What is meant by Essential Public Health Services?

The Essential Public Health Services are a national standard that provides a working definition of public health and a guiding framework for the responsibilities and public health activities that should be undertaken in all communities. All essential public health services are categorized into three overarching core public health functions: Assessment, Assurance, and Policy Development. Within those three core public health functions, you can find each of the ten essential public health services. The ten Essential Public Health Services include:

1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8. Ensure a competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.

The Three Core Public Health Functions and how they relate to the Ten Essential Public Health Services

Public health surveillance of reportable diseases/conditions is linked to the Core Public Health Function of Assessment and to the Essential Public Health Services #1 - Monitor health status to identify and solve community health problems and #2 - Diagnose and investigate health problems and health hazards in the community.

What is the difference between reportable and notifiable diseases/conditions?

State Reportable Diseases/Conditions. Missouri has the authority to define conditions of public health importance, also known as State Reportable Diseases/Conditions. Potential (suspect) cases of disease are reported from hospitals, laboratories, and health care providers to local, regional, or state public health agencies in a process known as “reporting”. Reporting can be based on a positive laboratory test, clinical symptoms, or epidemiologic criteria (called Reporting Criteria). A public health investigation is sometimes conducted to determine and implement appropriate public health interventions. Each state has its own list of State Reportable Diseases/Conditions (printer-friendly version of list) detailing diseases and events necessary to report.

National Notifiable Diseases/Conditions. The Centers for Disease Control and Prevention (CDC) and the Council of State and Territorial Epidemiologists (CSTE) designate certain diseases/conditions as nationally notifiable. CDC requests that states notify them when an instance of a disease or condition occurs that meets notification criteria. When a reported case is determined to meet notification criteria, de-identified data is sent to CDC. This can include information reported to public health by laboratories and health care providers, along with other information collected during public health investigations. A condition might be on the Missouri list of State Reportable Diseases/Conditions that is not on the national list. Each state carries the authority to determine which diseases/conditions are required to be reported by its health care entities.

Why report communicable diseases/conditions?

The reporting, investigation, and surveillance of communicable diseases/conditions is linked to the Core Public Health Function of Assessment and to the Essential Public Health Services #1 - Monitor health status to identify and solve community health problems and #2 - Diagnose and investigate health problems and health hazards in the community. The public health system depends upon reports of diseases to monitor the health of the community and to provide the basis for preventive action. Prompt reporting by mandated reporters such as physicians, laboratory scientists, and other health care professionals of both diagnosed and suspected communicable diseases, allows for timely action by local and state public health personnel. This teamwork makes possible important benefits, as listed below, for individual patients and the community.

1. To identify outbreaks and epidemics. If an unusual number of cases occur, local health authorities will investigate and implement measures to control the spread of the disease.
2. To enable preventive treatment and/or education to be provided.
3. To help target prevention programs, identify needs, and efficiently use scarce resources.
4. To evaluate the success of long term prevention and control efforts.
5. To comply with Missouri’s public health laws and rules (RSMo 192.020, 19 CSR 20- 20.020, and 19 CSR 20-20.070). All health care providers and laboratories are required to report certain cases of communicable disease.
6. To facilitate epidemiologic research to uncover a preventable cause.
7. To assist with national and international disease surveillance efforts. Missouri is part of a national network that the federal government depends on to determine whether national or international investigations are needed.

Accurate and complete disease reporting is essential to the community’s health.

Where and how should health care providers report?

The presence or suspected presence of State Reportable Diseases/Conditions requires reporting to the appropriate local public health agency or to the Missouri Department of Health and Senior Services (MDHSS). To report to MDHSS during business hours, call 573-751-6113; after hours and on weekends, call 800-392-0272 or by fax 573-526-0235. The "appropriate local public health agency" means:

• The local public health agency that has jurisdiction where an individual who has a disease or condition resides or
• The local public health agency in which the service provider or facility is located.

Communicable diseases or conditions may be reported using the MDHSS Communicable Disease Case Reports (CD-1) and should be faxed or mailed to your local public health agency or MDHSS. NOTE: Influenza, Vancomycin-resistant Enterococci (VRE), and Methicillin-resistant Staphylococcus aureus (MRSA) are not reported via a CD-1. Please refer to 19 CSR 20-20.020 for specifics. The telephone numbers of your county or city public health agency are usually listed in the phone book with other county services. For a Directory of Missouri’s Local Public Health Agencies, you may visit this website.

In some jurisdictions, the local public health agency where your practice or facility is located may desire to have all reports routed through them. Please contact your local public health agency for further information on the mechanism of reporting for your area. A Directory of Missouri’s Local Public Health Agencies can be found by visiting this website.

What conditions should be reported, when should these conditions be reported to public health, and why should health care providers report communicable diseases/conditions?

The MDHSS rule for the Reporting of Communicable, Environmental and Occupational Diseases is 19 CSR 20-20.020. The rule designates the disease(s) or suspected case of disease(s) and/or a positive laboratory result(s) that must be reported to the local health authority or MDHSS and establishes when they must be reported. A list of State Reportable Diseases/Conditions may be found by visiting this website (this list contains all of Missouri’s reportable diseases and conditions with the required reporting timeframes).

The information collected through 19 CSR 20-20.020 flows from the local public health jurisdictions to the Department and on to the national CDC. Data are linked to the national level through the CDC’s National Notifiable Diseases Surveillance System (NNDSS). This information is critical for two reasons:

1. It enables public health agencies to act quickly to prevent the spread of disease and,
2. It provides an overall picture of disease trends at the local, state and national levels. Analyzing these trends allows public health to target resources where they are most needed and to assess public health’s effectiveness in preventing and controlling disease.

What is the CDIRM?

The Communicable Disease Investigation Reference Manual (CDIRM) was written to provide technical assistance for public health disease investigations, establish appropriate control measures, and assistance with disease reporting and reportable disease surveillance activities for the protection of public health as described in RSMo. 192.020. This document contains disease-specific information, reporting criteria, reporting forms, case investigation forms, and other tools to assist the local and state health departments with the above-mentioned tasks.

The CDIRM is compiled from a number of references, is based on current science, and is considered appropriate by medical experts. Some of the references used are from the CDC, American Public Health Association, American Academy of Pediatrics, and Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, to name a few. The references used for each disease section are provided at the end of the disease section. The CDIRM is a dynamic document and will be revised as needed or required by funding sources.

What are the roles and responsibilities of Missouri’s local and state public health agencies regarding communicable disease reporting?

When case reports are received by the local public health agencies, they should report the conditions as soon as possible to MDHSS. This can be done by faxing the report to the appropriate MDHSS district office or entering the case report into the Missouri Health Surveillance Information System, known as ShowMe WorldCare. The case should be entered as a “suspected” case until the local health department has determined if the report meets the case definition of a reportable condition as provided in CDC’s National Notifiable Diseases Surveillance System (NNDSS). Since not all positive laboratory reports represent cases and not all initial case reports are supplemented or confirmed by a positive laboratory report, additional information will be needed.

Complete information, including clinical and laboratory findings, should be obtained by the local public health agency from the reporter, allowing a decision to be made regarding the status of the report. Once it is determined that a report represents a suspected, probable, or confirmed case status; staff at the local public health agency should enter this information in WebSurv and forward any additional reports and forms not available in WebSurv to the appropriate MDHSS district office.

Some reportable diseases require supplemental reports that should be completed by public health as part of the case investigation. Some of these forms are from MDHSS; others are from the CDC. Generally, these forms are completed by the local public health agency.

Forms can be completed in ShowMe WorldCare. Those that are not available in WorldCare should be sent to the appropriate MDHSS district office. This information allows for disease prevention and control measures to be instituted, and in some cases, allows identification of outbreaks. MDHSS will adhere to the following protocol to notify CDC about the occurrences of Nationally Notifiable Conditions:

Protocol for MDHSS to Notify CDC about the Occurrences of Nationally Notifiable Conditions, 2013.

Source: CSTE Official List of Nationally Notifiable Conditions.

¹ Viral hemorrhagic fever diseases: Ebola, Marburg, Lassa, Lujo, new world Arenavirus (Guanarito, Machupo, Junin, and Sabia viruses), or Crimean-Congo.

² Arboviral diseases: California serogroup virus disease (Calif. Serogroup), Eastern equine encephalitis virus disease (EEE), Powassan virus disease (Powassan), St. Louis encephalitis virus disease (SLE), Western equine encephalitis virus disease (WEE), West Nile virus disease (WNV).

³ Notification for all confirmed cases of cancers should be made at least annually.

⁴ Outbreaks are defined by state and local health departments, all situations deemed by a local or state health department to be an outbreak are notifiable.

⁵ Notification for lead exposure screening results should be submitted quarterly for children and twice a year for adults.

Information from individual case reports is forwarded to CDC by MDHSS without personal identifiers. State statistical summaries are published annually, and national statistical summaries appear weekly in CDC's Morbidity and Mortality Weekly Report. There are limitations to the data provided in these reports for the following reasons:

• Sick people do not always seek medical care, and
• Healthcare providers and others do not always recognize, confirm, or report notifiable conditions.

Therefore, reported cases may represent only a fraction of the actual burden of disease.

What is ShowMe WorldCare?

ShowMe WorldCare is a comprehensive reportable conditions system that can receive electronic reports from laboratories, health care providers, and other data submitters. Public health staff review incoming data and take appropriate action to reduce further spread and lessen the impact of these conditions. ShowMe WorldCare allows these staff to review for potential clusters or outbreaks and provide any necessary case management services to affected individuals. For more information, visit the ShowMe WorldCare Resource Hub.

What is the local public health agency system and communicable disease services in Missouri?

Missouri is served by a system of local public health agencies that provide many public health services, including communicable disease-related services, to all citizens and health care providers in their jurisdictions.

Local public health agencies function as administratively autonomous units, separate from MDHSS. As such, they set their own priorities for how they allocate the resources available to them. Most local public health agencies are able to provide a wide range of communicable-disease-related services. Some of the communicable disease services that are frequently offered include:

• Communicable disease consultation, including information on testing and specimen requirements
• Provision of diagnostic, treatment, and partner services for sexually-transmitted diseases and HIV infection
• Childhood immunization clinics
• Animal bite consultation services
• Tuberculosis consultation and treatment services

The primary role of the MDHSS (the state health department) in communicable disease control and prevention is to provide the framework for the three core public health functions: assurance, assessment, and policy development. These core public health functions may be supported by, but are not limited to, the following activities: expert consultation, reference-level diagnostic laboratory services, providing childhood vaccines, providing support as needed to Missouri’s local public health agencies, and ensuring the health and safety of the public. MDHSS also interfaces with the CDC on issues related to multistate outbreak investigation, analysis of unusual organisms, and reviews case reports in WebSurv for national case definitions and key variables accuracy. Select data stored in WebSurv is forwarded to CDC to comply with National Notifiable Diseases/Conditions reporting.

What authorizes health care professionals to report communicable diseases/conditions?

The rule 19 CSR 20-20.020 may be viewed online. Section (6) states: A physician, physician’s assistant, nurse, hospital, clinic, or other private or public institution providing diagnostic testing, screening or care to any person with any disease, condition or finding listed in sections (1)–(4) of this rule or who is suspected of having any of these diseases, conditions or findings, shall make a case report to the local health authority or the Department of Health and Senior Services, or cause a case report to be made by their designee, within the specified time.

What are the laboratory reporting requirements?

The rule 19 CSR 20-20.080 Duties of Laboratories may be viewed online. The purpose of this rule is to establish the responsibility of laboratories to report to the MDHSS specified results of tests and to submit isolates/specimens to the state public health laboratory for certain diseases and conditions.

Why are reportable disease case definitions needed?

The case definitions provided in this manual are from CDC’s National Notifiable Diseases Surveillance System (NNDSS). They were developed by epidemiologists at the CDC in collaboration with the CSTE. They are used by all states so that reporting to the National Electronic Telecommunications System for Surveillance (NETSS), maintained by CDC is standardized and uniform to allow for comparison of data across all states. CDC receives case notifications from 57 reporting jurisdictions. Each state has laws requiring certain diseases to be reported at the state level, but it is voluntary for states to provide information or notifications to CDC at the federal level.

The notifiable disease data voluntarily shared by these 57 jurisdictions represents a small portion of the public health surveillance data that jurisdictions collect and use to make decisions and conduct public health activities in their communities (e.g., outbreak detection and control). [A few case definitions were modified in this manual to make them consistent with their use in Missouri. In some instances, there was no case definition in the MMWR reference cited above for the condition being reported in Missouri.]

What impact does HIPAA have on communicable disease/condition reporting?

None, the Privacy Rule in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows for the disclosure of protected health information, without individual client or patient authorization, to public health authorities, who are legally authorized to receive such reports for the purpose of preventing or controlling disease. Physicians or other health care providers who are concerned about reporting communicable diseases as required under Missouri’s public health law and rules can be reassured by visiting the U.S. Department of Health and Human Services website “Understanding HIPAA Privacy / Public Health”.

Should confidential information from a patient’s medical records be provided to public health?

Yes, this is allowed under Missouri law RSMo 192.067 Patients' medical records, department may receive information from--purpose--confidentiality--immunity for persons releasing records, exception--reimbursement of costs of abstracting data — penalty.. The statute states:

1. The department of health and senior services, for purposes of conducting epidemiological studies to be used in promoting and safeguarding the health of the citizens of Missouri under the authority of this chapter is authorized to receive information from patient medical records. The provisions of this section shall also apply to the collection, analysis, and disclosure of nosocomial infection data from patient records collected pursuant to section 192.667 and to the collection of data under section 192.990.
2. The department shall maintain the confidentiality of all medical record information abstracted by or reported to the department. Medical information secured pursuant to the provisions of subsection 1 of this section may be released by the department only in a statistical aggregate form that precludes and prevents the identification of patient, physician, or medical facility except that medical information may be shared with other public health authorities and coinvestigators of a health study if they abide by the same confidentiality restrictions required of the department of health and senior services and except as otherwise authorized by the provisions of sections 192.665 to 192.667, or section 192.990. The department of health and senior services, public health authorities and coinvestigators shall use the information collected only for the purposes provided for in this section, section 192.667, or section 192.990.
3. No individual or organization providing information to the department in accordance with this section shall be deemed to be or be held liable, either civilly or criminally, for divulging confidential information unless such individual organization acted in bad faith or with malicious purpose.
4. The department of health and senior services is authorized to reimburse medical care facilities, within the limits of appropriations made for that purpose, for the costs associated with abstracting data for special studies.
5. Any department of health and senior services employee, public health authority or coinvestigator of a study who knowingly releases information which violates the provisions of this section shall be guilty of a class A misdemeanor and, upon conviction, shall be punished as provided by law.

What is the authority granting public health agencies in Missouri the ability to control communicable diseases?

The rule 19 CSR 20-20.040 Measures for the Control of Communicable, Environmental and Occupational Diseases which may be viewed online. The purpose of this rule is to define the investigative and control measures for reportable diseases and establishes who is responsible for them

What is the authority addressing exclusion from school for persons who have a reportable disease or who are liable to transmit a disease in school?

The rule 19 CSR 20-20.030 Exclusion from School and Readmission may be viewed online. This rule requires the exclusion of persons from school who have a reportable disease or who are liable to transmit a reportable disease and also provides the methods of readmission to school that have been established.

What is the authority addressing quarantine and isolation practices of persons, animals, and their contacts with a communicable disease?

The rule 19 CSR 20-20.050 Quarantine or Isolation Practices and Closing of Schools and Places of Public and Private Assembly may be viewed online. The purpose of this rule provides for the isolation or quarantine of persons and animals with a communicable disease and their contacts; it also authorizes the closing of schools and places of public and private assembly when necessary to control disease.

What is the authority addressing control measures for food handlers having or suspected of having a communicable disease to prevent further spread among the community?

The rule 19 CSR 20-20.060 Control Measures for Food Handlers may be viewed online. The purpose of this rule establishes control measures for persons working with food products who are suspected of having a communicable disease to prevent further spread among the community.

Disclaimer.

This manual is designed to provide general guidance regarding public health investigations, surveillance activities, prevention and control strategies for select state-reportable diseases. In clinical practice, certain circumstances and individual cases require professional judgment beyond the scope of this manual. Practitioners and users of this manual should not limit their judgment on the management and control of communicable disease to this publication, and are well advised to review the references contained in each bibliography and remain informed of new developments and resulting changes in recommendations on communicable disease prevention and control.

This manual is not intended to be a therapeutic guide; therefore, while dosages of antimicrobials and immunobiologics are discussed in the context of prophylaxis and treatment for case-patients and contacts, physicians and other health-care professionals should review the package inserts prepared by the manufacturers to determine appropriate dosages. Because recommendations for use of vaccines may change, readers should consult their local or state health department or the Centers for Disease Control and Prevention's vaccines website.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the Missouri Department of Health and Senior Services (MDHSS). References to non-MDHSS Internet sites are provided as a service to readers and do not constitute or imply endorsement of these organizations or their programs by MDHSS. MDHSS is not responsible for the content of these sites. URL addresses were current as of the date of publication in the manual.

Terms, Abbreviations, and Symbols used in the Communicable Disease Investigation Reference Manual.

• AIDS - Acquired immunodeficiency syndrome
• ACIP – Advisory Committee on Immunization Practices
• ALT - Alanine aminotransferase levels
• anti-HBc - Antibody to hepatitis B core
• antigen anti-HCV - Hepatitis C antibodies
• APIC – Association for Professionals in Infection Control
• ARDS – Acute Respiratory Distress Syndrome
• ASC-US - Atypical squamous cells of undetermined significance
• AST - Aspartate aminotransferase levels
• BCDCP - Bureau of Communicable Disease Control and Prevention
• BEHS - Bureau of Environmental Health Services
• BMAT - Brucella microagglutination
• test C – Celsius
• CBC - Complete blood count
• CCDM - Control of Communicable Diseases Manual
• CCHF - Crimeam Congo Hemorrhagic Fever
• CD - Communicable Disease
• CDC - Centers for Disease Control and
• Prevention CD-1 - Disease Case Report form
• CD-2 - Record of Investigation of Communicable Disease
• CIE - Counter immunoelectrophoresis
• CDIRM - Communicable Disease Investigation Reference Manual
• CJD - Creutzfeldt-Jakob Disease
• CLD - Chronic liver disease
• CNS - Central nervous system
• CRS - Congenital rubella syndrome
• CSF - Cerebrospinal fluid
• CSR - Missouri Code of State Regulations
• CSTE - Council of State and Territorial Epidemiologists
• DHF - Dengue Hemorrhagic Fever
• DFA - Direct fluorescent antibody
• DNA - Deoxyribonucleic acid
• DRSP - Drug-Resistant Streptococcus Pneumoniae
• EEE - Eastern Equine Encephalitis
• EIA - Enzyme immunoassay
• EITB - Electrophoretic immunotransblot
• ELISA - Enzyme-linked immunosorbent assay
• e.g. – “For example”
• EOC - Emergency Operations
• Center ERC – Emergency
• Response Center F - Fahrenheit
• FAQ – Frequently asked question FDA - Food and Drug Administration
• GAS - Group A Streptococcus
• GNID - Gram-negative intracellular diplococci
• HAV - Hepatitis A virus
• HBIG - Hepatitis B immune globulin
• HbsAg - Hepatitis B surface antigen
• HBV - Hepatitis B virus
• HEV - Hepatitis E virus
• HCV - Hepatitis C virus
• HICPAC - Healthcare Infection Control Practices Advisory Committee
• Hib - Haemophilus influenzae type B
• HIPAA - Health Insurance Portability and Accountability Act
• HIV - Human immunodeficiency virus
• HPS - Hantavirus Pulmonary Syndrome
• HUS - Hemolytic Uremic Syndrome
• IAMFES - International Association of Milk, food, and Environmental Sanitarians
• IDU - Injection-drug user
• i.e. – “That is” or “In other words”
• IFA - Immunofluorescence assay IG - Immune globulin
• IgG – Immunoglobulin G antibodies
• IgM - Immunoglobulin M antibodies
• IHC - Immunohistochemistry
• IM – Intramuscularly
• IV - Intravenous or intravenously
• kg - kilograms
• LA - Latex agglutination
• LAC - LaCrosse encephalitis
• LCMV - Lymphocytic Choriomeningitis Virus
• LTCF - Long Term Care Facility
• LPHA - Local Public Health Agency
• MAC - Mycobacterium avium complex
• MDHSS – Missouri Department of Health and Senior Services
• MOHSIS - Missouri Health Surveillance Information System
• mL - Milliliter
• MMWR - Morbidity and Mortality Weekly Report
• MMR - Measles, mumps, and rubella vaccine
• MMRV - Measles, mumps, rubella, and varicella vaccine
• MRSA – Methicillin-Resistant Staphylococcus
• MSM - Men who have sex with men
• MSPHL – Missouri State Public Health Laboratory
• MTB - Mycobacterium tuberculosis
• NAAT - Nucleic acid amplification test
• NF - Necrotizing Fasciitis
• NNDSS - National Notifiable Diseases Surveillance System
• NORS - National Outbreak Reporting System
• OVPH – Office of Veterinary Public Health
• O&P - Ova and Parasite (stool kits, laboratory test)
• PCR - Polymerase chain reaction
• PDF - Portable document format
• PEP - Postexposure prophylaxis
• PFGE - Pulsed Field Gel Electrophoresis
• pH - Power of hydrogen
• RIBA - Recombinant Immunoblot Assay
• RNA - Ribonucleic Acid
• rRT-PCR - Real-time reverse transcriptase polymerase chain reaction
• RSMo. - Missouri Revised Statutes
• RT-PCR - Reverse transcriptase polymerase chain reaction
• SLE - St. Louis encephalitis
• STD - Sexually transmitted disease
• STSS - Staph Toxic Shock Syndrome
• TB - Tuberculosis
• TSS - Toxic Shock Syndrome
• TTP - Thrombocytopenic purpura
• US - United States
• USDA – United States Department of Agriculture
• VEE - Venezuelan Equine Encephalitis
• VPD - Vaccine-preventable Disease
• VRE - Vancomycin Resistant Enterococcus
• WB - Western blot
• WBC - White blood count
• WEE - Western Equine encephalitis
• WHO - World Health Organization
• WSW - Women who have sex with women
• ° - Degrees
• > - Greater than
• < - Less than
• ≤ - Less than or equal to
• ≥ - Greater than or equal to
• ~ - Approximately
• % - Percent

Case Definition

2024 Case Definition - Anaplasmosis

Overview

• Agents – Anaplasmosis is caused by the bacteria Anaplasma phagocytophilum.
• Reservoir – Anaplasmosis reservoirs include deer, ruminants, small rodents, and dogs.
• Occurrence – Anaplasmosis is commonly reported in North and South America as well as parts of Asia and Europe. Within the U.S., anaplasmosis is more frequently reported from the upper-Midwest and northeastern regions.
• Risk Factors – Individuals aged 40 and older or those are immunocompromised are considered high risk and may experience more severe illness. Individuals that spend a lot of time outdoors for work/recreation are also considered high risk due to increased tick exposures.
• Mode of Transmission – Transmission primarily occurs through the bite of an infected tick. Anaplasmosis is transmitted by Ixodes species of ticks. Most commonly, transmission is associated with the blacklegged tick (Ixodes scapularis) in the upper-Midwest and northeastern regions of the U.S., but can also occur with the Western blacklegged tick along the west coast. Risk of transmission through blood, organ, or tissue donation is also possible.
• Incubation Period – 7-14 days
• Clinical Illness – Most individuals who become infected are asymptomatic. If disease develops, it can range from mild febrile illness to severe illness and even death. Commonly reported symptoms are non-specific and include acute onset of fever, headache, malaise, and myalgia. Laboratory findings may include leukopenia, thrombocytopenia, and elevated liver enzymes.
• Laboratory Testing – Testing for tickborne diseases, including anaplasmosis, can be obtained through many commercial laboratories. The Missouri State Public Health Laboratory (MSPHL) does not currently conduct tickborne disease testing. In special cases, arrangements can be made to send specimens to CDC for testing.
• Treatment – Doxycycline is the antibiotic of choice to treat most tickborne diseases including anaplasmosis. Alternative antibiotics may be used if doxycycline is contraindicated, but use of other antibiotics may not reduce the likelihood of death.
• Priority – Routine.

Quick References / Factsheets

• Health Professionals:
  • Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis – United States (CDC MMWR)
  • Tickborne Diseases of the United States – A Reference Manual for Health Care Providers, Sixth Edition, 2022 (CDC)
  • Web-Based Training (CDC): Diagnosis and Treatment of Ehrlichiosis and Anaplasmosis – WB4504R
  • Ehrlichiosis and Anaplasmosis among Transfusion and Transplant Recipients in the United States (EID article)
  • Diagnostic Testing and Interpretation Resources (CDC):
    • YouTube video
    • Fact sheet
  • Research (CDC): Doxycycline and Tooth Staining

Forms

• Disease Case Report (CD-1)
  • PDF format
  • Word format 
• Tickborne Rickettsial Disease Case Report Form
• Missouri Outbreak Report Form (MORF)

Reporting Requirements

• Anaplasmosis is a Category 3 disease and shall be reported to the local health authority or to the MDHSS within three (3) calendar days of first knowledge or suspicion.
• Anaplasmosis is a nationally notifiable condition in the standard reporting category. The MDHSS reports confirmed and probable cases to the CDC by routine electronic transmission
• Anaplasmosis reporting includes the following:
  • For all cases, complete a Disease Case Report (CD-1).
  • For confirmed and probable cases, complete the Tickborne Rickettsial Disease Case Report Form.
  • All outbreaks or suspected outbreaks must be reported as soon as possible (by phone, fax or e-mail) to the District Epidemiologists.
  • Within 90 days from the conclusion of an outbreak, submit the final outbreak to the District Epidemiologists.

Laboratory Testing and Diagnosis

Laboratory confirmation of infection is vital to understanding the epidemiology and public health impact of tickborne rickettsial diseases (e.g., ehrlichiosis, anaplasmosis, and Rocky Mountain spotted fever). Confirmatory testing by polymerase chain reaction (PCR) testing is available for anaplasmosis. PCR testing is most sensitive during the first week of illness. PCR sensitivity can decrease after tetracycline-class antibiotics are administered, so this testing should be conducted prior to starting antibiotic treatment. For testing that occurs after the first week of illness, it is recommended to obtain paired, appropriately timed acute and convalescent specimens for serological analysis. A single serologic test does not provide the diagnostic strength of paired acute and convalescent specimens or confirmatory testing by PCR.

Routine anaplasmosis diagnostic testing is available through commercial laboratories. The Missouri State Public Health Laboratory (MSPHL) does not perform any tickborne disease diagnostic testing. In special situations, testing for anaplasmosis can be conducted by CDC. All requests for anaplasmosis testing to be performed by CDC should be coordinated through the Zoonotic Disease Program.

Conducting the Investigation

1. Verify the diagnosis. What laboratory tests were conducted, and what were the results? Obtain demographic, clinical, and laboratory information on the case from the provider, laboratory, and/or patient. Complete both the Disease Case Report (CD-1) and the Tickborne Rickettsial Disease Case Report Form.
   
   In addition to PCR or antibody testing, patients may have had complete blood cell count or comprehensive metabolic blood testing done that may indicate anemia, thrombocytopenia, leukopenia, and/or liver enzyme elevation. If the patient was hospitalized during their illness, verify the availability of these results as part of the investigation.
   
   Regarding antibody testing, patients may lack detectable antibody titers in the first 7 days of illness. Positive IgG titers or index values can indicate a past infection or early response to a current infection. IgM tests are not specific, and detectable IgM may persist for months or longer. For these reasons, IgM titers or index values without detectable IgG response should be interpreted with caution.
2. Establish the extent of illness. The investigation should consider family members, pets, and other contacts who have or have recently had a febrile illness and shared environmental exposures with the patient.
3. Establish the source of infection. Prior to symptom onset:
   1. What was the case’s travel history (including specific travel dates)?
   2. Are there household or other contacts with a similar illness?
   3. Was the case’s tick exposure in-state, out-of-state, or out-of-country?
   4. Rule out non-tick transmission pathways (which may fall outside the two week timeframe):
      1. Does the case work in a laboratory or clinical setting?
      2. Is the case a neonate, pregnant, or breastfeeding?
      3. Has the case recently received any blood, blood products, tissues, or organs?
   5. If the case is a recent organ, tissue (e.g., corneas, skin), or blood donor or recipient within the last 30 days:
      1. Notify the Zoonotic Disease Program.
      2. Assure that relevant partners (blood collection agencies, hospitals, etc.) have been notified.
      3. Determine the patient/donor identification numbers and any other available details regarding blood products/organs received.
      4. Assure quarantine of any remaining co-component blood or tissues.
      5. If necessary, investigate all recipients of transfused co-components from the implicated donation and other potentially contaminated donations from implicated donor(s).

Control Measures

In the United States, there is currently no licensed vaccination to prevent anaplasmosis. Even with a reported tick exposure or attachment, treatment for anaplasmosis is not recommended by CDC unless compatible symptoms develop. Prophylactic antibiotic treatment in the absence of symptoms has not been demonstrated to prevent infection from occurring and may prolong the onset of symptoms in some patients. Aside from cases associated with blood donation, tissue, or organ transplants, contact tracing is not required because anaplasmosis infections are not transmitted person-to-person.

The best way to avoid infection with anaplasmosis is to avoid tick bites. Key personal prevention methods for avoiding tick bites include:

• Whenever possible, avoid tick habitat during the peak time of year when ticks are most active (generally April through September). Ticks are generally found in areas with tall grass, brush or in heavily wooded areas. However, they can also be present in neighborhoods and backyards!
• Use an insect repellent product with at least 20% DEET, picaridin, or other EPA-registered active ingredients labeled specifically for ticks.
  • The American Academy of Pediatrics has recommended that repellents containing up to 30% DEET are safe for children over 2 months of age.
  • For other active repellent ingredients, check the product label for minimum age requirements before applying to children.
  • EPA offers an insect repellent search tool that can be used by the public to identify repellent products that work best for their needs.
• Weather-permitting, wear long sleeves and pants to help reduce the amount of exposed skin. This will make it harder for ticks to find a place to attach.
  • Wearing light-colored clothing can make it easier to spot ticks that may be crawling on clothing when you are outdoors.
• Consider applying permethrin to clothing, boots, and outdoor gear when spending time in tick habitat. Permethrin binds tightly to fabric and will remain effective after multiple washings.
  • This product should not be applied directly to the skin. Product directions and labels should be read carefully before use.

Resources

1. American Academy of Pediatrics. [Ehrlichia, Anaplasma, and Related Infections]. In: Kimberlin DW, Barnett, ED, Lynfield, R, Sawyer, MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021: [308-311]
2. American Public Health Association. [Ehrlichiosis]. In: Heymann DL, ed. Control of Communicable Diseases Manual. 21st ed. Washington, DC: American Public Health Association; 2022 [189-193]
3. Centers for Disease Control and Prevention. Anaplasmosis. https://www.cdc.gov/anaplasmosis/about/ (7/24)

Overview

For a complete description of diseases transmitted to humans via animal -inflicted injuries(bites, scratches, etc.) and for additional information, refer to the following sources:

• Control of Communicable Diseases Manual (CCDM) ⁽¹⁾
• Red Book, Report of the Committee on Infectious Diseases ⁽²⁾
• The Merck Veterinary Manual ⁽³⁾
• Rabies section of this Manual

Case Definition

Clinical Description

The potential for zoonotic (animal-to-human) transmission of disease must be considered in any situation where a person is injured by an animal. Of the approximately 1700 known human pathogens, about 50 percent are zoonotic. Of the 156 emerging pathogens, 73 percent are zoonotic. Of the 14 most likely agents of bioterrorism, 57 percent are zoonotic. In considering the likelihood of disease transmission, many factors must be assessed, such as the species of animal, type of injury, severity of injury, vaccination status of animal and/or human (when applicable), interval between incident and treatment, and various attributes of the injured person (age, underlying health, etc.). Zoonotic diseases can be transmitted by a variety of means such as trauma (bite or scratch), direct contact, arthropod vectors, aerosols, and contamination of food and water. Animal bites are a major mechanism of pathogen conveyance.

Case classification ⁽⁴⁾

Confirmed (reportable): “Animal bite wound to human” – only bites from mammals are reportable (all mammal bites are reportable). A “bite wound” is define d as breaking of the skin by the teeth of an animal. In some situations, a physician’s assessment might be needed to determine whether a bite wound exists.

Other traumatic exposures of humans to animals(such as a scratch) could result in disease transmission. Local public health agencies (LPHAs) are encouraged to follow up such cases, as circumstances dictate. While not reportable, the Missouri Department of Health and Senior Services (DHSS)will assist LPHAs in investigating such incidents and in devising prevention/control strategies, at the request of the LPHA.

Disease Risk by Species

Some of the pathogens transmitted by direct animal trauma include:

• Dogs and Cats: rabies; bacterial infections (Capnocytophaga canimorsus, Pasteurella multocida and P. haemolytica, Staphylococcus aureus, streptococci, anaerobes, Moraxella, Corynebacterium, Neisseria, tetanus, tularemia).
• Cats: cat “scratch” fever (Bartonella henselae, B. quintana); plague.
• Rodents (domestic): bacterial infection.
• Rodents (wild): rabies (from larger rodents such as beavers and groundhogs); bacterial infection (including tetanus and tularemia); rat bite fever – rare (Streptobacillus moniliformis, Spirillum minus).
• Wild Animals (terrestrial, non-rodent) e.g., skunk, fox, raccoon, opossum: rabies; numerous bacterial pathogens (including tetanus and tularemia).
• Bats: rabies.
• Primates (non-human): rabies; numerous bacterial pathogens (including tetanus); simian B herpesvirus (macaques or non-macaques housed with macaques); hepatitis A, B, and C (certain great apes). Note: Primate exposures generally also require assessment for potential aerosol transmission of tuberculosis.

Disposition of Animals in Bite/Injury Incidents

• Animal Quarantine:
  • The only species for which the 10-day quarantine is formally recognized are dogs, cats, and ferrets. Wild animals are never quarantined (they are euthanized and tested, with the exception of very low-risk species such as lagomorphs and small rodents). Large domestic animals (cattle, horses, etc.) and captive wild animals (e.g., non-human primates) are handled on a case-by-case basis.
  • If a quarantine is warranted, the LPHA should contact the animal owner to establish quarantine at an animal control facility (if available) or local veterinarian's clinic (at animal owner’s expense as required in 322.140 RSMo). A home quarantine may be acceptable under some circumstances, as described below.
  • If a secure animal control facility or veterinarian’s clinic is not available/used, the LPHA should present the animal owner with notice that the owner must quarantine the animal in a secure location and that they are assuming all liability for the quarantine (including patient medical care if the animal escapes from quarantine and postexposure prophylaxis is required).
  • If the owner is unwilling to quarantine the animal, DHSS may issue an “Order of Quarantine” to the local law enforcement official to quarantine the animal.
• Animal Testing:
  • Testing of animals for rabies in lieu of quarantine is indicated in some instances, including:
    • Dogs, cats, and ferrets currently exhibiting symptoms compatible with rabies.
    • Unwanted dogs, cats, and ferrets that would be euthanized following a quarantine (if one was to be accomplished).
    • Wild animals, with the usual exception of lagomorphs and small rodents.
  • Animals are tested for rabies by having the brain tested at the Missouri State Public Health Laboratory (SPHL). There are no reliable rabies tests that can be conducted on a living animal.
  • The LPHA should have the person in possession of the animal (owner, animal control officer, etc.) present the animal to a veterinarian for euthanasia, removal of the head, and packaging of the specimen for shipment to the laboratory. These procedures may vary with the species of animal involved, e.g., the entire body of small animals such as puppies and kittens may be shipped to the laboratory in lieu of removing the head; the brain of very large animals (horses, cattle) should be removed from the skull and shipped to the laboratory.
  • The LPHA should advise the veterinarian on matters such as method of packaging specimens, address and point of contact at the laboratory, and courier pick-up points for the SPHL. LPHA staff should not personally euthanize animals nor conduct any invasive procedures needed to ship specimens to the laboratory. Staff may package those specimens where the entire body is submitted, as long as they take precautions against contamination (e.g., use gloves when handling the animal).
  • If the owner is unwilling to have an animal tested for rabies, DHSS may issue an “Order to Euthanize and Test for Rabies” to the local law enforcement official to have the animal presented to a veterinarian so the appropriate specimen can be submitted to the laboratory.

Determination of Risk in Animal Bite/Injury Incidents

• In an animal bite/injury incident, the animal is normally either put under a rabies quarantine for ten days or euthanized and the brain submitted for rabies testing. In either situation, the LPHA should monitor the process until it has a successful public health outcome.
• Quarantine:
  • Veterinary or animal control facility: This is the normal procedure when an animal has not received a rabies vaccination or the vaccination is out of date. The LPHA should ensure that the quarantining official has a point of contact and telephone number at the LPHA so that this individual can be contacted immediately if the animal begins to show signs of rabies. The LPHA should then arrange for the animal to be immediately euthanized and the brain submitted to the laboratory for testing.
  • Home of the animal’s owner: A less preferable method of quarantine is at the animal owner’s home. This may be an authorized alternative under some local animal control ordinances. In these instances, it is usually reserved for low-risk situations, i.e., animal’s rabies vaccination is up-to-date, animal is in apparent good health, owner is able to secure the animal on the premises, and the incident was provoked. Whenever a home quarantine is instituted, the LPHA should present the owner with a notice (see “Letter of Notification”) that they must quarantine the animal in a secure location and that they are assuming all liability for the quarantine (including patient medical care if the animal escapes from quarantine and postexposure prophylaxis is required). A “secure” location is defined as being inside the owner’s home or in a well fenced-in area outdoors. Tethering the animal outdoors, even for a short period, is never a suitable method of securing the animal. The LPHA or other official (law enforcement, animal control) should physically check on the animal beginning, mid, and end of quarantine to ensure that the animal is still securely confined and is in apparent good health. If LPHA staff do not directly conduct this function, they should regularly contact the official who is making these inspections.
• Rabies testing:
  • If rabies testing is indicated in lieu of quarantine or during a quarantine, the LPHA should use the services of a local veterinarian to ensure that the appropriate specimen is submitted to the laboratory for testing. The LPHA should provide the veterinarian with necessary information and should disseminate final laboratory results to interested parties such as the patient, animal owner, law enforcement, and animal control officials.
• The LPHA should, in almost all instances, recommend that an animal bite/injury patient seek medical evaluation. The LPHA should consult with the patient and the patient’s physician to ensure that the physician has all information needed for decision making and that basic wound precautions have been taken (e.g., wound cleansed, need for antibiotics assessed, tetanus vaccination current). In the event that rabies postexposure prophylaxis is needed, the LPHA should provide the physician with product-ordering information if needed and follow up with the patient to ensure that the month-long series of shots is obtained.
• If an animal bite/injury results in the potential transmission of diseases other than rabies (e.g., herpes B virus, tuberculosis), the LPHA should also arrange for the animal and exposed person to receive indicated laboratory tests and appropriate prophylaxis for the person.
• DHSS will work with the LPHA in determining disease risk factors, developing recommendations, facilitating proper animal disposition, and ensuring patient follow up. If routine quarantine procedures do not work, an “Order of Quarantine” may be issued by DHSS. A similar order can be issued to have the animal seized, euthanized, and tested if that should become necessary.

Information Needed for Investigation

• Verify that the person has sustained an injury from an animal.
• Establish the extent of exposure. Determine if additional persons (household members, visitors, neighbors, etc.) have been exposed to the animal.
• Determine if the individual’s exposure has been assessed by a physician. If the wound was recently sustained, advise the person to wash it thoroughly with soap and water for at least 15 minutes. Most individuals should be referred to a physician. Medical personnel should clean the wound further, provide antibiotic therapy and tetanus immunization if needed, and assess for other threats such as rabies.
• Determine the circumstances of the incident. Obtain information from reliable sources regarding the actions of the animal and injured person at the time of the incident.
• Obtain information about the animal. This includes information such as physical description, rabies vaccination status (if applicable), apparent health, present location, and animal’s veterinarian (if applicable).
• Contact Veterinary Public Health (573-751-6113) or the Regional Communicable Disease Coordinator to collaborate in the investigation, as needed.

Control Measures

Control measures vary, depending upon the disease in question. For rabies control, the following four cardinal public health measures should be emphasized to the public (especially children):

• Ensure dogs, cats, and ferrets are up-to-date on rabies vaccinations; vaccinations are also available for horses, cattle, and sheep.
• Keep pets under control; do not allow them to run loose.
• Avoid contact with stray pets and wild animals; do not keep wild animals or wild animal crosses as pets.
• Report wild animals exhibiting unusual behavior or stray pets to animal control officials.

Laboratory Procedures

• Rabies Testing: Human and animal testing procedures through the SPHL are described in the “Rabies” section of this Manual. Additional information on laboratory procedures can be obtained from Veterinary Public Health, the Regional Communicable Disease Coordinator, or the SPHL. The SPHL telephone number is 573-751-3334 and the website is: State Public Health Laboratory.
• Simian B Herpesvirus: Human and primate (non-human) testing is available through the B Virus Resource Laboratory, Georgia State University, Atlanta, GA. The website for this laboratory is: B Virus Resource Laboratory. The website provides information on simian B herpesvirus, specimen submission instructions, a case evaluation checklist, etc. The following specimens should be submitted for the bitten human who is being tested: serum collected at the time of the bite, plus two weeks and six weeks post-bite; bite wound culture. The following specimens should be submitted from the non-human primate: serum (antibody testing) and buccal mucosal swab (culture) at the time of the bite.
  • Note: The process of obtaining specimens from non-human primates should be undertaken only by an experienced veterinarian who understands the procedures and risks involved.
  • Note: Macaque bites should be regarded as a medical emergency until suspicion of herpesvirus is disproven. Antiviral prophylaxis must be administered within 24 hours of the bite if it is to be effective. The treating physician should not wait for herpesvirus serology test results to come back on the macaque (these results are used to determine further medical follow up and to help establish the prognosis). Asymptomatic adults are generally prophylaxed with valacyclovir while acyclovir is used for children.
  • Note: Simian B herpesvirus exposure risk assessments are complex, and LPHAs/physicians are encouraged to consult with the Missouri Department of Health and Senior Services.
• Other Laboratory and Clinical Testing: Information regarding testing for other pathogens may be obtained from Veterinary Public Health, 573-751-6113.

Reporting Requirements

Mammalian animal bites are a Category I(A) condition and shall be reported to the local health authority or to the Missouri Department of Health and Senior Services (DHSS) within 24 hours of first knowledge or suspicion by telephone, facsimile or other rapid communication.

1. For all bites, complete a “Disease Case Report” (CD-1) and send the completed form to the DHSS Regional Health Office.
2. For all bites, complete an “Animal Bite/Injury – Supplemental Case Report”.
3. Entry of the completed CD-1 into the MOHSIS database negates the need for the paper CD-1 to be forwarded to the Regional Health Office.
4. Send the completed secondary investigation form to the Regional Health Office.
5. All outbreaks or "suspected" outbreaks of zoonotic disease must be reported as soon as possible (by phone, fax or e-mail) to the Regional Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51).
6. Within 90 days of the conclusion of an outbreak, submit the final outbreak report to the Regional Communicable Disease Coordinator.

References

1. Chin, James ed. “Other Infections Associated with Animal Bites.” Control of Communicable Diseases Manual. 17th ed. Washington, DC: American Public Health Association, 2000: 89 -90 (refer also to sections on specific diseases).
2. American Academy of Pediatrics. “Bites Wounds”, “ Pasteurella multocida Infections”, and “Rabies.” In: Pickering, L. 2000 Red Book: Report of the Committee on Infectious Diseases . 25th Ed. Elk Grove Village, IL. 2000: 155 -159, 426-427, 475-482.
3. The Merck Veterinary Manual. “Zoonoses.” 8th Ed. Ed. Susan E. Aiello. Whitehouse Station, NJ: Merck & Co., Inc., 1998: 2161. https://www.merckvetmanual.com/public-health/zoonoses (search “zoonoses")
4. Missouri Department of Health and Senior Services - Section for Communicable Disease Prevention, surveillance case definition.

Web Resources and Information

1. Missouri Revised Statutes, RSMO Chapter 322, “Protection Against Rabies,” August 28, 2002, https://revisor.mo.gov/main/OneChapter.aspx?chapter=322
2. Rabies vaccination must be given by licensed veterinarian:
   1. RSMO 322.010, “Definitions,” August 28, 2002 https://revisor.mo.gov/main/OneSection.aspx?section=322.010&bid=17210&h…;
   2. 4 CSR 270-4.031, “Minimum Standards for Practice Techniques,” paragraph (4)(B), https://www.sos.mo.gov/cmsimages/adrules/csr/previous/4csr/4csr0906/4c 270-4.pdf
3. Centers for Disease Control and Prevention, “Rabies”, https://www.cdc.gov/rabies/index.html&nbsp;
4. B Virus Resource Laboratory, Georgia State University, Atlanta, GA. The website for this laboratory is: https://biotech.gsu.edu/virology/.

Overview ^(1,2)

Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax most commonly occurs in wild and domestic mammalian species (cattle, sheep, goats, camels, antelopes, and other herbivores), but it can also occur in humans when they are exposed to infected animals or to tissue from infected animals or when anthrax spores are used as a bioterrorist weapon.⁵

Anthrax is a potential bioterrorism weapon. The key identifying sign for anthrax is a widened mediastinum (present in about 80% of patients). A widened mediastinum, if present, will be visible on x-ray 2-3 days after onset of symptoms. If you suspect that you are dealing with a bioterrorism situation, contact your Senior Epidemiology Specialist for the District, or the Department of Health and Senior Service’s Situation Room (DSR) at 800-392-0272.

For a more complete description of anthrax, refer to the following texts:

• Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008.
• American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. 2009.

Case Definition⁽³⁾

Clinical description

An illness with acute onset characterized by several distinct clinical forms, including the following:

• Cutaneous Anthrax: An acute illness, or post-mortem examination revealing a painless skin lesion developing over 2 to 6 days from a papular through a vesicular stage into a depressed black eschar with surrounding edema. Fever, malaise and lymphadenopathy may accompany the lesion.
• Inhalation Anthrax: An acute illness, or post-mortem examination revealing a prodrome resembling a viral respiratory illness, followed by hypoxia, dyspnea or acute respiratory distress with resulting cyanosis and shock. Radiological evidence of mediastinal widening or pleural effusion is common.
• Gastrointestinal Anthrax: An acute illness, or post-mortem examination revealing severe abdominal pain and tenderness, nausea, vomiting, hematemesis, bloody diarrhea, anorexia, fever, abdominal swelling and septicemia.
• Oropharyngeal Anthrax: An acute illness, or post-mortem examination revealing a painless mucosal lesion in the oral cavity or oropharynx, with cervical adenopathy, edema, pharyngitis, fever, and possibly septicemia.
• Meningeal Anthrax: An acute illness, or post-mortem examination revealing fever, convulsions, coma, or meningeal signs. Signs of another form will likely be evident as this syndrome is usually secondary to the above syndromes.

Laboratory criteria for diagnosis

• Isolation of Bacillus anthracis from a clinical specimen, or
• Anthrax electrophoretic immunotransblot (EITB) reaction to the protective antigen and/or lethal factor bands in one or more serum samples obtained after onset of symptoms, or
• Demonstration of B. anthracis in a clinical specimen by immunofluorescence.

Case classification

Confirmed: A clinically compatible illness with one of the following:

• Culture and identification of B. anthracis from clinical specimens by the Laboratory Response Network (LRN).
• Demonstration of B. anthracis antigens in tissues by immunohistochemical staining using both B. anthracis cell wall and capsule monoclonal antibodies.
• Evidence of a four-fold rise in antibodies to protective antigen between acute and convalescent sera or a fourfold change in antibodies to protective antigen in paired convalescent sera using Centers for Disease Control and Prevention (CDC) quantitative anti-PA IgG ELISA testing.
• Documented anthrax environmental exposure AND evidence of B. anthracis DNA (for example, by LRN-validated polymerase chain reaction) in clinical specimens collected from a normally sterile site (such as blood or CSF) or lesion of other affected tissue (skin, pulmonary, reticuloendothelial, or gastrointestinal).

Probable: A clinically compatible illness that does not meet the confirmed case definition, but with one of the following:

• Epidemiological link to a documented anthrax environmental exposure.
• Evidence of B. anthracis DNA (for example, by LRN-validated polymerase chain reaction) in clinical specimens collected from a normally sterile site (such as blood or CSF) or lesion of other affected tissue (skin, pulmonary, reticuloendothelial, or gastrointestinal);.
• Positive result on testing of clinical serum specimens using the Quick ELISA AnthraxPA kit.
• Detection of Lethal Factor (LF) in clinical serum specimens by LF mass spectrometry.
• Positive result on testing of culture from clinical specimens with the RedLine Alert test.⁽⁴⁾

Information Needed for Investigation

Verify the diagnosis. What laboratory tests were conducted? What were the results? What are the patient’s clinical symptoms?

Establish the extent of illness. Determine if household or other close contacts are, or have been, ill by contacting the health care provider, patient or family members.

Notification And Control Measures

If terrorist activity is suspected:

• Contact appropriate law enforcement authorities.
• Contact the Senior Epidemiology Specialist for the District, or the Department of Health and Senior Services’ Situation Room (DSR) at 800-392-0272 (24/7) immediately upon learning of a suspected case. Complete the “Suspicious Substance Data Collection Questionnaire” for an incident with a known source of exposure (e.g., white powder in an envelope).
• Complete the “Missouri Department of Health and Senior Services, Anthrax Case Investigation Form” for an incident with an unknown source of exposure (e.g., people coming into an emergency room with symptoms consistent with anthrax exposure).

General follow-up:

• Determine the source of infection to prevent other cases:
• Does the case work with animals, especially sheep, cattle, goats, or their products?
• Has the case been exposed to recent excavation sites or to places where animal products are handled?
• Has the case traveled out of the country, especially to places where anthrax is currently known to be occurring? Contact your District Communicable Disease Coordinator for a list of countries.
• Does the case or his/her close associates know of any other similar cases?

Control Measures:

See the Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008, Anthrax, “Methods of control.”

See the American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. 2009. Anthrax, “Control Measures.”

Naturally occurring anthrax stems from animal origins. Although this disease is rarely transmitted person-to-person, body substance precautions for the duration of illness are indicated for cases. Identification and control of contaminated exposure sites is paramount.

Laboratory Procedures

The State Public Health Laboratory (SPHL) currently conducts the following tests for Bacillus anthracis:

Testing available/ estimated turnaround times:

• Presumptive results:
  • Real-time PCR (polymerase chain reaction): 4 hours
  • TRF (time-resolved fluorescence): 4 hours
• Confirming test:
  • Culture: Turn-around time on culturing specimens is 24-hours minimum for a “presumptive;” complete identification and positive confirmation would depend on how quickly the organisms grew and other variables. Usually, identification is complete in 48 hours, but it can take up to three to four days.

Additional information on laboratory procedures can be obtained from the District Communicable Disease Coordinator or from staff at the SPHL. Visit the SPHL web site (February 3, 2011)

Reporting Requirements

Anthrax is a Category IA disease and shall be reported to the local health authority or to the Missouri Department of Health and Senior Services immediately upon first knowledge or suspicion by telephone (800-392-0272), facsimile or other rapid communication.

1. For confirmed and probable cases, complete a “Disease Case Report” (CD-1).
2. For confirmed and probable cases, complete a “Record of Investigation of Communicable Disease” (CD-2) for non-bioterrorism exposures only.
3. Entry of the completed CD-1 into WebSurv negates the need for the paper CD-1 to be forwarded to the District Health Office.
4. Send the completed secondary investigation form to the District Health Office. All outbreaks or “suspected” outbreaks must be reported as soon as possible (by phone, fax, or e-mail) to the District Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51).
5. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

DHSS Health Alerts and Related Information

Current health alerts related to Anthrax or other Bioterror information is available on the DHSS website (February 3, 2011)

References

1. Control of Communicable Diseases Manual. Anthrax. In: Heymann, DL, ed. 19thed. Washington, D.C.: American Public Health Association, 2008: 22-30.
2. American Academy of Pediatrics. Anthrax. In: Pickering, LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL.: 211-214.
3. CDC. Nationally Notifiable Infectious Conditions (2010) http://www.cdc.gov/ncphi/disss/nndss/casedef/antrax_current_1.htm (February 3, 2011)
4. Missouri Department of Health and Senior Services, Bureau of Communicable Disease Control and Prevention, surveillance case definition.
5. CDC. Questions and Answers About Anthrax http://emergency.cdc.gov/agent/anthrax/faq/ (February 3, 2011)

Other Sources of Information

1. Martin Gregory, Friedlander Arthur “Bacillus anthracis (Anthrax)” Eds. Gerald L. Mandell, John E. Bennett, & Raphael Dolin, Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, 7th ed. New York: Elsevier, 2010: 2715 – 2725.
2. Brachman, Phillip S and Arnold F Kaufmann. “Anthrax”.. Bacterial Infections of Humans: Epidemiology and Control. 3rd ed. Eds Alfred S Evans and Phillip S Brachman. New York: Plenum, 1998: 95-107.
3. The Merck Veterinary Manual. 8th Ed. Ed. Susan E. Aiello. Whitehouse Station, NJ: Merck & Co., Inc., 1998: 432, 2162. http://www.merckvetmanual.com/mvm/index.jsp (search “anthrax”). (February 3, 2011)
4. U.S. Army Medical Research Institute of Infectious Diseases. Medical Management of Biologic Casualties Handbook. 6th ed. April, 2005: 17-24. PDF (February 3, 2011)

Web Resources and Information

1. World Health Organization Emerging and other Communicable Diseases Surveillance and Control, “Guidelines for the Surveillance and Control of Anthrax in Humans and Animals. http://www.who.int/csr/resources/publications/anthrax/WHO_EMC_ZDI_98_6/… (February 3, 2011)
2. Todar, Kenneth, Todar’s Online Textbook of Bacteriology. http://www.textbookofbacteriology.net/ (Search “Anthrax”) (February 3, 2011)
3. Cranmer, Hilarie and Maurcio Martinez. “CBRNE – Anthrax Infection” eMedicine Journal, October 26, 2009, Vol 8, No 2 http://www.emedicine.com/emerg/topic864.htm (February 3, 2011)
4. Department of Defense. Anthrax Vaccine Immunization Program. http://www.anthrax.osd.mil (February 3, 2011)
5. Center for Infectious Disease Research & Policy Academic Health Center. University of Minnesota. “Anthrax: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis.” http://www.cidrap.umn.edu/cidrap/content/bt/anthrax/biofacts/anthraxfac… (February 3, 2011)

Subtypes

• California Serogroup Viruses
  • including La Crosse Virus
• Powassan Virus
• St. Louis Encephalitis Virus
• Chikungunya Virus
• Venezuelan Equine Encephalitis Virus
• Eastern Equine Encephalitis Virus
• West Nile Virus
• Heartland Virus
• Western Equine Encephalitis Virus

Overview^{1, 2, 3, 5}

Arbovirus is short for arthropod-borne virus. In nature, arboviruses are maintained in a biological cycle between vertebrates (mainly animals, sometimes humans) and bloodsucking arthropods that can include ticks, mosquitoes, sand flies, and black flies. Arboviruses are responsible for causing a wide spectrum of clinical syndromes, ranging from mild to severe febrile illness to hemorrhagic fever to neuroinvasive disease. Until the introduction of West Nile virus (WNV) to the Western Hemisphere, most arboviral disease activity in the world was focused in tropical and sub-tropical climates. Global scale changes in travel, worldwide commercial trade, and landscape use have provided opportunities for these pathogens and their vectors to expand their geographical range.

Most arbovirus infections are asymptomatic or subclinical, but this generalization should be taken with caution as very high illness rates (between 75 – 97%) have been associated with epidemics of chikungunya virus (CHIKV). Arboviral illnesses can be classified into three clinical syndromes:

• Systemic acute febrile illness typically accompanied by headache, arthralgia, and myalgia, with or without rash and/or polyarthritis;
• Hemorrhagic fever that might be extensive, and associated with capillary leakage, shock, jaundice, liver damage, and death; and
• Acute central nervous system illness ranging from mild aseptic meningitis to encephalitis with coma, paralysis, and death.

Incubation periods for most arboviruses range between 2 days and 2 weeks. While vector transmission is the most common exposure pathway for arboviruses, blood transfusion, organ transplantation, and in utero and breast milk transmission have been documented. Laboratory technicians have been infected with WNV and CHIKV via accidental skin puncture with contaminated necropsy tools. With the exception of yellow fever and Japanese encephalitis, human vaccinations are not yet available for preventing arbovirus infections. Antiviral treatments have not yet proved effective for arbovirus infection, so the primary treatment is supportive care.

Humans infected with an arbovirus are usually classified as incidental or dead-end hosts. In WNV, St. Louis encephalitis virus (SLEV), eastern and western equine encephalitis virus, and California encephalitis virus infections, humans do not produce a level of viremia sufficient to contribute to the host-vector-host transmission cycle.

Two currently emerging arboviruses, however, dengue virus and CHIKV, are exceptions to this general rule because these pathogens produce significant viremia in infected persons. Until the infection resolves, a viremic person can serve as a reservoir of the virus, and uninfected mosquitoes can pick up and later transmit the infection to another person. Public health interventions in arboviral outbreaks involving a human reservoir host require not only traditional mosquito control efforts but measures to shelter viremic individuals from mosquito bites.

The seasonality of most North American arbovirus infections varies with the hostseeking behavior of the arthropod vector. Outbreaks of WNV and SLEV tend to occur in late summer after mosquitoes shift their host-seeking preferences from birds (the reservoir host) to mammals and humans. Epidemiologic investigations into the Heartland virus in Missouri have coincided with the host-seeking behavior of the Lone Star tick, the imputed vector of that virus.

Host behavior also influences the timing of disease reports, with imported cases of both dengue virus and CHIKV infections peaking during the winter months when vacationers from the United States are visiting tropical climates.

The nationally reportable arboviral diseases endemic to North America include the numerous viruses in the California serogroup (including La Crosse virus), chikungunya, eastern equine encephalitis, Powassan, St. Louis encephalitis, West Nile, and western equine encephalitis. Because it can be easily weaponized, human Venezuelan equine encephalitis virus disease is designated as reportable in Missouri. In addition, public health reporting of other emerging arboviral disease is encouraged, including Colorado tick fever, Rift Valley disease, tickborne encephalitis, and the newly recognized Heartland virus disease.

Objectives of Domestic Arboviral Surveillance³

The unpredictable nature of arbovirus disease outbreaks necessitates public health surveillance systems capable of detecting increases in arboviral activity. Human disease surveillance provides a nationwide assessment of the impact of arboviral diseases and over the past decade has demonstrated where arboviral incidence and total disease burden are greatest.

The annually robust WNV outbreaks of the upper Great Plains states illustrate that niche adaptations can develop even in newly-arrived viruses. A pattern like this is important to monitor from year to year to determine whether climatic variables and land use changes are affecting the ecological boundaries that influence the distribution of WNV. In addition, at the local level, public health surveillance is important to policy makers’ evaluation of the effectiveness of insect bite prevention messaging and mosquito control strategies.

Surveillance systems and public health intervention measures developed for one arbovirus do not necessarily transfer to other arboviruses. Surveillance systems for WNV, for example, rely on detection of viral activity in mosquitoes and sentinel animals to provide early warning of increased human disease risk. In contrast, public health officials responding to the massive Caribbean outbreaks of CHIKV that began in 2013 determined that human syndromic surveillance was more effective in determining where mosquito spraying should occur.

In the absence of effective human arboviral vaccines, preventing disease in humans depends on large-scale outbreak prevention and public awareness activities to keep infected vectors from biting people.

For a more complete description of arboviral diseases, refer to the following texts:

• Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 20th ed. 2015.
• American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. 2012.
• Centers for Disease Control and Prevention (CDC), Epidemic/Epizootic West Nile Virus in the United States: Guidelines for Surveillance, Prevention, and Control, 4th ed. 2013.

2015 Case Definition – Arboviral diseases, Neuroinvasive and Non-neuroinvasive⁴

Subtypes

• California Serogroup Viruses
  • including La Crosse Virus
• Powassan Virus
• St. Louis Encephalitis Virus
• Chikungunya Virus
• Venezuelan Equine Encephalitis Virus
• Eastern Equine Encephalitis Virus
• West Nile Virus
• Western Equine Encephalitis Virus

Background

Arthropod-borne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes, ticks, sand flies, or midges. Other modes of transmission for some arboviruses include blood transfusion, organ transplantation, perinatal transmission, breast feeding, and laboratory exposures.

More than 130 arboviruses are known to cause human disease. Most arboviruses of public health importance belong to one of three virus genera: Flavivirus, Alphavirus, and Orthobunyavirus.

California serogroup viruses include: California encephalitis, Jamestown Canyon, Keystone, La Crosse, Snowshoe hare, and Trivittatus viruses.

Clinical Description

Most arboviral infections are asymptomatic. Clinical disease ranges from mild febrile illness to severe encephalitis. For the purposes of surveillance and reporting, based on their clinical presentation, arboviral disease cases are often categorized into two primary groups: neuroinvasive disease and non-neuroinvasive disease.

Neuroinvasive disease

Many arboviruses cause neuroinvasive disease such as aseptic meningitis, encephalitis, or acute flaccid paralysis (AFP). These illnesses are usually characterized by the acute onset of fever with headache, myalgia, stiff neck, altered mental status, seizures, limb weakness, or cerebrospinal fluid (CSF) pleocytosis. AFP may result from anterior ("polio") myelitis, peripheral neuritis, or postinfectious peripheral demyelinating neuropathy (i.e., Guillain-Barré syndrome). Less common neurological manifestations, such as cranial nerve palsies, also occur.

Non-neuroinvasive disease

Most arboviruses are capable of causing an acute systemic febrile illness (e.g., West Nile fever) that may include headache, myalgias, rash, or gastrointestinal symptoms. Some viruses also can cause more characteristic clinical manifestations, such as severe polyarthralgia or arthritis due to chikungunya virus or other alphaviruses (e.g., Mayaro, Ross River, and O’nyong-nyong).

Clinical Criteria

A clinically compatible case of arboviral disease is as defined as follows:

Neuroinvasive disease

• Meningitis, encephalitis, acute flaccid paralysis, or other acute signs of central or peripheral neurologic dysfunction, as documented by a physician, AND
• Absence of a more likely clinical explanation. Other clinically compatible symptoms of arbovirus disease include: headache, myalgia, rash, arthralgia, vertigo, vomiting, paresis, and/ or nuchal rigidity.

Non-Neuroinvasive disease

• Fever (chills) as reported by the patient or a health-care provider, AND
• Absence of neuroinvasive disease, AND
• Absence of a more likely clinical explanation. Other clinically compatible symptoms of arbovirus disease include: headache, myalgia, rash, arthralgia, vertigo, vomiting, paresis, and/ or nuchal rigidity.

Laboratory Criteria for Diagnosis

• Isolation of virus from, or demonstration of specific viral antigen or nucleic acid in, tissue, blood, CSF, or other body fluid, OR
• Four-fold or greater change in virus-specific quantitative antibody titers in paired sera, OR
• Virus-specific IgM antibodies in serum with confirmatory virus-specific neutralizing antibodies in the same or a later specimen, OR
• Virus-specific IgM antibodies in CSF or serum.

Case Classification

Probable

Neuroinvasive disease

A case that meets the above clinical criteria for neuroinvasive disease and the following laboratory criteria:

• Virus-specific IgM antibodies in CSF or serum but with no other testing.

Non-Neuroinvasive disease

A case that meets the above clinical criteria for non-neuroinvasive disease and the laboratory criteria for a probable case:

• Virus-specific IgM antibodies in serum but with no other testing.

Confirmed

Neuroinvasive disease

A case that meets the above clinical criteria for neuroinvasive disease and one or more of the following laboratory criteria for a confirmed case:

• Isolation of virus from, or demonstration of specific viral antigen or nucleic acid in, tissue, blood, CSF, or other body fluid, OR
• Four-fold or greater change in virus-specific quantitative antibody titers in paired sera, OR
• Virus-specific IgM antibodies in serum with confirmatory virus-specific neutralizing antibodies in the same or a later specimen, OR
• Virus-specific IgM antibodies in CSF and a negative result for other IgM antibodies in CSF for arboviruses endemic to the region where exposure occurred.

Non-Neuroinvasive disease

A case that meets the above clinical criteria for non-neuroinvasive disease and one or more of the following laboratory criteria for a confirmed case:

• Isolation of virus from, or demonstration of specific viral antigen or nucleic acid in, tissue, blood, or other body fluid, excluding CSF, OR
• Four-fold or greater change in virus-specific quantitative antibody titers in paired sera, OR
• Virus-specific IgM antibodies in serum with confirmatory virus-specific neutralizing antibodies in the same or a later specimen.

Comment(s)

Imported arboviral diseases

Human disease cases due to dengue or yellow fever viruses are nationally notifiable to CDC using specific case definitions. However, many other exotic arboviruses (e.g., Japanese encephalitis, tickborne encephalitis, Venezuelan equine encephalitis, and Rift Valley fever viruses) are important public health risks for the United States as competent vectors exist that could allow for sustained transmission upon establishment of imported arboviral pathogens. Healthcare providers and public health officials should maintain a high index of clinical suspicion for cases of potentially exotic or unusual arboviral etiology, particularly in international travelers. If a suspected case occurs, it should be reported to the appropriate local/state health agencies and CDC.

Interpreting arboviral laboratory results:

• Serologic cross-reactivity: In some instances, arboviruses from the same genus produce cross-reactive antibodies. In geographic areas where two or more closely-related arboviruses occur, serologic testing for more than one virus may be needed and results compared to determine the specific causative virus. For example, such testing might be needed to distinguish antibodies resulting from infections within genera (e.g., flaviviruses such as West Nile, St. Louis encephalitis, Powassan, dengue, or Japanese encephalitis viruses).
• Rise and fall of IgM antibodies: For most arboviral infections, IgM antibodies are generally first detectable at 3 to 8 days after onset of illness and persist for 30 to 90 days, but longer persistence has been documented (e.g., up to 500 days for West Nile virus). Serum collected within 8 days of illness onset may not have detectable IgM and testing should be repeated on a convalescent-phase sample to rule out arboviral infection in those with a compatible clinical syndrome.
• Persistence of IgM antibodies: Arboviral IgM antibodies may be detected in some patients months or years after their acute infection. Therefore, the presence of these virus-specific IgM antibodies may signify a past infection and be unrelated to the current acute illness. Finding virus-specific IgM antibodies in CSF or a fourfold or greater change in virus-specific antibody titers between acute- and convalescent-phase serum specimens provides additional laboratory evidence that the arbovirus was the likely cause of the patient’s recent illness. Clinical and epidemiologic history also should be carefully considered.
• Persistence of IgG and neutralizing antibodies: Arboviral IgG and neutralizing antibodies can persist for many years following a symptomatic or asymptomatic infection. Therefore, the presence of these antibodies alone is only evidence of previous infection and clinically compatible cases with the presence of IgG, but not IgM, should be evaluated for other etiologic agents.
• Arboviral serologic assays: Assays for the detection of IgM and IgG antibodies commonly include enzyme-linked immunosorbent assay (ELISA), microsphere immunoassay (MIA), or immunofluorescence assay (IFA). These assays provide a presumptive diagnosis and should have confirmatory testing performed. Confirmatory testing involves the detection of arboviral-specific neutralizing antibodies utilizing assays such as plaque reduction neutralization test (PRNT).
• Other information to consider. Vaccination history, detailed travel history, date of onset of symptoms, and knowledge of potentially cross-reactive arboviruses known to circulate in the geographic area should be considered when interpreting results.

Information Needed for Investigation

Verify the diagnosis. Obtain demographic, clinical, laboratory information, and other epidemiological information necessary to complete the Arbovirus Infections Case Report Form from the attending physician, hospital, and/or laboratory and patient or a knowledgeable family member. Epidemiologically significant attributes of an infection include:

• Demographics (age, sex, race/ethnicity, place of residence, occupation, or other characteristics that can reveal seasonal, geographic, and demographic patterns).
• Clinical symptoms and syndrome (e.g., asymptomatic blood donor, uncomplicated fever, meningitis, encephalitis, acute flaccid paralysis, other).
• Date of illness onset.
• Hospitalization and outcome.

Investigate laboratory reports of presumptive viremic blood donors. Presumptive viremic blood donors (PVDs) are people who had no symptoms at the time of donating blood, but whose blood, tissue, or hematopoietic progenitor cells tested positive when screened for the presence of WNV. The public health impact of PVD reporting and case investigation includes the following:

• PVDs that develop symptoms after donation should be included in morbidity counts.
• Identification of WNV infected persons – even those without illness – is a tool that municipal and county public works and public health mosquito control programs can use to prioritize areas for mosquito monitoring and pesticide treatment.
• An epidemiologic dataset of the demographic attributes, preexisting risk factors, and geographic incidence of both symptomatic and asymptomatic WNV infections can be used to evaluate the effectiveness of insect bite prevention messaging and mosquito control strategies.

Establish the source of the infection. Look back approximately two weeks:

• Travel history in the 2 weeks prior to illness onset (obtain from the patient or the patient’s family, neighbors, co-workers, social worker, or health care provider)
• Are there household or workplace contacts with a similar illness?
• Was the patient’s arthropod exposure (e.g., mosquito/tick bites) in-state, out-of-state, or out-of-country?
• Rule out non-arthropodborne transmission pathways (which may fall outside the two week timeframe):
  • Was case a transfusion or transplant recipient in the last two months?
  • Does case work in laboratory or clinical setting?
  • Is case a neonate, pregnant, or breast feeding?
• If the patient is a recent organ, tissue (e.g., corneas, skin), or blood donor or recipient:
  • Assure relevant partners have been notified (blood collection agencies, hospitals, CDC, other health departments).
  • Assure quarantine of remaining co-component blood or tissues.
  • If necessary, investigate recipients of transfused co-components from implicated donation and other potentially contaminated donations from implicated donor(s).
  • Notify Bureau of Communicable Disease Control and Prevention (BCDCP).

Provide information on Arboviral disease to persons at risk for infection and the general public as needed. Efforts should be made to promote arboviral disease awareness among international travelers and persons visiting family and friends where these diseases are known to occur. To the extent possible, travelers should avoid known foci of epidemic disease transmission. Although mosquitoes may bite at any time, peak biting activity for vectors of chikungunya is during daylight hours. Residents of and travelers to areas with endemic arboviral disease can reduce their risk of infection by using mosquito repellent, wearing long-sleeved shirts and pants, and sleeping in locations with air conditioning or screens on doors and windows. Additional information on “Protection against Mosquitoes, Ticks, & Other Insects & Arthropods” can be found on the CDC website.

Arboviral Disease Surveillance. Medical providers should report arboviral cases promptly. Local public health agencies (LPHAs) should review WebSurv to determine whether there have been other cases reported. When cases are related by person, place, or time, efforts should be made to identify a common source.

Data collected from arboviral disease surveillance is used to monitor trends; identify areas of risk and risk factors in the United States. Further public health surveillance can enhance healthcare provider awareness of arboviral disease so that cases can be rapidly identified, thereby reducing the possibility of local transmission or establishment of endemicity in this country of certain arboviral diseases.

Notification

• The local public health agency (LPHA) should immediately contact the District Communicable Disease Coordinator, or the Senior Epidemiology Specialist for the District, or the Missouri Department of Health and Senior Services (MDHSS) - BCDCP, phone (573) 751-6113, Fax (573) 526-0235, or for afterhours notification contact the MDHSS/Emergency Response Center (ERC) at (800) 392-0272 (24/7) immediately if an outbreak* of an arbovirus is suspected.
• If a case(s) is associated with a childcare center, BCDCP or the LPHA will contact the Bureau of Environmental Health Services, phone (573) 751-6095, Fax (573) 526-7377 and the Section for Child Care Regulation, phone (573) 751-2450, Fax (573) 526-5345.
• If a case(s) is associated with a long-term care facility, BCDCP or the LPHA will contact the Section for Long Term Care Regulation, phone (573) 526-8524, Fax (573) 751-8493.
• If a case is associated with a hospital, hospital-based long-term care facility, or ambulatory surgical center BCDCP or the LPHA will contact the Bureau of Health Services Regulation phone (573) 751-6303, Fax (573) 526-3621.

*Outbreak is defined as the occurrence in a community or region, illness(es) similar in nature, clearly in excess of normal expectancy and derived from a common or a propagated source.

Prevention and Control^{3, 5, 6, 7}

Without a human vaccine for WNV and the other mosquito-transmitted viruses, the only way to prevent human infection and disease is to prevent infected mosquitoes from biting people. This is accomplished by:

• Community-based integrated mosquito management programs (described below under Integrate Vector Management)
• By effective personal protection behaviors and practices, particularly
  • Mosquito-avoidance
  • Use of personal repellents
  • Removal of residential mosquito breeding habitat (e.g., manmade and natural pools of stagnant water)

Every year, more and more personal repellent products are introduced onto the market. DHSS and CDC recommend products containing active ingredients that have been registered by the Environmental Protection Agency (EPA) for use as repellents that are applied to skin and clothing. Products that do not have an EPA registration number have not been scientifically evaluated and approved for effectiveness or human safety.

In addition, because repellents are used to prevent disease, over and above the annoyance of preventing insect bites, CDC also has reviewed scientific literature and data available from EPA. The result of this additional review is a list of several EPAregistered products that are recommended by CDC because they can be used to help people avoid the bites of disease-carrying mosquitoes. Products containing these active ingredients typically provide reasonably long-lasting protection:

• DEET (Chemical Name: N,N-diethyl-m-toluamide or N,N-diethly-3-methylbenzamide)
• Picaridin (KBR 3023, Chemical Name: 2-(2-hydroxyethyl)-1- piperidinecarboxylic acid 1-methylpropyl ester )
• Oil of Lemon Eucalyptus or PMD (Chemical Name: para-Menthane-3, 8-diol) the synthesized version of oil of lemon eucalyptus (NOTE: This recommendation refers to EPA-registered repellent products containing the active ingredient oil of lemon eucalyptus (or PMD). “Pure” oil of lemon eucalyptus (e.g. essential oil) has not received similar, validated testing for safety and efficacy, and is not covered by this CDC recommendation.)
• IR3535 (Chemical Name: 3-[N-Butyl-N-acetyl]-aminopropionic acid, ethyl ester)

Reduce Mosquito Production at the Home

Encourage residents to regularly remove standing water around the home, such as clogged rain gutters, flowerpots, old tires, empty containers, buckets, and wading pools. Water in birdbaths should be changed at least once per week. CDC provides resources that list these and other steps for reducing mosquito breeding habitat.

Integrated Vector Management

Mosquito abatement programs can employ integrated pest management principles to reduce mosquito abundance, providing important community services to protect quality of life and public health. Prevention and control of WNV and other arboviral diseases is accomplished most effectively through a locally-based integrated vector management (IVM) program that conducts surveillance, assesses infectivity rates in mosquito populations, and monitors the effectiveness of control operations.

IVM is based on an understanding of the underlying biology of the arbovirus transmission system, and utilizes regular monitoring of vector mosquito populations and arboviral pathogen activity levels to determine if, when, and where interventions are needed to keep mosquito numbers below levels that produce risk of human disease, and to respond appropriately to reduce risk when it exceeds acceptable levels.

Operationally, IVM is anchored by a monitoring program providing data that describe:

• Conditions and habitats that produce vector mosquitoes.
• Abundance of those mosquitoes over the course of a season.
• Arbovirus transmission activity levels expressed as pathogen infection rate in mosquito vectors.
• Parameters that influence local mosquito populations and arboviral transmission.

Mosquito monitoring data inform decisions about implementing mosquito control activities appropriate to the situation, such as:

• Source reduction through habitat modification.
• Larval mosquito control using the appropriate methods for the habitat.
• Adult mosquito control using pesticides applied from trucks or aircraft when established thresholds have been exceeded.
• Community education efforts related to mosquito-borne disease risk levels and intervention activities.

IVM also provides quality control for the program, allowing evaluation of:

• Effectiveness of larval control efforts.
• Effectiveness of adult control efforts.
• Causes of control failures (e.g., undetected larval sources, pesticide resistance, and equipment failure).

Vector Management

• No models have been developed to provide long-term predictions of how and where a variety of biotic and abiotic factors will combine to produce WNV outbreaks.
• The use of public health human case surveillance by itself is insufficient for predicting or preventing outbreaks of WNV disease.
• Intensive early season adult mosquito control efforts can decrease WNV transmission activity and result in reduced human risk.
• As evidence of sustained or intensified virus transmission in a region increases, emergency vector control efforts to reduce the abundance of infected, biting adult mosquitoes must be implemented.
• Delaying adulticide applications until numerous human cases occur negates the value and purpose of the surveillance system. Timely application of an effective adulticide interrupts WNV transmission and prevents human cases.

Emergency Mosquito Abatement Protective Measures Following a Declared Emergency or Major Disaster

• Federal Emergency Management Agency (FEMA) Recovery Policy RP9523.10 describes FEMA criteria to determine eligibility for mosquito abatement measures following a declared emergency or major disaster.
• Where possible, a determination of the need for mosquito abatement measures is based on surveillance data provided by local agencies, or on surveillance conducted as a component of the emergency response.
• Insecticide formulations must be among those registered by the U.S. Environmental Protection Agency for use in urban areas for mosquito abatement and must be applied according to label directions and precautions by appropriately trained and certified applicators.

Laboratory Procedures^{8, 9}

The front-line screening assays for laboratory diagnosis of human WNV infection is the IgM enzyme-linked immunosorbent assay (ELIZA) and the enzyme immunoassay (EIA). The Missouri State Public Health Laboratory (MSPHL) also uses a microsphere-based immunoassay for the detection of IgM antibodies that can differentiate WNV from SLE.

Because the IgM and IgG ELISA tests can cross-react among the various species in the flavivirus genus (e.g., WNV SLE, dengue, yellow fever, Japanese encephalitis), they should be viewed as screening tests only. For a case to be considered confirmed, serum samples that are antibody-positive on initial screening should be evaluated by a more specific test. Currently the plaque reduction neutralization test (PRNT) is the recommended test for differentiating between flavivirus infections.

Although WNV is the most common cause of arboviral encephalitis in the United States, there are several other arboviral encephalitides present in the country and in other regions of the world. Specimens submitted for WNV testing should also be tested by ELISA and PRNT against other arboviruses known to be active or be present in the area or in the region where the patient traveled.

Instructions for submitting diagnostic specimens for serological testing for WNV and SLEV are available on the MSPHL website. In addition, testing for CHIKV infection is available through CDC following approval from a MDHSS epidemiologist to assure symptoms and likely exposure. Providers and disease investigators should contact the Vectorborne Disease Program at 573 526 4780 or afterhours contact the MDHSS/ERC at 800 392 0272 (24/7).

MSPHL testing for eastern equine encephalitis (EEE), western equine encephalitis (WEE), and La Crosse/California encephalitis group is available and also requires consultation with the Vector-Borne Disease Program 573 751 6113 or 800 392 0272 (24/7).

A completed MSPHL Virology Test Request form (LAB-158) must accompany all specimens.

Reporting Requirements

Arboviral diseases (neuroinvasive and non-neuroinvasive) are Category 3 reportable diseases and shall be reported to the local public health agency or to the Missouri Department of Health and Senior Services (MDHSS) within three days of first knowledge or suspicion by telephone, facsimile, or rapid communication. The MDHSS is requesting the following arboviral infections to be reported:

• California Serogroup Viruses
• Powassan Virus
• La Crosse Virus
• St. Louis Encephalitis Virus
• Chikungunya Virus
• West Nile Virus
• Eastern Equine Encephalitis Virus
• Western Equine Encephalitis Virus

Note: The exception to this is Venezuelan equine virus neuroinvasive and nonneuroinvasive disease. Because of its possible use as a weapon of bioterrorism, it is classified as a Category IB condition and suspected or confirmed cases must be reported to the local health authority or to the Missouri Department of Health and Senior Services within 24 hours. MDHSS may be contacted 24 hours a day, 7 days a week at (800) 392-0272 (24/7).

1. For all reported cases, complete a “Disease Case Report” (CD-1) and a “Arbovirus Infection Case Report” (MO 580-2601) and send the completed forms to the DHSS District Health Office.
2. Entry of the completed CD-1 into WebSurv negates the need for the paper CD-1 to be forwarded to the District Health Office.
3. MDHSS will report to CDC following the above reporting criteria (see box).
4. All outbreaks or “suspected” outbreaks must be reported as soon as possible (by phone, fax, or e-mail) to the District Communicable Disease Coordinator or the District Senior Epidemiology Specialist. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51).
5. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

References

1. American Public Health Association. Arboviral Diseases. In D. Heymann (Ed.), Control of Communicable Diseases Manual. 20th ed. Washington, DC: American Public Health Association; 2015: 26-46.
2. American Academy of Pediatrics. Arboviruses. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Disease, 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012: 232-238.
3. Centers for Disease Control and Prevention, Epidemic/Epizootic West Nile Virus in the United States: Guidelines for Surveillance, Prevention, and Control, Fort Collins, Colorado: U.S. Department of Health and Human Services, 4th ed. 2013. http://www.cdc.gov/westnile/resources/pdfs/wnvGuidelines.pdf (4/15).
4. Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System (NNDSS) and Case Definitions. http://wwwn.cdc.gov/nndss/ (4/15).
5. Association of State and Territorial Health Officials (ASTHO). Before the Swarm: Guidelines for the Emergency Management of Vector-Borne Disease Outbreaks. 2nd ed. Arlington, VA: 2015. http://www.astho.org/Programs/EnvironmentalHealth/Natural-Environment/B… (4/15).
6. Lothrop, Hugh D., Lothrop, Branka B., Gomsi, Donald E., and Reisen, William K. Intensive Early Season Adulticide Applications Decrease Arbovirus Transmission Throughout the Coachella Valley, Riverside County, California. Vector Borne Zoonotic Dis. 2008 Aug; 8(4): 475–489. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978539/ (4/15).
7. Carney, Ryan M., Husted, Stan Husted, Jean, Cynthia, Glaser, Carol, and Kramer, Vicki. Efficacy of Aerial Spraying of Mosquito Adulticide in Reducing Incidence of West Nile Virus, California, 2005. Emerg Infect Dis. 2008 May; 14(5): 747– 754. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600250/pdf/07- 1347_finalR.pdf (4/15).
8. Johnson, Alison J., Noga, Amanda J., Kosoy, Olga, Lanciotti, Robert S., Johnson, Alicia A., and Biggerstaff, Brad J. Duplex Microsphere-Based Immunoassay for Detection of Anti-West Nile Virus and Anti-St. Louis Encephalitis Virus Immunoglobulin M Antibodies. Clin Diagn Lab Immunol. 2005 May; 12(5): 566– 574.
9. Basile, Alison J., Horiuchi, Kalanthe, Panella, Amanda J., Laven, Janeen, Kosoy, Olga, Lanciotti, Robert S., Venkateswaran, Neeraja, and Biggerstaff, Brad J. Multiplex Microsphere Immunoassays for the Detection of IgM and IgG to Arboviral Diseases. PLoS One. 2013; 8(9).

Case Definition

https://ndc.services.cdc.gov/case-definitions/babesiosis/

Overview

• Agent – Babesiosis is caused by protozoan parasites of the genus Babesia that infect red blood cells. While more than 100 species of Babesia parasites have been reported, only a few have been identified as causing human infections, including B. microti, B. divergens, B. duncani, and an un-named strain designated MO-1. B. microti is the most commonly identified agent of babesiosis in the U.S.
• Reservoir – The primary reservoir for Babesia parasites is the white-footed mouse (Peromyscus leucopus)
• Occurrence – Babesiosis most commonly occurs in the Northeast and upper Midwest regions of the U.S. The primary tick vector (the blacklegged or deer tick, Ixodes scapularis) for this infection is widely found in these areas.
• Risk Factors – Individuals residing in or traveling to the Northeast and upper Midwest regions of the U.S. and spending time outdoors and in tick habitat are at an increased risk of infection. Most cases of babesiosis are reported during the late spring, summer, and fall months like many other tick-borne pathogens.
• Mode of Transmission – Babesiosis is primarily transmitted through the bite of an infected tick (the blacklegged or deer tick, Ixodes scapularis). Other possible but less common modes include via blood transfusion; vertical transmission (mother to baby during pregnancy); and transmission via breastfeeding.
• Incubation Period – Typical incubation can range from approximately 1-5 weeks following a tick bite. Transfusion-associated cases have a median incubation period of about 37 days (range of 11-176 days) but could be longer.
• Clinical Illness – The majority of people who become infected are asymptomatic. If symptoms develop, they can range from mild febrile illness to severe illness and even death. Severe illness is more likely for individuals who are asplenic, immunocompromised, or elderly. Commonly reported symptoms include fever and hemolytic anemia that may be accompanied by chills, sweats, headache, myalgia, arthralgia, headache, nausea, anorexia, malaise, and fatigue. Severe babesiosis may require hospitalization due to marked anemia, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), renal impairment, shock, or splenic rupture.
• Laboratory Testing – Microscopic identification of Babesia parasites on Giemsa- or Wright-stained blood smears can be used to diagnose acute, symptomatic cases. Babesia species can be difficult to distinguish from malaria trophozoites, and confirmation of diagnosis with a reference laboratory may be necessary. Presumptive positive smears can be sent to the Missouri State Public Health Laboratory (MSPHL). MSPHL will coordinate with CDC to determine the species of Babesia. If blood smears are negative but clinical suspicion of babesiosis infection remains high, PCR testing can be conducted through a commercial laboratory. Most available PCR tests will be specific for B. microti. Serologic tests are also available through commercial laboratories, but a single serology test cannot reliably distinguish between past exposure or infection and present illness.
• Treatment – Combination treatment for B. microti typically includes atovaquone (oral) plus azithromycin (oral for mild to moderate disease, intravenously for severe disease) for 7-10 days. Alternative combination treatment is available for patients with B. duncani or B. divergens infections or patients that don’t respond to treatment with atovaquone and azithromycin combination. However, the alternative combination treatment may have an increased risk of adverse effects. Extended length of treatment and/or higher dosage may be indicated for patients that are immunocompromised.
• Priority – Routine.

Quick References / Factsheets

• Health Care Providers:
  • Tickborne Diseases of the United States: A Reference Manual for Healthcare Providers (07/25)
  • Clinical Care of Babesiosis (07/25)

Forms

• Disease Case Report (CD-1)
• CDC Babesiosis Case Report Form
• Missouri Outbreak Report Form (MORF)

Notifications

• If babesiosis infection is suspected, the local public health agency (LPHA) should notify the District Epidemiologists or the Missouri Department of Health and Senior Services (MDHSS) Bureau of Communicable Disease Control and Prevention (BCDCP), phone (573) 751-6113, Fax (573) 526-0235.

Reporting Requirements

• Babesiosis is a Category 3 disease and shall be reported to the LPHA or to the Missouri Department of Health and Senior Services (MDHSS) within one (3) calendar days of first knowledge or suspicion by telephone, fax, or other rapid communication.
  • For confirmed and probable cases, complete a Disease Case Report (CD-1) and a CDC Babesiosis Case Report Form.
  • Entry of the completed CD-1 into the ShowMe World Care (SMWC) database negates the need for the paper CD-1 to be forwarded to the District Office.
  • All outbreaks or “suspected” outbreaks must be reported as soon as possible (by phone, fax, or e-mail) to the District Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Report Form (MORF).
  • Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

Laboratory Testing and Diagnosis

Hospital laboratory staff may be able to conduct microscopic identification of Babesia parasites on Giemsa- or Wright-stained blood smears for acute, symptomatic cases. Multiple blood smears may need to be examined to detect Babesia parasites. Health care providers should explicitly request a manual (non-automated) review of blood smears for symptomatic patients. Presumptive positive smears can be sent to the Missouri State Public Health Laboratory (MSPHL). Facilities should reach out to MSPHL for detailed instructions prior to submission of smears. MSPHL will coordinate with CDC to determine the species of Babesia. Other types of testing for babesiosis are available through commercial laboratories including PCR and serology. Most available PCR tests will be specific for B. microti, not B. duncani or B. divergens. PCR testing may remain positive for several months after successful treatment. Serologic tests are also available through commercial laboratories, but caution should be exercised regarding the interpretation of a single serology test. A single positive serology test cannot reliably distinguish between past exposure or infection and present illness.

Conducting the Investigation

• Verify the diagnosis. Obtain demographic, clinical and laboratory information on the case from the health care provider, hospital, and/or laboratory. Does the laboratory test result provide evidence of a recent babesiosis infection? Obtain other epidemiological information necessary to complete the Disease Case Report (CD-1) and the CDC Babesiosis Case Report Form.
• Establish the extent of illness. Determine if household, traveling companions or other close contacts that have shared environmental exposures are, or have been, ill by contacting the health care provider, patient, and/or family members. Persons with similar illness may require medical evaluation and should be encouraged to contact their physician to discuss.
• Establish the source of infection. For all cases, please obtain the following information from the patient, patient’s family, or health care provider:
  • Travel history:
    • Determine the start and end dates of the trip and the location(s) of travel. Start and end dates will be requested for all locations if patient visited multiple locations.
    • If there is no history of foreign travel consistent with exposure to DENV, please contact your District Epidemiology team and/or the Zoonotic Disease Program. Sporadic outbreaks of DENV have occurred in Florida, Texas, California, and Hawaii in recent years. Cases that are suspected to have been acquired within the U.S. need to be promptly reported.
  • Outdoor exposures or time spent in tick habitat (including in-state, out-of-state, or out-of-country)
  • Non-tick transmission pathways:
    • Does case work in a laboratory or clinical setting?
    • Is the case a neonate, pregnant, or breastfeeding?
    • Has the case recently received any blood, blood products, tissues, or organs within the last 30 days?
      • If yes, please notify your District Epidemiologists.
      • Ensure that relevant partners have been notified (blood collection agencies, hospitals, etc.).
      • Determine the patient/donor identification numbers and any other available details regarding blood products/organs donated or received.
      • Assure quarantine of any remaining co-component blood or tissues.
      • If assistance is needed with this tracing process, please reach out to the Zoonotic Disease Program for guidance.

Control Measures

No vaccine is available to protect people against babesiosis. Generally, asymptomatic individuals need not be treated unless Babesia is detected on blood smear or PCR for more than three months. Suspected babesiosis should not be treated if reliable blood smear and PCR results are negative. When Babesia is detected, symptomatic patients should be treated.

The best way to avoid infection with babesiosis is to avoid tick bites. Key personal prevention methods for avoiding tick bites include:

• Whenever possible, avoid tick habitat during the peak time of year when ticks are most active (generally April through September). Ticks are generally found in areas with tall grass, brush or in heavily wooded areas. However, they can also be present in neighborhoods and backyards.
• Use an insect repellent product with at least 20% DEET, picaridin, or other U.S. Environmental Protection Agency (EPA)-registered active ingredients labeled specifically for ticks on all exposed skin.
  • The American Academy of Pediatrics has recommended that repellents containing up to 30% DEET are safe to use on children over 2 months of age.
  • For other active repellent ingredients, check the product label for minimum age requirements before applying to children.
  • EPA offers an insect repellent search tool that the public can use to identify repellent products that work best for their needs.
• Weather-permitting, wear long sleeves and pants to help reduce the amount of exposed skin. This will make it harder for ticks to find a place to attach.
  • Wearing light-colored clothing can make it easier to spot ticks that may be crawling on clothing when you are outdoors.
• Consider applying permethrin to clothing, boots, and outdoor gear when spending time in tick habitat. Permethrin binds tightly to fabric and will remain effective after multiple washings.
  • This product should not be applied directly to the skin. Product directions and labels should be read carefully before use.

Resources

1. American Academy of Pediatrics. [Babesiosis]. In: Kimberlin DW, Barnett, ED, Lynfield, R, Sawyer, MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021: [217-219].
2. American Public Health Association. [Babesiosis]. In: Heymann DL, ed. Control of Communicable Diseases Manual. 21st ed. Washington, DC: American Public Health Association; 2022 [58-61].
3. Centers for Disease Control and Prevention. Babesiosis. https://www.cdc.gov/babesiosis/about/index.html (07/25)
4. Centers for Disease Control and Prevention. Tickborne Diseases of the United States: A Reference Manual for Healthcare Providers. https://www.cdc.gov/ticks/hcp/dataresearch/tickborne-disease-reference-… (07/25)

Overview ^{1, 2, 3, 6, 7, 12, 13}

All forms of botulism can be fatal and are considered medical emergencies. Suspected botulism cases thought to be the result of an intentional release; foodborne; a cluster or outbreak of infant botulism; or cases of unknown etiology not meeting standard notification criteria should be immediately reported to your local public health agency (LPHA). If the LPHA cannot be immediately reached, contact the Missouri Department of Health and Senior Services (MDHSS) at (800) 392-0272 (24/7).

Botulism is a rare but serious paralytic illness caused by botulinum neurotoxins (BoNTs) that are produced by the bacterium Clostridium botulinum. There are seven types of BoNTs designated by the letters A through G; only types A, B, E and F cause illness in humans. Non-botulinum species of Clostridium rarely may produce these neurotoxins and cause disease [Clostridium butyricum (type E) and Clostridium baratii (types E and F)]. C. botulinum spores can be found in soils and dust worldwide.

There are five main kinds of botulism. Foodborne botulism is caused by eating foods that contain the BoNTs. Wound botulism is caused by BoNTs produced from a wound infected with C. botulinum. Infant botulism is caused by consuming the spores of the botulinum bacteria, which then grow in the intestines and release the BoNTs. Adult intestinal toxemia (adult intestinal colonization) botulism is a very rare kind of botulism that occurs among adults by the same route as infant botulism. Lastly, iatrogenic botulism can occur from an accidental overdose of therapeutic BoNTs. Foodborne botulism is a public health emergency because many people can be poisoned by eating a contaminated food. In a bioterrorist attack, BoNTs could be delivered by aerosols, as well as in food or water. Should aerosol transmission occur the clinical disease is expected to be similar to foodborne botulism.

Classic botulism disease generally begins with evidence of cranial nerve dysfunction (such as double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth), and then progresses to muscle weakness/paralysis. The latter is typically described as an afebrile descending symmetric paralysis that may progress to respiratory dysfunction as a result of involvement of the respiratory muscles. Abdominal pain, nausea, vomiting, and/or diarrhea can be present in some patients.

Infants with botulism appear lethargic, feed poorly, are constipated, and have a weak cry and poor muscle tone. These are all symptoms of the muscle paralysis caused by the BoNTs.

In foodborne botulism, symptoms generally begin 18 to 36 hours after eating a contaminated food, but they can occur as early as 6 hours or as late as 10 days.¹ In infant botulism, the incubation period is estimated at 3 to 30 days. For wound botulism, the incubation period is 4 to 14 days from time of injury, until onset of symptoms.⁷

Botulism can be tentatively diagnosed by the clinical signs and the exclusion of other neurologic diseases. The laboratory diagnosis relies on identifying the BoNTs and/or the bacterium in feces, blood/ serum, vomitus, gastric aspirates, wounds or food samples.⁷

For a complete description of botulism, refer to the following texts:

• Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008.
• American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. 2012.

2011 Case Definitions – (12/13)⁴

Botulism, Foodborne

Clinical description

Ingestion of botulinum toxin results in an illness of variable severity. Common symptoms are diplopia (double vision), blurred vision, and bulbar weakness. Symmetric paralysis (descending) may progress rapidly.

Laboratory criteria for diagnosis

• Detection of botulinum toxin in serum, stool, or patient’s food, or
• Isolation of C. botulinum from stool.

Case classification

Confirmed: a clinically compatible case that is laboratory confirmed or that occurs among persons who ate the same food as persons who have laboratory-confirmed botulism.

Probable: a clinically compatible case with an epidemiologic link (e.g., ingestion of a home-canned food within the previous 48 hours).

Botulism, Infant

Clinical description

An illness of infants, characterized by constipation, poor feeding, and “failure to thrive” that may be followed by progressive weakness, impaired respiration, and death.

Laboratory criteria for diagnosis

• Detection of botulinum toxin in stool or serum, or
• Isolation of C. botulinum from stool.

Case classification

Confirmed: a clinically compatible cases that is laboratory-confirmed, occurring in a child aged <1 year.

Botulism, Wound

Clinical description

An illness resulting from toxin produced by C. botulinum that has infected a wound. Common symptoms are diplopia, blurred vision, and bulbar weakness. Symmetric paralysis may progress rapidly

Laboratory criteria for diagnosis

• Detection of botulinum toxin in serum, or
• Isolation of C. botulinum from wound.

Case classification

Confirmed: a clinically compatible case that is laboratory confirmed in a patient who has no suspected exposure to contaminated food and who has a history of a fresh, contaminated wound during the 2 weeks before onset of symptoms, or a history of injection drug use within the 2 weeks before onset of symptoms

Probable: a clinically compatible case in a patient who has no suspected exposure to contaminated food and who has either a history of a fresh, contaminated wound during the 2 weeks before onset of symptoms, or a history of injection drug use within the 2 weeks before onset of symptoms.

Botulism, Other

Clinical description

See Botulism, Foodborne.

Laboratory criteria for diagnosis

• Detection of botulinum toxin in clinical specimen, or
• Isolation of C. botulinum from clinical specimen.

Case classification

Confirmed: A clinically compatible case that is laboratory-confirmed in a patient aged greater than or equal to 1 year who has no history of ingestion of suspect food and has no wounds.

Information Needed for Investigation

Verify the diagnosis. Obtain demographic, clinical, laboratory information, and other epidemiological information necessary to complete the Disease Case Report (CD-1) for all suspected botulism cases. Complete the Guide to Investigation of Infant Botulism form for all infant botulism cases. Complete the Botulism Alert Summary form for all non-infant botulism reports. The Record of Investigation of Enteric Illness (CD-2C) should also be completed for all suspected foodborne botulism cases. The information to complete the forms can be obtained from the attending physician, hospital, and/or laboratory and patient or a knowledgeable family member.

Establish the extent of illness. Determine if household or other close contacts are, or have been ill, or are at risk for disease (consumption of suspected contaminated food) by contacting the health care provider, patient, or knowledgeable family member. Identify symptomatic household members, associates, or co-workers and strongly urge them to contact their healthcare provider immediately for a medical evaluation. Determine whether the case is associated with a food recall. NOTE: Laboratory examination or culturing of specimens is routinely available from the Centers for Disease Control and Prevention (CDC). Arrangements for such testing must be made through your District Communicable Disease Coordinator or the Senior Epidemiology Specialist for the District, and the Missouri State Public Health Laboratory (MSPHL).

Identifying the source of infection. Every case of foodborne botulism should be treated as a public health emergency because the responsible food, whether homemade or commercial, might still be available for consumption and could make unsuspecting persons ill. Information obtained from the Botulism Alert Summary, the Record of Investigation of Enteric Illness (CD-2C), or the Guide to Investigation of Infant Botulism, is used to identify the source. However, sometimes the source is not identified. Note: No person-to-person transmission of botulism has been documented.

Provide information about botulism to persons at risk for infection and the general public. Efforts should be made to promote botulism awareness and provide prevention information to the public to reduce the risk of disease. Most U.S. outbreaks of foodborne botulism are caused by home-processed and home-canned foods. Therefore, for foodborne botulism: 1) Persons who do home canning should follow strict hygienic procedures to reduce contamination of foods, and carefully follow instructions on safe home canning including the use of pressure canners/cookers as recommended through county extension services or from the U.S. Department of Agriculture. 2) Because the BoNT is destroyed by high temperatures, persons who eat home-canned foods should consider boiling the food for 10 minutes before eating it to ensure safety. 3) Oils infused with garlic or herbs should be refrigerated. Potatoes which have been baked while wrapped in aluminum foil should be kept hot until served or refrigerated. 4) Never taste a product to determine if it is safe; when in doubt, throw it out. Do not taste or eat foods from containers that are leaking, have bulges or are swollen, look damaged or cracked, or seem abnormal in appearance. For additional consumer information and resources on botulism, see CDC’s website.

Wound botulism can be prevented by promptly seeking medical care for infected wounds and by not using injectable street drugs. Most infant botulism cases cannot be prevented because the bacteria that causes this disease is in soil and dust. The bacteria can be found inside homes on floors, carpet, and countertops even after cleaning. Honey can contain the bacteria that causes infant botulism, so children less than 12 months old should not be fed honey. Honey is safe for persons 1 year of age and older.

Botulism Surveillance. Review WebSurv to determine whether there have been other cases, especially in the same geographic area. When cases are related by person, place, or time, efforts should be made to identify a common source. Information obtained through the Guide to Investigation of Infant Botulism, Botulism Alert Summary, or Record of Investigation of Enteric Illness (CD-2C) is used to identify a possible source of the disease and to characterize persons or geographic areas in which additional efforts may be needed to raise awareness and reduce disease incidence.

Botulism is a potential Class A Bioterrorism Agent. If botulism is the result of a terrorist act or an intentional or deliberate release, BoNT would most likely be disseminated via an aerosol, but BoNT can also exist in forms ranging from crude microbiological cultures to isolated powders which may be white or colorless crystals. An intentional release of BoNT may result in ingestional or inhalational exposure. BoNT is a possible water threat. No natural cases of inhalational botulism have been reported. Symptoms are dose-dependent and may begin as early as 12-36 hours after inhalation, but can take several days to develop after exposure to low doses of toxin. Onset is 6 hours to 10 days (typically 12- 36 hours) after ingestion. ^{6, 12}

It may be difficult to determine whether an outbreak occurred through nefarious means. For additional bioterrorism resources for botulism, see CDC’s website.

Note: If botulism is suspected to be the result of a terrorist act or other intentional or deliberate release, the LPHA should:

1. Notify local law enforcement and the Senior Epidemiology Specialist for the District or MDHSS’ Emergency Response Center (ERC) at (800) 392-0272 (24/7) immediately.
2. Work with law enforcement and implement “Chain of Custody” procedures for all laboratory samples, as they will be considered evidence in a criminal investigation.
3. Work to define the population at risk which is essential to guide response activities. Public health authorities will play the lead role in this effort, but must consult with law enforcement, emergency response and other professionals in the process.
4. Once the mechanism and scope of delivery has been defined, identify symptomatic and asymptomatic individuals among the exposed and recommend medical evaluation/treatment as appropriate.
5. Establish and maintain a detailed line listing of all cases and contacts with accurate identifying and locating information. A botulism questionnaire for community use in a mass casualty incident is available at: Form 3A: Bioterrorism Agent Case Exposure Investigation Form.

Notification

• Contact the District Communicable Disease Coordinator, the Senior Epidemiology Specialist for the District, or MDHSS’ – Bureau of Communicable Disease Control and Prevention (BCDCP), phone (573) 751-6113, Fax (573) 526-0235, or for after hours notification contact the MDHSS’ ERC at (800) 392-0272 (24/7) immediately if botulism is suspected.
• If a case(s) is associated with a childcare center, BCDCP or the LPHA will contact the Bureau of Environmental Health Services (BEHS), phone (573) 751-6095, Fax (573) 526-7377 and the Section for Child Care Regulation, phone (573) 751-2450, Fax (573) 526-5345.
• If a case(s) is thought to be the result of a product obtained through a commercial food operation, BCDCP or the LPHA will contact BEHS, phone (573) 751-6095, Fax (573) 526-7377.
• If a case(s) is associated with a long-term care facility, BCDCP or the LPHA will contact the Section for Long Term Care Regulation, phone (573) 526-8524, Fax (573) 751-8493.
• If a case is associated with a hospital, hospital-based long-term care facility, or ambulatory surgical center, BCDCP or the LPHA will contact the Bureau of Health Services Regulation phone (573) 751-6303, Fax (573) 526-3621.
• Contact the Department of Natural Resources, Public Drinking Water Branch, at (573) 751-1187, Fax (573) 751-3110 if cases are associated with a public water supply, or BEHS, phone (573) 751- 6095, Fax (573) 526-7377, if cases are associated with a private water supply.

Control Measures ^{1, 2, 3, 6, 7, 12, 13}

Botulism presenting as endemic disease.

• Any botulism case should be reported immediately to the LPHA or to MDHSS upon first knowledge or suspicion of botulism; do not wait for lab confirmation. MDHSS may be contacted 24 hours a day, 7 days a week at (800) 392-0272.
• Determine the source of infection to prevent other cases. In identifying suspect food sources, home-canned foods have traditionally been the major culprit, however it is extremely important to consider all possible food sources. Recent botulism cases have been traced to baked potatoes, frozen pot pies, garlic stored in oil, grilled onions, and fermented ethnic foods. Note: Prophylactic equine antitoxin is not recommended for asymptomatic persons who have ingested food known to contain BoNT.⁷
• Immediate administration of antitoxin is the key to successful therapy.
• Public health education is the primary means of control and prevention. Education regarding safe practices in food preparation and home-canning methods should be promoted. For consumer information and resources on botulism, see CDC’s website. 
• Wound botulism can be prevented by promptly seeking medical care for infected wounds and by not using injectable street drugs. Should wound botulism occur, it is usually treated surgically to remove the source of the toxin-producing bacteria, followed by administration of appropriate antibiotics (penicillin or metronidazole). Antibiotics should be given to patients with wound botulism after antitoxin has been administered.
• Most infant botulism cases cannot be prevented because the bacteria that causes this disease is in soil and dust. The bacteria can be found inside homes on floors, carpet, and countertops even after cleaning. Comments: Most cases occur in breastfed infants at the time of first introduction of nonhuman milk substances. Human-derived antitoxin is given urgently. Antimicrobial therapy is not indicated for infant botulism. Notes: The role of antimicrobial therapy in the adult intestinal colonization form of botulism is not established. Aminoglycoside agents potentiate paralytic effects of the toxin and should be avoided.⁷
• Honey can contain the bacteria that causes infant botulism, so children less than 12 months old should not be fed honey. Honey is safe for persons 1 year of age and older.

Important: To obtain botulinum antitoxin for infant forms of botulism: BabyBIG® is a product licensed to treat type A and B infant botulism cases and only available through the California Department of Public Health, Infant Botulism Treatment and Prevention Program (IBTPP). For maximum benefit, treatment with BabyBIG® should occur as early as possible.

Clinicians and health departments with a suspect infant botulism case should contact IBTPP immediately (24/7) at (510) 231-7600 for clinical consultation and/or obtaining BabyBIG® . General information about infant botulism can be found on the IBTPP website

Important: To obtain botulinum antitoxin for non-infant forms of botulism from CDC, contact the MDHSS’ ERC at (800) 392-0272 (24/7). If contact cannot be made, the CDC Emergency Operations Center can be contacted at (770) 488-7100 for botulism case consultation and antitoxin.

For information on the medical management of botulism, see: Botulism in the United States 1899-1996: Handbook for Epidemiologists, Clinicians & Laboratory Workers, or the Medical Management of Biologic Causalities Handbook, or the most current edition of the Red Book: Report of the Committee on Infectious Diseases, or the Principles and Practice of Infectious Diseases, or other suitable reference.

Botulism suspected to be the result of a terrorist act or intentional/deliberate release.

If the source of infection cannot be determined and cases are presenting as multiple cases, temporally/spatially clustered and/or the epidemiologic clues suggest an intentional or deliberate use of a biological agent, then – law enforcement must be involved in the investigation. Because the laboratory confirmation could be delayed, specific epidemiological, clinical, or laboratory findings that suggest an intentional release of BoNT should result in the issue of a MDHSS Health Alert.

Laboratory Procedures

Because laboratory testing for botulism can take several days, the initial diagnosis depends on accurate and rapid clinical assessment of the patient. After appropriate assessment, if botulism is still suspected, the requestor/health care provider should contact the District Communicable Disease Coordinator, or the Senior Epidemiology Specialist for their area. One of these staff will discuss the case with the requestor/health care provider and a Scientist from the MSPHL, and the state epidemiologist as needed. If testing is indicated, the MSPHL Scientist will provide a MSPHL number that will accompany the specimen(s) to be tested. (Notes: Specimen(s) require a MSPHL number. To obtain a MSPHL number, the District Communicable Disease Coordinator, or the Senior Epidemiology Specialist should call (573) 751-3334 (MSPHL) and ask for David Byrd, Sarah Sharr, or Stephen Gladbach. The MSPHL Scientist can also provide technical assistance on the collection and shipment of specimens to CDC. The specimen(s) should be sent directly from the requestor/health care provider to the CDC. The specimen(s) should NOT be sent to the MSPHL. A CDC form 50.34 will need to be properly filled out by the requesting health agency and accompany the specimen(s) to the CDC.)

The Senior Epidemiology Specialist, District Communicable Disease Coordinator, or MSPHL Scientist will call the CDC Emergency Operations Center (EOC) (770) 488-7100, which will page the Foodborne and Diarrheal Diseases Branch medical officer holding the botulism beeper and provide CDC with the name of the medical facility as well as the patient’s name.

Reporting Requirements

Botulism is a Category 1 (A) state reportable disease or finding and is immediately reportable by telephone, facsimile, or other rapid communication to the LPHA or MDHSS upon first knowledge or suspicion of botulism; do not wait for lab confirmation. MDHSS may be contacted 24 hours a day, 7 days a week at (800) 392-0272.

As a Nationally Notifiable Condition – sporadic infant and wound botulism cases are a STANDARD report to CDC prior to case classification. STANDARD reporting requires MDHSS to report to CDC by electronic transmission via WebSurv within the next normal reporting cycle.

1. For all cases prior to classification, complete a “Disease Case Report” (CD-1).
2. For cases of infant botulism complete a Guide to Investigation of Infant Botulism (CDC52.73).
3. For all non-infant botulism cases prior to classification complete the Botulism Alert Summary form.
4. For suspected foodborne botulism cases also complete the Record of Investigation of Enteric Illness.
5. If a terrorist act and/or the intentional or deliberate release of BoNT is suspected, an investigation tool will be provided by the District Communicable Disease Coordinator, or the Senior Epidemiology Specialist, or state epidemiologist. A botulism questionnaire for community use in a mass casualty incident to help identify exposed persons is available at: Form 3A: Bioterrorism Agent Case Exposure Investigation Form.
6. MDHSS will report to CDC following the above reporting criteria (see boxes above).
7. Entry of the completed CD-1 into the WebSurv database negates the need for the paper CD-1 to be forwarded to the District Health Office.
8. Send the completed secondary investigation form(s) to the District Health Office.
9. All outbreaks or “suspected” outbreaks must be reported as soon as possible (by phone, fax or e-mail) to the District Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51).
10. If an outbreak is associated with food, a CDC 52.13 form (National Outbreak Reporting System – Foodborne Disease Transmission) is to be completed and submitted to the District Communicable Disease Coordinator at the conclusion of the outbreak.
11. If an outbreak is associated with the use of water for drinking, or ingestion, a CDC 52.12 form (National Outbreak Reporting System - Waterborne Disease Transmission) is to be completed and submitted to the District Communicable Disease Coordinator at the conclusion of the outbreak.
12. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District CD Coordinator.

References

1. CDC. National Center for Emerging and Zoonotic Infectious Diseases. Botulism: General information: https://www.cdc.gov/botulism/ (12/13).
2. CDC. National Center for Emerging and Zoonotic Infectious Diseases. Botulism: Technical Information: https://www.cdc.gov/botulism/health-professional.html (12/13).
3. CDC, Emergency Preparedness and Response; Botulism: https://www.cdc.gov/botulism/bioterrorism/index.html (12/13).
4. CDC’s National Notifiable Diseases Surveillance System (NNDSS) and Case Definitions http://wwwn.cdc.gov/nndss/ (12/13).
5. U.S. Army Medical Research Institute of Infectious Diseases. Medical Management of Biologic Causalities Handbook. 7th Ed. Sep. 2011 (12/13).
6. American Academy of Pediatrics. Botulism and Infant Botulism, (Clostridium botulinum). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics 2012: 281-285.
7. CDC. National Center for Infectious Diseases, Division of Bacterial and Mycotic Diseases. Botulism in the United States 1899-1996: Handbook for Epidemiologists, Clinicians & Laboratory Workers. (12/13).
8. Reddy, Pavani / Bleck, Thomas P. Clostridium botulinum (Botulism). In: Gerald L. Mandell, John E. Bennett, & Raphael Dolin, Eds. Principles and Practice of Infectious Diseases, 7 th ed., Pennsylvania: Churchill Livingstone Elsevier, 2010: pp 3097-3101.
9. American Public Health Association. Botulism. In: Heymann, D Ed. Control of Communicable Diseases Manual. 19th ed. Washington, D.C. American Public Health Association, 2008: 79-87.
10. Pavlin JA. Epidemiology of Bioterrorism. Emerging Infectious Diseases, Volume 5, Number 4- August 1999. Available from: http://wwwnc.cdc.gov/eid/article/5/4/99-0412.htm (12/13).
11. National Response Team (NRT) Quick Reference Guide: Botulinum Toxin (causes botulism) http:// nrt.org/Production/NRT/NRTWeb.nsf/AllAttachmentsByTitle/A-1009WMDQRGBotulinumToxin/ $File/120216_BoNT_QRG_Final.pdf?OpenElement (12/13).
12. Botulism Fact Sheet (Center for Food Security and Public Health) Iowa State University, College of Veterinary Medicine. http://www.cfsph.iastate.edu/Factsheets/pdfs/botulism.pdf (12/13).
13. MDHSS. Disaster and Emergency Planning, Emergency Response and Terrorism, Medical. http:// health.mo.gov/emergencies/ert/med/botulism.php (12/13).
14. Burkholder-Allen, Kelly / Rega, Paul / Bork, Christopher / Budd, Churton, Departments of Public Health and Disease Prevention, Emergency Medicine and Clinical Informatics, University of Toledo, Health Science Campus, Toledo, Ohio, USA. Education Article; Botulism Questionnaire: A tactical tool for community use in a mass casualty incident. In: Nursing and Health Sciences (2009), 11, 374–377. © 2009 The Authors Journal Compilation © 2009 Blackwell Publishing Asia Pty Ltd.

Other Sources of Information

1. CDC. MMWR, March 19, 2010 / Vol. 59 (10); 299. Investigational Heptavalent Botulinum Antitoxin (HBAT) to Replace Licensed Botulinum Antitoxin AB and Investigational Botulinum Antitoxin E. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5910a4.htm (12/13).
2. CDC. MMWR, August 15, 2003 / Vol. 52 (32); 774-774. Notice to Readers: New Telephone Number to Report Botulism Cases and Request Antitoxin. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a8.htm (12/13).
3. Cox, Nadine and Hinkle, Randy Infant Botulism, American Family Physician 2002; 65:1388-92. American Academy of Family Physicians. http://www.aafp.org/afp/2002/0401/p1388.html (12/13). 4. Peter P Taillac, MD; CBRNE – Botulism, June 1, 2012, http://emedicine.medscape.com/article/829125-overview (12/13).

Overview^{1, 2, 3, 9, 12}

Brucellosis is a bacterial disease caused by members of the genus Brucella. Brucellosis is an important zoonosis and a significant cause of reproductive losses in animals. Brucellosis is usually caused by Brucella abortus in cattle, B. melitensis or B. ovis in small ruminants, B. suis in pigs, and B. canis in dogs. Some Brucella species are also maintained in wildlife populations. Because this pathogen can be easily cultured, aerosolized, stored, and disseminated, it is classified as a potential bioterrorism agent.

In humans, brucellosis can be a serious, debilitating, and sometimes chronic disease that can affect a variety of organs. Naturally-occurring human infection is most often acquired through direct or indirect exposure to aborted fetuses or tissues or fluids of infected animals. Transmission occurs by ingestion of undercooked meat or unpasteurized dairy products; inoculation through mucous membranes or cuts and abrasions in the skin; or inhalation of contaminated aerosols. Person-to-person transmission is unusual; however, rare cases in which sexual transmission was suspected have been reported. In addition, blood transfusions and bone marrow transplants have been sources of infection, indicating a need for screening in endemic areas. People in occupations such as farming, ranching, and veterinary medicine as well as slaughterhouse workers, meat inspectors, and laboratory personnel are at increased risk of acquiring brucellosis.

The incubation period in people varies from 5 to 60 days after exposure (generally beginning 2 to 4 weeks after inoculation). Asymptomatic infections are common. In symptomatic cases, brucellosis has a wide range of symptoms; some of these are similar to the flu and can include: fever, chills, sweats, malaise, anorexia, headache, weight loss, pain in muscles, joints, or back, fatigue, and abdominal pain. Physical findings may include lymphadenopathy, hepatosplenomegaly, and arthritis. Some signs and symptoms may persist for longer periods. Others may never go away or reoccur. These can include: recurrent fevers, arthritis, swelling of the testicle and scrotum area, swelling of the heart (endocarditis), neurologic symptoms (in up to 5% of all cases), chronic fatigue, and depression, swelling of the liver and/or spleen.

Human brucellosis can be prevented by controlling the infection in animals. The incidence of human disease is low in the United States, where 100 to 150 cases occur each year. Brucellosis can be quite common, however, in countries where animal disease control programs have not reduced the prevalence of brucellosis among host species. Areas currently recognized as high risk are the Mediterranean Basin, the Middle East, Mexico, South and Central America, the Caribbean, Eastern Europe, Asia, and Africa. Unpasteurized cheeses, sometimes called "village cheeses” and raw or undercooked animal products (including bone marrow) may pose a particular risk for people visiting or traveling in these areas. Confirmed infections with B. suis have occurred among feral swine hunters as a result of their field dressing and butchering activities. Exposure to the organism via unsafe laboratory practices and accidents has led to infections among clinical diagnostic and research laboratorians.

For a complete description of brucellosis, refer to the following references:

• Control of Communicable Diseases Manual (CCDM), American Public Health Association, 19th ed. 2008.
• American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. 2012.
• Principles and Practice of Infectious Diseases, 7th ed., Pennsylvania: Churchill Livingstone Elsevier, 2010.

2010 Case Definition – Brucellosis (Brucella spp.)⁴ - (10/13)

Clinical Description

An illness characterized by acute or insidious onset of fever and one or more of the following: night sweats, arthralgia, headache, fatigue, anorexia, myalgia, weight loss, arthritis/spondylitis, meningitis, or focal organ involvement (endocarditis, orchitis/epididymitis, hepatomegaly, splenomegaly).

Laboratory Criteria for Diagnosis

Definitive

• Culture and identification of Brucella spp. from clinical specimens.
• Evidence of a fourfold or greater rise in Brucella antibody titer between acute- and convalescent-phase serum specimens obtained greater than or equal to 2 weeks apart.

Presumptive

• Brucella total antibody titer of greater than or equal to 160 by standard tube agglutination test (SAT) or Brucella microagglutination test (BMAT) in one or more serum specimens obtained after onset of symptoms.
• Detection of Brucella DNA in a clinical specimen by PCR assay.

Case Classification

Confirmed

A clinically compatible illness with definitive laboratory evidence of Brucella infection.

Probable

A clinically compatible illness with at least one of the following:

• Epidemiologically linked to a confirmed human or animal brucellosis case.
• Presumptive laboratory evidence, but without definitive laboratory evidence, of Brucella infection.

Information Needed for Investigation

Verify the diagnosis. Obtain demographic, clinical, laboratory information, and other epidemiological information necessary to complete the Disease Case Report (CD-1) and the Brucellosis Case Report Form from the attending physician, hospital, and/or laboratory and patient or a knowledgeable family member. Comments: Brucella microagglutination test (BMAT), a modified version of the serum (tube) agglutination test (SAT) can detect antibodies to Brucella species - abortus, melitensis, or suis. Currently there is no serological test available to detect antibodies to B. canis. ¹² Some commercial laboratories include a brucellosis screening test in a “febrile antibodies panel; the physician’s office should be asked whether follow-up assays have been ordered.

Establish the extent of illness. Determine if household or other close contacts are, or have been ill by contacting the health care provider, patient, or family member. Identify symptomatic household members, associates, or co-workers and strongly urge them to contact their physician for a medical evaluation. Infections caused by B. melitensis may produce endocarditis if left untreated. Although human-to-human transmission is rare, congenital brucellosis has been reported, and infected mothers may transmit Brucella spp. to their infants through breastfeeding.²

Identifying the source of infection. Determine the occupation of the index case since this information may help narrow the search for the route of exposure. Information to obtain:

• Do you work in a laboratory? If so, does the lab handle unidentified isolates or Brucella specimens?
• Do you work in a slaughterhouse or meat-packing environment?
• Have you assisted animals giving birth? Determine if the case was exposed to abortive livestock or animal fetuses.
• Determine if the case was exposed to brucellosis vaccine.
• Do you hunt? If so, have you come into contact with moose, elk, caribou, bison or wild hogs (feral swine)? Comment: B. melitensis has become the major cause of human brucellosis in Latin America. Although it is normally associated with goats and their dairy products, it can infect cattle and sheep as well. Other sources of B. melitensis include bison, elk, caribou, deer, and swine.
• Determine if the case had a history of foreign travel. If so, where? Collect the dates of travel. Comment: Brucellosis is common in most Latin American countries, around the Mediterranean, Africa, Central Asia, India and the Middle East.
• While traveling, did you consume any undercooked meat or unpasteurized dairy products? Comment: Brucellosis is rarely contracted through milk in the United States, but the case or their household contacts should be questioned about consumption of raw milk, particularly in rural areas. Imported cheeses can be a potential source for Hispanic immigrants if they obtain soft or unpasteurized cheeses from Mexico. ³

Note: Contact the District Communicable Disease Coordinator if the case appears to have acquired the disease in the state of Missouri. The District Communicable Disease Coordinator will alert the State Public Health Veterinarian who will alert the Missouri Department of Agriculture, if needed. Additional information may need to be collected (e.g. job duties, food histories, and unusual risk factors).

Provide information about brucellosis to persons at risk for infection and the general public. Efforts should be made to promote brucellosis awareness and provide prevention information to the public to reduce the risk of infection. 1) Educate on potential hazards of drinking or eating unpasteurized milk products. 2) Educate high-risk workers (i.e., farmers, slaughterhouse workers, etc.) about the risk of brucellosis and stress methods to reduce occupational exposure such as proper ventilation, appropriate carcass disposal and barrier precautions. Information on brucellosis prevention can be found on CDC’s website.

Brucella Surveillance. Review WebSurv to determine whether there have been other cases in the same geographic area. When cases are related by person, place, or time, efforts should be made to identify a common source. Information obtained through the Brucellosis Case Report Form is used to identify a possible source of infection and to characterize persons or geographic areas in which additional efforts may be needed to raise awareness and reduce disease incidence.

Brucella species are a potential Class B Bioterrorism Agent. If brucellosis is the result of a terrorist act or the intentional or deliberate release, Brucella would most likely be disseminated via an infectious aerosol and is an inhalation threat to humans and wild and domestic animals. It is estimated that inhalation of only 10-100 bacteria is sufficient to cause disease in humans. Aerosolization of Brucella in biological weapons could result in a shorter incubation period, lead to higher clinical attack rates, and result in more prolonged, incapacitating and disabling disease than in its natural form. ⁷ Infection is possible through abraded skin and is possible by eating/drinking contaminated products. Brucella spp. are persistent in the soil for 125 days and the bacteria are stable in water for 20-72 days.⁸

None of the following clues alone constitute proof of intentional use of a biological agent, but together they can assist greatly in determining if further investigation is warranted.¹¹

1. The presence of a large epidemic, with greater case loads than expected, especially in a discrete population.
2. More severe disease than expected for a given pathogen, as well as unusual routes of exposure.
3. A disease that is unusual for a given geographic area, is found outside the normal transmission season, or is impossible to transmit naturally in the absence of the normal vector for transmission.
4. Multiple simultaneous epidemics of different diseases.
5. A disease outbreak with zoonotic as well as human consequences, as many of the potential threat agents are pathogenic to animals (death or illness among animals that precedes or accompanies illness or death in humans).
6. Unusual strains or variants of organisms or antimicrobial resistance patterns disparate from those circulating.
7. Higher attack rates in those exposed in certain areas, such as inside a building if the agent was released indoors, or lower rates in those inside a sealed building if an aerosol was released outdoors.
8. Intelligence that an adversary has access to a particular agent or agents.
9. Claims by a terrorist of the release of a biologic agent.
10. Direct evidence of the release of an agent, with findings of equipment, munitions, or tampering.

Even with the presence of more than one of the above indicators, it may not be easy to determine that an attack occurred through nefarious means.

Note: If brucellosis is suspected to be the result of a terrorist act or the intentional or deliberate release thereof; the LPHA should:

1. Notify local law enforcement and the Senior Epidemiology Specialist for the District, or the Missouri Department of Health and Senior Service’s Emergency Response Center (ERC) at (800) 392-0272 (24/7) immediately.
2. Work with law enforcement and implement “Chain of Custody” procedures for all laboratory samples, as they will be considered evidence in a criminal investigation.
3. Work to define the population at risk which is essential to guide response activities. Public health authorities will play the lead role in this effort, but must consult with law enforcement, emergency response and other professionals in the process.
4. Once the mechanism and scope of delivery has been defined, identify symptomatic and asymptomatic individuals among the exposed and recommend treatment and/or chemoprophylaxis.
5. Establish and maintain a detailed line listing of all cases and contacts with accurate identifying and locating information.

Notification

• Contact the District Communicable Disease Coordinator, the Senior Epidemiology Specialist for the District, or the Missouri Department of Health and Senior Services (MDHSS) - BCDCP, phone (573) 751-6113, Fax (573) 526-0235, or for afterhours notification contact the MDHSS/ERC at (800) 392-0272 (24/7) immediately if brucellosis is suspected.
• If a case(s) is associated with a childcare center, BCDCP or the LPHA will contact the BEHS, phone (573) 751-6095, Fax (573) 526-7377 and the Section for Child Care Regulation, phone (573) 751-2450, Fax (573) 526-5345.
• If a case(s) is associated with a food handler, BCDCP or the LPHA will contact BEHS, phone (573) 751-6095, Fax (573) 526-7377.
• If a case(s) is associated with a long-term care facility, BCDCP or the LPHA will contact the Section for Long Term Care Regulation, phone (573) 526-8524, Fax (573) 751-8493.
• If a case is associated with a hospital, hospital-based long-term care facility, or ambulatory surgical center BCDCP or the LPHA will contact the Bureau of Health Services Regulation phone (573) 751-6303, Fax (573) 526-3621.
• If a case(s) is associated with animal or animal product exposure within Missouri, OVPH will contact Missouri Department of Agriculture, Animal Health Division, phone (573) 751- 3377, Fax (573) 751-6919.
• Contact the Department of Natural Resources, Public Drinking Water Branch, at (573) 751- 1187, Fax (573) 751-3110 if cases are associated with a public water supply, or BEHS, phone (573) 751-6095, Fax (573) 526-7377, if cases are associated with a private water supply.

Control Measures

Brucellosis presenting as endemic disease.

The control of human brucellosis depends on eradication of Brucella spp. from cattle, goats, swine, and other animals.² The best way to prevent brucellosis infection is to avoid consuming undercooked meat and unpasteurized dairy products, including: milk, cheese, and ice cream.¹² Pasteurization of dairy products for human consumption is important to prevent disease, especially in children.² People who handle animal tissues (such as hunters and animal herdsmen) should protect themselves by using: good hygiene, rubber gloves, goggles, and gowns or aprons. This will help ensure that bacteria from potentially infected animals do not get into eyes or inside a cut or abrasion on the skin.¹²

If possible, obtain copies of the laboratory reports. If the Brucella species is available on the laboratory reports, this may help with identifying the source of infection. See the “Humans and Brucella Species” table on the CDC’s website.

B. abortus RB51 is a strain of Brucella developed specifically for immunization of cattle against brucellosis to allow serological differentiation between naturally infected and vaccinated animals. Accidental human exposure to RB51, though uncommon, has resulted in development of symptoms consistent with brucellosis. Exposures have included needle sticks, eye and wound splashes, and contact with infected material. Other vaccines, such as B. abortus S19 for cattle and B. melitensis Rev-1 for sheep and goats, can also cause infection in humans. Information on how to reduce the risk of infection from exposure to RB51 can be found on CDC’s website.

Brucellosis is the most commonly reported laboratory-associated bacterial infection. For information on: 1) Laboratory Risks, 2) Recommendations for Safe Laboratory Practices, or 3) Assessing Laboratory Risk Level and Post-Exposure Prophylaxis (PEP) see the following CDC website.

Note: Women who are pregnant and have been exposed to brucellosis should consult with their obstetricians/healthcare provider for evaluation. Laboratory tests and PEP may be recommended.¹²

Tourists seeking information for vaccination or travel recommendations should be advised there is a high prevalence of this disease in underdeveloped countries. Travelers should avoid any dairy product unless they can be absolutely certain it has been pasteurized.

Foreign travel recommendations may be found via the Internet using CDC’s Travel Health site.

PEP is not generally recommended after possible exposure to endemic disease. A three to six week course of oral antibiotics should be considered for high-risk exposure in the following situations:⁷

1. Inadvertent wound or mucous membrane exposure to infected livestock tissues and body fluids and to livestock vaccines.
2. Exposure to laboratory aerosols or to secondary aerosols generated from contaminated soil particles in calving and lambing areas.
3. Confirmed bioterrorism exposure.

For information on the medical management (treatment and chemoprophylaxis) see the U.S. Army Medical Research Institute of Infectious Diseases. Medical Management of Biologic Causalities Handbook. 7th Ed. Sep. 2011, the American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. 2012, Principles and Practice of Infectious Diseases, 7th ed., Pennsylvania: Churchill Livingstone Elsevier, 2010 or other suitable reference; several such references are listed at the end of this document.

Brucellosis suspected to be the result of a terrorist act or intentional / deliberate release. If the source of infection cannot be determined and cases are presenting as multiple cases, temporally/spatially clustered; and/or the epidemiologic clues discussed above suggest an intentional or deliberate use of a biological agent – law enforcement must be involved in the investigation. Even if no conclusive answer can be derived quickly, the means employed in determining the cause of an attack will still provide medical personnel with information that may prevent illness and death.11 Because the laboratory confirmation could be delayed, specific epidemiological, clinical, and microbiological findings that suggest an intentional release of Brucella spp. should result in the issue of a health alert.

Laboratory Procedures¹²

Testing for brucellosis is available through commercial clinical laboratories. The isolation and identification of Brucella can confirm a diagnosis of brucellosis. Brucella is most commonly isolated from blood cultures. It can also, however, be isolated from: bone marrow, cerebrospinal fluid, wounds, purulent discharge, and joint fluid. In addition to bacterial isolation, serological tests can be performed. CDC utilizes a test called BMAT, which is a modified version of the serum (tube) agglutination test (SAT), that can detect antibodies to Brucella species - abortus, melitensis, or suis. There is no serological test available to detect antibodies to B. canis. For a diagnosis to be made using serology, two serum samples are required. The first serum sample should be taken when a person is acutely ill (< 7 days after symptom onset); the second serum sample should be drawn 2 to 4 weeks later to check for a rise in antibodies (a fourfold or greater rise in antibodies would mean an individual is positive for brucellosis). Note: When sending specimens to any laboratory for culture and isolation, please be sure the laboratory is aware of the suspected diagnosis.

For information on the collection or shipment of specimens to the Missouri State Public Health Laboratory (MSPHL), refer to their website at:

• Brucellosis Fact Sheet, and
• Special Bacteriology

Comment: Brucella spp. grows very slowly and raw clinical specimens will have to be held up to 10 days before the MSPHL reports a negative result. If colonies appear, a presumptive positive using the real-time PCR test could be reported in 4-6 hours, with confirmation within an additional 48 hours.

Additional information may be found on CDC’s website at:

• Zoonoses Lab, or 
• Brucella species

The CDC Specimen Submission Form: Specimens of Human Origin is used for confirmation testing.

Note: Reliance should not be placed on gallery type rapid identification systems as these have misidentified Brucella as Moraxella phenylpyruvica, with serious consequences for laboratory staff.¹³

Reporting Requirements

Instances of brucellosis that appear to be the result of a terrorist act or the intentional or deliberate release of a biological agent is a Category 1(B) disease and shall be reported to the local health authority or to the Missouri Department of Health and Senior Services (MDHSS) immediately upon of first knowledge or suspicion by telephone, facsimile or other rapid communication. The MDHSS may be contacted afterhours through the MDHSS/ERC by calling (800) 392-0272 (24/7).

As a Nationally Notifiable Condition, confirmed and probable brucellosis cases; presenting as multiple cases, temporally/spatially clustered are an IMMEDIATE, URGENT report to the Centers of Disease Control and Prevention (CDC). IMMEDIATE, URGENT reporting requires MDHSS to call the CDC EOC at 770-488-7100 within 24 hours of cases meeting the notification criteria; followed by submission of an electronic case notification via (WebSurv) in the next regularly scheduled electronic transmission.

Brucellosis also occurs naturally and is a Category 2 (A) disease and shall be reported to the local health authority or to MDHSS within one (1) day of first knowledge or suspicion by telephone, facsimile or other rapid communication. The MDHSS may be contacted afterhours through the MDHSS/ERC by calling (800) 392-0272 (24/7).

As a Nationally Notifiable Condition, confirmed and probable brucellosis cases; not temporally/spatially clustered are a STANDARD report to the Centers of Disease Control and Prevention (CDC). STANDARD reporting requires the Missouri Department of Health and Senior Services (MDHSS) to report to CDC by electronic transmission via WebSurv within the next normal reporting cycle.

1. For confirmed and probable cases, complete a “Disease Case Report” (CD-1) and Brucellosis Case Report Form” and send the completed forms to the DHSS District Health Office.
2. Entry of the completed CD-1 into the MOHSIS database negates the need for the paper CD-1 to be forwarded to the District Health Office.
3. MDHSS will report to CDC following the above reporting criteria (see boxes).
4. All outbreaks or “suspected” outbreaks must be reported as soon as possible (by phone, fax or email) to the District Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51).
5. If an outbreak is associated with food, a CDC 52.13 form (National Outbreak Reporting System – Foodborne Disease Transmission) is to be completed and submitted to the District Communicable Disease Coordinator at the conclusion of the outbreak.
6. If an outbreak is associated with the consumption or use of water for drinking, or with ingestion, contact, or inhalation of recreational water, a CDC 52.12 form (National Outbreak Reporting System - Waterborne Disease Transmission) is to be completed and submitted to the District Communicable Disease Coordinator at the conclusion of the outbreak.
7. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

References

1. American Public Health Association. Brucellosis (Undulant fever, Malta fever, Mediterranean fever). In: Heymann, D Ed. Control of Communicable Diseases Manual. 19th ed. Washington, D.C. American Public Health Association, 2008: pp 87-90.
2. American Academy of Pediatrics, Brucellosis. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Disease, 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012: pp 256-258.
3. Young, Edward J. Brucella Species. In: Gerald L. Mandell, John E. Bennett, & Raphael Dolin, Eds. Principles and Practice of Infectious Diseases, 7th ed., Pennsylvania: Churchill Livingstone Elsevier, 2010: pp 2921-2925.
4. CDC’s National Notifiable Diseases Surveillance System (NNDSS) and Case Definitions. http://wwwn.cdc.gov/nndss/. (10/13)
5. Centers for Disease Control and Prevention. Human Exposure to Brucella abortus Strain RB51 -- Kansas, 1997. MMWR 1998:47 (09): 172-175. http://www.cdc.gov/mmwr/preview/mmwrhtml/00051495.htm. (10/13)
6. Bacterial Infections of Humans Epidemiology and Control. “Brucellosis.” Young, Edward J., and Hall, Wendall H. 3rd ed. Eds. Alfred S. Evans and Philip S. Brachman. New York: Plenum, 1998: 155-167.
7. U.S. Army Medical Research Institute of Infectious Diseases. Medical Management of Biologic Causalities Handbook. 7th Ed. Sep. 2011. (10/13)
8. Biological Quick Reference Guides (NRT) http://nrt.org/Production/NRT/NRTWeb.nsf/PagesByLevelCat/Level3Biologic… endocument. (10/13)
9. Brucellosis Fact Sheet (Center for Food Security and Public Health) http://www.cfsph.iastate.edu/Factsheets/pdfs/brucellosis.pdf. (10/13)
10. Biological Threats - Medical Professionals (DHSS) http://health.mo.gov/emergencies/ert/biomed.php. (10/13)
11. Pavlin JA. Epidemiology of Bioterrorism. Emerging Infectious Diseases, Volume 5, Number 4-August 1999. Available from: http://wwwnc.cdc.gov/eid/article/5/4/99-0412.htm. (10/13)
12. Centers for Disease Control and Prevention. Brucellosis. http://www.cdc.gov/brucellosis/index.html. (10/13)
13. Corbel MJ. Brucellosis: an Overview. Emerging Infectious Diseases. Volume 3, Number 2- 1997, June. Available from: http://wwwnc.cdc.gov/eid/article/3/2/97-0219.htm. (10/13)

Other Sources of Information

1. The Merck Veterinary Manual. 9thEd. Ed. Susan E. Aiello. Whitehouse Station, NJ: Merck & Co., Inc., 2005. http://www.merckvetmanual.com/mvm/index.jsp. (search “brucellosis”). (10/13)
2. Acha P.N., Szyfres B. Zoonoses and Communicable Diseases Common to Man and Animals. 3rd ed. Vol. 1, Brucellosis. Washington, DC: Pan American Health Organization; 2003. p. 40-67.
3. Gerald E Maloney, Jr., DO. "Brucellosis" eMedicine Journal. May 10 2006, Volume 7, Number 5. Available from: http://www.emedicine.com/emerg/topic883.htm. (10/13)

Case Definition

Campylobacteriosis - 2015 Case Definition

Overview

• Agent - Campylobacter species (spp.)
• Reservoir – Animals, most frequently poultry and cattle. Other sources of infection include pets such as kittens and puppies along with swine, sheep, rodents and birds.
• Environment - Campylobacter spp. grow in the 86–113°F temperature range. Although unable to grow below 86°F, Campylobacter spp. survive at temperatures as low as 39.2°F under moist conditions. Survival in food is extended at refrigeration temperatures compared with room temperature, with viable cells being found after 7 months storage at 39.2°F. Although Campylobacter spp. survive well at cold temperatures, they are sensitive to heat and are readily inactivated by pasteurization treatment or domestic cooking. Poultry should be cooked until it reaches a minimum internal temperature of 165°F. Campylobacter spp. are highly sensitive to loss of moisture and do not survive well on dry surfaces.
• Occurrence – Campylobacter is found throughout the world. Campylobacter jejuni and Campylobacter coli are the species isolated most commonly from patients with diarrhea.
• Risk Factors – Persons who consume raw dairy products or undercooked meats, particularly poultry; persons who consume untreated water, persons who are immune compromised; persons who have direct contact with infected animals.
• Mode of Transmission - Primarily by consumption of raw dairy, undercooked meats (especially poultry) or water contaminated with the organism; direct contact with infected animals such as farm animals and pets such as kittens and puppies.
• Period of Communicability – Person-to-person transmission occurs occasionally, particularly among very young children, and risk is greatest during the acute phase of illness.
• Incubation Period – Usually 2-5 days (range 1-10 days).
• Clinical Illness – Diarrhea (which may be bloody), abdominal cramps, nausea and vomiting along with fever and malaise which may precede diarrhea by a day or more. Symptoms may last from a period of 1-2 days to two weeks.
• Laboratory Testing – Culture and culture-independent diagnostic tests (CIDTs) which include PCR and enzyme immunoassay (EIA) methods.
• Treatment – Most patients do not require antimicrobial therapy. Azithromycin and erythromycin shorten the duration of illness and excretion of susceptible organisms and may prevent relapse when administered early in gastrointestinal tract infection. Fluoroquinolones can also be used for persons >18 years of age. Anti-motility agents should not be used.
• Priority – Prompt investigation and implementation of control measures are required.

Quick References / Factsheets

• Public - About Campylobacter Infection (CDC)
• Health Professionals – Clinical Overview of Campylobacter (CDC)

Forms

• Disease Case Report (CD-1)
• Missouri Outbreak Report Form (MORF)
• National Outbreak Reporting System (NORS) Form
• Child Care Establishment Inspection Related to Enteric Infection (CD-8)
• Record of Investigation of Enteric Illness (CD-2C)

Notifications

• Contact the District Epidemiologists or the Missouri Department of Health and Senior Services (MDHSS) - BCDCP, phone (573) 751-6113, if an outbreak due to Campylobacter is suspected.

Reporting Requirements

• Campylobacteriosis is a Category 3 disease and shall be reported to the local health authority or to the MDHSS within three (3) calendar days of first knowledge or suspicion.
• Campylobacteriosis is a nationally notifiable condition in the standard reporting category. The MDHSS reports confirmed and probable campylobacteriosis cases to the CDC by routine electronic transmission.
• Campylobacteriosis reporting includes the following:
  • For all cases, complete a “Disease Case Report” (CD-1).
  • For confirmed and probable cases, complete the “Record of Investigation of Enteric Illness” (CD-2C).
  • Attach the completed Record of Investigation of Enteric Illness form into WebSurv.
  • All outbreaks or suspected outbreaks must be reported as soon as possible (by phone, fax or e-mail) to the District Epidemiologists.
  • If an outbreak is associated with the consumption or use of water for drinking, or with ingestion, contact, or inhalation of recreational water, a CDC 52.14 form (National Outbreak Reporting System (NORS) Form) is to be completed and submitted to the District Epidemiologists at the conclusion of the outbreak.
  • Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Epidemiologists.

Laboratory Testing and Diagnosis

Campylobacter can be detected in stool, body tissue, or fluids. The most common tests for Campylobacter include culture and nucleic acid tests, including like culture-independent diagnostic tests (CIDTs) and polymerase chain reaction (PCR).

The Missouri State Public Health Laboratory (MSPHL) can test clinical and food specimens for Campylobacter spp.

Clinical Specimens: The MSPHL can perform culture or PCR testing for Campylobacter. Inoculated culture slants, raw stool specimens, and Shiga toxin-positive enrichment broths are acceptable specimen types for culture. Stool in Cary-Blair media is the only acceptable specimen type for the BioFire GI Panel, which can detect C. jejuni, C. coli and C. upsaliensis. Stool should be collected in Cary-Blair media, refrigerated until transported to the laboratory, and shipped on cold packs. Raw stool specimens will only be accepted from city or county health departments, unless there are special circumstances and previous approval has been obtained.

Food Samples: Food samples can be sent chilled to the MSPHL to be tested for Campylobacter as part of an epidemiological investigation. Samples are to be collected and submitted by an official of the local public health agency or state health office. Samples should be collected in their final intact package for testing. If an intact sample of a product is too large to submit to the lab, submit a sterile sample container with at least four ounces of the product to be tested. Prior to collection and submission of food samples, the District Epidemiologists, the Bureau of Environmental Health Services, and the Environmental Bacteriology Unit at the MSPHL should be consulted. For additional information concerning food sample collection or food sample transport visit the MSPHL website or call the MSPHL - Environmental Bacteriology Unit at (573) 751-3334.

Conducting the Investigation

1. Verify the diagnosis. What laboratory tests were conducted and what were the results? Obtain demographic, clinical and laboratory information on the case from the provider and/or laboratory. Obtain the other epidemiological information necessary to complete the Record of Investigation of Enteric Illness (CD-2C) from the patient or a knowledgeable family member.
2. Establish the extent of illness. Have there been other cases linked by time, place or person? Ask about illnesses among household, child care, hospital or long-term care, sexual and other contacts. Determine if the case provided child or patient care, or prepared food for anyone outside the household while symptomatic. Ask if the case lived or spent significant time in another household. If ill persons are identified, advise them to contact their medical provider. Note: Campylobacter fetus predominantly causes systemic illness in neonates and debilitated hosts.
3. Identify potential sources of infection. The information obtained from the public health investigation will be used to help identify the source.
   1. Does the case or a member of the case’s household attend a child care center or nursery school?
   2. Does the case or a member of the case’s household work as a food handler or health care provider?
   3. Does the case handle animals or otherwise have contact with feces from wild or domestic animals?
   4. What is the case’s primary source of drinking water?
   5. Has the case ingested untreated water from a lake or stream?
   6. Did the case eat raw or undercooked poultry?
   7. Has the case traveled recently?
   8. Has the case consumed unpasteurized dairy products?
   9. Have there been other cases linked by time, place or person?
   10. Is this case related to a food recall?
       
       Notes: Person-to-person spread of Campylobacter occasionally occurs, particularly in very young children. While outbreaks of diarrhea in child care centers have been reported, they appear to be uncommon.²
4. Provide Campylobacter information to persons at risk for infection and the general public as needed. Efforts should be made to promote Campylobacter awareness and provide prevention information to the public to reduce the risk of campylobacteriosis. Cases should be educated on the importance of personal hygiene, particularly after using the toilet and before and after food handling. Information on campylobacteriosis prevention can be found on CDC’s website.
5. Campylobacter Surveillance. Review WebSurv to determine whether there have been other campylobacteriosis cases in your jurisdiction. When cases are related by person, place or time and serotype, efforts should be made to identify a common source. Information obtained through the public health investigation will be used to identify a possible source of infection and to characterize persons or geographic areas in which additional efforts are needed to raise awareness and reduce disease incidence.

Control Measures (General Setting)

General

Currently, there is no vaccine to prevent campylobacteriosis. The best defense against campylobacteriosis is thorough, frequent handwashing and proper cooking, handling and storage of food. General control measures include:

• Do not prepare food or pour beverages for others while ill with diarrhea.
• Wash hands and surfaces often.
• Do not cross-contaminate.
• Cook food to safe temperatures.
• Refrigerate food promptly and properly.

Additional information can be found in the Missouri Food Code.

Treatment

Almost all persons infected with illness caused by Campylobacter recover without any specific treatment. Antimicrobial therapy is warranted only for patients with severe disease or those at high risk for severe disease, such as those with immune systems severely weakened from medications or other illnesses. Rehydration is the mainstay for all children with diarrhea. Azithromycin and erythromycin shorten the duration of illness and excretion of organisms and prevent relapse when given early in gastrointestinal tract infections.

Travelers

Travelers should be advised to follow CDC’s food and water precautions and drink from a safe water supply.

Drinking and Recreational Water

• If coliform bacteria are detected in a private water supply (e.g., cistern, well), advise the family to boil the water (bring water to a full rolling boil for one minute) used for drinking, food preparation, dishwashing, and tooth brushing until the problem in the water supply can be corrected.
• If cases are associated with a public water supply, notify the District Epidemiologists and the Bureau of Environmental Health Services (BEHS), who will notify the Department of Natural Resources (DNR). If possible, DNR should be contacted before the collection of any public water samples.
• Avoid swallowing water from ponds, lakes, or untreated pools. For cases associated with recreational water activities or with private drinking water contact the District Epidemiologists and BEHS.
• Infected persons should refrain from recreational water venues (e.g., swimming pools, water parks) for 2 weeks aftersymptoms resolve.

Control Measures (Special Settings)

Food Handlers

Educate all food handlers about the importance of handwashing before, during and after food preparation, refrigerate prepared foods in small containers, thoroughly cook all food products derived from animal sources, avoid recontamination within the kitchen after cooking is complete, and maintain a sanitary kitchen and protect foods against rodent and insect contamination.

Food handlers with vomiting or diarrhea should be excluded until asymptomatic for at least 24 hours. Individuals with questionable hygiene may return to work when symptoms resolve, but should be reassigned to other duties (non-food handling) until they can be trained and are likely to follow proper hygienic measures. Refer to the Missouri Food Code for additional information regarding individuals working in food establishments.

Health Care Workers

Health care workers (HCWs) should be excluded from care of patients until after the diarrhea has ceased for 24 hours. HCWs who are asymptomatic need not be excluded from work if proper personal hygiene measures, including hand hygiene, are maintained.²

Schools

Exclude symptomatic children and teachers from schools until diarrhea stops. Stress proper handwashing.

Child Care

Increased surveillance within the child care facility to identify others with diarrheal illness is important. Child care staff with diarrhea should be excluded from the facility until after the diarrhea has ceased for 24 hours. Infants and children in diapers with diarrhea should be excluded from the facility until after the diarrhea has ceased for 24 hours or may be cared for in a separate protected area until diarrhea has subsided. Antibiotic treatment (e.g., azithromycin or erythromycin) may further limit the potential for transmission.²

• Emphasize handwashing to all staff and children because good hand hygiene is the best preventive measure. Supervised handwashing after visiting the bathroom and before eating is essential for all children. Waterless hand sanitizers may also be helpful in addition to washing hands with soap and warm water.
• Employees handling food in child care settings should follow the criteria listed above in the Missouri Food Code.
• Staff that prepare food should not change diapers or assist children in using the toilet.
• If a child in diapers has campylobacteriosis, everyone who changes the child’s diapers should be sure the diapers are disposed of properly in a closed-lid garbage can and should wash their hands and the child’s hands carefully with soap and warm water immediately after changing the diaper. After use, the diaper changing area should be wiped down with a disinfectant such as diluted household bleach, Lysol or bactericidal wipes.
• Other surfaces and objects should be decontaminated regularly and on a daily basis during an outbreak of campylobacteriosis.
• If several cases occur in a child care center, the local public health agency should coordinate efforts to improve handwashing among the staff, children, and their families. Contact the District Epidemiologists, who will notify the Section for Child Care Regulation for an Environmental Public Health Specialist to perform an assessment of the child care facility. The inspection should include emphasis on the items listed in “Day Care Establishment Inspection Related to Enteric Infection” (CD-8).
• Access to shared water-play areas and dirty diapers should be eliminated.

To prevent the spread of infection, efforts should be made to avoid the transfer of children to other child care centers. Closure of affected child care centers may lead to placement of infected children in other centers (with subsequent transmission in those centers) and is counterproductive.

References / Resources

1. American Public Health Association, Campylobacter Enteritis. In Heymann D Ed. Control of Communicable Diseases Manual. Washington, DC: American Public Health Association; 2022: pp. 80-83.
2. American Academy of Pediatrics. Campylobacter Infections. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Disease, 32nd ed. Itasca, IL: American Academy of Pediatrics; 2018: pp. 243-246.
3. Centers for Disease Control and Prevention, Campylobacter (Campylobacteriosis), https://www.cdc.gov/campylobacter/index.html (9/23).
4. Centers for Disease Control and Prevention, National Notifiable Diseases Surveillance System (NNDSS) and Case Definitions. http://www.cdc.gov/nndss/ (9/23).
5. Centers for Disease Control and Prevention. In: Campylobacter. https://www.cdc.gov/campylobacter/index.html and Centers for Disease Control and Prevention. In: Healthy Swimming/Recreational Water. https://www.cdc.gov/healthywater/swimming/index.html. (9/23).
6. Centers for Disease Control and Prevention. Campylobacteriosis. Tobolowsky F, Laughlin M, Aubert R, Payne D.In: CDC Health Information for International Travel 2023. New York: Oxford University Press; 2023. https://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/campyl…. (9/23).
7. Department of Health, Victoria, Australia. Campylobacteriosis In: Blue Book – Guidelines for the Control of Infectious Diseases. Communicable Disease Prevention and Control Unit Victorian Department of Health. http://ideas.health.vic.gov.au/diseases/campylobacteriosis.asp. (4/19).
8. Missouri Department of Health and Senior Services. Missouri Food Code for the Food Establishments of the State of Missouri. Publication date: June 3, 2013. http://health.mo.gov/safety/foodsafety/pdf/missourifoodcode.pdf (4/19).
9. Missouri Department of Health and Senior Services. 19 CSR 30-62--Health. Chapter 62-- Licensing Rules for Group Day Care Homes and Child Day Care Centers. https://www.sos.mo.gov/cmsimages/adrules/csr/previous/19csr/19csr0611/1…. (9/23).
10. Missouri Department of Health and Senior Services, Missouri State Public Health Laboratory, Enteric Bacteriology and Food Testing for Bacteria: http://health.mo.gov/lab/enterics.php and http://health.mo.gov/lab/foodtesting.php (4/19).
11. Fast Facts Disease Summary – Campylobacteriosis. (Center for Food Security and Public Health) Iowa State University, College of Veterinary Medicine. http://www.cfsph.iastate.edu/FastFacts/pdfs/campylobacteriosis_F.pdf. (4/19).
12. United States Department of Agriculture (USDA). Washington D.C., United States. In: Campylobacter Questions and Answers. Food Safety and Inspection Service. https://www.fsis.usda.gov/sites/default/files/media_file/2021- 02/Campylobacter_Questions_and_Answers.pdf. (9/23).
13. Prevention and Control of Communicable Diseases - A Guide for School Administrators, Nurses, Teachers, Child Care Providers, and Parents or Guardians http://health.mo.gov/living/families/schoolhealth/pdf/Communicable_Dise…. (4/19).

Overview^(1,2)

Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae serogroups O1 and O139. Although the infection is usually mild or asymptomatic, about 5% of those infected have a more severe illness. Symptoms include sudden onset of profuse, painless watery stools (described as rice-water stools), nausea, and profuse vomiting, without abdominal cramps or fever. Severe symptoms include rapid dehydration, acidosis, circulatory collapse, hypoglycemia, and renal failure, and, if left untreated, can rapidly lead to death.

Cholera is strongly linked to consumption of unsafe water, poor hygiene, poor sanitation and crowded living conditions. It is most common in developing countries, especially in India and sub-Saharan Africa. Manmade or natural disasters that disrupt sanitary facilities or water supplies can lead to epidemics.

Humans are the usual reservoir for Vibrio cholerae, although environmental foci are known to exist in coastal waters and estuaries in the U.S., Australia, and Bangladesh. Food contamination by infected food handlers has been the cause of several small outbreaks in the U.S. Person-to-person transmission is rare.

The incubation period ranges from a few hours to 5 days, with an average of 2-3 days. Cholera is usually communicable for only a few days after recovery, although occasionally a carrier state may persist for several months.

Although many cases of cholera occur worldwide every year from natural causes, cholera is also a potential bioterrorism weapon. All cases reported in Missouri in recent years have been from sources outside the United States. Contact your District Communicable Disease Coordinator or District Senior Epidemiology Specialist immediately if you suspect a source of infection originating in the United States or if you suspect that you are dealing with a bioterrorism situation.

For a complete description of cholera, please refer to the following texts:

• Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008.
• American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. 2009.

Case Definition⁽³⁾

Clinical description:

An illness characterized by diarrhea and/or vomiting; severity is variable.

Laboratory criteria for diagnosis:

• Isolation of toxigenic (i.e. cholera toxin-producing) Vibrio cholerae O1 or O139 from stool or vomitus, or
• Serologic evidence of recent infection.

Case classification:

Confirmed: a clinically compatible case that is laboratory confirmed.

Comment:

Illnesses caused by strains of V. cholerae other than toxigenic V. cholerae O1 or O139 should not be reported as cases of cholera. The etiological agent of a case of cholera should be reported as either V. cholerae O1 or V. cholerae O139.

Information Needed for Investigation

Verify the diagnosis. Diagnosis of cholera is made by isolation of the bacterium in culture. What laboratory tests were conducted? What were the results? What laboratory conducted the testing and what is their phone number? What are the patient’s clinical symptoms? What is the name and phone number of the attending physician?

Establish the extent of illness. Determine whether household or other close contacts are, or have been, ill by contacting the health care provider, patient or family members. Obtain stool specimens, if symptomatic. Review surveillance data to determine whether there has been a recent increase in gastrointestinal illness in the same geographic area or institution. When cases related by time, place, or person are identified, efforts should be made to identify a common source.

When investigating a suspected outbreak of gastrointestinal illness of unknown etiology, see the Outbreaks of Acute Gastroenteritis Section. Outbreaks of Acute Gastroenteritis Section.

Determine the five-day food and beverage intake history. Cholera has been transmitted in the U.S. from shellfish eaten raw. Outbreaks related to food handlers have been reported.

Determine whether the case had a history of recent foreign travel. Cholera has a relatively short incubation period, but the disease is common in Asia, Africa, and the countries of the former Soviet Union and is present in Latin America. Cholera is not endemic in North America and one case may be considered an outbreak.

Determine the presence of risk factors for spread of the disease.

• Does the case or a member of the case’s household attend or work in childcare, food service, or healthcare?
• Does the case engage in sexual or other practices that would put him/her or others at increased risk?

Notification

• Contact the District Communicable Disease Coordinator, District Senior Epidemiologist, or the Department of Health and Senior Services’ Situation Room (DSR) at 800-392-0272 (24/7) immediately upon learning of a suspected case of cholera. If the source appears to be inside the U.S., call immediately.
• Contact the Section for Child Care Regulation at (573) 751-2450 if a case is associated with a child care facility.
• Contact the Section for Long-Term Care Regulation at (573) 526-8524 if a case is associated with a long-term care facility.
• Contact the Bureau of Health Facility Regulation at (573) 751-6303 if a case is associated with a hospital or hospital-based long-term care facility.

Control Measures

General:

• No vaccine is currently available in the United States. Antibiotic prophylaxis of contacts is not generally recommended in the U.S. but may be considered for household contacts with a high probability of fecal exposure.^(2,4)
• Appropriate antibiotic therapy reduces the length of the time the organism is excreted, and decreases the duration of diarrhea and fluid loss. It should only be considered for people who are moderately to severely ill. Oral doxycycline as a single dose, or tetracycline for 3 days are the drugs of choice for cholera. Treatment may differ for children less than 8 years of age. If the strain is resistant to tetracycline, alternative antibiotics are ciprofloxacin, ofloxacin, or trimethoprim-sulfamethoxazole.^(1,2)
• A search for unreported cases is recommended only among household members or those exposed to a possible common source.

Food handlers:

• Appropriate antibiotic therapy reduces the length of the time the organism is excreted, and decreases the duration of diarrhea and fluid loss.
• Food handlers should be excluded from the preparation of food until three consecutive stool specimens, collected 24 hours apart and after symptoms cease, are negative for V. cholerae. If the patient has followed a prescribed course of appropriate antibiotic therapy, a single negative stool specimen collected after symptoms cease is sufficient for return to food preparation.

Child care:

• Appropriate antibiotic therapy reduces the length of the time the organism is excreted, and decreases the duration of diarrhea and fluid loss.
• Children and staff should be excluded until asymptomatic. Staff that handle food should adhere to the control recommendations under “Food Handlers” above.

Health Care:

• Appropriate antibiotic therapy reduces the length of the time the organism is excreted, and decreases the duration of diarrhea and fluid loss.
• Health care workers should be excluded from patient care until asymptomatic. Although person-to-person transmission is rare, scrupulous attention to hand washing should be observed.

For additional information about control measures, please see the References.

Laboratory Procedures

Testing of stool specimens for Vibrio cholerae is not routinely offered at the State Public Health Laboratory. Preparations must be made to test these specimens. Contact the District Communicable Disease Coordinator, the District Senior Epidemiology Specialist, or the Bureau of Communicable Disease Prevention and Control for directions prior to collecting and shipping any specimens to the State Public Health Laboratory.

Reporting Requirements

Cholera is a Category 2 (A) disease and shall be reported to the local health authority or to the Missouri Department of Health and Senior Services within one (1) calendar day of first knowledge or suspicion.

1. For confirmed or probable cases, complete a Disease Case Report (CD-1). Disease Case Report
2. Complete a “Cholera and Other Vibrio Illness Surveillance Report” (CDC 52.79).
3. Attach an additional sheet with a five-day food and beverage history for each case.
4. Entry of the completed CD-1 into the Websurv database negates the need for the paper CD-1 to be forwarded to the District Health Office.
5. Send the completed secondary investigation form(s) to the District Health Office.
6. All outbreaks of cholera should be reported as soon as possible (by phone, fax or e-mail) to the District Communicable Disease Coordinator or District Senior Epidemiology Specialist. This can be accomplished by completing the “Missouri Outbreak Surveillance Report” (CD-51). Outbreak Surveillance Report
7. When there is an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

References

1. Cholera and other vibrioses (Vibrio cholerae serogroups O1 and O139)." Control of Communicable Diseases Manual. 19th Ed. Heymann D. Washington, D.C: American Public Health Association, 2008. Print.
2. "Vibrio Infections--Cholera." Red Book: 2009 Report of the Committee on Infectious Diseases. 28th Ed. Pickering, LK. Elk Grove Village, IL: American Academy of Pediatrics, 2009. Print.
3. "Case definitions for infectious conditions under public health surveillance." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 2011. https://ndc.services.cdc.gov/case-definitions/cholera-1996/
4. "Vibrio cholerae." Principles and Practice of Infectious Diseases. 7th Ed. Mandell G, Bennett J and Dolin R. Philadelphia: Elsevier, Churchill, Livingstone, 2010. Print.
    

Overview^(1,2,3,4)

Coccidioidomycosis is a fungal disease caused by the Coccidioides species including Coccidioides immitis and Coccidioides posadasii. The natural reservoir of the fungi is soil typically from areas with an arid climate. The fungi and resulting disease is endemic in the southwestern states (California, New Mexico, Arizona, Nevada, Utah, and Texas) and parts of Mexico, Central and South America. However, the disease has been reported in person who merely traveled through an endemic area. Approximately 10-50% of persons who live in an endemic area will have evidence of exposure to Coccidioides.

Infection with Coccidioides typically results from the inhalation of the fungal spores that can become airborne after disturbance of the contaminated soil through activities or events such as construction, dust storms, and earthquakes. Coccidioidomycosis is not spread person-to- person or animal-to-human, however, cases have resulted from laboratory accidents. The incubation period for primary infection is 1-4 weeks, though disseminated disease may develop years after the primary infection.

The majority of persons (60%) with Coccidioides infections will not experience any symptoms. For those with symptoms, the primary infection can resemble an acute influenza- like illness including fever, cough, shortness of breath, headache, rash, and muscle aches. Symptoms typically last weeks to months and most ill persons will make a full recovery. A small percentage of persons will develop a potentially fatal pulmonary infection or widespread disseminated infection affecting the meninges, soft tissues, joints, and bone. A variety of serological tests have been developed to diagnose coccidioidomycosis. Diagnosis can also be made through microscopic examination or culture of sputum, pus, urine, CSF or biopsies of skin lesions or organs. Note: Handling cultures of Coccidioides is extremely hazardous and must be carried out in a class II biological safety cabinet under BSL-3 containment.

Symptoms from the acute infection may resolve on their own without treatment. However, some health care providers prefer to prescribe antifungal drugs to treat patients with acute, uncomplicated coccidioidomycosis. There is not enough information about whether treating acute, uncomplicated pulmonary coccidioidomycosis is beneficial or not, although many experts feel that persons at risk for developing severe diseases should received treatment. Treatment includes the use of antifungal drugs, such as fluconazole, prescribed by a physician. In more severe infections, treatment with anifungal drugs is necessary.

High-risk groups include persons living in areas with endemic disease who have occupations exposing them to dust. Military trainees participating in exercises in endemic areas are also at risk. Persons at high risk for disseminated disease include those with AIDS or other immunocompromising conditions, African-Americans and Asians, people of Filipino descent and pregnant women during the third trimester.

For a complete description of coccidioidomycosis, refer to the following texts:

• Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008.
• American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. 2009.

2023 Coccidioidomycosis / Valley Fever ( Coccidioides spp .) Case Definition⁽⁵⁾

Information Needed for Investigation

Verify the diagnosis. Identify and list all completed laboratory tests and subsequent test results for Coccidioides.

Identify risk factors for exposure. Coccidioides species are found extensively in soil from endemic areas and are not transmitted person-to-person. For cases appearing in non-endemic areas it is important to investigate the possible source of the infection. The investigation should include determining residence, work exposure and travel history of the case. Obtain travel history for the past 30 days to endemic areas in the southwestern United States, including areas in California, New Mexico, Texas, Utah; northern Mexico, Central and South America and record in the “Comments” sections on the CD-1 report form or document the information in WebSurv.

Notification

Immediately contact the Senior Epidemiology Specialist for the District, or the Department of Health and Senior Services Coordinator, or the Department of Health and Senior Services Situation Room (DSR) at 800-392-0272 (24/7) if an outbreak of coccidioidomycosis is suspected or for a case of coccidioidomycosis occurring in a high-risk setting or job such as a laboratory worker.

Control Measures

Standard precautions are recommended for the care of a person with coccidioidomycosis. Care should be taken in handling, changing, and discarding dressings, casts, and similar materials in which contamination could occur.

Measures to control dust are recommended in areas with endemic infection, including construction sites and other activities that cause excessive soil disturbance.

Immunocompromised people residing in or traveling to areas with endemic infection should be counseled to avoid exposure to activities that may aerosolize spores in contaminated soil.

Laboratory Procedures

Specimens:

Contact the District Communicable Disease Coordinator Senior Epidemiology Specialist for the District for assistance. The Missouri State Public Health Laboratory does not culture for Coccidioides.

Reporting Requirements

Coccidioidomycosis is a Category 3 disease and shall be reported to the local health authority or to the Missouri Department of Health and Senior Services (DHSS) within three (3) calendar days of first knowledge or suspicion.

• 1. For confirmed and probable cases, complete a “Disease Case Report” (CD-1).Disease Case Report
• 2. Entry of the completed CD-1 into WebSurv negates the need for the paper CD-1 to be forwarded to the District Health Office.
• 3. All outbreaks or "suspected" outbreaks must be reported immediately (by phone, fax or e-mail) to the District Communicable Disease Coordinator or the Senior Epidemiology Specialist or the Department of Health and Senior Services Situation Room (DSR) at 800-392-0272 (24/7). This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51). Surveillance Report
• District Communicable Disease Coordinator. For an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

References

1. Control of Communicable Diseases Manual. “Coccidioidomycosis (Valley fever, San Joaquin fever, Desert fever, Desert rheumatism, Coccidioidal granuloma).” Heymann, David L., ed 19th ed. Washington, DC: American Public Health Association, 2008: 139- 141.
2. American Academy of Pediatrics. “Coccidioidomycosis”. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006: 266- 268.
3. Galgiani, J. (2005). Coccidioides Species. In G.L. Mandell, J.E. Bennett & R.D. Dolin (Eds.), Principles and Practice of Infectious Diseases: Vol. 2. (7th ed., pp. 3333-3343). Philadelphia: Elsevier Churchill Livingstone.
4. https :// www . cdc . gov / valley - fever / index . htmler (Coccidioidomycosis). https://www.cdc.gov/valley-fever/index.html (5/25)
5. Centers for Disease Control and Prevention. (2023). Case definitions for infectious conditions under public health surveillance. https://ndc.services.cdc.gov/case-definitions/coccidioidomycosis-2023/ (2/23)
    

Overview^1,2,3,5,6,8

Prion diseases also known as transmissible spongiform encephalopathies (TSEs) are a family of rare progressive neurodegenerative disorders that affect both humans and animals. Human prion diseases include: Creutzfeldt-Jakob disease (sporadic sCJD) which comprises approximately 85- 90% of all human prion disease, Gerstmann-Straüssler-Scheinker syndrome (GSS), fatal familial insomnia (FFI), Kuru and variant Creutzfeldt-Jakob disease (vCJD) which has been causally linked with bovine spongiform encephalopathy (BSE), a disease of cattle. Prion diseases affecting animals include scrapie, BSE (commonly called "mad cow" disease) and chronic wasting disease of mule deer and elk.

"Prion" usually pronounced "PREE-on" in the U.S. and "PRY-on" in the U.K. was coined to mean "proteinaceous infectious particle" an abnormal form of a normally harmless protein found in the brain. For reasons not fully understood, these pathogenic agents are able to induce abnormal folding of specific normal cellular proteins which clump together and accumulate in the brain. This abnormal accumulation of protein in the brain can cause memory impairment, personality changes, and difficulties with movement. The diseases are characterized by long incubation periods, sponge-like holes in brain tissue, associated with neuronal loss, and a failure to induce inflammatory response. Prion diseases can be difficult to diagnose, treatment of prion diseases remains supportive; no specific therapy has been shown to stop the progression of these diseases, prion diseases are ultimately fatal.

CJD has four different categories: sporadic (spontaneous), iatrogenic (associated with medical use of infected pituitary-derived hormones and dura mater), familial (inherited), and vCJD, which is believed to be associated with dietary consumption of tissue from cattle infected with BSE or "mad cow" disease. Starting in 1989, the USDA began taking steps to prevent BSE from entering the U.S., including severe restrictions on the importation of live ruminants, such as cattle, sheep and goats, and certain ruminant products from countries where BSE was known to exist. These restrictions were later extended to include importation of ruminants and certain ruminant products from all European countries. vCJD is also thought to have been spread to people receiving cornea transplants from infected donors and from contaminated medical equipment.

Typically patients with sCJD onset later in life (mean age at onset 57 to 66 years)3 and occur worldwide at approximately 1 case per million population annually. Most victims of sCJD die in their late sixties after developing relatively slow-onset mental deterioration. In vCJD, most deaths have occurred among young adults in their late twenties and are often preceded by sudden behavior changes initially diagnosed as psychiatric illness.

Currently, the only method for a definitive diagnosis of CJD is to examine the affected individual’s brain tissue. However, there are several clinical tests that aid clinicians in making a diagnosis of probable CJD; which include: cerebrospinal fluid analysis (obtained by "spinal tap") to measure certain proteins, electroencephalogram (EEG), and magnetic resonance imaging (MRI) of the brain.

For a more information on CJD, refer to the following texts:

• Control of Communicable Diseases Manual (CCDM). 20th ed. Washington, D.C.: American Public Health Association, 2015.
• American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL. American Academy of Pediatrics; 2015.
• Mandell, Douglas, and Bennett’s Principles and Practices of Infectious Diseases: 8th ed. 2015.

2010 CDC’s Diagnostic Criteria for CJD and vCJD4 – (5/16)

1. Sporadic CJD (sCJD)

Confirmed:

• Diagnosed by standard neuropathological techniques; and/or
• Immunocytochemically; and/or
• Western blot confirmed protease-resistant PrP; and /or
• Presence of scrapie-associated fibrils.

Probable:

Rapidly progressive dementia; and at least two out of the following four clinical features:

• Myoclonus – seizure-like severe muscle contractions.
• Visual or cerebellar signs – double or blurred vision, and/or inability to visually recognize familiar objects.
• Pyramidal/extrapyramidal signs – poor control or poor initiation of skilled movement (primarily hands and fingers), poor control of speech, and difficulty forming words.
• Akinetic mutism - no spontaneous movement or attempt to formulate speech.

AND a positive result on at least one of the following laboratory tests:

1. A disease-typical EEG (periodic sharp wave complexes) during an illness of any duration; and/or
2. A positive 14-3-3 cerebrospinal fluid (CSF) assay in patients with disease duration of less than 2 years.
3. Magnetic resonance imaging (MRI) high signal abnormalities in caudate nucleus; and/or a putamen on diffusion-weighted imaging (DWI), or fluid attenuated inversion recovery (FLAIR).
   
   AND without routine investigations indicating an alternative diagnosis.

Suspect:

Progressive dementia; and at least two out of the following four clinical features:

• Myoclonus.
• Visual or cerebellar signs.
• Pyramidal/extrapyramidal signs.

• Akinetic mutism.

  AND the absence of a positive result for any of the three laboratory tests that would classify a case as “probable” (see laboratory tests above for bullets a, b and c).

  AND duration of illness less than two years

  AND without routine investigations indicating an alternative diagnosis.

COMMENT: A death certificate indicating CJD as a cause of death (this means the mention of CJD anywhere on the death certificate) should be investigated to determine status.

2. Iatrogenic CJD

• Progressive cerebellar syndrome in a recipient of human cadaveric-derived pituitary hormone; OR
• sCJD with a recognized exposure risk (e.g., antecedent neurosurgery with dura mater implantation.)

3. Familial CJD

• 1. Confirmed or probable CJD and definite or probable CJD in a first degree relative; and/or
• 2. Neuropsychiatric disorder plus disease-specific PrP gene mutation.

4. Variant CJD

Confirmed:

Neuropathologic examination of brain tissue is required to confirm a diagnosis of vCJD. The following confirmatory features should be present:

• Numerous widespread kuru-type amyloid plaques surrounded by vacuoles in both the cerebellum and cerebrum-florid plaques AND
• Spongiform change and extensive prion protein deposition shown by immunohistochemistry throughout the cerebellum and cerebrum.

Suspect:

1. Current age or age at death <55 years (a brain autopsy is recommended, for all physician-diagnosed CJD cases) AND
2. Psychiatric symptoms at illness onset and/or persistent painful sensory symptoms (frank pain and/or dysesthesia) AND
3. Dementia, and development ≥4 months after illness onset of at least two of the following five neurologic signs: poor coordination, myoclonus, chorea, hyperreflexia, or visual signs. (If persistent painful sensory symptoms exist; ≥4 months delay in the development of the neurologic signs is not required) AND
4. A normal or an abnormal EEG, but not the diagnostic EEG changes often seen in classic CJD AND
5. Duration of illness of over 6 months.
6. Routine investigations of the patient do not suggest an alternative, non-CJD diagnosis AND
7. No history of receipt of cadaveric human pituitary growth hormone or a dura mater graft AND
8. No history of CJD in a first degree relative or prion protein gene mutation in the patient.

NOTE: All of the suspect criteria (a–h) for CJD may not be available at the initial report of the patient, however without the above information it will be difficult to make a diagnosis. If a patient has the typical bilateral pulvinar high signal on MRI scan, a suspected diagnosis of vCJD requires the presence of a progressive neuropsychiatric disorder, d, e, f and g of the above criteria, and four of the following five criteria:

• Early psychiatric symptoms (anxiety, apathy, delusions, depression, withdrawal);
• Persistent painful sensory symptoms (frank pain and/or dysesthesia);
• Ataxia;
• Myoclonus or chorea or dystonia; and
• Dementia.

COMMENT: A history of possible exposure to bovine spongiform encephalopathy (BSE) such as residence or travel to a BSE-affected country after 1980 increases the index of suspicion for a variant CJD diagnosis.

Information Needed for Investigation

Verify the diagnosis. Obtain a copy of the CD-1 or death certificate. What laboratory tests were conducted? If a biopsy and/or an autopsy were performed, obtain results. If laboratory tests were not conducted, are specimens available? What are/were the patient’s clinical symptoms?

IMPORTANT: In order to provide effective surveillance for CJD and other prion diseases, it is strongly recommend that an effort be made to have an autopsy performed for all suspected cases of prion disease (a brain autopsy is recommended for all physician-diagnosed CJD cases). The National Prion Disease Pathology Surveillance Center (NPDPSC) is available to coordinate autopsies. Please contact one of their Autopsy Coordinators at 216-368-0587 for more information.

For patients diagnosed with CJD (all categories) that are deceased.

Perform a chart extraction and obtain copies of the following:

1. Discharge summary
2. Neurology consultation notes
3. Psychiatric consultation notes
4. EEG reports
5. MRI reports
6. Pathology report from brain biopsy or autopsy
7. Obtain demographic, clinical, labor CJD Case Report and other epidemiological information necessary to complete the Disease Case Report (CD-1) and the CJD Case Report form. Affix the above chart extraction documents to the CJD Case Report Form. NOTE: The Local Public Health Agency (LPHS) should inform the District Communicable Disease Coordinator immediately if a vCJD or iCJD case is reported.

For patients diagnosed with CJD (all categories) that are not deceased.

Obtain as much of the above information as is available (bullets 1 through 6 above) to complete the Disease Case Report (CD-1) and the CJD Case Report form. Affix the chart extraction documents to the CJD Case Report form. NOTE: The LPHA should inform the District Communicable Disease Coordinator immediately if a vCJD or iCJD case is reported.

IMPORTANT: If diagnostic laboratory testing has not been performed on patients, inform the physician that laboratory services are available from:

NPDPSC
Institute of Pathology
Case Western Reserve University
2085 Adelbert Road, Room 418
Cleveland, Ohio 44106-4907
Tel: 216-368-0587
Email: cjdsurv@case.edu
Fax: 216-368-2546
216-368-2546

NOTE: The NPDPSC charges for CSF and genetic testing, as well as brain biopsy examinations, including Western blot and immunohistochemistry. Refer to the NPDPSC web site for more information: http :// case . edu / med / pathology / centers / npdpsc / contact . html .

N.B.: However, if the patient is accepted for autopsy assistance, all autopsy related costs are covered by the NPDPSC. These costs included the autopsy itself, any transportation or use-of- facility fees associated with the autopsy, and the testing for prion diseases (CJD). For additional information: http :// case . edu / med / pathology / centers / npdpsc / resources - autopsyfaqs . html .

Establish the extent of illness. Early onset of CJD should prompt a thorough search for iatrogenic sources of infection and is characteristic of some cases of vCJD and fCJD.

Provide information on CJD to persons at risk for disease and the general public. Efforts should be made to promote CJD awareness and educate the public on sources of infection. Additional information on CJD and other prion diseases can be found at:

• http://www.cdc.gov/prions/ 
• http://case.edu/med/pathology/centers/npdpsc/aboutprion.html 
• http://www.cjdfoundation.org/webfm_send/76. 

CJD Surveillance. The Centers for Disease Control and Prevention (CDC) will enhance its current program to identify and investigate possible cases of vCJD. Through cooperative agreements with state and local health departments, CDC also will enhance and expedite the oversight of illness and deaths from CJD so that any possible vCJD cases will be rapidly detected. CDC will also increase its technical assistance to state and local health personnel develop new laboratory capacity to support its investigations and enhance its current collaborative agreement with the NPDPSC at Case Western Reserve University.

Notification

• Immediately contact the District Communicable Disease Coordinator, the Senior Epidemiology Specialist for the District, or the Missouri Department of Health and Senior Services (MDHSS) - BCDCP, phone (573) 751-6113, Fax (573) 526-0235, or for afterhours notification contact the MDHSS/Emergency Response Center (ERC) at (800) 392-0272 (24/7) upon notification of a case of vCJD or iCJD.

Control Measures

To monitor the prevalence of prion diseases in Missouri and investigate possible cases in which the disease has been acquired from other persons or from animals.

• The Medical Certifier should clearly indicate the diagnosis of CJD on the patient’s death certificate when the clinical diagnosis applies because CJD is also monitored from mortality data.
• Performing a brain autopsy in patients with suspected or clinically diagnosed CJD is encouraged to confirm the diagnosis and detect other emerging forms of CJD. Testing is available from the NPDPSC. If the patient is accepted for autopsy assistance, all autopsy related costs are covered by the NPDPSC; these costs included the autopsy itself, any transportation or use-of-facility fees associated with the autopsy, and the testing for prion diseases (CJD). However, the NPDPSC is only funded to test for prion diseases (CJD). If negative, the NPDPSC can send any remaining tissue to a physician or medical center for further neuropathological workup. N.B.: The NPDPSC cannot cover funeral or embalming charges. For additional information you may contact the NPDPSC at: 216-368-0587 or visit their web site at: http://case.edu/med/pathology/centers/npdpsc/resources-autopsyfaqs.html 
• Information for Funeral and Crematory Practitioners can be found at: http :// www . cdc . gov / prions / cjd / funeral - directors . html .
• The "WHO infection control guidelines for transmissible spongiform encephalopathies. http :// www . who . int / csr / resources / publications / bse / WHO _ CDS _ CSR _ APH _ 2000 _ 3 / en /.
• The "Guidance for Industry - Revised Preventive Measures to Reduce the Possible Risk of Transmission of Creutzfeldt-Jakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD) by Blood and Blood Products" can be found at: http :// www . fda . gov / BiologicsBloodVaccines / GuidanceComplianceRegulatoryInformation / Guidances / Blood / ucm074089 . htm .
• Control web site is located at: http :// www . cdc . gov / prions / cjd / infection - control . html .

Laboratory Procedures

Physicians suspect a diagnosis of CJD on the basis of the typical signs and symptoms and progression of the disease. In most CJD patients, the presence of 14-3-3 protein in the cerebrospinal fluid and/or a disease-typical EEG pattern (periodic sharp wave complexes), both of which are believed to be diagnostic for CJD, have been reported. However, a confirmatory diagnosis of CJD currently requires neuropathologic and/or immunodiagnostic testing of brain tissue obtained either at biopsy or autopsy.5

NOTE: The NPDPSC charges for CSF and genetic testing, as well as brain biopsy examinations, including Western blot and immunohistochemistry. Please review the corresponding protocol pages for more information on specimen collection: http :// case . edu / med / pathology / centers / npdpsc / protocols . html .

N.B.: If the patient is accepted for autopsy assistance, all autopsy related costs are covered by the NPDPSC. These costs included the autopsy itself, any transportation or use-of-facility fees associated with the autopsy, and the testing for prion diseases (CJD); for more information: http :// case . edu / med / pathology / centers / npdpsc / resources - autopsyfaqs . html .

For the contact and shipping information for NPDPSC see their web site: http :// case . edu / med / pathology / centers / npdpsc / contact . html .

All shipments should be addressed to:

NPDPSC
Institute of Pathology
Case Western Reserve University
2085 Adelbert Road, Room 418
Cleveland, Ohio 44106-4907
Tel: 216-368-0587
Email: cjdsurv@case.edu

Reporting Requirements

Creutzfeldt-Jakob disease is a Category 3 disease and shall be reported to the LPHA or to the Missouri Department of Health and Senior Services within three days of first knowledge or suspicion by telephone, facsimile or other rapid communication. The MDHSS may be contacted by phone at (573) 751-6113, Fax (573) 526-0235, or for afterhours notification contact the MDHSS/ERC at (800) 392-0272 (24/7).

1. CJD Case Report sporadic CJD, iatrogenic CJD, familial CJD, or variant CJD complete a Disease Case Report (CD-1) and CJD Case Report form. Affix the chart extraction documents to the CJD Case Report Form. Send the forms and all chart extraction materials to the District Health Office.
2. Contact the District Communicable Disease Coordinator immediately for all confirmed, probable, or suspect cases of variant CJD or iatrogenic CJD.
3. Entry of the complete CD-1 by the LPHA into WebSurv negates the need for the paper CD-1 to be forwarded to the District Health Office.
4. All outbreaks or “suspected” outbreaks must be reported as soon as possible (by phone, fax or e-mail) toordinator. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51).
5. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the Regional Communicable Disease Coordinator.

References

1. American Public Health Association. Prion Diseases (Transmissible spongiform encephalopathies). In: D. Heymann, (Ed.). Control of Communicable Diseases Manual. 20th ed. Washington, D.C. American Public Health Association; 2015: 484-490.
2. American Academy of Pediatrics. Prion Diseases: Transmissible Spongiform Encephalopathies. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015: 653-656.
3. Elsevier Inc. Prions & Prion Diseases of the Central Nervous System (Transmissible Neurodegenerative Diseases). Bosque PJ, Tyler, KL. In: Bennett JE, Dolin R, Blaser MJ eds. Mandell, Douglas, and Bennett’s Principles and Practices of Infectious Diseases: Vol. 2. 8th ed. 2015: 2142-2153.
4. Centers for Disease Control and Prevention’s (CDC). CDC’s Diagnostic Criteria for CJD and vCJD. http://www.cdc.gov/prions/cjd/diagnostic-criteria.html and http://www.cdc.gov/prions/vcjd/diagnostic-criteria.html (5/16).
5. CDC, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). Prion Diseases. http://www.cdc.gov/prions/ (5/16).
6. U.S. National Library of Medicine, Bethesda, MD, U.S. Department of Health and Human Services, National Institutes of Health. Creutzfeldt-Jakob Disease. In: MedlinePlus. https://www.nlm.nih.gov/medlineplus/ency/article/000788.htm (5/16).
7. National Prion Disease Pathology Surveillance Center, Institute of Pathology, Case Western Reserve University, 2085 Adelbert Rd. Room 418, Cleveland Ohio, 44106. http :// case . edu / med / pathology / centers / npdpsc /
8. The Johns Hopkins University, The http://www.hopkinsmedicine.org/psychiatry/specialty_areas/neuropsychiatry/frontotemporal_dementia/conditions/what_is_CJD.html (5/16).
9. Creutzfeldt-Jakob Disease Foundation, Inc. 341 W. 38th Street, Suite 501 New York, NY 10018. http://www.cjdfoundation.org/ (5/16).

Acknowledgements

State of California-Health and Human Services Agency, California Department of Public Health, Center for Infectious Diseases, Division of Communicable Disease Control, Infectious Diseases Branch, Surveillance and Statistics Section, MS 7306, P.O. Box 997377, Sacramento, CA 95899- 7377 for our adaptation of the Creutzfeldt-Jakob Disease Case Report form for use in Missouri.

 

Overview ^1,2,3

Cryptosporidiosis or “Crypto” is a diarrheal disease caused by microscopic parasites of the genus Cryptosporidium. Cryptosporidium is found in soil, food, water, or surfaces that have been contaminated with infected human or animal feces. If a person swallows the parasite they can become infected. Transmission does not occur through contact with blood. The most common symptoms of Crypto are profuse, watery diarrhea and abdominal cramps, sometimes severe. Weight loss, nausea, vomiting, and fever occur less frequently. Some people with cryptosporidiosis may have no symptoms at all. The disease is often self- limiting, but it can be a life-threatening illness in immunocompromised individuals, especially HIV-infected persons.

Symptoms of Crypto generally begin 2 to 14 days (average 7 days) after becoming infected with the parasite.² In persons with healthy immune systems, symptoms often wax and wane, usually lasting about 1 to 2 weeks. Shedding of the organism in stools may continue for several weeks after symptoms resolve, and the hardy, infectious fecal oocysts may survive in the environment for several months and are resistant to many chemicals used to disinfect water.

Cryptosporidia may be found in every region of the United States and throughout the world. Subgroups at increased risk for contracting cryptosporidiosis include: animal handlers, travelers, men who have sex with men, children under the age of two, and close contacts of infected persons. During the past two decades, cryptosporidiosis has become recognized as one of the most common causes of waterborne disease within humans in the United States. The number of reported cryptospordiosis outbreaks associated with treated recreational water sources increased more than threefold between 1997-98 and 2005-2006.

For a complete description of cryptosporidiosis, please refer to the following texts:

• Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008.
• American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 29th ed. 2012.
• Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. 2010.

Cryptosporidiosis (Cryptosporidium spp .) 2012 Case Definition⁽⁴⁾

Information Needed for Investigation

Verify the diagnosis. What laboratory tests were conducted, and what were the results? Was cryptosporidiosis confirmed?

Establish the extent of illness. Determine if household or other close contacts are, or have been ill, by contacting the health care provider, patient or family member.

Determine the source of infection to prevent other cases.

• Does the case or a member of the case's household attend a childcare center or nursery school?
• What is the case’s primary source of drinking water?
• Has the case ingested untreated water from a lake or stream?
• Had the case participated in recreational water activities in a pool, water park, lake or stream?
• Has the case traveled recently?
• Does the case handle animals or otherwise have contact with feces from wild or domestic animals, especially a calf with diarrhea?
• Have there been other cases linked by time, place or person (persons who drink from the same water supply, consumed fresh fruit or vegetables)?
• Does the case engage in sexual practices that might place them or others at increased risk?

Notification

• Contact the District Communicable Disease Coordinator, or the Senior Epidemiology Specialist, or the Department of Health and Senior Services’ Situation Room (DSR) at 800-392-0272 (24/7) immediately if an outbreak* of cryptosporidiosis is suspected.
• Contact the Bureau of Environmental Health Services at (573) 751-6095 and the Section for Child Care Regulation at (573) 751-2450, if the case is associated with a child care center.
• Contact the Section for Long Term Care Regulation at (573) 526-8524, if the case is associated with a long term-care facility.
• Contact the Bureau of Health Services Regulation at (573) 751-6303, if the case is associated with a hospital, hospital-based long-term care facility, or ambulatory surgical center.

*Outbreak is defined as the occurrence in a community or region, illness(es) similar in nature, clearly in excess of normal expectancy and derived from a common or a propagated source.

Control Measures

General

• It should be the general practice of all food establishments, childcare centers, and health care facilities to exclude persons with poor hygiene from working in these facilities.
• Identify symptomatic individuals and obtain stool specimens.
• Individuals found positive should be interviewed and referred for medical assessment.
• If cases are associated with a public water supply, notify the District Communicable Disease Coordinator or Senior Epidemiology Specialist, who will notify the Department of Natural Resources (DNR). DNR should be contacted before the collection of any public water samples.
• If coliform bacteria are detected in a private water supply (e.g. cistern, well), advise the family to boil their water (bring water to a full rolling boil for one minute) used for drinking, food preparation, dishwashing, and tooth brushing until the problem with the water supply can be corrected.
• All individuals with diarrhea should not use public recreational water (e.g., swimming pools, water parks, lakes, ponds), and individuals with a diagnosis of cryptosporidiosis should not use recreational waters for 2 weeks after symptoms resolve.²
• If fresh fruits or vegetables are suspected as the vehicle in an outbreak, trace back of the product may prevent additional cases.
• Epidemiological investigation of a cluster of cases or an outbreak, try to determine the source of the infection and the mode of transmission. Search for a common vehicle, such as recreational water, drinking water, raw milk or other potentially contaminated food or drink. Control person- to-person or animal-to-person transmission, and institute applicable prevention or control measures.1 Recommendations related to prevention or control measures may need to be modified or changed as needed.

Foodhandlers and Health Care Workers

• Exclude symptomatic individuals from food handling and direct care of hospitalized and institutionalized patients until asymptomatic. Stress proper handwashing.¹
• For individuals with questionable hygiene, they may return to work when symptoms resolve, but should be reassigned to other duties (non-food handling or direct patient care) until they can be trained and are likely to follow good hygienic measures.⁹
• If a food service employee no longer has diarrhea, but is being treated, they should not work handling foods that will not be subsequently cooked or heated (salad bar duties, preparing sandwiches, etc.) until therapy has been completed.9

Child Care & School

• Exclude symptomatic children and teachers from childcare facilities and school until diarrhea stops. Stress proper handwashing.¹
• Upon identification of an acute case in childcare, the facility should be provided with the “Sample Letter to Parents of Children in Childcare Center Exposed to Cryptosporidiosis” for parent notification and the “Sample Letter to Childcare Center: Crypto Notification”. The fact sheet and sample letter can be reproduced for use in the facility.
• All rules and guidelines regarding handwashing, toileting, diapering, and food handling, referenced in “Licensing Rules for Group Child Care Homes and Child Care Centers”⁷ should be followed rigorously.
• Contact the Section for Child Care Regulations for the Environmental Public Health Specialist to perform an assessment of the childcare facility.
• In the laboratory, Cryptosporidium is relatively resistant to commonly used disinfectants. However, it is extremely sensitive to drying. Therefore, the practical approach to environmental disinfection of surfaces potentially contaminated with Cryptosporidium involves physical cleaning with a good detergent to remove the soiling, followed by thorough drying of the surfaces.⁹

CDC Healthy Swimming and Recreational Water Recommendations (Cryptosporidium)¹⁰

• Those who swim when ill with diarrhea place other swimmers at a significant risk for getting sick. Diarrheal accidents are much more likely than formed stool to contain germs. Cryptosporidiosis is extremely resistant to chlorine, therefore, it is important that all pool managers stress to patrons that swimming when ill with diarrhea is an unhealthy pool behavior.

Laboratory Procedures

Specimens:

Microscopic examination for Ova and Parasites:

1. Use an ova and parasite (O&P) kit, which contains two different preservatives, polyvinyl alcohol (PVA) and formalin to collect specimens. Specimens must be placed in both preservatives. Specimens may be shipped at room temperature. The Missouri State Public Health Laboratory (SPHL) performs this test. Specifically request testing for Cryptosporidium on the specimen submission form. Initial specimens should also be screened for Giardia lamblia. The same specimen can be used for both tests. Additional information on specimen collection and submission is available at: http://health.mo.gov/lab/microbiology/parasitology.php [BROKEN LINK]
2. If a large number of samples will be submitted (+15), or if sampling will continue over a long period, contact the Regional Communicable Disease Coordinator so arrangements may be made with the laboratory.

Enzyme immunosorbent assay (EIA) antigen testing:

The SPHL does not routinely perform EIA testing of stool specimens for Cryptosporidium. However, many commercial laboratories do. Generally, the specimens can be fresh unpreserved stool, rectal swabs in culturettes or stool collected in formalin. Consult with the testing laboratory before specimen collection.

Enteric cultures:

When investigating diarrheal illness of unknown etiology specimens should be initially screened for Salmonella, Shigella, Campylobacter and E. coli O157:H7. Collect specimens in Cary-Blair media using the enteric specimen collection kit supplied by the SPHL. Specimens should be shipped refrigerated.

Environmental samples:

Water supplies will not be tested for Cryptosporidium without substantial and convincing epidemiological evidence. If the water supply is suspected as the source of infection, it can be screened for coliform bacteria, which is a general indicator of the safety of the water.

Reporting Requirements

Cryptosporidiosis is a Category 3 disease and shall be reported to the local health authority or to the Missouri Department of Health and Senior Services within three (3) calendar days of first knowledge or suspicion:

1. For confirmed and probable cases, complete a “Disease Case Report” (CD-1) and a “Record of Investigation of Cryptosporidiosis Infection” (CD-18).
2. If food is suspected to be the source of the illness, complete the “Record of Investigation of Enteric Infection” (CD-2C) and collect the case’s food history for the seven days prior to the onset of the illness
3. Entry of the completed CD-1 into the ShowMe WorldCare database negates the need for the paper CD-1 to be forwarded to the District Health Office.
4. Send the completed secondary investigation form(s) to the District Health Office.
5. All outbreaks or "suspected" outbreaks must be reported as soon as possible (by phone, fax or e-mail) to the District Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Report Form (MORF).
6. If an outbreak is associated with the consumption or use of water for drinking, or with ingestion, contact, or inhalation of recreational water, a CDC 52.14 form (Reporting Waterborne Disease and Outbreaks) is to be completed and submitted to the Bureau of Communicable Disease Control and Prevention.
7. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator.

References

1. Center for Disease Control and Prevention.“About Crypto Infections,” https://www.cdc.gov/cryptosporidium/about/ (6/24)
2. Control of Communicable Diseases Manual. Cryptosporidiosis. In: Heymann DL, ed.19th ed. Washington, D.C.: American Public Health Association; 2008: 157-160.
3. American Academy of Pediatrics. Cryptosporidiosis. In: Pickering LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009: 272-273.
4. Centers for Disease Control and Prevention. Division of Notifiable Diseases and Healthcare Information, Nationally Notifiable Infectious Conditions: https://ndc.services.cdc.gov/casedefinitions/cryptosporidiosis-2012/ (4/21)
5. Whitley, RJ. Cryptosporidiosis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases.7th ed. Philadelphia, Pa.: Elsevier Churchill Livingston; 2010: vol.2: 3547-3560.
6. J Clin Microbiol. “Evaluation of nine immunoassay kits (enzyme immunoassay and direct fluorescence) for detection of Giardia lamblia and Cryptosporidium parvum in human fecal specimens.” Garcia LS; Shimizu RY: 1997 Jun;35(6):1526-9.
7. NCCLS Document M28-P, 1993: Procedures for the recovery and identification of parasites from the intestinal tract; proposed guidelines. National Committee for Clinical Lab. Standards, Villanova, PA.
8. Missouri Department of Health and Senior Services. 19 CSR 30-62-Health. Chapter 62- Licensing Rules for Group Day Care Homes and Child Day Care Centers.
9. Missouri Department of Health and Senior Services. Section for Community Protection. 2005.
10. Centers for Disease Control and Prevention, Healthy Swimming/Recreational Water, http://www.cdc.gov/healthyswimming/ (8/11)

Other Sources of Information

1. Infection Control in the Child Care Center and Preschool, 4th Edition, Donowitz, 1999: 117- 119.
2. Medscape Reference, Cryptosporidiosis: http://emedicine.medscape.com/article/215490-overview

Overview

Case Definition - Cyclosporiasis – 2010 Case Definition

• Agent - Cyclospora cayetanensis (a sporulating coccidian protozoan).
• Reservoir - Humans are the only known host.
• Environment - Cyclospora can be stable in the environment for months. Cyclospora oocysts are relatively resistant to most disinfectants used in food and water processing and can remain viable for long periods of time in cool, moist environments. Sporulation must occur at temperatures between 22°C and 32°C (71.6°F and 89.6°F) for 7-13 days outside the human host in order to become infective.
• Occurrence – Cyclosporiasis is found in many resource-limited countries worldwide and is known to cause travelers’ diarrhea. It is endemic in tropical and subtropical regions, particularly South America, Africa, and Southeast Asia. In the United States, outbreaks of foodborne-related infections have been linked to imported fresh produce such as basil, cilantro, raspberries, sugar snap peas, and lettuce. These outbreaks mainly occur between May and August.
• Risk Factors –Individuals who have visited countries where cyclosporiasis is prevalent or those who consume contaminated food or water are susceptible to infection. The level of sanitation also affects transmission.
• Mode of Transmission – Oocysts must sporulate to become infective. Transmission happens when an individual ingests contaminated food or water, and the oocysts present in them have sporulated. As a result, direct person-to-person contact or ingestion of freshly contaminated food or water is not likely to result in transmission.
• Period of Communicability – Direct person-to-person transmission is unlikely because Cyclospora oocysts are not infectious at the time of excretion.
• Incubation Period - Approximately 7 days (in moderate temperatures, sporulation occurs within 7-13 days).
• Clinical Illness – An upper small bowel infection with symptoms that typically include watery diarrhea, nausea, anorexia, abdominal cramps, fatigue, myalgia, and weight loss. Fever is rarely present. In some cases, diarrhea can often follow an influenza-like illness. Though cyclosporiasis is a self-limiting illness, symptoms may persist for several weeks. In untreated cases, relapsing symptoms are common, lasting for weeks or even months. Individuals with weakened immune systems, such as due to HIV/AIDS, cancer, or taking immunosuppressive medications, are at risk of severe infections and may experience prolonged illness. Asymptomatic infections can occur.
• Laboratory Testing – Testing for cyclosporiasis includes the detection of Cyclospora through microscopic examination or molecular diagnosis by polymerase chain reaction (PCR) in stool, intestinal fluid/aspirate or intestinal biopsy specimens. Oocysts in stool may be visualized using a modified acid-fast stain.
• Treatment – Trimethoprim-sulfamethoxazole (TMP-SMX) is the recommended treatment for cyclosporiasis given for a duration of 7-10 days. Individuals that cannot be treated with TMP-SMX may be treated with Ciprofloxacin (500 mg orally twice daily for 7 days). HIV-infected patients may need longer courses of therapy. See the RedBook or visit Clinical Overview of Cyclosporiasis (CDC) for additional information.
• Priority – Prompt investigation and implementation of control measures required.