Program to Prevent the Transmission of Enteric

Transcription

Program to Prevent the Transmission
of Enteric Infections in
Cree Communities
Prepared by: Christina Smeja, consulting physician
Public Health Module — Cree Region
Montreal General Hospital
April 1995
Table des matières
List of appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ii
1.
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2.
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
3
4.
Follow-Up on Sporadic Cases of Gastroenteritis . . . . . . . . . . . . . . . . . . .
3
5.
Specific Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
6.
Monitoring Number of Gastroenteritis Cases in the Village . . . . . . . . . .
4
7.
Epidemiological Survey during Epidemics of Enteric Disease . . . . . . . . .
5
8.
Public Education Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Program to Prevent the Transmission of Enteric Infections
in Cree Communities
i
List of appendices
Appendix 1
Follow-up questionnaire for enteric infection
Appendix 2
Intervention Guides
•
Salmonellosis (other than typhic or paratyphic)
•
Typhic or paratyphic salmonellosis
•
Amebiasis (Entamoeba histolytica)
•
Giardiasis in day care settings
•
Hepatitis A
•
Shigellosis
Appendix 3
Questionnaire for follow-up on cases of enteric infection
Appendix 4
Epidemiological questionnaire for hepatitis A cases (HAV)
Appendix 5
Information on:
Appendix 6
Table for the monitoring of enteric diseases
Appendix 7
Sampling methods
ii
•
•
•
•
•
•
•
Amebiasis
Campylobacter infection
Giardiasis
Hepatitis A
Salmonellosis
Typhoid
Yersiniosis
in Cree Communities
1.
Objectives
To prevent and contain outbreaks of gastroenteritis and hepatitis A in Cree
communities
2.
Definitions
•
Sporadic cases
Cases which, based on available data, cannot be linked to one or
more acute cases or carriers.
•
Diarrhea of seemingly infectious origin
Frequent passage of unformed watery stool accompanied by one of
the following symptoms:
•
Nausea or vomiting
•
Fever
•
Linkage with other cases of diarrhea in the entourage
•
Outbreak
Two or more cases (cases or carriers) epidemiologically linked (in
time, space, or by interpersonal contact) and usually sharing a
common source.
•
Epidemic
Greater number of cases of gastroenteritis than expected for a given
period. For example, more than 5 to 8 cases a week in Chisasibi,
Mistissini, or Waskaganish or more than 3 or 4 cases per week in
Nemaska, Wemindji, Eastmain, or Whapmagoostui.
•
Food handler
All workers who handle unwrapped food which is to be eaten raw or
reheated by the public (restaurants, cafeterias, food chains, day
cares, and, in our region, food prepared for community festivals).
•
Carrier
Someone who, though symptom-free, has been excreting pathogenic
organisms in his or her stool or urine either continuously or
intermittently for more than 12 months.
•
Source
Origin, cause of infection.
in Cree Communities
1
3.
Introduction
Though recent decades have brought improvements in the territory's socio-sanitary
conditions, Cree communities are still plagued by epidemics of enteric diseases.
Overcrowded housing is no doubt a contributing factor. As most CBHSSJB personnel
are recent arrivals, they may not be aware of the population's memories of the 1983
Wemindji epidemic of rotavirus gastroenteritis, which killed one infant and
hospitalized 20 others.
There are several different infectious agents which can cause gastroenteric symptoms.
The seriousness of the disease will vary depending on the agent and the subject's state
of health. In order to prevent epidemics of enteric diseases, follow-up of subjects
with seemingly infectious diarrhea must include an epidemiological component. An
effort must be made to spot any other infected members of the entourage and
measures must be taken to prevent secondary transmission: education in hygiene and
withdrawal of certain cases from their work milieu. The source of the infection must
also be sought in order to prevent the infection of other people.
When laboratory tests identify certain infectious agents, specific measures may be in
order to prevent spread of the infection.
By keeping a watchful eye on the number of cases of seemingly infectious diarrhea in
the village (not only the cases seen in the clinic but also those brought to light by the
epidemiological questionnaire), clinical personnel can detect the early signs of an
outbreak of infectious diarrhea and try to discover a common source. In such
circumstances, water quality should be checked by consulting the Band Council's
Local Environment Officer (LEO).
In the event of an epidemic, a more thorough survey will require the collaboration of
the Public Health Unit and Quebec's Laboratoire de sante publique (LSPQ) to search for
the etiological agent and determine the common source.
The nurse will seek the help of the Community Health Representative (CHR) and the
band's Public Health Officer (PHO) in carrying out primary prevention activities
(especially in spring) or public education campaigns during outbreaks.
This document includes measures for preventing and controlling hepatitis A viral
infections (HAV). The clinical pattern of hepatitis A is quite different from that of
gastroenteritis, but the former's direct oral and fecal transmission or transmission via
contaminated food or water put it in the category of enteric disease.
2
in Cree Communities
ACTIVITIES
1.
Follow-up on sporadic cases of gastroenteritis
•
Clinical follow-up
•
Epidemiological questionnaire
•
Investigation p.r.n. (as circumstances may require)
•
Treatment and education
2.
Epidemiological survey and, if needed, treatment of contacts as
prescribed in the protocol for cases confirmed by lab tests for:
•
Salmonellosis (typhoid fever and others)
•
Hepatitis A
•
Shigellosis
•
Giardiasis in children under 6
•
3.
Monitoring number of cases of gastroenteritis in the village:
•
If outbreak of gastroenteritis suspected:
•
Notify CLSC health coordinator
•
Contact the LEO to test quality of water samples
4.
Epidemiological survey during confirmed epidemics
•
Attempt to determine the source
•
Search for etiological agent (PHU/LSPQ)
•
Daily follow-up on number of cases
5.
Public education activities to prevent enteric infections, in the spring
and during outbreaks (as needed).
4.
Follow-Up on Sporadic Cases of Gastroenteritis
Diagnosis and treatment are discussed elsewhere. Note that babies making their first
visit for gastroenteritis symptoms should be weighed naked. If the clinical portrait
should then deteriorate over the following days, weight changes could be accurately
monitored and proper treatment given for dehydration.
An epidemiological questionnaire should be included in all evaluations of seemingly
infectious diarrhea (see example in appendix 1).
When should stool samples be taken?
•
•
•
If the diarrhea persists for more than a week.
If there is bloody diarrhea.
If the patient is toxic.
in Cree Communities
3
Education and review of hygiene practices are important elements of treatment:
•
•
•
5.
Washing hands
Preparing/preserving food
Eliminating waste
Specific Protocols
In addition to routine measures, certain enteric infections may require specific
measures of control and treatment, such as stricter criteria for containing very
contagious cases (e.g. shigellosis) or the administration of immunoglobulins to
hepatitis A contacts. Appendix 2 contains the protocols for:
•
•
•
•
•
Salmonellosis
Hepatitis A
Shigellosis
Giardiasis in children under 6
Appendices 3 and 4 contain the epidemiological survey questionnaires for:
Infectious diarrhea
Hepatitis A
Upon reception of laboratory results, the appropriate intervention guide should be
consulted.
Antibiotics are not to be prescribed immediately. The patient's clinical state should first
be evaluated and discussed with the physician. The antibiotics usually given for
salmonellosis can prolong the carrier state of this infection and are thus not
recommended except in serious cases.
Information sheets describing the different pathogens causing enteric diseases are
included in appendix 5 (in English and in French).
6.
Monitoring Number of Gastroenteritis Cases in the
Village
Whenever there seems to be an increased number of consultations for gastroenteritis or
when epidemiological questionnaires turn up several cases, clinical personnel should
use the form in appendix 6 to track the number of cases in the village. The
4
in Cree Communities
CLSC health coordinator or the agent in charge of community health programs
should be notified of the situation.
In order to determine if the infection might have its source in contaminated drinking
water, the Band Council's Local Environment Officer (LEO) should be asked to check
water quality.
7.
Epidemiological Survey during Epidemics of Enteric
Disease
When the number of cases or seriousness of the disease are of epidemic proportions, a
more thorough investigation will require the collaboration of the CLSC health
coordinator, the Public Health Unit, and the LSPQ. The first step will be to look for
the etiological agent by examining 10 to 20 acute cases: stool and serum samples for
each patient will be sent to the LSPQ (see document dealing with preparation of the
samples in appendix 7).
Samples must be collected as quickly as possible, in order to obtain valid results.
Better results are obtained if stool samples are collected in the acute phase: within 48
hours after the first symptoms appear. The services of a nurse specially trained to
take samples would facilitate the survey.
If a hydric or food source is suspected, analysis of appropriate samples (if available)
can be carried out by MENVIQ or MAPAQ. Consult the Public Health Unit for such
cases.
Collaboration of the Public Health Officer or the Community Health Representative
will be sought in carrying out public information and education campaigns on local
radio.
8.
Public Education Activities
•
Primary prevention
•
Information campaigns during an outbreak or an epidemic
in Cree Communities
5
References
Comite de travail, Maladies entériques sporadiques: programme cadre de surveillance et
contrôle. Document 1 - Notions générales. Regroupement de DSC Montréal
Métropolitain et des DSC de la Montérégie. Montréal 1993.
Comite de travail, Maladies entériques sporadiques: programme cadre de surveillance et
contrôle. Document 2 - Guides et outils. Regroupement de DSC Montréal
Métropolitain et des DSC de la Montérégie. Montréal 1993.
D'Halewyn Marie-Alix, Investigation d'une 6closion de diarrhée infectieuse; recherche de
I'agent étiologique. Laboratoire de Santé publique du Québec (non date).
6
in Cree Communities
APPENDIX 1
Questionnaire following a gastro-intestinal infection
APPENDIX 2
Intervention Guides
INTERVENTION GUIDE
SALMONELLOSIS (OTHER THAN TYPHIC OR PARATYPHIC)
INDEX CASE
•
Conduct survey to find the vehicle of transmission.
•
Forward information documents including the information sheet on this
disease.
Salmonellosis (other than typhic or paratyphic) 1/..1
INTERVENTION GUIDE
* NOTE:
(TYPHIC OR PARATYPHIC) SALMONELLA
Certain reference documents recommend the same interventions for both paratyphoid fever and
typhoid fever, whereas others make no recommendation for the former.
The small number of paratyphoid cases reported and the ambiguity surrounding the whole
matter led us to treat the two illnesses together in this document.
INDEX CASE
EXCLUSION: Authorization for return to work (food handler or attendant to sick or
elderly) or to day care requires at least THREE CONSECUTIVE, NEGATIVE STOOL
CULTURES, taken at least one month after onset of the disease and at least 24-hour
intervals. If antibiotics have been prescribed, the first specimen must be collected at
least 48 hours following end of treatment.
Some authors recommend that one of the 3 specimens be collected after a magnesium
sulfate purge.
If one of the cultures turns out to be positive, repeat a stool culture each month for
the next 12 months or until 3 consecutive, negative cultures are obtained.
Forward information documents including the information sheet on this disease.
CONTACTS
FAMILY CONTACT: An investigation should be conducted to find out if any
family contacts hold a high-risk job or attend a day care. If so: EXCLUDE THESE
SUBJECTS FROM WORK OR DAY CARE until at least 2 negative stool cultures
taken at least 24-hour intervals are obtained. If the cultures are negative, the subject
may be allowed to return to his or her milieu, but monitoring will continue for 4
weeks.
DAY CARE: All the children and personnel should be systematically screened (two
stool cultures) and any person with positive results should be excluded. They should
be considered index cases.
FOOD HANDLER: All the other food handlers should be systematically screened
(two stool cultures) and the clientele (if in a closed milieu) should be monitored for
the appearance of symptoms (especially fever) during one month.
(Typhic or paratyphic) Salmonella 1/..2
•
ATTENDANT TO THE SICK OR ELDERLY: Contacts should be watched for the
appearance of symptoms (especially fever) for a month.
•
TRAVELLER: All members of the same group of travellers must be
monitored for the appearance of symptoms during the 4 weeks following
exposure.
•
INDEX CASE REMAINS CARRIER OF TYPHIC SALMONELLA:
Vaccination against typhoid may be considered for the carrier's family
contacts.
MILIEU
•
Step up application of hygiene measures.
•
If the infection was caught in Quebec, focus the survey on finding the
source of the infection.
2/..2 (Typhic or paratyphic) Salmonella
INTERVENTION GUIDE
AMEBIASIS (ENTAMOEBA HISTOLYTICA)
INDEX CASE
•
Make sure that the subject has received treatment.
•
Forward information documents including the information sheet on the
disease.
CONTACTS
•
Persons in close contact with the subject, especially family members and
sexual partners, must be tested for parasites in the stool (3 times), in order to
spot symptom-free carriers. Anyone with positive test results should be
referred to his or her physician for treatment.
MILIEU
•
Amebiasis (Entamoeba histolytica) 1/..1
INTERVENTION GUIDE
GIARDIASIS IN DAY CARE
INDEX CASE
•
NO EXCLUSION if appropriate antibiotic course of treatment is underway
and if the subject shows no symptoms.
•
There is no need for stool analyses unless symptoms persist or reappear. If
analyses give positive results, it might be useful to repeat the treatment.
•
Forward information documents including the information sheet on the
disease.
CONTACTS
•
To be considered as contacts are: children in the same group as the index
case or children in any other group with an increased number of diarrhea
cases, as well as members of the staff caring for those groups.
•
Look for Giardia (1 time) in the stools of all contacts who showed no
symptoms at the time of the survey or during the two last weeks. Consult
the laboratory in organizing this activity. If the culture is positive,
see the index case.
•
Keep an eye open for the appearance of new asymptomatic cases during the
8 weeks following the outbreak of the last case.
If new confirmed cases of giardiasis occur during this period,
contacts must be reinvestigated.
MILIEU
•
•
Investigate the water supply if it is suspect.
Giardiasis in day care 1/..1
INTERVENTION GUIDE
HEPATITIS A
INDEX CASE
•
EXCLUSION up to two weeks after the onset of the disease, but not more
than one week after the onset of jaundice, if present.
•
disease.
CONTACTS
•
FAMILY OR SEXUAL CONTACT: All family and sexual contacts must
receive 0.02/mL/kg of immunoglobulins as soon as possible and at the latest
14 days after the last infectious contact (that is no later than 21 days after
the onset of jaundice). Serologic screening is not required.
•
DAY CARE: If the day care does not admit babies in diapers:
Administer immunoglobulins (at maximum 2 weeks following contact) to
children and personnel in the same group as the index case.
If the day care does admit babies in diapers and:
•
If there is one case in the day care or 1 case each in 2 different families
whose children attend the same day care, administer IGs (at maximum 6
weeks following the contact) to all the children and staff members in the
day care.
•
If there are several cases in the day care or if there is one case each in 3
different families or more whose children attend the same day care,
administer IGs (at maximum 6 weeks following contact) to all the children
and staff members in the day care, to family members of the cases, as well as
to all members of families with babies in diapers.
•
Any new child or staff member admitted to the day care within the 6 weeks
following the appearance of the last case must receive IGs. Consider
excluding from the day care all receptive contacts who refuse to take the
IGs.
•
SCHOOL: IGs are not normally administered to contacts.
Hepatitis A 1/..2
•
FOOD HANDLER: IGs are normally administered to the other food handlers,
the milieu is monitored for two months, and the attempt is made to find all
other symptom-free cases.
Administration of IGs is appropriate treatment for clients if:
(a)
(b)
(c)
the index case has been negligent about hygiene;
food handled will not be cooked later;
clients can be reached in less than 14 days.
MILIEU
•
2/..2 Hepatitis A
INTERVENTION GUIDE
SHIGELLOSIS
INDEX CASE
•
EXCLUSION: Authorization for return to work (food handler or health
attendant) or to day care requires at least TWO CONSECUTIVE,
NEGATIVE STOOL CULTURES, taken at at least 24-hour intervals.
In symptomatic cases, the first specimen must be collected at least 24
hours after the diarrhea stops.
If antibiotics are prescribed, the first specimen must be collected at least
48 hours following the end of the course of treatment.
•
disease.
CONTACTS
•
FAMILY CONTACT: A survey should be conducted to find out if any family
contacts hold high-risk jobs or attend a day care. If so and:
•
if the case is symptomatic : Exclude from work or day care
and collect two stool cultures. If the cultures are negative, authorize
return to work or the day care when subjects have been at least 24
hours without any symptoms. If a culture is positive, see the index
case.
•
if the case is asymptomatic: Take a stool culture and wait for the
results before excluding the subject. If the culture is positive, see
index case.
•
DAY CARE: In day care, the following are to be considered as a "family"
contact (see above): children and personnel in the same group as the subject
or those in any other group with an increased number of diarrhea cases,
as well as the members of their family.
•
FOOD HANDLER OR HEALTH CARE ATTENDANT: Find out if there is
an outbreak (i.e. look for other cases in the milieu). If other cases are
spotted, take stool cultures from all asymptomatic persons having any
epidemiological links with the index case. Apply the measures
recommended for family contacts.
MILIEU
•
Shigellosis 1/..1
APPENDIX 3
Questionnaire for follow-up on cases of enteric infection
(available in french only "Formulaire pour le suivi d'une infection enterique")
APPENDIX 4
Epidemiological questionnaire for hepatitis A cases (HAY)
(available in french only "Questionnaire
épidémiologique pour les cas d'hépatite A (HAV)")
APPENDIX 5
Information on....
UNDERSTANDING
AMEBIASIS
Amebiasis is an infection caused by a parasite called "Entamoeba histolytica". The infection
sometimes affects the intestines, causing symptoms of varying severity. For example, a person
may have severe, bloody diarrhea with fever, or abdominal pain with a few episodes of diarrhea, or
no symptoms at all. In some instances, the parasite finds its way to organs other than the
intestines, causing different types of health problems.
Where is this parasite found?
E. histolytica is present in the stools of persons with amebiasis.
E. histolytica is found in water that has been contaminated by fecal material, particularly in areas
where the sewage systems are not very advanced or are poorly maintained, and where drinking
water is not treated. This is the case in certain tropical countries.
How may a person get amebiasis?
a)
b)
via contaminated food:
•
Food prepared by a person infected with E. histolytica can become contaminated
if the person is not sufficiently careful about practicing proper hygiene.
•
While traveling in certain countries, a person can get infected particularly by
drinking untreated water or using it to wash food.
via contact with the stools of an infected person:
•
An infected person who does not wash his or her hands properly may pass the
virus on to another person.
•
A person who changes the diapers of an infected baby may become contaminated
him or herself.
•
In day care centres, the infection may be transmitted from one child to another,
especially if the children have not yet been taught to wash their hands.
Understanding .. 1
How can I help prevent the spread of Amebiasis?
•
•
You must wash your hands thoroughly with soap and water:
-
before handling food and/or cooking utensils; it is not sufficient to wipe them on a
damp cloth.
-
after each bowel movement, especially if you have diarrhea. Also, remember to
wash your hands after changing a child's diaper or touching an animal.
Avoid drinking untreated water (from lakes or streams). If you use well water, insure that
it is tested regularly. Do not drink untreated water or use ice cubes made from untreated
water, while travelling.
GENERAL GUIDELINES TO BE FOLLOWED TO PREVENT THE SPREAD OF
FOODBORNE DISEASES
•
Cook all animal and poultry products at temperatures high enough to kill bacteria, as
generally recommended in cookbooks. As most people know, chicken, pork, and now
even eggs must be cooked well.
•
Wash knives, other utensils, such as cutting boards, and your hands when switching
from one food to another.
•
Do not drink unpasteurized milk.
Understanding .. 2
UNDERSTANDING
CAMPYLOBACTER INFECTIONS
Campylobacter infection, which affects the intestinal tract, is caused by bacteria called
"Campylobacter". Symptoms of the disease include diarrhea, abdominal pain, fever, and, in some
cases, blood in the stools. The infection usually lasts less than a week.
Where are these bacteria found?
Campylobacter is widespread in birds, which are known to contaminate lakes and streams.
Puppies, kittens, chickens, dogs and cattles can also be infected by Campylobacter, as can
unpasteurized milk.
How may a person be infected by Campylobacter?
a)
•
By eating undercooked meat or poultry.
•
By drinking unpasteurized milk - usually directly from a farm - as opposed to
milk sold commercially, which is pasteurized.
•
By eating food that has been contaminated during its preparation. This can occur
when the same utensils, especially cutting boards, are used first for uncooked
meat, and then for food that is to be eaten raw.
•
b)
c)
By drinking untreated water (from lakes or streams).
•
A person who changes the diapers of a baby with a Campylobacter infection may
become contaminated him - herself.
•
An infected person who does not wash his or her hands properly - especially in
the presence of diarrhea - may spread the infection to another person.
via contact with the stools of an infected animal:
•
The disease can be spread especially by kittens and puppies with diarrhea.
Understanding .. 3
How can I help prevent the spread of Campylobacter infections?
•
-
-
before handling food and/or cooking utensils; it is not sufficient to wipe your
hands on a damp cloth.
•
Refrigerate meats as soon as possible after buying them.
•
generally recommended in cookbooks. As most people know, chicken, pork and now
•
•
•
it is tested regularly.
Understanding .. 4
UNDERSTANDING E. COLI
0157:H7 INFECTIONS
E. coli 0157:H7 infection, a disease of the intestinal tract, is caused by bacteria called
"Escherichia coli 0157:H7". This illness, also known as hemorraghic colitis, may present
symptoms such as diarrhea, abdominal pain, vomiting, and, in some cases, blood in the stools. It
usually lasts less than a week. In children, the infection can even lead to serious, lifethreatening kidney complications.
E. coli 0157:H7 is found chiefly in the intestines of cattle. In our kitchens, the organism may be
present in ground beef and unpasteurized milk.
How may a person be infected by E. coli 0157:H7?
a)
b)
•
By eating undercooked meat, especially ground beef.
•
•
•
•
him or herself.
•
Understanding .. 5
How can I help prevent the spread of E. coli 0157:H7 infections?
•
-
-
•
•
•
•
•
Avoid drinking untreated water (from lakes or streams). If you use well water, insure that it
is tested regularly.
Understanding .. 6
UNDERSTANDING
GIARDIASIS
Giardiasis is an infection of the intestinal tract. It is caused by "Giardia lamblia", a parasite that is
invisible to the naked eye. Most giardiasis patients are symptom-free, although some may
complain of frequent, light-coloured, foul-smelling stools, with abdominal cramps and abdominal
gas. If left untreated, the illness may last several weeks.
Where is this parasite found?
Giardia lamblia is often found in water that has been contaminated by domestic or wild animals, for
example, in lakes, streams and wells. The parasite can also make its way into an aqueduct system
via leaks or cracks in the system. Humans with the infection shed the organism in their stools,
whether they have diarrhea or not. Giardia transmission may occur in day care centres.
How may a person be infected by Giardia?
a)
b)
via contact with the stools of an infected person or animal:
•
Food prepared by a person with Giardia in his or
contaminated if the person is not sufficiently careful
hygiene. Similarly, the parasite can contaminate the
changes the diapers of an infected baby; any food
subsequently may then become contaminated, as well.
her stools can become
about practicing proper
hands of a person who
handled by the person
•
especially if the children are still in diapers, or if they have not yet been taught
to wash their hands.
•
The parasite may also be present in the stools of domestic or wild animals,
particularly rodents (rabbits and beavers, for example). A person who has touched
infected animals or cleaned out their cages is therefore at risk of acquiring the
infection him or herself
via contaminated water:
•
By drinking unfiltered water from a lake or stream, or by washing food with such
water.
•
By drinking unfiltered water while traveling (be wary of ice served in drinks).
Understanding .. 7
How can I help prevent the spread of Giardia infections?
•You must wash your hands thoroughly with soap and water:
•after each bowel movement, especially if you have diarrhea. Also, remember to wash your
hands after changing a child's diaper or touching an animal.
•
before handling food and/or cooking utensils; it is not sufficient to wipe your hands on a
damp cloth.
•
•
•
Understanding .. 8
UNDERSTANDING
HEPATITIS A
Hepatitis A is an infection of the liver caused by the hepatitis A virus (HAV). Common initial
symptoms of the illness include fever, fatigue, loss of appetite and abdominal discomfort. After a
few days, the patient may develop jaundice. Some persons have the infection without
developing any symptoms; this is especially true of children. As a rule, one week following the
onset of symptoms, the patient is no longer contagious.
Where is this virus found?
The hepatitis A virus is found primarily in the feces of infected persons. Water can therefore be
contaminated by the virus in areas where the sewage systems are inadequate or break down.
Consequently, mussels and oysters caught in contaminated waters may also harbour the hepatitis A
virus.
In addition, HAV can be spread by food that has been prepared and contaminated by an infected
person or washed in contaminated water. Often, hepatitis A affects travellers visiting tropical
countries.
How may a person be infected by the Hepatitis A virus?
a)
•
Food prepared by a person infected with the hepatitis A virus can become
contaminated if the person is not sufficiently careful about practicing proper
hygiene.
•
A person can get infected by eating raw mussels or oysters, especially in tropical
countries.
•
A person can be infected by drinking contaminated water.
Understanding .. 9
b)
•
An infected person who does not wash his or her hands properly may pass the
virus on to another person.
•
him or herself.
•
especially if the children are still in diapers, or if they have not yet been taught
to wash their hands.
How can I help prevent the spread of Hepatitis A?
•
•
•
Avoid drinking untreated water.
If you travel, it is strongly recommended that you make an appointment at a travel
immunization clinic before you leave the country. You will be given an immune globulin
injection if it is indicated for your destination.
Understanding .. 10
UNDERSTANDING
SALMONELLOSIS
Salmonellosis, an infection of the intestinal tract, is caused by bacteria called "Salmonella".
Patients with the disease usually develop diarrhea, abdominal pain and fever; occasionally,
vomiting and blood-streaked stools are present.
The illness generally lasts less than a week. It should be noted that some persons carry the
bacteria without showing any signs of illness; despite their asymptomatic state, these carriers can
nonetheless spread the infection to others. This carrier state may persist for several weeks or
even several months.
Wild and domestic animals, especially poultry, cattle, pigs, broiler chickens, turtles and other
reptiles may be carrier of Salmonella. This organism may be found also in uncooked chicken,
eggs, unpasteurized milk and raw meat.
How may a person be infected by Salmonella?
a)
•
b)
By eating undercooked meat, poultry and eggs.
•
•
•
•
him or herself.
Understanding .. 11
How can I help prevent the spread of Salmonella?
•
-
-
•
•
Thaw meats and, particularly, chicken inside the refrigerator.
•
•
•
•
Try not to keep turtles or other reptiles as household pets. If you do, make sure you
wash your hands after touching them and cleaning out their tanks or cages.
•
Understanding .. 12
UNDERSTANDING
SHIGELLOSIS
Shigellosis, an infection of the intestinal tract, is caused by bacteria called "Shigella". Patients
with the illness may develop diarrhea accompanied by fever and abdominal cramps. Occasionally,
blood and pus are present in the stools. The disease is very contagious, and infected persons can
transmit the bacteria to others for up to four weeks, even if they themselves no longer have any
symptoms.
Shigella organisms inhabit the feces of infected persons. Animals do not serve as reservoirs (i.e.,
hosts or carriers) of the bacteria. Often, persons with shigellosis have recently returned from a
tropical country.
How may a person be infected by Shigella?
a)
•
b)
Food prepared by a person with shigellosis can become contaminated if the person
is not sufficiently careful about practicing proper hygiene.
•
•
him or herself.
•
Understanding .. 13
How can I help prevent the spread of Shigella?
•
•
-
wash your hands after changing a child's diaper.
-
GENERAL GUIDELINES TO BE FOLLOWED TO PREVENT THE SPREAD OF
FOODBORNE DISEASES
•
•
•
Understanding .. 14
UNDERSTANDING
TYPHOID FEVER
Typhoid fever is an infectious disease caused by the bacteria called "Salmonella typhi". This
illness, which is not common in Quebec, is characterized by fever, headaches, loss of appetite, a
rose-coloured rash, and, in adults especially, constipation. Diarrhea may also be present. Some
individuals become infected with S. typhi without feeling ill. Note that, despite their lack of
symptoms, these carriers can nonetheless spread the organism to others.
Salmonella typhi is shed in the stools or urine of infected persons. Animals do not serve as
reservoirs (i.e., hosts or carriers) of the bacteria.
How may a person be infected by Salmonella typhi?
a)
b)
•
Food prepared by a person with Salmonella typhi can become contaminated if the
person is not sufficiently careful about practicing proper hygiene.
•
A person can get infected by eating uncooked seafood caught in water that has
been contaminated by the bacteria.
•
An infected person who does not wash his or her hands properly - especially in the
presence of diarrhea - may spread the infection to another person.
Understanding .. 15
How can I help prevent the spread of typhoid fever?
Typhoid fever most often affects persons who are travelling abroad, especially those visiting
tropical countries. Travellers are generally advised to avoid drinking untreated water, eating raw
fruits and vegetables, and using ice cubes made from water of a questionable source in drinks. If
you are planning a trip, it is strongly recommended that you make an appointment at a travel
immunization clinic before you leave the country. You will be given a typhoid vaccine if it is
indicated for your destination (even if you have already had the disease). Pamphlets on the
prevention of illnesses such as typhoid fever will also be available. Read them carefully.
GENERAL GUIDELINES TO BE FOLLOWED TO PREVENT THE
SPREAD OF FOODBORNE DISEASES.
•
-
-
•
•
•
•
- Avoid drinking untreated water (from lakes or streams). If you use well water, insure that
Understanding .. 16
UNDERSTANDING
YERSINIA INFECTIONS
Yersinia infections, a disease of the intestinal tract, is caused by bacteria called "Yersinia".
Symptoms of the illness include diarrhea and abdominal pain. Some patients have fever,
headaches and vomiting. The infection usually lasts less than a week.
Yersinia may be present in foods such as raw meat (pork, in particular), unpasteurized milk and
unwashed vegetables. Some farm animals, as well as domestic and wild animals, may harbour the
organism in their intestines and contaminate streams and well water with it.
How may a person be infected by Yersinia?
a)
b)
•
By eating undercooked meat or poultry.
•
By drinking unpasteurized milk - usually, directly from a farm - as opposed to
•
when the same utensils, especially cutting boards, are used first for uncooked meat
(especially pork), and then for food that is to be eaten raw.
•
By using contaminated well water, or by drinking water from a stream.
•
•
him or herself.
Understanding ..17
How can I help prevent the spread of Yersinia?
•
-
wash your hands after changing a child's diaper.
-
•
Cook all animal, especially pork and poultry products, at temperatures high enough to kill
bacteria, as generally recommended in cookbooks. As most people know, chicken, pork
and now even eggs must be cooked well.
•
•
•
Avoid drinking untreated water (from lakes or streams). If you use well water, insure that it
is tested regularly.
Understanding .. 18
APPENDIX 6
Table for the monitoring of enteric diseases
(available in french only "Surveillance des maladies entériques")
Période, du: _____________ au: _______________
Surveillance des Maladies Entériques
Clinique ____________________________________
Date
Nom
Age
Type de consult.
Tél.
Clin.
Diar. Naus. Vom.
Symptômes
T
Sang :selles Cramps
Autres personnes Culture de
Dans le ménage
selles
Avec symptômes
APPENDIX 7
Sampling methods
(available in french only "Prelevements")
Les pages qui suivent sont tirées de documents produits par le LSPQ
I
1.
LA RECHERCHE DE L'AGENT ÉTIOLOGIQUE: MÉTHODOLOGIE
Sélection des personnes infectées à investiguer
Le LSPQ peut collaborer à la mise en évidence et à l'identification des
principaux microorganismes responsables d'infection entérique chez un premier
échantillon de la population des malades en cause. Cet échantillon est constitué d'un
groupe d'une dizaine à une vingtaine de maladies symptomatiques en phase aiguë,
répondant de près aux critères de la définition de cas, faisant partie d'au moins 5 à 10
familles différentes, s'il s'agit de cas dans la communauté; les échantillons prélevés sont
ensuite groupés, de préférence en un envoi. Pour faciliter et accélérer le recueil de ces
prélèvements, une infirmière pourrait se rendre sur les lieux ou les individus peuvent
être regroupés lors d'une clinique spécifique.
D'autres malades pourraient éventuellement faire partie de l'enquête si un
échantillonnage plus large des malades s'avérait nécessaire.
2.
Nature des prélèvements à effectuer
Les échantillons suivants sont demandés pour chaque patient1:
•
•
•
un prélèvement de selles
un premier sérum en même temps que le prélèvement de selles
un deuxième sérum prélevé 3 à 4 semaines plus tard.
La liste des fournitures nécessaires pour ces prélèvements se retrouve en à la fin
de cette annexe.
3.
Résultats des analyses
Un rapport préliminaire téléphonique sera émis en dedans d'une semaine pour
toutes les analyses.
Pour les analyses bactériologiques et parasitologiques, un rapport final sera
généralement émis deux semaines après la réception des échantillons et cultures. Le
rapport final contenant les résultats des analyses virologiques sera émis deux à quatre
semaines après la réception du sérum de phase convalescente.
1
Ces directives doivent être suivies lorsque le LSPQ est mis à contribution. Cette consigne ne
s'applique pas nécessairement à la recherche de l'agent étiologique d'une gastro-entérite en
pratique courante.
Prélèvements ..... 1
II - PRÉPARATION ET ACHEMINEMENT DES ÉCHANTILLONS (résumé: tableau 1)
Prélever les échantillons le plus rapidement possible
après le début des symptômes.
Toujours avertir le LSPQ avant d'envoyer les
spécimens.
1.
Échantillons de selles
1.1
Prélèvements de selles et partage des échantillons
Un échantillon est prélevé directement du malade dans un contenant vide et
propre en évitant tout contact avec l'urine. Le minimum recueilli doit être de 25 ml pour
que toutes les analyses puissent être effectuées.
Le prélèvement de selles est partagé de la façon suivante avant d'être expédié au
LSPQ:
une portion (5 ml)1 sert à saturer deux écouvillons qui sont mis dans 2 tubes de
milieu de Cary-Blair pour la culture des bactéries
une deuxième portion (10 ml)1 est envoyée sans fixateur pour la recherche de
•
•
virus
•
une troisième portion (5ml)1 est envoyée dans un fixateur (SAF ou formol 10%)
dans un rapport 1:3 (v:v) pour la recherche de parasites.
1.2
Conservation des échantillons de selles et délai acceptable avant la
livraison au LSPQ
Les échantillons doivent être expédiés le plus rapidement possible aux LSPQ.
Les portions de l'échantillon peuvent être conservées un maximum de 48 heures
avant la livraison, réfrigérées à 2-8°C.
1
Les quantités citées représentent un minimum souhaitable.
Il est essentiel de prélever les selles pendant la phase aiguë de la maladie, afin de ne pas compromettre
l'identification de l'agent étiologique. Toutes les analyses sont généralement demandées simultanément.
Tableau 1
Recommandations pour la collecte des échantillons
Directives de
prélèvement
Virus
Bactéries
Parasites
Sérums
Quand
En dedans de 48-72
heures après
l'apparition des
symptômes
Pendant la période de
diarrhée active, le plus
tôt possible après le
début des symptômes
Pendant la période de
diarrhée active, le plus
tôt possible après le
début des symptômes
Sérum-1: en phase
aiguë (en même temps
que le prélèvement de
selles) sérum 2: 15-20
jours après le sérum-1
Quantité
Un minimum de 10 ml
de selles fraîches
2 écouvillons saturés
(approx. 5ml)
Un minimum de 5 ml
de selles fraîches
Un minimum de 2-3 ml
de sérum (à la rigueur
7-10 ml sang)
Méthode
Placer l'échantillon
sans fixateur dans un
contenant propre à
large ouverture
Insérer chaque écouvillon saturé dans un
tube de milieu CaryBlair, casser l'extrémité
puis visser à fond le
bouchon du tube C-B
Placer immédiatement
le volume de selles
fraîches dans 3 volumes
de fixateur, SAF ou
formol 10% (ex: 5ml
selles + 15 ml SAF).
Bien mélanger
Prélever le sang
veineux dans un tube
"Vacutainer" sans anticoagulant; ôter le
caillot
Conservation
Réfrigérer
immédiatement, à 28°C. Ne pas congeler
si la microscopie
électronique est
demandée
Réfrigérer
immédiatement, à 28°C.
Conserver à
température de la pièce
ou réfrigérer à 2-8°C.
Ne pas congeler.
Si livré en dedans de 48
hres au LSPQ, réfrigérer
immédiatement à 28°C; si livré plus tard,
congeler à -20°C.
Transport
Envoyer le(s)
spécimen(s) dans un
contenant réfrigéré1;
envoyer
immédiatement par
courrier privé livrant en
moins de 24 hres.2
Envoyer le(s)
envoyer immédiatement
par courrier privé
livrant en moins de 24
hres.2
Envoyer le(s)
envoyer immédiatement
par courrier privé
livrant en moins de 24
hres.2
Envoyer le(s)
envoyer
immédiatement par
courrier privé livrant
en moins de 24 hres.2
Note:
Adapté de: Centers for Diseases Control. Recommendations for collection of laboratory specimens
associates with outbreaks of gastroenteritis. MMWR 1990, 39(RR14);1-13.
1
Un contenant rigide, doublé d'un sac de plastique, pouvant contenir tous les échantillons et le
matériel nécessaire pour immobiliser tous les tubes et bouteilles; ajouter de la glace sèche
seulement s'il s'agit d'échantillons congelés.
2
Il est essentiel d'envoyer les contenants de façon à empêcher le bris, notamment en se conformant
aux consignes de Transport Canada, de Postes Canada et du LSPQ.
Prélèvements…..3
2.
Échantillons de sérum
Tous les échantillons de selles pour analyse virologique devraient, dans la
mesure du possible, être accompagnés de sérums parce que la mise en évidence de
certaines particules virales dans les selles doit être complétée par une analyse
nécessitant un sérum de phase aiguë et un sérum prélevé en phase de convalescence,
soit de 3 à 4 semaines après l'apparition des symptômes.
2.1
Prélèvements
2.1.1 Un premier échantillon de sérum de 2-3 ml (1ml pour la population pédiatrique)
est prélevé en même temps que l'échantillon de selles en phase aiguë ou du moins en
dedans des premiers 5 jours après le début des symptômes. Lorsqu'il est impossible à
la clinique de préparer un échantillon de sérum à partir du prélèvement sanguin, un
échantillon de 7-10ml (3ml, pédiatrique) de sang dans un tube de type "Vacutainer"
sans anticoagulant peut être envoyé, à la rigueur.
2.1.2 Un deuxième sérum, en phase convalescente, est prélevé 3 à 4 semaines après
l'apparition des symptômes.
2.2
Conservation et délai acceptable avant la livraison au LSPQ
2.2.1 Conserver à 2-8°C et faire parvenir le plus rapidement possible au LSPQ; l'envoi
des sérums de phase aiguë devrait se faire si possible en même temps que celui des
échantillons de selles.
2.2.2 Dans les cas exceptionnels où la clinique désirerait conserver les sérums de phase
aiguë jusqu'à l'obtention du sérum de phase convalescente, il faut conserver les sérums
congelés (-10°C à -20°C) et les faire parvenir congelés au LSPQ, par la suite.
Tableau 2
Liste des principaux microorganismes pouvant être recherchés dans les
spécimens humains et identifiés au LSPQ
Incubation
Durée des
symptômes
Transmission
Source/Mode
Sujets les plus à
risques
Adenovirus
entérique
7 - 8 jrs
8 - 12 jrs
fécal-oral
jeunes enfants
Astrovirus
1 - 4 jrs
2 - 3 jrs
aliments, eau, fécaloral
jeunes enfants, gens
âgés
Calcivirus
1 - 3 jrs
1 - 3 jrs
bébés, jeunes enfants,
adultes
Norwalk Norwalk- 18 - 48 hres
like
12 - 48 hres
aliments, eau, p à p,
?air
enfants, adultes
Rotavirus groupe 1 - 3 jrs
A
5 - 7 jrs
eau, p à p, ?aliments, bébés, jeunes enfants
?air, fécal-oral
Rotavirus groupe 2 - 3 jrs
B
3 - 7 jrs
eau, p à p, fécal-oral
enfants, adultes
Rotavirus groupe 24 - 48 hres
C
3 - 7 jrs
fécal-oral
bébés, enfants,
adultes
Agent étiologique
Incubation
Durée des
symptômes
Transmission
Source/Mode
Sujets les plus à
risques
Aeromonas
*
*
*
*
Campylobacter
3 - 5 jrs
1 - 4 jrs
aliments, eau,
animaux de
compagnie fécal-oral
bébés, jeunes adultes
Escherichia coli
toxigène
12 - 72 hres
3 - 5 jrs
fécal-oral
bébés, enfants, adultes
Escherichia coli
hémorragique
3 - 5 jrs
7 - 10 jrs
aliments, p à p, fécal- enfants
oral
Salmonella
8 - 48 hres
3 - 5 jrs
bébés, jeunes enfants
Shigella
1 - 7 jrs
4 - 7 jrs
fécal-oral
enfants
Vibrio
9 - 72 hres
3 - 4 jrs
fécal-oral
tous
Yersinia
enterocolitica
2 - 7 jrs
1 - 21 jrs
animaux de
compagnie, fécal-oral
enfants, jeunes,
adultes
Agent étiologique
VIRUS
BACTÉRIES
Agent étiologique
Incubation
Durée des
symptômes
Transmission
Source/Mode
Sujets les plus à
risques
Cryptosporidum
7 - 14 jrs
4 - 21 jrs
aliments, eau, p à p, enfants, adultes
animaux de
(SIDA)
compagnie, fécal-oral
Entamoeba
histolytica
14-28jrs
semaines, mois
adultes
Giardia lamblia
5 - 25 jrs
1 - 2 semaines,
mois, années
enfants
PARASITES
•
p a p : personne a personne
* données épidémiologiques insuffisantes
Adapté de: Centers for Diseases Control, Recommendations for collection of laboratory spécimens
associated with outbreaks of gastroenteritis, MMWR 1990, 39(RR14);1-13.
Liste des fournitures pour prélèvements
II est essentiel de prélever les selles pendant la phase aiguë de la maladie,
afin de ne pas compromettre l'identification de l'agent étiologique.
Nécessaire à prélèvement pour effectuer les prélèvements et envoi pour 10 sujets
10
contenants à large ouverture pour recevoir directement les selles (pour
recueillir l'échantillon primaire de selles sans fixateur qui sera partagé dans
différents contenants avant d'être envoyé au LSPQ).
20
écouvillons stériles pour transférer l'échantillon de selles Cary-Blair.
20
tubes de milieu de transport Cary-Blair pour les analyses bactériologiques.
10
abaisse-langue ou autre instrument pour transférer l'échantillon de selles aux
deux contenants de plastique.
10
contenants en plastique, propres et étanches, d'une capacité minimum de 30
ml, à large ouverture, sans fixateur pour recherche de virus.
10
contenants en plastique, propres et étanches. d'une capacité minimum de 30ml,
contenant 15ml de fixateur (SAF ou formol 10%) pour les échantillons de selles de
5ml, pour la recherche des parasites.
(S'il est prévu d'envoyer des échantillons de plus de 5ml, il faut choisir des
contenants semblables mais pouvant contenir à la fois un volume de fixateur
égal à trois fois le volume de selles à fixer et l'échantillon, sans jamais remplir le
contenant à ras bord.)
10
tubes "Vacutainer" de 10ml, sans anticoagulant (bouchon rouge) pour prélever le
sang.
10
réquisitions du LSPQ ou, à défaut, 10 formules de CH, indiquant clairement le
nom, le sexe, la date de naissance ou l'âge et l'adresse du malades, l'éclosion
étudiée, les analyses demandées, le nom du médecin requérant.
NB:
toujours inclure avec la demande, les renseignements obtenus, en
particulier, les données de l'enquête et les résultats de laboratoire.
1
contenant rigide, doublé d'un sac de plastique, pouvant contenir tous les
échantillons et le matériel nécessaire pour immobiliser1 tous les tubes et
bouteilles.
TOUJOURS AVERTIR LE LSPQ AVANT D'ENVOYER LES SPÉCIMENS
Téléphone: (514) 457-2070
Télécopieur: (514) 457-6346
1
REMARQUE:
II est essentiel d'envoyer les contenants de façon à empêcher le bris et les fuites,
notamment en se conformant aux consignes de TRANSPORT CANADA, de POSTES
CANADA et du LSPQ.

Program to Prevent the Transmission of Enteric

Transcription

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