1. Shigellosis OutbreakKanawha CountyFall 2010 Rachel Holloway, CDC Public Health Associate Brandon Merritt, Regional Epidemiologist

2. Objectives • To describe an outbreak of Shigella sonnei in Kanawha County in Fall 2010 • To explain the epidemiologic procedures used during the shigellosis outbreak • To describe recommendations made by KCHD as a result of this outbreak

3. Shigellosis • CDC clinical definition: • An illness of variable severity characterized by diarrhea, fever, nausea, cramps, and tenesmus. • Caused by the shigella bacterium: • Shigella dysenteriae • Shigella flexneri • Shigella boydii • Shigella sonnei

4. Shigellosis • Mode of transmission: • Person to person via fecal-oral route • Food handlers • Incubation Period:1-3 days • Infectious Period: up to several weeks • Duration of illness: 5-7 days • Medical treatment: • Self-limiting • Antibiotics

5. Shigellosis in Kanawha Co. • Between 1999-2008, Kanawha County had an endemic rate of <1 case per 100,000 population.

6. And so it begins… • August 30, 2010: • Four confirmed S. sonnei at CAMC • 1 from elementary School “A” • 3 from elementary School “B” • Outbreak investigation opened • Reported to DIDE • Case definition established • Line list developed • Phone questionnaire created • Health Alert Network Advisory issued county wide

7. Case Definition • Confirmed case: • Laboratory confirmed s. sonnei stool specimen • Probable case: • Onset after August 28, 2010 with three or more episodes of diarrhea in a 24 hour period and an epi-link to a confirmed case

10. School Return Guidelines • Children with culture confirmed shigellosis who had begun antibiotic treatment were allowed to return to school after the diarrhea and fever was resolved for 24 hours; • Children with culture confirmed shigellosis and who were not given antibiotics were required to have a negative stool sample prior to returning to school; • Children who were showing symptoms of shigellosis, but were not culture confirmed, could only return to school 24 hours after diarrhea and fever had resolved.

11. Other Steps • On-site visit to School B • Provided staff education • Environmental cleaning procedures • Recommended limiting bathroom use • Health advisory to school nurses • Requested absence lists from prior weeks • Health advisory to daycares • Press release to local media • CAMC Emergency Room physician education

12. Results

13. Results

14. Results

15. Results

16. Shigella Sonnei PFGE Patterns With band markings: J16X01.wv021 J16X01.wv021 J16X01.wv014 J16X01.wv014 Without band markings:

17. Results

18. Results

19. Results

20. School B Floorplan 1 of 19 2 of 17 0 of 24 4 of 20 4 of 21 6 of 23 3 of 23 1 of 25 2 of 21 9 of 22 Speech Therapist 4 of 19 6 of 19 7 of 22 Clinic Bathroom

21. Other Results • Ill household contacts • 61% mentioned at least one ill contact • City X • 81% of cases located in one city • School B (49%) and School C (21%) located within 1 mile of each other

22. Recommendations • Schools and daycares should notify their local health department (LHD) immediately upon recognizing increased clusters of illness or higher than normal absenteeism; • Schools and daycares should implement additional hand-washing tutorials for students and staff especially after return to school from extended breaks and during flu season; • School administration should provide staff with sanitizing products, such as wipes and hand-sanitizer, to encourage frequent cleaning throughout the day; • Schools should always restrict clinic bathrooms to sick children only; • Physicians, clinics, and hospitals should stay up to date on all community health advisories and inform their LHD of any reportable illness as instructed.

23. Thank you! 108 LEE STREET EASTCHARLESTON, WV 25301304-344-KCHD(5243)