1. Salmonella typhimurium Casey County, KY Jasie L. Jackson, MPH Regional Epidemiologist Epidemiology Rapid Response Team Fall Conference Sept. 15-16 2004

2. Clinical Description Infection of variable severity commonly manifested by diarrhea, abdominal pain, nausea, fever, and sometimes vomiting. Asymptomatic infections may occur and the organism may cause extraintestinal infections. ~ Kentucky Reportable Disease Desk Reference

3. Salmonellosis > 2000 known serotypes  200 serotypes are detected each year in the United States Two most common (in most countries) –Salmonella Typhimurium –Salmonella Enteritidis

4. Casey County Statistics

5. Positive Case March 4, 2004 Case reported Galilean Home for Children – Angel House Infant – 4 months old (Baby 1) Sx – diarrhea and vomiting 3 more cases developed subsequently

6. Galilean Children’s Home A home for children that are either castaways or come from homes whose parents are unable to care for them. Also a few are placed by loving families who need assistance in caring for their severely disabled children.

7. The Angel House Home to infants from birth Separate structure from home where other children reside. Most of the babies’ mothers are in prison 15 workers 9 babies 3 babies per room Each has own bed Common room for play-time

8. Investigation Initiated Objectives –Confirm other cases –Determine mode of transmission –Determine source –Culture all workers/childcare personnel –Culture all infants –Education on proper hygiene –Institute prevention/protection measures

9. Site Visit Site visit conducted by: –Nursing Supervisor –Environmentalist –Regional Epidemiologist Interviews conducted with: –Director of Angel House –Employees

10. Investigation Standard Case definition used All workers and infants in “Angel House” cultured Stool specimens collected and sent to State Lab All workers negative 5 of 9 infants negative 4 infants with symptoms –3 initially cultured positive for S. typhimurium –Baby 4 cultured positive one week later after re-culture due to prolonged illness

11. Cases InfantSexAgeResults 1F4 mo. S. Tryphimurium v. copenhagen 2M3 mo. S. Tryphimurium v. copenhagen 3F2 mo. S. Tryphimurium v. copenhagen 4F2 mo. S. Tryphimurium v. copenhagen

12. Epidemic Curve

13. Investigation Findings All infants use same formula All positive cultures were S. typhimurium Common Source?? –Couldn’t be identified Infants do not have assigned caretaker Kitchen and sleeping areas inspected Sanitary practices discussed –Use bleach as sanitizing solution

14. Investigation Findings (continued) 3 of 4 infants slept in same bedroom 2 caretakers sick prior to infant illness –Continued to work Baby 1 visited mother in prison week prior to onset

15. Recommendations Good hygiene Stress handwashing Stress sanitization of changing areas Exclude sick caretakers Exclude sick infants Only one caretaker per infant Do not wash hands in the same sink as dishes are washed DO NOT drink unpasteurized milk or juices Caution on handling and contact with reptiles, chicks, ducklings, amphibians, etc Clean and disinfect bathrooms Clean and disinfect toys at least daily and when soiled Thoroughly cook all foods Store uncooked meats on a shelf lower than other foods

16. Further Developments Initially the outbreak was contained to 4 infants in the Angel House 2 months later another infant (Baby 5) associated with the Angel House develops symptoms and cultures positive for S. typhimurium

17. More Cultures Mother of Baby 5 works at Galilean Home for Children Baby 5 stays at “Angel House” while mother works Baby 5 re-cultured Family of Baby 5 cultured Original 4 infants repeat cultures Mother and sister of Baby 5 negative Father positive Baby 1 still positive –Returned home with mother week prior to culture results

18. Culture, Culture, Culture Father cultured 6 times –S. typhimurium Father works in restaurant operated by Galilean Home –Advised – can’t work till 2 negative cultures 2 negative cultures –7-20-04 –7-27-04

19. Conclusions Common Source of infection Source could not be identified 2 possible scenarios 1.Father of Baby 5 is carrier and passed via Baby 5 to other infants 2.Baby 1 is carrier and passed to all other infants. Baby 5 passed infection to Father during day-to-day care.

20. References Chin, James, MD ed. Control of Communicable Diseases Manual. 17 th ed. Baltimore: United, 2000. Hooker, Carol, Mary Beth Grimm, and Claudia Miller, eds. Infectious Diseases in Childcare Settings and Schools: Information for Directors, Caregivers, Parents or Guardians and School Health Staff. 5 th ed. Hopkins, MN: Hennipen County Community Health Department, 2003. Kentucky Reportable Disease Desk Reference. Div. Of Epidemiology and Health Planning. 2003. Reportable Diseases in Kentucky: 2002 Summary. Division of Epidemiology and Health Planning.