant in Luebeck, north east of Hamburg. The former medieval hospital offers traditional fare based on meat and potatoes. On May 13 it had served dinner to a large group of female tax officials. Then 17 people who had eaten there had fallen sick -- and one of the tax officers had died.
Owner Joachim Berger said health inspectors turned the place upside down without finding anything and when Reuters visited at lunchtime on June 4, the Kartoffelkeller was open for business and full. None of his staff had become ill, Berger said. "Everything has been re-disinfected and inspected, but it's clear nobody here is sick, and we all eat the food ourselves."
But public health officials believed they were on the right track. On June 5, Lower Saxony state agriculture minister Gert Lindemann said a "really hot lead" pointed to sprout varieties (alfalfa, mung bean, radish and arugula) from a supplier that sold the Kartoffelkeller its vegetables. Johanna Tramma at the Fruchthof, a family firm in the state of Schleswig-Holstein, said her sprouts had come from a farm in Lower Saxony which also supplied Hamburg's wholesale market.
Perhaps the E.coli detectives should have focused in on sprouts more quickly. An outbreak in Japan in 1996, which killed 11 people, was traced back to a similar source, and a U.S. outbreak in 1997 came from alfalfa sprouts.
Officials rushed to the Gaertnerhof farm in the town of Bienenbuettel in Lower Saxony, but the order to shut it down came almost too late. It was sealed off at 5:10 p.m. on Sunday -- 20 minutes after a truckload of sprouts left for Hamburg for sale. It was recalled and returned to the farm while health officials told people to avoid bean sprouts as well as the other raw salad vegetables already on the danger list.
The farm's owner Klaus Verbeck told a local paper -- before retreating behind a fence patrolled by security guards -- that the Gaertnerhof had been growing organic sprouts for 25 years and was given a clean bill of health for E.coli as recently as the second half of May. Neighbor Sibylle Lange, 45, described the owners as "very serious, hardworking people who were very early producers of organic products".
In many ways the bean sprout theory sounds reassuringly likely. Scientists say the steamy temperatures at which sprouts are cultivated are an ideal incubation ground for any microbe.
But even the sprouts may not be the culprits. Evidence so far is circumstantial and the first tests on suspect sprouts from Lower Saxony have been inconclusive, said the regional agriculture ministry.
The exact source may never be pinned down.
"We can't rule out that the source of the outbreak cannot be retraced anymore. That's not unusual in these circumstances," said Burger at the RKI, adding that the original source of the infection may no longer exist.
"It's something different every day," complained Uwe Ruge, accompanying an E.coli patient at the Regio clinic in Pinneberg, a Hamburg suburb. "First it was the Spanish cucumbers. Now it's this, then it's that and suddenly it's bean sprouts. I have no clue what it'll be tomorrow. I can't just avoid all food."
TOXINS AND ANTIBIOTICS
Of the 660 or so people to have developed HUS, more than 100 have been diagnosed at the University Medical Center Hamburg-Eppendorf in the northern port city of Hamburg. Confirmed HUS cases are treated in an intensive care unit kept closed to the media. At the entry to the unit and to the separate blood-testing unit for outpatients are antiseptic handwash dispensers and signs telling visitors to use them.
The patient profile is confusing: more women than men have developed the worst symptoms, and the women tend to be young -- in the 25-35 age bracket. Most of them also tend to be slim. That may be because young women tend to eat more raw vegetables and salad as a "healthy" option, health experts say.
The German E.coli strain was first sequenced by a laboratory at the Beijing Genomics Institute, the world's largest DNA sequencing center. On June 3 it identified the E.coli as a new and "highly infectious and toxic" strain.
There is no a clear indication yet if the rate of infection has peaked. "We hope that it fades and in the past few days, when we look at the numbers, we see it's getting better," Joerg Debatin, the medical director and CEO at Hamburg-Eppendorf, told Reuters. "But we honestly said the same thing a week ago."
E.coli turns into HUS when bacterial or "Shiga" toxins enter the bloodstream, according to kidney specialist Professor Rolf Stahl, head of nephrology at the Hamburg university clinic. That can lead to potential kidney and neurological damage and even trigger epilepsy.
Like other E.coli patients, Erika was given medicine to repair her intestinal flora and told to disinfect her household and drink plenty of liquids. But she was not given antibiotics as doctors say this strain of the bug can be resistant and there is growing concern among scientists about the spread of resistance to antibiotics among many common bacteria.
NOT SO HEALTHY
Even when it is contained, the outbreak will have done lasting damage to at least some conceptions about 'healthy' organic food in a part of the world where enthusiasm for natural produce is high.
"Genfood? Nein, Danke!" reads a bumper sticker with a smiley tomato logo on a truck at the Gaertnerhof farm in Bienenbuettel. Adapting the smiley sun-logo of the German anti-nuclear lobby to oppose genetically modified food -- "Genfood" -- proponents of natural foods have seen the organic market in Germany grow to 5.8 billion euros by 2009 (the latest figures available from the national organic trade body). Just under a fifth of that comes from German farms.
Yet some studies suggest organic food is risky, especially when eaten raw, because farmers shun chemicals and rely on fertilizers such as manure or slurry. The Shiga toxin-producing Escherichia coli behind this outbreak are known to lurk in cattle guts.
The fact that health food and organic produce has been the focus of suspicion from the outset underlines the vulnerability of the food chain to accidents of biology, even in the one of the world's wealthiest nations. Germany already had a food scare earlier this year over dioxins in eggs and poultry.
Among the anxious patients wearing post blood-test bandaids waiting for their results at the Hamburg clinic, Erika said she had planned to go on holiday in Majorca this month with her bowling gang, to help her get over the death of her husband. She has canceled the trip for fear of making her friends sick.
"All I can do is wait," she said tearfully. "The germs are inside me."
(Additional reporting by Eric Kelsey and Erik Kirschbaum; writing by Stephen Brown; editing by Simon Robinson and Sara Ledwith)