A review of gastrointestinal outbreaks in schools: effective infection control interventions

Nongovernmental Organization Practitioners' Perspectives on the Challenges and Solutions to Changing Handwashing Behavior in Older Children: A Qualitative Study

BACKGROUND

Increasing handwashing with soap (HWWS) among older children (aged 5-14 years) can achieve a substantial public health impact. However, HWWS interventions targeting older children have had mixed success. Recent research has attempted to quantitatively identify effective intervention techniques; however, success is likely also influenced by the wider context of implementation. We explore nongovernmental organization (NGO) practitioners' perspectives on the challenges and solutions to HWWS interventions targeting older children to enhance understanding of what is required, beyond intervention content, for them to be effective.

METHODS

We conducted in-depth, semistructured interviews in April-November 2020 with 25 practitioners employed across 11 NGOs and involved in HWWS interventions targeting older children in development and humanitarian settings. We used purposive and snowball sampling to recruit participants in roles at the global, national/regional, and local levels. Interviews were audio-recorded, transcribed, and thematically analyzed to identify challenges and solutions to HWWS interventions targeting older children. Results were organized according to program development cycle stages.

RESULTS

Twelve themes relating to perceived challenges emerged: (1) lack of prioritization, (2) funding inconsistency, (3) insufficient formative research, (4) demand on resources, (5) unengaging intervention content, (6) non-enabling physical environments, (7) availability of skilled implementers, (8) reaching out-of-school children, (9) community mistrust, (10) lack of coordination, (11) lack of evaluation rigor, and (12) failure to assign older children's HWWS as a primary outcome in evaluations of hygiene interventions. Recommended solutions were at the intervention, organization, and sector levels.

CONCLUSION

Intervention design and delivery are important for the success of HWWS interventions for older children, but contextual factors, such as the availability of human and material resources and the level of coordination within and beyond the NGO sector, should also be considered. NGOs need to prioritize HWWS promotion among older children and support programs accordingly.

Assessment of Microbial Source Tracking Marker and Fecal Indicator Bacteria on Food-Contact Surfaces in School Cafeterias

Food poisoning outbreaks in schools can affect many students, causing physical and psychological damage and time and economic loss. Fecal indicator bacteria (FIB) have been used to monitor the contamination; however, the detection is time-consuming and confirms the contamination from all warm-blooded animals. Microbial source tracking (MST) is a molecular-based detection method that is host specific. This study aimed to evaluate MSTs and FIBs for tracing contamination in the school cafeteria. The average total aerobic count was 0.89 to 3.63 log CFU/100 cm2, and the faucets in the cooking area showed a significantly high aerobic count. The stove valve, faucet, and hand-washer were the most contaminated area, with a concentration of 1.90 to 6.80 log CFU/100 cm2 from the frequent hand contact. Escherichia coli was not detected on any surfaces, and coliform was detected on five surfaces: the sink and faucet in the food preparation area, the faucet in the cooking area, the hand-washer, and the toilet seat in the restroom with 0.33 to 3.64 log CFU/100 cm2. Human-specific crAssphage appeared on a faucet in the food preparation area, while HF183 was not detected. The result indicates that the continuous monitoring of frequent hand-contact areas is recommended to maintain the hygiene condition in the school cafeteria.

A Point Source Gastroenteritis Outbreak in a High School Putatively Due to Clostridium perfringens: Timely Investigation Is Everything

On May 28, 2021, several gastroenteritis cases were reported among students and staff of a high school on a Greek island. Lunches were delivered daily at the school by a catering company. We conducted a retrospective cohort study. Cases were defined as students or school staff presenting with diarrhea and abdominal pain between May 27 and 29, 2021. We used a self-administered questionnaire to collect the data. In the univariate analysis, we calculated food-specific attack rates (ARs), relative risks (RRs), and confidence intervals (95% CIs). Statistically significant variables (p < 0.05) were included in the multivariable model. Stool samples were collected from students on the same day of notification and were tested for bacteria, viruses, and parasites. The local food safety authority also inspected the school and the catering company premises. The food samples were sent to the reference laboratory for analysis. We received 129 responses from 174 students and staff members (response rate: 74%). Thirty cases were identified (AR, 23%). Of the 11 significant food items in the univariate analysis, the consumption of spaghetti with minced meat on May 27 (odds ratio 53.40, 95% CI: 3.9-736.1, 97% of cases exposed) was independently associated with the onset of gastroenteritis. Clostridium perfringens was detected in two of the three students' stool samples. Six samples from spaghetti with minced meat were positive for C. perfringens and four of those also tested positive for Bacillus cereus. Environmental investigation revealed non-compliances concerning food personnel training and Hazard Analysis and Critical Control Points (HACCP) plan implementation in the food establishment. Timely investigation and samples collection allowed the identification of the probable source of the outbreak. Changes, regarding the reception and distribution of meals in the school, were applied. Recommendations were given to the catering establishment focusing on adequate personnel training and HACCP issues, especially regarding temperature/time controls during all production, handling, and distribution phases.

Risk factors associated with outbreaks of seasonal infectious disease in school settings, England, UK

Children are important transmitters of infection. Within schools they encounter large numbers of contacts and infections can spread easily causing outbreaks. However, not all schools are affected equally. We conducted a retrospective analysis of school outbreaks to identify factors associated with the risk of gastroenteritis, influenza, rash or other outbreaks. Data on reported school outbreaks in England were obtained from Public Health England and linked with data from the Department for Education and the Office for Standards in Education, Children's Services and Skills (Ofsted). Primary and all-through schools were found to be at increased risk of outbreaks, compared with secondary schools (odds ratio (OR) 5.82, 95% confidence interval (CI) 4.50–7.58 and OR 4.66, 95% CI 3.27–6.61, respectively). School size was also significantly associated with the risk of outbreaks, with higher odds associated with larger schools. Attack rates were higher in gastroenteritis and influenza outbreaks, with lower attack rates associated with rashes (relative risk 0.17, 95% CI 0.15–0.20). Deprivation and Ofsted rating were not associated with either outbreak occurrence or the subsequent attack rate. This study identifies primary and all-through schools as key settings for health protection interventions. Public health teams need to work closely with these schools to encourage early identification and reporting of outbreaks.

Surveillance of the 'bud event of norovirus-associated gastroenteritis' in schools: does it work in the prevention of norovirus infection outbreaks in Shanghai?

Outbreaks of norovirus-associated gastroenteritis have been reported in schools in recent decades in China. For early warning and response to infectious disease outbreaks, the Shanghai Infectious Diseases Bud Event Surveillance System (IDBESS) was established in 2016. Bud event is a term used for the early sign of a potential infectious disease outbreak in public settings when the first few cases appear. This study aimed to describe the epidemiological characteristics of Norovirus-associated gastroenteritis bud events from June 2016 to December 2017 and to understand factors influencing the severity of events. Data were extracted from the IDBESS, supplemented by field investigations and school absence surveillance. In total, 189 bud events of Norovirus-associated gastroenteritis were reported in schools and kindergartens, affecting 3827 individuals and 52.38% happened in primary schools. The attack rate of Norovirus-associated gastroenteritis was 3.82% on average in students in the affected schools. In each event, case numbers varied between 5 and 148, with a median of 16. The duration of bud events lasted for 2 days on average. School absence happened in 47.93% (1797/3749) of affected students and the average duration of absence was 3.07 days. It was found that a longer delay before reporting was associated with a longer-lasting duration of bud event (OR = 2.25, 95% CI: 1.65, 3.07). In conclusion, ascribed to the sensitive threshold for alerting and the timely field investigation, the surveillance of bud events of Norovirus-associated gastroenteritis is effective in the control of Norovirus infection among preschool children and students in Shanghai.

Rinse-free hand wash for reducing absenteeism among preschool and school children

BACKGROUND

Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children.

OBJECTIVES

1. To assess the effectiveness of rinse-free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse-free hand washing products are the most effective (if head-to-head comparisons exist), and what effect additional strategies in combination with rinse-free hand washing have on the outcomes of interest.

SEARCH METHODS

In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions.

DATA COLLECTION AND ANALYSIS

Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings.

MAIN RESULTS

This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.

Optimizing the performance of conventional water treatment system using quantitative microbial risk assessment, Tehran, Iran

The performance of conventional drinking water treatment plants (WTPs) can be improved using quantitative microbial risk assessment (QMRA). A QMRA study on Cryptosporidium using actual pathogen density was conducted to examine the performance of Jalaliyeh WTP in Tehran, Iran. The infection risk and the burden of disease attributed to the parasite presence in finished water were estimated incorporating physical and chemical log reduction values (LRVs), using stochastic modeling and disinfection profiling. The risk and burden of disease were compared with health-based targets, i.e. one case of infection per 10,000 people or 10^-6 DALYs per person per year. The parasite's LRVs were 2.31 and 0.034 log provided by physico-chemical treatment and disinfection processes, respectively. The mean of estimated risk (111 cases per 10⁴ people per year) and the burden of disease (11.7 DALYs per 10⁶ people per year) both exceeded the targets. To control the excess risk, three QMRA-based disinfection scenarios were examined including: (1) employing chlorine dioxide (ClO₂) instead of chlorine (2) ozonation with a concentration of 0.75 mg/L (Ct = 22.5 min mg/L) and (3) UV irradiation with a dose of 10 mJ/cm². The LRV of parasite may be increased to 3.0, 5.1 and 4.9 log by employing ClO₂, ozonation and UV irradiation, respectively. The use of ozone or UV as alternative disinfectants, could enhance the disinfection efficacy and provide sufficient additional treatment against the excess risk of parasite. QMRA could make it easier applying appropriate improvement to conventional WTPs in order to increase the system performance in terms of health-based measures.

Key Dimensions for the Prevention and Control of Communicable Diseases in Institutional Settings: A Scoping Review to Guide the Development of a Tool to Strengthen Preparedness at Migrant Holding Centres in the EU/EEA

Migrant centres, as other institutions hosting closed or semi-open communities, may face specific challenges in preventing and controlling communicable disease transmission, particularly during times of large sudden influx. However, there is dearth of evidence on how to prioritise investments in aspects such as human resources, medicines and vaccines, sanitation and disinfection, and physical infrastructures to prevent/control communicable disease outbreaks. We analysed frequent drivers of communicable disease transmission/issues for outbreak management in institutions hosting closed or semi-open communities, including migrant centres, and reviewed existing assessment tools to guide the development of a European Centre for Disease Prevention and Control (ECDC) checklist tool to strengthen preparedness against communicable disease outbreaks in migrant centres. Among articles/reports focusing specifically on migrant centres, outbreaks through multiple types of disease transmission were described as possible/occurred. Human resources and physical infrastructure were the dimensions most frequently identified as crucial for preventing and mitigating outbreaks. This review also recognised a lack of common agreed standards to guide and assess preparedness activities in migrant centres, thereby underscoring the need for a capacity-oriented ECDC preparedness checklist tool.

Importance of implementation level when evaluating the effect of the Hi Five Intervention on infectious illness and illness-related absenteeism

BACKGROUND

There is limited research on the importance of implementation when evaluating the effect of hand hygiene interventions in school settings in developed countries. The aim of this study was to examine the association between an implementation index and the effect of the intervention. The Hi Five Intervention was evaluated in a 3-armed cluster randomized controlled trial involving 43 randomly selected Danish schools.

METHODS

Analyses investigating the association between implementation of the Hi Five Intervention and infectious illness days, infectious illness episodes, illness-related absenteeism, and hand hygiene were carried out in a multilevel model (school, class, and child).

RESULTS

The level of implementation was associated with hand hygiene and potentially associated with number of infectious illness days and infectious illness episodes among children. This association was not found for illness-related absenteeism.

CONCLUSIONS

Classes that succeeded in achieving a high level of implementation of the Hi Five Intervention had a lower number of infectious illness days and infectious illness episodes, suggesting that the Hi Five Intervention, if implemented adequately, may be relevant as a tool to decrease infectious illness in a Danish school setting.

Assessing the Food Safety Attitudes and Awareness of Managers of School Feeding Programmes in Mpumalanga, South Africa

The managers of school feeding programmes are responsible for ensuring the safety of the food which is provided to schoolchildren, but very few studies have been conducted on the food safety knowledge and awareness of these managers. The objective of this study is to evaluate the food safety attitudes and awareness of managers of the National School Nutrition Programme (NSNP) in schools in Mpumalanga, a province of South Africa. A cross-sectional survey study was conducted in which questionnaires were used to collect data from 300 NSNP food service managers. The majority of schools offering NSNP meals were located in informal settlements and most were found to lack basic resources such as electricity (power supplies to the food preparation facility) and potable tap water in their kitchens. No school was found to have implemented the hazard analysis and critical control points (HACCP) programme, and only a few staff had received food safety training. Food safety implementation is worst in informal schools in rural areas due to limited resources and infrastructure. The NSNP food service managers in some schools-especially those located in rural settlements-were found to have little knowledge and awareness of HACCP. These results indicate an urgent need to provide NSNP managers with food safety training and resources (potable water supplies, electricity, dedicated food preparation facilities), particularly in schools in rural settlements.

An outbreak of Escherichia coli O157:H7 infections following a dairy education school field trip in Washington state, 2015

On 27 April 2015, Washington health authorities identified Escherichia coli O157:H7 infections associated with dairy education school field trips held in a barn 20-24 April. Investigation objectives were to determine the magnitude of the outbreak, identify the source of infection, prevent secondary illness transmission and develop recommendations to prevent future outbreaks. Case-finding, hypothesis generating interviews, environmental site visits and a case-control study were conducted. Parents and children were interviewed regarding event activities. Odds ratios (OR) and 95% confidence intervals (CI) were computed. Environmental testing was conducted in the barn; isolates were compared to patient isolates using pulsed-field gel electrophoresis (PFGE). Sixty people were ill, 11 (18%) were hospitalised and six (10%) developed haemolytic uremic syndrome. Ill people ranged in age from <1 year to 47 years (median: 7), and 20 (33%) were female. Twenty-seven case-patients and 88 controls were enrolled in the case-control study. Among first-grade students, handwashing (i.e. soap and water, or hand sanitiser) before lunch was protective (adjusted OR 0.13; 95% CI 0.02-0.88, P = 0.04). Barn samples yielded E. coli O157:H7 with PFGE patterns indistinguishable from patient isolates. This investigation provided epidemiological, laboratory and environmental evidence for a large outbreak of E. coli O157:H7 infections from exposure to a contaminated barn. The investigation highlights the often overlooked risk of infection through exposure to animal environments as well as the importance of handwashing for disease prevention. Increased education and encouragement of infection prevention measures, such as handwashing, can prevent illness.

Cryptosporidium in humans and animals-a one health approach to prophylaxis

Cryptosporidium is a major cause of moderate-to-severe diarrhoea in humans worldwide, second only to rotavirus. Due to the wide host range and environmental persistence of this parasite, cryptosporidiosis can be zoonotic and associated with foodborne and waterborne outbreaks. Currently, 31 species are recognized as valid, and of these, Cryptosporidium hominis and Cryptosporidium parvum are responsible for the majority of infections in humans. The immune status of the host, both innate and adaptive immunity, has a major impact on the severity of the disease and its prognosis. Immunocompetent individuals typically experience self-limiting diarrhoea and transient gastroenteritis lasting up to 2 weeks and recover without treatment, suggesting an efficient host antiparasite immune response. Immunocompromised individuals can suffer from intractable diarrhoea, which can be fatal. Effective drug treatments and vaccines are not yet available. As a result of this, the close cooperation and interaction between veterinarians, health physicians, environmental managers and public health operators is essential to properly control this disease. This review focuses on a One Health approach to prophylaxis, including the importance of understanding transmission routes for zoonotic Cryptosporidium species, improved sanitation and better risk management, improved detection, diagnosis and treatment and the prospect of an effective anticryptosporidial vaccine.

A Systematic Review of the Use of Social Media for Food Safety Risk Communication

This article covers the current published literature related to the use of social media in food safety and infectious disease communication. The aim was to analyze literature recommendations and draw conclusions about how best to utilize social media for food safety risk communication going forward. A systematic literature review was conducted, and 24 articles were included for analysis. The inclusion criteria were (i) original peer-reviewed articles and (ii) primary focus on communication through social media about food safety and/or infectious diseases. Studies were coded for themes about social media applications, benefits, limitations, and best practices. Trust and personal beliefs were important drivers of social media use. The wide reach, immediacy, and information gathering capacities of social media were frequently cited benefits. Suggestions for social media best practices were inconsistent among studies, and study designs were highly variable. More evidence-based suggestions are needed to better establish guidelines for social media use in food safety and infectious disease risk communication. The information gleaned from this review can be used to create effective messages for shaping food safety behaviors.

Probable secondary transmission of antimicrobial-resistant Escherichia coli between people living with and without pets

Companion animals are considered as one of the reservoirs of antimicrobial-resistant (AR) bacteria that can be cross-transmitted to humans. However, limited information is available on the possibility of AR bacteria originating from companion animals being transmitted secondarily from owners to non-owners sharing the same space. To address this issue, the present study investigated clonal relatedness among AR E. coli isolated from dog owners and non-owners in the same college classroom or household. Anal samples (n=48) were obtained from 14 owners and 34 non-owners; 31 E. coli isolates were collected (nine from owners and 22 from non-owners). Of 31 E. coli, 20 isolates (64.5%) were resistant to at least one antimicrobial, and 16 isolates (51.6%) were determined as multi-drug resistant E. coli. Six isolates (19.4%) harbored integrase genes (five harbored class I integrase gene and one harbored class 2 integrase gene, respectively). Pulsed-field gel electrophoretic analysis identified three different E. coli clonal sets among isolates, indicating that cross-transmission of AR E. coli can easily occur between owners and non-owners. The findings emphasize a potential risk of spread of AR bacteria originating from pets within human communities, once they are transferred to humans. Further studies are needed to evaluate the exact risk and identify the risk factors of secondarily transmission by investigating larger numbers of isolates from pets, their owners and non-owners in a community.

Cryptosporidium hominis Is a Newly Recognized Pathogen in the Arctic Region of Nunavik, Canada: Molecular Characterization of an Outbreak

Background

Cryptosporidium is a leading cause of childhood diarrhea in low-resource settings, and has been repeatedly associated with impaired physical and cognitive development. In May 2013, an outbreak of diarrhea caused by Cryptosporidium hominis was identified in the Arctic region of Nunavik, Quebec. Human cryptosporidiosis transmission was previously unknown in this region, and very few previous studies have reported it elsewhere in the Arctic. We report clinical, molecular, and epidemiologic details of a multi-village Cryptosporidium outbreak in the Canadian Arctic.

Methodology/Principal Findings

We investigated the occurrence of cryptosporidiosis using a descriptive study of cases with onset between April 2013 and April 2014. Cases were defined as Nunavik inhabitants of any age presenting with diarrhea of any duration, in whom Cryptosporidium oocysts were detected by stool microscopy in a specialised reference laboratory. Cryptosporidium was identified in stool from 51 of 283 individuals. The overall annual incidence rate (IR) was 420 / 100,000 inhabitants. The IR was highest among children aged less than 5 years (1290 /100,000 persons). Genetic subtyping for stool specimens from 14/51 cases was determined by DNA sequence analysis of the 60 kDa glycoprotein (gp60) gene. Sequences aligned with C. hominis subtype Id in all cases. No common food or water source of infection was identified.

Conclusions/Significance

In this first observed outbreak of human cryptosporidiosis in this Arctic region, the high IR seen is cause for concern about the possible long-term effects on growth and development of children in Inuit communities, who face myriad other challenges such as overcrowding and food-insecurity. The temporal and geographic distribution of cases, as well as the identification of C. hominis subtype Id, suggest anthroponotic rather than zoonotic transmission. Barriers to timely diagnosis delayed the recognition of human cryptosporidiosis in this remote setting.

In mid-2013, an outbreak of moderate-to-severe diarrhea caused by Cryptosporidium was identified in the Arctic region of Nunavik, Quebec, and it predominantly affected young children. Cryptosporidium is a leading cause of childhood diarrhea in low-resource settings, but was previously unknown in this region. This is important because cryptosporidiosis has been repeatedly associated with impaired growth and development, and may interact with other challenges currently faced by children in remote Arctic communities, such as overcrowding and food-insecurity. Although animals in the Arctic have previously been found to harbour Cryptosporidium parvum, which can infect both animals and humans, we found that the Cryptosporidium identified in the stool of affected people all belonged to the species C. hominis, which is only known to infect humans. Together with the temporal and geographic distribution of cases, this suggests that cryptosporidiosis in this outbreak was transmitted person-to-person, rather than acquired from contact with animals. The emergence of Cryptosporidium infections in Arctic communities may have public health impacts beyond the occurrence of diarrhea.

Molecular genotyping and sub-genotyping of Cryptosporidium spp. isolates from symptomatic individuals attending two major public hospitals in Madrid, Spain

Infections by members of the protozoan genus Cryptosporidium are among the most common causes of human gastrointestinal illness worldwide. In Spain cryptosporidiosis is not a compulsory notifiable disease, so the actual burden of the infection in both clinical and general populations remains largely unknown. We present here data on the diversity and frequency of the Cryptosporidium species and sub-genotypes identified in symptomatic individuals seeking medical care in two major hospitals in Madrid, Spain, between December 2013 and January 2015. Initial detection of the parasite was conducted on a total of 122 stool samples collected from 120 patients by microscopy with modified Ziehl-Neelsen and/or immunochromatographic tests. We used immunofluorescence, PCR-based methods and sequence analyses of the 60-kDa (GP60) glycoprotein and the small subunit ribosomal RNA (SSU rRNA) genes for confirmatory purposes and to characterize Cryptosporidium isolates. A total of 110 patients were confirmed with cryptosporidiosis. Overall, 101 isolates were successfully sub-genotyped at the GP60 locus, and an additional seven at the SSU rRNA locus. The analyses of all amplicons defined 10 distinct sequence types representing the GP60 family sub-genotypes IbA10G2 (78.7%), IeA11G3T3 (3.7%) of C. hominis, and the GP60 family sub-types IIaA15G2R1 (5.6%), IIaA18G6R1 (0.9%), IIcA5G3a (0.9%), IIdA18G1 (0.9%), IIdA19G1 (0.9%), IIdA21G1 (0.9%), and IIdA22G1 (0.9%) of C. parvum. A single isolate was assigned to C. felis (0.9%), two C. parvum isolates (1.9%) could not be characterized at the sub-genotype level and an additional four isolates (3.7%) were not typable. These results strongly suggest that transmission of cryptosporidiosis is mostly anthroponotic in origin in the clinical sample under study. We expect that our molecular epidemiological data will make a significant contribution to unravel the actual epidemiological situation of cryptosporidiosis in Spain, providing health care and policy makers with solid baseline information to unavoidably improve the national surveillance system and allocate additional resources to research, diagnosis, and treatment of cryptosporidiosis.

School outbreak of Escherichia coli O157 with high levels of transmission, Staffordshire, England, February 2012

BACKGROUND

Verocytotoxin-producing Escherichia coli (VTEC) are bacteria that cause infectious gastroenteritis and in certain settings can cause widespread infection due to secondary transmission. We describe the findings of an investigation of a school-based outbreak of VTEC in Staffordshire, England.

METHODS

Outbreak investigation at a school in February 2012 after two children were diagnosed with VTEC infection. Cases were defined as pupils and staff (or their household contacts) with gastrointestinal symptoms or asymptomatic screened persons, with laboratory confirmed VTEC O157 infection (phage type 32, verocytotoxin 2) occurring on or after 1 February 2012. Microbiological tests of food and faecal samples plus screening of asymptomatic contacts were undertaken. Epidemiological and clinical data were descriptively analysed.

RESULTS

Thirty-eight cases were detected. Nineteen were asymptomatic and identified via screening of 191 pupils. Infection was introduced into the school from an earlier household cluster, followed by extensive person-to-person transmission within the nursery/infant group with limited spread to the wider school population.

CONCLUSIONS

Control measures included several interventions, in particular, universal screening of pupils and staff. Screening during school outbreaks is not underpinned by guidance but proved to be a key control measure. Screening of asymptomatic contacts should be considered in similar outbreaks.

Comparative efficacy of a simplified handwashing program for improvement in hand hygiene and reduction of school absenteeism among children with intellectual disability

BACKGROUND

Infectious diseases are common among schoolchildren as a result of their poor hand hygiene, especially in those who have developmental disabilities.

METHODS

A quasi-experimental study using a pre- to post-test design with a control group was used to test the feasibility and sustainability of simplified 5-step handwashing techniques to measure the hand hygiene outcome for students with mild intellectual disability. Sickness-related school absenteeism was compared.

RESULTS

The intervention group experienced a significant increase in the rating of their handwashing quality in both hands from pre- to post-test: left dorsum (+1.05, P < .001); right dorsum (+1.00, P < .001); left palm (+0.98, P < .001); and right palm (+1.09, P < .001). The pre- to post-test difference in the intervention group (+1.03, P < .001) was significantly greater than the difference in the control group (+0.34, P = .001). There were no differences between the post-test and the sustainability assessment in the intervention group. The intervention school experienced a significantly lower absenteeism rate (0.0167) than the control group in the same year (0.028, P = .04).Students in this study showed better performance in simplified handwashing techniques and experienced lower absenteeism than those using usual practice in special education school settings.

CONCLUSION

The simplified 5-step hand hygiene technique has been proven effective in reducing the spread of infectious diseases.

Scoping Review of Research on the Effectiveness of Food-Safety Education Interventions Directed at Consumers

Improper food handling by consumers at home is a major cause of foodborne illness. Therefore, effective education strategies are essential to change consumers' food safety attitudes and behaviors. The purpose of this scoping review was to identify and characterize primary literature examining the effectiveness of consumer food-safety education interventions. Ten bibliographic databases were searched using a comprehensive search strategy. Citations were identified; two reviewers screened them for relevance and characterized relevant articles. To ensure results would be applicable to end users, stakeholders were engaged to provide input on the review scope, methods, and results. We identified 246 relevant articles, of which 150 were quantitative, 66 qualitative, and 30 mixed-method research studies. Most studies (64.2%) were published in the United States, using an uncontrolled before-and-after study design (31.3%), and investigated the effectiveness of community-based training sessions and workshops (52.0%). Research gaps were found in the number of randomized controlled studies conducted, academic- and school-based courses and curricula investigated, and interventions targeting high-risk populations (e.g., pregnant women, those who are immunocompromised) and using new media channels (e.g., social media). Key opportunities to enhance the utility of future primary research investigating consumer food-safety interventions include the following: using studies based on behavior-change theories and formative research; engaging the target population in the research; using validated instruments to measures outcomes; and reporting intervention characteristics and outcomes completely. Results of this review can be used to prioritize future primary research and decision-making in this area.

A survey on the status of hepatitis e virus infection among slaughterhouse workers in South Korea

Objectives:

The seroprevalence of hepatitis E virus (HEV) among high-risk groups overseas is high, but studies in these groups are rare in South Korea. We conducted the present study from April to November 2012 to obtain data on the seroprevalence and associated risk factors for HEV among slaughterhouse workers in South Korea.

Methods:

Slaughterhouse workers from 80 workplaces nationwide were surveyed in South Korea in 2012. The subjects comprised 1848 cases: 1434 slaughter workers and 414 residual products handlers. By visiting 80 slaughterhouses, which were mixed with 75 of which also performed residual products handling, we conducted a questionnaire survey for risk factors and obtained blood samples in order to determine the seropositivity and seroprevalence of HEV. Anti-HEV IgG and IgM were measured using HEV IgG and IgM enzyme-linked immunospecific assay kits and HEV antigen was measured by reverse transcription polymerase chain reaction (RT-PCR).

Results:

The seropositivity of anti-HEV IgG was 33.5% (slaughter workers 32.8% and residual products handlers 36.2%), and among the seropositive individuals the seroprevalence of anti-HEV IgM was 0.5% (slaughter workers 0.5%, residual products handlers 0.7%). The response rate of HEV-antigen as measured by RT-PCR was 0.2%. Risk factors significantly related to anti-HEV IgG seropositivity were age, sex , and working duration (slaughter workers only).

Conclusions:

There were significant risk factors (sex, age, and working duration) for HEV identified in our study. All three positive cases for HEV-antigen by RT-PCR were related to pig slaughter but without statistical significance. To prevent HEV, an educational program and working guidelines may be needed for high risk groups.

To evaluate the effects of a simplified hand washing improvement program in schoolchildren with mild intellectual disability: a pilot study

A quasi-experimental study using a pretest-posttest design with a control group was used to evaluate the effects of a simplified 5-step multimedia visualization hand hygiene improvement program by schoolchildren with mild intellectual disability (MID). A total of twenty schoolchildren aged 6-12 years old with MID (12 males) were recruited and they were assigned into intervention (n=10) and control (n=10) groups. To evaluate the quality of their hand washing, Glow gel, which contains plastic simulated germs that are visible under an ultra-violet lamp, was applied to participants' hands to assess the quality of hand washing by comparing the amount of visible Glow gel before and after hand washing using a 4-point scale. Four raters used this 4-point scale to assess the quality of hand washing through digital photo images of the participants' hands. A total of eight digital photos per participant were taken. A fifteen-minute hand washing training session was conducted every school day for 4 weeks for the intervention group. Those in the control group received no training. A multimedia visual package on steps of hand washing was presented together with a reward system, whereby a number of stars were earned each week depending on the quality of hand washing. Results showed encouraging findings, as the schoolchildren in the intervention group showed significant improvement in hand washing (p<0.001) and the improvement was stronger than that of the control group (p=0.02). To conclude, a systematic instruction emphasizing multimedia visualization in a hand washing improvement program can be successfully implemented in a special school, and the effect of integrating multimedia visuals in the hand hygiene program could improve hand hygiene among schoolchildren with MID.

Effectiveness of a multifactorial handwashing program to reduce school absenteeism due to acute gastroenteritis

BACKGROUND

Acute gastroenteritis (AGE) is one of the most common diseases among children and an important cause of school absenteeism. The aim of this study was to assess the effectiveness of a handwashing program using hand sanitizers for the prevention of school absenteeism due to AGE.

METHODS

A randomized, controlled and open study of a sample of 1341 children between 4 and 12 years of age, attending 5 state schools in Almería (Spain), with an 8-month follow up (academic year). The experimental group (EG) washed their hands with soap and water, complementing this with the use of a hand sanitizer, and the control group (CG) followed the usual handwashing procedure. Absenteeism rates due GI were compared between the 2 groups through the multivariate Poisson regression analysis. Percent days absent in both groups were compared with a Z-test.

RESULTS

446 cases of school absenteeism due to AGE were registered. The school children from the EG had a 36% lower risk of absenteeism due to AGE (IRR: 0.64, 95% confidence interval: 0.52-0.78) and a decrease in absenteeism of 0.13 episodes/child/academic year (0.27 of EG vs 0.40 CG/episodes/child/academic year, P < 0.001). Pupils missed 725 school days due to AGE and absent days was significantly lower in the EG (EG: 0.31%, 95% confidence interval: 0.28-0.35 vs. CG: 0.44%, 95% confidence interval: 0.40-0.48, P < 0.001).

CONCLUSIONS

The use of hand sanitizer as a complement to handwashing with soap is an efficient measure to reduce absent days and the number of school absenteeism cases due to AGE.

Animal Health: Global Antibiotic Issues

Antibiotics are antimicrobial compounds that can inhibit and even destroy bacterial and fungal growth. Antibiotics are used in both human diseases to kill bacterial and fungal pathogens and in farm animals to reduce incidences of animal diseases as veterinary drugs, promote animal weight gain, and control the zoonotic pathogens in milk, egg, meat, and meat products. Use of antibiotics in agricultural farm animals may aid bacterial antibiotic resistance. Though it is still a debatable topic, a comprehensive understanding of using antibiotics in farm animal production and the replacement of these antibiotics with some natural products is under pressure.

Fun on the farm: evaluation of a lesson to teach students about the spread of infection on school farm visits

Background

School visits to farms are a positive educational experience but pose risks due to the spread of zoonotic infections. A lesson plan to raise awareness about microbes on the farm and preventative behaviours was developed in response to the Griffin Investigation into the E. coli outbreak associated with Godstone Farm in 2009. This study evaluated the effectiveness of the delivery of the lesson plan in increasing knowledge about the spread of infection on the farm, amongst school students.

Methods

Two hundred and twenty-five 9–11 year old students from seven junior schools in England participated. Two hundred and ten students filled in identical questionnaires covering microbes, hand hygiene, and farm hygiene before and after the lesson. Statistical analysis assessed knowledge change using difference in percentage correct answers.

Results

Significant knowledge improvement was observed for all sections. In the ‘Farm Hygiene’ section, girls and boys demonstrated 18% (p<0.001) and 11% (p<0.001) improvement, respectively (girls vs. boys p<0.004). As girls had lower baseline knowledge the greater percentage improvement resulted in similar post intervention knowledge scores between genders (girls 80%, boys 83%).

Conclusions

The lesson plan was successful at increasing awareness of microbes on the farm and infection prevention measures and should be used by teachers in preparation for a farm visit.

Medical services of a multicultural summer camp event: experiences from the 22nd World Scout Jamboree, Sweden 2011

Background

Prevention and treatment of medical issues are the main task of a health service at a youth camp. However, only few reports about organisation and implementation of camp health care are available. This makes it difficult for future camp directors to plan and estimate the health care needed for a certain camp size. We summarize the experience in planning and running health care for the 22nd World Scout Jamboree (WSJ) 2011 in Sweden.

Methods

During the WSJ, 40,061 participants from 146 nations were gathered in southern Sweden to a 12 day summer camp. Another 31,645 people were visitors. Members for the medical service were 153 volunteering medical professionals with different language and cultural backgrounds from 18 different countries.

Results

Of 40,061 participants 2,893 (7.3%) needed medical assistance. We found an equal distribution of cases to approximately one third surgical, one third medical and one third unspecified cases. Much energy was spent on health prevention, hygiene measures and organizing of psychological support.

Conclusions

A youth camp with a multicultural population and a size of a small city demands flexible staff with high communication skills. Special attention should be paid in prevention of contagious diseases and taking care of psychological issues.

Epidemiological investigation of two parallel gastroenteritis outbreaks in school settings

BACKGROUND

Two parallel gastroenteritis outbreaks occurred in an elementary school and a neighboring kindergarten in Kilkis, Northern Greece in 2012. The aim of the study was the investigation of these two parallel outbreaks as well as their possible source.

METHODS

Two retrospective cohort studies were performed to identify the mode and the vehicle of transmission as well as the possible connection between them.

RESULTS

Elementary school and kindergarten populations of 79.9% (119/149) and 51.1% (23/45) respectively, participated in the study. Case definition was satisfied by 65 pupils from the elementary school and 14 from the kindergarten. For elementary school, 53 cases were considered primary cases of the outbreak and were included in the analysis. Based on the results of the multivariate analysis, consumption of tap water was the only statistically significant independent risk factor of gastroenteritis (RR = 2.34, 95% C.I.: 1.55-3.53).; a finding supported by the shape of the epidemic curve which referred to a common point source outbreak with secondary cases. For kindergarten, no statistically significant risk factor was identified, and the epidemic curve supported a person-to-person transmission according univariate analysis. Norovirus GI and GII and human Adenovirus were detected by Real Time PCR in stool samples from seven children of elementary school, but stool samples were not collected by children of the kindergarten.

CONCLUSIONS

Even though the etiological agent of the outbreak was not verified, combined epidemiological and laboratory results were in favor of a waterborne viral gastroenteritis outbreak at the elementary school, followed by a person to person spread at the kindergarten.

Challenges to mapping the health risk of hepatitis A virus infection

Background

World maps are among the most effective ways to convey public health messages such as recommended vaccinations, but creating a useful and valid map requires careful deliberation. The changing epidemiology of hepatitis A virus (HAV) in many world regions heightens the need for up-to-date risk maps. HAV infection is usually asymptomatic in children, so low-income areas with high incidence rates usually have a low burden of disease. In higher-income areas, many adults remain susceptible to the virus and, if infected, often experience severe disease.

Results

Several challenges associated with presenting hepatitis A risk using maps were identified, including the need to decide whether prior infection or continued susceptibility more aptly indicates risk, whether to display incidence or prevalence, how to distinguish between different levels of risk, how to display changes in risk over time, how to present complex information to target audiences, and how to handle missing or obsolete data.

Conclusion

For future maps to be comparable across place and time, we propose the use of the age at midpoint of population susceptibility as a standard indicator for the level of hepatitis A endemicity within a world region. We also call for the creation of an accessible active database for population-based age-specific HAV seroprevalence and incidence studies. Health risk maps for other conditions with rapidly changing epidemiology would benefit from similar strategies.

Intestinal parasitic infections in an industrialized country; a new focus on children with better DNA-based diagnostics

In recent years, the isolation of parasitic DNA from faecal samples and PCR techniques, have been improved and simplified. Moreover, the introduction of real-time PCR has made it possible to multiplex different targets into one reaction. These new technical possibilities make it feasible to introduce PCR with its unsurpassed sensitivity and specificity in a routine laboratory setting for the diagnosis of intestinal parasites. Detection rates of the parasitic infections included in the PCR are increased significantly compared with microscopy. Molecular diagnostics, especially in children, reveal a possible cause of the gastrointestinal complaints in many more cases compared with conventional methods. Usually in GP patients no other pathogenic parasites are detected using microscopy and in the returning travellers additional parasites are found with microscopy in a minority of cases only. Multiplex real-time PCR offers a highly sensitive and specific diagnostic alternative for labour intensive microscopy in clinical laboratory practice. Additional diagnostic methods for the detection of parasitic infections that are not included as PCR target can be limited to a selected group of patients.