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DIRECT CONTACT, RESPIRATORY ROUTES, AND
THROUGH THE PROVISION OF HEALTHCARE
List of Section Contents
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Bacterial Conjunctivitis
Clostridium Difficile
Creutzfeldt-Jakob Disease (Classical)
Creutzfeldt-Jakob Disease (New Variant)
Fifth Disease (Human Parvovirus Infection)
Group A Streptococcus – Invasive
Group A Streptococcus – Non-Invasive
Group B Streptococcal Disease of the Newborn
Hand / Foot / Mouth Disease (Coxsackie virus)
Impetigo
Influenza
Legionellosis
Menigococcal Disease – Invasive
MRSA / VRE
Pediculosis (Lice)
Pneumococcal Disease-Invasive
Scabies
Viral Meningitis
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within the District
Health Authorities. This manual is constantly under revision. Public Health staff will be informed of the changes as
they occur. However, information contained on this site may not contain the latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this information
by any other groups or organizations aside from Public Health staff within the District Health Authorities.
BACTERIAL CONJUNCTIVITIS (PINK EYE)
1. Information
1.1 Case definition
Clinical findings including purulent exudate, lacrimation and irritation of the
palpebral and bulbar conjunctiva of one or both eyes.
1.2 Causative agent
Haemophilus influenzae (H. influenzae) and Streptococcus pneumonia (S
pneumoniae) are the most important. Staphylococci, streptococci and
Pseudomonas aeuginosa (P. aeruginosa) may cause disease in newborns.
1.3 Symptoms
Puffiness of the eyelid, irritation under the eyelid, “bloodshot” eyes, often there
may be a mucopurulent yellowish discharge and a crusting of this discharge
overnight. Some individuals may experience photophobia. Viral and bacterial
cannot be differentiated based on symptoms.
1.4 Incubation
24-72 hours.
1.5 Source
Humans.
1.6 Transmission
Contact with upper respiratory tract discharges of infected persons, especially
those with symptoms of conjunctivitis. Contamination by hands and fingers or by
sharing articles such as make-up applicators is also possible.
1.7 Communicability
During the period of active infection.
1.8 Treatment
Local application of antibiotic drops or ointment containing a sulphonamide,
gentamicin or combination antibiotics such as polymyxin B with neomycin or
trimethoprim.
1.9 Core Messages for Prevention
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Wash hands frequently in the presence of any active upper respiratory
disease.
Avoid sharing of any articles that are used near or on the eyes, such as
make-up etc.
Launder articles of clothing, washcloths and bed linen of anyone who is
infected.
Prompt treatment of infected eye to prevent transmission to other eye
or other sites.
Children should be excluded for 24 hours after antibiotic treatment has
been initiated.
Avoid hand to eye contact.
1.10 Prophylaxis
None.
2. Procedure
No public health follow-up required. This is not a notifiable disease.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
CONJUNCTIVITIS FACT SHEET
What is Conjunctivitis?
Conjunctivitis or pink eye is an infection of the lining of eyelid caused by a virus or
bacterium.
Who Can Get Conjunctivitis?
Children are most likely to get pink eye but adults can get it too. The viruses or bacteria
are found in the discharge from the infected eye. Hands become contaminated by
touching\rubbing the infected eye or coming in contact with the drainage from the eye.
What are the Symptoms?
Symptoms include:
• Redness of the whites of the eye(s) and inside the eyelids.
• Itchiness and tearing.
• Scratchy feeling or pain in the eye.
• Discharge at the corners of the eye, which may crust over during sleep
causing the eyelids to stick together.
What is the Treatment?
Most cases are caused by a virus, and will get better without treatment. Some cases are
caused by bacteria, and can be treated with eye drops or ointment prescribed by your
doctor. If there is pus or discharge from the eye(s), see your doctor.
If a child has pink eye caused by bacteria (yellow or white discharge or doctor diagnoses)
and is using an antibiotic ointment, the child should stay out of school or day care until
24 hours after the treatment was started. If a child has pink eye caused by a virus, the
child does not have to stay home from school.
How Can You Prevent Conjunctivitis?
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Wash hands often, especially before and after treatment.
Separate the hand and face towels of the infected person from all others
in the house.
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Do not share personal articles used near or on the eyes such as make-up
applicators.
Wash in hot water all clothing and personal articles (e.g. pillow cases) of
the infected person.
Teach children good hand washing practices.
Avoid hand to eye contact.
CLOSTRIDIUM DIFFICILE
MARCH 2012
1.0 Information
1.1 Case Definition
Confirmed Case:
A patient is defined as a case if they are one year of age or older
AND have one of the following requirements:
A laboratory confirmation of a positive toxin assay for C. difficile
OR
A diagnosis of pseudomembranes on sigmoidoscopy or colonoscopy or
histological/pathological diagnosis of C. difficile
OR
A diagnosis of toxic megacolon
1.2 Causative Agent
Clostridium difficile (C. difficile) is a spore-forming, obligate anaerobic, grampositive bacillus. Disease is related to the action of toxin(s) produced by these
organisms. Although other toxins exist, toxins A and B have been associated
most strongly with human disease.
1.3 Symptoms
Symptoms associated with C. difficile range from:
watery diarrhea
fever
loss of appetite
nausea
abdominal pain/tenderness.
Pseudomembranous colitis generally is characterized by diarrhea, abdominal
cramps, fever, systemic toxicity and abdominal tenderness.
1.4 Diagnostic Testing
The laboratory diagnosis of C. difficile can be accomplished by a variety of testing
methods which include:
Detection of toxins by enzyme-linked immunoassays (EIAs)
Cytotoxicity assay using tissue culture
Nucleic acid amplification techniques
Bacterial culture to isolate the organism with subsequent testing of the
ability of the isolate to produce toxin
Histological examination of the colon.
Specimen Required: Stool - Only liquid specimens, “taking the shape of the
container”, should be processed in a dry sterile container and transported at 4:C.
C. difficile toxin is unstable and may become undetectable within a few hours if a
stool specimen is left at room temperature. Formed specimens and “test of
cure” specimens should not be sent or processed. Currently, in Nova Scotia, all
Regional Hospitals perform EIA for toxin. The cytotoxicity test is performed at
Capital District Health Authority and some Regional hospitals use antigen testing
and refer specimens for further testing if toxin negative but antigen positive.
The approach to testing is evolving quickly, and changes can be anticipated over
the next few years.
1.5 Treatment
Discontinue all current antibiotic therapy as soon as possible if significant
diarrhea or colitis develops. Drugs that decrease intestinal motility should not
be administered. Antimicrobial therapy for C. difficile disease is indicated for
patients whose diarrhea persists after antimicrobial therapy is discontinued.
Strains of C. difficile are susceptible to metronidazole and vancomycin.
Treatment recommendations for at least 10 days are as follows:
Metronidazole (30 mg/kg per day in 4 divided doses, max 2 g/day) is
the drug of choice for the initial treatment of most children and
adolescents with colitis.
Oral vancomycin (40 mg/kg per day, orally, in 4 divided doses, to a
maximum of 125 mg, orally, 4 times/day) for initial therapy for
patients with severe disease (hospitalized in an intensive care unit,
pseudomembranous colitis on endoscopy, underlying intestinal tract
disease).
1.6 Incubation Period
The incubation period is unknown. However; the onset of clinical disease is
typically 5-10 days after initiation of antimicrobial treatment.
1.7 Source
The reservoir is mainly humans; however, spores are also present in soil and
water. The source of C. difficile may be endogeneous (colonized patient flora) or
exogeneous, such as hospital environment and equipment that have been
contaminated with stool (commodes, bedrails, and bedpans).
1.8 Transmission
The transmission of C. difficile occurs through fecal-oral transmission, direct
contact or indirect contact transmission from hands or items contaminated with
stool from symptomatic and/or asymptomatic (colonized) patients.
1.9 Communicability
The period of communicability is not well defined because asymptomatic
patients may be colonized with the bacteria and patients who have been
successfully treated may still have organisms and spores in their stools.
C. difficile spores can survive up to 60 days (and sometimes longer) in the
environment.
1.10 Core Messages for Prevention
A collaborative approach to communication starts with the timely identification
of C. difficile.
Exercising meticulous hand hygiene with soap and water.
Alcohol-based hygiene products do not inactivate C. difficile spores
Proper waste handling (including diapers).
Cleaning and disinfecting of surfaces contaminated with vomitus and
feces.
Limiting the use of antimicrobial and proton pump inhibitor agents.
Thorough cleaning and disinfecting of hospital rooms and bathrooms of
patients with C. difficile.
2.0 Public Health Management and Control Measures
2.1 Case Management
Individual cases of C. difficile are not followed by Public Health.
** For additional information and procedures related to C. difficile in Long Term
Care Facilities and Community settings, refer to “Guidelines-Partners for
Infection Control“ available in all district Public Health Offices and at:
http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infection_Control_Guidelines
.pdf
2.1.1 Case Follow-up
There will be no Public Health follow-up unless there is an outbreak.
2.2 Contact Tracing
Not available at this time.
2.3 Outbreak Management
Refer to Chapter 2 on Outbreak Management of the CD manual.
2.4 Guidelines
2.4.1 Guidelines for Institutions/Long Term Care Facilities
The CDPC nurse is typically the lead in investigations of communicable disease
outbreaks. Upon request of the CDPC lead/MOH, a Public Health Inspector with
the Department of Agriculture may complete an on-site inspection of the facility
to ensure compliance with outbreak management directives.
For Outbreak Management, routine practices should be used with all clients at
all times:
Contact precautions for the case(s)
Conduct a risk assessment considering the potential for:
o Exposure to body fluids (i.e. active vomiting, explosive diarrhea)
o Exposure to large deposits of body fluids (vomitus, feces) on
environmental surfaces
o Resident’s continence level and ability to comply with instructions
Care givers should wear the following Personal Protective Equipment when
giving direct care to symptomatic residents/clients:
o Gloves - for providing any direct care
o Gowns - when contamination of HCPs clothing is possible
o Surgical mask with eye protection/face shield to protect mucus
membranes from exposure to viral particles when assisting someone who
is actively vomiting, has explosive uncontained diarrhea or when cleaning
an area grossly contaminated with vomitus or feces.
Hand washing with soap and water is the most effective hand hygiene
practice. Alcohol-based hand sanitizers are less effective in destroying C.
difficile spores.
Resident/Client Placement:
o Contact Precautions – residents/clients should be confined to their rooms
as much as possible until asymptomatic for 48 hours.
o Contact precautions may be discontinued when the patient has had at
least 48 hours without symptoms of diarrhea (e.g. formed or normal
stool for the individual).
o In a shared room, a resident/client with symptoms should not share a
toilet with a well resident/client. Assign a dedicated toilet or commode, if
possible.
o In shared rooms, roommates and all visitors must be aware of the
precautions.
o Whenever possible, dedicate equipment to be used only on the ill
resident/client. In the event that equipment must be shared, thorough
cleaning and disinfection is required in between residents.
Ill health care workers and food handlers should not work, if they develop
symptoms consistent with a GI infection (e.g. vomiting, diarrhea) while at
work the employee should be required to leave work immediately.
Staff should remain off work when experiencing diarrhea, unless there is a
known underlying non-infectious cause.
Exclude ill staff from work until 48 hours after symptoms have stopped (e.g.
formed or normal stool for the individual).
Limitation and restriction of visitors may be necessary in an outbreak
situation. Visitors and volunteers should be advised that they may be at risk
of acquiring an infection within the facility, instructed how to wear
appropriate PPE and required to use hand hygiene before and after their
visit. Visitors should visit only their own friend/relative in their own room,
unless otherwise approved by the Heath care provider.
Effective cleaning of the environment around clients/patients/residents who
have C. difficile is essential in limiting the acquisition and spread of C.
difficile.
Contact the Department of Agriculture as necessary. Food Safety Specialists
(FSS) may visit the facility to ensure all precautions are being adhered to
when cases are found in the facility and they can provide environmental
sanitation advice and resources.
The Infection Prevention and Control Centre at Department of Health and
Wellness can provide advice on environmental sanitation in patient care
areas.
Please refer to “Guidelines-Partners for Infection Control“ at:
http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infection_Control_Guidelines
.pdf.
2.4.2 Guidelines for Childcare Centres
Children and ill staff with C. difficile diarrhea should be excluded from child
care settings for the duration of diarrhea, and infection control measures
should be enforced.
Contact the Department of Agriculture as necessary. Food Safety Specialists
(FSS) are able to provide advice and resources regarding environmental
sanitation.
Please refer to the “Guidelines for Communicable Disease Control for Childcare
Programs and Home Day Care Agencies”, November 2008
http://www.gov.ns.ca/hpp/publications/Childcare-Manual-November-2008.pdf
3.0 Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.na.ca/hpp/cdpc/CDCManual.
4.0 Communication Plan
Develop as needed
5.0 References
Control of Communicable Disease Manual, 19th Edition. 2008. David Heymann, editor.
American Public Health Association.
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases
under National Surveillance. CCDR 2009;3552,1-123. Retrieved from http://www.phacaspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Red Book. Report of the Committee on Infectious Diseases, 28 th Edition. 2009. American
Academy of Pediatrics.
Testing, Surveillance and Management of Clostridium Difficile (May 2010). Retrieved
from:
http://www.oahpp.ca/resources/documents/pidac/RPAP%20Annex%20C%20Testing%2
0Surveillance%20Management%20of%20C%20diff.pdf
Viswanathan, V.K., Mallozzi, M.J. & Vedantam, G. (2010). Clostridium difficile Infection:
An overview of the disease and its pathogenesis, epidemiology and interventions. Gut
Microbes, 1(4), 234-242
6.0 Appendices
A. Clostridium Difficile Fact Sheet - English
B. Clostridium Difficile Fact Sheet - French
CLOSTRIDIUM DIFFICILE FACT SHEET
What is Clostridium Difficile?
Clostridium difficile (C. difficile) is a kind of bacteria. It causes:
mild to severe diarrhea
more serious intestinal conditions like inflammation
(pseudomembranous colitis).
of
the
colon
C. difficile is normally found in soil and other natural environments. It can also live in
our own gut or bowel.
C. difficile is the most common cause of infectious diarrhea in Canadian hospitals and
long-term care facilities.
Who can get C. difficile?
Any patient receiving antibiotics is at risk for C. difficile. Here’s why: Many different
kinds of bacteria live in our gut and bowel. Most of these are “good” bacteria—that is,
they help us to stay healthy. Antibiotics can change the mix of bacteria in the bowel and
may decrease the amount of good bacteria. This allows C. difficile to take over. When
this happens, the C. difficile bacteria produce toxins that can irritate the bowel and
cause diarrhea.
The elderly, people who have other illnesses, and people who are already taking
antibiotics are at a greater risk of infection.
Healthy people do not usually get C. difficile infections.
What are the Symptoms?
Symptoms include:
watery diarrhea
fever
loss of appetite
nausea
abdominal pain/tenderness.
It is possible to be infected with C. difficile and not show any symptoms.
How is it spread?
C. difficile is most often spread through direct contact—for example with infected hands
or gloves. Shared items such as contaminated thermometers or commodes may also
spread it.
How is it treated?
People with mild symptoms may not need any treatment at all.
For more severe cases, a healthcare provider will prescribe medication (like antibiotics)
to be taken for 10 days. The drugs used to treat C. difficile are effective and have few
side effects.
How can you prevent C. difficile infection?
Hand washing with soap and water is the most effective way of preventing the spread of
infections like C. difficile. Alcohol-based hand sanitizers are less effective than washing
with soap and water because they do not destroy all of the C. difficile.
C. difficile can also be limited by:
Careful use of antibiotics
Strictly following infection prevention and control measures in hospitals, longterm care facilities and other healthcare facilities.
FICHE D’INFORMATION SUR CLOSTRIDIUM
DIFFICILE
Qu'est que Clostridium difficile?
Clostridium difficile, communément appelé C. difficile, est une bactérie. Il cause :
une diarrhée qui peut être de légère à grave,
des conditions intestinales plus graves comme une inflammation du colon (colite
pseudo-membraneuse).
C. difficile est présent dans le sol et d’autres environnements naturels. Il peut aussi vivre
dans nos intestins.
C’est la cause la plus commune de la diarrhée infectieuse dans les hôpitaux et les
établissements de soins de longue durée au Canada.
Qui peut être infecté par C. difficile?
Tout patient qui prend des antibiotiques court le risque d'une infection au C. difficile.
Voici pourquoi. De nombreux types de bactéries vivent dans nos intestins. La plupart de
ces bactéries sont de bonnes bactéries qui nous aident à rester en santé. Les
antibiotiques peuvent modifier la variété de bactéries présentes dans les intestins et
réduire le nombre de bonnes bactéries. Cela permet au C. difficile de prendre le dessus.
Quand cela arrive, C. difficile produit des toxines qui peuvent irriter les intestins et
causer la diarrhée.
Les personnes âgées, celles qui souffrent d’autres maladies et les personnes qui
prennent des antibiotiques courent un plus grand risque d’infection.
En général, les personnes en santé ne font pas d’infection au C. difficile.
Quels sont les symptômes?
Les symptômes sont :
une diarrhée aqueuse
de la fièvre
la perte de l'appétit
des nausées
une sensibilité ou des douleurs abdominales.
Il est possible d’être infecté par C. difficile et de n’avoir aucun symptôme.
Comment C. difficile se propage-t-il?
C. difficile se propage le plus souvent par contact direct, par exemple avec des mains ou
des gants souillés. Il se propage aussi par l’utilisation d’objets contaminés comme des
thermomètres ou des chaises d’aisance.
Comment traite-t-on C. difficile?
Les personnes qui montrent des symptômes légers pourraient ne pas avoir besoin de
traitement.
Pour les cas plus graves, un fournisseur de soins de santé prescrira un médicament
(p. ex. des antibiotiques) à prendre pendant dix jours. Les médicaments pour traiter
C. difficile sont efficaces et ont peu d’effets secondaires.
Comment prévenir une infection au C. difficile?
La façon la plus efficace de prévenir la propagation des infections comme celle au
C. difficile est de se laver les mains avec de l’eau et du savon. Les désinfectants pour les
mains à base d'alcool sont moins efficaces que le lavage des mains à l’eau et au savon
parce qu'ils ne détruisent pas toutes les bactéries C. difficile.
Voici d’autres façons de limiter la propagation de C. difficile :
une utilisation prudente des antibiotiques
une adhésion stricte aux mesures de prévention et de contrôle des infections
dans les hôpitaux, les établissements de soins de longue durée et les autres
établissements de soins de santé.
CREUTZFELDT-JAKOB DISEASE (CJD), CLASSIC
APRIL 2006
1. Information
This section describes the three etiologic subtypes of classic Creutzfeldt-Jakob disease
(CJD) (sporadic CJD, iatrogenic CJD and genetic prion diseases)
1.1 Case definition
Creutzfeldt - Jakob disease, Classic
Sporadic Creutzfeldt-Jakob Disease (sCJD)
Confirmed case:
Neuropathologically and/or immunocytochemically and/or biochemically
confirmed, through observation of one or more neuropathologic features (see
List 1) and no evidence of iatrogenic CJD or genetic human prion disease
(described below)
Probable case:
Routine investigation should not suggest an alternative diagnosis:
Rapidly progressive dementia + at least two features of list I + II (see List 2)
OR
Possible CJD + cerebrospinal fluid positive for 14-3-3 by immunoblot + duration <
2 years
Possible case:
Rapidly progressive dementia + two of list I (see List 2) plus duration < 2 years
plus no electroencephalography (EEG) or atypical EE
List 1:
I.
Spongiform encephalopathy in cerebral and/or cerebellar cortex and/or
subcortical grey matter
II.
Encephalopathy with prion protein (PrP) immunoreactivity in plaque-like
and/or diffuse synaptic and/or patchy/perivacuolar patterns, by
examination of tissue either directly or with assistance of capillary
III.
IV.
List 2:
I
A.
B.
C.
D.
II
transfer from paraffin-embedded tissue (PET) to secondary support (PET
blot)
Presence of scrapie-associated fibrils (SAF) by electron microscopy
Presence of protease-resistant PrP by Western blot
Myoclonus
Visual disturbances or cerebellar dysfunction (ataxia)
Pyramidal or extrapyramidal features
Akinetic mutism
Typical EEG pattern: period sharp-wave complexes ca. 1HZ
Iatrogenic Creutzfeldt –Jakob Disease (iCJD)
Confirmed Case:
Definite iCJD:
Definite CJD (see List 1) with a recognized risk factor for iatrogenic transmission
(see List 3)
Probable Case:
Progressive predominant cerebellar syndrome in a recipient of cadaverically
derived human pituitary growth hormone
OR
Probable CJD with a recognized risk factor for iatrogenic transmission (see List 3)
List 3:
Note: Assessment of the relevance of any proposed risk factor to disease
causation should take into account the timing of the putative exposure in
relation to disease onset, especially where the putative exposure is recent. As
well, this list is provisional, as the risks of iatrogenic transmission of prion disease
by other routes are currently incompletely understood.
I.
Treatment with human cadaveric pituitary growth hormone, human
pituitary gonadotrophin or human dura mater graft
II.
III.
Corneal graft in which the corneal donor has been classified as having a
definite or probable prion disease
Neurosurgical exposure to instruments previously used on a patient
classified as having definite or probable prion disease
Genetic Prion Diseases
Confirmed Case:
Definite Genetic Human Prion Disease:
Definite (pathologically confirmed) prion disease + definite or probable prion
disease in a first-degree relative
OR
Definite prion disease + pathogenic mutation in prion protein gene (PRNP) (see
List 4)
OR
Typical neuropathologic phenotype of Gerstmann-Sträussler-Scheinker disease
(GSS)*
*Presence of multicentric PrP-immunoreactive plaques in cerebral and/or
cerebellar cortex, with neuron loss and spongiosis. Other large amorphic plaques
or neurofibrillary tangles immunoreactive for PrP have been described in subsets
of GSS, but these are associated with less frequent PRNP mutations (A117V and
F198S). Florid or Kuru plaques are not considered diagnostic for GSS.
Probable Case:
Progressive neuropsychiatric disorder + definite or probable prion disease in a
first degree relative
OR
Progressive neuropsychiatric disorder + pathogenic mutation in PRNP (see List 4)
List 4:
I.
PRNP mutations associated with a neuropathologic phenotype of CJD
(see sCJD List 1): P105T, G114V, R148H, D178N, V180I, V180I+M232R,
T183A, T188A, T193I, E196K, E200K, V203I, R208H, V210I, E211Q,
M232R; octapeptide repeat insertions (various lengths) and deletion (48
bp)
II.
PRNP mutations associated with a neuropathologic phenotype of GSS
(see previous footnote above): P102L, P105L, A117V, G131V, A133V,
III.
IV.
Y145Stop, H187R, F198S, D202N, Q212P, Q217R, M232T; octapeptide
repeat insertions (various lengths)
PRNP mutations associated with a neuropathologic phenotype of Familial
Fatal Insomnia (FFI): D178N
PRNP mutations associated with other neuropathologic phenotypes:
I138M, G142S, Q160Stop, T188K, T188R, P238S, M232R; octapeptide
repeat insertions (various lengths)
1.2 Causative agent
Thought to be a unique, self-replicating protein called a prion that replicates by a
poorly understood mechanism
1.3 Symptoms
Classic CJD has an insidious onset, symptoms include: confusion, poor
concentration, lethargy, progressive dementia, intermittent unsteadiness when
standing or walking, and variable ataxia. As the disease progresses, mental
impairment becomes more severe and cases may develop involuntary muscle
jerks (myoclonus), lose the ability to move or speak, and eventually enter a
comatose state. Death invariably occurs within three to twelve months.
Approximately 80% of patients with sporadic CJD are between 50 and 70 years of
age, although familial cases usually have an onset of around 40 years of age.
1.4 Incubation
Fifteen months to possibly more than 30 years
1.5 Source
Humans
1.6 Transmission
The mode of transmission in most cases in unknown. CJD may either occur
sporadically (approximately 90% of cases), through iatrogenic transmission of
infective agents (<1% of cases) or as an autosomal dominant inheritence
(approximately 10% of cases). Potential sources of iatrogenic transmission
include any medical or surgical procedures involving tissues with “high
infectivity” such as the brain, spinal cord, and eyes.
1.7 Communicability
Central nervous system (CNS) tissues are infectious throughout symptomatic
illness. Other tissues and cerebral spinal fluids (CSF) are sometimes infectious.
1.8 Treatment
There is no known effective treatment available to cure or control CJD and the
disease appears to be uniformly fatal. Current treatment is therefore aimed at
controlling symptoms and making the person as comfortable as possible.
1.9 Core messages for prevention
In health care settings, great care must be taken to follow infection
control guidelines for CJD
Any persons who spent six or more cumulative months between January
1, 1980 and December 31, 1996 in the United Kingdom should not donate
blood, organs or other body tissues or fluids
1.10 Prophylaxis
None
1.11 Surveillance
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
2. Procedures
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health (MOH)
a. Determine investigative responsibility.
The MOH must ensure that all reports of CJD (including those classified as
possible, probable and confirmed) are received within the appropriate
timeframe (i.e. 3 to 5 days) and disseminated to the appropriate personnel for
investigation. In the absence of the MOH, the communicable disease control
manager may assume this role.
2.1.2 Investigator
Upon receiving the case report, the investigator should initiate the following:
a. Determine the case status as per the case definition (see Section 1.1).
b. Discuss the case with the MOH.
c. Initial follow-up procedures include:
Contact and interview the client or an immediate family member
Obtain the client’s medical history including symptoms, date of onset,
treatment, surgical procedures of concern, and/or hospitalization and
any potential sources of exposure, particularly a history of any receipt or
donation of blood, blood products, cells, tissues or organs
If necessary, contact the client’s physician to obtain further information
and clarification of the client’s history, especially with respect to past
surgical procedures and blood/tissue/organ receipt and/or donation
If the client has a history of receipt or donation of blood, cells, tissues or
organs, inform the MOH immediately and fax the “CJD Case Report
Form” to the OCMOH so that appropriate lookback and traceback
procedures may be initiated immediately
If client has a history of surgical procedures of concern when
symptomatic, inform infection control program in hospital where
procedure occurred
Discuss the role of PHS and provide information to the client or family
(i.e., fact sheets) Complete the “CJD/vCJD Case Report Form” and update
as new information becomes available
If client is deceased, ensure that attending physician has notified the
funeral director of CJD diagnosis so appropriate infection control
precautions can be taken (refer to, Infection Control Guidance for
Handling of Human Remains of Individuals with Communicable Diseases,
currently in draft form).
2.1.3 Physician
Report all cases of CJD (possible, probable and confirmed) by telephone
to the MOH as soon as suspected
Provide the public health investigator with the available information as
requested
2.1.4 Laboratory
Report all positive laboratory results to the MOH by telephone and fax
2.1.5 Canadian Blood Services (CBS)
Work with PHS, the Provincial Blood Program and hospital blood banks on
‘lookback’ and ‘traceback’ procedures for CJD
2.1.6 Provincial Blood Program
Work with PHS, CBS and hospital blood banks on CJD related blood safety
2.1.7. Regional Tissue Bank and Multi-Organ Transplant Program
Work with PHS on CJD related issues on a case-by-case basis
See Figure 1: Flow chart for public health follow-up of CJD
3. Lookbacks & Tracebacks
3.1. Nova Scotia Lookback/Traceback Protocols for CJD
If case has ever received or donated blood or blood products, follow the general
“Lookback and/or Traceback Protocols” located in the “Blood Borne Pathogens”
section of the Nova Scotia Communicable Disease Manual.
4. Follow-up of Organ/Tissue Donors who Test Positive
for CJD
4.1 Follow up of Organ/Tissue Donors
If case has received or donated cells, tissue or organs, work with the Regional
Tissue Bank and the Multi-Organ Transplant Program on a case-by-case basis to
ensure appropriate follow-up.
CLASSIC CREUTZFELDT-JAKOB DISEASE FACT
SHEET
DECEMBER 2006
What is Classic Creutzfeldt-Jakob Disease?
Classic Creutzfeldt-Jakob disease (CJD) is a rare and fatal disease that causes rapid and
progressive damage to the brain and nervous system.
Who can get Classic Creutzfeldt-Jakob Disease?
Classic CJD is extremely rare, affecting on average only one person per million each year
worldwide. Approximately 30 Canadians will be diagnosed with CJD each year; of these,
only 1-2 cases will occur in Nova Scotia. The majority of persons with classic CJD are
between 50 to 70 years of age.
Classic CJD should not be confused with variant CJD which is believed to be transmitted
to humans through the consumption of beef products contaminated with bovine
spongiform encephalopathy (BSE or ‘mad cow disease’).
What are the symptoms?
Early symptoms of classic CJD include confusion, difficulty concentrating, tiredness and
lack of coordination. As the disease progresses, individuals with classic CJD will develop
loss of muscle control, difficulty speaking and may enter a comatose state.
What is the treatment?
There is no known effective treatment for classic CJD. Current treatment is therefore
aimed at controlling symptoms and making the person as comfortable as possible.
How can you prevent Classic Creutzfeldt-Jakob Disease?
Classic CJD cannot be spread from person-to-person and the risk to the general
population is extremely low.
VARIANT CREUTZFELDT-JAKOB DISEASE (VCJD)
APRIL 2006
1.
Information
1.1 Case definition
Confirmed case:
Definite vCJD:
IA (see List 5) and neuropathologic confirmation as per pathologic features (see
footnote a, List 5)
Probable case:
I + four or five criteria of II + IIIA + IIIB (see List 5)
OR
I + IVA (see List 5)
Possible CJD:
I + four or five criteria of II + IIIA (see List 5)
List 5:
I
A.
B.
C.
D.
E.
Progressive neuropsychiatric disorder
Duration > 6 months
Routine investigations do not suggest alternative diagnosis
No history of potential iatrogenic exposure
No evidence of genetic prion disease
II
A.
B.
C.
D.
E.
Early psychiatric symptoms b
Persistent painful sensory symptoms c
Ataxia
Myoclonus or chorea or dystonia
Dementia
III
A. EEG does not show typical appearance of sporadic CJD d (or no EEG
performed) in the early stages of the illness
B. Bilateral pulvinar high signal on MRI scan e
IV
A – Tonsil biopsy positive for prion protein immunoreactivity f
A. Spongiform change, extensive PrP deposition, florid plaques throughout
the cerebrum & cerebellum
B. Depression, anxiety, apathy, withdrawal, delusions
C. Frank pain and/or dysaesthesia
D. Generalized triphasic period complexes at ca. 1 Hz. Rarely, these may
occur in the late stages of vCJD
E. Relative to the signal intensity of other deep grey matter nuclei & cortical
grey matter
F. Tonsil biopsy is not recommended routinely or in cases with EEG
appearance typical of sporadic CJD, but may be useful in suspect cases in
which the clinical features are compatible with vCJD and MRI does not
show bilateral pulvinar high signal
1.2 Causative agent
Thought to be a unique, self-replicating protein called a prion that replicates by
a poorly understood mechanism
1.3 Symptoms
Persons with vCJD usually experience psychiatric symptoms, early in illness,
which most commonly take the form of depression, or a “schizophrenic-like”
psychosis. As the illness progresses, neurological signs include: unsteadiness,
difficulty walking and involuntary muscle movements.
Variant CJD typically affects younger patients (average 28 years) and has a
relatively long duration of illness – 14 months compared to 4.5 months for
classic CJD.
1.4 Incubation
Fifteen months to possibly more than 30 years
1.5 Source
Humans. Variant CJD is believed to be associated with a disease in cattle called
bovine spongiform encephalopathy (BSE), more commonly known as ‘mad cow
disease’.
1.6 Transmission
Although there is strong evidence that the agent responsible for human cases of
vCJD is the same agent responsible for BSE in cattle, the specific foods that may
be associated with the transmission of this agent from cattle to humans are
unknown.
1.7 Communicability
Central nervous system (CNS) tissues are infectious throughout symptomatic
illness. Other tissues and cerebral spinal fluid (CSF) are sometimes infectious.
1.8 Treatment
There is no known effective treatment available to cure or control vCJD and the
disease appears to be uniformly fatal. Current treatment is therefore aimed at
controlling symptoms and making the person as comfortable as possible.
1.9 Core messages for prevention
In health care settings, great care must be taken to follow infection
control guidelines for vCJD.
Person who spent 6 or more cumulative months between January 1, 1980
and December 31, 1996 in the United Kingdom should not donate blood,
organs, or other body tissues or fluids.
1.10 Prophylaxis
None
1.11 Surveillance
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
2. Procedures
2.1 Roles and responsibilities
2.1.1 Medical Officer of Health (MOH)
a. Determine investigative responsibility
The MOH must ensure that all reports of vCJD (including those classified as
possible, probable and confirmed) are received within the appropriate
timeframe (i.e. 3 to 5 days) and disseminated to the appropriate personnel for
investigation. In the absence of the MOH, the communicable disease control
manager may assume this role.
2.1.2 Investigator
Upon receiving the case report, the investigator should initiate the following:
a. Determine the case status as per the case definition (see Section 1.1).
b. Discuss the case with the MOH.
Note, DHW Surveillance Team should be informed immediately of all reports
that meet the case definitions for possible, probable and/or confirmed vCJD.
c. Initial follow-up procedures include:
Contact and interview the client or an immediate family member
Obtain the client’s medical history including symptoms, date of onset,
treatment, surgical procedures of concern, and/or hospitalization and
any potential sources of exposure, particularly a history of any receipt or
donation of blood, blood products, cells, tissues or organs
If necessary, contact the client’s physician to obtain further information
and clarification of the client’s history, especially with respect to past
surgical procedures and blood/tissue/organ receipt and/or donation
If the client has a history of receipt or donation of blood, cells, tissues or
organs, inform the MOH immediately and fax the “CJD Case Report
Form” to the OCMOH so that appropriate ‘lookback’ and ‘traceback’
procedures may be initiated immediately
If client has a history of surgical procedures of concern when
symptomatic, inform infection control program in hospital where
procedure occurred
Discuss the role of PHS and provide information to the individual or
family (i.e., fact sheets)
Complete the “CJD/vCJD Case Report Form” and update as new
information becomes available
If client is deceased, ensure that attending physician has notified the
funeral director of vCJD diagnosis so appropriate infection control
precautions can be taken (see Infection Control Guidance for Handling of
Human Remains of Individuals with Communicable Diseases – currently in
draft form)
2.1.3 Physician
Report all cases of vCJD (possible, probable and confirmed) by telephone
to the MOH as soon as suspected
Provide the public health investigator with the available information as
requested on the “CJD/vCJD Case Report Form”
2.1.4 Laboratory
Report all positive laboratory results to the MOH by telephone and fax
2.1.5 Canadian Blood Services (CBS)
Work with PHS, the Provincial Blood Program and hospital blood banks
on ‘traceback’ and ‘lookback’ procedures for vCJD
2.1.6 Provincial Blood Program
Work with PHS, CBS and hospital blood banks on vCJD related blood
safety issues
2.1.7 Regional Tissue Bank and Multi-Organ Transplant Program
Work with PHS on vCJD related issues on a case-by-case basis
3. Lookbacks and Tracebacks
3.1 Nova Scotia Lookback / Traceback Protocols for vCJD
If case has received or donated blood or blood products, follow the general
“Lookback and/or Traceback Protocols” located in the “Blood Borne Pathogens”
section of the Nova Scotia Communicable Disease Manual.
4. Follow-up of Cell / Tissue / Organ Donors with vCJD
4.1 Follow-up
If case has received or donated cells, tissue or organs, work with the Regional
Tissue Bank and the Multi-Organ Transplant Program on a case-by-case basis to
ensure appropriate follow-up.
VARIANT CREUTZFELDT-JAKOB DISEASE FACT
SHEET
DECEMBER 2006
What is variant Creutzfeldt-Jakob Disease?
Variant Creutzfeldt-Jakob disease (vCJD) is a rare and fatal disease that causes rapid and
progressive damage to the brain and nervous system. It was first identified in the United
Kingdom in the early 1990s and has since been linked to the consumption of beef
products that have been contaminated with bovine spongiform encephalopathy (or
‘mad cow disease’).
Who can get Variant Creutzfeldt-Jakob Disease?
Variant CJD is extremely rare with less than 200 cases having been reported worldwide.
Compared to the classic form of CJD, variant CJD typically affects younger patients with
the average age being less than 30 years.
What are the symptoms?
Persons with vCJD usually experience psychiatric symptoms such as depression or a
‘schizophrenic-like’ psychosis early in the illness. As the disease progresses, neurological
symptoms include unsteadiness, difficulty walking and involuntary muscle movements.
What is the treatment?
There is no known effective treatment for variant CJD. Current treatment is therefore
aimed at controlling symptoms and making the person as comfortable as possible.
How can you prevent Variant Creutzfeldt-Jakob Disease?
Since 1996, strict measures have been put in place in the United Kingdom and other
European countries to control the spread of BSE (i.e., mad cow disease) among cattle. In
addition, Canada has banned the importation of beef and beef products from countries
that are not designated as being free of BSE.
Persons who have spent six months or more in the United Kingdom between 1980 and
1996 should not donate blood, organs or other body tissues or fluids.
FIFTH DISEASE (HUMAN PARVOVIRUS
INFECTION)
1. Information
1.1 Case definition
Compatible clinical illness and laboratory evidence of infection.
1.2 Causative agent
Human parvovirus B19, a member of the Parvoviridae family.
1.3 Symptoms
Children are most susceptible. Most often manifested as erythematous
eruption, characterized by a distinctive red rash on the face, with a “slapped
cheek” appearance. This rash may be followed in a few days by a spidery like
rash on the trunk and on the arms and legs that fades but may recur for 1-3
weeks on exposure to sunlight. Mild systemic symptoms may also precede this
rash. Arthralgia and arthritis may occur in adults, especially women. 25% of
infections are asymptomatic.
1.4 Incubation
Usually 14 days, can be from 4-20 days to development of rash
1.5 Source
Humans
1.6 Tranmission
Contact with respiratory secretations and parenterally through blood and blood
products. Congenital transmission is possible.
1.7 Communicability
For those with rash alone, communicability is limited to the time just before the
onset of the rash. For those individuals who are immunosuppressed with
chronic infection and severe anemia, the period of communicability could be as
long as months or years.
1.8 Treatment
Supportive therapy for most cases. For chronic
immunosuppressed individual, IG therapy is effective.
infection
in
an
1.9 Core Messages for Prevention
Routine attention to good hygienic practices such as frequent and
thorough hand washing can help control the spread of the disease.
Individuals with underlying anemias, immunodeficiencies and non
immune
pregnant women may choose to avoid exposure to potentially infectious
people in hospitals or outbreak situations.
1.10 Prophylaxis
None. Exposed pregnant women should be offered B19 IgG and IgM antibody
testing to determine susceptibility and to assist with pregnancy counseling
regarding risks to fetus.
2. Procedure
No public health follow-up required. This disease is not notifiable.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association. Report of the Committee on Infectious Diseases, 2000. American
Academy of Pediatrics.
FIFTH DISEASE (HUMAN PARVOVIRUS
INFECTION) FACT SHEET
What is Fifth Disease?
Fifth disease is a mild illness, caused by a virus. The disease is spread by droplets or
discharge from the nose and throat of an infected person (coughing or sneezing).
Children with fifth disease may be infectious from 4-14 days before the onset of a rash.
Who Can Get Fifth Disease?
It usually affects school age children. Many people get fifth disease before they reach
adulthood and are then protected for life. In children and most adults the disease does
not cause problems. Pregnant women may be in danger of miscarriage or stillbirth if
they get fifth disease in the first half of their pregnancy.
What are the Symptoms?
Symptoms usually occur within 1-2 weeks after a person has been in contact with
someone with the disease.
Symptoms may include:
Red patchy rash on the face, looks like a “slapped cheek”.
Lace-like rash, which may become more noticeable after a bath or
physical exertion.
Fever.
Headache and body ache.
Sore throat.
Cough, congestion and runny nose.
What is the Treatment?
There is no treatment or vaccine for fifth disease. It is not recommended that children
stay home from school. Once the rash appears they are no longer contagious.
How Can You Prevent Fifth Disease?
Practice good hand washing, especially if working with children in a
school, childcare or health care setting.
Individuals who have any immune disease should avoid contact with
anyone with fifth disease.
GROUP A STREPTOCOCCUS – INVASIVE
NOVEMBER 2006
1. INFORMATION
1.1 Case Definition
Confirmed case:
Laboratory confirmation of infection with or without clinical evidence of invasive
disease:
isolation of group A streptococcus (Streptococcus pyogenes) from a
normally sterile site (a normally sterile site is defined as: blood,
cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, deep
tissue specimen taken during surgery [e.g. muscle collected during
debridement for necrotizing fasciitis], bone or joint fluid excluding the
middle ear and superficial wound aspirates [e.g. skin and soft tissue
abscesses]).
Clinical evidence of invasive disease may be manifested as one or more of
several conditions:
Soft tissue necrosis, including necrotizing fasciitis, myositis or gangrene
Meningitis
Streptococcal toxic shock syndrome, which is characterized by
hypotension (systolic blood pressure ≤90 mm Hg in an adult and <5
percentile for age for children) and at least two of the following signs:
 Renal impairment (creatinine level ≥177 umol/L for adults)
 Coagulopathy (platelet count ≤100,000/mm3 or disseminated
intravascular coagulation)
 Liver function abnormality (SGOT, SGPT or total bilirubin ≥2x upper limit
of normal)
 Adult respiratory distress syndrome
 Generalized erythematous macular rash that may desquamate
Probable case:
Clinical evidence of invasive disease (see clinical evidence above) in the absence
of another identified etiology and with non-confirmatory laboratory evidence of
infection:
isolation of group A streptococcus from a non-sterile site
OR
positive group A streptococcus antigen detection
1.2 Causative Agent
Streptococcus pyogenes, Group A Streptococcus
1.3 Symptoms
Symptoms preceding the onset of invasive GAS disease may include unusually
severe pain, swelling, fever, chills, flu-like symptoms, myalgias, generalized
macular rash, nausea, vomiting, diarrhea, malaise and joint pain.
Clinical evidence of disease may manifest as several conditions including:
Streptococcal Toxic Shock Syndrome (STSS)
Necrotizing Fasciitis (NF)
Necrotizing Myositis (NM
STSS is the most serious manifestation of invasive GAS disease. It comprises a
primary site of GAS infection together with hypotension, adult respiratory
distress syndrome, renal impairment, rapid onset of shock and multi-organ
failure.
The most common primary site of invasive GAS infections is soft tissue, but
pneumonia, septic arthritis and primary bacteremia may also occur.
Pneumonia with isolation of GAS from a sterile site, or from a bronchoalveolar
lavage (BAL) non-sterile site when no other cause has been identified, should be
regarded as a form of invasive disease for the purposes of public health
management.
Upper respiratory tract manifestations of GAS are more common with children,
arthritis and pelvic infections are more common in young adults, and NF is more
common in the elderly.
NF and NM alone are less severe than STSS with a mortality rate of
approximately 20%.
However, they may progress to STSS, which has a mortality rate of 80%.
1.4 Incubation
Usually 1 to 3 days.
1.5 Source
GAS may be carried in the nasopharynx, gastro intestinal tract and on the skin of
humans.
1.6 Transmission
Transmission occurs via large respiratory droplets, or by direct contact with
infected clients or carriers; rarely through contaminated objects. Person-toperson transmission occurs through exposure to secretions from wounds, nasal
and oral cavities.
1.7 Communicability
Transmissibility generally ends within 24 hours of treatment. If untreated,
uncomplicated cases are communicable for 10-21 days or until infection is
resolved. Asymptomatic carriage is quite common (up to 15% of the population).
In cases with purulent discharges, communicability extends for weeks or months.
1.8 Treatment
Advice should be sought from infectious disease specialists.
1.9 Core Prevention Messages
Practice proper hand-hygiene, especially after coughing or sneezing, and
before preparing or eating foods and before and after each completed
patient contact.
Ensure all wounds are kept clean and watch 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 immediately.
2.0 PUBLIC HEALTH CASE MANAGEMENT AND CONTROL
MEASURES
Further to the case definitions in Section 1.1, please note the following definitions for
Public Health management.
Sporadic Case: A single case of invasive GAS disease occurring a community where there
is no evidence of an epidemiologic link (by person, place or time) to another case.
Index Case: The first identified in an organization – or community-based outbreak.
Identifying the index case in an outbreak is important for the characterization and
matching of GAS isolate strains.
Subsequent Case: A case with onset of illness occurring within 21 days and caused by
the same strain as another case (including sporadic or index cases) and with whom an
epidemiologic link can be established. Most subsequent cases in the community will
occur within 7 days of another case.
Severe Case: Case of STSS, soft tissue necrosis (including necrotizing fasciitis, myositis
or gangrene), meningitis, GAS pneumonia, other life threatening conditions or a
confirmed case resulting in death.
To establish an epidemiological link, a person must have one or both of the following in
common with a confirmed case:
Contact with a common, specific individual (including confirmed or
probable cases).
Presence in the same location (e.g. school, long-term care facility, child
care centre) at or around the same time.
For public health management, cases that occur subsequent to the index case with
whom an epidemiologic link can be established may have acquired the disease directly
from the index case or may have acquired the disease from another common source.
The public health response to a sporadic case of invasive GAS include:
Case Management
Contact tracing
Maintenance of surveillance for further cases.
2.1 Case
Follow-up of invasive GAS is a priority and the following steps must be taken
immediately:
(a) Contact physician to obtain clinical information on case
(b) Record age, gender and address of case
(c) Interview case or a proxy for the case to determine close contacts (see
Section 2.2.1.).
2.1.1 Exclusion
No exclusion required.
2.1.2 Education
See Section 1.9, Core Prevention Messages.
2.2 Contact Tracing
The cornerstone of prevention of secondary cases of invasive GAS is aggressive
contact tracing to identify people at increased risk for disease (e.g. close
contacts).
2.2.1. Definition of Close Contacts
Household contacts of a case who have spent at least 4 hours/day on
average in the previous 7 days or 20 hours/week with the case
Non-household persons who share sleeping arrangements with the case
or had sexual relations with case
Persons who have had direct mucous membrane contact with the oral or
nasal secretions of a case (e.g. mouth-to-mouth resuscitation, open
mouth kissing) or unprotected direct contact with an open skin lesion of
the case
Injection drug users who have shared needles with the case
Selected LTCF contacts (See Section 2.4)
Selected child care and nursery school contacts (See Section 2.4.2)
Selected hospital contacts (Infection Control responsibility in respective
hospitals).
Note: School classmates (kindergarten and older), work colleagues, as well as
social or sports contacts of a case are usually not considered close contacts
unless they fit into one of the above categories.
2.2.2 Susceptibility
The risk of invasive GAS is significantly associated with the following underlying
conditions:
Age >65 years
Heart disease
Diabetes Mellitus
Cancer
Alcohol abuse
Chronic lung disease
HIV infection
Injection drug use (IDU)
High dose steroid use
(immunosuppressive doses)
Presence of varicella infection in the 2-week
period following the onset of symptoms
Skin trauma
2.2.3 Initiate Contact Tracing
Obtain names and information for all contacts who meet the definition outlined
in Section 2.2.1
2.2.4 Prophylaxis
Chemoprophylaxis is offered to prevent disease in colonized individuals and in
those who have recently been exposed, thereby decreasing transmission of
strain known to have caused severe infection.
Chemoprophylaxis should only be offered:
1) to close contacts (Section 2.2.1.) of a confirmed severe case. A
confirmed severe case is defined as a case of STSS, soft tissue
necrosis (including necrotizing fasciitis, myositis or gangrene),
meningitis, GAS pneumonia, other life threatening conditions or a
confirmed case resulting in death; AND
2) if close contacts have been exposed to the case during the period
from 7 days prior to onset of symptoms in the case to 24 hours
after the case’s initiation of antimicrobial therapy.
Chemoprophylaxis of close contacts should be administered as soon as possible
and preferably within 24 hours of case identification, but is still recommended
for up to 7 days after the last contact with an infectious case.
Table 1: Chemoprophylaxis for Close Contacts of Invasive GAS
Drug
Dosage
Comments
First generation
cephalosporins:
cephalexin,
cephadroxill,
cephradine
First line: Children and
adults: 25 – 50
mg/kg/day, to a
maximum of 1 g/day in 2
to 4 divided doses x 10
days
Recommended drug for pregnant and lactating
women.
Erythromycin
Clarithromycin
Clindamycin
Second line: Children: 5
to 7.5 mg/kg every 6
hours or 10 to 15 mg/kg
every 12 hours (base) x
10 days (Not to exceed
maximum adult dose)
Adults: 500 mg every 12
hours (base) x 10 days
Second line:
Children: 15 mg
/kilogram /day in divided
doses every 12 hours to a
maximum of 250 mg PO
BID x 10 days
Adults: 250 mg PO BID x
10 days
Second line:
Children: 8 to 16
mg/kg/day
divided into 3 or 4 equal
does x 10 days (Not to
exceed maximum of
adult dose)
Adults: 150 mg every 6
hours x 10 days
Should be used with caution in patients with
allergy to pencillin.
Use of cephalosporins with nephrotoxic drugs
(e.g. aminoglycosides, vancomycin) may
increase the risk of cephalosporin-induced
nephrotoxicity.
Erythromycin estolate is contraindicated in
persons with pre-existing liver disease or
dysfunction and during pregnancy.
Sensitivity testing is recommended in areas
where macrolide resistance is unknown or
known to be ≥ 10%.
Contraindicated in pregnancy.
Sensitivity testing is recommended in
areas where macrolide resistance is
unknown or known to be ≥ 10%.
Alternative for persons who are unable to
tolerate beta-lactam anitibiotics.
2.2.5 Immunization
Currently there are no vaccines approved for use in Canada for the prevention of
GAS infections.
2.2.6 Exclusion
Exclusion of contacts is not necessary.
2.2.7 Education
Review signs and symptoms of invasive GAS disease with close contacts
of all confirmed cases regardless of whether the case is a severe case.
Provide contacts with a fact sheet (refer to Appendix 1 or 2)
Instruct contacts to seek medical attention immediately should they
develop febrile illness or any other clinical manifestation of GAS infection
within 30 days of diagnosis in the index case.
2.2.8 Follow-Up
Inquire to confirm that contacts completed appropriate
chemoprophylaxis and did not become secondary cases.
There is no role for routine culturing for a test of cure for contacts
receiving antibiotic chemoprophylaxis.
2.3 Outbreak Management
An outbreak is defined as increased transmission of GAS causing invasive disease
in a population. Community outbreaks of invasive GAS rarely occur and usually
involve two cases who have had close contact.
Criteria outlining the impetus for action for organization-based outbreaks or
clusters are found in Table 2.
Table 2: Impetus for Action for Organization-based Outbreaks or Clusters
Organization
Long-Term
Care Facility
Child
Centre
Hospital
Care
Inpetus for Action
An incidence rate of culture-confirmed invasive GAS infections Facility >1
per 100 residents per month or at least 2 cases of culture- confirmed
invasive GAS infection in one month in facilities with less than 200 residents
or an incidence rate of suggested invasive or non-invasive GAS infections >
4 per 100 residents per month.
One severe case of invasive GAS disease in a child attending a child care
centre.
One or more linked invasive or non-invasive GAS cases in either patients or
staff occurring within one month of an invasive GAS case.
Refer to Section 2.4 for specific guidelines for the management of invasive GAS
in long-term care facilities (LTCF) and child care centre (CCC). Management of
invasive GAS in a hospital setting is the responsibility of the Infection Control
Department within that organization.
2.4 Guidelines
2.4.1 Guidelines for Institutions / Long-Term Care Facilities
GAS infections within LTCF are often spread through person-to-person contact,
with a clustering of cases by room or care unit. Outbreaks in LTCF are often
patient- propagated, whereas within acute care facilities, staff who are carriers
are more likely to be the source of infection or outbreaks.
In addition to strict enforcement of standard infection control practices, the
following approach may be useful in the investigation and control of invasive
GAS disease in LTCF:
When a confirmed case of invasive GAS disease (as described in Section
1.1.) occurs in a LTCF such as a nursing home, the facility should:
 Report the case to the Public Health Units within the District
 Conduct a retrospective chart review of the entire facility’s residents
over the previous 4 – 6 weeks, for culture-confirmed cases of GAS
disease and any suggested cases of invasive or non-invasive GAS
infection, including skin and soft tissue infections (e.g. pharyngitis and
cellulites) and excluding non-culture- confirmed pneumonia and
conjunctivitis. An excess of GAS infection, or LTCF outbreak, is defined
in Table 2
 Assess the potential for a source of infection from outside the facility
(e.g. regular visits from children who have recently been ill)
• If an excess of GAS infection is identified, the following actions should be
considered:
 All patient care staff should be screened for GAS with throat, nose
and skin lesion cultures. In LTCF with <100 beds, all residents should
be screened for GAS. In LTCF with 100 beds or greater, screening can
be limited to all residents within the same care unit as the infected
case and contacts of the case if necessary, unless patient and care
staff movement patterns or epidemiologic evidence (e.g. from the







chart review) suggest that screening should be conducted more
broadly.
Anyone colonized with GAS should receive chemoprophylaxis (see
Section 2.2.4.).
Non-patient care staff should be asked about possible recent GAS
infections. Those with a positive history should be screened for GAS
and persons positive should be treated with antibiotics as per
recommended regimen.
All GAS isolates should have further typing (see Section 2.5 Public
Health laboratory Role). Culturing for a test of cure is recommended
for individuals found to have the outbreak-related strain, particularly
if there is epidemiologic evidence indicating that contact with the
individual is significantly related to illness.
Culturing for a test of cure is not necessary for individuals infected
with a non- outbreak-related strain of GAS.
Re-screen all GAS positive residents and staff including their throat
and skin lesion(s) 14 days after chemoprophalaxis has been started.
Follow by screening at two weeks and at four weeks after the first rescreening. If the person is found to be positive, a second course of
chemoprophalaxis should be offered. If the person is still colonized
after the second treatment, discontinue chemoprophalaxis unless the
facility has an ongoing problem with GAS infection.
Active surveillance for GAS infection should be initiated and
continued for 1 to 2 months.
Appropriate specimens should be taken for culture to rule out GAS
when suspected infections are detected by active surveillance.
If no excess is identified, especially if there is evidence of an outside
source of infection for the index case, then active surveillance alone for
two to four weeks to ensure the absence of additional cases is warranted.
2.4.2 Guidelines for Child Care Centres (CCC)
Child care centres include groups or institutional child care centres (day cares),
family or home day care and preschools.
When a confirmed case of invasive GAS disease (as described in Section 1.1)
occurs in a child attending a CCC, staff must report to district public health units
as required by legislation.
When one severe case of invasive GAS disease (Table 2) occurs in a child
attending a CCC, public health practitioners should consider the following:
1) The nature of the CCC (e.g. type of centre, including the size and physical
structure, number and ages of the children, type of interaction of the
children).
2) The characteristics of the case (e.g. if the case occurred secondary to a
varicella infection.
3) The potential for a source of infection from within the CCC:
i. whether there has been any suggested invasive or non-invasive
infections (e.g. other cases of invasive GAS, pharyngitis, impetigo)
ii. potential of a point source of infection (foodborne outbreaks of
pharyngitis have occurred and are a consequence of human
contamination of food in conjunction with improper preparation
or refrigeration procedures.
4) The presence of varicella cases within the CCC in the previous two weeks.
If a case of varicella has occurred in the CCC within the two weeks prior
to onset of GAS symptoms in the index case, all attendees should be
assessed for varicella vaccination history. Two weeks was chosen as the
time interval based on findings that risk of GAS was significantly
increased two weeks after onset of varicella infection. Varicella
vaccination should be recommended for those without a history of prior
varicella infection or vaccination as per the NACI guidelines; CCDR 2004;
30.
5) The potential for a source of infection from outside the CCC (e.g.
exposure to a family member with suggest invasive or non-invasive GAS
infection).
6) Parents and/or guardians of attendees should be informed of the
situation, alerted to the signs and symptoms of invasive GAS disease and
be advised to seek medical attention immediately should their child
develop febrile illness or any other clinical manifestations of GAS (see
Section 1.3)
7) In family or home day care settings, chemoprophylaxis should be
recommended for all children and staff (see Section 2.2.4).
8) In group or institutional CCC and preschools, chemoprophylaxis is
generally not warranted, but may be considered in certain situations,
including the occurrence of >1 case of invasive GAS disease in children or
staff of the CCC within one month or a concurrent varicella outbreak at
the CCC. Cases of invasive GAS occurring among children or staff of a CCC
within one month should be considered as part of the same cluster.
Consideration could be given to testing isolates from invasive GAS cases
occurring in a CCC more than one month apart, to determine strainrelatedness.
9) A test of cure is not warranted for persons receiving chemoprophylaxis.
10) Appropriate specimens can be taken for culture to rule out GAS when
suspected infections are detected during this period, however routine
screening of attendees is not recommended.
2.5 Public Health Laboratory Role
The provincial Public Health Laboratory may perform specific molecular analysis
in support of outbreak investigations.
The National Centre for Streptococcus (NCS) is the only laboratory in Canada that
performs M-typing/emm sequencing of S. pyogenes isolates for routine
surveillance.
During an investigation of clusters or outbreaks of invasive GAS, the local Public
Health Outbreak team must coordinate the shipment of isolates and required
information along with a brief description of the event to the NCS through the
provincial laboratory or designate laboratory.
3.0 SURVEILLANCE
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Invasive Group A Streptococcal Disease Guidelines Working Group. Guidelines for the Prevention and
Control of Invasive Group A Streptococcal (GAS) Disease, Public Health Agency of Canada, 2006 National
Advisory Committee on Immunization (NACI). Update on Varicella. CCDR 2004; 30: 1-27
APPENDIX 1:
NECROTIZING FASCIITIS / MYOSITIS (FLESH
EATING DISEASE) FACT SHEET
What is Necrotizing Fasciitis and Myositis?
Necrotizing fasciitis (NF) is more commonly known as flesh eating disease. It is a rare
illness that causes extensive tissue destruction. NF is caused by a number of different
bacteria, one of them being group A streptococcus (GAS). Usually GAS spreads through
close personal contact and causes mild illness. Sometimes GAS causes serious life
threatening diseases such as flesh eating disease. Some strains of GAS are more likely to
cause severe disease than others.
When the disease spreads along the layers of tissue that surround the muscle (the
fascia), it is called necrotizing fasciitis. When the disease spreads into the muscle tissue,
it is called necrotizing myositis.
Who Can Get Necrotizing Fasciitis?
NF is very rare but may be associated with the person’s ability to fight off the infection
because of a chronic illness or an illness that affects the immune system. The illness is
often related to injury or trauma.
What are the Symptoms?
Symptoms include:
• Fever
• Severe pain
• Red painful swelling that spreads rapidly.
What is the Treatment?
NF can be treated with antibiotics and surgical intervention if necessary. Early treatment
may reduce the risk of serious complications.
How Can You Prevent Necrotizing Fasciitis?
Good hand washing practices.
All wounds should be kept clean and watched for possible signs of
infection such as redness, swelling, drainage, and pain at the wound site.
Seek medical attention if a wound gets infected.
APPENDIX 2:
STREPTOCOCCAL TOXIC SHOCK SYNDROME
(STSS) FACT SHEET
What is STSS?
Streptococcal Toxic Shock Syndrome (STSS) is a serious infection caused by a bacteria
called group A streptococcus (GAS). Some strains of GAS are more likely to cause severe
illness than others.
Who Can Get STSS?
STSS is a rare disease. It can occur in individuals who have soft tissue infection. It may
also occur in people with invasive infections such as pneumonia. It occurs when the
bacteria overcome the body’s defenses or when the person’s ability to fight off
infections is decreased because of chronic illness or an illness that affects the immune
system.
What are the Symptoms?
Symptoms include:
Fever
Severe pain
Tiredness
Breathing difficulty.
What is the Treatment?
Antibiotics are used to treat STSS. The sooner antibiotics are started the better the
chance for the individual to recover.
How Can You Prevent STSS?
Wash hands well with soap and water
Seek medical attention if a wound gets infected
GROUP A STREPTOCOCCUS – NON-INVASIVE
1. Information
1.1 Case definition
Laboratory identification of group A streptococcus.
1.2 Causative agent
Streptococcus pyogenes.
1.3 Symptoms
Streptococcal sore throat typically exhibits sudden onset of fever, sore throat,
exudative tonsillitis or pharyngitis.
Streptococcal skin infections (impetigo) refer to section on impetigo.
Scarlet fever is a form of streptococcal disease characterized by a skin rash.
It occurs when the infecting strain of streptococcus produces a pyogenic
exotoxin and the individual is sensitized but not immune to the toxin.
The symptoms may include the symptoms of streptococcal sore throat as well as
a rash and a strawberry tongue.
1.4 Incubation
Usually 1 to 3 days.
1.5 Source
Humans.
1.6 Transmission
Transmitted via large respiratory droplets or direct contact with carriers. Nasal
carriers are particularly likely to transmit the disease.
1.7 Communicability
If untreated, 1 to 21 days.
1.8 Treatment
Pharyngitis: Penicillin V. Orally administered erythromycin is indicated for those
allergic to penicillin.
1.9 Core Messages for Prevention
Good hand washing practices, especially after coughing or sneezing, and
before preparing or eating foods.
1.10 Prophylaxis
None.
2. Procedure
No Public Health follow-up required. This is not a notifiable disease.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
STREPTOCOCCAL (STREPT) THROAT FACT SHEET
What is Strept Throat?
Strept throat is caused by a bacteria called Group A streptococci. The same bacteria can
cause other diseases such as impetigo.
The bacteria are spread through contact with droplets from the throat of an infected
person (via coughing). The person carrying the bacteria may not have any symptoms at
all.
What are the Symptoms?
Strept Throat:
Fever.
Sore throat.
Swollen glands (usually at the neck).
Headache.
What is the Treatment?
If you suspect strep throat, your child should be seen by a doctor for diagnosis and
treatment. An antibiotic may be prescribed. Children with strep throat should not
attend school until they have been taking antibiotics for 24 hours.
How Can You Prevent Strept Throat?
Wash your hands often.
Discard used tissues in the garbage.
Avoid direct contact with anyone who has the disease.
SCARLET FEVER FACT SHEET
What is Scarlet Fever?
Scarlet fever is caused by a bacteria called Group A streptococci. The same bacteria can
cause other diseases such as impetigo.
Scarlet fever is spread through contact with droplets from the throat of an infected
person (via coughing). The person carrying the bacteria may not have any symptoms at
all.
What are the Symptoms?
Fever.
Sore throat.
Swollen glands (usually at the neck).
Headache.
A fine rash with a sandpaper feel covering the chest, neck, back, arms,
legs and stomach.
Peeling of the skin at the tips of the fingers and toes, palms of hands and
soles of feet. This usually occurs a few days to a few weeks after other
symptoms appear.
What is the Treatment?
If you suspect scarlet fever, your child should be seen by a doctor for diagnosis and
treatment. An antibiotic may be prescribed. Children with scarlet fever should not
attend school until they have been taking antibiotics for 24 hours.
How Can You Prevent Scarlet Fever?
Wash your hands often.
Discard used tissues in the garbage.
Avoid direct contact with anyone who has the disease.
Group B Streptococcal Infection of the Newborn
1. Information
1.1 Case definition
Confirmed case:
Clinical illness in an infant less than 1 month of age with laboratory confirmation
of infection:
isolation of group B Streptococcus (Streptococcus agalactiae) from a
normally sterile site (such as blood or cerebrospinal fluid)
OR
demonstration of group B Streptococcus DNA in a normally sterile site
Probable case:
Clinical illness in an infant less than 1 month of age with laboratory confirmation
of infection:
detection of group B Streptococcus antigen in a normally sterile site
1.2 Causative agent
Streptococcus agalactiae.
1.3 Symptoms
Invasive disease in infants is divided into two categories:
Early onset disease (1-7 days), characterized by sepsis, respiratory
distress, apnea, shock, pneumonia, and meningitis
Late onset disease (7 days to 1 month) characterized by bacteremia,
meningitis and other focal infections
Group B streptococci also cause chorioamnionitis and post-partum endometritis
and systemic infections in non-pregnant adults.
1.4 Incubation
Early onset disease: Usually occurs within the first 24 hours of life (range
0-6 days).
Late onset disease: occurs at 3 to 4 weeks of age (range 7 days to 3
months).
1.5 Source
Humans.
1.6 Transmission
Transmission from mother to infant occurs shortly before or during delivery.
After delivery, person-to-person transmission can occur.
1.7 Communicability
Unknown.
1.8 Treatment
Ampicillin plus an aminoglycoside is the initial treatment of choice for
a newborn. For treatment of meningitis, consult appropriate specialist.
1.9 Core Messages for Prevention
Any pregnant woman who has previously had a baby with GBS disease
should discuss this with her physician.
1.10 Prophylaxis
Refer to current Reproductive Care guidelines for management of group
B streptococcus in pregnant women and newborns.
2. Procedure
No public health follow-up required. This is a notifiable disease.
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
HAND/FOOT/MOUTH DISEASE (COXSACKIE
VIRUS)
1. Information
1.1 Case definition
Compatible clinical illness or laboratory evidence of infection.
1.2 Causative agent
Coxsackievirus group A, type A16 predominantly and types 4,5,9 and 10; group
B, types 2 and 5.
1.3 Symptoms
Diffuse oral lesions on the buccal surfaces of the cheeks and gums and on the
sides of the tongue. Papulovesicular lesion, also commonly occur as an
exanthem especially on the palms, fingers, and soles. Lesions may persist from
7-10 days. Occasionally, maculopapular lesions appear on the buttocks.
1.4 Incubation
Usually 3-5 days.
1.5 Source
Humans.
1.6 Transmission
Direct contact with respiratory secretions and feces of infected people (who may
be asymptomatic). Also via aerosol droplet spread.
1.7 Communicability
During the acute stage of the illness, and perhaps longer because these viruses
persist in the stool for several weeks.
1.8 Treatment
None.
1.9 Core Messages for Prevention
Hand washing and good basic hygiene. Always wash hands after using the toilet
or after changing diapers.
1.10 Prophylaxis
None.
2. Procedure
No Public Health follow-up required. This disease is not notifiable.
References: Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association.
HAND, FOOT AND MOUTH DISEASE
(COXSACKIE VIRUS) FACT SHEET
What is Hand, Foot and Mouth Disease?
Hand, Foot and Mouth Disease is an illness caused by the coxsackievirus. It occurs most
often in the summer and fall months. It is usually a mild infection.
The virus lives in the mouth, throat and feces of an infected person. It is spread
by direct contact or breathing in the virus that is coughed or sneezed into the air by an
infected person.
Who Can Get Hand, Foot and Mouth Disease?
Anyone can get this disease, however, people who work with diapered infants and
young children are more at risk of getting the virus.
What are the Symptoms?
It could take 3-6 days before symptoms appear.
Symptoms may include:
Sores inside the mouth (tongue and gums).
Blisters on the hands and feet. Sometimes there may be blisters on the
buttocks as well.
What is the Treatment?
There is no specific treatment for this disease. A mild pain medication may be
helpful.
It is not necessary for children with this disease to stay home from school.
How Can You Prevent Hand, Foot and Mouth Disease?
Wash hands after using the toilet or changing diapers and follow good basic hygiene.
IMPETIGO
1.1 Case definition
Compatible clinical illness or isolation of Staphylococcus aureus or, group A beta
hemolytic streptococci (GABS), from the site of a lesion of the skin.
1.2 Causative agent
Staphylococcus aureus (S aureus) and/or group A beta hemolytic streptococci
(GABS).
1.3 Symptoms
Small blisters first appear on the face, around the mouth or nose, or on other
parts of the body where there has been a cut, scratch, abrasion or a bite. The
sores become purulent and then scab over with a yellowish crust. This lesion can
last up to several weeks.
1.4 Incubation
Usually 4 to 10 days.
1.5 Source
S. aureus are found on most environmental surfaces, especially the human body,
where there are infected skin sites. GAS are found in human skin lesions and in
the nasopharyngeal tract.
1.6 Transmission
Close contact with individuals who either have a purulent lesion or are an
asymptomatic carrier. The hands are the most important means for transmitting
infection.
1.7 Communicability
Communicable until active drainage has disappeared. Autoinfection may
continue for the duration of active lesions or during the period of nasal
colonization.
1.8 Treatment
Topical and systemic antibiotics may be necessary. S aureus carriers may need
more aggressive antibiotic therapy. Children with impetigo should be kept home
from school or childcare for 24 hours after the treatment has been initiated.
1.9 Core Messages for Prevention
Keep cuts, scratches or bites clean by washing with hot water and soap.
Avoid contact with lesions that may be infectious.
Avoid contact with any personal articles, like face cloths or towels or
clothing of an infected person.
1.10 Prophylaxis
Good personal hygiene.
2. Procedure
No Public Health follow-up required. This disease is not notifiable.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association. Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G.
Donowitz editor Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
IMPETIGO FACT SHEET
What is Impetigo?
Impetigo is an infection of the skin caused by bacteria. It usually begins as small blisters
or sores on the face, ears and hands. Impetigo starts where there is a break in the skin,
such as in cuts. Most often the sores appear on the arms, legs and face, near the corners
of the mouth and nose.
Who Can Get Impetigo?
Children and adults can get impetigo, though children get it more often. It is spread
through direct contact with anyone who is infected with these bacteria. Using towels or
other personal articles of anyone who is infected may also spread impetigo.
What are the Symptoms?
Symptoms include:
Small blisters on the face around the nose, mouth, chin or other part of
the body.
Redness and a honey coloured discharge may ooze out of the blister.
Itching around the sore.
Scabbing over the blister site with a yellowish crust.
Stays longer than an ordinary pimple.
What is the Treatment?
Your doctor can diagnose and treat impetigo. The doctor may prescribe an antibiotic
cream or ointment.
Your child will have to stay home from school until 24 hours after the treatment begins.
How Can You Prevent Impetigo?
Wash your hands often, especially after touching or treating the sores.
If someone in the family has impetigo, each member of the family should
have their own personal articles such as face cloths, towels and soap.
Keep cuts, scratches and bites clean.
1
Influenza
January, 2014
1. INFORMATION ........................................................................................................ 3
1.1.
Case Definition..................................................................................... 3
1.2.
Causative Agent ................................................................................... 3
1.3.
Symptoms............................................................................................ 3
1.4.
Incubation ........................................................................................... 4
1.5.
Source ................................................................................................. 4
1.6.
Transmission ........................................................................................ 4
1.7.
Communicability .................................................................................. 4
1.8.
Treatment............................................................................................ 4
1.9.
Core Prevention Messages ................................................................... 5
1.10. Immunization ...................................................................................... 5
2. PUBLIC HEALTH CASE MANAGEMENT AND CONTROL MEASURES ........................ 5
2.1.
Cases ................................................................................................... 5
2.2.
Exclusion.............................................................................................. 6
2.3.
Contacts .............................................................................................. 6
2.4.
Outbreak Management ........................................................................ 6
2.4.1. Definition of an Outbreak and Guidelines for Investigation and
Management .................................................................................................. 6
2.4.2. Reporting of Outbreaks ......................................................................... 6
3. SURVEILLANCE ........................................................................................................ 6
3.1.
Objectives of Influenza Surveillance in the 2013-2014 Influenza Season 7
3.2.
Surveillance Systems and Sources of Data ............................................ 7
3.3.
Surveillance of Laboratory-Confirmed Influenza ................................... 8
3.3.1. Objectives of Surveillance of Laboratory-Confirmed Influenza .............. 8
3.3.2. Laboratory Testing and Reporting ........................................................ 8
3.3.3. Procedures........................................................................................... 9
3.4.
Surveillance of Influenza-Like-Illness (ILI) ........................................... 10
3.4.1. ILI Case Definition for Surveillance Purposes ...................................... 10
3.4.2. ILI in Sentinel Primary Health Care Settings ........................................ 10
January 2014
2
3.4.3. ILI in Emergency Departments ............................................................ 10
3.5.
Surveillance of Outbreaks of Influenza and ILI .................................... 11
3.5.1. School / Daycare Absenteeism ........................................................... 11
3.5.2. Influenza/ILI Outbreaks in LTC/ARC and Acute Care Facilities ............. 12
3.5.3. Public Health Alerts............................................................................ 13
3.6.
Reporting ........................................................................................... 13
3.6.1. Respiratory Watch ................................................................... 13
4. REFERENCES .......................................................................................................... 15
5. APPENDICES .......................................................................................................... 16
Appendix A: 2013-14 Publicly Funded Seasonal Influenza Vaccine Information for
Immunization Providers* ............................................................................................ 17
Appendix B: ANDS Quick Reference: Influenza Case Entry ......................................... 25
Appendix C: ILI in Emergency Departments (ED)/Outpatient Centres ........................ 26
Appendix D: School and Daycare Absenteeism ........................................................... 27
Appendix E: FluWatch Reporting Procedure through CNPHI ...................................... 28
Appendix F: 2013-14 NS Influenza Vaccine Coverage and Reporting ......................... 32
Appendix G: Laboratory Procedures ........................................................................... 32
1. Laboratory Diagnosis/Overall Testing Rationale ..................................... 32
2. Specimen Collection ................................................................................ 32
3. Specimen Labeling Requirements ........................................................... 33
4. Specimen Transport Conditions .............................................................. 33
5. Laboratory Testing................................................................................... 33
6. Point of Care Testing (POC) ..................................................................... 34
7. Reporting of Results ................................................................................ 34
8. To Access Results ..................................................................................... 34
9. After Hours .............................................................................................. 34
Appendix H: Influenza Case Report Form.................................................................... 35
January 2014
3
1. INFORMATION
1.1. Case Definition
Confirmed case
Clinical illness with laboratory confirmation of infection:




Isolation of influenza virus from an appropriate clinical specimen
OR
Demonstration of influenza virus antigen in an appropriate clinical specimen
OR
Significant rise (e.g. fourfold or greater) in influenza IgG titre between acute and
convalescent sera
OR
Detection of influenza RNA
1.2. Causative Agent
Influenza viruses belong to the family Orthomyxoviridae and are classified into three
distinct types on the basis of major antigenic differences: influenza A, B and C. Influenza
A and B are routinely associated with regional and widespread epidemics whereas
influenza C is more commonly responsible for sporadic cases and minor localized
outbreaks. Influenza A is further categorized into subtypes based on the presence of
two surface antigens: hemagglutinin (H) and neuraminidase (N). Three types of
hemagglutinin in humans (H1, H2 and H3) have a role in virus attachment to cells. Two
types of neuraminidase (N1 and N2) have a role in virus penetration into cells. The most
common circulating subtypes of human Influenza A are H1N1 and H3N2. Influenza B is
more stable than Influenza A, with less antigenic drift. There are two main Influenza B
lineages-Yamagata and Victoria. (U.S. Department of Health and Human Services, 2011)
1.3. Symptoms
Influenza-like illness (ILI) is defined as:
 acute onset of respiratory illness with fever
and
 cough
and
 one or more of sore throat, arthralgia, myalgia or prostration.
Other symptoms may include: headache, chills, loss of appetite, runny nose, sneezing
and watery eyes. Fever may not be prominent in the elderly and children under five.
Nausea, vomiting and diarrhea are uncommon but can occur, especially in children
under 5. Most people will recover within 5-7 days. (Heymann, 2008)
January 2014
4
1.4. Incubation
The incubation period for influenza ranges from one to four days. On average,
symptoms may appear within two days of exposure to the virus.
1.5. Source
Humans are the primary reservoir for human infections. Birds and other mammals such
as swine may serve as potential sources of new human subtypes thought to emerge
through genetic reassortment or antigenic shift.
1.6. Transmission
Primary transmission occurs through large droplets from a cough or sneeze of an
infected person propelled (generally up to 2 meters) through the air and deposited on
the mouth or nose of people nearby. The virus also can be spread through direct and
indirect transmission via surfaces, e.g. a person touches respiratory droplets on another
person or an object and then touches their own mouth or nose (or someone else’s
mouth or nose) before washing their hands. Influenza virus may persist for hours on
solid surfaces, particularly in lower temperatures and lower humidity. (Heymann, 2008)
1.7. Communicability
Adults are typically infectious from the day before symptoms begin until approximately
5-7 days after illness onset. Children can be infectious for more than 10 days; young
children can shed virus for up to 6 days before symptom onset.
1.8. Treatment
In Canada, two neuraminidase inhibitors (oseltamivir and zanamivir) are licensed for use
as treatment and prophylaxis against influenza. The choice of drug depends on the type
(A or B) and subtype (H1 or H3) of influenza. The effectiveness of antivirals is
determined each season and recommendations may change as new information
becomes available.
 Oseltamivir is effective against influenza A/H3 (but not A/H1), influenza B, and
Pandemic H1N1 ;
 Zanamivir is effective against influenza A (H3 and H1) and B and Pandemic H1N1.
To be effective in treating influenza, antivirals must be started within 48 hours of
developing symptoms. Antiviral medication is unlikely to benefit those who have been ill
for more than 48 hours, although recent information with Pandemic H1N1 does indicate
it still may be effective. Antiviral treatment is continued for a maximum of 5 days.
The use of antivirals for the treatment and/or prophylaxis is typically reserved for
controlling outbreaks among residents and staff of long-term care facilities and other
residential institutions. For further instructions regarding the use of antivirals in
outbreak settings, please refer to the Guide to Influenza Control for Long-Term Care
Facilities and Adult Residential Centres. (Revised and distributed annually).
January 2014
5
1.9. Core Prevention Messages

Basic personal hygiene is important in reducing transmission (i.e., covering nose and
mouth when coughing or sneezing and regular hand washing).
 Immunization is the best protection against Influenza.
 Individuals at high risk of influenza-related complications and people capable of
transmitting influenza to those at high risk* (e.g. health care workers) should receive
annual immunization for influenza.
* For high risk groups please refer to the following annual document: National Advisory
Committee on Immunization (NACI) - Statement on Influenza Vaccination 2013-14
1.10. Immunization
Immunization against influenza is publicly funded and advised for all Nova Scotians but
is strongly recommended for people at high risk of influenza related complications and
for those who live with or care for them.
2. PUBLIC HEALTH CASE MANAGEMENT AND CONTROL
MEASURES
2.1. Cases
Case investigation for all laboratory confirmed cases of influenza should be conducted
to determine if the case;
 resides in a LTCF/ARC,
 is hospitalized or
 is in the community
Follow up as outlined in Table 1 and complete the Influenza Case Report Form
(Appendix H)
Table 1: Influenza Case Management Summary
Report via ANDS
Case follow-up
Fax case report form to DHW
Community LTCF Case
Case
Yes
Yes
No
Yes**
No
No
Hospitalized Case*
Yes
Yes
Yes
* Defined as any person admitted to hospital with laboratory confirmed influenza.
**As outlined in Guidelines for Influenza Control in LTCF/ARC
Important notes regarding hospitalized cases:


Case follow-up is required for all hospitalized cases of influenza, regardless of type
Hospitalized cases should be followed by Public Health Services until discharge, or
death (maximum follow-up of 4 weeks).
January 2014
6
Upon receipt of a laboratory-confirmed influenza case (either by a faxed report or
through the Electronic Lab Reporting (ELR) system), the following steps should be taken:
a) Determine if the case is a resident of a LTCF/ARC or residential institution.
 This may be evident based on the lab report (i.e., the name and/or address of
the ordering physician).
 If not evident, contact the physician to obtain the relevant information and if
necessary, interview the case.
b) If the case does reside in a LTCF/ARC or residential institution:
 Contact the facility and determine if there is an outbreak occurring.
 Refer to Section 2.4 for the definition of an outbreak and for outbreak
management guidelines.
 If the facility is not experiencing an outbreak, no further action is required.
c) If the case does not reside in a LTCF/ARC or residential institution no further followup is required.
2.2. Exclusion
People who are ill should be advised to stay away from work, school, daycares, etc. until
they are feeling well and are able to fully participate in their usual day-to-day activities.
Health Care Workers who are symptomatic/ infected with influenza should be
excluded from work until 7 days after onset of symptoms with the first day of symptoms
being counted as day 1, unless they have been immunized at least two weeks previously
and have started on antiviral therapy. Refer to http://ipc.gov.ns.ca/standards-andpractice-guidelines
2.3. Contacts
The identification and follow-up of contacts is relevant only in the context of an
outbreak in a LTCF/ARC or residential institution. See Section 2.4 for further guidelines.
2.4. Outbreak Management
2.4.1. Definition of an Outbreak and Guidelines for Investigation and
Management
Refer to the annual Guide to Influenza Control for Long-Term Care Facilities and Adult
Residential Centres and the “Guidelines for Outbreak Management” section of the CDC
Manual
2.4.2. Reporting of Outbreaks
Refer to Section 3.6 for the outbreak reporting procedure.
3.
SURVEILLANCE
Both laboratory-confirmed influenza (regardless of type) and influenza of pandemic
potential are notifiable diseases in Nova Scotia, as mandated under the regulations of
the Health Protection Act. Physicians and managers of laboratories must report positive
January 2014
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influenza test results to the medical officer of health with jurisdiction in the locality in
which the reporting person works. Outbreaks of respiratory illness are also notifiable.
Monitoring influenza is an ongoing activity in Nova Scotia and the capacity of the
influenza surveillance system is assessed at the beginning of each influenza season. The
system monitors seasonal influenza in addition to other respiratory viruses, such as
parainfluenza, adenovirus, and respiratory syncytial virus (RSV). The components of the
current influenza surveillance system and the approach for the 2013-2014 influenza
season are described here.
3.1. Objectives of Influenza Surveillance in the 2013-2014
Influenza Season




To monitor the trend of influenza-like illness (ILI) in the community in order to
determine waning, re-emergence and activity levels of disease.
To monitor the geographic spread of influenza viruses across Nova Scotia and
Canada.
To monitor the severity of illness.
To monitor for changes in the antigenicity and antiviral sensitivity of the virus (labbased).
3.2. Surveillance Systems and Sources of Data
The objectives of influenza surveillance will be met through the implementation of a
number of different surveillance systems. The majority of surveillance systems are
created and maintained by Nova Scotia, while a few are federal initiatives. They
include:
 Overview of Nova Scotia Influenza Surveillance Systems (Figure 1)
1.Laboratory-confirmed cases of influenza
2.Influenza-like illness
 ILI in emergency departments
3.Outbreaks
 LTCF/ARC and acute care facilities
 Reporting of absenteeism and potential outbreaks in schools and
daycare facilities
 Federal surveillance initiatives and special studies
 Severe Outcome Surveillance (SOS)
 Canadian Nosocomial Infection Surveillance Program (CNISP)
 Immunization Program Monitoring-Active (IMPACT)
 FluWatch sentinel physicians
January 2014
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3.3. Surveillance of Laboratory-Confirmed Influenza
3.3.1. Objectives of Surveillance of Laboratory-Confirmed Influenza




To detect cases of influenza in a timely manner
To detect clusters of influenza in long-term care and acute care facilities
To detect types of respiratory pathogens circulating within the community
To monitor the severity of influenza.
3.3.2. Laboratory Testing and Reporting
Confirmed cases are reported by the CDHA laboratory to Public Health Services in the
DHAs and to DHW on a daily basis through the Electronic Laboratory Reporting System
(ELR). See Appendix G for Laboratory Procedures.
Important Points for Laboratory Testing in the 2013-2014 Season:
 Community specimens or Emergency room visits with discharge will not be tested
for influenza, with the exception of those recommended for testing after
consultation with a CDHA microbiologist.
 Laboratory testing will be conducted on specimens from in-patients and LTCF/ARC.
 Laboratory testing will involve multiplex PCR testing in the shoulders of the influenza
season, and influenza/RSV PCR testing during the peak of the influenza season.
January 2014
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
Laboratory testing may change earlier if surveillance indicators suggest increased
influenza activity.
3.3.3. Procedures
a) District Health Authority
Reporting of Cases using ANDS

All confirmed cases of influenza are entered into ANDS upon receipt of laboratory
results (Table 2)
Table 2: ANDS Influenza Entry Summary
Influenza Result on
Lab Report
Disease Name in ANDS
Case Status
in ANDS
Agent
Sub/Serotype in
ANDS
 Influenza virus Type A
detected by PCR
 Positive for Influenza virus
Type A
Influenza A (labconfirmed) Subtyping not
performed
Confirmed
Updated by DHW
Surveillance if
applicable*
 Influenza virus Type B
detected by PCR
 Positive for Influenza virus
Type B
Influenza (lab-confirmed)
Influenza B
Confirmed
–
*Influenza A subtyping (H1N1, pH1N1, H3N2, etc.) is performed at the discretion of
PPHLN, CDHA Microbiology. Results are provided to DHW Surveillance as available.
ANDS will be updated by DHW
 Enter cases using the ANDS date hierarchy, to reflect the earliest episode date
available (refer to ANDS Quick Reference: Influenza Case Entry)
 Update ANDS as new information becomes available.
 ANDS Cognos reports are available to DHAs and include an influenza report for type
of influenza by selected DHA(s) for a selected time period (named ‘Notifiable
Diseases by DHA’), and type of influenza by age group and sex for selected DHA(s)
over a selected time period (named ‘Notifiable Diseases by Sex & Age’).
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b) Department of Health and Wellness



Obtain data on laboratory-confirmed cases via ANDS
Update ANDS with PPHLN reports subtyping results (if performed)
Report data on laboratory-confirmed cases weekly in Respiratory Watch (refer to
section 3.6)
3.4. Surveillance of Influenza-Like-Illness (ILI)
3.4.1. ILI Case Definition for Surveillance Purposes
Acute onset* of respiratory illness with fever and cough and one or more of the
following: sore throat, arthralgia, myalgia or prostration, which could be due to
influenza virus. In children less than five years of age, gastrointestinal symptoms may
also be present. In patients less than five years of age or older than 65 years of age,
fever may not be prominent.
*distinct change from normal status to respiratory illness over 1-3 days, based on
clinical judgement
3.4.2. ILI in Sentinel Primary Health Care Settings
Sentinel physicians participate in surveillance for ILI in Nova Scotia through FluWatch, a
federal surveillance program that has been in place since 1996.
Procedures

FluWatch sentinel physician data are sent from PHAC in aggregate form to DHW via
email and are also posted in the FluWatch module of the CNPHI website
Role of Department of Health and Wellness

DHW will analyze and summarize aggregate data and include this information in
Respiratory Watch (refer to section 3.6)
3.4.3. ILI in Emergency Departments
Emergency departments in hospitals and out-patient centres across Nova
Scotia are monitored for ILI activity on a daily basis. Infection control practitioners
report ILI data to DHW from the emergency departments for which they are
responsible.
Procedures





Infection control practitioners (or delegate) complete the one page aggregate report
form (Appendix C) for patients seen in the Emergency Department (ED).
Data are collected daily and reported to DHW weekly.
The surveillance period is in accordance with influenza surveillance weeks (Sunday
to Saturday).
Data provided include the total number of patients seen and the total number
meeting the ILI case definition on a daily basis for the specified time period.
Tally sheets are emailed to [email protected] or faxed to DHW (902-4240550) on Mondays.
January 2014
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Role of Department of Health and Wellness


DHW will coordinate and maintain the ED surveillance network
DHW will analyze and summarize aggregate data and include this information in
Respiratory Watch.
3.5. Surveillance of Outbreaks of Influenza and ILI
Table 3: Summary of ILI Outbreak/Absenteeism Reporting
Flu Watch Report
CIOSC Report
Email/Fax Form to DHW
LTC/ARC Yes*
Yes
No
School
Yes
No
No
Daycare
Yes
No
No
*ONLY laboratory confirmed influenza outbreaks.
3.5.1. School / Daycare Absenteeism
School and daycare-based surveillance for ILI is ongoing in Nova Scotia. Schools are
requested to report absenteeism that may be due to ILI directly to their district public
health office.
Procedures
a) District Health Authority
Schools and daycares should report absenteeism to Public Health Services according to
the criteria below:
Schools: greater than 10% absenteeism or absenteeism that is higher (e.g. >5-10%) than
expected level as determined by school or public health services, which is likely due to
ILI.
Daycares: staff or children absenteeism, which is likely due to ILI, that is higher than
baseline levels, as determined by daycare.




Encourage the school/daycare to ask for the reason for absenteeism when
parents/students call to report an absence due to illness
Initiate daily active surveillance should be initiated when absenteeism at a school or
daycare exceeds 10% OR is higher than baseline levels as determined by the
school/daycare or PHS, which is likely due to ILI
Note that active surveillance is required on a daily basis until absenteeism, likely due
to ILI, becomes less than 10% OR lower than baseline levels as determined by the
school or daycare
Determine the number and percentage of students/clients and staff absent and the
predominant symptoms. It is important to distinguish between respiratory and
gastrointestinal illness, noting that schools commonly refer to vomiting and diarrhea
illnesses as the “flu.” The School Surveillance Tool or Daycare Surveillance Tool
should be used to ensure complete information.
January 2014
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

Report this information to the CDC team as outlined and alert the CDPC
Manager/Lead if aware of an unusual presentation or increased morbidity
(hospitalizations, deaths)
Report school/daycare outbreaks through normal FluWatch procedures
b) Department of Health and Wellness

DHW uses this information to validate influenza activity levels for FluWatch
3.5.2. Influenza/ILI Outbreaks in LTC/ARC and Acute Care Facilities
LTCF/ARC and acute care facilities are required to report outbreaks or suspected
outbreaks of influenza and/or ILI to District Public Health Services. Please refer to the
Guidelines for Influenza Control in LTCF/ARC for more detailed information
Important note regarding reporting of influenza/ILI outbreaks in LTCF/ARC and acute
care facilities:
 All outbreak reporting of the above to DHW will be done through the CNPHI website.
 Refer to table 4: Influenza/ILI LTCF/ARC Reporting through Outbreak Summaries.
Procedures
a) District Health Authority






LTCF/ARC and acute care facilities should immediately report any outbreaks of ILI or
lab-confirmed cases of influenza to Public Health Services
Collect line list data
Ensure that the LTCF/ARC or acute care facility has sent NP swabs for influenza
testing. Specimens and requisitions must be clearly labeled with an outbreak
number (see below), which the facility must obtain from Public Health Services.
Name, health card number etc. must also be provided to the lab to ensure that any
further testing specified is completed
 Swabs from a LTCF/ARC will be processed by Multiplex PCR during the
summer months and the shoulders of the influenza season, and for
influenza/RSV PCR during the influenza season
 The outbreak number should follow the standard N.S. format, which
includes: the 4 digit year – the 2 digit district number – the 3 digit district
outbreak number for the relevant calendar year, e.g.: 2012-09-001
Complete the Initial Outbreak Summary form on CNPHI as soon as possible once the
DHA is made aware of the situation
 When applicable, provide the number of residents/patients/staff who
received immunization or were hospitalized
Complete the Update Outbreak Summary Report form on CNPHI when positive
laboratory results have been received or as new outbreak information becomes
available.
Complete the Final Outbreak Summary Report form on CNPHI when the outbreak is
declared over
January 2014
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

When applicable, provide the final number of residents/patients/staff who received
treatment, received post-exposure prophylaxis, were hospitalized, and the number
who died.
Report the outbreak through normal FluWatch procedures.
Table 4: Influenza/ILI LTCF/ARC Reporting through Outbreak Summaries
Outbreak of
influenza/ILI
in LTCF/ARC
Initial Report Update Report
Final Report
Required
Required
As new
information
becomes available
(i.e. lab results)
Comprehensive
Final Report
Only if
requested
b) Department of Health and Wellness


DHW uses this information to validate influenza activity levels for FluWatch
DHW will collate aggregate data and include this information in Respiratory Watch
(refer to section 3.6)
3.5.3. Public Health Alerts
Although outbreak reporting in LTCF/ARC will be done in Nova Scotia using CNPHI,
Public Health Alerts will not be used routinely to report school/daycare absenteeism or
outbreaks in LTCF/ARC. However, Public Health Services may consider the use of a
Public Health Alert to notify other jurisdictions of certain outbreaks or unusual events
(note that the definition of unusual is subjective and may require a certain level of
public health professional discretion). Please refer to the “Guidelines for Outbreak
Management” section of the CDC Manual for further detail.
3.6. Reporting
3.6.1. Respiratory Watch
DHW produces a report called Respiratory Watch, an analysis and summary of
respiratory activity including the following surveillance information:
 The number of lab-confirmed cases, with descriptive epidemiology
 Percentage of patients from emergency departments (mixture of daily and weekly
reporting) that met ILI case definition
 LTCF/ARC outbreaks
 School/daycare absenteeism of greater than 10% or above baseline likely due to ILI
 Influenza and ILI activity levels (using FluWatch criteria)
 Number of specimens positive for RSV, with available descriptive epidemiology
 Number of specimens positive for parainfluenza and adenovirus
 Number of specimens positive for other respiratory viral pathogens
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

Any additional pertinent respiratory information as determined by the DHW
Surveillance team
Respiratory Watch is distributed on a weekly basis via e-mail to staff in DHW, district
communicable disease managers/leads, Medical Officers of Health, DHW
Communications, and the Directors of Long-Term Care, as well as selected infectious
disease physicians, microbiologists, and infection control practitioners. Other individuals
can be added to this mailing list on request. Respiratory Watch is also posted on the
DHW website, where it is accessible to the public.
January 2014
15
4.
REFERENCES
IPCNS. (2012, March). Retrieved August 26, 2013, from Occupational Management of
Communicable Disease Exposure and Illness in Healthcare Workers:
http://ipc.gov.ns.ca/standards-and-practice-guidelines
Canadian Public Health Laboratory Network. (2010). Guidance for Laboratory Testing for
Detection and Characterization of Human Influenza Virus for the 2010-2011
Respiratory Virus Season.
Evans, G. (2013, July 12). Interim Guidance for Antiviral Prophylaxis and Treatment of
Influenza Illness due to Avian Influenza A(H7N9) Virus. Retrieved July 24, 2013,
from AMMI Canada:
http://www.ammi.ca/media/54869/revised_h7n9_antiviral_guidance_july_16_2
013_final.pdf
FY Aoki, U. A. (2012, April 23). The use of antiviral drugs for influenza: Guidance for
practitioners 2012/2013. Can J Infect Dis Med Microbiol , pp. 79-e92.
Heymann, D. (2008). Control of Communicable Diseases Manual. American Public Health
Association.
National Advisory Committee on Immunization (2013). Statement on Seasonal Influenza
Vaccine for 2013-2014. CCDR.
Members of the Pandemic Influenza Laboratory Preparedness Network (PILPN). (2009).
Commentary:The Limitations of Point of Care Testing for Pandemic Influenza:
What Clinicians and Public Health Professionals Need to Know. Canadian Journal
of Public Health, 2004-207.
Public Health Agency of Canada. (2009, November). CCDR Volume35S2. Retrieved
August 26, 2013, from Case Definitions for Communicable Diseases under
National Surveillance: http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/09vol35/35s2/index-eng.php
Public Health Agency of Canada. (2013). Public Health Agency of Canada Website.
Retrieved August 26, 2013, from FluWatch: http://www.phacaspc.gc.ca/fluwatch/index-eng.php
U.S. Department of Health and Human Services. (2011). Epidemiology and Prevention of
Vaccine-Preventable Diseases.
January 2014
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5. APPENDICES
Appendix A: 2013-14 Seasonal Influenza Vaccine Information for Immunizers
Appendix B: ANDS Quick Reference: Influenza Case Entry
Appendix C: ILI in Emergency Departments/Outpatient Centres
Appendix D: School and Daycare Absenteeism
Appendix E: FluWatch Reporting Procedure through CNPHI
Appendix F: Influenza Vaccine Coverage and Reporting: Procedures
Appendix G: Laboratory Procedures
Appendix H: Influenza Case Report Form
January 2014
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Appendix A: 2013-14 Publicly Funded Seasonal Influenza Vaccine
Information for Immunization Providers*
1. What are my accountabilities as an immunization provider?
A. Reporting
 Adverse Events Following Immunization (AEFI) are to be reported to local Public
Health Services (PHS) as per It’s the Law – Reporting Adverse Events Following
Immunization (see Q 20).
 Physicians are to use MSI billing codes that are specific to the 2013-2014
seasonal influenza vaccine (see Q 18).
 Pharmacists are to use Pharmacy billing codes that have been introduced in the
2013-14 publicly funded influenza immunization program (see Q 19).
 Other immunization providers are to complete aggregate data collection forms
that are provided by and returned to Public Health.
Management of Vaccine/Cold Chain
 Keep vaccine refrigerated between 2°C to 8°C and never freeze.
 Report all cold chain breaks to local Public Health Services. Keep vaccine
refrigerated while waiting to receive direction from Public Health on use of
affected vaccines.
 Attention must be paid to the duration of stability of vaccine once it has been
opened or reconstituted.
Competency
 Immunizers will follow their respective professional guidelines, e.g. CRNNS,
CPSNS, CLPNNS, NSCP with respect to immunization competency and
professional responsibility. Immunizers may need to be deemed competent by
their employing agency to provide immunization.
Safety
 Adrenalin must be present during vaccine administration.
 Clients must be monitored for at least 15 minutes post-immunization.
 Documentation must include the lot number of the vaccine in case of recall or
adverse event.
Role Model/ Duty of Care
 Annual influenza immunization of health care workers is very important for
reducing influenza-related morbidity and mortality among high risk groups and
individuals to whom you provide care. All immunization providers are
encouraged to receive an annual influenza vaccine.
January 2014
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Ordering Vaccine
 As is the case every year, there is always potential for delays in vaccine
development and distribution from vaccine manufacturers.
 Seasonal influenza vaccine is sent from the manufacturer to the N.S. Provincial
Biodepot over a period of 6-8 weeks in varying quantities. It’s therefore critical
for Public Health to manage the supply of vaccine to ensure equitable
distribution to all immunization providers.
 Immunization providers should not order their whole season’s supply at once as
the supply needs to be shared among all immunization providers. We encourage
you to first immunize people at greatest risk of influenza-related complications
and those people who live with or care for them.
2. Who is eligible to receive publicly funded seasonal influenza vaccine?
A. Immunization against influenza is publicly funded and advised for all Nova Scotians ≥
6 months of age, but is strongly recommended for people at high risk of influenzarelated complications and for those who are capable of spreading influenza to
individuals at high risk of complications, including those who live with or care for
them. The vaccine will be free of charge.
As in previous years, to provide the best protection for all residents in Nova Scotia
against seasonal influenza, all students, including international students, are eligible
to receive publicly funded influenza vaccine.
3. What is the dosage and frequency of the seasonal influenza vaccines?
A. For intramuscular influenza vaccine, the dose is now 0.5 ml for all age groups. This
information differs from the product monograph. N.S. has based its
recommendations on the current National Advisory Committee on Immunization
(NACI) statement.
Recommended Influenza Vaccine Doses by Age, 2013-2014
Age Group
9 years and older
6 months-8 years*
Dose
0.5 ml
0.5 ml
No. of Doses
1
1 or 2*
* Children 6 months to less than 9 years of age receiving seasonal influenza vaccine
for the first time should be given two doses, with a minimum interval of four weeks
between doses. Children less than 9 years who have been previously immunized
with one or more doses of seasonal influenza vaccine are to receive one dose of
influenza vaccine each year thereafter. The seasonal influenza vaccine is not licensed
or recommended for infants less than 6 months of age.
4. Which groups are considered high risk for influenza-related complications?
The following groups are considered at high risk:
January 2014
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 Adults and children with the following chronic health conditions:
o cardiac or pulmonary disorders;
o diabetes mellitus and other metabolic diseases;
o cancer, immune compromising conditions and treatments;
o renal disease;
o anemia or hemoglobinopathy;
o conditions that compromise the management of respiratory secretions
and are associated with an increased risk of aspiration;
o morbid obesity (BMI≥40); and
o children and adolescents with conditions treated for long periods with
acetylsalicylic acid.
 People of any age who are residents of nursing homes and other chronic care
facilities.
 People ≥65 years of age.
 All children 6 to 59 months of age.
 Pregnant women.
 Aboriginal peoples.
5. What are the components of the seasonal influenza vaccines?
A. The antigenic strains included in the 2013-2014 seasonal influenza vaccine (northern
hemisphere) are:
 A/California/7/2009 (H1N1)pdm09-like virus.
 A(H3N2) virus antigenically like A/Victoria/361/2011.
 B/Massachusetts/2/2012-like virus (Yamagata lineage).
The only two products being used in Nova Scotia for the 2013-14 publicly funded
influenza immunization program are Fluviral® (GSK) and Agriflu® (Novartis).
6. Who should NOT routinely be given seasonal influenza vaccine?
A. The following people should not receive seasonal influenza vaccine:
 Infants less than 6 months of age;
 People who have had a serious allergic reaction (anaphylaxis) to a previous dose
of any influenza vaccine;
 People who have had a serious allergic reaction (anaphylaxis) to any of the
components of influenza vaccine;
 People who have a serious acute febrile illness;
 People known to have had Guillain-Barré Syndrome within 6 weeks of a previous
influenza vaccine.
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7. Should people who have experienced Ocular Respiratory Syndrome (ORS) following
receipt of a previous seasonal influenza vaccine be immunized?
A. There is no evidence to suggest that ORS will be a concern following immunization.
Individuals who have experienced ORS, including those with a severe presentation
(bilateral red eyes, cough, sore throat, hoarseness, facial swelling) but without lower
respiratory tract symptoms, may be safely reimmunized with influenza vaccine.
Persons who experienced ORS with lower respiratory tract symptoms should have a
consultation with an allergist.
8. Should people who are allergic to eggs receive the seasonal influenza vaccine?
A. Egg allergy: The National Advisory Committee on Immunization (NACI) has
recommended that egg-allergic individuals may be vaccinated against influenza
using trivalent inactivated vaccine (TIV) without prior influenza vaccine skin test and
with the full dose, irrespective of a past severe reaction to egg with the following
conditions: Those with mild reactions such as hives, or those who tolerate eggs in
baked goods may be vaccinated in a regular vaccination clinic. Those who have
suffered from anaphylaxis with respiratory or cardiovascular symptoms should be
vaccinated in a medical clinic, allergy office or hospital where appropriate expertise
and equipment to manage respiratory or cardiovascular compromise is present.
These individuals should always be kept under observation for 30 minutes. Referral
to a specialist with expertise in allergies may be necessary in occasional
circumstances where there is strong concern about proceeding with the
recommendation above and the individual is at risk of complications from influenza.
If the individual is not in a high-risk group, the need for vaccination must be weighed
against their risk for a severe allergic reaction.
This information differs from the product monograph. N.S. has based its
recommendations on the current NACI statement.
9. Should pregnant women receive the seasonal influenza vaccine?
A. Yes. All pregnant women should receive seasonal influenza vaccine as evidence
demonstrates they are at higher risk of complications from influenza.
10. Is seasonal influenza vaccine safe for breastfeeding mothers?
A. Yes. Seasonal influenza vaccine is safe for breastfeeding mothers and their babies.
11. How should the seasonal influenza vaccines be stored?
A. Vaccine Cold Chain should be maintained at all times (2°C to 8°C). The vaccine
should not be frozen and must be protected from light.
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12. How long can a vial of influenza vaccine be used once it is opened?
A. An opened vial of Fluviral® (GSK) should be used within 28 days from the date it was
opened. It’s a good idea to record the date it was opened on the vial.
Agriflu® (Novartis) comes as a pre-filled syringe so this is not a concern for this
product.
13. Can I draw up the seasonal influenza vaccine into syringes to be used at a later
time?
A. No. The manufacturer has no data to confirm that immunogenicity of the product
will be preserved after prolonged exposure to the plastic of the syringe. The
company also has concerns regarding bacterial contamination. Therefore, influenza
vaccine should be injected as soon as possible after being drawn up.
14. How is the publicly funded seasonal influenza vaccine administered?
A. The publicly funded seasonal influenza vaccine is administered intramuscularly. The
deltoid muscle is the recommended site in adults and children over 12 months of
age. The anterolateral thigh is the recommended site in infants 6 -12 months of age.
15. How soon following immunization does protection develop and how long does it
last?
A. Protection from the seasonal influenza vaccine generally begins 10 to 14 days after
immunization and may last 6 months or longer.
16. What are the side effects of the seasonal influenza vaccine?
A. One third of those vaccinated report soreness at the injection site for up to two
days. Flu-like symptoms (fever, sore muscles, and tiredness) may occur within 6 to
12 hours after vaccination and last 1 to 2 days, especially in those receiving the
vaccine for the first time. Anaphylactic hypersensitivity reactions occur rarely.
17. What information is used to determine influenza immunization coverage?
A. Immunization data from the following sources is collated to inform the N.S.
provincial influenza immunization coverage report:
 Physician MSI billing codes that are specific to the influenza vaccine. (See Q18).
 Pharmacist billing information specific to the publicly funded influenza vaccine
(Q19).
 All other providers are required to submit aggregate influenza information at
the end of the influenza season to their local Public Health office on forms
provided by Public Health. All this information will be collated to calculate the
provincial immunization coverage report.
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18. How do physicians bill for influenza immunization?
A. MSI Billing Information for Administration of Seasonal Influenza (Flu) and
Polysaccharide Pneumococcal (PC) Vaccines 2013-2014
Billing requires a health service code, a modifier, and a diagnostic code
Immunization
Health Service Modifier
MSUs
Diagnostic Code
Code
Influenza
13.59L
RO=INFL
6.0
Select diagnostic
code from the
table below
Pneumococcal
13.59L
RO=PNEU
6.0
Patient Status
Pregnant
Males & non-pregnant females
Diagnostic Codes
FLU
V221
V048
PC and FLU
N/A
V066
Refer to the following table when billing for a provincial immunization tray fee.
Health Services Code
13.59M
Description
MSUs
Provincial immunization tray fee 1.5 per multiple (max
4/visit)
Notes for billing:
1. If one vaccine is administered but no associated office visit is billed (i.e. the sole
purpose for the visit is the immunization), claim the immunization at a full fee of
6.0 MSUs.
2. If two vaccines are administered at the same visit but no associated office visit is
billed (i.e. the sole purpose for the visit is the immunization), claim for each
immunization at a full fee of 6.0 MSUs each.
3. If one vaccine is administered in conjunction with a billed office visit, claim both the
office visit and the immunization at full fee.
4. If two vaccines are administered in conjunction with a billed office visit, claim the
office visit and the first injection can be claimed at full fee. All subsequent
injections will be paid at 50%.
5. For children less than 12 months of age, if a vaccine is administered in conjunction
with a well-baby care visit, claim the well-baby care visit and the immunization.
January 2014
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19. How do pharmacists bill for influenza immunization?
A. Pharmacy billing information is used to collect data on pharmacist-administered
vaccines as part of assessing overall vaccine coverage rates.
For billing, the following DIN and PIN should be used:
 Pregnant Women
o Agriflu PIN 93899922
o Fluviral PIN 93899921
 Males and Non-Pregnant Females
o Agriflu DIN 02346850
o Fluviral DIN 02015986
 Second Dose for Children
o Agriflu PIN 93899920
o Fluviral PIN 93899919
20. What adverse events need to be reported to Public Health Services?
A. All adverse events not normally expected (i.e. listed in the product monograph), that
are temporally related to the administration of the vaccine, need to be reported in
accordance with the It's the Law: Reporting of Adverse Events Following
Immunization poster.
21. Can the seasonal influenza vaccine cause influenza illness?
A. No. The seasonal influenza vaccine does not contain live virus and cannot cause
influenza.
22. Can you receive seasonal influenza vaccine before or after having donated/received
blood or Immune Globulin?
A. Yes.
23. Can seasonal vaccine, adult pertussis vaccine and pneumococcal vaccine be given at
the same time?
A. Yes they can be administered at the same time but with separate needles and
syringes in different sites. Pneumococcal vaccination is recommended once in a
lifetime, except in certain high risk individuals as specified in the Canadian
Immunization Guide. Pertussis vaccine is recommended in childhood and
adolescence and once as an adult.
January 2014
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24. Can seasonal influenza vaccine be administered if other vaccines have been
received recently?
A. Yes, you can administer seasonal influenza vaccine if other vaccines have been
received recently. There is no interval of time needed between receiving seasonal
influenza vaccine and any other vaccines.
25. Where can I get more information on seasonal influenza vaccine?
A. For more information on influenza vaccine, contact your local Public Health office.
You may also check the following websites:
a. Nova Scotia Department of Health and Wellness web site
b. Public Health Agency of Canada (NACI): Statement on Seasonal Trivalent
Inactivated Influenza vaccine for 2013-2014
c. Canadian Public Health Association
January 2014
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Appendix B: ANDS Quick Reference: Influenza Case Entry
This table outlines data entry for cases of influenza in ANDS. *Indicates a mandatory field in the ANDS application
ANDS Variable
Definition and Use
Case Status*
The classification of the case at time of entry according to current provincial case
definitions:

Confirmed – refer to Table 1 for further detail.

Confirmed – Laboratory confirmed – Do Not Use

Confirmed – Epidemiologically linked – Do Not Use

Probable – Do Not Use

Possible – Do Not Use
Investigation Status*
Left to discretion of DHA to use as applicable to case management. However, once
complete, all investigations should be closed in ANDS.
Investigation Closed Date
The date the investigation was completed.
Date Reported*
The earliest date that Public Health was notified of the case.
The DHA responsible for case management. This is the DHA that enters the case into
ANDS.
DHA*
Disease Name*
Enter influenza type as appropriate from lab result (see Table 1). Please note that ANDS
entry will vary according to lab result and Table 2 is essential.
Agent Sub/Serotype
Entered by DHW Surveillance if known.
Other lab Info
Free text field. Please enter Accession Number from lab report.
Episode Date*
Episode Date Type*
Clinical Presentation
Outcome
Risk Factors for STIs Only
Where case’s illness was most
likely acquired?
Associated with an outbreak?
Outbreak Number
Received Vaccine
Vaccine Date 1 (& 2)
Vaccine Name
Comments
January 2014
The date the subject became a case of disease being reported. This field is linked with the
Episode Date Type described below. Note that the Episode Date must be the same or
earlier than the Date Reported.
(See ANDS Episode Date Hierarchy for data entry example).
The episode date type entered should follow the following hierarchy:
1. Onset date of symptoms – Use as preferred Episode Date
2. Clinical diagnosis date – Use if onset date not available
3. Specimen collection date – Use if onset date & clinical diagnosis date not
available
4. Lab test result date – Use if onset date, clinical diagnosis date & specimen
collection date not available
(See ANDS Episode Date Hierarchy for data entry example).
Do Not Use
The outcome of the case. Note that if “deceased” is selected, a date of death must be
entered.
Do Not Use
If known, enter information.
Indicate whether the case is associated with an existing outbreak.
The outbreak number of the associated outbreak, if applicable. (Follow outbreak
numbering system described in Section 3.5.3).
Do Not Use
Do Not Use
Do Not Use
Free text. Use as appropriate for case management.
26
Appendix C: ILI in Emergency Departments (ED)/Outpatient Centres
ER ICP ILI Surveillance Weekly Report Form
Emergency Department (ED) and Outpatient Centre Influenza-Like Illness Surveillance
Protocol
Background


The ED surveillance system was implemented in April 2009 with the
support of Infection Control Practitioners across Nova Scotia
ILI reports are sent to Department of Health and Wellness (DHW) and
reported weekly in Respiratory Watch
Case Definition for Surveillance Purposes
ILI is reported using the following surveillance case definition:
Acute onset* of respiratory illness with:
 Fever AND cough
 One or more of the following: sore throat, malaise, myalgia or prostration
which could be due to influenza virus. In children less than 5 years,
gastrointestinal symptoms may also be present. In those less than 5 years
or older than 65 years, fever may not be prominent.
*distinct change from normal status to respiratory illness over 1-3 days,
based on clinical judgement
Reporting to DHW

The current surveillance system is a mixture of time periods:
Daily ILI Surveillance:


 Facilities record the total number of patients seen and the number
with ILI each day for the entire surveillance week (Sunday to
Saturday)
 Data are reported to DHW once each week
 Data are reported using the ‘Daily ILI Surveillance Form’
DHW will accept, analyze and report all data
It is requested that the report be sent even if zero ILI cases were seen
Reporting Timelines



Report forms are sent to DHW via email or fax each Monday
Email: [email protected]
Fax: 902-424-0550
Please note:

If facility has chosen to create a custom report using an administrative
database with ILI data, please email or fax to DHW as above
If you have any questions, please call 902-424-6567.
January 2014
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Appendix D: School and Daycare Absenteeism
Forms available at the following websites:
School Reporting Tool
Daycare Reporting Tool
January 2014
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Appendix E: FluWatch Reporting Procedure through CNPHI
FluWatch Reporting using CNPHI
Please note that the submission deadline is Tuesday at noon
Entering a Sub-Regional Report
The data must be manually entered. After the data has been entered, click Submit to send the
data to Regional and Provincial/Territorial Reviewers and to make the report viewable to other
users within the same region.
1. In CNPHI site, select “Sub-Regional Reports” from the menu as shown:
2. Select the appropriate DHA from the drop-down menu:
3. Select the appropriate sub-region from the drop-down menu:
January 2014
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4. Manually enter the data (note that mandatory fields are marked with an asterisk):
5. Scroll down the page and click “submit” to send the data to DHW:
6. Submitted data will appear as “Published” in the application:
January 2014
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Entering a Regional Report
Please note that the submission deadline is TUESDAY at NOON.
A regional report computes a summary of influenza activity levels for the region including
detailed information from the sub-regional level reports.
Creating a Regional Report after Sub-Regional data has been entered:
1. Select “Regional Reports” from the menu as shown:
2. Select the appropriate DHA from the drop-down menu:
3. Click on the “Update Table” button to upload the data from the Sub-Regional Report into the
Regional Report:
January 2014
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4. Scroll down the page and click “submit” to send the data to DHW:
5. Submitted data will appear as “Published” in the application:
January 2014
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Appendix F: 2013-14 NS Influenza Vaccine Coverage and
Reporting
Forms available at the following website:
http://novascotia.ca/dhw/populationhealth/surveillanceguidelines/APPENDIX_C_Surveil
lance_Forms.pdf
Appendix G: Laboratory Procedures
1.
Laboratory Diagnosis/Overall Testing Rationale
Respiratory pathogen testing including Influenza testing will be available for the acute
care setting and long term care / adult residential care settings. Testing from the
community will not be performed unless special circumstances exist and on the
approval of a CDHA Microbiologist.
2.
Specimen Collection
Appropriate specimen types:
 Nasopharyngeal swab and aspirate
 Endotracheal aspirate
 Bronchial Wash/Lavage
 CSF
 Tissue
Non-appropriate specimen types (will be rejected by lab):
 Nose
 Throat and throat washings
Specimen Container:
 Flocked swab supplied with viral transport medium. These can be stored at
room temperature until use. Districts 1 through 8 should obtain their viral
collection kits from their local/regional laboratory. For District 9 (Capital District
Health only), collection kits can be ordered directly from CDHA Microbiology.
Collection Notes:
 Please check the expiration date of the container as out of date swabs will be
rejected by the laboratory.
 Specimens should be collected within 5 days of onset of symptoms, preferably
within 48 hours.
 Sampling beyond 5 days may be considered in patients with persisting or
worsening symptoms regardless of age; in young children or the elderly; and in
the immunocompromised.
 An instructional collection video is available at
http://www.youtube.com/watch?v=TFwSefezIHU
January 2014
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3.
Specimen Labeling Requirements
All specimens must be appropriately labelled with 2 unique patient identifiers and
accompanied by a completed requisition with corresponding information. One identifier
must be the patient's legal name and the other can be the medical record number for
in-patient and ambulatory care patients or the provincial health card number for
referred-in patients. If the patient does not have either a medical record or health card
number, other unique identifiers associated with the patient should be used, such as:
 registered health card equivalent
 passport number
 Capital Health invoice number
 private insurance policy number
 immigration number
 physician office’s patient chart number
Outbreak numbers are provided by Public Health Services and should be clearly
identified on the laboratory requisition.
The patient/resident setting should be clearly indicated on the laboratory requisition
 LTC/ARC facility name
 Inpatient facility name and location (ICU, Floor, etc.).
4.
Specimen Transport Conditions
Patient specimens should be kept at 4°C and received for testing at the CDHA laboratory
within 72 hours. If swabs are to be delayed in transit longer than this, they should be
frozen at -70oC or colder.
5.
Laboratory Testing
Laboratory testing during the non-peak influenza season will consist of a multiplex
nucleic acid amplification assay (NAAT) for a broad range of respiratory viral pathogens.
This includes: Influenza A, Influenza B, Respiratory Syncytial Virus as well as other viral
agents.
Laboratory testing during the peak influenza season will consist of primarily a
streamlined nucleic acid amplification assay for the detection of Influenza A, Influenza B,
Respiratory Syncytial Virus only. Additional use of the multiplex assay will be limited to
outbreaks and critically ill acute care patients unless otherwise determined in
consultation with a CDHA Microbiologist.
Public Health Surveillance Subtyping of Influenza virus type A positive samples will be
performed. Testing during the season will determine the strains which are circulating.
The CDHA Anchor Microbiology laboratory also participates in the WHO Influenza
Program offered through the National Microbiology Laboratory (NML) in Winnipeg. This
program provides valuable reference / surveillance services for influenza strain
characterization, antiviral susceptibility and molecular typing.
January 2014
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Testing frequency (weekday/weekend) is assessed on an ongoing basis by CDHA
Microbiology. Please note that turnaround time may be further impacted by
transportation from local/ regional labs to the CDHA microbiology testing facility.
IWK Health Centre
IWK Health Centre Microbiology (PPHLN Pediatric Anchor Lab) performs viral respiratory
testing for its facility. This service is under the guidance of the IWK Microbiology,
Division Head.
6.
Point of Care Testing (POC)
Rapid Influenza detection tests (RIDT) also referred to as Near-patient or POC tests, use
antigen detection technologies which can generate results in less than 30 minutes;
however the tradeoff is that of suboptimal accuracy when compared to RT-PCR. The
positive and negative predictive values of POC tests depend on the prevalence of
influenza. Performance depends on the type of specimen tested, the timing of
collection, age of the patient, and the skill with which the specimens are collected and
the tests performed.
Although there may be some utility in using RIDTs during seasonal influenza the primary
limitation of currently available RIDTs is poor sensitivity which can be as low as 10% for
pH1N1. This translates into an inability to rule out the diagnosis of influenza. As such,
RIDT have limited utility in the management of individual patients presenting with
influenza-like illness (ILI) (CPHLN, 2010).
The relatively high specificity of most RIDTs allows clinicians to be fairly confident in the
accuracy of a positive result from a patient presenting with ILI during the influenza
season. However, because of the potential for false positive results during periods of
low prevalence (i.e., summer months), positive results specimens need to be confirmed
with more specific methods such as RT-PCR.
7.




8.



9.
Reporting of Results
Positive Influenza reports including subtyping will be phoned for acute care and
LTCF/ARC settings.
Positive Influenza results will be reported to the DHA Public Health Services.
Reports for identifiable outbreaks will be followed up with Public Health Services.
All other results will be sent to the referring entity via regular reporting mechanisms.
To Access Results
Results inquiries can be directed to your local/regional lab or CDHA Central Lab
Reporting at 902-473-2266 as appropriate.
Public Health Services may contact Janice Pettipas (PPHLN Program Coordinator)
902-473-8280 for questions about results.
For other questions contact the laboratory director.
After Hours
The Microbiologist on call is accessible through QE II HSC Locating at 902-473-2222.
January 2014
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Appendix H: Influenza Case Report Form
Case Report Form: Influenza Case Report Form with Data Dictionary
January 2014
LEGIONELLOSIS
1. Information
1.1 Case definition
Confirmed case:
Clinical illness (see clinical evidence below) with laboratory confirmation of
infection:
isolation of Legionella species or detection of the antigen from
respiratory secretions, lung tissue, pleural fluid or other normally sterile
fluids
OR
a significant (e.g. fourfold or greater) rise in Legionella species IgG titre
between acute and convalescent sera
OR
IgG titre > 1:128 against Legionella species
OR
demonstration of L. pneumophila antigen in urine
Probable case:
Clinical illness with demonstration of Legionella species DNA
Clinical Evidence:
Legionellosis comprises two distinct illnesses: Legionnaires’ disease,
characterized by fever, myalgia, cough and pneumonia, and Pontiac fever, a
milder illness without pneumonia.
1.2 Causative agent
Legionella pneumophila, serogroup 1 is most commonly associated with disease,
however there are 18 serogroups. Related organisms have been isolated,
including L. micdadei, L. bozemanii, L. longbeachae and L. dumoffi. In total, 35
species of Legionella with at least 45 serogroups are currently recognized.
1.3 Symptoms
There are two distinct clinical and epidemiological manifestations of
legionellosis:
Legionnaire’s Disease.
Pontiac Fever.
The early symptoms of both diseases include anorexia, malaise, myalgia,
headache, and rapidly rising fever with chills (temperatures commonly reach 39
C to 40.5 C). Non-productive cough, abdominal pain and diarrhea are common.
For Legionnaire’s disease, chest x-rays often show pneumonia that may progress
to bilateral involvement and ultimately respiratory failure. Case fatality rates for
Legionnaire’s disease have reached as high as 39%. Pontiac fever is a milder
illness, which is not associated with pneumonia or death. Clients with Pontiac
fever usually recover spontaneously in 2-5 days.
1.4 Incubation
Legionnaire’s Disease: Usually 5-6 days, ranges from 2-10 days.
Pontiac Fever: Usually 24 to 48 hours, ranges from 5 to 6 days.
1.5 Source
Primarily sources of water, such as hot water systems (showers), air conditioning
cooling towers, evaporative condensers, humidifiers, whirlpool spas, respiratory
therapy devices and decorative fountains.
1.6 Transmission
Inhalation of mists from a contaminated water source (as named above). Person
to person transmission has not been documented.
1.7 Communicability
No person-to-person transmission.
1.8 Treatment
For Legionnaire’s disease, erythromycin is given in high doses intravenously
initially, followed by oral therapy when condition is improving. Rifampin is
recommended for patients with confirmed disease who are severely ill or
immunocompromised or in whom the infection does not respond promptly to
intravenous erythromycin. Rifampin should not be used alone.
Pontiac fever requires no specific treatment.
1.9 Core Messages for Prevention
Improved design and maintenance of cooling towers and plumbing
systems to limit the growth and spread of Legionella organisms are the
foundations of legionellosis prevention.
Tap water should not be used in respiratory therapy devices.
1.10 Prophylaxis
None.
2. Procedure
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health
a. Determine investigative responsibility.
The MOH must ensure that all reports of legionellosis are received and
disseminated to the appropriate personnel for investigation. The CDC
coordinator/ manager may assume this role in the absence of the MOH.
2.1.2 Investigator
Upon receiving the report the investigator should initiate the follow-up.
a. Determine case status.
b. Discuss case with the MOH.
c. Contact and educate the individual and /or family
Discuss the role of public health. Provide information to the individual or
family and provide fact sheets.
Inquire about water source.
Inquire about the use of humidifiers and respiratory equipment.
Inquire about whether immunocompromised
Inquire about whether the individual knows anyone else with symptoms
2.1.3 Role of the Physician
Report all cases to Public Health Services.
2.1.4 Role of the Laboratory
Report all cases to Public Health Services
2.2. Guidelines for Childcare Institutions
Investigate potential water source and air conditioners.
2.3. Guidelines for Institutions
Investigate whether there are any other cases or anyone with symptoms (case
find) indicating nosocomial transmission.
3.0 Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Legionellosis: http://www.cdc.gov/ncidod/dbmd/diseaseinfo.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics
LEGIONELLOSIS FACT SHEET
What is Legionellosis?
Legionellosis is an infection caused by the bacterium Legionella pneumophila.
The disease has two distinct forms:
Legionnaires’ disease, the more severe form of infection which includes
pneumonia, and
Pontiac Fever, a milder illness.
Outbreaks of legionellosis have occurred after persons have breathed mists that come
from a water source (e.g., air conditioning cooling towers, whirlpool spas, showers)
contaminated with Legionella bacteria. Persons may be exposed to these mists in
homes, workplaces, hospitals, or public places. Legionellosis is not passed from person
to person, and there is no evidence of persons becoming infected from auto air
conditioners or household window air- conditioning units.
Who Can Get Legionellosis?
People of any age may get Legionnaires’ disease, but the illness most often affects
middle-aged and older persons, particularly those who smoke cigarettes or have chronic
lung disease. Also at increased risk are persons whose immune system is suppressed by
diseases such as cancer, kidney failure requiring dialysis, diabetes, or AIDS. People who
take drugs that suppress the immune system are also at higher risk.
Pontiac Fever most commonly occurs in persons who are otherwise healthy.
What are the Symptoms?
Symptoms of Legionnaire’s disease may include:
Fever.
Chills.
Dry cough.
Muscle aches.
Headache.
Loss of appetite.
Diarrhea.
Pneumonia.
Symptoms of Pontiac Fever may include the symptoms above except for pneumonia.
What is the Treatment?
Antibiotics are prescribed for people with Legionnaires disease, and hospitalization is
often required. People with Pontiac fever usually recover without treatment in 2 to 5
days.
MENINGOCOCCAL DISEASE – INVASIVE
JANUARY 2007
1.0 Information
1.1 Case Definition
Confirmed case:
Clinical evidence of invasive disease1 with laboratory confirmation of
infection:
isolation of Neisseria meningitidis from a normally sterile site (blood, CSF,
joint, pleural or pericardial fluid)
OR
demonstration of N. meningitidis DNA by an appropriately validated
nucleic acid test (NAT)2 from a normally sterile site
Probable case:
Clinical evidence of invasive disease¹ with purpura fulminans or petechiae, with
no other apparent cause and with non-confirmatory laboratory evidence:
detection of N. meningitidis antigen in the CSF
Note: Meningococcal DNA can be found in the CSF up to 90 hours after
antibiotics have been started
Further to Case Definitions in this section, please note the description of
cases in the footnotes that may be useful for epidemiological purposes.3
1
Invasive meningococcal disease usually manifests itself as mentingitis and/or septicemia, although other
manifestations may be observed (e.g. orbital cellulitis, septic arthritis). Invasive disease may progress
rapidly to purpura fulminans, shock and death.
2
Each jurisdiction will have a validation process for the NAT that they have in place.
3
Sporadic Case: A single case occurring in a community where there is no evidence of an epidemiologic
link (by person, place, or time) to another case; Index Case: The first case occurring in a community;
Subsequent Case: A case with onset of illness subsequent to another case with whom an epidemiologic
link can be established. This category includes co-primary cases (a person who develops illness within 24
hours of onset of illness in the index case), as well as secondary cases (a person developing illness> 24
hours after onset of illness in the index case).
1.2 Causative Agent
Neisseria meningitidis, the meningococcus, is a gram negative aerobic
diplococcus with at least 13 serogroups. Strains belonging to groups A,C,Y and
W-135 are most commonly implicated in invasive disease.
1.3 Symptoms
Sudden onset of fever, intense headache, nausea and often vomiting, stiff neck
and photophobia. Meningococcaemia, or meningococcal sepsis, is the most
severe form of infection with petechial rash, hypotension, disseminated
intravascular coagulation and multi- organ failure.
1.4 Incubation
Usually 3 to 4 days, ranges from 1 to 10 days.
1.5 Source
Humans: Up to 5% to 10% of people may be asymptomatic carriers with
nasopharyngeal colonization of N. meningitidis. Less than 1% of those colonized
will progress to invasive disease. See Section 1.9, Core Prevention Messages.
1.6 Transmission
Person-to-person by direct contact with saliva or respiratory secretions.
1.7 Communicability
Communicable from 7 days before the onset of symptoms to 24 hours
after the institution of antibiotic treatment.
For asymptomatic carriers, communicability is difficult to determine
1.8 Treatment
Penicillin administered parenterally is the preferred choice
Cefotaxime, ceftriaxone, and ampicillin are acceptable alternatives
Chloramphenicol is recommended in patients with a penicillin allergy
Five to seven days of antibiotic treatment is adequate for most cases of
invasive disease
1.9 Core Prevention Messages
Reduce direct contact and exposure to discharge from nose and mouth
(e.g. coughing, kissing, sharing utensils, drinking glasses, cigarettes, etc.)
Reduce overcrowding in living quarters and workplaces (e.g. barracks,
dormitories, sleep-away camps and ships)
Immunize following the Nova Scotia Immunization Schedule
Consult travel health clinics if traveling to countries where disease is
endemic
Follow hand hygiene practices using plain or antimicrobial soap with
running water or an alcohol-based hand sanitizer
2.0 PUBLIC HEALTH CASE MANAGEMENT AND CONTROL
MEASURES
2.1 Case
Follow-up of meningococcal disease is a priority and the following steps must be
taken immediately:
a) Contact physician to obtain clinical information on case
b) Record age, gender, address of case
c) Interview parent or guardian to determine if case:
i. has had recent travel
ii. attends or is employed at a childcare centre or school
iii. participated in recent athletic or recreational events and/or gatherings
2.1.1 Exclusion
No exclusion required.
2.1.2 Education
See Section 1.9, Core Prevention Messages.
2.2 Contact Tracing
The cornerstone of prevention of secondary cases of invasive meningococcal
disease (IMD) is aggressive contact tracing to identify people at increased risk for
disease (e.g. close contacts) and providing chemoprophylaxis to this group of
susceptible individuals.
Chemoprophylaxis is necessary to eliminate nasopharyngeal carriage of
meningococci from any carrier within the network of close contacts.
2.2.1 Definition of Close Contacts
Household contacts of a case
Persons who share sleeping arrangements with the case
Persons who have direct contamination of their nose or mouth with the
oral/nasal secretions of a case (e.g. kissing on the mouth, shared
cigarettes, shared drinking bottles, etc.)
Health care workers (HCWs) who have had intensive unprotected contact
(without wearing a mask) with infected patients (e.g. intubating,
resuscitating or closely examining the oropharynx)
Children and staff in child care and nursery school facilities
Airline passengers sitting immediately on either side of the case (but not
across the aisle) when the total time spent aboard the aircraft was at
least 8 hours
2.2.2 Susceptibility
Susceptibility to the clinical disease is low and decreases with age, which induces
a high ratio of carriers to cases. Asplenic individuals are susceptible to this
bacteremic illness.
2.2.3 Initiate Contact Tracing
Obtain names and information for all contacts who meet the definition
outlined in Section 2.2.1.
If the case traveled within the last 10 days on a flight of 8 hours or more
(including ground time on the tarmac) during the infectious period (7
days before onset of symptoms to 24 hours after the onset of effective
treatment), then a decision must be made in consultation with the MOH
to obtain the passenger manifest. It is important to note that aircraft
passenger manifests are rarely kept after 48 hours.
Contacts do not need to be excluded from any activities.
2.2.4. Prophylaxis
Chemoprophylaxis should be offered to all persons having close contact with an
invasive meningococcal disease (IMD) case during the infectious period (the 7
days before onset of symptoms in the case to 24 hours after onset of effective
treatment), regardless of their immune status.
Chemoprophylaxis of close contacts should be administered as soon as possible
and preferably within 24 hours of case identification but is still recommended
for up to 10 days following last contact.
Chemoprophylaxis should be considered for close contacts of a case that is
strongly suspected to be IMD, even if laboratory confirmation cannot be
obtained within 24 hours.
Provide primary care physicians with “Guidelines for Prophylaxis of Contacts of
Meningococcal Disease” (Appendix 1).
Table 1: Chemoprophylaxis for Close Contacts of IMD Cases
DruDrug
DODosage
Comments
Ciprofloxacin Adults >18 years of age:
Contraindicated during pregnancy
500 mg x 1 dose PO
and lactation
Only approved for persons >18
years of age. Not recommended
for prepubertal children.
Rifampin
Adults:
Contraindicated in pregnancy.
600 mg PO q12h x 4 doses
Urine and tears may be stained
Children >1 month of age: red. Advise against wear of soft
10 mg/kg (maximum 600
contact lenses as they can also be
mg) per dose PO q12h x 4
stained.
doses
Can reduce effectiveness of oral
Infants <1 month of age:
contraceptives.
5 mg/kg per dose PO q12h Advise use of alternative
X 4 doses
contraceptive measures.
Ceftrixone Adults:
Recommended drug for pregnant
250 mg IM x 1 dose
women.
Children <12 years:
Alternative for persons who
125 mg IM x 1 dose
cannot tolerate oral medication.
Dilute in 1% lidocaine to reduce
pain at injection site.
2.2.5 Immunization
Publicly funded meningococcal vaccine should be offered to contacts of cases of
invasive meningococcal disease (IMD), as per the NACI recommendations, in
order to further reduce the risk of secondary cases beyond the benefit of
chemoprophylaxis alone.
Unimmunized household and intimate social contacts (e.g. kissing,
sharing of toothbrush) of a case of IMD due to serogroup C should
receive meningococcal C conjugate vaccine (preferable) or MenACYW-Ps
or MenAC-Ps alternatives (depending upon age) as soon as serogroup C is
identified.
Unimmunized household and intimate social contacts (e.g. kissing,
sharing of toothbrush) of a case of IMD with serogroup A, should receive
MenACYW-Ps or MenAC-Ps.
NOTE: for contacts who had a one-time exposure (e.g. health care workers
and air travel contacts) rather than ongoing exposure, chemoprophylaxis
alone is sufficient rather than immunization and chemoprophylaxis
2.2.6 Exclusion
Exclusion of contacts is not necessary.
2.2.7 Education
Review signs and symptoms of meningococcal disease and provide
contacts with the Fact Sheet (refer to Appendix 3).
Instruct contacts to seek medical attention immediately if they develop
signs and symptoms
If the index case attended a child care centre or school, see Section 2.6.2,
Guidelines for Child Care
2.2.8 Follow-Up
Inquire to confirm that contacts received appropriate prophylaxis and did
not become secondary cases
Arrange for contacts to receive vaccination if the serogroup is vaccine
preventable.
2.3 Outbreak Management
An outbreak is defined as increased transmission of N. meningitidis in a
population, manifested by an increase in cases in the same serogroup.
Outbreaks can be subdivided into organization-based or community-based
using the following criteria:
Organization-Based:
Increased transmission of N. meningitidis in an organization or institution with
two or more cases of the same serogroup occurring within a 4-week interval.
This includes restricted populations such as schools, day care centers, sports or
social groups, as well as nursing homes or long-term care facilities.
Community-Based:
Increased transmission of N. meningitidis in a community with three or more
confirmed cases of the same serogroup occurring within a three-month interval
AND an age-specific incidence OR specific community population incidence of
approximately 10/100,000, where there is an absence of an epidemiologic link
between cases. This is not an absolute threshold and should be considered in
the context of other factors.
Refer to CCDR Volume 3151, May 2005, Guidelines for the Prevention and
Control of Meningococcal Disease, Section 7.2.
2.4 Guidelines
2.4.1 Guidelines for Institutions / Long-Term Care Facilities
In health care facilities, when caring for a case with meningococcal
disease, only persons with intensive exposure to nasopharyngeal or
respiratory secretions require prophylaxis. This is in the absence of a
mask as during an attempt to resuscitate an individual.
For residents of long-term care facilities, please refer to Section 2.2.1. to
determine which individuals meet the contact definition.
2.4.2 Guidelines for Child Care
Attendees and staff should be evaluated as to whether they meet the
definition of a contact. See Section 2.4.1.
If the index case attended a childcare centre or school, all parents of
children within the centre/school must be notified and given information
regarding signs and symptoms of IMD and whether or not their child(ren)
are considered to be contacts of the case. See sample letters in Appendix
2.
Consider providing education sessions to staff of the childcare centre or
school regarding signs and symptoms of IMD and the necessity of prompt
medical attention should symptoms develop in the children or staff.
2.5 Public Health Laboratory Role
Contact Laboratory:
Meningococcal isolates from all IMD should routinely be sent to the
provincial laboratory (located at the QEII Health Sciences Centre, Halifax)
to ensure appropriate and timely monitoring of serogroups and for
antibiotic susceptibility testing.
consider requesting provincial laboratory to forward isolates to the
Public Health Agency of Canada’s National Microbiology Laboratory
(NML) for further phenotypic typing and genetic analysis.
3.0 SURVEILLANCE
CIOSC Public Health Alert is recommended.
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 18th edition. 2004. David L. Heymann, Editor.
American Public Health Association.
Guidelines for the Prevention and Control of Meningococcal Disease. CCDR, May 2005. Public
Health Agency of Canada.
Report of the Committee on Infectious Diseases. 2003. American Academy of Pediatrics.
De Wals P, Hertoghe L, Borlée-Grimée I, et al. Meningococcal disease in
Belgium. Secondary attack rate among household, day-care nursery and preelementary school contacts. J Infect 1981; 3 (suppl 1): 53-61
Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Prophylactic use of antibiotics for prevention of
meningococcal infections: systematic review and meta-analysis of randomised trials. Eur J Clin
Microbiol Infect Dis 2005; 24(3): 172-81.
Meningococcal Disease Surveillance Group. Meningococcal disease: secondary attack rate and
chemoprophylaxis in the United States, 1974. JAMA 1976; 235: 261-265.
Cooke RPD, Riordan T, Jones DM, et al. Secondary cases of meningococcal infection among close
family and household contacts in England and Wales, 1985-1987. Br Med J 1989; 298: 555-558.
Stroffolini T, Rosmini F, Curiano CM. A one year survey of meningococcal disease in Italy. Eur J
Epidemiol 1987; 3: 399-403.
Olivares R, Hubert B. Clusters of meningococcal disease in France (1987- 1988). Eur J Epidemiol
1992; 8: 737-42.
APPENDIX 1: PHYSICIAN GUIDELINES FOR
PROPHYLAXIS OF CONTACTS OF
MENINGOCOCCAL DISEASE
The following information is provided by Public Health Services to assist you in the
chemoprophylaxis of close contacts of a case of invasive meningococcal disease.
Close contacts are defined as:
household contacts of a case
persons who share sleeping arrangements with the case
persons who have direct contamination of their nose or mouth with the
oral/nasal secretions of a case (e.g. kissing on the mouth, shared
cigarettes, shared drinking bottles)
health care workers who have had intensive unprotected contact
(without wearing a mask) with infected patients (e.g. intubating,
resuscitating or closely examining the oropharynx)
children and staff in child care and nursery school facilities
airline passengers sitting immediately on either side of the case (but not
across the aisle) when the total time spent aboard the aircraft was at
least 8 hours
Chemoprophylaxis for Close Contacts of IMD Cases
DruDrug
DODosage
Comments
Ciprofloxacin Adults >18 years of age:
Contraindicated during pregnancy
500 mg x 1 dose PO
and lactation
Only approved for persons >18
years of age.
Not recommended for
prepubertal children.
Rifampin
Adults:
Contraindicated in pregnancy.
600 mg PO q12h x 4 doses
Urine and tears may be stained
Children >1 month of age: red. Advise against wear of soft
10 mg/kg (max 600 mg) per contact lenses as they can also be
dose PO q12h x 4 doses
stained.
Infants <1 month of age:
Can reduce effectiveness of oral
5 mg/kg per dose PO q12h contraceptives.
X 4 doses
Advise use of alternative
contraceptive measures.
Ceftrixone Adults:
Recommended drug for pregnant
250 mg IM x 1 dose
women.
Children <12 years:
Alternative for persons who
125 mg IM x 1 dose
cannot tolerate oral medication.
Dilute in 1% lidocaine to reduce
pain at injection site.
APPENDIX 2: SAMPLE LETTERS
APPENDIX 3: MENINGOCOCCAL DISEASE FACT
SHEET
What is Meningococcal Disease?
Meningococcal disease is a bacterial infection that is spread by direct contact with
secretions from the nose and mouth. The infection can be in the blood
(meningococcemia) or in the lining of the brain and spinal cord (meningitis).
Who Can Get Meningococcal Disease
Anyone can get meningococcal disease. It is spread by direct contact with secretions
from the nose and mouth through activities such as kissing, sharing food, drinks, water
bottles, toothbrushes, eating utensils or cigarettes.
What are the Symptoms?
Symptoms may include:
fever
headache
change in the level of alertness
stiff neck
small, purplish rash may develop on the upper body
nausea
vomiting
What is the Treatment?
Meningococcal disease can be treated with antibiotics. Early diagnosis and treatment
are important. If symptoms occur, contact your family doctor or visit the nearest
emergency department to you immediately.
How Can Meningococcal Disease be prevented?
Reduce direct contact and exposure to discharges from nose and mouth
(e.g. coughing, kissing, sharing utensils, drinking glasses, cigarettes, etc.)
Reduce overcrowding in living quarters and workplaces (e.g. barracks,
dormitories, sleep away camps, ships, etc.)
Immunize following the Nova Scotia Immunization Schedule
Consult a travel health clinic if traveling to countries where
meningococcal disease is endemic
Follow hand hygiene practices using plain or antimicrobial soap with
running water or an alcohol-based hand sanitizer
MRSA / VRE
JANUARY 2007
1. Information
For information and procedures related to methicillin-resistant Staphylococcus auresus
(MRSA) and vancomycin-resistant enterococci (VRE), refer to Partners for Infection
Control Manual, available in all district Public Health Services Offices.
COMMUNITY-ASSOCIATED MRSA (CAMRSA) FACT SHEET
OCTOBER 2008
What is CA-MRSA?
CA-MRSA (Community-Associated Methicillin Resistant Staphylococcus Aureus) is a type
of bacteria or germ that is not killed by the most common antibiotics (like Penicillin). If
these germs cause an infection, then a stronger antibiotic must be used. Most often
these bacteria cause skin infections (like pimples and boils); but they can also cause
more serious infections (like pneumonia or infections in an incision after an operation).
What is the Difference between Being Colonized and
Being Infected?
MRSA is a germ that lives on the skin and in the nose of about 25 per cent of us. This is
called colonization, and occurs with other germs all over our bodies. It does not
normally cause a problem. MRSA, however, can cause infections such as boils and
abscesses. In the hospital, it can cause more serious infections in those patients who are
already ill.
How do you get CA-MRSA?
Most MRSA infections happen to people in hospitals or nursing homes who have weak
immune systems. MRSA can also cause infections in people who have not been in the
hospital or a nursing home, and these infections are called community-associated MRSA
(CA-MRSA). You can get this infection from:
skin-to-skin contact with someone who has this infection.
touching things (e.g., towels) or surfaces (e.g., benches) that have
drainage or pus on them.
openings in your skin, like cuts or scrapes.
not washing your hands or not washing them well enough.
What are the Symptoms?
Most people with CA-MRSA have skin infections. Symptoms on the skin may include:
a pimple or boil
redness or swelling
pain
pus or other drainage
More serious infections can cause pneumonia or bloodstream infections.
What is the Treatment?
Many of these infections can be treated by draining the abscess or boil and may not
need antibiotics. Drainage should only be done by a health-care provider. Contact your
doctor if the infection is not getting better after a few days following drainage. At that
point, you may need to be treated with an antibiotic for a period of time. If you are
given an antibiotic, take all of the doses, even if the infection is getting better, unless
your doctor tells you to stop taking it. Do not share or save your antibiotics. If other
people you know or live with get the same kind of infection, tell them to go to their
doctor.
How can you Prevent CA-MRSA?
Practice good general hygiene (e.g., take regular baths or showers).
Keep your hands clean by washing them often with soap and water. If
there is no soap or water available, you can use an alcohol-based hand
sanitizer.
Keep cuts and scrapes clean and covered with a bandage or dressing until
healed.
Do not touch other people’s cuts or bandages.
Do not share personal items such as towels, razors, creams, lotions, and
soaps.
Clean
sports
equipment
that
touches
the
skin
with
detergents/disinfectants (e.g., Lysol). It’s very important that gym
equipment be cleaned before and after each use.
Make sure that your family and others in close contact with you wash
their hands often with soap and water or use an alcohol-based hand
sanitizer if there’s no soap and water available.
PEDICULOSIS (LICE)
This is not an infectious disease. Lice are a nuisance.
1. Information
Identification of adult lice or nits (eggs) on the head or attached to hair shaft, on the
body and/or the pubic areas and the presence of symptoms consistent with infestation.
1.2 Causative agent
Three species of lice: Pediculosis humanus capitis (head louse), P. humanus
corporis (body louse), and Pthirus pubis (pubic or crab louse).
1.3 Symptoms
Intense itching, worse at night. The louse bites develop as painless macules and
then papules, especially on the scalp. Scratching may lead to excoriation.
Secondary infection may occur with ensuing regional lymphadenitis.
1.4 Incubation
The eggs (nits) usually take 1 week to hatch. There may be a slightly longer
incubation period depending on the type of contact. The egg-to-egg cycle is
approximately 3 weeks.
1.5 Source
Humans.
1.6 Transmission
Direct contact is the most frequent mode of transmission; however the lice can
live on clothing, bedding or other personal items, like hats or hairbrushes. Pubic
lice are usually transmitted through sexual contact, or bedding or shared towels.
1.7 Communicability
Exists as long as the lice and nits are alive, on the individual or in clothing and
other personal articles.
1.8 Treatment
Shampooing a permethrin-based product into the hair, to be left on for 10
minutes is the treatment of choice. The permethrin solution should kill the nits
as well. In the case of a pregnant woman or a child under two, the physician
should be contacted. Lindane based products may have some potential toxicity,
however they are still effective when used according to product instructions. A
second treatment 7-10 days after the first is suggested to kill newly hatched lice.
Lindane should be used with caution in pregnant women, children under 2 years
of age and on people with inflamed or traumatized skin.
1.9 Core Messages for Prevention
Avoid contact with the personal belongings such as hats, brushes etc. of
individuals known to have lice or nits.
Launder clothing, bedding and other personal belongings in hot water (55
degrees C or 131 degrees F for 20 minutes).
Educate the public especially children about lending combs, brushes, hats
and other personal belongings.
1.10 Prophylaxis
None.
2. Procedure
Refer to the “Guidelines for Treatment of Pediculosis Capitis (Head Lice)
document located at:
http://www.gov.ns.ca/hpp/resources/policiesandreports.asp
For useful facts and other information for the public please refer to the “How to
Prevent, Find, and Treat Headlice” pamphlet located at:
http://www.gov.ns.ca/hpp/resources/other.asp
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association. Infection Control in the Child Care Center and Preschool 3rd edition –
1996-Leigh G. Donowitz editor Head Lice Information
Package, Developed by Public Health Services, Nova Scotia Central Regional Health Board, Aug.
2000
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
PNEUMOCOCCAL DISEASE-INVASIVE
1.0 Information
1.1 Case definition
Confirmed case:
Clinical evidence of invasive disease (see clinical evidence) with laboratory
confirmation of infection:
isolation of Streptococcus pneumoniae from a normally sterile site
(excluding the middle ear and pleural cavity)
OR
demonstration of S. pneumoniae DNA from a normally sterile site
(excluding the middle ear and pleural cavity)
Probable case:
Clinical evidence of invasive disease with no other apparent cause and with
non-confirmatory laboratory evidence:
demonstration of S. pneumoniae antigen from a normally sterile site
(excluding the middle ear and pleural cavity)
Clinical Evidence
Clinical illness associated with invasive disease manifests itself mainly as
pneumonia with bacteremia, bacteremia without a known site of
infection, and meningitis. Pneumonia without bacteremia is not notifiable
1.2 Causative agent
Streptococcus pneumoniae (pneumococcus). 23 of the most common types
account for about 90% of infections.
1.3 Symptoms
Sudden onset of fever, pleural pain, difficulty or rapid breathing, productive
cough of rusty sputum. If pneumococcal meningitis, symptoms may include:
fever, lethargy, severe headache, vomiting, and stiff neck.
1.4 Incubation
May be as short as 1-3 days.
1.5 Source
Humans. Pneumococci are commonly found in the upper respiratory tract of
healthy people.
1.6 Transmission
By droplet spread or direct oral contact, or indirectly via articles contaminated
with respiratory secretions. Person to person transmission is common, but illness
among casual contacts or attendants is infrequent.
1.7 Communicability
Until respiratory discharges no longer contain bacteria in significant numbers.
14-28 hours after administration of penicillin.
1.8 Treatment
Penicillin G parenterally. Erythromycin may be used for clients who are allergic
to penicillin. Penicillin-resistant strains are known, therefore identification of the
strain is important.
1.9 Core Messages for Prevention
Avoid crowded living conditions wherever possible.
Vaccinate high-risk populations with pneumococcal vaccine:
People 65 years of age or older.
Residents of nursing homes and homes for the aged.
All persons, 2 years of age or older with chronic:
 Cardiac diseases
 Pulmonary diseases
 Asthma (only if associated with chronic bronchitis, emphysema or
long term use of systemic corticosteroids)
 Diabetes and other metabolic disorders
 Renal diseases
 Liver diseases
 Sickle cell disease or sickle cell anaemia, splenectomy
 Immunosuppression (Hodgkin’s disease, lymphoma, organ
transplantation, cancers)
 Human Immunodeficiency Virus
 Alcoholism
Routine revaccination is not recommended, however, revaccination
should be considered for those of 2 years of age or older at highest risk of
invasive infection, including those with functional or anatomic asplenia,
or sickle-cell disease, debilitating cardio-respiratory disease, hepatic
cirrhosis, chronic renal failure or nephrotic syndrome, HIV infection and
other conditions associated with immunosuppression. A single
revaccination is recommended after 5 years in those over 10 years of age
and after 3 years in those younger than 10 years. Experience with
revaccination is still limited and there are no data on the relative
effectiveness of a second dose.
1.10 Prophlyaxis
None.
2.0 Procedure
No Public Health follow-up required. This disease is notifiable.
3.0 Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Canadian Immunization Guide 5th Edition. 1998.Health Canada.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association.
Pneumococcal Polysaccharide Vaccine: What You Should Know.
www.cdc.nip/publication/VIS/VIS-ppv.pdf Streptococcus Pneumoniae Disease.
www.cdc.gov/ncidod/dbmd/diseaseinfor/streppneum_t.htm
Pneumococcal Disease Fact Sheet
What is Pneumococcal Disease?
Pneumococcal disease is caused by bacteria. There are many different types of
pneumococcal bacteria that can cause serious infections of the lungs (pneumonia), the
blood (bacteremia), and the coverings of the brain (meningitis). If not treated, the
disease can cause death.
Who Can Get Pneumococcal Disease?
Anyone can get Pneumococcal disease. However, some people are at greater risk from
the disease. These include:
People 65 years or older.
Children less than 2 years old.
People with problems such as alcoholism, heart or lung disease, kidney
failure, diabetes, HIV infection or certain types of cancer.
People who have had their spleen removed.
People with sickle cell disease.
What are the Symptoms?
Symptoms may include:
Fever
Difficult or rapid breathing
Cough that may produce rusty-coloured mucous
If pneumococcal meningitis, symptoms may include:
Fever
Loss of appetite
Stiff neck
Severe headache
Tiredness
Vomiting
What is the Treatment
Drugs such as penicillin were once effective in treating these infections, but the disease
has become more resistant to these drugs, making treatment more difficult. Your doctor
will decide which antibiotic is best to treat the disease.
How Can You Prevent Pneumococcal Disease?
There is a vaccine to prevent most types of pneumococcal infections. People who are at
greater risk from the disease (see above) should talk to their doctor or Public Health
Services about getting the vaccine.
SCABIES
1. Information
1.1 Case definition
Identification of the itch mites’ eggs or scybaia (feces) from skin scrapings of
unexcoriated lesions. Intensely pruritic papular eruptions and linear burrows on
the finger webs, wrists, elbows, axillary folds, knee folds, belt line, thighs, navel,
abdomen, genitals and buttocks, in adults. In infants, the head and neck as well
as the palms and soles are often affected.
1.2 Causative agent
The mite Sarcoptes scabiei.
1.3 Symptoms
Severe itching, especially at night, in the areas of the papular eruptions. Small
blisters or vesicles may be evident. In infants, there may be a generalized rash
instead of the typically separated scabies lesions in the adult. If scratching is
vigorous, secondary infection of the lesions may be evident.
1.4 Incubation
Two to six weeks before onset of itching, if not previously exposed. In those who
have been previously infested, the incubation may be only 1-4 days
1.5 Source
Humans.
1.6 Transmission
Direct skin to skin contact or through sexual contact or possibly through contact
with the bedclothes or towels of infected individuals.
1.7 Communicability
Usually until after 1 or 2 courses of treatment, 7 days apart.
1.8 Treatment
The recommended treatment is one application of a cream or lotion containing
5% Permethrin. The cream or lotion should be left on for only 8-14 hours and
then washed off. Alternative treatment by lindane containing products can also
be effective, though they should be used with caution in children under 2 years
of age. The individual should check with a physician if pregnant or if a child under
2 years of age is infected.
1.9 Core Messages for Prevention
Avoid skin-to-skin contact with those who are known to have or
suspected of having scabies.
Avoid sharing personal belongings of those who are known to have or are
suspected of having scabies.
Launder bedding and clothing of infected individuals and all those who
are in close contact with the infected individual. Wash clothes in hot
water or dry in hot drying cycle. For heavy blankets, jackets, etc., put in
dryer on high for 15 minutes.
Exclude from school or childcare anyone who has been diagnosed with
scabies until 24 hours after treatment has been completed.
1.10 Prophylaxis
None.
2. Procedure
Refer to Partners for Infection Control manual for management in long term care
facilities.
2.1 Roles and Responsibilities
2.1.1 Investigator
Follow-up is optional. Follow up cases of scabies from either physicians or school
with a phone call or visit if the individual needs education or help with
treatment.
a. Discuss treatment regimen with the individual, parent or guardian.
Permethrin containing products are recommended in the treatment of scabies.
However, the family physician may have prescribed another medication. It is
important to make sure that the treatment regimen is understood.
Stress that the individual follow the instructions enclosed with the
product.
Discuss the need for lotion to be used only for 8-12 hour period and then
washed off. Tell individuals to keep fingernails short and clean in order to
minimize the risk of secondary infection from scratching.
Educate about the need for laundering of bedclothes of infected
individuals and other close contacts in the household.
b. Contacts
All family or close household contacts that have skin-to-skin contact with the
infected individual should also be treated with a full treatment regimen, to
ensure that the infection does not spread.
c. Exclusion and return to work
Tell the individual, parent or guardian that they or their children may return to
work, childcare or school the day after treatment is completed.
2.2 Criteria for Exclusion
Exclude infected individuals from work, school and childcare until 24 hours after
treatment is completed.
2.3 Guidelines for Child Care Centres
Exclude until child has been treated.
2.4 Guidelines for Institutions
Scabies outbreaks in chronic care facilities are not unusual. It may also be
necessary to treat staff and their families when care involves skin-to-skin
contact. Accurate diagnosis, timely treatment and supportive therapy of
continuous outbreaks are recommended. Refer to the document Partners for
Infection Control manual available from Public Health Services.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association. Working Guide: Notifiable Disease Reporting System in Nova Scotia.
1998. Nova Scotia Department of Health.
VIRAL MENINGITIS
1. Information
1.1 Case definition
Clinically compatible symptoms or laboratory-confirmed virus identification
1.2 Causative agent
A wide variety of agents, many of which are associated with other diseases.
Many viruses are capable of producing features of meningeal irritation. Half of all
cases have no etiology demonstrated. In Canada, enteroviruses cause most cases
of known etiology, particularly coxsackievirus and echovirus. In addition,
arboviruses, measles, herpes simplex and varicella viruses, adenovirus and
others are responsible for sporadic cases.
1.3 Symptoms
Viral meningitis is a relatively common but rarely serious syndrome with multiple
viral etiologies. It usually presents as a sudden onset of fever, with headache,
and other signs of meningeal involvement and abnormal CSF findings. A rash
resembling rubella characterizes certain types of viral meningitis caused by
echoviruses and coxsackieviruses; vesicular and petechial rashes may also occur.
Active illness seldom exceeds 10 days. Recovery is usually complete. GI and
respiratory symptoms may be associated with infection with enteroviruses.
1.4 Incubation
Depends on the specific virus, but for enteroviruses often 3 to 5 days.
1.5 Source
Humans and probably certain birds, mammals and reptiles.
1.6 Transmission
Depends on specific virus, but for enteroviruses, generally directly by fecal-oral
or respiratory droplet contact with an infected person, or indirectly by contact
with articles freshly soiled with feces or throat discharges from an infected
person.
1.7 Communicability
Depends on the specific virus.
1.8 Treatment
None for the usual causative agents.
1.9 Prophylaxis
None.
2. Procedure
No public health follow-up required. It is notifiable.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Manitoba CDC Manual
VIRAL MENINGITIS FACT SHEET
What is Viral Meningitis?
Viral meningitis is an inflammation of the lining of the brain caused by a virus. It is a
relatively common but rarely serious disease.
Who Can Get Viral Meningitis?
Anyone can get viral meningitis. It can be caused by any of the common viruses such as
the common cold, or chicken pox, mumps, etc.
What are the Symptoms?
Symptoms may include:
Headache
Nausea
Vomiting
Fever
Stiff Neck
Chills
What is the Treatment?
There is no specific treatment but the symptoms may be treated.
How Can You Prevent Viral Meningitis?
Practice good hand washing.
Cover your mouth when coughing or sneezing.