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Germany’s Scattered Model Draws Fire for E. Coli Response

Germany’s Scattered Model Draws Fire for E. Coli Response
A lab technician holds a bacteria culture that shows a positive infection of enterohemorrhagic E. coli, also known as the EHEC bacteria, from a patient at the University Medical Center Hamburg-Eppendorf in Hamburg. Photographer: Sean Gallup/Getty Images

German states’ broad powers over health and safety may have slowed response to the E. coli outbreak, with no single federal agency responsible for tracking the bug and assigning the blame.

German officials have struggled to pinpoint the source of the infection as the number of deaths rose to 27, and were criticized for delays as well as targeting Spanish cucumbers and organic sprouts not yet proven to be the culprits. At least 2,899 people have been stricken since May 2, with most of the cases in or tied to northern Germany, the European Centre for Disease Prevention and Control said today.

The decentralized system may have compounded a lack of leadership, Baerbel Hoehn, a Green Party member and environment minister of North Rhine-Westphalia state, told the N24 television channel yesterday. Each of the 16 states is responsible for tracking cases inside their borders. Federal authorities give advice to the states and to consumers.

“Clearly a more centralized structure is probably better suited to handle this,” Joerg F. Debatin, the medical director of the University Medical Center Hamburg-Eppendorf, the biggest hospital in the area affected worst by the disease, said in an interview yesterday. “But that really goes down to the roots of what the German political system is made up of.”

German states run their own police forces and education and health systems. The federal powers led to conflicts in recent years on issues from drives to introduce smoking bans to efforts to harmonize admissions procedures for universities.

Consumer Protection

Imposed after World War II, the system was modeled on the U.S. federal structure in part as a bulwark against centralized political power like that of the Nazi regime.

In the case of the E. coli outbreak, decentralization means officials from each state only asked for help from the Robert Koch Institute, Germany’s disease-control agency, after establishing that people were getting sick. Institute investigators make non-binding recommendations, which states usually follow, Ina Klaus, a Health Ministry spokeswoman, said in a phone interview yesterday.

Then another federal agency, the institute for risk assessment, tells consumers what they should do to protect themselves. That agency was split from the health ministry more than a decade ago, Klaus said.

There’s no reason to change the structure in Germany, Health Minister Daniel Bahr said at a news conference in Berlin yesterday. Instead, cooperation between the agencies is important, he said.

“In a choir there are many voices, and nevertheless there’s harmony,” Bahr said.

Harmony, Cacophony

For those following the epidemic, harmony sometimes sounded like cacophony. State health and agricultural ministers called their own press conferences. Individual states sent out their own updates about the number of infections and deaths. Figures reported in local media, tallying the states’ numbers, were often higher than the Koch Institute’s total.

Authorities in the city-state of Hamburg initially blamed Spanish cucumbers. On June 5, officials from the state of Lower Saxony said sprouts from an organic farm in their region played a role in the outbreak. Tests from the sprout farm aren’t complete, though so far show no evidence of the bacteria.

Officials at the Berlin-based Koch institute declined to comment on whether health authorities may have acted more quickly under a more centralized system.

“We are well networked with the state health authorities, and it always depends on someone on location being watchful,” Susanne Glasmacher, an institute spokeswoman, said in an e-mail.

U.S. System

As in Germany, the U.S. system dictates that state and local authorities take the lead responding to disease outbreaks and investigating their causes, said Patricia Quinlisk, the state epidemiologist and medical director of the Iowa Department of Public Health in Des Moines. State and federal public health officials closely collaborate, which prevents them from working at cross purposes, she said. “There’s not an artificial barrier between the two,” Quinlisk she today in a telephone interview. “We’re a community of scientists,” she said.

U.S. health authorities grappled with a similar E. coli outbreak in 2006 that killed three people and sickened at least 205. They identified spinach from a California farm as the source due to close cooperation between the lead federal agency, the Atlanta-based Centers for Disease Control and Prevention, and state health officials, said Patrick Kennelly, chief of the California Department of Public Health’s food safety section.

Exchanging Information

The CDC collected data from all affected states and convened telephone conference calls almost daily with health officials in those states, Kennelly said.

“It was a team effort,” he said yesterday in a telephone interview. “We’d share information and knowledge, draw conclusions, then go back out in the field out and get clarifying information, more cases, more isolates from labs.”

While the U.S. public-health system is fragmented, centralizing control wouldn’t lead to a more rapid response to a future outbreak, said Georges Benjamin, the executive director of the American Public Health Association in Washington.

A single national agency “would be so large that it would still be segmented,” said Benjamin, who is a former head of the health agencies in Maryland and the District of Columbia.

Australian Experience

In Australia, where health is predominantly a state responsibility, nationwide networks facilitate the sharing of laboratory data and information on communicable diseases, said John Mackenzie, a Melbourne-based microbiologist who chaired the World Health Organization’s emergency pandemic flu committee and who advises governments on outbreaks.

“All the health departments meet on a regular basis and whenever there is a problem, it’s known about very rapidly,” Mackenzie said in a telephone interview today. “A committee that keeps all the health departments in constant contact at different levels is really very important, and this process certainly does that.”

The strain of E. coli in this outbreak produces a toxin that attacks the kidneys and blood vessels and can lead to a potentially fatal complication called hemolytic uremic syndrome.

Different definitions for when patients got sick have made it more difficult to track the outbreak, said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, in an interview.

Cross Purposes

“That shows the difficulties in the federal system, where the states don’t want to collaborate with the center,” said David Heymann, chairman of the U.K.’s Health Protection Agency and a former WHO assistant director-general for health security and environment.

If infections have stopped and new cases are being reported only in patients who picked up the bug weeks ago, the threat may be diminishing, Heymann said in a telephone interview from London yesterday.

“It could be that you will never find the source and the epidemic is on the downstream,” he said.

Officials in Germany reiterated that people shouldn’t eat lettuce, tomatoes, cucumbers and salad ingredients such as vegetable sprouts. Lower Saxony still sees a connection between the outbreak and the sprout farm in the town of Bienenbuettel, state Agriculture Minister Gert Lindemann told N24 in an interview.

More Deaths

The number of reported deaths increased by two from yesterday, while cases of E. coli sickness rose by 156, according to ECDC statistics. Still, many of the new cases may be old sicknesses that are only now being confirmed in laboratories, according to the Robert Koch Institute, Germany’s disease-control agency. Data from routine surveillance in emergency rooms suggests a decrease in the number of newly ill people, the ECDC said.

In Hamburg, there were 27 new cases of E. coli in the past day, compared with 30 the previous day and 49 the day before that, authorities said in a statement today.

“The hope that we really have reached the peak increases every day,” said Cornelia Pruefer-Storcks, Hamburg’s senator for health.

Germany may review its response after the outbreak to determine what could be improved, though there’s no need to change the structure of the existing system, Stefan Gruettner, social minister of the state of Hesse and chairman of a meeting of health ministers from the 16 states, said in an interview.

“We don’t need centralism,” Gruettner said. “Everything went well.”

Download: CDC Teleconference on Europe E. Coli Outbreak

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