Appendix 2: Enteric disease

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1 Appendix 2: disease December 2017 Appendix 2: disease Although the terms enteric and food and waterborne illness are sometimes used interchangeably, not all enteric diseases are caused primarily by food or water. Conversely, some diseases that can be transmitted by food or water are not considered enteric. Most of the diseases covered in this appendix have to a greater or lesser extent an association with food or water, hence the terms foodborne and waterborne are used. Nevertheless, animal and farm environment contact should be considered important routes of infection in New Zealand. In all cases of enteric illness, health services should refer to the specific disease chapters or the chapter on acute gastroenteritis in this manual and base the scope of their investigation on an assessment of the risk of disease spread. It is essential to obtain a clinical history of s and exposure through possible food, water or animal contacts as well as through the case s occupation. Whenever possible, arrangements should be made for appropriate specimen (s) to be sent for laboratory testing to confirm the diagnosis. If a reported case is thought to be part of an outbreak, it is essential that health services follow the approach outlined in the Guidelines for the Investigation and Control of Disease Outbreaks (ESR 2012) to ensure the assessment of the possibility of shared risk factors in order to prevent further cases. Food and waterborne illnesses are itemised in Section A of the list of notifiable diseases. They are therefore notifiable by the attending health practitioner and laboratories to a medical officer of health and by the attending health practitioner to the territorial authority (TA). This ment for reporting to TAs can be fulfilled by summary reporting from the public health unit. Roles and responsibilities Liaison with the Ministry for Primary Industries (MPI) is d when food/food businesses are suspected of being the cause of illness. MPI is the New Zealand regulatory authority for food safety, including domestic food and imports and exports of food and food-related products. MPI is the lead agency for investigating, improving and promoting food safety and protecting consumers from risks (including nutrition and public health risks) that may arise in connection with the consumption of food. Where food/food businesses are thought to be involved inform MPI. This includes commercially prepared food and recreationally gathered food. Table 2.1 summarises responsibilities of public health units when investigating an outbreak of foodborne illness. Communicable Disease Control Manual Appendix 2 1

2 Appendix 2: disease December 2017 Table 2.1: Responsibilities of public health units when investigating an outbreak of a foodborne illness MPI foodborne illness responsibilities (Action taken under the Food Act 2014, Animal Products Act 1999) Conducting surveillance of risk factors relating to foods or food businesses Receiving reports of foodborne illness incidents or outbreaks Investigating issues and risk factors related to food or food businesses following reports of foodborne illness outbreaks Infection control, hazard control, risk minimisation and management related to food or food businesses including food handler identification during investigation, eg, product recall Promoting risk prevention and safe food handling to the food business and/or the sector and consumers as appropriate Taking food samples at the food business Ministry of Health-contracted areas under notification of foodborne illness (Action taken under Health Act 1956) Conducting surveillance of cases, all activities including trends and distribution of illness Recording notifications of foodborne illness (in EpiSurv) Reporting any outbreaks/incidents to MPI Conducting epidemiological investigations Tracing contacts Controlling infectious cases exclusion and of cases from food businesses Advising the public about disease and protection measures Taking specimens from case or contacts. Taking samples of any leftover food not at the food business Recording all actions on the appropriate MPI database Reporting issues, findings and action taken to Ministry of Health Providing recommendations or reporting to MPI 2 Appendix 2 Communicable Disease Control Manual

3 Appendix 2: disease December 2017 Incubation periods Common incubation periods for enteric disease are summarised in Table Table 2.2: Incubation period (variable and dose-dependent) for enteric disease Cause Bacillus cereus (diarrhoea) Bacillus cereus (vomiting) Campylobacteriosis Ciguatera fish poisoning Clostridium botulinum Clostridium perfringens Cryptosporidiosis Diarrhetic shellfish poisoning Entamoeba histolytica adenoviruses Enteropathogenic E. coli (EPEC) Enterotoxigenic E. coli (ETEC) Giardiasis Hepatitis A Norovirus Rotavirus Salmonellosis Salmonella Paratyphi Salmonella Typhi Shigellosis Staphylococcus aureus Vibrio cholerae O1 or O139 Vibrio parahaemolyticus Yersiniosis (not Y. pestis) Incubation period (range) days (1 10 days) (6 24 ) 7 days (1 12 days) Hours Days to months 3 10 days days (3 25 days) days (15 50 days) (6 72 ) 1 10 days (up to about 30 days) 1 3 weeks (3 days 90 days) 1 3 days (12 1 week) days (2 5 days) days (< 10 days) 47 Where food/food businesses are thought to be involved inform the Ministry for Primary Industries. Communicable Disease Control Manual Appendix 2 3

4 Appendix 2: disease December 2017 Mode of transmission Most notifiable enteric diseases are transmitted to a greater or lesser extent by ingestion of contaminated food or water. Nevertheless, person-to-person spread via the faecal-oral route is a particularly important route of transmission for norovirus, rotavirus, enteric adenovirus and Shigella. E. histolytica may also be transmitted person to person by the faecal-oral route. Norovirus may be transmitted by aerosol around infected vomit or faeces. Period of communicability For those diseases that have a significant degree of person-to-person transmission, periods of communicability are summarised in Table 2.3. Table 2.3: Period of communicability for enteric disease with significant personto-person transmission Infection adenoviruses Period of communicability Highest risk in the first few days of s; up to months E. histolytica Up to months Giardiasis Norovirus Rotavirus Shigellosis Up to months During s and until 48 after diarrhoea ceases During s and until approximately 8 days after onset of s. Up to 30 days after onset of s in immunocompromised patients Up to 4 weeks after infection. Aatic carriage may also occur. Rarely, faecal shedding may persist for months Exclusion/Restriction Cases of most enteric disease should be considered infectious and should remain off work/school until 48 after s have ceased. Certain individuals pose a greater risk of spreading infection and additional restriction/exclusion criteria may apply. Microbiological may be d for individuals infected with/exposed to certain pathogens. The key criteria are: the decision to exclude any worker is based on individual risk assessment. As a general rule, any worker with s of gastrointestinal infection (diarrhoea and/or vomiting) should remain off work until clinical recovery and stools have returned to normal (where the causative pathogen has not been identified). Where the pathogen has been identified, specific criteria are summarised in Table 2.4 the overriding prerequisite for fitness to return to work is strict adherence to personal hygiene, whether atic or not. 4 Appendix 2 Communicable Disease Control Manual

5 Appendix 2: disease December 2017 The circumstances of each case, carrier or contact should be considered and factors such as their type of employment, availability of toilet and hand washing facilities at work, school or institution and standards of personal hygiene taken into account. For example, a carrier may be relocated temporarily to a role that does not pose an infectious risk. Pathogen specific exclusion criteria for people at increased risk of transmitting an infection to others Pathogen specific exclusion (restricting criteria for people from work, school or an early childhood service and for subsequent are summarised in Table 2.4. Additional information is also included in the table for the following groups: 1. people whose work involves preparing or serving unwrapped food to be served raw or not subject to further heating (including visitors or contractors who could potentially affect food safety) 2. staff, inpatients and residents of health care, residential care, social care or early childhood facilities whose activities increase risk of transferring infection via the faecal-oral route 3. children under the age of 5 attending early childhood services/groups 4. other adults or children at higher risk of spreading the infection due to illness or disability. The Health (Infectious and Notifiable Diseases) Regulations 2016 do not contain any exclusionary powers or incubation periods for infectious children, or for high risk occupational groups such as people who work with children or food handlers. Instead the medical officers of health can resort to broader powers in Part 3A of the Health Act 1956, which include directions to cases and contacts to remain at home until no longer infectious. This Manual contains the recommended exclusion periods for specific diseases (Refer: Table 2.4). There is guidance published about the 2016 regulations and Part 3A of the Health Act in The legislation is principles based. In this context this means that medical officer of health must weigh protection of public health (the paramount consideration) with the following principles: trying voluntary means first if likely to be effective, choosing a proportionate, and the least restrictive measure d in the circumstances, fully informing the case or contact of the steps to be taken and clinical implications, treating them with dignity and respect for their bodily integrity and taking account of their special circumstances and vulnerabilities, and applying the measures no longer than is necessary (sections 92A to 92H). Under Part 3A a medical officer of health can direct a case or a contact to stay home (section 92I(4)(b) or 92J(4)(b)). This is when the officer believes on reasonable grounds that the case or contact poses a public health risk (as defined in the s2 Act). The direction must specify duration. Communicable Disease Control Manual Appendix 2 5

6 Appendix 2: disease December 2017 Alternatively, in the context of attendance at an educational institution, if the officer believes the infection risk is unlikely to be effectively managed by directing the case or contact, he or she can approach the head and direct them to direct the case or contact to remain at home. In serious cases, the medical officer of health can also direct the head to close the institution or part of it (s 92L). Medical officers of health have no powers to direct closure of premises or places where people congregate, other than educational institutions. If a medical officer of health needs to manage a public health risk by excluding infectious people from certain occupations, public pools, campsites, concerts and other public environments, he or she can use directions to the individuals concerned to stay away from a certain place, or not to associate with certain people. The Ministry for Primary Industries has powers to close commercial food premises. In contrast, medical officer of health powers focus on the risk the person poses. Note that while there are provisions that apply to early childhood service workers, there are no provisions for health care workers instead, advice should be provided to employers in terms of the Health and Safety at Work Act Employers may decide to implement more stringent exclusion/restriction criteria in response to their own or their customers ments. Exclusion and criteria for people at increased risk of transmitting an infection to others Table 2.4: Exclusion and criteria (NB: refer to the Pathogenic specific criteria for definitions of groups 1, 2, 3 & 4 above) Pathogen or disease name Acute gastroenteritis, including due to Bacillus species, Clostridium perfringens, Cyclospora, norovirus and rotavirus, Staph. Aureus Control Exclusions Microbiological 48 Contacts Appendix 2 Communicable Disease Control Manual

7 Appendix 2: disease December 2017 Pathogen or disease name Control Exclusions Microbiological Contacts Entamoeba histolytica (amoebic dysentery) until treatment complete 1,2,3,4 One negative stool, at least one week after end of treatment Screen household Campylobacter Cryptosporidium Should avoid swimming pools for two weeks after free E.coli VTEC/STEC 1,2,3,4 1,2,3,4: two consecutive negative stools at least 48 apart 1,2,3,4: exclude until one negative faecal specimen Giardia lamblia If index case in Group 3 and there are reports of diarrhoeal illness in previous 2 weeks in childcare centre attended by case, screen atic classmates Hepatitis A 1 wk after onset of s 1,2,3,4: seven days after onset of jaundice and/or other s Consider vaccination of contacts (especially if index case identified within 1 week of onset or if at continuing risk). Alternatively consider passive immunisation. People who have recently been exposed to food prepared by a case may benefit from active or passive immunisation Salmonella Communicable Disease Control Manual Appendix 2 7

8 Appendix 2: disease December 2017 Pathogen or disease name S. typhi and paratyphi Shigella Control Exclusions Microbiological 1, 2, 3, 4 and school children 1*, 2*, 3, 4* and school children**: exclude until and three consecutive negative stools have been provided at least 48 apart after completing treatment with effective antibiotics. If not treated with effective antibiotics, no earlier than 1 month after onset of s * Carriers, including chronic: a risk assessment should be carried out to consider safe arrangements for continuing work or alternative occupations and for continuing need for strict hygiene both within household and at work ** Schoolchildren: criteria are satisfied or as discussed with the medical officer of health Contacts 1*, 2*, 3, 4*; exclude until two negative faecal samples have been provided at least 48 apart All household and close contacts other than 1,2,3,4: collect two faecal samples provided at least 48 apart. No exclusion is necessary If case is considered to have acquired the infection overseas cotravelling contacts should provide a faecal sample as soon as possible. Exclusion is not necessary Other contacts who are unlikely to have been exposed to same source: samples or exclusion not necessary Note: In an outbreak situation, for potential common-source contacts consider collecting one faecal sample * Carriers, including chronic: a risk assessment should be carried out to consider safe arrangements for continuing work or alternative occupations and for continuing need for strict hygiene both within household and at work S. sonnei S.Boydii, Dysenteriae, and Flexneri Groups 1,2,3,4 1, 2, 3, 4: exclude until free for 48 and two consecutive negative 1, 2, 3, 4: exclude until one negative faecal specimen has been provided. 8 Appendix 2 Communicable Disease Control Manual

9 Appendix 2: disease December 2017 Pathogen or disease name Control Exclusions Microbiological stools at least 48 apart Contacts Vibrio cholerae O1 or O139 Clinical surveillance of those who shared food and drink with case for five days from shared exposure 1,2,3,4 1, 2, 3, 4: exclude until free for 48 and two consecutive negative stools at least 48 apart Yersinia 1,2,3,4: until Not d In exceptional circumstances, eg, where workplace hygiene or sanitation is uncertain, a case may need to be excluded until they have submitted appropriate negative stool(s), taken at a suitable interval. References and further information ESR Guidelines for Investigating Communicable Disease Outbreaks. Porirua: Institute of Environmental Science & Research Limited. Heyman, D.L. (2015). Control of Communicable Disease Manual, 20 th Edition. American Public Health Association, Washington DC. Communicable Disease Control Manual Appendix 2 9

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