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Communicable
Disease Control
Manual
Communicable Disease
Prevention and Control
© Crown copyright, Province of Nova Scotia, 2003
Prepared by the Nova Scotia Department of Health and Wellness, Public Health Services, and published by
Communications Nova Scotia.
ISBN: 0-88871-791-1
06033/03
CONTENTS
Tuberculosis .................................................................7
Policies ..................................................................... 10
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within the District
Health Authorities. This manual is constantly under revision. Public Health staff will be informed of the changes as
they occur. However, information contained on this site may not contain the latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this information
by any other groups or organizations aside from Public Health staff within the District Health Authorities.
ACKNOWLEDGEMENTS
The revision of the Communicable Disease Control Manual was undertaken by the Nova Scotia
(NS) Communicable Disease Prevention and Control Responsibility Centre and approved
through the Communicable Disease Prevention Control Committee for the Public Health System
and was made possible by the financial support of the Nova Scotia Department of Health and
Wellness (DHW), and by the support and cooperation received from Public Health Services staff
across the province. The committee acknowledges their support and is grateful for the time and
resources devoted to this revision.
The Coordinators/Managers for Communicable Disease Prevention and Control at DHW were
instrumental in helping to make the manual clinically accurate and at the same time practical
for use by Public Health staff. The Department of Agriculture and Fisheries, Food Safety
Division, played a major role in ensuring the Enteric Section of the manual was accurate and
consistent with today’s practice. The hard work, expertise and dedication shown by these staff
is graciously acknowledged.
The support received from Public Health Services management in providing opportunities for
the staff to participate in the revision of the manual was crucial to the success of this revision.
The contributions of each member and their organization’s support for time and effort invested
in the review and preparation of this manual is much appreciated.
The committee also acknowledges the hard work and diligence of the writers in the revision of
the manual.
INTRODUCTION
The first edition of the Communicable Disease Control Manual was developed in 1993 as an
integral part of the communicable disease surveillance program.
As in 1993, the purpose of this revision was to provide both reference information and
procedural guidelines including policies relating to prevention and control of communicable
diseases for use by Public Health staff across the province.
In this revision, thorough research has been done to provide the most current, accurate and
complete information available.
The manual is developed for use by Public Health staff within the district health authorities in
conjunction with local Public Health Service’s goals and objectives. Although procedural
guidelines for communicable disease investigation are made clear in the manual, it does not
replace critical thinking and decision making that Public Health staff should use in their practice.
The manual has been organized under broad general disease categories:
Enteric, Foodborne and Waterborne Diseases; Blood Borne Pathogens; Sexually Transmitted
Diseases; Vaccine Preventable Diseases; Tuberculosis; Direct Contact, Respiratory Routes and
Through the Provision of Healthcare; Vectorborne and other Zoonotic Diseases, and Policies.
Each specific disease section includes accurate and up-to-date information; public health
services policies; investigative procedures; educational fact sheets and other information to
assist staff in the investigation of the disease.
There have been four broad procedural sections written for the manual; they are the Enteric
Diseases, Blood-Borne Pathogen Diseases, Sexually Transmitted Diseases, and Vaccine
Preventable Diseases. These sections provide general information on investigative procedures
that are appropriate for all diseases in each specific area.
This manual is only one of many references available to Public Health staff for communicable
disease prevention and control. It is a tool to assist Public Health staff in their investigation and
follow up of communicable diseases. Nevertheless, staff should continue to look for the latest
relevant information when dealing with a communicable disease.
STANDARD PRECAUTION GUIDELINES
This section is excerpted from the document “Partners for Infection Control, May 1999”
1. Introduction
Standard Precaution Guidelines provide direction for all service providers, clients and
visitors who may be at risk to exposure to communicable diseases.
Service providers or clients may carry an infectious disease. A person appearing healthy
can carry organisms without having any symptoms and can spread the organisms to
someone who is already compromised and at risk of becoming ill following contact with
organisms.
Standard Precautions combine Universal Blood and Body Precautions and Body
Substance Precautions. The combination of these precautions reduces the risk of
contacting and transmitting infections related to blood-borne pathogens and pathogens
from moist body substances e.g. urine, feces, saliva, wound discharge etc.
The following guidelines apply to direct caregivers or clients who are at risk for contact
and/or transmission of a communicable disease.
Terms marked with a star* will be defined in the glossary, found at the end of this
section.
2. Guidelines
HAND WASHING
Hand washing is the key to infection prevention and must be done by service providers
and clients.
BARRIERS
Barriers include gloves, gowns, masks, eye wear, and mouth pieces. Barriers are only
effective when worn properly.
GLOVES
Disposable* gloves should be worn when touching blood, body fluids, secretions*
(saliva), excretions* (urine, feces), and items contaminated with these fluids. Gloves
should be worn when touching mucous membranes* and broken skin. Gloves should be
removed immediately after use, hands washed and new gloves used between client care
or cleaning areas. Wash hands before touching non-contaminated* areas.
If you have an allergy to disposable gloves cotton gloves may be worn under the vinyl or
latex gloves. If you have a chronic skin condition and your hands have open areas or
bleed, contact your supervisor for instructions on precautions.
GOWNS/APRONS
Gowns/apron are required only when soiling from splashes or sprays of blood, body
fluids, secretions or excretions is likely. Wash your hands after removing the
gown/apron.
MOUTH PIECES
Mouth pieces are available and should be used when resuscitation is indicated.
3. Preventative Measures
DIETARY
Established dietary policies and procedures for food handling and care of equipment
must be followed. The use of disposable dishes are not routinely required to prevent the
spread of infection. Hand washing is essential.
Food handling courses are available through the Department of Agriculture and
Fisheries. Guidelines are available in the “Home Support Workers, Curriculum Standard,
1998"
This includes:
• Personal grooming e.g. showering/bathing, hand care, nails trimmed and
cleaned, proper diet and exercise and meticulous and frequent hand washing.
• Reduce splashes or sprays when completing procedures that involve blood, body
fluids, secretions or excretions e.g. handling soiled linen.
• Do not eat, drink, smoke, apply make up, handle contact lenses or brush teeth
when there is a reasonable risk for contact with blood, body fluids, infectious
secretions or excretions.
• Do not store food and drink in an area where contact with blood, body fluids,
secretions or excretions is likely.
• Follow guidelines for the use of personal protective equipment; wear as much or
as little as needed to maintain safety.
Bathrooms may be shared with others and routine cleaning procedures are sufficient. It
is essential that visible soiling with blood, body fluids, secretions or excretions is
immediately cleaned and disinfected. Instructions for increased cleaning and or use of
designated commodes will be provided if enteric precautions require that separate
bathroom facilities are required.
Frequently handled areas such as door knobs, hand rails and bedrails should be cleaned
and disinfected as a part of routine housekeeping procedures.
INFECTIOUS WASTE
Follow your organizations and municipality guidelines for infectious waste.
LABORATORY SPECIMENS
Specimens must be transported in a manner that prevents contact with or leakage of
contents. Follow organization’s recommendation for handling specimens.
LINEN
All linen soiled with blood, body fluids, secretions or excretions should be handled,
transported and processed in a manner that prevents skin and mucous membrane*
exposure and soiling of clothing.
Follow your organization’s recommendation when special precautions are required e.g.
Clostridium difficile.
Wash your hands after handling soiled linen and before handling clean linen.
NEEDLES, SYRINGES AND ALL DISPOSABLE SHARPS
Needles, syringes and all disposable sharps should be handled with care to prevent
accidental exposure to blood-borne pathogens. Needles, lancets, razor blades and other
disposable sharps are to be discarded immediately after use into a puncture-proof
container specifically designed for disposal of sharps.
Do Not:
Bend, break, or otherwise manipulate used needles by hand
Recap used needles, or other capped sharp items.
Overfill sharps containers
All non - disposable equipment, designated for a specific client, must be cleaned and/or
disinfected prior to being used for another client.
Equipment: disposable gloves, plastic garbage bag, paper towel, disinfectant (preferably
bleach 1:10.)
Procedure:
• Wear gloves
• Wipe as much as possible and dispose in plastic bag
• Cover with paper towel and soak with disinfectant
• Leave for 10 minutes
• Remove gloves and wash hands
• Identify wet floors as appropriate
• Reapply gloves
• Remove paper towel and dispose in plastic bag
• Disinfect area
• Dispose of infectious material as per facility policy
• Remove gloves and wash hands.
TRANSPORTING CLIENTS
When being transported, clients’ clothing and bedding should be free from visible soiling
with blood, body fluids, secretions or excretions. All drainage systems (e.g. catheter
bags) are to be adequately contained according to your organizations procedures.
VISITORS
Standard precautions do not require visitor restrictions. Visitors will be notified of
communicable diseases based on their risk of contact e.g. loved one is currently
symptomatic with a communicable infection.
If visible soiling with blood, body fluids, secretions or excretions, is noticed visitors are
asked to alert a staff member immediately.
Table of Contents
1. Introduction
2. Definitions
3. Principles of Outbreak Management
4. Outbreak Team
5. Roles and Responsibilities of the Outbreak Team Members
6. Steps in Outbreak Investigation and Management
7. Surveillance
References
Appendices
Appendix 1. Recommended Outbreak Response Kit Components
Appendix 2. CIOSC (Outbreak Application) Role-Based User Matrix
Appendix 3. Comprehensive Final Outbreak Report Outline
Appendix 4. Outbreak Evaluation Guide
Appendix 5. Acronym List
GUIDELINES FOR OUTBREAK
MANAGEMENT
1. Introduction
This section of the Nova Scotia Communicable Disease Control Manual provides
guidelines for the investigation and management of a communicable disease outbreak
in Nova Scotia. Specific procedures for cases and special-risk groups are included in the
individual disease sections of the manual. See other sections for handling of index cases
of specific diseases. The outbreak guidelines also recommend the key components of a
CDC Outbreak Response Kit (Appendix 1), which district Public Health Services should
have available at all times. Additionally, the outbreak guidelines include details for final
reporting of outbreaks.
The following chapter deals with outbreaks and not with public health emergencies.
Further development is necessary with respect to public health emergency response.
The Health Protection Act has provisions for the Minister of Health and Wellness to have
special powers during a public health emergency. If the issues in the public health
emergency become broader than public health, then the legislation and processes of
emergency management may apply.
2. Definitions
Community Outbreak
Two* or more unrelated cases** with similar illness that can be
epidemiologically linked to one another (i.e., associated by time and/or place
and/or exposure).
Institutional Outbreak
Three* or more cases with similar illness that can be epidemiologically linked to
one another (i.e., associated by exposure, within a 4-day period, in an
institutional setting).
For other symptom or disease groupings refer to specific response plans (e.g.,
Guide to Influenza Control for Long-Term Care Facilities).
District Public Health Services, with support from the Nova Scotia Department of Health
and Wellness (NSDHW), leads the investigation of an outbreak occurring in their district
health authority or shared service area.
DHW leads and coordinates an outbreak that involves more than one shared service
area.
4. Outbreak Team
The Outbreak Team works in conjunction with appropriate partners (external and
internal) to investigate and manage an outbreak. The initial team may be at the district,
shared service area, provincial, or federal level. Membership may be dependent upon
the geographical extent or potential source of exposure of the outbreak.
Core Outbreak Team Members
The core Outbreak Team may include the following members:
• Medical Officer of Health (MOH)
• district communicable disease prevention and control (CDPC) manager
• public health nurse(s)
• epidemiologist (NSDHW or district, if available)
• NSDHW Population Health Assessment and Surveillance (PHAS)
representative
• NSHDHW CDPC coordinator and/or immunization coordinator
• administrative support
• Provincial Public Health Laboratory Network representative
• NSDHW Environmental Health Consultant
• communications staff (district and/or NSDHW)
• district laboratory and/or CDHA anchor laboratory representative
In a district-level outbreak these steps apply to the district Outbreak Team. If the
outbreak is at a provincial level, the steps apply to the provincial Outbreak Team. The
following steps are not necessarily in order of priority and may be done simultaneously,
depending on the outbreak situation encountered.
2009 – 04 – 013
Outbreak DHA Sequential number
Year assigned by DHA
Person
• personal characteristics (date of birth, sex, immune status, marital status,
medical conditions, occupation, cultural norms, activities, predisposing or
protecting factors)
• symptom inquiry: type of symptoms
• classification as case or contact when appropriate
Time
• time period over which people became ill
• onset of symptoms
• duration of symptoms
• time between exposure to potential source (if known) and onset of
symptoms
Place
• common social event, such as a wedding, reception, anniversary, party,
sports, event; common places visited (mall, school, beach, etc.); or other
• travel
• possible exposures (e.g., menus, common food item, pool)
• contact with animals, pets, vectors, as appropriate.
Individual enteric and respiratory outbreaks within agencies such as long- term
care facilities will require only the final outbreak report via the CIOSC tool. More
complex outbreaks will require a comprehensive final outbreak report as
outlined in Appendix 3. The CMOH reserves the right to request a further
detailed report at any time. The CMOH will ensure that final reports are
completed and may request further review and debriefing of outbreaks at any
time.
Table 1: Reports Required for Outbreaks
Initial Update Report Final Final Comprehensive
Outbreak Summary (via Report Outbreak Report
Report CIOSC) Summary Outline
Summary (via (MS Word Doc, see
(via CIOSC) Appendix 3)
CIOSC)
Viral gastroenteritis in YES Only if requested YES Only if requested
institution(s)
Viral Respiratory (e.g. YES Only if requested YES Only if requested
RSV, influenza) in
institution(s)
All other outbreaks YES YES YES YES
*Institutions may include LTCFs, day-care centres, schools, correctional
facilities, residential care facilities, and acute care facilities.
7. Surveillance
The Nova Scotia Illness Outbreak Reporting Tool (Initial, Updates, and Final Report) will
be used for outbreak reporting, via an electronic application, through CIOSC at
http://www.cnphi-rcrsp.ca (log on and go to Outbreak Summaries).
References
Control of Communicable Diseases Manual, 19th edition. David L. Heymann, ed.
Washington, DC: American Public Health Association, 2008.
Outbreak Summary Reporting Application User Manual v.1. Public Health Agency of
Canada, 2008.
Procedures to Investigate Foodborne Illness, 5th edition. Des Moines, IA: International
Association for Food Protection, 2007.
Skills Enhancement for Public Health. Public Health Agency of Canada, 2006.
APPENDIX 1: RECOMMENDED OUTBREAK
RESPONSE KIT COMPONENTS
• specimen containers (check expiry dates), such as:
Carey-Blair/enteric pathogen transport media—culture and sensitivity
SAF fixative—ova and parasites
Sterile container for virology including stools
Viral nasal swabs (viral transport swab collection kits)
• resealable plastic bags with pockets
• laboratory requisitions
• stamps with MOH name and address; ink pad
• outbreak stickers—bright coloured
• note paper and sticky notes
• pens and highlighters
• case management forms
• Nova Scotia Illness Outbreak Reporting Form as necessary
• instruction for specimen collection and labeling
• elastic bands
• brown paper bags
• gloves
• hand sanitizer
• current list of contact names and phone numbers (MOH, Department of
Health and Wellness CDPC RC, Provincial Public Health Laboratory Network
contacts, microbiologists, NSDHW PHAS, CFIA, Department of Agriculture,
Department of Environment, and appropriate district staff)
Outbreak Response Kits should not be stored in vehicles, as specimen containers may
not be effective if exposed to extreme temperatures.
APPENDIX 3: COMPREHENSIVE FINAL
OUTBREAK REPORT
Outline of Comprehensive Final Outbreak Report
I. Executive Summary
II. Introduction and Background
III. Methods
a) Epidemiological
b) Laboratory
c) Environmental Public Health
IV. Results
a) Epidemiological
b) Laboratory
c) Environmental Public Health
V. Discussion
VI. Conclusions
VII. Evaluation/Recommendations (See Appendix 4)
VIII. Acknowledgements
IX. Signature Block
X. Appendices
Explanation
I. Executive Summary
Include the key features of the outbreak, addressing the “who, what, where, and
when” of the outbreak. A description of the outbreak or the causal hypothesis
based on the evidence should be included. Identify lessons learned,
recommendations, interventions (could be ongoing), or areas that need further
attention. Include important points in the report and be prepared to answer any
questions with detail.
III. Methods
Outline the steps taken to investigate the outbreak.
Laboratory analysis: Describe the number and types of specimens submitted for
analysis.
IV. Results
Describe what was discovered.
Laboratory results: Summarize the results of human and food or source testing.
V. Discussion
This section brings together all aspects of the outbreak. Discussion will include
the main hypotheses and justification of conclusions and actions being based on
evidence or balance of probabilities. Actions taken to protect public health are
described. As well, highlight the problems encountered during the investigation
including the lessons learned during the outbreak, including those identified in
the debriefing(s).
VI. Conclusion
Give a brief summary of the outbreak.
VII. Evaluation/Recommendations
Describe what should be done to control the outbreak, prevent future
outbreaks, and improve management of outbreaks in the future. The purpose of
this section is to educate, so specificity is important. Recommendations for any
changes to the Outbreak Response Plan should be included.
VIII. Acknowledgements
This is an opportunity to thank those who assisted with the outbreak.
IX. Appendices
These may include a chronology of events, Outbreak Team membership, terms
of reference for the team, maps and references, questionnaires, letters to
health-care professionals, media releases, and fact sheets.
X. Signature Block
This report requires sign-off by the CDC manager and MOH in the district as well
as by the CMOH. See the following signature block template.
TEMPLATE
SIGNATURE BLOCK
Signature Date
Clinical Services
Evaluation Questions Indicator Method
Were the clinical • Physician use of the clinical case definition when Interview
services responsive to requesting laboratory tests? (i.e. confirming the
the outbreak. diagnosis)
Document
• Development of an acceptable (accurate)
Review
treatment algorithm if applicable
• A reliable case definition established within an
acceptable time frame
• Accurate diagnosis of cases by physician Interview
• Timely processing of laboratory specimens
• Perceived strengths/challenges in establishing a
Document
case definition and processing of laboratory
Review
specimens
Evaluation Questions Indicator Method
EVALUATION GUIDE for OUTBREAK MANAGEMENT
Surveillance
What were the strengths/challenges of the surveillance function
(i.e. the collection, analysis, and dissemination of the disease outbreak)?
Was the data • Timely reporting of positive lab results to DHW Interview
collection process & PHS (immediately by phone and follow-up in
accurate, timely and writing to ordering physician, PHS and DHW)
efficient? Document
• Physician case reporting met provincial Review
guidelines for reporting (re: timeliness &
accuracy)?
• Established procedures and tools for reporting
positive lab results and related information
(ex. patient contact information)
• Established procedures/mechanisms to avoid
data entry errors or duplication
• Adequacy of the available human and
technical resources to efficiently perform the
data analysis
• Timeliness of the data analysis process
• Perceptions of strengths/challenges in case
reporting (What worked well? What could
improve? e.g. receiving data from DHA/Lab in
timely manner; accuracy of data from
DHA/Lab; barriers/breakdown in the data
collection process)
Was the data • Perceptions of the timeliness of the data Interview
collection process analysis
timely and efficient? • Perceptions of what worked well in the Document
process of data analysis Review
• Perceptions of what could have been
improved?
Was the data analysis Ability of the outbreak team leader to report on Interview
process timely and the outbreak (number of cases, location, etc.)
efficient? What were in a timely manner Document
the challenges? How
• Timeliness of the epi-curve Review
could this have been
• Use of the epi-curve (how, by whom?)
improved?
• Formulation of tentative hypothesis (how? by
whom? Timeliness)
• Timeliness of establishing/verifying the
existence of an outbreak
Was data analysis • Ability of analysis to provide field interview Interview
used to inform and and investigation staff to better focus work
update the case • Was the analysis usefully in validating the Document
definition and inform infective agent, mode of transmission, Review
application of effectiveness of intervention or prevention
community public methodology?
health measures?
Principles
General Guidelines
Sample Letters
Amebiasis
Botulism
Campylobacteriosis
Cholera
Cryptosporidiosis
Cyclosporiasis
E. Coli (Verotoxigenic)
Giardiasis
Hepatitis A
Listeriosis
Norovirus
Salmonellosis
Shellfish Poisoning
Shigellosis
Trichinellosis
Typhoid/Paratyphoid
Viral Gastroenteritis
Yersiniosis
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within the District
Health Authorities. This manual is constantly under revision. Public Health staff will be informed of the changes as
they occur. However, information contained on this site may not contain the latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this information
by any other groups or organizations aside from Public Health staff within the District Health Authorities.
Enteric Food and Waterborne Diseases
Principles
These guidelines aim to define control measures for enteric illness in Nova Scotia.
Specific procedures for cases and contacts in special risk groups are included with each
disease. The authority for the Medical Officer of Health comes from the Health Act of
the Province of Nova Scotia.
This section explains the general roles and responsibilities of the parties normally
involved in the investigation of enteric illnesses. For some diseases, additional
responsibilities are placed on some or all of the parties. In these instances, the specific
responsibilities are noted in the procedures section for each disease.
1.2.9 Seek approval from MOH for exclusions for clients and
contacts where required
Refer to the general guidelines about exclusions in section 2, and refer to
the specific disease sections for specific guidelines about exclusions for
the case and contacts.
If the client or contact is excluded from work/child care, continue contact
with the case/parents until returned to work/child care. This may entail
periodic checks to determine if the case’s symptoms have subsided or if
the case has submitted stool specimens. In order to expedite the process,
it may be necessary to telephone the lab for specimen results.
1.2.10 Ensure the case management form(s) are completed and
submitted for each case. The case management forms are located
http://www.gov.ns.ca/hpp/cdpc/CDCManual
1.2.11 Exclusions
It is the responsibility of Public Health Services to determine when a case may
return to work/child care in cases of exclusion.
1.3.3 Exclusions
It is the responsibility of Public Health Services to determine when a case may
return to work/child care in cases of exclusion.
The Food Safety Specialist will be responsible for the inspection of the food
source or food establishments implicated in an enteric disease, including, as
necessary, trace back of foods to the primary producer.
The Food Safety Specialist will, as needed, communicate with the CFIA and the
Department’s Fisheries Licensing and Investigation branch.
1.5.3 Education
The Food Safety Specialist will provide education on required food safety
practices and control measures to food service employers and employees, food
service establishments, institutions and agencies as part of the enteric illness
investigation.
1.5.4 Resource
The Food Safety Specialist will be a resource for information and advice on food
safety, food handling practices and techniques to the Investigator.
3. Surveillance Forms
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
4.1.2 Cooking
Meat, poultry, fish or eggs, or foods like casseroles, stews and pies made from
them are potential sources of enteric bacteria that may cause foodborne illness.
These foods must be cooked to a safe (proper) internal temperature before
eating. The internal temperature must be checked with a meat thermometer.
The following internal temperatures will ensure safe cooking.
Pork, Veal & Lamb 71ºC 160ºF
Ground Meat 71ºC 160ºF
Whole chicken/turkey 82ºC 180ºF
Poultry Stuffing (inside temperature) 74ºC 165ºF
Chicken/turkey pieces 77ºC 170ºF
Ground poultry 72ºC 165ºF
Beef steak/roasts: Medium rare 63ºC 145ºF
Beef steak/roasts: Medium 71ºC 160ºF
Beef steak/roasts: Well done 75ºC 170ºF
4.1.3 Reheating
Not all bacteria are killed by cooking, and foods may become re-contaminated
after cooking. When foods are reheated they should reach an internal
temperature (measured by a food thermometer) of 74ºC.
4.1.4 Cooling
Potentially hazardous foods if improperly cooled will promote growth of enteric
bacteria that can cause foodborne illness. After cooking, food should not be left
at room temperature for longer than 2 hours and cooled to refrigeration
temperature (4ºC) within 4 hours. Large items such as whole turkeys, roasts
or soups may be separated into smaller portions to ensure proper cooling.
4.1.5 Separating
Meat, poultry and fish should be safely separated from other foods in the
shopping cart and refrigerator. Make sure packages are sealed to prevent spilling
of juices on other foods. Raw foods should be placed in sealed containers or
plastic bags and stored on the lowest shelf of the refrigerator. Never place
cooked, ready to eat foods on the same plate that has been used for raw foods.
Drinking of unpasteurized fruit juice and cider has been associated with
foodborne illness. Juice and cider in juice boxes, cans and bottles stocked on
shelves in grocery stores is pasteurized. Some juices and ciders sold at roadside
stands, on ice or in refrigerated cases in grocery stores may not be pasteurized.
It is recommended that people do not drink unpasteurized juice/cider or boil it
for at least 2 minutes before drinking.
Surface water such as lakes and streams are more likely to be contaminated than
ground water. Deep wells are less likely to be contaminated than shallow wells.
In fact, poorly constructed shallow wells may be as contaminated as lakes or
streams.
Many community and public water supplies are chlorinated; however few
provide additional treatment such as filtration. These water supplies may
become contaminated when there is a breakdown in treatment. Chlorination will
control bacterial contamination in water, but often is not effective for protozoa.
Filtration is required to remove protozoa from water supplies.
4.2.1 Disinfection Required
Drinking water should be disinfected when:
A boil water advisory is issued for a public water supply.
Water is used directly from a lake or stream.
Coliform tests show that the water contains coliform bacteria. Individual
water supplies, whether wells or surface water should be tested as per
the Nova Scotia Department of Labour and Environment guidelines.
Note: Pregnant women should not use iodine drops to disinfect water. Iodine
should not be used over long periods of time to disinfect water.
4.3.1 Foods
Foods may be contaminated by the unwashed hands of the food worker; by
contact with human excrement used as fertilizer; or by contaminated water used
in irrigation or washing fruit and vegetables. Avoid foodborne illness when
travelling to these countries by:
Eating only foods that are well cooked and served hot right after cooking.
Never eat leftovers or reheated foods.
Avoiding raw shellfish.
Ensuring all meat or poultry is well cooked.
Washing and peeling your own fruit and vegetables. Discard if the skin or
peel is broken or bruised. Avoid salads and raw vegetables.
Avoiding cold cuts, salads, watermelons, puddings.
Avoiding canned food if the tin appears “brown” or “swollen”.
Consuming only canned, carbonated or commercially bottled beverages.
Consuming pasteurised milk and dairy products (cheese, yogurt) only.
Using only boiled water for mixing formula for bottle fed or weaned
infants.
4.3.2 Water
Safe drinks include boiled water and drinks made with boiled water, canned or
bottled carbonated beverages and clear bottled water with unbroken seals.
Where chlorinated water is not available, avoid both water and ice.
When you are not sure if the water is safe, follow the recommendations below:
Boiling - boil water vigorously for at least 1 minute.
Halzone tablets - these are available through pharmacies and sporting
goods stores. Take them with you as they may not be available in the
country you visit. Follow manufacturer’s instructions for use.
Unscented household bleach - add 2 drops per litre (4 drops if water is
cloudy), mix thoroughly and let stand 30 minutes. A slight chlorine odour
should be detected. If odour is not detected, repeat chlorination and let
stand a further 5 minutes.
Iodine - add 5 drops of Tincture of Iodine (2.5%) to clear water or 10
drops to cloudy water and let stand for 30 minutes. Cloudy water may
require several hours standing time. Pregnant women should not use
iodine drops to disinfect water.
Water Filters - portable water filters can be purchased from sporting
goods and travel stores. They should be rated “1 micrometer absolute”.
Packaging should indicate that the filter will remove bacteria, viruses and
protozoa. Chlorine and iodine are not effective against protozoa that can
be effectively removed by filtration.
4.4 Swimming and Recreational Water
Water in swimming pools, hot tubs, rivers, lakes, streams or ocean may be
contaminated with fecal material. Swallowing or drinking this water should be
avoided as it could result in an enteric illness. Avoid swimming in lakes, rivers,
streams, ocean or other surface water near a sewage or storm water discharge.
Diapered children or anyone with diarrhea should be kept from a swimming pool
or hot tub. Younger children should not wear diapers in a pool. If a young child
should have an accident in the pool, clean it up at once and add extra chlorine to
that part of the pool.
Swimming pools should always be clear and a free chlorine residual of 1–2 ppm
should be maintained at all times. Larger pools and public pools should be
equipped with an operating automatic chlorination system. Pool water should
be tested regularly for bacteriological quality. Public pools should be tested
weekly. Bacteriological Standards as contained in Department of Health
Guidelines for Swimming Pools is 0/100 ml for both total and fecal coliform
microorganisms.
These systems if not properly installed and maintained can cause contamination
of water supplies and surface waters with enteric bacteria, viruses and protozoa.
Untreated sewage may also accumulate on the ground surface and be a source
of contamination. Signs of a malfunctioning sewage disposal system may include
wet spots and odours in the vicinity of the disposal system and fecal coliform
contamination in water supplies.
All sewage disposal systems in Nova Scotia must be approved and conform to
Sewage Disposal Regulations of the Department of Environment and Labour.
Information on the approval, maintenance and identifying problems with
systems, may be obtained from Inspectors with that Department.
Flow Chart Showing Sequence of Events in Investigating Enteric
Illnesses
References:
Communicable Disease Protocol Manual, Manitoba Health, 2001.
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Infection Control in the Child Care Center and Preschool, Third edition. 1996 Donowitz LG (ed.), Williams
and Wilkins.
Policy for the Control of Gastrointestinal Infections in Special Risk Groups, Nova Scotia Department of
Health and Fitness, January 1984.
Procedures to Investigate Foodborne Illness, 5th edition. International Association of Food and
Environmental Sanitarians Inc. 1999.
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Letters for Use in Daycares
Letters for Use in Workplaces
AMEBIASIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection (presence of cysts or trophozoites of
Entamoeba histolytica in appropriate laboratory specimens)
Probable case:
Signs and symptoms compatible with Amebiasis and positive serologic tests for
E. histolytica
1.3 Symptoms
Many cases are asymptomatic. More severe cases may experience acute amebic
dysentery, including 1-3 weeks of increasing diarrhea containing blood and
mucus, lower abdominal pain, tenesmus, possible weight loss and fever.
1.4 Incubation
Varies from a few days to months, usually 2-4 weeks.
1.5 Source
Stool of infected humans.
1.6 Transmission
Ingestion of fecally contaminated food or water containing amebic cysts or
sexual transmission.
1.7 Communicability
Infected people excrete cysts intermittently, occasionally for years if left
untreated.
1.8 Treatment
Metronidazole followed by iodoquinol, paromomycin or diloxanide furoate for
acute amebic dysentery. Asymptomatic carriers are treated with iodoquinol,
paromomycin or diloxanide furoate.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for amebiasis.
2.1.2 Investigator
Use general guidelines. No additional guidelines.
2.1.3.Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
2.2 Criteria for Exclusion
Exclude clients in the risk groups below according to the general guideline as
well as any additional noted requirements:
Amebic dysentery is a severe form of amebiasis. The symptoms include stomach pain,
bloody stools, and fever. In rare cases E. histolytica invades the liver and forms an
abscess. Even less commonly, it spreads to other parts of the body, such as the lungs or
brain.
Clinical evidence and indication that the client ate the same suspect food as an
individual with laboratory-confirmed botulism
Wound Botulism
Laboratory confirmation of infection: laboratory detection of botulinum toxin in
serum
OR
- Isolation of C. botulinum from a wound
AND
- Presence of a freshly infected wound in the 2 weeks before symptoms and
no evidence of consumption of food contaminated with C. botulinum
Infant Botulism
Laboratory confirmation with symptoms compatible with botulism in a person
less than one year of age:
- Detection of botulinum toxin in stool or serum
OR
- Isolation of C. botulinum from the patient’s stool, or at autopsy
Colonization Botulism
Laboratory confirmation with symptoms compatible with botulism in a patient
aged 1 year or older with severely compromised gastrointestinal tract
functioning (i.e. abnormal bowel) due to various diseases, such as colitis, or
intestinal bypass procedures, or in association with other conditions that may
create local or widespread disruption in the normal intestinal flora:
- Detection of botulinum toxin in stool or serum
OR
- Isolation of C. botulinum from the patient’s stool, or at autopsy
Probable case
Foodborne
A probable case requires clinical evidence and consumption of a suspect food
item in the incubation period (12-48 hours).
1.3 Symptoms
Foodborne and wound botulism present as diseases of the nervous system
characterized by blurred or double vision, dysphagia, dysphonia, dry mouth and
dysarthria. Descending symmetrical flaccid paralysis may follow. Vomiting,
constipation and diarrhea may also be present. Fever is usually absent.
1.4 Incubation
Foodborne botulism: 12-36 hours or more after eating contaminated food.
Wound botulism: 4-14 days between time of injury and onset of symptoms.
Intestinal (infant) botulism: Unknown.
1.5 Source
Spores are present in soil and in vegetables and other agricultural products.
They are also present in sea sediment and in the intestinal tract of animals
including fish.
1.6 Transmission
Foodborne botulism occurs from ingesting of preformed toxin present in
contaminated food. Usually this results from home canning and preserving.
1.7 Communicability
C. botulinum toxins have been recovered from feces of infected individuals for
weeks to months after onset of disease. No person to person transmission has
been documented.
1.8 Treatment
Foodborne and wound botulism: Immediate respiratory assessment and
management is essential. IV and IM administration of trivalent botulism antitoxin
types A, B and E (Trivalent [ABE] Antitoxin) is indicated after sensitivity testing to
the equine sera. Supportive nutritional and physical care for symptoms is also
indicated. Contact Department of Health and Wellness for antitoxin.
1.10 Prophylaxis
Assessment should be made regarding the prophylactic use of antitoxin
depending on the possibility of outbreak conditions involving shared food. If the
shared food is identified as containing C. botulinum toxin, measures including
use of cathartics and gastric lavage are indicated. For adults, prophylactic
administration of the antitoxin within 1-2 days of eating the implicated food is
warranted, if the individual is not sensitive to the equine preparation of the
antitoxin (regardless of whether or not the individual is symptomatic).
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for botulism.
2.1.4 Laboratory
Use general guidelines. Also use additional guidelines re:
a) Phone reporting.
Laboratories must immediately report all cases of botulism by phone to
Public Health Services.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Botulism. Centers for Disease Control and Prevention. 1995. www.cdc.gov.ncidod/diseases/foodborn/
botulism.htm
Botulism Fact Sheet. New York State Department of Health. February 1999. www.health.state.ny.us/
nysdoh/consumer/botulism.htm
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
BOTULISM FACT SHEET
What is Botulism?
Botulism is caused by a toxin (poison) produced by bacteria called Clostridium
botulinum. There are three types of botulism:
Food-borne and intestinal (or infant) botulism are caused by eating contaminated
food.
Wound botulism is often caused by contamination of an open wound with soil or
gravel. It has also been reported among injection drug users.
The illness can progress to complete paralysis, respiratory failure and death.
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case
1.3 Symptoms
Severity of symptoms may vary. Symptoms include diarrhea, abdominal pain,
fever, nausea, vomiting, malaise, and bloody stool.
1.4 Incubation
Usually 2-5 days, ranges from 1-10 days.
1.5 Source
Feces of an infected animal or human. The gastrointestinal tract of animals and
birds (especially pets, cattle, chickens, turkey and water fowl) can be a reservoir.
1.6 Transmission
Ingestion of contaminated food, including unpasteurised milk, non-chlorinated
water and under cooked poultry (most common source). Fecal-oral contact from
infected human or animal is also possible, especially with young children and
pets. Person to person spread has occurred with persons with fecal
incontinence. Exposure to a small number of organisms may lead to infection.
1.7 Communicability
Clients are contagious for 2-3 days after antibiotics are started. In persons not
treated with antibiotics, communicability ranges from 2-7 weeks.
1.8 Treatment
Supportive therapy. Erythromycin, azithromycin, tetracycline and quinolones will
shorten the period of excretion and duration of illness only when administered
early in the illness and the infecting organism is known.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for campylobacteriosis.
2.1.2 Investigator
Use general guidelines. No additional guidelines.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
Health care, nursery or other staff General guidelines until symptoms have
who have contact with susceptible subsided and client has two well formed
persons stools.
References:
Public Health Agency of Canada. (2009).Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Campylobacter Infections. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/campylobacter_g.htm
Control of Comunicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz editor
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
CAMPYLOBACTERIOSIS FACT SHEET
What is Campylobacteriosis?
Campylobacteriosis is a disease caused by bacteria called Campylobacter. Symptoms
include diarrhea, stomach cramps, fever, nausea, vomiting, and bloody stool that usually
lasts 2-5 days. These symptoms may be mild or severe.
Some people have become infected from touching the infected stool of an ill dog or cat.
People don’t usually pass the germ to other people, but this can happen if the infected
person is a small child or is producing a large amount of diarrhea that others touch.
Probable case:
Clinical evidence of illness in a person who is epidemiologically linked to a
confirmed case.
1.3 Symptoms
Most cases are asymptomatic. Some cases experience mild to moderate
diarrhea. Less than 5% experience more severe symptoms including profuse
amounts of watery diarrhea without abdominal pain or fever, nausea and
vomiting.
1.4 Incubation
Usually 2-3 days, ranges from a few hours to 5 days.
1.5 Source
Stool or vomit of infected human, contaminated water, raw or undercooked
shellfish from contaminated water, and any food prepared with contaminated
water.
1.6 Transmission
Ingestion of food or water that has been contaminated by feces or vomitus of
infected human.
1.7 Communicability
Presumed to be the period during which the stool remains positive, usually a few
days after recovery.
1.8 Treatment
Tetracycline or doxycycline. Oral or parenteral rehydration to prevent
dehydration should be initiated as soon as a diagnosis is suspected.
1.10 Prophylaxis
Where there is a high likelihood of secondary transmission within the household,
household members should be given chemoprophylaxis (tetracycline or
doxycycline). Prohylaxis for whole communities is not recommended.
Immunization of contacts is not recommended.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for cholera.
2.1.2 Investigator
Use general guidelines. Use additional guidelines re:
a) Contacting Department of Environment
If a water source is suspected, contact the Department of Environment
and Labour immediately.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Cholera. http://www.cdc.gov/ncidod/dbmd/diseaseinfo
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
CHOLERA FACT SHEET
What is Cholera?
Cholera is an illness caused by an infection of the intestine with the bacteria
Vibrio cholerae.
The disease is spread by contaminated human stool. Water can get contaminated when
sewage and drinking water are not properly treated. Cholera bacteria have also been
found in some brackish rivers and coastal waters. A few people have been infected with
cholera after eating raw or undercooked shellfish from these waters.
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case.
1.3 Symptoms
Many cases are asymptomatic. Symptoms may include watery diarrhea
accompanied by abdominal pain, and sometimes fever, malaise, vomiting and
loss of appetite. In immunocompromised people (e.g. persons with HIV
infection) chronic severe diarrhea can result in dehydration and possibly death.
1.4 Incubation
Usually 7 days, ranges from 1-12 days.
1.5 Source
Stool of infected humans, cattle and other domestic animals.
1.6 Transmission
Fecal-oral contact between humans and between animals and humans.
Ingestion of contaminated food and water.
1.7 Communicability
From onset of symptoms until several weeks after symptoms resolve. Outside
the body the pathogen remains infective for 2-6 months in a moist environment.
1.8 Treatment
Rehydration if necessary.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for cryptosporidiosis.
2.1.2 Investigator
Use general guidelines. Also use additional guidelines re:
a) Contacting Department of Environment.
If a water source is suspected, contact the Department of Environment
immediately.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
Probable case:
Clinical illness in a person with evidence of:
An epidemiologic link to a confirmed case either by consumption of the same
food or exposure to food known to be handled by a confirmed case, OR
A history of travel to a cyclospora-endemic area
1.3 Symptoms
Characterized by watery diarrhea, loss of appetite, weight loss, abdominal
bloating and cramping, increased flatus, nausea, fatigue and low-grade fever.
Vomiting may also be noted. Relapses and asymptomatic infections can occur.
Some evidence suggests that symptoms may be more severe and long-lasting in
immunocompromised individuals
1.4 Incubation
Approximately 7 days, range 1-14 days.
1.5 Source
Contaminated food or water. Some outbreaks have been associated with
consumption of fresh produce, but the way in which the produce was
contaminated has not been identified. Person to person or animal to person
transmission has not been documented.
1.6 Transmission
Primarily consumption of contaminated water, or swimming in contaminated
water. Some outbreaks have been associated with consumption of fresh
produce, but the way in which the produce was contaminated has not been
identified. Person to person or animal to person transmission has not been
documented.
1.7 Communicability
Uncertain.
1.8 Treatment
Oral trimethoprim-sulfamethoxazole for 7 days.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for cyclosporiasis.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
CYCLOSPORIASIS FACT SHEET
What is Cyclosporiasis?
Cyclosporiasis is a disease caused by a parasite called Cyclospora cayetanensis.
1.0 Information
Probable Case:
Clinical illness in a person who is epidemiologically linked to a confirmed case,
which would include persons with hemolytic uremic syndrome (HUS).
1.3 Symptoms
Diarrhea often beginning as non-bloody progressing to visible or occult blood,
severe abdominal pain, vomiting, fever in less than one-third of cases. Illness
may be complicated by hemolytic uremic syndrome (HUS), thrombocytopenic
purpura (TTP) or pulmonary edema. Asymptomatic infections may also occur
and the microorganism may cause extra intestinal infections.
1.6 Incubation
Most E. coli strains have an incubation period of 10 hours to 6 days. E. coli
0157:H7 incubation period is usually 3 to 4 days (range 1-10 days).
1.7 Source
E. coli bacteria can sometimes contaminate the surface of meat when animals
are slaughtered, despite precautions. In highly processed or ground meat, the
mechanical process can spread the bacteria through the meat. Raw fruits and
vegetables can become contaminated with pathogens while in the field, by
improperly composted manure, contaminated water, wildlife and poor
hygienic practices of the farm workers.
E. coli bacteria are most often spread from person-to-person. Both animals and
people infected with the bacteria can be carriers. E. coli has been linked to
ground beef, raw fruits and vegetables, including sprouts, untreated water,
unpasteurized milk and milk products, including raw cheese, unpasteurized
apple juice/cider, contact with farm animals and petting zoos.
1.8 Transmission
Consumption of undercooked ground beef, unpasteurized milk and milk
products including raw milk cheese, juice or cider, untreated water, fruit and
vegetables, including sprouts, swimming in contaminated water, and person to
person transmission. Transmission has been associated with farms, petting zoos
and agricultural fairs.
1.9 Communicability
1 week or less in adults. 3 weeks in one third of children. Long term carriers are
uncommon.
1.10 Core Messages for Prevention
Refer to general guidelines.
Use the General Guidelines for Investigation at the beginning of this section.
Closure of the facility or restriction of visitors is not usually required but may be
implemented in consultation with the MOH and the facility management.
During an outbreak, the MOH and/or facility management may recommend closure of a
facility temporarily (usually not necessary, although the number of ill staff and children
may make it logistically impossible or unfeasible to operate). If the facility is closed, it is
important for parents to keep ill children at home and not send the ill child to an
alternative child care location.
Please refer to the “Guidelines for Communicable Disease Control for Childcare
Programs and Home Day Care Agencies”, November 2008
http://www.gov.ns.ca/hpp/publications/Childcare-Manual-November-2008.pdf
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
4.0 References
E. coli. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G.
Donowitz ed Williams and Wilkins.
Heymen, DL. (ED.). (2008). Control of Communicable Diseases Manual. (19th ed).
Information for Sharing with Parents and Families: Hamburger Disease or Barbeque
Syndrome VTEC Gastroenteritis. 1995. Canadian Journal of Infectious Diseases, Vol.6
No. 2.
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases
under National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from
http://www.phac-aspc.gc.ca/publicat/ccdr-r60. mtc/09pdf/35s2-eng.pdf
5.0 Appendices
In some people (particularly children under five years of age), Verotoxigenic E. coli can
cause a hemolytic uremic syndrome (HUS). This happens in about 2 to 7% of cases. HUS
is a serious disease that destroys red blood cells and causes kidney failure. Most people
recover from HUS but it can be fatal.
How is it spread?
You can get Verotoxigenic E. coli by:
• Eating undercooked meat, especially ground beef (Contaminated meat looks and
smells normal.)
• Drinking unpasteurized milk or juice
• Drinking or swimming in water contaminated by sewage
• Petting animals that may carry the bacteria
You can also get E. coli by coming in contact with the stools of infected persons. This
happens when proper hand washing technique is not followed.
Individuals with E. coli can still spread the germ for days to weeks after symptoms stop.
L’E. coli producteur de vérotoxines rend parfois les gens très malades.
Chez certaines personnes (en particulier les enfants en bas de cinq ans), l’E. coli
producteur de vérotoxines peut provoquer le syndrome hémolytique et urémique
(SHU). Cela survient dans environ 2 à 7 p. 100 des cas. Le SHU est une maladie grave qui
détruit les globules rouges et cause une insuffisance rénale. La plupart des gens
guérissent mais la maladie peut être mortelle.
N’importe qui peut avoir une infection à l’E. coli producteur de vérotoxines.
On peut aussi attraper l’E. coli en étant en contact avec les selles de personnes
infectées. Cela se produit quand on ne se lave pas les mains de façon adéquate.
Les personnes ayant une infection à l’E. coli peuvent encore transmettre la bactérie
pendant des jours, voire des semaines, après la disparition des symptômes.
Quels sont les symptômes?
Voici les symptômes possibles :
Une diarrhée grave et sanglante
Des crampes abdominales
Des vomissements
Il arrive que l’infection cause une diarrhée non sanglante. Parfois, la personne infectée
n’a aucun symptôme. En général, l’E. coli producteur de vérotoxines ne provoque
pratiquement pas de fièvre.
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case.
1.3 Symptoms
Usually asymptomatic. Symptoms include diarrhea, abdominal cramps, bloating,
weight loss or malabsorption.
1.4 Incubation
3-25 days or longer, median 7-10 days.
1.5 Source
Stool of infected human or animal, human cysts may be more infectious.
1.6 Transmission
Fecal-oral - Transmission occurs from hand to mouth transfer of cysts from feces
of an infected individual, from fecally contaminated water, such as streams and
lakes, and rarely through contaminated food.
1.7 Communicability
Varies. Without treatment 50% of adults clear the infection within 1-3 months.
Long-term carriers may carry Giardia indefinitely.
1.8 Treatment
Metronidazole (Flagyl), quinacrine hydrochloride or furazolidone.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for giardiasis.
2.1.2 Investigator
Use general guidelines. Also use additional guidelines re:
a) Educating client and household.
Emphasize the importance of avoiding untreated water.
b) Contacting Department of Environment and Labour
if a cluster of cases is identified and a water source is suspected, contact
the Department of Environment and Labour.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
Probable case:
Acute clinical illness in a person without laboratory confirmation of infection
who is epidemiologically linked to a confirmed case.
1.3 Symptoms
Characterized by discrete onset of symptoms, including fever, malaise, anorexia,
nausea and abdominal pain followed by jaundice or elevated aminotransferase
levels within a few days. Usually asymptomatic in children, may be asymptomatic
in adults.
1.4 Incubation
28 to 30 days with a range of 15-50 days.
1.5 Source
Humans and some non-human primates.
1.6 Transmission
Person to person transmission via fecal-oral contact, ingestion of contaminated
water and food including shellfish from contaminated water. Rarely, cases can
be associated with injection drug users and transfusion of blood products.
1.7 Communicability
1-2 weeks before the onset of illness to 1 week after the onset of jaundice, when
risk becomes minimal. HAV can be detected in the stool for up to six months in
some children and neonates.
1.8 Treatment
Supportive therapy.
1.10 Prophylaxis
1.10.1 Pre-exposure
Routine immunization is recommended for persons at risk of
HAV infection older than 1 year of age, including:
a) Hepatitis C positive individual (publicly funded).
b) Injection drug users (publicly funded).
c) Persons travelling to locations where HAV infection is endemic (not
publicly funded).
HAV vaccine is recommended for people who travel to areas where there
is a risk of being infected. Children under the age of 1 year may receive
immunoglobulin.
1.10.2 Post-exposure
For close contacts older than 1 year (household, sexual and drug using contacts),
Hepatitis A vaccine should be administered as soon as possible post exposure
(preferably within one week), followed by a second dose six months later. The
vaccine is made available through a publicly funded program by Public Health
Services. Ensure the product is appropriate for age.
If the client is a food handler, other food handlers in the same institution should
receive Hepatitis A vaccine. Administration of Hepatitis A vaccine to patrons of
the food establishment may be considered when:
The infected food handler prepared foods that were not heated, or
Lack of proper hand washing is suspected or the food handler has
diarrhea and
Vaccine can be administered within 1 week.
NOTE: Do not give live virus vaccine (i.e. MMR) except oral polio for 3
months after the administration of IG. If a live virus vaccine was given
within 2 weeks prior to IG administration, the vaccine should be repeated
in 3 months.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for Hepatitis A.
2.1.2 Investigator
Use general guidelines, as well as additional guidelines re:
a) Following up all close contacts of the client during the period of
communicability. Contact all household, sexual and close contacts and
determine the need for prophylaxis.
b) Determine if children who are contacts are HAV positive. If a contact
attends a child care centre, confirming the HAV status of the child will
assist in determining if there may be additional cases at the child care
centre.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
Children < 5 years attending Exclude until one week after onset of jaundice
day care etc. or if not jaundiced until one week after onset
of symptoms.
Case contacts who are in Symptomatic: Exclude until one week after
special risk groups onset of symptoms
Asymptomatic: Consult with MOH to assess
on a case by case basis.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Hepatitis A. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G. Donowitz ed Williams
and Wilkins.
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
HEPATITIS A FACT SHEET
What is Hepatitis A?
Hepatitis A is a virus that causes an infection of the liver. The virus is passed in
a person’s stool (bowel movement).
If you have come in contact with someone who has Hepatitis A, immune globulin or
vaccine may be recommended. You must have the vaccine within 1 week of contact
with the infected person. Talk to your doctor or Public Health Services.
LISTERIOSIS OCTOBER 2008
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection with symptoms:
isolation of Listeria monocytogenes from a normally sterile site (e.g.
blood, cerebral spinal fluid, joint, pleural or pericardial fluid)
OR
in the setting of miscarriage or stillbirth, isolation of L. monocytogenes
from placental or fetal tissue (including amniotic fluid and meconium)
1.3 Symptoms
Those at highest risk are the frail elderly, immunocompromised people, pregnant
women and neonates. The disease is often manifested in the frail elderly,
immunocompromised people and newborns as meningoencephalitis (with
symptoms of fever, intense headache, nausea, vomiting, neck stiffness,
confusion) and/or as septicemia. Delirium and coma may also appear early.
Maternal infection can be characterized by fever, malaise, nausea, vomiting,
diarrhea and headache. Infection in pregnancy may result in fetal loss through
miscarriage, stillbirth, neonatal meningitis or bacteremia. Other adults and
children may exhibit only an acute, mild febrile, gastrointestinal illness.
1.4 Incubation
Incubation may be from 2 to 70 days; median is 21 days.
1.5 Source
Listeria is found in soil, vegetation, animal feed and human and animal feces.
Vaginal carriage has been seen in humans.
1.6 Transmission
Listeria is primarily food borne and is transmitted by ingesting the bacterium in
raw, unpasteurized or contaminated milk, soft cheeses, vegetables and ready-to-
eat meats. Listeria can be spread by contact with an infected product or surface,
such as hands or countertops, during food preparation. It is often found in the
environment and unlike most other harmful bacteria, it can grow slowly on food
stored in a refrigerator. Vertical transmission is also possible from an infected
mother to fetus in utero or during passage through the infected birth canal.
1.7 Communicability
None
1.8 Treatment
Ampicillin, or for those who are penicillin allergic, cotrimoxazole (use with
caution in pregnant patients) or vancomycin, is preferred.
2.1.2 Education
See Section 1.9, Core Messages for Prevention.
Distribute the Listeriosis Fact Sheet to physicians, clients, families, employers,
etc.
i. Healthy patients:
Healthy patients are not likely to become ill from eating food containing
listeria bacteria.
2. If patients have consumed food items that have been recalled and they DO
HAVE symptoms of diarrhea and fever:
ii. High Risk patients: If these patients have fever, they may be bacteremic.
Two aerobic blood cultures should be drawn, at least 15 minutes apart to
maximize sensitivity of detection of the bacteremia. Blood culture vials
are available in emergency departments and at regional hospitals.
3. Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 18th edition. 2004. James Chin, editor. American
Public Health Association.
Red Book: 2006 Report of the Committee on Infectious Diseases, 27th edition. American
Academy of Pediatrics.
LISTERIOSIS FACT SHEET
What is Listeriosis?
Listeriosis is a serious infection caused by eating food contaminated with the bacteria,
Listeria monocytogenes. Listeria is found in soil, water and sewage. Vegetables can
become contaminated from the soil or from manure used as fertilizer. Animals can carry
the bacteria and can contaminate foods of animal origin (meats, dairy products, etc).
Listeria can be detected in a variety of raw foods, such as uncooked meats and
vegetables. It is also found in foods that become contaminated after processing, such as
soft cheeses, hot dogs and deli meats.
Unpasteurized (raw) milk or foods made from raw milk may contain Listeria. Babies can
be born with listeriosis if their mothers eat contaminated food during pregnancy.
Healthy adults and children may consume contaminated foods without becoming ill.
Those at highest risk for infection, however, can get listeriosis after eating food
contaminated with even a few bacteria.
While pregnant women may only have mild symptoms, infections can lead to
miscarriages, premature delivery, infection of the newborn or even stillbirth.
However, if you are in a high-risk group, have eaten the contaminated product, and
within two months become ill with fever or signs of serious illness, you should contact
your physician and inform him or her about this exposure.
1.0 Information
1.3 Symptoms
Acute onset of nausea, vomiting, non-bloody diarrhea, abdominal pain, myalgia,
headache, malaise, low-grade fever or a combination of these symptoms,
generally lasting 24 to 48 hours.
1.7 Source
The main source is stool and vomit from infected persons. Humans are the only
known reservoir.
1.8 Transmission
Transmission occurs via fecal-oral route. Person to person transmission occurs
either directly or indirectly through environmental contact such as contaminated
food, water and fomites. Aerosolization transmission from vomitus has been
reported. Single or multiple modes of transmission have been reported.
1.9 Communicability
Transmissibility usually occurs during the acute stage of the disease, but can be
up to 48 hours after the diarrhea stops and sometimes longer.
Resident/Client Placement:
o Contact precautions- resident/client should be confined to their
room as much as possible until asymptomatic for 48 hours.
o In a shared room, a resident/client with symptoms should not
share a toilet with a well resident/client. Assign a dedicated toilet
or commode, if possible.
o In shared rooms, roommates and all visitors must be aware of the
precautions.
o Whenever possible, dedicate equipment to be used only on the ill
resident/client. In the event that equipment must be shared,
thorough cleaning and disinfection is required in between
residents.
Ill health care workers and food handlers should not work, if they develop
symptoms consistent with a GI infection (e.g. vomiting, diarrhea) while at
work the employee should be required to leave work immediately.
Exclude ill staff from work until 48 hours after symptoms have stopped.
Cleaning –See SECTION 4.0.
Limitation and restriction of visitors may be necessary in outbreak
situation. Visitors and volunteers should be advised that they may be at
risk of acquiring an infection within the facility, instructed how to wear
appropriate PPE and required to use hand hygiene before and after their
visit. Visitors should visit only their own friend/relative in their own room,
unless otherwise approved by the Heath care provider.
Contact the Department of Agriculture as soon as an outbreak has been
established. Food Safety Specialists (FSS) routinely visit this type of
facility to conduct food related and facility inspections. The FSS may visit
the facility to rule out food as a source of the illness as well as conduct an
inspection of the facility to ensure all precautions are being adhered to.
FSS are also able to provide environmental sanitation advice and
resources.
Also refer to “Guidelines-Partners for Infection Control“ available in all
district Public Health Services Offices and at:
http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infection_Control_Gu
idelines.pdf
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
General Household:
Use an appropriate disinfectant agent. Hypochlorite-based products (i.e.
house bleach 1000 ppm) or accelerated hydrogen peroxide products are
effective disinfectants.
o If using regular household bleach, a detergent must be used prior
to bleach application.
Disinfect the area with a fresh 1/10 dilution of household bleach 5.25%
(e.g. 1 part bleach to 50 parts water or 20 ml of bleach to 980 ml of
water) and allow to air dry naturally. (ensure that area is very well
ventilated) or an accelerated hydrogen peroxide following the
manufacturer’s directions for dilution and contact time.
Increase frequency of cleaning during norovirus outbreak, especially of
commonly touched surfaces. Do not reuse cleaning cloth or sponge for
other areas of the site to avoid spreading the virus.
5.0 References
Centres for Disease Control and Prevention; Guidelines for the Prevention and Control
of Norovirus Gastroenteritis Outbreaks in Healthcare Settings. Retrieved from
http://www.ahe.org/ahe/content/cdc_noroguide_2011.pdf
Control of Communicable Diseases Manual, 19th edition. 2008. James Chin, editor.
Ministry of Health and Long Term Care, Norovirus Facts. CIB-2150473, March 2007.
Retrieved from
http://www.health.gov.on.ca/english/providers/pub/disease/noroviruses.html
Morbidity and Mortality Weekly Report Updated Norovirus Outbreak Management and
Disease Prevention Guidelines. U.S. Department of Health and Human Services. Centers
for Disease Control and Prevention, March 4, 2011.
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases
under National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from
http://www.phac-aspc.gc.ca/publicat/ccdr-r60. mtc/09pdf/35s2-eng.pdf
6.0 Appendices
A. Norovirus Fact Sheet - English
B. Norovirus Fact Sheet - French
Norovirus Fact Sheet_____________
What are noroviruses?
The term “norovirus” is the official name for a group of viruses that cause
gastroenteritis. They are also called caliciviruses (because they belong to the virus family
Caliciviridae). They used to be called Norwalk-like viruses (NLVs).
Norovirus illnesses are common and affect all age groups. They can occur anytime but
are more common in the winter months.
How is it spread?
Noroviruses are spread mainly through contact with the vomit or feces of an infected
person. This happens because:
The virus can spread easily from person to person on unwashed hands.
The virus can also spread through food, water, or ice that has been handled by a
sick person.
Vomiting may spread the virus short distances through the air.
The virus can survive on surfaces such as door handles, countertops or sink taps
for a long time.
You can get a norovirus illness while caring for someone who is infected with it.
Noroviruses spread easily in places where people are in close contact—for example,
schools, daycare centres, long-term care facilities, health-care facilities and cruise ships.
Handwashing tips
What should I do if someone in
Wet your hands with warm
my family is vomiting and has running water.
diarrhea? Add soap and scrub for at
least 15 seconds. Wash all
Anyone who is vomiting and has diarrhea
parts of your hands -- the
should stay home from work, school or backs, between fingers,
daycare. thumbs and under the nails.
Food handlers and health care workers
Rinse off soap under
should not return to work until 48 hours
running water for 5 to 10
after diarrhea and vomiting have
seconds.
stopped.
Dry your hands with a
Wash hands often, especially after using
towel. Pat them dry. Do not
the bathroom or changing diapers and
rub.
before eating or preparing food.
Turn off the tap with a
Thoroughly clean floors, counters, and towel.
bathrooms. Pay extra attention to
surfaces that are often touched.
Don’t share glasses or dishes.
Use separate towels for sick family members.
Do not vacuum vomit or feces from carpets. Clean as above and, if possible, follow up
with steam cleaning before vacuuming.
www.phac-aspc.gc.ca/id-mi/norovirus_e.html
For more information on proper handwashing, visit:
www.hc-sc.gc.ca/ewh-semt/pubs/occup-travail/handwashing-lavage-eng.php
www.caringforkids.cps.ca/healthybodies/handwashing.html.
Fiche d'information sur les norovirus
Que sont les norovirus?
Le terme « norovirus » est le nom officiel d'un groupe de virus qui causent la
gastroentérite. On les appelle également les calicivirus (parce qu'ils sont membres de la
famille des Caliciviridés). On les appelait autrefois les virus semblables à Norwalk.
Les maladies causées par les norovirus sont courantes et touchent les gens de tous les
âges. Elles peuvent se produire en tout temps, mais sont plus courantes pendant l'hiver.
la nausée
les vomissements
la diarrhée
le virus peut se transmettre facilement d'une personne à une autre par des
mains qui n'ont pas été lavées;
le virus peut également se transmettre par la nourriture, l'eau ou la glace
manipulée par une personne malade;
lors des vomissements, des gouttelettes sont projetées dans l’air sur de courtes
distances;
le virus peut survivre sur des surfaces telles que les poignées de porte, les
comptoirs et les robinets pendant de longues périodes.
Vous pouvez contracter une maladie causée par les norovirus si vous prenez soin d'une
personne infectée.
Les norovirus se répandent facilement dans des milieux où les gens ont des contacts
directs, y compris dans les écoles, les garderies, les établissements de soins de longue
durée, les établissements de santé et les bateaux de croisière.
Le virus est transmissible pendant la présence des symptômes et jusqu'à deux jours
après le rétablissement. Chez certaines personnes, le virus est transmissible aussi
longtemps que deux semaines après la disparition des symptômes. C'est pourquoi il est
important de bien se laver les mains, même si les symptômes sont disparus.
www.phac-aspc.gc.ca/id-mi/norovirus-fra.php
Pour obtenir de l'information sur la façon appropriée de se laver les mains, consultez le :
www.phac-aspc.gc.ca/im/iif-vcg/wh-lm-fra.php#a
www.soinsdenosenfants.cps.ca/corpsensante/LavageDesMains.htm
SALMONELLOSIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection with or without clinical illness:
isolation of Salmonella sp. (excluding Salmonella typhi) from an
appropriate clinical specimen (e.g. sterile site, deep tissue wounds, stool,
vomit or urine).
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case.
Note: For Public health management of Salmonella paratyphi, please see the
Typhoid and Paratypohoid Fever chapter.
1.3 Symptoms
Any of the following: sudden onset of headache, fever, abdominal pain, diarrhea,
dehydration, nausea and sometimes vomiting. May be asymptomatic.
1.4 Incubation
Usually 12 to 36 hours, may be from 6 to 72 hours.
1.5 Source
Stool of an infected person or animal, including poultry, swine, cattle, rodents,
dogs, cats, reptiles and turtles.
1.6 Transmission
Fecal-oral, from person/animal to person, or by ingestion or handling of food
derived from infected animals or contaminated by feces of infected person or
animal.
1.7 Communicability
Shedding of the bacteria in the stool occurs throughout entire infection, usually
several days to several weeks. About 1% of adults and 5% of children go on to
carry and excrete the bacteria for >1 year.
1.8 Treatment
None, antibiotic treatment may lengthen the period of communicability. Under
special circumstances an antibiotic may be given (i.e. client is infant under 2
months, elderly, persons with sickle cell disease or HIV infection, or persons with
continued or high fever).
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for salmonellosis.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G. Donowitz ed Williams
and Wilkins.
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Salmonellosis http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
SALMONELLOSIS FACT SHEET
What is Salmonellosis?
Salmonellosis is an infection of the intestine with bacteria called Salmonella. The effects
of the disease can range from mild to severe. In the worst cases, the disease spreads to
the blood stream and can cause death. Salmonella live in the intestines of humans and
other animals, including birds. Salmonella are usually transmitted to humans by eating
foods contaminated with animal stools. Contaminated foods usually look and smell
normal. Salmonella may also be found in the stool of some pets, especially those with
diarrhea. People can become infected if they do not wash their hands after contact with
the stool. Most reptiles (90%) shed salmonella in their stool.
Confirmed Case:
Clinical illness and:
detection of saxitoxin in epidemiologically related, ingested shellfish
OR
detection of high levels of dinoflagellates associated with shellfish
poisoning in water from which epidemiologically related shellfish were
gathered.
Probable Case:
Clinical illness within 12 hours of consumption of bivalve mollusc shellfish (e.g.
oysters, clams, mussels).
Confirmed Case:
Confirmation of the shellfish toxin (Domoic acid) from the contaminated tissue.
Probable Case:
Clinical presentation of symptoms and recent consumption of shellfish.
1.4 Incubation
Five minutes to 30 minutes from consumption.
1.5 Source
Contaminated shellfish, including oysters, clams, mussels and certain crabs and
snails.
1.6 Transmission
Consumption of raw or cooked contaminated shellfish.
1.7 Communicability
None.
1.8 Treatment
Supportive. Evacuation of stomach contents may help if consumption was
recent.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for shellfish poisoning.
2.1.2 Physician
Use general guidelines. No additional guidelines.
2.1.3 Laboratory
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Amnesic Shellfish Poisoning, Lora E. Fleming, National Institute of Environmental Health Sciences
Marine and Freshwater Biomedical Sciences Center 2001, http://www.redtide.whoi.edu/hab/illness
Paralytic Shellfish Poisoning, Lora E. Fleming, National Institute of Environmental Health Sciences
Marine and Freshwater Biomedical Sciences Center 2001, http://www.redtide.whoi.edu/hab/illness
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association.
SHELLFISH POISONING FACT SHEET
What is Shellfish Poisoning?
In some coastal waters, shellfish eat a type of algae that contains a poison. When
people eat the shellfish, they may become seriously ill.
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case.
1.3 Symptoms
Diarrhea, fever, nausea, and occasionally toxemia, vomiting, cramps and
tenesmus; illness ranges from mild to severe. Asymptomatic infections occur.
1.4 Incubation
1-3 days ranging from 12 hours to 1 week.
1.5 Source
Humans: from feces of infected person.
1.6 Transmission
Fecal-oral, direct or indirect contact primarily due to a failure to adequately
wash hands after using the toilet, through sexual contact, and possibly also
through contaminated water, milk and contamination by flies. Only a very small
dose is required (10-100 bacteria) for infection to occur.
1.7 Communicability
Usually shedding ends within 4 weeks, carriage for longer periods is possible but
rare. Antibiotic treatment reduces communicability to less than a week.
1.8 Treatment
Fluid replacement, antibiotic treatment useful for severe infections and to
shorten duration of shedding. Multi-drug resistance is common, so antimicrobial
treatment depends on the isolated strain.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for shigellosis.
2.1.2 Investigator
Use general guidelines. No additional guidelines.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
2.2 Criteria for Exclusion
Exclude clients in the risk groups below according to the general guideline as
well as any additional noted requirements:
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G. Donowitz ed Williams
and Wilkins.
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Shigellosis. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
SHIGELLOSIS FACT SHEET
What is Shigellosis?
Shigellosis is a disease caused by a group of bacteria called Shigella. The bacteria are
found in the stools of infected people. Most infections are the result of the bacteria
passing from the stools or unwashed hands of an infected person to the mouth of
another person. This happens when good hygiene and proper hand washing techniques
are not followed.
Shigella can also be passed in contaminated food. The food becomes contaminated
when infected food handlers do not wash their hands after using the toilet. Flies can
breed in infected stool and then land on and contaminate food. Contaminated food
may look or smell fine. Water can also be contaminated if sewage runs into it or
someone with shigellosis swims in it.
Probable case:
Clinically compatible symptoms and epidemiologically linked to a confirmed case
or to meat known to contain trichinella larvae.
1.3 Symptoms
Infections range from inapparent infection to fulminating fatal illness depending
on the dose of larvae ingested. Most infections are inapparent. Gastrointestinal
symptoms may appear first, including diarrhea, nausea, and abdominal pain.
Other early signs of infection can include muscle soreness, fever and edema of
upper eyelids. Thirst, profuse sweating, chills, and weakness follow. Cardiac and
neurological conditions may appear in 3-6 weeks.
1.4 Incubation
Gastrointestinal symptoms may occur within a few days. Systemic usually appear
within 8 to 15 days of ingestion of infected meat. Can range from 5 to 45 days
depending on number of parasites ingested.
1.5 Source
Swine, dogs, cats, horses, rats and carnivores.
1.6 Transmission
Consumption of raw or insufficiently cooked meat from an animal containing
encysted larvae, primarily pork and beef when mixed with pork and bear meat.
Not transmitted from person to person.
1.7 Communicability
Animals remain infected for months; meat from infected animals remains
communicative for long periods unless meat is cooked, frozen or irradiated.
1.8 Treatment
Albendazole and mebendazole are effective. Coadministration of corticosteroids
is recommended in severe cases to alleviate symptoms of inflammation.
1.10 Prophylaxis
Persons known to have ingested contaminated meat should be treated with
mebendazole.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for.
2.1.2 Investigator
Use general guidelines. No additional guidelines.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
Trichinosis. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
TRICHINELLOSIS FACT SHEET
What is Trichinosis?
Trichinosis, also called trichinellosis is caused by eating raw or undercooked pork and
wild game infected with the larvae of a species of worm called Trichinella. The disease
can be mild to severe, and can cause death in some people.
Paratyphoid:
Confirmed and Probable cases are defined as per Salmonellosis (refer to
Salmonella chapter for case definition).
Note: Paratyphoid symptoms are similar to Salmonella typhi but are less severe.
Public health management for partyphoid is provided in this chapter.
1.3 Symptoms
Characterized by insidious onset of sustained fever, headache, malaise, anorexia,
splenomegaly, constipation or diarrhea, and non-productive cough. Relative
bradycardia and rose spots (less than 25% of individuals) may be seen. Atypical
presentations occur, and the severity of illness varies. Chronic carrier state (<5%
of population) is usually linked to the biliary or urinary tract and should be
distinguished from short-term fecal carriage
1.4 Incubation
From 3 days to 1 month, range of 8-14 days.
1.5 Source
Stool and/or urine of infected person. No animal reservoir is known for typhoid
fever, and rarely domestic animals are a reservoir for paratyphoid fever.
1.6 Transmission
Fecal-oral from person to person, or by ingestion of food or water contaminated
by feces or urine of the infected person, (flies may be a vehicle for the
contamination of food). Consumption of shellfish taken from beds contaminated
by sewage, raw fruits and vegetables, fertilized by human waste and eaten raw.
1.7 Communicability
Usually from the first week of illness throughout convalescence; 2 to 5 percent
may become chronic carriers of S. typhi.
1.8 Treatment
Treat in acute stage with antibiotics.
1.10 Prophylaxis
For paratyphoid fever there is no prophylaxis. For typhoid fever, immunization
may be considered for household and nursing home contacts of carriers only.
Vaccination also warranted for persons travelling to endemic areas and those at
risk because of occupation.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for typhoid/paratyphoid fever.
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health
Use general guidelines. No additional guidelines.
2.1.2 Investigator
Use general guidelines. Additional guidelines re:
1. Investigating contacts:
If the case was travelling in an endemic area, all members of the travel
group should be considered contacts, followed up and given advice to be
screened. When attempting to determine source, all contacts with a
history of travel to an endemic area should be screened for Salmonella
typhi or paratyphi. In the absence of foreign travel, all close and
household contacts should be screened in an effort to determine source.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. In addition, it is the responsibility of the laboratory to
report immediately, by telephone, all positive results for S. typhi or S. paratyphi
to Public Health Services.
2.2 Criteria for Exclusion
Exclude clients in the risk groups below according to the general guideline as
well as any additional noted requirements:
Maintain surveillance of chronic carriers until they are cleared; this requires they
submit 3 consecutive negative stool cultures, taken not less than 24 hours apart
and at least 48 hours after the termination of any antibiotic therapy. Chronic
carriers may submit one culture a month.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G. Donowitz ed Williams
and Wilkins.
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
Typhoid Fever. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
TYPHOID AND PARA TYPHOID FACT SHEET
What is Typhoid Fever?
Typhoid fever is a life-threatening illness caused by the bacteria Salmonella Typhi. The
infection is spread directly from person to person or through contaminated food or
water.
Some infected persons (chronic carriers of the bacteria) may not show any symptoms,
but can pass the bacteria in their bowel movements and urine for many years. Animals
do not carry the bacteria.
1.3 Symptoms
Acute onset of nausea, vomiting, abdominal cramps, and diarrhea. Headache,
fever, chills, and myalgia are frequently reported.
1.4 Incubation
12 to 48 hours.
1.5 Source
Human feces.
1.6 Transmission
Fecal oral, although airborne and fomite transmission facilitate spread during
outbreaks. Also via fecally contaminated food and water.
1.7 Communicability
Communicable until approximately 48 hours after symptoms have finished.
1.8 Treatment
Supportive therapy.
1.10 Prophylaxis
None.
2. Procedure
NOTE: Viral Gastroenteritis is not followed up unless outbreak is suspected. Use the
General Guidelines for Investigation at the beginning of this section. The following are
additional guidelines for viral gastroenteritis.
2.1.2 Investigator
Viral gastroenteritis is not reportable and does not need to be followed up
unless a cluster of cases is identified. If an outbreak is identified, use general
guidelines.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G. Donowitz ed Williams
and Wilkins.
Norwalk-Like Viruses: Public Health Consequences and Outbreak Management. 2001. Morbidity and
Mortality Weekly Report, 50(RR-9). Centers for Disease Control
VIRAL GASTROENTERITIS FACT SHEET
What is Viral Gastroenteritis?
Gastroenteritis means inflammation of the stomach and small and large intestines. Viral
gastroenteritis is an infection caused by a variety of viruses that results in vomiting or
diarrhea. Some of the viruses that can cause gastroenteritis include rotaviruses,
adenoviruses, caliciviruses, astroviruses, Norwalk virus, and a group of Norwalk-like
viruses.
Symptoms begin 1 to 2 days following infection with a virus. The illness usually lasts
between 12 and 60 hours.
What is the Treatment?
There are no drugs to cure viral gastroenteritis. It is important to drink plenty of fluids to
prevent dehydration.
1.3 Symptoms
Y. enterocolitica is most often linked with gastroentrocolitis and can
cause acute watery diarrhea, with leucocytes, blood and mucous in the
stool, fever, headache, anorexia and vomiting.
Y. pseudotuberculosis presents with fever, abdominal pain, adenitis,
appendicitis or terminal ileitis.
1.4 Incubation
Usually 3-7 days, can range from 1-14 days.
1.5 Source
The principal reservoirs are animals. Y. enterocolitica is found in swine and Y.
pseudotuberculosis is found in many types of birds and animals, especially
among rodents and other small mammals.
1.6 Transmission
Ingestion of food or water contaminated by the bacteria or contact with infected
persons or animals. Y. enterocolitica infection is most often associated with
undercooked meat and pork products. Transfusion with blood from donors who
were asymptomatic or direct fecal- oral, person to person transmission is also
possible.
1.7 Communicability
2-6 weeks or longer if untreated, up to 6 months. Long term carriers are
possible.
1.8 Treatment
Yersinia is usually resistant to penicillin and its derivatives, however it is
susceptible to aminoglycosides, cefotaxime and other cephalosporins. Newer
quinlones such as ciproflaxin are also effective. Tetracyclines can be given to
adults and children older than 9 years of age. These antibiotics can help reduce
the time of excretion.
1.10 Prophylaxis
None.
2. Procedure
Use the General Guidelines for Investigation at the beginning of this section.
The following are additional guidelines for yersiniosis.
2.1.3 Physician
Use general guidelines. No additional guidelines.
2.1.4 Laboratory
Use general guidelines. No additional guidelines.
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control Measures for Gastrointestinal Infections. Department of Health and Social Services, Prince Edward
Island, April 1991.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Giardiasis Infections. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
Infection Control in the Child Care Center and Preschool. 3rd edition –1996-Leigh G. Donowitz ed Williams
and Wilkins.
Ready Reference Set, Maryland Department of Health and Mental Hygiene, August 1990.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
Working Guide: Notifiable Disease Reporting System in Nova Scotia. 1998. Nova Scotia Department of
Health.
YERSINIOSIS FACT SHEET
What is Yersiniosis?
Yersiniosis is a disease caused by either the bacteria Yersinia enterocolitica or Yersinia
pseudotuberculosis. Infection is usually caused by eating contaminated food, especially
raw or undercooked pork. Drinking contaminated unpasteurised milk or untreated
water can also transmit the infection. Sometimes infection occurs after contact with
infected animals. On rare occasions, it can be transmitted as a result of the bacteria
passing from the stools or soiled fingers of one person to the mouth of another person.
This may happen when basic hygiene and hand washing habits are inadequate.
• Principles
• General Guidelines
• Hepatitis B
• Hepatitis C
• HIV/AIDS
• Management of Occupational Exposures to HBV, HCV, & HIV
• Lookback/Traceback Protocol
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public
Health staff within the District Health Authorities. This manual is constantly under
revision. Public Health staff will be informed of the changes as they occur. However,
information contained on this site may not contain the latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for
the use of this information by any other groups or organizations aside from Public
Health staff within the District Health Authorities.
BLOOD BORNE PATHOGENS
Principles
The principles for the management of blood borne pathogens are:
1. Investigate and manage cases in a timely manner and prevent transmission.
2. Educate and counsel individuals, their partners and contacts.
3. Add all new cases of blood borne pathogens to the provincial database for
notifiable diseases.
4. Educate the general public.
General Guidelines for Blood Borne Pathogens
This section provides guidelines for the investigation and management of cases of blood
borne pathogens in Nova Scotia. Specific procedures for HIV, Hepatitis B and Hepatitis C
follow-up are found under the specific disease. Specific procedures for syphilis are found
in the sexually transmitted diseases section, with the exception of the traceback
protocol, which is found in this section.
3. Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
4. Core Messages for Prevention
Education for prevention should include:
• Practice safer sex including limiting the number of partners and using
condoms (see section 3 in the General Guidelines of the STD section).
• Discuss the use of clean needles.
• Discourage needle sharing and the sharing of paraphernalia and wash.
• Encourage the use of needle exchange programs
• Advise the infected individual not to donate blood, body tissue or organs.
• Encourage Hepatitis B vaccine for those with high risk behaviour and
those with occupational risk.
• Avoid exposure to blood and body fluids.
• Use standard precautions in institutional and community settings where
there is potential for contact with blood or body fluids.
• In household settings where there is an individual with HIV or HBV or
HCV, do not share toothbrushes, razors, nail files etc.
• Household and sexual contacts of a Hepatitis B carrier should receive
Hepatitis B vaccine.
• Sexual contacts of an acute Hepatitis B individual should receive Hepatitis
B vaccine.
• Individuals who are Hepatitis C positive should receive Hepatitis A and B
vaccine.
• All pregnant women should be tested for HBV and HIV.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Guidelines for Practice for Partner Notification in HIV/AIDS. 1997.
Federal/Provincial/Territorial Advisory Committee on AIDS Working Group on Partner Notification. Nova
Scotia Children and Family Services Act, 1991.
Working Guide: Notifiable Disease Reporting System in Nova Scotia. 1998. Nova Scotia Department of
Health.
HEPATITIS B (HBV)
1. Information
1.1. Case definition:
Laboratory confirmation of the infection:
Acute Case
Confirmed case
• Hepatitis B surface antigen (HBsAg) and immunoglobulin M antibody to
hepatitis B core antigen (anti-HBcIgM) positive in the context of a
compatible clinical history (including serum aminotransferase levels >2.5
times the upper limit of normal)or probable exposure
Probable case
Acute clinical illness in a person who is epidemiologically linked to a confirmed
case
Chronic Carrier
Confirmed case
• HBsAg positive for more than 6 months
OR
• Detection of HBsAg in the documented absence of anti-HBc-IgM
OR
• Detection of HBV DNA for more than 6 months
Unspecified
Confirmed case
• Does not fit the criteria for acute or chronic hepatitis B
AND
• HBsAg positive
OR
• Detection of HBV DNA
1.3. Symptoms:
May be asymptomatic. Symptoms may include jaundice, malaise, anorexia,
nausea, vomiting, myalgia, rash and arthlagia. Fever may be absent or mild.
Chronic infections may present with disease flares with similar symptoms and
signs
1.4. Incubation:
45 to 160 days, average 120 days.
1.5. Source:
Blood and blood products, semen, and vaginal fluids.
1.6. Transmission:
Routes of transmission include sexual contact, percutaneous exposure (needle
stick or injection drug use when equipment is shared), permucosal exposure, and
perinatal transmission. HBV is stable on environmental surfaces in blood for at
least 7 days making indirect transmission from objects contaminated with
infected blood possible.
1.7. Communicability:
From several weeks before symptoms until infection is resolved. However,
5%-10% of infected adults go on to carry the HBV for life. Chronic infection
occurs in 90% of infants infected at birth, and 25–50% of children infected at
age 1–5 years. Carriers may transmit the virus at anytime.
1.8. Treatment:
Supportive for acute hepatitis B. Specialized treatment is available for some
patients.
1.9. Core Messages for Prevention:
Use core messages in general guidelines (section 3.0). In addition:
• Avoid exposure to blood and body fluids: use standard precautions in
settings where there is a risk of exposure and at home where there is a
known HBV infected person. (See manual section on standard
precautions).
• Wash hands meticulously if exposure to blood or body fluids is
experienced.
• Consider hepatitis B immunization for those at risk. Refer to Table 2.
1.10. Prophylaxis
1.10.1 Pre-exposure
a. Hepatitis B Immunizations
Immunization recommendations are based on the Canadian Immunization
Guide, 6th edition, 2002. Readers are encouraged to refer to the most recent
version of this document, which is updated regularly.
1.10.2 Post-exposure
a. Percutaneous or permucosal exposure
Refer to Management of Occupational Exposures later in this section of the
manual.
*In high-risk situations, the MOH may review the circumstances and determine
that publicly funded vaccine should be provided. Although HBV vaccine is
recommended for certain professions in which there is an increased risk of
contracting HBV, payment is deemed to be the responsibility of the employer or
the individual.
2. Procedure
Use the General Guidelines for Blood Borne Pathogens at the beginning of this section.
The following are additional guidelines for Hepatitis B.
2.1.2. Investigator:
All cases of HBsAg+ should be followed up unless the person is a documented
carrier who has been followed up as a carrier. Each district should keep a list of
hepatitis B carriers (more information below on carriers).
2.1.3. Physician:
Use general guidelines. Also use the following additional guidelines re:
a. Patient education.
In addition to the general guidelines, educate HBV infected persons as
per section 5.1.2 (a & b above).
2.1.4. Laboratory:
All new cases of HBV require telephone and written reporting within one
working day to PHS.
2.2. Criteria for Exclusion.
None. See special note re: food handlers in general guidelines section 2.1.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Canadian Immunization Guide, 6th edition. 2002. Health Canada. Control of Communicable
Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health Association.
Infection Control in the Child Care Center and Preschool, Third edition. 1996 Donowitz LG (ed.),
Williams and Wilkins. Your Child’s Best Shot: A Parent’s Guide to Vaccination. 1997. Canadian
Pediatric Society.
HEPATITIS B FACT SHEET
What is Hepatitis B?
Hepatitis B is an infection of the liver caused by a virus. The virus is in the blood, semen
and vaginal fluids of a person with hepatitis B.
People with the hepatitis B virus should tell their doctors, dentists, dental hygienists and
all of their sexual partners that they are infected.
All sexual partners of those who carry hepatitis B should be vaccinated. All persons
who have been exposed to hepatitis B should contact their doctor.
HEPATITIS C (HCV) JULY 07
1. INFORMATION
1.1. Case Definition
Confirmed Case (Does Not Distinguish Acute from Chronic Infection):
Detection of anti-hepatitis C antibodies (positive anti-HCV tests should be
confirmed by a second manufacturer’s EIA, immunoblot or NAT for HCV RNA).
OR
Detection of hepatitis C virus RNA
Anti-HCV testing should not be performed in infants < 18 months of age as the
anti-HCV may represent passive maternal antibody. As most infections occur at
the time of childbirth, if testing for HCV RNA is considered, it should be delayed
beyond 4 to 12 weeks to avoid false-negative HCV RNA test results. Cord blood
should not be used because of potential cross-contamination with maternal
antibody.
a. Nominal Testing
Nominal testing means that the client’s name is used on the form that is sent to
the laboratory with the blood sample. The name is also used on the test result
when the lab sends it back to the physician. If the result is positive, the lab and
physician report the test result and name to the Medical Officer of Health (MOH)
in the Public Health office covering the jurisdiction where the testing originated.
b. Non-nominal Testing
Non-nominal testing for HCV is done in some settings like the STI Clinics and
Corrections. A code is used on the form that is sent to the laboratory with the
blood sample. The code is also used on the test result when the lab sends it back
to the physician. If the result is positive, the lab and physician report the test
result to the MOH. Public Health Services must call the reporting physician for
the client’s name.
1.4. Symptoms
Onset of symptoms is usually insidious. Symptoms may include anorexia, vague
abdominal discomfort, nausea and vomiting, and occasionally jaundice. Usually
symptoms are milder than those of hepatitis B. Between 50 and 80% develop
chronic infection. Chronic infections may present with disease flares and similar
symptoms and signs.
1.5. Incubation
Usually 45-180 days, average 60-90 days.
1.6. Source
Humans.
1.7. Transmission
Possible routes of transmission include:
• percutaneous exposure to HCV contaminated equipment (injection drug use
paraphernalia, needle stick puncture, razors, tattoo and piercing equipment,
etc)
• HCV infected blood gets into an open cut or a mucous membrane
• transfusion or transplantation
• rarely sexual contact
• rarely perinatal transmission from an HCV infected mother
1.8. Communicability
From one or more weeks before the onset of symptoms (if present); virus
persists indefinitely in most persons without treatment. Cases testing PCR
negative after treatment should still take steps to prevent transmission due to
the remote possibility of transient viremia.
1.9 Treatment
There is treatment available for people with hepatitis C infection. Consult with a
specialist for the latest treatment.
1.11. Education
See Section 4, Core Prevention Messages. Also use additional guidelines
regarding educating.
Educating the client about the following:
• Range of clinical presentation from very ill to no symptoms
• Incubation period
• Routes of transmission, risk behaviours and prevention outlined in the
general guidelines section. Note that the risk of sexual transmission
appears to be lower for hepatitis C than for HBV or HIV, however HCV
infected persons have a responsibility to inform potential sexual partners
that there is a risk of infection. The risk of transmission may increase with
repeated sexual exposures, therefore long term sexual partners of HCV
infected persons should be offered testing by their physicians. Safer sex
practices should always be used
• Long-term prognosis and concept of carrier status note that 80% of
patients progress to chronic liver disease over a period of 30 to 40 years
with the associated risks for developing cirrhosis or liver cancer. Reassure
and support clients when discussing long-term prognosis
• Benefits of receiving publicly funded hepatitis A and B vaccine
2.0 PUBLIC HEALTH CASE MANAGEMENT AND CONTROL
MEASURES
Note, a flow chart has been developed to delineate the work processes involved
in case management. Flow chart 4.1 HCV Initial Case and Contact Management
describe the steps for follow-up.
2.2 Cases
For the process to determine whether a case has been previously reported or a
new case refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases
and Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
As per the general guidelines, follow up and education is usually managed by the
PHN assigned to the case.
The PHN contacts the physician named on the lab report and informs them that
hepatitis C follow-up is done by Public Health. The PHN contacts the client and
documents required case management including risk factors and receipt or
donation of blood products, cells, tissues or organs. If blood transfusion and/or
donation has been identified, specific information with respect to the dates of
transfusion and/or donation, institution, and the case’s address at the time of
transfusion and/ or donation are collected with as much detail as possible. If
the client donated or received blood products in the United States, his or her
Social Security Number is required. (See lookback / traceback protocol.)
2.3 Contacts
There are three types of contacts: sexual, injection drug use, and recipients of
cells, tissues and organs.
2.3.1 Susceptibility
Susceptibility is universal.
2.3.2 Prophylaxis
• Refer to Management of Occupational Exposures later in this section of
the manual.
• No prophylaxis is available.
2.3.3 Exclusion
No exclusion is required.
2.3.4 Follow-Up
• For donation or receipt of blood products, cells, tissues and organs see
lookback / traceback procedure.
• Because the risk of sexual transmission of HCV appears to be lower than
for HBV or HIV, contact tracing is not warranted. However, HCV infected
persons have a responsibility to inform sexual partners that there is a risk
of infection.
• Consider follow-up for other individuals if there is exposure to a common
source (i.e. Tattooing).
References:
Public Health Agency of Canada. (2009).Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 18th edition. 2004. David L. Heymann, editor. American
Public Health Association.
Hepatitis C Lab Result interpretation
Result Interpretation
Anti-HCV negative Unlikely to have HCV infection.
Occasionally immunosuppressed
individuals, particularly HIV patients
will not have any serologic evidence of
infection but will be PCR positive.
Clinical correlation is required.
HCV-RNA (PCR) positive Active HCV infection
Anti-HCV positive Past infection with resolution and viral
HCV PCR negative clearance or current infection with viral
HCV-RIBA positive RNA that is below the limit of
detection. If clinically warranted, send
a repeat specimen for HCV-RNA testing
in one month.
Anti-HCV positive Window period during seroconversion
HCV PCR negative or a false positive. Patient should have
HCV-RIBA indeterminate repeat testing in 3 months.
HEPATITIS C FACT SHEET FEBRUARY 2008
What is Hepatitis C?
Hepatitis C is an infection of the liver caused by a virus. This virus is not spread
by casual contact such as hugging, kissing, sneezing, coughing, or sharing food or
drink. Between 50 and 80% of people who are infected with hepatitis C will go
on to carry the virus for the rest of their lives. Up to 25% of these carriers may
develop cirrhosis or possibly liver cancer.
People with the hepatitis C virus should tell their doctors, dentists, dental hygienists and
all of their sexual partners that they are infected. People with hepatitis C should not
donate blood, organs or semen.
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
JULY 2007
1. INFORMATION
1.1. Case Definition
Confirmed case
Adults, Adolescents and Children ≥ 18 months:
• detection of HIV antibody with confirmation (e.g. EIA screening with
confirmation by Western blot or other confirmatory test)
OR
• detection of HIV nucleic acid (e.g. DNA PCR or plasma RNA)
OR
• HIV p24 antigen with confirmation by neutralization assay
OR
• isolation of HIV in culture
There are three options for HIV testing. These options are noted in the Reporting
Requirements of HIV Positive Persons Regulations.
a. Nominal testing
Nominal testing means that the client’s name is used on the form that is sent
to the laboratory with the blood sample. The name is also used on the test
result when the lab sends it back to the physician. If the result is positive, the
lab and physician report the test result and name to the Medical Officer of
Health (MOH) in the Public Health office covering the jurisdiction where the
testing originated.
b. Non-nominal testing
Non-nominal testing means that a code developed by the physician is used
on the form that is sent to the laboratory with the blood sample. The code
includes 6 numbers representing the full date of birth (day, month, year), 1
letter representing gender (either M or F), first 3 letters of the county of
residence, and 3 letters chosen by the individual. The code is also used on
the test result when the lab sends it back to the physician. If the result is
positive, the lab and physician report the test result and code to the MOH.
The MOH has the authority to request the name and other identifying
information from the physician in some circumstances e.g. positive individual
has donated or received blood.
c. Anonymous testing
Anonymous testing means that the client’s name is not used on any forms.
The client contacts an anonymous testing clinic and makes an appointment
using their first name or pseudonym only. At no time is the client’s name
recorded.
1.4. Symptoms
80-90% of HIV infected people develop a flu-like illness within a month 4 to 8
weeks after exposure to the virus. This non-specific illness may include recurring
fever or profuse night sweats, headaches, malaise, pharyngitis and
lymphadenopathy. These symptoms usually disappear within a week to a month
and are often mistaken for those of another viral infection. During this period,
HIV is present in large quantities in genital fluids.
1.6. Source
Humans
1.7. Transmission
Possible routes of transmission include:
• sexual contact with an HIV infected person
• percutaneous exposure to an HIV contaminated implement (injection
drug use paraphernalia, needle stick puncture, razors, body modification,
etc)
• perinatal transmission from an HIV infected mother
• HIV infected blood coming in contact with an open cut or mucous
membrane
• transfusion, transplantation or ingestion of HIV contaminated blood,
blood products, cells, organs, tissues or breast milk
1.8. Communicability
HIV infection is communicable from early infection onward, throughout the
entire course of infection, until death
1.9 Treatment
HIV infection is currently viewed as a chronic illness with on-going advancements
in treatment modalities. HIV infected individuals should be advised to consult
their family physician or local infectious disease clinic for treatment options.
Note: Flow charts have been developed to show the work processes involved in both
case management and surveillance of the case. Although some of these processes are
concurrent and steps are valid for both workflows, they have been separated for clarity.
Flow chart 4.1: HIV Initial Case and Contact Management describes the steps for follow
up and Flow chart 4.2: HIV Surveillance describes the steps for surveillance.
2.2. Cases
For the process to determine whether a case has been previously reported or a
new case refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases
and Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
The public health nurse (PHN) assigned to the case calls the attending physician
to determine the status of the case. As per the general guidelines, follow up,
partner notification and education is usually managed by the physician.
The PHN contacts the physician and documents required case management
information including risk factors and receipt or donation of blood products,
cells, tissues or organs. If blood transfusion or donation has been identified,
specific information with respect to the dates of transfusion/ donation,
institution and the case’s address at the time of transfusion/ donation are
collected with as much detail as possible.
If the physician requests assistance or the PHN deems that it is necessary, the
PHN proceeds with case management, contact notification, and follow up as per
section 1.2.3.
2.3 Contacts
Reporting Requirements for HIV Positive Persons Regulations have been made
under Sections 74 and 106 of the Health Protection Act. Section 13 of the
Regulations details the responsibility of the HIV positive person to notify
partners that may have been exposed to the HIV virus.
2.3.2. Susceptibility
Susceptibility is universal.
2.3.3. Prophylaxis
Refer to Management of Occupational Exposures later in this section of the
manual.
2.3.4. Exclusion
No exclusion is required, however sexual contacts should be counseled to
practice safer sex by using latex condoms with oral, vaginal and anal sex at least
until the results of HIV testing have been determined and preferably on an on-
going basis.
2.3.5. Follow-Up
No follow up is necessary.
2.3.6. Education
See Section 4, Core Prevention Messages.
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association.
Laboratory Definitions and Case Definitions for Infectious Diseases under National Surveillance,
Laboratory Standardization Subcommittee, May 15, 2006.
Reporting Requirements for HIV Positive Persons Regulations made under Sections 74 and 106 of the
Health Protection Act, S.N.S 2004, c.4, O.I.C. 2005-457 (October 14, 2005, effective November 1, 2005),
N.S. Reg. 197/2005.
http://www.phac-aspc.gc.ca/aids-sida/hiv_aids/index.html
http://www.phac-aspc.gc.ca/publicat/epiu-aepi/index.html
http://www.canadian-health network.ca/servlet/ContentServer?cid=1048003175132&pagename=CHN-
RCS%2FPage%2FGTPageTemplate&c=Page&lang=En
http://www.cdc.gov/hiv/
HIV FACT SHEET JUNE 2008
What is HIV?
HIV (Human Immunodeficiency Virus) is a virus that attacks your immune system. Your
immune system helps you fight off illness. If your immune system fails, you can become
very sick. Once the virus gets inside your body, you may not look or feel sick for years
but you can still infect others. Over time, your immune system grows weak, and you
can become sick with different illnesses. This is called AIDS (Acquired
ImmunoDeficiency Syndrome).
An infected mother can pass the infection to her newborn child during the pregnancy
and delivery and through breastfeeding.
The virus is not spread by casual contact such as hugging, kissing, sneezing, coughing or
sharing food or drink.
Many people who have HIV feel healthy. The only way to know for sure if you are
infected with HIV is to have a blood test. Your doctor can give you a confidential test,
or you can be tested anonymously at an anonymous testing clinic. Call Public Health
Services for information about the anonymous testing clinic closest to you. Counselling
will be offered before and after the test is done.
What is the treatment?
There is no cure for HIV infection or AIDS. There are many treatments that slow the
damage done by the virus. Your doctor can discuss available treatments with you and
can refer you to an HIV clinic.
• Do not share needles, razors, toothbrushes, nail clippers, sexual toys, etc.
• Limit the number of sexual partners. Use a latex condom and/or oral dam
every time you have sex, including oral and anal sex.
• Wear gloves to clean up spills of blood of an infected person. Then
disinfect the area with a freshly prepared mixture of 1 part household
bleach and 9 parts water (1:10 solution).
• If you are pregnant or think you might soon become pregnant, ask your
doctor or Public Health Services about being tested for HIV. Drug
treatments are recommended to help reduce the chance of passing HIV
to your baby.
• Use only professional tattoo artists and body- piercing artists working in
reputable salons.
People with HIV are legally required to tell all of their sexual partners that they are
infected. They should also tell their doctors, dentists and dental hygienists. People with
HIV should not donate blood, organs or semen.
GUIDELINES FOR THE MANAGEMENT OF
OCCUPATIONAL EXPOSURES TO HBV, HCV,
AND HIV AND RECOMMENDATIONS FOR
POST-EXPOSURE PROPHYLAXIS
The following guidelines are intended for health care workers (HCW) and can also be
used to guide exposures involving blood or body fluids that occur outside of the health
care setting.
1. Information
1.1. Definition of Exposure
Avoiding occupational blood exposures is the primary way to prevent
transmission of Hepatitis B (HBV), Hepatitis C (HCV) and human
immunodeficiency virus (HIV) in health care settings. An exposure that might
place a HCW at risk of HBV, HCV, or HIV infection is defined as a percutaneous
injury (e.g. a needle stick or cut with a sharp object) or contact with a mucous
membrane or non-intact skin (e.g. eczema) with blood, tissue, or other body
fluids that are potentially infectious.
In addition to blood and body fluids containing visible blood, the following fluids
are considered potentially infectious:
• Semen
• Vaginal secretions
• Cerebrospinal fluid
• Pleural fluid
• Peritoneal fluid
• Pericardial fluid
• Amniotic fluid
The risk of transmission of HBV, HCV, and HIV via these body fluids in
occupational settings is unknown. Feces, nasal secretions, saliva, sputum, sweat,
urine, tears and vomitus are not considered potentially infectious unless they
contain blood. Any direct contact (i.e. contact without barrier protection) to
concentrated virus in a research laboratory is considered an exposure that
requires clinical evaluation.
For human bites, the clinical evaluation must include the possibility that both the
person bitten and the person who inflicted the bite were exposed to blood borne
pathogens. This has rarely been reported as the route of transmission of HBV or
HIV.
1.5.2. Reporting
The exposed health care worker should report the injury to a designated person
in their organization. Details of the accident should be documented and the
significance of the exposure assessed (see section 1.5.3). It is urgent that the
assessment occurs as soon as possible after the exposure, in case there is a
possibility of post-exposure chemoprophylaxis that should be initiated no later
than 48 hours after exposure.
a. Type of exposure
• Percutaneous injury
• Mucous membrane exposure
• Non-intact skin exposure
• Bites resulting in blood exposure to either person involved
All exposed persons should receive follow-up counseling, post- exposure testing
and medical evaluation regardless of whether they receive PEP or not. Perform
HIV-antibody testing at 6 weeks, 12 weeks and 6 months post-exposure.
Extended follow- up (12 months) is recommended for persons who become
infected with HCV following exposure to a source co-infected with HCV and HIV.
1.7 Counseling
Counseling the exposed person is a critical part of the post-exposure follow-up
process.
• The person should not donate blood, plasma, organs, tissue or semen
until status is known.
• The person does not need to modify sexual practices, refrain from
becoming pregnant, or discontinue breastfeeding.
• Exposed persons who care for patients do not need to alter their patient
care responsibilities based on an exposure to HBV or HCV. Persons who
become acutely or chronically infected should follow relevant
institutional policies (including infection control practices and standard
precautions.)
• During the follow-up period (especially during the first 6-12 weeks after
exposure when most HIV-infected persons are expected to seroconvert),
the person should:
- Not donate blood, plasma, organs, tissue or semen.
- Abstain from sex or use condoms to prevent transmission
and avoid pregnancy.
- Consider discontinuing breastfeeding.
• Exposed persons who care for patients do not need to alter their patient
care responsibilities based on an exposure to HIV. Persons who become
HIV infected should follow relevant institutional policies (including
infection control practices and standard precautions.)
b. Determine if the source is HBV, HCV or HIV positive or at risk for blood
borne pathogens.
It is important to determine this immediately (within 2 hours for HIV and
within 48 hours for hepatitis B and C) in case post-exposure prophylaxis is
required. Ask the client if there is a known source, and whether it is
possible to contact the source immediately. Contact the source and seek
consent for testing (pre and post-test counselling is required for both
source and contact). Ensure the source is aware that although test results
are confidential, if the source is positive for HBV, HCV or HIV the exposed
person may become aware of this because the results will determine the
intervention for the exposed person.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Canadian Immunization Guide, 6th edition. 2002. Health Canada. Integrated Protocol to Manage
Health Care Workers Exposed to Bloodborne Pathogens. 1997. Minister of Public Works and
Government Services.
Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. 2001. Morbidity and
Mortality Weekly Report, 50 (RR-11).
NOVA SCOTIA LOOKBACK PROTOCOL
BLOOD BORNE PATHOGEN (BBP)
INFECTION
Definition
A lookback is the process of identifying and contacting recipients of blood components
of a donor who, on a subsequent donation or testing, is confirmed positive with the
presence of an infectious agent.
If the MOH identifies that a client who is positive for BBP, donated blood products, then
the Medical Officer of Health decides if a lookback is required and initiates one
accordingly. CBS-Halifax will initiate a lookback based on positive results from their
testing or notification from other provincial Public Health departments or physicians.
Protocol
1. The MOH writes a letter to the Chief Medical Officer of Health (CMOH)
requesting that a lookback be initiated and providing the following information:
• Full name including all possible surnames
• Date of birth
• Place and date of donation in as much detail as possible; city and
province
• Copy of lab report
• Address at time of donation
3. With receipt of information about the positive donor, CBS-Halifax will initiate a
lookback and notify hospital Blood Bank Director, Blood Bank section head and
Chief Executive Officer of any of the components that were issued to hospitals.
1. Receives the lookback form that contains information re: donor and all
the recipients.
2. Screens information for each recipient. If there is indication that the
recipient died in the hospital of transfusion within 4 weeks of transfusion,
end lookback at this stage.
3. Keeps record of date information received, sent to region and lookback
completed.
4. Sends pertinent information for lookback to each region for follow-up.
Highlights name of clients to be followed up in each region on the
tracking form.
5. Ensures all reports are received from the regions according to time lines
and completes tracking form.
6. Provides CBS-Halifax with an interim report of progress of the lookback,
as necessary.
7. Provides CBS-Halifax with a summary of the investigation including the
recipient tracking record. CBS-Halifax will decide if the lookback
investigation will be continued on prior donations based on their
standard operating procedures.
Uses the content of the follow-up letter to indicate reason for call and follow-up
actions required. Seeks physician’s cooperation in completing follow-up within
30 days.
4. If the recipient of the blood product is deceased and if there is no evidence that
they were ever tested, the physician is advised by phone and follow-up letter to
counsel and test any regular sexual partners still living (sample letter attached).
If physician is unable, or unwilling, to do this, CDC Nurse will start contact
tracing.
5. Contact physician 30 days after letter has been sent, to review testing results. If
results not known within 30 days, contact physician periodically until follow-up is
completed.
6. Document all pertinent facts on the tracking form.
7. Once follow-up is complete, date and make a copy. Send completed lookback
form and a report containing all the details of the investigation to Regional CDC
Coordinator/Manager.
Dear Dr:
The Canadian Blood Services (CBS) and Nova Scotia Department of Health and Wellness
(Public Health Services) have undertaken a lookback.
Blood Borne Pathogen (BBP) positive individuals who donated blood will have a
lookback done to attempt to contact those individuals who received a blood product.
Although the individual who donated blood may not have been infected at the time of
the blood donation, it is important to attempt to trace the patient to counsel about the
risk of being infected.
Please contact me if you have any questions or concerns about this investigation.
Sincerely,
This information has been obtained as part of a lookback investigation performed by Public Health Services, the
Canadian Blood Services and provincial hospitals.
Although the individual who donated may not have been infected at the
(Component)
time of the blood donation, it is important to counsel your patient about the risk of being infected with blood borne
pathogens and to recommend testing.
To help you in your counselling, I have enclosed information about blood borne pathogens. Working with the Medical
Officer of Health, I am coordinating the lookback investigation that is taking place.
Because one infected individual who donates blood can infect more than one recipient, it is important that the results
of your counselling and testing be provided to Nova Scotia Health Promotion and Protection. If your patient has died
for other reasons, and if he/she had a sexual partner who is still alive, then the partner should be advised of the risk
of blood borne pathogen infection so that they can decide if they wish to be tested.
If you cannot contact your patient, or if you have problems informing him/her of the risk of infection, please let me
know so that I can arrange for Public Health Services to contact and inform them.
Please complete the enclosed form and return it marked confidential, within 30 days. Ensuring that individuals are
not infected is extremely important. If the Medical Officer of Health does not receive information within 30 days,
he/she will be contacting you to see if you require assistance in obtaining the information.
Please contact me at 902- if you have any questions or concerns about this investigation.
Sincerely,
- and -
Enclosure
Lookback: Public Health
Infected Donor
MOH or CBS-Halifax initiates Lookback
Databases Queried
Not on Database
On Database
Central Case Manager distributes recipients to regions
Protocol:
CBS-Halifax can open a traceback via other reporting routes ie: from
compensation, other Public Health departments, other CBS, physicians.
PHS discusses with physicians and individuals what risk factors are associated
with the infection and ensures that an accurate transfusion history is obtained
from index patient where appropriate.
If the individual has received blood or blood products, the Medical Officer of
Health (MOH) reviews all other risk factors to determine whether blood- product
transmission was a likely route of infection. *Note: If transfusion occurred within the
last year, initiate traceback immediately. This will ensure all indate product can be
retrieved.
If blood product infection is considered to be a likely route, the MOH completes the top
part of the form #F040587 and sends to CMOH. This form is forwarded to CMOH who
sends it to the appropriate hospital blood banks.
The hospital will send form back to CMOH who will forward it to CBS-Halifax. If the
hospital is out of province, a memo will be sent to CBS-Halifax, including name, date of
birth, hospital, province, test results, date of transfusion.
CBS-Halifax reviews Form #F040587 and initiates traceback. CBS-Halifax reviews donor
records and determines if donor has a known status (positive or negative).
CBS-Halifax sends a letter to donors with unknown infection status that encourages
them to be tested. CBS-Halifax ensures that any blood products still available from
donors under investigation are retrieved and destroyed.
If any donors are found to be positive, CBS-Halifax opens a lookback investigation. This
investigation will be investigated as per Nova Scotia’s lookback protocol.
These definitions are adapted from Guidelines for Practice for Partner Notification in
HIV/AIDS, Federal/Provincial/Territorial Advisory Committee on AIDS Working Group on
Partner Notification.
Index person: The index person is the individual diagnosed with a blood borne disease.
The index person’s sexual and/or injection equipment-sharing partners are the ones
considered for partner notification. There may be others who require notification
because they have had a significant contact with an index person through other
recognized modes of transmission such as perinatal, blood transfusion, tissue or organ
transplantation, tattooing and sharing of razors or other skin-piercing instruments.
Partner: An individual who had sex or shared injection drug equipment with an index
person during the period of infectiousness.
Period of infectiousness: The period of infectiousness is the period for possible risk of
transmission of blood borne pathogens (HBV, HBC and HIV).
Partner notification: The spectrum of public health activities in which sexual and
injection equipment-sharing partners of individuals with blood borne pathogens are
notified, counseled about their exposure and offered services.
Partner notification consists of two general approaches: patient referral and provider
referral.
Patient referral: The strategy by which clients infected with blood borne pathogens are
encouraged to notify partners of their diagnosis of a blood borne pathogen, without the
direct involvement of health care providers. In this approach, the health care provider
counsels the infected person about the information to be passed on to their partners
and the techniques for providing it.
Provider referral: The strategy by which health care providers notify a blood borne
pathogen infected client’s partners. In this approach, the client gives their partners’
names to a health care provider who then confidentially notifies the partners directly,
maintaining the anonymity of the index person.
SEXUALLY TRANSMITTED DISEASES
Section Contents
• Principles
• General Guidelines
• Chancroid
• Chlamydia
• Genital Herpes
• Genital Warts
• Gonorrhea / PPNG
• Lymphogranuloma Venereum (LGV)
• Syphilis
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within
the District Health Authorities. This manual is constantly under revision. Public Health staff will be
informed of the changes as they occur. However, information contained on this site may not contain the
latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this
information by any other groups or organizations aside from Public Health staff within the District Health
Authorities.
SEXUALLY TRANSMITTED DISEASES
Principles
Note: Hepatitis B, C, and HIV/AIDS are covered in the Blood Borne Diseases Section.
• Inform the physician that follow-up for chlamydia is done only with the
physician unless assistance is needed by the client or the physician.
Explain your role in assisting with education and partner notification if
required.
1.3.1. Report
It is the responsibility of the physician to report STDs to the Medical Officer of
Health as follows:
• Within 1 working day by telephone: PPNG.
• Within 5 working days by reporting form: chancroid, chalmydia,
gonorrhea and syphilis.
2. Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
Safer sex recommendations also vary with the particular STD - for example safe
sex guidelines for avoiding herpes or Chlamydia will vary slightly from specific
advice given for avoiding HIV infection (one needs to be aware of the mode of
transmission of each STD). Therefore, general guidelines for safer sex should
focus on, non-exchange of body fluids and to a lesser extent on avoiding
penetrative sex (see Table below).
Safer sex means avoiding sexual contact where semen, blood or vaginal
secretions of one person can enter the body or bloodstream of another person.
Condoms, used properly, are the most effective means of reducing the
transmission of semen or vaginal fluids from one person to another. It is
necessary to continuously reinforce the correct use of condoms and encourage
people to use them. Although it has been clearly shown that condoms effectively
reduce the transmission of most STDs many people are still reluctant to use
them. This is due to many factors—but often it relates to a lack of perception of
being ‘at risk’. It has also been reported that even in motivated gay men who
practice safer sex ‘always’, there are times when condoms are not used—for
example when under the influence of alcohol. Safer sex guidelines therefore
need to focus on general principles of moderating behaviour and lifestyle as well
as specific advice with regard to sexual practices. Other reasons given for not
using condoms include decreased sensation, unacceptability to the sexual
partner, embarrassment associated with purchase or lack of knowledge or
interest.
Source: www.stdservices.on.net/std/prevention/safersex_guidelines.htm
3.2. Core Messages for STD Prevention
• Limit the number of sexual partners.
• Practice safer sex.
• Learn about prevention and control of STDs.
References:
Canadian Guidelines for the Diagnosis and Management of Sexually Transmitted Diseases, by Syndrome,
in Children, Adolescents and Adults. Canada Diseases Weekly Report, March 1989 Vol.15S1.
Canadian Guidelines for the Prevention, Diagnosis, Management and Treatment of Sexually Transmitted
Diseases in Neonates, Children, Adolescents and Adults Canada Communicable Disease Report, Health and
Welfare Canada, April 1992 Vol.18S1 .
Canadian STD Guidelines, 1998 Edition. Health Canada.
Report of the Committee on Infectious Diseases, 1991. American Academy of Pediatrics.
Nova Scotia Children and Family Services Act, 1991.
Working Guide: Notifiable Disease Reporting System in Nova Scotia, 1998. Nova Scotia Department of
Health.
CHANCROID
1. Information
1.1. Case definition:
Clinically compatible symptoms and a culture taken from an ulcerated lesion in
the genital area, positive for Haemophilus.ducreyi.
1.3. Symptoms:
Chancroid is most often seen in non-white males, with only 10% occurring in
females. The lesion begins as a tender papule with surrounding erythema, which
becomes pustular and then erodes to form an ulcer. There is tenderness at the
site of the lesion and it becomes painful when the ulcer erupts. The lesion is
found in the preputial orifice, the internal surface of the prepuce, and the
frenulum in men. Lesions are found on the labia, clitoris, cervix and anus in
women. Tenderness in the inguinal lymph glands is present in about half of the
cases of chancroid. The symptoms can be confused with syphilis and a culture is
needed to confirm diagnosis.
1.4. Incubation:
From 3- 5 days, up to 14 days.
1.5. Transmission:
Sexual contact (genital-genital or genital-anal contact) with a person who has
been infected. Nonsexual transmission is rare. It is possible to become infected
by an asymptomatic carrier of H.ducreyi. Sexual abuse must be considered when
chancroid is found in children beyond the neonatal period. H.ducreyi is often
found in the presence of syphilis and HIV infection and consideration should be
given to testing for syphilis and HIV in individuals who may be at high risk.
1.6. Communicability:
Ulcers usually clear within 1-2 weeks after treatment begins although the
disease may continue to be communicable for several weeks, especially if the
individual becomes a carrier.
1.7. Treatment:
A seven-day regimen of oral erythromycin or a single intramuscular dose of
ceftriaxone have both been found to be effective. Also, azithromycin or
ciproflaxin for adults. Many strains of H. ducreyi have been found to be resistant
to tetracycline, which should no longer be used in the treatment of chancroid.
1.9. Prophylaxis:
None.
2. Procedure
Use the General Guidelines for Sexually Transmitted Diseases at the beginning of this
section. The following are additional guidelines for chancroid.
2.1.2. Investigator:
Use general guidelines. Also use additional guidelines re:
a) Treatment follow-up.
When contacting the client for partner notification, ensure that the
treatment regimen is being followed and that the client returns to their
physician for a recheck after the treatment.
b) Partner notification.
Advise the client to notify any individual with whom they had sexual
contact up to 14 days before the appearance of the lesions. If the client is
uncomfortable with this, offer to do the partner notification yourself.
2.1.3. Physician:
Use general guidelines. Evaluate for other sexually transmitted diseases,
including syphilis, HIV/AIDS and hepatitis B virus.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association.
Principles and Practices of Infectious Diseases, Third Edition, 1990. Mandell, G., Douglas, Gordon Jr. and
John Bennett. Churchill Livingstone, New York.
Working Guide: Notifiable Disease Reporting System in Nova Scotia. 1998. Nova Scotia Department of
Health.
CHANCROID FACT SHEET
What is Chancroid?
Chancroid is a sexually transmitted disease caused by a bacteria. This infection is most
often seen in men; however, women can get this infection as well.
1.3. Symptoms:
More than 50% of males and 70% of females are asymptomatic. Symptoms may
include:
1.4. Incubation:
2-6 weeks, but it can take longer.
1.5. Source:
C. trachomatis grows in the vagina and/or urethra of infected persons. It may be
found in the rectum as well. The bacteria may spread to other parts of the
reproductive tract and cause cervicitis, pelvic inflammatory disease (PID),
epididymitis, proctitis, urethritis, perihepatitis, conjunctivitis, Reiter’s syndrome
and lymphogranuloma venereum.
1.6. Transmission:
Exchange of infected secretions during intimate contact is necessary for
infection. Vaginal, oral and anal intercourse is the primary source of
transmission, however newborns delivered vaginally are at risk and may develop
conjunctivitis and pneumonia. As well, prepubertal children who have genital,
urethral or rectal infections should be considered for possible cultures to rule
out sexual abuse.
1.7. Communicability:
Extent unknown. Infectious as long as bacteria are present in the genital or rectal
tract, even without symptoms. Individuals are advised to refrain from sexual
contact until the course of antibiotic therapy is completed.
1.8. Treatment:
For youth and adults, azithromycin in a single dose (preferred), doxycycline or
erythromycin usually taken orally for a period of 7-14 days. It is important that
all sexual partners of the infected person be tested and treated, whether
symptomatic or not. See Canadian STD Guidelines.
1.10. Prophylaxis:
If there is contact with a known or suspected case of Chlamydia, report to a
physician immediately for testing. Prophylactic antibiotic treatment of sexual
partners is recommended (without waiting for the confirming test results).
2. Procedure
Use the General Guidelines for Sexually Transmitted Diseases at the beginning of this
section. The following are additional guidelines for chlamydia.
2.1.2. Investigator:
Chlamydia is followed up with the physician only, unless assistance is requested.
Use general guidelines. Also use additional guidelines re:
a) Treatment follow-up.
When contacting the client for partner notification, ensure that the
treatment regimen is being followed and that the client returns to their
physician for retesting after the treatment. Ensure client is comfortable
with the treatment regimen and discuss risks to pregnant women and
newborns, where appropriate.
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Canadian STD Guidelines, 1998 Edition. Health Canada.
Centers for Disease Control, Morbidity and Mortality Weekly Report; Recommendations and Reports. U.S.
Department of Health and Human Services Public Health Services, Vol. 38, No.S-8, September 1989.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
What You Need to Know About STDs. Health Canada. 1997. Population and Public Health Branch.
Report of the Committee on Infectious Diseases, 1991. American Academy of Pediatrics.
CHLAMYDIA FACT SHEET
What is Chlamydia?
Chlamydia is sexually transmitted disease caused by a bacteria. Chlamydia is the most
common sexually transmitted disease in North America.
Females Males
Discharge from vagina Discharge from penis
Pain in the lower abdomen Pain when urinating
Bleeding after intercourse
Pain when urinating
Pain during sex
1.3. Symptoms:
First symptomatic episode:
Initial infections are often asymptomatic. Symptoms when present may include
lesions that appear as blisters on the genital area as a single blister or in clusters.
Lesions are sometimes itchy and often very painful and affect the vulva, vagina,
and/or cervix, penis, urethra, rectum, thighs and buttocks. Often in women these
lesions are accompanied by a grey-white exudate. Other symptoms may include
dysuria, muscle ache, fever and swollen glands in the groin area. The primary
lesions usually form scabs and heal in about 3-4 weeks.
Recurrent episodes
Some individuals may not have recurrences. Frequency of recurrences for HSV-2
is very high (98%) of patients. Symptoms are usually less severe and of shorter
duration than the primary episode, and are usually limited to the external
genitalia.
1.4. Incubation:
Usually 2-21 days after sexual contact with infected person.
1.5. Source:
The virus is present in the lesions or blisters. Some individuals may never
develop symptoms or blisters, but may transmit the virus in oral or genital fluids.
1.6. Transmission:
Transmission occurs primarily through the spread of secretions. When an
infected person has any sexual contact (oral-genital, genital-genital, genital-
rectal, oral-rectal) with another individual, transmission can occur.
Transmission can also occur if individuals touch an active lesion and then touch a
part of their own or someone else’s body. In this way it is possible for individuals
to autoinoculate from one site to another on their own bodies.
There is evidence to suggest that days before active lesions appear viral shedding
can occur. Transmission of HSV-2 to other body sites can also occur when infants
are born to mothers having genital infection. Genital lesions in prepubertal
children may be the result of an HSV-1 autoinoculation, but sexual abuse should
not be ruled out.
1.7. Communicability:
Once HSV has invaded the host, it travels to the nerve ganglion along the sensory
nerve pathways. It remains latent long after any signs of active infection have
disappeared. Reactivation of the virus allows it to travel back down the nerves to
the affected area to cause a recurrent infection. For this reason it is important to
recognize that once an individual has contracted the virus, he or she continues to
be at risk for transmitting the disease for life. Most transmissions occur from a
day or two before the lesions are present and up to 72 hours after they have
disappeared.
1.8. Treatment:
At present there is no cure for herpes. Some medications reduce pain and aid in
healing lesions, however it is only effective if given in the early stages of the
symptomatic episode. Acyclovir (Zovirax), famiciclovir or valacyclovir are
recommended. Topical antivirals are not recommended. Daily suppressive
antiviral therapy may significantly reduce viral shedding and therefore reduce
the risk of transmission.
1.9. Core Messages for Prevention:
Use core messages in general guidelines (section 3.2). Other messages include:
• Refrain from sexual contact if ulcers/lesions are observed or when there
are any signs of herpetic outbreak (tingling or redness in usual outbreak
area).
• Use of condoms may have a preventative effect, but only if herpes lesions
are restricted to cervix, vagina and penis.
• Because of the suspected link between HSV infection and cervical cancer
it is recommended that those women or partners of women with HSV
infection have routine pap smears every 6 months.
• Women with HSV infection or female partners of men with HSV may be
at risk for transmitting the virus to an infant during childbirth. Talking
with the family physician about precautions during pregnancy and
childbirth is strongly recommended.
1.10. Prophylaxis:
None. If experiencing any of the symptoms described or if in contact with a
known case of HSV, contact physician immediately.
2. Procedure
Use the General Guidelines for Sexually Transmitted Diseases at the beginning of this
section. The following are additional guidelines for genital herpes.
2.1.2. Investigator:
Genital herpes is not actively followed up unless assistance is required.
Inform clients about the course of the disease, its implications for future
health, as well as treatment regimens and outbreak strategies. Most
clients will experience at least one further outbreak and it will be
important to reassure them about this possibility.
Discuss strategies for informing present and future sexual partners about
their condition. Clients need to understand that it is essential that they
disclose this information, even though it may be difficult. If they are
reluctant to do this, offer to do the contacting yourself.
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Canadian STD Guidelines, 1998 Edition. Health Canada.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Principles and Practices of Infectious Diseases, Third Edition, 1990. Mandell, G., Douglas, Gordon Jr. and
John Bennett. Churchill Livingstone, New York.
Working Guide: Notifiable Disease Reporting System in Nova Scotia, 1998. Nova Scotia Department of
Health.
GENITAL HERPES FACT SHEET
What is Genital Herpes?
Herpes is an infection caused by the herpes simplex virus (HSV). This virus has two
types: HSV type 1 and HSV type 2. HSV-2 is more often seen in genital infections, but
either virus can infect you anywhere.
HSV-2
HSV-2 is mostly spread through sexual contact, from an infected person to their partner.
Sometimes if a pregnant woman is infected with genital herpes she can pass the virus on
to her baby during childbirth. It is important for her to tell her doctor so that the infant
can be protected. Both of these viruses can live in the nerve cells. They cause infections
and symptoms that can come back again and again. The disease never leaves the body
and right now, there is no cure.
HSV-2, which often causes genital herpes, can cause symptoms about 2-21 days after
the contact occurs. The first outbreak of these symptoms is usually the worst. If the
infection is going to reoccur the skin blisters will appear at the same site. Often this can
happen when a person is under stress or has an illness. The symptoms usually last a
week or two.
If you have genital herpes you must tell your sexual partners of the infection. You
should have no sexual contact if you have lesions. If you are female you should see your
doctor regularly for a pap smear and to discuss pregnancy and childbirth options.
GENITAL WARTS
1. Information
1.1. Case definition:
Visible lesions of hyperkeratotic exophytic papules on genital or anal area or in
the oral cavity of men and women.
1.3. Symptoms:
Many people are asymptomatic, even though they carry the virus. Genital warts
usually appear as flat growths in moist areas like the vagina or on the cervix and
tend to be white or grey. Because the virus lives in skin cells it can be found on
other genital areas like the labia and the scrotum. These lesions have a
cauliflower-like appearance with jagged edges. Warts may be painless or itchy or
tender or cause a burning sensation.
1.4. Incubation:
About 2-3 months, range is 1-20 months.
1.5. Source:
The virus may be present in men on the glands of the penis, under the foreskin
and its frenulum, in the coronal sulcus or urethral opening, in the rectum or on
the scrotum. In women, the common sites of infection are the labia, the
introitus, the vaginal walls and the cervix. Some warts have also been observed
in the oral cavity on the tongue.
1.6. Transmission:
HPV is transmitted to sexual partners by direct skin contact or to infants during
vaginal childbirth when the delivery is vaginal. Autoinoculation is possible but
rare. If genital warts are diagnosed in prepubescent children, sexual abuse must
be considered.
1.7. Communicability:
Unknown, but probably as long as visible lesions persist.
1.8. Treatment:
Treatment can reduce but not eliminate the risk of sexual transmission or the
risk of cancerous changes at the cervix. See Canadian STD Guidelines 1998
Edition (page 170) for details on each of the treatment modalities that are briefly
noted below.
• Cryotherapy: a procedure where the warts are frozen using liquid
nitrogen. This procedure may be necessary every one to two weeks until
warts disappear. This is the preferred treatment.
• Topical treatments: topical medications are applied several times a week,
and include podofilox, podophyllin, and bi- or trichloracetic acid.
• Electrocautery: a surgical procedure that usually requires anesthesia and
is used primarily for lesions in the vagina and rectum.
• Laser: a laser therapy treatment is not available in all centres and can be
quite costly.
1.10. Prophylaxis:
None. If in contact with a known case, report to a physician for diagnosis and
treatment, if appropriate.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Canadian STD Guidelines, 1998 Edition. Health Canada.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Report of the Committee on Infectious Diseases, 1991. American Academy of Infectious Diseases.
Working Guide: Notifiable Disease Reporting System in Nova Scotia. 1998. Nova Scotia Department of
Health.
GENITAL WARTS FACT SHEET
What are Genital Warts?
Genital Warts are caused by a virus. Some of the types of viruses that cause genital
warts may also cause changes in the cells of the cervix linked to cervical cancer. It is
important for every female who has genital warts to have a Pap smear regularly.
Females Males
Vaginal discharge Urethral discharge
Dysuria Dysuria
Abdominal pain Urethral itch
Abnormal vaginal bleeding Epididymal pain
Dyspareunia Rectal pain and discharge if proctitis
Rectal pain and discharge if proctitis
If the infection is located in the pharynx the individual may experience a sore
throat and difficulty swallowing. If untreated the gonococcus may settle in other
parts of the body, causing infection of the joints, skin, heart and brain.
1.4. Incubation:
2-7 days or longer.
1.5. Source:
Exudate and secretions of infected mucous surfaces. The bacteria grow in
infected fluids from the penis, vagina, mouth or rectum.
1.6. Transmission:
Transmission occurs by direct sexual contact from one sexual partner, via oral,
vaginal, urethral, rectal or cervical routes. The bacteria may also spread from the
primary sites, causing infection of the uterus (endometritis); the fallopian tubes
(salpingitis); the abdominal cavity (peritonitis); the glands of the vulvar area
(bartholinitis); and the testicles in men (epididymitis).
1.8. Treatment:
The preferred treatment is oral cefixime (alternatives include ceftriaxone or
ofloxacin) except for pregnant or nursing mothers. See Canadian STD Guidelines,
1998 Edition for further details about treatment (page 144).
All partners who have had sexual contact with the client within at least 60 days
before the onset of symptoms, parents of infected neonates, and persons
implicated in sexual abuse cases must be identified, tested and treated with the
same regimen as the client. Person treated for gonococcal infections should also
be treated for chlamydia since co-infections are common.
2. Procedures
Use the General Guidelines for Sexually Transmitted Diseases at the beginning of this
section. The following are additional guidelines for gonorrhea/PPNG.
2.1. Roles and Responsibilities
2.1.1. Medical Officer of Health:
Use general guidelines. No additional guidelines.
2.1.2. Investigator:
Use general guidelines. Also use additional guidelines re:
a) Educating the client.
Special attention should be given to those clients with PPNG, so that
accurate treatment regimens are followed, retesting is done and diligent
partner notification is pursued. Determine if follow-up testing is required
(see section on treatment) and encourage client to seek testing if
appropriate.
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
Gonorrhea
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Canadian STD Guidelines, 1998 Edition. Health Canada.
Centers for Disease Control, Morbidity and Mortality Weekly Report; Recommendations and Reports. U.S.
Department of Health and Human Services, Public Health Services, Vol.38, No. S-8, September 1989.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Principles and Practice of Infectious Diseases, Third Edition, 1990. Mandell, G., Douglas, Gordon Jr. and
John Bennett. Churchill Livingstone , New York.
Working Guide: Notifiable Disease Reporting System in Nova Scotia. 1998. Nova Scotia Department of
Health.
GONORRHEA FACT SHEET
What is Gonorrhea?
Gonorrhea is a sexually transmitted disease (STD) caused by bacteria.
Probable Case:
Positive result on culture, NAAT or serologic testing for C. trachomatis plus the
presence of proctitis OR inguinal or femoral lymphadenopathy OR a sexual
partner with LGV.
1.3. Symptoms
LGV is commonly divided into three stages and the manifestations of the disease
follow three distinct patterns. It is important to note that some cases may be
asymptomatic.
Stage Incubation Period Manifestation/Comments
Primary 3-30 days • Small painless papule at the site of
inoculation (vulva, vagina, penis,
rectum, occasionally cervix, oral cavity)
that may ulcerate
• Self-limited and may go unnoticed in up
to 50% of people
Secondary Within 2-6 weeks • Often accompanied by significant
of primary lesion systemic symptoms such as low-grade
fever, chills, malaise, myalgias,
arthralgias; occasionally by arthritis,
pneumonitis or hepatitis/perihepatitis;
rarely with cardiac involvement, aseptic
meningitis and ocular inflammatory
disease
• Abscesses and draining sinuses possible
(< 1/3 of patients)
• Involves the inguinal/femoral lymph
nodes and/or anus and rectum:
• inguinal secondary LGV
characterized by painful inguinal
and/or femoral
lymphadenopathy (usually
unilateral) – painful lymph nodes
are referred to as buboes
• “groove sign” – inguinal nodes
above and femoral nodes below
the inguinal ligament (once
considered pathognomonic for
LGV)
• cervical lymphadenopathy has
been described in cases with
oral contact
• Anorectal Secondary LGV characterized
by acute hemorrhagic proctitis
bloody, purulent or mucous
discharge from the anus and
constipation
Tertiary • More common in females than males
(chronic LGV • Chronic inflammatory lesions lead to
occurring in scarring:
10-20% of - Lymphatic obstruction causing
untreated genital elephantiasis
cases) - Rectal strictures and fistulae
• Possible extensive destruction of
genitalia (esthiomene)
• Surgery may be required to repair
genital/rectal damage of tertiary LGV.
1.4. Incubation
See table above
1.5. Source
Bacteria from a small, painless lesion on the genitalia, anus or in the mouth
1.6. Transmission
Sexual contact (genital-genital, genital-oral, genital-anal or oral-anal) with an
infected person
1.7. Communicability
Variable, from weeks to years during presence of active lesions
1.8. Treatment
Doxycycline erythromycin and azithromycin can be used for treatment. For
specific treatments consult Canadian STI Guidelines 2006.
2.2. Case
Patients diagnosed with LGV should be followed until chlamydial tests are
negative (test of cure) and the patient has clinically recovered. Test of cure
should be done 3-4 weeks after completion of successful treatment.
It is important to discuss with the physician the potential for co-infection with
HIV, syphilis, HSV, gonorrhea, hepatitis B, hepatitis C and the importance of
testing for these infections.
As well, testing for chancroid and donovanosis (granuloma inguinal) should also
be considered in persons with LGV, especially if there has been travel to regions
where these infections are endemic.
2.2.1. Exclusion
No exclusion required, however cases should refrain from sexual activity until
proof of cure or practice safer sex by using latex condoms with oral, vaginal and
anal sex.
2.2.2. Education
See Section 1.9, Core Prevention Messages.
2.3 Contact Tracing
2.3.1. Definition of Contacts
An individual who has had sexual contact (genital-genital, genital-oral, genital-
anal or oral-anal) with the case in the past sixty days.
2.3.2. Susceptibility
Susceptibility is universal.
2.3.3. Prophylaxis
Sexual partners from the last 60 days should be contacted, tested and treated
empirically (regardless of whether signs/symptoms are present) as follows:
• Azithromycin 1 g PO in a single dose OR
• Doxycycline 100 mg PO BID x 7 days 2.3.4. Exclusion
No exclusion required, however contacts should refrain from sexual activity until
treatment is completed or practice safer sex by using latex condoms with oral,
vaginal and anal sex.
2.3.4. Exclusion
No exclusion required, however, contacts should refrain from sexual activity until
treatment is completed or practice safer sex by using latex condoms with oral,
vaginal and anal sex.
2.3.5. Follow-Up
If test results confirm an LGV infection, case should receive treatment as
outlined in Section 1.8, followed by test of cure in 3-4 weeks after completion of
treatment.
2.3.6. Education
See Section 1.9, Core Prevention Messages
3.0 SURVEILLANCE GUIDELINES
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
LYMPHOGRANULOMA VENEREUM (LGV)
FACT SHEET
What is LGV?
LGV is a sexually transmitted infection caused by bacteria called Chlamydia trachomatis,
serotypes L1, L2 and L3. These serotypes are related to but distinct from other
chlamydial infections, which are common in Canada and other developed countries. The
infections caused by LGV are more invasive than those caused by other chlamydia
infections.
1.0 Information
1.1. Case definition
Confirmed case—Early Congenital Syphilis (within 2 years of birth)
Laboratory confirmation of infection:
• identification of Treponema pallidum by dark-field microscopy,
fluorescent antibody or equivalent examination of material from nasal
discharges, skin lesions, placenta, umbilical cord or autopsy material of a
neonate (up to four weeks of age).
OR
• reactive serology (non-treponemal and treponemal) from venous blood
(not cord blood) in an infant/child with clinical, laboratory or radiographic
evidence of congenital syphilis (including evidence on physical
examination, on radiographs of long bones, a reactive CSF VDRL, an
elevated CSF cell count or protein without other cause), whose mother is
without documented evidence of adequate treatment.
OR
• detection of T. pallidum DNA in an appropriate clinical specimen.
1
Confirmed Case—Secondary Syphilis
Laboratory evidence of infection:
• identification of T. pallidum by dark-field microscopy, fluorescent
antibody, nucleic acid testing or equivalent examination of
mucocutaneous lesions, condylomata lata and reactive serology (non-
treponemal and treponemal).
OR
• presence of typical signs or symptoms of secondary syphilis (e.g.
mucocutaneous lesions, alopecia, loss of eyelashes and lateral third of
eyebrows, iritis, generalized lymphadenopathy, fever, malaise or
splenomegaly) AND either a reactive serology (non-treponemal and
treponemal) OR a fourfold or greater increase in titre over the previous
known non-treponemal test.
2
Confirmed Case—Neurosyphilis (Infectious vs Non-infectious)
Infectious Neurosyphilis (< 1 year after infection)
Laboratory confirmation of infection:
Fits the criteria for Primary, Secondary OR Early Latent AND one of the
following:
o reactive CSF-VDRL in non-bloody cerebrospinal fluid (CSF)
o clinical evidence of neurosyphilis AND either elevated CSF
leukocytes OR elevated CSF protein in the absence of other known
causes.
3
1.3 Symptoms
Syphilis is classified into stages that reflect the degree of infectivity and
progression of the disease (see table 1 below).
Table 1: Symptoms
Stage Incubation Period Clinical Manifestations
Primary 3 weeks (3-90 days) Chancre, regional
lymphadenopathy
Secondary 2 - 12 weeks Rash, fever, malaise,
(2 weeks– 6 months) lymphadenopathy, mucus lesions,
condyloma lata, patchy or diffuse
alopecia, meningitis, headaches,
uveitis, retinitis
Latent Early: <1 year Asymptomatic
Late: ≥1 year
Tertiary Aortic aneurysm, aortic
Cardiovascular 10 - 30 years regurgitation, coronary artery
syphilis ostial stenosis
4
Hutchinson’s teeth, neurosyphilis
1.5 Treatment
Although regimens containing daily IM procaine penicillin for 10-14 days are
equally efficacious to regimens containing benzathine penicillin G, the latter are
preferred because of better adherence with less frequent dosing (weekly).
See table 3 for more details. Monitoring of serologic tests and other follow up
and adequate serologic response after treatment of each stage are outlined in
tables 4a and 4b below.
5
NOTE: PHAC has indicated that there have been reports of inappropriate use of
short-acting benzylpenicillin (penicillin G) (IM) for the treatment of infectious
syphilis rather than the standard long-acting benzathine penicillin G (Bicillin-LA).
Practitioners, pharmacists and purchasing agents should be aware of the similar
names of these two products to prevent and avoid inappropriate and inadequate
treatment. Long-acting benzathine penicillin achieves detectable serum levels of
penicillin for 2-4 weeks in non-pregnant adults and is required to adequately
treat infectious syphilis; short acting penicillin agents are not adequate for
achieving cure.
Table 3: Treatment
Stage Preferred treatment
All non-pregnant adults Benzathine penicillin G 2.4 million
Primary units IM as a single dose*
Secondary
Early latent (<1 year duration)
All non-pregnant adults Benzathine penicillin G 2.4 million
Late latent syphilis units IM weekly for 3 doses
Latent syphilis of unknown
duration
Cardiovascular syphilis and other
tertiary syphilis not involving the
central nervous system
All adults Penicillin G 3-4 million units IV q 4
Neurosyphilis h(16-24 million units/day) for 10-14
days
Pregnant women Benzathine penicillin G 2.4 million
Primary units IM weekly for 1-2 doses*‡
Secondary
Early latent (<1 year duration)
Pregnant women Benzathine penicillin G 2.4 million
Late latent syphilis units IM weekly for 3 doses
Latent syphilis of unknown
duration
Cardivascular syphilis and other
tertiary syphilis not involving the
central nervous system
Congenital syphilis <1 month of age
Crystalline penicillin G
50,000 units/kg IV every 12 hours for
the first week of life and every 8 hours
6
thereafter for 10 days of total therapy
Addendum:
Benzathine penicillin G
50,000 units/kg IM in a single dose
has been recommended by some
experts for infants not diagnosed with
congenital syphilis but born to mothers
with infectious syphilis:
1. In whom adequate maternal
treatment is confirmed
AND
2. Where there is no concern
regarding re-infection in the mother
AND
3. In infants with no clinical or
laboratory evidence of congenital
syphilis
Alternatively, meticulous follow up
(e.g., monthly clinical/laboratory follow
up) until clearance of passively
transferred antibodies may be
indicated if there is good indication
that adequate maternal treatment
occurred.
≥1 month of age
Crystalline penicillin G
50,000 units/kg IV every 6 hours for
10-14 days
7
1.6 Incubation
See Table 1 above.
1.7 Source
Bacteria (spirochetes) from a chancre that may be in the mouth, on the genitalia,
or other parts of the body. It is also present in the blood of untreated individuals.
1.8 Transmission
The primary mode of transmission is vaginal, anal, and oral sexual contact (direct
contact with infectious exudates from obvious or concealed moist, early lesions
of skin, and with mucous membranes of infected people during sexual contact).
Kissing, sharing of needles and injection equipment, blood transfusion,
accidental inoculation (e.g., needle stick injury) and solid organ transplantation
have rarely been reported as routes of transmission. The majority of infants with
congential syphilis are infected in utero, but they can also be infected by contact
with an active genital lesion at the time of delivery. Breastfeeding does not
result in syphilis transmission to the child unless an infectious lesion is present
on the breast.
1.9 Communicability
An infected individual can transmit the infection to his/her sexual partner usually
during the primary, secondary and early latent stages of the disease.
Transmission of syphilis from mother to fetus is most probable during early
maternal syphilis, but can occur throughout the latent period. See Section 2.2.1
for more information.
8
In patients with confirmed infectious (primary, secondary and early
latent) syphilis, patients and their partners should abstain from all forms
of sexual activity until treatment of both partners is complete and an
adequate serologic response is determined. If the case can not abstain
then it is important to educate the person that condoms are most
commonly used in safe sex practice to reduce the risk of transmission of
infectious diseases. There are male and female condoms. Dental dams
are effective barriers that can also be used for oral sex.
Syphilis can also be passed from mother to child during pregnancy and
therefore routine prenatal screening for syphilis is an important means of
prevention. If there is ongoing high-risk activity, test again in later
pregnancy. See revised January 2010 syphilis chapter in the 2006 edition
of the Canadian STI Guidelines for more information regarding special
considerations in pregnant women and newborn infants.
9
Some initial information that should be collected from the physician prior to
contacting the case are:
Prior history of treatment for syphilis and prior serologic results (every
attempt should be made to obtain this prior history in order to avoid
unnecessary retreatment).
Reason for testing.
Symptoms.
Risk factors.
Referral to specialist.
Appropriate treatment initiated.
Is case pregnant (In an attempt to prevent congenital syphilis pregnant
cases and their infant should be clinically assessed/managed by a
specialist).
Any pregnant contacts.
Staging of syphilis.
Tested for other STIs (i.e. HIV).
Co-infection (Persons co-infected with HIV may require a longer course of
treatment, as well as closer and longer follow-up).
10
Table 4a: Monitoring of serologic tests and other follow up
Primary, secondary, early latent (*), 3, 6, 12 months after
treatment
Late latent, tertiary 12 and 24 months after treatment
(EXCEPT NEUROSYPHILIS)
Neurosyphilis 6, 12 and 24 months after treatment.
Patients with CSF abnormalities
require follow up CSF at 6 monthly
intervals until normalization of CSF
parameters (see revised January 2010
syphilis chapter in the 2006 edition of
the Canadian STI Guidelines for more
info)
Other clinical follow up may be
indicated on a case by case basis
HIV infected (any stage) (*), 3, 6, 12 and 24 months after
treatment and yearly thereafter
Pregnant women with reactive syphilis See revised January 2010 syphilis
serology chapter in the 2006 edition of the
Canadian STI Guidelines
Babies born to mothers with reactive See revised January 2010 syphilis
syphilis serology chapter in the 2006 edition of the
Canadian STI Guidelines
2.1.2 Exclusion
In most situations, no exclusion is necessary. If syphilis case’s work
involves activity that could potentially put the public at risk (e.g. sex trade work),
consult MOH.
2.1.3 Education
Explain to the case the importance of contact tracing and Public Health’s
role in preventing or controlling a current or potential outbreak.
Educate the case regarding abstaining from unprotected sex until he/she
is considered non-infectious.
Educate the case regarding the risks associated with various sex acts,
including the risk of transmission via oral sex and ensure the use of a
barrier method for oral sex (i.e., although the risk of STI transmission is
lower via oral sex than vaginal or anal sex, many STIs, including syphilis
can be transmitted through unprotected oral sex).
Discuss the importance of complying to the treatment regimen and
subsequent follow up.
12
Cases should be made aware of the possible Jarisch-Herxheimer reaction
to treatment, especially with penicillin.
13
2.2 Contact Tracing
The goal of partner elicitation is to obtain sufficient information to confidentially
locate, notify, and refer the partners for necessary examination and treatment (if
appropriate). Public Health takes the lead in coordinating this process.
2.2.2 Susceptibility
Susceptibility is universal. Infection leads to gradual development of immunity
against T. pallidum; immunity often fails to develop because of early treatment
in the primary and secondary stages.
14
health can assist with this. Reassure case that Public Health Nurses are
trained in contact tracing procedures and that it is an anonymous process
Follow up with contact (s).
Determine how contacts will be notified. This may be dependent on
contact’s culture and/or their social environment (e.g. place/venue
where case and contact met).
All sexual or perinatal contacts within the following time periods need to be located,
tested, and treated if serology is reactive- if exposure to a primary, secondary or early
latent syphilis case occurred within the past 90 days, presumptive treatment is
recommended, even if the contact (s) are seronegative. If exposure was more than 90
days ago, treatment should be based on serologic test results.
NOTE: Public Health will contact all of the contacts and will follow-up contacts until
above criteria are met.
15
3) If all partners traced (according to recommended trace-back period) test
negative, then the partner prior to the trace-back period should be notified.
Public Health should be reviewing the contact’s test results and other
information (i.e. past cases and possible connections) in an attempt to
determine the source case and to assess whether an outbreak may be occuring.
2.2.4 Prophylaxis
The preferred treatment of sexual contacts in the preceding 90 days to primary,
secondary, and early latent syphilis is Benzathine penicillin G 2.4 million units IM
as a single dose.
2.2.5 Immunization
There is no immunization against syphilis.
2.2.6 Exclusion
Not applicable.
2.2.7 Education
Educate the contacts regarding the risks associated with various sex acts,
including the risk of transmission via oral sex and ensure the use of a barrier
method for oral sex (i.e., although the risk of STI transmission is lower via
oral sex than vaginal or anal sex, many STIs, including syphilis can be
transmitted through unprotected oral sex. Transmission through oral sex is
well documented).
Explain to the contact the importance of following up with public health
recommendations and the rationale for the recommendation (s).
16
3.0 Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual .
4.0 References
Centers for Disease Control and Prevention. (2010). Syphilis – CDC Fact Sheet.
Retrieved from http://www.cdc.gov/std/syphilis/stdfact-syphilis.htm
Genc M, Ledger WJ. (2000). Syphilis in Pregnancy. Sexually Transmitted Infections, 76,
73-79. doi:10.1136/sti.76.2.73
Heymen, DL. (ED.). (2008). Control of Communicable Diseases Manual. (19th ed.).
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases
under National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from
http://www.phac-aspc.gc.ca/publicat/ccfr-rmtc/09pdf/35s2eng.pdf
17
Syphilis Fact Sheet
What is Syphilis?
Syphilis is a sexually transmitted infection. It is caused by a kind of bacteria called
Treponema pallidum.
Babies can get syphilis if their mother is infected because the bacteria can pass through
the placenta during pregnancy.
While in the body, syphilis passes through many stages. At each of these stages there
are different symptoms. The symptoms are:
• A painless sore that is round, flat and raised on the sides, like a large boil.
Because this sore is painless and can be hidden somewhere that you cannot see,
you may not know you have a sore.
• Rashes anywhere on the body, especially on the palms of the hands and soles of
the feet.
• Swollen glands.
In its later stages syphilis can cause symptoms of the heart, brain or other organs.
The first symptoms can start from 10 to 90 days (average 21 days) after contact with
someone who has the infection.
18
What is the Treatment?
Syphilis can be treated with a penicillin injection or with other antibiotics prescribed by
a doctor. It is important to take the medication until it is gone.
If you have syphilis, you must work with public health to notify your sex partners so that
they also can be tested and treated if necessary.
19
Fiche d’information sur la Syphilis
Qu’est-ce que la syphilis?
La syphilis est une maladie transmissible sexuellement. Elle est causée par la bactérie
Treponema pallidum.
Comme la bactérie peut traverser le placenta durant la grossesse, une femme qui a la
syphilis peut transmettre la maladie à son bébé.
Une fois contractée, l'infection évolue par stades. Les symptômes, qui sont différents à
chaque stade, sont :
• Une lésion indolore, ronde, plate et soulevée sur les côtés, comme un gros
furoncle. Parce que la lésion est indolore et peut se trouver à un endroit que
vous ne pouvez pas voir, vous pourriez ignorer que vous avez une lésion.
• Des éruptions cutanées n'importe où sur le corps, en particulier sur la paume des
mains et la plante des pieds.
• Une inflammation des ganglions
Dans ses derniers stades, la syphilis peut affecter le cœur, le cerveau ou d'autres
organes.
20
Les premiers symptômes apparaissent entre 10 et 90 jours après un contact avec une
personne infectée. La moyenne est de 21 jours.
Si vous avez la syphilis, vous devez travailler avec le personnel des Services de la santé
publique pour informer vos partenaires sexuels afin que ces derniers puissent se faire
examiner et soigner s’il y a lieu.
21
• Renseignez-vous sur la prévention et le contrôle des maladies transmissibles
sexuellement.
• Parlez à votre médecin pour savoir si vous devriez passer un test de dépistage de
la syphilis et d'autres infections transmissibles sexuellement.
Consultez votre médecin si vous présentez l’un ou l’autre des symptômes de la syphilis.
22
VACCINE PREVENTABLE DISEASES
Section Contents
• Principles
• General Guidelines
• Diphtheria
• Invasive Haemophilus Influenzae Type b (Hib) Disease
• Measles
• Mumps
• Pertussis
• Polio
• Rubella
• Smallpox
• Tetanus
• Varicella
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within
the District Health Authorities. This manual is constantly under revision. Public Health staff will be
informed of the changes as they occur. However, information contained on this site may not contain the
latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this
information by any other groups or organizations aside from Public Health staff within the District Health
Authorities.
VACCINE PREVENTABLE DISEASES
Principles
The principles for the management of vaccine preventable diseases are:
1. All individuals infected with vaccine preventable diseases and their contacts will
be followed up by a PHS investigator in accordance with provincial guidelines.
2. All individuals infected with vaccine preventable disease that is routinely
followed up by PHS will be offered information to minimize the complications of
the disease and advised of appropriate chemoprophylaxis and immunization.
3. All schools, daycares and other institutions that infected individuals attend will
receive information and education materials on the specific vaccine preventable
disease reported.
4. All cases of vaccine preventable diseases listed as notifiable diseases will be
reported to Public Health Services and added to the provincial database for
notifiable diseases.
1.2. Investigator:
Upon receiving the report of the vaccine preventable illness, the investigator
should begin investigation.
a) Determine case status and clinical details.
Call physician to discuss the case. Advise about the importance of contact
investigation. Inform physician that Public Health Services will provide
contact investigation in order to administer prophylaxis or treatment as
indicated for the specific disease.
b) Report case.
Discuss case information with the MOH.
d) Contact tracing.
• Communicate with all identified contacts, discuss exposure,
susceptibility, and educate.
• Immunize and/or offer prophylaxis for contacts as per the
guidelines in the specific disease sections.
• Discuss exclusion with MOH as required.
1.3 Physician:
1.3.1. Report all cases to Public Health Services.
Consult the document “It’s the Law” for reporting requirements for each disease.
1.3.3. Exclusions
Discuss with PHS the potential exclusion of individuals with vaccine preventable
illnesses from work, school or child-care centres.
1.4. Laboratory:
Report all cases of vaccine preventable diseases as outlined in section 1.3.1.
5. Surveillance Guidelines
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
DIPHTHERIA
1. Information
1.1. Case definition:
Confirmed case
Clinical illness or systemic manifestations compatible with diphtheria in a person
with an upper respiratory tract infection or infection at another site (e.g. wound,
cutaneous) PLUS at least one of the following:
Probable case
Clinical illness in the absence of laboratory confirmation or epidemiologic link to
a laboratory-confirmed case
Suspect case
Upper respiratory tract infection (nasopharyngitis, laryngitis or tonsillitis) with or
without an adherent nasal, tonsillar, pharyngeal and/or laryngeal membrane
1.2. Causative agent:
Corynebacterium diphtheriae (C. diphtheriae), a gram positive rod bacterium.
These bacteria are capable of producing a potent toxin when infected by
corynebacteriophage.
1.3. Symptoms:
Diphtheria usually occurs as membranous nasopharyngitis or obstructive
laryngotracheitis. These manifestations of the illness begin with a low grade
fever, a sore throat and a yellow-white discharge over the tonsils, uvula and
throat. This discharge becomes grey, patchy and membranous and may involve
the larynx, where it can present as airway obstruction. There may be marked
edema of the neck. There may be progression to cardiac (myocarditis) and/or
neurologic involvement (motor and /or sensory palsies) 1-6 weeks after onset.
Nasal diphtheria is often a mild form of the disease and is characterized by one-
sided nasal secretions. Less commonly, the disease may present as cutaneous,
vaginal, or conjunctival infections.
1.4. Incubation:
Usually 2-5 days, sometimes longer.
1.5. Source:
Humans.
1.6. Transmission:
Spread occurs through intimate contact with nasal or oral secretions of an
infected individual or through contact with infected skin lesions. Rarely, contact
with articles contaminated with discharge from lesions of infected people. Raw
milk has served as a vehicle.
1.7. Communicability:
In untreated individuals, communicability may be from 2 to 4 weeks. Chronic
carriers are rare and may shed the bacteria for up to 6 months. Usually
communicability will end less than 4 days after the administration of antibiotics.
1.8. Treatment:
For pharyngeal or laryngeal diphtheria, early administration of diphtheria
antitoxin is recommended. A single dose of diphtheria antitoxin is indicated to
neutralize the circulating diphtheria toxin and should be given in the early stages
if diphtheria is suspected, without waiting for laboratory confirmation. Dosage is
based on the degree of disease involvement.
Treat with erythromycin for 14 days. Antibiotics are not a replacement for
antitoxin. Supportive treatment, in hospital or home is advised under strict
isolation until 2 consecutive throat cultures are negative for diphtheria bacilli.
These cultures should be taken not less than 24 hours apart and not less than 24
hours after the completion of the course of antibiotics.
For cutaneous diphtheria, the skin lesions should be cleaned with soap and
water and a course of oral antibiotics should be given for a 10 day period.
Antitoxin may be of some use in cutaneous disease, because of toxic sequelae.
1.10. Prophylaxis:
Close contacts of a confirmed case that were previously immunized should
receive a booster dose of diphtheria toxoid if more than 5 years have elapsed
since their last booster. A primary series should be initiated in previously non-
immunized contacts. Treatment with antibiotics for all household contacts
regardless of immune status is recommended. Other close contacts of the
infected individual who are culture positive should receive treatment with
antibiotics.
2. Procedure
2.2. Roles and Responsibilities
2.1.1. Medical Officer of Health:
Use general guidelines. No additional guidelines.
2.1.2. Investigator:
The investigator should begin investigation immediately upon receipt of the
report of diphtheria. Use general guidelines. Also, use additional guidelines re:
a) Contacting and educating individual or family.
• Ensure that infected individuals follow prescribed therapy.
• Strict respiratory isolation of patients with pharyngeal or laryngeal
diphtheria in hospital or home is important until 2 consecutive
cultures are negative for diphtheria bacilli. Where culture is
impractical, isolation may be ended after 14 days of appropriate
antibiotic treatment.
• Active immunization against diphtheria should begin during
convalescence because there is no guarantee that immunity to
diphtheria is necessarily conferred.
• In the case of cutaneous diphtheria, contact isolation is warranted
until 2 negative skin lesion cultures are obtained 24 hours apart and
at least 24 hours after antibiotic therapy is completed. Thorough
cleaning of the infection site with soap and water is advised.
• All bedclothes and clothing articles that have been used in the care
of any infected individual should be washed with hot soapy water.
b) Contact tracing.
• All household members should be considered at risk of secondary
disease, as well as all those who have had habitual close contact
with and/or who may have been directly exposed to oral secretions
of the infected individual.
• Schools and child-care centres should be visited to determine if
there are other ill children. Check immunization records of children
in the child-care centre for immunization status. Send a letter to
parents of attendees to inform them of the case of diphtheria and
possible risks to their children. A sample letter is included in the
appendix.
• Worksites of individuals working in the food-handling field should
be visited and information circulated among staff regarding follow-
up with their family physician.
• The investigator should also be looking for atypical cases and
carriers among the contacts. Take cultures where suspected.
• Contacts of the infected individual, regardless of their immune
status should have cultures taken from nose and throat. Keep under
surveillance for 7 days.
• Seek approval from MOH for necessary exclusions as outlined in
section 2.2.
2.1.3. Physician:
Use general guidelines.
2.1.4. Laboratory:
Use general guidelines.
Those who handle food or work with children should be excluded from work
until nose/throat swabs demonstrate they are not carriers.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 19th edition. 2008. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz editor
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics
A Sample Letter To Parents of Children Who May Have
Been Exposed to Diphtheria.
Date:
Dear Parent,
This is to inform you that there has been a diagnosed case of diphtheria in the child-care
centre or school that your child attends. Diphtheria is a rare disease that may cause
fever, sore throat and a yellow-white discharge over the back of the throat. An
information sheet about diphtheria is included with this letter.
To stop the spread of the disease and to protect your child, it is recommended that you
contact your family doctor for testing and to update vaccinations if necessary.
If the doctor diagnoses your child with the disease, follow the instructions about
medications and immunization and contact Public Health Services.
Please contact me at Public Health Services if you have any questions or concerns.
Sincerely,
Phone:
DIPHTHERIA FACT SHEET
What is Diphtheria?
Diphtheria is a disease of the nose and throat that is caused by bacteria. The bacteria
are spread through contact with drops of fluid from the nose and throat of someone
who has the disease. Diphtheria is rare in Nova Scotia because of routine childhood
immunization.
Symptoms may start as early as 2 days after a person has been in contact with someone
who has the disease. Some people can become very ill and have problems breathing.
They will need to be isolated from others, usually in hospital.
Probable case
Clinical evidence of invasive disease with laboratory evidence of infection:
• demonstration of H. influenzae type b antigen in cerebrospinal fluid
OR
• demonstration of H. influenzae DNA in a normally sterile site
OR
• buccal cellulitis or epiglottitis in a child < 5 years of age with no other
causative organisms isolated
1.3. Symptoms:
Illnesses often caused by H. influenzae type B include meningitis, epiglottitis,
pneumonia, pericarditis, osteomyelitis, empyema, septic arthritis and
bacteremia. Onset of symptoms is usually sudden and includes fever,
drowsiness, meningeal irritation (stiff neck or back). Progressive stupor or coma
is common. Most cases are in children 3 months to 4 years of age.
1.4. Incubation:
Unknown, possibly 2-4 days.
1.5. Source:
Humans.
1.6. Transmission:
Person-to-person from direct contact or droplet contact of oral or nasal
secretions, e.g. saliva, nasal mucous, or respiratory secretions.
1.7. Communicability:
As long as organisms are present, asymptomatic carriage may occur indefinitely
in up to 2%-5% of children. Communicability ends within 24-48 hours after the
beginning of antibiotic therapy.
1.8. Treatment:
Ampicillin has been the drug of choice, however, with 30% of strains now
resistant, ceftriaxone or cefotaxime is recommended concurrently or singly until
antibiotic sensitivities are known.
1.10. Prophylaxis:
1.10.1. Definitions
The following definitions apply to the prophylaxis guidelines listed below:
Household contact: an individual residing with the infected person or a
non-resident who spent four or more hours with the index case for at
least 5 of the 7 days preceding the day of hospital admission of the index
case (not school contacts). This includes people who share sleeping
arrangements, such as military personnel in a barracks setting.
2. Procedure
2.1. Roles and Responsibilities
2.1.1. Medical Officer of Health:
Use general guidelines. No additional guidelines.
2.1.2. Investigator:
This is a priority follow-up and must be dealt with immediately. Use general
guidelines. Also use additional guidelines re:
a) Contacting physician.
The Invasive Haemophilus Influenzae type b Disease Appendix 1 contains
an information sheet for physicians that include definitions of contacts
and rifampin dosages.
c) Educating contacts.
Advise contacts to watch for signs and symptoms of illness, as outlined on
fact sheet.
d) Following up contacts.
Follow-up all contacts to confirm that they have received appropriate
prophylaxis and that they have not become cases (within 2 weeks).
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association.
Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz editor
Report of the Committee on Infectious Diseases, 2009. American Academy of Pediatrics.
HAEMOPHILUS INFLUENZAE TYPE B
INVASIVE DISEASE FACT SHEET
What is Hib?
Haemophilus influenzae type b (Hib) is a bacterial infection that causes serious
infections. Hib can infect the throat and then can spread to cause meningitis (an
infection of the covering of the brain and spinal cord), pneumonia or ear, skin, joint, or
blood infections.
Childcare centre contact: a child who has attended a childcare centre where an
infected individual has been identified.
Empty the contents of four rifampin 300 mg capsules into a 4 oz. amber glass bottle.
• Add 20 ml. of simple syrup (USP). Shake vigorously.
• Add 100 ml. of simple syrup (USP). Shake again.
• Store in a refrigerator at 2-8°C. (36-46°F) for no more than 6 weeks.
Date:
Dear Parent:
This letter is to let you know that your child attends a childcare centre with a child who
has been diagnosed with an infection caused by Haemophilus influenzae type b or
“Hib”. More information about “Hib” is on the attached fact sheet.
Public Health Services recommends that you watch your child for fever, excessive
sleepiness, or a stiff neck or upper back. Seek medical attention immediately if your
child becomes sick.
You should also make sure that your child’s immunizations are up to date. If either you
or your doctor needs more information, please contact Public Health Services.
Sincerely,
Date:
Dear Parent:
This letter is to let you know that your child attends a childcare centre where a child has
been diagnosed with an infection caused by Haemophilus influenzae type b or “Hib”.
More information about “Hib” is on the attached fact sheet.
Public Health Services recommends that your child receive a medicine that can help
prevent the spread of the disease. This medicine is called rifampin and it is prescribed by
your doctor. We suggest that your child see your family doctor within the next 24 hours
to discuss rifampin for your child, and to make sure your child’s vaccines are up to date.
Public Health Services also recommends that you watch your child for fever, excessive
sleepiness, or a stiff neck or upper back. Seek medical attention immediately if your
child becomes sick. If either you or your doctor needs more information, please contact
Public Health Services.
Sincerely,
Probable case
Clinical illness
• in the absence of appropriate laboratory tests
OR
• in the absence of an epidemiologic link to a laboratory-confirmed case
OR
• in a person who has recently travelled to an area of known measles
activity
1.2. Causative agent:
Measles virus.
1.3. Symptoms:
Prodromal fever, conjunctivitis, coryza, cough, Koplik spots, red maculopapular
confluent rash on 3rd to 7th day beginning on face and becoming generalized.
1.4. Incubation:
About 10 days, but may be 7-18 days from exposure to onset of fever (rarely as
long as 19-21 days). Average time from exposure to onset of rash is 14 days.
Immune globulin (IG) given for possible protection later than the third day of the
incubation period may extend the incubation period.
1.5. Source:
Humans.
1.6. Transmission:
Airborne by droplet spread; direct or indirect contact with nasal or throat
excretions of infection person.
1.7. Communicability:
From 1 day before the onset of symptoms (or 3 to 5 days before the onset of
rash) to 4 days after the appearance of the rash. Minimal after 2nd day of rash.
1.8. Treatment:
None.
1.10. Prophylaxis:
Vaccination and/or Immune Globulin (IG) may be required for those who have
been exposed to an infected individual and are susceptible. Exposure is defined
as greater than 2 hours of close contact with an infectious person.
Children and adults who meet the following requirements are considered
susceptible:
• Born after 1970.
• No previous documentation of live measles vaccine on or after 1 year of
age.
• No past history of measles, either documented, clinical or lab confirmed.
• No contraindication to the vaccine.
• Infants 0 to 5 months of age: Administer IG within 6 days of exposure
(0.25mL/kg given intramuscularly). Measles vaccine should be given at 1
year.
• Infants 6 to 12 months of age: Administer MMR within 72 hours of
exposure. IG can be considered on a case-by-case basis for those who did
not receive MMR. Administer IG within 6 days of exposure (0.25mL/kg
given intramuscularly). When children receive MMR before their first
birthday, they must receive MMR again on or after their first birthday and
continue with the routine schedule.
• Susceptible children and adults should be vaccinated with MMR within 72
hours of exposure.
• IG may be used within six days of exposure for susceptible household or
other contacts for whom risk of complications is very high (particularly
contacts under 1 year of age, pregnant women and immunocompromised
persons), or for whom measles vaccine is contraindicated. The dose is
0.25 ml/kg up to a maximum of 15 ml. IG is not indicated for household
contacts who have received one dose of vaccine at 12 months of age or
older unless they are immunocompromised. For immunocompromised
persons, 0.5 ml/kg is given, up to a maximum of 15 ml.
2. Procedure
Note: The single most important factor in preventing measles outbreaks is rapid
separation of susceptible contacts and infected persons. Immediate reporting,
investigation and vaccination of susceptible contacts can stop secondary cases.
2.1.2. Investigator:
Use general guidelines. Also use additional guidelines re:
c) Contact tracing.
When contact tracing, ask the client about:
• Travel history.
• Group functions/social events.
• Visitors from out of province/country.
• Knowledge of other suspect cases (persons with symptoms).
• Household contacts.
• Medical facilities visited.
• Work.
• School/day care.
• Apartment complex where client lives.
• Transportation, public conveyances.
Use a calendar to help the client recall activities.
d) Investigating contacts.
• Reach all contacts by telephone or in person. Determine if they have
been exposed and are susceptible.
g) Educating contacts.
• Educate contacts about the signs and symptoms of measles and what to
do if they develop symptoms (isolate themselves, notify their physician
and notify PHS).
• Ask the contact to keep a diary of activities for 2 weeks.
h) Following up contacts.
• Follow up with contacts within 1 week to confirm that they received
appropriate vaccination and to determine if they have or have not
become cases.
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
2.2. Criteria for Exclusion
2.2.1. Persons infected with measles.
Cases should be excluded from school, childcare, university or work until 4 days
after the appearance of the rash. They should strive to remain isolated from
susceptible individuals during this time. PHS will inform the case (or parents of
the case) of the exclusion as well as informing the school or day care operator.
a) Case finding.
Absent school/childcare attendees should be reached in order to
determine if they are cases. Those absent for 3 or more days are the
highest priority to be contacted. Case finding for source should be done
for a period of 2-3 weeks prior to current case to 2-4 weeks after the rash
onset of the last associated case.
b) Excluding cases.
Student’s ill during school that are suspect measles cases should be sent
home but not on public transportation or the school bus. These suspect
cases should be reported to PHS.
c) Evaluating staff, students, attendees and parents and siblings of
attendees.
For contacts that are determined to be susceptible, administer
vaccination and IG as per section 1.10.
d) Informing parents.
Inform parents of the need for their children to be vaccinated within 72
hours if their children are susceptible.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz editor
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
MEASLES FACT SHEET MAY 2008
What is Measles?
Measles, also known as Red Measles or Rubeola, is a serious disease caused by a virus.
It is spread very easily through the air when someone with measles coughs or sneezes
and by direct contact with infected nose or throat secretions.
Measles usually starts with a fever, cough, runny nose and red, puffy, watery eyes.
Small, white spots may be seen in the mouth. A few days later, a red rash appears on
the face and head, and then spreads over the rest of the body. The rash lasts 4 to 7
days.
Treatment
Symptomatic
• Exclude case from day care, school or other setting with susceptible
individuals until 4 days after onset of rash
Contacts
Public Health will follow up contacts.
• Contact means any one who shared the same space with a case. Consider
daycare, school, school bus, doctor’s office, Emergency room, etc.
• Family physicians should deal with family members with assistance from Public
Health Services.
• Public Health will deal with other contacts.
Routine Immunization
• Routine immunization is the most important preventive measure
• Give MMR at 12 months and again at 4-6 years (school entry)
MUMPS
1. Information
1.1. Case definition:
Confirmed case
Clinical illness and laboratory confirmation of infection in the absence of recent
immunization with mumps-containing vaccine:
• isolation of mumps virus from an appropriate clinical specimen
OR
• detection of mumps virus RNA
OR
• seroconversion or a significant rise (e.g. fourfold or greater) in mumps IgG
titre by any standard serologic assay between acute and convalescent
sera
OR
• positive serologic test for mumps IgM antibody in a person who is either
epidemiologically linked to a laboratory-confirmed case or has recently
travelled to an area of known mumps activity
OR
• Clinical illness in a person with an epidemiologic link to a laboratory-
confirmed case
Probable case
Clinical illness
• in the absence of appropriate laboratory tests
OR
• in the absence of an epidemiologic link to a laboratory-confirmed case.
1.4. Incubation:
14-25 days, usually 15 to 18 days.
1.5. Source:
Humans.
1.6. Transmission:
Airborne transmission via droplet spread and by direct contact with respiratory
secretions from an infected individual.
1.7. Communicability:
Communicable for 6 to 7 days before onset of symptoms and for as long as 9
days after onset of the illness.
1.8. Treatment:
Supportive. Individuals with severe CNS involvement may require hospitalization.
2. Procedure
2.1. Roles and Responsibilities
2.1.1. Medical Officer of Health:
Use general guidelines. No additional guidelines.
2.1.2. Investigator:
Use general guidelines. No additional guidelines.
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz editor
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
MUMPS FACT SHEET
What is Mumps?
Mumps is a disease caused by a virus. Mumps is spread by contact with the discharges
from the nose and throat. The virus can be spread for a few days before symptoms
appear and up to 9 days after.
Most people recover from the illness but mumps can be serious. Those who become
very ill may have encephalitis (an infection of the brain), meningitis (a swelling of the
covering of the brain), arthritis and deafness.
Pregnant women who get mumps are in danger of having a miscarriage, premature or
early labour, and low birth weight babies. Pregnant women who are in contact with
anyone with mumps should contact their family doctor.
Children should not attend school while they can spread the virus.
PERTUSSIS
1. Information
1.1. Case Definition
Confirmed case
Laboratory confirmation of infection:
• isolation of Bordetella pertussis from an appropriate clinical specimen
OR
• detection of B. pertussis DNA from an appropriate clinical specimen AND
one or more of the following:
• cough lasting 2 weeks or longer
• paroxysmal cough of any duration
• cough with inspiratory "whoop"
• cough ending in vomiting or gagging, or associated with apnea
OR
• Epidemiologic link to a laboratory-confirmed case AND one or more of
the following for which there is no other known cause:
• paroxysmal cough of any duration
• cough with inspiratory "whoop"
• cough ending in vomiting or gagging, or associated with apnea
Probable case
Cough lasting 2 weeks or longer in the absence of appropriate laboratory tests
and not epidemiologically linked to a laboratory-confirmed case AND one or
more of the following, with no other known cause:
• paroxysmal cough of any duration
• cough with inspiratory "whoop"
• cough ending in vomiting or gagging, or associated with apnea
Suspect case
One or more of the following, with no other known cause:
• paroxysmal cough of any duration
• cough with inspiratory "whoop"
• cough ending in vomiting or gagging, or associated with apnea
1.3. Symptoms
In classical pertussis, there are three clinical stages of the disease:
• Catarrhal: cough, rhinorrhea and possible fever; lasts 1-2 weeks
• Paroxysmal: paroxysmal cough that may be followed by vigorous
inspiration (whoop), expulsion of clear mucous and vomiting; lasts 1-2
months
• Convalescent: gradual recovery with possible set-backs
In some cases of infant, childhood or adult pertussis, classical symptoms may not
be present.
1.4.Incubation
Usually from 7-20 days
1.5.Source
Humans
1.6.Transmission
Direct contact with airborne droplets from the respiratory system
1.7.Communicability
From the early catarrhal stage to 3 weeks after the onset of typical paroxysms in
individuals not treated with antibiotics. Individuals treated with appropriate
antibiotics should be considered non-infectious after 5 days from the onset of
treatment.
1.8.Treatment
Antibiotic treatment shortens the period of communicability but does not reduce
symptoms unless given during incubation, catarrhal stage or early paroxysmal
stage.
Any of the following can be used for treatment of pertussis. All have the same
efficacy. Newer macrolides tend to be better tolerated but are more expensive:
• Azithromycin 10mg/kg once a day for 1 day then 5mg/kg once a day for 4
days
• Clarithromycin 15 mg/kg/day twice daily in a divided dose for 7 days
• Erythromycin 40 mg/kg/day three times a day in divided doses for 7 days
Infants <2 months of age who are receiving macrolide antibiotics should
be monitored for symptoms and signs of pyloric stenosis.
1.10. Prophylaxis
Indications
Prophylaxis should be given, regardless of age or immunization status to:
• All household contacts (including attendees at family day care centres) of
a lab-confirmed or clinical pertussis case where there is a vulnerable
person living in that household (or attending the family daycare)
• Vulnerable individuals who have had face-to-face exposure and/or have
shared confined air for >1 hour with a lab-confirmed or clinical pertussis
case in a non-household setting
For the purpose of pertussis prophylaxis, vulnerable individuals are defined as:
• A child less than 1 year of age regardless of their pertussis vaccination
status
• A woman in the third trimester of pregnancy
Immunization
Use the opportunity to update routinely scheduled immunizations in school or
day care contacts as required.
1.11. Exclusion
Exclusion is not a proven effective strategy in pertussis control. However, it can
be recommended by the MOH in high-risk situations (in case of close contact
with vulnerable individuals). When indicated, exclusion should be implemented:
• Until 5 days after the start of antibiotic therapy
OR
• If no treatment is given, until after 21 days from onset of cough and
negative
PCR or culture results have been obtained
2. Procedure
2.1. Roles and Responsibilities
2.3. Investigator
Use general guidelines. Also use additional guidelines re:
a) Educating the case and family:
• Very often the parents are concerned about their children’s symptoms,
especially their whooping. Offer information regarding medications.
Parents may be concerned about other children and their susceptibility to
the disease. Advise parents about immunization of children, especially
those who may not have begun their primary immunization series.
Discuss actions that may be taken to limit transmission
• Pertussis can be treated with an antibiotic such as erythromycin,
azithromycin or clarithromycin
• Advise the parents that their child is considered infectious for three
weeks after the onset of the paroxysmal cough or until 5 days after they
begin antibiotic therapy with a macrolide
b) Case management:
• Investigate and determine the likely source of the infection by
interviewing the case or family
• Ensure the case has received appropriate treatment (see section 1.8)
c) Contact tracing:
• Contact means face-to-face contact or sharing continued air space with
the case for a prolonged period (i.e. > one hour)
• Identified contacts should be followed up to:
Determine if there are further cases
Determine if there are any individuals who require
prophylaxis
Determine if there are situations where exclusion may be
necessary. Such situations need to be discussed with the
MOH
• Exposed individuals, especially those who are incompletely immunized
should be informed about pertussis symptoms and asked to contact
Public Health Services if these symptoms develop within 20 days of
exposure
• Recommend immunization for contacts whose immunization is not up-to-
date
2.4. Physician
Use general guidelines. No additional guidelines
2.5. Laboratory
Use general guidelines. No additional guidelines
2.6. Guidelines for Child Care Centres
Use general guidelines. Also use the following guidelines regarding:
a) Informing parents:
• Check health records of children in the childcare centre for
immunization status
• Send a letter (see Appendix A) to parents of attendees to inform
them of the case of pertussis and their child’s immunization status
and possible risk
b) Identifying cases:
• Discuss with staff the signs and symptoms of the disease. If any
other children have a cough, phone the parents to inquire about
whether the child fits the case definition
• Childcare centres should be monitored for a three-week period to
determine if there are any other ill children
c) Exclusion:
• Inform the staff that routine exclusion of cases is not
recommended but that in high-risk situations (i.e. when the case
has close contact with a vulnerable individual) exclusion may be
recommended by the MOH
References:
Public Health Agency of Canada. (2009).Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
National Consensus Conference on Pertussis, 2003, Health Canada,
Control of Communicable Diseases Manual, 19th Edition 2008. James Chin, Editor. American Public Health
Association.
Infection Control in the Child Care Center and Preschool 3rd Edition –1996-Leigh G. Donowitz Editor
Report of the Committee on Infectious Diseases, 2009. American Academy of Pediatrics.
PERTUSSIS FACT SHEET
What is Pertussis?
Pertussis is a disease of the lungs and the throat caused by bacteria. It is also known as
whooping cough. The germ that causes pertussis is very easily spread from person to
person. It is spread by close contact with drops of fluid from the nose and throat of
someone who has the disease. Pertussis can be spread to others from the time
someone catches the disease until 3 weeks after the symptoms start. If the person is
treated, then this time period would be only 5 days.
These symptoms will start 7-10 days after a person has been exposed. The symptoms
can last for 6-10 weeks. Although most people recover from the disease, some people
can be very ill. Pneumonia and seizures can occur.
There are specific guidelines for the follow-up of pertussis in the community.
Contacts
Management of contacts must take into account the degree of risk to the
individuals who are contacts. The risk of getting severe disease is greater for
children < 1 year of age. Risk of transmission of infection in decreasing order of
risk is:
• family
• family daycare
• daycare
• physician’s waiting rooms and hospital clinics
• school
• community
Chemoprophylaxis
Chemoprophylaxis should be given as soon as possible, and no later than 14 days
after first contact with a primary case during his/her infectious period, from the
early catarrhal stage to 3 weeks after the onset of symptoms. The drug of choice
is erythromycin (40 to 50 mg/kg/day, orally, in 4 divided doses: maximum 2g/day
for 10 days.)
Immunization:
Close contacts younger than 7 years who are unimmunized or who have received
fewer than 4 doses of pertussis vaccine should have pertussis immunization
initiated or continued, according to the N.S. routine immunization schedule.
Children who received their third dose 6 months or more before exposure should
be given a fourth dose at this time. Those who have had at least four doses of
pertussis vaccine should receive a booster dose of DaPTP unless a dose had been
given within the last three years or they are 7 years of age or older.
Exclusion:
Children with pertussis should be excluded from school and daycare for either
three weeks after paroxysmal cough or whoop began, or until five days after
initiation of antibiotic therapy. Contacts should receive prophylaxis but do not
have to be excluded. Control of pertussis and management of outbreaks
requires a close partnership between the primary care physician and Public
Health Services.
SAMPLE LETTER TO DAYCARE
Date:
Dear Parent:
This letter is to advise you that a case of whooping cough (pertussis) has been identified
in your child’s classroom and that your child may have been exposed.
In order to protect your child (children) from this serious disease, please follow the
instructions below.
Take your child to your family doctor if he/she has or develops persistent cold
symptoms, repeated violent coughing, cough ending in vomiting/gagging or cough with
a high-pitched whoop or crowing sound when breathing in. Please bring this letter to
show to your family doctor.
If your child develops the symptoms listed above, please also call me because family and
friends who are exposed to your child while he/she is sick may require antibiotics tom
prevent further whooping cough illness. Public Health Services can help in determining
this.
It is important for your child to be fully immunized with pertussis vaccine – this means
that he/she has received three doses of pertussis vaccine as an infant (usually at age 2,
4 and 6 months), a fourth dose at around age 18 months and a fifth dose before starting
Grade Primary. If your child has NOT had all his/her immunizations, please contact your
family doctor or Public Health Services.
If you have any further questions or concerns about this illness, please do not hesitate
to call me at______________________________________
Sincerely,
This child may have been exposed to a case of pertussis in his/her daycare/classroom and has
been asked to see his/her family doctor if experiencing symptoms suggestive of pertussis (see
overleaf). Recommended measures are outlined below.
1. Cultures: Nasopharyngeal cultures should be obtained from symptomatic contacts,
preferably before initiating antibiotic therapy.
2. Antibiotics: Any of the following can be used for treatment of pertussis. All have the
same efficacy. Newer macrolides tend to be better tolerated but are more expensive:
• Azithromycin 10mg/kg once daily for 1 day then 5 mg/kg once daily for 4 days
• Clarithromycin 15 mg/kg/day twice daily in a divided dose for 7 days
• Erythromycin 40 mg/kg/day three times a day in divided doses for 7 days
Patients should no longer be considered infectious after 5 days of therapy. Infants < 2 months
of age who are receiving macrolide antibiotics should be monitored for symptoms and signs of
pyloric stenosis.
Pertussis is a notifiable disease in Nova Scotia. Please report all suspect and confirmed cases to
Public Health Services.
If you wish to discuss any of this information, please do not hesitate to call me at:
_____________
Sincerely,
Probable case
Clinical illness without detection of polio virus from an appropriate clinical
specimen and without evidence of infection with other neurotropic viruses but
with one of the following laboratory confirmations of infection:
• significant rise (e.g. fourfold or greater) in polio IgG titre, by any standard
serologic assay, between acute and convalescent sera
OR
• positive serologic test for polio IgM antibody in the absence of recent
immunization with polio virus-containing vaccine
Suspect case
Clinical illness and no laboratory confirmation of infection (no polio virus
detection or serologic evidence), including negative test results and inadequate
or no investigation
1.4. Incubation:
Can range from 3-35 days, but usually between 7-14 days.
1.5. Source:
Humans.
1.6. Transmission:
Fecal-oral route where sanitation is poor or secretions of the nose and throat
(respiratory route).
1.7. Communicability:
Transmission is possible as long as the virus is excreted. Communicability is
greatest just before to just after the onset of symptoms.
1.8. Treatment:
Supportive. Attention to respiratory needs of those with severe illness.
2. Procedure
2.1. Roles and Responsibilities
2.1.1. Medical Officer of Health
Use general guidelines. A diagnosis of polio would be an unusual event and
would require immediate action.
2.1.2. Investigator
Immediately begin the investigation. Use general guidelines. Also use additional
guidelines re:
a) Contacting and educating the individual and family
Interview client and family to identify source:
• Explore if travel has taken place.
• Explore if there have been visitors from other countries.
• Explore if client had received any immunizations.
• Enteric precautions for the case in hospital.
• Educate family on transmission.
b) Contact tracing
• All household members should be considered at risk. Household
contacts can be infected before poliomyelitis has been diagnosed.
• Explore the type of contact, if the individuals have been
immunized and whether any contacts have symptoms.
• Immunize family and other close contacts. This may be too late to
contribute to the control.
• Thoroughly search for additional cases.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Poliomyelitis: http://www.who.int/inf-fs/en/fact114.html
POLIO FACT SHEET
What is Polio?
Poliomyelitis (polio) is a highly infectious disease caused by a virus. It invades the
nervous system, and can cause total paralysis in a matter of hours. The virus enters the
body through the mouth and multiplies in the intestine. One in 200 infections leads to
irreversible paralysis (usually in the legs). Of those paralyzed, 5%-10% die when their
breathing muscles become immobilized. There is a worldwide effort to eradicate polio
through immunization.
Probable case
Clinical illness
• in the absence of appropriate laboratory tests
OR
• in the absence of an epidemiologic link to a laboratory-confirmed case
OR
• in a person who has recently travelled to an area of known rubella
activity
1.2. Causative agent:
Rubella virus, of the genus Rubivirus.
1.3. Symptoms:
Usually a mild febrile disease characterized by a maculopapular discrete rash,
slight fever, conjunctivitis and postauricular, occipital or posterior cervical
lymphadenopathy. Children usually will have few or no symptoms, but adults
may experience a 1-5 day low-grade fever, headache and malaise. Some arthritis
and arthralgia may accompany symptoms, especially in female adults.
Encephalitis and thrombocytopenia are rare.
1.4. Incubation:
Usually 14-17 days, but can be as long as 21 days.
1.5. Source:
Humans.
1.6. Transmission:
Rubella is spread through direct or droplet contact from nasopharyngeal
secretions from someone with the infection. Congenital rubella syndrome is
transmitted to the fetus during pregnancy in 25% of cases of susceptible women
who were exposed to rubella during their first trimester of pregnancy. Infants
with congenital rubella may shed the virus for up to a year after birth.
1.7. Communicability:
One week before and at least 4 days after the onset of the rash. Infants with
congenital rubella may shed the virus for up to one year after birth.
1.8. Treatment:
None. Supportive care in the home, unless symptoms of fever and headache
indicate encephalitis.
1.9. Core Messages for Prevention:
• Immunization of all infants according to the N.S. immunization schedule.
• Immunization of all susceptible contacts including:
All post-pubertal females who do not have immunity to rubella (they
should not receive vaccine if they are pregnant),
All individuals with no documentation of MMR vaccine and born after
1970.
• Prenatal tests for rubella immunity should be done on a routine basis.
Vaccine should be administered to all postpartum women who are non-
immune before discharge from hospital.
• Investigation of immune status of health care personnel and
immunization given to all who are non-immune.
1.10. Prophylaxis
No prophylaxis. Offer rubella vaccine if contacts have not had immunizations.
2. Procedure
2.1 Roles and Responsibilities
2.1.1. Medical Officer of Health:
Use general guidelines. No additional guidelines.
2.1.2. Investigator:
Use general guidelines. Also use additional guidelines re:
a) Educating case and family.
• If individual is pregnant, discuss serological testing for immune status.
Provide counselling regarding possible risks of rubella infection for
the fetus. Refer to family doctor for further discussion.
• Educate the individual or family about rubella, including transmission,
communicability and the need to isolate the individual from public
places for 7 days from the appearance of the rash.
• Determine the infection source. Discuss social events, visitors from
out of province, any contact with others who have been ill or with
infants who may have congenital rubella syndrome.
b) Contact tracing.
Discuss in detail the dates, names and places where the individual may
have been in contact with others during the time of communicability,
with special emphasis on exposure for pregnant women. Include:
• Household contacts and extended family members.
• Social events.
• Work, school, childcare centres.
• Medical or clinical facilities.
Use a calendar to help the client recall dates and activities.
c) Identifying and immunizing susceptible contacts.
• Reach all contacts in phone or in person. Anyone who cannot
establish immunity should be considered susceptible. Individuals who
are considered immune are those who have:
Documented evidence of immunization since 1970 with
rubella vaccine after the first birthday, or
Physician documented evidence of rubella; or
Laboratory evidence of immunity.
• Immunity for infants who are born with congenital rubella syndrome
usually lasts only 1 year, during which time they may shed the virus.
Immunization for these infants is an important consideration after the
first year of life.
• All individuals who have been exposed to the virus and who have no
medical contraindications to the vaccine should immediately be given
rubella vaccine. Post-pubertal females, after receiving rubella vaccine
should be advised not to get pregnant for one month. Immunization
with rubella vaccine is contraindicated in pregnancy. Postpartum
women who are non-immune should be given rubella vaccine before
discharge from hospital.
• Provide information about rubella to all individuals who may have
been exposed to the virus, especially women who may be pregnant or
of reproductive age. Information about the signs and symptoms of
the disease and the importance of isolation from other possible
contacts, including health care workers, childcare centres and
schools, and especially other pregnant women, is essential.
• Follow-up contacts within 1 week to confirm that they have had
immunization or that they have or have not become infected.
2.1.3. Physician:
Use general guidelines. No additional guidelines.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
a) Case finding.
Absent school/childcare attendees should be reached in order to
determine if they are cases. Case finding for source should be done for
the 3 weeks prior to the onset of the rash.
b) Excluding cases.
Students who are ill during school that are suspect rubella cases should
be sent home but not on public transportation or the school bus. These
suspect cases should be reported to PHS.
c) Evaluating staff, students, attendees and parents and siblings of
attendees.
Investigate all women of reproductive age for possible exposure and
refer to their family physician.
d) Informing parents.
Inform parents of the need for their children to be immunized
immediately if their children are susceptible (sample letter is at the end
of this section).
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association.
Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz editor
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
RUBELLA FACT SHEET
What is Rubella?
Rubella is also known as German measles. Rubella is caused by a virus that is spread by
contact with discharges from the nose or throat of someone who has the disease.
Date: _____________
Dear Parent,
This is to inform you that there has been a diagnosed case of rubella in the
school/childcare centre that your child attends. Rubella begins with a mild rash and
fever, but many children may not have any symptoms at all.
An information sheet about rubella is included with this letter. In order to stop the
spread of the disease it is recommended that you follow these steps.
• Check with your family doctor about your child’s immunization status.
• Children whose immunizations are up to date are protected against rubella and
should not become ill. If your child does become ill, contact your family doctor
and our office. Any pregnant woman who may be in contact with a diagnosed
case of rubella should contact her family doctor.
If you have any questions or concerns, please contact me at Public Health Services.
Sincerely,
Probable case
Clinical evidence of illness in a person who is epidemiologically linked to a
laboratory-confirmed case or to a probable case
OR
Laboratory evidence of infection:
• negative stain electron microscopic identification of variola virus in an
appropriate clinical specimen
Suspect case
Clinical evidence of illness in a person who is not epidemiologically linked to a
laboratory-confirmed case or to a probable case of smallpox
OR
Atypical lesion known to be associated with the variola virus on a person who is
epidemiologically linked to a laboratory-confirmed or probable case
1.3. Symptoms:
Fever, malaise, headache, prostration, occasional abdominal pain and vomiting.
The skin eruptions progress through stages of macules, papules, vesicles, and
pustules. The lesions start on the face and extremities and subsequently on the
trunk—the so-called centrifugal rash.
1.4. Incubation:
7-19 days. Commonly 10-14 days to onset of illness and 2-4 days more to onset
of rash.
1.5. Source:
Officially, only in designated freezers—potential for bioterrorism.
1.6. Transmission:
Person to person. If used in biowarfare, the agent would most likely be
disseminated in an aerosol cloud.
1.7. Communicability:
From the time of development of the earliest lesions to disappearance of all
scabs; about 3 weeks. The person is most contagious during the pre-eruptive
period by aerosol droplets.
1.8. Treatment:
Supportive-antibiotics for secondary infections
1.10. Prophylaxis:
Under epidemic circumstances, widespread immunization would be indicated.
Smallpox vaccine has been successfully administered to persons of all ages in the
past. However, there are certain groups of peoples for whom elective
immunization has not been recommended because of the risk of complications.
Under epidemic conditions, however, such contraindications will have to be
weighed against the grave risks posed by smallpox. Vaccinia immune globulin
(VIG) can be administered concomitantly with vaccine to minimize the risk of
complications in these people. VIG is also recommended for the treatment of
severe cutaneous reaction occurring as a complication of immunization.
2. Procedure
Refer to Public Health Agency of Canada Guidelines.
1.3. Symptoms:
Characterized by acute onset of hypertonia and/or painful muscular contractions
(usually of the muscles of the jaw and neck), and generalized muscle spasms
without other apparent medical cause
1.4. Incubation:
3-21 days although may range from 1 day to several months, depending on the
character, extent and location of the wound; average 10 days. Most cases occur
within 14 days.
1.5. Source:
Intestines of horses and other animals including humans, where the bacillus is in
its normal habitat, and in soil contaminated with human and animal feces.
Tetanus spores are ubiquitous in the environment.
1.6. Transmission:
C. tetani spores introduced into the bloodstream through a wound, laceration or
puncture. Transmission can also occur through injection of contaminated street
drugs.
1.7. Communicability:
Not transmitted directly from person to person.
1.8. Treatment:
Tetanus Immune Globulin (TIG) is recommended. If TIG is not available, tetanus
antitoxin (TAT) should be given. Metronidazole is the antibiotic of choice.
Supportive care and effective wound management are recommended.
1.10. Prophylaxis:
• For individuals who have a severe or contaminated wound and who have
not had a booster in 5 years, a booster dose of Td should be given
immediately.
• For those who have not completed a primary series of tetanus toxoid
immunization, an immediate dose of tetanus toxoid should be given and
a dose of Tetanus Immune Globulin (TIG) if the wound is severe or
contaminated (different syringes and sites should be used). Completion
of the primary series of immunization is recommended.
• Wound debridement is essential in the management of tetanus.
Probable case
Clinical evidence of illness in the absence of laboratory confirmation or
epidemiologic link to a laboratory confirmed case
1.4. Incubation:
14-16 days; can be as early as 10 days or as late as 21 days.
1.5. Source:
Humans.
1.6. Transmission:
Direct person to person contact with respiratory secretions or by air-borne
droplet infection. There may be some viral transmission through direct contact
with lesions. Indirect transmission may occur through contact with respiratory
secretions or discharge from lesions in soiled linens or towels. The virus persists
in a latent form in the body and reactivation of the virus years later may result in
herpes zoster infection or shingles.
1.7. Communicability:
Can be up to 5 days but usually 1-2 days before the onset of symptoms and until
all lesions are crusted (usually about 5 days). Susceptible individuals should be
considered infectious from 10-21 days following exposure.
1.8. Treatment:
Supportive care. Oral antiviral treatment may be useful within the first 24 hours
of onset of the rash, to reduce the number and duration of skin lesions. Children
should not be given salicylates because of the increased risk of subsequent
Reye’s syndrome.
1.9. Core Messages for Prevention:
• If a susceptible pregnant woman or a susceptible immunocompromised
individual comes in contact with chickenpox, they should contact their
family doctor for consideration of VZIG.
• There is a vaccine available. It is recommended at one year of age.
1.10. Prophylaxis:
See flow chart in the appendix in this section.
2. Procedure
2.1. Roles and Responsibilities
2.1.1. Medical Officer of Health:
Use general guidelines. No additional guidelines.
2.1.2. Investigator:
Use general guidelines. Also use additional guidelines re:
a) Educating the case and family.
• Discuss treatment, if prescribed. Ensure that parents are aware that
salicylates, including ASA and aspirin, should NOT be used in the
treatment of chickenpox because of the risk of Reye ’s syndrome.
Advise the use of acetaminophen or ibuprofen for fever and
discomfort.
• Susceptible contacts should be given VZIG prophylaxis as per section
1.10.
• Discuss how transmission can be limited.
• Launder clothing and linens used by infected individual, especially if
soiled by respiratory secretions.
2.1.3. Physician:
Susceptible contacts should be given VZIG prophylaxis as per section 1.10.
2.1.4. Laboratory:
Use general guidelines. No additional guidelines.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G. Donowitz
editor Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
Statement on Recommended Use of Varicella Virus Vaccine. National Advisory Committee on
Immunization. Canada Communicable Disease Report Vol 25 (ACS-1) May 1999.
VARICELLA (CHICKENPOX) FACT SHEET
What is Chickenpox?
Chickenpox is caused by a virus called varicella-zoster. Chickenpox is a very common
infection in childhood and is usually a mild disease. Chickenpox can be very serious for
people who have immune diseases like leukemia or AIDS. Pregnant women who have
not had chickenpox as children may be affected, and their unborn babies may be at risk.
Dear Parent,
This is to inform you that someone in your child’s class/childcare centre has been
diagnosed with chickenpox and your child may have been exposed.
Chickenpox is caused by a virus and can spread quite easily and quickly. Information on
chickenpox is enclosed. Please check your child for signs and symptoms of the disease
over the next few days and weeks.
Contact your doctor if there are any persons in your household who have immune
diseases or are pregnant and have never had chickenpox. If your child is ill DO NOT give
them ASA or any products containing ASA or aspirin.
Contact the school or childcare centre that your child attends to alert the staff to your
child’s condition.
Please feel free to contact this office if you have any questions or concerns.
Sincerely,
2. Susceptible Persons
VZIG is recommended for the following susceptible persons, providing significant
exposure has occurred.
a) Immunocompromised children, adolescents and adults.
b) Newborn infant of a mother who had onset of varicella within 5 days
before delivery or within 48 hours after delivery.
c) Hospitalized infant (29 to 38 weeks) whose mother is not immune to
chickenpox.
d) Hospitalized premature infant (<28 weeks gestation or <1000 grams)
regardless of maternal immune status.
e) Susceptible pregnant women.
3. Availability of VZIG
Family physician can obtain from Public Health Services.
See latest Canadian Immunization Guide for more information.
VARICELLA EXPOSURE, CHICKENPOX OR
SHINGLES – FLOWCHART
Significant exposure to case of Varicella
NO YES
• Principles
• General Guidelines
• Protocol for Follow up of Individuals Placed Under Surveillance for
Inactive TB
• Tuberculosis Appendices:
• Appendix 1: Drug Monitoring Policy
• Appendix 2: Treatment of Latent TB Infection
• Appendix 3: Additional Disease Information
• Appendix 4: Patient Information
• Appendix 5: Request for Chest X-ray
• Appendix 6: Flow Charts
• Appendix 7: Mantoux testing
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within
the District Health Authorities. This manual is constantly under revision. Public Health staff will be
informed of the changes as they occur. However, information contained on this site may not contain the
latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this
information by any other groups or organizations aside from Public Health staff within the District Health
Authorities
TUBERCULOSIS
Principles
OR
1.3. Symptoms:
Symptoms may include cough, pleuritic pain, fever, night sweats, unexplained
weight loss. Primary tuberculosis is often a sub-clinical or mild self-limited illness.
1.4. Incubation:
Exposure to mycobacterium tuberculosis may result in tuberculosis infection (as
measured by tuberculin skin test) but not tuberculosis disease. Tuberculosis
disease may occur months to years after infection or may never occur.
1.5. Source:
Human. Rarely animal.
1.6. Transmission:
Tuberculosis is an airborne disease transmitted via droplet spread.
1.7. Communicability:
The communicability of tuberculosis depends on the infectiousness of the index
case, the degree of contact (i.e. in terms of the likelihood of the contact having
breathed the same air as the index case when he or she was infectious) and the
susceptibility of those contacts. It is important to consider the potential
infectiousness of the index case. Factors that indicate a high degree of infectivity
include:
• Sputum is smear positive.
• Index case has laryngeal TB.
• Index case has an abnormal Chest X-Ray (cavities).
• Index case has a productive cough.
1.8 Treatment:
Mycobacterium tuberculosis is slow to produce disease and equally slow to
respond to drug therapy. A combination of anti-TB drugs with full compliance for
a minimum of six months is required to achieve 100% cure rate. See Canadian TB
Standards document.
1.9. Prophylaxis:
Tuberculosis occurs as a result of infection that most commonly takes place
months to years before the onset of clinically apparent disease. The tuberculin
test is used to identify those who are carrying the tubercular bacillus before
clinical disease is evident. There is now well documented evidence that isoniazid
(INH), prescribed as a chemoprophylactic agent, is effective in preventing the
future development of tuberculosis (see Appendix for more information).
2. Procedure
2.1 Roles and Responsibilities
2.1.1. Medical Officer of Health
a. Assess case.
At time of referral of the index case, the MOH makes an assessment of the
likelihood of the client having the disease by reviewing clinical, laboratory and
radiological information with the attending physician. Depending on assessment
and the potential degree of infectivity, MOH initiates the contact tracing process
by Public Health Services (PHS) staff.
• The main priority in infectious cases is to ensure that no new individuals
are exposed to the index case until the index case is rendered non-
infectious by appropriate chemotherapy.
• For program purposes tuberculosis is classified into Active or Suspect
Active.
• Suspect Active is a ‘holding’ category and clients should be reclassified as
Active or Presumed Inactive within 6 months of first being labelled
Suspect Active.
• It is presumed Inactive when the lesion appears to be inactive but there
is no documentation of previous active disease. The site of the lesion
determines further clinical classification.
Tuberculosis becomes Inactive when client has completed an adequate course of
treatment and follow-up, and investigation has confirmed the inactive status.
b. Coordinate investigation:
• Co-ordinate communication among all staff involved in management of a
case and contacts after initial testing of high-risk contacts has occurred.
• Supervise ongoing contact tracing to ensure that the protocol for contact
tracing is completed.
• Ensure that all necessary clinical and epidemiological information on
clients and contacts is completed.
• Initiate and review any screening for tuberculosis infection that occurs
within the District.
• Act as a resource to other health professionals about tuberculosis control
principles and provide advice about national treatment standards for
individual cases.
2.1.2. Investigator:
Contact tracing and examination is undertaken at the earliest opportunity for all
clients with active or suspected active respiratory tuberculosis, whether or not
tubercle bacilli are found in the sputum.
• If there is any doubt about the time the index case could have been
infectious and hence how far back to trace contacts, then this should be
discussed with the Medical Officer of Health.
• All Accredited Acute Care facilities should have tuberculosis control
policies in place. The investigator should contact the responsible person
in the hospital to ensure that contact tracing is co ordinated.
• In situations where facilities do not have tuberculosis control policies, the
investigator should provide the responsible professional in the institution
with direction in contact tracing of clients and staff.
• In situations where the index patient has been in a hospital, contact
tracing among staff and clients who are hospitalized will be the
responsibility of the hospital infection control practitioner.
• All clients who are determined to be contacts and have been discharged
from hospital should be referred to PHS for follow-up in the community.
The hospital should supply PHS with name, gender, age, address, phone
number and name of family physician. It should be noted when the
contact occurred and type of contact (e.g. same room, same Unit) and
length of exposure.
Close contacts are the group most likely infected. These persons are therefore
the priority for investigation. If there is no evidence of infection in this group it is
unlikely that further investigation of the casual and community contacts will be
necessary. If, however evidence of infection is found in close contacts, then
extension of the contact tracing protocol to casual and community contacts
becomes important. This enables best deployment of resources on those at
greatest risk.
All contacts must be advised that they should see a physician if they develop
symptoms suggestive of tuberculosis (e.g. cough, pleuritic pain, fever, night
sweats, unexplained weight loss, etc.).
All contacts that are approached should be provided with information about
tuberculosis, the way it is transmitted and the types of treatment and
chemoprophylaxis available.
Tuberculin Testing:
Read in 48 - 72 hours. Record the amount of induration in mm. People with
documented evidence of a previous positive tuberculin reaction and those with a
documented history of tuberculosis may be exempted from tuberculin skin
testing.
Previous BCG is not a contraindication to tuberculin testing (see Appendix 7 for
more information on Tuberculin Testing).
Chest X-Ray
A chest X-Ray should be performed on:
• All contacts exempted from tuberculin testing.
• Contacts with a tuberculin reaction greater than 4 mm.
• All contacts with symptoms of tuberculosis even if their tuberculin test is
negative.
• In the case of a pregnant woman chest X-rays should be delayed until after the
delivery. It is important that the diagnosis of tuberculosis be considered should
the woman become ill during the pregnancy.
The following information will help the physician in making a decision about the
medical management of the contact and the investigator should provide the
physician with any of the following found during contact tracing:
• The degree of infectiousness of the index case.
• The degree of closeness of the contact.
• The history of a BCG given.
• The results of any past and recent TST’s.
• The past history of any treatment for tuberculosis.
• The results of the most recent Chest X Ray performed (if available).
The Medical Officer of Health should be informed of any situations where the
physician does not follow the contact tracing protocol.
Recommendations from the Medical Officer of Health will take into account the
following:
• A person known to be tuberculin skin test positive is unlikely to develop
disease from this exposure. However, they must be assessed for latent
tuberculosis infection and for active tuberculosis.
i. Record keeping.
At the completion of contact tracing, the investigator will complete the
Tuberculosis Contact Screening Worksheet and discuss it with the Medical
Officer of Health. Records of past TB history, past BCG history, past PPD history,
of cases and contacts must be kept to allow optimum management should
contacts investigated in the past become contacts of new index cases.
2.1.3. Physician:
a. Report new TB cases to PHS.
The physician is required to notify PHS of all new cases of Tuberculosis Disease.
This should be done by phone within 48 hours of the diagnosis being made in
order to ensure prompt attention to potential contacts and so that timely
recommendations can be made by the Medical Officer of Health about any
isolation precautions.
b. Treatment.
The attending physician determines the therapy prescribed for index cases and
contacts diagnosed with active tuberculosis.
• It is important that PHS be made aware of situations where compliance with
chemotherapy is likely to be a problem in order that consideration to
Directly Observed Therapy (DOT) can be given
• Public Health Services is often asked to provide suggestions regarding
treatment in which case national treatment standards are recommended.
The current standard for treatment is “Canadian Tuberculosis Standards, 5th
edition”
Individuals newly arrived in Canada are referred for medical surveillance for TB
by Citizenship and Immigration Canada (CIC) because of a previous history of TB,
or an abnormal chest radiograph suggestive of inactive TB.
The activities of CIC’s Medical Surveillance Unit (MSU) includes checking the
legibility/completeness of the information on the IMM 0535. Every attempt will
be made to capture an in-Canada contact address/telephone number of entrants
placed under medical surveillance
The MSU will then provide the IMM 0535 to the public health authority of the
entrant’s declared destination in Canada.
(b) S code (Box 8) – 2.02 needs to be checked off on form. This indicates that
surveillance to be done is for inactive tuberculosis. The other codes listed are for
the following diseases:
If code not checked off or clearly indicated contact CIC Officer, for clarification or
Ottawa Medical Surveillance.
2. Once address and code is complete and confirmed 2.02 for inactive TB
surveillance, contact client either by phone or home visit. If client’s English
language fluency is inadequate a home visit may be appropriate, particularly
if a family member can interpret.
5. Prior to client’s medical assessment, the Public Health Nurse contacts client’s
family physician, informing the physician that the client is under medical
surveillance undertaking for inactive tuberculosis and requires a chest x-ray
and physical examination. Please refer to ‘Guidelines for the Investigation of
Individuals Placed Under Surveillance for Tuberculosis Post Landing in
Canada” (CCDR October 2001, Vol. 27, Number 19). Requisition form for chest
x-ray should indicate, “chest x-ray is necessary for medical purposes”. Advise
physician to fax or mail chest x-ray results to Public Health Services.
7. Once both chest x-ray reports are available, the MOH will arrange for the
Hospital’s Radiology Dept. to compare films. Recommendations for client
follow-up will be made to the family physician.
APPENDIX 1: DRUG MONITORING POLICY
1. Overview
Public Health Services will cover the cost of the drugs necessary for treatment of
tuberculosis. The cost of chemoprophylaxis is also covered. Only those drugs that are
recommended as part of national treatment standards will be covered.
Any exceptions to this must be discussed with the Medical Officer of Health.
PHS should not dispense medication. PHS should develop a mechanism for dispensing
anti-tuberculosis medication using the local retail or hospital pharmacies. PHS should
supply the anti-tuberculosis medication to the pharmacy or hospital as necessary and
arrange to cover the cost of dispensing the medication.
If the case’s compliance cannot be achieved after the above, the Medical Officer
of Health must be informed.
DOT with a suitable regimen should ideally prevent the emergence of drug
resistance. Since resistance rates as low as 2.1% have been reported in program
DOT evaluations, this rate is the recommended program standard. These
objectives are best met with compliance rates that should reach at least 80% of
the total prescribed doses. Therefore, treatment should continue until a
minimum of 76 doses have been taken for a 95-dose regimen, even if the
regimen extends beyond the expected six months.
Treatment of LTBI is recommended for persons at greatest risk of TB disease (see table
below). INH is recommended in a dose of 10 – 50 mg/kg daily for children, up to a
maximum of 300 mg per day. For adults, the dose is 300 mg daily. The twice-weekly
dose is 20-40 mg/kg, to a maximum of 900 mg/dose in children and 900 mg/dose in
adults. The addition of vitamin B6 is indicated when there is poor nutrition, alcoholism,
pregnancy, diabetes, uremia, or other disorders that might predispose to neuropathy. It
is also recommended in the neonatal period.
*Consider treatment of LTBI in other persons, particularly those ≤ 35 years of age, who have a
tuberculin reaction size ≥ 10 mm and are from one of the following groups: foreign-born from TB
endemic countries, Aboriginals, health care workers, and residents in communal care.
APPENDIX 3: ADDITIONAL DISEASE
INFORMATION
1. Introduction
Pulmonary disease remains the most common and the most important form of
tuberculosis. Tuberculosis is spread from person to person only when an individual with
pulmonary tuberculosis coughs and discharges Mycobacterium tuberculosis into the air.
Pulmonary tuberculosis should be considered in any patient who has been coughing for
more than 4 weeks and, usually, for less than one year. Such a symptom whether with
haemoptysis, fever, weight loss, night sweats or not should be sufficient indication for a
chest x-ray and sputum culture for tuberculosis.
Apart from cough, tuberculosis should be suspected in any patient who has an
otherwise unexplained fever or loss of weight, drenching sweats at night, or coughs up
blood.
TB should be considered in all patients with the following: HIV infection, diabetes,
malignant disease, silicosis, those on long term corticosteroid or immunosuppressive
therapy.
Having considered a diagnosis of tuberculosis, the next step is to assess the tuberculin
status and arrange for a chest x-ray and mycobacterial studies of appropriate
specimens.
2. Primary tuberculosis
The initial infection with Mycobacterium tuberculosis causes a small pulmonary
parenchyma infiltrate with enlargement of the regional lymph node. In the immune
competent host, the infection is usually asymptomatic (90%-95%). The lesion heals with
fibrosis and may calcify late, producing the Ghon lesion. In children, the intensity of the
lymph node enlargement may cause symptoms due to compression of an adjacent
bronchus. A dry cough may be associated with mild systemic symptoms. A chest X-ray at
this stage would demonstrate the “primary complex” of enlarged hilar or paratrachael
nodes and parenchyma infiltrate usually in the lower lobe. Of all symptomatic primaries
approximately 30% show lymph node enlargement alone. The sputum or gastric wash in
such patients is only positive for Mycobacterium tuberculosis in about 35% of cases.
Diagnosis is therefore often based on a positive tuberculin skin test and the radiological
appearance alone.
Bronchial compression may cause lobar consolidation and atelectasis with secondary
bacterial infection. Allergic manifestations such as erythema nodosum and phlyctenular
conjunctivitis can be associated with primary TB, but also with fungal infection,
streptococcal infection, sarcoidosis and some drug administration.
Cavity formation is usually associated with large numbers of organisms and prolonged
infectivity. Haemoptysis may occur and is usually due to bronchial mucosal ulceration.
Rarely the pulmonary vasculature is eroded causing a massive and sometimes fatal
bleed. Pleural disease, due to rupture of subpleural caseous lesion, produces an
exudative effusion with predominant lymphocytosis, protein greater than 30 g/litre, an
elevated LDH, and pH less than 7.2. Mycobacterium tuberculosis is cultured from the
pleural fluid in less than 50% of cases. Pleural biopsy is a more useful diagnostic tool and
yields a greater percentage of positive cultures and characteristic histology.
4. Extra-pulmonary tuberculosis
Tuberculosis may present in sites other than the lung. Non-pulmonary tuberculosis
presents in lymph nodes, the genito-urinary system and less commonly in other sites
such as central nervous system, gastrointestinal tract, bone, pericardium and soft tissue.
Approximately 40% of tuberculosis cases in Canada are extrapulmonary.
The knees and hips are the most common joints affected by tuberculosis. Often
extension through the articular cartilage into the joint is the cause of the first
signs and symptoms of osseous tuberculosis. The fibrosis of healing often leads
to fusion. Treatment consists of anti tuberculosis drugs and surgery is seldom
necessary.
Tuberculous joint disease should be considered in any case of monoarthritis.
The knees and hips are the most common joints affected by tuberculosis. Often
extension through the articular cartilage into the joint is the cause of the first
signs and symptoms of osseous tuberculosis. The fibrosis of healing often leads
to fusion. Treatment consists of anti tuberculosis drugs and surgery is seldom
necessary.
CNS tuberculosis accounts for 0.5% of all active cases annually. It originates in a
cerebral focus which ruptures with predominant lymphocytosis (although the
initial response may show a predominance of polymorphs) elevation of protein
and low CSF sugar relative to the blood sugar. Z-N smears are positive in less
than 25% and cultures in less than 50%. The diagnosis is often delayed due to the
slow onset of symptoms of headache, lethargy and varied neurological
complaints. The mortality is still 25% and increases with increasing delay in
diagnosis. Neurological sequelae are common and may affect 40-50% of cases
when diagnosis and treatment are delayed. The most frequent neurological
complications are single cranial neuropathies, hemiplegia, hydrocephaly and
mental retardation. These disorders are thought to be caused by tuberculous
arteritis involving the intracranial vessels resulting in thrombosis and focal tissue
infarction.
Corticosteroid drugs are usually added for 1-3 months to diminish the intense
inflammatory response and frequency of late neurological sequelae due to
vasculitis. (But steroid therapy may decrease the penetration of the blood brain
barrier by Rifampin.)
The bacilli enter the bloodstream during the initial stages of primary infection,
before the host’s immune system has fully responded, or later during
reactivation of disease in a respiratory or non-respiratory site (late generalized
TB). The disease may be manifest as a military pattern on chest radiograph, as a
bone marrow aspirate/biopsy or blood culture positive for M. tuberculosis, or
with widespread tuberculosis granulomas at histopathologic analysis.
When the prevalence of tuberculosis is high, disseminated TB occurs most
commonly in childhood; when prevalence of TB is low, it is mainly a disease of
adults, including the elderly, and those infected with HIV.
APPENDIX 4: PATIENT INFORMATION
INH (ISONIAZID) TREATMENT
USE
INH is one of the drugs your doctor has prescribed for treatment of your
tuberculosis (TB).
INSTRUCTIONS:
• If you have any allergies or are taking any other drugs you should
mention this to your doctor before taking this drug.
• It is very important to follow the directions on the label about the
number of pills to be taken and at what time or times of day they should
be taken.
• The drugs should be taken regularly as prescribed. Skipping pills can lead
to delays in your recovery.
SIDE EFFECTS
This drug may have some side effects. These can include:
• Excessive tiredness.
• Yellowish colour to the skin.
• Pain in joints.
• Numbness or pins and needles in hands and or feet.
Should one of these or any other unusual symptoms occur you should contact
your doctor immediately.
Your doctor should order tests before starting medication. Your doctor will be
seeing you regularly while you are under treatment for TB and will do blood
tests during this period. It is very important to keep all scheduled appointments.
USE
INH is a drug commonly used for people who have been in contact with
tuberculosis (TB) to prevent them from developing TB.
INSTRUCTIONS
• If you have any allergies or are taking any other drugs, mention this to
your doctor before taking this drug.
• It is very important to follow the directions on the label about the
number of pills to be taken and at what time or times of day they should
be taken.
• The drugs should be taken regularly as prescribed.
SIDE EFFECTS
This drug may have some side effects. These can include:
• Excessive tiredness.
• Yellowish colour to the skin.
• Pain in joints.
• Numbness or pins and needles in hands and or feet.
Should one of these or any other unusual symptoms occur you should contact
your doctor immediately.
Your doctor should order tests before starting medication. Your doctor will be
seeing you regularly while you are under treatment with INH. Your doctor should
do blood tests during this period. It is very important to keep all scheduled
appointments.
USE
Ethambutol is one of the drugs your doctor has prescribed for treatment
of your tuberculosis (TB).
INSTRUCTIONS
• If you have any allergies or are taking any other drugs, you should
mention this to your doctor before taking this drug.
• It is very important to follow the directions on the label as to the number
of pills to be taken and at what time or times of day they should be
taken.
• The drugs should be taken regularly as prescribed. Skipping pills can lead
to delays in your recovery.
SIDE EFFECTS
This drug may have some side effects. These may include:
• Vision problems.
• Stomach upset.
• Rash.
• Dizziness.
• Headache.
Should one of these or any other unusual symptoms occur you should contact
your doctor immediately. Your doctor should order tests before starting
medication. Your doctor will be seeing you regularly while you are under
treatment for TB and may do some blood tests during this period. It is very
important to keep all scheduled appointments.
USE
Rifampin is one of the drugs your doctor has prescribed for treatment of your
tuberculosis (TB).
INSTRUCTIONS
• If you have any allergies or are taking other drugs you should mention
this to your doctor before taking this drug.
• It is very important to follow the directions on the label as to the number
of pills to be taken and at what time or times of day they should be
taken.
• The drugs should be taken regularly as prescribed. Skipping pills can lead
to delays in your recovery.
SIDE EFFECTS
This drug may have some side effects. These can include:
• Turning urine, stool, sweat and tears red. As a result, contact lenses
should not be worn while on this drug.
• Birth control pills may not be effective, so another birth control method
should be used while on this medication.
• Stomach upset.
• Headache.
• Drowsiness.
• Tiredness.
• Itching.
• Vision problems.
• Muscle weakness.
Should one of these or any other unusual symptoms occur you should contact
your doctor immediately. Your doctor should order tests before starting
medication. Your doctor will be seeing you regularly while you are under
treatment for TB and should do blood tests during this period. It is very
important to keep all scheduled appointments.
USE
Pyrazinamide (PZA) is one of the drugs your doctor has prescribed for treatment
of your tuberculosis (TB).
INSTRUCTIONS
• If you have any allergies or are taking any other drugs, you should
mention this to your doctor before taking this drug.
• It is very important to follow the directions on the label as to the number
of pills to be taken and at what time or times of day they should be
taken.
• The drugs should be taken regularly as prescribed. Skipping pills can lead
to delays in your recovery.
SIDE EFFECTS
This drug may have some side effects. These can include:
• Stomach problems.
• Yellow skin.
• Tiredness.
• Skin rash.
Should one of these or any other unusual symptoms occur you should contact
your doctor immediately. Your doctor should order tests before starting
medication. Your doctor will be seeing you regularly while you are under
treatment for TB and should do some blood tests during this period. It is very
important to keep all scheduled appointments.
The Test
The test can show if you have been exposed to TB at anytime in the past. A small
amount of tuberculin is injected just under the skin of the lower part of the arm.
For a short time after the needle is given, a small raised area under the skin may
appear at the site of injection.
The Result
Your arm will need to be looked at by a nurse or doctor 48-72 hours after the
test to see if there is a positive or negative reaction. The result of the test may
vary from no reaction at all to a red raised area with some surrounding redness.
Occasionally someone very sensitive to the tuberculin may have some blistering
at the site of the test. This will usually clear up without treatment.
Sometimes after the test is read and after reviewing your medical history it may
be recommended that a chest x-ray be done.
APPENDIX 5: REQUEST FOR CHEST X-RAY
Dear Dr:
Re:
Address:
Date Of Birth:
5TU PPD Date: Result:
Past History:
Your patient named above has been a contact of tuberculosis and was screened as part
of the contact tracing. He/she requires a Chest X-Ray as part of the screening protocol
developed by Public Health Services. Please send a copy of the Chest X-Ray report to
your local Public Health Services office to help us evaluate the need for further contact
tracing.
The Chest X-Ray Report may help in determining whether the patient is a candidate for
consideration of Isoniazid (INH) prophylaxis. If the result of the contact tracing indicates
that your patient might benefit from INH chemoprophylaxis, the patient will be referred
back to you. We will also send you current Public Health Guidelines about INH
chemoprophylaxis to help you in making your decision about further patient
management.
If your patient has or develops respiratory symptoms, he or she should be evaluated for
any evidence of tuberculosis disease.
If you would like further information about our contact tracing protocol or about INH
chemoprophylaxis, please do not hesitate to call.
The following guidelines are designed to assist Long Term Care facilities (LTC) to
ensure necessary screening and follow up for the residents. Although screening
for tuberculosis (TB) is the responsibility of the LTC, identified cases of active TB
should be referred to Public Health Services for follow up purposes.
Knowing the tuberculin skin test status of the staff is also important but this is a
pre-employment and occupational health issue that should be addressed by the
organization/employer.
Organism
Tuberculosis is a mycobacterial infection caused by Mycobacterium tuberculosis,
an acid -fast bacillus (AFB).
Transmission
Most commonly, the tubercle bacillus is transmitted from one person to another
in minute droplets of moisture that become increasingly reduced by
evaporation, creating “droplet nuclei”. Droplet nuclei are created by forceful
expiratory efforts such as coughing, sneezing, singing and playing wind
instruments. Certain procedures such as bronchoscopy, autopsy and even
irrigation of tuberculous abscesses may also produce infectious aerosols.
Tubercle bacilli that are lodged on fomites (linen, furniture, books, floors) do not
constitute a significant source of infection; most die quickly through the action of
drying, heat or sunlight. Several factors combine to permit transmission of
infection and its sequelae in the exposed person. Transmission involve4s the
contagiousness of the source case, the nature of the contact, the environment
and susceptibility of those exposed.
Primary Infection
More than 90% of patients are entirely asymptomatic at the time of primary
infection and can be identified only through conversion of the tuberculin skin
test.
The tuberculin skin test is positive in about 90% of patients with tuberculosis.
Some reports have recorded anergy in up to 20% or more of patients in the
earlier acute phase, prior to treatment. This is more likely to occur in the very ill,
those with miliary disease or advanced pulmonary disease or those who are
malnourished.
Indications
Why do a tuberculin skin test?
The tuberculin skin test (Mantoux) is one of the screening methods used to:
• document a base line tuberculin test on all new residents
• investigate persons in whom active tuberculosis is suspected
• identify persons who have been infected with Mycobacterium
tuberculosis.
• find out the extent of transmission in contacts.
Contraindication
• Residents with severe blistering tuberculin reaction in the past;
• Residents with documented active TB or documented treatment (active
or passive) in the past;
• Residents with extensive burns or eczema;
• Residents with vaccination with a live vaccine in the past month.
What is a Tuberculin Skin Test (Mantoux)?
An intradermal injection of a small amount (0.1 mL) of purified protein derived
from tubercle bacilli.
• Equipment:
• 1cc tuberculin syringe
• 3/8in. 26 or 27 gauge needle
• alcohol swab
• 5 TU Tuberculin purified protein derivative (Mantoux)
• gauze sponge
• Preparation:
• provide privacy to ensure confidentiality
• obtain TB history (previous TB disease and treatment, exposure,
previous skin test result) and assess for current symptoms
• explain procedure to client and obtain informed consent
• plan to read 48 to 72 hours after administration
• provide good lighting
• wash hands
• wipe rubber cap of PPD vial with alcohol swab and allow drying
• draw up PPD into syringe
• draw up a bit more than 0.1 mL to allow for losses
• tap syringe to break up air bubbles and squirt out a drop of antigen
until there is exactly 0.1 mL PPD in syringe
• draw up PPD immediately before injection
• choose a test site that is free of blood vessels, lesions, hair or edema
on the volar or lexor (palm side) surface of the forearm, 10
centimeters (4 inches) below the elbow crease; the standard site is
the left forearm.
How do you administer the test?
Procedure:
• support arm on firm surface
• wipe injection site with alcohol swab and allow to dry completely
• stretch arm at injection site taut before inserting needle
• hold syringe almost parallel to the skin with needle bevel up
• insert needle into the superficial layers of skin until bevel is fully inserted
and the tip is visible under the skin
• release tautness and stabilize syringe
• inject antigen slowly; resistance will be felt as tuberculin enters between
the layers of skin and forms a bleb 5 to 10 mm in diameter
Two Step
Policy:
All new residents to LTC should have a two-step tuberculin test unless
contraindicated on assessment.
A 2-step procedure should be used for all new residents to long term care. A 2-
step initial testing procedure allows the clinician to distinguish between a
booster response and conversions caused by new infection. This procedure is
only done once on an individual to determine baseline status.
2-Step Procedure:
• The initial test is administered as per normal practice.
• If the size of the reaction is significant, no further testing is required and the
person is referred for a tuberculosis assessment.
• If the reaction is not significant, a second test should be repeated 7-21 days
later.
• Record first and second results on client record. Second result serves as the
baseline.
• Measurement must be recorded in millimeters - e.g., 0-mm.
Product Information
• 5 TU dosage available in l mL (10 test) vial.
• Store between 2° to 8°C. Ensure cold chain has not been broken.
• Avoid exposure to light. Store in the box.
• Date vial when opened.
• Once opened, discard after one month.
Conclusion:
TB continues to be a health risk to the resident’s of long term care facilities.
Screening of residents at the time of admission helps to identify active cases of
TB and to document base line tuberculin skin testing status of the residents. This
in turn will help prevent and control TB in the LTC more effectively.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
The Canadian Lung Association, Canadian Tuberculosis Standards, Fourth edition, 1996. Health Canada,
Guidelines For Preventing The Transmission Of Tuberculosis in Canadian Health Care Facilities and Other
Institutional Settings, April 1996 Health Canada, Infection Control Guidelines For Occupational Health in
Health Care Facilities, 1987. “Recommendations For TB Control”, Canadian Nursing Home, Vol. 6,
Number 2, May - June 1995.
APPENDIX 8: GLOSSARY OF TERMS
Active Disease:
The presence of current active tuberculosis most often on the basis of positive
bacteriologic confirmation but in approximately 15% of cases on the basis of
appropriate clinical and radiologic presentation with a response to therapy.
Anergy:
The failure of a subject to respond to skin test antigens because of immune deficiency
that is due, for example, to infection with the human immudodeficiency virus or to
immunosuppressive therapy.
Booster Phenomenon:
The presence of initial negative PPD response followed by a positive response when the
test is repeated, usually within one to four weeks. The phenomenon often occurs
many years after infection, most notably in the elderly. The initial negative response is
based on the subject’s initial failure to “recall” immunologically prior infection. To
avoid inadvertent labeling of a positive response as due to a PPD conversation, initial
two-stage skin testing, especially when serial skin testing is planned, is usually
recommended.
Conversion:
The presence of a significant 10 mm or greater PPD response following an insignificant
response in the previous two years.
Culture Positive:
The presence of positive mycobacteriologic culture of body secretions, most notably
sputum, for the presence of M. tuberculosis.
Index Case:
The initial active case from which the process of contact investigation begins.
Induration:
The skin test response to an antigen, which is read 48 to 72 hours after injection. It is
measured in millimeters and refers to elevated response to the antigen, excluding any
associated erythema.
Infection:
Infection of a host by the M.tuberculosis organism, which lies dormant in an
asymptomatic state. There is a subsequent approximate 10% risk of life time future
reactivation and development of active disease in an immune competent host.
Infectious:
The condition whereby the subject can transmit infection to others by virtue of the
production of infectious aerosols.
DIRECT CONTACT, RESPIRATORY ROUTES, AND
THROUGH THE PROVISION OF HEALTHCARE
• Bacterial Conjunctivitis
• Clostridium Difficile
• Creutzfeldt-Jakob Disease (Classical)
• Creutzfeldt-Jakob Disease (New Variant)
• Fifth Disease (Human Parvovirus Infection)
• Group A Streptococcus – Invasive
• Group A Streptococcus – Non-Invasive
• Group B Streptococcal Disease of the Newborn
• Hand / Foot / Mouth Disease (Coxsackie virus)
• Impetigo
• Influenza
• Legionellosis
• Menigococcal Disease – Invasive
• MRSA / VRE
• Pediculosis (Lice)
• Pneumococcal Disease-Invasive
• Scabies
• Viral Meningitis
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within the District
Health Authorities. This manual is constantly under revision. Public Health staff will be informed of the changes as
they occur. However, information contained on this site may not contain the latest information.
Nova Scotia Department of Health and Wellness does not assume any responsibility for the use of this information
by any other groups or organizations aside from Public Health staff within the District Health Authorities.
BACTERIAL CONJUNCTIVITIS (PINK EYE)
1. Information
1.3 Symptoms
Puffiness of the eyelid, irritation under the eyelid, “bloodshot” eyes, often there
may be a mucopurulent yellowish discharge and a crusting of this discharge
overnight. Some individuals may experience photophobia. Viral and bacterial
cannot be differentiated based on symptoms.
1.4 Incubation
24-72 hours.
1.5 Source
Humans.
1.6 Transmission
Contact with upper respiratory tract discharges of infected persons, especially
those with symptoms of conjunctivitis. Contamination by hands and fingers or by
sharing articles such as make-up applicators is also possible.
1.7 Communicability
During the period of active infection.
1.8 Treatment
Local application of antibiotic drops or ointment containing a sulphonamide,
gentamicin or combination antibiotics such as polymyxin B with neomycin or
trimethoprim.
1.10 Prophylaxis
None.
2. Procedure
No public health follow-up required. This is not a notifiable disease.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
CONJUNCTIVITIS FACT SHEET
What is Conjunctivitis?
Conjunctivitis or pink eye is an infection of the lining of eyelid caused by a virus or
bacterium.
If a child has pink eye caused by bacteria (yellow or white discharge or doctor diagnoses)
and is using an antibiotic ointment, the child should stay out of school or day care until
24 hours after the treatment was started. If a child has pink eye caused by a virus, the
child does not have to stay home from school.
1.0 Information
1.1 Case Definition
Confirmed Case:
A patient is defined as a case if they are one year of age or older
AND have one of the following requirements:
1.3 Symptoms
Symptoms associated with C. difficile range from:
watery diarrhea
fever
loss of appetite
nausea
abdominal pain/tenderness.
Pseudomembranous colitis generally is characterized by diarrhea, abdominal
cramps, fever, systemic toxicity and abdominal tenderness.
Specimen Required: Stool - Only liquid specimens, “taking the shape of the
container”, should be processed in a dry sterile container and transported at 4:C.
C. difficile toxin is unstable and may become undetectable within a few hours if a
stool specimen is left at room temperature. Formed specimens and “test of
cure” specimens should not be sent or processed. Currently, in Nova Scotia, all
Regional Hospitals perform EIA for toxin. The cytotoxicity test is performed at
Capital District Health Authority and some Regional hospitals use antigen testing
and refer specimens for further testing if toxin negative but antigen positive.
The approach to testing is evolving quickly, and changes can be anticipated over
the next few years.
1.5 Treatment
Discontinue all current antibiotic therapy as soon as possible if significant
diarrhea or colitis develops. Drugs that decrease intestinal motility should not
be administered. Antimicrobial therapy for C. difficile disease is indicated for
patients whose diarrhea persists after antimicrobial therapy is discontinued.
Strains of C. difficile are susceptible to metronidazole and vancomycin.
Treatment recommendations for at least 10 days are as follows:
1.8 Transmission
The transmission of C. difficile occurs through fecal-oral transmission, direct
contact or indirect contact transmission from hands or items contaminated with
stool from symptomatic and/or asymptomatic (colonized) patients.
1.9 Communicability
The period of communicability is not well defined because asymptomatic
patients may be colonized with the bacteria and patients who have been
successfully treated may still have organisms and spores in their stools.
C. difficile spores can survive up to 60 days (and sometimes longer) in the
environment.
2.4 Guidelines
For Outbreak Management, routine practices should be used with all clients at
all times:
Contact precautions for the case(s)
Conduct a risk assessment considering the potential for:
o Exposure to body fluids (i.e. active vomiting, explosive diarrhea)
o Exposure to large deposits of body fluids (vomitus, feces) on
environmental surfaces
o Resident’s continence level and ability to comply with instructions
Care givers should wear the following Personal Protective Equipment when
giving direct care to symptomatic residents/clients:
o Gloves - for providing any direct care
o Gowns - when contamination of HCPs clothing is possible
o Surgical mask with eye protection/face shield to protect mucus
membranes from exposure to viral particles when assisting someone who
is actively vomiting, has explosive uncontained diarrhea or when cleaning
an area grossly contaminated with vomitus or feces.
Hand washing with soap and water is the most effective hand hygiene
practice. Alcohol-based hand sanitizers are less effective in destroying C.
difficile spores.
Resident/Client Placement:
o Contact Precautions – residents/clients should be confined to their rooms
as much as possible until asymptomatic for 48 hours.
o Contact precautions may be discontinued when the patient has had at
least 48 hours without symptoms of diarrhea (e.g. formed or normal
stool for the individual).
o In a shared room, a resident/client with symptoms should not share a
toilet with a well resident/client. Assign a dedicated toilet or commode, if
possible.
o In shared rooms, roommates and all visitors must be aware of the
precautions.
o Whenever possible, dedicate equipment to be used only on the ill
resident/client. In the event that equipment must be shared, thorough
cleaning and disinfection is required in between residents.
Ill health care workers and food handlers should not work, if they develop
symptoms consistent with a GI infection (e.g. vomiting, diarrhea) while at
work the employee should be required to leave work immediately.
Staff should remain off work when experiencing diarrhea, unless there is a
known underlying non-infectious cause.
Exclude ill staff from work until 48 hours after symptoms have stopped (e.g.
formed or normal stool for the individual).
Limitation and restriction of visitors may be necessary in an outbreak
situation. Visitors and volunteers should be advised that they may be at risk
of acquiring an infection within the facility, instructed how to wear
appropriate PPE and required to use hand hygiene before and after their
visit. Visitors should visit only their own friend/relative in their own room,
unless otherwise approved by the Heath care provider.
Effective cleaning of the environment around clients/patients/residents who
have C. difficile is essential in limiting the acquisition and spread of C.
difficile.
Contact the Department of Agriculture as necessary. Food Safety Specialists
(FSS) may visit the facility to ensure all precautions are being adhered to
when cases are found in the facility and they can provide environmental
sanitation advice and resources.
The Infection Prevention and Control Centre at Department of Health and
Wellness can provide advice on environmental sanitation in patient care
areas.
Please refer to the “Guidelines for Communicable Disease Control for Childcare
Programs and Home Day Care Agencies”, November 2008
http://www.gov.ns.ca/hpp/publications/Childcare-Manual-November-2008.pdf
5.0 References
Control of Communicable Disease Manual, 19th Edition. 2008. David Heymann, editor.
American Public Health Association.
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases
under National Surveillance. CCDR 2009;3552,1-123. Retrieved from http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Red Book. Report of the Committee on Infectious Diseases, 28 th Edition. 2009. American
Academy of Pediatrics.
Viswanathan, V.K., Mallozzi, M.J. & Vedantam, G. (2010). Clostridium difficile Infection:
An overview of the disease and its pathogenesis, epidemiology and interventions. Gut
Microbes, 1(4), 234-242
6.0 Appendices
A. Clostridium Difficile Fact Sheet - English
B. Clostridium Difficile Fact Sheet - French
CLOSTRIDIUM DIFFICILE FACT SHEET
What is Clostridium Difficile?
Clostridium difficile (C. difficile) is a kind of bacteria. It causes:
mild to severe diarrhea
more serious intestinal conditions like inflammation of the colon
(pseudomembranous colitis).
C. difficile is normally found in soil and other natural environments. It can also live in
our own gut or bowel.
C. difficile is the most common cause of infectious diarrhea in Canadian hospitals and
long-term care facilities.
The elderly, people who have other illnesses, and people who are already taking
antibiotics are at a greater risk of infection.
How is it spread?
C. difficile is most often spread through direct contact—for example with infected hands
or gloves. Shared items such as contaminated thermometers or commodes may also
spread it.
How is it treated?
People with mild symptoms may not need any treatment at all.
For more severe cases, a healthcare provider will prescribe medication (like antibiotics)
to be taken for 10 days. The drugs used to treat C. difficile are effective and have few
side effects.
C. difficile est présent dans le sol et d’autres environnements naturels. Il peut aussi vivre
dans nos intestins.
C’est la cause la plus commune de la diarrhée infectieuse dans les hôpitaux et les
établissements de soins de longue durée au Canada.
Les personnes âgées, celles qui souffrent d’autres maladies et les personnes qui
prennent des antibiotiques courent un plus grand risque d’infection.
Pour les cas plus graves, un fournisseur de soins de santé prescrira un médicament
(p. ex. des antibiotiques) à prendre pendant dix jours. Les médicaments pour traiter
C. difficile sont efficaces et ont peu d’effets secondaires.
1. Information
This section describes the three etiologic subtypes of classic Creutzfeldt-Jakob disease
(CJD) (sporadic CJD, iatrogenic CJD and genetic prion diseases)
Confirmed case:
Neuropathologically and/or immunocytochemically and/or biochemically
confirmed, through observation of one or more neuropathologic features (see
List 1) and no evidence of iatrogenic CJD or genetic human prion disease
(described below)
Probable case:
Routine investigation should not suggest an alternative diagnosis:
Rapidly progressive dementia + at least two features of list I + II (see List 2)
OR
Possible CJD + cerebrospinal fluid positive for 14-3-3 by immunoblot + duration <
2 years
Possible case:
Rapidly progressive dementia + two of list I (see List 2) plus duration < 2 years
plus no electroencephalography (EEG) or atypical EE
List 1:
I. Spongiform encephalopathy in cerebral and/or cerebellar cortex and/or
subcortical grey matter
II. Encephalopathy with prion protein (PrP) immunoreactivity in plaque-like
and/or diffuse synaptic and/or patchy/perivacuolar patterns, by
examination of tissue either directly or with assistance of capillary
transfer from paraffin-embedded tissue (PET) to secondary support (PET
blot)
III. Presence of scrapie-associated fibrils (SAF) by electron microscopy
IV. Presence of protease-resistant PrP by Western blot
List 2:
I
A. Myoclonus
B. Visual disturbances or cerebellar dysfunction (ataxia)
C. Pyramidal or extrapyramidal features
D. Akinetic mutism
II
Confirmed Case:
Definite iCJD:
Definite CJD (see List 1) with a recognized risk factor for iatrogenic transmission
(see List 3)
Probable Case:
Progressive predominant cerebellar syndrome in a recipient of cadaverically
derived human pituitary growth hormone
OR
Probable CJD with a recognized risk factor for iatrogenic transmission (see List 3)
List 3:
Note: Assessment of the relevance of any proposed risk factor to disease
causation should take into account the timing of the putative exposure in
relation to disease onset, especially where the putative exposure is recent. As
well, this list is provisional, as the risks of iatrogenic transmission of prion disease
by other routes are currently incompletely understood.
Confirmed Case:
Definite Genetic Human Prion Disease:
Definite (pathologically confirmed) prion disease + definite or probable prion
disease in a first-degree relative
OR
Definite prion disease + pathogenic mutation in prion protein gene (PRNP) (see
List 4)
OR
Typical neuropathologic phenotype of Gerstmann-Sträussler-Scheinker disease
(GSS)*
Probable Case:
Progressive neuropsychiatric disorder + definite or probable prion disease in a
first degree relative
OR
Progressive neuropsychiatric disorder + pathogenic mutation in PRNP (see List 4)
List 4:
I. PRNP mutations associated with a neuropathologic phenotype of CJD
(see sCJD List 1): P105T, G114V, R148H, D178N, V180I, V180I+M232R,
T183A, T188A, T193I, E196K, E200K, V203I, R208H, V210I, E211Q,
M232R; octapeptide repeat insertions (various lengths) and deletion (48
bp)
1.3 Symptoms
Classic CJD has an insidious onset, symptoms include: confusion, poor
concentration, lethargy, progressive dementia, intermittent unsteadiness when
standing or walking, and variable ataxia. As the disease progresses, mental
impairment becomes more severe and cases may develop involuntary muscle
jerks (myoclonus), lose the ability to move or speak, and eventually enter a
comatose state. Death invariably occurs within three to twelve months.
Approximately 80% of patients with sporadic CJD are between 50 and 70 years of
age, although familial cases usually have an onset of around 40 years of age.
1.4 Incubation
Fifteen months to possibly more than 30 years
1.5 Source
Humans
1.6 Transmission
The mode of transmission in most cases in unknown. CJD may either occur
sporadically (approximately 90% of cases), through iatrogenic transmission of
infective agents (<1% of cases) or as an autosomal dominant inheritence
(approximately 10% of cases). Potential sources of iatrogenic transmission
1.8 Treatment
There is no known effective treatment available to cure or control CJD and the
disease appears to be uniformly fatal. Current treatment is therefore aimed at
controlling symptoms and making the person as comfortable as possible.
1.10 Prophylaxis
None
1.11 Surveillance
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
2. Procedures
2.1.2 Investigator
Upon receiving the case report, the investigator should initiate the following:
a. Determine the case status as per the case definition (see Section 1.1).
2.1.3 Physician
Report all cases of CJD (possible, probable and confirmed) by telephone
to the MOH as soon as suspected
Provide the public health investigator with the available information as
requested
2.1.4 Laboratory
Report all positive laboratory results to the MOH by telephone and fax
2.1.5 Canadian Blood Services (CBS)
Work with PHS, the Provincial Blood Program and hospital blood banks on
‘lookback’ and ‘traceback’ procedures for CJD
Classic CJD should not be confused with variant CJD which is believed to be transmitted
to humans through the consumption of beef products contaminated with bovine
spongiform encephalopathy (BSE or ‘mad cow disease’).
1. Information
1.1 Case definition
Confirmed case:
Definite vCJD:
Probable case:
I + four or five criteria of II + IIIA + IIIB (see List 5)
OR
I + IVA (see List 5)
Possible CJD:
I + four or five criteria of II + IIIA (see List 5)
List 5:
I
A. Progressive neuropsychiatric disorder
B. Duration > 6 months
C. Routine investigations do not suggest alternative diagnosis
D. No history of potential iatrogenic exposure
E. No evidence of genetic prion disease
II
A. Early psychiatric symptoms b
B. Persistent painful sensory symptoms c
C. Ataxia
D. Myoclonus or chorea or dystonia
E. Dementia
III
A. EEG does not show typical appearance of sporadic CJD d (or no EEG
performed) in the early stages of the illness
B. Bilateral pulvinar high signal on MRI scan e
IV
A – Tonsil biopsy positive for prion protein immunoreactivity f
1.3 Symptoms
Persons with vCJD usually experience psychiatric symptoms, early in illness,
which most commonly take the form of depression, or a “schizophrenic-like”
psychosis. As the illness progresses, neurological signs include: unsteadiness,
difficulty walking and involuntary muscle movements.
Variant CJD typically affects younger patients (average 28 years) and has a
relatively long duration of illness – 14 months compared to 4.5 months for
classic CJD.
1.4 Incubation
Fifteen months to possibly more than 30 years
1.5 Source
Humans. Variant CJD is believed to be associated with a disease in cattle called
bovine spongiform encephalopathy (BSE), more commonly known as ‘mad cow
disease’.
1.6 Transmission
Although there is strong evidence that the agent responsible for human cases of
vCJD is the same agent responsible for BSE in cattle, the specific foods that may
be associated with the transmission of this agent from cattle to humans are
unknown.
1.7 Communicability
Central nervous system (CNS) tissues are infectious throughout symptomatic
illness. Other tissues and cerebral spinal fluid (CSF) are sometimes infectious.
1.8 Treatment
There is no known effective treatment available to cure or control vCJD and the
disease appears to be uniformly fatal. Current treatment is therefore aimed at
controlling symptoms and making the person as comfortable as possible.
1.10 Prophylaxis
None
1.11 Surveillance
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
2. Procedures
2.1 Roles and responsibilities
2.1.2 Investigator
Upon receiving the case report, the investigator should initiate the following:
a. Determine the case status as per the case definition (see Section 1.1).
2.1.3 Physician
Report all cases of vCJD (possible, probable and confirmed) by telephone
to the MOH as soon as suspected
Provide the public health investigator with the available information as
requested on the “CJD/vCJD Case Report Form”
2.1.4 Laboratory
Report all positive laboratory results to the MOH by telephone and fax
1.3 Symptoms
Children are most susceptible. Most often manifested as erythematous
eruption, characterized by a distinctive red rash on the face, with a “slapped
cheek” appearance. This rash may be followed in a few days by a spidery like
rash on the trunk and on the arms and legs that fades but may recur for 1-3
weeks on exposure to sunlight. Mild systemic symptoms may also precede this
rash. Arthralgia and arthritis may occur in adults, especially women. 25% of
infections are asymptomatic.
1.4 Incubation
Usually 14 days, can be from 4-20 days to development of rash
1.5 Source
Humans
1.6 Tranmission
Contact with respiratory secretations and parenterally through blood and blood
products. Congenital transmission is possible.
1.7 Communicability
For those with rash alone, communicability is limited to the time just before the
onset of the rash. For those individuals who are immunosuppressed with
chronic infection and severe anemia, the period of communicability could be as
long as months or years.
1.8 Treatment
Supportive therapy for most cases. For chronic infection in an
immunosuppressed individual, IG therapy is effective.
1.10 Prophylaxis
None. Exposed pregnant women should be offered B19 IgG and IgM antibody
testing to determine susceptibility and to assist with pregnancy counseling
regarding risks to fetus.
2. Procedure
No public health follow-up required. This disease is not notifiable.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association. Report of the Committee on Infectious Diseases, 2000. American
Academy of Pediatrics.
FIFTH DISEASE (HUMAN PARVOVIRUS
INFECTION) FACT SHEET
What is Fifth Disease?
Fifth disease is a mild illness, caused by a virus. The disease is spread by droplets or
discharge from the nose and throat of an infected person (coughing or sneezing).
Children with fifth disease may be infectious from 4-14 days before the onset of a rash.
1. INFORMATION
1.1 Case Definition
Confirmed case:
Laboratory confirmation of infection with or without clinical evidence of invasive
disease:
isolation of group A streptococcus (Streptococcus pyogenes) from a
normally sterile site (a normally sterile site is defined as: blood,
cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, deep
tissue specimen taken during surgery [e.g. muscle collected during
debridement for necrotizing fasciitis], bone or joint fluid excluding the
middle ear and superficial wound aspirates [e.g. skin and soft tissue
abscesses]).
Clinical evidence of invasive disease may be manifested as one or more of
several conditions:
Soft tissue necrosis, including necrotizing fasciitis, myositis or gangrene
Meningitis
Streptococcal toxic shock syndrome, which is characterized by
hypotension (systolic blood pressure ≤90 mm Hg in an adult and <5
percentile for age for children) and at least two of the following signs:
Renal impairment (creatinine level ≥177 umol/L for adults)
Coagulopathy (platelet count ≤100,000/mm3 or disseminated
intravascular coagulation)
Liver function abnormality (SGOT, SGPT or total bilirubin ≥2x upper limit
of normal)
Adult respiratory distress syndrome
Generalized erythematous macular rash that may desquamate
Probable case:
Clinical evidence of invasive disease (see clinical evidence above) in the absence
of another identified etiology and with non-confirmatory laboratory evidence of
infection:
isolation of group A streptococcus from a non-sterile site
OR
positive group A streptococcus antigen detection
1.3 Symptoms
Symptoms preceding the onset of invasive GAS disease may include unusually
severe pain, swelling, fever, chills, flu-like symptoms, myalgias, generalized
macular rash, nausea, vomiting, diarrhea, malaise and joint pain.
The most common primary site of invasive GAS infections is soft tissue, but
pneumonia, septic arthritis and primary bacteremia may also occur.
Upper respiratory tract manifestations of GAS are more common with children,
arthritis and pelvic infections are more common in young adults, and NF is more
common in the elderly.
NF and NM alone are less severe than STSS with a mortality rate of
approximately 20%.
However, they may progress to STSS, which has a mortality rate of 80%.
1.4 Incubation
Usually 1 to 3 days.
1.5 Source
GAS may be carried in the nasopharynx, gastro intestinal tract and on the skin of
humans.
1.6 Transmission
Transmission occurs via large respiratory droplets, or by direct contact with
infected clients or carriers; rarely through contaminated objects. Person-to-
person transmission occurs through exposure to secretions from wounds, nasal
and oral cavities.
1.7 Communicability
Transmissibility generally ends within 24 hours of treatment. If untreated,
uncomplicated cases are communicable for 10-21 days or until infection is
resolved. Asymptomatic carriage is quite common (up to 15% of the population).
In cases with purulent discharges, communicability extends for weeks or months.
1.8 Treatment
Advice should be sought from infectious disease specialists.
Further to the case definitions in Section 1.1, please note the following definitions for
Public Health management.
Sporadic Case: A single case of invasive GAS disease occurring a community where there
is no evidence of an epidemiologic link (by person, place or time) to another case.
Subsequent Case: A case with onset of illness occurring within 21 days and caused by
the same strain as another case (including sporadic or index cases) and with whom an
epidemiologic link can be established. Most subsequent cases in the community will
occur within 7 days of another case.
Severe Case: Case of STSS, soft tissue necrosis (including necrotizing fasciitis, myositis
or gangrene), meningitis, GAS pneumonia, other life threatening conditions or a
confirmed case resulting in death.
To establish an epidemiological link, a person must have one or both of the following in
common with a confirmed case:
For public health management, cases that occur subsequent to the index case with
whom an epidemiologic link can be established may have acquired the disease directly
from the index case or may have acquired the disease from another common source.
2.1 Case
Follow-up of invasive GAS is a priority and the following steps must be taken
immediately:
(a) Contact physician to obtain clinical information on case
(b) Record age, gender and address of case
(c) Interview case or a proxy for the case to determine close contacts (see
Section 2.2.1.).
2.1.1 Exclusion
No exclusion required.
2.1.2 Education
See Section 1.9, Core Prevention Messages.
2.2.2 Susceptibility
The risk of invasive GAS is significantly associated with the following underlying
conditions:
2.2.4 Prophylaxis
Chemoprophylaxis is offered to prevent disease in colonized individuals and in
those who have recently been exposed, thereby decreasing transmission of
strain known to have caused severe infection.
2.2.6 Exclusion
Exclusion of contacts is not necessary.
2.2.7 Education
Review signs and symptoms of invasive GAS disease with close contacts
of all confirmed cases regardless of whether the case is a severe case.
Provide contacts with a fact sheet (refer to Appendix 1 or 2)
Instruct contacts to seek medical attention immediately should they
develop febrile illness or any other clinical manifestation of GAS infection
within 30 days of diagnosis in the index case.
2.2.8 Follow-Up
Inquire to confirm that contacts completed appropriate
chemoprophylaxis and did not become secondary cases.
There is no role for routine culturing for a test of cure for contacts
receiving antibiotic chemoprophylaxis.
2.4 Guidelines
2.4.1 Guidelines for Institutions / Long-Term Care Facilities
GAS infections within LTCF are often spread through person-to-person contact,
with a clustering of cases by room or care unit. Outbreaks in LTCF are often
patient- propagated, whereas within acute care facilities, staff who are carriers
are more likely to be the source of infection or outbreaks.
When a confirmed case of invasive GAS disease (as described in Section 1.1)
occurs in a child attending a CCC, staff must report to district public health units
as required by legislation.
When one severe case of invasive GAS disease (Table 2) occurs in a child
attending a CCC, public health practitioners should consider the following:
1) The nature of the CCC (e.g. type of centre, including the size and physical
structure, number and ages of the children, type of interaction of the
children).
2) The characteristics of the case (e.g. if the case occurred secondary to a
varicella infection.
3) The potential for a source of infection from within the CCC:
i. whether there has been any suggested invasive or non-invasive
infections (e.g. other cases of invasive GAS, pharyngitis, impetigo)
ii. potential of a point source of infection (foodborne outbreaks of
pharyngitis have occurred and are a consequence of human
contamination of food in conjunction with improper preparation
or refrigeration procedures.
4) The presence of varicella cases within the CCC in the previous two weeks.
If a case of varicella has occurred in the CCC within the two weeks prior
to onset of GAS symptoms in the index case, all attendees should be
assessed for varicella vaccination history. Two weeks was chosen as the
time interval based on findings that risk of GAS was significantly
increased two weeks after onset of varicella infection. Varicella
vaccination should be recommended for those without a history of prior
varicella infection or vaccination as per the NACI guidelines; CCDR 2004;
30.
5) The potential for a source of infection from outside the CCC (e.g.
exposure to a family member with suggest invasive or non-invasive GAS
infection).
6) Parents and/or guardians of attendees should be informed of the
situation, alerted to the signs and symptoms of invasive GAS disease and
be advised to seek medical attention immediately should their child
develop febrile illness or any other clinical manifestations of GAS (see
Section 1.3)
7) In family or home day care settings, chemoprophylaxis should be
recommended for all children and staff (see Section 2.2.4).
8) In group or institutional CCC and preschools, chemoprophylaxis is
generally not warranted, but may be considered in certain situations,
including the occurrence of >1 case of invasive GAS disease in children or
staff of the CCC within one month or a concurrent varicella outbreak at
the CCC. Cases of invasive GAS occurring among children or staff of a CCC
within one month should be considered as part of the same cluster.
Consideration could be given to testing isolates from invasive GAS cases
occurring in a CCC more than one month apart, to determine strain-
relatedness.
9) A test of cure is not warranted for persons receiving chemoprophylaxis.
10) Appropriate specimens can be taken for culture to rule out GAS when
suspected infections are detected during this period, however routine
screening of attendees is not recommended.
The National Centre for Streptococcus (NCS) is the only laboratory in Canada that
performs M-typing/emm sequencing of S. pyogenes isolates for routine
surveillance.
3.0 SURVEILLANCE
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Invasive Group A Streptococcal Disease Guidelines Working Group. Guidelines for the Prevention and
Control of Invasive Group A Streptococcal (GAS) Disease, Public Health Agency of Canada, 2006 National
Advisory Committee on Immunization (NACI). Update on Varicella. CCDR 2004; 30: 1-27
APPENDIX 1:
NECROTIZING FASCIITIS / MYOSITIS (FLESH
EATING DISEASE) FACT SHEET
What is Necrotizing Fasciitis and Myositis?
Necrotizing fasciitis (NF) is more commonly known as flesh eating disease. It is a rare
illness that causes extensive tissue destruction. NF is caused by a number of different
bacteria, one of them being group A streptococcus (GAS). Usually GAS spreads through
close personal contact and causes mild illness. Sometimes GAS causes serious life
threatening diseases such as flesh eating disease. Some strains of GAS are more likely to
cause severe disease than others.
When the disease spreads along the layers of tissue that surround the muscle (the
fascia), it is called necrotizing fasciitis. When the disease spreads into the muscle tissue,
it is called necrotizing myositis.
1.3 Symptoms
Streptococcal sore throat typically exhibits sudden onset of fever, sore throat,
exudative tonsillitis or pharyngitis.
1.4 Incubation
Usually 1 to 3 days.
1.5 Source
Humans.
1.6 Transmission
Transmitted via large respiratory droplets or direct contact with carriers. Nasal
carriers are particularly likely to transmit the disease.
1.7 Communicability
If untreated, 1 to 21 days.
1.8 Treatment
Pharyngitis: Penicillin V. Orally administered erythromycin is indicated for those
allergic to penicillin.
1.10 Prophylaxis
None.
2. Procedure
No Public Health follow-up required. This is not a notifiable disease.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
STREPTOCOCCAL (STREPT) THROAT FACT SHEET
What is Strept Throat?
Strept throat is caused by a bacteria called Group A streptococci. The same bacteria can
cause other diseases such as impetigo.
The bacteria are spread through contact with droplets from the throat of an infected
person (via coughing). The person carrying the bacteria may not have any symptoms at
all.
Scarlet fever is spread through contact with droplets from the throat of an infected
person (via coughing). The person carrying the bacteria may not have any symptoms at
all.
1. Information
1.1 Case definition
Confirmed case:
Clinical illness in an infant less than 1 month of age with laboratory confirmation
of infection:
isolation of group B Streptococcus (Streptococcus agalactiae) from a
normally sterile site (such as blood or cerebrospinal fluid)
OR
demonstration of group B Streptococcus DNA in a normally sterile site
Probable case:
Clinical illness in an infant less than 1 month of age with laboratory confirmation
of infection:
detection of group B Streptococcus antigen in a normally sterile site
1.3 Symptoms
Invasive disease in infants is divided into two categories:
Early onset disease (1-7 days), characterized by sepsis, respiratory
distress, apnea, shock, pneumonia, and meningitis
Late onset disease (7 days to 1 month) characterized by bacteremia,
meningitis and other focal infections
Group B streptococci also cause chorioamnionitis and post-partum endometritis
and systemic infections in non-pregnant adults.
1.4 Incubation
Early onset disease: Usually occurs within the first 24 hours of life (range
0-6 days).
Late onset disease: occurs at 3 to 4 weeks of age (range 7 days to 3
months).
1.5 Source
Humans.
1.6 Transmission
Transmission from mother to infant occurs shortly before or during delivery.
After delivery, person-to-person transmission can occur.
1.7 Communicability
Unknown.
1.8 Treatment
Ampicillin plus an aminoglycoside is the initial treatment of choice for
a newborn. For treatment of meningitis, consult appropriate specialist.
1.10 Prophylaxis
Refer to current Reproductive Care guidelines for management of group
B streptococcus in pregnant women and newborns.
2. Procedure
No public health follow-up required. This is a notifiable disease.
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
HAND/FOOT/MOUTH DISEASE (COXSACKIE
VIRUS)
1. Information
1.1 Case definition
Compatible clinical illness or laboratory evidence of infection.
1.3 Symptoms
Diffuse oral lesions on the buccal surfaces of the cheeks and gums and on the
sides of the tongue. Papulovesicular lesion, also commonly occur as an
exanthem especially on the palms, fingers, and soles. Lesions may persist from
7-10 days. Occasionally, maculopapular lesions appear on the buttocks.
1.4 Incubation
Usually 3-5 days.
1.5 Source
Humans.
1.6 Transmission
Direct contact with respiratory secretions and feces of infected people (who may
be asymptomatic). Also via aerosol droplet spread.
1.7 Communicability
During the acute stage of the illness, and perhaps longer because these viruses
persist in the stool for several weeks.
1.8 Treatment
None.
1.9 Core Messages for Prevention
Hand washing and good basic hygiene. Always wash hands after using the toilet
or after changing diapers.
1.10 Prophylaxis
None.
2. Procedure
No Public Health follow-up required. This disease is not notifiable.
References: Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association.
HAND, FOOT AND MOUTH DISEASE
(COXSACKIE VIRUS) FACT SHEET
What is Hand, Foot and Mouth Disease?
Hand, Foot and Mouth Disease is an illness caused by the coxsackievirus. It occurs most
often in the summer and fall months. It is usually a mild infection.
The virus lives in the mouth, throat and feces of an infected person. It is spread
by direct contact or breathing in the virus that is coughed or sneezed into the air by an
infected person.
It is not necessary for children with this disease to stay home from school.
1.3 Symptoms
Small blisters first appear on the face, around the mouth or nose, or on other
parts of the body where there has been a cut, scratch, abrasion or a bite. The
sores become purulent and then scab over with a yellowish crust. This lesion can
last up to several weeks.
1.4 Incubation
Usually 4 to 10 days.
1.5 Source
S. aureus are found on most environmental surfaces, especially the human body,
where there are infected skin sites. GAS are found in human skin lesions and in
the nasopharyngeal tract.
1.6 Transmission
Close contact with individuals who either have a purulent lesion or are an
asymptomatic carrier. The hands are the most important means for transmitting
infection.
1.7 Communicability
Communicable until active drainage has disappeared. Autoinfection may
continue for the duration of active lesions or during the period of nasal
colonization.
1.8 Treatment
Topical and systemic antibiotics may be necessary. S aureus carriers may need
more aggressive antibiotic therapy. Children with impetigo should be kept home
from school or childcare for 24 hours after the treatment has been initiated.
1.10 Prophylaxis
Good personal hygiene.
2. Procedure
No Public Health follow-up required. This disease is not notifiable.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public
Health Association. Infection Control in the Child Care Center and Preschool 3rd edition –1996-Leigh G.
Donowitz editor Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
IMPETIGO FACT SHEET
What is Impetigo?
Impetigo is an infection of the skin caused by bacteria. It usually begins as small blisters
or sores on the face, ears and hands. Impetigo starts where there is a break in the skin,
such as in cuts. Most often the sores appear on the arms, legs and face, near the corners
of the mouth and nose.
1
2.4.7 Reporting of Results ......................................................................... 11
2.4.8 To Access Results ............................................................................. 11
2.4.9 After Hours ....................................................................................... 11
3.0 SURVEILLANCE ............................................................................................................ 11
3.1. Introduction................................................................................................... 11
3.2. Influenza Surveillance Guidelines 2012–2013 ................................................. 12
3.2.1 Objectives of Influenza Surveillance in the 2012–2013................... 12
3.2.2 Surveillance Systems and Sources of Data ...................................... 12
3.3 Surveillance of Laboratory-Confirmed Influenza .............................................. 14
3.3.1 Introduction ..................................................................................... 14
3.3.2 Objectives of Surveillance of Laboratory-Confirmed Influenza ....... 14
3.3.3 Laboratory Testing and Reporting ................................................... 14
3.3.4 Procedures ....................................................................................... 15
3.4 Surveillance of Influenza-Like-Illness (ILI) ........................................................ 17
3.4.1 ILI Case Definition for Surveillance Purposes .................................. 17
3.4.2 ILI in Sentinel Primary Health Care Settings .................................... 17
3.4.3 ILI in Emergency Departments ......................................................... 17
3.5 Surveillance of Outbreaks of Influenza and ILI ................................................. 18
3.5.1 School / Daycare Absenteeism ........................................................ 18
3.5.2 Influenza / ILI Outbreaks in Long Term Care/ARC and Acute Care
Facilities..................................................................................................... 19
3.5.3 Procedures ....................................................................................... 20
3.5.4 Public Health Alerts.......................................................................... 21
3.6 Federal Surveillance Initiatives and Special Studies ......................................... 21
3.6.1 Severe Outcome Surveillance (SOS) ................................................ 21
3.7 Reporting........................................................................................................ 22
3.7.1 Respiratory Watch ........................................................................... 22
4.0 COMMUNICATION PLAN............................................................................................. 23
Communications Objectives: ................................................................................ 23
Talking Points and Media Lines: ....................................................................................... 24
2
5.0 REFERENCES ................................................................................................................ 26
6.0 APPENDICES ................................................................................................................ 27
Appendix A: 2012-2013 Seasonal Influenza Vaccine Information for Immunization
Providers ........................................................................................................................... 28
Appendix B: ANDS Quick Reference: Influenza Case Entry ............................................... 36
Appendix C: ILI in Emergency Departments (ED)/Outpatient Centres .............................. 37
Appendix D: School and Daycare Absenteeism ................................................................. 38
Appendix E: FluWatch Reporting Procedure through CNPHI ............................................ 39
Appendix F: 2012-13 NS Influenza Vaccine Coverage and Reporting ............................... 44
3
1.0 INFORMATION
1.1. Case Definition
Confirmed case
Clinical illness with laboratory confirmation of infection:
Isolation of influenza virus from an appropriate clinical specimen
OR
Demonstration of influenza virus antigen in an appropriate clinical specimen
OR
Significant rise (e.g. fourfold or greater) in influenza IgG titre between acute
and convalescent sera
OR
Detection of influenza RNA
1.3. Symptoms
Influenza-like illness (ILI) is defined as:
acute onset* of respiratory illness with fever and
cough and
one or more of sore throat, arthralgia, myalgia or prostration.
Fever may not be prominent in the elderly and children under five. Other
symptoms may include: headache, chills, loss of appetite, runny nose, sneezing and
watery eyes. Nausea, vomiting and diarrhea are uncommon but can occur, especially
in children under 5. Most people will recover within 7-10 days.
*distinct change from normal status to respiratory illness over 1-3 days, based
on clinical judgement
1.4. Incubation
The incubation period for influenza ranges from one to four days. On average,
symptoms may appear within two days of exposure to the virus.
4
1.5. Source
Humans are the primary reservoir for human infections. Birds and other
mammals such as swine may serve as potential sources of new human subtypes
thought to emerge through genetic reassortment or antigenic shift.
1.6. Transmission
Person to person by droplet spread. This happens when droplets from a cough or
sneeze of an infected person are propelled (generally up to 2 meters) through
the air and deposited on the mouth or nose of people nearby. Though much less
frequent, the viruses also can be spread when a person touches respiratory
droplets on another person or an object and then touches their own mouth or
nose (or someone else’s mouth or nose) before washing their hands.
1.7. Communicability
Adults are typically infectious from the day before symptoms begin until
approximately five to seven days after illness onset. Children can be infectious
for more than ten days; young children can shed virus for up to six days before
symptom onset.
1.8. Treatment
In Canada, two neuraminidase inhibitors (oseltamivir and zanamivir) are licensed
for use as treatment and prophylaxis against influenza. The choice of drug
depends on the type (A or B) and subtype (H1 or H3) of influenza. The
effectiveness of antivirals is determined each season and recommendations may
change as new information becomes available.
Oseltamivir is effective against influenza A/H3 (but not A/H1), influenza B,
and Pandemic H1N1 ;
Zanamivir is effective against influenza A (H3 and H1) and B and Pandemic
H1N1.
5
Guide to Influenza Control for long-Term Care Facilities and Adult Residential
Centres (revised and distributed annually).
1.10 Immunization
Immunization against influenza is publicly funded and advised for all Nova
Scotians but is strongly recommended for people at high risk of influenza related
complications and for those who live with or care for them.
6
c) If the case does not reside in a LTCF/ARC or residential institution no further
follow-up is required.
2.1.1. Exclusion
People who are ill should stay away from work, school, daycares, etc until they
are feeling well and are able to fully participate in their usual day-to-day
activities.
Health Care Workers who are symptomatic/ infected with influenza should be
excluded from work:
until 7 days after onset of symptoms with the first day of symptoms being
counted as day 1,
OR
they have been immunized at least two weeks previously and have started
on antiviral therapy.
2.1.2. Education
See section 1.9, Core Prevention Messages.
2.2. Contacts
The identification and follow-up of contacts is relevant only in the context of an
outbreak in a LTCF/ARC or residential institution. See Section 2.3 for further
guidelines.
7
2.4 Laboratory Procedures
2.4.1 Laboratory Diagnosis/Overall Testing Rationale
CDHA Microbiology
Respiratory pathogen testing including Influenza testing will be available for the
acute care setting and long term care / adult residential care settings. Specific
influenza surveillance testing will be available in emergency departments as
directed by Nova Scotia Department of Health and Wellness. Testing from the
community will not be performed unless special circumstances exist and on the
approval by a CDHA Microbiologist.
Specimen Container:
Flocked swab supplied with viral transport medium. These can be stored
at room temperature until use. Viral collection kits can be obtained from
local / regional hospital laboratories. District 1 through 8 should obtain
their viral collection kits from their local/regional laboratory. For District
9 (Capital District Health only), collection kits can be ordered directly
from CDHA Microbiology.
Collection Notes:
Please ensure that the expiration date of the container is still in-date as
out of date swabs will be rejected by the laboratory.
Specimens should be collected within 5 days of onset of symptoms,
preferably within 48 hours.
8
Sampling beyond 5 days may be considered in patients with persisting or
worsening symptoms regardless of age, in young children or the elderly,
and in the immunocompromised.
An instructional collection video is available at
http://www.youtube.com/watch?v=TFwSefezIHU
Surveillance Specimens:
Specimens collected as part of the Public Health Sentinel Program should
be collected as indicated above on patients with influenza like illness.
Outbreak numbers are provided by Public Health Services and should be clearly
identified on the laboratory requisition.
9
2.4.5 Laboratory Testing (CDHA)
Laboratory testing during the non-peak influenza season will consist of a
multiplex nucleic acid amplification assay (NAAT) for a broad range of respiratory
viral pathogens. This includes: Influenza A, Influenza B, Respiratory Syncytial
Virus as well as other viral agents.
Laboratory testing during the peak influenza season will consist of primarily a
streamlined nucleic acid amplification assay for the detection of Influenza A,
Influenza B, Respiratory Syncytial Virus only. Additional use of the multiplex
assay will be limited to outbreaks and critically ill acute care patients unless
otherwise determined in consultation with a CDHA Microbiologist.
2.4.6 Point of Care Testing (POC) (Hatchette, T.F., and Members of PILPN, 2009).
Rapid Influenza detection tests (RIDT) also referred to as Near-patient or POC
tests, use antigen detection technologies which can generate results in less than
30 minutes; however the tradeoff is that of suboptimal accuracy when compared
to RT-PCR. The positive and negative predictive values of POC tests depend on
the prevalence of influenza. Performance depends on the type of specimen
tested, the timing of collection, age of the patient, and the skill with which the
specimens are collected and the tests performed.
Although there may be some utility in using RIDTs during seasonal influenza the
primary limitation of currently available RIDTs is poor sensitivity which can be as
low as 10% for pH1N1. This translates into an inability to rule out the diagnosis
of influenza. As such, RIDT have limited utility in the management of individual
patients presenting with influenza-like illness (ILI) (CPHLN, 2010).
10
The relatively high specificity of most RIDTs allows clinicians to be fairly
confident in the accuracy of a positive result from a patient presenting with ILI
during the influenza season. However, because of the potential for false positive
results during periods of low prevalence (i.e., summer months), positive results
specimens need to be confirmed with more specific methods such as RT-PCR.
11
viruses, such as parainfluenza, adenovirus, and respiratory syncytial virus (RSV).
The components of the current influenza surveillance system and the approach
for the 2012–2013 influenza season are described here.
12
13
3.3 Surveillance of Laboratory-Confirmed Influenza
3.3.1 Introduction
Influenza is a notifiable disease in Nova Scotia, regardless of type. All laboratory-
confirmed cases of influenza must be reported to Public Health Services, who in
turn report to Department of Health and Wellness (DHW).
14
Important Points for Laboratory Testing in the 2012–2013 Season:
Community specimens will not be tested for influenza, with the exception of
those recommended for testing after consultation with a CDHA
microbiologist.
Laboratory testing will be conducted on specimens from in-patients and
LTCF/ARC.
Patients presenting with ILI in emergency rooms are considered sentinels for
what is happening in the community. Limited sentinel surveillance testing in
selected emergency departments will be conducted weekly. Each ER site will
collect a maximum of 5 specimens one day per week for testing.
Laboratory testing will involve multiplex PCR testing in the shoulders of the
influenza season, and influenza/RSV PCR testing during the peak of the
influenza season.
Laboratory testing may change earlier if surveillance indicators suggest
increased influenza activity.
Clinical specimens for influenza testing are submitted to the microbiology laboratories
at Capital District Health Authority (CDHA) and the IWK Health Centre in Halifax. Please
refer to Figure 2 for detailed information on laboratory diagnosis of influenza through
the Provincial Public Laboratory Network (PPHLN).
3.3.4 Procedures
a) District Health Authority
i) Reporting of Cases using ANDS
All confirmed cases of influenza are entered into ANDS upon receipt of
laboratory results (refer to Table 1)
Important notes:
Be sure to enter the case into ANDS with the disease name
corresponding to that provided on the laboratory report
If subtyping is performed, ANDS will be updated by DHW Surveillance
when results are reported.
15
Agent
Influenza Result on Disease Name in Case Status in
Sub/Serotype
Lab Report ANDS ANDS
in ANDS
Influenza virus Type A Updated by
Influenza A (lab-
detected by PCR DHW
confirmed) Subtyping Confirmed
Positive for Influenza Surveillance if
not performed
virus Type A applicable*
16
3.4 Surveillance of Influenza-Like-Illness (ILI)
3.4.1 ILI Case Definition for Surveillance Purposes
Acute onset* of respiratory illness with fever and cough and one or more of the
following: sore throat, arthralgia, myalgia or prostration, which could be due to
influenza virus. In children less than five years of age, gastrointestinal symptoms
may also be present. In patients less than five years of age or older than 65 years
of age, fever may not be prominent.
*distinct change from normal status to respiratory illness over 1-3 days, based
on clinical judgement
Introduction
Sentinel physicians participate in surveillance for ILI in Nova Scotia through
FluWatch, a federal surveillance program that has been in place since 1996.
Procedures
FluWatch sentinel physician data are sent from PHAC in aggregate form to
DHW via email and are also posted in the FluWatch module of the CNPHI
website
Role of Department of Health and Wellness
DHW will analyze and summarize aggregate data and include this
information in Respiratory Watch (refer to section 3.7)
Introduction
Emergency departments in hospitals and out-patient centres across Nova
Scotia are monitored for ILI activity on a daily basis. Infection control
practitioners report ILI data to DHW from the emergency departments for which
they are responsible.
Procedures
Infection control practitioners (or delegate) complete the one page
aggregate report form (Appendix C) for patients seen in the Emergency Dept
(ED).
Data are collected daily and reported to DHW weekly.
17
The surveillance period is in accordance with influenza surveillance weeks
(Sunday to Saturday).
Data provided include the total number of patients seen and the total
number meeting the ILI case definition on a daily basis for the specified time
period.
Tally sheets are emailed to surveillancehpp@gov.ns.ca or faxed to DHW
(902-424-0550) on Mondays.
18
Encourage the school/daycare to ask for the reason for absenteeism when
parents/students call to report an absence due to illness
Daily active surveillance should be initiated when absenteeism at a school or
daycare exceeds 10% OR is higher than baseline levels as determined by the
school/daycare or PHS, which is likely due to ILI
Note that active surveillance is required on a daily basis until absenteeism,
likely due to ILI, becomes less than 10% OR lower than baseline levels as
determined by the school or daycare
Designate a public health nurse to carry out the initial investigation and
active surveillance
The public health nurse should determine the number and percentage of
students/clients and staff absent and the predominant symptoms. It is
important to distinguish between respiratory and gastrointestinal illness,
noting that schools commonly refer to vomiting and diarrhea illnesses as the
“flu.” The School Surveillance Tool or Daycare Surveillance Tool should be
used to ensure complete information. (Appendix D)
The public health nurse should report this information to the CDC team as
outlined and alert the CDPC Manager if aware of an unusual presentation or
increased morbidity (hospitalizations, deaths)
Report school/daycare outbreaks through normal FluWatch procedures
(Appendix E)
b) Department of Health and Wellness
DHW uses this information to validate influenza activity levels for FluWatch
19
3.5.3 Procedures
a) District Health Authority
LTCF/ARC and acute care facilities should immediately report any outbreaks
of ILI or lab-confirmed cases of influenza to Public Health Services
Collect line list data
Ensure that the LTCF/ARC or acute care facility has sent NP swabs for
influenza testing. Specimens and requisitions must be clearly labeled with an
outbreak number (see below), which the facility must obtain from Public
Health Services. Name, health card number etc. must also be provided to the
lab to ensure that any further testing specified is completed
Swabs from a LTCF/ARC will be processed by Multiplex PCR during the
summer months and the shoulders of the influenza season, and for
influenza/RSV PCR during the influenza season (see Figure 2)
The outbreak number should follow the standard N.S. format, which
includes: the 4 digit year – the 2 digit district number – the 3 digit
district outbreak number for the relevant calendar year, e.g.: 2012-
09-001
Complete the Initial Outbreak Summary form on CNPHI as soon as possible
once the DHA is made aware of the situation
When applicable, provide the number of residents/patients/staff who
received prior immunization or were hospitalized
Complete the Final Outbreak Summary Report form on CNPHI when the
outbreak is declared over
When applicable, provide the final number of residents/patients/staff who
received treatment, received post-exposure prophylaxis, were hospitalized,
and the number who died.
Report the outbreak through normal FluWatch procedures (Appendix E)
20
b) Department of Health and Wellness
DHW uses this information to validate influenza activity levels for FluWatch
DHW will collate aggregate data and include this information in Respiratory
Watch (refer to section 3.7)
21
The SOS Study will enhance, within participating hospitals, the active surveillance
in place for detection of hospitalized cases of influenza in Nova Scotia.
3.7 Reporting
3.7.1 Respiratory Watch
The Department of Health and Wellness produces a report called Respiratory
Watch, an analysis and summary of respiratory activity including the following
surveillance information:
The number of lab-confirmed cases, with descriptive epidemiology
Percentage of patients from emergency departments (mixture of daily and
weekly reporting) that met ILI case definition
LTCF/ARC outbreaks
School/daycare absenteeism of greater than 10% or above baseline likely due
to ILI
Influenza and ILI activity levels (using FluWatch criteria)
Number of specimens positive for RSV, with available descriptive
epidemiology
Number of specimens positive for parainfluenza and adenovirus
Number of specimens positive for other respiratory viral pathogens
Any additional pertinent respiratory information as determined by the DHW
Surveillance team
Respiratory Watch is distributed on a weekly basis via e-mail to staff in the
Department of Health and Wellness, regional communicable disease
managers, Medical Officers of Health, DHW Communications, and the
Directors of Long-Term Care, as well as selected infectious disease
physicians, microbiologists, and infection control practitioners. Other
individuals can be added to this mailing list on request.
Respiratory Watch is also posted on the DHW website, where it is accessible
to the public.
22
4.0 COMMUNICATION PLAN
Communications Objectives:
To launch the 2012-2013 Influenza Vaccination Campaign
To promote the free influenza vaccine to all Nova Scotians and to especially
encourage high risk individuals, their household contacts, health care
professionals and health care students to be immunized
To inform Nova Scotians of the benefits of the influenza vaccine
To associate the influenza campaign with Better Care Sooner, government’s
overall plan to improve health care for Nova Scotians.
To re-convey the message that the Government of Nova Scotia is committed
to improving the health of Nova Scotians
Background:
Influenza occurs in Canada every year. For most people this is not a life-threatening
illness. During a typical influenza season in Canada, over 21,000 physician visits, 2,500
hospitalizations and 450 deaths in Canada are attributed to the flu.
Immunization is widely recognized as the most effective means for reducing the illness
and death associated with influenza. Each year in Canada, the National Advisory
Committee on Immunization (NACI) publishes a statement with recommendations as to
which groups should be targeted by annual immunization programs.
The strains of virus causing flu change every year, but can be reliably predicted so that
health professionals can prepare an appropriate vaccine.
In 2012-2013, the H1N1 strain will be included in the influenza vaccine.
In 2012-2013, the Department of Health and Wellness will once again provide a publicly
funded vaccine to all Nova Scotians.
High risk individuals and those capable of transmitting the virus to high risk individuals
are strongly encouraged to become vaccinated. These include:
23
adults or children with chronic cardiac or pulmonary disorders, diabetes and other
metabolic diseases, cancer, immunodeficiency, immunosuppression due to
underlying disease and/or therapy (including HIV,) renal disease, anemia and
hemoglobinopathy;
children and adolescents (6 months to 18 years of age) with conditions treated for
long periods with acetylsalicylic acid;
people living with, or caring for, individuals in the high risks groups listed above
people living in a home that is expecting a newborn in the influenza season which
runs between November and April;
health-care workers and students in health-care educational programs;
First responders such as police officers, firefighters and emergency health services.
Key Message:
The Department of Health and Wellness is offering a free flu vaccine to all Nova
Scotians. Get your flu shot to protect you and your loved ones against influenza.
Talking Points
Since flu viruses change from year to year, vaccination needs to be repeated every fall.
Along with immunization, frequent hand washing is a strong line of defense against flu,
especially after being in public places or shaking hands with people.
Also, we recommend that you try avoiding close contacts with others who have cold and
flu symptoms such as a sudden high fever, headache, general aches and pains, fatigue
and weakness, a runny, stuffy nose, sneezing and sore throat.
24
If you have flu symptoms, you should stay at home, minimize close contact with others
and wash your hands frequently, especially after coughing or sneezing.
You should also refrain from visiting hospital patients and long term care residents as
this will help protect those with weakened immune systems.
The press conference will be followed by a photo opportunity of Minister Wilson and Dr
Strang or Dr. Atherton receiving their flu shot.
DHW will provide communications materials to District Health Authorities across the
province and health care partners in the week before the flu launch.
Communications Materials:
Note to Editors
Media Kit
News Release
Flu Website
Posters
Questions and Answers
Better Care Sooner ads: Get Your Flu Shot and Stay Healthy during Flu Season
Recommended spokespersons for 2012-2013:
Minister of Health and Wellness David Wilson
Chief Medical Officer of Health Robert Strang
Deputy Chief Medical Officer of Health Frank Atherton
25
5.0 REFERENCES
Canada Communicable Disease Report. (2012). NACI Statement on Seasonal Trivalent Inactivated
Influenza Vaccine 2012-2013. Retrieved from http://www.phac-aspc.gc.ca/naci-ccni/
Canadian Public Health Laboratory Network. (2010). Guidance for Laboratory Testing for
Detection and Characterization of Human Influenza Virus for the 2010 – 2011 Respiratory Virus
Season. Retrieved from http://www.nml-lnm.gc.ca/new-
nouv/assets/pdf/EN_Influenza_Seasonal_Best_Practices_2010-2011.pdf
Hatchette TF and Members of the Pandemic Influenza Laboratory Preparedness Network (PILPN)
(2009). Commentary: The Limitations of Point of Care testing for Pandemic Influenza: What
Clinicians and Public Health Professionals Need to Know. Can J Pub Health 100:204-207.
Occupational Management of Communicable Disease Exposure and Illness in Healthcare Workers IPCNS,
Dept. of Health and Wellness, March 2012
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
26
6.0 APPENDICES
27
Appendix A: 2012-2013 Seasonal Influenza Vaccine Information
for Immunization Providers
Table of Contents
1. What are my accountabilities as an immunization provider? ...................................... 29
2. Who is eligible to receive publicly funded seasonal influenza vaccine? ...................... 30
3. What is the dosage and frequency of the seasonal influenza vaccines? .................... 30
4. Which groups are considered high risk for influenza-related complications? ............. 30
5. What are the components of the seasonal influenza vaccines? .................................. 31
6. Who should NOT routinely be given seasonal influenza vaccine? ............................... 31
7. Should people who have experienced Ocular Respiratory Syndrome (ORS) following
receipt of a previous seasonal influenza vaccine be immunized?.................................... 31
8. Should people who are allergic to eggs, components of the vaccine, or a previous
dose receive the seasonal influenza vaccine? .................................................................. 32
9. Should pregnant women receive the seasonal influenza vaccine? .............................. 32
10. Is seasonal influenza vaccine safe for breastfeeding mothers? ................................. 32
11. How should the seasonal influenza vaccines be stored? .......................................... 33
12. How long can a vial of influenza vaccine be used once it is opened? ....................... 33
13. Can I draw up the seasonal influenza vaccine into syringes to be used at a later
time? ................................................................................................................................. 33
14. How is the seasonal influenza vaccine administered? .............................................. 33
15. How soon following immunization does protection develop and how long does it
last? ................................................................................................................................... 33
16. What are the side effects of the seasonal influenza vaccine? ................................... 33
17. What information is used to determine influenza immunization coverage? ............ 33
18. How do physicians bill for influenza immunization? ................................................. 34
19. What adverse events need to be reported to Public Health Services? ...................... 34
20. Can the seasonal influenza vaccine cause influenza illness? ..................................... 35
21. Can you receive seasonal influenza vaccine before or after having donated/received
blood or Immune Globulin? .............................................................................................. 35
22. Can seasonal vaccine, adult pertussis vaccine and pneumococcal vaccine be given at
the same time? ................................................................................................................. 35
23. Can seasonal influenza vaccine be administered if other vaccines have been
received recently? ............................................................................................................. 35
24. Where can I get more information on seasonal influenza vaccine? ......................... 35
28
2012-2013 Seasonal Influenza Vaccine Information for Immunization
Providers (This information does not apply to enhanced or live influenza vaccines)
Competency
Immunizers will follow their respective professional guidelines, e.g. CRNNS,
CPSNS, CLPNNS, with respect to immunization competency and professional
responsibility. Immunizers may need to be deemed competent by their
employing agency to provide immunization
Safety
Adrenalin must be present during vaccine administration
Clients must be monitored for at least 15 minutes post-immunization
Documentation must include the lot number of the vaccine in case of recall or
adverse event
Ordering Vaccine
As is the case every year, there are potential delays in vaccine development and
distribution from the manufacturers
Seasonal influenza vaccine is sent from the manufacturer to the N.S. Provincial
Biodepot over a period of 6-8 weeks in varying quantities. It’s therefore critical
29
for Public Health to manage the supply of vaccine to ensure equitable
distribution to all immunization providers.
Immunization providers should not order the whole season’s supply at once as
the supply needs to be shared among all immunization providers. We encourage
you to first immunize people at greatest risk of influenza-related complications
and those people who live with or care for them.
30
anemia or hemoglobinopathy;
conditions that compromise the management of respiratory secretions and are
associated with an increased risk of aspiration; and
children and adolescents with conditions treated for long periods with
acetylsalicylic acid.
People of any age who are residents of long term care and other chronic care
facilities.
Adults ≥65 years of age.
Children 6 to 59 months of age.
Pregnant women (the risk of influenza-related hospitalization increases with length
of gestation, i.e. it is higher in the third than in the second trimester).
31
8. Should people who are allergic to eggs, components of the vaccine, or a
previous dose receive the seasonal influenza vaccine?
A. Egg allergy: Since the 2011-12 influenza season, the National Advisory Committee
on Immunization (NACI) has recommended that egg-allergic individuals may be
vaccinated against influenza using trivalent inactivated vaccine (TIV) without a prior
influenza vaccine skin test based on an assessment of risk for a severe allergic
reaction to guide the method of vaccination.
The Canadian Society of Allergy and Clinical Immunology (CSACI) define
seriousness of allergies and protocols for immunization of allergic persons. Vaccine
providers administering influenza vaccine to egg allergic individuals can obtain
details on the CSACI website (www.csaci.ca) or in the Statement on Seasonal
Trivalent Inactivated Influenza vaccine for 2012-2013
CSACI define egg allergy as: immediate symptoms within 1-2 hours after exposure,
such as urticaria and angioedema, respiratory, gastrointestinal or cardiovascular
symptoms plus confirmatory allergy tests (skin test or egg specific IgE). The risk of
severe allergic reaction or anaphylaxis in egg-allergic individuals can be determined
by assessing their history of reactions to eggs.
Lower Risk: CSACI considers an egg-allergic individual to be at lower risk for severe
allergic reaction if they have mild gastrointestinal or mild local skin reaction, can
tolerate ingestion of small amounts of egg, or have a positive skin/specific IgE test
to egg when exposure to egg is unknown.
Individuals at lower risk for severe allergic reaction can be vaccinated for
influenza using a single vaccine dose and should be observed for 30 minutes
following administration for symptom development.
Higher Risk: An egg-allergic individual is considered to be at higher risk for severe allergic
reaction by CSACI, if they have had a previous respiratory or cardiovascular reaction or
generalized hives when exposed to egg; or have poorly controlled asthma.
Referral to a specialist with expertise in assessment and management of
egg-allergic individuals may be necessary in circumstances where there is
strong concern about proceeding with administration of influenza vaccine
and the individual is at risk of complications from influenza. If the individual
is not in a high-risk group, the need for vaccination may be reassessed.
32
11. How should the seasonal influenza vaccines be stored?
A. Vaccine Cold Chain should be maintained at all times (2°C to 8°C). The vaccine
should not be frozen and must be protected from light.
12. How long can a vial of influenza vaccine be used once it is opened?
A. An opened vial of Fluviral® (GSK) should be used within 28 days from the date it was
opened. It’s a good idea to record the date it was opened on the vial.
Agriflu® (Novartis) comes as a pre-filled syringe so this is not a concern for this
product.
13. Can I draw up the seasonal influenza vaccine into syringes to be used
at a later time?
A. No. The manufacturer has no data to confirm that immunogenicity of the product
will be preserved after prolonged exposure to the plastic of the syringe. The
company also has concerns regarding bacterial contamination. Therefore, influenza
vaccine should be injected as soon as possible after being drawn up.
15. How soon following immunization does protection develop and how
long does it last?
A. Protection from the seasonal influenza vaccine generally begins 10 to 14 days after
immunization and may last 6 months or longer.
16. What are the side effects of the seasonal influenza vaccine?
A. One third of those vaccinated report soreness at the injection site for up to two
days. Flu-like symptoms (fever, sore muscles, and tiredness) may occur within 6 to
12 hours after vaccination and last 1 to 2 days, especially in those receiving the
vaccine for the first time. Anaphylactic hypersensitivity reactions occur rarely.
33
18. How do physicians bill for influenza immunization?
A. MSI Billing Information for Administration of Seasonal Influenza (Flu) and
Polysaccharide Pneumococcal (PC) Vaccines 2012-2013
Diagnostic Codes
Patient Status
FLU PC and FLU
Pregnant V221 N/A
Males & non-pregnant females V048 V066
Refer to the following table when billing for a provincial immunization tray fee.
34
20. Can the seasonal influenza vaccine cause influenza illness?
A. No. The seasonal influenza vaccine does not contain live virus and cannot cause
influenza.
21. Can you receive seasonal influenza vaccine before or after having
donated/received blood or Immune Globulin?
A. Yes.
35
Appendix B: ANDS Quick Reference: Influenza Case Entry
ANDS Variable Definition and Use
The classification of the case at time of entry according to current provincial case
definitions:
Confirmed – refer to Table 1 for further detail.
Case Status* Confirmed – Laboratory confirmed – Do Not Use
Confirmed – Epidemiologically linked – Do Not Use
Probable – Do Not Use
Possible – Do Not Use
Left to discretion of DHA to use as applicable to case management. However, once
Investigation Status*
complete, all investigations should be closed in ANDS.
Investigation Closed Date The date the investigation was completed.
Date Reported* The earliest date that Public Health was notified of the case.
The DHA responsible for case management. This is the DHA that enters the case into
DHA*
ANDS.
Enter influenza type as appropriate from lab result (see Table 1). Please note that ANDS
Disease Name*
entry will vary according to lab result and Table 2 is essential.
Agent Sub/Serotype Entered by DHW Surveillance if known.
Other lab Info Free text field. Please enter Accession Number from lab report.
The date the subject became a case of disease being reported. This field is linked with the
Episode Date Type described below. Note that the Episode Date must be the same or
Episode Date*
earlier than the Date Reported.
(See ANDS Episode Date Hierarchy for data entry example).
The episode date type entered should follow the following hierarchy:
1. Onset date of symptoms – Use as preferred Episode Date
2. Clinical diagnosis date – Use if onset date not available
3. Specimen collection date – Use if onset date & clinical diagnosis date not
Episode Date Type*
available
4. Lab test result date – Use if onset date, clinical diagnosis date & specimen
collection date not available
(See ANDS Episode Date Hierarchy for data entry example).
Clinical Presentation Do Not Use
The outcome of the case. Note that if “deceased” is selected, a date of death must be
Outcome
entered.
Risk Factors for STIs Only Do Not Use
Where was case’s illness most If known, enter information.
likely acquired?
Associated with an outbreak? Indicate whether the case is associated with an existing outbreak.
The outbreak number of the associated outbreak, if applicable. (Follow outbreak
Outbreak Number
numbering system described in Section 3.5.3).
Received Vaccine Do Not Use
Vaccine Date 1 (& 2) Do Not Use
Vaccine Name Do Not Use
Comments Free text. Use as appropriate for case management.
This table outlines data entry for cases of influenza in ANDS. *Indicates a mandatory field in the ANDS application
36
Appendix C: ILI in Emergency Departments (ED)/Outpatient Centres
ER ICP ILI Surveillance Weekly Report Form
Emergency Department (ED) and Outpatient Centre Influenza-Like Illness Surveillance
Protocol
Background
The ED surveillance system was implemented in April 2009 with the
support of Infection Control Practitioners across Nova Scotia
ILI reports are sent to Department of Health and Wellness (DHW) and
reported weekly in Respiratory Watch
Case Definition for Surveillance Purposes
ILI is reported using the following surveillance case definition:
Acute onset of respiratory illness with:
Fever AND cough
One or more of the following: sore throat, malaise, myalgia or prostration
which could be due to influenza virus. In children less than 5 years,
gastrointestinal symptoms may also be present. In those less than 5 years
or older than 65 years, fever may not be prominent.
*distinct change from normal status to respiratory illness over 1-3 days,
based on clinical judgement
Reporting to DHW
The current surveillance system is a mixture of time periods:
Daily ILI Surveillance:
Facilities record the total number of patients seen and the number
with ILI each day for the entire surveillance week (Sunday to
Saturday)
Data are reported to DHW once each week
Data are reported using the ‘Daily ILI Surveillance Form’
DHW will accept, analyze and report all data
It is requested that the report be sent even if zero ILI cases were seen
Reporting Timelines
Report forms are sent to DHW via email or fax each Monday
Email: surveillancehpp@gov.ns.ca
Fax: 902-424-0550
Please note:
If facility has chosen to create a custom report using an administrative
database with ILI data, please email or fax to DHW as above
37
Appendix D: School and Daycare Absenteeism
Forms available at the following websites:
38
Appendix E: FluWatch Reporting Procedure through CNPHI
FluWatch Reporting using CNPHI
39
3. Select the appropriate sub-region from the drop-down menu:
4. Manually enter the data (note that mandatory fields are marked with an asterisk):
5. Scroll down the page and click “submit” to send the data to DHW:
40
6. Submitted data will appear as “Published” in the application:
A regional report computes a summary of influenza activity levels for the region
including detailed information from the sub-regional level reports.
41
2. Select the appropriate DHA from the drop-down menu:
3. Click on the “Update Table” button to upload the data from the Sub-Regional Report
into the Regional Report:
4. Scroll down the page and click “submit” to send the data to DHW:
42
5. Submitted data will appear as “Published” in the application:
43
Appendix F: 2012-13 NS Influenza Vaccine Coverage and
Reporting
Forms available at the following website:
http://www.gov.ns.ca/hpp/populationhealth/surveillanceguidelines/Appendix_C_Surveillance_Forms.pdf
44
45
LEGIONELLOSIS
1. Information
1.1 Case definition
Confirmed case:
Clinical illness (see clinical evidence below) with laboratory confirmation of
infection:
isolation of Legionella species or detection of the antigen from
respiratory secretions, lung tissue, pleural fluid or other normally sterile
fluids
OR
a significant (e.g. fourfold or greater) rise in Legionella species IgG titre
between acute and convalescent sera
OR
IgG titre > 1:128 against Legionella species
OR
demonstration of L. pneumophila antigen in urine
Probable case:
Clinical illness with demonstration of Legionella species DNA
Clinical Evidence:
Legionellosis comprises two distinct illnesses: Legionnaires’ disease,
characterized by fever, myalgia, cough and pneumonia, and Pontiac fever, a
milder illness without pneumonia.
1.4 Incubation
Legionnaire’s Disease: Usually 5-6 days, ranges from 2-10 days.
Pontiac Fever: Usually 24 to 48 hours, ranges from 5 to 6 days.
1.5 Source
Primarily sources of water, such as hot water systems (showers), air conditioning
cooling towers, evaporative condensers, humidifiers, whirlpool spas, respiratory
therapy devices and decorative fountains.
1.6 Transmission
Inhalation of mists from a contaminated water source (as named above). Person
to person transmission has not been documented.
1.7 Communicability
No person-to-person transmission.
1.8 Treatment
For Legionnaire’s disease, erythromycin is given in high doses intravenously
initially, followed by oral therapy when condition is improving. Rifampin is
recommended for patients with confirmed disease who are severely ill or
immunocompromised or in whom the infection does not respond promptly to
intravenous erythromycin. Rifampin should not be used alone.
Pontiac fever requires no specific treatment.
1.9 Core Messages for Prevention
Improved design and maintenance of cooling towers and plumbing
systems to limit the growth and spread of Legionella organisms are the
foundations of legionellosis prevention.
Tap water should not be used in respiratory therapy devices.
1.10 Prophylaxis
None.
2. Procedure
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health
a. Determine investigative responsibility.
The MOH must ensure that all reports of legionellosis are received and
disseminated to the appropriate personnel for investigation. The CDC
coordinator/ manager may assume this role in the absence of the MOH.
2.1.2 Investigator
Upon receiving the report the investigator should initiate the follow-up.
a. Determine case status.
b. Discuss case with the MOH.
c. Contact and educate the individual and /or family
Discuss the role of public health. Provide information to the individual or
family and provide fact sheets.
Inquire about water source.
Inquire about the use of humidifiers and respiratory equipment.
Inquire about whether immunocompromised
Inquire about whether the individual knows anyone else with symptoms
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Legionellosis: http://www.cdc.gov/ncidod/dbmd/diseaseinfo.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics
LEGIONELLOSIS FACT SHEET
What is Legionellosis?
Legionellosis is an infection caused by the bacterium Legionella pneumophila.
The disease has two distinct forms:
Legionnaires’ disease, the more severe form of infection which includes
pneumonia, and
Pontiac Fever, a milder illness.
Outbreaks of legionellosis have occurred after persons have breathed mists that come
from a water source (e.g., air conditioning cooling towers, whirlpool spas, showers)
contaminated with Legionella bacteria. Persons may be exposed to these mists in
homes, workplaces, hospitals, or public places. Legionellosis is not passed from person
to person, and there is no evidence of persons becoming infected from auto air
conditioners or household window air- conditioning units.
Pontiac Fever most commonly occurs in persons who are otherwise healthy.
1.0 Information
1.1 Case Definition
Confirmed case:
Clinical evidence of invasive disease1 with laboratory confirmation of
infection:
isolation of Neisseria meningitidis from a normally sterile site (blood, CSF,
joint, pleural or pericardial fluid)
OR
demonstration of N. meningitidis DNA by an appropriately validated
nucleic acid test (NAT)2 from a normally sterile site
Probable case:
Clinical evidence of invasive disease¹ with purpura fulminans or petechiae, with
no other apparent cause and with non-confirmatory laboratory evidence:
detection of N. meningitidis antigen in the CSF
1
Invasive meningococcal disease usually manifests itself as mentingitis and/or septicemia, although other
manifestations may be observed (e.g. orbital cellulitis, septic arthritis). Invasive disease may progress
rapidly to purpura fulminans, shock and death.
2
Each jurisdiction will have a validation process for the NAT that they have in place.
3
Sporadic Case: A single case occurring in a community where there is no evidence of an epidemiologic
link (by person, place, or time) to another case; Index Case: The first case occurring in a community;
Subsequent Case: A case with onset of illness subsequent to another case with whom an epidemiologic
link can be established. This category includes co-primary cases (a person who develops illness within 24
hours of onset of illness in the index case), as well as secondary cases (a person developing illness> 24
hours after onset of illness in the index case).
1.2 Causative Agent
Neisseria meningitidis, the meningococcus, is a gram negative aerobic
diplococcus with at least 13 serogroups. Strains belonging to groups A,C,Y and
W-135 are most commonly implicated in invasive disease.
1.3 Symptoms
Sudden onset of fever, intense headache, nausea and often vomiting, stiff neck
and photophobia. Meningococcaemia, or meningococcal sepsis, is the most
severe form of infection with petechial rash, hypotension, disseminated
intravascular coagulation and multi- organ failure.
1.4 Incubation
Usually 3 to 4 days, ranges from 1 to 10 days.
1.5 Source
Humans: Up to 5% to 10% of people may be asymptomatic carriers with
nasopharyngeal colonization of N. meningitidis. Less than 1% of those colonized
will progress to invasive disease. See Section 1.9, Core Prevention Messages.
1.6 Transmission
Person-to-person by direct contact with saliva or respiratory secretions.
1.7 Communicability
Communicable from 7 days before the onset of symptoms to 24 hours
after the institution of antibiotic treatment.
For asymptomatic carriers, communicability is difficult to determine
1.8 Treatment
Penicillin administered parenterally is the preferred choice
Cefotaxime, ceftriaxone, and ampicillin are acceptable alternatives
Chloramphenicol is recommended in patients with a penicillin allergy
Five to seven days of antibiotic treatment is adequate for most cases of
invasive disease
2.1.1 Exclusion
No exclusion required.
2.1.2 Education
See Section 1.9, Core Prevention Messages.
2.2.2 Susceptibility
Susceptibility to the clinical disease is low and decreases with age, which induces
a high ratio of carriers to cases. Asplenic individuals are susceptible to this
bacteremic illness.
2.2.4. Prophylaxis
Chemoprophylaxis should be offered to all persons having close contact with an
invasive meningococcal disease (IMD) case during the infectious period (the 7
days before onset of symptoms in the case to 24 hours after onset of effective
treatment), regardless of their immune status.
Chemoprophylaxis of close contacts should be administered as soon as possible
and preferably within 24 hours of case identification but is still recommended
for up to 10 days following last contact.
2.2.5 Immunization
Publicly funded meningococcal vaccine should be offered to contacts of cases of
invasive meningococcal disease (IMD), as per the NACI recommendations, in
order to further reduce the risk of secondary cases beyond the benefit of
chemoprophylaxis alone.
Unimmunized household and intimate social contacts (e.g. kissing,
sharing of toothbrush) of a case of IMD due to serogroup C should
receive meningococcal C conjugate vaccine (preferable) or MenACYW-Ps
or MenAC-Ps alternatives (depending upon age) as soon as serogroup C is
identified.
Unimmunized household and intimate social contacts (e.g. kissing,
sharing of toothbrush) of a case of IMD with serogroup A, should receive
MenACYW-Ps or MenAC-Ps.
NOTE: for contacts who had a one-time exposure (e.g. health care workers
and air travel contacts) rather than ongoing exposure, chemoprophylaxis
alone is sufficient rather than immunization and chemoprophylaxis
2.2.6 Exclusion
Exclusion of contacts is not necessary.
2.2.7 Education
Review signs and symptoms of meningococcal disease and provide
contacts with the Fact Sheet (refer to Appendix 3).
Instruct contacts to seek medical attention immediately if they develop
signs and symptoms
If the index case attended a child care centre or school, see Section 2.6.2,
Guidelines for Child Care
2.2.8 Follow-Up
Inquire to confirm that contacts received appropriate prophylaxis and did
not become secondary cases
Arrange for contacts to receive vaccination if the serogroup is vaccine
preventable.
Community-Based:
Increased transmission of N. meningitidis in a community with three or more
confirmed cases of the same serogroup occurring within a three-month interval
AND an age-specific incidence OR specific community population incidence of
approximately 10/100,000, where there is an absence of an epidemiologic link
between cases. This is not an absolute threshold and should be considered in
the context of other factors.
Refer to CCDR Volume 3151, May 2005, Guidelines for the Prevention and
Control of Meningococcal Disease, Section 7.2.
2.4 Guidelines
2.4.1 Guidelines for Institutions / Long-Term Care Facilities
In health care facilities, when caring for a case with meningococcal
disease, only persons with intensive exposure to nasopharyngeal or
respiratory secretions require prophylaxis. This is in the absence of a
mask as during an attempt to resuscitate an individual.
For residents of long-term care facilities, please refer to Section 2.2.1. to
determine which individuals meet the contact definition.
3.0 SURVEILLANCE
CIOSC Public Health Alert is recommended.
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions
at http://www.gov.ns.ca/hpp/cdpc/CDCManual
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 18th edition. 2004. David L. Heymann, Editor.
American Public Health Association.
Guidelines for the Prevention and Control of Meningococcal Disease. CCDR, May 2005. Public
Health Agency of Canada.
Report of the Committee on Infectious Diseases. 2003. American Academy of Pediatrics.
De Wals P, Hertoghe L, Borlée-Grimée I, et al. Meningococcal disease in
Belgium. Secondary attack rate among household, day-care nursery and pre-
elementary school contacts. J Infect 1981; 3 (suppl 1): 53-61
Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Prophylactic use of antibiotics for prevention of
meningococcal infections: systematic review and meta-analysis of randomised trials. Eur J Clin
Microbiol Infect Dis 2005; 24(3): 172-81.
Meningococcal Disease Surveillance Group. Meningococcal disease: secondary attack rate and
chemoprophylaxis in the United States, 1974. JAMA 1976; 235: 261-265.
Cooke RPD, Riordan T, Jones DM, et al. Secondary cases of meningococcal infection among close
family and household contacts in England and Wales, 1985-1987. Br Med J 1989; 298: 555-558.
Stroffolini T, Rosmini F, Curiano CM. A one year survey of meningococcal disease in Italy. Eur J
Epidemiol 1987; 3: 399-403.
Olivares R, Hubert B. Clusters of meningococcal disease in France (1987- 1988). Eur J Epidemiol
1992; 8: 737-42.
APPENDIX 1: PHYSICIAN GUIDELINES FOR
PROPHYLAXIS OF CONTACTS OF
MENINGOCOCCAL DISEASE
The following information is provided by Public Health Services to assist you in the
chemoprophylaxis of close contacts of a case of invasive meningococcal disease.
1. Information
For information and procedures related to methicillin-resistant Staphylococcus auresus
(MRSA) and vancomycin-resistant enterococci (VRE), refer to Partners for Infection
Control Manual, available in all district Public Health Services Offices.
COMMUNITY-ASSOCIATED MRSA (CA-
MRSA) FACT SHEET OCTOBER 2008
What is CA-MRSA?
CA-MRSA (Community-Associated Methicillin Resistant Staphylococcus Aureus) is a type
of bacteria or germ that is not killed by the most common antibiotics (like Penicillin). If
these germs cause an infection, then a stronger antibiotic must be used. Most often
these bacteria cause skin infections (like pimples and boils); but they can also cause
more serious infections (like pneumonia or infections in an incision after an operation).
1. Information
Identification of adult lice or nits (eggs) on the head or attached to hair shaft, on the
body and/or the pubic areas and the presence of symptoms consistent with infestation.
1.3 Symptoms
Intense itching, worse at night. The louse bites develop as painless macules and
then papules, especially on the scalp. Scratching may lead to excoriation.
Secondary infection may occur with ensuing regional lymphadenitis.
1.4 Incubation
The eggs (nits) usually take 1 week to hatch. There may be a slightly longer
incubation period depending on the type of contact. The egg-to-egg cycle is
approximately 3 weeks.
1.5 Source
Humans.
1.6 Transmission
Direct contact is the most frequent mode of transmission; however the lice can
live on clothing, bedding or other personal items, like hats or hairbrushes. Pubic
lice are usually transmitted through sexual contact, or bedding or shared towels.
1.7 Communicability
Exists as long as the lice and nits are alive, on the individual or in clothing and
other personal articles.
1.8 Treatment
Shampooing a permethrin-based product into the hair, to be left on for 10
minutes is the treatment of choice. The permethrin solution should kill the nits
as well. In the case of a pregnant woman or a child under two, the physician
should be contacted. Lindane based products may have some potential toxicity,
however they are still effective when used according to product instructions. A
second treatment 7-10 days after the first is suggested to kill newly hatched lice.
Lindane should be used with caution in pregnant women, children under 2 years
of age and on people with inflamed or traumatized skin.
1.10 Prophylaxis
None.
2. Procedure
Refer to the “Guidelines for Treatment of Pediculosis Capitis (Head Lice)
document located at:
http://www.gov.ns.ca/hpp/resources/policiesandreports.asp
For useful facts and other information for the public please refer to the “How to
Prevent, Find, and Treat Headlice” pamphlet located at:
http://www.gov.ns.ca/hpp/resources/other.asp
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association. Infection Control in the Child Care Center and Preschool 3rd edition –
1996-Leigh G. Donowitz editor Head Lice Information
Package, Developed by Public Health Services, Nova Scotia Central Regional Health Board, Aug.
2000
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
PNEUMOCOCCAL DISEASE-INVASIVE
1.0 Information
1.1 Case definition
Confirmed case:
Clinical evidence of invasive disease (see clinical evidence) with laboratory
confirmation of infection:
isolation of Streptococcus pneumoniae from a normally sterile site
(excluding the middle ear and pleural cavity)
OR
demonstration of S. pneumoniae DNA from a normally sterile site
(excluding the middle ear and pleural cavity)
Probable case:
Clinical evidence of invasive disease with no other apparent cause and with
non-confirmatory laboratory evidence:
demonstration of S. pneumoniae antigen from a normally sterile site
(excluding the middle ear and pleural cavity)
Clinical Evidence
Clinical illness associated with invasive disease manifests itself mainly as
pneumonia with bacteremia, bacteremia without a known site of
infection, and meningitis. Pneumonia without bacteremia is not notifiable
1.3 Symptoms
Sudden onset of fever, pleural pain, difficulty or rapid breathing, productive
cough of rusty sputum. If pneumococcal meningitis, symptoms may include:
fever, lethargy, severe headache, vomiting, and stiff neck.
1.4 Incubation
May be as short as 1-3 days.
1.5 Source
Humans. Pneumococci are commonly found in the upper respiratory tract of
healthy people.
1.6 Transmission
By droplet spread or direct oral contact, or indirectly via articles contaminated
with respiratory secretions. Person to person transmission is common, but illness
among casual contacts or attendants is infrequent.
1.7 Communicability
Until respiratory discharges no longer contain bacteria in significant numbers.
14-28 hours after administration of penicillin.
1.8 Treatment
Penicillin G parenterally. Erythromycin may be used for clients who are allergic
to penicillin. Penicillin-resistant strains are known, therefore identification of the
strain is important.
1.10 Prophlyaxis
None.
2.0 Procedure
No Public Health follow-up required. This disease is notifiable.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under
National Surveillance. CCDR 2009; 3552, 1-123.
Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
Canadian Immunization Guide 5th Edition. 1998.Health Canada.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association.
Pneumococcal Polysaccharide Vaccine: What You Should Know.
www.cdc.nip/publication/VIS/VIS-ppv.pdf Streptococcus Pneumoniae Disease.
www.cdc.gov/ncidod/dbmd/diseaseinfor/streppneum_t.htm
Pneumococcal Disease Fact Sheet
What is Pneumococcal Disease?
Pneumococcal disease is caused by bacteria. There are many different types of
pneumococcal bacteria that can cause serious infections of the lungs (pneumonia), the
blood (bacteremia), and the coverings of the brain (meningitis). If not treated, the
disease can cause death.
1.3 Symptoms
Severe itching, especially at night, in the areas of the papular eruptions. Small
blisters or vesicles may be evident. In infants, there may be a generalized rash
instead of the typically separated scabies lesions in the adult. If scratching is
vigorous, secondary infection of the lesions may be evident.
1.4 Incubation
Two to six weeks before onset of itching, if not previously exposed. In those who
have been previously infested, the incubation may be only 1-4 days
1.5 Source
Humans.
1.6 Transmission
Direct skin to skin contact or through sexual contact or possibly through contact
with the bedclothes or towels of infected individuals.
1.7 Communicability
Usually until after 1 or 2 courses of treatment, 7 days apart.
1.8 Treatment
The recommended treatment is one application of a cream or lotion containing
5% Permethrin. The cream or lotion should be left on for only 8-14 hours and
then washed off. Alternative treatment by lindane containing products can also
be effective, though they should be used with caution in children under 2 years
of age. The individual should check with a physician if pregnant or if a child under
2 years of age is infected.
1.10 Prophylaxis
None.
2. Procedure
Refer to Partners for Infection Control manual for management in long term care
facilities.
b. Contacts
All family or close household contacts that have skin-to-skin contact with the
infected individual should also be treated with a full treatment regimen, to
ensure that the infection does not spread.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American
Public Health Association. Working Guide: Notifiable Disease Reporting System in Nova Scotia.
1998. Nova Scotia Department of Health.
VIRAL MENINGITIS
1. Information
1.1 Case definition
Clinically compatible symptoms or laboratory-confirmed virus identification
1.3 Symptoms
Viral meningitis is a relatively common but rarely serious syndrome with multiple
viral etiologies. It usually presents as a sudden onset of fever, with headache,
and other signs of meningeal involvement and abnormal CSF findings. A rash
resembling rubella characterizes certain types of viral meningitis caused by
echoviruses and coxsackieviruses; vesicular and petechial rashes may also occur.
Active illness seldom exceeds 10 days. Recovery is usually complete. GI and
respiratory symptoms may be associated with infection with enteroviruses.
1.4 Incubation
Depends on the specific virus, but for enteroviruses often 3 to 5 days.
1.5 Source
Humans and probably certain birds, mammals and reptiles.
1.6 Transmission
Depends on specific virus, but for enteroviruses, generally directly by fecal-oral
or respiratory droplet contact with an infected person, or indirectly by contact
with articles freshly soiled with feces or throat discharges from an infected
person.
1.7 Communicability
Depends on the specific virus.
1.8 Treatment
None for the usual causative agents.
1.9 Prophylaxis
None.
2. Procedure
No public health follow-up required. It is notifiable.
References:
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Manitoba CDC Manual
VIRAL MENINGITIS FACT SHEET
What is Viral Meningitis?
Viral meningitis is an inflammation of the lining of the brain caused by a virus. It is a
relatively common but rarely serious disease.
Disclaimer Statement
The Nova Scotia Communicable Disease manual was developed for the use of Public Health staff within the District
Health Authorities. This manual is constantly under revision. Public Health staff will be informed of the changes as
they occur. However, information contained on this site may not contain the latest information.
Department of Health and Wellness does not assume any responsibility for the use of this information by any
other groups or organizations aside from Public Health staff within the District Health Authorities.
ANTHRAX
1. Information
1.1 Case definition
Confirmed case:
Clinical illness with laboratory confirmation of infection:
Isolation of Bacillus anthracis in a clinical specimen
OR
Demonstration of B. anthracis in a clinical specimen by
immunofluorescence
Probable case:
Suspected case with detection of B. anthracis DNA
Possible Case:
Clinical illness in a person who is epidemiologically linked to a confirmed or
suspected animal case or contaminated animal product
1.3 Symptoms
Cutaneous: Appearance of small, painless but often pruritic papules. As the
papule enlarges, it becomes vesicular and, within two days, ulcerates to form a
distinctive black eschar, with surrounding edema
1.5 Source
Anthrax is a zoonotic disease. Spores of B anthracis are found on hides,
carcasses, hair, wool and other by-products of domesticated animals and wild
animals such as goats, sheep, cattle, swine, horses, buffalo and deer. Anthrax
may also be used as an agent of bioterrorism.
1.6 Transmission
Human cases occur after contact with infected animals or their contaminated
products. There is also the potential for use by bioterrorists.
1.7 Communicability
Inhalation: not transmitted person to person Cutaneous: Discharges from
cutaneous lesions are potentially infectious.
1.8 Treatment
High doses of I.V. penicillin and doxycycline. Ciprofloxacin also is recommended
therapy for adults with inhalation anthrax.
1.9 Prophylaxis
For individuals believed to be exposed to an aerosol of bacillus anthracis,
chemoprophylaxis needs to be discussed with the MOH.
2. Procedure:
b. Contact tracing.
If there are individuals who have been exposed to an aerosol they should
be contacted and referred for prophylaxis after an assessment is made.
2.1.3 Physician
Use general guidelines.
2.1.4 Laboratory
Use general guidelines
Anthrax usually occurs in farm animals such as cows and sheep. It is uncommon in
humans.
In a skin infection, a small painless bump appears on the skin. This bump
then becomes a blister and then an ulcer with a black centre. This is the
most common type of infection.
In a stomach infection, the signs are fever, loss of appetite, vomiting and
diarrhea.
In a lung infection, the first signs resemble the flu. Symptoms may include
fever, sore throat and feeling unwell. After several days, this is followed
by trouble breathing. This is the most serious type of infection.
Signs of illness usually do not appear until 1 to 7 days after exposure to the anthrax
spores. It can take as long as 60 days for a lung (inhalation) infection.
HANTAVIRUS PULMONARY SYNDROME
(HPS)
1. Information
1.1 Case definition
Confirmed case:
Clinical illness with laboratory confirmation of infection:
Detection of IgM antibodies to hantavirus
OR
Detection of a significant (e.g. fourfold or greater) increase in hantavirus-
specific IgG
OR
Detection of hantavirus RNA in an appropriate clinical specimen
OR
Detection of hantavirus antigen by immunohistochemistry
1.3 Symptoms
Characterized by:
A febrile (>38.3C oral) illness requiring supplemental oxygen
AND
Bilateral diffuse infiltrates (may resemble acute respiratory distress
syndrome [ARDS])
AND
Develops within 72 hours of hospitalization in a previously healthy person
OR
An unexplained illness resulting in death plus an autopsy examination
demonstrating non-cardiogenic pulmonary edema without an identifiable
specific cause of death
1.4 Incubation
9 to 35 days.
1.5 Source
The major source for the Sin Nombre virus is the deer mouse. Antibodies have
also been found in other rodents.
1.6 Transmission
Aerosol transmission from rodent feces and urine.
1.7 Communicability
Person to person spread has not occurred in North America.
1.8 Treatment
There is no proven effective antiviral therapy. Clinical management depends on
careful fluid administration (avoid overhydration) and ventilatory support.
1.10 Prophylaxis
None.
2. Procedure
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health
a. Determine investigative responsibility.
The Medical Officer of Health (MOH) must ensure that all reports of hantavirus
are received and disseminated to the appropriate personnel for investigation.
The CDC manager/team lead may assume this role in the absence of the MOH.
2.1.2 Investigator
Upon receiving the report the investigator should initiate the follow-up.
b. Report case.
Discuss case with the MOH.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Case Definitions for Diseases Under National Surveillance. 2000. Laboratory Centre for Disease Control.
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Hantavirus Pulmonary Syndrome in Canada, 1989-1999.A. Bruneau & C. Duchesne. Canada
Communicable Disease Report. April 15, 2000. Hantavirus:
http://www.cdc.gov/ncidod/dbmd/diseaseinfo.
HANTAVIRUS PULMONARY SYNDROME
FACT SHEET
What is Hantavirus Pulmonary Syndrome (HPS)?
Hantavirus Pulmonary Syndrome, or HPS is a severe illness that is caused by a virus. This
rare disease was first described in the Southwestern United States in 1993. It is believed
that the virus has been present for a long time, but was only just recently recognized.
The first time HPS was found in Canada was in 1994, when 3 cases were reported in
British Columbia. The disease is been reported in all of the United States and Canada
considered to be extremely rare – only about 300 cases have.
People at most risk of catching HPS include anyone who frequently handles or is
exposed to rodents, such as wildlife biologists and pest exterminators. Others who
might be at higher risk would be people who often find themselves working in attics or
crawl spaces, or who are involved in cleaning or major renovations of homes that have
been infested with rodents. These people should take special precautions during their
work, including wearing protective clothing and using masks.
What are the Symptoms?
HPS begins as a “flu-like” illness. In the early stage of the disease, a person may have
fever, sore muscles, headaches and shortness of breath. As the disease gets worse, fluid
builds up in the lungs.
All these factors can cause dust which can carry the virus if it is present, and infect
people who breathe it in.
Clean areas where rodents have lived. To prevent stirring up dust when you are cleaning
up areas where rodents have lived, you should ventilate and then spray area with
household disinfectant before you start. Damp mop floors, shampoo carpets, wash
clothing and bedding, and disinfect counter-tops, cabinets and drawers. Avoid raising
dust when sweeping or vacuuming.
1. Information
Probable case:
Clinical evidence of illness without a history of residence in, or visit to, an
endemic* area and with laboratory evidence of infection:
positive serologic test using the two-tier ELISA and Western Blot criteria
OR
Clinician-observed erythema migrans without laboratory evidence but with
history of residence in, or visit to, an endemic* area
Note: An erythematous skin lesion present while a tick vector is still attached or
that has developed within 48 hours of detachment is most likely a tick bite
hypersensitivity reaction (i.e. a non-infectious process), rather than erythema
migrans. Tick bite hypersensitivity reactions are usually < 5 cm in largest
diameter, sometimes have an urticarial appearance and typically begin to
disappear within 24-48 hours.
OR
Disseminated Lyme disease
Objective evidence of disseminated Lyme disease includes any of the
following when an alternative explanation is not found:
1.4 Incubation
From tick bite to appearance of single or multiple EM 3-32 (see
http://www.cdc.gov/travel/content/yellowbook/home-2010.aspx
days with a mean of 7-10 days. Late manifestation occurs months to years later.
1.5 Source
The Ixodes scapulari, commonly known as the Blacklegged or deer tick, and the I.
pacificus ticks are the vectors. Deer and wild rodents are the reservoir for these
ticks. I. scapulari have been found in areas in Nova Scotia.
The risk of Lyme disease is generally low but increases in areas with endemic
populations of Blacklegged ticks. Blacklegged ticks have become endemic in a
few areas in NS. An area is considered endemic when Blacklegged ticks
reproduce from year to year and can be found in an area at all stages, from
nymph to adult. Endemic areas are found on the DHW website at
www.gov.ns.ca/hpp/cdpc/lyme.asp. Migrating birds can also carry Blacklegged
ticks into other areas of Nova Scotia. These ticks often do not become endemic
as the appropriate climate and habitat are not always present.
Adult Blacklegged ticks normally feed on deer while nymphs primarily feed on
small rodents such as mice and squirrels.
1.6 Transmission
Tick-borne; transmission occurs after the infected nymphal, larval or adult
Blacklegged tick (BLT) has been attached for 24 hours or more.
Other ticks in NS, such as the common dog tick, cannot transmit Lyme disease.
The risk of Lyme disease is generally low but increases in areas with endemic
populations of Blacklegged ticks. Patients with active disease should not donate
blood because spirochetemia occurs in early Lyme disease.
1.7 Communicability
There is no evidence of natural person to person transmission. Rare cases of
congenital transmission have been documented but epidemiological studies
have not shown any links between maternal Lyme disease and adverse
outcomes of pregnancy.
1.8 Treatment
Early localized (erythema migrans) and early disseminated (except if there is CNS
involvement, see below) can be treated with oral antibiotics (doxycycline,
amoxicillin, or cefuroxime).
CNS manifestations, except for cranial nerve 7 palsy (which can be treated with
oral antibiotics), should be treated with IV antibiotics (IV ceftriaxone, cefotaxime,
or penicillin).
IgM antibodies appear 2 to 4 weeks after the onset of EM, peak in the
bloodstream at 6 to 8 weeks, and decline to low levels 4 to 6 months post-
infection. However, occasionally IgM antibodies can persist for months to years.
IgG antibodies appear 4 to 6 weeks after onset of EM, peak at 4 to 6 months and
remains elevated indefinitely.
Pamphlets and posters are distributed by Public Health staff at the District
Health Authorities to community partners (hospitals, physician officers,
campgrounds, golf courses, municipal parks, etc.) DHW distributes pamphlets
and posters to other government agencies (e.g. Department of Natural
Resources, who distributes to provincial parks, Department of Tourism for
distribution in NS Visitor Information Centres).
6.0 References
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases
under National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf
American Academy of Pediatrics and Committee on Infection Diseases (2009). Red
Book: 2009 Report of the Committee on Infectious Diseases, 28th ed. Elk Grove Village,
IL: American Academy of Pediatrics.
Heymann, David (2008). Control of Communicable Diseases Manual, 19th ed.
Washington, D.C.: American Public Health Association.
Nova Scotia Department of Health Promotion and Protection (2009). Nova Scotia
Communicable Disease Control Manual. Halifax, Nova Scotia.
Ogden, NH., Lindsay, LR., Morshed, M., Sockett, P., Artsob, H. The Rising Challenges of
Lyme Borreliosis in Canada. Canadian Communicable Disease Report, January 1, 2008.
Volume 34, Number 01.
Provincial Public Health Laboratory Network of Nova Scotia PPHLN: Microbiology Users
Manual, 2009. http://www.cdc.gov/travel/content/yellowbook/home-2010.aspx
CDC Health Information for International Travel, 2010.
APPENDIX 2: LYME DISEASE FACT SHEETS
LYME DISEASE FACT SHEET (ENGLISH)
What is Lyme Disease?
Lyme Disease is a bacterial infection transmitted by a certain species of ticks known as
the Blacklegged tick, sometimes called the deer tick. Ticks, seen mostly in summer
months, are small insects that will stick to the skin and feed on the blood of animals,
including humans. The tick is brown or black and may be as small as the period at the
end of this sentence. Before feeding they can be three to five millimetres in length.
The Lyme disease bacteria can be carried by mice, squirrels, birds and other small
animals. It can be passed to humans when ticks feed on infected animals such as birds
and become infected and then bite people.
The risk of Lyme disease is usually low. It takes 24 hours for the tick to transmit the
disease. Removing the tick may help to stop the spread of Lyme disease into the body.
Use tweezers or your fingers to grasp the body of the tick and remove it gently. After
tick removal, wash the area and your hands thoroughly.
La bactérie qui cause la maladie de Lyme peut être portée par des souris, des écureuils,
des oiseaux et d‟autres petits animaux. Elle peut être transmise aux humains quand des
tiques se nourrissent du sang d‟animaux infectés, deviennent elles-mêmes infectées,
puis mordent un humain.
Le risque d‟attraper la maladie de Lyme est habituellement faible. Une tique met 24
heures à transmettre la maladie. Enlever la tique peut aider à prévenir la propagation de
la maladie de Lyme dans le corps. Utilisez une pince à épiler ou vos doigts pour prendre
le corps de la tique et l‟enlever délicatement. Après avoir enlevé la tique, lavez bien
l‟endroit de la morsure et vos mains.
As temperatures rise and the days become longer we are more likely to be participating
in outdoor activities. This time of year it is important to be careful in areas where there
may be a lot of blacklegged ticks. These ticks can carry the germ that causes Lyme
disease. These locations include the area around Admiral’s Cove Park in Bedford, the
countryside surrounding the Town of Lunenburg as well as the area along Gunning
Cove in Shelburne County (from Churchover to Roseway).
These precautions are recommended if you or members of your family spend time in
the brush or forests in the above areas.
More information can be found in the Department of Health and Wellness pamphlet
and website (http://www.gov.ns.ca/hpp/cdpc/lyme.asp) or from your local Public
Health Services office.
APPENDIX 4: LETTER FOR USE IN SCHOOLS
(FRENCH)
Objet : Tiques à pattes noires et la maladie de Lyme
À mesure que la température augmente et que les jours rallongent, nous sommes plus
enclins à participer à des activités de plein air. En ce temps de l‟année, il est important
de se protéger dans les endroits où il pourrait y avoir beaucoup de tiques à pattes
noires. Les tiques peuvent êtres porteuses du germe qui cause la maladie de Lyme. Ces
endroits comprennent le parc Admiral's Cove à Bedford, la campagne dans la région de
Lunenburg et la région de Gunning Cove, dans le comté de Shelburne (de Churchover à
Roseway).
Ces précautions sont recommandées si vous ou les membres de votre famille passez du
temps dans les broussailles ou les forêts des régions ci-dessus.
Public Health Services would like to remind you that Blacklegged (deer) ticks are
established / endemic (consistently found) in the area around Admiral’s Cove Park in
Bedford, the countryside around the Town of Lunenburg and along Gunning Cove in
Shelburne County (from Churchover to Roseway). This means that there is an increased
risk of becoming infected with Lyme disease in these areas.
However, there are several things you can do to decrease this risk. Public Health
encourages you continue to enjoy the outdoors safely.
You can take simple precautions to protect yourself from infection with Lyme disease.
You can also make some changes to your property to make it less inviting to Blacklegged
ticks and decrease exposure to them.
These include:
PERSONAL PROTECTION
CLOTHING
Wear light coloured clothing with long sleeves and closed shoes and tuck
pant legs into your shoes when in areas with long grass and shrubbery.
Covering the skin reduces the chances for deer ticks to find skin to attach to.
Light coloured clothing makes it easier to see deer ticks and brush them off.
Walk in the middle of trails, away from grass and underbrush.
INSECT REPELLANT
Apply insect repellents containing DEET to clothing and to exposed skin.
This makes you a less inviting target for deer ticks.
TICK CHECKS
When you return from a walk in areas with long grass and shrubbery, check
your skin for any deer ticks that may have become attached.
DEER TICKS NEED TO BE ATTACHED FOR 24 HOURS OR LONGER IN
ORDER TO INFECT YOU WITH LYME DISEASE
Did you know that ticks that carry Lyme disease can be found as late as November on
your pets and you?
Enclosed is a pamphlet on Lyme disease with helpful hints on how to stay safe and
healthy.
The Plan also incorporates other tickborne diseases such as Human Granulocytic
Anaplasmosis (HGA) which is caused by infection with Anaplasma
phagocytophilum (Ap). Ap can also be transmitted to humans by the BLT. There
are other tick borne diseases as well that are briefly mentioned including
Babesiosis.
Objectives:
To assess the presence and spread of ticks and tick borne disease in NS.
To assess the risk of human infection from tick borne disease in NS.
To assess the incidence of infection of humans with tick borne diseases in
NS.
To increase the awareness of the public and health care professionals
(HCP‟s) about where, in NS, the risk for being infected with a tick borne
disease is increased.
To increase awareness of the public and HCP‟s about typical symptoms
and signs of tick borne diseases.
To provide information to the public and HCP‟s about effective ways to
prevent exposure to and infection with tick borne diseases.
To identify and implement strategies to control the spread of vectors of
tick borne disease if possible.
3.0 BACKGROUND
Ixodes Scapularis (Blacklegged ticks) are the primary source for vector borne
diseases in Nova Scotia, including human anaplasmosis and Lyme disease.
Blacklegged ticks
were first identified in Nova Scotia in 2002 and the first human cases of Lyme
disease were confirmed as well. Migrating birds can carry BLT’s which may be
brought into areas of NS. Blacklegged ticks often do not become
established/endemic as the appropriate climate and habitat are not always
present. BLT’s have become established/endemic in a few areas in NS. An area is
considered established/endemic when Blacklegged ticks reproduce from year to
year and can be found at all stages, from nymph to adult. Adult Blacklegged ticks
normally feed on deer while nymphs primarily feed on small rodents such as
mice and squirrels.
Humans may become infected through the bite of an infected nymphal, larval or
adult BLT. People may be exposed to BLT’s that are often present in long grass or
shrubbery in areas where they have become established/endemic. The risk of
infection is very low if the tick is removed within 24 hours of attachment.
The risk of Lyme disease, Anaplasmosis and other tick borne diseases is generally
low but increases in areas with established/endemic populations of Blacklegged
ticks. Other ticks in NS, such as the common dog tick, cannot transmit Lyme
disease or Anaplasmosis.
Human cases of Lyme disease and Anaplasmosis rarely cause death.
Transmission of bacteria from BLT’s to humans usually occurs after the infected
nymphal, larval or adult BLT has been attached for 24 hours or more.
Early localized:
A distinctive rash occurs at the site of a recent tick bite. The rash, erythema
migrans (EM), appears 3-32 days after the tick bite (mean of 7-10 days) as a red
macule or papule and expands over days to weeks to form a large, annular,
erythematous lesion that is usually 5 cm or more in diameter. Lesions less than 5
cm in diameter are less likely to represent EM and may be local reactions to the
tick saliva. The lesion may have a partial central clearing and is usually painless
and not pruritic. Localized EM can vary greatly in shape and size and may have
necrotic or vesicular areas in the centre. With or without EM other symptoms
may include fever, malaise, headache, fatigue, stiff neck, and myalgia and
arthralgias. 70-80% of those infected with Lyme disease have an EM rash. Not all
patients who develop Lyme disease present with initial EM.
Early disseminated:
15% of patients present with multiple erythema migrans. This rash often occurs
several weeks after the tick bite. Rash consists of secondary annular,
erythematous lesions, usually smaller than, the primary lesion. Other symptoms
in this stage may include palsies of the cranial nerves, lymphocytic meningitis,
and conjunctivitis. Arthralgia, myalgia, headache and fatigue may also be seen.
Rarely, various degrees of heart block can be seen.
Late disease:
Most commonly seen is relapsing arthritis usually in large joints, particularly
knees. Peripheral neuropathy and central nervous system symptoms can rarely
occur.
Late disease is rarely, if ever, fatal. Many symptoms and signs can resolve
spontaneously and are effectively treatable with antibiotics. Non-cutaneous
signs and symptoms are usually prevented with prompt antibiotic treatment.
HUMAN GRANULOCYTIC ANAPLASMOSIS (HGA)
Clinical Illness
Typical symptoms of HGA include acute self limited fever, headache, malaise,
thrombocytopenia, leucopenia, and increased hepatic transaminases. Illness can
range from mild to severe, with less than 1% case-fatality.
The incubation period for HGA ranges from 5 – 14 days. (Heyman 2008 and
American Academy of Pediatrics 2009)
BABESIOSIS
Clinical Illness
Human cases are often asymptomatic or associated with mild symptoms that
may include fever, nonspecific flu-like symptoms, and hemolytic anemia.
Common findings include fever, chills, myalgia, fatigue and jaundice that may
occur secondary to hemolytic anemia and can last from several days to a few
months.
3.2 Epidemiology
Sampling of BLT’s submitted by the public, veterinarians and health care
professionals has sporadically shown the presence of isolated BLT’s that test
positive for tick borne diseases, in several locations in the province. However, it
does not appear that BLT’s or Ld have become established/endemic in all areas.
To date, only 3 areas have been confirmed to have established/endemic
Blacklegged tick populations; Areas in and around Lunenburg, Admiral’s Cove
area in Bedford, and Gunning Cove in Shelburne county.
BLT’s in all three established/endemic BLT areas have tested positive for Borrelia
burgdorferi (Lyme) The infectivity rate varies. As well, all three
established/endemic BLT areas have had low rates of Anaplasmosis detected in
BLT’s. Babesios has only been detected in a small mammal sample in Lunenburg
area to date.
The risk for human infection with Ld or other tick borne diseases in areas where
BLT’s are not established/endemic is considered to be very low.
Human cases of Lyme disease and Anaplasmosis are reportable under the Health
Protection Act to Department of Health and Wellness. Lyme disease has been
confirmed in humans in NS. There have been no human cases of Anaplasmosis to
date. One horse was confirmed with Anaplasmosis in 2009. No cases of
Babesiosis have been reported in NS.
The working group meets regularly to monitor all activities related to the
response plan.
National case definitions are available for human Lyme disease. Health care
workers are required to notify Public Health of all human cases of Lyme disease
and Human Granulocytic Anaplasmosis. Public Health will determine if the case
meets the case definition and will then initiate investigation of the case.
Details on Public Health investigation and management, as well as case report
forms are found in the Communicable Disease Prevention and Control Manual.
Also, please refer to section 4.6 for information on laboratory diagnostics.
Objectives:
To monitor geographic location and spread of black legged ticks (BLT’s) in
NS over time.
To identify the percentage of BLT’s positive for Lyme disease, babesiosis
and/or Anaplasmosis (Ap).
To inform decisions concerning where to conduct active surveillance.
DHW invites members of the public, physicians and veterinarians to submit ticks
that have been found to be attached to people or pets for identification.
Samples can be sent to local offices of Department of Natural Resources (DNR)
or can be mailed to the Museum of Natural History in Halifax. Ticks other than
dog ticks are forwarded by DNR to the National Microbiology Laboratory (NML)
for further identification and testing for Borrelia burgdorferi, Ap and Babesiosis.
ACTIVE SURVEILLANCE
Objectives:
To identify locations within NS where BLT’s and Ld are established.
Dragging for Blacklegged ticks (a process to collect BLT’s) to assess the presence
of various life stages of BLT’s and testing of small mammals to assess the
presence of Borrelia burgdorferi and Ap is conducted in areas where there is
reason to suspect that BLT’s Lyme or Ap may be prevalent. Suspicion about
establishment may be based on clusters of BLT’s submitted as part of the passive
surveillance system, the reporting of confirmed human cases in an area,
surveillance for BLT’s on deer or reports from veterinarians about dogs that test
positive for Ld with the IDEXX test.
Active surveillance is conducted by DNR and the Public Health Agency of Canada
(PHAC). Serological samples from small mammals and all collected BLT’s are
tested for, Borrelia burgdorferi, Ap and Babesia microti at the NML in Winnipeg.
DEER SURVEILLANCE
Staff of DNR has inspected deer killed on highways in western NS and the Halifax
area during the spring and fall for the presence of BLT’s. Samples of deer killed
by hunters have been inspected in the Lunenburg area for the presence of BLT’s.
Continuation of this initiative will be determined with analysis of passive and
active surveillance initiatives by the Vector Borne Diseases working group. These
activities are designed to complement active and passive surveillance activities.
Cover skin when walking, working, or playing in areas where ticks are
found.
Wear enclosed shoes, tucking shirt in pants and pant legs in socks
Walk on well-traveled paths, avoiding high grass and vegetation.
Use an insect repellent (DEET) following label directions carefully.
Check yourself, children and pets after walking in grassy or wooded
areas, particularly where BLT’s have become established/endemic. Check
clothing and inspect skin including arm pits, groin and scalp.
Remove ticks as soon as they are found. Carefully grasp ticks with
tweezers as close to the skin as possible and pull the tick straight out.
Clean the area where the tick was attached to the skin.
See a health care professional if symptoms of Lyme disease or other tick
borne disease develops after exposure to a Blacklegged tick..
Use simple landscaping techniques to reduce the number of BLT’s around
homes and parks (www.gov.ns.ca/hpp/cdpc/lyme.asp)
See Section 8.0 for a more detailed communications plans. Information on Lyme
disease is a part of a comprehensive „Enjoy the Outdoors Safely‟ campaign,
which currently includes West Nile virus, and Rabies.
Press releases and media interviews will keep the public updated during the
spring, summer and fall months as needed.
For further information on laboratory please refer to the Provincial Public Health
Lab Network: Users Manual. - 2009
While BLT’s infected with Borrelia burgdorferi (Lyme) have been found
sporadically in several areas of Nova Scotia, the risk for human infection is
greatest in areas where infected BLT’s have become established/endemic and
are more common. The reporting of probable and confirmed human cases of Ld
to DHW by laboratories and physicians is required as per the Health Protection
Act. Several cases of confirmed Ld have been reported from the area near
Lunenburg since 2002, and more recently, the Bedford area.
BLT’s testing positive for Ap have been found on occasion in the area around
Lunenburg and Bedford.
DHW shares information about the distribution and presence of BLT’s, Lyme
disease, Ap and Babesiosis with the public, media and health care professionals
on a regular basis. The information is used to provide guidance about the risk of
infection from Lyme disease, Ap and Babesiosis in Nova Scotia.
7.0 RISK REDUCTION AND MANAGEMENT
To reduce the risk of tick borne diseases such as Lyme disease, and Human
Anaplasmosis in NS, a number of steps can be considered:
Target Audiences
General public
Media
Health care professionals
Municipalities
Tourists/Outdoor recreationalists
DHW Ld pamphlet
DHW Ld poster (intended for areas where BLT’s and/or Ld or Ap are
established/endemic)
Annual DHW letters to NS health care providers
DHW updates provided to Doctors NS
Media articles and press releases from DHW
DHW website
The pamphlets and posters are distributed by PH staff to various community and
health care setting (hospitals, clinics, physician offices, school boards,
community and recreation centres, municipal offices, visitor information centres,
campgrounds, golf courses, parks, etc.).
9.0 RESOURCES
American Academy of Pediatrics and Committee on Infection Diseases (2009).
Red Book: 2009 Report of the Committee on Infectious Diseases, 28th ed. Elk
Grove Village, IL: American Academy of Pediatrics.
Nova Scotia Department of Health Promotion and Protection (2009). Nova Scotia
Communicable Disease Control Manual. Halifax, Nova Scotia.
Ogden, NH., Lindsay, LR., Morshed, M., Sockett, P., Artsob, H. The Rising
Challenges of Lyme Borreliosis in Canada. Canadian Communicable
Disease Report, January 1, 2008. Volume 34, Number 01.
Probable case:
Laboratory confirmation of infection with or without clinical evidence of
infection:
detection of Plasmodium sp. antigen in an appropriate clinical specimen
1.3 Symptoms:
There are four human malarias that present similar symptoms, making
laboratory differentiation necessary.
Vivax, Malariae and Ovale malaria are generally not life threatening. Illness
may begin with malaise and a slowly rising fever of several days in duration,
followed by a shaking chill and rapidly rising temperature. Headache, nausea
and profuse sweating normally accompany these symptoms. After an interval
free of fever, the cycle of chills, fever and sweating is repeated either daily or
every second or third day. The duration of an untreated primary attack lasts
from a week to a month or longer. Relapses may occur at irregular intervals for
up to five years.
Persons who are partially immune or who have been taking prophylactic drugs
may show an atypical clinical picture.
1.4 Incubation
Time between infective bite and appearance of clinical symptoms is about 7 to
14 days for P. falciparum, 8-14 days for P. vivax and P. ovale, and 7-30 days for P.
malariae.
1.5 Source
Humans are the only important reservoir for human malaria.
1.6 Transmission
By the bite of an infective female Anopheles mosquito. Most species feed during
dusk or during the early evening hours. A few important vectors have biting
peaks around midnight or in the early hours of the morning. Malaria may also be
transmitted by injection or transfusion of blood from infected persons or by use
of contaminated needles or syringes. Congenital transmission is rare.
1.7 Communicability
Untreated or insufficiently treated clients may be a source of mosquito infection
for more than 3 years in malariae, 1-2 years in vivax, and usually not more than 1
year in falciparum malaria. Stored blood can remain infectious for
at least a month.
1.8 Treatment
Treatment will depend on geographical area where malaria was acquired.
1.10 Prophylaxis
Non-immune individuals who will be travelling in malarious areas should use
measures to protect themselves from mosquito bites, and may benefit from anti-
malarial drugs for chemoprophylaxis. The geographic distribution and specific
drug sensitivities of malaria parasites change rapidly, so the most recent
information should be sought from a travel clinic prior to prescribing
chemoprophylaxis.
2. Procedure
2.1 Roles and Responsibilities
2.1.1 Investigator
Follow up malaria cases to determine:
Where the client was travelling.
If the client attended a travel clinic prior to departure.
If the client was taking any anti-malaria medication prior to travel.
If the client donated or received blood or blood products.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Malaria: http://www.cdc.gov/ncidod/dbmd/diseaseinfo. Report of the Committee on
Infectious Diseases, 2000. American Academy of Pediatrics.
MALARIA FACT SHEET
What is Malaria?
Malaria is a serious, sometimes fatal, disease caused by a parasite. There are four
kinds of malaria that can infect humans.
Probable case:
Clinical evidence of illness with any of the following laboratory evidence:
demonstration of elevated serum antibody titre(s) to Y. pestis F1 antigen
(without documented significant [i.e. fourfold or greater] change) in a
patient with no history of plague immunization
OR
demonstration of Y. pestis F1 antigen by immunofluorescence
OR
detection of Y. pestis nucleic acid
OR
>1:10 passive hemagglutination/inhibition titre in a single serum sample
in a patient with no history of vaccination or previous infection
OR
detection of Y. pestis antibody by EIA
1.4 Incubation
From 1 to 7 days.
1.5 Source
Wild rodents, rabbits, hares, wild carnivores and domestic cats may also be
a source of infection.
1.6 Transmission
The most frequent source of infection has been the bite of infected fleas
(especially the oriental rat flea). Transmission also can occur via contact with
infected tissues or fluids from handling sick or dead animals. Pneumonic plague
can be transmitted via respiratory droplets from infected humans and cats.
1.7 Communicability
Bubonic plague is not usually transmitted from person to person unless there is
contact with pus from buboes. Pneumonic plague may be highly contagious in
certain conditions (e.g. overcrowding).
1.8 Treatment
Streptomycin is the drug of choice, and gentamicin can be used when
streptomycin is not available. Tetracylines and chloramphenicol are alternative
choices. All are highly effective if used early (within 8 to 18 hours).
1.9 Core Messages for Prevention
If you live in areas where rodent plague occurs, homes should be rodent-
proof. Eliminate sources of food and nesting places for rodents around
homes, work places, and recreation areas; remove brush, rock piles, junk,
cluttered firewood, and potential-food supplies, such as pet and wild
animal food.
If you anticipate being exposed to rodent fleas, apply insect repellents to
clothing and skin, according to label instructions, to prevent fleabites.
Wear gloves when handling potentially infected animals.
If you live in areas where rodent plague occurs, treat pet dogs and cats
for flea control regularly and do not allow these animals to roam freely.
Safely clean up rodent-infested areas using guidelines to avoid potential
risk of exposure (contained in hantavirus section).
1.10 Prophylaxis
Close contacts of confirmed or suspected plague pneumonia should be
provided with chemoprophylaxis using tetracycline or chloramphenicol
2. Procedure
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health
a. Determine investigative responsibility.
Ensure that reports of plague are received and disseminated to the appropriate
personnel for investigation within Public Health Services.
2.1.2 Investigator
a. Begin investigation.
Contact client to identify contacts.
b. Offer Chemoprophylaxis.
Close or household contacts with exposure to pneumonic plague should be
offered chemoprophylaxis and placed under surveillance for 7 days. Contacts
who refuse chemoprophylaxis should be strictly isolated and carefully monitored
for 7 days.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Plague: http://www.cdc.gov/ncidod/dbmd/diseaseinfo. Report of the Committee on Infectious Diseases,
2000. American Academy of Pediatrics.
PLAGUE FACT SHEET
What is Plague?
Plague is a serious illness caused by a bacteria.
1.3. Symptoms:
Sudden onset with fever, chills, headache, weakness, malaise, anorexia and
severe sweats. Severity and duration varies widely. Illness usually lasts 1 to 4
weeks. About one half of infected people experience symptoms.
1.4. Incubation:
Usually 2 to 3 weeks, depending on the size of the infecting dose.
1.5. Source:
Sheep, cattle, goats, cats, dogs, some wild animals, birds and ticks.
1.6. Transmission:
Organisms are excreted in milk, urine, and feces of infected animals. Most
importantly, during birthing, the organisms are shed in high numbers within the
amniotic fluids and the placenta of infected animals. The organisms are resistant
to heat, drying, and many common disinfectants. These features enable the
bacteria to survive for long periods in the environment. Infection of humans
usually occurs by inhalation of these organisms from air that contains airborne
barnyard dust contaminated by dried placental material, birth fluids, and excreta
of infected herd animals. Airborne particles containing the organisms may be
carried for a half-mile or more. Direct contact with infected animals has also
been a mode of transmission, as has direct contact with straw, wool, fertilizer
and laundry. Raw milk may be a source of transmission, but this has not yet been
proven.
1.7. Communicability:
Person to person transmission occurs rarely, however, contaminated clothing
may be a source of infection.
1.8. Treatment:
Q Fever is treated with an antibiotic.
1.10. Prophylaxis:
None.
2. Procedure
2.1. Roles and Responsibilities
2.1.1. Medical Officer of Health:
a. Determine investigative responsibility.
The MOH must ensure that all reports of Q fever are received and
disseminated to the appropriate personnel for investigation. The CDC
manager/team lead may assume this role in the absence of the MOH.
2.1.2. Investigator:
Upon receiving the report the investigator should initiate the follow-up.
a. Determine case status.
b. Report case.
Discuss case with the MOH.
c. Contact and educate the individual and /or family.
Discuss the role of public health. Provide information to the individual or family
and provide fact sheets.
Inquire about any activities, farm visits, work or association with animals.
Inquire about consumption of raw milk.
Advise on the necessity for adequate disinfection and disposal of animal
products of birth.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association. Q Fever: http://www.cdc.gov/ncidod/dbmd/diseaseinfo.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics.
Q FEVER FACT SHEET
What is Q Fever?
Q fever is a disease caused by a bacteria. Cattle, sheep, and goats as well as a wide
variety of other animals, including other breeds of livestock and domestic pets, carry the
bacteria. Although infected animals do not usually get sick from these bacteria, they
excrete the bacteria in milk, urine, feces and the placenta and amniotic fluid during the
birthing process. The bacteria live for a long time in the environment. Inhaling the
bacteria from air that contains contaminated barnyard dust infects humans.
1. Information
1.1. Case Definition
Confirmed case
Clinical evidence of illness with laboratory confirmation of infection:
detection of viral antigen in an appropriate clinical specimen, preferably
the brain or the nerves surrounding hair follicles in the nape of the neck,
by immunofluorescence
OR
isolation of rabies virus from saliva, cerebrospinal fluid (CSF), or central
nervous system tissue using cell culture or laboratory animal
OR
detection of rabies virus RNA in an appropriate clinical specimen
Probable case
Clinical evidence of illness with laboratory evidence:
demonstration of rabies-neutralizing antibody titre ≥ 5 (complete
neutralization) in the serum or CSF or an unvaccinated person
1.3. Symptoms
Acute febrile illness with headache, fever, malaise, sensory changes at the bite
site and increasing apprehension. These symptoms will progress to central
nervous system changes and acute encephalomyelitis that almost always
progresses to coma and death. Death usually results from respiratory paralysis
and cardiac failure.
1.4. Incubation
Usually 3-8 weeks but uncommonly may be as short as several days or as long as
a year or more (prophylaxis may be started as late as six or more months after
exposure). The incubation period is often influenced by the severity and site (in
relation to nerve supply and closeness to the brain) of the wound.
1.5. Source
The virus is present in the saliva or other potentially infectious materials such as
the brain tissue of infected wild animals, including foxes, coyotes, wolves,
skunks, bats and raccoons. Rats, rabbits, squirrel and mice are rarely infected.
Domesticated animals such as dogs and cats may be at risk of contracting rabies
if exposed to infected animals and then pose a further risk to their owners.
1.6. Transmission
The virus is introduced into another animal or a human through a bite or licking
of an open wound. Person to person transmission is theoretically possible
through exchange of saliva with an infected individual, but has not been
documented. Corneal grafts from an infected person have resulted in rabies in
the recipients.
1.7. Communicability
In dogs, cats and other biting animals, 3-7 days before the signs of illness and for
the entire course of the disease.
1.8. Treatment
Clean and flush the wound area with soap and water and apply antiseptic or
alcohol to the area. No suturing or wound closure is advised. Tetanus
prophylaxis and antibacterial treatment may be indicated. See section 1.10 for
post-exposure prophylaxis guidelines.
1.10 Prophylaxis
1.10.1 Post-exposure prophylaxis
a. Categories of exposure.
Two broad categories of exposure are recognized as warranting post-
exposure prophylaxis
Bite:
A bite includes any penetration of skin by teeth. Bites inflicted by most
animals are readily apparent.
As per the NACI Guidelines 2009, in an adult, a bat landing on clothing would be
considered reason for intervention (prophylaxis or testing of the bat) only if a
bite, scratch, or saliva exposure into a wound or mucous membrane could not be
ruled out. In a child, any direct contact with a bat should be considered a reason
for an intervention, including contact through clothes, as a history to rule out a
bite, scratch, or mucous membrane exposure may not be reliable.
When a bat is found in the room with a child or an adult who is unable to give a
reliable history, assessment of direct contact can be difficult.
Factors indicating that direct contact may have occurred include the individual
waking up crying or upset while the bat was in the room, or observation of an
obvious bite or scratch mark. (NACI, November 2009).
Non-bite:
Includes contamination of scratches, abrasions or cuts of skin or mucous
membranes by saliva or other potentially infectious material, such as the brain
tissue of a rabid animal. Also may include inhalation of aerosolized virus by
spelunkers exploring bat infected caves or laboratory personnel homogenizing
tissues infected with rabies.
Non-risk:
Petting a rabid animal or handling its blood, urine or feces is not considered to
be exposure nor is being sprayed by a skunk. See above information in 1.10.1 a
‘Bite’ section re bat landing on clothing of an adult.
Five doses of Human Diploid Cell Vaccine (HDCV) -1 ml per dose- plus Rabies
Immune Globulin (RIG) should be given.
The first dose of HDCV plus RIG (20 IU/kg of body weight) is given at separate
sites and with separate syringes on day 0. See Appendix 1
If anatomically feasible, the full dose of RIG should be thoroughly infiltrated into
the wound and surrounding area. If any dosage remains, the remainder should
be given intramuscularly at a site distant from vaccine administration.
HDCV is given in the deltoid or anterolateral thigh. HDCV must not be given
intragluteally
Healthy people immunized with an appropriate schedule will develop rabies
antibody and will be protected. Routine post-immunization assessment of
antibody levels is not recommended. Serology to confirm protection should be
considered after post-exposure prophylaxis for people whose response may be
impaired by immunosuppression caused by medication, illness or advanced age.
c. Post-exposure prophylaxis of previously immunized persons
Determine the rabies immunization history of the exposed person.
1. Two doses of HDCV, one given as soon as possible and the other 3 days later,
without RIG, are recommended for exposed people with the following rabies
immunization history:
Completion of an approved course of pre-or post-exposure prophylaxis
with HDCV or purified chick embryo cell vaccine (PCECV).
Completion of immunization with other types of rabies vaccine or with
HDCV or PCECV according to unapproved schedules as long as
neutralizing rabies antibody has been demonstrated in serum
2. A complete course of HDCV or PCECV plus RIG is recommended for those
who may have received rabies vaccines in the past but do not fulfill the
criteria listed above. A serum sample may be collected before vaccine is
given, and if an acceptable antibody level (≥ 0.5 IU/ml) is demonstrated, the
course may be discontinued, provided at least two doses of vaccine have
been given. (CIC, 2006 and Errata, 2008).
1. Contact the Health care provider to obtain clinical information on the case if
reported via a care provider. The health care provider can advise observation of
an animal (when appropriate, such as a dog, cat) for 10 days and only contact
Public Health services if there are concerns about the animal’s (involved in the
exposure) behaviour or health or the animal becomes ill during the observation
period. In this situation, the DHA investigator may not need to interview the
client unless there are concerns with the animal under observation and the
potential need for Rabies post exposure prophylaxis.
3. Educate the client and/or family about Rabies and prevention measures,
providing access to pamphlets, fact sheets, website as indicated
4. Determine the need for observation or testing of the animal, if available, and
the authorization for Rabies Post Exposure prophylaxis (RIG and Vaccine) when
necessary.
5. Ensure the health and behaviour of a suspect animal is assessed, the animal is
confined and observed for 10 days after the exposure (dogs, cats or ferrets
only) or is euthanized for testing as appropriate. The assessment may be done
by phone with the animal’s owner or with the assistance of local municipal
animal control services (if available). Inform owner of the animal that they must
inform Public Health and have the animal examined by a veterinarian
immediately if it becomes ill or its behavior becomes abnormal.
If the animal will be tested, ensure that the animal is taken to a veterinarian, is
euthanized and kept frozen until picked up by CFIA. Inform the CFIA District
Veterinarian of the location of the animal and inform the veterinarian where
the animal was euthanized that it should be frozen until it can be picked up by
CFIA.
All wild animals potentially infected with rabies (such as coyotes, raccoons,
skunks, bats, and fox) that have exposed a person must be observed or tested if
available. Department of Natural Resources (DNR) must be consulted about
apprehending and euthanizing any suspect wild animal. DNR will assist with
determining if location, capture and euthanasia of wildlife are necessary or
possible when there has been human contact and the transmission of rabies is a
possibility. If necessary or possible, DNR will coordinate the required actions,
recognizing that the captured animal may not be the actual one involved in the
incident. If captured, DNR will euthanize and store the animal frozen. DNR will
notify CFIA and arrange pick up and testing with CFIA.
PHS investigator contacts the Canadian Food Inspection Agency (CFIA) to make
the necessary arrangements with the CFIA District Veterinarian if the animal is
to be sent for testing. Staff must provide the CFIA District Veterinarian with the
name, phone number and address of the person(s) who will receive the verbal
and written report of the test results.
6. Arrange for administration of RIG, and rabies vaccine through Public Health
Services or family physician, nurse practitioner, duty clinic, Emergency
department providing advice re dosing and administration. See Appendix 1
7. In high-risk situations (bites to the head and neck or behavior that is suggestive
of rabies infection, especially in an unimmunized or wild animal), post-exposure
prophylaxis may be started immediately pending the results from animal
testing. If testing confirms that the animal does not have rabies, the series does
not require completion.
8. Local Animal Control staff may be available to search for and identify a dog, cat
or ferret that has been involved in a significant exposure (bite or saliva or
neurological tissue exposure of broken skin or mucosal surface) of humans.
Animal Control staff may obtain information about the rabies immunization
status, health and behaviour of the animal, and may assist with ensuring that
the animal is kept under the owner’s control and observed for the required
observation period checking to ensure that the animal remains healthy at the
conclusion of the observation period.
Animal Control staff may also make arrangements for apprehending a pet,
transporting it and confining to an animal shelter when requested by Public
Health. This may be required if there is concern about people being attacked by
the animal if left in the community or there is any concern that the owner will
not cooperate with the confinement and observation of the animal.
Animal Control staff will inform the Public Health investigator about their initial
assessment of the animal as well as the status of the animal at the end of the
observation period. If the animal becomes unwell and there is any suspicion of
rabies, Animal Control staff will assist Public Health and CFIA to ensure that it is
euthanized and tested for rabies infection.
Animal Control staff may also assist Public Health to search for and apprehend
any stray animals that have been involved in the significant exposure of
humans. The stray animal must be either placed in an appropriate shelter for
the observation period or euthanized and tested for rabies as required by Public
Health.
9. PHS in the DHA may be involved in the completion of Rabies post exposure
prophylaxis that was initiated outside of the province. PHS will arrange for the
completion of the vaccine series by a physician, duty clinic, nurse practitioner,
or PHS.
Key Messages
See Section 1.9 Core Messages for Prevention
5.0 References
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
American Academy of Pediatrics and Committee on Infection Diseases (2009). Red Book: 2009 Report of
the Committee on Infectious Diseases, 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Heymann, David (2008). Control of Communicable Diseases Manual, 19th ed. Washington, D.C.: American
Public Health Association.
Public Health Agency of Canada (2006). Canadian Immunization Guide, 7th ed.
Ottawa, Ontario: Public Works and Government Services Canada.
What is Rabies?
Rabies is a disease of the brain and spinal cord that is 100% fatal if it is not
treated.
It is caused by a virus that lives in the saliva (spit) of infected animals. It is spread
when the infected animal bites, scratches or licks broken skin of a person, or spit
comes in contact with the lining of the mouth, nose or eyes of a person.
Animals that can carry rabies are bats, skunks, foxes, raccoons, as well as cats
and dogs that have not had rabies needles.
If the animal is caught and can be tested for rabies then the treatment of the
exposed person can wait until the test results are known.
Treatment Schedule:
A person who is exposed to rabies and has never had rabies shots should receive
one dose of RIG and 5 doses of Rabies Vaccine – the first dose right away with
the RIG and the other doses on day 3, day 7, day 14 and day 28.
A person who has received Rabies Vaccine before should get 2 doses of vaccine –
one right away and the next dose on day 3. This person does not require RIG.
If the schedule is not followed correctly the treatment has to start over again.
CAUTION
Before you receive Rabies Vaccine, tell your doctor/nurse if:
you are allergic to any ingredient in the vaccine (amphotericin B,
chlortetracycline, human serum albumin, neomycin, polygeline, ovalbumin)
you have a weakened immune system because of:
-a disease that affects your immune system
-treatment with drugs that affect your immune system
-cancer or cancer treatment with drugs or radiation
you are pregnant or breastfeeding
As with any medication, there is always the slight chance of a severe allergic reaction
such as hives, swelling of the face, trouble breathing, weakness, or racing heart.
Therefore you should always be observed for 15 minutes after getting RIG and/or
Rabies Vaccine.
APPENDIX 3: RABIES GENERAL FACT
SHEET FOR THE PUBLIC
Rabies Fact Sheet
What is Rabies?
Rabies is a very serious disease for both animals and humans. The virus lives
in the saliva and the brain tissue of the infected animal. The virus will affect the brain
and the behaviour of the animal. It may be difficult to tell if an animal has rabies, so any
animal that bites a person should be captured and watched for signs of the disease.
When an animal has rabies it is called "rabid".
The doctor should not stitch the wound. There are vaccines that doctors can use to
protect the individual from the disease.
How Can you Prevent Rabies?
Individuals in high-risk groups including, veterinarians, lab workers, wild life
workers and conservationists, hikers or cave explorers and individuals travelling
to areas where rabies is endemic should be immunized.
Register, license and vaccinate all domestic animals such as dogs and cats.
Pet owners should be aware of the signs and symptoms of rabies.
The public should be aware of the dangers of picking up sick or hurt animals or
domesticating wild animals.
Wild animals should not be relocated to other areas of province or to other
provinces.
Do not feed wild animals or leave leftover food around yards, parks etc. as it
may attract wild animals
Seal small holes and entryways where bats could potentially enter homes,
cottages, sheds, and other areas where they might have contact with people,
pets or farm animals
Vaccinate farm animals and livestock
APPENDIX 4: RABIES RESPONSE PLAN
Prepared by:
August 2012
Nova Scotia Rabies Post-Exposure Prophylaxis Guidelines
1.0 INTRODUCTION
Domestic and wild animals such as foxes, coyotes, wolves, skunks, bats and
raccoons can serve as the source for rabies virus. Rats, rabbits, squirrels and
mice are rarely infected. Domesticated animals such as dogs, cats and ferrets
may be at risk of contracting rabies if exposed to infected animals and then pose
a further risk to their owners. The virus can live in the saliva and the brain tissue
of the infected animal and can be transmitted by a bite of an infected animal or
contact with brain tissue of an infected animal. Additionally, non-bite
contamination of scratches, abrasions and open wounds or mucous membranes
by saliva or other potentially infectious material such as brain tissue can transmit
the virus.
3.0 BACKGROUND
Domestic and wild animals such as foxes, coyotes, wolves, skunks, bats and
raccoons can serve as the source for rabies virus. Rats, rabbits, squirrels and
mice are rarely infected. Domesticated animals such as dogs, cats and ferrets
may be at risk of contracting rabies if exposed to infected animals and then pose
a further risk to their owners. The virus can live in the saliva and the brain tissue
of the infected animal and can be transmitted by a bite of an infected animal or
contact with brain tissue of an infected animal. Additionally, non-bite
contamination of scratches, abrasions and open wounds or mucous membranes
by saliva or other potentially infectious material such as brain tissue can transmit
the virus.
Symptoms can include acute febrile illness with headache, fever, malaise,
sensory changes at the bite site and increasing apprehension. These symptoms
will progress to central nervous system change, including paresis or paralysis,
dysphagia and convulsions. Death usually results form respiratory paralysis and
cardiac failure.
3.2 Epidemiology
Rabies virus has been found in most provinces and territories of Canada, most
often in wild animals. Few cases have been documented in domestic or farm
animals.
Since 1998 there have been 6 lab confirmed cases of rabies in animals in Nova
Scotia. A bat was laboratory confirmed in 2010, two fox were diagnosed in 2007,
one cat in 2003 and two bats in 2000. All of these were bat strain rabies virus.
Nova Scotia has not seen any raccoon strain rabies in the province, but the
bordering province of New Brunswick has had cases of raccoon rabies. There
have been no lab confirmed human cases of rabies in Nova Scotia.
The working group meets regularly, to monitor all activities related to the
response plan.
Nova Scotia has also been working with the other Atlantic Provinces to share
expertise and resources in this area. The Rabies Working Group links with
experts throughout the country in other provinces/territories and at the Public
Health Agency of Canada regarding Rabies.
As well, the Department of Agriculture will notify DHW (chair of the Rabies
Working Group) if any positive reports of rabies virus are diagnosed or highly
suspected.
See Section 9.0 for the detailed Communications Plan. Information on rabies
virus is part of a comprehensive ‘Enjoy the Outdoors Safely’ campaign, which
currently includes Lyme disease, and West Nile virus.
The Department of Health and Wellness website has been updated to include
easy-to-find information on rabies virus. The public can get information on
health aspects of rabies virus by calling local Public Health Services.
Press releases and media interviews will keep the public updated during the
summer months as needed.
The Department of Natural Resources will assist the Department of Health and
Wellness in any wild life rabies vaccination program.
Prompt reporting of exposures ensures that steps are taken to locate the animal
(if possible), place it in confinement or have it euthanized, and make appropriate
and timely decisions regarding post exposure prophylaxis.
The First Nations Environmental Health Officer will notify the local PHS office of
the exposure. PHS will follow up the exposure as outlined in this document.
a) The nature of the exposure (including bite or non-bite, severity and location
of the wound),
b) The type of animal (wild animal versus domestic animal), including the risk of
rabies in the animal species involved,
c) Behaviour of the animal (provoked or unprovoked attack) at the time of the
bite,
d) The availability of the animal for observation and/or laboratory testing of the
animal brain.
The assessment may include consultation by PHS staff with the nearest CFIA
Animal Health Office and/or DNR staff or others as appropriate. If it is
considered that an animal may need testing, consultation must take place with
the CFIA Animal Health Office. Once a decision is made that the client requires
prophylaxis, both Rabies Immune Globulin and rabies vaccine should be given to
previously unvaccinated clients. Those with previous rabies immunizations may
only require vaccine and not RIG – this will be determined in the assessment of
the situation.
6.1.1 Bites
Rabies is most commonly transmitted through bites (any penetration of
the skin by teeth).
Bites from bats may not always be apparent therefore, it is important to
obtain details on whether there was direct contact with a bat and a bite,
scratch or saliva exposure into a wound or mucous membrane cannot be
ruled out. See Section 6.1.2 for further information on direct contact.
A bite with prominent salivary contamination (i.e. through exposed skin)
is more likely to produce rabies than one through thick clothing that
removes saliva from the animal's teeth. Multiple bites are more likely to
transmit the disease than a single bite.
The severity of the wound, the site of the wound in relation to the
richness of the nerve supply and its distance from the brain can influence
the incubation period. It has been reported that the incubation period
may be shorter when the site of the bite is on the head than when it is on
an extremity. Bites on the face are more likely to result in disease than
those on the extremities.
When a domestic animal has inflicted a facial bite (due to distance from
the brain and influence on the incubation period), PHS staff may decide
to initiate RPEP before the end of a 10-day observation period. PHS
should consult with the nearest CFIA Animal Health Office to decide
whether immediate euthanasia and testing of the animal may be
warranted.
If possible, the bat involved in the exposure should be captured and tested to
determine whether it is infected and if RPEP is required.
If the animal is not available for observation and/or testing, PHS staff should
generally consider and recommend RPEP for exposure from:
wild animals,
stray dogs, cats and ferrets
pet dogs and cats in an unprovoked attack (especially if no previous
history of unprovoked attacks and incomplete or inadequate
immunization against rabies)
bat exposures when both of the following conditions apply:
o There has been direct contact with a bat and
A bite, scratch, or saliva exposure into a wound or mucous membrane
cannot be ruled out. See Section 6.1.2 for further details
.small rodents almost never warrant prophylaxis
7.0 RISK REDUCTION AND MANAGEMENT OF ANIMALS
INVOLVED IN INCIDENTS
It is not practical to carry out any degree of detailed planning for rabies
vaccination program in wildlife at this time but if necessary, this will be
addressed.
PHS staff must consult with the MOH and the CFIA Animal Health Office about
the need to euthanize any domestic animal for rabies testing.
Target Audiences:
General public
Media
Health care professionals
Tourists/outdoor recreationalists
DHW provides information and resources about the risk of Rabies in Nova Scotia
as well as recommendations to prevent unwanted exposures from potential
animals with rabies to the public, media and health care workers. The tools used
to provide information include:
The pamphlets and posters are distributed by PH staff to various community and
health care settings (hospitals, clinics, physician offices, school boards,
community and recreation centres, municipal offices, visitor information centres,
campgrounds, golf courses, parks, etc.).
The key messages provided include:
REFERENCES
American Academy of Pediatrics and Committee on Infection Diseases (2009). Red Book: 2009 Report of
the Committee on Infectious Diseases, 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Heymann, David (2008). Control of Communicable Diseases Manual, 19th ed. Washington, D.C.: American
Public Health Association.
Nova Scotia Department of Health Promotion and Protection (2009). Nova Scotia Communicable Disease
Control Manual. Halifax, Nova Scotia.
Public Health Agency of Canada (2006). Canadian Immunization Guide, 7th ed. Ottawa, Ontario: Public
Works and Government Services Canada.
Public Health Agency of Canada (2008) Errata/Clarifications to the Canadian immunization Guide. CCDR,
Volume 34, Number 05, 2008
APPENDIX A
Dr Susan Burzynski
District Veterinarian
Telephone: (902)679-5742
APPENDIX B
DNR DISTRICT SUPERVISOR or AREA SUPERVISOR
Exposure
Saliva or Bite
No Saliva or Bite
Exposure
End
Unknown or Owner’s or
Stray Neighbour’s
Bite, Saliva, Brain Tissue, or Bat Direct Contact No Bite, Saliva, Brain Tissue
End
Animal Available Animal Not Available
Stray Wildlife
End PHS determines
rabies risk (consult
CFIA arranges testing with CFIA as needed)
Unwell Well
PHS considers need for interim PHS recommends
RPEP RPEP if appropriate
CFIA arranges Observe x10
testing days
End
APPENDIX E
Exposure to Domestic Animals
End
PHS consider need
for interim RPEP
PHS arranges
Interim RPEP
for RPEP or
stopped
continues RPEP
End
TOXOPLASMOSIS
1. Information
1.1. Case definition:
Identification of toxoplasma in serum or identification of toxoplasma cysts in the
body tissues or fluids. The presences of specific IgM or rising IgG titres in
sequential sera.
1.3. Symptoms:
Infections are often asymptomatic. When symptoms are present they may
include flu-like symptoms such as fever, sore throat, myalgia, fatigue and
lymphadenopathy or resembling mononucleosis and may persist for weeks.
1.4. Incubation:
From 10 to 23 days.
1.5. Source:
Cats and other felines, which acquire the infection from eating infected
mammals (rodents and birds), and rarely from the feces of other felines.
1.6. Transmission:
Infections may occur due to ingestion of undercooked meats or unpasteurized
milk. Ingestion of cat feces from the hands after working or playing in dirt or
sand where cats have defecated, or by ingestion of food or water that may be
contaminated by cat feces. Transplacental transmission also occurs, and rarely,
infection is acquired from donated blood or organs from an infected donor.
Transmission from inhalation of sporulated oocysts has been documented.
1.8. Treatment:
Treatment is not normally required in an immunocompetent client.
For treatment consult appropriate specialist.
1.10. Prophylaxis:
Chemoprophylaxis is recommended for HIV-infected adults who are T. gondii
seropositive. Appropriate specialists should be consulted.
1.11. Surveillance
Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and
Conditions at http://www.gov.ns.ca/hpp/cdpc/CDCManual
2. Procedure
2.1. Roles and Responsibilities
2.1.1 Medical Officer of Health:
a. Determine investigative responsibility
Ensure that reports of toxoplasmosis are received and disseminated to the
appropriate personnel for investigation within Public Health Services.
2.1.2 Investigator:
a. Begin investigation:
Contact client to identify contacts and source of infection. In congenital cases,
discuss follow up with MOH. In acquired cases, determine contact with infected
animals and common exposure to cat feces, soil or raw meat.
b. Report case.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Plaque: http://www.cdc.gov/ncidod/dbmd/diseaseinfo.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics
TOXOPLASMOSIS FACT SHEET
What is toxoplasmosis?
Toxoplasmosis is a common infection found in birds and mammals across North
America. The infection is caused by a parasite and affects 10 to 20 out of every 100
people in North America by the time they are adults.
A growing fetus can become infected with the toxoplasmosis parasite if the mother is
infected with the parasite while pregnant or before she becomes pregnant. Infection in
the unborn child early in pregnancy can result in miscarriage, poor growth, early
delivery or stillbirth. If a child is born with toxoplasmosis he/she can experience eye
problems, hydrocephalus (water on the brain), convulsions or mental disabilities.
Treatment of an infected pregnant woman may prevent or lessen the disease in her
unborn child. Treatment of an infected infant will also lessen the severity of the disease
as the child grows.
Cats which have been raised indoors have never caught and eaten mice or birds, and
who have never been fed raw meat are not likely to be infected. A stray or unfamiliar
cat that appears sick should not be handled but should be reported to the animal
shelter.
Here are some tips to help you enjoy your pet cat;
Wash your hands after patting, brushing or being licked by your cat;
Wear gloves when cleaning the litter box, then thoroughly wash your
hands with hot, soapy water;
Clean the litter box daily so that the parasite does not have a chance to
become infectious;
Be careful not to breathe in dust when cleaning the cat litter box;
Dispose of cat feces in a plastic bag in the garbage - do not compost the
cat litter, or dispose of the litter near your garden;
Avoid cleaning cat litter boxes if you are pregnant or trying to become
pregnant;
If pregnant, keep cats inside and do not adopt or handle stray cats;
Place a secure lid on your sandbox to prevent cats from using it as a litter
box;
Don’t feed raw meat to your cat;
See a vet if there are any signs of illness in your cat.
CLEAN. Wash hands, utensils and surfaces with hot soapy water before, during and
after preparing foods. Sanitize countertops, cutting boards and utensils with a mild
bleach and water solution. Wash all produce thoroughly before eating or cooking.
SEPARATE. Keep raw meats and poultry away from other foods during storage and
preparation. Keep separate cutting boards for raw meats and vegetables.
Always keep foods covered.
COOK. Cook food thoroughly — cooking times and temperatures vary for different
meat and poultry. Prepare foods quickly, and serve immediately so foods don’t linger at
room temperatures where bacteria can grow.
CHILL. Refrigerate or freeze perishable foods, prepared food and leftovers within two
hours. Make sure the refrigerator is set at a temperature of 4°C (40°F), and keep the
freezer at -18°C (0°F).
Adapted by Public Health Services, Capital District Health Authority, July 2001 from “From the Health
Files...Toxoplasmosis” (1995), BC Ministry of Health and Ministry Responsible for Seniors and from the
Fight BAC Campaign, Health Canada.
WEST NILE VIRUS
1. Information
1.1. Case definition:
Case Classification-West Nile Virus Neurological Syndrome (WNNS)
The Public Health Laboratory at the Queen Elizabeth II Health Sciences Centre
will be consulted on appropriate specimens etc.
1.3 Symptoms:
Most people with West Nile virus infection are asymptomatic, or have a mild
illness such as fever, headache, stiff neck, nausea, vomiting, muscle weakness,
and alteration in the level of consciousness.
1.4 Incubation:
Usually 3 to 12 days after being bitten by a mosquito.
1.5 Source:
Infected birds.
1.6 Transmission:
Transmitted via the bite of an infected mosquito, receipt of infected blood,
organs or tissues, from infected mother to baby before birth or via breast milk
(one report in the literature). There have also been reports of pecutaneous
transmission to laboratory workers handling infected birds.
1.7 Communicability:
Not transmitted from person to person. Infected mosquitoes probably remain
infected for life.
1.8 Treatment:
Supportive therapy.
1.10 Prophylaxis:
None.
2. Procedure
2.1 Roles and Responsibilities
2.1.1 Medical Officer of Health:
a. Determine investigative responsibility.
The MOH must ensure that all reports of West Nile virus are received and
disseminated to the appropriate personnel for investigation. The CDC
coordinator/ manager may assume this role in the absence of the MOH.
2.1.2 Investigator:
Upon receiving the report the investigator should initiate the follow-up.
a. Determine case status.
b. Report case.
Discuss case with the MOH.
References:
Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National
Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/09pdf/35s2-eng.pdf
Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health
Association.
Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics. West Nile Virus:
http://www.cdc.gov/ncidod/dbmd/diseaseinfo. West Nile Virus. Middlesex-London Health Unit.
WEST NILE VIRUS FACT SHEET
What is West Nile Virus?
West Nile Virus (WNV) was first identified in North America in 1999. WNV is spread to
humans and animals through the bite of an infected mosquito.* There is no evidence of
transmission of the virus between people, or between animals and people.
Chapter 10 – Policies
POLICY STATEMENT
Public Health in the District Health Authorities (DHA’s) shall manage the communicable disease
and immunization records in their custody or under their control to comply with the
Communicable Disease Records Retention Schedule as approved by the above authorities.
POLICY OBJECTIVES
To ensure that Public Health within the DHA’s properly maintain the communicable disease
records in their custody or under their control.
To ensure all client identifiable case management information related to Notifiable Disease and
Conditions as per the Health Protection Act and immunization are filed and retained in
accordance with the Communicable Disease Records Retention Schedule.
POLICY APPLICATION
This policy applies to all Public Health staff in the employ of, seconded to, or under contract to
the DHA’s who are involved in filing and maintaining communicable disease and immunization
records.
Chapter 10 – Policies
The person responsible for the management and/or coordination of the Communicable Disease
Program in each DHA will communicate this policy to appropriate individuals.
Public Health Services in each DHA will follow the Communicable Disease Record Retention
Schedule as outlined in the NS Communicable Disease Manual and the NS Immunization
Manual.
ACCOUNTABILITY
Public Health staff within the DHA’s are responsible to adhere to this policy.
The Public Health Services director or delegate is accountable to ensure this policy is
communicated and Public Health staff in the DHA’s are informed about this policy.
MONITORING
The Public Health Services director or delegate is responsible for monitoring of the
implementation of this policy.
INQUIRIES
Chapter 10 – Policies
Chapter 10 – Policies
00000-01 General
Records documenting individual client identifiable case management information relating
to Communicable Disease as a whole. Used for records which cannot be classified in any
existing case file secondary. Examples: case report forms, nursing progress notes,
contact tracing line lists, vaccine release forms, notification letters for vaccine-
preventable diseases, diseases transmitted through direct contact or respiratory route,
and zoonotic disease materials.
Chapter 10 – Policies
Chapter 10 – Policies
Approved by: Communicable Disease Prevention and Control Committee for the Public
Health System
I. POLICY STATEMENT
Public Health in the District Health Authorities (DHAs) will cover the cost of the medications
necessary for tuberculosis chemoprophylaxis if the individual does not have third party drug
coverage. Drugs prescribed that are not recommended as part of national chemoprophylaxis
standards must be discussed with the Medical Officer of Health prior to approval.
To ensure Public Health within the DHA’s have consistent payment processes in place that are
both reasonable and cost effective for the public health system.
This policy applies to all Communicable Disease Prevention and Control Public Health staff in
the employ of, seconded to, or under contract to the DHAs.
Public Health Services in each DHA will follow the Payment of LTBI Medication Policy as
outlined in the NS Communicable Disease Manual.
V. ACCOUNTABILITY
Public Health staff within the DHA’s are responsible to adhere to this policy.
The Public Health Services Director or delegate is accountable to ensure this policy is
communicated and Public Health staff in the DHA’s are informed about this policy.
VI. MONITORING
The Public Health Services Director or delegate is responsible for monitoring of the
implementation of this policy.
VII. INQUIRIES
Chapter 10 – Policies