The locus of enterocyte effacement (LEE) and genomic O island 122 (OI-122) are pathogenicity islands in verocytotoxin-producing Escherichia coli (VTEC) serotypes that are associated with outbreaks and serious disease. Composed of three modules, OI-122 may occur as "complete" (with all three modules) or "incomplete" (with one or two modules) in different strains. OI-122 encodes two non-LEE effector (Nle) molecules that are secreted by the LEE type III secretion system, and LEE and OI-122 are cointegrated in some VTEC strains. Thus, they are functionally linked, but little is known about the patterns of acquisition of these codependent islands. To examine this, we conducted a population genetics analysis, using multilocus sequence typing (MLST), with 72 VTEC strains (classified into seropathotypes A to E) and superimposed on the results the LEE and OI-122 contents of these organisms. The wide distribution of LEE and OI-122 modules among MLST clonal groups corroborates the hypothesis that there has been lateral transfer of both pathogenicity islands. Sequence analysis of a pagC-like gene in OI-122 module 1 also revealed two nonsynonymous single-nucleotide polymorphisms that could help discriminate a subset of seropathotype C strains and determine the presence of the LEE. A nonsense mutation was found in this gene in five less virulent strains, consistent with a decaying or inactive gene. The modular nature of OI-122 could be explained by the acquisition of modules by lateral transfer, either singly or as a group, and by degeneration of genes within modules. Correlations between clonal group, seropathotype, and LEE and OI-122 content provide insight into the role of genomic islands in VTEC evolution.Verocytotoxin-producing Escherichia coli (VTEC) and Shiga toxin-producing E. coli (STEC) are emerging zoonotic pathogens consisting of multiple serotypes, over 200 of which have been isolated from cases of human disease (48). Human infection by some VTEC serotypes, notably O157:H7, is associated with significant outbreaks and may lead to serious complications, such as hemorrhagic colitis and the hemolytic-uremic syndrome (HUS) (23,25,34). Karmali et al. (24) have classified VTEC into five seropathotype groups based on the relative frequency with which the serotypes are associated with serious and epidemic human disease (Table 1). There is a strong association between VTEC seropathotypes A and B that cause serious or epidemic disease and the presence of two genomic islands, the locus of enterocyte effacement (LEE), which is associated with the characteristic "attaching and effacing" lesions (20, 34), and genomic O island 122 (OI-122) (24).All of the virulence factors necessary for the formation of the attaching and effacing lesions in VTEC are encoded by the LEE pathogenicity island (18,20,34,47), which encodes the structural, accessory, and effector molecules of this type III secretion system (4,12,13,18,19). The LEE of VTEC serotype O157:H7 reference strain EDL 933, which is ϳ43.4 kb long, contains 41 open reading fram...