A novel strain of ''Escherichia coli'' O104:H4 bacteria caused a serious outbreak of

foodborne illness Foodborne illness (also known as foodborne disease and food poisoning) is any illness resulting from the contamination of food by pathogenic bacteria, viruses, or parasites, as well as prions (the agents of mad cow disease), and toxins such ...

focused in northern Germany in May through June 2011. The illness was characterized by bloody

diarrhea Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration d ...

, with a high frequency of serious complications, including

hemolytic–uremic syndrome Hemolytic–uremic syndrome (HUS) is a syndrome characterized by low red blood cells, acute kidney injury (previously called acute renal failure), and low platelets. Initial symptoms typically include bloody diarrhea, fever, vomiting, and weakne ...

(HUS), a condition that requires urgent treatment. The outbreak was originally thought to have been caused by an enterohemorrhagic (EHEC) strain of ''

E. coli ''Escherichia coli'' ( )Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. is a gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus ''Escherichia'' that is commonly foun ...

'', but it was later shown to have been caused by an enteroaggregative ''E. coli'' (EAEC) strain that had acquired the genes to produce

Shiga toxin Shiga toxins are a family of related toxins with two major groups, Stx1 and Stx2, expressed by genes considered to be part of the genome of lambdoid prophages. The toxins are named after Kiyoshi Shiga, who first described the bacterial ori ...

s, present in organic

fenugreek Fenugreek (; ''Trigonella foenum-graecum'') is an annual plant in the family Fabaceae, with leaves consisting of three small Glossary_of_leaf_morphology#Leaf_and_leaflet_shapes, obovate to oblong leaflets. It is cultivated worldwide as a semiar ...

sprouts. Epidemiological fieldwork suggested fresh vegetables were the source of infection. The agriculture minister of

Lower Saxony Lower Saxony is a States of Germany, German state (') in Northern Germany, northwestern Germany. It is the second-largest state by land area, with , and fourth-largest in population (8 million in 2021) among the 16 ' of the Germany, Federal Re ...

identified an

organic farm Organic farming, also known as organic agriculture or ecological farming or biological farming,Labelling, article 30 o''Regulation (EU) 2018/848 of the European Parliament and of the Council of 30 May 2024 on organic production and labelling of ...

in Bienenbüttel, Lower Saxony, Germany, which produces a variety of sprouted foods, as the likely source of the ''E. coli'' outbreak. The farm was shut down. Although laboratories in Lower Saxony did not detect the bacterium in produce, a laboratory in

North Rhine-Westphalia North Rhine-Westphalia or North-Rhine/Westphalia, commonly shortened to NRW, is a States of Germany, state () in Old states of Germany, Western Germany. With more than 18 million inhabitants, it is the List of German states by population, most ...

later found the outbreak strain in a discarded package of sprouts from the suspect farm. A control investigation confirmed the farm as the source of the outbreak. On 30 June 2011, the German ''Bundesinstitut für Risikobewertung (BfR)'' (Federal Institute for Risk Assessment), an institute of the German Federal Ministry of Food, Agriculture and Consumer Protection, announced that seeds of organic

imported from

Egypt Egypt ( , ), officially the Arab Republic of Egypt, is a country spanning the Northeast Africa, northeast corner of Africa and Western Asia, southwest corner of Asia via the Sinai Peninsula. It is bordered by the Mediterranean Sea to northe ...

were likely the source of the outbreak. In all, 3,950 people were affected and 53 died, 51 of whom were in Germany. 800 people suffered hemolytic–uremic syndrome (HUS), which can lead to kidney failure.New insight from whole-genome sequencing of Europe's 2011 ''E. coli'' outbreaks
Biotechnology, 6 February 2012. A handful of cases were reported in several other countries including

Switzerland Switzerland, officially the Swiss Confederation, is a landlocked country located in west-central Europe. It is bordered by Italy to the south, France to the west, Germany to the north, and Austria and Liechtenstein to the east. Switzerland ...

Poland Poland, officially the Republic of Poland, is a country in Central Europe. It extends from the Baltic Sea in the north to the Sudetes and Carpathian Mountains in the south, bordered by Lithuania and Russia to the northeast, Belarus and Ukrai ...

, the

Netherlands , Terminology of the Low Countries, informally Holland, is a country in Northwestern Europe, with Caribbean Netherlands, overseas territories in the Caribbean. It is the largest of the four constituent countries of the Kingdom of the Nether ...

Sweden Sweden, formally the Kingdom of Sweden, is a Nordic countries, Nordic country located on the Scandinavian Peninsula in Northern Europe. It borders Norway to the west and north, and Finland to the east. At , Sweden is the largest Nordic count ...

Denmark Denmark is a Nordic countries, Nordic country in Northern Europe. It is the metropole and most populous constituent of the Kingdom of Denmark,, . also known as the Danish Realm, a constitutionally unitary state that includes the Autonomous a ...

, the UK, Canada and the USA. Essentially all affected people had been in Germany or France shortly before becoming ill. Initially, German officials made incorrect statements on the likely origin and strain of ''

Escherichia coli ''Escherichia coli'' ( )Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. is a gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus '' Escherichia'' that is commonly fo ...

''. The German health authorities, without results of ongoing tests, incorrectly linked the O104 serotype to

cucumber The cucumber (''Cucumis sativus'') is a widely-cultivated creeping vine plant in the family Cucurbitaceae that bears cylindrical to spherical fruits, which are used as culinary vegetables. Later, they recognised that Spanish

greenhouse A greenhouse is a structure that is designed to regulate the temperature and humidity of the environment inside. There are different types of greenhouses, but they all have large areas covered with transparent materials that let sunlight pass an ...

s were not the source of the ''E. coli'' and cucumber samples did not contain the specific ''E. coli'' variant causing the outbreak. Spain consequently expressed anger about having its produce linked with the deadly ''E. coli'' outbreak, which cost Spanish exporters US$200 million per week. Russia banned the import of all fresh vegetables from the European Union from early June until 22 June 2011.

Background

Enterohemorrhagic ''E. coli'' has been linked to foodborne outbreaks of bloody diarrhea and hemolytic–uremic syndrome around the world since at least the early 1980s. The majority of disease has been attributed to ''E. coli'' with the

serotype A serotype or serovar is a distinct variation within a species of bacteria or virus or among immune cells of different individuals. These microorganisms, viruses, or Cell (biology), cells are classified together based on their shared reactivity ...

O157:H7; however, over 100 ''E. coli'' serotypes have been associated with human diarrheal disease. In the five years before the outbreak (2006 to 2010) Germany experienced an

average In colloquial, ordinary language, an average is a single number or value that best represents a set of data. The type of average taken as most typically representative of a list of numbers is the arithmetic mean the sum of the numbers divided by ...

of 218 cases of EHEC gastroenteritis and 13 cases of hemolytic–uremic syndrome each year. According to the German National Reference Centre for ''Salmonella'' and Other Enteric Pathogens, the most common serotypes in those years were O157, O26, O103, and O91. Serotype O104 was relatively rare in Europe in the years preceding the outbreak, with just 11 reported cases in the EU and Norway between 2004 and 2009.

Outbreak

Cases

Cases began as early as 1 May 2011 with a man in

Aachen Aachen is the List of cities in North Rhine-Westphalia by population, 13th-largest city in North Rhine-Westphalia and the List of cities in Germany by population, 27th-largest city of Germany, with around 261,000 inhabitants. Aachen is locat ...

reporting bloody diarrhea. Cases then rapidly increased, with over 100 cases of EHEC gastroenteritis and/or HUS were being reported each day by 16 May. The outbreak centered on the five northern German states of Hamburg, Schleswig-Holstein, Bremen, Lower Saxony, and Mecklenburg-Western Pomerania. Cases would eventually be reported in all 16 German states; however most cases outside of the northern states were linked to travel in northern Germany. Additionally, a small number of cases were reported from other countries, although most of those ill had previously travelled to Germany. The most substantial outbreak outside of Germany was in Bordeaux, France where 15 cases of EHEC gastroenteritis were associated with the same strain of ''E. coli'' which caused the outbreak in Germany. The French cases had not previously travelled to Germany, suggesting they acquired the bacteria from contaminated sprouts grown in France. Cases of EHEC HUS and gastroenteritis peaked on 21 and 22 May respectively. Cases then slowly decreased over the following month, with cases reported throughout the month of June and ending during July 2011. German authorities deemed the outbreak over in early July 2011. The outbreak disproportionately affected adults and the elderly. 88% of hemolytic–uremic syndrome patients were over 17 years of age, and the median age of hemolytic–uremic syndrome patients was 42 years. The median age of patients who died of gastroenteritis was 82 years, while the median age of patients who died from hemolytic–uremic syndrome was 74 years. Most or all victims were believed to have become infected in Germany or France. Confirmed cases are listed below according to their location when diagnosed.

Source investigation

The investigation into the cause of the outbreak officially began with the notification of the

Robert Koch Institute The Robert Koch Institute (RKI) is a German federal government agency and research institute responsible for disease control and prevention. It is located in Berlin and Wernigerode. As an upper federal agency, it is subordinate to the Federa ...

on 19 May concerning three cases of HUS in children in Hamburg. On 26 May, German health officials hastily and prematurely announced that cucumbers from Spain were identified as a source of the ''E. coli'' outbreak in Germany, when in fact the source were Egyptian sprouts. On 27 May 2011, German officials issued an alert distributed to nearby countries, identifying organic cucumbers from Spain and withdrawing them from the market. The European Commission on 27 May said the two Spanish greenhouses suspected to be the sources had been closed, and were being investigated. The investigation included analyzing soil and water samples from the greenhouses in question, located in the

Andalusia Andalusia ( , ; , ) is the southernmost autonomous communities of Spain, autonomous community in Peninsular Spain, located in the south of the Iberian Peninsula, in southwestern Europe. It is the most populous and the second-largest autonomou ...

region, with results expected by 1 June. Cucumber samples from the Andalusian greenhouses did not show ''E. coli'' contamination, but cross-contamination during transport in Germany and distribution in

Hamburg Hamburg (, ; ), officially the Free and Hanseatic City of Hamburg,. is the List of cities in Germany by population, second-largest city in Germany after Berlin and List of cities in the European Union by population within city limits, 7th-lar ...

are not discounted; in fact, the most probable cause is cross-contamination inside Germany. The

advises against eating raw tomatoes, cucumbers, and lettuces in Germany to prevent further cases. On 31 May, an EU official said the transport chain was so long, the cucumbers from Spain could have been contaminated at any point along the transit route. Spanish officials said before, there was no proof that the outbreak originated in Spain; Spanish Secretary of State for European Affairs

Diego López Garrido Diego López Garrido (born 8 September 1947) is a Spanish politician, university professor and Secretary of State for the European Union in the Spanish Ministry of Foreign Affairs and Cooperation, as well as a former minister of the Spanish gover ...

said, "you can't attribute the origin of this sickness to Spain." On Tuesday 31 May, lab tests showed two of the four cucumbers examined did contain toxin-producing ''E. coli'' strains, but not the O104 strain found in patients. The bacteria in the other two cucumbers have not yet been identified.

Genomic sequencing DNA sequencing is the process of determining the nucleic acid sequence – the order of nucleotides in DNA. It includes any method or technology that is used to determine the order of the four bases: adenine, thymine, cytosine, and guanine. The ...

by BGI Shenzhen confirm a 2001 finding that the O104:H4 serotype has some enteroaggregative ''E. coli'' (EAEC or EAggEC) properties, presumably acquired by

horizontal gene transfer Horizontal gene transfer (HGT) or lateral gene transfer (LGT) is the movement of genetic material between organisms other than by the ("vertical") transmission of DNA from parent to offspring (reproduction). HGT is an important factor in the e ...

. The only previous documented case of EHEC O104:H4 was in

South Korea South Korea, officially the Republic of Korea (ROK), is a country in East Asia. It constitutes the southern half of the Korea, Korean Peninsula and borders North Korea along the Korean Demilitarized Zone, with the Yellow Sea to the west and t ...

in 2005, and researchers pointed at contaminated

hamburger A hamburger (or simply a burger) consists of fillings—usually a patty of ground meat, typically beef—placed inside a sliced bun or bread roll. The patties are often served with cheese, lettuce, tomato, onion, pickles, bacon, or chilis ...

s as a possible cause. On 4 June, German and EU officials had allegedly been examining data that indicated an open catering event at a restaurant in

Lübeck Lübeck (; or ; Latin: ), officially the Hanseatic League, Hanseatic City of Lübeck (), is a city in Northern Germany. With around 220,000 inhabitants, it is the second-largest city on the German Baltic Sea, Baltic coast and the second-larg ...

, Germany, was a possible starting point of the ongoing deadly ''E. coli'' outbreak in Europe. German hospitals were nearly overwhelmed by the number of ''E. coli'' victims. A spokesman for the agriculture ministry in

, warned people on 5 June to stop eating local

bean sprouts Sprouting is the natural process by which seeds or spores germinate and put out shoots, and already established plants produce new leaves or buds, or other structures experience further growth. In the field of nutrition, the term signifies ...

, as they had become the latest suspected cause of the ''E. coli'' outbreak. A farm in Bienenbuettel, Lower Saxony, was announced as the probable source, but on 6 June, officials said this could not be substantiated by tests. Of the 40 samples from the farm that were being examined, 23 had tested negative. But on 10 June, the head of the Robert Koch Institute confirmed the sprouts were the source of the outbreak, and people who ate the sprouts were nine times more likely to have bloody diarrhea. The

WHO The World Health Organization (WHO) is a specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Geneva, Switzerland, and has 6 regional offices and 15 ...

have confirmed on 10 June this statement on the update 13 of the EHEC outbreak. According to the head of the national ''E. coli'' lab at the German Federal Institute for Risk Assessment, the strain responsible for the outbreak has been circulating in Germany for 10 years, and in humans not cattle. He said it is likely to have gotten into food via human feces. A joint risk-assessment by EFSA/

ECDC The European Centre for Disease Prevention and Control (ECDC) is an agency of the European Union (EU) whose mission is to strengthen Europe's defences against infectious diseases. It covers a wide spectrum of activities, such as: surveillance, e ...

, issued 29 June 2011, made a connection between the German outbreak and a HUS outbreak in the

Bordeaux Bordeaux ( ; ; Gascon language, Gascon ; ) is a city on the river Garonne in the Gironde Departments of France, department, southwestern France. A port city, it is the capital of the Nouvelle-Aquitaine region, as well as the Prefectures in F ...

area of France, first reported on 24 June, in which infection with ''E. coli'' O104:H4 has been confirmed in several patients. The assessment implicated

seeds imported from

in 2009 and 2010, from which sprouts were grown, as a common source of both outbreaks, but cautioned, "there is still much uncertainty about whether this is truly the common cause of the infections", as tests on the seeds had not yet found any ''E. coli'' bacteria of the O104:H4 strain. The potentially contaminated seeds were widely distributed in Europe. Egypt, for its part, steadfastly denied it may have been the source of deadly ''E. coli'' strain, with the Minister of Agriculture calling speculations to that effect "sheer lies". Using epidemiological methods the outbreaks in 2011 were traced to a shipment of seeds from Egypt that arrived in Germany in December 2009.

International response

European Union

On 22 May, Health Commissioner

John Dalli John Dalli (born 5 October 1948) is a Maltese former politician who served as Cabinet Minister in various Maltese governments between 1987 and 2010. He was European Commissioner for Health and Consumer Policy between 2010 and 2012. Maltese p ...

of the

European Commission The European Commission (EC) is the primary Executive (government), executive arm of the European Union (EU). It operates as a cabinet government, with a number of European Commissioner, members of the Commission (directorial system, informall ...

declared the issue to be an 'absolute priority', saying the commission is working with member states, particularly Germany, to identify the source of the outbreak.''Escherichia coli'' outbreak in Germany: Shiga toxin-Producing ''Escherichia coli'' (STEC)

Speaking again on 1 June, Commissioner Dalli noted the outbreaks have been limited in origin to the greater Hamburg area and declared any product ban would be disproportionate. He also said he is working with Agriculture Commissioner

Dacian Cioloş Dacian may refer to: Relating to "Dacia" * of or relating to Dacia in southeastern Europe ** Dacians, the ancient Indo-European inhabitants of the cultural region of Dacia ** Dacian language * of or relating to one of the other meanings of Dacia ...

"to address the hardship faced by this group of our citizens that has also been hit hard by the ''E. coli'' outbreak". He also said, "In the future, we need to see how the timing of the alerts can be closer to the actual scientific basis and proof." By 7 June, EU Ministers held an emergency meeting in

Luxembourg Luxembourg, officially the Grand Duchy of Luxembourg, is a landlocked country in Western Europe. It is bordered by Belgium to the west and north, Germany to the east, and France on the south. Its capital and most populous city, Luxembour ...

to discuss the growing crisis, which had left 23 people dead, and more than 2,000 ill so far. Germany's Federal Agriculture Minister, Ilse Aigner, repeated her warnings to EU consumers to avoid eating any bean sprouts, cucumbers, tomatoes, and

salad A salad is a dish consisting of mixed ingredients, frequently vegetables. They are typically served chilled or at room temperature, though some can be served warm. Condiments called '' salad dressings'', which exist in a variety of flavors, a ...

s. The United States

Center for Disease Control The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency under the Department of Health and Human Services (HHS), and is headquartered in Atlanta, ...

and the

United States Department of Agriculture The United States Department of Agriculture (USDA) is an executive department of the United States federal government that aims to meet the needs of commercial farming and livestock food production, promotes agricultural trade and producti ...

has long been concerned regarding risks involving the ''E. coli'' risk in raw bean sprout production.

EU member states

Apart from the German government, which warned against the consumption of all raw cucumbers, tomatoes, and lettuce, several countries implemented restrictions or bans on the import of produce.

Non-EU European nations

Many other European countries took restrictive actions or lost sales of produce, including Albania, Croatia, and Russia. The ban on EU vegetables was lifted on 10 June, but stiff safety measures remained in place.

Middle East

Many countries took restrictive action. Egypt was a focus of the epidemiological investigation because the fenugreek seeds were imported into Germany from Egypt. Egypt's Minister of Health Ashraf Hatem denied his nation had any patients infected with the new ''E. coli'' strain, due to the strict precautions brought in to test overseas tourists entering the country on 2 June. Responding to claims that Egyptian fenugreek seeds were the cause of the ''E. coli'' outbreak, Egyptian Minister of Agriculture Ayman Abu-Hadid told the Egyptian press the problem had nothing to do with Egypt and instead asserted, "Israel is waging a commercial war against Egyptian exports."

North America

Canada and the United States reported cases of ''E. coli'' infection that had been acquired in Europe. On 2 June, Canada brought in stricter anti ''E. coli''-related food inspections, and by 3 June the

Public Health Agency of Canada The Public Health Agency of Canada (PHAC; ) is an agency of the Government of Canada that is responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. History The PHAC was f ...

said no Canadians had been reported sick with the strain as of that date. The Canadian government also brought in heavier import and hygiene restrictions on EU cucumbers, lettuces, and tomatoes. The

and the

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respo ...

(FDA) stated that emerging strains of ''E. coli'' are a significant problem, but regulatory bodies in the US have concentrated on the more infamous ''E. coli'' O157 serotype. The FDA noted nearly all of America's fresh produce is grown in the US and areas of Central America, and the EU has not been a significant source of fresh produce for the US.

Other countries

Other countries, including Nigeria, Hong Kong, and Thailand, expressed concern regarding imported produce.

Economics

By 1 June, Italian, Austrian, and French cucumber sales had begun to decline sharply, but the Austrian Health Ministry official, Dr. Pamela Rendi-Wagner, claimed Austrian customers were still safe. On 3 June, the governments of Spain, Portugal, and Germany said they would formally request EU agricultural aid for farmers affected by the outbreak. That day, Russia also set up plans for new imports of cucumbers from Ukraine, Azerbaijan, Egypt, and Turkey. By 7 June, the EU's farmers had reported they had lost millions of dollars in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying its growers had $256,000,000 in turnover. French, Swiss, Bulgarian, German, Dutch, Belgian, and Portuguese producers have also been similarly affected. That day, the EU proposed issuing £135,000,000 in agricultural compensation to its farmers. The EU agriculture commissioner said the EU's farmers could get back up to 30% of the cost of vegetables they were unable to sell. The EU's health commissioner, John Dalli, had formally criticised Germany earlier that day for rushing out "premature conclusions" about the source of an outbreak, and only helped to spread alarm among the public and farmers and untimely leading to the damaging the EU's agriculture sector. John Dalli also told the EU parliament in Strasbourg that claims had to be scientifically sound, unbiased, and fool-proof in nature before it was publicised in future. Spain then rejected the

's €150,000,000/£135,000,000 compensation deal for their farmers who were hit by the ''E. coli'' outbreak, on 8 June, saying it was too small. France, the European Union's largest agricultural grower, said it would support the plan to compensate producers hurt by the outbreak, according to the French Agriculture Minister

Bruno Le Maire Bruno Le Maire (; born 15 April 1969) is a French politician, writer, and former diplomat who served as Economy and Finance Minister from 2017 to 2024 under President Emmanuel Macron. A former member of The Republicans (LR), which he left in ...

. Ministers from both EU and Russia were scheduled to meet on 8 June over Russia's earlier decision to ban all its vegetable imports from the EU. On 8 June, the EU's ''E. coli'' O104:H4 outbreak was estimated to have cost $2,840,000,000 in human losses (such as sick leave), regardless of material losses (such as dumped cucumbers). Consumers across Europe were shunning fruit and vegetables ''en masse'' by 8 June, as the German government's edict against eating raw cucumbers, tomatoes, lettuce and sprouts remained in place. EU farmers claimed to have losses up to C$417,000,000 a week as ripe vegetables rotted in their fields and warehouses. On 8 June, The EU Farm Commissioner Dacian Cioloş said the EU had increased its offer of compensation to farmers for the losses caused by the ''E. coli'' outbreak to C$210,000,000.

Cause

The outbreak was caused by a strain of ''E. coli'' of the serotype O104:H4, that was unusual for having characteristics of both enteroaggregative ''E. coli'' and enterohemorrhagic ''E. coli''. The strain has a number of virulence genes typical of enteroaggregative ''E. coli'', including ''attA'', ''aggR'', ''aap'', ''aggA'', and ''aggC'', in addition to the

variant 2. All bacteria isolated from patients in this outbreak were resistant to beta-lactam antibiotics, third-generation

cephalosporin The cephalosporins (sg. ) are a class of β-lactam antibiotics originally derived from the fungus '' Acremonium'', which was previously known as ''Cephalosporium''. Together with cephamycins, they constitute a subgroup of β-lactam antibio ...

s, and partially resistant to

nalidixic acid Nalidixic acid (tradenames Nevigramon, NegGram, Wintomylon and WIN 18,320) is the first of the synthetic quinolone antibiotics. In a technical sense, it is a naphthyridone, not a quinolone: its ring structure is a 1,8-naphthyridine nucleus that ...

, but susceptible to

carbapenem Carbapenems are a class of very effective antibiotic agents most commonly used for treatment of severe bacterial infections. This class of antibiotics is usually reserved for known or suspected multidrug-resistant (MDR) bacterial infections. Si ...

s and

ciprofloxacin Ciprofloxacin is a fluoroquinolone antibiotic used to treat a number of bacterial infections. This includes bone and joint infections, intra-abdominal infections, certain types of infectious diarrhea, respiratory tract infections, skin ...

References

{{DEFAULTSORT:E. coli O104:H4 outbreak, 2011 Germany 2011 disease outbreaks 2011 in Denmark 2011 in Germany 2011 in Poland 2011 in Sweden 2011 in Switzerland 2011 in the Netherlands 2011 in the United Kingdom

2011 The year marked the start of a Arab Spring, series of protests and revolutions throughout the Arab world advocating for democracy, reform, and economic recovery, later leading to the depositions of world leaders in Tunisia, Egypt, and Yemen ...

Disease outbreaks in Denmark Health disasters in Poland Disease outbreaks in the United Kingdom Disease outbreaks in Germany Food safety in the European Union May 2011 in Europe June 2011 in Europe May 2011 in Germany June 2011 in Germany May 2011 in the United Kingdom June 2011 in the United Kingdom 2011 disasters in Europe Health disasters in Sweden Health disasters in Switzerland Health disasters in the Netherlands Health disasters in the United Kingdom Health disasters in Germany