Rachel Holloway, CDC Public Health Associate Brandon Merritt, Regional Epidemiologist

 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

 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

 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

 Between , Kanawha County had an endemic rate of <1 case per 100,000 population.

 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

 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

Patient Last Name, First NameSchoolCase StatusPatient DOBPatient AgePatient SexPatient Home PhonePatient Parent/Guardian Onset DateRecovery DateLength of IllnessOther SymptomsDoctor VisitStool CollectedMedicationsIll Contacts

 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.

 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

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

2 of 21 4 of 19 9 of 22 1 of 25 0 of 24 6 of 197 of 22 6 of 233 of 23 Speech Therapist 4 of 20 4 of 21 1 of 19 2 of 17 Clinic Bathroom

 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

 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.

108 LEE STREET EAST CHARLESTON, WV KCHD(5243)