Anna Bowen

A Waterborne Outbreak of Gastroenteritis with Multiple Etiologies among Resort Island Visitors and Residents: Ohio, 2004

BACKGROUND The implementation of treated municipal water systems in the 20th century led to a dramatic decrease in waterborne disease in the United States. However, communities with deficient water systems still experience waterborne outbreaks. In August 2004, we investigated an outbreak of gastroenteritis on South Bass Island, Ohio, an island of 900 residents that is visited by >500,000 persons each year. METHODS To identify the source of illness, we conducted a case-control study and an environmental investigation. A case was defined as diarrhea in a person who traveled to the island during the period from May 1 through 30 September 2004 and became ill within 2 weeks after the visit. Healthy travel companions served as matched control subjects. We also performed an environmental assessment and extensive testing of island water sources. RESULTS Among the 1450 persons reporting illness, Campylobacter jejuni, norovirus, Giardia intestinalis, and Salmonella enterica serotype Typhimurium were identified in 16, 9, 3, and 1 persons, respectively. We interviewed 100 case patients and 117 matched control subjects. Case patients were more likely to drink water on the island than control subjects (68% vs. 35%; matched odds ratio, 4.3; 95% confidence interval, 2.2-9.3). Sampling of ground water wells indicated contamination with multiple fecal microbes, including Escherichia coli, C. jejuni, Salmonella species, and Giardia species. Irregularities in sewage disposal practices that could have contaminated the underground aquifer were noted. CONCLUSIONS The combined epidemiological and environmental investigation indicated that sewage-contaminated ground water was the likely source of this large outbreak. Long-term changes to the islands water supply and sewage management infrastructure are needed.

Hospitalization and Mortality Among Primarily Nonbreastfed Children During a Large Outbreak of Diarrhea and Malnutrition in Botswana, 2006

Background:In 2006, a pediatric diarrhea outbreak occurred in Botswana, coinciding with heavy rains. Surveillance recorded a 3 times increase in cases and a 25 fold increase in deaths between January and March. Botswana has high HIV prevalence among pregnant women (33.4% in 2005), and an estimated 35% of all infants under the age of 6 months are not breastfed. Methods:We followed all children <5 years old with diarrhea in the countrys second largest referral hospital at the peak of the outbreak by chart review, interviewed mothers, and conducted laboratory testing for HIV and enteric pathogens. Results:Of 153 hospitalized children with diarrhea, 97% were <2 years old; 88% of these were not breastfeeding. HIV was diagnosed in 18% of children and 64% of mothers. Cryptosporidium and enteropathogenic Escherichia coli were common; many children had multiple pathogens. Severe acute malnutrition (kwashiorkor or marasmus) developed in 38 (25%) patients, and 33 (22%) died. Kwashiorkor increased risk for death (relative risk 2.0; P = 0.05); only one breastfeeding child died. Many children who died had been undersupplied with formula. Conclusions:Most of the severe morbidity and mortality in this outbreak occurred in children who were HIV negative and not breastfed. Feeding and nutritional factors were the most important determinants of severe illness and death. Breastfeeding is critical to infant survival in the developing world, and support for breastfeeding among HIV-negative women, and HIV-positive women who cannot formula feed safely, may prevent further high-mortality outbreaks.

Incidence of Cronobacter spp. infections, United States, 2003-2009.

During 2003–2009, we identified 544 cases of Cronobacter spp. infection from 6 US states. The highest percentage of invasive infections occurred among children <5 years of age; urine isolates predominated among adults. Rates of invasive infections among infants approximate earlier estimates. Overall incidence of 0.66 cases/100,000 population was higher than anticipated.

Decreased Susceptibility to Ciprofloxacin among Shigella Isolates in the United States, 2006 to 2009

ABSTRACT We characterized 20 Shigella isolates with decreased susceptibility to fluoroquinolones. Most patients (80%) from whom a travel history was obtained reported travel to South or Southeast Asia. Mutations within the quinolone resistance determining regions of gyrA and parC and plasmid-mediated resistance determinants (qnrB, qnrS, and aac(6′)-Ib-cr) were identified. The rise in antimicrobial resistance among Shigella isolates may necessitate the increased use of extended-spectrum cephalosporins or macrolides in some patients.

Outbreak of Infections Caused by Shigella sonnei with Reduced Susceptibility to Azithromycin in the United States

Shigellosis is the third most common enteric bacterial infection in the United States (9).…

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.

Background: Shigellosis outbreaks in daycare centers result in substantial disease and economic burdens in the United States. The emergence of multidrug resistant Shigella strains raises questions regarding control of transmission within daycare centers and treatment for children. From May to October 2005, 639 Shigella sonnei cases were reported in northwest Missouri, mostly among persons exposed to daycare centers. Methods: We conducted a case-control investigation among licensed daycare centers (LDCs) in northwest Missouri to determine transmission risk factors, tested isolates for antimicrobial resistance, and described treatment practices. Case LDCs had secondary attack rates of shigellosis ≥2% (range, 2%–25%) and control LDCs ≤2% (range, 0%–1.3%). We interviewed LDC staff and performed on-site inspections. Thirty-one outbreak isolates were tested for antimicrobial resistance. We interviewed physicians and reviewed health department outbreak-related treatment data. Results: We enrolled 18 case and 21 control LDCs. LDCs with ≥1 sink in every room (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.02–0.5) or a diapering station in every room (OR: 0.1; 95% CI: 0.01–0.6) were less likely to be case-LDCs. Resistance to ampicillin and trimethoprim-sulfamethoxazole was found in 90% of the outbreak strains. Among 210 children treated with antimicrobial agents, azithromycin was used in 92 (44%) while a fluoroquinolone was used in 11 (5%) children. Conclusions: During a large daycare center-associated shigellosis outbreak, strains were highly resistant to ampicillin and trimethoprim-sulfamethoxazole. Children were frequently treated with azithromycin and occasionally fluoroquinolones. Appropriate handwashing and diapering infrastructure are necessary to minimize spread of shigellosis within daycare centers, and could reduce use of antimicrobial agents.

Systematic review of behavior change research on point-of-use water treatment interventions in countries categorized as low- to medium-development on the human development index

Point-of-use water treatment (i.e., water purification at the point of consumption) has proven effective in preventing diarrhea in developing countries. However, widespread adoption has not occurred, suggesting that implementation strategies have not motivated sustained behavior change. We conducted a systematic literature review of published behavioral research on factors influencing adoption of point-of-use water treatment in countries categorized as low- to medium-development on the United Nations Development Programme Human Development Index. We used 22 key words to search peer-reviewed literature from 1950 to 2010 from OVID Medline, CINAHL, and PsycINFO. Twenty-six (1.7%) of 1551 papers met our four inclusion criteria: 1) implemented a point-of-use water treatment intervention, 2) applied a behavioral intervention, 3) evaluated behavior change as the outcome, and 4) occurred in a low- or medium-development country. We reviewed these 26 publications for detailed descriptions of the water treatment intervention, theoretical rationales for the behavioral intervention, and descriptions of the evaluation. In 5 (19%) papers, details of the behavioral intervention were fully specified. Seven (27%) papers reported using a behavioral theory in the design of the intervention and evaluation of its impact. Ten (38%) studies used a comparison or control group; 5 provided detailed descriptions. Seven (27%) papers reported high sustained use of point-of-use water treatment with rates >50% at the last recorded follow-up. Despite documented health benefits of point-of-use water treatment interventions in reducing diarrheal diseases, we found limited peer-reviewed behavioral research on the topic. In addition, we found the existing literature often lacked detailed descriptions of the intervention for replication, seldom described the theoretical and empirical rationale for the implementation and evaluation of the intervention, and often had limitations in the evaluation methodology. The scarcity of papers on behavior change with respect to point-of-use water treatment technologies suggests that this field is underdeveloped.

Case-control study to determine risk factors for diarrhea among children during a large outbreak in a country with a high prevalence of HIV infection.

OBJECTIVES Between January and March of 2006, over 35 000 diarrhea cases and 532 deaths were reported among children aged <5 years in Botswana. We conducted an investigation to characterize the outbreak, identify risk factors for diarrhea, and recommend control strategies. METHODS We enrolled children <5 years of age presenting to the emergency department between March 2 and March 20, 2006. Cases had ≥3 loose stools per day and no antecedent diarrhea among household members. Controls had had no diarrhea since January 1, 2006. We conducted a multivariate logistic regression analysis controlling for socioeconomic status, age, and maternal HIV status. RESULTS Forty-nine cases with median age of 12 months (range 0-45 months) and 61 controls with median age of 24 months (range 0-59 months) were enrolled; 33 (30%) were born to HIV-positive mothers. Case-parents were more likely to report storing household drinking water (adjusted odds ratios (AOR) 3.9, 95% confidence interval (CI) 1.2-15.7). Lack of hand washing after using the toilet or latrine (AOR 4.2, 95% CI 1.1-20.4) was more likely to be reported by case-parents. Case-children were less likely to be currently breastfeeding (AOR 30.3, 95% CI 2.0-1000.0). Five (10%) case-patients and no control-patients died. Multiple causal pathogens were identified. CONCLUSIONS During this diarrhea outbreak in a country with a national program to prevent mother-to-child transmission of HIV, ill children were less likely to be breastfed and more likely to have been exposed to environmental factors associated with fecal contamination. These findings underscore the importance of adequate access to safe water, sanitation, hygiene, and nutrition education among populations using breast milk substitutes.

Association Between Intensive Handwashing Promotion and Child Development in Karachi, Pakistan: A Cluster Randomized Controlled Trial

OBJECTIVE To evaluate associations between handwashing promotion and child growth and development. DESIGN Cluster randomized controlled trial. SETTING Informal settlements in Karachi, Pakistan. PARTICIPANTS A total of 461 children who were enrolled in a trial of household-level handwashing promotion in 2003 and were younger than 8 years at reassessment in 2009. INTERVENTIONS In 2003, neighborhoods were randomized to control (n = 9), handwashing promotion (n = 9), or handwashing promotion and drinking water treatment (n = 10); intervention households received free soap and weekly handwashing promotion for 9 months. MAIN OUTCOME MEASURES Anthropometrics and developmental quotients measured with the Battelle Developmental Inventory II at 5 to 7 years of age. RESULTS Overall, 24.9% (95% CI, 20.0%-30.6%) and 22.1% (95% CI, 18.0%-26.8%) of children had z scores that were more than 2 SDs below the expected z scores for height and body mass index for age, respectively; anthropometrics did not differ significantly across study groups. Global developmental quotients averaged 104.4 (95% CI, 101.9-107.0) among intervention children and 98.3 (95% CI, 93.1-103.4) among control children (P = .04). Differences of similar magnitude were measured across adaptive, personal-social, communication, cognitive, and motor domains. CONCLUSIONS Although growth was similar across groups, children randomized to the handwashing promotion during their first 30 months of age attained global developmental quotients 0.4 SDs greater than those of control children at 5 to 7 years of age. These gains are comparable to those of at-risk children enrolled in publicly funded preschools in the United States and suggest that handwashing promotion could improve child well-being and societal productivity. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01538953.

Elevated Risk for Antimicrobial Drug–Resistant Shigella Infection among Men Who Have Sex with Men, United States, 2011–2015

These men were 3–77 times more likely than other persons to have shigellae resistant to >1 key drugs.