Enteric Illness Protocol

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					     Enteric Illness Protocol
                          MARCH 2008

C O M M U N I C A B L E      D I S E A S E   C O N T R O L
 Communicable Disease Management Protocol

 Enteric Illness
                                                             Communicable Disease Control Branch

 Table of Contents
 Executive Summary                                                                          3
 Contact Information                                                                        4
 List of Acronyms                                                                           5
 1. Introduction                                                                            6
     1.1   Purpose                                                                          6
     1.2   Definitions                                                                      6
     1.3   Etiology of Enteric Illnesses                                                    7
     1.4   Epidemiology                                                                     7
           1.41 Transmission                                                                7
           1.42 Occurrence                                                                  8
 2. Prevention of Enteric Illness Outbreaks                                                 8
     2.1   Surveillance                                                                     8
     2.2   Public Facility Inspections                                                    10
 3. Response to Enteric Illness Outbreaks                                                 10
     3.1   Detection                                                                      10
     3.2   Reporting Requirements                                                         11
     3.3   Risk Assessment                                                                11
     3.4   Initial Control Measures                                                       11
     3.5   Outbreak Investigation                                                         12
     3.6   Exclusion                                                                      16
     3.7   Communication                                                                  16
     3.8   Enteric Illness Outbreak Summary Report                                        17
     3.9   Roles and Responsibilities                                                     18

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    4. Appendices                                                                                            23
       4.1   List of Enteric Organisms Which May be Transmitted by Food and/or Water                         23
       4.2   Attack Rate Table                                                                               29
       4.3   Food Protection Measures in Manitoba                                                            30
       4.4   Measures Taken to Protect Manitoba’s Drinking Water                                             33
       4.5   Norovirus (NV) Enteric Illness                                                                  37
       4.6   Routine Infection Control Practices in Health Care                                              38
       4.7   Communicable Disease Control Investigation Form                                                 39
       4.8   Summary of Case Histories/Epidemiological Table                                                 41
       4.9   Initial Control Measures                                                                        42
       4.10 Sample Outbreak Investigation Report                                                             46
       4.11 Instructions for Stool Sample Collection                                                         51
       4.12 Format for Completing Requisition Forms for CPL                                                  53
       4.13 Laboratory Foodborne Illness Investigation                                                       54
       4.14 Environmental Specimen Testing                                                                   57
       4.15 Explanation of ALS Laboratory Group Bacteriological Results                                      60
       4.16 Outbreak Report                                                                                  62
       4.17 Foodborne Illness Premises Inspection Report                                                     64
       4.18 Sample Letter of Exclusion                                                                       66
       4.19 Foodborne/Waterborne Illness Investigation Checklist                                             67
    References                                                                                               69

March 2008                                             Communicable Disease Management Protocol – Enteric Illness
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 Executive Summary                                           procedures for internal, external and media
                                                             communications. The steps for the preparation of
 The purpose of the enteric illness protocol is to:          the Enteric Illness Outbreak Summary Report are
 1) outline the initial control measures that should         outlined.
    be implemented to help contain the outbreak              A list of contacts and acronyms is found at the
    and prevent spread,                                      beginning of the protocol. The appendices section
 2) detail the procedures and reporting that should          contains the forms that need to be completed for
    be undertaken during an enteric illness                  enteric illness investigations as well as instructions for
    outbreak investigation,                                  specimen collection and submission. A section on
                                                             noroviruses (NV) is contained in the appendices as
 3) explain the terms and calculations used to               they are the most common agents implicated in
    determine whether an environmental exposure              enteric illness outbreaks. In addition, a listing of
    such as food or water is the source of the               other enteric illness-causing agents that may be
    illness, and                                             transmitted by food or water is included. The
 4) define the roles and responsibilities of the             appendices also contain detailed information on
    individuals and organizations that may be                prevention measures, including water and food
    involved in the investigation.                           protection, routine infection control practices and
                                                             initial control measures in public facilities. A sample
 To help guide the enteric illness investigation,
                                                             outbreak investigation report is included in the
 information on the etiology and epidemiology of
                                                             appendices section in order to guide documentation.
 enteric illness has been included. Surveillance
                                                             A list of references for further reading is found at the
 activities that aid in prevention are briefly
                                                             end of the protocol.
 described. The exclusion process for affected
 employees is detailed as well as the communication

Communicable Disease Management Protocol – Enteric Illness                                               March 2008
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    Contact Information
    Name of Organization                        Contact                                    Phone No.
    Manitoba Health and Healthy Living –        Chief Provincial Public Health Officer     204-788-6666
    Office of the Chief Provincial
    Public Health Officer
    Manitoba Health and Healthy Living –        Director of Food Protection                204-788-6745
    Food Protection
    Manitoba Health and Healthy Living –        Manager of Public Health Inspectors        204-788-6726
    Public Health
    Manitoba Health and Healthy Living –        A listing may be found at
    Regional MOHs                               www.gov.mb.ca/health/publichealth/cmoh/contactlist.html
    Manitoba Health and Healthy Living –        Referral Liaison Inter/Intra Province      204-788-6736
    CDC Surveillance Unit
    Manitoba Health and Healthy Living –        Epidemiologist                             204-788-6786
    CDC Epidemiology
    Manitoba Health and Healthy Living –        Infection Control Practitioner             204-945-6685
    Infection Control
    Cadham Provincial Laboratory                Outbreak Co-ordinator                      204-945-7473
    ALS Environmental (formerly Enviro-Test)    Manager                                    204-255-9737
    Winnipeg Regional Health Authority (WRHA)   Medical Officers of Health                 204-926-8083
    First Nations and Inuit Health              Medical Officer of Health                  204-984-8924
    Canadian Food Inspection Agency             Regional Director                          204-983-2202
    Manitoba Water Stewardship – Office of      Manager                                    204-945-5762
    Drinking Water
    City of Winnipeg – Environmental            Program Co-ordinator                       204-986-2919
    Health Services
    City of Winnipeg – Environmental                                                       204-986-2443
    Health Services (Branch Intake Line)

March 2008                                      Communicable Disease Management Protocol – Enteric Illness
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 List of Acronyms
 CDC         Communicable Disease Control
 CFIA        Canadian Food Inspection Agency
 CIDPC       Centre for Infectious Disease Prevention and Control
 CIOSC       Canadian Integrated Outbreak Surveillance Centre
 CLSN        Canadian Laboratory Surveillance Network
 CNPHI       Canadian Network for Public Health Intelligence
 CPL         Cadham Provincial Laboratory
 DWO         Drinking Water Officer
 EHO         Environmental Health Officer
 FNIHB       First Nations & Inuit Health Branch
 HACCP       Hazard Analysis Critical Control Points
 HPC         Heterotrophic Plate Count
 IAMFES      International Association of Milk, Food and Environmental Sanitarians
 MOH         Medical Officer of Health
 NESP        National Enteric Surveillance Program
 NLV         Norwalk-like virus
 NML         National Microbiology Laboratory
 NSAGI       National Studies on Acute Gastrointestinal Illness
 NV          Norovirus
 ODW         Office of Drinking Water
 PHAC        Public Health Agency of Canada
 PHI         Public Health Inspector
 PHN         Public Health Nurse
 P/T         Provincial/Territorial
 RHA         Regional Health Authority
 SRSV        Small round structured virus
 TC          Total Coliform

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    1. Introduction                                                    Enteric Illness Outbreak
                                                                       An outbreak of enteric illness is defined as the
    1.1 Purpose                                                        occurrence of case(s) in a particular area and period
    This protocol is intended to act as a resource for                 of time, which is in excess of the expected number
    enteric illness investigations by:                                 of cases.
    1) Outlining the initial control measures that                     Foodborne Illness Outbreak
       should be implemented to help contain the
       outbreak and prevent spread.                                    An incident in which two or more persons
                                                                       experience a similar illness, usually gastrointestinal,
    2) Detailing the procedures and reporting that                     after ingestion of a common food AND
       should be undertaken during an enteric illness                  epidemiological analysis implicates the food as the
       outbreak investigation.                                         source of illness as demonstrated by:
    3) Explaining the terms and calculations used to                   • isolation of agent from food in agreement with
       determine whether an environmental exposure                       laboratory criteria for confirming etiologic agent
       such as food or water is the source of the                        (Appendix 4.1); OR
                                                                       • hazard analysis indicating obvious contamination
    4) Defining the roles and responsibilities of the                    and time-temperature abuse of epidemiologically-
       personnel and organizations involved in the                       incriminated food; OR
       outbreak investigation. The investigation                       • analysis of attack rate table (Appendix 4.2).
       requires the effort of an inter-professional team
       of many individuals with different areas of                     Outbreaks may be of:
       expertise. Investigations seldom respect                        • known etiology – outbreaks in which laboratory
       jurisdictional boundaries and require the                         evidence of a specific etiologic agent is obtained
       team(s) to operate in a seamless and consistent                   and criteria in Appendix 4.1 are met.
       manner. Structure is provided for co-ordinating
       the activities of the various public health                     • unknown etiology – outbreaks in which the
       agencies that have responsibility for the                         epidemiological evidence implicates a food
       investigation, prevention and control of enteric                  source, but adequate laboratory confirmation is
       diseases in the province of Manitoba.                             not available.

    This protocol is intended as a guide only, as the                  A foodborne illness outbreak may also be indicated
    investigation procedures will vary according to the                by a single case of rare or unusual illness such as
    nature and size of the outbreak. The goal of the                   one case of botulism.
    investigation is to identify the source of the illness, so         See Appendix 4.3, Food Protection Measures in
    that potential control measures can be implemented.                Manitoba.
    While it may be difficult to detect and prove the
                                                                       Waterborne Illness Outbreak
    existence of small outbreaks (1, 2), large outbreaks
    are self-evident (1).                                              An incident in which two or more persons
                                                                       experience a similar illness, usually gastrointestinal,
    1.2 Definitions                                                    after consumption of water; OR contact with water
    Enteric Illness                                                    used for recreational purposes (e.g., swimming pools,
                                                                       lakes, hot tubs); AND epidemiological evidence
    Enteric illness, for the purposes of this protocol, is             implicates water as the source of the illness.
    defined as a gastrointestinal infection or intoxication.
    Enteric illness may be of either known (laboratory                 Characteristics common to documented
    confirmed) or unknown etiology.                                    waterborne disease outbreaks include:

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 • association with specific watershed events such as        and/or transient contamination (3, 5). In the
   heavy rainfall, failures or upsets of water               United States, it was estimated that unidentified
   treatment equipment, exceeded water treatment             agents accounted for approximately 81% of
   parameters such as turbidity, and defects in the          foodborne illnesses and hospitalizations (14).
   distribution system (3, 4);
                                                             Of reported enteric illness outbreaks in Canada
 • sudden and widespread occurrence of cases (4);            (1996–2003) having a confirmed or suspected
 • rapid increase in associated syndromic cases (4);         causative agent, 68% were viral, 27% were
                                                             bacterial, 4% were parasitic and 0.2% were due to
 • cases associated with residence in a specific water
                                                             toxin/poison or yeast/fungus (15). The most
   supply area with fewer cases found in an
                                                             commonly confirmed viral agent in these outbreaks
   adjacent supply area (4);
                                                             was norovirus (80% of viral enteric outbreaks)
 • close proximity to animal populations (3).                while the most commonly confirmed bacterial
 If an epidemiological analysis reveals these                agent was Salmonella (34% of bacterial enteric
 characteristics, the Medical Officer of Health              outbreaks) (15). Giardia was associated with 76%
 (MOH) or Communicable Disease (CD) Co-                      of confirmed parasitic enteric outbreaks (15).
 ordinator/Specialist must advise the authority              Foodborne and waterborne diseases are listed in
 having jurisdiction that a complete investigation of        Appendix 4.1; however, the list is not exhaustive.
 the drinking/recreational water is to be carried out        Appendix 4.5 contains more information on
 and reported back to the MOH.                               norovirus enteric illness.
 See Appendix 4.4, Measures Taken to Protect                 1.4 Epidemiology
 Manitoba’s Drinking Water Systems.
                                                             1.4.1 Transmission
 Non-foodborne/Non-waterborne Enteric Illness
                                                             It is difficult to categorize enteric illness by mode of
                                                             transmission (12) and the transmission route often
 Two or more cases of enteric illness related by time        goes undetermined in outbreak settings (15). Of
 and place in which an epidemiological investigation         reported enteric outbreaks in Canada for which a
 is conducted and the results do not implicate food          mode of transmission was available, 53% were
 or water as a source of the outbreak. This type of          person-to-person, 40% were foodborne and 2% were
 enteric illness outbreak is the most common and is          waterborne (15). While some bacterial pathogens
 not always categorized as the result of a formal            that cause enteric illness such as Staphylococcus aureus,
 investigation. It may be difficult to distinguish           Clostridium perfringens and Salmonella are almost
 whether an enteric illness is caused by person-to-          always associated with foodborne transmission, other
 person transmission or whether it is indicative of an       bacterial pathogens such as Shigella are more
 environmental exposure, such as food, water or              frequently transmitted person-to-person (14).
 other environmental source.                                 Parasitic outbreaks are usually associated with
                                                             waterborne or person-to-person transmission (14,
 1.3 Etiology of Enteric Illnesses                           15). In outbreaks, viruses are most often reported as
 Enteric illnesses may be caused by chemicals or             being transmitted person-to-person (15). Direct and
 biological agents and/or their toxins including             indirect transmission of enteric pathogens has been
 bacteria, viruses, protozoans, algae, fungi and             responsible for outbreaks at venues where the public
 parasites (5-9). Larger foodborne and waterborne            comes into contact with farm animals (16, 17).
 enteric illness outbreaks are more likely to have           See Appendix 4.1 for information on incubation,
 their etiology identified (3, 12, 13). The specific         principal symptoms, typical food vehicles, mode of
 etiologic agent(s) responsible is frequently not            contamination and disease prevention for specific
 identified (3, 10, 11). Identification is hindered          disease agents.
 through failure to sample, sampling difficulties

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    1.4.2 Occurrence                                               organizations. Surveillance activities and public
    Canada: Enteric diseases are widely under-reported             facility inspections are briefly described below. Food
    due to no or mild symptoms, short duration, lack               and water protection are also important and are
    of a physician visit and the absence of laboratory             detailed in Appendices 4.3 and 4.4 . Routine
    diagnosis even when attending a physician (3). As              Infection Control Practices are found in Appendix
    well, not all organisms that cause enteric disease are         4.6.
    reportable. For an eight-year period (January 1,
                                                                   2.1 Surveillance
    1996 to December 31, 2003), Canadian provinces
    and territories reported 5,854 enteric disease                 Ongoing surveillance to support early identification
    outbreaks involving 179,801 cases (15). The                    of outbreaks is an important public health function
    majority of outbreaks (55%) occurred in residential            (92) and may include:
    institutions such as personal care homes and                   • monitoring the environment for climatic events
    hospitals (15). Most outbreaks occurred between                  and natural disasters (e.g., flooding) that may
    November and March, an event driven in part by                   have an impact on water used for drinking
    viral outbreaks, particularly norovirus (15).                    and/or recreational purposes (4, 20, 21);
    Bacterial outbreaks peaked between June and
    August (15).                                                   • investigating complaints of food and water
                                                                     quality reported to a water utility (5, 21);
    Manitoba: In 2004, 48 enteric illness outbreaks                • identifying food processing deviations during
    were reported of which 67% had an undetermined                   inspection activities (22);
    etiology (19). Of the outbreaks for which a
    causative agent was identified, 14 (88%) were due              • detecting unacceptable levels of contaminants
    to small round enteric viruses, one (6%) was due to              through routine sampling in food (23, 24),
    Salmonella and one (6%) was due to Clostridium                   drinking water (25, 26) and water used for
    perfringens (19). While the small round enteric                  recreational purposes (27);
    virus category used in Manitoba would include                  • identifying and removing contaminated products
    norovirus, it is not specific for norovirus (18). Also           from the commercial market (6);
    captured in this category would be astroviruses,               • investigating consumer complaints concerning a
    parvoviruses and picornaviruses as the identification            food which may involve reports of illness (22);
    techniques used did not permit further
    differentiation (18). In 2005, 46 enteric outbreaks            • reporting of a food safety problem from external
    were reported with 46% having an undetermined                    sources (e.g., foreign health officials) (22);
    etiology (19). Of the outbreaks for which a                    • recognizing, treating and reporting cases of
    causative agent was identified, 18 (72%) were due                gastrointestinal illness in general practices and in
    to small round enteric viruses, two (8%) were due                hospitals (clinical surveillance) (20, 28);
    to Salmonella, two (8%) were due to Hepatitis A,               • documenting an increase of positive laboratory
    and there was one outbreak each (4%) of                          results indicating possible enteric/foodborne/
    Cryptosporidium, E. coli and Clostridium difficile               waterborne agents (laboratory surveillance) (28,
    (19). No transmission or source information was                  29);
    available (19).
                                                                   • monitoring over-the-counter drug sales in
                                                                     pharmacies (syndromic surveillance) (30, 31);
    2. Prevention of Enteric Illness
                                                                   • integrating information from investigations
       Outbreaks                                                     based on interviews and standardized
    Programs and activities to prevent enteric illness               questionnaires (28, 32).
    outbreaks have been developed through the                      See Manitoba Health and Healthy Living
    collaboration of many individuals and                          Communicable Disease Surveillance Protocol.

March 2008                                                   Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Surveillance data from enteric illness and outbreak         authorities in Manitoba are registered users of the
 investigations may be acquired through:                     CIOSC Public Health Alerting /Notification
                                                             application (37). CIOSC was developed by the
 • Regional Health Authorities (RHAs) in
                                                             Canadian Network for Public Health Intelligence
   Manitoba – Reportable disease cases are tracked
                                                             (CNPHI) to improve the surveillance and
   and investigated by RHA public health staff.
                                                             identification of multi-jurisdictional outbreaks,
 • Communicable Disease Control (CDC) Branch,                including enteric outbreaks (22). Enteric Alerts is
   Manitoba Health and Healthy Living – The                  a tool for posting alerts concerning confirmed or
   CDC Branch receives case reports from the RHAs            suspected enteric outbreaks under investigation
   as well as from Cadham Provincial Laboratory              that allows for public health authorities to read
   (CPL). A monthly summary of communicable                  the alerts and make contact with those responsible
   diseases is published on the CDC website at               for the investigation (22). Enteric Alerts was
   www.gov.mb.ca/health/publichealth/cdc/                    designed to detect outbreaks early through
   surveillance/index.html. Other updates and                recognition of identical cases across jurisdictions
   reports on specific reportable diseases are also          (22). Users are contacted by e-mail.
                                                             National Enteric Surveillance Program
 • National and International Enteric Disease                (NESP) – Cadham Provincial Laboratory (CPL)
   Surveillance Systems                                      participates in NESP which compiles laboratory-
   C-EnterNet is a comprehensive sentinel site               based surveillance data on enteric pathogens that
   surveillance system in Canada that will be                has been collected at regional and provincial
   implemented through local health units (34). The          levels. The information is used for detecting
   sentinel sites are localized networks enabling a co-      emergent and re-emergent pathogens, serovars,
   ordinated investigation into potential sources and        phage types, molecular types and increasing or
   reservoirs of pathogens known to have the greatest        decreasing trends of particular enteric pathogens
   potential to cause enteric disease in Canada. The         (41).
   information collected may be extended to the              PulseNet Canada – Manitoba is a participant in
   general population. Sentinel site surveillance will       PulseNet Canada through the CPL and the
   involve active sampling of people with infectious         National Microbiology Laboratory (NML) (38).
   enteric disease at specific sentinel sites as well as     As part of the Canadian Laboratory Surveillance
   water, agriculture and retail food sampling in the        Network (CLSN), PulseNet Canada was
   community to determine potential sources of               established to identify clusters of foodborne
   disease (34).                                             pathogens based on DNA fingerprints (39).
   National Studies on Acute Gastrointestinal                With large food production facilities distributing
   Illness (NSAGI) was developed by The                      products over a broader area, there has been a
   Foodborne, Waterborne and Zoonotic Infections             shift from point source outbreaks to more
   Division of the Public Health Agency of Canada            diffuse, widespread outbreaks that occur over
   (PHAC) to generate baseline period prevalence             many communities with only a few illnesses in
   rates of self-reported acute gastrointestinal illness     each community (38). Finding similar patterns
   (AGI) in communities across Canada (35). Data             through PulseNet, scientists can determine
   generated from this program indicated that for            whether an outbreak is occurring, even if the
   each case of enteric illness reported to the              affected persons are geographically far apart (38).
   province of Ontario, an estimated 313 cases of            Outbreaks and their causes can be identified in a
   infectious gastrointestinal illness occurred in the       matter of hours rather than days (38). A
   community (36).                                           memorandum of understanding (MOU) was
   Canadian Integrated Outbreak Surveillance                 signed allowing simultaneous exchange and
   Centre (CIOSC) – All of the regional health               comparison of information between PulseNet
                                                             USA and PulseNet Canada (40).

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     ProMED-mail – An informal global electronic                              Enteric Illness Investigation
     reporting system for outbreaks sponsored by the
     International Society for Infectious Diseases                                    Laboratory-based Reporting
     where clinicians and public health officials post                                    of Individual Case
     unusual occurrences of infectious diseases (33).
                                                                             1) Fill out form in Appendix 4.7.
 2.2 Public Facility Inspections                                             2) Clinical specimen sent to appropriate clinical
 Public health inspectors/environmental health
 officers (PHIs/EHOs) routinely inspect and enforce
 disease prevention measures for community
 shelters, group homes, child care centres, preschools
 and public recreational water facilities as well as
 food establishments (Appendix 4.3 Food Protection
 Measures in Manitoba). PHIs/EHOs should be
 notified immediately by Public Health whenever a
                                                                             1) Receive laboratory result.
 foodborne illness outbreak is suspected in a public                         2) If applicable, follow specific protocol (i.e., Shigella)
 facility. The medical officer of health (MOH) may                              in the Manitoba Health Communicable Disease
                                                                                Management Protocol Manual. Available at:
 seek the assistance of the PHI/EHO or public                                   www.gov.mb.ca/health/publichealth/cdc/
 health nurse (PHN) in non-foodborne cases of                                   protocol/index.html

 enteric illness in a public facility.

 3. Response to Enteric Illness
    Outbreaks (5, 8)                                                                  Epidemiologically Linked or
                                                                                   Clinical Reports of Multiple Cases
 It is the responsibility of each unit identified within
 this document to ensure staff are appropriately
 trained in the response procedures to follow in the                        1) Fill out form in Appendix 4.7 ( by PHN or PHI/EHO)
                                                                               for index case and develop customized form
 event of an enteric illness outbreak.                                         based on form in Appendix 4.8 for multiple/
                                                                               additional cases.
       Multijurisdictional Outbreak Situations
 Situation                 Lead Investigational Body
 Region-specific           Regional Health Authority
 Multiregional (i.e.,      Manitoba Health and Healthy
 Parkland, Interlake and   Living
 Winnipeg regions)
                                                                            1) Follow Sections 3.1 through 3.8 under Response
 Interprovincial           Public Health Agency of Canada                      to Enteric Illness Outbreaks.
                           (PHAC) Centre for Infectious                     2) Organizational roles and responsibilities are
                                                                               described in Section 3.9.
                           Disease Prevention and                           3) The roles and responsibilities of individual
                           Control/Canadian Food                               outbreak members are detailed in Table 1.
                           Inspection Agency (CFIA)
 Reserve and Off-Reserve   First Nations & Inuit Health
                           Branch (FNIHB)/Regional
                           Health Authority                       3.1 Detection
 International             PHAC/CFIA                              As indicated in the surveillance section above
                                                                  (Section 2.1), there are many routes through which
                                                                  an enteric illness outbreak can be detected by
                                                                  surveillance activities. In non-outbreak situations

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 there is reliance on passive disease surveillance, which    investigation will be initiated (see step 6 below,
 involves the receipt of reports of infections/disease       Plan and Conduct On-Site Investigation under
 from physicians, laboratories and other health              Outbreak Investigation Procedures, p. 13).
 professionals who are required to submit such reports
                                                             Drinking water officers and public health inspectors
 as defined by public health legislation. In outbreak
                                                             conduct risk assessments and will notify the
 situations, active disease surveillance may also be used
                                                             medical officer of health in accordance with
 to identify additional cases. Active disease surveillance
                                                             established notification protocols if a potential
 involves contacting physicians, hospitals, laboratories
                                                             public health risk is identified. The RHA’s medical
 and individuals in a community to “actively” search
                                                             officer of health (or designate), under the authority
 for cases. See Communicable Disease Surveillance in
                                                             of the Chief Provincial Public Health Officer (or
 the Manitoba Health and Healthy Living
                                                             designate) of Manitoba, has ultimate responsibility
 Communicable Disease Management Protocol Manual.
                                                             and authority over decisions made concerning the
 3.2 Reporting Requirements                                  investigation of any reportable enteric illness in the
 Prompt notification is essential for reportable diseases,
 and required under The Public Health Act Disease and        The nature of the outbreak will define the areas of
 Dead Bodies Regulation. Certain communicable                responsibility for the various disciplines involved.
 enteric illnesses (Appendix 4.1), and all identified        The investigation will require a co-ordinated team
 disease outbreaks are reportable by laboratory and          effort involving public health nurses (PHNs), public
 health professionals to the Communicable Disease            health inspectors (PHIs)/environmental health
 Control Branch, Manitoba Health and Healthy                 officers (EHOs), epidemiologists, communicable
 Living (Telephone 204-788-6736, fax 204-948-2040            disease (CD) co-ordinators, drinking water officers
 or in accordance with other accepted communication          (DWOs), medical officers of health (MOH) and
 protocols). Information is then forwarded to Public         others. The MOH will assume the lead role for
 Health authorities in the relevant region. If the RHA       assessment, management and decision-making
 is notified first, they are to report to the                during an outbreak investigation.
 Communicable Disease Control Branch, Manitoba
 Health and Healthy Living. In addition, all public          3.4 Initial Control Measures
 health events of significance should be reported to the     Initial control measures for acute care hospitals, long-
 Chief Provincial Public Health Officer (CPPHO).             term care facilities, child care centres and the home
 Protocols for specific communicable diseases can be         are found in Appendix 4.9. The control measures
 found in Manitoba Health and Healthy Living’s               found in Appendix 4.9 are guidelines that should
 Communicable Disease Management Protocol Manual             be considered in consultation with facility infection
 at www.gov.mb.ca/health/publichealth/cdc/protocol/          control and regional public health staff and in
 index.html                                                  accordance with available resources in the event of
                                                             an enteric illness outbreak. The facility Infection
 3.3 Risk Assessment                                         Prevention and Control staff would manage the
 The source of enteric illness is not always                 outbreak and bring in Public Health if needed.
 determined at a specific stage of the investigation.        Routine Practices and Contact Precautions should be
 Identifying the source of illness will help to guide        followed. Initial control measures should be reviewed
 the investigation. Non-infectious causes of                 and assessed to determine whether they are effective
 gastrointestinal symptoms such as medication                (96), and then modified if necessary. For outbreaks
 reactions should be ruled out before deciding the           where a specific organism is known or suspected,
 outbreak is due to a communicable disease.                  refer to the Manitoba Health and Healthy Living
                                                             Communicable Disease Management Protocol Manual
 If food or water is implicated (i.e., point source          available at: www.gov.mb.ca/health/publichealth/cdc/
 outbreak), a foodborne/waterborne illness                   protocol/index.html .

Communicable Disease Management Protocol – Enteric Illness                                             March 2008
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 3.5 Outbreak Investigation                                            • The association of illness with an implicated
                                                                         vector is rarely perfect for a number of reasons:
 General Points
                                                                             – the implicated item may not be
 Interviews should be conducted as soon as possible
                                                                                 contaminated throughout;
 as memories fade, people scatter and the suspect
 vectors — including food(s) or water samples —                              – host susceptibility varies;
 may be discarded and unavailable for testing or                             – the quantity consumed varies;
 worse, consumed by others.                                                  – case histories may contain reporting errors
 • In small outbreaks an effort should be made to                                through lack of recall, uncertainty or
   question all individuals who were exposed,                                    deliberate misinformation; there may also
   whether ill or not, for symptoms and history of                               be errors in recording food and water
   food and water consumption (form in Appendix                                  source history details;
   4.8 should be filled out by PHN or PHI/EHO).                              – those who report illness but have no
 • To identify the responsible agent(s), a method                                reported exposure to the incriminated
   analogous to prospective study design is                                      vector may have coincidental illness or
   commonly used (Appendix 4.2). Rates of illness                                secondary infection due to the outbreak,
   in those who consumed specific items are                                      or their illness may be due to trace
   calculated and compared with the rates of illness                             contamination of other foods by the
   in those who did not consume those items:                                     implicated foods when these were
                                                                                 prepared or served.
     Attack  Number of ill people who ate specific food                • If an outbreak is large and it is not possible to
     Rate =                                              X 100
     (%)    Total number of people who ate specific food                 interview all participants, a random sample of 25
                                                                         ill and 25 well individuals should be selected and
 • Persons with the highest exposure to implicated                       questioned for symptoms and history of
   vectors generally have the highest attack rates.                      exposures. Six to 10 stool samples from ill
 • The implicated food/water should have the                             individuals is adequate sampling for
   greatest difference between the attack rate for                       microbiologic purposes. Large outbreaks may be
   those who consumed it and the attack rate for                         investigated using a case control study design,
   those who did not consume it when compared to                         and in fact, there may be no alternative to case
   the differences in attack rates for those who                         control studies when the overall attack rate is low
   consumed and those who did not consume for                            and the exposed population is large.
   each of the other foods or water sources studied.                   Procedures
   This difference is referred to as the attributable                  The following procedures are based on the procedures
   risk, which is the rate of disease that can be                      developed by the International Association of Milk,
   attributed to the food product or water source                      Food and Environmental Sanitarians, Inc. (IAMFES)
   under consideration. For example, if 86% of                         for waterborne and foodborne illness investigations.
   people who were ill ate the meatballs and 2% of                     The procedures are presented in the sequence usually
   people who were ill did not have the meatballs,                     followed during investigations; however, depending
   and 66% of people who were ill ate the egg salad                    upon the nature and size of the outbreak, procedures
   and 50% of people who were ill did not eat the                      may be conducted simultaneously or in an alternative
   egg salad; the attributable risk for meatballs                      order. These steps are similar to those described in
   would be 84% (86% - 2%) and 16% (66% -                              the Manitoba Health and Healthy Living
   50%) for the egg salad. As the meatballs have a                     Epidemiological Investigation of Outbreaks found at:
   much higher attributable risk, they are much                        www.gov.mb.ca/health/publichealth/cdc/protocol/
   more likely to be the cause of the illness.                         investigation.pdf. See Appendix 4.10 for how to write
                                                                       the outbreak investigation report.

March 2008                                                       Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 1) Act on Notification of Illness                           4) Make Epidemiologic Associations
     •   Log all food and water-related complaints              •   Make time, place and/or person associations.
         and refer ill individuals to proper health care
                                                                •   Determine whether outbreak has occurred
         and/or other facility as necessary. It is
                                                                    according to enteric outbreak definition
         important to complete and submit
                                                                    (Section 1.2).
         information for each complaint. First
         indication of illness may be through a                 •   Formulate hypothesis based on existing
         laboratory report. For single cases, fill out              information and modify case definition as
         form in Appendix 4.7 (by PHN or                            needed.
         PHI/EHO). This form should be faxed to                 •   Based on hypothesis, if evidence is strong,
         the Manitoba Health and Healthy Living                     recommend or take precautionary control
         CDC Branch at 204-948-2040. If it has                      actions.
         been established that multiple cases of enteric
         illness originated from a single source, the           •   Submit initial outbreak report form to
         PHN or PHI/EHO should fill out the form                    Manitoba Health and Healthy Living
         in Appendix 4.8 to summarize case histories.               Communicable Disease Control Branch
                                                                    (Appendix 4.16, filled out by CD
 2) Confirm Diagnosis                                               Coordinator/Specialist or MOH delegate).
     •   Obtain case histories (Appendix 4.7,                5) Expand the Investigation
         previously filled out by public health nurse
         or PHI/EHO).                                           •   Obtain assistance if necessary from other
                                                                    organizations (i.e., if epidemiological
     •   Obtain clinical specimens (Appendices 4.11,                associations indicate imported product,
         4.12 and 4.13). As soon as an outbreak is                  CFIA and Public Health Agency of Canada
         identified or suspected in a region, regardless            should be involved).
         of who is collecting the stool specimens, the
         MOH or designate should call the Cadham                •   Find and interview additional persons at
         Provincial Laboratory (CPL) ahead of sample                risk.
         submission to obtain the outbreak code the             •   Find and interview controls. An instruction
         specimens must be labeled with. See                        sheet for interviewing purposes specifically
         Appendix 4.13. The PHI/EHO should alert                    designed for the outbreak should be prepared
         ALS Environmental (formerly Enviro-Test)                   by the MOH or designate.
         or other accredited laboratory, if appropriate.
                                                                •   Modify procedures if necessary.
     •   Obtain and transport food and water
         samples that have been collected to                 6) Plan and Conduct On-Site Investigation
         laboratory for analysis (Appendices 4.14,              (Environmental Investigation, conducted by
         4.15).                                                 PHI/EHO) (See Appendix 4.17)
 3) Develop a Case Definition                                   NOTE: There should be a water plant
                                                                inspection report if the drinking water system is
     •   See example in Appendix 4.10.                          suspected, general sanitation report if person-
     •   Start off with broad definition to detect as           to-person spread is suspected, a recreational
         many potential cases as possible.                      water inspection report or other depending on
                                                                suspected environmental exposure.
     •   Review case histories to refine case
         definitions.                                           •   Inspect equipment and observe operations
                                                                    at water source or food establishment.
     •   Consider using multiple case definitions
         (i.e., confirmed, suspected).                          •   Gather and review monitoring records.

Communicable Disease Management Protocol – Enteric Illness                                            March 2008
 Communicable Disease Management Protocol

     •   Conduct hazard analysis if applicable. The            8) Test Hypothesis Based on Results
         hazard analysis involves determining what
                                                                   •   Factors such as incubation period, type of
         specific factors contributed to the outbreak
                                                                       illness, duration of illness, population
         and may include:
                                                                       affected and contributing factors leading to
         –   checking calibration of temperature-                      contamination of food/water and the
             measuring devices;                                        proliferation or survival of organism in food/
         – measuring temperature, pH or water                          water should be consistent with the
             activity of foods;                                        suspected agent.
         – investigating locations where foods                 9) Recommend and Implement Control
             were harvested, processed, stored, etc.              Measures
     •   Identify contributing factors to the survival             Appropriate control measures may involve:
         and amplification of pathogens.
                                                                   •   informing the public;
     •   Collect original food, water or other
                                                                   •   excluding infected persons from handling
         environmental samples if not previously
                                                                       food or from attending a facility (in
         done and submit to ALS Laboratory
                                                                       consultation with Medical Officer of
         Group (See Appendix 4.14 and 4.15).
                                                                       Health, see Section 3.6 and Appendix
     •   Interview employees and collect clinical                      4.18);
         specimens if indicated (See Appendix
                                                                   •   stopping distribution, recalling and
                                                                       destroying epidemiologically implicated
     •   Trace and confirm source of                                   food;
                                                                   •   closing establishment implicated in
     •   Detain questionable and suspect food(s) and                   outbreak until problem is corrected;
         water until further information is obtained;
                                                                   •   issuing boil water advisory;
         confiscation may be necessary (6).
                                                                   •   certifying all food handlers in
     •   Provide training on safe food handling (6).
                                                                       establishment implicated in outbreak under
 7) Analyze Data from Outbreak Investigation                           the Food Handlers Certification Program
     •   Plot the epidemic curve as it helps to
         determine whether the outbreak originated             10) Prepare and Submit Written Reports (CD
         from a common source vehicle, such as                     Co-ordinator/Specialist or MOH delegate,
         water or food, or via person-to-person                    see Appendices 4.10 and 4.16)
                                                                   •   Disseminate to outbreak team members
     •   Determine the main signs and symptoms                         (6).
         of illness; summarize case histories if not
                                                                   •   Disseminate abbreviated report to the
         previously done (see Appendix 4.8).
     •   Determine responsible or suspect
                                                                   •   Use as a basis for the development of
         food/water source.
                                                                       preventive measures.
     •   Calculate attack rates (see Appendix 4.2)
                                                                   •   Staff training (6).
     •   Interpret laboratory and other results (see
                                                               See Figure A for a flow chart representation (based
         Appendix 4.10).
                                                               on the IAMFES flow charts) of the sequence of
                                                               events for a typical enteric illness investigation.

March 2008                                               Communicable Disease Management Protocol – Enteric Illness
                                                                                      Develop                                                                     Refer non-illness                No
                                                                                    surveillance                 Single                                             complaint to
                                                                                     program                     cases                                             proper agency

                                                                                    Notification    1       Refer complaint        Log                               Review log                 whether
                                                                     Illness                                 to responsible      complaint                         and other data               to make
                                                                                     of illness
                                                                                                                 person                                           for related cases           investigation

                                                                                                                                Collect food/
                                                                       No                                                       water samples
                                                                                                             Initial control    in possession                                                     Yes
                                                                                                               measures           of patient
                                                                                         4                                                                                    2
                                                                   Determine            Make                       3
                                                                                   epidemiologic                                                                     Take steps                Prepare for
                                                                   whether an                                 Develop a         Obtain clinical                       to verify
                                                                    outbreak        (time, place,                                                                                             investigation
                                                                                       person)              case definition      specimens                           diagnosis
                                                                  has occurred

                                                                                                                                   Get case                           Analyze

     Communicable Disease Management Protocol – Enteric Illness
                                                                                                                Obtain                                               samples/                                     Take
                                                                                                                                    history                                                                   control action   9
                                                                                                               assistance                                           specimens
                                                                       Yes               5
                                                                                                                Find and        Collate data, make                                    Assess disease              Test         8
                                                                                    Expand the                 interview          calculations,                                         exposure               hypotheses
                                                                                   investigation               additional         analyze data                                         relationship
                                                                    Formulate                                 cases at risk
                                                                   hypotheses                                                   Collect food, water samples and                                                  Submit        10
                                                                                                                                examine workers environment                                                      report
                                                                                                                                                                                                                                                                                                                         Communicable Disease Management Protocol

                                                                      Take                                                           Determine source of
                                                                  precautionary                                                  contamination/infection and                                                       Use
                                                                  control action                            Conduct on-site          amplification factors                                                    investigative
                                                                                                             environmental                                                                                       data for
                                                                                                              investigation       Interview owner/manager                                                      prevention
                                                                                                        6   (hazard analysis       and staff, review records
                                                                                                             of food, water
                                                                                                            treatment plant
                                                                                                            inspection, etc.)         Observe operations,
                                                                                                                                  instructions and training on
                                                                                                                                       proper procedures
                                                                                                                                                                                                                                    Figure A. Sequential events in investigating a typical outbreak of enteric illness

                                                                                                                                   Trace and confirm source
                                                                                                                                  of contamination/infection

     March 2008
 Communicable Disease Management Protocol

 3.6 Exclusion                                                    contains the employer’s name and address as well as
 At times it is necessary to exclude the food handlers/           the employee’s name, and indicates that the
 caregiver from employment to prevent potential                   individual has a gastrointestinal infection (specific
 transmission of the disease-causing organism from                disease not named) and should be excluded until a
 the employee to other individuals. Food and Food                 further letter allows the employee to return
 Handling Establishments Regulations provide                      (Appendix 4.18).
 authority to exclude food handlers and may be                    This letter is signed by the MOH under whose
 referred to for more details. It may also be necessary           authority the exclusion is enforced and sent by fax
 to exclude a child from a child care facility or                 or courier to the employer with a copy given to the
 school. See also Manitoba Health and Healthy                     client and to the PHN/PHI/EHO managing the
 Living Communicable Disease Management Protocol                  case. At times the employee may voluntarily absent
 Manual for disease or organism-specific exclusion                himself/herself from work until symptoms resolve,
 requirements.                                                    but may need such a letter to validate his/her
 Consideration of exclusion as a control strategy                 absence.
 should take into account:                                        A second letter allowing the person to return to work
 • the potential risk for serious illness to be spread to         is sent once the risk is deemed to be reduced (i.e.,
   others;                                                        laboratory tests may indicate the infection is
                                                                  resolved, or the symptoms have resolved, or the
 • the vulnerability of the specific population                   person is able to comply with good hygienic
   exposed;                                                       practices).
 • the behaviour or modification of such by the
                                                                  For reasons of a practical nature and so as not to
   infected individual.
                                                                  create unnecessary hardship, exclusion is reserved as
 The PHN will usually assess the individual’s personal            a last effort and the length of time is minimized
 hygiene practices. Alternatively, if a PHI/EHO is                according to the above criteria. If a worker is
 carrying out a food inspection, the general hygiene              excluded, Manitoba Health and Healthy Living is
 of the infected individual as well as the personal               not responsible for any economic adversities that the
 knowledge, awareness and consideration of the                    individual may experience because of this situation.
 individual’s ability to maintain good handwashing
 practices may be determined by the PHI/EHO. As                   3.7 Communication
 well, the specifics about any existing related                   3.7.1 Internal
 symptoms are reviewed in detail. If either of these
 two areas raise concerns that the potential for further          Develop and maintain regular lines of
 transmission exists, the PHN/PHI/EHO should                      communication between key investigation team
 encourage the individual to refrain from any                     members including the MOH, CDC Branch,
 activities that could spread the organism. Thus, the             PHI/EHO supervisor, PHN and PHI/EHO.
 person may work at activities other than food                    Occasional or daily teleconferences (co-ordinated
 handling with the agreement of the employer, or if               by the MOH or designate) may be indicated in
 their entire job presents some risk, the person will             more serious and complex outbreaks.
 need to be absent from work.                                     3.7.2 External
 Where this is not possible, and if the PHN/PHI/                  Develop and maintain regular lines of
 EHO feels there may continue to be a risk for the                communication with the water system or
 person to spread the infection, they may call the                establishment presumed to be the source of the
 Communicable Disease Control (CDC) Branch to                     outbreak, as well as with the affected clients. These
 review the assessment and to request that a letter of            external lines of communication are best established
 exclusion be sent to the employer. This letter                   by the “field” workers (PHNs and PHIs/EHOs and

March 2008                                                  Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 DWOs) in collaboration with the MOH, CDC                    3.8 Enteric Illness Outbreak Summary
 Branch and PHI/EHO supervisor. The                              Report
 involvement of the MOH, CDC Branch and
                                                             This report is intended to provide a framework for
 PHI/EHO supervisor in external communications
                                                             documenting the complete investigation. Once
 is especially important in more serious and complex
                                                             completed, the report will be filed in a central
 outbreaks. Communication with external partners
                                                             outbreak file. It will also be circulated within the
 should remain objective, as meticulous
                                                             department and to external agencies as appropriate.
 microbiologic sampling and carefully collected
                                                             See Appendix 4.10 for a sample report.
 epidemiologic data will usually lead to an analysis
 with clear results, obviating the need to “point the        1. What prompted the investigation? (e.g.,
 finger.” The goal of external communications                   community concerns, pathogen/infectious
 should be to rectify the source of the problem as              agent)
 soon as possible, ensure that steps are taken to
                                                             2. Dates of investigation
 prevent a future recurrence and reassure the affected
 clients that the problem has been resolved.                 3. Outbreak contact person and outbreak code
 3.7.3 Media                                                 4. Community/regions involved
 Media intervention is rarely indicated in a                 5. Facility/institution involved
 foodborne illness outbreak. However, in a more              6. Food handling establishment involved
 serious or complex outbreak, it may be appropriate
 to involve the media. When multiple stakeholders            Clinical Description
 are involved such as the CFIA, province and                 • Summary of Cases and Controls – give total
 regional health authorities, there is an option to            numbers, age and gender distribution, range of
 coordinate with all agencies before initiating a              dates and times of onset of illness
 media intervention. Some basic principles that
 should be followed when communicating to the                • Data collection tool
 public through the media include:                           • Verify the diagnosis
 • assign one media spokesperson (usually the                • Cases: description of symptoms, treatment, lab
   MOH);                                                       confirmation, infectious agent
 • be proactive rather than reactive (as much as             • Controls: number, type of symptoms (if any),
   possible, anticipate what the public/media                  laboratory testing
   need/want to know and prepare appropriate                 Epidemiologic Data
   messages in advance including a Q & A sheet);
                                                             • Date of onset of symptoms of first and last case
 • prepare daily media bulletins in collaboration              (epidemiological curve)
   with Manitoba Health and Healthy Living media
   communication services (may be posted on the              • Food history results (two-by-two tables with
   Manitoba Health and Healthy Living website);                odds ratios)
 • be accessible and approachable to the media and           • Prevalence of this organism compared to
   respect their deadlines;                                    expected incidence in the community (link with
                                                               CD surveillance personnel)
 • be honest (especially with bad news; “take the
   high road” rather than trying to cover up);               • Possible sources – suspected or confirmed,
                                                               summarize the findings of the various health
 • be knowledgeable, but not afraid to say, “I don’t           professionals and any food/water results, lab
   know” when that is the appropriate answer;                  results of food/water samples
 • be calming (especially in the midst of potential          • Association of cases with a common
   hysteria over a foodborne illness outbreak).                environmental source

Communicable Disease Management Protocol – Enteric Illness                                           March 2008
 Communicable Disease Management Protocol

 • Suspected foods, brands, places purchased,                    • First Nations & Inuit Health Branch
   preparation, handling or storage                                (FNIHB) – In split jurisdiction communities,
 • Total population at risk/exposed, total tested, total           RHA staff may be required to work closely with
   number of clinical and number of laboratory                     FNIHB staff. FNIHB may have their own
   confirmed cases                                                 protocols in place and there should be one lead
                                                                   person directing the investigation.
 Case Characteristics
                                                                 • Manitoba Conservation – Manitoba
 • Final case definition                                           Conservation maintains a 24-hour reporting line
 • Association of individual characteristics                       for environmental spills 204-945-4888. The
 • Compare these characteristics with unaffected                   Manitoba Emergency Plan identifies Manitoba
   individuals related to the outbreak                             Conservation as the lead provincial agency in
                                                                   Manitoba for dangerous goods incidents that
 Community Interventions                                           may have an impact on the environment or
 Education, immunization clinics,                                  Public Health. Manitoba Conservation and its
 chemoprophylaxis, exclusion from school or                        regional environment officers also have
 workplace, facility inspection, implementation of                 knowledge of livestock operations and
 additional infection control measures among staff,                wastewater treatment facilities such as lagoons.
 facility disinfection, closure.                                 • Manitoba Water Stewardship – Manitoba
                                                                   Water Stewardship is responsible for the long-
                                                                   term maintenance of healthy watersheds in
 • Source of outbreak (confirmed or suspect) and                   Manitoba.
   method of transmission.
                                                                 • Office of Drinking Water – The Office of
 • Recommendations for follow-up for immediate                     Drinking Water (ODW) will have a technical/
   control and future prevention (individual,                      support role to the health authority in a
   community and system recommendations).                          waterborne disease outbreak. A Drinking Water
 • Include any interagency recommendations.                        Officer (DWO) should be assigned to evaluate the
                                                                   public, semi-public or private water supply system
 3.9 Roles and Responsibilities                                    in question and report findings to the health
 Table 1 (adapted from the Winnipeg Regional                       authority. Recreational waters (pools, beaches)
 Health Authority Enteric Illness protocol) outlines               remain assigned to the PHIs.
 outbreak investigation procedures, including                    • Planning and Co-ordination Branch –
 notification and documentation, and associated                    Watershed management including source water
 roles and responsibilities of the PHN, PHI /EHO,                  protection and conservation districts.
 Epidemiologist, CD Co-ordinator/Specialist,
                                                                 • Water Science and Management Branch –
 PHI/EHO Supervisor, MOH and Communicable
                                                                   Employs water quality specialists and is
 Disease Clerk.
                                                                   responsible for groundwater, surface water and
 Other Outbreak Team Members                                       recreational beach monitoring (Manitoba Clean
                                                                   Beaches Program).
 Depending upon the location, nature and size of
 the outbreak, the following organizations in                    • Canadian Food Inspection Agency (CFIA) –
 addition to Manitoba Health and Healthy Living,                   The CFIA delivers all federal inspection and
 Cadham Provincial Laboratory, the regional health                 enforcement services related to food production
 authority and the City of Winnipeg Environmental                  and manufacturing. In addition, the CFIA
 Health Services Branch may participate in the                     inspects the seed, livestock feed, fertilizers, plants
 outbreak investigation.                                           and animals on which a safe food supply

March 2008                                                 Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

   depends. The CFIA contributes to the                      outbreaks and is responsible for public health
   investigation and control of foodborne illness            surveillance and applied epidemiological studies.
   outbreaks through its regional and nation-wide            When human illness is recorded in two or more
   food safety investigation and recall activities, as       provinces/territories (P/T), or there is exposure
   well as its regulatory compliance and                     to a common food distributed to more than one
   enforcement activities (22).                              P/T, CIDPC will co-ordinate the epidemiological
 • Public Health Agency of Canada (PHAC) –                   investigation, in collaboration with the affected
   The Centre for Infectious Disease Prevention              P/Ts (22). In an international foodborne illness
   and Control (CIDPC) is the usual first point of           outbreak, CIDPC will act as the main liaison
   contact for provinces on cross-jurisdictional             (22).
   issues related to actual or potential enteric illness

Communicable Disease Management Protocol – Enteric Illness                                        March 2008
 Communicable Disease Management Protocol

                            Table 1. Suspected/Confirmed Outbreak of an Enteric Illness
 Role           Responsibilities                                             Notification and Documentation
 Public Health Telephone Complaint:           Confirmed CD Investigation:    Telephone Complaint:           Confirmed CD Investigation:
 Nurse (PHN) 1. Complete a health             1. Inform physician of         1. Complete summary of         1. Consult with CD
                   history (Appendix 4.7)        positive lab results            case histories/epi table      Co-ordinator/
               2. Orient case histories       2. Interview client and            (Appendix 4.8)                Specialist or MOH
                   according to person,          provide education           2. Notify MOH                     to determine if
                   place and time             3. Obtain case history of      3. Notify CD                      high-risk categories
               3. Refer symptomatic              current illness                 Co-ordinator/Specialist       require exclusion
                   individuals to physician      (Appendix 4.7)              4. If food or water is            and to rule out
               4. Obtain name of event        4. Discuss etiology (cause),       suspected as a                outbreak
                   organizer or guest/           epidemiology of pathogen        transmission vehicle,      2. Notify PHI/EHO if
                   staff list                    (source, transmission,          notify PHI/EHO as             public premise is
               5. Ensure that clinical           incubation period and           soon as possible in           involved such
                   specimens are obtained        period of                       order to begin food,          as home child care,
                   to verify diagnosis           communicability) and            water or environmental        licensed child care,
               6. Participate in problem         treatment – as required         sampling requirements         restaurant
                   solving, management        5. Discuss preventive              and to see if PHI/         3. Complete all
                   and control                   measures, including safe        EHO has received              documentation as
                                                 food handling and               similar complaints            appropriate and refer
                                                 hygiene practices.          5. Document as                    completed investigation
                                                 Clients may be referred         appropriate                   to CD Co-ordinator/
                                                 to the Canadian                                               Specialist and MOH as
                                                 Partnership for                                               appropriate
                                                 Consumer Food Safety
                                                 Education website at
                                              6. Determine list of
                                                 contacts and obtain
                                                 clinical specimens
                                                 (Appendix 4.11) – as
                                              7. Determine occupation
                                                 and assess risk factors
                                                 for transmission
                                              8. Obtain follow-up
                                                 clinical specimens – as
                                              9. Refer client/contacts to
                                                 physician – as required
                                              10.Complete follow-up
                                                 teaching, referral for
                                                 counseling – as required
                                              11.Participate in additional
                                                 investigation (e.g., case
                                                 control study)

March 2008                                                     Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

                            Table 1. Suspected/Confirmed Outbreak of an Enteric Illness
 Role               Responsibilities                                                 Notification and Documentation
 Public Health      Complaint or Referral:                                           1. Complete foodborne illness complaint form
 Inspector (PHI)/   1. Receive complaints involving food services establishments        (Appendix 4.7) and submit to FBI
 Environmental      2. Interview ill person(s) for a thorough case history              Notification Registry
 Health Officer        (Appendix 4.7)                                                2. Notify and consult with EHO/PHI supervisor
 (EHO) (See also    3. Obtain information regarding:                                 3. Notify and consult with MOH/CD
 PHI/EHO               • location of event/place                                        Co-ordinator/Specialist
 Supervisor)           • event organizer                                             4. Notify and consult with PHNs
                       • guest list/staff list                                       5. Notify and consult with Office of Drinking
                       • menu (including beverages)                                     Water/DWO
                       • food sources/suppliers, other suspect items                 6. Notify CPL regarding submission of clinical
                    4. Refer to reference material for possible causative agent(s)      specimens and environmental laboratory
                    5. Obtain and transport clinical and original food/water/           regarding submission of environmental
                       environmental specimens to appropriate laboratories as           specimens; complete corresponding
                       quickly as possible (Appendix 4.11, 4.13, 4.14)                  requisitions; attach copy of case history to
                    6. Conduct HACCP based inspection (Environmental                    CPL requisitions (refer to Appendices 4.11,
                       Investigation, Appendix 4.17) of incriminated food service       4.12, 4.13, 4.14)
                       establishment, known food/water supplies and other
                       potential sources (sanitation, housing)
                    7. May determine occupation and assess risk factors for
                    8. Institute immediate prevention and control actions to
                       prevent further illness
                    9. Advise complainant and food handling operator of food
                       testing results
                    10.Participate in problem solving, management/control of
                       the outbreak
                    11.Provide enforcement of Public Health legislation.
                    12.Provide follow-up investigation and, if necessary,
                       education of food handlers.
 Communicable       1. Co-ordinate public health nursing aspects of outbreak         1. Notify MOH, team managers and EHO/
 Disease (CD)          response, including assignment of PHN case managers;             PHI supervisor and consult with Outbreak
 Co-ordinator/         act as resource for PHN regarding case management                Response Team
 Specialist         2. Carry out epidemiologic investigation                         2. Obtain outbreak code from CPL
                    3. Liaison – outbreak response team and other stakeholders       3. Complete and submit Manitoba Health
                    4. Identify and arrange for additional staff and material           Outbreak Report Form (initial assessment
                       resources (as required)                                          and final report ( Appendix 4.16)
                    5. Participate in problem solving, management/control of         4. Ensure that all aspects of case/contact
                       the outbreak                                                     management are documented appropriately
                    6. Participate in the development and implementation of          5. Maintain updated line-list
                       preventive measures                                           6. Contribute to outbreak investigation
                    7. Outbreak debriefing, staff development and training              summary report (public health nurse
                    8. Participate in outbreak report writing.                          management and response)
                    9. In the absence of this position, the MOH should either
                       assign or handle these duties.

Communicable Disease Management Protocol – Enteric Illness                                                            March 2008
 Communicable Disease Management Protocol

                             Table 1. Suspected/Confirmed Outbreak of an Enteric Illness
 Role                Responsibilities                                                   Notification and Documentation
 PHI/EHO             1. Co-ordinate environmental investigations/inspections            1. Notify MOH/CD Co-ordinator/Specialist
 Supervisor             associated with outbreak response, including assembly of           and consult with Outbreak Response Team
 NOTE: If the           environmental health case managers and team leader              2. Notify and consult with Manitoba Health and
 region does         2. Liaison – outbreak response team and other stakeholders            Healthy Living (Food Protection) and/or CFIA
 not have a          3. Identify and allocate additional staff and material resources   3. Maintain foodborne illness notification
 PHI/EHO                (as required)                                                      registry
 Supervisor, these   4. Participate in problem solving, management/control of           4. Contribute to outbreak investigation
 responsibilities       the outbreak                                                       summary report (environmental investigation/
 may be assumed      5. Participate in the development and implementation of               inspection, results and response)
 by the PHI/            preventive measures
 EHO.                6. Outbreak debriefing, staff development and training
                     7. Participate in outbreak report writing
 Epidemiologist      1. Receives outbreak notification and outbreak code from CPL 1. Notifies and consults with Outbreak
 or Delegate         2. Provides epidemiologic support and leadership to the         Response Team
                        managing region, which may include:                       2. Notifies other regions and provinces through
                        • provision of provincial stats                              CIOSC alerts as needed
                        • development of investigation forms                      3. Notifies and consults with PHAC
                        • development of outbreak database and management of
                          database entry
                        • alerting and sharing information with PHAC if national
                          implications for outbreak
                     3. Manages alerting system – creates CIOSC alert if outbreak
                        has potential to spread outside a given region or outside
                        the province
                     4. PulseNet contact (when similar strains or patterns are
                        detected in other geographical regions)
 Medical Officer     1. Outbreak response team lead role (decision-making               1. Notify and consult with Outbreak Response
 of Health              authority): confirm existence of an outbreak, establish            Team
 (MOH)                  case definition, carry out surveillance, develop or             2. Notify and consult with Manitoba Health
                        coordinate Outbreak Specific Instruction Sheet for                 and Healthy Living senior management and
                        interviewing potential cases, epidemiologic and                    Communications Services Manitoba
                        environmental investigations, risk assessments;                 3. Notify and consult with WRHA and Public
                        implement response, management and control actions,                Health Agency of Canada (as required)
                        communicate internally and externally and formulate             4. Notify and consult with other agencies: Office
                        policy recommendations.                                            of Drinking Water (Manitoba Water
                     2. Enforcement of regulations under The Public Health Act,            Stewardship), First Nations Inuit Health
                        The Drinking Water Safety Act, Environment Act as required.        Branch (FNIHB), Manitoba Conservation,
                     3. Submit report and conduct debriefing.                              CFIA
                     4. Implementation of policy recommendations
 Communicable        1. Receives and refers positive lab results and clinical case      1. Notify CD Co-ordinator/Specialist/PHN of
 Disease Control        reports to case managers                                           positive lab results or clinical case reports
 Clerk               2. Receives and disseminates outbreak documentation to team        2. Maintains central documentation file
                     3. Assists with data entry (as required)

March 2008                                                       Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.1
 List of Enteric Organisms Which May be Transmitted by Food and/or Water
 * Denotes when a single case is reportable by laboratory to the Communicable Disease Control Branch,
 Manitoba Health and Healthy Living as required under The Diseases and Dead Bodies Regulations of The
 Public Health Act. ALL outbreaks are reportable.
 + Can be found in the Manitoba Health and Healthy Living Communicable Disease Management Protocol
 Manual. Bracketed text indicates the name that the organism is listed under in the manual.
         Aeromonas hydrophila sobria
         *Bacillus cereus
         *+Campylobacter jejuni, Campylobacteriosis, (Campylobacter Infection)
         *+Clostridium botulinum (Botulism)
         *+Clostridium difficile
         *Clostridium perfringens
         *+Cryptosporidium parvum (Cryptosporidiosis)
         Cyclospora cayetanensis
         *+Entamoeba histolytica, Amebic Dysentery, (Amebiasis)
         *+Escherichia coli – verotoxin-producing (VTEC), (Verotoxigenic E. coli {VTEC} Infection)
         Escherichia coli – other than VTEC
         *+Giardia lamblia (Giardiasis)
         *+Hepatitis A virus
         *+Listeria monocytogenes (Listeriosis)
         Microsporidium spp.
         *+Salmonella species (Salmonellosis, non-Typhoid)
         *+Salmonella typhi/paratyphi (Typhoid and Paratyphoid Fever)
         *+Shigella species (Shigellosis)
         Small round structured viruses, also called Norovirus, Norwalk and Norwalk-like
         *+Staphylococcus aureus (Staphylococcal Food Intoxication)
         Streptococcus pyogenes
         *+Vibrio cholerae 01
         *+Vibrio non-cholerae 01
         *+Yersinia pseudotuberculosis/enterocolitica (Yersiniosis)
         *+Toxoplasmosis (Toxoplasma gondii)
 The following tables have been taken and adapted from the Massachusetts Department of Public Health
 Foodborne Illness Investigation and Control Manual (50) and the Rhode Island Department of Health
 Guidelines for Investigating Foodborne Illness Outbreaks (9).

Communicable Disease Management Protocol – Enteric Illness                                      March 2008
 Communicable Disease Management Protocol

                                        Common Foodborne Diseases Caused by Bacteria
 Disease                   Latency           Principal                        Typical Foods                Mode of                     Prevention of
 Causative agent           Period            Symptoms                                                      Contamination               Disease
 Bacillus cereus food      8 – 16 hours      Diarrhea, cramps,                Meat products, soups,        From soil or dust           Thorough heating and
 poisoning diarrheal       (12 – 24 hours)   occasional vomiting              sauces, vegetables                                       rapid cooling of foods
 Bacillus cereus food      1 – 5 hours       Nausea, vomiting,                Cooked rice and pasta        From soil or dust           Thorough heating and
 poisoning, emetic         (6 – 24 hours)    sometimes diarrhea                                                                        rapid cooling of foods
                                             and cramps
 Clostridium botulinum     12 – 36 hours     Fatigue, weakness, double        Types A and B: vegetables,   Types A and B: from soil    Thorough heating and
 Botulism food poisoning   (months)          vision, slurred speech,          fruits, meat, fish and       or dust                     rapid cooling of foods
 (heat-labile toxin)                         respiratory failure,             poultry products,            Type E: water and
                                             sometimes death                  condiments                   sediments
                                                                              Type E: fish and fish
 Clostridium botulinum     Unknown           Constipation, weakness,          Honey, soil                  Ingested spores from soil Do not feed honey to
 Botulism food poisoning                     respiratory failure,                                          or dust or honey colonize infants – will not
 infant infection                            sometimes death                                               intestine                 prevent all
 Campylobacter jejuni      3 – 5 days        Diarrhea, abdominal pain,        Infected food-source         Chicken, raw milk           Cook chicken
 Campylobacteriosis        (2 – 10 days)     fever, nausea, vomiting          animals                                                  thoroughly, avoid
                                                                                                                                       irradiate chickens,
                                                                                                                                       pasteurize milk
 Vibrio cholerae Cholera   2 – 3 days        Profuse, watery stools,          Raw or undercooked           Human feces in marine       Cook seafood
                           (hours to days)   sometimes vomiting,              seafood                      environment                 thoroughly; general
                                             dehydration, often fatal                                                                  sanitation
                                             if untreated
 Clostridium perfringens   8 – 22 hours      Diarrhea, cramps, rarely         Cooked meat and poultry      Soil, raw foods             Thorough heating and
 food poisoning            (12 – 24 hour)    nausea and vomiting                                                                       rapid cooling of foods
 Escherichia coli          12 – 60 hours     Watery, bloody diarrhea          Raw or undercooked           Infected cattle             Cook beef thoroughly;
 foodborne infections      (2 – 9 days)                                       beef, raw milk                                           pasteurize milk
 Escherichia coli          At least 18 hr    Cramps, diarrhea, fever,         Raw foods                    Human fecal                 Cook foods
 Foodborne infections      (uncertain)       dysentery                                                     contamination, direct, or   thoroughly,
 enteroinvasive                                                                                            via water                   general sanitation
 Escherichia coli          10 – 72 hour      Profuse watery diarrhea,         Raw foods                    Human fecal                 Cook foods
 Foodborne infection:      (3 – 5 days)      sometimes cramps,                                             contamination, direct or    thoroughly,
 enterotoxigenic                             vomiting                                                      via water                   general sanitation
 Listeria monocytogenes    3 – 70 days       Meningoencephalitis:             Raw milk, cheese and         Soil or infected animals,   Pasteurization of milk;
 Listeriosis                                 stillbirths, septicemia          vegetables                   directly or via manure      cooking
                                             meningitis in newborns
 Salmonella species        5 – 72 hours      Diarrhea, abdominal pain,        Raw and undercooked          Infected food source,       Cook eggs, meat
 Salmonellosis             (1 – 4 days)      chills, fever, vomiting,         eggs, raw milk, meat         animals, human feces        and poultry
                                             dehydration                      and poultry                                              thoroughly;
                                                                                                                                       pasteurize milk,
                                                                                                                                       irradiate chickens
 Shigella species          12 – 96 hours     Diarrhea, fever, nausea,         Raw foods                    Human fecal                 General sanitation;
 Shigellosis               (4 – 7 days)      sometimes vomiting,                                           contamination, direct or    cook foods thoroughly
                                             cramps                                                        via water
 Staphylococcus aureus     1 – 6 hours       Nausea, vomiting, diarrhea, Ham, meat and poultry             Handlers with colds, sore Thorough heating and
 Staphylococcal food       (6 – 24 hours)    cramps                      products, cream-filled            throats or infected cuts, rapid cooling of foods
 poisoning (heat stable                                                  pastries, whipped butter,         food slicers
 enterotoxin)                                                            cheese
 Streptococcus pyogenes    1 – 3 days        Various, including sore          Raw milk, deviled eggs       Handlers with sore          General sanitation,
 Streptococcal foodborne   (varies)          throat, erysipelas, scarlet                                   throats, other “strep       pasteurize milk
 infection                                   fever                                                         infections”

March 2008                                                                 Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Disease                       Latency           Principal                     Typical Foods            Mode of                       Prevention of
 Causative agent               Period            Symptoms                                               Contamination                 Disease
 Vibrio parahaemolyticus       12 – 24 hour      Diarrhea, cramps,             Fish and seafood         Marine coastal                Cook fish and seafood
 foodborne infection           (4 – 7 days)      sometimes nausea,                                      environment                   thoroughly
                                                 vomiting, fever, headache
 Vibrio vulnificus             In persons with   Chills, fever, prostration,   Raw oysters and clams    Marine coastal                Cook shellfish
 foodborne infection           high serum        often death                                            environment                   thoroughly
                               iron: 1 day
 Yersinia enterocolitica       3 – 7 days        Diarrhea, pains,              Raw or undercooked       Infected animals              Cook meats
 Yersiniosis                   (2 – 3 weeks)     mimicking appendicitis,       pork and beef, tofu      especially swine,             thoroughly,
                                                 fever, vomiting, etc.         packed in spring water   contaminated water            chlorinate water

                                              Common Foodborne Diseases Caused by Viruses
 Disease                       Latency           Principal                     Typical Foods            Mode of                       Prevention of
 Causative agent               Period            Symptoms                                               Contamination                 Disease
 Hepatitis A virus             15 – 50 days      Fever, weakness, nausea,      Raw or undercooked       Human fecal                   Cook shellfish
 Hepatitis A                   (weeks to         discomfort; often             shellfish; sandwiches,   contamination, via water      thoroughly: general
                               months)           jaundice                      salads, etc.             or direct                     sanitation
 Norwalk-like viruses          1 – 2 days        Nausea, vomiting,             Raw or undercooked       Human fecal                   Cook shellfish
 Viral gastroenteritis         (1 – 2 days)      diarrhea, pains, headache,    shellfish; sandwiches,   contamination, via water      thoroughly; general
                                                 mild fever                    salads, etc.             or direct                     sanitation
 Rotaviruses                   1 – 3 days        Diarrhea, especially in       Raw or mishandled        Probably human fecal          General sanitation
 Viral gastroenteritis         (4 – 6 days)      infants and young             foods                    contamination

 See Appendix 4.5 on Norovirus (NV) Enteric Illness
                            Common Foodborne Illnesses Caused by Fungi Other than Mushrooms
 Disease                       Latency           Principal                     Typical Foods            Mode of                       Prevention of
 Causative agent               Period            Symptoms                                               Contamination                 Disease
 Aspergillus flavus and        Varies with dose Vomiting, abdominal            Grains, peanuts, milk    Molds grow on grain and       Prevent mold growth;
 related molds)                                 pain, liver damage; liver                               peanuts in fields and         do not eat or feed
 Aflatoxicosis                                  cancer (mostly Africa                                   storage: cows fed moldy       moldy grain or
                                                and Asia)                                               grain                         peanuts; treat grain to
                                                                                                                                      destroy toxins
 Alimentary toxic aleukia      1 – 3 days        Diarrhea, nausea,             Grains                   Mold grows on grain           Harvest grain in the
 (trichothecene toxin of       (weeks to         vomiting; destruction of                               especially if left in the     fall; do not use moldy
 fusarium molds)               months)           bone marrow;                                           fields through winter         grain
                                                 sometimes death
 Ergotism (toxins of           Varies with dose Gangrene (limbs die and        Rye or wheat, barley     Fungus grows on grain         Remove sclerotia from
 Claviceps purpurea)                            drop off); or convulsions      and oats                 in the fields; grain kernel   harvested grain
                                                and dementia; abortion                                  is replaced by sclerotia
                                                (now not seen in the US)

Communicable Disease Management Protocol – Enteric Illness                                                                                  March 2008
 Communicable Disease Management Protocol

                             Common Foodborne Diseases Caused by Protozoa and Parasites
 Disease                     Latency           Principal                      Typical Foods               Mode of                     Prevention of
 Causative agent             Period            Symptoms                                                   Contamination               Disease
 Amebic dysentery            2 – 4 weeks       Dysentery, fever, chills;      Raw or mishandled           Cysts in human feces        General sanitation;
 (Entamoeba histolytica)     (varies)          sometimes liver abscess        foods                                                   thorough cooking
 Cryptosporidiosis           1 – 12 days       Diarrhea; sometimes            Mishandled foods            Oocysts in human feces      General sanitation;
 (Cryptosporidium parvum)    (1 – 30 days)     fever, nausea and                                                                      thorough cooking
 Giardiasis                  5 – 25 days       Diarrhea with greasy           Mishandled foods            Cysts in human and          General sanitation;
 (Giardia lamblia)           (varies)          stools, cramps, bloat                                      animal feces, directly or   thorough cooking
                                                                                                          via water
 Cyclosporiasis              1 – 7 days        Diarrhea; sometimes            Mishandled foods            Oocysts in human feces      General sanitation;
 (Cyclospora cayetanensis)   ( 5 – 40 days)    fever, nausea and                                                                      thorough cooking
 Toxoplasmosis               10 – 23 days      Resembles                      Raw or undercooked          Cysts in pork or            Cook meat thoroughly;
 (Toxoplasma gondii)         (varies)          mononucleosis; fetal           meats; raw milk;            mutton, rarely beef;        pasteurize milk;
                                               abnormality or death           mishandled foods            oocysts in cat feces        general sanitation

 Anisakiasis                 Hours to weeks    Abdominal cramps,              Raw or undercooked          Larvae occur naturally in   Cook fish thoroughly
 (Anisakis simplex,          (varies)          nausea, vomiting               marine fish, squid or       edible parts of seafood     or freeze at minus 4
 Pseudoterranova                                                              octopus                                                 degrees F. for 30 days
 Ascariasis                  10 days –         Sometimes pneumonitis,         Raw fruits or vegetables    Eggs in soil, from human Sanitary disposal of
 (Ascaris lumbricoides)      8 weeks           bowel obstructions             that grow in or near soil   feces                    feces, cooking food
                             (1 – 2 years)
 Trichinosis                 8 – 15 days     Muscle pain, swollen             Raw or undercooked          Larvae encysted in          Thorough cooking of
 (Trichinella spiralis)      (weeks, months) eyelids, fever;                  pork or meat of             animals muscles             meat; freezing pork for
                                             sometimes death                  carnivorous animals                                     30 days; irradiation
                                                                              (e.g., bears)

 Beef tapeworm               10 – 14 weeks     Worm segments in stool;        Raw or undercooked          Cysticerci in beef muscle   Cook beef thoroughly;
 (Taenia saginata)           (20 – 30 years)   sometimes digestive            beef                                                    freeze below 23
                                               disturbances                                                                           degrees F
 Fish tapeworm               3 – 6 weeks       Limited; sometimes             Raw or undercooked          Pleroceroids in fish        Heat fish 5 minutes at
 (Diphyllobothrium latum)    (years)           vitamin B-12 deficiency        fresh water fish            muscle                      133 degrees F or freeze
                                                                                                                                      24 hours at 0 degrees F.
 Pork tapeworm               8 weeks –         Worm segments in stool;        Raw or undercooked          Cysticerci in pork muscle; Cook pork thoroughly
 (Taenia solium)             10 years          sometimes cysticercosis        pork; any food              any food-human feces       or freeze below 23
                             (20 – 30 years)   of muscles, organs, heart      mishandled by a             with T. solium eggs        degrees F.; general
                                               or brain                       T. solium carrier                                      sanitation

March 2008                                                                 Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

                                      Foodborne Diseases Caused by Chemicals and Metals
 Disease                      Latency          Principal                     Typical Foods               Mode of                     Prevention of
 Causative agent              Period           Symptoms                                                  Contamination               Disease
 Ciguatera poisoning          3 – 4 hrs        Diarrhea, nausea,             “Reef and island” fish:     (Sporadic); food chain,     Eat only small fish
 (ciguatoxin, etc)            (rapid onset)    vomiting, abdominal           grouper, surgeon fish,      from algae
                              12 – 18 hrs      pain                          barracuda, pompano,
                              (days-months)    Numbness and tingling         snapper, etc.
                                               of face; taste and
                                               vision aberrations,
                                               sometimes convulsions,
                                               respiratory arrest and
                                               death (1 – 24 hrs)
 Fugu or pufferfish           10 – 45 min to   Nausea,vomiting, tingling     Pufferfish, “fugu” (many    Toxin collects in gonads,   Avoid pufferfish or
 poisoning                    ≥ 3 hrs          lips and tongue, ataxia,      species)                    viscera                     their gonads
 (tetrodotoxin, etc.)                          dizziness, respiratory
                                               distress/arrest and
                                               sometimes death
 Scombroid or histamine       Minutes to few   Nausea,vomiting,              “Scombroid” fish (tuna,     Bacterial action            Refrigerate fish
 poisoning (histamine, etc)   hours            diarrhea, cramps, flushing,   mackerel etc):                                          immediately when
                              (few hours)      headache, burning in          mahi-mahi, others                                       caught

 Amnesic shellfish                             Vomiting, abdominal           Mussels, clams              From algae                  Heed surveillance
 poisoning (domoic acid)                       cramps, diarrhea,                                                                     warnings
                                               disorientation, memory
                                               loss; sometimes death
 Paralytic shellfish          < 1 hr           Vomiting, diarrhea,           Mussels, clams, scallops,   From “red tide” algae       Heed surveillance
 poisoning (saxitoxin, etc)   (< 24 hrs)       paresthesias of face,         oysters                                                 warnings
                                               sensory and motor
                                               disorders; respiratory
                                               paralysis, death

 Mushroom poisoning           < 2 hrs to       Nausea, vomiting,             Poisonous mushrooms         Intrinsic                   Don’t eat wild
 (varies greatly among        ≥ 3 days         diarrhea, profuse                                                                     mushrooms
 species)                                      sweating, intense thirst,
                                               hallucinations, coma,

 Cyanide poisoning            (Large doses)    Unconsciousness,              Bitter almonds, cassava,    Intrinsic, natural          Proper processing;
 (cyanogenetic glycosides     1 – 15 minutes   convulsions, death            some lima bean varieties,                               avoid some so-called
 from plants)                                                                apricot kernels                                         foods

Communicable Disease Management Protocol – Enteric Illness                                                                                 March 2008
 Communicable Disease Management Protocol

 Disease             Latency         Principal                   Typical Foods              Mode of                     Prevention of
 Causative agent     Period          Symptoms                                               Contamination               Disease
 Cadmium             Depends on      Nausea, vomiting,           Acid foods, food grilled   Acid or heat mobilizes      Select food contact
                     dose            diarrhea, headache,         on shelves from            cadmium plating             surfaces carefully
                                     muscular aches,             refrigerator
                                     salivation, abdominal
                                     pain, shock, liver
                                     damage, renal failure
 Copper poisoning    Depends on      Nausea, vomiting,           Acid foods, foods          Acid mobilizes copper       Select food contact
                     dose            diarrhea                    contacting copper, soda                                surfaces carefully
                     (24 – 48 hrs)                               fountains, beverages
 Lead poisoning      Depends on      Metallic taste, abdominal   Glazes, glasses, illicit   Lead dissolves in           Test glazes and glasses;
                     dose            pain, vomiting, diarrhea,   whiskey                    beverages and foods         avoid illicit whiskey
                                     black stools, oliguria,
                                     collapse coma (also
                                     chronic effects)
 Mercury poisoning   Depends on      Metallic taste, thirst,     Treated seeds              International; food chain   Eat only seeds
                     dose            abdominal pain,vomiting,    (fungicide); fish                                      intended for food
                                     bloody diarrhea, kidney
 Zinc poisoning      Depends on      Nausea, vomiting,           Acid foods in galvanized   Acid mobilizes zinc         Select food contact
                     dose            diarrhea                    containers                 plating                     surfaces carefully
                     (24 – 48 hrs)

March 2008                                                   Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.2
 Attack Rate Table
                        Place of Outbreak                                                                                                Complaint Number

                                                                                                                 Difference In Percent              Significance
         Food                 Number of Persons Linked to Vector        Number of Persons Not Linked to Vector
                                                                                                                  (Attributable Risk)
                                                          Percent                                    Percent
                              ill    Well     Total   ill (Attribute)     ill     Well     Total        ill

 Remarks and Interpretation                                                                                      Suspect Vector

Communicable Disease Management Protocol – Enteric Illness                                                                                                  March 2008
 Communicable Disease Management Protocol

 Appendix 4.3                                                           •   Maximum levels of some chemical
 Food Protection Measures in Manitoba                                       contaminants in retail foods have been
                                                                            established by Health Canada and are
 Food inspection in Manitoba is a shared                                    enforceable by the CFIA (47).
 responsibility of the federal and provincial
 governments and the City of Winnipeg (23). The                         •   Bacterial guidelines for some food
 measures taken to protect the food supply in                               categories based on public health
 Manitoba are described below. Public health                                requirements pertaining to food safety and
 inspectors and environmental health officers will                          disease prevention have been established
 follow up food complaints and notify the medical                           (48). See Appendix 4.15 for
 officer of health immediately when it is believed                          Recommended Guidelines for Ready-to-
 that a foodborne illness outbreak has occurred. In                         Eat foods.
 some situations it is the medical officer of health                    •   Some large processing firms perform
 that notifies public health inspectors/environmental                       routine microbiological sampling of their
 health officers of a food complaint or potential                           food products (23).
 foodborne illness outbreak.
                                                                        •   See Manitoba’s Food and Food Handling
 1) Regulations and Guidelines                                              Establishments Regulation under The
     •   All food manufactured or sold in Canada                            Public Health Act.
         must comply with The Food and Drugs Act                    2) Inspection
         and The Consumer Packaging and Labelling
         Act (43). Factual information such as the                      •   Inspections of all food processing plants,
         ingredients must be declared on the labels of                      restaurants, institutional food services, meat
         food products (44). This information is                            processing plants, retail food stores, mobile
         particularly important for individuals with                        canteens, caterers and temporary food
         allergies (44), intolerances or restrictive diets.                 services are conducted for identification
                                                                            and remediation of unsafe food practices
     •   Food handling establishments in Manitoba                           (23, 45). Establishments are generally
         require registration and permits (45).                             inspected by the same organization that
         Depending on the jurisdiction and the type                         issued the permit or registered the
         of food involved, registration and                                 establishment.
         permitting in Manitoba may be handled by
         the Canadian Food Inspection Agency                            •   The CFIA inspects foods produced at
         (CFIA), Manitoba Agriculture Food and                              federally registered establishments within
         Rural Initiatives (MAFRI), Manitoba                                Manitoba (49). Inspections may involve
         Health and Healthy Living or the City of                           product testing activities (46). Food
         Winnipeg Environmental Health Services                             samples are collected and tested by the
         (45).                                                              CFIA for chemical, microbiological and
                                                                            physical hazards (24).
     •   All potentially hazardous food products
         sold in retail stores in Manitoba must come                    •   Imported foods are examined by the CFIA
         from an approved source (23).                                      to ensure their compliance with Canadian
                                                                            standards (24, 45).
     •   The CFIA encourages and in some cases
         (fish and seafood) legislatively mandates                      •   Bilateral arrangements with foreign
         industry’s adoption of science-based risk                          countries allow Canadian officials to
         management practices such as the Hazard                            conduct audits of foreign inspection
         Analysis Critical Control Points (HACCP)                           systems to verify that Canadian
         (46).                                                              requirements are met (46).

March 2008                                                    Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 3) Regulations Enforcement and Follow-up                    5) Partnerships and Education
     •   Where non-compliance with regulations                  •   Food safety information is provided to the
         occurs, enforcement action may include                     public by Manitoba Health and Healthy
         detentions, seizures, recalls, license                     Living and City of Winnipeg PHIs. (45).
         suspensions, canceling of registration,
                                                                •   Manitoba Health and Healthy Living co-
         injunctions, prosecutions and monetary
                                                                    ordinates food handler training programs
         penalties (46).
                                                                    in Manitoba (24). Food handler training is
     •   Following a recall, the CFIA monitors the                  mandatory within the City of Winnipeg
         actions taken by recalling firms in                        (bylaw).
         removing affected products from the
                                                                •   Many produce growers in the province use
         Canadian marketplace by conducting recall
                                                                    third-party audits to verify that they are
         effectiveness checks (46).
                                                                    following Good Agricultural Practices
     •   Other actions that may be taken after                      (GAP) (24).
         regulation violations include targeted
                                                                •   Health Canada and the CFIA have
         sampling, follow-up inspection and testing
                                                                    developed active surveillance and
         of production facilities, mandatory testing
                                                                    monitoring programs for potentially
         of subsequent shipments (import alert) and
                                                                    hazardous chemicals in foods (51).
         reviewing importing practices (46).
                                                                •   Manitoba Health and Healthy Living
     •   At the discretion of the MOH and
                                                                    partners with the Canadian Partnership for
         depending upon the type of illness and
                                                                    Consumer Food Safety Education
         level of personal hygiene, a food handler
                                                                    Information. Information on safe food
         who is ill may be excluded from work (23).
                                                                    handling practices may be obtained from
     •   The City of Winnipeg posts enforcement                     their web site at www.canfightbac.org/en/ .
         statistics for public review.
 4) Foodborne Complaint Investigations
     •   All complaints by patrons of food
         establishments are investigated by public
         health inspectors (PHIs) (23). Foodborne
         illness outbreak investigations that
         transcend more than one RHA may be
         co-ordinated by Manitoba Health and
         Healthy Living (24).
     •   If there is laboratory proof of
         contamination of a retail food product
         available for sale in Manitoba, Health
         Canada performs a health risk assessment
         that might result in the CFIA initiating a
         recall for the food item (23).
     •   Available food samples suspected of being
         involved in a foodborne illness are collected
         by the assigned PHI and submitted to the
         laboratory (ALS Laboratory Group,
         formerly Enviro-Test) for analyses (23).

Communicable Disease Management Protocol – Enteric Illness                                         March 2008
 Communicable Disease Management Protocol

 Protection of Manitoba’s Food Supply

           PHI receives food complaint                                                            Possible contamination of
     associated with retail food establishment   Annual inspection of food establishment     food product released for distribution

      Actions that may be taken                                                              Action that may be taken
      1) PHI watches food preparation                                                        1) Processing firm initiates voluntary
         to identify unsafe practices                                                           recall by notifying CFIA
      2) PHI instructs on remedial                                                              (responsible for most recalls in
         measures                                                                               province)
      3) Microbiological sampling                                                            2) For foods under federal jurisdiction,
      4) Notification of appropriate                                                            Health Canada performs health
         authority (e.g., dairy inspector                                                       risk assessment, then informs CFIA
         for stringy milk)                                                                      to do recall
      5) Notification of MOH if it is                                                        3) Laboratory proof of contamination
         believed that foodborne                                                                is required before recall is initiated;
         outbreak has occurred                                                                  less commonly, epidemiologic
                                                                                                linkages may be sufficient

                                                    Reveals elevated levels of metals,
                                                 drug residues, pesticides, food additives
                                                                                                Reveals positive or unacceptable
             Reveals suspect practices              or other chemicals (much more
                                                                                                     microbiological result
                                                   common in CFIA inspections than
                                                      in provincial PHI inspections)

      Actions that may be taken                    Actions that may be taken                 Actions that may be taken
      1) More thorough inspection                  1) Implemented direct sampling            1) Recall of affected product
         to identify unsafe practices              2) Compliance sampling                    2) Follow-up inspection and testing
      2) Instruction on remedial                   3) Animal detentions                         at production facility
         measures                                  4) On-farm follow-up inspections          3) Targeted sampling
      3) Microbiological sampling                  5) Recalls                                4) Prevention of distribution
                                                   6) Mandatory testing of all               5) Review of importing practices
                                                      subsequent shipments
                                                      (import alert)

March 2008                                                      Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.4                                                     •     Chemical standards for key health-related
 Measures Taken to Protect Manitoba’s                                   parameters including trihalomethanes for
                                                                        surface water-sourced systems, and arsenic
 Drinking Water                                                         and uranium for groundwater-sourced
 The provincial Office of Drinking Water, under the                     systems
 direction of the Minister of Water Stewardship,
                                                                  •     Corrective actions that must be undertaken
 with support and advice from Manitoba Health
                                                                        in the event that a turbidity standard or
 and Healthy Living along with the provincial
                                                                        bacteriological standard (see CHART 1) is
 medical officers of health, is responsible for the
 inspection of drinking water systems. Exceptions
 include drinking water systems under federal                     •     Application for and acquisition of a licence
 jurisdiction, such as those serving First Nations                      detailing the general and specific standards
 communities, military bases and national parks.                        for the particular water system prior to
 While private1 water systems are the responsibility                    operating a drinking water system
 of the owner, the Office of Drinking Water
                                                                  •     Periodic third-party assessments of public
 provides technical advice. Public2 water systems
                                                                        and semi-public water systems
 and smaller semi-public3 water systems are
 regulated under The Drinking Water Safety Act.                   •     Monitoring and reporting requirements,
                                                                        including disinfectant residuals, Total
 1) Regulations and Guidelines
                                                                        Coliform (TC), E.coli (EC) and turbidity
     The Drinking Water Safety Act and its                              (for surface water or groundwater under the
     supporting regulations (25, 26, 52) set out                        influence of surface water-sourced systems)
     requirements for public and semi-public water
                                                                  •     Emergency notification procedures for
     systems. Public water systems have historically
                                                                        laboratories if the results of a water sample
     been regulated under The Public Health Act.
                                                                        analysis indicate a serious health risk.
     The Drinking Water Safety Act requirements are
     being phased in for semi-public water systems           2) Inspection and Enforcement
     with the initial focus on bacteriological and                •     Drinking water officers (DWOs) conduct
     microbial safety of the water supply. Public                       regular inspections of public water systems
     water systems will have up to five years (or                       and issue inspection letters identifying
     more) to comply with the new drinking water                        deficiencies, and required and
     regulations. The regulatory requirements are                       recommended remedial actions.
     listed below.
                                                                  •     DWOs may also conduct inspections in
     •   Water treatment standards, including                           response to a water quality issue, at the
         disinfection requirements                                      request of the water system, to confirm that
     •   Bacteriological standards for total coliform                   remedial actions have been undertaken.
         and E. coli                                              •     DWOs undertake bacteriological,
     •   Microbial standards for surface water and                      disinfectant, turbidity and chemical
         groundwater under the influence of surface                     sampling as part of inspection activities.
         water systems for Cryptosporidium, Giardia
         and virus removal/inactivation                      1 Private water systems refer primarily to wells owned by private citizens
                                                               for their own domestic use.
     •   Physical standards (turbidity) for surface          2 Public water systems refer to those systems that serve cities or towns
         water and groundwater under the influence             and have 15 or more connections.
         of surface water systems                            3 Semi-public water systems have fewer than 15 connections but still
                                                               serve the public (i.e., schools, day cares, community wells and
                                                               restaurants which use their own wells).

Communicable Disease Management Protocol – Enteric Illness                                                           March 2008
 Communicable Disease Management Protocol

     •   The Office of Drinking Water works co-                   controlling excess turbidity in Manitoba drinking
         operatively with the owners and operators                water systems.
         of water systems to identify and remediate
                                                                      •   Specific turbidity standards for each
         water system component or operational
                                                                          category of filtration system employed by
                                                                          public water systems.
     •   The DWO is notified in the event of water
                                                                      •   Continuous monitoring of water turbidity
         treatment system failures or other major
                                                                          for large public systems (53).
         upsets and events (53).
                                                                      •   Periodic reporting of turbidity monitoring
     •   Where an immediate concern over the
                                                                          results to a DWO (53).
         safety of the water supply is identified, a
         boil water advisory is issued.                               •   If the turbidity standard for the specific
                                                                          filtration system employed by a public
     •   The Drinking Water Safety Act empowers
                                                                          water system is exceeded, the regional
         the Office of Drinking Water or Medical
                                                                          DWO is notified (53). The DWO may
         Officer of Health to issue a drinking water
                                                                          consult with the MOH. Resulting action is
         safety order requiring a water system owner
                                                                          dependent upon the level of excess
         to undertake actions in response to an
                                                                          turbidity, the condition of the source water
         identified or potential public health risk.
                                                                          and redundancy in the system and may
 3) Partnerships and Education                                            include a boil water advisory (53).
     •   Information is provided to owners and                    It should be emphasized that contaminant
         operators of water systems through the                   categories are not mutually exclusive; interactions
         regional DWOs and through the Office of                  occur between them (55). Turbidity caused by high
         Drinking Water website.                                  levels of organic matter can provide a substrate for
                                                                  bacterial growth (55, 57). Similarly, bacterial
     •   DWOs provide on-site assistance to water
                                                                  growth increases turbidity.
         system operators.
     •   Operator training is provided through                    Microbiological Parameters
         various agencies including Red River                     1) Disinfection
         College and the Manitoba Water and
         Wastewater Association.                                      •   Every public water supplier is required to
                                                                          use chlorine or other approved disinfection
     •   Manitoba Conservation manages the                                method(s) (25, 26).
         provincial water and wastewater operator
         certification program.                                       •   Semi-public water systems may be required
                                                                          to use a disinfection process depending
     •   A series of well water fact sheets are available                 upon individual circumstances (25, 26).
         through the Manitoba Health and Healthy
         Living website, and include procedures for                   •   Water suppliers that are required to
         testing and disinfecting private wells.                          disinfect must ensure the disinfected water
                                                                          is tested for disinfectant residuals by an
 Turbidity                                                                approved method at specified times and
                                                                          locations (25, 26).
 Turbidity itself does not represent a threat to
 human health, but MAY indicate the presence of                   2) Bacteriological
 pathogens or other biological or chemical concerns
                                                                      Measures taken to protect Manitoba drinking
 or interfere with water treatment processes such as
                                                                      water systems from bacterial contamination
 chlorine or ultraviolet light (UV) disinfection (55).
                                                                      include the following:
 The following actions are aimed at preventing and

March 2008                                                  Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

     •   Standards where every public water                       •     Specific corrective actions for public or
         supplier and semi-public water supplier                        semi-public water systems when
         must ensure that all water in the                              background4 bacteria or heterotrophic plate
         distribution system meets specific                             counts (HPC)5 are exceeded, when total
         bacteriological standards (25, 26).                            coliform (TC) standards are exceeded,
                                                                        when high6 total coliform readings or
     •   Specified sampling intervals, locations (raw
                                                                        multiple7 total coliform positive samples
         and treated samples), and number of
                                                                        are found and when E .coli is detected
         samples that are to be collected by water
         supplier (25, 26). Typically bi-weekly
         sampling is required.                                    •     Corrective actions may include retesting at
                                                                        problem sites, increasing disinfectant levels,
     •   Routine reporting requirements of water
                                                                        flushing water lines, implementing
         analysis results by the laboratory to the
                                                                        treatment process changes, boil water
         DWO (53).
                                                                        advisories and/or other actions as directed
     •   The laboratory undertaking bacteriological                     by the DWO or MOH (25).
         analysis must give immediate notification
                                                             See CHART 1 (next page) for a flow chart
         to the regional DWO/MOH where the
                                                             representation of protective measures for
         analysis indicates that the water sample
                                                             microbiological safety of drinking water systems in
         does not meet a bacteriological drinking
         water quality standard (53).
     •   Subsidized bacteriological testing of private       4 Background bacteria refer to bacterial colonies formed by
         and semi-public drinking water systems                heterotrophic bacteria, other than those sought to test the
                                                               bacteriological safety of water.
         (58). Although there is no requirement for
                                                             5 Heterotrophic plate count refers to the determination of the general
         bacteriological testing of private water              bacterial content of a water sample.
         systems, it is recommended that water               6 A high reading is where a sample has a total coliform concentration
         samples be submitted for bacterial analysis           that is > 10 coliforms per 100 ml.
         at least annually (59), with this data being        7 Multiple positive samples refers to when the number of samples taken
                                                               in a four-week period or in a month i) is 10 or more, and analyses
         used for pattern surveillance.                        show that more than 10% of the samples test positive for total
                                                               coliform, or ii) is fewer than 10, and analyses show that two or more
                                                               samples test positive for total coliform.

Communicable Disease Management Protocol – Enteric Illness                                                         March 2008
 Communicable Disease Management Protocol

                      Chart 1: Protective Measures for Microbiological Safety of Drinking Water

                             Water sampling indicates potential bacteriological concern                                 Turbidity standard exceeded

      Any sample from public or                  Any sample at any time              Any sample from a public or      1) Water utility notifies DWO
     semi-public system that is TC            from a public or semi-public             semi-public water system       2) Possible consultation with MOH
      positive but E.coli negative,                water system that is                 tested using membrane         3) Action dependent upon level
        has no high readings or                  E. coli positive or has a          filtration where background          of excess turbidity, condition
       multiple positive readings                  high total coliform               bacterial or HPC standard           of source water and
                                                  reading or multiple                  not met but TC negative,          redundancy of system, and
                                                      total coliform               E.coli negative, no high reading      may include a boil water
                                                    positive readings               or multiple positive readings        advisory

     1) Verify disinfectant residual          Water supplier immediately            1) Re-testing at positive
        and increase if necessary             notifies the DWO and takes               sampling sites
     2) Re-testing at positive sites          action as directed by DWO             2) Verify disinfectant residual
                                                or MOH such as a boil                  and increase if necessary
                                                     water advisory

      If re-testing does not meet                                                   1) Further re-testing
       TC standard but no E. coli,                                                  2) Notification of DWO if
       high readings or multiple                                                       background bacterial
          positive readings, the                                                       standard is not met but
             DWO is notified                                                           other bacteriological
                                                                                       standards are

     Further action such as:                                               Further action such as:
     1) flushing water lines,                                              1) flushing water lines,
     2) evaluation of treatment process,                                   2) evaluation of treatment process,
     3) implementation of changes and                                      3) implementation of changes and
        improvements,                                                         improvements,
     4) boil water advisory or use of other                                4) re-testing, and/or
        safe water,                                                        5) other action as directed by DWO
     5) continued re-testing until 2                                          and MOH.
        consecutive samples test negative,
     6) other action as directed by DWO
        and MOH.

March 2008                                                                     Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.5                                                The most common settings reported for NV
 Norovirus (NV) Enteric Illness                              outbreaks are catered meals (62, 63), nursing homes
                                                             and hospitals (61, 63), schools (62, 63), child care
 While it is known that hepatitis A virus, rotaviruses       centres (63), camps (63) and cruise ships (63, 87, 88).
 and certain adenoviruses are significantly associated       Outbreaks of NV have been traced to foods
 with gastrointestinal illness, noroviruses are              contaminated at the source (65) and to foods
 responsible for more than 50% of all reported               contaminated by food handlers (65, 76, 89). Almost
 enteric outbreaks in Canada (15). The majority of           any type of food that has contact with contaminated
 outbreak cases with an unidentified etiology are            water may serve as a vehicle for outbreaks of norovirus
 also now believed to be due to noroviruses (65).            gastroenteritis (68). A food handler is more likely to
                                                             be implicated in a NV outbreak than in a bacterial
 Norovirus                                                   outbreak (73). However, infected food handlers
 Noroviruses (NVs) are members of the Caliciviridae          identified during investigations may be victims rather
 family and have also been called Norwalk-like viruses       than sources of infection (90). NV outbreaks are
 (NLVs), caliciviruses and small round structured            strongly associated with eating salads, sandwiches and
 viruses (SRSVs) (66). In the past, human enteric            produce (73), suggesting that contamination of foods
 caliciviruses have been designated according to the         that require handling without subsequent heating is an
 location where each strain was detected (e.g., Hawaii,      important source of NV infection (73). Linking NV
 Snow Mountain) (65). In Manitoba, noroviruses are           outbreaks to a common source may be difficult due to
 included in the small round enteric virus category          the high secondary attack rate that results from rapid
 and cannot presently be differentiated from                 person-to-person transmission (71). NV outbreaks on
 astroviruses, parvoviruses and picornaviruses.              cruise ships are associated with multiple modes of
 Sapoviruses, previously referred to as “Sapporo-like        transmission (88), and environmental contamination
 viruses” and also members of the Caliciviridae family,      has been suggested as a mechanism that prolongs the
 are associated with gastroenteritis as well (67, 68).       course of NV outbreaks (11, 88). Prolonged viral
 Sapoviruses appear more frequently to infect young          shedding has been demonstrated in human volunteers
 children (67, 69) and have rarely been associated           challenged with norovirus (42, 91). The following
 with outbreaks of gastroenteritis (67).                     characteristics (often referred to as Kaplan’s criteria)
 Noroviruses are hardy and capable of surviving on           (54) are associated with NV outbreaks:
 many surfaces including door handles, sinks,                • incubation period of 24 to 48 hours (42, 64, 68,
 railings and glassware (70). Although NV                      76, 89);
 transmission is primarily from person-to-person             • illness of short duration (12 to 60 hours) (56,
 (71, 72), NV has been efficiently transmitted by              68, 73, 76, 89);
 food (62, 63, 73-77, 79), drinking water (63, 65,
                                                             • high percentage of patients with vomiting (56,
 67, 75, 78), recreational water (80-82) and
                                                               68, 73, 76, 89);
 contaminated environmental surfaces (71, 83). The
 major route of person-to-person transmission is             • lack of identifiable pathogens on routine
 fecal-oral (42, 68). Airborne spread has been                 examinations of stool samples (56, 68);
 suggested as an additional route of person-to-              • high secondary attack rates (61, 68, 71).
 person transmission (64, 75, 79). The low                   The characteristics of NV that facilitate spread
 infectious dose of NV permits efficient                     during epidemics are (5, 86):
 transmission (74). NV transmission occurs year
 round (63, 75, 84); however, cold weather peaks             •   low infectious dose;
 have been documented (75). NV infects individuals           •   prolonged asymptomatic shedding;
 of all ages (64, 84), but is more common among              •   environmental stability;
 older children and adults (84). Humans are the
 only known reservoir (64).                                  •   substantial strain diversity; and
                                                             •   lack of lasting immunity.
Communicable Disease Management Protocol – Enteric Illness                                             March 2008
 Communicable Disease Management Protocol

 Appendix 4.6                                                  • Gowns are used to protect uncovered skin and
 Routine Infection Control Practices in                           prevent soiling of clothing during procedures
                                                                  and patient/resident/client care activities likely to
 Health Care                                                      generate splashes or sprays of blood, body fluids,
 Routine Practices, briefly described below, are the              secretions and excretions.
 foundation for preventing transmission of                     • Masks/face protection/eye protection should be
 infections in all health care settings. Routine                  worn to protect the mucous membranes of the
 Practices refer to the level of care that should be              nose and mouth during procedures and
 provided for all patients/residents/clients. This                patient/resident/client care activities likely to
 standard of practice, as recommended by the Public               generate splashes, sprays or aerosols of blood,
 Health Agency of Canada, is required to prevent                  body fluids, secretions or excretions.
 and/or minimize transmission of micro-organisms.
 Hands shall be washed with soap and water when                • Appropriate cleaning and disinfection of
 hands are visibly soiled with blood, body fluids,                patient/resident/client care equipment and
 secretions, excretions and exudates from wounds.                 environmental surfaces is required.
                                                               For more information on specific routine practices
 • Hand hygiene for Clostridium difficile requires
                                                               for acute care, long-term care, ambulatory care and
   soap and water washing and is addressed in
                                                               home care settings see the Public Health Agency of
   Manitoba Health and Healthy Living’s
                                                               Canada document Routine Practices and Additional
   Clostridium difficile – Associated Diseases
                                                               Precautions for Preventing the Transmission of
   (CDAD) Infection Control Guidelines available
                                                               Infection in Health Care, available at:
   at: www.gov.mb.ca/health/publichealth/cdc/
   protocol/index.html .
                                                               cdr25s4e.pdf . Additional precautions are used for
 • When hands are not visibly soiled, use an                   patients/residents/clients known or suspected to be
   alcohol-based hand rub or wash with soap and                infected or colonized with certain micro-organisms.
   water.                                                      The additional precautions are based on the modes
 • Gloves are used as an additional measure and are            of transmission of these micro-organisms such as
   not a substitute for hand hygiene. Hand hygiene             airborne, droplet or contact transmission. There are
   should be performed immediately after removing              also additional precautions for antimicrobial
   gloves.                                                     resistant organisms (AROs). See Manitoba
 • Clean, non-sterile gloves of appropriate size shall         Guidelines for the Prevention and Control of
   be worn:                                                    Antibiotic Resistant Organisms (AROs) available at:
                                                               www.gov.mb.ca/health/publichealth/cdc/ipc.html .
      – whenever contact with blood, body fluids,              The Manitoba Health and Healthy Living
           secretions and excretions, mucous                   document Infection Control Guidelines for
           membranes, draining wounds or non-                  Community Shelters and Group Homes may also be
           intact skin is likely;                              accessed from this website.
      – for handling items visibly soiled with
           blood, body fluids, secretions or
      – when a health care worker has open
           lesions on his/her hands.

March 2008                                               Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.7


Communicable Disease Management Protocol – Enteric Illness   March 2008
 Communicable Disease Management Protocol


March 2008                  Communicable Disease Management Protocol – Enteric Illness
                                                                                                                          Place of Outbreak                  Dates of                                         Complaint Number
                                                                                                                                                                                                                                                                                Appendix 4.8
                                                                                                                                                                Signs and                                         Severity
                                                                         Name of ill                                       Time of  Time of                     Symptoms
                                                                          person or                                        Eating    Initial Incubation
                                                                         well person                                               Symptom      period
                                                                            (list all                                                         (difference
                                                                   No.                  Address     Phone   Sex Age Ill
                                                                          exposed                                                              between
                                                                           persons                                                              eating
                                                                          whether                                         Day Hour Day Hour and onset)
                                                                          or not ill)

                                                                                                                                                                                Abdominal cramps
                                                                                                                                                                                                                                        Physician seen

     Communicable Disease Management Protocol – Enteric Illness
                                                                                                                                                                                                                                                                                Summary of Case Histories/Epidemiological Table
                                                                                                                                                                                                                                                                                                                                  Communicable Disease Management Protocol

                                                                  Investigator                    Title                                        Median                                                         Suspected Etiology

     March 2008
 Communicable Disease Management Protocol

 Appendix 4.9                                                   • Minimize or eliminate movements of staff
 Initial Control Measures                                         between affected and unaffected wards (93-95,
                                                                  99). When this is not possible, affected wards
 Control Measures for Acute Care Hospitals                        should be visited after unaffected wards (93).
 Internal infection control policies should be                  • Exclude non-essential staff/volunteers from
 reviewed within their respective regions on a regular            affected clinical areas (93, 95).
 basis, prior to outbreak situations.                           • Emphasize the importance of handwashing
                                                                  before and after patient/environmental contact
 • Inform the infection control practitioner/ team (if
                                                                • Institute enteric precautions (in addition to
   applicable) whenever there is an outbreak of
                                                                  routine precautions) in affected areas (95, 96,
   unexplained vomiting or diarrhea among patients
   or staff on a ward (93).
 • Refer to facility outbreak policy (93).                      Visitors
 • Alert other departments and wards so that                    • Caution visitors that they may be exposed to
   surveillance is increased (93).                                infection (93).
 • Guidelines and a summary of the outbreak                     • Instruct visitors to perform hand hygiene on
   situation with regular updates should be issued                entering and leaving the facility (99).
   to all staff (96).                                           • Discourage or restrict visitors, particularly the
                                                                  young and the elderly, and those who are unwell
 Patient Control Measures
                                                                  (93, 95).
 • Isolate (93) or cohort symptomatic patients if
   possible (93, 95, 96).                                       Facility Cleaning and Disinfection
 • Confine ill patients to their rooms until 48                 Routine cleaning and disinfection, paying special
   hours after symptoms resolve (99).                           attention to bathroom and other frequently
 • Restrict communal gatherings of patients as                  touched environmental surfaces, should occur more
   much as possible (96).                                       frequently than usual (106). Routine Practices
                                                                should be followed.
 • If possible, avoid transferring patients or
   admitting new patients to affected ward (93, 94,             Vomit and Feces
   95).                                                         • Use paper towels to soak up excess liquid and
 • If possible, avoid transferring patients who have              dispose along with any solid matter into a plastic
   been exposed to an ill patient to another room                 garbage bag (93, 99).
   or area of the facility (99).                                • Clean the soiled area with detergent and hot
 Staff Control Measures                                           water using a disposable cloth (93, 99).
 • Exclude affected staff until they are symptom-               • Disinfect contaminated area with freshly
   free. Some sources recommend excluding                         prepared 1,000 ppm chlorine bleach8 solution
   affected staff until at least 48 hours post recovery           (generally a dilution of 1 part household bleach
   (93-96, 99).                                                   solution to 50 parts water) (98, 99).
 • Remind staff of the often abrupt onset of                    8 Household bleach = 5.25% hypochlorite
   vomiting and the need to leave an affected area
   rapidly if nausea arises while at work (93).

March 2008                                                Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Cleaning up Vomit in Food Preparation Areas                 NOTE: While bleach is a good disinfectant, good
 • Disinfect the food preparation area (including            air exchange is necessary to reduce occupational
   vertical surfaces) using freshly prepared 1:50            health issues associated with fumes. Alternative
   (1,000 ppm) bleach solution (93, 99).                     hospital grade disinfectant cleaners are described in
                                                             the Ontario Ministry of Health and Long-Term
 • Discard any exposed food, food that may have              Care document Best Practices for Cleaning,
   been contaminated and food that has been                  Disinfection and Sterilization in All Health Care
   handled by an infected person (93, 99).                   Settings at www.health.gov.on.ca/english/providers/
 • Use a commercial dishwasher with hot water                program/infectious/diseases/ic_cds.html .
   rinse (82°C) or chemical sanitizer rinse (99).
                                                             Control Measures for Long Term Care (LTC)
 Treatment of Specific Materials
 • Contaminated hard surfaces, such as floors,
   should be washed with detergent and hot water             LTC facilities should ensure that regular, ongoing
   using disposable cloths, and then disinfected             measures are in place to mitigate outbreaks of
   with freshly prepared 1:50 bleach solution (93,           enteric illness, including:
   99).                                                      • education to staff and residents about
 • Furniture and soft furnishings should be cleaned            gastroenteritis (105). This should include a focus
   with detergent and hot water, using a disposable            on recognizing signs and symptoms, and
   cloth (93, 99). Disinfection can be achieved by             infection control measures that can be taken.
   placing in the sun for several hours if possible,         • surveillance for enteric illness that is able to
   steam cleaning or by using bleach, if bleach                identify new cases in both residents and staff
   resistant (93, 99).                                         (101, 105).
 • Vinyl covered furnishings should be cleaned with          Resident Control Measures
   hot water and detergent, and then wiped down
                                                             • Restrict ill residents to their rooms as much as
   with a freshly prepared 1:50 bleach solution
                                                               possible until 48 hours after resolution of
                                                               symptoms (99-101, 105).
 • Contaminated linens should be handled as little
                                                             • Cohort symptomatic residents if possible (109).
   as possible, placed in laundry bags, machine
   washed with detergent and hot water at the                • If possible, postpone new admissions or transfers
   maximum cycle length and machine dried (99,                 to other-aged care facilities until outbreak is over
   106).                                                       (101, 104).
 • Contaminated carpets should be cleaned with               • Residents should not be moved from an affected
   detergent and hot water, then disinfected with              area to an unaffected area (106).
   chlorine bleach (1:50), if bleach resistant or            • In multi-bed rooms, transfer of well residents
   steam cleaned (93, 99, 107). Dry vacuuming is               into an ill resident’s room should not occur (99).
   not recommended since the infectious agents               • Keep well residents away from affected floors
   may become airborne (107).                                  and/or wings (99, 101).
 • Bathroom fixtures, door handles etc. should be            • Inform other facilities of the occurrence of the
   washed with hot water and detergent using a                 outbreak when residents who are not ill attend
   disposable cloth, then disinfected with freshly             medically necessary appointments (99).
   prepared bleach solution (1:50) (93, 99).
                                                             • Hospitalization of severely dehydrated residents
 • Non-disposable mop heads should be washed                   should not be delayed due to an outbreak of
   with detergent in hot water at the maximum                  gastroenteritis (99).
   cycle length (recommended 71°C for 25 min.),
   and then machine (hot air) dried (99).

Communicable Disease Management Protocol – Enteric Illness                                            March 2008
 Communicable Disease Management Protocol

 • Ill residents should be served meals in their room         Facility Cleaning and Disinfection
   (108, 109).                                                See Facility Cleaning and Disinfection under
 • Limit self-service in the cafeteria/dining room to         Control Measures for Acute Care Hospitals (p. 42).
   minimize food handling by residents (107, 109).
 • Consider restricting or discontinuing group                Typical Control Measures for Child Care
   activities and outings until the outbreak is               Centres and Schools
   resolved (99). Outings with family or friends do           Facility-specific protocols may be available for staff
   not need to be restricted (99).                            to follow.
 Staff Control Measures                                       Children
 • A meeting should be scheduled with staff to                • Children who become ill with nausea, vomiting
   review infection control procedures (106).                   or diarrhea should be removed from the
 • Review and reinforce hand hygiene with all staff             classroom immediately (99, 112).
   (99-101, 104, 105).                                        • Symptomatic children should be segregated
 • Exclude affected staff (care providers and food              (112) or grouped (85) and sent home as soon as
   handlers) until symptom-free. Some sources                   arrangements can be made (99, 112).
   recommend excluding affected staff until at least          • Affected children should not return to school
   48 hours after symptoms have resolved (99-102,               until symptoms resolve (85, 99, 111, 112).
                                                              • Children should be instructed to wash their
 • Staff should not work in other facilities while              hands or have a staff member wash their hands
   they are ill or convalescing (110).                          on arrival, after going to the toilet or after a
 • Instruct employees to monitor themselves for                 diaper change, and before all snacks and meals
   gastrointestinal (GI) symptoms and stop                      (111). Children should have access to liquid
   working if they feel ill (99).                               soap, running water and single-use towels (99,
 • Cohort staff if possible during the course of the            111). Staff should monitor young children to
   outbreak (99, 105).                                          ensure proper handwashing.
 • Avoid transferring staff (104).                            • Children should not prepare food or serve food
                                                                and should be discouraged from sharing food
 • Since some transmission through aerosolization               (111).
   of infectious material has been documented (95,
   97), workers may consider wearing surgical                 Staff/Caregivers
   masks when caring for residents who are                    • Daily attendance records and reasons for
   vomiting or when cleaning areas grossly                      absences should be maintained (111).
   contaminated by feces and vomit (86, 98, 99,               • Inform all parents of exposed children about the
   106, 107, 109); however, expert opinion varies.              illness, and ask parents to watch their children
 Visitor and Volunteer Control Measures                         for signs and symptoms of the disease (112).
 • Post signs to notify persons entering the building         • Staff should wash their hands on arrival, after
   of the outbreak (99, 102).                                   diaper changes, after assisting children at the
 • Instruct visitors/volunteers to perform hand                 toilet and before preparing, serving or eating
   hygiene upon entering and leaving the facility               food (112).
   (99).                                                      • Staff that prepare or serve food should not
 • Instruct visitors/family caregivers on measures to           change diapers or assist children in using the
   take to decrease the transmission of illness (99).           toilet, if possible (111).
 • Discourage ill individuals from visiting (99).

March 2008                                              Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Cleaning and Disinfection                                   • Do not share towels (99). Quickly remove and
 • Immediately wash, rinse and sanitize any object             machine wash towels, linens etc. used by sick
   or surface that has been soiled with discharge              household members (99).
   (i.e., feces) (112).                                      • Clean contaminated carpets with detergent and
 • Diaper tables, potty chairs and toilets should be           hot water and then steam clean if possible (99).
   cleaned and disinfected with a dilute bleach              • If conditions permit, place contaminated cloth-
   solution or other disinfectant used according to            covered furnishings (that cannot tolerate bleach)
   product label after each diaper change or use               outdoors in the sun for a few hours (99).
   (111, 112). If the diapering surface cannot be            • If possible, use the dishwasher “hot cycle” for all
   easily cleaned, use a disposable material such as           dishes, glasses, utensils etc. (99).
   wax paper (112).
                                                             • Symptomatic individuals should not prepare
 • Plastic toys should be disinfected each day. Cloth          food for others (107).
   toys that cannot be disinfected should be
   removed (111).                                            • Any food that has been handled by someone
                                                               who is sick with vomiting and/or diarrhea
 • Other frequently touched surfaces and play                  should be thrown out (99, 107).
   equipment should be disinfected with bleach
   according to product label. (85, 111-113).                • Food that was uncovered when someone
                                                               vomited nearby in the room should be disposed
 Control Measures in the Home                                  of (99).
 • Everyone in the family should wash their hands            • Thoroughly clean and disinfect floors, counters,
   well with soap and water (99).                              bathrooms and furniture when sickness is over
 • Having visitors while individuals in the home are           (99).
   ill should be discouraged (99).
 • Prompt clean-up and disinfection (1:50 bleach
   solution) after episodes of vomiting or diarrhea is
   essential (99, 107).

Communicable Disease Management Protocol – Enteric Illness                                            March 2008
 Communicable Disease Management Protocol

 Appendix 4.10
 Sample of Outbreak Investigation Report

 Wedding Reception
 (Enter Date)
 Reason for Investigation
 A large number of people who attended a wedding reception at the (enter location) on (enter date) reported
 becoming ill with an enteric illness. A foodborne outbreak was suspected on the basis of preliminary
 information, and an investigation was initiated.

 On (enter date) the Public Health Inspector (PHI), received a phone call from a person who had attended the
 banquet on (enter date). This individual reported that numerous attendees had become ill with gastrointestinal
 symptoms. The Communicable Disease and Immunization Co-ordinator (CDIC) and the Medical Officer of
 Health (MOH) were notified on (enter date), and the decision made to proceed with the investigation on
 (enter date). The PHI conducted an inspection of the facility and interviewed staff on (enter date).
 Public Health Nurses (PHNs) from _________________ , ____________________________ and the
 WRHA worked collaboratively to interview affected individuals and arrange for collection of clinical
 specimens. The PHI arranged for collection of food specimens from the kitchen of ___________________.
 The groom provided a list of the wedding reception attendees and the decision was made to interview as many
 of the 20 symptomatic individuals as possible, and approximately the same number of asymptomatic
 individuals. Investigation into the food and food handling was planned, and both stool and food specimens
 were to be obtained. Cadham Provincial Laboratory (CPL) was notified and an outbreak code
 assigned ( ________ ).
 Initial interviews anecdotally identified that 18 of 20 symptomatic individuals had consumed the meatballs
 and the reception attendees seemed convinced that this was the source of their illness. A questionnaire was
 developed and sent to all reception attendees to obtain data to establish the time of onset, symptoms and
 duration of illness. Food histories were obtained for both symptomatic and asymptomatic individuals. A menu
 of the buffet-style meal served at 6 pm on (enter date) was entered on a spread sheet to facilitate standardized
 interviewing. In total, completed questionnaires were obtained from 18 ill and 19 asymptomatic attendees,
 which was approximately 90% of all attendees at the function. Interview data was analyzed in EpiInfo 6.04c.
 A case-control analysis was run to identify a suspect food, as well as a descriptive analysis of the symptoms,
 duration of symptoms and incubation period.
 Stool specimens were obtained from six individuals who had been symptomatic. One stool was obtained from
 an asymptomatic individual. Most specimens were obtained within one week of the onset of illness. An
 investigation into the suspected food, and food handling procedures was conducted by the PHI.

March 2008                                           Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Cases                                                       Clinical Description
 Cases were defined as those who attended the                Age
 function and subsequently had diarrhea (two or
                                                             For all interviewees, the mean was 33.4 years and
 more loose stools in 24 hours).
                                                             median was 33.9. The range was 1.5-68.6. For
 Total # interviewed by questionnaire: 37                    females the mean age was 31.8 and the median was
                                                             33.9 with a range of 1.5-65.9. For males, the mean
 # Symptomatic and meeting case definition: 18
                                                             was 35.7 and median age was 32.1 with a range of
 # Asymptomatic: 19                                          6.4-68.6. Predominantly, the outbreak occurred in
 # Ill and having mild GI symptoms but not                   a young adult population.
 meeting case definition: 0                                  Gender
 Attack Rate: 18/37= 48.6%                                   Twenty females and 17 males were interviewed. Of
                                                             the females, 10 were ill and 10 were not ill. Of the
                                                             males, eight were ill and nine were not ill. There
                                                             was no difference in attack rates, and hence
                                                             susceptibility, between males and females.

 Symptoms                       Diarrhea   Bloody Diarrhea    Abdominal Cramps      Nausea    Vomiting     Fever
 Number ill                        18                 0                  13            6          3             1
 (% of total attendees)            (49)              (0)                 (35)         (16)       (8)            (3)
 Number ill                        18                 0                  13            6          3             1
 (% of symptomatic attendees)     (100)              (0)                 (72)         (33)       (17)       (5.5)

 Incubation and Duration of Illness
                                             Mean               Median             Minimum             Maximum
 Incubation (hrs)                             11.0                10.0                8.0                25.0
 Duration (hrs)                               24.9                11.0                6.0                 180

 NOTE: All incubation periods were within 14                 No epidemiological curve is shown as all but 1 case
 hours except one outlier at 25 hours. The one               became ill between 02:00 hrs and 07:30 hrs on
 outlier illness duration of 180 hours was in an             (enter date) and no secondary transmission was
 individual with preexisting inflammatory bowel              reported. The pattern is clearly one of a point
 disease.                                                    source exposure.
 Overall, the illness had a fairly short incubation
 period (9-10 hours) and a short duration (10-12

Communicable Disease Management Protocol – Enteric Illness                                              March 2008
 Communicable Disease Management Protocol

 Food History Results:
 Food                     People who ate the food         People who did not eat the food    OR     CI and p
                         ill      not ill      total         ill      not ill     total
 Meat balls and gravy    17         3           20            1         16         17        90.7    6.9-2810
 Cabbage rolls           12         3           15            5         16         21        12.8    2.0-586
 Chicken                 17         12          29            1          7          8         9.9    1.0-249
 Strawberries            9          2           11            9         17         26         8.5    1.2-74
 Scalloped potatoes      14         8           22            4         11         15         4.8    0.9-27
 Cubed cheeses           11         6           17            6         13         19         4.0     0.8-21
 Beverages               16         14          30            2          5          7         2.9     0.4-26
 Marshmallow salad       2          1           3            14         18         32         2.6     0.2-82
 Garlic sausage          7          4           11           11         15         26         2.4    0.5-13.3
 Bean salad              5          3           8            12         16         28         2.2     0.4-15
 Garden salad            11         9           20            7         10         17         1.8     0.4-8
 Black forest cake       7          5           12           11         14         25         1.8    0.4-9.2
 Potato salad            8          6           14           10         13         23         1.7    0.4-8.4
 Pork and beans          3          2           5            15         17         32         1.7     0.2-18
 Hot peppers             1          1           2            17         18         35         1.1     0-44
 Macaroni salad          1          1           2           116         18         34         1.1     0-46
 Salmon jelly salad      1          1           2            17         18         35         1.1     0-44
 Ham                     9          9           18            9         10         19         1.1    0.3-5.0
 Veg tray and dip        9          10          19            9          9         18         0.9    0.2-4.0

March 2008                                          Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Food                         People who ate the food        People who did not eat the food         OR       CI and p
                             ill       not ill      total       ill      not ill        total
 Mushrooms                   2           3             5        16         16            32           0.7      0.1-6.1
 Pasta salad                 4           7           11         14         12            26           0.5      0.1-2.6
 Dinner rolls                8           13          21         10          6            16           0.4      0.1-1.7
 Caesar salad                5           10          15         13          9            22          0.35      0.1-1.7

 The most suspect food was the meatballs and gravy,          #4 stool positive for Bacillus cereus in an individual
 as originally suggested by attendees, with an odds          who was not ill
 ratio of 90.7, confidence intervals well above 1, and
 p<0.001. Other foods with significantly high odds           Summary
 ratios were cabbage rolls (12.8; p=0.003), chicken          This was a point source outbreak of an enteric
 (9.9; p=0.04), and strawberries (8.5; p=0.02). Other        illness without secondary spread, likely related to
 foods with moderately elevated odds ratios such as          food ingested at a wedding reception on (enter
 scalloped potatoes and cubed cheeses did not attain         date) at the (enter location). On the basis of the
 statistical significance. The remaining foods had odds      incubation time, and duration and type of
 ratios of less than 3, and none were statistically          symptoms, the clinical picture is compatible with a
 significant. On the basis of the food analysis, the         C. perfringens foodborne illness. The food most
 most implicated food was the meatballs and gravy.           strongly implicated on the basis of the statistical
                                                             analysis was meatballs and gravy. Three stool
 Lab Results                                                 specimens yielded C. perfringens. Although other
 Food Samples (see enclosed PHI report)                      pathogens were also found in food and stool
                                                             specimens, C. perfringens is the pathogen that best
 The only food sample obtained was meatballs and             fits the scenario, and therefore it is likely the
 gravy. They yielded a positive culture for                  etiologic agent.
 Staphylococcus aureus. However, contamination of
 the sample during collection in the kitchen was the         Results of Investigation
 most likely explanation for the positive culture.           Place:     (enter location)         - wedding reception
 Clinical Samples                                            Time:       (enter date)           Buffet served at 6 pm
 Four of the seven stool specimens submitted                 Total guests: 41 attended
 yielded a positive result. The three negative stool
 results were from individuals who had been ill, but         Number of guests interviewed: 37
 were receiving antibiotics.                                 Number of guests who became ill: 18
 #1 stool positive for Clostridium perfringens               (estimated attack rate = 44% to 49%)
 > 1 million in an individual who was ill                    Symptom pattern: Of the 18 cases interviewed, 18
 #2 stool positive for Clostridium perfringens               (100%) had diarrhea, 13 (72%) had abdominal
 > 1 million in an individual who was ill                    cramps, 6 (33%) had nausea, 3 (17%) had
                                                             vomiting, 1 (5.5%) had fever, and none had bloody
 #3 stool positive for Clostridium perfringens               diarrhea. Thus the most prominent symptom was
 > 1 million in an individual who was ill                    diarrhea.

Communicable Disease Management Protocol – Enteric Illness                                                  March 2008
 Communicable Disease Management Protocol

 The average time of onset from eating at the                  Results of restaurant inspection:
 reception was 11 hrs. The average duration of                 Action taken: Inspection of the kitchen and
 illness was 11 hrs, excluding one outlier with                education of the staff occurred on the day the
 underlying inflammatory bowel disease. Everyone               Public Health Inspector was notified (enter date).
 recovered and none required hospitalization.
                                                               Implications for prevention: A similar foodborne
 Results of food inquiry analysis: The most suspect            illness outbreak also caused by C. perfringens
 food was the meatballs and gravy with an odds                 associated with ingestion of meat balls and gravy
 ratio of 90.7. Other foods with high odds ratios              occurred at a Christmas party banquet function on
 were cabbage rolls, chicken, and strawberries. The            (enter date) at the same facility. It would therefore
 remaining foods had odds ratios of less than 5, and           seem prudent that food handling practices be
 none were statistically significant. On the basis of          reviewed once again by the Public Health Inspector
 the food analysis, the most strongly implicated food          with the kitchen staff.
 was the gravy and meatballs.
 Results of food sample tests: Leftover meatballs
 and gravy were sampled. No other foods were                   Based on the information gathered, the following
 sampled. The positive culture for S. aureus was               conclusions were made:
 likely due to specimen contamination upon                     1. A foodborne illness outbreak occurred at (enter
 collection.                                                      location) on (enter date).
 Results of clinical tests on guests: Four of the              2. On the basis of available clinical, epidemiologic,
 seven stool specimens submitted yielded a positive               and laboratory data the outbreak was most
 result, three for Clostridium perfringens > 1 million            likely caused by Clostridium perfringens.
 in individuals who had been ill and one for Bacillus
 cereus in an individual who had not been ill.                 3. The food most strongly implicated on the basis
                                                                  of the analysis was meatballs and gravy.

March 2008                                               Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.11                                               4. Clean up
 Instructions for Stool Sample Collection                        Flush the rest of the stool down the toilet.
                                                                 Carefully throw the plastic bag or plastic
 NOTE: Clinical specimens should be collected                    container in the garbage. (Don’t throw away
 A.S.A.P.                                                        the sample).
 1. Things you will need                                     5. Wash your hands
     To collect the sample you will need a clean                 Use soap and warm water to wash your hands
     plastic container (e.g., an ice cream-pail or               well (for at least 30 seconds).
     margarine container) or saran wrap or a new
     (unused) plastic bag. You have been given a             6. Get the sample ready
     sample bottle to put it in, a plastic scoop to              The stool sample should always be placed into
     scoop it and a sample bottle bag. You may                   a plastic re-sealable sample bag with the
     have a form to fill out.                                    requisition on the outside, then placed into a
 2. Collect the stool (poop) sample                              paper bag. Keep the sample in the fridge. DO
                                                                 NOT LET THE SAMPLE FREEZE. Follow
     If using a plastic container:                               the instructions given for pick up or drop off of
     •   Sit on the toilet and hold the container                the sample. Make sure the patient
         under you, or sit right on the container.               information data is completed on the
                                                                 requisition form.
     If using a plastic bag or saran wrap:
     •   Lift the toilet lid and seat.                       Clearance Stool Samples
                                                             If clearance stool specimens are required and the
     •   Place the plastic bag or saran wrap over half       client is taking antibiotics, the sample should be
         of the toilet bowl and put the seat back            collected at least 48 hours after treatment has been
         down.                                               completed. If more than one clearance specimen is
     •   Sit on the toilet over the bag or saran wrap.       required, specimens must be at least 24 hours apart.
     THEN:                                                   Stool Submissions by Public Health
     Go (poop) into the clean plastic container or           Inspector
     into the bag or saran wrap over the toilet. Do          On occasion, it may be advantageous for a public
     not get any urine (pee) in it. Wipe without             health inspector to facilitate the submission of a
     putting the toilet paper into the stool (poop).         stool specimen directly to CPL as part of a
     (NEVER take a sample of stool right from                foodborne illness (FBI) investigation. The
     the toilet water!)                                      PHI/EHO will review the Stool Submission
                                                             Checklist below prior to collecting stool specimens
 3. Scoop the stool sample into the sample                   from the client.
     Use the scoop attached to the sample bottle lid
     to fill the bottle one-third (1/3) full. (Don’t
     overfill — it might spill!) Put the lid on tightly.
     Put the sample bottle into the sample bag

Communicable Disease Management Protocol – Enteric Illness                                           March 2008
 Communicable Disease Management Protocol

                                             Stool Submission Checklist
 Eligibility Criteria         •   All clients at least 16 years of age with clinical symptoms of a gastrointestinal illness
                                  consistent with FBI.
                              •   All clients under 16 years of age must have parental/legal guardian documented consent.
 Mental Status                •   The individual is able to understand the information, benefits and risks that are relevant to
                                  making a decision to be tested. If any doubts about the individual’s capacity to consent,
                                  testing should NOT be done by the PHI and the client should be referred to a physician.
 Informed Consent             •   The individual must be provided with:
                              •   explanation of the testing procedure;
                              •   implications of negative and positive results;
                              •   a plan for follow-up and sharing of results.
 Specimen Collection          •   The specimen submission slip (i.e., lab requisition) should contain:
                                  – PHI’s full name and phone number;
                                  – indication that this is a “suspect FBI”;
                                  – request for C&S, viral cultures, and EM;
                                  – appropriate facility number and
                                  – CD Coordinator/MOH phone number.
 Documentation                •   On the appropriate Client Record (i.e., Case History Form), the PHI will document:
                                  – client has provided verbal informed consent;
                                  – date of specimen collection;
                                  – follow-up plan for sharing of results (i.e., identification of who will be sharing results
                                      with the client);
                                  – risk reduction education and resources offered.
 Notification                 •   Notify the Manitoba Health CD Co-ordinator/Specialist (by fax or phone).

 NOTE: CPL will notify the physician, PHN or PHI/EHO whose name and contact information appears on
 the requisition.

 Instructions for Vomit Sample Collection
 If you have been asked to collect a vomit (throw up) sample:
      •    vomit (throw up) directly into the plastic bag provided; or
      •    vomit (throw up) into a clean plastic container and then put it into the bag provided;
 then seal the bag tightly.
 For more information call: __________________________________________

March 2008                                                Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.12
 Format for Completing Requisition Forms for CPL
 1. Fill in client’s name, address, date of birth, gender and Manitoba Health number.
 2. All requisitions are to be submitted under the CDC Branch facility number 05470.
 3. Identify the type of specimen and its source, date of onset and symptoms, type of testing required (be
    specific) and outbreak code. Be sure to note that it is a foodborne outbreak and the
    restaurant/facility/event involved.
 4. Once requisition is complete, attach lab requisition numbered sticker on each specimen container and on
    the client record.
 5. The client should fill in the “date collected” or if the specimen is dropped off, the PHN should obtain this
    information and complete the requisition before submitting the specimen.
 6. Once the specimen is obtained, arrange for appropriate delivery to the CPL.
 7. Results will be sent to the central CDC Branch to be reviewed by the CDC and forwarded to the
    appropriate PHN or PHI/EHO whose contact information appears on the requisition.


Communicable Disease Management Protocol – Enteric Illness                                         March 2008
 Communicable Disease Management Protocol

 Appendix 4.13                                                    illness, are reported electronically to the central
 Laboratory Foodborne Illness                                     office CD Clerk. Central Office will relay the
                                                                  results to the appropriate branch office (based on
 Investigation                                                    the branch code listed on the requisition).
 While Cadham Provincial Laboratory (CPL)                       • Supplies: CPL provides various supplies for the
 processes most enteric illness clinical specimens, the           collection and transportation of specimens. Each
 Westman Laboratory in Brandon receives clinical                  office can order supplies by calling 945-6123 or
 specimens from all of western Manitoba in addition               in writing.
 to some specimens from northern Manitoba.
 Specimens are sent to CPL for definitive serotyping.           Clinical Specimen Collection
 While CPL will initiate a foodborne or waterborne              • Requisition: Ensure all required information is
 illness investigation, Westman Laboratory does not.              provided on the requisition regarding the client,
 One of the authorities that Westman Laboratory                   i.e., name, date of birth, home address and
 reports to may decide to initiate an investigation.              MHSC # if available. The importance of clinical
 The Westman Laboratory reports results to the                    information cannot be overstated. This should
 primary care physician, the regional health authority            include details of immunization, treatment, date of
 and the Communicable Disease Control Branch,                     onset of illness and clinical diagnosis. Mention any
 Manitoba Health and Healthy Living. Westman                      domestic or foreign travel and countries visited.
 Laboratory handles clinical specimens only, and does             The more information sent with the specimens,
 not test water and food samples.                                 the more relevant will be the tests performed and
                                                                  the results reported. Each specimen requires a
 Guide to CPL Usage
                                                                  separate requisition. This will allow you to
 • Location: 750 William Avenue                                   distinguish between a positive result and a negative
 • Services Available: Analysis of clinical specimens             result. Where an enteric illness is possibly food-
   for the purposes of investigating an enteric                   related, indicate on requisition “Suspect
   illness. Specimens should be submitted by a                    Foodborne Illness.” Include outbreak code (when
   PHI/EHO, PHN, or physician.                                    applicable) and a copy of the FBI complaint
 • Hours of Operation: Regular hours of service                   form. Ensure facility #, central office phone # (or
   are 0830 to 1630 hrs, Monday to Friday. Most                   if a physician, give physician’s phone #), office
   sections are partially staffed on weekends and                 code and PHN or EHO/PHI initials or name are
   statutory holidays. Selected tests are available 24            included on the requisition (Appendix 4.12).
   hours a day.                                                 • Specimen Containers: All specimen containers
 • Specimen Delivery: During regular business                     must be clearly labeled with the client’s name.
   hours, specimens can be taken to the receiving                 Tear off a numbered stub from the requisition
   room. After hours, ring for the security guard                 and place onto the specimen container. A
   and place specimens in the fridge on the main                  numbered stub should also be placed on the
   floor. PHNs and PHI/EHOs whose worksite is                     interview/investigation form, and on any other
   601 Aikins Street or 385 River Avenue can have                 forms related to the investigation. Using a black
   specimens delivered to CPL via courier. The                    marker, indicate the one-third full line on the
   time of specimen pickup and where to store the                 outside of the container. Place each specimen
   specimens differs with the site. For staff working             container into a plastic bag. The correlating
   at other sites, specimens are delivered by the                 requisition should then be attached to the
   PHN or PHI/EHO.                                                outside of the plastic bag with an elastic band or
                                                                  inserted inside the pocket of the plastic bag. Do
 • Reporting Results: Positive results of reportable              not staple the requisition onto specimen bags
   diseases (see Appendix 4.1), which covers most                 (can cause injuries). Specimens that leak or are
   organisms commonly associated with foodborne                   damaged will not be processed.

March 2008                                                Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 • Stool Specimens: Sterile screw-capped container,          Bacteriology
   no more than one-third full and tightly capped. If        Specimens labeled “F1” are automatically examined
   clearance specimens are required and client is            for Staphylococcus aureus, Bacillus cereus,
   taking antibiotics, collect sample at least 48            Clostridium perfringens, Salmonella, Shigella,
   hours after treatment is completed. If more than          Yersinia, Aeromonas, Listeria monocytogenes and
   one clearance specimen is required, specimens             Campylobacter. Specimens are examined for C.
   must be at least 24 hours apart.                          perfringens only if >1.5 grams of stool are available.
 • Storage of Specimens: Take or send specimens              Specimens are only tested for vibrios if symptoms
   as soon as possible to Cadham Lab. Where                  or patient history are consistent with Vibrio
   possible, keep refrigerated until sent to lab.            infection. If S. aureus is isolated from more than
   Extreme heat or cold (freezing) can destroy some          two epidemiologically linked individuals, or if the
   organisms and give false negatives. Specimens             chief investigator feels it is warranted, S. aureus
   should not be left out of the fridge for longer than      toxin testing will also be conducted. For sporadic
   four hours. In general, when stool specimens are          FBI (F1) investigations, all stools (both liquid and
   left out and not refrigerated, other                      solid) will be assayed for verocytotoxin activity.
   microorganisms can overgrow those organisms               Specimen results will be reported as they are
   being sought. Specimens can be refrigerated for           completed, therefore, multiple reports for a single
   up to 48 hours; however, it is best to send in as         specimen may be received over a period of two to
   soon as possible for testing.                             seven days. For example, culture of some organisms
 • Contact Person: Set up one contact person                 like Salmonella may be completed within 24 to 48
   through PHI/EHO supervisor or CD Co-                      hours and will be reported at that time, while toxin
   ordinator/Specialist to communicate with CPL              testing will require longer periods of time to
   and environmental laboratory (ALS).                       complete.
 • Log Sheet: Develop a log sheet to record all data         If one of the suspect organisms is present in the
   concerning clinical specimens (i.e., name,                sample, it is reported as organism isolated (e.g.,
   specimen/food, lab requisition #, date submitted,         organism isolated — Salmonella typhimurium).
   results, epidemiological associations and other           Clostridium perfringens is reported as positive if
   pertinent information).                                   >106 organisms per gram of stool are isolated. All
                                                             other organisms would be reported as present if
 Laboratory Procedure                                        there are sufficient numbers in the specimen for
 If a sporadic case of foodborne illness (FBI) is            them to be isolated and identified. The standard
 suspected, stool samples should be sent to Cadham           negative result is: No S. aureus, Salmonella, Shigella,
 Provincial Laboratory (CPL) for FBI investigation.          Campylobacter, Aeromonas, Yersinia, B. cereus, or C.
 The requisition should be labeled FBI and F1 to             perfringens isolated. L. monocytogenes negative
 alert the laboratory technologists that an FBI              results would be reported on a separate line as
 investigation is required. Specimens labeled in this        Listeria monocytogenes not isolated. Verotoxin results
 manner are automatically examined by Bacteriology           are reported as 1) Verotoxin positive or negative or
 and Virus Detection. Stool specimens for                    2) Verotoxigenic organisms detected or not detected.
 bacteriology and virus testing should be sent in            Nurses and inspectors receiving results should note
 dry containers with NO preservatives or                     that S. aureus and C. perfringens can be normal
 transport media. The same container may be sent             flora in some individuals. Their significance in
 for both tests. If the potential FBI appears to             terms of the FBI may need to be determined in
 involve a large number of individuals and an                conjunction with the clinical symptoms present.
 outbreak is suspected, a separate special study code        Their potential significance also increases if they are
 (outbreak code) will be assigned. This code,                isolated from several linked cases or if they are
 assigned by CPL personnel, would then be used in            isolated from food samples. DNA fingerprinting
 place of the F1 code on the requisition.

Communicable Disease Management Protocol – Enteric Illness                                             March 2008
 Communicable Disease Management Protocol

 techniques (PFGE) can be used to provide more                  For hepatitis A (HAV) investigations, the diagnosis
 definitive information on whether the same strain              of acute HAV is based on the detection of IgM
 of a given bacterial species has infected several              against HAV in serum. The anti-HAV IgM is
 individuals. Please contact CPL (945-7473) to                  detected from the very onset of the symptoms and
 determine if PFGE is warranted for a given                     remains positive for approximately four months.
 outbreak.                                                      Some patients have been IgM positive for one year
                                                                after the appearance of the clinical symptoms of
 Care must be taken to indicate on the requisition
                                                                infection. Given that HAV detection requires a
 that the specimen is for an FBI (F1) investigation,
                                                                serum specimen, this test is not a routine part of an
 as culture and sensitivity for stools normally
                                                                FBI investigation. For further information on this
 includes testing only for Salmonella, Shigella,
                                                                test type please refer to the 2005 Cadham
 Yersinia, Aeromonas and Campylobacter. Note that
                                                                Provincial Laboratory Guide to Services or consult
 if an MOH or their representative feels this reduced
                                                                with the serology section of CPL.
 testing menu is sufficient (e.g., if a virus is strongly
 suspected) they may request that we conduct                    Parasitology
 routine culture and sensitivity only.
                                                                Parasite testing is not normally included in FBI
 Virology                                                       investigations unless the chief investigator feels it is
                                                                warranted. Separate stool specimens must be sent in
 All FBI specimens are tested by electron
                                                                for this diagnostic service and the requisition must
 microscopy (EM) and culture. The specimen is
                                                                specify ova and parasite (O and P) testing. Stool
 read by EM within 48 hours, Monday to Friday.
                                                                specimens for parasite testing must be sent in SAF
 This is reported as a preliminary result. The culture
 will be examined for up to 14 days if the specimen
 continues to be negative. The culture result will be           Written 1998/11/13
 a separate report. The lab is able to detect Rotavirus
                                                                Revised 2006/27/11
 and Small Round Enteric Virus (SREV) by EM
 only. Adenovirus and Enterovirus (which includes
 Coxsackievirus and Echovirus) can be detected by
 EM and/or culture. However, SREV is the virus
 indicated in most viral FBI investigations.

March 2008                                                Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.14                                                 results will be faxed or telephoned with
 Environmental Specimen Testing                                confirmations mailed later. Interpretation of ALS
                                                               results is outlined in Appendix 4.15.
 (Current contract is with ALS
 Laboratory Group, formerly Enviro-                          • Supplies: The ALS Laboratory provides various
                                                               supplies for the collection and transportation of
 Test)                                                         specimens. Each office can order supplies
 Guide to ALS Usage                                            including requisition forms by calling the
                                                               shipping department at 255-9733, or by
 • Location: Unit 12, 1329 Niakwa Road East,                   submitting a written request.
   Winnipeg, Manitoba, R2J 3T4
 • Phone Numbers: Reception: 255-9720, Micro                 Specimen Collection
   Water: 255-9724, Micro Food: 255-9753,                    In any suspected foodborne/waterborne illness
   Shipping: 255-9733, Customer Service:                     investigation, and especially if it appears to be an
   255-9740, 255-9753, 255-9755                              outbreak, obtaining samples (and specimens)
 • Services Available: Bacteriological analysis of           quickly is of the utmost importance. The most
   food, drinking water and recreational water               valuable sample is one that is left over from the
   samples for the purposes of investigating a               meal that is suspected to have caused the illness.
   waterborne or foodborne illness. These samples            • All samples should be collected by a PHI/EHO,
   must be submitted through a PHI/EHO, DWO                    DWO or PHN using standard aseptic processes.
   or PHN. Routine bacteriological analysis is also            Samples submitted by the patient/client may not
   performed on water samples from public, semi-               provide accurate results. Sterile “Whirlpak” bags
   public and private water sources.                           should be used for solid foods and liquids, and
 • Hours of Operation: Regular hours of service                sterile water collection bottles (treated with a
   are 0800 to 1630 hrs, Monday to Friday. Partial             dechlorinating agent) should be used for
   staffing on weekends ensures that all samples are           sampling chlorinated water/ice. Where possible,
   processed within 24 hours. (Note: Samples                   submit sample in its original container (i.e., it is
   received at the lab after 2 pm may not be                   not necessary to transfer bottled water to another
   processed until the following day.)                         sample bottle).
 • Sample Delivery: When food/water samples are              • Food wraps such as foil, plastic or “baggies” are
   being submitted, please call ahead to advise ALS            not an acceptable alternative to the sterile
   that samples are forthcoming (255-9724).                    Whirlpak bags. However, if the patient has a
   During regular business hours, samples can be               small amount of the suspect meal left over in a
   taken to the sample receiving counter, accessible           plastic, foil or foam container, submit the entire
   through the front entrance. After hours:                    container and its contents to the lab.
   evenings, weekends or holidays call emergency             • Samples should be submitted to the lab
   pager number 931-3145. The call will be                     immediately after collection. Where this is not
   returned within one hour and will allow access              possible, arrangements must be made to keep the
   to the lab for receipt and storage of specimens.            sample under refrigeration temperatures (5°C). If
   After-hours analysis of specimens may be                    a food or water sample is accidentally frozen,
   arranged (Surcharge: Emergency-weekend/                     consult with supervisor at ALS for instructions.
   holiday service, Rush-priority service or Legal             Transport the sample in a cooler with frozen
   Samples).                                                   icepack. To maintain temperature, the food
 • Reporting Results: Results are usually mailed to            should be secured to the icepack.
   the submitter named on the requisition form. If           • Solid Food and Ice Samples: Use sterile (or
   notification of results is urgent, then mark the            appropriately sanitized) utensils to obtain a
   appropriate box(es) on the requisition form and             minimum 250-gram sample. Record

Communicable Disease Management Protocol – Enteric Illness                                             March 2008
 Communicable Disease Management Protocol

   temperature of food using an infrared                        • Submission/Requisitions: Chain of Custody
   temperature probe or sterilized thermometer.                   submission forms/requisitions must be filled out
   Note temperature of sample, hot or cold (i.e.,                 completely. Ensure that samples are numbered
   storage conditions, whether sample was left out                and labeled clearly, and that they are consistent
   or refrigerated immediately). Do not                           with the information on the requisition. Include
   compromise the sample by opening container.                    batch numbers, lot numbers, bar codes or expiry
   Ensure the sample is transported to the lab, in a              dates whenever possible. Where applicable,
   cooler with ice, within 24 hours of sampling.                  include specimen ID numbers or food outbreak
   Upon receipt at the lab, the temperature of the                code for specimens submitted to the laboratory.
   food sample is taken using an infrared                       • “Suspect Foodborne Illness” should be clearly
   temperature probe.                                             marked on the requisition form below.
 • Liquid/Semi-liquid Foods: To subsample large                 • Legal samples must be indicated as such on the
   volumes: Thoroughly mix or stir the product                    Chain of Custody submission form. There is
   (with sterile utensil) prior to sampling to ensure a           extra documentation required and a surcharge
   homogeneous mixture. Use sterile (or                           for legal samples. A sample may be rejected as a
   appropriately sanitized) equipment to obtain a                 legal sample upon receipt if there are deficiencies
   250-mL sample. Record temperature of food                      with the sampling procedures.
   using an infrared temperature probe or sterilized
   thermometer. Note temperature of sample, hot or              Specimen Analysis
   cold (i.e., storage conditions, whether sample was           • ALS is able to analyze food and water samples
   left out or refrigerated immediately). Do not                  for the organisms listed on the attached
   compromise the sample by opening container.                    requisition form. The analysis (organism) is
   Ensure the sample is transported to the lab, in a              determined at the lab based on the following
   cooler with ice, within 24 hours of sampling.                  information: symptoms/onset of symptoms
   Upon receipt at the lab, the temperature of the                (time), type of food product, type of processing
   food is taken using an infrared temperature probe.             and the indicator organisms (total coliform),
 • Water Samples: The Water and Waste                             Staphylococcus and heterotrophic plate count
   Department routinely carries out sampling and                  (HPC) to assess cross-contamination. The
   analysis of City of Winnipeg water. Public                     PHI/EHO, DWO or PHN may indicate
   drinking water purveyors and swimming pool                     organisms on the submission form.
   operators are required to routinely submit water             • Viral testing of food and water samples is not
   for microbiological analysis. If samples from a                performed but specimens may be split with one
   faucet in a home or place of business are                      part being sent to the National Microbiology
   required, call the water quality complaints line at            Laboratory if a viral agent is suspected. The
   986-4683. A laboratory technician will respond                 sample should be split in the lab using aseptic
   as necessary. If the PHI/EHO, DWO or PHN                       technique. Note: It is important to obtain a
   must obtain water samples, remove the aerator                  uniform sample from solid food.
   screen from the tap, then wash the tap with a
   strong disinfectant solution (as per Info Sheet on           • Specimens may be analyzed for parasites such as
   Well Water from the Office of the Chief Medical                Cryptosporidium parvum if requested (i.e., if
   Officer of Health, MB Health, March 2001).                     outbreak is associated with a swimming pool). A
   Flush for three to five minutes with fast-running              10L sample of water is required for
   cold water prior to collecting the sample. For                 Cryptosporidium/Giardia analysis (preservative
   well water samples, by-pass the water softener.                not required). A collapsible jug is available from
   Multiple samples may be necessary depending                    the lab.
   on the tests required; consult with ALS prior to

March 2008                                                Communicable Disease Management Protocol – Enteric Illness
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Communicable Disease Management Protocol – Enteric Illness   March 2008
 Communicable Disease Management Protocol

 Appendix 4.15                                                  Coagulase Positive Staph
 Explanation of ALS Laboratory Group                            Certain staphylococci produce enterotoxins that
 Bacteriological Results and                                    cause food poisoning. Coagulase positive
 Recommended Guidelines (City of                                staphylococci are considered to be strains of
 Winnipeg) for Ready-to-Eat Foods                               Staphylococcus aureus, many of which are capable of
                                                                causing food poisoning. The presence of S. aureus
 S.P.C. – Standard Plate Count                                  in a processed food usually indicates contamination
                                                                from the mouth, nose, or skin infections of workers
 High counts may indicate contaminated raw                      handling food, or from inadequately cleaned
 materials, unsatisfactory sanitation methods, post-            equipment. Large numbers of staphylococci are an
 process cross-contamination or improper                        indication of inadequate sanitation or temperature
 time/temperature conditions during production,                 control. The recommended GUIDELINE for
 storage or transportation (temperature abuse).                 coagulase-positive staphylococci in ready to eat
 PLATE COUNT for ready to eat food items                        foods is 150 CFU per gram or less.
 should be 300,000 CFU per gram or less.
                                                                All Salmonella species are considered to be potential
 The presence of coliforms indicates exposure to                pathogens of humans. Therefore, the GUIDELINE
 conditions that might introduce or allow                       for ready to eat food is that Salmonella must not be
 proliferation of pathogenic (harmful) species.                 detected in a sample of 25 grams of food.
 Therefore, coliforms are used as ‘indicator
 organisms’ as an index of sanitation. In a processed           Listeria monocytogenes
 food, coliforms indicate inadequate processing or              No tolerance exists for this organism although
 post processing contamination, sources of which                several other species of Listeria (not considered
 may be workers, dirty equipment and surfaces, or               pathogenic for humans) are prevalent at
 raw food before processing. GUIDELINE for                      refrigeration temperatures.
 coliforms in ready to eat foods is 100 CFU per
 gram or less.                                                  NOTE: More information on standards and
                                                                guidelines for the microbial safety of food may be
 E. coli                                                        obtained from the Food Directorate’s (Health
 The native habitat for E. coli is the intestinal tract         Canada’s) web site at: www.hc-sc.gc.ca/ahc-
 of humans and other warm blooded animals. The                  asc/branch-dirgen/hpfb-dgpsa/fd-da/index_e.html
 presence of E. coli is an indicator of fecal
 contamination in most foods; therefore, the
 bacteriological GUIDELINE in ready to eat foods
 is 0 CFU per gram.

March 2008                                                Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Food Bacterial Guidelines
 The guidelines are based on public health requirements pertaining to food safety and disease prevention and
 on results that have been researched and shown can be achieved by industry.

 “Ready to Eat” Foods                                        Yogurt
 (sandwiches, salads, cold cuts etc. but excluding           Coliforms                              <10/g/ml
 cultured or fermented products)
                                                             Milk Products or “Ready to Eat”
 STD Plate Count (SPC)                      <300,000/g
                                                             Listeria monocytogenes                    0/g
 Coliforms                                    <100/g
                                                             Shigella                                  0/g
 Yeasts                                       <100/g
                                                             Bacillus cereus                          100/g
 Coagulase-positive Staph.                    <150/g
                                                             All Food Products (except raw meat)
 Clostridium perfringens                      <100/g
                                                             E. coli                                   0/g
 Salmonella                                   0/25g
                                                             Raw Ground Beef
 E. coli                                       0/g
                                                             STD Plate Count (SPC)                 10,000,000/g
 Campylobacter jejuni                         0/25g
                                                             Total coliform                          1000/g
 S. faecalis                                  <10/g
                                                             E. coli                                  500/g
 Moulds                                       <10/g
                                                             S. aureus                               1000/g
 Milk Products (excluding fluid milk)
                                                             Salmonella                               0/25g
 STD Plate Count (SPC)                     <50,000/g/ml
 Coliforms                                   <10/g/ml
 Soft Ice Cream
 STD Plate Count (SPC)                     <50,000/g/ml
 Coliforms                                   <10/g/ml

Communicable Disease Management Protocol – Enteric Illness                                         March 2008
 Communicable Disease Management Protocol

 Appendix 4.16


March 2008                  Communicable Disease Management Protocol – Enteric Illness
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Communicable Disease Management Protocol – Enteric Illness   March 2008
 Communicable Disease Management Protocol

 Appendix 4.17
 Foodborne Illness Premises Inspection Report

 A. Establishment: Name_______________________________ Type __________________________
                      Address _____________________________ Phone No. ______________________
                      Contact Person _______________________ Position ________________________
 B. General Sanitation of Establishmant (Critical Control Points)
 C. Suspected Food:
     1. Obtain menu and ingredients (if applicable) _____________________________________________
     2. Source__________________________________________________________________________
     3. Handling and preparation procedures __________________________________________________

     4. Preparation date __________________________________________________________________

     5. Consumption date ________________________________________________________________

     6. Food temperature recording a) Cooking: (final temp.) ____________________________________
                                    b) Cooling: Method __________________         Time ______________
                                    c) Storage: Method ___________________        Time ______________
                                    d) Reheating: Method _________________        Time ______________
                                    e) Display: Method ___________________        Time ______________
     7. Infestation ______________________________________________________________________
     8. Storage of toxic items ______________________________________________________________
     9. Food additives ___________________________________________________________________
 D. Equipment:
     1. Refrigeration facilities ______________________________________________________________
     2. Utensils_________________________________________________________________________
     3. Work tables (cutting boards, etc.) _____________________________________________________
     4. Hot holding facilities ______________________________________________________________
     5. Dishwashing ________________________         Temperature _________       Chemical ____________

March 2008                                        Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 E. Personnel Involved in Food Preparation:
         Name                        Address                           Illness             Hygiene
                                                                    (Yes or No)         (Good or Poor)
     1. _______________________________________________________________________________
     2. _______________________________________________________________________________
     3. _______________________________________________________________________________
     4. _______________________________________________________________________________
 F. Observations and Comments:
 G. Conclusion:
 H. Attachments::        F.B.I. Report ■       Lab. Analysis Form ■      Specimen Report ■



Communicable Disease Management Protocol – Enteric Illness                                   March 2008
 Communicable Disease Management Protocol

 Appendix 4.18
 Sample Letter of Exclusion

 Name and Address of Employer

 Dear Sir/Madam:

 Re: Client’s Name, Date of Birth, Address
 Please be advised that the above named employee has been identified as having an infection that can be
 transmitted by food. Since he/she is involved in the handling of food, this individual must be excluded from
 the workplace until the signs of illness have resolved and he/she has been tested with results documenting that
 he/she is clear of the infection.
 You will be notified at once when he/she is permitted to resume his/her duties.

 Medical Officer of Health

March 2008                                           Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

 Appendix 4.19
 Foodborne/Waterborne Illness Investigation Checklist

     ■ Complete Case History (Appendix 4.7, 4.8 as appropriate)
     ■ Notify MOH
     ■ Notify supervisor
     ■ Notify Food Protection, Public Health Division, Manitoba Health and Healthy Living/Drinking
       Water Office, Water Stewardship/Manitoba Conservation as appropriate
     ■ Notify Cadham Provincial Laboratory
     ■ Notify Environmental Laboratory
     ■ Notify DWO or PHI/PHN as appropriate
     ■ Secure guest lists/menu information
     ■ Collect food/water samples and arrange delivery to Environmental Laboratory
     ■ Arrange clinical specimen/record requisition number
     ■ Arrange clinical sample/specimen delivery to CPL with completed Case History Form
     ■ Determine Investigation Expansion
     ■ Develop Case Definition
     ■ Instruction Sheet for interviewing prepared
     ■ Preventative Health Education
     ■ Interview additional cases
     ■ Notification of other involved jurisdictions
     ■ PHI inspects establishment using HACCP/DWO inspects water treatment system/Manitoba Health
       and Healthy Living PHIs inspect recreational water facility/beach
     ■ Collection of food/water samples (actual/representative)
     ■ Correlation of food/water samples and clinical specimens (record requisition numbers)
     ■ Determination of employee work exclusion
     ■ Determination of facility closure (i.e., pool)
     ■ Advise outbreak team members of sample/specimen results
     ■ Follow reporting requirements

Communicable Disease Management Protocol – Enteric Illness                                     March 2008
 Communicable Disease Management Protocol

     ■ Data correlation
     ■ Complete report detailing involvement
     ■ Final report correlation
     ■ Report forwarded to Food Protection/Drinking Water Office, Water Stewardship/Manitoba Health
       and Healthy Living PHIs as appropriate
     ■ Advise complainant of results
     ■ Advise establishment of results
     ■ Debriefing
     ■ Follow-up education of food handlers/establishment staff
     ■ Follow-up clients with additional health support
     ■ Implement policy recommendations

March 2008                                        Communicable Disease Management Protocol – Enteric Illness
 Communicable Disease Management Protocol

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