This Podcast Will Kill You - Ep 37 E. coli (unless it's beets)

Episode Date: November 12, 2019

E. coli. Such a short name for such a massive topic. This episode we explore the delightful diversity of Escherichia coli, the ubiquitous bacterium that predates humans and can range in virulence anywhere from “you won’t even know I’m there” to “this is really, really, really gonna hurt”. Today we cover the good, the bad, and the ugly: you’ll hear about the innumerable contributions of E. coli to the fields of genetics, evolution, and microbiology, a detailed account of how pathogenic strains can wreak havoc on your guts, and an exploration of one of the most infamous food-borne illness outbreaks in US history. Hoping we’d end it on a happy note? Better luck next time, folks. See omnystudio.com/listener for privacy information.

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Val, bad pun. Outdo it with Intuit QuickBooks. Feature availability varies by product. By the time paramedics removed Breanne Kiner from the ambulance and wheeled her into the ER at Children's Hospital, Suzanne Kiner was doing all she could to hold herself together. Brianne was writhing in pain, and the diarrhea just kept coming. So did the blood. Suzanne was afraid to leave Brienne's side. It looked and sounded like her little girl was dying.

Her breathing was rapid. She had deep pain in her chest. Her urine output had practically disappeared. Even her mental condition was deteriorating and she was slurring her words when she tried to speak. When the hospital transferred Brienne to the ICU for round-the-clock observation, Suzanne wanted answers. The doctors informed her that Brienne's stool culture had come back and definitely showed the presence of E. coli O157-H7. And her symptoms suggested she had hemolytic uremic syndrome. Shortly after arriving in the ICU, Brie Ann suffered a seizure and stopped breathing. Doctors scrambled to resuscitate her. They gave her dylanin intravenously, along with phenobarbital. Tubes were inserted in her chest. By the time doctors emerged to give Suzanne an update, Brianne was in a coma.

Suzanne had trouble swallowing. She wanted to scream, but all she could do was cry. Yeah. Did she survive? She did. Phew. Yes. So that first-hand account is pieced together from a book called Poisoned, the true story of the deadly E. coli outbreak that changed the way Americans eat by Jeff Benedict. And it's about the outbreak of E. coli 0157 that you're going to hear a lot more about in 1993. And Breanne was one of the children who was infected. with E. coli and she did survive, but she has had a lot of lingering problems because of this infection. Hi, I'm Erin Welsh. And I'm Aaron Omen Updike. And this is, this podcast will kill you. And today we're talking about E. coli. Do you know I always raise my hands up when I say the disease that we're talking about and no one can see except you? But I appreciate it. Thank you. So, so,

Today's a big one. It's massive, Aaron. I did not realize that when we were like, let's do E. coli. Yeah. It's like, well, yeah, we'll get into it. It's so big. It's so big. It's going to be a short episode, though.

Don't worry. Well, to help us through this episode, I think it's time for quarantini. I think it's quarantine time. I have my first real quarantini. in 11 months. Yay. Which feels quite exciting. What are we drinking today?

We are drinking the cookie don't. And in the cookie don't, it's actually quite delicious. It is. It's really tasty. It is dark rum and chocolate liqueur, Amaretto, ice cream, ice, chocolate syrup. You blend it. And then you pour it into a glass that is rimmed with chocolate and crushed cookies. It's so tasty.

It's really good. It's so good. It's like too good, I think. Yeah. We'll post the full recipe for this quarantini as well as our non-alcoholic placebo burita on all of our social medias and our website. So you can drink along with us. Yes.

And it's called the cookie don't for reasons that I'm sure you'll go into. Oh, yeah. We'll talk all about it. And I'm sure that everyone here can guess. You can guess. Cookie dough. Don't. Yeah.

It works. It works better if you read it, I think. It does. We didn't think this one through. It's still great. I like it. Okay. So, speaking of cookie dough and don'ts and whatever, Aaron, should we just get started?

I think so. We have merch. Check it out on our website. Click on merch, et cetera. business, let's do it. All right, cool. We'll take one quick break. Dinner shows up every night, whether you're prepared for it or not.

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Blue Apron no longer requires a subscription. You can order meals when you want them and skip when you don't without adding another recurring charge. Order now at blueapron.com. Get 50% off your first two orders plus free shipping with code this podcast 50. Terms and conditions apply. Visit blue apron.com slash turrets. Terms for more information. Anyone who works long hours knows the routine.

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Quince.com slash this podcast. All right. E- coli. I wrote that maybe this is the most important back to the time. bacterial species we'll ever talk about, but I feel like that's overkill. Well, I feel like a lot of people might have opinions about that. They probably would. So I'm not going to make that statement, even though I just said it. But it is massively important.

It is massively important. The thing about it is that E. coli is everywhere. It's everywhere and it's everything. And it causes almost every type of illness that you can think of. And we also use it in the lab to study every other disease, pretty much. E. coli is like the lab bacteria. Oh, and not just every other disease, but life itself. And how life works. Like literally. That's not an exaggeration. Yeah, no, I'm going to talk about it.

Oh, excellent. I can't wait. Because I'm not going to talk about it. Oh, good. Oh, but we will get some of the basics out of the way first, and then we'll talk about the diseases that E. coli causes. Cool? Perfect. Okay. So E. coli is a bacterium. It's a gram-negative bacterium. So it's pink when we stain it on the microscope. That's what it means for the purposes of this podcast. That's really the important takeaway. Is that it's a pink bacteria? It's a pink little bacterium. If you're going to paint it, that's what color you should choose. It's

rod shaped. So it looks like a little tick-tacet. Okay? Yeah. You have it in your mind now. For the most part, in our bodies, E. coli is a normal and important component of our gut microflora. It's always there, and it's supposed to be there. It's part of a healthy microbiome. But this is, this podcast will kill you. So that's not the E. coli that we're going to talk about today. Nope. Although we could talk a little bit about those guys. Sure, sure. So, Aaron. When you think of the E. coli that makes you sick, what do you think of? You mean like what symptoms and signs and stuff? Oh, I would say, well, after reading that

first-hand account, I would say bloody diarrhea. Bloody diarrhea. And then also whatever H-U-S is, but I was hoping you were going to tell me about that. Don't worry, I'm going to. Okay. Bloody diarrhea is the thing that probably comes to most people's minds when they think of e-coli first. And that's because of just like you said, that 0157 outbreak, which we'll talk about, you'll talk about, etc. Yeah. The diaryogenic, that's their official name, the diarrheagenic E. coli are probably the most infamous of the E. coli's that cause disease, but they're not the only ones. So here's how I'm going to structure this biology section, because E. coli is so big.

First, we're going to talk really quickly about what makes the pathogenic e coli strains different than all of the normal E. coli or all of the non-pathogenic E. coli that live in our gut happily. Okay. And then we'll talk about the non-diaryogenic E. coli just briefly. And then we'll talk poop. Cool? Oh, great. I love talking poop. Me too. It's one of my favorite things to talk about. Okay. So the main difference between the E. E. coli hanging out in our guts happily right now and the E. coli that made that little girl in the

first hand account massively sick are what are called virulence factors. We've talked about these before, right? I think so. Sure. I think so. Sure. Well, if you don't remember what a virulence factor is, it's basically just stuff, things. Yeah, that clears it up. Things that a bacteria or a virus or a site makes that helps it to cause disease in an organism. So let me give you some examples. Sometimes virulence factors allow for bacteria to attach to certain cells and colonize a new area in a host that they wouldn't be able to before. Oh yeah.

Okay. Like little Velcro strips. Exactly. Yeah. Perfect. Sometimes it might be like a capsule kind of like an armor that allows it to evade a certain part of our immune response. That could be a virulence factor. It could be an endotoxin that the bacterium produces that also allows it to evade the immune system, or an exotoxin that it produces

and sends out into our body and actually causes damage to other cells. Cool. Okay. So virulence factors are literally anything that a pathogen can make that makes it more virulent, aka makes you get sicker. Cool. Sounds reasonable. So these subtypes of E. coli that are they're called different pathotypes because they are pathogenic. Collectively have a couple of main virulence factors that allow them to get us sick. And those two things are different types of adhesons, which allow them to adhere and colonize new areas. And toxins. Those are the two things that E. coli tends to use to be able to invade,

new organs in our body and make us sick in new ways. So another important thing about the virulence factors in E. coli is that a large number of them are on plasmids, which we've talked about before, I think, right? Oh, did we talk about it with cholera? Maybe, because cholera definitely has plasmids. Anyways, plasmids are little round pieces of DNA that bacteria can move from like one bacterium to another. They can like pass it off. And so basically this allows for E. coli to hand off virulence factors in like between different strains of bacteria. Right. Okay. Okay. That's like that's the whole pathogenesis. Like that's how all of these E. coli have come to be is just little changes in their toxins or their very,

factors or their adhesons, whatever, that allows them to make us sick. Okay. So what kinds of ways can E. coli make us sick? So many different ways. Yeah. All right. The two main kinds of disease that you can get from E. coli besides diarrhea are urinary tract infections. Oh yeah. Did you know that? I think I did know that at one point. I don't know. It feels like a recovered memory. Yeah. So these strains of E. coli are called UPEC. So many ridiculous acronyms with E. coli. No. I don't love, I don't love acronyms. UPEC is Europathogenic E. coli.

Okay. Okay. They're all like that. They're all like blah, blah, pathogenic E. coli. They're really easy. So they all end in Peck? Yeah, they're all, most of you all. Sometimes they're like, heck's. You'll see. Heck and E. E. A heckin E. coli. That was funny. She sounds surprised.

I liked it. It was good. Okay. So the UPEC, the Europathogenic E. coli, are strains of E. coli that are really good at attaching to our urinary tract walls. Okay. So they have adhesants that allow them to do that. And they are the most common cause by far of UTIs. So that means like.

Okay. Right? Like 80% of UTIs or something like that are caused by E. coli. And if you don't know what a UTI is, the symptoms generally are things like burning on urination. Increased frequency, meaning you have to pee way more often than normal or urgency where you're like, if I don't pee right now, I'm going to pee my pants. So that sounds a lot like gonorrhea, Aaron. How are people going to distinguish between the two? So another thing that UPEC can cause is prostititis. No, but it is prostititis. And gonorrhea is another common cause of prostititis, actually.

So that's if it goes up the urethra far enough to invade the prostate. But then these strains of ecoli can actually keep going up and then can also cause like pylonephritis, which is kidney infections as well. Which is you can imagine more serious than only a bladder infection. infection. Okay. So we covered three already. We've got bladder infection, kidney infection, prostate infection, all from UPEC. Then we have the M-neck. I don't know if you're supposed to say it like that, but these are the meningitis associated E. coli. Oh, that's right. Yeah. So this is one of the most common causes of meningitis in neonates, so tiny babies. Okay. It can also cause meningitis in adults, but it's much less common compared to other causes. Why? I think that just

other bacteria are better at colonizing the meninges, and so you'd have to be pretty sick already or have a root of entry. So these strains of E. coli are associated mostly with meningitis following like a neurosurgical procedure in adults. Oh, okay. Okay. Okay. Yeah. But what's really scary is that in neonates, this type of E. coli infection has a fatality rate of like 15 to 40%. Wow. Yeah. It's really, it's really gnarly. And it's also an extremely common cause overall adults and children of bacterial sepsis. So bloodstream infections. Right. And that can actually be from any strain of E.E.C. Not only the UPEC or MNEC strains.

You can have any way that E. coli can get into your blood once it gets there, it's pretty good at establishing an infection. Yikes. Yeah. So those are collectively, you want another acronym here? Oh, gosh. Does it end in heck or peck or? Yeah, it does. What is it?

Okay. They're the ex pecs. I can't. I can't, Aaron. I can't. These are the extra intestinal pathogenic ecoli. Oh, yeah. Oh, yeah.

Easy to remember. Sure. XPEC. XPEC. XPEC. X-PEC. That's all we've learned so far? M-neck.

Oh, goodness. I can't. Okay. M-neck. Okay. Now we get into the more fun ones. Oh, yikes. Okay.

The EPEX. Oh, God. People are going to hate me. Yeah. So now we're going to talk about the ones that actually colonize your gut in a way that is bad, the enteropathogenic e. coli. The most famous of which we've heard a little bit about already, and that is the entero hemorrhagic e. E.hek. Okay. So Ehek is a form of EPEC.

Yeah, bra. Okay. It totally is. Do you want to know what gets even worse, though, Aaron? Even I, this is too much for even me. Ehek is also called S-Tec or V-Tek. Why? Let me tell you why.

I'm so glad you asked. Oh, no. The enterohemorrhagic E. coli are the strains that cause bloody diarrhea. Okay. Entero-hemorrhagic, like hemorrhage means bleeding out. Entero means your gut, okay? So that's like a broad umbrella term that encompasses a, number of different strains of E. coli, all of which end up with symptoms like bloody diarrhea.

Some of those strains produce a toxin called Shiga toxin. Oh, yeah. S-T. S-Tek. S-Tek. Cigotoxin E-Col. Some other strains produce a toxin that's really, really similar to Shigotoxin that is called Shigalike toxin. Oh, okay. Or varotoxin. Veroxin. Sure. So those two phrases are interchangeable, and yet they still give rise to two different acronyms. Three. Oh, I'm sorry. Yes, three. Yeah. V-Tech, S-Tek. I think it's annoying. So I just go with E-HEC because it's the broadest one and it encompasses all of them. Cool. I mean, I'm just rolling with it. Yeah. All right. So let's talk about what this actually does inside of your body. This shigga toxin or shigalifes. toxin. It's the same toxin that's produced by another bacteria, Shigella, which arguably might actually just be a subspecies of E. coli. Okay. Yeah. So I'm glad. I talk a little bit about it,

but yeah. Yeah. It's basically, they are so closely related, it might as well be a subspecies. It's also possible that E. coli 0157 should actually be a shegela. It's like some E. coli strains should be chigella and some chigella strains should be ecoli. Yes. 100%. Yeah. Yeah. Yeah. That blew my mind, by the way. Yeah. Yeah. So they all produce this toxin that the bacteria can then release that causes damage directly to the mucosa of your intestine. These bacteria tend to colonize in your large intestine, in your colon. And when they release this toxin, they can cause perforated. of your intestine. They can cause necrosis, so they can cause your colon to actually die in places. And this is what results in the bloody stools that you see in enterohemorrhagic E. coli infections.

Question about the stools, unless you're going to cover this in the poop section. Oh, we're in the poop section, girl? Oh, great. Okay. Okay. I thought so. I didn't want to get my hopes up in case we weren't. So bloody diarrhea doesn't mean red or red, blood in your poop? Great question. It can. And in this case, it probably does. Okay. It all depends on where you're bleeding from. Yeah. So the higher up you bleed in your GI tract, the more black your stool is going to look when you poop it out. Right. The lower down you're bleeding, the more bright red this blood is going to be. But these S-Tech, V-tech, etc., whatever ones that actually cause the hemorrhage, Ehek, cause the hemorrhgin, your gut, that can produce any shade of bloody diarrhea?

Yeah, yeah, because they colonize your colonize your colonized your colonize your colonized closer to, oh, no, Aaron. I'm going to get my, oh, my anatomy. If they're colonizing closer to the left side where the outlet is, then it might be more bright red blood. If they're colonizing closer to the start of your colonel, it might be. a darker color. Okay. In any case, seek medical attention. Yeah. Ra. Unless you ate beats the night before. Unless you, unless it's beats.

I feel like we've had so many good title possibilities already. Well, I also feel like we've mentioned beats on a couple other podcasts or a couple other episodes before. E. coli, unless it's beats. It's a coli unless it's beats. Okay. Beats by E. Beets by... Okay. So that's the damage that this toxin and that this bacteria causes in your colonin where it's actually colonizing. But what's really, really dangerous about these enterohemorrhagic E. coli is that the toxin can actually leave the intestine and get into your bloodstream. If that happens, it can make it all the way to the kidneys, where it causes inflammation in the kidneys that can end up causing kidney failure.

Yikes. And then what it also does is it causes damage in your small blood vessels that then leads to small clots forming inside of your blood vessels, like little teensy tiny clots, that when your blood then, passes over these clotted chunks in your blood vessels, it shears your red blood cells. Oh, my goodness. Right. And so this is what's called a hemolytic anemia because your red blood cells are literally bursting open. Whoa.

Because they're traveling over these tiny microclots. And those clots are formed by platelets. So now all your platelets in your blood are being used up. So the three main signs that you see are renal failure, kidney failure. kidney failure, this hemolytic anemia, and thrombocytopinia, which means your platelet count is low. And that collectively is what's known as hemolytic uremic syndrome. Oh, wasn't that funny? Okay. Wow. So, I have a question. Okay. How does it benefit E. coli to produce this toxin in terms of their replication or in terms of their ability to colonize new areas,

like why do they, why do some strains produce this toxin and some don't? Does it give them some sort of fitness advantage? That's a really, really good question. I don't fully know the answer to that, but what I can tell you is that a lot of these strains of E. coli, especially like 0157, are naturally found in the guts of ruminants like cows and sheep. Okay. So I want to, wonder if it provides a fitness advantage in those environments in some way. Hmm. Right? Like, the guts of cows are bananas.

They have five stomachs and stuff. I know. What if the microflora is totally different at each one of them? Oh, it probably is. I know, but like, there's probably a study out there, but. But we just haven't read it. Isn't that fascinating? Some veterinarian is going to be like, you guys, let me tell you.

Tell us. This is like old hat. Yeah. We want to know. That's a really good question, though. because yeah toxins are expensive for bacteria to produce

so presumably in some way it has to be you would think because these strains are so prevalent you would think that yeah it does cause some kind of fitness advantage probably great question so yeah

that's that is the enterohemorrhagic ecolies the most famous of which is E. coli O1 5.000 7, H7, specifically. Let's just call it 0157.

That's what I do for most of... Yeah. Yeah. This is what causes outbreaks very often, but it also causes tons of infection across the globe and in the U.S. That isn't outbreak associated. So we actually often never know what the source of infection is. But in general, you get sick between one and three days.

you'll start having this diarrhea that's often bloody within one to three days after exposure, although it can be as long as 10. And about 5 to 10% of people that get infected with Ehech will end up getting hemolytic Yurumic syndrome. Wow. I didn't know it was that high. The thing is, that number varies a lot based on age. So in kids, it's potentially even higher, especially in very young children.

But in adults, that number is quite a lot less. So on balance. Yeah. So that's the anterior hemorrhagic. There's one last kind of poop that I'd like to talk about before we're done here. Wonderful. So there's another strain of E. coli called E.Tech. This is me. Do we not talk about E. Tech already? Nope, no, we haven't. We've had EHEC, and now we have E. Tech. Extraterrestrial E. coli.

Very, very good guess. So close. enterotoxogenic. Okay. So entero toxicogenic. Yeah. It has a toxin and it's in your gut. And it's somehow different than Shigella or than Shiga toxin. Yes, exactly.

That's exactly right. This is another kind of toxin and specifically this type of toxin is more similar to a toxin produced by vibrio cholera. Oh, yeah. So it's not the same toxin, but it's very similar. So you can imagine that the diarrhea that you have with this type is more similar to cholera diarrhea, which is what, Aaron? Rice water stool. Exactly. So this is a watery diarrhea, not a bloody diarrhea. Okay. Is that cool? Yes, I mean, cool is maybe not the word I would choose. I think it's pretty cool. I mean, it's actually not cool because E-Tech, as it turns out, is the cause of what's often called Travelers diarrhea. Oh.

Yes, that's E-Tech. Which what that means is that E-Tech is an extremely important cause of diarrhea in children in developing countries. So second only to like ROTavirus and probably up there in competition with rhodovirus for the most important diarrheal disease. Okay. In the developing world. So it's a huge cause of morbidity and mortality. And it's a watery diarrhea. So it's not bloody, but you're losing so much water that you then can end up dying from dehydration.

Right. Okay. There are other enteropathogenic ecolis. This is too big of a topic. I know. We're not going to talk about them because quite honestly, we don't know as much about them and we don't have time and et cetera. If you want all of the nitty-gritty details of all these different pathotypes, there was a great nature review from 2004 that I read that goes into way too much detail and that will be posted on our website. That's the biology of E.

Cool, I, Erin. Beautiful. Thank you. Thank you. I made it myself. So tell me how the heck did it get here. Where did this thing come from and why does some strains just want to kill us? Oh, great questions.

First, let's take a little break. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keeffe's Working Hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working Hands creates a protective layer on the skin that locks in moisture.

It's non-greasy, unscented, and absorbs quickly. A little goes a long way. Moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving environments. It's been relied on for decades by people who wash their hands constantly or work in harsh conditions because it actually works. O'Keefs is my hand cream of choice in these dry Colorado winters

when it feels like my skin is always on the verge of cracking. It keeps them soft and smooth, no matter how harsh it is outside. We're offering our listeners 15% off their first order of O'Keef's. Just visit O'Keef's company.com slash this podcast and code this podcast at checkout. This is Bethany Frankel from Just Be with Bethany Frankel. Listen, I have a bone to pick with these dog food brands calling themselves fresh, natural, healthy. Sounds great, but a lot of these, quote-unquote, fresh dog foods in your fridge are not even 100% human grade, which is why feed your babies, just food for dogs.

It's good enough for big and smalls, my precious babies, so it's good enough for your babies. 100% human grade, real ingredients, beef, sweet potatoes, green beans, delicious. These are foods that you would want to eat. Not that the babies would ever share. Just Food for Dogs is the number one bet recommended fresh dog food back by over a decade of research. No marketing fluff. My dogs lose their minds at dinner. They run to the bowl, tags wagging, paws tapping, full broad,

performance every single night. So I do care about the food I feed big and smalls. So go to just food for dogs.com for 50% off your first box, no code, no gimmicks, just real fresh food. Janice Torres here. And I'm Austin Hankwitz. We host the podcast, Mind the Business, small business success stories produced by Ruby Studio in partnership with Intuit QuickBooks. And we are back for season four. We're talking to small business owners who are doing incredible things in their industries, achieving their dreams, being their own bosses, putting in the work, and enjoying all the benefits that come with it. This is our most exciting season yet. We're talking to more entrepreneurs about how they launched

their vision, and more importantly, how QuickBooks on the Intuit platform helps them do more in less time. Working in QuickBooks just makes it easier to run the business, right? There's so much that you need to do when it comes to running a business, building products, setting up marketing campaigns. And to run a business, you have to make sure that your finances are in order. So it removes my anxiety from one side of it so that I can focus on everything else. Whether you're a long time listener or just getting started, tune in and join us. You'll be so glad you did. Listen on the IHeart Radio app, Apple Podcasts, or wherever you get your podcasts. I think that for most people, the words E. coli bring to mind these images that you kind of just went over

described, this writhing gut, bloody diarrhea, just doubled over in the bathroom trying to hang on. And a smaller subset may also think of E. coli's role as a model organism in the lab. That's what I think of, if we're being honest. Have you worked with E. coli before in the lab? Yes, I used it during my master's a lot. And also, because we use it as a water quality indicator. So I've worked with E. coli a lot actually in the past. Yeah.

Yeah. It's a stinky colonizer. Yeah. Does not smell good when you create those big cultures. It smells so bad. It's really bad. But I think that those two roles, you know, this like super pathogenic one and also this lab model organism, account for a tiny amount of the amazing diversity of E. coli.

Ooh, cool. Because, I mean, E. coli is found all over the earth. Yeah, bro. Oh, yeah. Inside people and animals and. stuff and also outside of them. Which is why it makes for a terrible water quality indicator. Right. Yeah. I was actually. Good point. Yes. Thank you. And also they're incredibly numerous. So Carl Zimmer estimated in his book about E. coli, which was great, by the way. He estimated that there are about a hundred billion billion E. coli on Earth, which is not a number I can comprehend. and I don't know. If anyone can comprehend it, please let us know. These bacteria are among the top,

if not the very top, most studied organisms on the planet. Research on E. coli has led to Nobel prizes, to genetic engineering, to insights into evolution and cellular biology, how genes work, and there could really be an entire podcast series on the contributions of E. coli to our understanding of how life works. So let's start at the beginning. beginning. And to do that, we have to go so far back, so, so far back before humans were even humans. Yes. Because E. coli has been with us for as long as we've been a species and way before, and probably caused occasional food-borne illnesses during that long relationship. But until microscopy and microbiology emerged, it's hard to pinpoint exactly what might have caused the fatal diarrhea of this or that person.

and be able to conclusively say that it was E. coli. So this is more, this history is less, these are the pandemics of E. coli. And more, yeah, more you're about to find out. So humans first learned about the existence of E. coli when in 1885, a German pediatrician named Theodore Escherish, which did we even say? Oh, my God, no, because do you know what? I can't pronounce it. And I didn't want another G.R.D.A. situation. Well, okay. Echiorichia.

Escherichia. Esherisha. Esherisha. I have never attempted to pronounce that word in my life. I don't. I mean, I've tried to do it, but I don't. I mean, it's an attempt, of course. But I remember my micro-professor in undergrad saying that one of his friends, who was also microbiologist, gave their daughter

the middle name of Escherichia because he thought it was so beautiful. Wow. Weird. Anyway. Okay. So anyway, Theodore Escherish was looking at baby poop under the microscope and noticed a bunch of rod-shaped bacteria. And the reason he was looking at baby poop is because he had been waging a full-on war against diarrhea, believing it to be one of the biggest killers of infants under his care. And he was right.

Totally trite. Yeah. Yeah. For sure. He was looking under the scope to try to see if he could figure out what's good bacteria and what's bad bacteria. Wow. Which I think, yeah, 1885, forward thinker. Yeah. And so he would look for bacteria in both healthy and unhealthy children and say, okay, what can I find in just the unhealthy ones versus what do I find them both? And he found e coli in both. And so he didn't really consider it to be that interesting of a lot. a finding. But he published it anyway, and absolutely no one took note of it. Shocker. Right. And the original name, which was much easier to pronounce, was bacterium coli, communists. So common bacteria of the colon. Wow. Yeah. But seven years after his death, in 1918, scientists renamed it after him. Wow. Okay, so just a few years after that, a biochemist named Edward Tatum, I don't know, I really want to know if he's related to Channing.

Mr. Channing, yeah. Edward Tatum started to culture a strain of E. coli, the K-12 strain, if you're curious, in the lab. And this K-12 strain that's so popular for lab work today was isolated from a dude who had diphtheria and was living in California in the early 1900. So, what? Yeah, there you go. And just happened to have the strain of E. coli? I don't really know the full story, but yeah, I assume that's...

Because this is a harmless strain. Like, this is a non-pathogenic strain. Yeah, right. So Tatum had recently gotten super interested in the very new field of genetics, because this is the early 1900s. And he had actually worked with Thomas Hunt Morgan and George Beetle, which, like, two of the biggest pioneers in the field. And up until this point of time, genetics had mostly been...

been studied using things like fruit flies and bread mold, which were more complex in some ways than bacteria, particularly in that they had sex, like gene exchange or were known to. Tatum wanted to see whether bacteria like E. coli also followed the one gene for every enzyme rule that had been the pattern he discovered in mold. And he chose E. coli because it has very few requirements in the lab, grows rapidly, and produces visible colonies, which is a is useful for monitoring what exactly is going on. And he blasted E. coli with x-rays, managing to produce a few mutants. Awesome. Which gave this huge indication, bacteria have genes. Because if you blast something with X-rays and then there are mutations that happen and there are differences in the bacteria

after that, then that shows that these things have changed based on how they... Right. Their DNA has been affected. Yeah. That was a huge finding. But did that matter that much? Did the fact that bacteria had genes matter that much if the bacteria couldn't reproduce sexually? Yeah. And so from these findings, another guy named Joshua Letterberg, who was 21 years old. Just wanted to say this. Yeah, I know. Oh, that hurts. Don't tell me that he got like the Nobel Prize. Oh, my. did. Okay, so Joshua Lederberg decided he would look for bacteria sex. So he was just convinced that people weren't looking hard enough. And he found it. So he found e. coli mutants could exchange genes somehow. And from this monumental discovery that led to basically the

amount of research is on, you can't count the number of like findings or new laws of biology or whatever, all these discoveries, these three dudes, so Letterberg, Tatum, and Beetle were given the Nobel Prize in 1958. And he was 21. He was 21, not in 1958, but he was 21 when he discovered bacteria sex. Yeah. Well, too late for me then. I mean, it's great. Come on, come on, it's never too late. It's never too late. No, that's true. It's not. Studying E. coli would lead to other huge advancements, such as discovering that viruses had genetic material, which was learned by looking at the bacteriophages of E. coli. It would also help to show conclusively that genes are made of DNA, which overturned the long-held hypothesis that DNA was made of proteins. And it even helped

to reveal the structure of DNA in what apparently is known as the most beautiful experiment in biology. And I'm not going to get into the details of it, but it has to do with like nitrogen of different weights and lots of centrifuging. If you want to know more, read the book Microcosm by Carl Zimmer. Okay. It keeps going, though. Echolai also helped to show how DNA was made up of codons and how these codons matched to certain amino acids.

By studying E. coli, scientists were learning about the rules that govern life itself and even what it means to be alive. It's amazing. Yeah, it's amazing. E. coli has thousands of genes, and scientists have a pretty good idea, if not. exactly the idea of what each of those genes do. Basically, you knock a gene out and you see what happens. And by fiddling with these mutant varieties of E. coli, researchers also figured out that genes can be turned off and turned on, that they don't work in isolation, but are rather connected

like a circuit board. E. coli has been subject to the whim of so many researchers who wanted to see if it could be grown at extremely high temperatures or super low levels of food or infected with tons of viruses. And what the scientists observed over and over again was evolution at work on a time scale that no one had thought was possible, even though now it kind of maybe seems obvious. Antibiotic resistance and all that. Exactly, yeah. Yeah. E. coli was used in genetic engineering, starting in the 1970s when it caused quite a stir. And now no one thinks twice, but people started using it for insulin production, which led to this huge industry, which was fueled initially by controversy and then by demand. Doctors sometimes would give or still give,

I don't know, you tell me, a strain of E. coli called A-034-86 to premature infants that don't have fully formed intestines because it helps them protect against nasty gut pathogens. I don't know if they still do that, but that's genius. Because babies get colonized with E. coli in like minutes, like after birth. It's amazing. It's amazing. And so this, this particular is like helpful strain or whatever. Some of its genes code for things that directly fight the weapons of strains like 0157. Stop it. Yeah. This is like a total role reversal. Usually you're the telling me about these strain differences. I love it. Okay. Okay. Just a couple more cool bits about E. coli before the history of the pathogenic one.

The poop. Yes. E. coli can sense each other. Oh, yeah. Oh, I'm so glad you're talking about this. It's amazing. Okay. So a group of researchers released E. coli labeled with a glowing protein into a maze and wanted to see how they would move and what would happen.

And at first, so you could trace these individual cells, right? Oh, my gosh. At first, everything was random. But then, eventually, the researchers saw a pattern emerge. The bacteria were moving towards other bacteria. And soon there was this giant cluster of E. coli just hanging out. Okay, so it turns out, you're doing a very happy dance. I like it.

It turns out that E. coli shoots out serene in its waist, and other E. coli might use that as a sensing mechanism to find other E. coliol. Once they're all together, they might even change their behavior. So instead of having their normal phlegelum, they grow a giant one that gets tied up with other flagella, creating a rat king of e coli. Oh my gosh. Echolai, like bacteria having behavior is one of the coolest things. And this whole, this whole rat king, whatever, like, tails or flagella type. Yeah.

Helps them move as a group across a petri dish or maybe even your intestinal wall. Definitely your intestinal wall. It's amazing. It's amazing. Dude. Okay. Even though now I think most of us think of E. coli as this deadly foodborne terror, for several decades after its description and even after its use in a lab as basically

the thing that revealed all secrets of life, people weren't aware of how sick it could make you. So it wasn't until 1945 that the link between E. coli and horrific gastrointestinal disease was really conclusively made. Have you ever heard of summer diarrhea? No. I know in, what was it, the polio episode? We talked to like about closing down pools and things, but summer diarrhea, no. Yeah. So this was like a known phenomenon as something called summer diarrhea. So if you go to like Google Scholar, you can find, reports of now analysis of what the summer diarrhea was in writings or whatever, but also in reports from the early 1900s. So every summer kids and infants in industrialized countries would get super sick with diarrhea, often bad enough to kill them. So it was this very seasonal trend of diarrhea.

And a British pathologist named John Bray decided to hunt for whatever pathogen might be causing this. Using antibody tests, he found that while only Only 4% of the healthy kids responded to the E. coli antibody test, like they were positive. 95% of sick kids did. Huh. And so then he would go on to describe this strain and several more that were pathogenic to humans. Interesting. Okay.

So now here's the part that you've probably been waiting for, maybe? I don't know. Maybe you've enjoyed all of this? I have enjoyed all of this. Okay, good. Enter 0157 H7. Although we can't say for sure, 0157 seems to be a pretty recent arrival, like 1975, to be exact. Wow, that's super recent.

Yeah, no samples can be found before then. Fascinating. It first made headlines in early 1982 in Medford, Oregon, and later that same year in Traverse City, Michigan. The source was undercooked burgers at McDonald's. Oh. And then it went quiet for about 10 years until the infamous 1993 Jack in the Box outbreak. JTV, baby. I've never had Jack in the Box. Do they not have it out here? Out east, no. Or like, I don't know, past the Mississippi River. Oh, interesting. Yeah, JTV, man. There have been dozens of 0157 outbreaks all over the world since its first appearance. And I could probably go into each one of them

to talk about the source of infection and the lessons learned. But I'm just going to focus on the 1993 Jack in the Box outbreak in the Western U.S. because this is probably the most famous foodborne or E. coli outbreak in the U.S. It's pretty. It's massive. Everyone still talks about it. Yeah. I mean, it put E. coli like in as a popular phrase or is like, a known phrase to people. Yeah. Totally. It resulted in landmark personal injury lawsuits, increased oversight of food production, and widespread public awareness of this deadly pathogen, which, you know, burgers used to be safe before this, maybe some worms. It started around Christmas 1992 when six-year-old Lauren Rudolph was rushed to the ER in San Diego after having bloody

diarrhea. After a few days of battling the illness, she passed away. And in January, 1993, doctors at Children's Hospital in Seattle started noticing an unusual number of kids with hemalytic uremic syndrome, which is that thing you described. Yeah. And this set off some alarm bells because you don't really see that number of cases very often. It's not, it's, it's, it's pretty rare, right? Yeah. And so the high. My number of HUS cases, which is the hemo-heolytic uremic syndrome, I'm just going to call it H-U-S. It pointed towards an E-Colai outbreak, but those usually happen in the summer. So where could these cases be coming from?

These children weren't connected to one another in any way, like at daycare or something like that, but there must have been a shared source somewhere. Epidemiologists that were assigned to the case did their thing, asking parents about their lives, their movement patterns, what food they ate at home, where they ate, and eventually a likely culprit emerged. Jack in the Box. The nation's, did you know, is the nation's oldest fast food chain? No, I did not know that. It beat out McDonald's by like a couple of months. Huh. Anyway, they, they, so Jack in the Box had recently been having this big promotion for their monster burger. So good, it's scary, which is like, in retrospect, not a great tagline. Not great.

don't make that burger anymore. No, I don't think so. Yeah, the PR campaign to get Jack in the Box to not fold as a company is pretty, I think also landmark. Yeah, there's like, that's a whole podcast in and of itself, I feel like. Oh, for sure. So the president of Jack in the Box, Bob Nugent, when notified that the company might be the source of this horrible outbreak, he immediately stopped all of the restaurants in the affected areas from serving their burgers and destroyed the possibly contaminated batches of beef. Wow. Yeah. Oh, he was, he acted as fast as he, I think, it seemed like as fast as you could. Yeah, that's awesome. And he did all this without being entirely convinced that it was the beef, that it was Jack in the Box in the first place.

I mean, but you have dead kids, so it's like. Exactly. Yeah. Well, and everyone was very, like a lot of the people who were at Jack in the Box, I think were, um, felt awful. Like, we're very, very troubled. I can't even imagine. By their, yeah, what their inactions, I think, had done. And so people knew at this time, people knew that undercooked chicken could be a problem in terms of salmonella, but no one really had heard of outbreaks of food poisoning associated with beef. It was a new thing at that point, or at least it seemed to be according to this book. And so even though there had been this E. coli outbreak just 10 years before the Jack in the Box, the one that was in McDonald's, it had gotten quite a little. buried, and so McDonald's wasn't really named. And so when Washington State epidemiologist,

John Kobayashi, told Bob Nugent, the president of Jack in the Box, that this horrible outbreak affecting all of these kids was likely tied to E. coli contaminated burgers. Nugent was like, what? So even though the contaminated beef had been stopped, it was too late for a lot of people, mostly children. By the end of the epidemic, 732 people, were infected with E. coli. 732 confirmed. Confirmed. Whoa.

All traced back to Jack in the Box restaurants in Washington. Idaho, Nevada. Nevada. How do you say Nevada? I say Nevada and I know that's wrong. So I need to say it properly. Nevada. Nevada and California.

Yeah. Please leave that in because it's the funniest thing I've ever heard. A lot of people say Nevada. Nevada. But the way that you went Nevada, Nevada. Because I knew it was wrong as soon as it left my mouth. It's embarrassing. Avoiding these restaurants wasn't enough, though.

One of the four children who died during the outbreak was 17-month-old Riley Detweiler, and he contracted E. coli from a friend in daycare who had picked up the bacteria from a burger. Oh. There were two other children who died. Selena Shribes and Michael Knoll, and all of the kids who died from this outbreak were six years or younger. Those babies. Yeah.

I can't. Yeah. Even if you were fortunate to survive the initial infection, many people, over 100, experience long-term side effects from the infection. Obviously, with so much tragedy and suffering, experienced as a result of the infection, epidemic, people wanted answers to questions like, how did this happen? And how can we make sure this doesn't happen again? The first question, how did this happen, actually ended up being fairly easy to answer? So in 1993, the federal regulations for the temperature for cooking

beef were at 140 degrees Fahrenheit, 60 degrees Celsius. Okay. However, so 140 degrees, keep that in your head. In Washington, the state law was actually 155 degrees. 68.3 degrees Celsius. This regulation, which was different than the federal regulation, higher temperature, was put in place by the same epidemiologist John Kobayashi that I mentioned earlier, and because he was aware of the danger that E. coli posed. Wow, way to go. He chose 155 degrees Fahrenheit because that was the temperature required to kill E. coli.

Whoa. Jack in the box in Washington was notified of this new regulation, but for whatever reason didn't change their practices. They followed the federal regulation of 140 degrees. So, yeah, a lot of the cases probably could have been prevented if they had followed Washington state law. But Jack in the Box argued that they weren't completely responsible for a contaminated product. The screening regulations for E. coli and beef weren't what they are today.

Like people didn't really screen that much for them. Dude, we should have had Matt Kmetk come on this episode. Oh, my God, you're right. What he does. It's so true. Shout out, Matt. And so researchers were desperately trying to figure out where the strain came from and how to prevent it from getting into the food supply.

And that's something that's way easier said than done, because it was found in around 28% of cows, and probably that number has jumped since this book was written. And so basically what happens is, that during the slaughtering process, if a cow's colon is cut, that E. coli that's in the gut can that escape? And basically all the meat is all blended together. That O1, like, ground together. Yeah. That O157 can travel through literal tons of beef. Yeah. That's so gross. Horrific. Proper cooking will kill the bacteria, but if a few escape, then there you go.

And do you know the infectious dose for E. coli is like as little as 10 organisms? I remember that from micro, yeah. Yeah. So that's how the E. coli got into the beef. But how do you make sure it doesn't happen again? That's a much trickier issue. And probably because we've had several outbreaks since then, it's obviously tricky. So there are several stages of food prep that could have been improved. First, there's the beef industry itself. You clean up that process. Maybe don't allow. dropped carcasses to be incorporated, maybe cleaning the floor on which they are dropped, maybe following a one cow, one burger practice, which isn't what happens. I need to not think about it or I'll never eat another burger again at my life. So it's funny that you said that because that was my exact response when I read this in Carl Zimmer's book. And then the next paragraph is, and if you're vegetarian, don't feel so

smug or something like that. Like you're not escaping it either because cows poop on crops. Oh, like most of the outbreak, not most, but a large number of the outbreaks recently have been in lettuce and spinach. Yeah. No one is safe. Cookie dough. We call it cookie like the title of our quarantine, cookie don't because raw flour is how people have gotten sick from the coli also. Yeah. Okay. But then there are also these restaurant quality control improvements that could be made cooking the beef at the temperature that actually kills e coli. So this this eukolai outbreak is notable not just because of its size, but because of the changes it led to in the food industry and the government oversight of it. So it really did. It was like a huge, huge deal. And a lot of people

who work in food safety are today still very unsatisfied by how it's done. And that's kind of a fair point, considering that outbreaks continue to happen. All right. So, you know, back to the whole vegetables are not necessarily safe. There was a 1997 outbreak of 0157 in Japan from tainted radish sprouts that made 12,000 people sick. Oh my, what? Yeah, three of whom died, 12,000. September 2006 in the U.S. There was an 0157 outbreak in spinach that made 205 people sick.

same year. Lettuce at Taco Bell made 71 people sick. Like, you could just go on and on and on and on. Yeah. So I could go on and on and on and on about all these different outbreaks, but I'm not going to. Instead, Aaron, I want you to tell me where do we stand today with E. coli? I can't wait to. All right. E. coli today. It's everywhere. Yeah. Yeah. It's still everywhere. everywhere. It causes so many different diseases. It's really hard to do in epidemiology section on this because, like, where do you even begin? I don't know. Let's start. Let's start where you left off with the inflammatory, bloody, eheck, foodborne outbreaks. Just looking over the last 10-ish years, which is basically where you left off around 2006, 2007, there have been

Pretty much between one and four multi-state outbreaks of like, ehech, really bad bloody diarrhea, e-coli, every year. Wow. Pretty much. And each of these multi-state outbreaks, the multi-state outbreaks are the only ones that are reported, like, easily accessible on the CDC website. You can go to every state health department and probably find a handful of outbreaks that were just contained to one single state.

But of these multi-state outbreaks, they range in size from like 18 or 20 cases on the low end to over 200 cases on the high end. And every year from each of these cases, a handful of people are hospitalized and end up getting hemolytic uremic syndrome. Most years, there aren't any deaths related to this, but every other year or so there's a bad outbreak and there are some deaths associated with this. So to put some numbers on that from the last couple of years, so far in 2019, there have been 263 cases in three multistate outbreaks associated with ground bison. Also, flour. Oh, aka cookie dough. Rout row. Yep.

And ground beef. Of these 263 cases, 50 of them were hospitalized. Nobody died. so far in 2019. 2018 was a little worse, although 2019 is not over yet. There were three outbreaks with 290 cases, but 127 hospitalizations. And that's because two of those outbreaks were actually 0157. Oh.

Yeah. So these are just all of the E-HEC or S-TEC, whatever you call it, outbreaks. Not all of those are 0157, and it turns out that 0157 is more likely to cause HUS than some of the other E-HEC strains. Just based on the amount of shigotoxin or what? Yeah, or just the specific subtype of that shigotoxin. Okay. Yeah.

Or sugar-like toxin. It's just more likely to end up causing HUS. So the years that you have 0157 outbreaks tend to be worse in terms of the number of people hospitalized and the number of deaths. But that's just the outbreaks. From the vast majority of EHec cases are actually not outbreak associated. They're just individuals who end up getting sick and maybe end up in the hospital. So in 2016, there were over 5,400 cases of EHEC reported.

Wow. Yeah. That's like 20 times higher than... Than the outbreak numbers. Yeah, the vast majority of people, they aren't actually part of an outbreak, which means that you never actually figure out where their infection came from. Oh, gotcha. And that's another important part of it.

The only time you can identify an outbreak is if you have multiple people coming to the same hospital or at least reporting to the same health district so that someone can pick up on the fact that there's a number of cases happening. Right. If just one person comes or even a couple people come but two different hospitals that somehow don't end up talking to each other, there's an outbreak going on. perhaps, but you'll never know about it. You just have a handful of cases.

Does that make sense? That makes sense. Okay. So yeah, and then like you mentioned that happened in the 1993 outbreak, about 10 to 20% of cases can actually end up in what's called like a secondary attack where people pass on that 0157 or that EHex strain to somebody else in a daycare facility, changing diapers, nursing homes, etc. So, yeah, EHEC is gnarly.

Yeah. But again, that's not the only eukolai out there. Great. There's the one that makes you have watery diarrhea instead of bloody diarrhea. So let's talk about that one real quickly. Great, let's. So E-Tech is what you were mentioning, the enterotoxygenic e-coli, is a hugely important cause of more

and mortality worldwide, especially for infants and children. So there's a lot of interest in developing a vaccine for something like E-Tech, because we're talking millions of children every year that are affected by this and potentially dying as a result of it. There are some candidates in trials that seem promising, but nothing so far is licensed. You're going to see that for all the different things. Okay, great. Yeah. Cool. The other big type of E. coli is of course the Europathogenic E. coli.

The UPEX. There's also a lot of interest in developing a vaccine for these because 80% of all UTIs are caused by E. coli and recurrent UTIs are really, really common.

So getting one UTI puts you at very high risk of getting a second UTI in a short period of time. So there's a lot of people working on. vaccines for the various types of UPEX. There's not really a lot promising so far, quite honestly. Does it have anything promising about this section? No, it ends on the worst note possible.

Great. Yeah. Yeah, it's so true. But yeah, it turns out that UTIs are a massive financial burden. Oh, that makes sense. Yeah, like $3.5 billion a year. in the U.S. alone is spent on UTIs. Three and a half billion dollars.

Yeah, dude. Well, what about other countries that don't have as outrageous health care situation? Good, good point, good point. But still, it's like 11 million doctors visits in the U.S. every year and 2 million emergency room visits for UTIs alone. Wow.

Wow, okay. So even though it's outrageously expensive. For understanding more than I do with money. That makes sense. So yeah, but there are a lot of, there is a lot of work going on on E-Tech, on UPEC, and even on the E-HEC, so the Anterohemeragic E-C, there are people trying to come up with vaccines for all of these strains. But it's proving to be pretty elusive, which isn't that surprising considering how ubiquitous E. coli is and how we have co-evolved with it for so, like literally the entire time that we've existed as humans. I mean, because, yeah, also, it's part of our normal microflora. So you'd have to attack it from a different angle.

And if you did like the shigga or shigga like toxin, because we have vaccines that are based on toxins. Yeah. And that's exactly what most of these vaccines do. They're either component vaccines or they're toxoid vaccines, which are inactivated forms of a toxin, essentially. And so that's exactly what people are trying to do is to target the things. that make these pathotypes different than our normal microflora. We just haven't been able to come up with one so far that produces a good immune response in humans to actually be protective, if that makes sense.

Yeah, okay. Yeah. And the other thing that's really scary is that antibiotic resistance is on the rise for E. coli in general, but especially for E. coli that tend to cause sepsis. So bacteremia, blood-borne infections. And those are most common in a hospital setting after surgery? Yeah, they're very common in hospital settings. They can happen also in babies, not just the meningitis, but just blood-borne infections in general.

And from what I saw in the paper that I will post on our website, from 2000 to 2009, the rates of antibiotic-resistant equal. coli have risen about 300% from 2000 to 2009. What? Yeah, 300% rise. It's really bad. And the numbers that I saw were that E. coli sepsis, so sepsis from E. coli in 2001 was estimated to have caused 40,000 deaths in the U.S. But in 2014, that number may have been as high as 85,000.

What? Yeah. What? E. coli is a very common cause of sepsis, and sepsis is a very high mortality rate. So these are estimate numbers. Right, but that's so many people. I know, yeah, it's really scary. Oh, my gosh. Oh, no, that's the end. Oh, Aaron.

It's literally the end of it. That's where my page ends, may have been as high as 85%. thousand. Great. Okay. So good night everyone. Sleep well. Oh my goodness. I'm so sorry. We're sorry. Okay. So not very much good news for E. coli. Yeah. I should have organized that to be a happier ending. But I mean, we could end it with the happiness that there is so much cool research going on using E. coli in a lab setting to develop other vaccines and cool stuff. And maybe things will get better somehow. Yeah. I mean, there's people working on it.

There are people out there trying really hard to make these vaccines happen, et cetera. Maybe looking back, these will be the dark days. Well, they kind of are the dark days. Right now, it's pretty dark days. We're in some weird timeline. Okay. Yeah. But yeah, that's E. coli.

What? This is this was a massive topic. Yeah, we just barely even scratched the surface of that auger plate. Let me tell you. Oh, I really like that. Thank you. I just came up with it. I didn't even plan that. Mm-hmm. She checks her notes. Do you do. Do I say this joke, check? All right. All right. Well, I guess on these really sad notes, should we discuss sources? Let's. So I read a, I read a couple of books. One is called Microcosm E. coli and the New Science of Life, and that's by Carl Zimmer. I loved it. Really fascinating, a lot about the lab research done on E. coli and how it's provided answers to evolution. Then I also read a book about the 1993 Jack in the Box outbreak called Poisoned, the true story of the deadly E. coli outbreak that changed

the way Americans eat. That's by Jeff Benedict. I can't necessarily. recommend this book. That's all I'll say about it. Okay. And then I also watched a New York Times retro report that was like a new study report on the 1993 outbreak. And I'll also post a few more articles that I read. Awesome. I will post all of the articles that I read, which included that really intense nature reviews microbiology paper if you want the Dietz on E. coli hypothotypes and then a bunch of reviews about the current status of various vaccines and things. All of these will be on This Podcast Will Kill You.com under the episodes tab. You can find the sources for this and all of our episodes.

Thank you to Bloodmobile for providing the music for this episode and all of our episodes. Thank you to all of you for listening. This is the most fun to make this podcast and we really love that you love it. Yes. Thank you for allowing us to keep talking at you. It's so fun. And with that, please wash your hands and cook your meat. Dear God, wash your hands, you filthy animals.

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