Journals / Dicle Üniversitesi Veteriner Fakültesi Dergisi / 2026 / Cilt: 18 Sayı: 1

The Threat of Foodborne "Big Six"

Gıda Kaynaklı “Büyük Altı” Tehlikesi

Tahacan Him(İSTANBUL ÜNİVERSİTESİ-CERRAHPAŞA)0000-0003-2353-9351
Samet Topçuoğlu(İSTANBUL ÜNİVERSİTESİ-CERRAHPAŞA)0000-0001-7458-5492
Karlo Muratoğlu(İSTANBUL ÜNİVERSİTESİ-CERRAHPAŞA)0000-0001-8705-6813
Pages
79–85
Publication Date
2025-06-30
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AI Summary & Key Takeaways

AI Insight
⚡ TL;DR(Too Long; Didn't Read)

This review discusses the importance of the Big Six E. coli serogroups, which are frequently encountered today and cause significant public health problems.

📌 3 Key Takeaways

🎯
Objective & Hypothesis:Foodborne diseases are infectious or toxic diseases that can cause serious health problems and significant economic losses.
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Key Findings & Data:These diseases cause 600 million illnesses and 420,000 deaths worldwide annually.
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Conclusion & Impact:This review discusses the importance of the Big Six E. coli serogroups, which are frequently encountered today and cause significant public health problems.
🔬Design:Review & Systematic Survey
📍Scope:Comprehensive Sample
⚙️Variables:Büyük Altılı E. coli · E. coli · gıda kaynaklı hastalıklar

Abstract

Foodborne diseases are infectious or toxic diseases that can cause serious health problems and significant economic losses. These diseases cause 600 million illnesses and 420,000 deaths worldwide annually. Most foodborne diseases are caused by microorganisms and the toxins they produce. One of the most important foodborne infectious agents is Escherichia coli (E. coli). E. coli strains are classified into six groups according to the diseases they cause, virulence factors, clinical symptoms they cause in patients, their interactions with the intestinal mucosa, epidemiology and serotypes. In recent years, among these serotypes, Shiga toxin-producing E. coli (STEC), which is seen as an important threat to public health, has come to the forefront of the literature. E. coli O157 was the most well-known STEC serotype in the world, affecting individuals of all age groups, especially young children, and causing significant health problems. However, in recent years, the isolation of other serogroups from serious infections caused by E. coli has raised serious concerns. In response, the US Food and Drug Administration (FDA) identified six non-O157 serogroups of E. coli (O26, O45, O103, O111, O121 and O145) found in foods, known as the "Big Six". Outbreaks from these serogroups have led to reports from the US Centres for Disease Control and Prevention (CDC) and the European Food Safety Authority (EFSA). This review discusses the importance of the Big Six E. coli serogroups, which are frequently encountered today and cause significant public health problems.

Özet

Gıda kaynaklı hastalıklar, ciddi sağlık problemlerine ve önemli ekonomik kayıplara yol açabilen, enfeksiyöz ya da toksik karakterli hastalıklardır. Bu hastalıklar, dünya çapında yıllık 600 milyon hastalığa ve 420.000 ölüme sebep olmaktadır. Gıda kaynaklı hastalıkların çoğunluğunu, mikroorganizmalar ile bunların ürettiği toksinler oluşturmaktadır. En önemli gıda kaynaklı enfeksiyon etkenlerinden biri Escherichia coli (E. coli)’dir. E. coli suşları, sebep oldukları hastalıklara, virulans faktörlerine, hastalarda oluşturdukları klinik semptomlara, bağırsak mukozası ile olan etkileşimlerine, epidemiyolojilerine ve serotiplerine göre sınıflandırılarak altı grupta toplanır. Son yıllarda bu serotiplerden halk sağlığı için önemli bir tehdit olarak görülen, shiga toksin üreten E. coli (STEC) literatürde ön plana çıkmıştır. E. coli O157, dünya üzerinde başta küçük çocuklar olmak üzere tüm yaş gruplarındaki bireyleri etkileyerek, önemli sağlık problemlerine sebep olan, en fazla bilinen STEC serotipiydi. Fakat son yıllarda E. coli’nin neden olduğu ciddi enfeksiyon tablolarından diğer serogrupların da izole edilmesi ciddi endişelere yol açmıştır. Bunun üzerine ABD Gıda ve İlaç Dairesi (FDA), “Büyük Altılı (Big Six)’’ olarak bilinen, gıdalarda bulunan ve O157 dışı altı serogrup E. coli (O26, O45, O103, O111, O121 ve O145) tanımlamıştır. Bu serogruplardan kaynaklanan salgınlar ABD Hastalık Kontrol ve Korunma Merkezleri (CDC) ve Avrupa Gıda Güvenliği Kurumu (EFSA)’nun raporlar yayınlamasına sebep olmuştur. Bu derlemede, günümüzde sıklıkla karşılaşılan ve önemli halk sağlığı problemlerine sebep olan Büyük Altılı (Big Six) E. coli serogruplarının önemi ele alınmıştır.

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Cite This Article

Him, T., Topçuoğlu, S., Muratoğlu, K. (2025). The Threat of Foodborne "Big Six". Dicle Üniversitesi Veteriner Fakültesi Dergisi, Cilt: 18 Sayı: 1, 79–85. https://doi.org/10.47027/duvetfd.1489397

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References (70)

  1. WHO (World Health Organization) (2015). World Health Day 2015: From Farm to Plate, Make Food Safe. https://www.who.int/news/item/02-04-2015-world-health-day-2015-from-farm-to-plate-make-food-safe. Erişim tarihi: 29.11.2024
  2. WHO (World Health Organization) (2022). Food Safety. https://www.who.int/news-room/fact-sheets/detail/food-safety. Erişim tarihi: 29.11.2024
  3. WHO (World Health Organization) (2018). E. coli. https://www.who.int/news-room/fact-sheets/detail/e-coli. Erişim tarihi: 29.11.2024
  4. Jung J, Bir C, Widmar NO, Sayal P (2021). Initial reports of foodborne illness drive more public attention than do food recall announcements. J Food Prot., 84(7): 1150-1159. https://doi.org/10.4315/JFP-20-383
  5. Sharif MK, Javed K, Nasir A (2018). Foodborne Diseases. Academic Press
  6. Sağlam D, Şeker E (2016). Gıda kaynaklı bakteriyel patojenler. Kocatepe Vet J., 9(2): 105-113.
  7. Assefa A, Bihon, A (2018). A systematic review and meta-analysis of prevalence of Escherichia coli in foods of animal origin in Ethiopia. Heliyon, 4(8): Article e00716. https://doi.org/10.1016/j.heliyon.2018.e00716
  8. Erol İ. (2007). Gıda Hijyeni ve Mikrobiyolojisi. Pozitif Matbaacılık, Ankara.
  9. Elitok B, Bingüler N (2018). Kanatlılarda Escherichia coli enfeksiyonları. Dicle Üniv Vet Fak Derg., 11(1): 34-38.
  10. Vasan A (2014). Thermal tolerance characteristics of non-O157 shiga-toxigenic Escherichia coli in meat systems. Doktora Tezi. University of Wisconsin – Madison.
  11. Erkmen O (2013). Gıda Mikrobiyolojisi. Efil Yayınevi, Ankara
  12. Sora VM, Meroni G, Martino PA, Soggiu A, Bonizzi L, Zecconi A (2021). Extraintestinal pathogenic Escherichia coli: virulence factors and antibiotic resistance. Pathogens. 10(11): 1355.
  13. Welinder-Olsson C, Kaijser B (2005). Enterohemorrhagic Escherichia coli (EHEC). Scand J Infect Dis. 37(6-7): 405–416. https://doi.org/10.1080/00365540510038523
  14. Biliński P, Kapka-Skrzypczak L, Posobkiewicz M, Bondaryk M, Hołownia P, Wojtyła A (2012). Public health hazards in Poland are posed by foodstuffs contaminated with E. coli O104:H4 bacterium from the recent European outbreak. Ann Agric Environ Med., 19(1): 3–10.
  15. Samie A (2017). Escherichia coli Recent Advances on Physiology, Pathogenesis and Biotechnological Applications. IntechOpen.
  16. EFSA and ECDC (European Food Safety Authority and European Centre for Disease Prevention and Control) (2023). The european union one health 2022 zoonoses report. EFSA Journal, 21(12): Article e8442. https://doi.org/10.2903/j.efsa.2023.8442
  17. Etcheverría AI, Padola NL (2013). Shiga toxin-producing Escherichia coli: factors involved in virulence and cattle colonization. Virulence, 4(5): 366–372. https://doi.org/10.4161/viru.24642.
  18. Söderlund R, Hedenström I, Nilsson A, Eriksson E, Aspán A. (2012). Genetically similar strains of Escherichia coli O157:H7 isolated from sheep, cattle and human patients. BMC Vet Res., 8: 200. https://doi.org/10.1186/1746-6148-8-200
  19. Detzner J, Pohlentz G, Müthing J (2022). Enterohemorrhagic Escherichia coli and a fresh view on shiga toxin-binding glycosphingolipids of primary human kidney and colon epithelial cells and their toxin susceptibility. Int J Mol Sci., 23(13): 6884. https://doi.org/10.3390/ijms23136884
  20. Dewsbury DMA, Cernicchiaro N, Sanderson MW, Dixon AL, Ekong PS (2022). A systematic review and meta-analysis of published literature on prevalence of non-O157 shiga toxin-producing Escherichia coli serogroups (O26, O45, O103, O111, O121, and O145) and virulence genes in feces, hides, and carcasses of Pre- and Peri-harvest cattle worldwide. Anim Health Res Rev., 23(1): 1-24. https://doi.org/10.1017/S1466252321000153
  21. Levinson W (2008). Tıbbi Mikrobiyoloji ve Immünoloji (B Esen, Çev., B Şener, Çev.). Öncü Basımevi, Ankara.
  22. El-Baz R, Said HS, Abdelmegeed ES, Barwa, R. (2022). Characterization of virulence determinants and phylogenetic background of multiple and extensively drug resistant Escherichia coli isolated from different clinical sources in Egypt. Appl Microbiol Biotechnol., 106(3): 1279–1298. https://doi.org/10.1007/s00253-021-11740-x
  23. Garrido P, Blanco M, Moreno-Paz M, Briones C, Dahbi G, Blanco J, Blanco J, Parro V (2006). STEC-EPEC oligonucleotide microarray: A new tool for typing genetic variants of the LEE pathogenicity Island of human and animal shiga toxin-producing Escherichia coli (STEC) and enteropathogenic E. coli (EPEC) strains. Clin Chem., 52(2): 192–201. https://doi.org/10.1373/clinchem.2005.059766.
  24. Scheutz F, Teel LD, Beutin L, Piérard D, Buvens G, Karch H, Mellmann A, Caprioli A, Tozzoli R, Morabito S, Strockbine NA, Melton-Celsa, AR, Sanchez M, Persson S, O'Brien AD (2012). Multicenter Evaluation of a Sequence-based Protocol for Subtyping Shiga Toxins and Standardizing stx Nomenclature. J Clin Microbiol., 50(9): 2951–2963. https://doi.org/10.1128/JCM.00860-12
  25. CDC (Centers for Disease Control and Prevention) (2014). Questions and Answers. https://www.cdc.gov/ecoli/general/index.html
  26. Rosove MH (2014). Thrombotic microangiopathies. Semin Arthritis Rheum. 43(6): 797–805. https://doi.org/10.1042/BCJ20220016
  27. Bolton DJ, Ennis C, Brain B, Monaghan A (2009). Serogroups and virulence genes in verocytotoxigenic Escherichia coli on beef farms and in the beef abattoir. Advancing Beef Safety Through Research and Innovation, 59. March 25-26, Dublin, Ireland.
  28. Brás A, Braz M, Martinho I, Duarte J, Pereira C, Almeida A (2024). Effect of bacteriophages against biofilms of Escherichia coli on food processing surfaces. Microorganisms, 12(2): 366. https://doi.org/10.3390/microorganisms12020366
  29. Costigan C, Raftery T, Carroll AG et al. (2022). Neurological involvement in children with hemolytic uremic syndrome. Eur J of Pediatr., 181: 501–512. https://doi.org/10.1007/s00431-021-04200-1.
  30. Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C (2017). Haemolytic uraemic syndrome. Lancet, 390(10095): 681–696. https://doi.org/10.1016/S0140-6736(17)30062-4.
  31. Harkins VJ, McAllister DA, Reynolds BC (2020). Shiga-toxin E. coli hemolytic uremic syndrome: Review of management and long-term outcome. Curr Pediatr Rep,. 8(1): 16–25. https://doi.org/10.1007/s40124-020-00208-7
  32. Kalalah AA, Koenig SSK, Bono JL, Bosilevac JM., Eppinger M (2024). Pathogenomes and virulence profiles of representative big six non-O157 serogroup shiga toxin-producing Escherichia coli. Front Microbiol., 15: (1364026). https://doi.org/10.3389/fmicb.2024.1364026
  33. Valilis E, Ramsey A, Sidiq S, DuPont HL (2018). Non-O157 shiga toxin-producing Escherichia coli-A poorly appreciated enteric pathogen: Systematic Review. Int J Infect Dis,. 76: 82-87. https://doi.org/10.1016/j.ijid.2018.09.002.
  34. Monaghan A, Byrne B, Fanning S, Sweeney T, McDowell D, Bolton DJ (2011). Serotypes and virulence profiles of non-O157 shiga toxin-producing Escherichia coli isolates from bovine farms. App Environ Microbiol., 77(24): 8662–8668. https://doi.org/10.1128/AEM.06190-11
  35. Bosilevac JM, Koohmaraie M (2011). Prevalence and characterization of non-O157 shiga toxin-producing Escherichia coli isolates from Commercial ground beef in the United States. Appl Environ Microbiol., 77(6): 2103–2112. https://doi.org/10.1128/AEM.02833-10.
  36. USDA (United States Department of Agriculture) (2011). Shiga toxin-producing Escherichia coli in certain raw beef products, https://www.federalregister.gov/documents/2011/11/23/2011-30271/shiga-toxin-producing-escherichia-coli-in-certain-raw-beef-products. Erişim Tarihi: 29.11.2024.
  37. Carbonari, C. C., Miliwebsky, E. S., Zolezzi, G., Deza, N. L., Fittipaldi, N., Manfredi, E., Baschkier, A., D’Astek, B. A., Melano, R. G., Schesi, C., Rivas, M., & Chinen, I. (2022). The importance of shiga toxin-producing Escherichia coli O145:NM[H28]/H28 infections in Argentina, 1998–2020. Microorganisms, 10(3), 582. https://doi.org/10.3390/microorganisms10030582.
  38. Bielaszewska M, Zhang W, Tarr PI, Sonntag AK, Karch H (2005). Molecular profiling and phenotype analysis of Escherichia coli O26:H11 and O26:NM: secular and geographic consistency of enterohemorrhagic and enteropathogenic isolates. J Clin Microbiol., 43(8): 4225–4228. https://doi.org/10.1128/JCM.43.8.4225-4228.2005.
  39. Durso LM, Bono JL, Keen JE (2005). Molecular serotyping of Escherichia coli O26:H11. Appl Environ Microbiol., 71(8): 4941–4944. https://doi.org/10.1128/AEM.71.8.4941-4944.2005
  40. CDC (Centers for Disease Control and Prevention) (2012). Multistate outbreak of shiga toxin-producing Escherichia coli O26 infections linked to raw clover sprouts at Jimmy John's Restaurants (Final Update). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2012/o26-02-12/index.html. Erişim Tarihi: 29.11.2024
  41. CDC (Centers for Disease Control and Prevention) (2013). Multistate outbreak of shiga toxin-producing Escherichia coli O121 infections linked to farm Rich Brand frozen food products (Final Update). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2013/o121-03-13/index.html. Erişim Tarihi: 29.11.2024
  42. Rodwell, EV, Simpson A, Chan YW, Godbole G, McCarthy ND, Jenkins C. (2023). The epidemiology of shiga toxin-producing Escherichia coli O26:H11 (clonal complex 29) in England, 2014-2021. J Infect., 86(6): 552-562. https://doi.org/10.1016/j.jinf.2023.04.006.
  43. De Schrijver K, Buvens G, Possé B, Van den Branden D, Oosterlynck O, De Zutter L, Eilers K, Piérard D, Dierick K, Van Damme-Lombaerts R, Lauwers C, Jacobs R (2008). Outbreak of verocytotoxin-producing E. coli O145 and O26 infections associated with the consumption of ice cream produced at a farm, Belgium, 2007. Euro Surveill., 13(7):8041. https://doi.org/10.2807/ese.13.07.08041-en.
  44. Ethelberg S, Smith B, Torpdahl M, Lisby M, Boel J, Jensen T, Mølbak K (2007). An outbreak of verocytotoxin-producing Escherichia coli O26:H11 caused by beef sausage, Denmark 2007. Euro Surveill., 12(22):3208. https://doi.org/10.2807/esw.12.22.03208-en.
  45. CDC (Centers for Disease Control and Prevention) (2016). Multistate outbreaks of shiga toxin-producing Escherichia coli O26 infections linked to chipotle Mexican grill restaurants (Final Update). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2015/o26-11-15/index.html. Erişim Tarihi: 29.11.2024.
  46. CDC (Centers for Disease Control and Prevention) (2016). Multistate outbreak of shiga toxin-producing Escherichia coli infections linked to flour (Final Update). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2015/o26-11-15/index.html. Erişim Tarihi: 29.11.2024.
  47. CDC (Centers for Disease Control and Prevention) (2018). Outbreak of E. coli Infections Linked to Ground Beef. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2018/o26-09-18/index.html. Erişim Tarihi: 29.11.2024.
  48. CDC (Centers for Disease Control and Prevention) (2019). Outbreak of E. coli Infections Linked to Flour. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2019/flour-05-19/index.html. Erişim Tarihi: 29.11.2024.
  49. Brooks JT, Bergmire-Sweat D, Kennedy M, Hendricks K, Garcia M, Marengo L, Wells J, Ying M, Bibb W, Griffin PM, Hoekstra RM, Friedman CR (2004). Outbreak of shiga toxin-producing Escherichia coli O111:H8 infections among attendees of a high school cheerleading camp. Clin Infect Dis., 38(2): 190–198. https://doi.org/10.1086/380634
  50. Schaffzin JK, Coronado F, Dumas NB et al. (2012). Public health approach to detection of non-O157 shiga toxin-producing Escherichia coli: Summary of two outbreaks and laboratory procedures. Epidemiol Infect., 140(2): 283–289. https://doi.org/10.1017/S0950268811000719.
  51. Luna-Gierke RE, Griffin PM, Gould LH., Herman K, Bopp CA, Strockbine N, & Mody RK (2014). Outbreaks of non-O157 shiga toxin-producing Escherichia coli infection: USA. Epidemiol Infect., 142(11): 2270–2280. https://doi.org/10.1017/S0950268813003233.
  52. FSA (Food Standards Agency) (2023). FSA and UKHSA warn of the possible presence of E.coli in various Mrs Kirkham’s Lancashire Cheese. https://www.food.gov.uk/news-alerts/news/fsa-and-ukhsa-warn-of-the-possible-presence-of-e-coli-in-various-mrs-kirkhams-lancashire-cheese. Tarihi: 29.11.2024.
  53. Fratamico PM, DebRoy C, Strobaugh TP Jr, Chen CY (2005). DNA Sequence of the Escherichia coli O103 O Antigen gene cluster and detection of enterohemorrhagic E. coli O103 by PCR amplification of the wzx and wzy genes. Can J Microbiol,. 51(6): 515–522. https://doi.org/10.1139/w05-049
  54. Sekse C, Sunde M, Hopp P, Bruheim T, Cudjoe KS, Kvitle B, Urdahl AM (2013). Occurrence of Potentially Human-Pathogenic Escherichia coli O103 in Norwegian Sheep. Appl Environ Microbiol., 79(23): 7502-7509. https://doi.org/10.1128/AEM.01825-13.
  55. Schimmer B, Nygard K, Eriksen HM et al. (2008). Outbreak of haemolytic uraemic syndrome in Norway caused by stx2-positive Escherichia coli O103:H25 traced to cured mutton sausages. BMC Infect Dis., 8:41. https://doi.org/10.1186/1471-2334-8-41.
  56. Mylius M, Dreesman J, Pulz M et al. (2018). Shiga toxin-producing Escherichia coli O103:H2 Outbreak in Germany after school Trip to Austria due to raw cow milk, 2017 - The important role of international collaboration for outbreak investigations. Int J Med Microbiol., 308(5): 539–544. https://doi.org/10.1016/j.ijmm.2018.05.005
  57. CDC (Centers for Disease Control and Prevention) (2019). Outbreak of E. coli infections linked to ground beef. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2019/o103-04-19/index.html. Erişim Tarihi: 29.11.2024.
  58. CDC (Centers for Disease Control and Prevention) (2019). Outbreak of E. coli infections linked to ground bison produced by Northfork Bison Distributions, Inc. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2019/bison-07-19/index.html. Erişim Tarihi: 29.11.2024.
  59. CDC (Centers for Disease Control and Prevention) (2020). Outbreak of E. coli infections linked to clover sprouts. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2020/o103h2-02-20/index.html. Erişim Tarihi: 29.11.2024.
  60. Viljanen, M. K., Peltola, T., Kuistila, M., Huovinen, P., Junnila, S. Y. T., Olkkonen, L., & Järvinen, H. (1990). Outbreak of diarrhoea due to Escherichia coli 0111: B4 in schoolchildren and adults: association of Vi antigen-like reactivity. Lancet, 336(8719), 831-834. https://doi.org/10.1016/0140-6736(90)92337-h.
  61. CDC (Centers for Disease Control and Prevention) (1995). Community Outbreak of Hemolytic Uremic Syndrome Attributable to Escherichia coli O111:NM--South Australia 1995. Morbidity and Mortality Weekly Report, 44(29): 550–558.
  62. Bradley KK, Williams JM, Burnsed LJ, Lytle MB, Mcdermott MD, Mody RK, Bhattarai A., Mallonee S., Piercefıeld EW, Mcdonald-Hamm CK, Smithee LK (2012). Epidemiology of a large restaurant-associated outbreak of shiga toxin-producing Escherichia coli O111:NM. Epidemiol Infect., 140(9): 1644–1654. https://doi.org/10.1017/S0950268811002329
  63. McCarthy TA, Barrett NL, Hadler JL, Salsbury B, Howard RT, Dingman DW, Brinkman CD, Bibb WF, Cartter ML (2001). Hemolytic-uremic syndrome and Escherichia coli O121 at a lake in Connecticut, 1999. Pediatrics, 108(4): 59. https://doi.org/10.1542/peds.108.4.e59.
  64. NIID (National Institute of Infectious Diseases) (2009). Enterohemorrhagic Escherichia coli infection in Japan as of April 2009. Infectious Agents Surveillance Report, 30(5): 119–120.
  65. CDC (Centers for Disease Control and Prevention) (2022). E. coli outbreak linked to frozen falafel. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2022/o121-10-22/index.html. Erişim tarihi: 29.11.2024.
  66. Taylor EV, Nguyen TA, Machesky KD et al. (2013). Multistate outbreak of Escherichia coli O145 infections associated with Romaine lettuce consumption, 2010. J Food Prot., 76(6): 939-944. https://doi.org/10.4315/0362-028X.JFP-12-503.
  67. CDC (Centers for Disease Control and Prevention) (2010). Multistate outbreak of human E. coli O145 infections linked to shredded Romaine lettuce from a Single processing Facility (Final Update). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2010/shredded-romaine-5-21-10.html. Erişim tarihi: 29.11.2024.
  68. CDC (Centers for Disease Control and Prevention) (2012). Multistate outbreak of shiga toxin-producing Escherichia coli O145 infections (Final Update). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/ecoli/2012/o145-06-12/index.html. Erişim tarihi: 29.11.2024.
  69. Alharbi MG, Al-Hindi RR, Esmael A, Alotibi IA, Azhari SA, Alseghayer MS, Teklemariam AD (2022). The "Big Six": Hidden emerging foodborne bacterial pathogens. Trop Med Infect Dis., 7(11): 356. https://doi:10.3390/tropicalmed7110356.
  70. New York State, Department of Health (2024). Shiga toxin-producing E. coli (STEC) infections. https://www.health.ny.gov/diseases/communicable/ecoli/stec.html. Erişim Tarihi: 10.10.2024.