Germany learns from E. coli outbreak

Germany aims to shorten the time it takes for information on infectious-disease outbreaks to reach federal authorities from up to 18 days to just 3, after this year's outbreak of enterohaemorrhagic Escherichia coli killed 53 people. But the medical community is calling for more action — from more comprehensive disease diagnostics to funding for specialist physician training. The outbreak, which started in May this year, infected more than 3,500 people in Germany, 855 of whom developed the rare, life-threatening complication haemolytic uraemic syndrome. At a meeting of the German Society of Nephrology in Berlin on 9 and 10 September, scientists, physicians and politicians heard that the duration of the outbreak and the time taken to identify its source compared favourably with previous E. coli outbreaks in other countries. "But we wouldn't have called a meeting if we thought everything went well," says Reinhard Brunkhorst, the society's president. The outbreak exposed deficiencies in the country's disease-reporting system, including a potential for notification delay that Brunkhorst describes as "not defendable". Under German law, doctors must notify local health agencies of reportable infections within 24 hours. The local agency then has until the third working day of the following week to report these to state authorities, who in turn have a week to inform national authorities. During the latest outbreak, infection reporting was accelerated to a daily basis, and that precedent has prompted a change to policy. Federal health minister Daniel Bahr told the meeting that next-working-day reporting for each stage will soon be the rule. Proactive diagnostics Gérard Krause, an epidemiologist at the federal disease-monitoring agency the Robert Koch Institute, welcomed the amendment, but says that other problems will require more effort to address. "The chain can only work well when accurate information is put into it the first place," he says. According to Krause, the German health-insurance system pressures physicians to perform only the minimum tests necessary to make treatment decisions — so patterns that could identify an outbreak may not be rapidly recognized. Krause would like to see a modern monitoring network established. "If we performed more in-depth diagnostics on a systematic sample of, say, every 10th notification, we would have a much better ability to detect new strains," he says. Bahr admitted that poor communication and inadequate demarcation of responsibility between state and federal ministries caused confusion during the outbreak, but said that it would be difficult to convince the multiple levels of the health administration to collaborate on a single digital reporting system, which is what meeting participants also called for. However, communication was remarkably effective elsewhere. Hospital staff pooled resources and expertise, and doctors' unorthodox actions extended to trialling treatment strategies that had never before been used for people with haemolytic uraemic syndrome. There is already evidence that immunoadsorption therapy1 worked to relieve severe neurological symptoms associated with the syndrome. And physicians are still waiting to see whether their idea to treat patients with eculizumbab — a monoclonal antibody usually used to treat a disorder of the immune system — worked in a clinical-trial setting (see 'German E. coli outbreak leads to drug trial'). Brunkhorst says that the doctors' initiative shows the importance of ongoing professional development to help specialists respond to crises. Researchers will continue to analyse the outbreak for months. Jan Kielstein, a nephrologist from Hannover Medical School, helped to set up a patient registry within a week of the outbreak being recognized. It now contains information for 418 people with haemolytic uraemic syndrome — a data gold mine. Kielstein says that it was difficult to choose what, and how much, data to ask for, and hindsight has brought some regrets. For example, the questionnaire didn't ask for white-blood-cell counts, which is frustrating in light of preliminary data presented at the conference suggesting that patients with severe neurological symptoms had high white-blood-cell numbers. But he adds that their decision to have open field-data entry, rather than tick-boxes, has given them information that they would not have thought to ask for, although it now makes for laborious analysis. Brunkhorst and Kielstein hope that documenting their experience with the registry will help in responding to future outbreaks. "We improvised," says Brunkhorst. "It worked well, but it would have worked better within a defined framework". Kielstein agrees, but adds that the enthusiasm of individuals remains vital in crisis situations. "If you are too prescriptive, you risk losing that energy and momentum."