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HEALTHY PEOPLE IN HEALTHY COMMUNITIES
COMMUNICABLE DISEASE INVESTIGATION
REFERENCE MANUAL
Section of Communicable Disease Control
and Veterinary Public Health
Division of Environmental Health and
Communicable Disease Prevention
The following information is taken from the Missouri Department of Health
Communicable Disease Investigation Reference Manual.
For more detailed information in this report, see…(internet address) or call 573-751-6002.
Table of Contents
1. Anthrax
2. Blastomycosis
3. Botulism
4. Brucellosis
5. Campylobacteriosis
6. Cholera
7. Coccidioidomycosis
8. Creutzfeldt-Jakob Disease
9. Variant Creutzfeldt-Jakob Disease Fact Sheet
10. Cryptosporidiosis
11. Escherichia coli/Other Hemorragic E. coli
12. Ehrlichiosis
13. Encephalitis, Arboviral
14. Mosquitoes and Disease
15. Giardiasis
16. Haemophilus influenzae, Invasive
17. Haemophilus influenzae type b (Hib)
18. Important Information about Rifampin for Prevention of Meningococcal
Disease
19. Hansen’s Disease (Leprosy
20. Hantavirus Pulmonary Syndrome
21. Hemolytic Uremic Syndrome, (Post Diarrheal) (HUS)
22. Hemorrhagic Fevers (Viral)
23. Lassa Fever
24. Ebola Hemorrhagic Fever
25. Marburg Hemorrhagic Fever
26. Crimean-Congo Hemorrhagic Fever
27. Dengue and Dengue Hemorrhagic Fever
28. Hepatitis A
29. Hepatitis B, acute/Delta Hepatitis
30. Hepatitis C
31. Influenza
32. Legionellosis
33. Leptospirosis
34. Listeriosis
35. Lyme-like Disease
36. Malaria
37. Meningococcal Disease (Neisseria meningitidis and other
septicemia/bacteremia, invasive pneumonia, and other disease)
38. Outbreak Investigation, Acute Gastroenteritis
39. Outbreaks, Nosocomial
40. Pediculosis
41. Plague
42. Pediculosis
43. Rabies
44. Rocky Mountain Spotted Fever
45. Salmonellosis
46. Scabies
47. Shigellosis
48. Streptococcus pneumoniae (pneumonia, meningitis)
49. Streptococcus group A (Gas) Disease
50. Toxic Shock Syndrome
51. Trichinosis
52. Tularemia
53. Typhoid Fever
54. Yellow Fever
55. Yersinia enterolitica ..
Anthrax
Anthrax is a potential bioterrorism weapon. The key identifying sign for anthrax is a
widened mediastinum (present in about 80% of patients). A widened mediastinum, if
present, will be visible on x-ray 2-3 days after onset of symptoms. If you suspect that you are
dealing with a bioterrorism situation, contact your District Communicable Disease
Coordinator and consult your emergency procedure manual.
What is anthrax?
Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus
anthracis. Anthrax most commonly occurs in warm-blooded animals, but can also infect
humans.
How common is anthrax and who can get it?
Although anthrax can be found globally, it is more often a risk in countries with less
standardized and effective public health programs. Anthrax is most common in
agricultural regions where it occurs in animals. Cases of human anthrax have not been
reported in Missouri within the past fifteen years.
When anthrax affects humans, it is usually due to an occupational exposure to infected
animals or their products. Workers who are exposed to dead animals and animal products
(industrial anthrax) from other countries where anthrax is more common may become
infected with B. anthracis. Anthrax in animals rarely occurs in the United States. Most
reports of animal infection are received from Texas, Louisiana, Mississippi, Oklahoma and
South Dakota.
How is anthrax transmitted?
Anthrax infection can occur in three forms; cutaneous (skin), inhalation, and
gastrointestinal. B. anthracis spores can live in the soil for many years and humans can
become infected with anthrax by handling animal products from infected animals or by
inhaling anthrax spores from contaminated animal products. Anthrax can also be spread
by eating undercooked meat from infected animals. It is rare to find infected animals in
the United States.
What are the symptoms of anthrax?
Symptoms of disease vary depending on how the disease was contracted, but symptoms
usually occur within seven days.

Cutaneous: Most anthrax infections occur when the bacterium enters a cut or abrasion
on the skin, such as when handling contaminated wool, hides, leather or hair products
(especially goat hair) of infected animals. Skin infection begins as a raised itchy bump
that resembles an insect bite, but within 1-2 days develops into a vesicle and then a
painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying)
area in the center. Lymph glands in the adjacent area may swell. About 20% of
untreated cases of cutaneous anthrax will result in death. Deaths are rare with
appropriate antimicrobial therapy.

Inhalation: Initial symptoms may resemble a common cold. After several days, the
symptoms may progress to severe breathing problems and shock. Inhalation anthrax
usually results in death in 1-2 days after onset of the acute symptoms.
Intestinal: The intestinal disease form of anthrax may follow the consumption of
contaminated meat and is characterized by an inflammation of the intestinal tract.
Initial signs of nausea, loss of appetite, vomiting, fever are followed by abdominal
pain, vomiting of blood, and severe diarrhea. Intestinal anthrax results in death in 25%
to 60% of cases.
Can anthrax be spread from person-to-person?
Naturally occurring anthrax stems from animal origins. This disease is rarely transmitted
person-to-person.
How is anthrax diagnosed?
Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory
secretions or by measuring specific antibodies in the blood of suspected cases.
Is there an anthrax vaccine for humans?
The anthrax vaccine for humans licensed for use in the Unites States is a cell-free filtrate
vaccine, which means it uses dead bacteria as opposed to live bacteria. The vaccine is
reported to be 93% effective in protecting against cutaneous anthrax. The anthrax vaccine
was developed and is manufactured and distributed by the Michigan Biologic Products
Institute, Lansing, Michigan. Anthrax vaccines intended for use in animals should not be
used in humans. For further information see http://www.anthrax.osd.mil/
Who should be vaccinated against anthrax?
Because anthrax is considered to be a potential agent for use in biological warfare, the
Department of Defense recently announced that it will begin systematic vaccination of all
U.S. military personnel. Among civilians, the Advisory Committee for Immunization
Practices (ACIP), recommends anthrax vaccine be given to individuals who come in
contact in the workplace with imported animal hides, furs, bonemeat, wool, animal hair
(especially goat hair), and bristles; and for individuals engaged in diagnostic or
investigational activities which may bring them into contact with anthrax spores. The
vaccine should only be administered to healthy men and women from 18 to 65 years of age
since investigations to date have been conducted exclusively in that population. Because it
is not known whether anthrax vaccine can cause fetal harm, pregnant women should not be
vaccinated.
What is the protocol for anthrax vaccination?
The immunization consists of three subcutaneous injections given two weeks apart
followed by three additional subcutaneous injections given at 6, 12, and 18 months.
Are there adverse reactions to the anthrax vaccine?
Mild local reactions occur in 30% of recipients and consist of slight tenderness and
rednessat the injection site. A moderate local reaction can occur if the vaccine is given to
anyone with a past history of anthrax infection. Severe local reactions are very infrequent
and consist of extensive swelling of the forearm in addition to the local reaction.
Systemic reactions occur in less than 0.2% of recipients and are characterized by flu-like
symptoms. Annual booster injections of the vaccine are required to maintain immunity.
Am I a risk to my family? Can I spread anything?
Most of the diseases caused by bioterrorist agents (e.g., anthrax) are NOT contagious from
person to person. Even in the unlikely event that you truly have been exposed to a contagious
agent of bioterrorism, you would have to become ill yourself to be able to spread infection.
Results of the laboratory tests on the suspect material will be available in time for you to take
antibiotics to prevent you from spreading anything to your family.
What should I do now?
You must complete a Data Collection Form before you leave the site of the incident so you can be
contacted with the results of the investigation. After Emergency Personnel authorize you to
leave, you may continue your usual activities at work or home. It is not necessary for you to visit
a hospital or doctor’s office. If you wish to contact your private physician to discuss your
possible exposure, please feel free to do so. As a precaution, we recommend that you take your
temperature daily to watch for fever.
What should I do if I develop any symptoms before the results of laboratory
tests are ready?
If you should develop any symptoms or a fever immediately contact your doctor; you and/or your doctor
should also contact your local public health agency. Recommendations will then be given to you and
your health care provider on how to best evaluate and treat your symptoms, based on the circumstances
of this possible exposure incident.
When will it be safe for me to return to the exposure site?
Investigators of the incident will notify the authorities when it is safe to return to the site. If this
is a place of work, your supervisor will then contact you when it is safe to return.
Who can my doctor or I contact if we have questions?
If you or your physician have medical questions about your possible exposure, please contact the
your local public health agency or:
BLASTOMYCOSIS
What is blastomycosis?
Blastomycosis is a disease caused by a fungus that grows in moist soils, particularly wooded areas
along waterways and in undisturbed placed like under porches or sheds.
Who gets blastomycosis?
Studies have shown that the risk for disease may be greater among middle-aged men, 30-59 years
of age. Also at greater risk are those with outdoor exposure during work such as farmers and
forestry workers or during recreational activities in wooded areas and along waterways. Exposure
to soil has also been associated with risk of illness.
How do you get blastomycosis?
You get blastomycosis by breathing dust that contains the spores. The disease also occurs in dogs,
cats and other animals. It is not transmitted from animals to people or from person-to-person.
How long after exposure to the fungus do symptoms start?
It takes from 3 weeks to 3 months but symptoms will usually start in 45 days.
What are the symptoms of blastomycosis?
The disease may present with sudden onset of fever or cough and can resolve after 1-3 weeks of
illness. But, more commonly, the onset is slow and the disease becomes a chronic form and spreads
from the lungs, causing skin lesions usually on the face and fingers. It may also cause weight loss,
weakness and low-grade fever. If untreated it can result in death.
How is blastomycosis diagnosed?
A physician should be seen for testing and diagnosis. Early diagnosis and treatment are important to
prevent serious illness and/or death.
Can blastomycosis be treated?
Yes, the disease can be treated with medication prescribed by your doctor.
How can blastomycosis be prevented?
Prevention measures are unknown. However, activities which bring individuals closer to rotting
wood and exposure with the soil such as hunting, fishing, or playing in soil near water may be
associated with a greater risk of developing blastomycosis.
If symptoms occur, see a doctor immediately. If you change doctors during the illness, be sure you
tell the new physician what your symptoms were then and what medication you were given.
Botulism
What is botulism?
Botulism is a rare but serious illness that can result in paralysis and death. The germ,
Clostridium botulinum, is commonly found in soil and can be carried in dust.
Eating foods that contain the botulism toxin causes foodborne botulism. Foodborne botulism
is especially dangerous because several people can be poisoned by a single contaminated food.
Infant or intestinal botulism is the most common form of botulism in the United States and
mainly affects infants under 1 year of age. It is caused when spores of the germ are
consumed. Once spores are consumed they grow in the intestines and release the botulism
toxin.
Who gets botulism?
A person who eats a food that contains the botulism toxin. It often involves improperly
processed home canned foods.
Botulism in infants under one year of age has been associated with the ingestion of
contaminated honey.
How is botulism spread?
By eating a food with the toxin present or a food item containing bacterial spores. Person to
person spread does not occur.
What are the symptoms of botulism?
Both foodborne and infant botulism affect the nervous system. The symptoms of foodborne
botulism include blurred or double vision, drooping eyelids, slurred speech, difficulty
swallowing, muscle weakness and paralysis (that starts from the head and spreads downward),
and sometimes death. Infant botulism has a wide range of symptoms generally starting with constipation
and followed by sluggishness and poor feeding to difficulty in swallowing, loss of head control,
poor feeding and poor reflexes (floppy baby).
How soon do symptoms appear?
Symptoms of foodborne botulism usually appear 12-36 hours after ingestion, but may take
several days. The time between exposure and onset of symptoms is unknown for infant/intestinal
botulism.
What is the treatment for botulism?
Good supportive care in a hospital is necessary for all forms of botulism. Difficulty in
breathing and the muscle weakness or paralysis which may occur and require a person to be
Who gets botulism?
A person who eats a food that contains the botulism toxin. It often involves improperly
processed home canned foods.
Botulism in infants under one year of age has been associated with the ingestion of
contaminated honey.
How is botulism spread?
By eating a food with the toxin present or a food item containing bacterial spores. Person to
person spread does not occur.
What are the symptoms of botulism?
Both foodborne and infant botulism affect the nervous system. The symptoms of foodborne
botulism include blurred or double vision, drooping eyelids, slurred speech, difficulty
swallowing, muscle weakness and paralysis (that starts from the head and spreads downward),
and sometimes death.
Infant botulism has a wide range of symptoms generally starting with constipation and
followed by sluggishness and poor feeding to difficulty in swallowing, loss of head control,
poor feeding and poor reflexes (floppy baby).
How soon do symptoms appear?
Symptoms of foodborne botulism usually appear 12-36 hours after ingestion, but may take
several days.
The time between exposure and onset of symptoms is unknown for infant/intestinal botulism.
What is the treatment for botulism?
Good supportive care in a hospital is necessary for all forms of botulism. Difficulty in
breathing and the muscle weakness or paralysis which may occur.
Brucellosis
Tourists seeking information for vaccination or travel recommendations should be advised
there is a high prevalence of this disease in underdeveloped countries. They should avoid any
dairy products unless they can be absolutely certain it has been pasteurized. Foreign travel
recommendations may be quickly found via the internet using www.cdc.gov (21 Sept. 1999)
or www.tripprep.com (21 Sept. 1999).
The incidence of human cases has been very low in the United States and most control
measures have been designed to prevent the disease according to the historic patterns of
transmission. However, new strategies may be necessary in the event of large outbreaks
involving unusual modes of transmission or bioterrorism events.
What is brucellosis?
Brucellosis is a bacterial disease also referred to as undulant fever in humans. The disease
is transferred from animals to man. The bacteria multiply in the reproductive organs and
mammary glands. Infected animals are most contagious when they deliver or abort. The
disease is uncommon in the United States with an annual incidence of approximately 100
human cases. The disease is very common in underdeveloped countries. There are several
different Brucella species.
Who gets brucellosis?
Anyone can get brucellosis if they are exposed. Occupations at highest risk in the United
States are veterinarians, cattle ranchers, and slaughterhouse employees. Persons who
consume unpasteurized milk and cheeses made with raw milk are also at risk. Brucellosis
may be accidentally transmitted to humans by careless handling of live virus animal
vaccine.
How do humans get brucellosis?
Brucellosis is spread to humans through contact with blood, body tissues, or body fluids
of infected animals. The most common method is consumption of unpasteurized milk and
dairy products. Human infections may occur through breaks in the skin when handling
infected animal tissues. In rare instances air borne transmission of the disease may occur
but only under artificial conditions.
What animals may carry the disease?
There are several species of Brucella bacteria. Domestic animals that may be infected include
cattle, sheep, goats, dogs, and swine. Bison, elk, caribou, coyotes, and some species of deer
may become infected. Brucella canis, the species that may infect dogs and coyotes is rarely
transmitted to man.
How would I know if an animal had brucellosis?
The only obvious sign may be a spontaneous abortion. If you believe your livestock or pets
may be infected, you should contact your veterinarian. They can arrange for the appropriate
laboratory testing. If you have inquires about livestock you may wish to call the Missouri
Department of Agriculture at 573-751-3377.
What are the symptoms of brucellosis?
In humans the disease is characterized by fever, night sweats, extreme fatigue, loss of appetite,
weight loss, headache, and joint pain. The onset may be acute or insidious and the fever may
be continuous, intermittent, or irregular. The disease may last for several days, months, or
even one year or more if not adequately treated.
How long is the incubation period for brucellosis?
The incubation period is usually 5 to 60 days. The average incubation period is 1 month but in
rare cases the incubation period may be longer.
How is brucellosis diagnosed?
Since the disease is uncommon in the United States, the diagnosis usually requires laboratory
tests. Several different methods are available from the commercial labs to aid the clinician to
diagnosis the disease. Exposure history is very important for the diagnosis of subsequent
cases.
What is the treatment for brucellosis?
Treatment usually requires long-term antibiotic therapy. Some regimens may include 2
different antibiotics for six weeks. Relapses are common.
Can human to human transmission of brucellosis occur?
It appears to be unlikely. As always you should consult with your physician if you have
concerns in this area.
What possible complications may arise out of an untreated infection?
Brucellosis may produce a mild disease in humans or cause severe temporary or permanent
injury if left untreated. Complications include injury to the bone, genitourinary tract,
meningitis, and endocarditis. Untreated Brucella melitensis infections associated with
unpasteurized goat’s milk and cheese will produce a 2 percent case fatality rate due to
endocarditis (an infection of the heart valves).
How can brucellosis be prevented?
The most important measures to control the disease are already in place in the United States.
Brucellosis causes fetal death and impairs the reproductive ability of livestock. Due to the
economic loss, there is a national brucellosis eradication program for cattle. The federal and
state agriculture departments working with the farmers and ranchers have been highly
successful in their eradication efforts in the United States.
While brucellosis is rare in the United States, it is up to the consumer to demand safe
pasteurized dairy products. Do not buy dairy products from unlicensed retailers, street
vendors, or other questionable sources. Food borne transmission has become the most
common means of exposure. Many of these cases are a result of consumption of cheese
originating outside the United States. Persons traveling to Latin America, Eastern Europe,
Central Asia, Africa, India, and the Mediterranean are at increased risk of exposure. Dairy
products should be avoided unless you can be absolutely certain they were made from
pasteurized milk.
Campylobacteriosis
Clinical Description
An infection that may result in diarrheal illness of variable severity
Contact Bureau of Child Care, if cases are associated with a child care facility.
Case/Contact Follow Up And Control Measures
Try to determine the source of infection:
Does the case or a member of the case's household attend a childcare center or nursery
school?
Does the case or a member of the case's household work as a foodhandler or healthcare
provider?
Has the case traveled out of the country to an endemic area?
Does the case have contact with excreta from wild or domestic animals (esp. kittens or
puppies)?
Does the case work in poultry or other animal operations?
Have there been other cases linked by time, place or person?
Control Measures
See the Campylobacteriosis
Because of the known risk of transmission of enteric pathogens from individuals with
diarrhea, food handlers and symptomatic health care personnel with patient care
responsibilities should not be permitted to work until the diarrheal episode has ended.
Asymptomatically infected food handlers or health care personnel need not be excluded
from work, but the need for handwashing after defecation should be stressed
Child Care Employees and Attendees:
Symptomatic childcare employees should not be permitted to work until the diarrheal
episode has ended. The need for handwashing after defecation should be stressed.
Exclusion of asymptomatic convalescent stool-positive individuals is indicated only for
those with questionable handwashing habits.
Children with diarrhea should be excluded from childcare, or cared for in a separate protected area until
diarrhea subsides
In childcare settings where children are not toilet-trained, it is prudent to treat with
antibiotics. Symptomatic children should be excluded from childcare for two days after
beginning antibiotics or until the child is asymptomatic, whichever is the shorter period of
time
Proper hand washing technique after changing diapers and before food prep is very important. Toys,
countertops, and diaper changing areas should be cleaned more
frequently, especially if used by children with diarrhea.
CAMPYLOBACTER INFECTION
(Campylobacteriosis)
What is campylobacter?
Campylobacter is a bacterium that infects the intestines (gut).
What are the symptoms?
Symptoms are usually diarrhea (sometimes bloody), stomachache, fever, nausea and
vomiting. Often the illness ends by itself, but it may require treatment with antibiotics.
How is campylobacter spread?
The bacteria are found in human and animal feces. It is very common in cattle and
chickens. People can get it by eating or drinking raw or contaminated water, milk,
poultry, meat or from infected pets and other animals. It is very rare to get campylobacter
from another person who has it.
How long from when a person is infected until they get ill?
Usually people get sick within 2-5 days of infection with these bacteria, but it can be as
little as 1 day to as long as 10 days before illness occurs.
How can campylobacter infection be prevented?
It can be prevented by properly cooking poultry and meats to at least 165° F; by hand-washing
after using the toilet, before handling any food and after handling raw foods;
only drinking pasteurized milk; and never drinking water from creeks, lakes or springs.
Where can I get more information about campylobacteriosis?
To find out more, call your doctor or local health department. Only a special lab test can
tell if someone is infected.
Cholera
Overview
Although many cases of cholera occur worldwide every year from natural causes, cholera
is also a potential bioterrorism weapon. All cases reported in Missouri to date have been
from naturally occurring causes. If you suspect that you are dealing with a bioterrorism
situation, contact your District Communicable Disease Coordinator and consult your
emergency procedure manual.
An illness characterized by diarrhea and/or vomiting; severity is variable.
What is cholera?
Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium
Vibrio cholerae. The infection is often mild or without symptoms, but sometimes it can be
severe. Approximately one in 20 infected persons will develop severe disease
characterized by profuse watery diarrhea, vomiting, and leg cramps. In these persons,
rapid loss of body fluids leads to dehydration and shock. Without treatment, death can
occur within hours.
How does a person get cholera?
A person may get cholera by drinking water or eating food contaminated with the cholera
bacterium. In an epidemic, the source of the contamination is usually the feces of an
infected person. The disease can spread rapidly in areas with inadequate treatment of
sewage and drinking water.
The cholera bacterium may also live in the environment in brackish rivers and coastal
waters. Shellfish eaten raw have been a source of cholera, and a few persons in the United
States have contracted cholera after eating raw or undercooked shellfish from the Gulf of
Mexico.
The disease is not likely to spread directly from one person to another; therefore, casual
contact with an infected person is not a risk for becoming ill.
What is the risk for cholera in the United States?
In the United States, cholera was prevalent in the 1800s but has been virtually eliminated
by modern sewage and water treatment systems. The disease is still common today in
other parts of the world, including the Indian subcontinent and sub-Saharan Africa.
As a result of improved transportation, more persons from the United States travel to
parts of Latin America, Africa, or Asia where epidemic cholera is occurring. U.S. travelers
to areas with epidemic cholera may be exposed to the cholera bacterium. In addition,
travelers may bring contaminated seafood back to the United States; contaminated
seafood brought into this country by travelers has caused foodborne outbreaks.
What should travelers do to avoid getting cholera?
The risk for cholera is very low for U.S. travelers visiting areas with epidemic cholera.
However, travelers should be aware of how the disease is transmitted and what can be
done to prevent it. When simple precautions are observed, contracting the disease is
unlikely.
All travelers to areas where cholera has occurred should observe the following
recommendations:
Drink only water that you have boiled or treated with chlorine or iodine. Other safe
beverages include tea and coffee made with boiled water and carbonated bottled
beverages with no ice.
Eat only foods that have been thoroughly cooked and are still hot, or fruit that you
have peeled yourself.
Avoid undercooked or raw fish or shellfish, including ceviche.
Make sure all vegetables are cooked--avoid salads.
Avoid foods and beverages from street vendors.
Do not bring perishable seafood back to the United States.
A simple rule of thumb is, "Boil it, cook it, peel it, or forget it. "
Is a vaccine available to prevent cholera?
A vaccine for cholera is available; however, it confers only brief and incomplete immunity
and is not recommended for travelers. There are no cholera vaccination requirements for
entry or exit in any Latin American country or the United States.
Can cholera be treated?
Although cholera can be life threatening, it is easily prevented and treated. Cholera can be
simply and successfully treated by immediate replacement of the fluid and salts lost
through diarrhea. Patients can be treated with oral rehydration solution, a prepackaged
mixture of sugar and salts to be mixed with water and drunk in large amounts. This
solution is used throughout the world to treat diarrhea. Severe cases also require
intravenous fluid replacement. With prompt rehydration, less than 1% of cholera patients
die.
Antibiotics shorten the course and diminish the severity of the illness, but they are not as
important as rehydration. Persons who develop severe diarrhea and vomiting in countries
where cholera occurs should seek medical attention promptly.
How long will the current epidemic last?
Predicting how long the epidemic in Latin America will last is difficult. The cholera
epidemic in Africa has lasted more than 20 years. In areas with inadequate sanitation, a
cholera epidemic cannot be stopped immediately, and there are no signs that the epidemic
in the Americas will end soon. Latin American countries that have not yet reported cases
are still at risk for cholera in the coming months and years. Major improvements in sewage
and water treatment systems are needed in many of these countries to prevent future
epidemic cholera.
What is the U.S. government doing to combat cholera?
U.S. and international public health authorities are working to enhance surveillance for
cholera, investigate cholera outbreaks, and design and implement preventive measures.
The Centers for Disease Control is investigating epidemic cholera wherever it occurs and
is training laboratory workers in proper techniques for identification of V.cholerae. In
addition, the Centers for Disease Control is providing information on diagnosis, treatment,
and prevention of cholera to public health officials and is educating the public about
effective preventive measures.
The U.S. Agency for International Development is sponsoring some of the international
government activities and is providing medical supplies to affected countries.
The Environmental Protection Agency is working with water and sewage treatment
operators in the United States to prevent contamination of water with the cholera
bacterium.
The Food and Drug Administration is testing imported and domestic shellfish for V.
cholerae and monitoring the safety of U.S. shellfish beds through the shellfish sanitation
program.
With cooperation at the state and local, national, and international levels, assistance will be
provided to countries where cholera is present, and the risk to U.S. residents will remain
small.
Where can a traveler get information about cholera?
The global picture of cholera changes periodically, so travelers should seek updated
information on countries of interest. The Centers for Disease Control maintains a
traveler’s information telephone line that provides information on cholera and other
diseases of concern to travelers. Data for this service are obtained from the World Health
Organization. This number is 404-332-4559.
This Fact Sheet was developed from information provided by:
The Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Road, Mailstop C09
Atlanta, Georgia 303
Coccidioidomycosis
Valley fever and San Joaquin Valley fever
What is Coccidioidomycosis?
A disease caused by breathing in a fungus found in the soil in certain parts of the southwestern
U.S., Mexico, and Central and South America.
What causes this disease?
Infection is caused by breathing in spores of a fungus found in desert regions.
What is the incubation period for this disease?
The incubation period is 10 to 30 days.
What are the symptoms?
Cough, chest pain (varies from mild sense of constriction to severe), fever, fatigue, headache,
joint aches, and rash. Occasionally painful red bumps appear on lower legs. These bumps
gradually turn brown.
How serious is this disease?
About 60% of infections cause no symptoms and are only recognized by a positive skin test.
In the remaining 40%, symptoms range from mild to severe. Dark-skinned people and people
with a weak immune system often have more serious infections. The acute form can develop
into widespread disseminated disease or into a chronic pulmonary (lung) disease after a long
latent period. Occasionally, the disease can spread throughout the body or develop into
chronic lung disease after a period of no symptoms.
How can I avoid exposure to the fungus that causes this disease?
Avoiding travel to regions where this fungus is found will prevent risk of developing this
disease. Serious illness from this infection is rare, so prevention is usually not a concern
except for immunocompromised people. In the southwestern U.S., it is estimated that 100,000
new infections occur each year.
How does the physician test for this disease?
Sputum smear, sputum culture, blood tests, skin tests, or chest X-rays may aid the physician
in the diagnosis.
What is the treatment for this disease?
The disease is almost always benign and goes away without treatment. Bed rest and treatment
of symptoms until fever disappears may be recommended.
Creutzfeldt-Jakob Disease (CJD)
Variant Creutzfeldt-Jakob Disease
(vCJD)
What is Variant Creutzfeldt-Jakob Disease (vCJD)?
Variant Creutzfeldt-Jakob disease (vCJD) is a rare and fatal human neuro-degenerative
condition. It is classified as a transmissible spongiform encephalopathy
(TSE) because of characteristic spongy degeneration of brain tissue. vCJD is a new
disease, which as of this date has not been identified in the United States. vCJD is often
confused with Creutzfeldt-Jakob (CJD) but reflects different onset and duration
characteristics.
Who gets vCJD?
vCJD affects younger patients (average age 29 years, as opposed to 65 years for
Sporadic CJD). It has a relatively longer duration of illness with a median of 14 months
(as opposed to 4.5 months for Sporadic CJD). vCJD is strongly linked to exposure,
probably through food, to a transmissible spongiform encephalopathy (TSE) of cattle
called Bovine Spongiform Encephalopathy (BSE). vCJD was first reported in the UK in
1986.
How is vCJD Transmitted/Acquired?
The nature of the TSE agent is being investigated and is still a matter of debate.
There are several theories under discussion. According to the prion theory, the infective
agent is composed largely of a self-replicating protein (prion). Another theory contends
that the agent is a "virus-like" agent. The most likely cause of vCJD is exposure to the
BSE agent, most plausibly due to dietary contamination by affected bovine central
nervous system tissue.
What are the Symptoms of vCJD?
Early in the illness, patients usually experience psychiatric symptoms, which most
commonly take the form of depression, or a "schizophrenia-like " psychosis.
Neurological signs, including unsteadiness, difficulty walking, and involuntary muscle
movements develop as the illness progresses. By the time of death, patients become
immobile and mute.
How soon do Symptoms vCJD occur?
vCJD affects younger patients (mean age, 26.3 years) with a relatively long
duration of illness (mean, 14.1 months).
How is vCJD diagnosed?
Neuropathological diagnosis is mandatory for confirmation of suspected vCJD.
Confirmatory examination of the brain should show the following neuropathological
features:
Numerous widespread amyloid plaques surrounded by vacuoles.
Spongiform change most evident in the basal ganglia and thalamus.
Prion protein accumulation in high density shown by immunocyto-chemistry,
particularly in the cerebellum.
As with CJD, the patient should be suspect for vCJD when the patient's history reveals a
rapid dementia and observed loss of muscle coordination. Confirmation of the disease is
done through brain biopsy or autopsy.
How is vCJD treated?
There is no known effective treatment available for vCJD. As with CJD,
treatment is aimed at controlling symptoms and providing comfort measures.
CJD (Sporadic, Inherited, or Iatrongenic)
For more information on CJD, you can request the Creutzfeldt-Jakob Disease Fact Sheet
from the Section of Communicable Disease Control and Veterinary Public Health.
* Does the case or a member of the case's household attend a child care center or nursery
school?
What is the case’s primary source of drinking water?
Has the case ingested untreated water from a lake or stream?
Had the case participated in water recreational activities in a pool, lake or stream?
Has the case traveled recently?
Does the case handle animals or otherwise have contact with feces from wild or domestic
animals especially calves with scours?
Have there been other cases linked by time, place or person (persons who drink from the
same water supply, consumed fresh fruit or vegetables)?
Does the case engage in sexual practices that might place them or others at increased risk?
Control Measures
See the Cryptosporidiosis section of the Control of Communicable Disease Manual
(CCDM), “Control of patient, contacts and the immediate environment”.
See the Cryptosporidiosis section of the Red Book.
General
Identify symptomatic contacts and obtain stool specimens. If the first stool specimen is
negative by microscopic examination for ova and parasites (O&P), examine two
additional specimens collected 24 hours apart.
If the initial specimen is negative by EIA
antigen testing of the stool, no additional specimens need testing for Cryptosporidium
parvum.
Positive contacts should be interviewed and referred for medical assessment.
Exclude foodworkers, health care workers, child care workers or child care attendees until
asymptomatic. For individuals with questionable hygiene, exclude until two consecutive
negative stools collected 24 hours apart are obtained, or a single negative EIA is obtained.
Upon identification of an acute case in child care, the facility should be provided with the
“Sample Letter To Parents Of Children Exposed to Cryptosporidiosis” for notification.
The fact sheet, sample letter, and pamphlet can be reproduced for use in the facility.
All rules and guidelines regarding handwashing, toileting, diapering, and food handling,
referenced in Licensing Rules for Group Child Care Homes and Child Care Center should be followed
rigorously.
Handwashing and toileting
! Toilet and handwashing facilities shall be in working order and convenient for the
children's use.
! Paper towels, soap and toilet paper shall be provided and easily accessible so the
children can reach them without assistance.
! Bathrooms shall be clean and odor free.
Diapering
! A safe diapering table with a waterproof washable surface shall be used for
changing diapers. The diapering table shall be located within or adjacent to the
group space so the caregiver using the diapering table can maintain supervision of
his/her group of children at all times.
! Facilities initially licensed for infant/toddler care after the effective date of these
rules or facilities adding new infant/toddler space shall have one (1) diapering table
for every group of eight (8) infant/toddlers and one (1) diapering table for every
group of sixteen (16) two (2)-year olds.
! Facilities initially licensed after the effective date of these rules and accepting two
(2)-year olds for care in the preschool unit shall have a diapering table available in
the preschool unit.
! Diapering supplies and warm, running water shall be adjacent to the diapering area.
Kitchens and Food Handling
! A kitchen shall be required for meal preparation unless meals are catered from a
source approved by the local or state sanitarian, or both.
! Kitchens used for meal preparation shall have sufficient equipment to
accommodate the licensed capacity of the facility. The equipment shall include a
stove, sink, hot and cold running water, a refrigerator and storage space for food,
dishes and cooking utensils.
! If meals are catered, a sink, hot and cold running water, a refrigerator and storage
space for food, dishes and cooking utensils shall be provided.
! Kitchens shall be maintained in compliance with state or local rules, or both,
governing food service sanitation.
! Kitchens shall not be used for children's play activities unless the activities are part
of the learning program and the children are supervised by adults.
! Kitchens shall not be used for napping or as passageways for children.
! The water and milk supply, and the method of dispensing, shall be approved by
local or state health authorities, or both.
! State or local rules, or both, governing food service sanitation shall be maintained
in the storage, preparation and service of foods.
! Drinking water shall be located conveniently near playrooms and the playground
so children may be free to drink as they wish. Water fountains or individual cups
shall be used.
! If preferred, formulas and special baby foods may be provided by the parent(s)
with individual identification on each container.
When two or more symptomatic cases of Cryptosporidiosis are identified in children or
employees of a child care facility, contact the District Communicable Disease Coordinator
and the Bureau of Child Care immediately.
For cases associated with recreational water activities contact the District Communicable
Disease Coordinator and the appropriate Environmental Public Health Specialist.
For cases associated with public water supplies, contact the Department of Natural
Resources.
Environmental samples:
1. Water supplies will not be tested for Cryptosporidium without substantial and convincing
epidemiological evidence. If the water supply is suspected as the source of infection, it
can be screened for coliform bacteria, which is a general indicator of the safety of the
water.
a. If coliform bacteria are detected in a public water supply, notify the district
communicable disease coordinator, who will notify the Department of Natural
Resources.
b. If coliform bacteria are detected in a private water supply (e.g. cistern, well), advise
the family to boil the water used for drinking, food preparation, dishwashing, and
tooth brushing until the problem in the water supply can be corrected.
c. If fresh fruits or vegtables are suspected as the vehicle in an outbreak, traceback of the
product may prevent additional cases.
CRYPTOSPORIDIOSIS
What is cryptosporidiosis?
Cryptosporidiosis (krip-toe-spo-rid-e-o-sis) is an illness caused by a microscropic parasite
Cryptosporidium parvum. The disease is often called “crypto.”
Is cryptosporidiosis a new disease?
Cryptosporidiosis is not a new disease; it was identified as a pathogen in 1976.
How is this parasite spread?
The cryptosporidium parasite passes in the stool of infected persons and animals. Infection
occurs when the parasite is ingested by a person and only a few of these parasites can cause an
infection. Likely means to get infected with cryptosporidium include:
persons who do not wash his/her hands properly after using the restroom or diapering;
food that is not washed after being in soil or water that contains cryptosporidium;
drinking water contaminated with cryptosporidium;
swimming or playing in rivers, streams, springs, lakes, swimming pools, and water parks
contaminated with cryptosporidium.
exposure to wild or domestic animals
Who gets cryptosporidiosis?
Anyone can get cryptosporidiosis. Persons with weakened immune systems are at higher risk
of getting infected after exposure to cryptosporidiosis. Those include:
people receiving cancer chemotherapy,
people receiving steroid therapy, and
people infected with HIV or Crohn's disease.
What are the symptoms of cryptosporidiosis?
The most common symptom is large amounts of watery diarrhea. There may also be cramps,
nausea, vomiting, fever, headache and loss of appetite. Persons with healthy immune systems
usually have symptoms for two weeks or less. However, symptoms may last as long as 30
days. During this time, symptoms may come and go. Occasionally, cryptosporidiosis can
cause an infection in the gall bladder or the lining of the lung, causing pneumonia. Persons
with weak immune systems may have much more severe and long lasting illness. Some
persons infected with cryptosporidiosis may not have any symptoms, but they can still pass the
parasite to others.
How do I know if I have cryptosporidiosis?
The stool of the ill person is sent to a laboratory where it is tested.
How soon do symptoms appear?
The symptoms may appear from 1 to 12 days after exposure, but usually within 7 days.
How long can an infected person infect others?
The infected person can infect others when symptoms begin and for several weeks after the
symptoms disappear. Infected persons who do not have symptoms can still infect others.
Should an infected person stay home from work, school, or child care?
People with diarrhea need to be excluded from child care, food service or any other group
activity where they may present a risk to others. Most infected people may return to work or
school when their diarrhea stops if they carefully wash their hands after using the restroom.
Foodhandlers, children and staff in child care settings, and health care workers must obtain the
approval of the local or state health department before returning to their routine activities.
How is cryptosporidiosis treated?
Persons generally recover without treatment. Persons with diarrhea should drink plenty of
fluids. Medicine used to control diarrhea sometimes helps. Cryptosporidiosis can be very
serious and even cause death in persons with weakened immune systems. Persons with a
weakened immune system should call their physician if they suspect they have
cryptosporidiosis.
What can be done to prevent getting and spreading cyrptosporidiosis?
Avoid drinking untreated and improperly filtered surface water.
Wash hands carefully for at least 30 seconds after use of restroom before preparation of foods
After completion of food preparation
After handling animals, especially cattle, or their feces
After working in soil
Wash fresh fruits and vegetables before eating.
Dispose of sewage waste properly so it does not contaminate surface or ground water.
What about boiling, filters and
bottled water?
Boiling drinking water for one minute will kill Crypto. There are many different types of
home water filters and bottled water. Not all of them can protect you against Crypto.
Bottled water that promises no Crypto will have one of the following on the label:
• reverse osmosis treated
• distilled
• filtered through an absolute
one micron or smaller filter
To learn more about a particular International, an independent testing group, at:
NSF International
3475 Plymouth Road
PO Box 130140
Ann Arbor, MI 48113-0140.
Phone 1-800-673-8010.
Fax 1-313-769-0109.
For more information about Crypto,
contact:
Section of Communicable
Disease Control
and Veterinary Public Health
P.O. Box 570
Jefferson City, MO 65102
1-800-392-0272
E. COLI O157:H7
What is E. coli O157:H7?
E. coli are bacteria that normally live in the intestines of humans and animals. Although most
strains of this bacteria are harmless, several are known to produce toxins that can cause
illness. One particular E. coli strain called O157:H7 can cause severe diarrhea and kidney
damage.
Who gets E. coli O157:H7 infection?
Anyone can become infected with E. coli O157:H7, but children and the elderly are more
likely to develop serious complications.
How is E. coli O157:H7 spread?
The illness is acquired by ingesting food or water containing the bacteria. The bacteria can be
found in the intestines of some cattle, and contamination of the meat may occur in the
slaughtering process. Eating meat (especially ground) that is rare or inadequately cooked is a
common way of getting the infection. Infection can also occur by contaminating surfaces and
utensils with raw meat then using them for uncooked foods without washing. Also vegetables,
fruits, and unpasteurized fruit juices can be contaminated. Person-to-person transmission can
occur if infected people do not wash their hands after using the toilet.
What are the symptoms of E. coli O157:H7 infection?
Most identified cases develop severe diarrhea and abdominal cramps. Blood is often seen in
the stool. Fever may or may not be present. Some infected people may have mild diarrhea or
no symptoms at all.
In some people, particularly children under five years of age, the infection causes a
complication called hemolytic uremic syndrome (HUS). This is a serious disease in which the
kidneys fail. Most people with HUS recover completely after medical treatment, but it can be
fatal.
How soon after the exposure do symptoms appear?
The symptoms usually appear about three days after exposure but may be as short as one day
or as long as nine days.
How is E. coli O157:H7 infection treated?
Most people recover without treatment within 5 to 10 days. Persons with bloody diarrhea
should consult a physician for treatment. Medications like Imodium or Lomotil should not be
given to persons suspected of having E coli O157:H7 or persons with bloody diarrhea.
How can infection with E. coli O157:H7 be prevented?
The single most important way to prevent the spread of disease is careful handwashing.
Wash hands thoroughly:
after use of restroom
before preparation of foods
after handling raw meat
after completion of food preparation
after handling animals or their feces
Thoroughly cook all foodstuffs derived from animal sources especially ground beef.
Use only pasteurized milk, dairy products, and juices.
Refrigerate foods promptly; don’t hold at room temperature any longer than necessary.
Wash cutting boards, utensils and food preparation counters with soap and water
immediately after use.
Use a meat thermometer to assure that the correct internal cooking temperature is
reached. The correct temperature is 160F for beef and pork, and 185F for poultry.
Prevent cross-contamination. Never let raw meat or their juices, come in contact with
cooked meat or any other food, raw or cooked.
Ehrlichiosis
What is Ehrlichiosis?
Ehrlichiosis in humans in the United States is a relatively uncommon tickborne illness caused
by rickettsial organisms such as E. chaffeensis. More than 400 cases of serologically-confirmed
E. chaffeensis infection have been documented at the CDC, primarily from the
southeastern and south-central states. Another type, E. sennetsu is the etiologic agent of
sennetsu fever, which is found in western Japan and Southeast Asia.
Who gets Ehrlichiosis?
Anyone can get ehrlichiosis, although the majority of known cases have been in adults.
People who spend time outdoors, in tick-infested areas from March until October are at
greatest risk for exposure.
How is Ehrlichiosis transmitted?
Ehrlichiosis is spread by a variety of ticks. Human monocytic ehrlichosis (HME) is
transmitted by the Amblyomma americanum (the Lone Star tick), Dermacentor variabilis
(the American dog tick), and the deer tick. Human granulocytic ehrlichiosis (HGE) is
suspected of being transmitted by either the Ixodes scapularis or Ixodes Pacificus tick.
What is the incubation period of Ehrlichiosis
The average incubation period from tick bite to illness is 7 to 11 days, with a range of 7-21
days.
What are the symptoms of Ehrlichiosis?
The most common symptoms are fever, headache, chills, sweats, malaise, muscle aches, joint
pains, weakness, nausea, vomiting, anorexia, and weight loss. A rash is not common. Should
a rash appear, it does not ususally involve the palms of the hands and soles of the feet.
How long does the disease last?
Typically, the disease lasts from 1 to 2 weeks and recovery occurs without long-lasting
problems. However complications can occur and include respiratory problems, blood and
kidney abnormalities, meningitis, and other central nervous system complications.
Occassionally, these complications may be life-threatening or even fatal.
What is the treatment for Ehrlichiosis?
Tetracycline antibiotics are effective therapies for ehrlichiosis. These antibiotics can cause
dental staining in children. Rifampin currently is being evaluated as a possible alternative
treatment for children.
How can Ehrlichiosis be prevented?
1. Avoid tick infested areas, especially during the warmer months.
2. Wear light colored clothing so ticks can be easily seen. Wear a long sleeved shirt, hat,
long pants, and tuck your pant legs into your socks.
3. Walk in the center of trails to avoid overhanging grass and brush.
4. Check your body every few hours for ticks when you spend a lot of time outdoors in tick
infested areas. Ticks are most often found on the thigh, arms, underarms, legs or where
tight fitting clothing has been.
5. Use insect repellents containing DEET on your skin or permethrin on clothing.
Permethrin (Permanone) should only be used on clothing. Be sure to follow the directions
on the container and wash off repellents when going indoors. Carefully read the
manufacturer’s label on repellents before using on children.
6. Remove attached ticks immediately.
How should a tick be removed?
Ticks should be removed promptly and carefully by using tweezers and applying gentle steady
traction. Do not crush the tick’s body when removing it and apply the tweezers as close to
the skin as possible to avoid leaving tick mouth parts in the skin. Do not remove ticks with
your bare hands. Protect your hands with gloves, cloth, or tissue and be sure to wash your
hands after removing a tick.
After removing the tick, disinfect the skin with soap and water or other available disinfectants.
Encephalitis, Arboviral
What is encephalitis?
Encephalitis is defined as an inflammation of the brain. Arboviral infections may cause this
disease in humans. There are many viruses found in wild animals that may be transmitted
occasionally to humans. The most common means of transmission is from a bite of an infected
mosquito. The annual disease incidence in the United States varies from 150-3000 cases a
year.
How many types of arboviruses may cause encephalitis?
There are over 100 different viruses found in wild animals that may cause this disease in
humans. The most well known viruses are named for historical outbreaks. In the United States
these are Eastern Equine Encephalitis, Western Equine Encephalitis, LaCrosse Encephalitis,
St. Louis Encephalitis and West Nile virus.
What animals may carry the virus?
Wild birds carry Eastern Equine Encephalitis, St. Louis Encephalitis, and Western Equine
Encephalitis. Small mammals such as chipmunks or squirrels carry LaCrosse Encephalitis.
Horses (equines) are susceptible to infection by the virus but do serve as the source of the
viruses.
What are the symptoms of arthropod-borne encephalitis?
The majority of cases result in a mild illness with headache and fever. However more severe
neurological symptoms may occur including seizures, convulsions, coma and even death.
How long is incubation period?
The incubation period is usually 5 to 15 days.
How is arboviral encephalitis diagnosed?
Since the disease is uncommon in the United States, the diagnosis requires laboratory tests.
Several different laboratory tests may need to be performed to rule out bacterial meningitis as
cause of the illness.
What is the treatment for encephalitis?
Currently, only supportive treatment is available.
Can you get encephalitis from another person?
No.
What possible complications may result from an infection?
It may produce mild to severe neurological disabilities even death.
How can outbreaks of arboviral encephalitis be prevented?
The most important measure to control the disease is to eliminate mosquitoes. Since it is not
practical to kill all the mosquitoes, barrier methods such as window screens can be used.
Additionally, homeowners should eliminate any artificial or natural breeding pools for
mosquitoes such as birdbaths, old tires, and standing water.
Vaccines are not available for use on humans to prevent the disease in the United States.
Vaccines are available for horse owners to protect their animals from the equine infecting
viruses.
While sporadic cases may continue to occur in the United States, the emergence of the next
outbreak cannot be predicted. Continued cooperation between private health care providers
and public health officials can ensure prompt and effective intervention methods if outbreaks
are detected.
MOSQUITOES AND DISEASE
Help keep mosquitoes out of our communities!
Disease Transmitted by Mosquitoes
Mosquitoes carry many diseases transmitted to man and animals. Mosquitoes-borne diseases
known to occur in Missouri include several encephalitis viruses in horses and humans and
heartworms in dogs. Arthropods (mosquitoes, ticks. etc.) are vectors that transmit disease
organisms to man and animals. Animals (birds, raccoons, rodents, etc.) that may harbor
disease organisms naturally are reservoirs.
St Louis Encephalitis (SLE)
The Northern House Mosquitoes (Culex pipiens), the principle vector of SLE, is found
throughout Missouri. Birds, such as house sparrows, blue jays, finches, etc., may serve as
reservoirs of SLE virus. Culex pipiens can acquire SLE virus while feeding on birds and are
capable of transmitting the virus to people after 8 to 12 days. The Northern House
Mosquitoes readily enter homes and bite people after dark. This small brownish mosquito is a
weak flyer, seldom flying more than 200-300 yards from its breeding site. It breeds in dark or
shaded, stagnant, polluted water sources commonly found around the community, such as
street-side catch basins, unkept polluted ditches, standing sewage effluent, and clogged rain
gutters. Additionally, they propagate in water found in birdbaths, flowers, cans, tires, and
buckets.
Western Equine Encephalitis (WEE)
Culex tarsalis, the vector of WEE, has a virus transmission cycle similar to SLE. Although it
is widely distributed, it is most common in rural habitats in the western part of Missouri.
Culex tarsalis feeds primarily on birds in the spring and early summer months and has a
preference for mammals during the later summer months, including man and horses. This
mosquito, a twilight biter, is a strong flier, capable of flying many miles from its breeding site.
It breeds in pastures and ditches with aquatic vegetation and irrigation waste water, preferring
sunlit areas.
La Crosse Encephalitis (LAC)
Aedes triseriatis, the vector of LAC, is distributed in forested areas throughout Missouri.
Unlike the vectors of SLE and WEE, LAC-infected A. triseratitis passes the virus to the next
generation through its eggs. A. triseriatis seldom flies far from its breeding sources and
disease is restricted to localized mosquitoes populations. A. triseriatis breeds in tree holes of
deciduous trees and will spread to adjacent areas where artificial containers such as cans,
buckets, vases, tire casings, etc., may hold water. The Asian Tiger Mosquito, Aedes
albopictus, recently introduced into the U.S., has requirements similar to A. triseriatus and
has spread to many areas in Missouri. Although the Asian Tiger Mosquito is not yet involved
as a vector of LAC virus in nature, it has significant potential to proliferate disease in Missouri
communities. A. triseriatis and A. albopictus will bite readily during the daylight hours,
increasing at twilight hours.
Canine Heart Worms
There are numerous mosquito species that transmit heartworms to dogs. Mosquitoes feeding
on infected dogs ingest the immature heart worms parasites. The parasite undergoes
maturation in the mosquito, crawls out through the mouthparts at subsequent feedings, and
penetrates the skin through the site of the bite. The tiny heartworms migrate through the
tissues and establish in the chambers of the heart where they grow maturity interfering with
heart functions.
What Can You Do?
You can help rid your property and community of mosquitoes by the following simple
practices:
1. Eliminate containers such as tin cans, bottles, buckets, and old tires that may hold water.
2. Ensure gutter down spouts are cleared of debri.
3. Cover or store boats and wheelbarrows upside down.
4. Stock rock garden pools and lily ponds with mosquito-feeding minnows or goldfish.
5. Empty wading pools weekly and maintain backyard swimming pools properly.
6. Fill or drain low areas that may hold water for longer than a week.
7. Cover rain barrels, cisterns, or fire barrels with 16-mesh screen.
8. Drain livestock water tanks weekly, or stock with mosquito-feeding minnows or goldfish.
9. Install splash blocks to carry water away from foundations to eliminate water in crawl
spaces.
Where Do Mosquitoes Come From?
All mosquitoes require water to complete their life cycle. Only female mosquitoes bite. A
blood meal usually is required before eggs will develop. Completion of the life cycle from egg
to adult may require as little as 8-10 days.
All Mosquitoes Are Not The Same
There are more than 50 species if mosquitoes in Missouri. Although most are not involved in
transmitting disease to man and animals, many are serious biting pests. Preferential feeding
times are unique to each species. While one species might only feed at night, others may feed
at dusk/dawn, or even during the day.
Personal Protection
Screen openings of your home.
Avoid mosquito-infested areas when possible.
Wear clothing that will provide protection (long sleeved shirts and long pants).
Wear repellents.
Avoid exposure during peak biting periods (twilight hours).
Giardiasis
What is giardiasis?
Giardiasis is an intestinal illness caused by a microscopic parasite called Giardia lamblia. It is
a common cause of diarrheal illness and over 800 cases are reported in Missouri each year.
Cases may occur sporadically or in clusters or outbreaks.
Who gets giardiasis?
Anyone can get giardiasis but it tends to occur more often in people in institutional settings,
children in child care centers, foreign travelers, and individuals who drink improperly treated
surface water. Homosexual males may also be at increased risk of getting giardiasis.
How is this parasite spread?
The giardia parasite is passed in the stool of an infected person or animal and may
contaminate water or food. The parasite is also spread by hand-to-mouth transfer from
contaminated body surfaces or objects such as toys or diapering areas. Person to person
spread may also occur in child care centers where there is close contact between preschool
children who have not yet learned good bathroom and handwashing habits.
What are the symptoms of giardiasis?
Most people with giardiasis will not have any symptoms. Others may have mild to severe
diarrhea, cramps, bloating, and gas. Occasionally, some will have diarrhea which lasts for
several weeks or months, with weight loss.
How soon do symptoms appear?
The symptoms may appear from five to 25 days after exposure but usually within 10 days.
How long can an infected person carry giardia?
The carrier stage generally lasts from a few weeks to a few months. Treatment with specific
medication may shorten the carrier stage.
Where are the giardia parasites found?
Giardia has been found in infected people (with or without symptoms) and wild and domestic
animals. The beaver has gained attention as a possible source of giardia contamination of
lakes, reservoirs and streams, but human fecal wastes are probably just as important.
Should an infected person be excluded from work or school?
People with diarrhea need to be excluded from child care, food service or any other group
activity where they may present a risk to others. Most infected people may return to work or
school when their diarrhea stops if they carefully wash their hands after using the bathroom.
What is the treatment for giardiasis?
Medications such as quinacrine, metronidazole or furazolidone are often prescribed by doctors
to treat giardiasis. However, some individuals may recover on their own without medication.
What can a person or community do to prevent the spread of giardiasis?
Three important preventive measures are:
Carefully wash hands thoroughly after toilet visits or changing diapers and before
preparing or eating foods.
Carefully dispose of sewage wastes so as not to contaminate surface or groundwater.
Avoid consuming improperly treated drinking water.
Haemophilus Influenzae Invasive Disease
Including Meningitis
Haemophilus Influenzae Type b (Hib)
What is Haemophilus influenza type b (Hib) disease?
Until recently, Hib was one of the most important causes of serious bacterial infection in
young children. Because of the new Hib vaccines, fewer cases of this disease are seen. Hib
can cause several diseases such as meningitis (inflammation of the coverings of the spinal
column and brain), blood stream infections, pneumonia, arthritis and infections of other parts
of the body.
Who gets Hib disease?
Hib disease is most common in unvaccinated children under three years of age.
How is Hib disease spread?
Hib disease may be spread from person to person through contact with mucus or droplets
from the nose and throat of an infected person.
What are the symptoms of Hib disease?
Symptoms may include fever, nausea and vomiting. Other symptoms depend upon the part of
the body affected.
How soon do symptoms appear?
The incubation period for Hib disease is unknown and widely variable.
When and for how long is a person able to spread Hib disease?
The contagious period varies. If the person is not treated, it may last for as long as the
bacteria is present in the nose and throat, even after symptoms have disappeared.
Does past infection with Hib disease make a person immune?
No. Children who have had Hib disease are at risk of getting it again.
What is the treatment for Hib disease?
Antibiotics are used to treat Hib infections. Rifampin is used to treat people who have had
close, prolonged contact with a person with Hib disease.
PRECAUTIONARY NOTATION:
Includes, but is not limited to:
Rifampin should be avoided by pregnant women.
Rifampin may reduce the effectiveness of oral contraceptives.
Studies have shown that Rifampin interacts with certain HIV/AIDS medications. Thus, if
you are taking any prescription medications for HIV/AIDS Disease, please check with
your physician prior to taking Rifampin.
Important Information About Rifampin
For Prevention of Hib Disease
Rifampin is an antibiotic. The full prescribed dosage should be taken as directed.
Contraindications:
Includes, but is not limited to:
Rifampin is not recommended for pregnant women.
Rifampin should not be used if there has been a previous reaction to similar antibiotics.
Important Facts:
Rifampin may stain body secretions red-orange, including urine, feces, saliva, sweat and
tears.
For this reason, soft contact lenses may be permanently stained. They should not be worn
while taking rifampin.
Rifampin may reduce the effectiveness of oral contraceptives and other drugs.
Studies have shown that Rifampin interacts with certain HIV/AIDS medications. Thus, if
you are taking any prescription medications for HIV/AIDS Disease, please check with
your physician prior to taking Rifampin.
Adverse Reactions:
Rifampin may cause nausea, vomiting, cramps and diarrhea in some individuals.
Headache, fever, drowsiness, fatigue, dizziness, mental confusion, and muscular weakness
may occur.
If any symptoms occur, please contact your physician.
Hansen’s Disease (Leprosy)
How can Hansen’s disease be prevented?
Carefully wash or dispose of handkerchiefs and other items soiled with secretions from the
nose and respiratory tract of Hansen’s patients.
The best way to prevent the spread of Hansen’s disease is the early diagnosis and treatment of
people who are infected. For household contacts, immediate and annual examination for at
least five years after last contact with a person who is infectious, is recommended.
Hantavirus Pulmonary Syndrome
What is Hantavirus Pulmonary Syndrome?
Hantavirus Pulmonary Syndrome is a disease caused by a virus identified in 1993. This virus
is called the Sin Nombre virus and belongs to a group of viruses with the collective name of
Hantavirus.
What are the symptoms of HPS?
The illness usually develops about 1–3 weeks following exposure and begins with a high fever,
chills and muscle aches. Within a few days, the illness can progress rapidly to serious
respiratory distress and difficulty breathing. In the United States, about 44% of the reported
cases have died. However, there is some evidence that milder forms of the illness may occur
and might not have been diagnosed or reported.
How does exposure happen?
The virus is in the droppings, urine and saliva of a particular kind of mouse, called the deer
mouse (Peromyscus maniculatus). A person can be exposed to the virus by breathing the dust
caused by cleaning rodent droppings, disturbing the nests of the deer mouse, or by living or
working in places infested with the deer mouse.
Can the virus be spread between people?
There is no evidence that the disease has spread from person-to-person in the United States.
An outbreak of the disease in South America, in which a physician may have gotten the
disease while treating a person with HPS in the hospital, is still under investigation.
How common is the disease?
The disease is very rare. Most of the 185 cases reported until 1998 have occurred in the
Western United States. However, the deer mouse is located throughout most of the United
States, including Missouri.
How can I protect myself and family from the disease?
First, avoid contact with rodents by keeping them out of your home and workplace. Plug
holes or gaps larger than ¼ inch. Remove sources of food from around your home or
business. Keep firewood, debris or other similar nesting sites as far from the home as
possible. When cleaning up rodent droppings, avoid creating dust by wetting the droppings
with a mixture of bleach and water. Don’t use a vacuum cleaner or broom. Wipe up the
droppings and place in a plastic bag. Wear rubber or latex gloves and use a dust mist mask.
Where can I get more information?
For more information about the disease, controlling mice or cleaning procedures contact your
local public health agency or the Missouri Department of Health.
Arenaviridae:
Including South American Hemorrhagic Viral Fevers
What are the Arenaviridae?
The Arenaviridae are a family of viruses whose members are generally associated with rodenttransmitted disease in humans. Each virus usually is associated with a particular rodent host
species in which it is maintained. Arenavirus infections are relatively common in humans in
some areas of the world and can cause severe illnesses. The virus particles are spherical and
have an average diameter of 110-130 nanometers. All are enveloped in a lipid (fat) membrane.
Viewed in cross-section, they show grainy particles that are ribosomes acquired from their
host cells. It is this characteristic that gave them their name, derived from the Latin "arena,"
which means "sandy." Their genome, or genetic material, is composed of RNA only, and while
their replication strategy is not completely understood, we know that new viral particles,
called virions, are created by budding from the surface of their hosts’ cells.
When were the members of this virus family recognized?
The first arenavirus, lymphocytic choriomeningitis virus (LCMV), was isolated in 1933 during
a study of an epidemic of St. Louis encephalitis. Although not the cause of the outbreak,
LCMV was found to be a cause of aseptic (non-bacterial) meningitis. By the 1960s, several
similar viruses had been discovered and they were classified into the new family Arenaviridae.
Since Tacaribe virus was found in 1956, new arenaviruses have been discovered on the
average of every one to three years. A number of arenaviruses cause hemorrhagic disease.
Junin virus, isolated in 1958, was the first of these to be recognized. This virus causes
Argentine hemorrhagic fever in a limited agricultural area of the pampas in Argentina. Several
years later, in 1963, in the remote savannas of the Beni province of Bolivia, Machupo virus
was isolated. The next member of the virus family to be associated with an outbreak of human
illness was Lassa virus in Africa in 1969. Most recently, Guanarito and Sabia viruses were
added to this family.
What viruses are included in the virus family?
The arenaviruses are divided into two groups: the New World or Tacaribe complex and the
Old World or LCM/Lassa complex. Viruses in these groups that cause illness in humans are
listed on the following page.
Virus Disease
Lymphocytic choriomeningitis virus Lymphocytic choriomeningitis
Lassa virus Lassa fever
Junin virus Argentine hemorrhagic fever
Machupo virus Bolivian hemorrhagic fever
Guanarito virus Venezuelan hemorrhagic fever
Sabia as yet unnamed (found in Brazil)
What kinds of animal hosts do these viruses have?
These viruses are zoonotic, meaning that, in nature, they are found in animals. Each virus is
associated with either one species or a few closely related rodents, which constitute the virus’
natural reservoir. Tacaribe complex viruses are generally associated with the New World rats
and mice (family Muridae, subfamily Sigmodontinae). The LCM/Lassa complex viruses are
associated with the Old World rats and mice (family Muridae, subfamily Murinae). Taken
together, these types of rodents are located across the greater proportion of the earth’s
landmass, including Europe, Asia, Africa, and the Americas. One notable exception is
Tacaribe virus, found in Trinidad, which was isolated from a bat.
How are arenaviruses spread?
The rodent hosts of arenaviruses are chronically infected with the viruses; however, the
viruses do not appear to cause obvious illness in them. Some Old World arenaviruses appear
to be passed from mother rodents to their offspring during pregnancy, and thus remain in the
rodent population generation after generation. Some New World arenaviruses are transmitted
among adult rodents, likely via fighting and inflicting bites. Only a portion of the rodents in
each host species is infected at any one time, and in many cases only in a limited portion of the
host’s geographical range. The viruses are shed into the environment in the urine or droppings
of their infected hosts. Human infection with arenaviruses is incidental to the natural cycle of
the viruses and occurs when an individual comes into contact with the excretions or materials
contaminated with the excretions of an infected rodent, such as ingestion of contaminated
food, or by direct contact of abraded or broken skin with rodent excrement. Infection can also
occur by inhalation of tiny particles soiled with rodent urine or saliva (aerosol transmission).
The types of incidental contact depend on the habits of both humans and rodents. For
example, where the infected rodent species prefers a field habitat, human infection is
associated with agricultural work. In areas where the rodent species’ habitat includes human
homes or other buildings, infection occurs in domestic settings. Some arenaviruses, such as
Lassa and Machupo viruses, are associated with secondary person-to-person and nosocomial
(health-care setting) transmission. This occurs when a person infected by exposure to the virus
from the rodent host spreads the virus to other humans. This may occur in a variety of ways.
Person-to-person transmission is associated with direct contact with the blood or other
excretions, containing virus particles, of infected individuals. Airborne transmission has also
been reported in connection with certain viruses. Contact with objects contaminated with
these materials, such as medical equipment, is also associated with transmission. In these
situations, use of protective clothing and disinfection procedures (together called barrier
nursing) help prevent further spread of illness.
Adapted from: 1999 Special Pathogens Branch Division of Viral and Rickettsial Diseases,
National Center for Infectious Diseases Centers for Disease Control and Prevention Public
Health Service, U.S. Department of Health and Human Services
Lassa Fever
What is Lassa fever?
Lassa fever is an acute viral illness that occurs in West Africa. The illness was discovered in
1969 when two missionary nurses died in Nigeria, West Africa. The cause of the illness was
found to be Lassa virus, named after the town in Nigeria where the first cases originated. The
virus, a member of the virus family Arenaviridae, is a single-stranded RNA virus and is
zoonotic, or animal-borne. In areas of Africa where the disease is endemic (that is, constantly
present), Lassa fever is a significant cause of morbidity and mortality. While the disease is
mild or has no observable symptoms in about 80% of people infected with the virus, the
remaining 20% have a severe multisystem disease. Lassa fever is also associated with
occasional epidemics, during which the case-fatality rate can reach 50%.
Where is Lassa fever found?
Lassa fever is an endemic disease in portions of West Africa. It is recognized in Guinea,
Liberia, Sierra Leone, as well as Nigeria. However, because the rodent species which carry the
virus are found in other regions outside of West Africa, the actual geographic range of the
disease may extend to other portions of Africa.
How many people become infected?
The number of Lassa virus infections per year in West Africa is estimated at 100,000 to
300,000, with approximately 5,000 deaths. Unfortunately, such estimates are crude, because
surveillance for cases of the disease is not uniformly performed. In some areas of Sierra Leone
and Liberia, it is known that 10%-16% of people admitted to hospitals have Lassa fever,
which indicates the serious impact of the disease on the population of this region.
In what animal host is Lassa virus maintained?
The reservoir, or host, of Lassa virus is a rodent known as the "multimammate rat" of the
genus Mastomys. It is not certain which species of Mastomys are associated with Lassa;
however, at least two species carry the virus in Sierra Leone: M. huberti and M.
erythroleucus. Mastomys rodents breed very frequently, produce large numbers of offspring,
and are numerous in the savannas and forests of West, Central, and East Africa. In addition,
some species, like M. huberti, prefer to live in human homes. All these factors together
contribute to the relatively efficient spread of Lassa virus from infected rodents to humans.
How do humans get Lassa fever?
There are a number of ways in which the virus may be transmitted, or spread, to humans. The
Mastomys rodents shed the virus in urine and droppings. Therefore, the virus can be
transmitted through direct contact with these materials, through touching objects or eating
food contaminated with these materials, or through cuts or sores. Because Mastomys rodents
often live in and around homes and scavenge on human food remains or poorly stored food,
transmission of this sort is common. Contact with the virus also occurs when a person inhales
tiny particles in the air contaminated with rodent excretions. This is called aerosol or airborne
transmission. Finally, because Mastomys rodents are sometimes used as a food source,
infection may occur via direct contact when they are caught and prepared for food. Lassa
fever may also spread through person-to-person contact. This type of transmission occurs
when a person comes into contact with virus in the blood, tissue, secretions, or excretions of
an individual infected with the Lassa virus. A person may also become infected by breathing
in small airborne particles which an already infected person may produce by actions like
coughing. The virus cannot be spread through casual contact (including skin-to-skin contact
without exchange of body fluids). Person-to-person transmission is common in both village
settings and in health care settings, where, along with the above-mentioned modes of
transmission, the virus also may be spread in contaminated medical equipment, such as reused
needles (this is called nosocomial transmission).
What are the symptoms of Lassa fever?
Symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into contact with
the virus. These include fever, retrosternal pain (pain behind the chest wall), sore throat, back
pain, cough, abdominal pain, vomiting, diarrhea, conjunctivitis, facial swelling, proteinuria
(protein in the urine), and mucosal bleeding. Neurological symptoms have also been
described, including hearing loss, tremors, and encephalitis. Because the symptoms of Lassa
fever are so varied and nonspecific, clinical diagnosis is often difficult.
Are there complications after recovery?
The most common complication of Lassa fever is deafness. Various degrees of deafness occur
in approximately one-third of cases, and in many cases hearing loss is permanent. As far as is
known, severity of the disease does not affect this complication: deafness may develop in mild
as well as in severe cases. Spontaneous abortion is another serious complication.
What proportion of people die from the illness?
Approximately 15%-20% of patients hospitalized for Lassa fever die from the illness.
However, overall only about 1% of infection with the Lassa virus result in death. The death
rates are particularly high for women in the third trimester of pregnancy, and for fetuses,
about 95% of which die in the uterus of infected pregnant mothers.
How is Lassa fever treated?
Ribavirin, an antiviral drug, has been used with success in Lassa fever patients. It has been
shown to be most effective when given early in the course of the illness. Patients should also
receive supportive care consisting of maintenance of appropriate fluid and electrolyte balance,
oxygenation and blood pressure, as well as treatment of any other complicating infections.
What groups are at risk for getting the illness?
Individuals at risk are those who live or visit areas with a high population of Mastomys
rodents infected with Lassa virus or are exposed to infected humans. Hospital staff are not at
great risk for infection as long as protective measures are taken.
How is Lassa fever prevented?
Primary transmission of the Lassa virus from its host to humans can be prevented by avoiding
contact with Mastomys rodents, especially in the geographic regions where outbreaks occur.
Putting food away in rodent-proof containers and keeping the home clean help to discourage
rodents from entering homes. Using these rodents as a food source is not recommended.
Trapping in and around homes can help reduce rodent populations. However, the wide
distribution of Mastomys in Africa makes complete control of this rodent reservoir
impractical. When caring for patients with Lassa fever, further transmission of the disease
through person-to-person contact or nosocomial routes can be avoided by taking preventive
precautions against contact with patient secretions (together called VHF isolation precautions
or barrier nursing methods). Such precautions include wearing protective clothing, such as
masks, gloves, gowns, and goggles; using infection control measures, such as complete
equipment sterilization; and isolating infected patients from contact with unprotected persons
until the disease has run its course.
Ebola Hemorrhagic Fever
What is Ebola hemorrhagic fever?
Ebola hemorrhagic fever is a severe, often-fatal disease in humans and nonhuman primates
(monkeys and chimpanzees) that has appeared sporadically since its initial recognition in 1976.
The disease is caused by infection with Ebola virus, named after a river in the Democratic
Republic of the Congo (formerly Zaire) in Africa, where it was first recognized. The virus is
one of two members of a family of RNA viruses called the Filoviridae. Three of the four
species of Ebola virus identified so far have caused disease in humans: Ebola-Zaire, Ebola-Sudan,
and Ebola-Ivory Coast. The fourth, Ebola-Reston, has caused disease in nonhuman
primates, but not in humans.
Where is Ebola virus found in nature?
The exact origin, locations and natural habitat (known as the "natural reservoir") of Ebola
virus remain unknown. However, on the basis of available evidence and the nature of similar
viruses, researchers believe that the virus is zoonotic (animal-borne) and is normally
maintained in an animal host that is native to the African continent. A similar host is probably
associated with the Ebola-Reston species isolated from infected cynomolgous monkeys that
were imported to the United States and Italy from the Philippines. The virus is not known to
be native to other continents, such as North America.
Where do cases of Ebola hemorrhagic fever occur?
Confirmed cases of Ebola hemorrhagic fever have been reported in the Democratic Republic
of the Congo, Gabon, Sudan, and the Ivory Coast. An individual with serologic evidence of
infection but showing no apparent illness has been reported in Liberia, and a laboratory
worker in England became ill as a result of an accidental needle-stick. No case of the disease
in humans has ever been reported in the United States. Ebola-Reston virus caused severe
illness and death in monkeys imported to research facilities in the United States and Italy from
the Philippines; during these outbreaks, several research workers became infected with the
virus, but did not become ill. Ebola hemorrhagic fever typically appears in sporadic outbreaks,
usually spread within a health-care setting (a situation known as amplification). It is likely that
sporadic, isolated cases occur as well, but go unrecognized.
How is Ebola virus spread?
Infection with Ebola virus in humans is incidental -- humans do not "carry" the virus. Because
the natural reservoir of the virus is unknown, the manner in which the virus first appears in a
human at the start of an outbreak has not been determined. However, researchers have
hypothesized that the first patient becomes infected through contact with an infected animal.
After the first case-patient in an outbreak setting (often called the index case) is infected,
humans can transmit the virus to each other in several ways. People can be exposed to Ebola
virus from direct contact with the blood and/or secretions of an infected person. This is why
the virus has often been spread through the families and friends of infected persons: in the
course of feeding, holding or otherwise caring for them, family members and friends would
come into close contact with such secretions. People can also be exposed to Ebola virus
through contact with objects, such as needles, that have been contaminated with infected
secretions. Nosocomial transmission has been associated frequently with Ebola outbreaks. It
includes both types of transmission described above, but it is used to describe the spread of
disease in a health-care setting such as a clinic or hospital. In African health-care facilities,
patients are often cared for without the use of a mask, gown, or gloves, and exposure to the
virus has occurred when health care workers treated individuals with Ebola hemorrhagic fever
without wearing these types of protective clothing. In addition, when needles or syringes are
used, they may not be of the disposable type, or may not have been sterilized, but only rinsed
before e-insertion into multi-use vials of medicine. If needles or syringes become contaminated
with virus and are then reused, numbers of people can become infected. The Ebola-Reston
virus species, that appeared in a primate research facility in Virginia, may have been
transmitted from monkey to monkey through the air in the facility. While all Ebola virus
species have displayed the ability to be spread through airborne particles (aerosols) under
research conditions, this type of spread has not been documented among humans in a real-world
setting, such as a hospital or household.
What are the symptoms of Ebola hemorrhagic fever?
The signs and symptoms of Ebola hemorrhagic fever are not the same for all patients. Within a
few days of becoming infected with the virus: high fever, headache, muscle aches, stomach
pain, fatigue, diarrhea, sore throat, hiccups, rash, red and itchy eyes, vomiting blood, bloody
diarrhea. Within one week of becoming infected with the virus: chest pain, shock, bleeding,
blindness, and death. Researchers do not understand why some people are able to recover
from Ebola hemorrhagic fever and others are not. However, it is known that patients who die
usually have not developed a significant immune response to the virus at the time of death.
How is Ebola hemorrhagic fever prevented?
The prevention of Ebola hemorrhagic fever in Africa presents many challenges. Because the
identity and location of the natural reservoir of Ebola virus are unknown, there are few
established primary prevention measures. If cases of the disease do appear, current social and
economic conditions favor the spread of an epidemic within health-care facilities. Therefore,
health-care providers must be able to recognize a case of Ebola hemorrhagic fever should one
appear. They must also have the capability to perform diagnostic tests, and be ready to employ
practical VHF isolation precautions, or barrier nursing techniques. These techniques include
the wearing of protective clothing, such as masks, gloves, gowns, and goggles; the use of
infection-control measures, including complete equipment sterilization; and the isolation of
Ebola hemorrhagic fever patients from contact with unprotected persons. The aim of all of
these techniques is to avoid any person’s contact with the blood or secretions of any patient.
If a patient with Ebola hemorrhagic fever dies, it is equally important that direct contact with
the body of the deceased patient be prevented. CDC has developed a set of tools to meet
health-care facilities’ needs. In conjunction with the World Health Organization, CDC has
developed practical, hospital-based guidelines that can help health-care facilities recognize
cases and prevent further hospital-based disease transmission using locally available materials
and few financial resources. A similarly practical diagnostic test that uses tiny samples from
patients’ skin has been developed to retrospectively diagnose Ebola hemorrhagic fever in
suspected case-patients who have died.
What challenges remain for the control and prevention of Ebola
hemorrhagic fever?
Scientists and researchers are faced with the challenges of developing additional diagnostic
tools to assist in early diagnosis of the disease and ecological investigations of Ebola virus and
the disease it causes. In addition, one of the research goals is to monitor suspected areas in
order to determine the incidence of the disease. More extensive knowledge of the nature of
the virus’ reservoir and how it is spread must be acquired to prevent future outbreaks
effectively.
Adapted from: 1999 Special Pathogens Branch Division of Viral and Rickettsial Diseases,
National Center for Infectious Diseases Centers for Disease Control and Prevention Public
Health Service, U.S. Department of Health and Human Services
Marburg Hemorrhagic Fever
What is Marburg hemorrhagic fever?
Marburg hemorrhagic fever is a rare, severe type of hemorrhagic fever which affects both
humans and non-human primates. Caused by a genetically unique zoonotic (that is, animal-borne)
RNA virus of the filovirus family, its recognition led to the creation of this virus family.
The four species of Ebola virus are the only other known members of the filovirus family.
Marburg virus was first recognized in 1967, when outbreaks of hemorrhagic fever occurred
simultaneously in laboratories in Marburg and Frankfurt, Germany and in Belgrade,
Yugoslavia (now Serbia). A total of 37 people became ill; they included laboratory workers as
well as several medical personnel and family members who had cared for them. The first
people infected had been exposed to African green monkeys or their tissues. In Marburg, the
monkeys had been imported for research and to prepare polio vaccine.
Where do cases of Marburg hemorrhagic fever occur?
Recorded cases of the disease are rare, and have appeared in only a few locations. While the
1967 outbreak occurred in Europe, the disease agent had arrived with imported monkeys from
Uganda. No other case was recorded until 1975, when a traveler most likely exposed in
Zimbabwe became ill in Johannesburg, South Africa – and passed the virus to his travelling
companion and a nurse. 1980 saw two other cases, one in Western Kenya not far from the
Ugandan source of the monkeys implicated in the 1967 outbreak. This patient’s attending
physician in Nairobi became the second case. Another human Marburg infection was
recognized in 1987 when a young man who had traveled extensively in Kenya, including
western Kenya, became ill and later died.
Where is Marburg virus found?
Marburg virus is indigenous to Africa. While the geographic area to which it is native is
unknown, this area appears to include at least parts of Uganda and Western Kenya, and
perhaps Zimbabwe. As with Ebola virus, the actual animal host for Marburg virus also remains
a mystery. Both of the men infected in 1980 in western Kenya had traveled extensively,
including making a visit to a cave, in that region. The cave was investigated by placing sentinel
animals inside to see if they would become infected, and by taking samples from numerous
animals and arthropods trapped during the investigation. The investigation yielded no virus.
The sentinel animals remained healthy and no virus isolations from the samples obtained have
been reported.
How do humans get Marburg hemorrhagic fever?
Just how the animal host first transmits Marburg virus to humans is unknown. However, as
with some other viruses which cause viral hemorrhagic fever, humans who become ill with
Marburg hemorrhagic fever may spread the virus to other people. This may happen in several
ways. Persons handling infected monkeys who come into direct contact with them or their
fluids or cell cultures, have become infected. Spread of the virus between humans has
occurred in a setting of close contact, often in a hospital. Droplets of body fluids, or direct
contact with persons, equipment, or other objects contaminated with infectious blood or
tissues are all highly suspect as sources of disease.
What are the symptoms of the disease?
After an incubation period of 5-10 days, the onset of the disease is sudden and is marked by
fever, chills, headache, and myalgia. Around the fifth day after the onset of symptoms, a
maculopapular rash, most prominent on the trunk (chest, back, stomach), may occur. Nausea,
vomiting, chest pain, a sore throat, abdominal pain, and diarrhea then may appear. Symptoms
become increasingly severe and may include jaundice, inflammation of the pancreas, severe
weight loss, delirium, shock, liver failure, massive hemorrhaging, and multi-organ dysfunction.
Because many of the signs and symptoms of Marburg hemorrhagic fever are similar to those
of other infectious diseases, such as malaria or typhoid fever, diagnosis of the disease can be
difficult, especially if only a single case is involved.
Which laboratory tests are used to diagnose Marburg hemorrhagic fever?
Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM-capture ELISA,
polymerase chain reaction (PCR), and virus isolation can be used to confirm a case of
Marburg hemorrhagic fever within a few days of the onset of symptoms. The IgG-capture
ELISA is appropriate for testing persons later in the course of disease or after recovery. The
disease is readily diagnosed by immunohistochemistry, virus isolation, or PCR of blood or
tissue specimens from deceased patients.
Are there complications after recovery?
Recovery from Marburg hemorrhagic fever may be prolonged and accompanied by
inflammation of the testis, spinal cord, eye, parotid gland, or by prolonged hepatitis.
Is the disease ever fatal?
Yes. The case-fatality rate for Marburg hemorrhagic fever is between 23-25%.
How is Marburg hemorrhagic fever treated?
A specific treatment for this disease is unknown. However, supportive hospital therapy
should be utilized. This includes balancing the patient’s fluids and electrolytes, maintaining
their oxygen status and blood pressure, replacing lost blood and clotting factors and treating
them for any complicating infections. Sometimes treatment also has used transfusion of fresh-frozen
plasma and other preparations to replace the blood proteins important in clotting. One
controversial treatment is the use of heparin (which blocks clotting) to prevent the
consumption of clotting factors. Some researchers believe the consumption of clotting
factors is part of the disease process.
Who is at risk for the illness?
People who have close contact with a human or non-human primate infected with the virus are
at risk. Such persons include laboratory or quarantine facility workers who handle non-human
primates that have been associated with the disease. In addition, hospital staff and family
members who care for patients with the disease are at risk if they do not use proper barrier
nursing techniques.
How is Marburg hemorrhagic fever prevented?
Due to our limited knowledge of the disease, preventive measures against transmission from
the original animal host have not yet been established. Measures for prevention of secondary
transmission are similar to those used for other hemorrhagic fevers. If a patient is either
suspected or confirmed to have Marburg hemorrhagic fever, barrier nursing techniques should
be used to prevent direct physical contact with the patient. These precautions include wearing
of protective gowns, gloves, and masks; placing the infected individual in strict isolation; and
sterilization or proper disposal of needles, equipment, and patient excretions.
What needs to be done to address the threat of Marburg hemorrhagic
fever?
Marburg hemorrhagic fever is a very rare human disease. However, when it does occur, it has
the potential to spread to other people, especially health care staff and family members who
care for the patient. Therefore, increasing awareness among health-care providers of clinical
symptoms in-patients that suggest Marburg hemorrhagic fever is critical. Better awareness can
help lead to taking precautions against the spread of virus infection to family members or
health-care providers. Improving the use of diagnostic tools is another priority. With modern
means of transportation that give access even to remote areas, it is possible to obtain rapid
testing of samples in disease control centers equipped with Biosafety Level 4 laboratories in
order to confirm or rule out Marburg virus infection. A fuller understanding of Marburg
hemorrhagic fever will not be possible until the ecology and identity of the virus reservoir are
established. In addition, the impact of the disease will remain unknown until the actual
incidence of the disease and its endemic areas are determined.
Crimean-Congo Hemorrhagic Fever
Overview
Crimean-Congo hemorrhagic fever (CCHF) is a viral hemorrhagic fever of the Nairovirus
group. Although primarily a zoonosis, sporadic cases and outbreaks of CCHF affecting
humans do occur. 1998 has already witnessed 2 outbreaks, one in Pakistan affecting four
people, with two deaths, and another in Afghanistan affecting 19 people with 12 deaths.
The disease was first described in the Crimea in 1944 and given the name Crimean
hemorrhagic fever. In 1969 it was recognized that the pathogen causing Crimean
hemorrhagic fever was the same as that responsible for an illness identified in 1956 in the
Congo, and linkage of the 2 place-names resulted in the current name for the disease and
the virus. CCHF is a severe disease in humans, with a high mortality. Fortunately, human
illness occurs infrequently, although animal infection may be more common. The
geographical distribution of the virus, like that of its tick vector, is widespread. Evidence
of CCHF virus has been found in Africa, Asia, the Middle East and Eastern Europe.
Healthcare workers in endemic areas should be aware of the illness and the correct
infection control procedures to protect themselves and their patients from the risk of
nosocomial (hospital-acquired) infection.
The Virus, the Reservoirs, and the Vectors
The virus which causes CCHF is a Nairovirus, a group of related viruses forming one of
the five genera in the Bunyaviridae family of viruses. All of the 32 members of the
Nairovirus genus are transmitted by argasid or ixodid ticks, but only three have been
implicated as causes of human disease: the Dugbe and Nairobi sheep viruses, and CCHF,
which is the most important human pathogen amongst them. The CCHF virus may infect a
wide range of domestic and wild animals. Many birds are resistant to infection, but
ostriches are susceptible and may show a high prevalence of infection in endemic areas.
Animals become infected with CCHF from the bite of infected ticks. A number of tick
genera are capable of becoming infected with CCHF virus, but the most efficient and
common vectors for CCHF appear to be members of the Hyalomma genus. Trans-ovarial
(transmission of the virus from infected female ticks to offspring via eggs) and venereal
transmission have been demonstrated amongst some vector species, indicating one
mechanism which may contribute to maintaining the circulation of the virus in nature.
However, the most important source for acquisition of the virus by ticks is believed to be
infected small vertebrates on which immature Hyalomma ticks feed. Once infected, the
tick remains infected through its developmental stages, and the mature tick may transmit
the infection to large vertebrates, such as livestock. Domestic ruminant animals, such as
cattle, sheep and goats, are viraemic (virus circulating in the bloodstream) for around one
week after becoming infected. Humans who become infected with CCHF acquire the virus
from direct contact with blood or other infected tissues from livestock during this time, or
they may become infected from a tick bite. The majority of cases have occurred in those
involved with the livestock industry, such as agricultural workers, slaughterhouse workers
and veterinarians.
Hepatitis A
What is hepatitis A?
Hepatitis A (formerly known as infectious hepatitis) is a liver disease caused by the hepatitis A
virus. The disease is fairly common in Missouri; during the 5 year period (1994-1998), there
was an average of 1032 cases each year.
Unlike hepatitis B and hepatitis C, hepatitis A causes no long-term liver damage and usually
does not cause death. Having had the disease produces lifelong immunity from future
hepatitis A infection.
Who gets hepatitis A?
Anyone can get hepatitis A, but it generally occurs more frequently in children. Children may
have mild infections or no symptoms at all and go unrecognized as a case of hepatitis A.
Another group of special concern is young adults from 15 to 30 years of age. People in this
age group tend to be more socially active, participating in activities that may involve sharing
food, beverages, or other substances. Also, they are frequently employed in occupations such
as food preparation and service, which could provide the opportunity to expose large numbers
of other people.
How is the virus spread?
The hepatitis A virus is spread from the stool (feces) of persons with hepatitis A. The virus is
often carried by minute particles on an infected person’s hands. Hepatitis A can be spread by
direct contact, or by placing something in the mouth that has been contaminated by a person
infected with hepatitis A. Very few virus particles are required for transmission of the
infection; therefore the hands may not be noticeably soiled with stool. Proper handwashing
after using the toilet is very important in preventing the spread of hepatitis A.
In some cases, it can be spread by drinking contaminated water. An increasing number of
hepatitis A cases have been reported in drug users, and it is suspected that contaminated drugs
or close personal contact is the cause. The sharing of items between users of both injectable
and inhalable drugs provides an ideal method for the transmission of the virus.
Hepatitis A is not spread by sneezing or coughing.
What are the symptoms of hepatitis A?
The symptoms of hepatitis A may include any or all of the following: fatigue, poor appetite,
fever, vomiting, dark urine, and jaundice (a yellowing of the skin and/or whites of the eyes).
Very few deaths are caused by hepatitis A. Most people recover in a few weeks without any
complications. Infants and young children tend to have no symptoms or very mild symptoms
and are less likely to develop jaundice than are older children and adults.
How soon do symptoms appear?
Symptoms appear 15 to 50 days after exposure, but generally 25 to 30 days.
How is it diagnosed?
Since there are several types of viral hepatitis, a blood test is needed to find out which type of
hepatitis is present.
For how long is an infected person able to spread the virus?
The contagious period begins about 14 days before the symptoms appear and ends about 7
days after jaundice appears. If jaundice is not present, the person should be considered
infectious for the 14 days before symptoms started until 14 days after the start of symptoms.
Infected persons with or without symptoms can spread the disease to others.
What is the treatment for hepatitis A?
Only supportive treatment is available for hepatitis A. Generally, rest and good nutrition are
all that is needed. Drugs and alcohol should be avoided.
How can the spread of hepatitis A be prevented?
The best way to prevent spread is careful handwashing after using the toilet or changing
diapers. Infected people should not prepare or handle food for others during the contagious
period.
Household members, sex partners, drug partners or others in close contact with an infected
person should call a doctor or the health department to get a shot of immune globulin.
Immune globulin must be given within 14 days of exposure to be effective.
For long term protection, hepatitis A vaccine is recommended and may be given
simultaneously when administering immune globulin at a separate anatomic injection site.
Child care operators and staff should be aware of the potential danger of an outbreak of
hepatitis A in their centers and should adopt preventive measures. Prevention should
focus on good hygiene at the center, with emphasis on handwashing by employees and by
children of all ages. Appropriate facilities and precautions should be used in diaper-changing
areas where feces may be handled directly. Clothing should be worn over
diapers to reduce fecal contamination of the environment.
Staff should wash their hands immediately after changing diapers or training pants or
assisting toddlers in using the toilet. Disposable diapers should be thrown away promptly
in a covered, plastic-lined container and the diaper-changing table washed and disinfected
after use.
When a case of hepatitis A is identified in an employee or child of a child care facility
where all children are more than two years old or toilet trained, administer IG to all
employees in contact with the index case and all children in the same room as the index
case.
When a case of hepatitis A is identified in an employee child of a child care facility where
children are not yet toilet trained, administer IG to all employees and enrolled children when
1. there is one case of hepatitis A virus (HAV) infection in a child care employee or child
or
2. there are cases of HAV infection in one or more household contacts of two of the
enrolled children.
During the six weeks after the last case is identified, new employees and newly enrolled
children should receive IG.
Emphasize improved sanitation and personal hygiene; provide materials and instructions
on handwashing; request that an Environmental Public Health Specialist do an inspection
of the center. Affected child care facilities should not close down, since this would permit infected
children to return to their homes and neighborhoods without their illness being recognized.
Closing one center may result in spread to other centers. Cooperation between public
health agencies and child care operators is essential for successful outbreak control.
Family child care homes serving infants and toddlers can also be a source of the spread of
Hepatitis.
Hepatitis B, acute/Delta Hepatitis
What is hepatitis B?
Hepatitis B (formerly known as serum hepatitis) is a liver disease caused by the hepatitis B virus.
The disease affects 140,000 - 320,000 persons per year in the United States.
Who gets hepatitis B?
Anyone can get hepatitis B, but those at greatest risk include:
babies born to mothers who are infectious with the hepatitis B virus (including carriers);
injection drug users (or persons who share needles);
persons in occupations where there is contact with infected blood and other infectious body
fluids which includes saliva - (persons who work in settings such as centers, health care
workers, first responders, etc.);
sexually active homosexual and bisexual men;
anyone with multiple sex partners;
men and women who have a recent diagnosis of another sexually transmitted disease;
hemodialysis patients;
persons who receive unscreened blood products;
certain household contacts of an infected person;
household contacts and sexual partners of hepatitis B carriers;
inmates of long-term correctional facilities;
persons from countries where hepatitis B is widespread (certain areas of Asia and Africa);
persons in the United States who are Alaskan Natives or Pacific Islanders.
How is the virus spread?
Hepatitis B virus can be found in the blood of infected persons; it is also present in lesser
amounts in semen, semen vaginal secretions, amniotic fluid, body fluids containing blood,
unfixed tissues and organs, and saliva. Hepatitis B virus is spread through sexual contact
(homosexual and heterosexual), needle sharing, needle stick injury, mucous membrane exposure,
and direct contact with infected body fluids. Hepatitis B virus is not spread by casual contact.
What are the symptoms of hepatitis B?
Many persons with hepatitis B infection have no symptoms at all, or they may be mild and flu-like
(i.e.: loss of appetite, nausea, vomiting, diarrhea, fatigue). Some patients may notice
darkened urine (iced-tea colored), light colored stools or yellowing of the skin and eyes
(jaundice). A few persons will experience a more severe disease syndrome and may die of
overwhelming liver failure.
How soon do symptoms appear?
The symptoms, if they appear, may occur as early as 45 days to as long as 180 days following
exposure, the average is 60-90 days. The variation in time for onset of symptoms is related in
part to the amount of virus transmitted at the time of exposure.
How is hepatitis B diagnosed?
Since there are several types of viral hepatitis, a blood test is needed to determine which type of
hepatitis is present.
For how long is a person able to spread the virus?
The virus can be present in blood and other body fluids several weeks before symptoms appear
and generally for several months afterward. About 1 in 10 adults and 3 of 10 children with
hepatitis B will go on to become ongoing carriers of the virus for the rest of their lives even
when they do not have symptoms. As long as the virus is present, it can be spread to others.
Persons with hepatitis B infection should not donate blood, organs or tissues.
What is the treatment for hepatitis B?
There are no special medicines to treat a person with acute hepatitis B disease. Generally, rest
and supportive treatment is all that is needed. Carriers of hepatitis B infection may benefit from
treatment with a medication called alpha-interferon.
What precautions should hepatitis B carriers take?
Hepatitis B carriers should practice good hygiene so that close contacts are not directly exposed
to their blood or other body fluids. Carriers must not share razors, toothbrushes or any other
object that may become contaminated with blood. In addition, household members, particularly
sexual partners, should be immunized with hepatitis B vaccine. Carriers should practice "safe
sex" if their partners are not immunized. It is important for carriers to inform their dentists and
other health care providers of their carrier state.
Can hepatitis B be prevented?
Yes, a vaccine to prevent hepatitis B has been available since 1982. It is safe, effective and
recommended for all newborns, 11-12 year olds and for any person at risk for getting infected
(see page 1, "Who gets hepatitis B?"). A special hepatitis B immune globulin (HBIG) is also
available for people who are not vaccinated and are exposed to the virus. If you are exposed to
hepatitis B, consult a doctor or your local health department immediately.
Hepatitis C
What is hepatitis C?
Hepatitis C is an inflammation of the liver that is caused by the hepatitis C virus. This
inflammation can result in serious liver damage. Eighty-five percent of hepatitis C-infected
individuals develop chronic hepatitis. Hepatitis C is now the major reason for liver transplantation
in the United States.
How common is hepatitis C?
This year alone, some 30,000 Americans will become infected with hepatitis C in the United
States. If the body does not clear the virus in six months, the infection is said to be chronic.
Currently, an estimated 4 million people have chronic hepatitis C in the United States. Missouri is
estimated to have 95,000 persons infected with hepatitis C.
Each year, up to 8,000 Americans die from complications of hepatitis C. The death rate is
expected to triple within the next 10 to 20 years, exceeding the death rate associated with AIDS.
Who is at risk for hepatitis C?
Hepatitis C is transmitted primarily by direct puncture of skin. Injection drug use accounts for
greater than 50% of chronic infections.
Other risks include:
Blood transfusion prior to 1992
Occupational exposure (health care workers)
Hemodialysis patients
Practicing high-risk sexual activity (multiple partners history of STDs, co-infected with
HIV)
Using non-injection illegal drugs (intranasal cocaine)
Tattooing and body piercing with contaminated equipment
* Transmission between mother and baby has been documented, although the risk is low, no more
than 6%. Breast feeding does not appear to transmit hepatitis C.
What are the symptoms?
Some people have loss of appetite, tiredness, nausea and vomiting, vague stomach pain and
jaundice (a yellowing of the skin and whites of the eyes). Some people do not have any
symptoms.
How soon do symptoms occur?
Symptoms may occur from two weeks to six months after exposure but usually within 6-9
weeks. These symptoms are during the acute phase of the disease. Liver cirrhosis and
permanent liver damage from hepatitis C may not be evident for up to 20 years after the initial
exposure to the virus.
When and for how long is a person able to spread hepatitis C?
A person with hepatitis C is contagious one or two weeks before symptoms appear and during the
entire time the person is ill. About 50% of the people with hepatitis C will go on to become
chronic carriers. Until more is learned about this disease, all persons who have been diagnosed as
having hepatitis C should be considered infectious (able to pass the hepatitis C virus through their
blood and body fluids).
What are the complications of hepatitis C?
Eighty-five percent (85%) of persons infected with hepatitis C develop chronic hepatitis and
remain infectious to other people. Cirrhosis (scarring of the liver) occurs within 2 years of the
onset of infection in at least 20% of persons with chronic hepatitis C. Risk for chronically
infected persons to develop liver cancer is 1-5%. The course of illness is influenced by various
factors, especially alcohol consumption.
Can hepatitis C be prevented?
There is no vaccine for hepatitis C.
A healthy lifestyle can reduce chances of infection. Avoid illegal injection drugs use, intranasal
cocaine use and contact with other people’s blood. Practice safe sex and limit sexual partners (a
monogamous relationship has the lowest risk for acquiring hepatitis C). Avoid sharing razors,
toothbrushes, pierced earrings, needles and syringes with anyone; and make certain needles for
body piercing and tattooing have been properly sterilized.
How is hepatitis C diagnosed?
There are tests that can be performed on blood to identify individuals who have the Hepatitis C
virus. Your doctor can perform these tests.
Is there a medical treatment for hepatitis C?
Treatment for hepatitis C is recommended only in a selected group of infected persons.
Vaccination against hepatitis A and B is recommended, since a liver compromised by hepatitis C
is more susceptible to hepatitis A and B.
Influenza
What is influenza?
Influenza is a highly contagious respiratory illness caused by a virus. There are two main types of
influenza viruses: type A and type B. Each type has many different subtypes or strains. Type A
influenza causes moderate to severe illness. Type B causes milder disease and primarily affects
children. Influenza can occur throughout the year, but seasonally peaks from December to
March.
What are the symptoms?
Symptoms include fever, headache, muscle aches, extreme fatigue, sore throat, runny nose, cough
and nasal congestion. Occasionally, intestinal symptoms such as nausea, vomiting, diarrhea, and
abdominal pain are present, but should not be confused with the “stomach flu.”
How is influenza spread?
Influenza is spread from person-to-person by direct contact with airborne particles or large
droplets from the respiratory tract of the infected person when coughing, sneezing, or talking.
Transmission can also occur through articles recently contaminated by secretions from the nose
and throat of the infected person. Handwashing and avoiding or limiting contact with an infected
person may reduce the risk of infection.
How soon do symptoms appear?
Symptoms of influenza usually appear 1 to 5 days after exposure.
How long can a person spread influenza?
Persons are most contagious during the 24 hours before symptoms appear and may be contagious
for up to 7 days.
How is influenza diagnosed?
The diagnosis on influenza is usually based on the symptoms. For a laboratory-confirmed
diagnosis, the virus is detected in specimens collected from the throat or nose by culture or rapid
antigen testing.
What is the treatment?
Basic treatment includes bedrest, fluids, and over-the-counter medications for the relief of
symptoms of runny nose, cough, sore throat, fever, and discomfort. Aspirin should not be used
for infants, children, or teenagers because of the associated risk for contracting Reye Syndrome.
Antiviral medications, such as amantadine and rimantadine, may reduce the severity and shorten
the duration of influenza type A in healthy adults when administered within 48 hours of illness
onset. These drugs may have side effects and must be ordered by a physician.
How serious is influenza?
Influenza can be very serious, especially during epidemics. Secondary bacterial pneumonia is a
serious complication of influenza and can cause death in persons at increased risk for
complications including the elderly and those with chronic disease.
Can influenza be prevented?
Annual influenza vaccination has been up to 90% effective in preventing influenza in young
healthy adults and 30% to 40% effective in preventing illness among frail elderly persons.
Influenza vaccine is updated annually to match the circulating strain and provides immunity for
approximately one year.
During community outbreaks of type A influenza, antiviral medications may be used by persons
who are unable to take the influenza vaccine. Antiviral medications are also indicated when
outbreaks are caused by a variant strain of influenza type A that might not be controlled by the
vaccine.
When is the influenza vaccine given?
The vaccine should be taken each fall, between October and mid-November. It takes about one
to two weeks for the antibody to develop and provide protection.
How safe is influenza vaccine?
The Influenza vaccine does not contain live viruses, so it cannot cause influenza. The most
common reaction is soreness where the shot was given. Some persons may have muscle aches,
tiredness, and low-grade temperature for 1 to 2 days.
Who should get influenza vaccine?
Persons who have a greater risk for developing complications from influenza should be
vaccinated, including:
Persons aged 65 years and older;
Residents of long term care facilities and other chronic care facilities;
Adults and children with chronic heart or lung conditions, including children with asthma;
Adults and children who require regular medical follow-up because of chronic metabolic
disease (including diabetes mellitus), kidney disease, blood disorder or immunosuppression;
Children and teenagers, aged 6 months to 18 years, who are receiving long-term aspirin
therapy and might be at risk for developing Reye syndrome after influenza.
Women who will be in the second or third trimester of pregnancy during the influenza season.
Other persons who should be vaccinated include:
Persons who live with or care for high-risk individuals.
Health care workers, physicians, staff and volunteers of health care facilities and home health
agencies;
Persons who work in public-safety occupations, such as, police, firefighter, and emergency
medical treatment.
Who should NOT get influenza vaccine?
Persons having the following conditions should NOT receive the influenza vaccine:
Persons who have had a severe allergic reaction to a vaccine component or following a prior
dose;
Persons who have severe reactions, such as hives or swelling of the lips, tongue, after eating
eggs because the vaccine is prepared form influenza viruses grown in eggs;
Fever or an active infection.
For more information about influenza, ask your physician or health care provider, infection
control professional, pharmacist or contact:
Legionellosis
(Legionnaires Disease, Pontiac Fever)
What is Legionellosis?
Legionellosis is an infectious disease caused by bacteria called Legionella. The disease may take
two forms; the more serious form may develop into pneumonia. Cases of disease may occur
throughout the year, but most cases occur in the summer and fall. Normally this disease occurs as
single cases, however, outbreaks have occurred in Missouri.
Who gets Legionellosis?
Anyone can get Legionellosis, but the disease is most common among middle-aged or older men.
Individuals who have weakened immune systems due to chronic diseases, such as diabetes, kidney
failure or HIV infection are at higher risk of the disease. In addition, those who have an immune
system that has been altered by medications, such as steroids or chemotherapy may get the disease
more often. Smokers and heavy drinkers are also more prone to get the disease.
How is the disease spread?
The bacteria are sometimes contained inside fine mists created by such things as water cooling
towers, hot tubs, and decorative fountains. It is possible for people to inhale the mist. Person to
person spread does not occur.
What are the symptoms of Legionellosis?
Most cases of Legionellosis probably present with very mild symptoms. However, for those who
develop more severe symptoms, there are two distinct forms. Usually, there is a flu-like illness
with body aches, loss of appetite and dry cough. Within 24 hours, there are chills and fever,
sometimes as high 1020 F – 1050 F. For those who develop the Pontiac Fever form of Legionellosis,
recovery will usually be in 2 – 5 days without treatment. For those who develop the Legionnaires form
of the disease, pneumonia usually develops and medical treatment is necessary.
How soon do symptoms appear?
For Pontiac fever, symptoms usually appear within 24-48 hours following exposure, although it
may be anywhere from 5 hours to 66 hours following exposure. The Legionnaires form of the
disease takes longer to develop, and symptoms may appear from 2 – 10 days following exposure,
although most cases occur within 5-6 days after exposure.
How long can an infected person carry Legionella?
There is no carrier state for Legionellosis. Testing the blood of someone years after they have
had the disease may reveal the presence of antibodies to Legionella. But this only means that
they once had the disease, not that they have the disease today.
Where are the Legionella bacteria found?
Legionella bacteria like water, and have been isolated from ponds, creeks, lakes, and moist soil.
They can also be found in many man-made environments such as hot-water tanks, water-cooling
towers, fountains and even in drinking water. Because these organisms are so common and so
rarely cause disease, testing of environmental samples is not usually done unless more than one
person becomes ill.
What is the treatment for Legionellosis?
Antibiotics, such as erythromycin, are usually used to treat the disease.
What can a person or community do to prevent the spread of Legionellosis?
People who own hot tubs or spas should follow the manufacturer’s directions about how often the
units should be cleaned. Home hot water tanks should be maintained above 122º F to prevent
growth of the bacteria. Large water cooling towers should be drained when not in use and
maintained according to the directions.
Where can I get more information?
Contact your physician, nurse or clinic. Another good place to get information is the local public
health agency or district health office. Their telephone numbers are always listed in the phone
book. You may also contact the Section of Communicable Disease Control and Veterinary Public
Health.
Leptospirosis
(Weil's disease)
What is leptospirosis?
Leptospirosis is a bacterial disease associated with wild and domestic animals.
Who gets leptospirosis?
Leptospirosis is primarily an occupational disease that affects farmers, veterinarians, sewer
workers, slaughterhouse workers or others whose occupation involves contact with urine from
infected animals.
How is leptospirosis spread?
Leptospirosis is spread mainly by ingestion of water or soil contaminated by the urine of infected
animals. It can be spread by ingestion of blood or other body fluids of infected animals. It is
generally not transmitted from person to person.
What are the symptoms of leptospirosis?
The symptoms of leptospirosis include fever, headache, chills, muscle aches, vomiting, jaundice,
anemia, and sometimes rash. People with leptospirosis are usually quite ill and require
hospitalization.
How soon after exposure does symptoms appear?
The incubation period is usually 10 days, with a range of 2 to 26 days.
How is leptospirosis diagnosed?
Leptospirosis is diagnosed using a specific antibody test.
What is the treatment for leptospirosis?
The antibiotics of choice include penicillin, streptomycin, tetracycline, or erythromycin. Kidney
dialysis may be necessary in severe cases.
What are the complications associated with leptospirosis?
If not treated, the patient could develop kidney damage, meningitis, liver failure, and respiratory
distress. In rare cases, death may occur.
How can leptospirosis be prevented?
Disease prevention consists of good sanitation. The use of boots and gloves in hazardous places,
rodent control, and immunization of farm and pet animals can also minimize the risk of spread.
Listeriosis
What is listeriosis?
Listeriosis is a bacterial infection caused by Listeria monocytogenes. While many bacteria
generally infect specific locations within the human body, listeria may infect many different
sites, such as the brain or spinal cord membranes, or the bloodstream.
Who gets listeriosis?
Anyone can get the disease, but those at highest risk are newborns, the elderly, people with
weakened immune systems and pregnant women. About 30 percent of cases occur in newborns
within the first three weeks of life.
When do listeria infections occur?
Infections occur throughout the year. Although most cases occur sporadically, foodborne
outbreaks do occur.
How is listeriosis spread?
Listeria bacteria are widely distributed in nature and can be found in water and soil. Infected
animals may also serve as sources. Unlike other organisms, listeria can be spread by several
different methods. Ingestion (foodborne transmission) of the organism, such as through
unpasteurized milk or contaminated vegetables is often a source of cases. In newborn infections,
the organism may be transmitted from mother to fetus in utero, or directly to the fetus at the time
of birth. Direct contact with the organism can cause lesions on the hands or arms, and person-to-person
transmission can occur through sexual contact. Infection is also possible by inhaling the
organism.
What are the symptoms of listeriosis?
Because listeriosis can affect many different parts of the body, the symptoms vary. For
meningoencephalitis, the onset can be sudden with fever, intense headache, nausea, vomiting
and signs of meningeal irritation. In other body locations, various types of lesions at the site of
infection are the primary symptom. In most cases, listeria infection causes fever and influenza-like
symptoms resembling many other illnesses.
How soon after exposure do symptoms appear?
Listeriosis has an extremely variable incubation period. In large outbreaks, the range has
extended from three to 70 days but usually within a month.
Who gets listeriosis?
Anyone can get the disease, but those at highest risk are newborns, the elderly, people with
weakened immune systems and pregnant women. About 30 percent of cases occur in newborns
within the first three weeks of life.
When do listeria infections occur?
Infections occur throughout the year. Although most cases occur sporadically, foodborne
outbreaks do occur.
How is listeriosis spread?
Listeria bacteria are widely distributed in nature and can be found in water and soil. Infected
animals may also serve as sources. Unlike other organisms, listeria can be spread by several
different methods. Ingestion (foodborne transmission) of the organism, such as through
unpasteurized milk or contaminated vegetables is often a source of cases. In newborn infections,
the organism may be transmitted from mother to fetus in utero, or directly to the fetus at the time
of birth. Direct contact with the organism can cause lesions on the hands or arms, and person-to-person
transmission can occur through sexual contact. Infection is also possible by inhaling the
organism.
What are the symptoms of listeriosis?
Because listeriosis can affect many different parts of the body, the symptoms vary. For
meningoencephalitis, the onset can be sudden with fever, intense headache, nausea, vomiting
and signs of meningeal irritation. In other body locations, various types of lesions at the site of
infection are the primary symptom. In most cases, listeria infection causes fever and influenza-like
symptoms resembling many other illnesses.
How soon after exposure do symptoms appear?
Listeriosis has an extremely variable incubation period. In large outbreaks, the range has
extended from three to 70 days but usually within a month.
How is this disease diagnosed?
Specific laboratory tests are the only way to identify this disease. Since many cases may be
mild, the disease may be more common than is realized.
Are there any unusual features of this disease?
Listeria infections are a significant risk for pregnant women, who may not experience obvious
symptoms. Infection of the fetus can occur before delivery and can cause abortion as early as the
second month of pregnancy, but more often in the fifth and six months. An infection later in
pregnancy may cause exposure during birth, sometimes resulting in infection of the newborn
which may be fatal.
Does past infection with listeria make a person immune?
Past infection appears to produce some protective immunity.
What is the treatment for listeria infection?
Several antibiotics are effective against this organism. Ampicillin, either alone or in combination
with other antibiotics, is frequently used.
What can be done to prevent the spread of this disease?
Since the organism is widespread in nature, basic sanitary measures such as using only
pasteurized dairy products, eating cooked meats and washing hands thoroughly before preparing
foods offer the best protection. Pregnant women and persons with weakened immune systems
may wish to avoid such foods as soft cheeses and raw hot dogs. Although the risk of listeriosis
associated with foods from deli counters is relatively low, pregnant women and immuno-supressed
persons may choose to avoid these foods or thoroughly reheat cold cuts before eating.
Lyme/Lyme-like Disease
What is Lyme disease?
Lyme disease is an infectious disease which can be transmitted by the bite of a tick.
What are the symptoms of Lyme disease?
The symptoms of Lyme disease vary a great deal from one case to the next. In general, the early
signs appear 3 to 32 days after a tick bite. The early symptoms of the disease can include: fever,
fatigue, headaches, aching joints, nausea and a characteristic skin rash. The rash, which occurs in
about half the cases of Lyme disease, is roughly circular in shape. Usually, the rash is found at
the site of the tick bite, although it can also be found on other parts of the body. In time, the rash
gets larger, and the center often becomes clear (not reddened).
When the early symptoms are present it is important to treat the disease, otherwise late symptoms
and complications can develop.
The late symptoms of the disease can include: severe headaches, stiff neck, weakness and/or pain
in the extremities, facial paralysis, cardiac problems and arthritis (very common in this stage of the
disease).
The late symptoms may occur weeks to years after being infected.
How does a person get Lyme disease?
The disease is transmitted through the bite of a tick infected with Lyme disease. The tick must be
actually attached to a person’s skin to transmit the infection. All ticks do not carry Lyme disease.
The tick commonly known as the deer tick can carry the disease. Some other kinds of ticks may
also spread Lyme disease, but this is not known with certainty. Because the tick may be very
small, many people may not be aware that they have been bitten.
Can Lyme disease be treated?
Yes, once Lyme disease is diagnosed a physician will prescribe an antibiotic. Prompt treatment
can cure the infection and usually prevents later complications.
How should a tick be removed?
Ticks should be removed promptly and carefully by using tweezers and applying gentle steady
traction. Do not crush the tick’s body when removing it and apply the tweezers as close to the
skin as possible to avoid leaving tick mouth parts in the skin. Do not remove ticks with your bare
hands. Protect your hands with gloves, cloth, or tissue and be sure to wash your hands after
removing a tick. After removing the tick, disinfect the skin with soap and water or other available
disinfectants.
How can Lyme Disease be prevented?
1. Avoid tick infested areas, especially during the warmer months.
2. Wear light colored clothing so ticks can be easily seen. Wear a long sleeved shirt, hat, long
pants, and tuck your pant legs into your socks.
3. Walk in the center of trails to avoid overhanging grass and brush.
4. Check your body every few hours for ticks when you spend a lot of time outdoors in tick
infested areas. Ticks are most often found on the thigh, arms, underarms, legs or where tight
fitting clothing has been.
5. Use insect repellents containing DEET on your skin or permethrin (Permanone) on your
clothing. Be sure to follow the directions on the container and wash off repellents when going
indoors. Carefully read the manufacturer’s label on repellents before using on children.
6. Remove attached ticks immediately.
clothing. Be sure to follow the directions on the container and wash off repellents when going
indoors. Carefully read the manufacturer’s label on repellents before using on children.
6. Remove attached ticks immediately.
MALARIA
What is malaria?
Malaria is caused by a parasite that is transmitted from person to person by the bite of an infected
Anopheles mosquito. These mosquitoes are present in almost all countries in the tropics and
subtropics. Anopheles mosquitoes bite during nighttime hours, from dusk to dawn. Therefore,
antimalarial drugs are only recommended for travelers who will have exposure during evening
and nighttime hours in malaria risk areas.
How can I protect myself from malaria?
Malaria can often be prevented by the use of antimalarial drugs and use of personal protection
measures against mosquito bites. The risk of malaria depends on the traveler’s itinerary, the
duration of travel, and the place where the traveler will spend the evenings and nights.
What if I am pregnant or breastfeeding?
Malaria infections in pregnant women may produce severe consequences. Malaria may increase
the risk of adverse pregnancy outcomes, including prematurity, abortion, and stillbirth.
Therefore, pregnant women who are traveling to a malaria risk area should consult a physician
and take prescription drugs to prevent malaria. In areas with chloroquine resistant P. falciparum,
MEFLOQUINE may be used during pregnancy for women traveling to areas with chloroquine-resistant
P. falciparum. DOXYCYCLINE should not be used during the entire pregnancy. In
chloroquine-sensitive areas, pregnant women should take CHLOROQUINE for malaria
prevention. Neither mefloquine nor chloroquine has been demonstrated to have a harmful effect
on the fetus when it is used to prevent malaria. Very small amounts of antimalarial drugs are
secreted in the breast milk of lactating women. The very small amount of drug that is transferred
in breast milk is neither harmful to the infant nor does it protect the infant against malaria.
Therefore, infants need to be given drugs to prevent malaria.
Are there any special precautions for children?
All children traveling to malaria risk areas, including young infants, should take antimalarial
drugs. Therefore, the recommendations for most preventive drugs are the same as for adults, but
it is essential to use the correct dosage. The dosage depends on the age and/or the weight of the
child.
OVERDOSAGE OF ANTIMALARIAL DRUGS CAN BE FATAL. MEDICATION
SHOULD BE STORED IN CHILDPROOF CONTAINERS OUT OF THE REACH OF
CHILDREN.
Are the preventive methods 100% effective?
Travelers can still get malaria, despite use of prevention measures. Malaria symptoms can
develop as early as 6-8 days after being bitten by an infected mosquito or as late as several
months after departure from a malarious area, after antimalarial drugs are discontinued. Malaria
can be treated effectively in its early stages, but delaying treatment can have serious
consequences.
What are the symptoms of malaria?
Symptoms of malaria include fever, chills, headache, muscle ache, and malaise. Early stages of
malaria may resemble the onset of the flu. Travelers who become ill with a fever during or after
travel in a malaria risk area should seek prompt medical attention and should inform their
physician of their recent travel history. Neither the traveler nor the physician should assume that
the traveler has the flu or some other disease without doing a laboratory test to determine if the
symptoms are caused by malaria.
How is malaria diagnosed?
The recognized detection method for diagnosis is blood smears. Your physician will need to
make several blood smears on glass slides to detect the parasite. Due to the cyclic nature of the
parasite’s development a negative set of smears from a single blood specimen does not rule out
malaria. Multiple blood specimens collected at 12 –24 hour intervals may be required to detect
the presence of the parasites.
General Information
Malaria (mah-LARE-ee-ah)
Malaria is a serious, sometimes fatal, disease caused by a parasite. There are four kinds of
malaria that can infect humans: Plasmodium falciparum (plaz-MO-dee-um fal-SIP-a-rum), P.
vivax (VI-vacks), P. ovale (o-VOL-ley), and P. malariae (ma-LER-ee-aa).
Where does malaria occur?
Malaria occurs in over 100 countries and territories. More than 40% of the people in the world
are at risk. Large areas of Central and South America, Hispaniola (Haiti and the Dominican
Republic), Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania are
considered malaria-risk areas (an area of the world that has malaria).
How common is malaria?
The World Health Organization estimates that yearly 300-500 million cases of malaria occur and
more than 1 million people die of malaria. About 1,200 cases of malaria are diagnosed in the
United States each year. Most cases in the United States are in immigrants and travelers
returning from malaria-risk areas, mostly from sub-Saharan Africa and the Indian subcontinent.
How do you get malaria?
Humans get malaria from the bite of a malaria-infected mosquito. When a mosquito bites an
infected person, it ingests microscopic malaria parasites found in the person’s blood. The malaria
parasite must grow in the mosquito for a week or more before infection can be passed to another
person. If, after a week, the mosquito then bites another person, the parasites go from the
mosquito’s mouth into the person’s blood. The parasites then travel to the person’s liver, enter
the liver’s cells, grow and multiply. During this time when the parasites are in the liver, the
person has not yet felt sick. The parasites leave the liver and enter red blood cells; this may take
as little as 8 days or as many as several months. Once inside the red blood cells, the parasites
grow and multiply. The red blood cells burst, freeing the parasites to attack other red blood cells.
Toxins from the parasite are also released into the blood, making the person feel sick. If a
mosquito bites this person while the parasites are in his or her blood, it will ingest the tiny
parasites. After a week or more, the mosquito can infect another person.
Each year in the United States, a few cases of malaria result from blood transfusions, are passed
from mother to fetus during pregnancy, or are transmitted by locally infected mosquitoes.
What are the signs and symptoms of malaria?
Symptoms of malaria include fever and flu-like illness, including shaking chills, headache,
muscle aches, and tiredness. Nausea, vomiting, and diarrhea may also occur. Malaria may cause
anemia and jaundice (yellow coloring of the skin and eyes) because of the loss of red blood cells.
Infection with one type of malaria, P. falciparum, if not promptly treated, may cause kidney
failure, seizures, mental confusion, coma, and death.
How soon will a person feel sick after being bitten by an infected mosquito?
For most people, symptoms begin 10 days to 4 weeks after infection, although a person may feel
ill as early as 8 days or up to 1 year later. Two kinds of malaria, P. vivax and P. ovale, can
relapse; some parasites can rest in the liver for several months up to 4 years after a person is
bitten by an infected mosquito . When these parasites come out of hibernation and begin
invading red blood cells, the person will become sick.
How is malaria diagnosed?
Malaria is diagnosed by looking for the parasites in a drop of blood. Blood will be put onto a
microscope slide and stained so that the parasites will be visible under a microscope.
Any traveler who becomes ill with a fever or flu-like illness while traveling and up to 1 year
after returning home should immediately seek professional medical care. You should tell
your health care provider that you have been traveling in a malaria-risk area.
Who is at risk for malaria?
Persons living in, and travelers to, any area of the world where malaria is transmitted may
become infected.
What is the treatment for malaria?
Malaria can be cured with prescription drugs. The type of drugs and length of treatment depend
on which kind of malaria is diagnosed, where the patient was infected, the age of the patient, and
how severely ill the patient was at start of treatment.
How can malaria and other travel-related illnesses be prevented?
Visit your health care provider 4-6 weeks before foreign travel for any necessary
vaccinations and a prescription for an antimalarial drug.
Take your antimalarial drug exactly on schedule without missing doses.
Prevent mosquito and other insect bites. Use DEET insect repellent on exposed skin and
flying insect spray in the room where you sleep.
Wear long pants and long-sleeved shirts, especially from dusk to dawn. This is the time
when mosquitoes that spread malaria bite.
Sleep under a mosquito bednet that has been dipped in permethrin insecticide if you are
not living in screened or air-conditioned housing.
Malaria-risk information is available from CDC’s Fax Information Service or
at CDC’s Internet Website:
To request fax information, call 1-888-232-3299 and listen to the instructions. For the
directory of all available traveler’s health faxes, arranged by regions of the world, request
document number 000005.
Meningococcal Disease
What is meningococcal disease?
Meningococcal disease is a bacterial infection caused by Neisseria meningitidis. When this
bacteria affects the lining of the brain and spinal cord (the meninges), the condition is called
meningococcal meningitis. It is a relatively rare disease and usually occurs as a single event.
It can cause meningococcemia, which is a more serious infection of the blood stream. Other
normally sterile sites (e.g. joints) may become involved. These infections may lead to death.
Who gets meningococcal disease?
Anyone can get meningococcal disease, but it is more common in infants and children.
What are the symptoms of meningococcal disease?
The symptoms may include any of the following: fever, severe sudden headache, nausea, vomiting,
stiff neck, pain in the shoulders and back, and a red pinpoint rash are the most common signs of this
disease. High fever and irritability are signs in a very young child. If the condition is
meningococcemia, then a purplish skin rash that looks like bruising may occur.
How soon do symptoms appear?
The symptoms may appear 1 to 10 days after exposure, but usually within 3 to 4 days.
How is meningococcal disease spread?
The meningococci bacteria are spread by direct close contact with nose and throat discharges of an
infected person. People may carry the bacteria in their noses and throats without becoming ill, these
persons are known as healthy carriers. Healthy carriers are able to spread the bacteria to other
people, who may develop meningococcal disease with serious symptoms.
When and for how long is a case infectious to other people?
A person may pass the bacteria from the time he/she is first infected and until the bacteria are no
longer present in discharges from the nose and throat. Persons are usually no longer infectious after
24 hours of effective antibiotic treatment.
How can you reduce the risk of contracting meningococcal disease?
Everyone should be sensitive to public health measures that decrease exposure to oral secretions,
such as covering one’s mouth when coughing or sneezing and washing hands after contact with oral
secretions. A healthy lifestyle that maximizes your body’s own immune system response, through
balanced diet, adequate sleep, appropriate exercise, and avoidance of excessive stress, is very important.
Presently there is a vaccine that will protect against four of the strains of meningococcal disease. The
use of the vaccine is recommended in outbreak situations, for individuals with specific medical
conditions, or for those traveling to areas where the illness is clearly in excess of normal expectancy.
The American College Health Association recommends immunization of college students. It is
important to note that meningococcal vaccine should not be used in place of preventive treatment
for those exposed to a meningococcal disease. The protection from immunization is too slowly
generated in this situation.
What should you do if you suspect meningococcal disease?
Individuals who experience any of the symptoms described above should consult their physician
immediately. Meningococcal disease can be rapidly progressive. With early diagnosis and treatment,
the likelihood of full recovery is increased. Early recognition and prompt initiation of antimicrobial
therapy are crucial.
What should I do if I have been in contact with a diagnosed case of
meningococcal disease?
The use of preventive treatment (such as rifampin or ciprofloxacin) is recommended for close
contacts exposed to a person diagnosed with meningococcal disease. Anyone who suspects
possible exposure should consult a physician immediately. Beginning preventive treatment more than
2 weeks after exposure to the case would be too late to prevent secondary cases.
Who is considered a close contact?
Close contacts are those who are likely to have been exposed to the nose and throat secretions of
the sick person. Close contacts include, but are not limited to the following:
Those living in the same house as the ill person,
Those sharing sleeping arrangements with the ill person,
Children sharing toys, such as in the same child care or nursery school, as the ill person,
Those who shared cigarettes, food, drinks, or other things that contain saliva with the ill person,
Those who have kissed the ill person,
Those who have given mouth-to-mouth resuscitation to, intubated, or suctioned the
nasopharyngeal secretions of the ill person.
Casual contact, such as being in the same classroom, workplace, or sitting at the same table with an
infected person is not usually significant enough to cause concern.
What is the treatment for this disease?
Certain antibiotics are very effective in the treatment of the disease and are available from your
physician. Generally, penicillin is the drug of choice for meningococcal infections.
PRECAUTIONARY NOTATION:
Important information associated with rifampin or ciprofloxacin usage for preventive treatment of
high-risk contacts can be found in the following Department of Health fact sheets titled: “Important
Information about Rifampin For Prevention of Meningococcal Disease” or “Important Information
about Ciprofloxacin For Prevention of Meningococcal Disease”.
Important Information About Rifampin
for Prevention of Meningococcal Disease
Rifampin is an antibiotic. The full prescribed dosage should be taken as directed.
Contraindications:
Includes, but is not limited to:
Rifampin is not recommended for pregnant women.
Rifampin should not be used if there has been a previous reaction to similar antibiotics.
Important Facts:
Rifampin may stain body secretions red-orange, including urine, feces, saliva, sweat and tears.
For this reason, soft contact lenses may be permanently stained. They should not be worn while
taking rifampin.
Rifampin may reduce the effectiveness of oral contraceptives and other drugs.
Studies have shown that Rifampin interacts with certain HIV/AIDS medications. Thus, if you are
taking any prescription medications for HIV/AIDS Disease, please check with your physician
prior to taking Rifampin.
Adverse Reactions:
Rifampin may cause nausea, vomiting, cramps, and diarrhea in some individuals.
Headache, fever, drowsiness, fatigue, dizziness, mental confusion, and muscular weakness may
occur.
If any symptoms occur, please contact your physician.
FOOD POISONING
In Foodborne Outbreaks
Organism Unknown
Exclusion. All foodhandlers in the implicated establishment who have symptoms similar to the
outbreak cases should be immediately excluded from foodhandling duties. They should not
return to foodhandling until their symptoms resolve, or if the causative organism is identified,
until the disease-specific guidelines below are met.
Epidemiologic investigation. Conduct a thorough investigation. Determine the predominant
symptoms, their duration and the incubation period. Develop a hypothesis regarding the
causative organism. Then follow the disease-specific guidelines below.
Bacillus Cereus
Clostridium Perfringens
Vibrio Parahemolyticus
Transmission. Not usually transmitted from person to person.
Exclusion. Exclude ill persons from handling food while symptomatic.
Screening. Collect one fecal specimen from each ill worker within the appropriate time
frame (24 hours for V. parahemolyticus, 3 days for B. cereus and C. perfringens). No screening of
asymptomatic foodhandlers is necessary.
Management. Employees may return to work when no longer symptomatic. No follow up culturing is
necessary.
Staphylococcal Food Poisoning
Transmission. May be transmitted by infected or colonized foodhandlers.
Exclusion. Exclude ill persons from handling food while symptomatic. Exclude
foodhandlers with boils, abscesses and other purulent lesions of the hands,
face or nose until lesions are healed.
Screening. Collect one feces or vomitus specimen from each foodhandler with
gastrointestinal symptoms within 24 hours of onset. Specimens should be
obtained from any purulent lesions, using culturettes.
If fecal specimens from cases and samples of implicated foods are available,
nasal cultures of foodhandlers may be considered. This should be done
only after consultation with the Bureau of Communicable Disease Control
and the Microbiology Unit.
Management. Employees may return to work when no longer symptomatic. No followup
culturing is necessary. Proper personal hygiene should be stressed.
Campylobacter Enteritis
Transmission. Person-to-person transmission is possible but infrequent.
Exclusion. Exclude ill persons from handling food while symptomatic.
Screening. Collect one stool specimen from each foodhandler for case finding
purposes. Rectal swabs are not recommended.
Management. Employees may return to work when no longer symptomatic. Antibiotic
treatment is recommended to shorten the duration of excretion. No
followup culturing is necessary. Give instructions in good handwashing
after defecation and proper foodhandling procedures.
Salmonella
Transmission. May be transmitted from infected foodhandlers, with or without symptoms.
Exclusion. Exclude ill persons from handling food immediately. Exclude asymptomatic persons with
positive stool cultures immediately.
Screening. Collect two stool specimens, at least 24 hours apart, from each foodhandler
for screening. Rectal swabs are not recommended.
Management. If both cultures negative. No additional culturing is necessary. If symptomatic, continue
to exclude from foodhandling until symptoms resolve. Give instructions in good handwashing after
defecation and proper foodhandling procedures.
Culture positive (one or both). Continue to exclude from foodhandling until followup cultures indicate
worker is no longer infected. Antibiotic therapy is not usually recommended, as it may prolong the
period of excretion. After symptoms resolve, worker may be assigned to non-foodhandling duties. This
should be encouraged, since excretion may last up to several months.
Followup cultures should be done as follows: Wait one week after initial specimens. Take two stool
specimens, at least 24 hours apart. If both are negative, worker may return to foodhandling duties. If one
or both stools are positive, wait one week and take two more specimens, 24 hours apart. Repeat this
procedure weekly until both specimens are negative.
Give instructions in good handwashing after defecation and proper foodhandling procedures.
Shigella
Transmission. May be transmitted from infected foodhandlers, with or without symptoms.
Exclusion. Exclude ill persons from handling food immediately. Exclude asymptomatic persons with
positive stool cultures immediately.
Screening. Collect two stool specimens, at least 24 hours apart, from each foodhandler
for screening. Rectal swabs are not recommended.
Management. Both cultures negative. No additional culturing is necessary. If symptomatic, continue to
exclude from foodhandling until symptoms resolve. Give instructions in good handwashing after
defecation and proper foodhandling procedures.
Culture positive (one or both). Continue to exclude from foodhandling until followup cultures indicate
worker is no longer infected. Appropriate antibiotic treatment can shorten the duration of illness and of
positive cultures.
Followup cultures should be done as follows: if not treated with antibiotics, wait one week after initial
specimens. If treated with antibiotics, wait at least 48 hours after dose is taken. Take stool specimens, at
least 24 hours apart. If both are negative, worker may return to foodhandling duties. If one or both stools
are positive, wait one week and take two more specimens, 24 hours apart. Repeat this procedure weekly
until both specimens are negative.
Give instructions in good handwashing after defecation and proper foodhandling procedures.
Viral Gastroenteritis
Transmission. May be transmitted by infected foodhandlers.
Exclusion. Exclude ill persons from handling food immediately.
Screening. Collect one stool specimen from each symptomatic foodhandler for testing.
Management. Employees may return to work when no longer symptomatic. No followup
testing is necessary. Give instructions in good handwashing after defecation and proper foodhandling
procedures.
Pediculosis (Head Lice)
What is pediculosis?
Pediculosis is an infestation of the scalp and hair of the head with live larvae or adult head lice or
nits (eggs). The crawling stages of the insect feed upon human blood which results in severe
itching. Nits are very small round eggs that stick to the hair close to the scalp. Head lice can be
found anywhere on the scalp, especially behind the ears and just above the hairline along the
nape of the neck. Occasionally head lice may be found in the moustache, beard, eyelashes and
eyebrows.
Who gets pediculosis?
Anyone can become infested with head lice under suitable conditions of exposure regardless of
age, sex, race, or standards of personal hygiene. Head lice are most common in children. Head
lice infestations are found frequently in home, child care, school, or institutional settings.
How is pediculosis transmitted?
Head lice cannot jump or fly. Head-to-head contact or sharing of personal items (such as combs,
brushes, hats, scarves, jackets, sweaters, sheets, pillows, mattresses, sleeping bags, blankets,
bedding, car seats, or upholstered furniture) of a person with head lice may result in transmission
from one individual to another. Lice from animals do not infest humans. They may transfer to a
person for a short time but do not reproduce and do not require treatment.
What are the symptoms of pediculosis?
Usually, the first indication of an infestation is itching or scratching of the scalp where the lice
feed. Scratching at the back of the head or around the ears should lead to an examination for
head louse nits (eggs) on the hair. If scratching is sufficiently intense, a secondary bacterial
infect ion may result.
How soon do symptoms appear?
It may take as long as two to three weeks or longer for a person to notice the intense itching
associated with head lice infestation.
How long is a person able to spread lice?
Pediculosis can be spread as long as lice or nits remain alive on the infested person, clothing, or
furniture.
What is the treatment for pediculosis?
Only persons with live lice and/or viable nits require treatment. Medicated shampoos or cream
rinses with a pediculocide are used to kill head lice. Over-the-counter preparations, such as RID
or NIX, are effective. Follow the package directions when using these products. Products
containing lindane are available only through a physician’s prescription. Lindane is not
recommended for infants, young children, or pregnant or lactating women. If a lindane or
pyrethrin product is used, retreatment after seven to ten days is recommended to assure that no
eggs have survived. Nit combs or solutions to soften nit glue are available to help remove nits
from the hair. Nit removal with a nit comb is recommended to insure adequate treatment. Nit
removal can be the sole treatment (i.e., no medication) for infants under one year, pregnant or
nursing women, and those individuals with eyelash or eyebrow infestations.
What can be done to prevent the spread of pediculosis?
! Avoid head-to-head contact with infested individuals and their belongings (especially
headgear, combs and brushes, clothing, and bedding).
! Household members, close contacts, and playmates of infested individuals should be
examined and treated if live lice or nits are found.
! Infested persons in school and child care are to be excluded until they have been treated and
found to be free of nits.
! Thorough cleaning of household items is recommended including: vacuuming upholstered
furniture and carpets; machine wash washable clothing in hot (13F) water, and dry in hot
dryer for at least ten minutes (if clothes are clean, just place in hot dryer). Environmental
spraying is not recommended. Dry cleaning is effective for non-washable clothing and
pillows.
! Combs and hair brushes can be washed with a pediculocide shampoo or soaked in hot water
(13F).
! Where large scale infestations involve several families, the importance of coordination of
treatment and prevention efforts is important.
Plague
(bubonic plague, pneumonic plague)
What is plague?
Plague is a serious illness caused by bacteria called Yersinia pestis. The disease is carried by
rodents (i.e., rats and mice) and their fleas, which can then transmit the disease to humans as
well as to other animals. Plague is very rare in the United States, but cases are still reported
in the southwestern states of New Mexico, Arizona, Colorado, Nevada, and California.
Bubonic plague is the most common form and affects the body's lymph nodes. When the
infection involves the lungs, the disease is called pneumonic plague.
How do people get plague?
People can get plague from the bite of infected fleas or by a scratch or bite while handling
infected animals. You can also get it by breathing in airborne droplets from people who have
the plague infection in their lungs or from infected household pets.
What are the symptoms of plague?
The first symptoms of bubonic plague include the sudden onset of fever with painful swelling
of the lymph nodes, called buboes in the areas closest to the flea bite (typically, in the groin,
armpit, or neck). Chills, muscle-aches, weakness, fatigue, nausea, and headache may also
occur. If the infection spreads to the lungs, it produces pneumonia that is highly contagious
and often, fatal. Pneumonic plague is characterized by fever, swelling of the lymph nodes,
cough, chest pain, and frequently, blood in the saliva.
When do symptoms start?
The symptoms of plague begin 1 to 7 days following the bite of an infected flea.
What is the treatment for plague?
Antibiotics can be prescribed by a doctor to treat plague. It is extremely important to detect
and treat the disease early in its course. If left untreated, about half of those with bubonic
plague and 100% of those with pneumonic plague will die. Prompt antibiotic treatment and
supportive therapy can reduce the case-fatality rate. Persons who are infected with
pneumonic plague should be quarantined for 3 full days of medical therapy.
How can people avoid getting plague?
Avoid rat-infested areas, if possible. If you go to areas where plague is endemic (an ongoing
problem), take precautions to protect yourself against rodents and their fleas.
Avoid contact with sick or dead animals found on the roadside or in the woods. The risk of
being bitten by infected fleas is high when plague infection kills large numbers of rodents.
The infected and starving fleas aggressively look for new hosts.
Carefully supervise the activities of all children and household pets (i.e., dogs and cats) when
outdoors in forest/picnic areas where rodents make their nests.
International travelers to a plague-endemic area (areas reported to have an ongoing plague
problem) are generally at low risk for infection for Y. pestis. If you are travelling to a plague-endemic
area call your doctor or the local public health agency for advice.
Report all suspected plague cases promptly to the local public health agency.
Psittacosis
What is psittacosis?
Psittacosis is a bacterial disease also referred to as Parrot fever or Ornithosis. The symptoms
of the disease are variable and may include fever, rash, muscle aches, chills, and a dry cough.
It may produce pneumonia, which may not be apparent except on x-ray. The disease is
transferred from animals to man. Parrots, parakeets, love birds, macaws, and cockatiels are
frequently involved in the transmission of the disease to humans. All birds are susceptible to
the disease and outbreaks have occurred on poultry farms, in pet shops, and in processing
plants.
Who gets psittacosis?
Anyone can get psittacosis if they are exposed to infected birds. Occupations at highest risk
in the United States are bird breeders, poultry processing workers, farmers who raise poultry,
veterinarians, pet shop owners and their employees. Sporadic cases also occur in individual
households who have pet birds.
How do humans get psittacosis?
The infection is acquired by inhaling dried secretions, dusts from feathers, or dried droppings
from infected birds.
How would I know if my birds have psittacosis?
Birds may be harboring the bacteria without any apparent ill effects. When birds develop the
disease they become quiet, withdrawn, loose weight, and exhibit a pronounced change in
their feces or droppings. If you believe your pet birds or poultry may be infected, you should
contact your veterinarian who can arrange for the appropriate laboratory testing.
What are the symptoms of psittacosis?
Fever, muscle aches, chills, headache, and a dry cough. A rash may also be present.
How long is incubation period for psittacosis?
The incubation period is 1 to 4 weeks.
How is psittacosis diagnosed?
Since the disease is uncommon in the United States, the diagnosis usually requires laboratory
tests. Several different methods are available from commercial labs to aid the clinician in
diagnosing the disease. Exposure history is very important for the diagnosis.
What is the treatment for psittacosis?
Antibiotics such as tetracycline or erythromycin for 10 to 14 days are usually sufficient.
Can human to human transmission of psittacosis occur?
Yes, but it is unlikely because the cough is usually non-productive and the ill individual does
not expel the bacteria from their lungs.
What possible complications may arise from an untreated infection?
Encephalitis, meningitis, endocarditis, and neurological complications may occur. For the
elderly or immuno-compromised severe pneumonia or death may occur.
How can psittacosis be prevented?
The most important measures to control the disease are already in place in the United States.
The United State Department of Agriculture requires all imported birds go through a 45 day
quarantine period at which time they are given medicated feed to help rid them of the
bacteria. Ongoing programs of the state departments of agriculture provide for prevention of
the spread of the disease in domestic poultry.
Consumers should purchase all birds only from legitimate retailers. Most pet shops,
hatcheries, and retailers maintain records which aid in the traceback of the infection.
Rabies
What animals get rabies?
Rabies is a disease that can affect all mammals and each year over 7,000 animals, most of
them wild, are diagnosed as having the disease in the United States. The disease is found
in all states except Hawaii.
How do humans get exposed to rabies?
People become infected with rabies when the skin is broken by a bite or scratch from a
rabid animal or a mucosal surface (e.g.:eye, mouth) is contaminated with the salvia of a
rabid animal. Although rabies in humans is very rare in the United States, more than
22,000 people each year receive treatment to prevent disease from occurring due to an
exposure.
How do I know if an animal has rabies?
Signs and symptoms which should lead one to suspect an animal may be rabid include:
nervousness, aggressiveness, excessive drooling and foaming at the mouth, or abnormal/
change in behavior (e.g., wild animal losing their fear of people or animals normally
active at night being seen in the daytime).
Which animals have caused the most cases of rabies in humans?
Since 1980, 17 of 32 cases of human rabies in the United States have been associated
with bat-related virus variants. Noteworthy, only one of these patients had a definite bite
history. These cases and recent findings suggest that limited or insignificant physical
contact with rabid bats may cause rabies, even without a clear history of animal bite.
How can I prevent exposure to rabies?
Avoid contact with wild animals; especially bats, foxes, raccoons and skunks.
Make sure all of your pets are vaccinated against rabies. This includes cats and ferrets
as well as dogs. Rabies vaccination is often neglected for cats, nationwide more cats
than dogs were reported rabid during all, but two, of the past 16 years.
Avoid contact with stray animals and teach your children not to approach strange
dogs, cats, or any wild animal (raccoon, fox) that might bite them.
If you suspect that an animal has rabies, notify your local animal control division or
health department for instruction. Do not attempt to capture the animal yourself.
What do I do if I think I am exposed to rabies?
If you are bitten or scratched by any animal wash the wound thoroughly with soap and
water as soon as possible, and notify animal control or the health department. If you
come into contact with a bat (e.g., awake to find one in your room or see one near an
unattended child or mentally challenged or intoxicated person), contact a doctor
immediately. Again, notify animal control or the health department.
What treatment will I receive if I am exposed to rabies?
Prevention of rabies in man is by neutralization of the rabies virus in a bite wound;
administering rabies immune globulin and rabies vaccine. The rabies immune globulin is
one dose and is injected into muscles near the site of the bite. The vaccine is five doses
and is given in the deltoid muscle of adults and in the thigh and/or upper arm of children.
The vaccine should not be given in the gluteal area. The initial dose of the vaccine is
administered at the same time as the rabies immune globulin but in different anatomical
areas and then on days 3,7, 14 and 28 after the first vaccination.
Rocky Mountain Spotted Fever
What is Rocky Mountain Spotted Fever?
Rocky Mountain spotted fever is a serious, generalized infection that is usually spread to
people by the bite of infected ticks. The disease gets its name from the Rocky Mountain area
where it was first identified.
How do people get Rocky Mountain Spotted Fever?
People get Rocky Mountain spotted fever from the bite of an infected tick or by
contamination of skin with the contents of an attached tick when it is removed from the skin.
It is not spread from person to person, except rarely by blood transfusion.
What are the symptoms?
Sudden fever (which can last for 2 or 3 weeks), severe headache, tiredness, deep muscle pain,
chills, or nausea. In about half of the cases, a red, raised rash appears on the arms and legs,
particularly on the palms of the hands and soles of the feet, and then spreads to the trunk.
Rocky Mountain spotted fever can be fatal if not treated promptly.
How soon after exposure do symptoms appear?
The symptoms begin between 3 to 14 days after the tick bite.
What is the treatment?
It can be treated with antibiotics. Many people with the disease require hospitalization.
How should a tick be removed?
Ticks should be removed promptly and carefully by using tweezers and applying gentle
steady traction. Do not crush the tick’s body when removing it and apply the tweezers as
close to the skin as possible to avoid leaving tick mouth parts in the skin. Do not remove
ticks with your bare hands. Protect your hands with gloves, cloth, or tissue and be sure to
wash your hands after removing a tick.
After removing the tick, disinfect the skin with soap and water or other available
disinfectants.
How can Rocky Mountain Spotted Fever be prevented?
1. Avoid tick infested areas, especially during the warmer months.
2. Wear light colored clothing so ticks can be easily seen. Wear a long sleeved shirt, hat,
long pants, and tuck your pant legs into your socks.
3. Walk in the center of trails to avoid overhanging grass and brush.
4. Check your body every few hours for ticks when you spend a lot of time outdoors in tick
infested areas. Ticks are most often found on the thigh, arms, underarms, legs or where
tight fitting clothing has been. Ticks should be removed immediately.
5. Use insect repellents containing DEET on your skin or permethrin on clothing. Be sure
to follow the directions on the container and wash off repellents when going indoors.
Carefully read the manufacturer’s label on repellents before using on children.
Salmonellosis
What is salmonellosis?
Salmonellosis is a bacterial infection that usually affects the intestines and occasionally the
bloodstream. It is one of the more common causes of gastroenteritis with several hundred
cases occurring in Missouri each year. Most cases occur in the summer months.
Who gets salmonellosis?
Any person can get salmonellosis, but it is identified more often in infants and children.
How are Salmonella bacteria spread?
Salmonella bacteria are spread by direct contact with an infected person, by eating or drinking
contaminated food or water or by contact with contaminated object or animal.
What are the symptoms of salmonellosis?
People with salmonellosis may have diarrhea, cramping, fever, nausea, vomiting and headache.
Some people may have very mild or no symptoms but some infections can be quite serious,
especially in the very young or elderly.
How soon after exposure does symptoms appear?
The symptoms generally appear 12 to 36 hours after exposure but may take days.
Where are Salmonella bacteria found?
Salmonella bacteria are found in many places in our food chain and environment. The
bacteria often contaminate raw meats, eggs, and unpasteurized milk and cheese products.
Other sources may include reptiles, chicks and other fowl, dogs, cats, and farm animals.
For how long can an infected person carry Salmonella?
A person can carry the bacteria from several days to many months. Infants and people who
have been treated with oral antibiotics tend to carry the bacteria longer than others.
Should infected people be excluded from school or work?
People with diarrhea need to be excluded from day care, food service or any other group activity where
they may present a risk to others. Most infected people may return to work or school when their
diarrhea stops if they carefully wash their hands after using the restroom. Foodhandlers, children and
staff in day care settings, and health care workers must obtain the approval of the local or state health
department before returning to their routine activities.
treatment for salmonellosis?
Antibiotics for Salmonella are usually not recommended for uncomplicated cases. Most
people with salmonellosis will recover on their own. Some may require fluids to prevent
dehydration.
How can salmonellosis be prevented?
The single most important way to prevent the spread of disease is careful handwashing.
Wash hands thoroughly:
after use of restroom
before preparation of foods
after handling raw meat
after completion of food preparation
after handling animals, especially reptiles, or their feces.
Thoroughly cook all foodstuffs derived from animal sources.
Refrigerate foods promptly; don’t hold at room temperature any longer than necessary.
Wash cutting boards, utensils and food preparation counters with soap and water
immediately after use.
Make sure that the correct internal cooking temperature is reached. The correct
temperature is 160F for beef and pork, and 185F for poultry.
Prevent cross-contamination. Never let raw meat and poultry, or their juices, come in
contact with cooked meat or any other food, raw or cooked.
Scabies
What is scabies?
Scabies is a highly communicable disease caused by tiny human mites burrowing under the
skin to lay eggs. Scabies causes intense itching, and a red, generally raised skin rash. Itching
is most intense at night. The rash can start anywhere on the body (generally the face is
spared) and continues to spread over time until appropriately treated.
Who gets scabies?
Anyone can get scabies. Scabies affects all persons regardless of economic status, color of
skin, age, or standard of personal hygiene.
How is scabies spread?
Scabies are passed from one infested person to another most commonly through direct skin to
skin contact. Occasionally, scabies can be transferred from undergarments, bedclothes, or
bedding of an infested person.
What are the symptoms?
Itching and scratching, especially at night. The rash can look like many other skin problems,
(eczema, dermatitis, poison ivy or oak, even chickenpox). Sometimes secondary bacterial
infections occur as a result of the constant scratching that leads to bleeding and/or abraded
skin that allows entry of bacteria.
How soon do symptoms appear?
For persons getting scabies for the first time, itching and the rash can take up to eight (8)
weeks to appear. Normal range is 2-6 weeks.
For a person who gets reinfested with scabies, itching and rash will occur within one to four
days.
How long can a person spread scabies?
The scabies mite is transferred most commonly by skin-to-skin contact with an infested
person. Therefore, persons who are yet to show symptoms can transfer the mite prior to their
knowledge of having scabies. This is why outbreaks of scabies can occur within institutions
like long term care facilities.
How is scabies diagnosed?
Because the rash caused by scabies can look like many other types of rashes, diagnosis is
important and easily achieved by performing skin scrapings. A nurse, nurse practitioner, or
physician may perform this procedure. Once a person is found to have scabies, it is
important to check all household members and close contacts for rashes.
What is the treatment for scabies?
A medicated lotion or cream, known as a “scabicide”, which must be prescribed by a
physician, is required to effectively treat a person with scabies. This lotion or cream must
cover the entire surface of the skin (generally from the tips of the earlobes to the ends of
one’s toes). Second and sometimes a third application may be necessary to adequately treat a
person. Scabicides are pesticides and must be used with caution. Products containing topical
5 percent permethrin are considered safer than products containing lindane. Oils may
enhance the absorption of lindane. Therefore the simultaneous use of creams, ointments, and
body lotions must be avoided if a scabicide containing lindane is used.
When a family member is found to have a rash caused by scabies, all household members
should be treated at the same time. Laundering of bed linens, bedclothes, and clothing worn
in the past three days must occur prior to reuse by anyone.
Do I need to treat furniture, other household items?
Vacuuming of upholstered furniture, rugs and other unwashables in close contact with the
infested person is recommended. It is not necessary to clean walls or curtains.
For items that can not be washed, either dry clean or place in a plastic bag and seal for 10
days.
Following treatment will itching cease?
Itching may continue for two or more weeks following treatment. Scabicides are very drying
to the skin plus the body must absorb eggs and fecal pellets left by the scabies mites under
the skin. Application of skin lotions and bath oils aid in minimizing dry skin.
Shigellosis
What is shigellosis?
Shigellosis is a bacterial infection that affects the intestines. It is a fairly common disease.
Who gets shigellosis?
Anyone can get shigellosis but it is recognized more often in young children. Children in day
care centers, travelers to certain foreign countries, institutionalized people, and active
homosexuals are at greatest risk.
How are Shigella bacteria spread?
Shigella bacteria are found in the intestines and stool of infected people who, in turn, may
contaminate food or water. The bacteria are spread by direct contact with an infected person, by
eating or drinking contaminated food or water, or by contact with a contaminated object.
What are the symptoms?
People infected with the Shigella bacteria may have mild or severe diarrhea (often with traces of
blood or mucous), abdominal cramping, fever, nausea, and vomiting. Some infected people may
not show any symptoms.
How soon do symptoms appear?
The symptoms usually appear 1 to 3 days after exposure and usually last for 4 to 7 days.
When and for how long is a person able to spread shigellosis?
People with shigellosis may be able to spread the disease even after they are well. Most people
pass the Shigella bacteria in their stool for one to two weeks. Sometimes people continue to
pass the bacteria for as long as 6 weeks.
Should infected people be excluded from school or work?
People with diarrhea need to be excluded from day care, food service or any other group activity
where they may present a risk to others. Most infected people may return to work or school
when their diarrhea stops if they carefully wash their hands after using the restroom.
Foodhandlers, children and staff in day care settings, and health care workers must obtain the
approval of the local or state health department before returning to their routine activities.
How is shigellosis treated?
Most people with shigellosis will recover on their own. Some may require fluids to prevent
dehydration. Antibiotics are sometimes used to treat severe cases or to shorten the carrier phase.
This may to allow foodhandlers, health care workers, children and staff in day care settings, and
institutionalized individuals to return sooner to their routine activities.
What can be done to prevent the spread of shigellosis?
Since Shigella bacteria are passed in the stool, the single most important way to prevent the
Disease is careful handwashing after using the toilet, after diapering, and before preparing food.
Shigellosis
CDC'S
Frequently Asked Questions
What is shigellosis?
Shigellosis is an infectious disease caused by a group of bacteria called Shigella. Most who
are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two
after they are exposed to the bacterium. The diarrhea is often bloody. Shigellosis usually
resolves in 5 to 7 days. In some persons, especially young children and the elderly, the
diarrhea can be so severe that the patient needs to be hospitalized. A severe infection with
high fever may also be associated with seizures in children less than 2 years old. Some
persons who are infected may have no symptoms at all, but may still pass the Shigella
bacteria to others.
What sort of germ is Shigella?
The Shigella germ is actually a family of bacteria that can cause diarrhea in humans. They
are microscopic living creatures that pass from person to person. Shigella were discovered
over 100 years ago by a Japanese scientist named Shiga, for whom they are named. There are
several different kinds of Shigella bacteria: Shigella sonnei, also known as "Group D"
Shigella, accounts for over two-thirds of the shigellosis in the United States. A second type,
Shigella flexneri, or "group B" Shigella, accounts for almost all of the rest. Other types of
Shigella are rare in this country, though they continue to be important causes of disease in the
developing world. One type found in the developing world, Shigella dysenteriae type 1,
causes deadly epidemics there.
How can Shigella infections be diagnosed?
Many different kinds of diseases can cause diarrhea and bloody diarrhea, and the treatment
depends on which germ is causing the diarrhea. Determining that Shigella is the cause of the
illness depends on laboratory tests that identify Shigella in the stools of an infected person.
These tests are sometimes not performed unless the laboratory is instructed specifically to
look for the organism. The laboratory can also do special tests to tell which type of Shigella
the person has and which antibiotics, if any, would be best to treat it.
How can Shigella infections be treated?
Shigellosis can usually be treated with antibiotics. The antibiotics commonly used for
treatment are ampicillin, trimethoprim/sulfamethoxazole (also known as Bactrim* or
Septra*), nalidixic acid, or ciprofloxacin. Appropriate treatment kills the Shigella bacteria
that might be present in the patient's stools, and shortens the illness. Unfortunately, some
Shigella bacteria have become resistant to antibiotics and using antibiotics to treat shigellosis
can actually make the germs more resistant in the future. Persons with mild infections will
usually recover quickly without antibiotic treatment. Therefore, when many persons in a
community are affected by shigellosis, antibiotics are sometimes used selectively to treat
only the more severe cases. Antidiarrheal agents such as loperamide (Imodium*) or
diphenoxylate with atropine (Lomotil*) are likely to make the illness worse and should be
avoided.
Are there long term consequences to a Shigella infection?
Persons with diarrhea usually recover completely, although it may be several months before
their bowel habits are entirely normal. About 3% of persons who are infected with one type
of Shigella, Shigella flexneri, will later develop pains in their joints, irritation of the eyes, and
painful urination. This is called Reiter's syndrome. It can last for months or years, and can
lead to chronic arthritis which is difficult to treat. Reiter's syndrome is caused by a reaction to
Shigella infection that happens only in people who are genetically predisposed to it.
Once someone has had shigellosis, they are not likely to get infected with that specific type
again for at least several years. However, they can still get infected with other types of
Shigella.
How do people catch Shigella?
The Shigella bacteria pass from one infected person to the next. Shigella are present in the
diarrheal stools of infected persons while they are sick and for a week or two afterwards.
Most Shigella infections are the result of the bacterium passing from stools or soiled fingers
of one person to the mouth of another person. This happens when basic hygiene and
handwashing habits are inadequate. It is particularly likely to occur among toddlers who are
not fully toilet-trained. Family members and playmates of such children are at high risk of
becoming infected.
Shigella infections may be acquired from eating contaminated food. Contaminated food may
look and smell normal. Food may become contaminated by infected food handlers who
forget to wash their hands with soap after using the bathroom. Vegetables can become
contaminated if they are harvested from a field with sewage in it. Flies can breed in infected
feces and then contaminate food. Shigella infections can also be acquired by drinking or
swimming in contaminated water. Water may become contaminated if sewage runs into it, or
if someone with shigellosis swims in it.
What can a person do to prevent this illness?
There is no vaccine to prevent shigellosis. However, the spread of Shigella from an infected
person to other persons can be stopped by frequent and careful handwashing with soap.
Frequent and careful handwashing is important among all age groups. Frequent, supervised
handwashing of all children should be followed in day care centers and in homes with
children who are not completely toilet-trained (including children in diapers). When possible,
young children with a Shigella infection who are still in diapers should not be in contact with
uninfected children.
People who have shigellosis should not prepare food or pour water for others until they have
been shown to no longer be carrying the Shigella bacterium.
If a child in diapers has shigellosis, everyone who changes the child's diapers should be sure
the diapers are disposed of properly in a closed-lid garbage can, and should wash his or her
hands carefully with soap and warm water immediately after changing the diapers. After use,
the diaper changing area should be wiped down with a disinfectant such as household bleach,
Lysol* or bactericidal wipes.
Basic food safety precautions and regular drinking water treatment prevents shigellosis. At
swimming beaches, having enough bathrooms near the swimming area helps keep the water
from becoming contaminated.
Simple precautions taken while traveling to the developing world can prevent getting
shigellosis. Drink only treated or boiled water, and eat only cooked hot foods or fruits you
peel yourself. The same precautions prevent traveler's diarrhea in general.
How common is shigellosis?
Every year, about 18,000 cases of shigellosis are reported in the United States. Because many
milder cases are not diagnosed or reported, the actual number of infections may be twenty
times greater. Shigellosis is particularly common and causes recurrent problems in settings
where hygiene is poor and can sometimes sweep through entire communities. Shigellosis is
more common in summer than winter. Children, especially toddlers aged 2 to 4, are the most
likely to get shigellosis. Many cases are related to the spread of illness in child-care settings,
and many more are the result of the spread of the illness in families with small children.
In the developing world, shigellosis is far more common and is present in most communities
most of the time.
What else can be done to prevent shigellosis?
It is important for the public health department to know about cases of shigellosis. It is
important for clinical laboratories to send isolates of Shigella to the City, County or State
Public Health Laboratory so the specific type can be determined and compared to other
Shigella. If many cases occur at the same time, it may mean that a restaurant, food or water
supply has a problem which needs correction by the public health department. If a number of
cases occur in a day-care center, the public health department may need to coordinate efforts
to improve handwashing among the staff, children, and their families. When a community-wide
outbreak occurs, a community-wide approach to promote handwashing and basic
hygiene among children can stop the outbreak. Improvements in hygiene for vegetables and
fruit picking and packing may prevent shigellosis caused by contaminated produce.
Some prevention steps occur everyday, without you thinking about it. Making municipal
water supplies safe and treating sewage are highly effective prevention measures that have
been in place for many years.
What is the government doing about shigellosis?
The Centers for Disease Control and Prevention (CDC) monitors the frequency of Shigella
infections in the country, and assists local and State health departments to investigate
outbreaks, determine means of transmission and devise control measures. CDC also conducts
research to better understand how to identify and treat shigellosis. The Food and Drug
Administration inspects imported foods, and promotes better food preparation techniques in
restaurants and food processing plants. The Environmental Protection Agency regulates and
monitors the safety of our drinking water supplies. The government has also maintained
active research into the development of a Shigella vaccine.
Streptococcus Pneumococcal Disease
Pneumonia, meningitis
What is pneumococcal disease?
Pneumococcal disease is a severe bacterial infection caused by Streptococcus pneumoniae also
called pneumococcus. It may cause pneumonia, meningitis or a blood stream infection
(bacteremia).
Penicillin-resistant and multidrug-resistant strains have begun to emerge in the United States and
are widespread in some communities.
Who gets pneumococcal disease?
Although anyone can get pneumococcal disease, it tends to occur in the elderly or in people with
serious underlying medical conditions such as chronic lung, heart or kidney disease. Others at
risk include alcoholics, diabetics, people with weakened immune systems and those without a
spleen.
How is the disease transmitted?
The pneumococcus is spread by airborne or direct exposure to respiratory droplets from a person
who is infected or carrying the bacteria.
When does pneumococcal disease occur?
Infections occur most often during the winter and early spring and less frequently during the
summer.
What are the symptoms?
Symptoms may include fever, chills, headache, cough, chest pain, disorientation, shortness of
breath and occasionally stiff neck.
How is pneumococcal disease diagnosed?
Doctors are able to diagnose pneumococcal disease based on the type of symptoms exhibited by
the patient and specific laboratory cultures of sputum, blood or spinal fluid. Sensitivity studies
on the organism can determine drug resistance.
How is it treated?
Prompt treatment with antibiotics is usually effective. However, drug resistant strains of
pneumococcus have occasionally been reported and require different antibiotics than normally
used.
Is there a vaccine to prevent infection?
Yes. A reasonably effective vaccine has been available for a number of years. Patients in high-risk
categories should ask their health care provider about pneumococcal vaccine.
Streptococcal group A (GAS) Disease
What is group A streptococcus (GAS)?
Group A streptococci are bacteria often found in the throat and on the skin. People may carry group
A streptococci in the throat or on the skin and have no symptoms of disease. The vast majority of
GAS infections are relatively mild illnesses, such as strep throat and impetigo. On rare occasions,
these bacteria can cause much more severe and even life-threatening diseases such as necrotizing
fasciitis or streptococcal toxic shock syndrome (STSS).
How are group A streptococci spread?
These bacteria are spread through direct contact with mucus from the nose or throat of persons who
are infected or through contact with infected wounds or sores on the skin. Ill persons, such as those
who have strep throat or skin infections, are most likely to spread the infection. Persons who carry
the bacteria but have no symptoms are much less contagious. Treating an infected person with an
antibiotic for 24 hours or longer generally eliminates their ability to spread the bacteria. However, it
is important to complete the entire course of antibiotics as prescribed. It is not likely that household
items like plates, cups, or toys spread these bacteria.
What kind of illnesses are caused by group A streptococcal infection?
Infection with GAS can result in a range of symptoms:
No illness
Mild illness (strep throat or a skin infection such as impetigo)
Severe illness (necrotizing faciitis, streptococcal toxic shock syndrome)
Severe, sometimes life-threatening, GAS disease may occur when bacteria get into parts of the body
where bacteria usually are not found, such as the blood, muscle, or the lungs. These infections are
termed "invasive GAS disease." Two of the most severe, but least common, forms of invasive GAS
disease are necrotizing fasciitis and STSS. Necrotizing fasciitis (occasionally described by the media
as "the flesh-eating bacteria") destroys muscles, fat, and skin tissue. STSS causes blood pressure to
drop rapidly and organs (e.g., kidney, liver, lungs) to fail. STSS is not the same as the "toxic shock
syndrome" frequently associated with tampon usage. About 20% of patients with necrotizing
fasciitis and more than half with STSS die. About 10%-15% of patients with other forms of invasive
group A streptococcal disease die.
How common is invasive group A streptococcal disease?
About 10,000 cases of invasive GAS disease occurred in the United States in 1998. Of these, about
600 were STSS and 800 were necrotizing fasciitis. In contrast, there are several million cases of
strep throat and impetigo each year. In 1998 there were 18 cases of invasive GAS disease reported
in Missouri.
Why does invasive group A streptococcal disease occur?
Invasive GAS infections occur when the bacteria get past the defenses of the person who is infected.
This may occur when a person has sores or other breaks in the skin that allow the bacteria to get
into the tissue, or when the person’s ability to fight off the infection is decreased because of chronic
illness or an illness that affects the immune system. Also, some virulent strains of GAS are more
likely to cause severe disease than others.
Who is most at risk of invasive group A streptococcal disease?
Few people who come in contact with a virulent strain of GAS will develop invasive GAS disease;
most will have a routine throat or skin infection and some may have no symptoms whatsoever.
Although healthy people can get invasive GAS disease, people with chronic illnesses like cancer,
and diabetes, people receiving kidney dialysis, and those who use medications such as steroids, are
at higher risk. In addition, breaks in the skin, like cuts, surgical wounds or chickenpox may provide
an opportunity for the bacteria to enter the body.
What are the early signs and symptoms of necrotizing fasciitis and streptococcal
toxic shock syndrome?
Early signs and symptoms of necrotizing
fasciitis:
Fever
Severe pain and swelling
Redness at a wound site
Early signs and symptoms of STSS:
Fever
Dizziness
Confusion
A flat red rash over large areas of the body
How is invasive group A streptococcal disease treated?
GAS infections can be treated with many different antibiotics. Early treatment may reduce the risk of
death from invasive group A streptococcal disease. However, even the best medical care does not
prevent death in every case. For those with very severe illness, supportive care in an intensive care
unit may be needed. For persons with necrotizing fasciitis, surgery often is needed to remove
damaged tissue.
What can be done to help prevent group A streptococcal infections?
The spread of all types of GAS infection can be reduced by good hand washing, especially after
coughing and sneezing and before preparing foods or eating. Persons with sore throats should be
seen by a doctor who can perform tests to find out whether the illness is strep throat. If the test
result shows strep throat, the person should stay home from work, school, or child care until 24
hours after taking an antibiotic. All wounds should be kept clean and watched for possible signs of
infection such as redness, swelling, drainage, and pain at the wound site. A person with signs of an
infected wound, especially if fever occurs, should seek medical care. It is not necessary for all
persons exposed to someone with an invasive group A strep infection (i.e. necrotizing fasciitis or
strep toxic shock syndrome) to receive antibiotic therapy to prevent infection. However, in certain
circumstances, antibiotic therapy may be appropriate. That decision should be made after consulting
with your doctor.
Toxic Shock Syndrome
What is toxic shock syndrome?
Toxic shock syndrome is a severe illness characterized by a sudden onset of high fever,
vomiting, profuse watery diarrhea, and muscle aches. It is typically followed by hypotension
(low blood pressure) and, in severe cases, shock.
There are two types of toxic shock syndrome. This fact sheet describes that type caused by
Staphylococcus aureus. The other kind of toxic shock syndrome is caused by group A
streptococcal bacteria and it is described on the Streptococcal Toxic Shock Syndrome fact sheet.
Who gets toxic shock syndrome?
Toxic shock syndrome occurs in some people who have Staphylococcus aureus infections. While
almost anyone could develop toxic shock syndrome, women who use vaginal tampons,
contraceptive diaphragms or vaginal contraceptive sponges, and women who have recently given
birth or had an abortion are at the greatest risk. Men and women who have an infection with S.
aureus are also known to be at risk for developing toxic shock syndrome.
How is toxic shock syndrome spread?
Toxic shock syndrome is not spread from one person to another.
What are the symptoms of toxic shock syndrome?
People who have toxic shock syndrome will have:
A sudden onset of high fever. A "sunburn-like" rash (diffuse macular erythroderma) Peeling of
the skin on the palms and soles of the feet 1 to 2 weeks after the onset of illness Hypotension
(low blood pressure) Involvement of three or more of the following organ systems:
gastrointestinal, muscular, mucous membranes, renal (related to the kidneys), hepatic (related to
the liver), hematologic (related to the blood), and central nervous system
For an illness to be called toxic shock syndrome, there must also be no other bacteria or virus
identified as a more likely cause of the illness. Toxic shock syndrome is probable when at least
four of the five major criteria are fulfilled. Patients who die before peeling of the skin would
have occurred but whose illness is otherwise compatible are considered definite cases.
How soon after exposure do symptoms appear?
For most people with toxic shock syndrome, the time when they are first exposed to
Staphylococcus aureus is unknown. However, for people with toxic shock syndrome that is
associated with an infected wound or surgical contamination, the time from exposure to their
onset of symptoms is two days.
How is toxic shock syndrome diagnosed?
A physician is needed to properly diagnose toxic shock syndrome.
What is the treatment for toxic shock syndrome?
People with toxic shock syndrome are treated for any symptoms or complications they may have.
Any cause of infection (i.e., wound or foreign body) should be removed as quickly as possible.
Doctors will also prescribe antibiotics to treat the infection.
How can toxic shock syndrome be prevented?
Women who are using vaginal tampons, contraceptive diaphragms or vaginal contraceptive
sponges need to read and follow the manufacturer's instructions as far as how long to leave the
products in place. Women who are menstruating and develop a high fever with vomiting and
diarrhea need to discontinue any vaginal tampon use immediately and contact their health care
provider.
Where can I get more information?
Your personal doctor.
Your local health department listed in your telephone directory.
Trichinosis (Trichinellosis)
What is trichinosis?
Trichinosis, also called trichinellosis (TRICK-a-NELL-o-sis), is caused by eating raw or
undercooked pork and wild game products infected with the larvae.
What are the symptoms of a trichinosis infection?
During the first week after ingesting infected meat, the patient may experience nausea, diarrhea,
vomiting, fatigue, fever, and abdominal discomfort. Two to 8 weeks later the following
symptoms may be observed: headaches, fevers, chills, cough, eye swelling, aching joints and
muscle pains, itchy skin, diarrhea, or constipation.
For mild to moderate infections, most symptoms subside within a few months. Often, mild cases
of trichinosis are never specifically diagnosed and are assumed to be the flu or other common
illnesses. In severe infections, patients may experience difficulty coordinating movements, and
have heart and breathing problems. Fatigue,weakness, and diarrhea may last for months. In
severe cases, death can occur.
Am I at risk for trichinosis?
If you eat raw or undercooked meats, particularly pork, bear, wild feline (such as a cougar), fox,
dog, wolf, horse, seal, or walrus, you are at risk for trichinosis. Wild animals are major reservoir
of trichinosis in the United States. The feral (wild) hog population in Missouri may be infected
with trichinosis.
Can I spread trichinosis to others?
No. Infection can only occur by eating raw or undercooked meat containing Trichinella larvae.
What should I do if I think I have trichinosis?
See your health care provider who can order tests and treat symptoms of trichinosis infection.
A blood test or muscle biopsy can show if you have trichinosis. Several safe and effective
prescription drugs are available to treat trichinosis,. Treatment should begin as soon as possible
Is trichinosis common in the United States?
Infection was once very common; however, infection is now relatively rare. From 1982-1986, an
annual average of 57 cases per year were reported in the United States. Cases are now less
commonly associated with pork products and more often associated with eating raw or
undercooked wild game meats.
How can I prevent trichinosis?
1. Cook meat and wild game products to an internal temperature of 160 degrees Fahrenheit.
2. Freeze pork at –13 degrees Fahrenheit for 20 days.
3. Freezing wild game meats even for long periods of time may not effectively kill all larvae.
4. Cook all meat fed to pigs or other animals.
5. Clean meat grinders thoroughly between species if you prepare ground meats.
6. Curing (salting), drying, smoking, or microwaving meat does not consistently kill infective
larvae.
Tularemia
What is tularemia?
Tularemia is a bacterial disease (Francisella tularensis) that infects both man and animals.
Alt hough many wild and domestic animals have been infected, the rabbit is most often
involved in disease outbreaks.
Who gets tularemia?
People who spend a great deal of time out-of-doors are at greater risk of exposure to
tularemia than people with other occupational or recreational interests. People who come
into contact with flesh or blood of infected animals, such as those in a high-risk occupations:
laboratory worker, farmer, veterinarian, sheep worker, hunter, trapper, meat handler, cook, or
spouse or other household member of a hunter.
How is tularemia spread?
Many routes of human exposure to the tularemia bacteria are known to exist.
Common means of spread are:
! contact of the skin or mucous membranes with blood or tissue while handling, dressing,
or skinning infected animals
! contact with meat from an infected animals
! contact with fluids from infected ticks or biting flies
! the bite from an infected tick or biting fly
! handling or eating insufficiently cooked rabbit meat (rabbit meat can remain infective
even after being frozen for several years)
Less common means of spread are:
! drinking contaminated water
! inhaling dust from contaminated soil
! handling contaminated paws or pelts of animals
Tularemia is not spread from person-to-person.
What are the symptoms of tularemia?
The symptoms of tularemia depend on whether the bacteria enter through the skin,
gastrointestinal tract, or lungs. Tularemia is usually recognized by the presence of an
ulcerative skin lesion and swollen glands. Ingestion of the organism may produce a throat
infection, abdominal pain, diarrhea, and vomiting. Inhalation of the organism may produce a
fever alone or combined with a pneumonia-like illness.
How soon do symptoms appear?
Symptoms generally appear within 1 to 21 days, but usually within 3 to 5 days.
What is the treatment for tularemia?
Certain antibiotics are effective in treating tularemia, such as streptomycin, gentamicin, or
tobramycin.
Does past infection make a person immune?
Long-term immunity will follow recovery from tularemia. However, reinfection has been
reported, particularly in laboratory workers.
How can the spread of tularemia be prevented?
1. Rubber gloves should be worn when skinning or handling animals, especially rabbits.
2. Wild rabbit, muskrat, and squirrel meat should be cooked thoroughly before eating.
3. Avoid drinking, swimming, or working in untreated water where infection may prevail
among wild animals.
4. Avoid bites of flies and ticks.
5. Avoid tick infested areas, especially during the warmer months.
6. Wear light colored clothing so ticks can be easily seen. Wear a long sleeved shirt, hat,
long pants, and tuck your pant legs into your socks.
7. Walk in the center of trails to avoid overhanging grass and brush.
8. Check your body every few hours for ticks when you spend a lot of time outdoors in tick
infested areas. Ticks are most often found on the thigh, arms, underarms, legs or where
tight fitting clothing has been.
9. Use insect repellents containing DEET on your skin or permethrin (Permanone) on your
clothing. Be sure to follow the directions on the container and wash off repellents when
going indoors. Carefully read the manufacturer’s label on repellents before using on
children.
10. Remove attached ticks immediately.
11. Ticks should be removed promptly and carefully by using tweezers and applying gentle
steady traction. Do not crush the tick’s body when removing it and apply the tweezers as
close to the skin as possible to avoid leaving tick mouth parts in the skin. Do not remove
ticks with your bare hands. Protect your hands with gloves, cloth, or tissue and be sure to
wash your hands after removing a tick.
12. After removing the tick, disinfect the skin with soap and water or other available
disinfectants.
13. Universal precautions pertaining to protection from drainage/secretions from infected
individuals should be followed.
What is the treatment for tularemia?
Certain antibiotics are effective in treating tularemia, such as streptomycin, gentamicin, or
tobramycin.
Does past infection make a person immune?
Long-term immunity will follow recovery from tularemia. However, reinfection has been
reported, particularly in laboratory workers.
How can the spread of tularemia be prevented?
1. Rubber gloves should be worn when skinning or handling animals, especially rabbits.
2. Wild rabbit, muskrat, and squirrel meat should be cooked thoroughly before eating.
3. Avoid drinking, swimming, or working in untreated water where infection may prevail
among wild animals.
4. Avoid bites of flies and ticks.
5. Avoid tick infested areas, especially during the warmer months.
6. Wear light colored clothing so ticks can be easily seen. Wear a long sleeved shirt, hat,
long pants, and tuck your pant legs into your socks.
7. Walk in the center of trails to avoid overhanging grass and brush.
8. Check your body every few hours for ticks when you spend a lot of time outdoors in tick
infested areas. Ticks are most often found on the thigh, arms, underarms, legs or where
tight fitting clothing has been.
9. Use insect repellents containing DEET on your skin or permethrin (Permanone) on your
clothing. Be sure to follow the directions on the container and wash off repellents when
going indoors. Carefully read the manufacturer’s label on repellents before using on
children.
10. Remove attached ticks immediately.
11. Ticks should be removed promptly and carefully by using tweezers and applying gentle
steady traction. Do not crush the tick’s body when removing it and apply the tweezers as
close to the skin as possible to avoid leaving tick mouth parts in the skin. Do not remove
ticks with your bare hands. Protect your hands with gloves, cloth, or tissue and be sure to
wash your hands after removing a tick.
12. After removing the tick, disinfect the skin with soap and water or other available
disinfectants.
13. Universal precautions pertaining to protection from drainage/secretions from infected
individuals should be followed.
Typhoid Fever (Salmonella typhi)
What is typhoid fever?
Typhoid fever is an infection of the intestinal tract and occasionally the bloodstream
caused by the bacteria, Salmonella typhi. It is an uncommon disease with less than 10
cases occurring in Missouri each year. Most of the cases in Missouri are acquired during
foreign travel to underdeveloped countries. Outbreaks are rare.
Who gets typhoid fever?
Anyone can get typhoid fever but the greatest risk exists to travelers visiting countries
where the disease is common. Occasionally, local cases can be traced to exposure to a
person who is a chronic carrier.
How is typhoid fever spread?
Typhoid germs are passed in the feces and, to some extent, the urine of infected people.
The germs are spread by eating or drinking water or foods contaminated by feces from
the infected individual.
What are the symptoms of typhoid fever?
Symptoms may be mild or severe and may include fever, headache, constipation or
diarrhea, rose-colored spots on the trunk and an enlarged spleen and liver. Relapses are
common. Fatalities are less than 1 percent with antibiotic treatment.
How soon do symptoms appear?
Symptoms generally appear one to three weeks after exposure.
For how long can an infected person carry the typhoid germ?
The carrier stage varies from a number of days to years. Only about 3 percent of cases go
on to become lifelong carriers of the germ and this tends to occur more often in adults
than in children.
How is typhoid fever treated?
Specific antibiotics such as chloramphenicol, ampicillin or ciprofloxacin are often used to
treat cases of typhoid.
Should infected people be isolated?
Because the germ is passed in the feces of infected people, only people with active
diarrhea who are unable to control their bowel habits (infants, certain handicapped
individuals) should be isolated. Most infected people may return to work or school when
they have recovered, provided that they carefully wash hands after toilet visits. Children
in day care and other sensitive settings must obtain the approval of the local or state
health department before returning to their routine activities. Food handlers may not
return to work until three consecutive negative stool cultures are obtained.
Is there a vaccine for typhoid?
A vaccine is available but is generally reserved for people traveling to underdeveloped
countries where significant exposure may occur. Strict attention to food and water
precautions while traveling to such countries is the most effective preventive method.
Yellow Fever
(Jungle Yellow Fever, Urban Yellow Fever)
What is yellow fever?
Yellow fever is an acute infectious disease caused by a virus. It is spread by the female
mosquito, Aedes aegypti. The disease occurs in tropical and subtropical areas of the world.
Yellow fever is not present in the United States.
Who gets yellow fever?
All people who live in or visit areas where yellow fever is present are at risk, unless they have
been properly vaccinated or had the disease.
How is yellow fever spread?
Aedes mosquitoes transmit yellow fever from person to person, and sometimes from monkeys
and other animals to humans.
What are the symptoms of yellow fever?
Symptoms of yellow fever range from mild to severe, and death occurs in about 5% of cases.
Initial symptoms may include fever, chills, headache, back pain, general muscle aches, nausea,
and vomiting. Jaundice (yellowing of the eyes and skin) usually develops and may progress
during the disease. Hemorrhaging (nosebleeds, gum bleeding, blood in vomitus and stool),
kidney, and/or liver failure can occur in severe cases.
How soon after infection does symptoms appear?
Symptoms generally appear 3 to 6 days after exposure.
Does past infection make a person immune?
Yes. People who have had yellow fever develop lifelong immunity.
How is yellow fever diagnosed?
Yellow fever is diagnosed by isolating the virus from blood, or a positive antibody test.
What is the treatment for yellow fever?
There is no specific treatment for yellow fever.
How can yellow fever be prevented?
Since transmission of yellow fever no longer occurs in the United States, it is important for
travelers to be immunized before visiting areas where yellow fever exists.
Yersiniosis
What is yersiniosis?
Yersiniosis is an acute infection of the intestinal tract caused by either of two bacteria, Yersinia
enterocolitica or Yersinia pseudotuberculosis. In Missouri, from 1994 to 1998, there was an
average of 25 cases of yersiniosis each year.
Who gets yersiniosis?
Anyone can get yersiniosis, however, most cases caused by Yersinia enterocolitis occur in
infants and young children, while Yersinia pseudotuberculosis mostly affects persons aged 5 to
20 years.
How is yersiniosis spread?
Yersiniosis is spread by contaminated food or water, or from infected people or animals. Raw
pork and pork products, especially pork intestines, i.e., chitterlings, are often contaminated.
Where are the Yersinia bacteria found?
Animals are the main source of Yersinia. Wastes from animals may contaminate water, milk, and
foods and become a source of infection for people or other animals. The bacteria has been found
in cold cuts, pork chitterlings, raw milk, ice cream, improperly processed milk, tofu, shellfish,
lakes and streams, and both wild and domestic animals.
What are the symptoms of yersiniosis?
People infected with Yersinia bacteria may have diarrhea, with fever and abdominal discomfort.
Children may have bloody diarrhea, and adults commonly experience joint pain. Persons five
years of age and older may have symptoms that mimic appendicitis.
How soon after infection do symptoms appear?
Symptoms usually appear within 3 to 7 days after exposure.
How is yersiniosis diagnosed?
Yersiniosis is diagnosed by identifying the Yersinia bacteria in the blood or stool (feces).
How is yersiniosis treated?
Yersiniosis may be treated with antibiotics. Consult your physician for treatment. Yersinia is
generally resistant to penicillin.
Should infected people be excluded from school or work?
People with diarrhea need to be excluded from day care, food service or any other group activity
where they may present a risk to others. Most infected people may return to work or school
when their diarrhea stops if they carefully wash their hands after using the restroom.
Foodhandlers, children and staff in day care settings, and health care workers must obtain the
approval of the local or state health department before returning to their routine activities.
How can yersiniosis be prevented?
The single most important way to prevent the spread of disease is careful handwashing.
Wash hands thoroughly:
after use of restroom
before preparation of foods
after handling raw meat
after completion of food preparation
after handling animals or their feces
Thoroughly cook all foodstuffs derived from animal sources.
Avoid using raw milk.
Refrigerate foods promptly; don’t hold at room temperature any longer than necessary.
Wash cutting boards, utensils and food preparation counters with soap and water
immediately after use.
Make sure that the correct internal cooking temperature is reached. The correct temperature
is 160º F for beef and pork, and 185F for poultry.
Prevent cross-contamination. Never let raw meat or their juices, especially pork or pork
products, come in contact with cooked meat or any other food, raw or cooked.
The Missouri Department Of Health Disclaimer
In clinical practice, certain circumstances and individual cases require professional judgment
beyond the scope of this manual. Practitioners and users of this manual should not limit their
judgment on the management and control of communicable disease to this publication and are
well advised to review the references contained in each bibliography and remain informed of
new developments and resulting changes in recommendations on communicable disease
prevention and control.