Shigellosis

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Shigellosis
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Shigellosis

• Serious gastrointestinal illness caused by the
  Shigella bacteria
• Very easy to spread from one person to another
• It is very serious in babies, older adults, and
  people who are not well

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Background

• Discovered over 100 years ago by a Japanese
  scientist named Shiga
• Different serotypes
• Shigella sonnei Group D 2/3
• Shigella flexneri Group B almost the rest
• Shigella dysenteriae type 1 deadly epidemics in
  developing world

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How is shigellosis spread?

• Shigella is shed in the stool of infected people
  and is most often spread
• on hands that have not been washed after using
  the bathroom
• from touching others or by touching food or
  drinks that others will eat
• by sexual practices that involve fecal-oral
  contact
• In countries with inadequate sewage disposal,
  flies can carry Shigella from feces to food

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Symptoms

• The symptoms of Shigella infection are
• sudden stomach pain
• stomach cramps
• diarrhea
• hospitalization
• Young children high fever seizures
• fever
• vomiting
• blood, pus, and mucus in the stool
• Symptoms begin about one day to one week after a
  person becomes infected and can last up to one
  week.
• Some people may have no symptoms but can still
  spread the infection to others.

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Incubation Period Duration

• Incubation Period
• - 1-4 days
• Duration
• 5-7 days

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Treatment

• Antibiotics may be used to treat shigellosis, but
  there are some resistant strains.

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Prevention

• Washing hands with soap and running water is the
  most important way to prevent the spread of
  Shigella
• after using the bathroom
• after changing diapers
• after cleaning the toilet
• after handling soiled towels or linens
• before eating
• before preparing food
• People with diarrhea should not fix or serve food
  that will be eaten by others

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Prevention in Day Care Setting

• Never send a child with Shigellosis to a day care
  center, especially if the child has diarrhea
• Use day care centers that do the following
• staff wash their hands after changing each diaper
• staff clean the changing area after each child
• children must wash their hands often
• children must wash their hands after using the
  toilet
• ill children are cared for at home or in a
  separate room
• facility is clean and sanitary

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MMWR Shigellosis Outbreak Associated With an
Unchlorinated Fill-and-Drain Wading Pool- Iowa
2001

• June 15, 2001
• Local physicians reported 11 cases of diarrhea to
  LHD
• 2 lab confirmed as Shigella sonnei
• 9 visited large water park with a wading pool
• Questionnaire
• Demographics
• Illness history
• Participation in group gatherings
• Water activities
• Use of the park or wading pool

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Shigellosis Outbreak Fill-and-Drain Wading Pool-
Iowa 2001

• Primary case
• Diarrhea within 72 hours of visiting the park
  during June 11-13
• Secondary case
• Diarrhea within 72 hours of household contact
  with a primary case patient
• 89 Interviewed
• 45 primary cases
• 16 lab confirmed Shigella sonnei
• 24 secondary cases
• 10 lab confirmed Shigella sonnei

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Shigellosis Outbreak Fill-and-Drain Wading Pool-
Iowa 2001

• Symptoms
• 100 diarrhea
• 51 nausea
• 47 vomiting
• 39 bloody diarrhea
• 29 headache
• 16 hospitalized

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Shigellosis Outbreak Fill-and-Drain Wading Pool-
Iowa 2001

• Pool exposure associated significantly with
  illness
• Pool frequented by diaper and toddler aged
  children
• 20-30 children at one time
• Fill Drain system
• Filled each morning with potable city water
• Drained Left empty each evening
• Backflow device- no recirculation or disinfection
  system (pump, filter, mechanical disinfection
  system)
• Each morning before filling, pool is rinsed with
  a high pressure washer and is scrubbed with a
  chlorine cleanser twice weekly
• Chlorine levels were not monitored and chlorine
  was not added to the pool water

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Shigellosis Outbreak Fill-and-Drain Wading Pool-
Iowa 2001

• Inadequate disinfection of pool
• Heavy use by diaper and toddler aged children
• Transmission of shigellosis result of residual
  contaminated water
• Infectious dose is low
• Small volume of ingested water can cause
  infection
• Lack of chlorination- increased risk of spread of
  E.coli 0157H7

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Shigellosis Outbreak Fill-and-Drain Wading Pool-
Iowa 2001

• Prevention
• Not swimming ill with diarrhea
• Not swallowing recreational water
• Practicing good hygiene when using the pool

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Shigellosis Outbreak Fill-and-Drain Wading Pool-
Iowa 2001

• Single outbreaks can expand to community-wide
  outbreaks
• Educate community about possible modes of
  transmission
• Child care facilities
• Food handlers
• Swimming
• Prevention recommendations
• Thorough handwashing after using restrooms,
  changing diapers and before handling/preparing
  foods
• Enforcement of exclusion criteria at child care
  facilities
• Exclusion of persons from swimming while ill with
  diarrhea

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MMWR Outbreak of Gastroenteritis Associated With
an Interactive Water Fountain at a Beachside Park
Florida, 1999

• Florida Dept. of Health
• 3 reports of Shigella sonnei linked to an
  interactive water fountain at a beachside park
• A case
• Abdominal cramps or diarrhea ( 3 or more loose
  stools within 24 hour period) in a person who
  visited the park on August 7-27 with illness
  onset

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Water Fountain Outbreak

• 86 park visitors were interviewed
• 38 met case definition
• Onsets of illness - August 15- September 2
• Median age - 8 years (Range 2-65 years)
• Symptoms
• 97 diarrhea
• 90 abdominal cramps
• 82 fever
• 66 vomiting
• 13 bloody diarrhea
• 5 Lab confirmed cases of Shigella and 2 cases of
  Cryptosporidium
• Water fountain ingestion (OR52.5)

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Water Fountain Outbreak

• Environmental assessment
• Fountain used re-circulated water that drained
  from the wet deck/play area floor into an
  underground reservoir
• Re-circulated water passed through a hypochlorite
  tablet chlorination system before being pumped
  back to the reservoir and then to several
  high-pressure fountain nozzles at ground level
  throughout the play area

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Water Fountain Outbreak

• Several potential opportunities for water
  contamination
• Fountain popular with diaper and toddler aged
  children who frequently stood directly over the
  nozzles
• Chlorine levels were not monitored
• Hypochlorite tablets were depleted after 7-10
  days of use and had not been replaced after the
  park opened on August 7

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Water Fountain Outbreak

• Park re-opened on December 12
• Cartridge filtration system installed
• Chlorine monitor installed to halt fountain
  operation automatically when residual chlorine
  levels fall below 3ppm
• Sign advising visitors to shower before entering
  the fountain and to avoid water consumption
• Children with diapers were excluded from entering
  the fountain

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Day Care-Related Outbreaks of Rhamnose-Negative
Shigella sonnei Six states June 2001-March 2003
MMWR 53 (3) 60-63, 2004

• June 2001- March 2003
• Shigella sonnei outbreaks
• Delaware, Maryland, New Jersey, North Carolina,
  South Carolina, and Virginia
• Five to forty-fold increases in statewide
  Shigella rates
• Outbreaks in multiple day care centers that
  became prolonged and communitywide
• Isolates genetically similar (PFGE)
• 3,081 lab confirmed cases
• A day care related case was defined as S.sonnei
  infection in a child attending day care or in a
  close contact of child attending day care

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Multi-state Day Care Outbreak MMWR 53 (3) 60-63,
2004

• Southeastern Virginia
• 878 lab confirmed cases
• Maryland
• 1,222 lab confirmed cases
• New Jersey
• 453 lab confirmed cases
• Delaware
• 506 lab confirmed cases
• North Carolina
• 935 lab confirmed cases
• New York City
• 115 lab confirmed cases
• Pennsylvania
• 317 lab confirmed cases

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Multi-state Day Care Outbreak MMWR 53 (3) 60-63,
2004

• PFGE
• 1,349 isolates submitted to PulseNet
• 2 dominant patterns found
• 505 (37)
• 382 (28)
• PFGE Rhamnose fermentation
• 386 isolates
• 246 had the dominant pattern
• 241 (98) rhamnose negative

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Multi-state Day Care Outbreak MMWR 53 (3) 60-63,
2004

• Public Health Interventions
• All Health departments excluded children with
  diarrhea from day care
• Not allowed to return until diarrhea ceased
• All but one health department did not allow
  children to return until two stool cultures
  testing negative for Shigella had been