Shiga Toxin--Producing Escherichia coli O157:H7 in Japan.

To the Editor: Shiga toxin-producing Escherichia coli (STEC) O157:H7 infection, which can cause hemolytic uremic syndrome and death, is a global public health concern. Patients younger than 5 years of age are at high risk for hemolytic uremic syndrome (1) and shed the organism longer than adults (2). The public health importance of this symptomatic shedding in transmission among preschool children is well established (3); however, that of symptom-free shedding in adults is unknown. We report here that the rate of symptom-free STEC O157:H7 shedding is higher in adults 30 to 49 years of age than in others.

STEC infections have been notifiable in Japan since August 1996. When STEC is found in the feces of patients in schools, families, and hospitals, local health centers and public health institutes must test (generally using MacConkey sorbitol agar with cefixime-potassium tellurite medium) for the pathogen in stool specimens of contacts of the patients. The pathogen is also sought twice a month in the stool specimens of food-handlers. All isolates from culture-positive patients are collected by Japan's National Institute of Infectious Diseases.

In 1997, 1,412 STEC O157:H7 human isolates were examined for subtyping of Shiga toxin genes stx1 and stx2 by polymerase chain reaction, for genotyping by XbaI-digested pulsed-field gel electrophoresis (PFGE) (4,5), and for their relationship with symptoms; 1,381 isolates (from culture-positive persons with well-characterized clinical status) were further analyzed. The rates by age group among STEC O157:H7-shedding persons reporting one or more symptoms (vs. culture-positive persons without symptoms) were as follows: 82% (475 of 576) younger than 10 years old; 81% (145 of 178), 10 to 19 years; 63% (98 of 156), 20 to 29 years; 25% (32 of 128), 30 to 39 years; 34% (34 of 100), 40 to 49 years; 54% (57 of 106), 50 to 59 years; 56% (38 of 68), 60 to 69 years; 68% (47 of 69), older than 70 years. Culture-positive persons under 20 years of age, especially children under 10 years of age, were more likely to have symptoms than other age groups. Intermediate rates of symptom-free persons with positive stool cultures occurred in young adults (20 to 29 years of age) and the elderly (70 years of age), while the highest rates of stool-positive, symptom-free persons were adults, especially those between 30 and 49 years of age. In terms of pathogen virulence, we did not find significant differences in the distribution of stx subtypes and PFGE genotypes between strains shed by symptomatic and asymptomatic persons. These results suggest that the rate of symptom-free STEC O157:H7 shedding may be associated with age rather than organism-related factors. Possible age-related host factors that could influence the presence of STEC O157:H7 in the stools of symptom-free persons include qualitative and quantitative differences in intestinal cross-reactive antibodies against STEC O157:H7, intestinal bacterial flora, or the sensitivity to Stx toxins between children and adults. Further investigations will be required to determine the relative importance of these and other host factors. Our finding of a high rate of asymptomatic shedding in adults may suggest the potential for secondary transmission of the bacteria from symptom-free STEC O157:H7-shedding adults to healthy children.

Acknowledgments

We thank investigators of prefectural and municipal public health institutes for their collaboration.

This work was supported by a grant from the Ministry of Health and Welfare of Japan.

References

(1.) Tarr PI. Escherichia coli O157:H7: clinical, diagnostic, and epidemiological aspects of human infection. Clin Infect Dis 1995;20:1-8.

(2.) Belongia EA, Osterholm MT, Soler JT, Ammend DA, Braun JE, MacDonald KL. Transmission of Escherichia coli O157:H7 infection in Minnesota child day-care facilities. JAMA 1993;269:883-8.

(3.) Karch H, Russman H, Schmidt H, Schwarzkopf A, Heesmann J. Long-term shedding and clonal turnover of enterohemorrhagic Escherichia coli O157:H7 in diarrheal diseases. J Clin Microbiol 1995;33:1602-5.

(4.) Watanabe H, Wada A, Inagaki Y, Itoh K, Tamura K. Outbreaks of enterohaemorrhagic Escherichia coli O157:H7 infection by two different genotype strains :in Japan. Lancet 1996;348:831-2.

(5.) Izumiya H, Terajima J, Wada A, Inagaki Y, Itoh K, Tamura K, et al. Molecular typing of enterohemorrhagic Escherichia coli O157:H7 isolates in Japan by using pulsed-field gel electrophoresis. J Clin Microbiol 1997;35:1675-80.

Jun Terajima, Hidemasa Izumiya, Akihito Wada, Kazumichi Tamura, and Haruo Watanabe National Institute of Infectious Diseases, Tokyo, Japan