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Epidemiologic Notes and Reports Shigellosis in Day-Care
Centers -- Washington, 1983
In late September 1983, two clusters of Shigella sonnei
infection
associated with high rates of diarrheal illness occurred among
children and staff in two Seattle, Washington, day-care centers.
No
link was discovered between the two centers, and the antimicrobial
resistance patterns associated with the isolates from the two
centers
differed. Circumstances dictated that the smaller center be
closed.
The larger one remained open, and in a departure from a previous
strict exclusionary policy, convalescent children and staff under
antimicrobial treatment were encouraged to return to the center,
where
they used a separate room, bathroom, and playground until they had
two
consecutive negative cultures off treatment. The parallel
occurence
of these two outbreaks at a time of low Shigella activity in the
community permitted the measurement of the efficacy of the control
strategies, using community surveillance.
Diarrheal illness attack rates were similar at the two centers
from September 5 to October 17 among the children (23/80 and
11/23),
staff (6/12 and 3/3), and family members of ill children (14/35 and
9/21) surveyed at the centers. Eighty-three other day-care centers
surveyed in the same or adjacent ZIP-code areas as the affected
centers showed a background diarrheal illness prevalence rate
during
September of 47/1313 (3.6%) of attending children, and 12/261
(4.6%)
of staff.
The two different intervention strategies produced differences
in
the requirements for alternate care at the two day-care centers.
The
first day-care center was closed for 24 working days, during which
alternate care arrangements had to be made for the 23 children who
had
attended it. At the second day-care center, alternate care
arrangements were necessary for the duration of diarrhea only for
the
estimated nine children who were ill at the time the isolation room
was created. A single case of culture-negative diarrheal illness
occurred among the children at each of the centers in the 2 weeks
following public-health intervention; no shigellosis was documented
among the children at either center in the next 2 months.
From September 1 to December 31, 11 S. sonnei isolates were
reported to the Seattle-King County Department of Public Health,
which
were not epidemiologically linked to either center. Plasmid
analysis
of these isolates is pending. Public-health management of these
two
simultaneous outbreaks may have limited the further spread of
illness
within both centers. The strategy of bringing convalescent
children
under treatment back into the center before they had negative
cultures
was not associated with further spread of Shigella in that center.
Reported by K Johnson, MPH, J Boase, MS, SD Helgerson, MD,
Seattle-King County Dept of Public Health, JM Kobayashi, MD, State
Epidemiologist, Washington State Dept of Social & Health Svcs;
Enteric
Diseases Br, Div of Bacterial Diseases, Center for Infectious
Diseases, CDC. Editorial Note
Editorial Note: It has been estimated that 11,000,000 children in
the
United States are in full- or part-time day care (1). The growing
need for day care has brought a growing need for controlling
infectious diseases that frequently affect children in day care.
First reported to CDC in 1972, shigellosis in day-care centers has
become a common and often frustrating problem. Day-care centers
play
an important role in the transmission of shigellosis in the
community
(2,3). Difficulties in controlling this infection in the day-care
setting include the low infectious dose, the unpredictable
acquisition
of antimicrobial resistance, the frequency of mild and inapparent
infections, and the frequency with which young children are
transferred from one day-care center to another. Although a
rigorous
handwashing policy has been shown to reduce the incidence of
nonspecific diarrheal illness in day-care centers, satisfactory
control measures for shigellosis have not been documented (4). On
one
occasion, the policy of rigid exclusion of convalescent children
until
they became culture-negative was associated with spread of the
infection to an adjacent county (5).
The Seattle outbreak suggests that shigellosis in day-care
centers
may be a controllable problem under certain circumstances. Control
strategies incorporating the early return of convalescent children
to
isolation settings in the day-care center are worthy of further
evaluation. Further evaluation of surveillance and control
strategies
is necessary before general recommendations can be made. A
symposium
entitled, "Infectious Diseases in Day Care: Management and
Prevention," will be held in Minneapolis, Minnesota, June 21-23,
1984. For further information, contact Donna Dacus, Department of
Conferences, University of Minnesota; telephone (612) 376-2578.
References
Abt Associates. Children at the center: summary findings and
policy implications of the national day care study. Cambridge,
Massachusetts: Abt Associates, Inc., 1979;I.
Weissman JB, Schmerler A, Weiler P, et al. The role of
preschool
children and day-care centers in the spread of shigellosis in
urban communities. J Pediatr 1974;84:797-802.
Weissman JB, Gangarosa EJ, Schmerler A, et al. Shigellosis in
day-care centres. Lancet 1975;I:88-90.
Black RE, Dykes AC, Anderson KE, et al. Handwashing to prevent
diarrhea in day-care centers. Am J Epidemiol 1981;113:445-51.
Tacket CO, Cohen ML. Shigellosis in day care centers: use of
plasmid analysis to assess control measures. Pediatr Infect
Dis
1983;2:127-30.
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