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An outbreak of gastroenteritis with 83 cases occurred at a conference venue in November 2017 in Halland County, Sweden. Stool samples from two venue visitors and a symptomatic secondary case attributed to household transmission were PCR-positive for the gene, a target found in both spp. and enteroinvasive (EIEC). EIEC was isolated from stool samples and whole genome sequencing analysis confirmed EIEC O96:H19 to be the aetiological agent. A cohort study was conducted among venue attendees and employees and the findings implicated contaminated leafy greens as the vehicle of infection, however, no microbiological evidence could support the study results. Here, we report the investigation into the first recorded EIEC outbreak in Sweden and illustrate the challenges associated with the differential laboratory diagnostics of /EIEC in an outbreak setting.


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  1. Croxen MA, Law RJ, Scholz R, Keeney KM, Wlodarska M, Finlay BB. Recent advances in understanding enteric pathogenic Escherichia coli. Clin Microbiol Rev. 2013;26(4):822-80.  https://doi.org/10.1128/CMR.00022-13  PMID: 24092857 
  2. Baker S, The HC. Recent insights into Shigella. Curr Opin Infect Dis. 2018;31(5):449-54.  https://doi.org/10.1097/QCO.0000000000000475  PMID: 30048255 
  3. DuPont HL, Formal SB, Hornick RB, Snyder MJ, Libonati JP, Sheahan DG, et al. Pathogenesis of Escherichia coli diarrhea. N Engl J Med. 1971;285(1):1-9.  https://doi.org/10.1056/NEJM197107012850101  PMID: 4996788 
  4. Taylor DN, Echeverria P, Pál T, Sethabutr O, Saiborisuth S, Sricharmorn S, et al. The role of Shigella spp., enteroinvasive Escherichia coli, and other enteropathogens as causes of childhood dysentery in Thailand. J Infect Dis. 1986;153(6):1132-8.  https://doi.org/10.1093/infdis/153.6.1132  PMID: 3517189 
  5. Vieira N, Bates SJ, Solberg OD, Ponce K, Howsmon R, Cevallos W, et al. High prevalence of enteroinvasive Escherichia coli isolated in a remote region of northern coastal Ecuador. Am J Trop Med Hyg. 2007;76(3):528-33.  https://doi.org/10.4269/ajtmh.2007.76.528  PMID: 17360879 
  6. Agbonlahor DE, Odugbemi TO. Enteropathogenic, enterotoxigenic and enteroinvasive Escherichia coli isolated from acute gastroenteritis patients in Lagos, Nigeria. Trans R Soc Trop Med Hyg. 1982;76(2):265-7.  https://doi.org/10.1016/0035-9203(82)90293-0  PMID: 7048653 
  7. Gordillo ME, Reeve GR, Pappas J, Mathewson JJ, DuPont HL, Murray BE. Molecular characterization of strains of enteroinvasive Escherichia coli O143, including isolates from a large outbreak in Houston, Texas. J Clin Microbiol. 1992;30(4):889-93.  https://doi.org/10.1128/JCM.30.4.889-893.1992  PMID: 1349307 
  8. Marier R, Wells J, Swanson R, Callahan W, Mehlman I. An outbreak of enteropathogenic Escherichia coli foodborne disease traced to imported French cheese. Lancet. 1973;302(7842):1376-8.  https://doi.org/10.1016/S0140-6736(73)93335-7 
  9. Snyder JD, Wells JG, Yashuk J, Puhr N, Blake PA. Outbreak of invasive Escherichia coli gastroenteritis on a cruise ship. Am J Trop Med Hyg. 1984;33(2):281-4.  https://doi.org/10.4269/ajtmh.1984.33.281  PMID: 6370005 
  10. Kotloff KL, Riddle MS, Platts-Mills JA, Pavlinac P, Zaidi AKM. Shigellosis. Lancet. 2018;391(10122):801-12.  https://doi.org/10.1016/S0140-6736(17)33296-8  PMID: 29254859 
  11. Rooney RM, Cramer EH, Mantha S, Nichols G, Bartram JK, Farber JM, et al. A review of outbreaks of foodborne disease associated with passenger ships: evidence for risk management. Public Health Rep. 2004;119(4):427-34.  https://doi.org/10.1016/j.phr.2004.05.007  PMID: 15219800 
  12. Nygren BL, Schilling KA, Blanton EM, Silk BJ, Cole DJ, Mintz ED. Foodborne outbreaks of shigellosis in the USA, 1998-2008. Epidemiol Infect. 2013;141(2):233-41.  https://doi.org/10.1017/S0950268812000222  PMID: 22361246 
  13. Taylor DN, Echeverria P, Sethabutr O, Pitarangsi C, Leksomboon U, Blacklow NR, et al. Clinical and microbiologic features of Shigella and enteroinvasive Escherichia coli infections detected by DNA hybridization. J Clin Microbiol. 1988;26(7):1362-6.  https://doi.org/10.1128/JCM.26.7.1362-1366.1988  PMID: 3045152 
  14. Niyogi SK. Shigellosis. J Microbiol. 2005;43(2):133-43. PMID: 15880088 
  15. Escher M, Scavia G, Morabito S, Tozzoli R, Maugliani A, Cantoni S, et al. A severe foodborne outbreak of diarrhoea linked to a canteen in Italy caused by enteroinvasive Escherichia coli, an uncommon agent. Epidemiol Infect. 2014;142(12):2559-66.  https://doi.org/10.1017/S0950268814000181  PMID: 24534429 
  16. Newitt S, MacGregor V, Robbins V, Bayliss L, Chattaway MA, Dallman T, et al. Two Linked Enteroinvasive Escherichia coli Outbreaks, Nottingham, UK, June 2014. Emerg Infect Dis. 2016;22(7):1178-84.  https://doi.org/10.3201/eid2207.152080  PMID: 27314432 
  17. Michelacci V, Prosseda G, Maugliani A, Tozzoli R, Sanchez S, Herrera-León S, et al. Characterization of an emergent clone of enteroinvasive Escherichia coli circulating in Europe. Clin Microbiol Infect. 2016;22(3):287.e11-9.  https://doi.org/10.1016/j.cmi.2015.10.025  PMID: 26551840 
  18. van den Beld MJ, Reubsaet FA. Differentiation between Shigella, enteroinvasive Escherichia coli (EIEC) and noninvasive Escherichia coli. Eur J Clin Microbiol Infect Dis. 2012;31(6):899-904.  https://doi.org/10.1007/s10096-011-1395-7  PMID: 21901636 
  19. Pasqua M, Michelacci V, Di Martino ML, Tozzoli R, Grossi M, Colonna B, et al. The intriguing evolutionary journey of enteroinvasive E. coli (EIEC) toward pathogenicity. Front Microbiol. 2017;8:2390.  https://doi.org/10.3389/fmicb.2017.02390  PMID: 29259590 
  20. Shea S, Kubota KA, Maguire H, Gladbach S, Woron A, Atkinson-Dunn R, et al. Clinical Microbiology Laboratories’ Adoption of Culture-Independent Diagnostic Tests Is a Threat to Foodborne-Disease Surveillance in the United States. J Clin Microbiol. 2016;55(1):10-9.  https://doi.org/10.1128/JCM.01624-16  PMID: 27795338 
  21. Hornick RB, DuPont HL, Music SI, Snyder MJ, Libonati JP. Investigations into the pathogenesis of diarrheal diseases. Trans Am Clin Climatol Assoc. 1971;82:141-7. PMID: 4934015 
  22. Hartman AB, Venkatesan M, Oaks EV, Buysse JM. Sequence and molecular characterization of a multicopy invasion plasmid antigen gene, ipaH, of Shigella flexneri. J Bacteriol. 1990;172(4):1905-15.  https://doi.org/10.1128/JB.172.4.1905-1915.1990  PMID: 1690703 
  23. Sethabutr O, Venkatesan M, Murphy GS, Eampokalap B, Hoge CW, Echeverria P. Detection of Shigellae and enteroinvasive Escherichia coli by amplification of the invasion plasmid antigen H DNA sequence in patients with dysentery. J Infect Dis. 1993;167(2):458-61.  https://doi.org/10.1093/infdis/167.2.458  PMID: 8421181 
  24. Løbersli I, Wester AL, Kristiansen Å, Brandal LT. Molecular Differentiation of Shigella Spp. from Enteroinvasive E. Coli. Eur J Microbiol Immunol (Bp). 2016;6(3):197-205.  https://doi.org/10.1556/1886.2016.00004  PMID: 27766168 
  25. von Seidlein L, Kim DR, Ali M, Lee H, Wang X, Thiem VD, et al. A multicentre study of Shigella diarrhoea in six Asian countries: disease burden, clinical manifestations, and microbiology. PLoS Med. 2006;3(9):e353.  https://doi.org/10.1371/journal.pmed.0030353  PMID: 16968124 
  26. Watkins LKF, Appiah GD. Chapter 3: Shigellosis. In: Yellow book. Health Information for International Travel. Atlanta: Centers for Disease Control and Prevention [Accessed: 28 Feb 2019]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/shigellosis
  27. European Centre for Disease Prevention and Control (ECDC). Shigellosis. In: ECDC. Annual epidemiological report for 2016. Stockholm: ECDC; 2018. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2016-shigellosis.pdf
  28. Folkhälsomyndigheten. Anmälningspliktiga smittsamma sjukdomar i Sverige 2017 – epidemiologisk årsrapport, tabellsamling. [Notifiable communicable diseases in Sweden 2017- Epidemiological report]. Solna: Folkhälsomyndigheten; 2018. [Accessed: 29 Nov 2018]. Swedish. Available from: https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/a/anmalningspliktiga-sjukdomar-sverige-2017/
  29. Desve G, Makary P. CSTABLE: Stata module to calculate summary table for cohort study. Statistical Software Components S456879. Boston: Boston College Department of Economics; 2007. Available from: https://ideas.repec.org/c/boc/bocode/s456879.html
  30. Folkhälsomyndigheten. Referensmetodik för laboratoriediagnostik vid kliniskt mikrobiologiska laboratorier. [Reference methodology for laboratory diagnostics in clinical microbiological laboratories]. Solna: Folkhälsomyndigheten. [Accessed: 30 Nov 2018]. Swedish. Available from: http://referensmetodik.folkhalsomyndigheten.se/w/Shigella-laboratoriediagnostik
  31. Salipante SJ, Hall BG. Inadequacies of minimum spanning trees in molecular epidemiology. J Clin Microbiol. 2011;49(10):3568-75.  https://doi.org/10.1128/JCM.00919-11  PMID: 21849692 
  32. Lynch MF, Tauxe RV, Hedberg CW. The growing burden of foodborne outbreaks due to contaminated fresh produce: risks and opportunities. Epidemiol Infect. 2009;137(3):307-15.  https://doi.org/10.1017/S0950268808001969  PMID: 19200406 
  33. Revez J, Espinosa L, Albiger B, Leitmeyer KC, Struelens MJECDC National Microbiology Focal Points and Experts Group. Survey on the Use of Whole-Genome Sequencing for Infectious Diseases Surveillance: Rapid Expansion of European National Capacities, 2015-2016. Front Public Health. 2017;5:347.  https://doi.org/10.3389/fpubh.2017.00347  PMID: 29326921 

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