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Multistate Outbreak of Shigella sonnei Gastroenteritis -- United States

CDC has received reports that shigellosis outbreaks have occurred in several states, affecting related religious communities. Dates of onset range from November 1986 through June 1987. The largest outbreak was in New York City, and outbreaks in other states began soon after the Passover holiday in April, when many persons visited relatives in New York. Epidemiologic data are incomplete, but in some of these outbreaks new cases continue to occur. A summary of the outbreaks follows. NEW YORK STATE

New York City. Between December 27, 1986, and May 16, 1987, 1,328 cases of culture-confirmed Shigella sonnei gastroenteritis were reported in Brooklyn, New York (Figure 1). On the basis of a sentinel-physician surveillance system, the actual number of cases is likely to have exceeded 13,000. The vast majority of infected persons were tradition-observant Jews belonging to several religious sects. Of the persons with culture-confirmed cases, 55% were less than5 years and 85% were less than17 years of age; 55% were female.

Since more than 25% of the initial isolates were resistant to ampicillian, trimethoprim-sulfamethoxazole (TMP-SXT) was initially recommended for treatment. One isolate of TMP-SXT-resistant Shigella was identified in early January, and TMP-SXT resistance among tested isolates increased from 2% in January to 12% in March. In mid-March, a recommendation was made that patients with mild symptoms should not be treated with antimicrobials.

Person-to-person transmission was thought to be likely, since investigations did not implicate a common source of food or water. With the cooperation of community and religious leaders and physicians, control efforts were directed toward improved sanitation and personal hygiene in schools and homes. Special efforts were made to encourage handwashing with soap and water. The measures were instituted in late March, in anticipation of a large influx of people into these communities to celebrate the Passover holiday during third week in April.

Culture-confirmed cases decreased after the first week in April, but cases continue to be reported above the expected background rates among these religious groups in Brooklyn. The decline in reported Shigella isolates reflects the implementation of hygienic control measures starting the third week in March, the closing of the religious schools during the Passover holiday, and a reduced number of stool specimens obtained for culture as a result of preparations for and observance of the holidays.

Upstate New York. Outbreaks of S. sonnei infections were also recognized in two other tradition-observant Jewish communities in New York State. Approximately 110 culture-confirmed cases were reported in an Orange County community between November 29, 1986, and February 20, 1987. Two-thirds of the patients were less than 5 years and 95% were less than 17 years of age. Cases decreased sharply after a shigellosis advisory bulletin written in Hebrew was distributed throughout the community and a handwashing campaign was directed at school-aged children. A majority of the 110 isolates tested were resistant to ampicillin, but none were resistant to TMP-SXT. Another outbreak with greater than260 culture-confirmed cases began November 22, 1986, in a Rockland County community. Although control efforts similar to those used in Orange County were attempted, cases continue to be reported in Rockland County; one outbreak in early June affected 100 (77%) of 130 persons at a private party.

The New York State Department of Health has notified camp directors and nurses in children's summer camps serving the affected communities of the potential for further Shigella transmission. Recommendations include obtaining cultures from children with diarrhea, isolating or excluding culture-positive children from camp activities, and emphasizing personal hygiene. NEW JERSEY

Between May 2 and June 3, 1987, 45 cases of febrile gastroenteritis occurred at a private Hebrew day school in northeast New Jersey, affecting 30% of the children enrolled; half of the affected children had bloody diarrhea, and one child was hospitalized because of convulsions. S. sonnei was isolated from 33 stool specimens. Interviews suggested that the source of the outbreak was a tradition-observant Jewish community in Brooklyn to which many schoolchildren return on weekends. The first cases occurred at the nursery and kindergarten levels, and person-to-person spread appeared to cause cases among other schoolchildren as well as among family members. It was recommended that any child with two loose bowel movements per day or a positive stool culture should remain at home until he or she was asymptomatic for at least 2 days. Teachers and parents were instructed to teach the children to wash their hands thoroughly after defecation and before handling food and playing with other children. OHIO

Five cases of confirmed S. sonnei infections have occurred at a Jewish Orthodox school in Ohio. The student with the earliest confirmed case had illness onset on May 14, but school attendance records indicate that absenteeism for diarrheal illness began a week after the Passover holiday. Preschool and kindergarten children are now being supervised in handwashing after the use of toilet facilities and before meals. Parents have been advised that children with diarrheal illness will be excluded from school. The outbreak is being investigated to establish a possible relationship to the York City outbreak. MARYLAND

On May 26, 1987, the Baltimore County Health Department was notified that shigellosis cases were occurring among students and families associated with four private Jewish schools in Baltimore County, Maryland. In the period 7-June 14, 42 culture-confirmed and 54 probable cases of S. sonnei gastroenteritis occurred in 33 families residing in northwest Baltimore City and adjacent Baltimore County. Of the 87 persons affected whose age was known, 43% were less than6 years old. Symptoms included diarrhea (98.9%), fever (73.6%), abdominal cramps (62.6%), vomiting (21.8%), and bloody diarrhea (10.3%). Index-case children had attended one day-care center, three day-care homes, four private Jewish schools, and one public school. All S. sonnei isolates tested have been resistant to ampicillin but sensitive to TMP-SXT and tetracycline.

No common source for the Baltimore outbreak has been identified, and person- to-person transmission appears likely. Although visiting with friends and family from New York was commonly reported, no cases have been linked directly to confirmed cases in New York. Inspections have been performed, and hygiene has been emphasized in schools, day-care facilities, summer camps, pools, restaurants, and food stores in an effort to prevent transmission. Reported by: SK Schulman, MD, Brooklyn, New York; A Werzberger, MD, Monroe, New York; S Schultz, MD, City Epidemiologist, New York City Dept of Health; LD Budnick, MD, DL Morse, MD, MS, State Epidemiologist, New York State Dept of Health. H Ragazzoni, DVM, MPH, M Teter, DO, WE Parkin, DVM, DrPH, State Epidemiologist, New Jersey State Dept of Health. LK Giljahn, MPH, T Kramer, TJ Halpin, MD, MPH, State Epidemiologist, Ohio Dept of Health. D Dwyer, MD, J Baumgardner, D Glasser, MD, MPH, Baltimore City Health Dept; E Hopf, MD, Baltimore County Health Dept; E Israel, MD, MPH, State Epidemiologist, Maryland State Dept of Health and Mental Hygiene. Div of Field Svcs, Epidemiology Program Office; Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Shigella sonnei has become the predominant serotype that causes community outbreaks of shigellosis (1). Children 1-5 years of age are at highest risk of infection; their lack of hygienic practices, combined with the low infectious dose, the frequency of mild illness, and the acquisit of antimicrobial resistance, all predispose to transmission in day-care and preschool settings and to spread within the community (2,3). The community outbreaks reported here appear to be linked, beginning in New York, extending over an 8-month period, and expanding into several states following the Passover holidays; continued transmission is likely. The long duration of the outbreak and the large proportion of cases involving children are consistent with person-to-person transmission, although the limited epidemiologic data obtainable do not clearly define the routes of transmission. In a recent investigation of an outbreak of hepatitis A in one of the communities affected by this shigellosis outbreak, many opportunities for person-to-person transmission were identified (4).

Devising successful control measures for shigellosis remains a challenge. Handwashing with soap after defecation and before eating has been shown to reduce secondary transmission of shigellosis (5). Although control strategies that emphasize effective handwashing are often difficult to implement among children and families at highest risk, they may interrupt chains of transmission. Creative interventions should be encouraged, including handwashing protocols, posters, and counseling sensitive to local language and custom. Antimicrobial treatment of persons infected with Shigella has also been used to decrease morbidity and the secondary spread of infection (6). However, the appearance of antimicrobial-resistant strains of Shigella, as observed in New York City, has repeatedly complicated the use of antimicrobials in controlling shigellosis (7). The decision to use antimicrobials in treating patients with mild, self-limited illness should be weighed against the risk of producing resistant strains of Shigella.

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