Shigellosis Shigellosis Serious gastrointestinal illness caused by the

Shigellosis

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

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

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

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.

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

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

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

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 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

MMWR: Shigellosis Outbreak Associated With an Unchlorinated Filland-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

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

Shigellosis Outbreak Fill-and-Drain Wading Pool- Iowa 2001 • Symptoms – 100% diarrhea – 51% nausea – 47% vomiting – 39% bloody diarrhea – 29% headache – 16% hospitalized

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

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 0157: H 7

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

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

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 <12 days after visit

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 (OR=52. 5)

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

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

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 3 ppm – Sign advising visitors to shower before entering the fountain and to avoid water consumption – Children with diapers were excluded from entering the fountain

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

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

Multi-state Day Care Outbreak MMWR 53 (3) 60 -63, 2004 • PFGE – 1, 349 isolates submitted to Pulse. Net • 2 dominant patterns found – 505 (37%) – 382 (28%) • PFGE & Rhamnose fermentation – 386 isolates • 246 had the dominant pattern – 241 (98%) rhamnose negative

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