A waterborne outbreak of gastroenteritis in the Golan Heights due to enterotoxigenic Escherichia coli

Background: Over a period of 4 days between May 18-21, 1998, a multifocal o utbreak of diarrhea, involving 175 Israel Defence Force soldiers and at lea st 54 civilians, occurred in the Golan Heights. Patients and Methods: Stool samples from 40 affected soldiers were collecte d for microbiological testing. In addition, a rapid PCR technique was emplo yed for the direct detection of the heat-labile (Li) and heat-stable toxin (ST) genes of enterotoxigenic Escherichia coli (ETEC) in stool samples. Results: All 40 stool specimens taken from patients with diarrhea was negat ive by culture. However, ETEC was detected in 16 stool specimens using the rapid PCR method. The epidemiological investigation found no association be tween the food items consumed prior to the onset of the outbreak and the at tack rate of diarrhea. A review of the water distribution system revealed t hat all affected military posts and civilian communities were supplied by a common water pipeline. Water sampled from various points along the distrib ution system showed inadequate chlorination and high concentrations of E. c oli. Conclusion: This report suggests that the involvement of ETEC in the etiolo gy of waterborne diarrheal outbreaks may be underestimated, probably due to the difficulties involved in the laboratory identification of th is entero pathogen. Adoption of our rapid method for the identification of ETEC, whic h is applicable to routine diagnostic laboratories, facilitates pathogen de tection within hours, and allows early intervention in cases of widespread diarrheal epidemics.