Epidemiologic Notes and Reports Multiply Resistant Shigellosis in a Day-Care Center -- Texas

Between October 10 and November 6, 1985, 15 children at a day-care center in Diboll, Texas, developed a diarrheal illness. Shigella sonnei was isolated from 10 ill children and from two of 19 asymptomatic children who were cultured on November 7. All isolates were colicin type 9, resistant to ampicillin, carbenicillin, streptomycin, cephalothin, and trimethoprim/sulfamethoxazole (TMP/SMX), and sensitive to tetracycline, nalidixic acid, chloramphenicol, and gentamicin. The attack rate was highest among the 12- to 22-month-old group. Family members of this group had the highest secondary attack rate (Table 1). No cases occurred among the 22 staff members. None of the children were hospitalized, but four of the five ill family members were.

The 89 children attending the center were cared for, by age group, in separate rooms. All groups except infants and toddlers had separate toilet and playground facilities. Infants and toddlers shared these facilities.

Symptomatic children were excluded from the center until their diarrhea had resolved. Then they were permitted to return, without treatment or cultures, to their classrooms. Handwashing and hygiene were emphasized; contact between age groups was limited; and the routine policy excluding food preparers from child care, particularly diaper-changing, was reinforced. No further cases were reported at the center after November 7, when this strategy was implemented.

During the following month, statewide surveillance for TMP/SMX-resistant S. sonnei infections detected an outbreak among kindergarteners in a town 100 miles away. Although this outbreak strain had the same colicin type and antimicrobial resistance profile as the Diboll strain, its plasmid content differed, and no direct connection between the two outbreaks was discovered. Reported by M Crowder, MD, W Joyce, J Connors, Public Health Region 7, A Quillian, M Czpiel, Angelina County and Cities Health Dist, J Taylor, MPH, DL Martin, MN, CE Alexander, MD, Bureau of Epidemiology, Texas Dept of Health; Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:Shigellosis in day-care centers can be difficult to control. Basic hygiene, exclusion of symptomatic persons, and routine antimicrobial therapy for all infected persons have been advocated as control measures (1). In the Texas outbreak reported here, antimicrobial therapy was not part of the control strategy because the strain was resistant to all drugs commonly used to treat shigellosis in children. Nonetheless, the straightforward control strategy in this well-designed day-care center was associated with the end of the outbreak, even though untreated convalescent children returned to the center and untreated asymptomatic carrier children remained there.

The elements contributing to this apparent success included vigorous emphasis on handwashing among staff and children; routine exclusion of ill children; separate areas and staff for diapering and food-preparation; and separate rooms, toilets, and play-facilities for different age groups. There is some evidence that each element is important. Handwashing has been shown to reduce the incidence of diarrheal illness in day-care centers (2). In day-care centers in Houston, Texas, the incidence of diarrheal illness was significantly associated with the proportion of staff who changed diapers and also served or prepared food (3). The usefulness of separating children by age was suggested by uniform shigellosis attack rates observed across ages 0 to 5 years at a day-care center where the children were grouped together (4). Additional study of the efficacy and utility of these specific control measures is needed (5,6).

Providing day-care in isolation for convalescent children may limit the spread of shigellosis in the community. In one outbreak, in which children with shigellosis were rigidly excluded from a day-care center until negative cultures were obtained, the outbreak strain spread to a day-care center in an adjacent county (7). In another outbreak, at a center where isolation of convalescent children was possible, treated, convalescent children without negative cultures were allowed to return to the day-care center, and there was no further spread of illness in either the center or the community (8). Further evaluation of convalescent day-care, with and without isolation, is needed before specific recommendations can be made.

To help day-care center directors, employees, and parents work with health departments to control disease in day-care centers, CDC has produced a training kit: "What To Do To Stop Disease in Child Day-Care Centers". This kit has been distributed to state health departments and licensing boards for distribution to licensed day-care centers. It also can be purchased for $4.00 from the Government Printing Office, Superintendent of Documents, Washington, D.C., 20402. The GPO Stock Number is 017-023-00172-8.

References

1. Child Day Care Infectious Disease Study Group, CDC. Public health considerations of infectious diseases in child day care centers. J Peds 1984;105:683-701.

2. Black RE, Dykes AC, Anderson KE, et al. Handwashing to prevent diarrhea in day-care centers. Am J Epidemiol 1981;113:445-51.

3. Lemp GF, Woodward WE, Pickering LK, Sullivan PS, DuPont HL. The relationship of staff to the incidence of diarrhea in day-care centers. Am J Epidemiol 1984;120:750-8.

4. Pickering LK, Evans DG, DuPont HL, Vollet JJ 3rd, Evans DJ Jr. Diarrhea caused by Shigella, rotavirus and Giardia in day-care centers: prospective study. J Pediatr 1981;99:51-6.

5. Pickering LK, Bartlett AV, Woodward WE. Acute infectious diarrhea among children in day care: epidemiology and control. Rev Inf Dis 1986;8:539-47.

6. Petersen NJ, Bressler GK. Design and modification of the day care environment. Rev Inf Dis 1986;8:618-21.

7. Tacket CO, Cohen ML. Shigellosis in day care centers: use of plasmid analysis to assess control measures. Pediatr Infect Dis 1983;2:127-30.

8. Tauxe RV, Johnson KE, Boase JC, Helgerson SD, Blake PA. Control of day care shigellosis: a trial of convalescent day care in isolation. Am J Publ Health 1986;76:627-30.

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