Shigella Prevention and Control Toolkit
Shigellosis is a highly contagious diarrheal disease caused by a group of bacteria called Shigella. Outbreaks of Shigella infection can occur from environmental,1 food,2, 3 water,4–9 or person-to- person10 exposure (see References section). Anyone can get sick from Shigella infection. However, groups that may be at particular risk include children,11–19 travelers,20, 21 men who have sex with men,22–37 and people with weakened immune systems. 35, 38–42 Shigella bacteria have increasing rates of antimicrobial resistance both in the United States43 and globally.20, 30, 34, 44–47
The information in this toolkit is intended to help state and local health departments respond to suspected or confirmed cases, clusters, or outbreaks of Shigella infection.
These materials include information on:
- Data collection
- Responding to an outbreak of Shigella infection
- Sanitation, hygiene, and cleaning
- Fact sheets, palm cards, and letter templates to aid communications with the public, including materials specific to key populations
In the event of a suspected or confirmed Shigella case, cluster, or outbreak, a hypothesis-generating questionnaire may be useful. A hypothesis-generating questionnaire could collect data on case demographics, clinical and treatment information, medical history, and exposure information, such as travel, recent activities, sexual health and history, occupation, and childcare center or school attendance.
An example of a hypothesis-generating questionnaire focused on food is the National Hypothesis Generating Questionnaire (NHGQ).
If you do not currently have access to a hypothesis-generating questionnaire for shigellosis, CDC can provide assistance, including sharing hypothesis-generating questionnaires used by other state and local health departments.
Responding to a Shigella Outbreak
Reviewing how other jurisdictions have approached Shigella outbreaks can be useful to inform outbreak investigation and response efforts. The following references (listed in the References section) discuss Shigella outbreaks that have occurred in different settings, among different populations, and across different modes:
- Intensified Control Measures for Shigellosis Outbreaks in a Childcare Setting
- Recreational Water Illness Outbreak Response Toolkit
- CDC Field Epidemiology Manual
- CDC’s Crisis and Emergency Risk Communication Manual
- Shigella Hypothesis Generating Questionnaire – English pdf icon[PDF – 8 pages] | Español pdf icon[PDF – 9 paginas]
Sanitation, Hygiene, and Cleaning
Sanitation, hygiene, and cleaning are recommended behaviors to prevent and control Shigella outbreaks. The following materials provide the best available information to help state and local health departments promote sanitation, hygiene, and cleaning behaviors as part of comprehensive prevention and control efforts.
Frequent handwashing helps reduce the spread of Shigella infection and is an intervention applicable to a range of outbreak settings and modes of transmission.
Recommended Handwashing Steps
- Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
- Lather your hands by rubbing them together with the soap.
Be sure to lather the backs of your hands, between your fingers, and under your nails.
- Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.
- Rinse your hands well under clean, running water.
- Dry your hands using a clean towel or air dry them.
Handwashing in Childcare Settings
Schedule and supervise handwashing of all children during the following times:
- Upon arrival at the facility
- After outdoor play
- Before meals and snacks
- Upon leaving the childcare setting
Also supervise handwashing after diaper changes and using the bathroom.
When Hands Should Be Washed
- Before, during, and after preparing food
- Before eating food
- Before and after caring for someone who is sick
- After using the toilet
- After blowing your nose, coughing, or sneezing
- After touching garbage
- After changing diapers or cleaning up a child who has used the toilet
- After touching an animal, animal feed, or animal waste
- After handling pet food or pet treats
- CDC handwashing website (English and Spanish)
- Handwashing health promotion materials (posters, fact sheets, social media, videos)
- Handwashing trainings and educational resources
Maintaining hygienic diaper changing practices is essential to reducing the spread of Shigella infection. Even a microscopic amount of feces (poop) can contain millions of germs.
Recommended Diapering Steps
- Cover the diaper changing surface with a disposable liner.
- If you will use diaper cream, dispense it onto a tissue now.
- Bring your supplies (e.g., clean diaper, wipes, diaper cream, gloves, plastic or waterproof bag for soiled clothing, extra clothes) to the diapering area.
- Clean Child
- Place the child on the diapering surface and unfasten the diaper.
- Clean the child’s diaper area with disposable wipes. Always wipe front to back!
- Keep the soiled diaper/clothing away from any surfaces that cannot be easily cleaned. Securely bag soiled clothing.
- Remove Trash
- Place used wipes in the soiled diaper.
- Discard the soiled diaper and wipes in the trash can.
- Remove and discard gloves, if used.
- Replace Diaper
- Slide a fresh diaper under the child.
- Apply diaper cream, if needed, with a tissue or a freshly gloved finger.
- Fasten the diaper and dress the child.
- Wash Child’s Hands
- Wash the child’s hands with soap and water and place him or her in a safe, supervised area.
- Clean Up
- Remove the liner from the changing surface and discard in the trash can.
- Wipe up any visible soil with damp paper towels or a baby wipe.
- Wet the entire surface with disinfectant; make sure you read and follow the directions on the disinfecting spray, fluid, or wipe. Choose disinfectant appropriate for the surface material.
- Wash Your Hands
- Wash your hands thoroughly with soap and water.
- CDC diapering website
- Diapering in the home (English and Spanish)
- Diapering for childcare providers
- Diapering in emergency settings (English and Spanish)
- Diapering in shelters
Facility Sanitation and Cleaning
Surfaces and objects in childcare centers and other facilities often have germs that can cause illnesses like diarrhea. In the event of an outbreak, surfaces may need to be cleaned and disinfected more often to reduce the chance of spreading Shigella infection. Childcare centers and other facilities can consider creating a schedule that helps facility staff routinely clean surfaces and objects.
Cleaning, Sanitizing, and Disinfecting
Cleaning, sanitizing, and disinfecting are all ways to remove germs from surfaces and objects in childcare centers and other facilities, but some of these methods do not remove all germs. Generally, a cleaning process uses soap and water only, but sanitizing and disinfecting require using stronger chemicals or bleach. Generally, disinfecting solutions kill more germs than sanitizing solutions.
Information in this table was adapted from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs.99
How to Use Bleach Safely
- Replace bleach often. Bleach loses strength over time. (For best results, replace bleach each month with new bleach.)
- Mix bleach solutions safely. If you use a bleach solution, you should:
- Add bleach to the water (DO NOT add water to bleach).
- Make a new batch of the mixture each time you need it.
- DO NOT mix bleach with any cleaner containing ammonia. This can result in harmful chlorine gas.
- Keep children away from cleaning products. Do not use cleaning products when children are present or in close proximity to children. Keep bleach and bleach solutions in locked cabinets that are inaccessible to children.
- Protect your own health. Use cleaning, sanitizing, and disinfecting products in an area with adequate ventilation to prevent inhalation of potentially harmful fumes.
- Be aware of health hazards related to bleach. Bleach may irritate skin and eyes, and has the potential to trigger asthma. If you are concerned about potential hazards related to bleach, use a disinfectant that says EPA-approved instead. Get more information on EPA-registered disinfecting productsexternal icon.
¼ cup of bleach + 1 gallon of cool water
1 tablespoon of bleach + 1 quart of cool water Add the bleach to the water
1 tablespoon of bleach + 1 gallon of cool water Add the bleach to the water
Recipes adapted from the ABCs of Safe and Healthy Child Care: A Handbook for Childcare Providers.100
During an outbreak of Shigella infection, communication with the public should be open and regular. Keep all key stakeholders and constituents informed with next steps and useful information, and if necessary schedule periodic communications. CDC’s Crisis and Emergency Risk Communication (CERC) Manual and CERC in an pdf icon[PDF – 1 page] Infectious Disease Outbreak Manual pdf icon[PDF – 1 page] can be used to guide communication and messaging strategies during an outbreak of Shigella infection.
- Identify all key partners within your organization.
- Designate clearly defined roles based on every partner’s departmental roles and strengths.
- Within your agency, designate a shared space to store outbreak materials, develop a communication distribution list, and establish the most efficient ways to communicate outbreak updates.
- Depending on the magnitude of the outbreak and the degree of involvement with other agencies, the department may decide to follow the Incident Command System to assist in command, control, and coordination of the emergency response.
Communications with Other Health Departments or Agencies
- Determine a schedule for regular conference calls with established key contacts. Use these calls to keep everyone informed, plan next steps, and share information. This should be done on a case-by-case basis; every outbreak or event will have different communication needs.
- Decide how to share information, such as e-mail, state communication systems, or national communication systems, such as Epi-X. Make sure all communication channels work.
- Consider using HAN announcements or Clinician Outreach and Communication Activity (COCA) to reach clinicians.
Press Releases, Internal Talking Points, and Social Media
- When appropriate, press releases should include information about:
- Who is affected by the outbreak or event
- What the pathogen or issue is
- Where the outbreak or event is occurring
- When it happened
- What is being done to solve the issue(s) and steps people can take to protect themselves
- Keep press releases brief and use clear and simple language. A sample press release template pdf icon[PDF – 1 page]is available from the CDC website.
- Consider posting press releases to the agency’s website and linking to them from the agency’s social media platforms.
- Determine the case definition and the number of cases for release in a public case count.
- In uncertain circumstances, it is acceptable to leave room for changing case counts, as ongoing tests are verified or case definitions change. For example, consider using language such as “more than” or “fewer than (x) cases,” rather than giving exact numbers.
- Identify a clearance chain for reviewing all public information before release.
- Share a draft of the press release with established key contacts and partners before release.
- Develop internal talking points with your public information officer (PIO). Consider including predetermined answers to questions that may be asked by reporters, the public, or other agencies once a press release is issued.
- Share internal talking points with established key contacts and partners for message consistency.
- Determine how and when to inform the public that the outbreak or event is over and the health risk has subsided.
- Determine the best channels for communicating with the public. These could include press releases, press conferences, website updates, social media messages, or emergency alerts.
- Identify and establish a working relationship with your PIO.
- Work with your PIO to develop and maintain a distribution list of local news agencies and reporters with current contact information.
- Use this list to send news and updates about outbreaks, recent events, and other information.
- Discuss and agree upon a schedule for sending updates to the media during an outbreak or event.
- This should be done on a case-by-case basis; every outbreak or event will have different reporting needs.
- Identify a primary spokesperson for media interviews. Identify a secondary spokesperson for backup in case the primary is not available. Share this information with your PIO.
Letters to Parents and Other Populations
Communicating with parents and other affected populations is an essential part of the outbreak response to ensure they feel informed about the outbreak and know the steps they can take to protect their health and the health of others. A letter template to parents and to a general population is provided in Appendix A and Appendix B of this toolkit.
Health Communication Materials
CDC has developed several health communication materials to assist in the dissemination of key information on Shigella and sanitation and hygiene.
This toolkit includes links to a range of materials, including fact sheets, infographics, palm cards, and social media messages. Some materials are available in multiple languages, and a selection of printed materials can be ordered from CDC-INFO On Demand.
CDC Shigella Website
- English (www.cdc.gov/shigella)
- Spanish (www.cdc.gov/shigella/esp)
Adult Shigella Infographic
- English (www.cdc.gov/shigella/do-you-have-diarrhea.html)
- Spanish (www.cdc.gov/shigella/esp/diarrhea.html)
Sexually Active Adult Shigella Infographic
- English (www.cdc.gov/shigella/are-you-sick-with-diarrhea.html)
- Spanish (www.cdc.gov/shigella/esp/infographic-partner-diarrhea.html)
Sexually Active Adult Shigella Palm Cards
- English (www.cdc.gov/shigella/palm-cards.html)
- Spanish (www.cdc.gov/shigella/esp/palm-cards.html)
CDC Shigella Website for Sexually Active People
- English (www.cdc.gov/shigella/audience-sexually-active.html)
- Spanish (www.cdc.gov/shigella/esp/audience-sexually-active.html)
- English (www.cdc.gov/handwashing/fact-sheets.html)
- Spanish (www.cdc.gov/handwashing/esp/fact-sheets.html)
Pediatric Shigella Infographic
- English (www.cdc.gov/shigella/child-diarrhea.html)
- Spanish (www.cdc.gov/shigella/esp/child-diarrhea.html)
- Arabic, Chinese, French, Somali, Tagalog, Vietnamese (bottom of page www.cdc.gov/shigella/child-diarrhea.html)
Safe Diapering in Childcare Settings
Safe Diapering in the Home
- English (www.cdc.gov/healthywater/hygiene/diapering/in-the-home.html)
- Spanish (www.cdc.gov/healthywater/hygiene/diapering/in-the-home-esp.html)
- Arabic, Chinese, French, Somali, Tagalog, Vietnamese
(Bottom of page www.cdc.gov/healthywater/hygiene/diapering/in-the-home.html)
Social Media Messages
- Tweets and Facebook Posts (www.cdc.gov/shigella/social-media-library.html)
Appendix A. School or Childcare Center Letter to Parents
Dear Parent or Guardian,
A student in your child’s class has been diagnosed with shigellosis. Therefore, there is a possibility that your child has been exposed to this disease. Shigellosis is a highly contagious diarrheal disease caused by a group of bacteria called Shigella. Shigella can spread through person-to-person contact and contaminated food or water . Symptoms may include severe or bloody diarrhea, fever, and stomach cramps.
Parents of children or anyone with symptoms of shigellosis should contact their health care provider for diagnosis and treatment. Careful attention to handwashing with soap and water is the single most important action to decrease spread of Shigella. The attached fact sheet provides more information on shigellosis, including the signs and symptoms, ways it spreads, and the time it takes to get sick after exposure to the germ.
If any friends or family have any of these symptoms, encourage them to talk to their healthcare provider . <STUDENTS OR CHILDCARE CENTER ATTENDEES> with shigellosis may be kept out of <SCHOOL OR THE CHILDCARE CENTER> until symptoms have stopped and the <STUDENT OR CHILDCARE CENTER ATTENDEE> has a note from the healthcare provider to return to <SCHOOL OR THE CHILDCARE CENTER>.
If you have any questions, please contact <SCHOOL OR CHILDCARE CENTER DEPARTMENT> at <SCHOOL OR CHILDCARE or CENTER DEPARTMENT TELEPHONE NUMBER>.
<SCHOOL OR CHILDCARE CENTER ADMINISTRATOR NAME>
Appendix B. Organization Letter to Affected Patrons
<ORGANIZATION TELEPHONE NUMBER>
Dear <ORGANIZATION NAME> patron,
A <ORGANIZATION NAME patron or employee> has been diagnosed with shigellosis. Therefore, there is a possibility that you have been exposed to this disease. Shigellosis is a highly contagious diarrheal disease caused by a group of bacteria called Shigella. Shigella can spread through person-to-person contact and contaminated food or water. Symptoms may include severe or bloody diarrhea, fever, and stomach cramps.
Anyone with symptoms of shigellosis should contact their health care provider for diagnosis and treatment. Careful attention to handwashing with soap and water is the single most important action to decrease spread of Shigella. The attached fact sheet provides more information on shigellosis, including the signs and symptoms, ways it spreads, and the time it takes to get sick after exposure to the germ.
If any friends or family have any of these symptoms, encourage them to talk to their healthcare provider. <ORGANIZATION NAME employees> with shigellosis may be kept out of <ORGANIZATION NAME> until symptoms have stopped and the <ORGANIZATION NAME employee> has a note from the healthcare provider to return to <ORGANIZATION NAME> .
If you have any questions, please contact <ORGANIZATION DEPARTMENT NAME> at <ORGANIZATION DEPARTMENT TELEPHONE NUMBER>.
<ORGANIZATION OFFICIAL NAME>
- Ekanem, E.E., et al., Transmission dynamics of enteric bacteria in day-care centers. American Journal of Epidemiology, 1983. 118(4): p. 562–572.
- Kimura, A.C., et al., Multistate shigellosis outbreak and commercially prepared food, United States. Emerging Infectious Diseases, 2004. 10(6): p. 1147–1149.
- Nandy, S., et al., Foodborne-associated Shigella sonnei, India, 2009 and 2010 . Emerging Infectious Diseases 2011. 17(11): p. 2072–2074.
- Fleming, C.A., et al., An outbreak of Shigella sonnei associated with a recreational spray fountain. American Journal of Public Health, 2000. 90(10): p. 1641–1642.
- Makintubee, S., J. Mallonee, and G.R. Istre, . American Journal of Public Health, 1987. 77(2): p. 166–168.
- Sorvillo, F.J., et al., Shigellosis associated with recreational water contact in Los Angeles County. American Journal of Tropical Medicine and Hygiene, 1988. 38(3): p. 613–617.
- Keene, W.E., et al., A swimming associated outbreak of hemmorhagic colitis caused by E coli 0157 and Shigella sonnei. New England Journal of Medicine, 1994. 331: p. 579–584.
- Blostein, J., Shigellosis from swimming in a park pond in Michigan . Public Health Reports, 1991. 106(3): p. 317–322.
- Iwamoto, M., et al., Shigellosis among swimmers in a freshwater lake . Southern Medical Journal, 2005. 98(8): p. 774–778.
- Wikswo, M.E., et al., Outbreaks of acute gastroenteritis transmitted by person-to-person contact, Environmental contamination, and unknown modes of transmission—United States, 2009–2013. MMWR Surveillance Summaries, 2015. 64(12): p. 1–16.
- Scallan, E., et al., Estimates of illnesses, hospitalizations and deaths caused by major bacterial enteric pathogens in young children in the United States . Pediatric Infectious Disease Journal, 2013. 32(3): p. 217–221.
- Ashkenazi, S., Shigella infections in children: New insights . Seminars in Pediatric Infections Diseases, 2004. 15(4): p. 246–252. 13.
- Arvelo, W., et al., Transmission risk factors and treatment of pediatric shigellosis during a large daycare center-associated outbreak of multidrug resistant Shigella sonnei: Implications for the management of shigellosis outbreaks among children . Pediatric Infectious Disease Journal, 2009. 28(11): p. 976–980.
- CDC, Outbreaks of multidrug-resistant Shigella sonnei gastroenteritis associated with day care centers—Kansas, Kentucky, and Missouri, 2005 . Morbidity and Mortality Weekly Report, 2006. 55(39): p. 1068–1071.
- Genobile, D., et al., An outbreak of shigellosis in a child care centre . Communicable Diseases Intelligence Quarterly Report, 2004. 28(2): p. 225–229.
- Drees, M. and A.L. Hathcock, Prolonged daycare-associated outbreak caused by Shigella sonnei—Delaware, July 2002–April 2003 . Delaware Medical Journal 2004. 76(6): p. 235–241.
- Adams, D.A.T., K. R. Jajosky, R. A. , et al., Summary of Notifiable Infectious Diseases and Conditions—United States, 2015. Morbidity and Mortality Weekly Report, 2017. 64(53): p. 1–143.
- Mohle-Boetani, J.C., et al., Communitywide shigellosis: Control of an outbreak and risk factors in child day-care centers. American Journal of Public Health, 1995. 85(6): p. 812–816.
- Caldwell, G.G., et al., Shigella in Tulsa County, 1993: Epidemiology, day care center association, and control. Journal of the Oklahoma State Medical Association, 1995. 88(5): p. 198–204.
- Kim, J.S., et al., Outbreak of ciprofloxacin-resistant Shigella sonnei associated with travel to Vietnam, Republic of Korea. Emerging Infectious Diseases, 2015. 21(7): p. 1247–1250.
- O’Donnell, A., et al., Quinolone-resistant Salmonella enterica serotype Enteritidis infections associated with international travel. Clin Infect Dis, 2014. 59(9): p. e139–141.
- Goulart, M.A. and A.G. Wurcel, Shigellosis in men who have sex with men: an overlooked opportunity to counsel with pre-exposure prophylaxis for HIV . International Journal of STD & AIDS, 2016. 27(13): p. 1236–1238.
- Bowen, A., et al., Elevated risk for antimicrobial drug-resistant shigella infection among men who have sex with men, United States, 2011–2015 . Emerging Infectious Diseases, 2016. 22(9): p. 1613–1616.
- Wilmer, A., et al., Shigella flexneri serotype 1 infections in men who have sex with men in Vancouver, Canada . HIV Medicine, 2015. 16(3): p. 168–175.
- Valcanis, M., et al., Outbreak of locally acquired azithromycin-resistant Shigella flexneri infection in men who have sex with men. Pathology, 2015. 47(1): p. 87–88.
- Cresswell, F.V., et al., Shigella flexneri: A cause of significant morbidity and associated with sexually transmitted infections in men who have sex with men . Sexually Transmitted Diseases, 2015. 42(6): p. 344.
- Bowen, A., et al., Outbreaks of Shigella sonnei infection with decreased susceptibility to azithromycin among men who have sex with men—Chicago and metropolitan Minneapolis–St. Paul, 2014. Morbidity and Mortality Weekly Report, 2015. 64(21): p. 597–598.
- Keay, R., et al., Shigella flexneri enteritis in risk-taking HIV-infected MSM . Journal of Infection, 2014. 68(1): p. 103–104.
- Heiman, K.E., et al., Shigella with decreased susceptibility to azithromycin among men who have sex with men—United States, 2002–2013 . Morbidity and Mortality Weekly Report, 2014. 63(6): p. 132–133.
- Gaudreau, C., et al., Shigella spp. with reduced azithromycin susceptibility, Quebec, Canada, 2012–2013 . Emerging Infectious Diseases, 2014. 20(5): p. 854–856.
- Hoffmann, C., et al., High rates of quinolone-resistant strains of Shigella sonnei in HIV-infected MSM . Infection, 2013. 41(5): p. 999–1003.
- Okame, M., et al., Shigella sonnei outbreak among men who have sex with men in Tokyo . Japanese Journal of Infectious Diseases, 2012. 65(3): p. 277–278.
- Borg, M.L., et al., Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009–2011 . Euro Surveillance, 2012. 17(13): p. pii=20137.
- Gaudreau, C., et al., Ciprofloxacin-resistant Shigella sonnei among men who have sex with men, Canada, 2010 . Emerging Infectious Diseases, 2011. 17(9): p. 1747–1750.
- Aragon, T.J., et al., Case-control study of shigellosis in San Francisco: the role of sexual transmission and HIV infection. Clinical Infectious Diseases, 2007. 44(3): p. 327–334.
- CDC, Shigella flexneri serotype 3 infections among men who have sex with men—Chicago, Illinois, 2003–2004 . Morbidity and Mortality Weekly Report, 2005. 54(33): p. 820–822.
- Morgan, O., et al., Shigella sonnei outbreak among homosexual men, London. Emerging Infectious Diseases, 2006. 12(9): p. 1458–1460.
- Baer, J.T., et al., HIV infection as a risk factor for shigellosis. Emerging Infectious Diseases, 1999. 5(6): p. 820–823.
- Shenker, B.S. and D. Wynn, Shigella flexeneri bacteremia in an adult male with newly diagnosed human immunodeficiency virus and acute Hepatitis B infection . Infectious Diseases in Clinical Practice, 2009. 17(2): p. 114–115.
- Yoo, N. and B. West, Severe acute colitis in an HIV-positive man caused by Shigella flexneri . Pathology Case Reviews, 2011. 16(6): p. 234–237.
- Mohan, K., et al., What is the overlap between HIV and shigellosis epidemics in England: Further evidence of MSM transmission? Sexually Transmitted Infections, 2018. 94: p. 67–70.
- Serafino Wani, R.L., et al., Invasive shigellosis in MSM. International Journal of STD AIDS, 2016. 27(10): p. 917–919.
- CDC, Antibiotic resistance threats in the United States, 2013 . 2013, Centers for Disease Control and Prevention: Atlanta, GA.
- Joseph, H.A., et al., What happens when “Germs don’t get killed and they attack again and again”: perceptions of antimicrobial resistance in the context of diarrheal disease treatment among laypersons and health-care providers in Karachi, Pakistan . American Journal of Tropical Medicine and Hygiene 2016. 95(1): p. 221–228.
- Chiou, C.S., et al., The worldwide spread of ciprofloxacin-resistant Shigella sonnei among HIV-infected men who have sex with men, Taiwan. Clinical Microbiology and Infection, 2016. 22(4): p. 383.e11–383.e16.
- Bhattacharya, D., et al., Changing patterns and widening of antibiotic resistance in Shigella spp. over a decade (2000–2011), Andaman Islands, India . Epidemiology & Infection, 2015. 143(3): p. 470–477.
- Shimosako, J., et al., An outbreak of extended-spectrum beta-lactamase (ESBL)-producing Shigella sonnei at a day care nursery in Sakai City, 2006 . Japanese Journal of Infectious Diseases, 2007. 60(6): p. 408–409.
- McKee Jr, K.T., et al., Application of a geographic information system to the tracking and control of an outbreak of shigellosis. Clinical Infectious Diseases, 2000. 31(3): p. 728–733.
- CDC, Day care-related outbreaks of rhamnose-negative Shigella sonnei—six states, June 2001–March 2003 . Morbidity & Mortality Weekly Report, 2004. 53(3): p. 60–3.
- Mahoney, F.J., et al., Evaluation of an intervention program in the control of an urban outbreak of shigellosis. American Journal of Preventive Medicine, 1991. 7(5): p. 292–297.
- Sobel, J., et al., A prolonged outbreak of Shigella sonnei infections in traditionally observant Jewish communities in North America caused by a molecularly distinct bacterial subtype . The Journal of Infectious Diseases, 1998. 177(5): p. 1405–1409.
- Shane, A.L., et al., Sharing Shigella: Risk factors for a multicommunity outbreak of shigellosis. Archives of Pediatrics and Adolescent Medicine, 2003. 157(6): p. 601–603.
- Gehlbach, S.H., et al., Spread of disease by fecal-oral route in day nurseries. Health Services Report, 1973. 88(4): p. 320–322.
- An epidemic of shigellosis in a day-care centre in Quebec . Canadian Medical Association Journal, 1985. 132(4): p. 399–400.
- CDC, Shigellosis in child day care centers—Lexington-Fayette County, Kentucky, 1991 . Morbidity & Mortality Weekly Report, 1992. 41(25): p. 440–442.
- Pilon, P.A., B. Camara, and S. Bekal, Outbreak of Shigella sonnei in Montreal’s ultra-Orthodox Jewish community, 2015. Canada Communicable Disease Report, 2016. 42(4): p. 89–95.
- Hoffman, R.E. and P.J. Shillam, The use of hygiene, cohorting, and antimicrobial therapy to control an outbreak of shigellosis. American Journal of Diseases of Children, 1990. 144(2): p. 219–21.
- Artieda, J., et al., Brote de Shigella sonnei en un centro escolar de Gipuzkoa . Enfermedades Infecciosas y Microbiología Clínica, 2015. 33(3): p. 145–148.
- Schulte, J.M., et al., How we didn’t clean up until we washed our hands: Shigellosis in an elementary and middle school in North Texas . Southern Medical Journal, 2012. 105(1): p. 1–4.
- Chen, K.T., C.J. Chen, and J.P. Chiu, A school waterborne outbreak involving both Shigella sonnei and Entamoeba histolytica. Journal of Environmental Health, 2001. 64(4): p. 9–13, 26.
- Strysko, J., et al., Notes from the field: Outbreak of multidrug-resistant Shigella sonnei infections in a retirement community— Vermont, October–November 2018 . Morbidity and Mortality Weekly Report, 2019. 68(17): p. 405–406.
- Lew, J.F., et al., An outbreak of shigellosis aboard a cruise ship caused by a multiple-antibiotic-resistant strain of Shigella flexneri. American Journal of Epidemiology, 1991. 134(4): p. 413–420.
- Lee, L., et al., An outbreak of shigellosis at an outdoor music festival . American Journal of Epidemiology 1991. 133(6): p. 608–615.
- Wharton, M., et al., A large outbreak of antibiotic-resistant shigellosis at a mass gathering . The Journal of Infectious Diseases, 1990. 162(6): p. 1324–1328.
- Gaynor, K., et al., International foodborne outbreak of Shigella sonnei infection in airline passengers . Epidemiology & Infection, 2009. 137(3): p. 335–341.
- Hedberg, C.W., et al., An international foodborne outbreak of shigellosis associated with a commercial airline. Journal of the American Medical Association, 1992. 268(22): p. 3208–3212.
- De Schrijver, K., et al., Outbreak of Shigella sonnei infections in the Orthodox Jewish community of Antwerp, Belgium, April to August 2008 . Eurosurveillance, 2011. 16(14): p. pii=19838.
- Garrett, V., et al., A recurring outbreak of Shigella sonnei among traditionally observant Jewish children in New York City: The risks of daycare and household transmission . Epidemiology and Infection, 2006. 134(6): p. 1231–1236.
- Hines, J.Z., et al., Heavy precipitation as a risk factor for shigellosis among homeless persons during an outbreak—Oregon, 2015–2016. Journal of Infection 2018. 76(3): p. 280–285.
- Hines, J.Z., et al., Shigellosis outbreak among men who have sex with men and homeless persons—Oregon, 2015–2016. Morbidity & Mortality Weekly Report, 2016. 65(31): p. 812–813.
- CDC, Shigella sonnei outbreak among men who have sex with men—San Francisco, California, 2000–2001 . Morbidity & Mortality Weekly Report, 2001. 50(42): p. 922–926.
- Marcus, U., et al., Shigellosis—a re-emerging sexually transmitted infection: Outbreak in men having sex with men in Berlin. International Journal of STD & AIDS 2004. 15: p. 533–537.
- Rowe, S., et al., An outbreak of shigellosis among men who have sex with men, Victoria, 2008 . Victorian Infectious Diseases Bulletin, 2010. 13(4): p. 125–127.
- Danila, R.N., et al., Two concurrent enteric disease outbreaks among men who have sex with men, Minneapolis–St. Paul area. Clinical Infectious Diseases, 2014. 59(7): p. 987–9.
- Wu, H.H., et al., Shigellosis outbreak among MSM living with HIV: A case-control study in Taiwan, 2015–2016. Sexually Transmitted Infections 2019. 95(1): p. 67–70.
- O’Sullivan, B., et al., Shigellosis linked to sex venues, Australia . Emerging Infectious Diseases, 2002. 8(8): p. 862–4.
- Strauss, B., et al., Clusters of Shigella sonnei in men who have sex with men, British Columbia, 2001 . Canada Communicable Disease Report, 2001. 27(13): p. 109–10; discussion 110–4.
- Benny, E., et al., A large outbreak of shigellosis commencing in an internally displaced population, Papua New Guinea, 2013. Western Pacific Surveillance and Response Journal, 2014. 5(3): p. 18–21.
- Georgakopoulou, T., et al., Resistant Shigella strains in refugees, August–October 2015, Greece . Epidemiology & Infection, 2016. 144(11): p. 2415–2419.
- Lederer, I., et al., Shigellosis in refugees, Austria, July to November 2015 . Eurosurveillance, 2015. 20(48): p. 30081.
- Tucker, C.B., G.C. Fulkerson, and R.M. Neudecker, A milkborne outbreak of shigellosis in Madison County, Tenn. Public Health Reports, 1954. 69(5): p. 432–436.
- Fredlund, H., et al., Water-melon as a vehicle of transmission of shigellosis . Scandinavian Journal of Infectious Diseases, 1987. 19(2): p. 219–221.
- Davis, H., et al., A shigellosis outbreak traced to commercially distributed lettuce . American Journal of Epidemiology, 1989. 128(6): p. 1312–1321.
- Reeve, G., et al., An outbreak of shigellosis associated with the consumption of raw oysters . New England Journal of Medicine, 1989. 321(4): p. 224–227.
- Gessner, B.D. and M. Beller, Moose soup shigellosis in Alaska. Western Journal of Medicine 1994. 160(5): p. 430–433.
- Dunn, R., et al., Outbreak of Shigella flexneri linked to salad prepared at a central commissary in Michigan . Public Health Reports, 1995. 110(5): p. 580–586.
- Kapperud, G., et al., Outbreak of Shigella sonnei infection traced to imported iceberg lettuce . Journal of Clinical Microbiology, 1995. 33(3): p. 609–614.
- Lewis, H.C., et al., Outbreaks of shigellosis in Denmark and Australia associated with imported baby corn, August 2007—Final summary . Eurosurveillance, 2007. 12(40): p. pii=3279.
- Kuo, H.W., et al., A food-borne outbreak of Shigella sonnei gastroenteritis, Austria, 2008. Wiener klinische Wochenschrift, 2009. 121(3–4): p. 157–163.
- Guzman-Herrador, B.R., et al., A Shigella sonnei outbreak traced to imported basil—the importance of good typing tools and produce traceability systems, Norway, 2011 . Eurosurveillance, 2013. 18(49): p. pii=20650.
- Garcia-Fulgueiras, A., et al., A large outbreak of Shigella sonnei gastroenteritis associated with consumption of fresh pasteurised milk cheese . European Journal of Epidemiology, 2001. 17(6): p. 533–538.
- Nygren, B.L., et al., Foodborne outbreaks of shigellosis in the USA, 1998–2008. Epidemiology and Infection, 2012. 141(2): p. 233–241.
- Merson, M.H., et al., An outbreak of Shigella sonnei gastroenteritis on Colorado River raft trips. American Journal of Epidemiology, 1974. 100(3): p. 186–196.
- CDC, Shigella sonnei outbreak associated with contaminated drinking water—Island Park, Idaho, August 1995. Morbidity & Mortality Weekly Report, 1996. 45(11): p. 229–231.
- Alamanos, Y., et al., A community waterborne outbreak of gastro-enteritis attributed to Shigella sonnei. Epidemiology & Infection, 2000. 125(3): p. 499–503.
- CDC, Shigellosis outbreak associated with an unchlorinated fill-and-drain wading pool—Iowa, 2001 . Morbidity & Mortality Weekly Report, 2001. 50(37): p. 797–800.
- Arias, C., et al., Waterborne epidemic outbreak of Shigella sonnei gastroenteritis in Santa Maria de Palautordera, Catalonia, Spain. Epidemiology & Infection 2006. 134(3): p. 598–604.
- Godoy, P., et al., Waterborne outbreak of Shigella sonnei caused by consumption of public supply water. Gaceta Sanitaria, 2011. 25(5): p. 363–367.
- American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education, Caring for Our Children: National health and safety performance standards; Guidelines for early care and education programs. 4th ed. 2019, Itasca, IL: American Academy of Pediatrics.
- Hale, C.M. and J.A. Polder, ABCs of safe and healthy child care: A handbook for child care providers. 1996, Centers for Disease Control and Prevention Atlanta, GA.