CDC Manual

Nova Scotia
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
Standard Precaution Guidelines ......................... 1 Guidelines for Outbreak Management .................... 2 Enteric Food and Waterborne Diseases .................... 3 Blood Borne Pathogens ............................................. 4 Sexually Transmitted Diseases .....................................5 Vaccine Preventable Diseases ......................................6 Tuberculosis .................................................................7 Direct Contact, Respiratory Routes and Through the Provision of Healthcare ....................................... 8 Vectorborne and Other Zoonotic............................. 9 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 todays 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 organizations 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 Services 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. The importance of meticulous and frequent hand washing is essential. Handwashing is the single most effective way to prevent the spread of infection. 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. MASKS, EYE PROTECTION AND FACE SHIELDS Masks, eye protection and face shields should be worn to protect mucous membranes* of the eyes, nose and mouth only when the situation/procedure is likely to result in splashes or sprays of blood, body fluids, secretions or excretions. 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" GOOD HYGIENE AND WORK HABITS Good hygiene and work habits are required to maintain health and minimize the risk of exposure and transmission of infection. 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. GENERAL HOUSEKEEPING AND CLEANING Routine housekeeping is sufficient. Follow your organizations recommendation for cleaning or disinfection products. Further instructions will be provided should situations occur requiring an alternate method of cleaning or disinfecting. 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. Do not over fill garbage bags. Garbage bags should be carried away from clothing to prevent soiling. Full garbage bags should be carried to prevent touching the floor and prevent ripping of the garbage bag. LABORATORY SPECIMENS Specimens must be transported in a manner that prevents contact with or leakage of contents. Follow organizations recommendation for handling specimens. A specimen must never be discarded in regular garbage. 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. Carry the linen away from your clothing to prevent soiling Do not throw linen freely on the floor. Carry linen bag to prevent contact with the floor. Wear gloves when handling soiled linen.
Follow your organizations 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 Any permucosal* or percutaneous* exposure must be reported immediately to the supervisor. Risk assessment must begin immediately. PERSONAL CARE AND MEDICAL EQUIPMENT All personal care or medical equipment e.g. adaptive aides, aerosols, suction equipment etc. must be changed regularly according to manufacturers guidelines or have a regular cleaning/disinfecting schedule. Follow your organizations recommendation for cleaning or disinfection products. All non - disposable equipment, designated for a specific client, must be cleaned and/or disinfected prior to being used for another client. SPILLS OF AN INFECTIOUS NATURE Follow your organizations recommendation Protocol. If there is no Blood/Body Spills Kit available the following procedure is used: 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. Visitors should wash their hands before and after visiting.
4. Glossary
Disposable: Not for reuse. Disposed of following use.
Contaminated:
The soiling or making inferior by contact or mixture, as by introduction of organisms into a wound.
Excretion:
The act, process, or function of throwing off or eliminating, as waste matter, by a normal discharge e.g. feces, urine.
Mucous Membranes:
A surface layer of epithelial tissue covering a deeper layer of connective tissue that line cavities or canals of the body that open to the outside. They protect the underlying structure, secrete mucous, and absorb water, salts, and other solutions.
Percutaneous:
Through the skin.
Permucosal:
Through the mucous membranes.
Secretion:
The cellular process of developing a specific product e.g. saliva, gastric juices.
GUIDELINES FOR OUTBREAK MANAGEMENT

Table of Contents
Guidelines for Outbreak Management
JANUARY 2010
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). * Within a province/territory for certain illnesses (e.g., botulism, measles), 1 case of the disease may constitute an outbreak. ** Cases who do not live in a common household, exclusive of an institutional event.
3. Principles of Outbreak Management

All reports of suspected outbreaks will be investigated immediately. Upon confirmation of the outbreak, an outbreak management plan will be developed. During and following an outbreak, appropriate intervention and education strategies will be undertaken. All appropriate agencies will be kept informed of the status of the outbreak. An outbreak report and debriefing(s) will be completed.
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
Supplemental Outbreak Team Members

The supplemental Outbreak Team may include the following members: appropriate experts from the departments and/or agencies listed below: Nova Scotia Department of Agriculture Nova Scotia Department of Environment Nova Scotia Department of Natural Resources Nova Scotia Department of Labour and Workforce Development, Occupational Health Health Services Emergency Management (HSEM), DOH/NSDHW Canadian Food Inspection Agency (CFIA) Public Health Agency of Canada (PHAC) First Nations and Inuit Health Nova Scotia Health and Wellness Outbreak Working Group others with expertise in infectious disease or other subject matter experts infection control information technology contact person from the affected institution (if applicable) others as deemed appropriate
5. Roles and Responsibilities of the Outbreak Team Members

5.1 Role of the Medical Officer of Health
Determine if an outbreak is present. Form an Outbreak Team. Function as the team leader, ensuring appropriate investigation and management of an outbreak situation. Inform the appropriate agencies. Oversee public health control measures, initiating specific interventions during an outbreak. Communicate outbreak information according to notifications guidelines (see Appendix 2). Ensure that debriefing occurs and final outbreak reporting is complete once the outbreak is over.
5.2 Role of the CD District/SSA Manager

Work closely with the MOH and actively participate on the outbreak team. Assign and manage staff involved in the outbreak.
5.3 Role of the Investigator

Public health nurses are most often the primary investigators, but the role may be filled by a food safety specialist from the Department of Agriculture, inspector specialists from the Department of Environment, officers from the Department of Natural Resources, staff from the Canadian Food Inspection Agency, Health Canada, First Nations and Inuit Health, and others as requested by the Medical Officer of Health. Collect outbreak-related information through interviews and by other means. Conduct inspections as necessary. Communicate with the MOH and the CD district manager. Provide education and information to the public and others as needed.
5.4 Role of Administrative Support

Organize and arrange meetings as required. Ensure that minutes are recorded for all meetings. Store records of minutes, details of the outbreak, and other information in a secure location. Disseminate information to team members, partners, and others as required.
5.5 Role of the Provincial Public Health Laboratory Network

Act as a consultant to review case findings and recommend and/or suggest further testing. Act as a liaison with other laboratories involved with testing (e.g., CFIA, regional labs, anchor labs). Provide input into testing recommendations.
5.6 Role of the District/Anchor Laboratory

Complete laboratory testing (in consultation and discussion with the physician, MOH, and district/anchor labs). Notify immediately by telephone (with follow-up in writing) all positive lab results related to the outbreak. Report negative lab results related to the outbreak. In consultation with the Outbreak Team, the PPHLN, and the regional labs, make early decisions regarding saving of specimens and/or isolates. Work with investigators to link cases to the outbreak.
5.7 Role of Communications

Provide communication support for outbreak initiatives including media and news releases, issue management, print materials, and others as required.
5.8 Role of Public Health Services in the District Health Authority

Lead the investigation of outbreaks occurring solely within their shared service area.
5.9 Role of Nova Scotia Health and Wellness Responsibility Centres

NSDHW CDPC Responsibility Centre
Provide support and recommendations, as required, to the Outbreak Team. Assist with the development of consistent, key provincial educational information and guidelines for public health measures.
NSDHW Environmental Health Responsibility Centre

Provide support and recommendations, as required, to the Outbreak Team with respect to environmental public health issues. Act as a liaison to other applicable agencies such as the Departments of Agriculture and Environment, as necessary.
NSDHW PHAS Responsibility Centre

Provide support for data management, analysis, and interpretation. Assist with data collection, and coordinate the development of an information management tool if required Summarize the descriptive epidemiology of an outbreak including regular and timely analysis of the data Analyze and interpret the outbreak data to determine interventions Track status of the outbreak reports (initial, update and final reports) Receive all final outbreak reports including evaluations and ensure they are reviewed and acted upon by the DHW Outbreak Working Group Administrate user access to Canadian Integrated Outbreak Surveillance Centre (CIOSC) outbreak manual
Health Service Emergency Management Responsibility Centre

Provide operational support, information exchange, and coordination as required
Support the coordination of the response to logistical demands as necessary
Department of Health and Wellness Outbreak Working Group

Review and revise the provincial outbreak management guidelines as necessary Ensure that the final comprehensive reports, evaluations, and lessons learned are reviewed and actions are followed up and acted upon as necessary
Role of Other Members

Other partners may have significant roles and responsibilities during an outbreak. These roles will be utilized depending upon the type of outbreak and at the request of the Medical Officer of Health.
6. Steps in Outbreak Investigation and Management

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.
6.1 Confirm the diagnosis

Upon receipt of report, confirm the diagnosis and existence of an outbreak.
6.2 Establish an Outbreak Team

See section 4.
6.3 Establish a case definition

This may include clinical symptoms and/or laboratory confirmation. Refer to the specific disease for details.
6.4 Notify NSDHW

Notify DHW using the initial outbreak documentation tools (CIOSC or other electronic applications as available). Assign an outbreak number. The format for
outbreak numbering consists of a 4 digit year, followed by the 2 digit DHA number, and a 3 digit sequential number.
2009 04 013
Outbreak Year DHA Sequential number assigned by DHA
6.5 Develop an interview tool

Develop or modify an interview tool (questionnaire) and other forms as required. Review with the investigators.
6.6 Collect information/data

The Outbreak Team determines which team members will investigate and collect all available current information, determining if any additional data is necessary. Information collected will focus on person, place, and time.
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.
If a common social event is identified, and the source is thought to be food borne, determine what food was served, obtain a guest list and menu, and identify where the food was purchased. Identify common food ingested and any other food that was served that might not be on the menu. Information sources may include: interviews with cases, relatives, and contacts environmental public health inspection (facility/site) reports literature review consultation with experts lab testing interview with primary care physicians, clinics, health-care facility staff review of events and sales records (reservation lists, invitation lists, credit card bills) interviews with people from agencies involved (school, day-care centre, restaurant, work places, public places)
6.7 Complete preliminary and ongoing analysis of information

Review the case definition. Determine attack rates and epidemic curve. Formulate a tentative hypothesis regarding source and transmission. Initiate geographic information system (GIS) tracking if available. Update data collection tools as required.
6.8 Develop notifications/alerts

These notifications are for confidential information sharing. For initial outbreak reports, updates (including related shared documents and correspondence), and final outbreak reports, consider notifying the following: Appropriate district and DHW PH staff and partners (e.g., labs): Notify through CIOSC outbreak summary reporting application. This will be preset by Informatics at DHW, set up with the appropriate district and DHW staff. (See Appendix 2.)
Within DHA: Consider notifying others (e.g., PH director, VP community health, and communications). Note: these people will not be included on the CIOSC reporting application. Within DHW: Consider informing the deputy minister and communications. National colleagues: Consider if a CIOSC alert is necessary.
6.9 Develop a communication plan/education

Work closely with appropriate communications advisor to: consider target groups (public, people at risk, health-care providers, media) consider key messages and methods to disseminate (fact sheets, web postings, press releases, letters, etc.) Assign an Outbreak Team member as media spokesperson. Consider whether a toll-free telephone information line is necessary.
6.10 Implement control measures based on findings

Determine interventions and treatment such as the following: necessity of contact tracing preventative measuresimmunization, exclusion, prophylaxis, treatment (of case to prevent transmission) removal of agents/exposure addressing the source of the outbreak (see specific sections for control measures for identified source of outbreak) closure of premises if required modification of procedures (e.g., swimming pool filtration) cleaning or disinfection of contaminated equipment or fittings (medical devices, cooling towers, food preparation equipment, etc.) Refer to the relevant outbreak management guidelines or related documents, such as the following: A Guide to the Investigation and Management of Enteric Outbreaks in Long-Term Care (LTC) Facilities in Guidelines Partners for Infection Control (Nova Scotia Department of Health, 2001)
Available in each district health authority or from http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infe ction_Control_Guidelines.pdf Enteric Outbreaks in the Community, International Association for Food Protection (IAFP) Procedures to Investigate Foodborne Illness, 5th edition, International Association for Food Protection (IAFP) Available for purchase from http://www.foodprotection.org/publications/otherpublications/ Influenza Outbreaks in Long-Term Care Facilities in Guidelines Partners for Infection Control (Nova Scotia Department of Health, 2001) Available in each district health authority or from http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infe ction_Control_Guidelines.pdf Guide to Influenza Control for Long-Term Care Facilities (Nova Scotia Department of Health Promotion and Protection, 2008-09) Available in each district health authority
6.11 Document the outbreak as it progresses

It is required that all outbreak-related activities are documented and the records stored in a secure location. For example, log the following: all minutes of outbreak-related team meetings and conference calls all notifications, alerts, and correspondence all pertinent dates such as date outbreak declared and date outbreak declared over
6.12 Re-evaluate most current information and outbreak control measures on a continuous basis
Consider the criteria for a public health emergency under the International Health Regulations.
6.13 Consider further studies or special investigations

Further studies or special investigations may be warranted to gain insight into the source, transmission, or more-effective control measures.
6.14 Determine when the outbreak is over

This will be decided by the Outbreak Team and communicated appropriately.
6.15 Evaluate the outbreak control and management

The Outbreak Team will review the investigation and management of the outbreak (debriefing sessions, lessons learned). The Outbreak Evaluation Guide (Appendix 4) may be useful for this process. Recommendations will be made as required. Modifications to policies/programs will be made as required.
6.16 Complete final report

Complete the final report using the NSDHW documentation tools (CIOSC or other electronic applications as available).
6.17 Complete comprehensive final outbreak report

The MOH is responsible for ensuring that the final, detailed report with epidemiology, inspection report, etc., (Appendix 3) is completed and distributed to the appropriate persons within 30 days following the declaration that the outbreak is over. 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 Outbreak Report Summary (via CIOSC) YES YES Update Report Summary (via CIOSC) Final Report Summary (via CIOSC) YES YES Final Comprehensive Outbreak Report Outline (MS Word Doc, see Appendix 3) Only if requested Only if requested
Viral gastroenteritis in institution(s) Viral Respiratory (e.g. RSV, influenza) in institution(s) All other outbreaks
Only if requested Only if requested
YES
YES
YES
YES
*Institutions may include LTCFs, day-care centres, schools, correctional facilities, residential care facilities, and acute care facilities.
6.18 Review reports

District Public Health Services will be responsible for ensuring that final outbreak reports are completed, and DHW will oversee final outbreak reporting on any outbreaks considered to be provincial. DHW, in conjunction with the Outbreak Team, will review recommendations from outbreak reports and update outbreak policies as necessary.
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).
7.1 Procedures in the District Health Authority

DHA notifies DHW through CIOSC electronic application. DHA ensures that each case related to the outbreak is electronically reported in ANDS. DHA completes and submits outbreak reports via CIOSC and Word documents. MOH or delegate determines the need for a national CIOSC/CNPHI alert. DHA sends CIOSC update reports as required. DHA completes the CIOSC outbreak final report within 48 hours after the outbreak is declared over.
MOH or delegate ensures the completion of the Comprehensive Final Outbreak Report (see Table 1), approves the final document, obtains appropriate signatures, and submits to the CMOH.
7.2 Procedures in the Department of Health and Wellness

DHW epidemiologist assigned to outbreaks reviews each CIOSC report. DHW epidemiologist assigned to outbreaks compiles a summary of outbreaks for monthly and annual reports. DHW Outbreak Working Group leads evaluation for provincial outbreaks. DHW Outbreak Working Group ensures that the final comprehensive reports, evaluations, and lessons learned are reviewed, followed up, and acted upon as necessary. DHW Outbreak Working Group signs the comprehensive final outbreak report after review, and submits to the DCMOH for approval. DCMOH submits the Comprehensive Final Outbreak Report to the CMOH for final review and signature. (The CMOH reserves the right to request a Comprehensive Final Outbreak Report at any time.)
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 mediaculture and sensitivity SAF fixativeova 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 stickersbright 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. II. III. Executive Summary Introduction and Background Methods a) Epidemiological b) Laboratory c) Environmental Public Health Results a) Epidemiological b) Laboratory c) Environmental Public Health Discussion Conclusions Evaluation/Recommendations (See Appendix 4) Acknowledgements Signature Block Appendices
IV.
V. VI. VII. VIII. IX. X.
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.
II. Introduction and Background

Describe the specific events that led to the investigation, including how the outbreak was first reported, steps taken to confirm the outbreak (including
surveillance trends), and who assisted in the investigation. Identify the members of the outbreak team and objectives of the investigation. Background information identifies the population demographics, previous, similar outbreaks, describing the area, site or facility involved.
III. Methods
Outline the steps taken to investigate the outbreak. Epidemiological methods: Explain how cases are defined and ascertained. Outline the analytical study methodology and include interview tools and techniques used for investigation. Environmental public health methods: Outline the number and types of environmental public health investigations that occurred and who conducted these investigations. This would include site visits, risk assessment, and trace back. Laboratory analysis: Describe the number and types of specimens submitted for analysis.
IV. Results
Describe what was discovered. Epidemiological results: Highlight the number of cases, personal details, and clinical features, including geographical distribution, epidemic curve, risk factor analysis, and attack rates. Environmental public health results: Describe the results of inspections, risk assessments, and trace back. 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 Comprehensive Final Outbreak Report Signature CDC Manager District MOH Outbreak Working Group (chair) Deputy Chief MOH Chief MOH _____________________ _____________________ _____________________ _____________________ _____________________ Date ________________ ________________ ________________ ________________ ________________
APPENDIX 4: OUTBREAK EVALUATION GUIDE

EVALUATION GUIDE for OUTBREAK MANAGEMENT Outbreak Management Effectiveness of the outbreak management structure Evaluation Questions Indicator
Was the Outbreak Management Team efficient and effective? What worked well? What could have been improved? Timely establishment of the Outbreak Team Appropriate composition of the Outbreak Team Clearly defined & understood roles and responsibilities for the Outbreak Team Engagement of Outbreak Team members Ability of the Outbreak Team to engage appropriate stakeholders (DHW, Health, PHS of DHA, QEII Provincial Lab; NS Agriculture, NS Environment, etc) in the response? Perceived strengths/challenges of the Outbreak Team in responding to the outbreak Established guidelines/documented procedures to coordinate the efficient flow of information Timely flow of information (re: resource needs) between the PHS of Districts and Outbreak Team and DHW? Established procedures to avoid duplication (example, double entry of the data by DHAs & DHW)? Development of strategies to address inefficient procedures Adequate (human, financial & other) resources available and accessible to attend to the outbreak Perceived strengths/challenges in the coordination across the system
Method
Interview Document Review
Was there a coordinated response to the outbreak? What worked well? What were the challenges?
Clinical Services Evaluation Questions

Were the clinical services responsive to the outbreak.
Indicator
Physician use of the clinical case definition when requesting laboratory tests? (i.e. confirming the diagnosis) Development of an acceptable (accurate) treatment algorithm if applicable A reliable case definition established within an acceptable time frame Accurate diagnosis of cases by physician Timely processing of laboratory specimens Perceived strengths/challenges in establishing a case definition and processing of laboratory specimens
Method
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) Document efficient? 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 collection process timely and efficient? Was the data analysis process timely and efficient? What were the challenges? How could this have been improved? Perceptions of the timeliness of the data analysis Perceptions of what worked well in the process of data analysis Perceptions of what could have been improved? Interview Document Review
Ability of the outbreak team leader to report on the outbreak (number of cases, location, etc.) in a timely manner Timeliness of the epi-curve Use of the epi-curve (how, by whom?) Formulation of tentative hypothesis (how? by whom? Timeliness) Timeliness of establishing/verifying the existence of an outbreak
Was data analysis used to inform and update the case definition and inform application of community public health measures? Evaluation Questions
Ability of analysis to provide field interview and investigation staff to better focus work Was the analysis usefully in validating the infective agent, mode of transmission, effectiveness of intervention or prevention methodology?
Indicator
Method
EVALUATION GUIDE for OUTBREAK MANAGEMENT Public Health Measures Case Management Establishment and adherence to process for What case case management (e.g. education of all management activities patients to prevent transmission) were used? Did case management occur for all patients? Contact Tracing Did contact tracing occur for all cases? Community Measures What community measures were Implemented? Established process for contact tracing Contact tracing process successfully identified those at high risk of transmitting the disease Perceived contribution of contact tracing to the management of the outbreak (prevention and control measures)? Perceived strengths/challenges with the contact tracing process
Challenges in implementing community measures?
Interview Description of community measures implemented and their target group If employed, were immunization strategies Document delivered in a timely manner if necessary Review Were community interventions undertaken (facility closure or sanitizing, food seizure, food destruction, water disinfection, etc.) If vaccines and/or immunization were employed, were the NACI standards for cold chain storage adhered to throughout the outbreak? What were the barriers?
Evaluation Questions
Indicator
Method
EVALUATION GUIDE for OUTBREAK MANAGEMENT Communications Effectiveness of Communication Strategies (1-800 line; letter to physicians; physician video; posters; DHA or DHW website) Was the process for communicating the onset of an outbreak (provincially? regionally? nationally?) efficient? Interview Communication strategies reached their target audiences? Messages of communication strategies were Document clear to the intended audience Review Target audience acted upon the communication messages Stakeholders consulted in the development of communication strategies Communication materials were culturally sensitive Reduction in the number of calls to PHS if a 1800 line was established Documented process for communicating the onset of an outbreak (Provincially? Regionally? Nationally?) Clear and timely communication to stakeholders of the process Perceptions of gaps Suggestions of how the process be improved in the future Increased awareness among public of the outbreak Interview Document Review
Were the resources developed for dissemination of information (i.e. fact sheets, FAQs) effective in increasing the publics awareness of the outbreak? Lessons learned re: communicating with the media Did communication with stakeholders address their needs for information on the outbreak? Roles and responsibilities in communicating the outbreak?
Perceptions of approaches that worked well in communicating with the media Recommendations for communicating with the media in future outbreaks Stakeholder satisfaction with information on the outbreak
Interview Document Review Interview Document Review
Were the roles and responsibilities clearly defined, and appropriate people involved in communicating the outbreak?
APPENDIX 5: ACRONYM LIST

ANDS CD CDC CDHA CDPC CFIA CIOSC CMOH CNPHI DCMOH DHA DHW GIS HSEM IAFP LTCF MOH NSDHW PH PHO PHN PHS PHAS PPHLN RSV SSA Application for Notifiable Disease Surveillance Communicable Disease Communicable Disease Control Capital District Health Authority Communicable Disease Prevention and Control Canadian Food Inspection Agency Canadian Integrated Outbreak Surveillance Centre Chief Medical Officer of Health Canadian Network for Public Health Intelligence Deputy Chief Medical Officer of Health District Health Authority Department of Health and Wellness Geographic information system Health Services Emergency Management International Association of Food Protection Long-Term Care Facility Medical Officer of Health Nova Scotia Department of Health and Wellness Public Health Public Health Officer Public Health Nurse Public Health Services Population Health Assessment and Surveillance Provincial Public Health Laboratory Network Respiratory syncytial virus Shared Service Area
ENTERIC, FOOD, AND WATERBORNE DISEASES

Section Contents
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
Enteric Food and Waterborne Diseases
Principles
The principles for the management of enteric diseases are: 1. All enteric diseases will be investigated in a timely manner upon receipt of the report. 2. Upon confirmation of disease, specific information will be offered to infected individuals to minimize complications and transmission of the disease. 3. Sources of specific diseases will be investigated and if necessary, recommendations made related to closure of public facilities, withdrawal of products from shelves, etc. 4. Information will be offered to the public on safe food preservation and handling. 5. All new cases of enteric diseases will be added to the provincial database for notifiable diseases.
General Guidelines for the Investigation of Enteric, Food and Waterborne Diseases
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.
1. Roles and Responsibilities

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.
1.1 Role of the Medical Officer of Health

1.1.1 Determine Investigative Responsibility
Ensure that reports of enteric illness are received and disseminated to the appropriate personnel for investigation within Public Health Services. The Communicable Disease Control Coordinator/Manager may assume this role in the absence of a MOH.
1.1.2 Approve Public Health Control Measures

When required, approve a work/child care exclusion due to an enteric illness. In the absence of the MOH, the Communicable Disease Control Coordinator/ Manager may approve this decision.
1.2 Role of the Investigator

See flow chart at the end of this section
1.2.1 Begin Investigation

In most cases, begin an investigation as soon as possible and within 1-2 working days of receipt of report. Where there are exceptions to this time frame, it is noted in the procedures section of specific diseases.
1.2.2 Call physician and inform of illness

Obtain appropriate information to contact client. Ask if client has been informed, educated and treated (if appropriate). If physician contact is not possible, omit this step.
1.2.3 Determine client status

Contact client and begin investigation, using the Enteric Report Form as a guide. Determine if the client is in a special risk group. If the client is in one of the special risk groups, exclusion from work/child care may be warranted (more on exclusion in section 2). Special risk groups include: FOOD HANDLERS whose work involves touching foods during preparation or cooking, or touching unwrapped foods to be consumed raw or without further cooking. HEALTH CARE, NURSERY OR OTHER STAFF who have direct contact, or contact through serving food with susceptible patients or persons in whom an intestinal infection would have serious consequences. (e.g. immunocompromised persons, surgical and medical patients, elderly, infants.) CHILDREN BELOW THE AGE OF FIVE YEARS attending child care centres or other similar groups. OLDER CHILDREN AND ADULTS WITH POOR STANDARDS OF PERSONAL HYGIENE, such as those residing in institutions for the mentally ill, handicapped or infirmed aged.
1.2.4 Determine most probable source of infection by asking about recent exposure
Persons with similar symptoms such as household members, sexual contacts, diapered children, and children in child care facilities. Animals, especially pets and farm animals. Ask if the animals are symptomatic. Food consumed at home, restaurants, or parties around the time of infection that may have been undercooked, improperly stored, contaminated, unpasteurised, etc. especially if derived specially from meat, seafood and milk. Derive approximate time of infection. Obtain the name and location of the restaurant, store, bakery, group meals attended, etc. that may be the source of infection. If a source is suspected, contact a Food Safety Specialist with this information. If the
approximate time of infection was more than 1 or 2 weeks before investigation, this information may be difficult to obtain. Possibly contaminated water. Foreign travel. Investigate to determine if the source and transmission are continuing since the travel. Foreign visitors. Refer to the information section of the specific disease for additional information for investigation about source and mode of transmission.
1.2.5 Contact Food Safety Specialist (Department of Agriculture and Fisheries) if food establishment is involved or in the case of an outbreak 1.2.6 Contact Department of Environment if water source is involved
It is the responsibility of the Department of Environment and Labour to investigate all circumstances of water contamination.
1.2.7 Educate client and household

Educate the client and household members about the importance of the following preventive practices: Thorough hand washing with soap and running water before, during, and after food preparation, before eating, after using the toilet, after handling soiled diapers, bed linen, commodes, and possibly soiled clothing, toys and other articles. Use proper food handling guidelines as follows: CLEAN. Wash hands, utensils and surfaces with hot soapy water before, during and after preparing foods. Sanitize countertops, cutting boards and utensils with a sanitizing solution. This solution can be made by mixing 5 milliliters (1 teaspoon) of household bleach with 1 litre of water [1 tablespoon (15 ml) per gallon]. 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 dont 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 4C (40F), and keep the freezer at 18C (0F). Avoid consumption of raw eggs, unpasteurised milk and cider, undercooked meats, especially poultry and pork. Proper disposal of excreta and soiled materials (in the home the toilet may be used for disposal). Soiled clothing and bed linen should be washed in a washing machine with a hot cycle. If this is impractical, flush away fecal matter in the toilet and soak the soiled articles in a household disinfectant such as diluted bleach at a concentration of (1:10), then wash as usual. Hands should be thoroughly washed afterwards. Wrap disposable diapers in a plastic bag before discarding in the garbage. Infected individuals should not share toys, towels, dishes, and other articles with others.
1.2.8 Investigate contacts

Household contacts are defined as persons residing in the same residence. Close contacts include sexual contacts and persons who have contact that may be fecal-oral (i.e. sharing meals the case cooked, or any activity that may entail hand to mouth contact with the case). Determine if any of the household or close contacts fall into a special risk group.
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 cases 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 Role of the Family Physician

1.3.1 Patient education, follow-up, and culture for special risk contacts
The physician may delegate this role to the Investigator; however, the physician is responsible for ensuring that the Investigator is aware of the delegation of responsibility.
1.3.2 Facilitate specimen collection

If a special risk case is excluded from work/child care, the physician may work with the investigator and Public Health Services to facilitate the collection of stool specimens.
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.
1.4 Role of the Laboratory

1.4.1 Report positive tests in writing
It is the responsibility of the laboratory to report all positive enteric lab results to the appropriate District Health Authority Public Health Services.
1.4.2 Telephone reporting

Cases of botulism, verotoxigenic E. coli, and suspect food borne illnesses require immediate telephone reporting.
1.5 Role of the Nova Scotia Department of Agriculture and Fisheries

1.5.1 Investigation
When notified that an enteric illness is associated with food or a food establishment, the Food Safety Specialist will begin an investigation. The Investigator will provide the Food Safety Specialist with all relevant information obtained during the initial interview of the client(s). 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 Departments Fisheries Licensing and Investigation branch.
1.5.2 Role of the Outbreak Team

The Food Safety Specialist is a member of an outbreak team for investigation of a food borne illness and enteric outbreaks in institutions e.g. day care and long term care facilities.
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.
1.6 Role of the Nova Scotia Department of Environment and Labour

1.6.1 Investigation
When notified that an enteric illness is associated with water, the Inspector Specialist will begin an investigation. The Investigator will provide the Inspector
Specialist with all relevant information obtained during the initial interview of the client. The Inspector Specialist will be responsible for the inspection of the water source implicated in an enteric disease.
1.6.2 Role on the Outbreak Team

The Inspector Specialist is a member of an outbreak team, for investigation of a water borne illness and enteric outbreaks where the source is unknown.
2. Criteria for Exclusion

2.1 Terms for Exclusions
All exclusions must be approved by the MOH. In the event of long-term exclusions (e.g. carrier states), the MOH may make a decision, on a case-by-case basis.
2.2 General Guideline

For all enteric illnesses of infectious etiology, exclude client from risk activities (See section 2.3) at least until symptoms have subsided and client has had 2 well formed stools. Additional exclusion requirements are listed under the individual diseases.
2.3 Procedure for Exclusions

2.3.1 Inform client
Once approval for exclusion has been granted by the MOH, the Investigator will immediately inform the client or parents of a child about the exclusion. The Investigator will ensure that a letter is sent to the client or parents confirming the exclusion and its terms. Sample letters are included with each disease.
2.3.2 Inform place of employment/child care centre

The Investigator will ensure that the employer/child care centre is immediately informed of the exclusion. This may be done by phone but the Investigator will ensure that a letter is sent to the employer or childcare centre confirming the exclusion and its terms. The Investigator will encourage employers to find alternative work for the client that does not involve participation in risk activities. Sample letters are enclosed at the end of these general guidelines.
2.4 Return from Exclusion

Terms for return to work/child care are listed under the specific diseases. All parties involved should be informed by the Investigator of the return from exclusion as soon as the client is eligible. Sample letters are enclosed at the end of these general guidelines.
2.5 Guidelines for Long Term Carriers, Child Care Centres and Institutions
Consult specific diseases for exclusion guidelines for each of the above.
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. Core Messages for Prevention

4.1 Safe Handling of Foods
4.1.1 Refrigeration
Enteric bacteria causing foodborne illness grow well between 4C and 60C (the temperature danger zone). All potentially hazardous foods (meat, fish, poultry, eggs, dairy and dairy products) must be either kept cold (4C or lower) or hot (60C or higher). These foods should not be left in the temperature danger zone for longer than 2 hours. Frozen foods should not be thawed at room temperature.
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 71C 160F Ground Meat 71C 160F Whole chicken/turkey 82C 180F Poultry Stuffing (inside temperature) 74C 165F Chicken/turkey pieces 77C 170F Ground poultry 72C 165F Beef steak/roasts: Medium rare 63C 145F Beef steak/roasts: Medium 71C 160F Beef steak/roasts: Well done 75C 170F
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 74C.
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 (4C) 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.
4.1.6 Wash and Sanitize

Foodborne illness happens when ready-to-eat foods are contaminated by using the same utensils, cutting boards and plates that were used for raw meat, poultry or seafood. Hands, countertops, cutting boards, plates and utensils that are used to prepare raw meat, poultry or seafood should be washed in warm soapy water, and sanitized after use. A sanitizing solution can be made by mixing 5 millitres (1 teaspoon) of household bleach with 1 litre of water (1 tablespoon per gallon).
4.1.7 Fresh Fruit and Vegetables

Fresh fruits and vegetables must always be washed thoroughly. Fresh fruits and vegetables such as melons and sprouts have been associated with foodborne illness. They may become contaminated by irrigation water, soil and unsanitary processing methods. Particular attention should be paid to fruits and vegetables that will be served raw or fruits that are not peeled before serving. Refrigeration of melons after slicing is recommended.
4.1.8 Pasteurized Milk, Juice/Cider

Raw or unpasteurized milk may contain many bacteria that cause foodborne illness. Pasteurized milk has been heat treated to destroy these bacteria. All milk sold in Nova Scotia is required to be pasteurized. People living in rural areas who raise cows or goats and use milk from their own herd should home-pasteurize the milk before using. Information on home pasteurizing may be obtained from the Food Safety Specialist at Nova Scotia Department of Agriculture & Fisheries. 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.
4.1.9 Foods to Avoid for People at Risk (High Risk Groups)

Some people with weakened immune systems may be at risk for foodborne illness. These include the elderly; people with HIV/AIDS, cancer, kidney disease; those being treated with immunosuppressive medications; young children (less than 5 years of age); and pregnant and early postpartum women. These people should be aware of the following: Always cook raw foods such as meat, fish and poultry to proper temperatures. Do not eat uncooked eggs. Do not drink unpasteurised milk, juices or cider. Soft cheeses such as Brie, Camembert and queso blanco fresco, as well as feta cheese and refrigerated pates, may be source of Listeria monocytogenes and should be avoided during pregnancy. Other dairy products such as hard cheese, processed cheese, cream cheese, cottage cheese, or yogurt can be freely consumed during pregnancy. Hot dogs have been implicated in outbreak of Listeria monocytogenes and should therefore be cooked until steaming hot before eating.
Although the risk of listeriosis associated with foods from deli counters, such as sliced package meat and poultry products, is relatively low, pregnant women and immunosuppressed persons may choose to avoid these foods. Avoid refrigerated smoked fish products unless you have cooked them, for example, in a casserole. Use all perishable foods that are precooked for ready-to-eat before expiration date. Enteric pathogens from contaminated waters may be found in bivalve shellfish such as clams, mussels and oysters. People at risk should not eat raw or undercooked bivalve shellfish. Seed sprouts (bean sprouts, alfalfa sprouts and others) have been the cause of foodborne illness. Raw sprouts should not be eaten. However sprouts that have been cooked are not risky. Fruits and vegetables should be cooked before eating, particularly those that grow near or in the ground. Special care should be taken when washing fruits and vegetables such as lettuce as it is harder to clean than fruit and vegetables with smooth skins.
4.2 Drinking Water Supplies

Enteric organisms may be spread through drinking water contaminated with bacteria or protozoa. These micro-organisms get into water when sources such as lakes, streams and community water supply pipes or reservoirs and wells are contaminated by animal wastes or human sewage. 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.
4.2.2 Disinfecting Water

Boiling: Boiling is the best way to kill bacteria, viruses, and protozoa in water. A full boil for at least 1 minute is required. Boiled water should be used for drinking, cooking, brushing teeth, washing uncooked fruit and vegetables, making ice cubes and in recipes. Chlorination: Unscented household bleach can be a good disinfectant if the water is not too heavily contaminated or when Giardia or Cryptosporidium are not a concern. Instructions on proper methods and amounts of bleach to use may be obtained from the Nova Scotia Department of Environment and Labour. Iodine: Iodine may also be used to disinfect small amounts of water. Manufacturers instructions for use of iodine tablets must be followed. Instructions on proper methods and amounts of iodine to use may be obtained from the Nova Scotia Department of Environment and Labour. 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 Information for Travelers

Travelers to some foreign countries may be at higher risk of contracting an enteric illness. This is often due to unsanitary conditions encountered in these countries. Travelers to these areas should be aware of the following precautions.
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. Use bottled water for brushing teeth. 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 manufacturers 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 12 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.
4.5 Sewage Disposal Systems

Many community sewage systems include collection and treatment of wastes from individual homes. Rural areas and many smaller and older communities and subdivisions are still serviced by individual on-site sewage disposal systems. 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
1.2 Causative agent

Entamoeba histolyica, a protozoan.
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.
1.9 Core Messages for Prevention

Refer to General Guidelines. In addition: Avoid unprotected anal contact. Keep diapered children or anyone with diarrhea out of swimming pools.
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 Roles and Responsibilities

2.1.1 Medical Officer of Health
Use general guidelines. No additional guidelines.
2.1.2 Investigator
2.1.3.Physician
2.1.4 Laboratory
2.2 Criteria for Exclusion

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food Handlers Criteria for Exclusion Exclude until asymptomatic and stool is formed.
Health care, nursery or other staff who Exclude until asymptomatic and stool have contact with susceptible persons is formed. Children < 5 years attending day care Exclude until asymptomatic and stool etc. is formed. Case contacts who are in special risk Contacts who develop gastrointestinal groups symptoms should be tested for E. histolytica.
2.3 Guidelines for Long Term Carriers

Use general guidelines.
2.4 Guidelines for Child Care Centres

Personnel should practice good hand washing technique especially after using the toilet and diapering. New children should not be admitted to the child care centre during an outbreak.
2.5 Guidelines for Institutions

Enteric precautions for symptomatic clients.
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/ccdrrmtc/09pdf/35s2-eng.pdf Amebiasis. http://www.cdc.gov/ncidod/dbmd/diseaseinfo 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. Working Guide: Notifiable Disease Reporting System in Nova Scotia. 1998. Nova Scotia Department of Health.
AMEBIASIS FACT SHEET

What is Amebiasis?
Amebiasis is a disease caused by a parasite called Entamoeba histolytica. The parasite is passed in the stool of an infected person. The parasite is protected by an outer shell that allows it to survive outside the body and in the environment for long periods of time.
Who Can Get Amebiasis?

Anyone can get amebiasis, although it is found more often in: Travelers who visit developing countries with poor sanitary conditions. Immigrants from a country with poor sanitary conditions. People who live in institutions with poor sanitary conditions. Men who have sex with men.
What are the Symptoms?

Most people who are infected with E. histolytica have no symptoms. For those people who do have symptoms, they are often quite mild and can include loose stools, and stomach pain. 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.
What is the Treatment?

Several medications are available to treat amebiasis. Your physician may prescribe medication.
How Can You Prevent Amebiasis?

The parasite is passed in the stool of humans. It also may be found in soil, food, water, or surfaces that have been contaminated with the feces from infected humans.
Ways to prevent the spread of E. histolytica infection are: Wash hands thoroughly with soap and water after using the toilet and before eating or handling food. Avoid swallowing recreational water (pools, hot tubs, lakes or rivers). Keep diapered children or anyone with diarrhea out of swimming pools. Avoid using ice or drinking untreated water when travelling in countries where the water supply might be unsafe. Use only safe water to wash all vegetables and fruits before eating.
BOTULISM
1. Information
1.1 Case definition
Confirmed case: Foodborne Botulism (Either 1 or 2)
Laboratory confirmation of intoxication with clinical evidence: - detection of botulinum toxin in serum, stool, gastric aspirate or food OR - isolation of Clostridium botulinum from stool or gastric aspirate 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 patients 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 patients 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).
1.2 Causative agent

Toxins produced by Clostridium botulinum (C. botulinum), a spore forming obligate anaerobic bacillus. Most outbreaks are due to neurotoxins A, B, E, F, and G.
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. Intestinal (infant) botulism may present initially as a gastrointestinal upset with constipation, listlessness, weak cry, poor feeding, diminished gag reflex, loss of head control and generalized weakness(floppy infant). These symptoms may lead to respiratory difficulties and arrest. The illness may be mild or severe and may be associated with Sudden Infant Death Syndrome (SIDS).
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. Wound botulism occurs when C. botulinum grows in a wound or injured area and produces its toxins. Often this results from contamination of the wound by soil or gravel. Intestinal (infant) botulism occurs when C botulinum spores colonize in the intestines and produce toxins there. Honey and corn syrups have been implicated in the production of spores in the intestines.
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. Intestinal (infant) botulism: Trivalent antitoxin is NOT used in the treatment of infant botulism, because of the chance of hypersensitivity to the equine preparation. Meticulous supportive care is indicated, with antibiotics used only to treat secondary infections.

Refer to General Guidelines. In addition: Home canning of low acid foods (vegetables, including tomatoes, meat and fish) is not recommended. Freezing is a preferred method of preserving these foods. However, if canning foods at home all low acid foods must be preserved using a pressure canner and following manufacturers instructions. Boil all home canned low acid foods for at least 10 minutes before eating. When home prepared foods are stored in oil (herbs, vegetables, etc.), use only fresh ingredients and keep refrigerated. Discard if product is more than one week old. Do not eat food from cans that are leaking or have blown ends, or foods that may have unusual odours, colour or texture. Remember, if in doubt, throw it out. All work surfaces, utensils and hands must be kept clean at all stages of the home canning process. Do not feed honey or corn syrup to infants less than one year.
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.

2.1.2 Investigator
The investigator should begin investigation immediately upon receipt of the report. A single case of botulism should arouse suspicion of an outbreak in the family or a group because of shared food experience. Use general guidelines. Also use additional guidelines re: a) Contacting physician. Call physician to confirm case report and to gain additional information for follow-up. Discuss possibility of wound botulism. b) Investigating contacts. Determine if any family members, friends or others who shared meals are ill and if further outbreak measures are necessary. If intestinal (infant) botulism, discuss foods given to baby, especially honey or corn syrups. c) Taking a food history. Discuss all contacts with restaurants, take-outs, eating at others homes for 3-4 days prior to illness. Take special note if any of the following have been ingested: Homemade preserves, anything bottled or canned, especially meats or vegetables. Fish, shellfish or meat of marine animals. Smoked salmon, smoked meats. Lightly cured or pasteurised foods that have been improperly refrigerated. Garlic in oil. d) Collecting food specimens, if suspect. Collect any food specimens that have unusual odour or appearance. Also collect samples of home canned food that seem suspect or in any of the above categories. Submit these specimens to laboratory for analysis. If commercial food is suspect, caution individuals not to use stocks of this food until investigation is completed. e) Advising those who have shared suspected food to see their doctor for evaluation. Antitoxin prophylaxis may be considered. f) Collecting stool specimens. Collect stool specimens from anyone suspected of sharing same food as the infected individual, even if asymptomatic. g) Notifying Food Safety Specialist. Notify a Food Safety Specialist, Department of Agriculture and Fisheries who will notify eating establishments or food vendor of suspected disease outbreak. The Food Safety Specialist will phone and then visit the site.
2.1.3 Physician
Use general guidelines. Also use additional guidelines re: a) Reporting case to the local Public Health office. If a physician identifies a case of botulism, the physician must report the suspected case of botulism to the local Public Health Services office immediately by phone. b) Discuss contact tracing and follow-up with the Investigators.
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.

None.

None.

None.

None.
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/ccdrrmtc/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.
Who Can Get Botulism?

Most cases of botulism are due to eating foods that have been improperly cooked or reheated. Improperly processed home canned foods are a common cause of food-borne botulism. Botulism is not spread from person to person. Intestinal (or infant) botulism has been associated with eating contaminated honey and corn syrup.

Symptoms of food-borne botulism usually occur within 12-36 hours of eating the contaminated food, but may take several days. The time for symptoms to appear for intestinal (infant) botulism is unknown. Early symptoms of botulism include: Blurred or double vision. Weakness. Poor reflexes. Difficulty in swallowing or speaking. Shortness of breath. The illness can progress to complete paralysis, respiratory failure and death.

Treatment for both adults and infants requires hospital care. Botulism antitoxin is given in some cases to adults, but not to infants. Untreated botulism can result in death.
How Can You Prevent Botulism?

All home canned products should be properly prepared. Infants less than one year old should not be fed honey or corn syrup. Bulging food containers should not be opened, and should be returned to the store. Foods with unusual odours or appearance should not be eaten or even tasted.
CAMPYLOBACTERIOSIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection with or without symptoms: isolation of Campylobacter sp. from an appropriate clinical specimen
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case
1.2 Causative agent

Campylobacter jejuni, a gram-negative rod.
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.

Refer to General Guidelines. In addition: Consider pets with diarrhea as a possible source of campylobacter.
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
2.1.3 Physician
2.1.4 Laboratory

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food handlers Criteria for Exclusion General guideline
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. Children < 5 years attending day Additional Guideline: Exclude until care etc. symptoms have cleared and stools are well formed or child has been on antibiotics for 2 days; whichever is the shorter period of time. Case contacts who are in special Symptomatic: General guideline Symptomatic risk groups Asymptomatic: Stools do not need to be screened. Exclude only when there is a concern about inadequate hand washing procedures.

None.

If there are epidemiologically linked cases in attendees or employees, diapered attendees and food handlers should be screened for Campylobacter. Educate parents and staff about Campylobacteriosis and proper hand washing. Instruct parents and staff to watch for symptoms of diarrhea.

For residents of an institution with a case of Campylobacteriosis, institute enteric precautions for that case. No action is recommended for other residents. If there are epidemiologically linked cases of Campylobacteriosis in the institution residents or employees, employees and food handlers should be screened for Campylobacter. If cases continue, investigate as an outbreak.
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/ccdrrmtc/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.
Who Can Get Campylobacteriosis?

Anyone can get a Campylobacter infection, however it is most common in children and young adults. Eating contaminated food, especially unpasteurized milk, non-chlorinated water and improperly cooked poultry, is a common way to get this disease. Even one drop of juice from raw chicken meat can infect a person. One way to become infected is to cut poultry meat on a cutting board, and then use the unwashed cutting board or utensil to prepare vegetables or other raw or lightly cooked foods. The Campylobacter organisms from the raw meat can then spread to the other foods. Some people have become infected from touching the infected stool of an ill dog or cat. People dont 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.

Most people with campylobacteriosis have diarrhea, abdominal pain, and fever within 2 to 5 days after contacting the germ. The diarrhea may be bloody and can be accompanied by nausea and vomiting. The illness typically lasts 1 week. Some persons who are infected with Campylobacter dont have any symptoms at all.

Almost all persons infected with Campylobacter will recover without any specific treatment. Patients should drink plenty of fluids as long as the diarrhea lasts. In more severe cases, antibiotics can be used. Sometimes antibiotics can shorten the duration of symptoms if they are given early in the illness. Individuals not treated can shed the organism in their stool for 27 weeks. Your doctor will make the decision about whether antibiotics are necessary.
How Can You Prevent Campylobacteriosis?

You can prevent campylobacteriosis by: Washing hands with soap and water after using the toilet, changing diapers, touching pets or their stool (e.g. after cleaning a litter box), and before preparing foods. Eating only well cooked meats, poultry, or eggs. Avoiding unpasteurised milk or cheese. Keeping raw foods away from cooked foods and by washing cutting boards, utensils, and hands.
CHOLERA
1. Information
1.1 Case definition
Confirmed case:
Clinical evidence of illness with laboratory confirmation of infection through isolation of cholera toxin producing Vibrio cholerae serotype O1 or O139 from vomitus or stool.
Probable case:
Clinical evidence of illness in a person who is epidemiologically linked to a confirmed case.
1.2 Causative agent

Vibrio cholerae, gram-negative bacteria.
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.

Refer to general guidelines.
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
2.1.4 Laboratory

None.

None.

Educate parents and staff about proper hand washing.

For severely ill hospitalized clients, implement enteric precautions.
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/ccdrrmtc/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.
Who Can Get Cholera?

Anyone who drinks water or eats food contaminated by the bacteria can get cholera. Cholera does not spread from person to person directly. 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.

Most people who get cholera have no symptoms, or only mild diarrhea. About 5% of infected people will have severe symptoms that include a large amount of watery diarrhea and vomiting. In these people, the rapid loss of fluids can lead to dehydration, which if not treated, can lead to death.

Cholera can be treated with antibiotics prescribed by your doctor. People with severe symptoms will be treated for dehydration.
How Can You Prevent Cholera?

Avoid eating raw or undercooked shellfish. When you travel to countries or areas where cholera has occurred: Drink only water that you have boiled or treated with chlorine or iodine. Avoid undercooked or raw shellfish. Eat only foods that have been thoroughly cooked. Eat only foods that you have peeled yourself. Eat only cooked vegetable and avoid salads.
CRYPTOSPORIDIOSIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection with or without symptoms from an appropriate clinical specimen (e.g. stool, intestinal fluid or small bowel biopsy): demonstration of Cryptosporidium oocysts OR detection of Cryptosporidium DNA OR demonstration of Cryptosporidium antigen by an approved method (e.g. EIA, immunochromatographic ICT)
Probable case:
Clinical illness in a person who is epidemiologically linked to a confirmed case.
1.2 Causative agent

Cryptosporidium parvum, a protozoan.
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.

Refer to General Guidelines.
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. Roles and Responsibilities

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
2.1.4 Laboratory

Health care, nursery or other staff who have General guideline contact with susceptible persons Children < 5 years attending day care etc. Case contacts who Symptomatic risk groups are in General guideline
special Symptomatic: general guidelines Asymptomatic: no exclusion required

None.

Educate parents and staff about proper hand washing.

Implement enteric precautions for the client.
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/ccdrrmtc/09pdf/35s2-eng.pdf Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health Association. Cryptosporidium. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/ 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.
CRYPTOSPORIDIOSIS FACT SHEET

What is Cryptosporidiosis?
Cryptosporidiosis is a disease caused by a parasite called Cryptosporidium parvum. The disease is also called Crypto. The parasite lives in the intestines of humans and animals and is passed in their stool. The parasite is protected by an outer shell that allows it to live outside the body for long periods of time. The outer shell also makes it very resistant to chlorine.
Who Can Get Cryptosporidiosis?

Anyone who accidentally swallows the parasite can get infected. The parasite is found in the food, water or soil that has been contaminated with infected human or animal stool.

Symptoms include diarrhea, stomach cramps, upset stomach and possibly a slight fever. The symptoms usually begin 1 to 12 days after being infected.

There is no effective treatment for Cryptosporidiosis. Most people with a healthy immune system will recover on their own. If you have a weak immune system (such as people with AIDS or cancer patients who are taking certain drugs), you could have more severe symptoms. Your health care provider can give you advice.
How Can You Prevent Cryptosporidiosis?

Ways to prevent the spread of the parasite include: Wash hands thoroughly with soap and water after using the toilet and before eating or handling food. Avoid swallowing recreational water (pools, hot tubs, lakes or rivers). Keep diapered children or anyone with diarrhea out of swimming pools. Avoid using ice or drinking untreated water when travelling in countries where the water supply might be unsafe. Use uncontaminated water to wash all vegetables and fruits before eating. Avoid drinking water from lakes, streams and rivers when camping or hiking.
CYCLOSPORIASIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection in a person with or without clinical illness: Demonstration of Cyclospora cayetanensis oocysts in stool, duodenal/jejunal aspirate or small bowel biopsy
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
1.2 Causative agent

Cyclospora cayetanensis, a protozoan.
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.

2.1.2 Investigator
2.1.3 Physician
2.1.4 Laboratory

None.

None.

None.

Standard precautions.
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/ccdrrmtc/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.
Who Can Get Cyclosporiasis?

Anyone who drinks contaminated water or produce can become infected with cyclospora. The ways in which water and food get contaminated with the parasite are still unclear. There have been no reported cases of direct person-to-person transmission of the disease.

The symptoms of cyclosporiasis include: Watery diarrhea. Stomach pain or cramps. Upset stomach. Lack of appetite. Tiredness. Weight loss. Fever occurs in about half of infected people.

See your doctor for medication.
How Can You Prevent Cyclosporiasis?

Wash produce carefully before eating. Avoid drinking untreated or recreational water (such as pools, streams, lakes). Follow safe food and water guidelines when travelling in other countries.
E. coli (Verotoxigenic)_
1.0 Information
1.1 Case definition
Confirmed Case:
APRIL 2012
Laboratory confirmation of infection with or without clinical illness: isolation of verotoxin producing E. coli from an appropriate clinical specimen(e.g. feces, urine, blood) OR detection of verotoxin antigen or nucleic acid
Probable Case:
Clinical illness in a person who is epidemiologically linked to a confirmed case, which would include persons with hemolytic uremic syndrome (HUS).
1.2 Causative Agent

Escherichia coli have many serotypes which produce verotoxin causing foodborne illness. The best known of these is E. coli O157:H7, a gram-negative bacterium. There are several other common serogroups in North America. In previous years some common serogroups have included 026, 011, 0103, -45, 121 and in Europe 0145.
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.
1.4 Diagnostic Testing

1.5 Treatment
Fluid and electrolyte replacement when diarrhea is watery. Role of antibacterial treatment is uncertain, however some evidence suggests that treatment with TMP-SMX fluoroquinolones may precipitate complications such as hemolytic uremic syndrome.
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. Feces of cattle, deer and other ruminants. Person to person transmission is common in outbreaks.
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.

2.0 Public Health Management and Control Measures

Use the General Guidelines for Investigation at the beginning of this section. The following are additional guidelines for verotoxigenic E. coli:
2.1 Case Management

2.1.1 Case Follow-up
Follow up the case as soon as possible using the following steps: 1. 2. 3. 4. Contact the health care provider to obtain clinical information on the case, if reported via a health care provider. Interview the client, review clinical information, determine food history and activities, employment and potential source of exposure. Educate the client and/or family about Verotoxigenic E. coli, and prevention measures, providing access to website, fact sheets, etc. If drinking water or recreational water has been identified as a potential source, consult with the Medical Officer of Health concerning initiating a request for assistance from Nova Scotia Environment. The MOH may request an inspection/investigation be conducted at the site to identify potential sources. This can be facilitated through the Environmental Health Consultant with the Department of Health and Wellness. If the case identifies consuming natural spring water, provide the fact sheet, Natural and Roadside Springs from the Nova Scotia Environment website: http://www.gov.ns.ca/nse/water/docs/droponwaterfaq_naturalsprings.p df as an education resource. If the case identifies a local food establishment as a possible source, contact a Food Safety Specialist with Department of Agriculture. Document the information on the Enteric Investigation Report Form.
5.
6. 7.
2.1.2 Exclusion
Excludes clients in the risk groups below according to the general guidelines, as well as any additional noted requirements.
Table 1.0: Criteria for Exclusion

Risk Group Food Handlers Criteria for Exclusion Until 2 negative stool samples have been obtained at least 24 hours apart and symptoms have cleared. Until 2 negative stool samples have been obtained at least 24 hours apart and symptoms have cleared. Check with regional laboratory for sampling protocol. Until 2 negative stool samples have been obtained at least 24 hours apart and symptoms have cleared. Check with regional laboratory for sampling protocol. Symptomatic: Exclude and have stool samples cultured for confirmation. If positive, handle as a case. If negative, exclude until symptoms have cleared and stools are well-formed. Asymptomatic: Must be evaluated on a case by case basis.
Health care, nursery or other staff who have contact with susceptible persons
Children < 5 years attending day care etc
Case contacts who are in special risk groups
2.2 Contact Tracing

N/A
2.3 Outbreak Management

If an outbreak is suspected, refer to Chapter 2 of the CD Manual-Guidelines for Outbreak Management.
2.4 Guidelines
2.4.1 Guidelines for Institutions/Long Term Care Facilities
Implement enteric precautions for the case. Refer to Table 1.0 for exclusion of staff. Contact the Department of Agriculture. 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. FSS are also able to provide environmental sanitation advice and resources. Consult with an Environmental Health Consultant if drinking water is identified as a potential source of exposure. The EH Consultant in collaboration with the MOH may request assistance from an Inspector specialist with Nova Scotia Environment.
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. Please 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_Guidelines .pdf
2.4.2 Guidelines for Child Care Centres

Refer to Table 1.0 for exclusion of staff and children. Screen close contacts of an infected child. Consider screening all children and staff if more than one case of verotoxin E. coli is identified in the daycare. Contact the Department of Agriculture. 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 assist in the
identification of other potential sources. FSS are also able to provide environmental sanitation advice and resources. Consult with an Environmental Health Consultant if drinking water is identified as a potential source of exposure. The EH Consultant in collaboration with the MOH may request assistance from an Inspector specialist with Nova Scotia Environment. 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
2.4.3 Guidelines for Long Term Carriers

None
3.0 Surveillance Guidelines

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 Report of the Committee on Infectious Diseases, 2000. American Academy of Pediatrics Screening Policies for Daycare Attendees Lessons Learned from an Outbreak of E. coli 0157:H7 in a Daycare in Waterloo, Ontario. Canadian Journal of Public Health. JulyAugust 2008.
5.0 Appendices
A. E. coli Fact Sheet English B. E. coli Fact Sheet French
E. COLI(VEROTOXIGENIC) FACT SHEET

What is Verotoxigenic E. coli?
E. coli (Escherichia coli) are bacteria that normally live in the intestines of humans and animals. Most strains are harmless but some make toxins that can cause diarrhea and more severe illness. One type of these toxin-producing strains is called Verotoxigenic E. coli. One of the more common strains is 0157:H7. Verotoxigenic E. coli can sometimes make people very sick. 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. Anyone can get Verotoxigenic E. coli.
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.
What are the symptoms?

The symptoms include: Severe bloody diarrhea Abdominal cramps Vomiting
Sometimes the infection causes non-bloody diarrhea. Sometimes there are no symptoms. Usually there is little or no fever.
What is the treatment?

Most persons recover in 5-10 days without treatment. There is no evidence that antibiotics help treat the disease.
How can you prevent Verotoxigenic E. coli?

Handle food safely: - Cook all ground beef until a thermometer pushed into center of the meat reads 71 C (160F). - Keep raw meat separate from other foods in the kitchen. - Wash hands, cutting boards and counter tops with hot soapy water if they touch raw meat. - Thaw frozen meat in the refrigerator. - Wash all fruit and vegetables before eating. Always wash hands: - Before eating or preparing food. - After using the toilet, changing a diaper, or touching an animal. Drink only water treated with chlorine or other effective disinfectants. Avoid swallowing lake or pool water while swimming. Drink only pasteurized milk, apple juice and cider. Eat only pasteurized cheese. If you have diarrhea: - Do not swim in public pools or lakes. - Do not share baths with others. - Do not prepare food for others. - Do not provide personal care for others. Use non chlorinated pools, wading pools, kiddie pools, backyard pools, hot tubs, lakes, etc. with caution.
Fiche dinformation sur lE. coli (producteur de vrotoxines)

Quest-ce que lE. coli producteur de vrotoxines?
LE. coli (Escherichia coli), aussi appel colibacille, est une bactrie qui vit dans les intestins des humains et des animaux. La plupart des souches sont inoffensives mais certaines produisent des toxines qui peuvent causer la diarrhe et des maladies plus graves. Lune des souches productrices de toxines est appele E. coli producteur de vrotoxines . La souche 0157:H7 est lune des plus communes. LE. coli producteur de vrotoxines rend parfois les gens trs malades. Chez certaines personnes (en particulier les enfants en bas de cinq ans), lE. coli producteur de vrotoxines peut provoquer le syndrome hmolytique et urmique (SHU). Cela survient dans environ 2 7 p. 100 des cas. Le SHU est une maladie grave qui dtruit les globules rouges et cause une insuffisance rnale. La plupart des gens gurissent mais la maladie peut tre mortelle. Nimporte qui peut avoir une infection lE. coli producteur de vrotoxines.
Comment lE. coli se propage-t-il?

On peut attraper lE. coli producteur de vrotoxines : en mangeant de la viande qui nest pas assez cuite, en particulier du buf hach (la contamination nest pas dcelable la vue ou lodeur); en buvant du lait ou des jus non pasteuriss; en buvant de l'eau ou en nageant dans des eaux contamines par les gouts; en caressant des animaux porteurs de la bactrie. On peut aussi attraper lE. coli en tant en contact avec les selles de personnes infectes. Cela se produit quand on ne se lave pas les mains de faon adquate. Les personnes ayant une infection lE. coli peuvent encore transmettre la bactrie pendant des jours, voire des semaines, aprs la disparition des symptmes.
Quels sont les symptmes?

Voici les symptmes possibles : Une diarrhe grave et sanglante Des crampes abdominales Des vomissements Il arrive que linfection cause une diarrhe non sanglante. Parfois, la personne infecte na aucun symptme. En gnral, lE. coli producteur de vrotoxines ne provoque pratiquement pas de fivre.
Quel est le traitement?

La plupart des gens mettent de 5 10 jours pour se rtablir, et ce, sans traitement. Il n'y a aucune preuve que les antibiotiques contribuent traiter cette maladie.
Comment prvenir une infection lE. coli producteur de vrotoxines?

Manipulez les aliments de faon scuritaire. - Faites cuire le buf hach jusqu' ce qu'un thermomtre insr au centre indique 71 oC (160 oF). - Sparez la viande crue des autres aliments dans la cuisine. - Lavez vos mains, les planches dcouper et les comptoirs avec de l'eau chaude savonneuse s'ils sont en contact avec de la viande crue. - Faites dcongeler la viande gele au rfrigrateur. - Lavez tous les fruits et tous les lgumes avant de les manger. Lavez-vous toujours les mains : - avant de prparer des aliments ou de manger; - aprs avoir t la toilette, chang une couche ou touch un animal. Buvez seulement de l'eau traite au chlore ou avec d'autres produits dsinfectants efficaces. vitez d'avaler l'eau des lacs ou des piscines lorsque vous nagez. Buvez seulement du lait, du jus de pommes et du cidre pasteuriss. Mangez seulement du fromage pasteuris. Si vous avez la diarrhe : - Nallez pas vous baigner dans une piscine publique ou un lac. - Ne partagez pas l'eau du bain avec quelquun dautre. - Ne prparez pas daliments pour les autres.
- Ne donnez pas de soins personnels quelquun dautre. Faites preuve de prudence dans les lacs ainsi que dans les piscines, les pataugeoires, les petites piscines denfants, les piscines prives, les bains tourbillons et autres lieux de baignade o leau nest pas chlore.
GIARDIASIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection with or without symptoms from stool, duodenal fluid or small bowel biopsy specimen: demonstration of Giardia lamblia OR demonstration of Giardia lambia antigen
Probable case:
1.2 Causative agent

Giardia lamblia, a protozoan.
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
2.1.4 Laboratory
2.2. Criteria for Exclusion

Health care, nursery or other staff who have General guideline contact with susceptible persons Children < 5 years attending day care etc. Case contacts who are in special risk groups General guideline Symptomatic: General guideline Asymptomatic: No exclusion required

Long term asymptomatic carriers should be educated about the proper prevention activities, (hand washing techniques, proper fecal disposal) but do not need to be excluded from risk activities.

Asymptomatic day care attendees and employees do not need to be tested. Symptomatic employees and attendees should be treated as cases.

Enteric precautions should be used while case is symptomatic.
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/ccdrrmtc/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.
GIARDIASIS FACT SHEET

What is Giardiasis?
Giardiasis an illness caused by Giardia lamblia, a parasite that lives in the intestine of people and animals. The parasite is passed in the stool of an infected person or animal. The parasite is protected by an outer shell that allows it to survive outside the body and in the environment for long periods of time.
Who Can Get Giardiasis?

Anyone can get giardiasis. Those at increased risk are: People in close contact with children or adults who have giardiasis. Children who attend child care centres. People who drink or accidentally swallow surface water that has not been properly treated (such as hikers, swimmers, and campers).

Symptoms include diarrhea, loose or watery stool, stomach cramps, and upset stomach. These symptoms may lead to weight loss and dehydration. Some people have no symptoms. It takes 1-4 weeks to get sick after being infected.

Several prescription drugs are available to treat Giardia. Consult with your health care provider. Drink plenty of fluids while ill to avoid dehydration.
How Can You Prevent Giardiasis?

Giardia is passed in the stool of humans and other wild animals and pets. Giardia can be shed in the stool for weeks to months, even if the person has no symptoms. Giardia may be found in soil, food, water, or surfaces that have been contaminated with the feces from infected humans or animals.
Ways to prevent the spread of giardia infection are:

Wash hands thoroughly with soap and water after using the toilet and before eating or handling food. Avoid swallowing recreational water (pools, hot tubs, lakes or rivers). Keep diapered children or anyone with diarrhea out of swimming pools. Avoid using ice or drinking untreated water when travelling in countries where the water supply might be unsafe. Use uncontaminated water to wash all vegetables and fruits before eating.
HEPATITIS A
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection in the absence of recent vaccination: detection of immunoglobulin M (IgM) antibody to hepatitis A virus (anti HAV) AND Acute clinical illness OR An epidemiologic link to a person with laboratory-confirmed hepatitis A infection.
Probable case:
Acute clinical illness in a person without laboratory confirmation of infection who is epidemiologically linked to a confirmed case.
1.2 Causative agent

Hepatitis A virus (HAV), an RNA picornavirus.
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.

Refer to general guidelines. In addition: Consume only shellfish purchased from an approved Department of Agriculture and Fisheries source. Do not harvest shellfish closed to harvesting by the Department of Fisheries and Oceans. Avoid eating raw shellfish. Before travelling to a country where Hepatitis A is common, consult a travel clinic (call Public Health Services for more information).
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. For infants (less than one year) and immunocompromised people, immunoglobulin is still the recommended immunoprophylaxis. 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
2.1.4 Laboratory

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food handlers Criteria for Exclusion Exclude until one week after onset of jaundice or if not jaundiced until one week after onset of symptoms. Exclude until one week after onset of jaundice or if not jaundiced until one week after onset of symptoms. Exclude until one week after onset of jaundice or if not jaundiced until one week after onset of symptoms. Symptomatic: Exclude until one week after onset of symptoms Asymptomatic: Consult with MOH to assess on a case by case basis.
Health care, nursery or other staff who have contact with susceptible persons Children < 5 years attending day care etc. Case contacts who are in special risk groups

None.

If one or more HAV cases are associated with a child care centre, or if cases are recognized in 2 or more households of the center attendees, vaccine or
immune globulin should be administered to the staff and attendees.

Enteric precautions for the case. Residents and staff in close personal contact with the index case should receive hepatitis A vaccine.
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/ccdrrmtc/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 persons stool (bowel movement).
Who Can Get Hepatitis A?

Anyone can get Hepatitis A if they havent had it before. Hepatitis A is usually spread from person to person by putting something in the mouth that has been contaminated with the stool of someone who has the virus (even though it might look clean). People at greatest risk for getting Hepatitis A include: People who share the same household with someone who is infected with Hepatitis A. Sexual partners of someone who is infected with Hepatitis A. People who travel to countries where Hepatitis A is common. Injecting and non-injecting drug users. People who eat raw or inadequately cooked shellfish.

Some adults and many children who are infected with Hepatitis A have no symptoms. Symptoms can include: Diarrhea Fever Loss of appetite Stomach pains Yellow skin Yellow eyes

There is no known treatment for Hepatitis A. Most people recover from the illness within a few weeks. Some people take a few months to recover.
How Can You Prevent Hepatitis A?

Wash hands with soap and water: o After using the toilet o After changing diapers Before touching food and before eating Before travelling to a country where Hepatitis A is common, consult a travel clinic (call Public Health Services for more information) Avoid eating raw shellfish
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
1. Information
1.1 Case definition
Confirmed case:
OCTOBER 2008
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)
1.2 Causative agent

Listeria monocytogenes, a gram-positive, rod-shaped bacterium.
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-toeat 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.

Consume only pasteurized dairy foods. Special risk groups, including pregnant women and immunocompromised individuals should avoid soft cheeses such as brie, camembert and Mexican style cheeses, refrigerated pts, smoked fish and processed, ready-to-eat meats. All meats, including hot dogs, should be properly cooked. Contact with potentially infected materials (such as aborted fetuses of farm animals) should be avoided. Thoroughly wash raw vegetables before eating. Wash hands, knives and cutting boards after handling uncooked foods. Refer to core prevention messages in the Enteric Diseases section of this manual for more information.
1.10 Prophylaxis
No prophylaxis is recommended.
2. Public Health Case Management and Control Measures

2.1 Case
Follow-up cases as soon as possible and take the following steps: 1. Contact the physician to obtain clinical information on the case. 2. Record the age, gender and address of the case. 3. Determine the mode of transmission, exploring in particular consumption of soft cheeses, processed meats, raw vegetables or other implicated food products. 4. Contact a Food Safety Specialist at the Department of Agriculture to advise them of a suspected illness: i. The Food Safety Specialist will begin an investigation of the possible source(s) of the disease. ii. They will provide information on their investigation to the investigator and the Medical Officer of Health.
2.1.1 Criteria for Exclusion

No exclusion is required.
2.1.2 Education
See Section 1.9, Core Messages for Prevention. Distribute the Listeriosis Fact Sheet to physicians, clients, families, employers, etc.
2.2 Contact Tracing

No contact tracing is required.

Follow the steps of outbreak management as outlined in Guidelines for Outbreak Management, Chapter 2 of the Nova Scotia Communicable Disease Control Manual.
2.3.1 Information for health care providers during an outbreak and/or a recall:
1. If patients have consumed food items that have been recalled and they DO NOT HAVE symptoms: i. Healthy patients: Healthy patients are not likely to become ill from eating food containing listeria bacteria. High Risk patients: In the absence of fever, bacteremia is unlikely. If they are well, no further testing is necessary, and they should be advised to seek medical attention should they develop symptoms.
ii.
2. If patients have consumed food items that have been recalled and they DO HAVE symptoms of diarrhea and fever: i. Healthy patients: NO specific investigation is required for listeria infection. Listeria-associated febrile gastroenteritis is of short duration and is self-limiting in this population. 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.
ii.
2.4 Guidelines for Laboratory Notification and Specimen Collection

The regional laboratories are to be contacted by PHS in an outbreak situation. They will communicate with the QEII anchor lab and the Provincial Public Health Laboratory Network (PPHLN), as necessary. Stool cultures are not usually recommended. Specimens of the affected sterile fluid are drawn for culture. The fluid should be collected in an appropriately labeled dry, sterile container (as used for urine cultures) and sent promptly to the laboratory with clinical details on the requisition.
Physicians are to submit the appropriate blood, CSF or sterile fluid samples for laboratory confirmation. Listeria isolates will be forwarded to the CDHA lab for confirmation and further epidemiologic testing, as soon as possible. Consider requesting provincial laboratory to forward isolates to the Public Health Agency of Canadas National Microbiology Laboratory (NML) for Pulse Field Gel Electrophoresis (PFGE) testing.
3. Surveillance 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/ccdrrmtc/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.
Who Can Get Listeriosis?

Those who are at highest risk are: Pregnant women/newborns Frail elderly people Adults with weakened immune systems from cancer, diabetes, transplant medications, kidney disease, AIDS, etc. 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.

Symptoms of may include: Fever Muscle aches Nausea / vomiting Diarrhea or constipation. Abdominal cramps Stiff neck Severe headache
If infection spreads to the nervous system, headache, stiff neck, confusion, loss of balance, or convulsions can occur. Symptoms usually show up from 2 to 70 days after eating a contaminated food. While pregnant women may only have mild symptoms, infections can lead to miscarriages, premature delivery, infection of the newborn or even stillbirth.
What should I do if Ive eaten a food recalled because of Listeria contamination?

The risk of an individual person developing Listeria infection after consumption of a contaminated product is very small. If you have eaten a contaminated product and do not have symptoms, we do not recommend that you have any tests or treatment, even if you are in a high-risk group. 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.
How Can You Prevent Listeriosis?

Contaminated food may not look, smell or taste different from safe food. The best way to reduce your risk for listeriosis is by following safe food handling procedures, washing your hands often, and avoiding certain foods if you are at higher risk of infection. Specifically: Thoroughly cook raw food from animal sources, such as beef, pork, or poultry. Wash raw vegetables and fruit thoroughly before eating. Keep uncooked meats separate from vegetables and from cooked foods and ready-to-eat foods. Avoid raw (unpasteurized) milk or foods made from raw milk. Wash hands, knives, and cutting boards after handling uncooked foods. Avoid using untreated manure (especially sheep or cattle) as fertilizer on your garden. In addition to the recommendations above, persons at high risk, such as pregnant women and persons with weakened immune systems should: Avoid soft cheeses such as brie, camembert, queso blanco fresco, and feta cheese, as they may be a source of Listeria monocytogenes. Other dairy products
such as hard cheese, processed cheese, cream cheese, cottage cheese, or yogurt can be freely consumed during pregnancy. Cook hot dogs until steaming hot before eating as hot dogs have been implicated in outbreaks of Listeria monocytogenes. Avoid refrigerated pates. Pregnant women and immunosuppressed persons may wish to avoid foods from deli counters, such as sliced packaged meat and poultry products. Avoid refrigerated smoked fish products unless they have been cooked, for example, in a casserole. Use all perishable foods that are precooked or ready-to-eat before expiration date.
Safe Food Handling

There are four main things you can do to reduce your risk of food borne illness: clean, separate, cook and chill. 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 4C (40F) or colder, and keep the freezer at -18C (0F).
NOROVIRUS
1.0 Information
1.1 Case Definition
FEBRUARY 2012
Individual cases of norovirus are not typically followed by public health. ONLY outbreaks are to be reported to public health. Any exclusions will be according to the general guidelines of enteric illness. Only case definitions for outbreak will be provided. Confirmed Outbreak: Three or more cases of clinical illness compatible with norovirus that can be epidemiologically linked to one another (i.e. associated by exposure with onsets within a 1-3 day period), at least one of which is laboratory confirmed. Institutional Outbreak: Three or more cases of clinical illness compatible with norovirus that are epidemiologically linked in an institutional setting.
1.2 Causative Agent

Noroviruses are a group of viruses that can cause gastroenteritis. The group of viruses have also been called Norwalk-like viruses (NLVs) and caliciviruses as they belong to the virus family Caliciviridae.
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.

Ensure any specimens sent to the lab from the suspect outbreak include an outbreak number.
1.5 Treatment
Supportive treatment.
1.6 Incubation Period

12 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.
1.10 Core Prevention Management

Stay home if you are ill. Thoroughly wash hands with soap and water. Do not share drinking glasses and dishes. Thoroughly clean floors, counters, commonly touched surfaces and bathrooms often when someone is ill (see section 4.0 re: cleaning practices). Food handlers and health care workers should not return to work until 48 hours after symptoms have stopped.

2.1 Case Management
Individual cases of norovirus are not typically followed by public health. ONLY outbreaks are to be reported to public health. Any exclusions will be according to the general guidelines of enteric illness.
2.2 Contact Tracing

N/A

Refer to the Outbreak chapter of the CD Manual for further information on 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 Residents 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. 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
2.3.2 Guidelines for Child Care Centres

Ill staff or children should not be at child care centres. Cleaning see SECTION 4.0. Contact the Department of Agriculture as necessary. Food Safety Specialists (FSS) may visit the facility to rule out food as a source of illness as well as conduct an inspection of the facility to identify other potential
sources. FSS are able to provide advice and resources regarding environmental sanitation. 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-November2008.pdf
2.3.3 Guidelines for Schools

Ill staff or children should not be at school. Cleaning see SECTION 4.0. Contact the Department of Agriculture as necessary. Food Safety Specialists may conduct an inspection of the food preparation facilities to rule out food as a source of illness within the school.

4.0 Cleaning Practices

Proper Cleaning and Disinfection Practices: All disinfectants must have a Drug Identification Number (DIN #) assigned by Health Canada. Follow the manufacturers directions for dilution and contact times. When organic matter is present (visible soil, vomit and/or feces) surfaces are required to be cleaned with detergent prior to disinfection. Clean surfaces first with detergent. Rinse product. Apply the appropriate disinfectant. Follow manufacturers directions for proper concentration and contact time. Apply hypochlorite-based product (5.25% Sodium Hypochlorite) at 1000 ppm or accelerated hydrogen peroxide. Grossly contaminated surface: Wear appropriate personal protective equipment if there is potential for spray during cleaning of grossly contaminated surfaces.
Ensure solid material is removed and surface is cleaned prior to disinfection. Remove gross soiled material, wiping up excrement using absorbent disposable material (e.g. paper towel) and placing in regular garbage. Disinfect the area (to a radius of 2 metres) with Household bleach or in institutions, accelerated hydrogen peroxide following manufacturers directions for dilution and contact time. 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 manufacturers 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. Institutions (e.g. LTCF, Schools, Daycares, etc): In institutional type settings, extra attention must be given to high touch surfaces including, railings, sinks, chairs, telephones, desks, toys, call bells, door handles, wall panel controls, blood pressure cuffs, IV poles and lines, keyboards, etc. Procedures for cleaning and disinfection must include appropriate contact times for the disinfectant used, appropriate strength of cleaning and disinfection solutions. Procedures must emphasize working from clean to dirty areas and eliminating double dipping a cloth into the cleaning solution after use for re-use on another surface. Cordon off vomit/fecal spills until cleaning and disinfection occurs: o Use paper towels to soak up liquids and remove solid material, throwing away the paper in a garbage bag immediately after. o Handle soiled items carefully to limit the amount of agitation and potentially aerosolized viral particles.
o Clean the area, rinse and disinfect. Follow manufacturer directions for dilution and contact time. Do not vacuum carpets that have been soiled with vomit or feces. Discard contaminated or suspect contaminated food. Cohort ill patients if possible. Cohort staff during assignment of residents. Soiled laundry (e.g. bedding, clothing) that has been soiled or used by an ill person can be washed with regular laundry: o Do not shake out sheets or clothes. o Use regular laundry detergent; wash in hot water, and dry using the warmest setting as possible. Wash hands after handling soiled laundry. o Rinsing of soiled linens is strongly discouraged. This action may aerosolize norovirus which can lead to further contamination.
5.0 References
British Columbia Provincial Infection Control Network. Outbreak Guidelines for Healthcare Facilities, June 2010 Gastrointestinal Infection
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.

Noroviruses cause gastroenteritis, a irritation of the stomach and intestines. The most common symptoms are: nausea vomiting diarrhea stomach cramps Sometimes there is a low-grade fever, chills, headache, muscle aches, and fatigue. Norovirus illness usually begins suddenly and lasts 1 to 3 days.
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 contactfor example, schools, daycare centres, long-term care facilities, health-care facilities and cruise ships.
It is important to wash hands carefully even after symptoms stop.
How is norovirus treated?

There are no medications to treat this infection. Drink plenty of fluids to prevent dehydration. See a doctor if vomiting or diarrhea lasts for more than 2 to 3 days. Healthy people usually recover on their own in about 48 hours.
Handwashing tips
What should I do if someone in my family is vomiting and has diarrhea?

Anyone who is vomiting and has diarrhea should stay home from work, school or daycare. Food handlers and health care workers should not return to work until 48 hours after diarrhea and vomiting have stopped. Wash hands often, especially after using the bathroom or changing diapers and before eating or preparing food. Thoroughly clean floors, counters, and bathrooms. Pay extra attention to surfaces that are often touched. Dont share glasses or dishes. Use separate towels for sick family members.
Wet your hands with warm running water. Add soap and scrub for at least 15 seconds. Wash all parts of your hands -- the backs, between fingers, thumbs and under the nails. Rinse off soap under running water for 5 to 10 seconds. Dry your hands with a towel. Pat them dry. Do not rub. Turn off the tap with a towel.
How should I clean if someone is vomiting and has diarrhea?

You can wear dishwashing or disposable gloves for cleaning, but they are not necessary.
Do not use these gloves for anything else other than cleaning. Throw them away them once you have finished. Use a new pair of gloves for each clean-up. To clean up vomit and feces: Use paper towels to soak up liquids and remove solid material. Throw away the paper towels in a garbage bag.
Clean the soiled area with detergent and water. Do not use the cloth or sponge for other areas of the house as this might spread the virus. Use separate cloths for the sink and for the toilet. Use cleaning cloths and sponges only once. Throw them away after you use them. Disinfect the area with a household cleaner that contains bleach or make your own bleach solution by mixing 1 part bleach with 50 parts water (20 ml of bleach to 980 ml of water). Make this solution fresh each time you need it. Make sure the disinfectant is safe for the surface being cleaned. Do not use bleach on carpets or fabrics. Allow the area to air dry. Wash your hands after cleaning, even if you wore gloves. Do not vacuum vomit or feces from carpets. Clean as above and, if possible, follow up with steam cleaning before vacuuming. To clean soiled laundry: Remove any solid material with paper towels or a gloved hand. Do not shake out soiled sheets or clothes. Wash bedding and clothing that is soiled or has been used by a sick family member with the regular laundry. Use regular laundry detergent. Wash in hot water. Dry using as hot a setting as possible. Wash your hands after handling soiled laundry.
For more information

For more information on noroviruses, visit: 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 gastroentrite. On les appelle galement les calicivirus (parce qu'ils sont membres de la famille des Calicivirids). On les appelait autrefois les virus semblables Norwalk. Les maladies causes par les norovirus sont courantes et touchent les gens de tous les ges. Elles peuvent se produire en tout temps, mais sont plus courantes pendant l'hiver.

Les norovirus causent la gastroentrite, une irritation de l'estomac et des intestins. Les symptmes les plus courants sont : la nause les vomissements la diarrhe les crampes abdominales Les symptmes comprennent aussi parfois une faible fivre, des frissons, des maux de tte, des douleurs musculaires et la fatigue. Les maladies causes par les norovirus apparaissent gnralement rapidement et durent d'un trois jours.
Comment les norovirus se propagent-ils?

Les norovirus se propagent principalement par le contact avec les vomissures ou les selles d'une personne infecte. La propagation se produit parce que : le virus peut se transmettre facilement d'une personne une autre par des mains qui n'ont pas t laves; le virus peut galement se transmettre par la nourriture, l'eau ou la glace manipule par une personne malade; lors des vomissements, des gouttelettes sont projetes dans lair sur de courtes distances; le virus peut survivre sur des surfaces telles que les poignes de porte, les comptoirs et les robinets pendant de longues priodes.
Vous pouvez contracter une maladie cause par les norovirus si vous prenez soin d'une personne infecte. Les norovirus se rpandent facilement dans des milieux o les gens ont des contacts directs, y compris dans les coles, les garderies, les tablissements de soins de longue dure, les tablissements de sant et les bateaux de croisire. Le virus est transmissible pendant la prsence des symptmes et jusqu' deux jours aprs le rtablissement. Chez certaines personnes, le virus est transmissible aussi longtemps que deux semaines aprs la disparition des symptmes. C'est pourquoi il est important de bien se laver les mains, mme si les symptmes sont disparus.
Comment est traite la maladie cause par les norovirus?

Il n'existe pas de mdicament pour traiter cette infection. Buvez beaucoup de liquide pour prvenir la dshydratation. Consultez un mdecin si les vomissements ou la diarrhe durent plus de deux ou trois jours. En gnral, il faut environ 48 heures aux gens en sant pour quils se rtablissent d'euxmmes.
Que faire en cas de vomissements et de diarrhe?

Toute personne qui souffre de vomissements ou de diarrhe doit viter de se rendre au travail, l'cole ou la garderie. Les gens qui manipulent des aliments et les travailleurs de la sant ne doivent pas retourner au travail avant un dlai de 48 heures aprs la disparition des symptmes. Lavez-vous les mains frquemment, particulirement aprs avoir t aux toilettes ou chang une couche, ou avant de manger ou de prparer des aliments. Nettoyez bien les planchers, les comptoirs et les meubles. Nettoyez particulirement bien les surfaces qui sont touches frquemment. N'utilisez pas les verres ou les assiettes des autres. Assurez-vous que les personnes malades utilisent des serviettes diffrentes.
Conseils pour le lavage des mains

Mouillez vos mains avec de l'eau tide. Ajoutez du savon et frottez pendant au moins 15 secondes. Lavez toutes les parties de la main, incluant le dos de la main, entre les doigts, les pouces et sous les ongles. Rincez le savon sous l'eau du robinet pendant 5 10 secondes. Schez-vous les mains l'aide d'une serviette. Tapotez vos mains pour les scher plutt que les frotter. Fermez le robinet l'aide d'une serviette.
Comment nettoyer la maison si quelqu'un souffre de vomissements et de diarrhe?

Vous pouvez porter des gants (p. ex. gants pour laver la vaisselle ou gants jetables) pour nettoyer, mais ils ne sont pas essentiels. N'utilisez pas les gants pour autre chose que le nettoyage. Jetez-les lorsque vous avez termin, et utilisez une nouvelle paire de gants pour chaque nettoyage. Pour nettoyer les vomissures et les selles : Utilisez des essuie-tout pour absorber les liquides et enlever les solides. Jetez les essuie-tout dans un sac ordures. Nettoyez la surface avec du dtergent et de l'eau. N'utilisez pas le chiffon ou l'ponge pour nettoyer d'autres surfaces afin d'viter de propager le virus. Utilisez des chiffons diffrents pour l'vier et pour la toilette. Utilisez les chiffons et les ponges une fois seulement. Jetez-les aprs les avoir utiliss. Dsinfectez la surface l'aide d'un produit nettoyant domestique qui contient de l'eau de Javel ou prparez votre propre solution en ajoutant une mesure d'eau de Javel 50 mesures d'eau (20 ml d'eau de Javel 980 ml d'eau). Prparez cette solution chaque fois que vous en avez besoin. Assurez-vous que le produit dsinfectant peut tre utilis en toute scurit sur la surface en question. N'utilisez pas d'eau de Javel sur les tapis ou les tissus.
Laissez la surface scher l'air. Lavez-vous les mains aprs le nettoyage, mme si vous avez port des gants.
Ne passez pas l'aspirateur pour nettoyer les vomissures ou les selles du tapis. Nettoyez selon la procdure ci-dessus et, si possible, nettoyez ensuite la vapeur avant de passer l'aspirateur. Pour nettoyer le linge sale : Enlevez toute matire solide l'aide de papier essuie-tout ou de gants. Ne secouez pas les draps ou les vtements souills. Lavez les draps et les vtements sales ou utiliss par une personne malade dans la lessive rgulire. Utilisez du dtergent lessive rgulier. Utilisez de l'eau chaude. Schez la temprature la plus leve possible. Lavez-vous les mains aprs avoir manipul du linge souill.
Pour obtenir plus de renseignements

Pour obtenir de l'information sur les norovirus, consultez le : www.phac-aspc.gc.ca/id-mi/norovirus-fra.php Pour obtenir de l'information sur la faon approprie 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.
1.2 Causative agent

Salmonella enterica, a gram negative enteric bacillus. There are over 2000 serotypes.
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).

Refer to general guidelines. In addition: Do not use raw eggs in eggnog, salad dressing, ice cream or desserts. Never use cracked or dirty eggs. Cook eggs until the yolks and whites are firm.
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.

2.1.2 Investigator
2.1.3 Physician
2.1.4 Laboratory

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food handlers Criteria for Exclusion General guidelines.
Health care, nursery or other staff who have General guidelines. contact with susceptible persons Children < 5 years attending day care etc. Case contacts who are in special risk groups General guidelines. Symptomatic: General guidelines. Asymptomatic: No exclusion required.

Chronic carriers do not need to be followed unless the risk of transmission is very likely. This may be decided on a case-by-case basis by the MOH.

For an isolated case, no action is recommended for other children or employees in a child care, as the likelihood of transmission is low. If there are epidemiologically linked cases of Salmonella in children or employees, employees, diapered attendees and food handlers should be screened and
parents should be educated about Salmonella and instructed to watch for symptoms of diarrhea. If cases continue, investigate as an outbreak.

For residents of an institution with a case of Salmonella, institute enteric precautions for that case. No action is recommended for other residents. If there are epidemiologically linked cases of Salmonella in the institution residents or employees, employees and food handlers should be screened for Salmonella.
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/ccdrrmtc/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.
Who Can Get Salmonellosis?

Anyone can get Salmonella. People who are most likely to get a severe infection include the elderly, infants and those with weak immune systems, such as people with HIV infection.

The symptoms usually begin 12 to 36 hours after infection but can occur from 6 to 72 hours, and include: Diarrhea Fever Stomach cramps Nausea Vomiting

Usually salmonella infections do not need to be treated. The person generally recovers in about 5 to 7 days. In some severe cases, people need to be treated in a hospital to receive fluids and antibiotics.
How Can You Prevent Salmonellosis?

You can prevent a salmonella infection by: Washing hands with soap and water after using the toilet, changing diapers, touching pets, and before and after handling foods. Eating only well cooked meats, poultry, or eggs; and washing hands after touching these uncooked foods. Avoiding unpasteurised milk or cheese. Keeping raw foods away from cooked foods by washing cutting boards, utensils, and hands, and throwing out used packages. Keeping raw foods separated from cooked foods by washing cutting boards and utensils after use and not reusing meat trays or other packaging.
SHELLFISH POISONING (AMNESIC, DOMOIC, PARALYTIC)

1. Information
There are two main types of shellfish poisoning that have occurred in Nova Scotia: paralytic (PSP) and domoic. Both types are covered in this section.
1.1 Case definition

Paralytic Shellfish Poisoning 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).
Domoic Shellfish Poisoning Confirmed Case:

Confirmation of the shellfish toxin (Domoic acid) from the contaminated tissue.
Probable Case:
Clinical presentation of symptoms and recent consumption of shellfish.
1.2 Causative agent

Domoic: Domoic acid, found in shellfish. PSP: Saxitoxins, found in shellfish.
1.3 Symptoms
Domoic: Acute symptoms include vomiting, diarrhea, headache and in some cases, confusion, loss of memory, disorientation, and seizures. PSP: Clinical illness is characterized by neurological symptoms such as paresthesia and/or paralysis involving the mouth and extremities, which may be accompanied by gastrointestinal symptoms.
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.

Purchase shellfish from Department of Agriculture and Fisheries approved sources only. Do not harvest shellfish from areas that have been marked as contaminated by the Department of Agriculture and Fisheries.
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.

Use general guidelines as well as additional guidelines re: a) Contacting Department of Agriculture and Fisheries. Call the Department of Agriculture and Fisheries to alert them to cases of shellfish poisoning and to identify who at the Department of Agriculture and Fisheries will be the contact for the Investigator. b) Alerting the public when appropriate. Provide factual information about the outbreak to the public. No information about individual cases should ever be disclosed to the public. c) Determine whether an outbreak has occurred. If complaints of illness are connected with the same eating places, food purchases or area of catch, and there is a close association of time, the probability that an outbreak has occurred is high. For PSP, precautionary control measures to stop the spread of the toxicant must be implemented.
2.1.2 Physician
2.1.3 Laboratory
2.1.4 Shellfish Investigator

Additional guidelines re: a) Contacting Department of Agriculture and Fisheries. Contact the person identified by the MOH (see step a above) to ensure that all specimen collection and follow-up is delegated to appropriate personnel. If necessary, designate one agency to be a source of public information and direct inquiries to this agency. b) Determine source of the toxic product. Try to determine if the shellfish was bought from a food shop, eating establishment, fish vendor, individual or other source. The designated individual from the Department of Agriculture and Fisheries will initiate the removal of the product. If the product was harvested or dug by individuals, determine
the area where the shellfish was harvested and inform the Department of Agriculture and Fisheries designate. The designated individual, as necessary, will contact the Department of Fisheries and Oceans. c) Identify and follow-up contacts who may have shared the food.

None.

None.

None.

None.
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/ccdrrmtc/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.
Who Can Get Shellfish Poisoning?

Anyone who eats contaminated shellfish that contain the poisons can get shellfish poisoning. Normal boiling, steaming or any other method of cooking does NOT destroy the poison.

Numbness and tingling around the lips and tongue Numbness and tingling in the hands and feet Muscle weakness, lack of muscle coordination Slurred speech Paralysis These symptoms may lead to coma, breathing problems and death.

There is no cure, antidote or vaccine for shellfish poisoning. If you suffer any of these symptoms after eating shellfish, contact your doctor or emergency centre immediately.
How Can You Prevent Shellfish Poisoning?

Shellfish should only be bought and eaten from restaurants and markets or sources approved by the Department of Agriculture and Fisheries. If you are planning to harvest shellfish, contact the Department of Agriculture and Fisheries to be sure the area is open to shellfish harvesting.
SHIGELLOSIS
1. Information
1.1 Case definition
Confirmed case:
Laboratory confirmation of infection with or without clinical illness: isolation of Shigella sp. from an appropriate clinical specimen (e.g. sterile site, deep tissue wounds, stool, vomit or urine)
Probable case:
1.2 Causative agent

The bacteria Shigella have 4 subgroups dysenteriae, flexneri, boydii, and sonnei. S.dysenteriae is often associated with severe illness.
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
2.1.3 Physician
2.1.4 Laboratory

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food handlers Criteria for Exclusion Until 2 negative stool samples have been obtained at least 24 hours apart and at least 48 hours after discontinuance of antibiotics and symptoms have cleared. Until 2 negative stool samples have been obtained at least 24 hours apart and at least 48 hours after discontinuance of antibiotics and symptoms have cleared. Until 2 negative stool samples have been obtained at least 24 hours apart and at least 48 hours after discontinuance of antibiotics and symptoms have cleared. Symptomatic: Exclude and have stool samples cultured for confirmation. If positive, handle as a case. If negative, exclude until symptoms have cleared and stools are well formed. Asymptomatic: This must be evaluated on a case by case basis.
Health care, nursery or other staff who have contact with susceptible persons Children < 5 years attending day care etc.
Case contacts who are in special risk groups

Long term carriers are rare, exclude from risk activities during carriage.

For an isolated case, no action is recommended for other children or employees in a day care. If there are epidemiologically linked cases of Shigella in children or employees, stool cultures should be done on all staff and attendees in order to identify and treat positive individuals. Hand washing practices should be thoroughly reviewed.

For residents of an institution with a case of Shigella, institute enteric precautions for that case. No action is recommended for other residents. If there are epidemiologically linked cases of Shigella in the institution residents or employees, employees with direct contact and food handlers should be screened for Shigella. If cases continue, investigate as an outbreak
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/ccdrrmtc/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.
Who Can Get Shigellosis?

Anyone can get Shigellosis, but people at increased risk include: People who travel to certain foreign countries. Men who have sex with men. People who live in institutions.

The symptoms of Shigellosis include: Diarrhea Stomach cramps Fever Vomiting or upset stomach

People with mild cases often recover on their own. For more serious cases, a physician can prescribe antibiotics to treat shigellosis.
How Can You Prevent Shigellosis?

To prevent shigellosis: Wash hands carefully after using the toilet, after changing diapers and before preparing or eating food. Avoid swallowing recreational water (pools, hot tubs, lakes or rivers). Keep diapered children or anyone with diarrhea out of swimming pools. Help children to wash their hands properly. Avoid using ice or drinking untreated water when travelling in countries where the water supply might be unsafe.
TRICHINELLOSIS
1. Information
1.1 Case definition
Confirmed case:
Clinically compatible symptoms with a positive muscle biopsy or positive serology.
Probable case:
Clinically compatible symptoms and epidemiologically linked to a confirmed case or to meat known to contain trichinella larvae.
1.2 Causative agent

Trichinella spiralis, an intestinal nematode.
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
2.1.3 Physician
2.1.4 Laboratory

None.

None.

None.

None.
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/ccdrrmtc/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.
Who Can Get Trichinellosis?

Anyone who eats raw or undercooked meat, especially pork or wild animals is at risk for trichinosis. The disease is not passed from human to human.

Some people only have mild symptoms while other people develop a very serious illness. The first symptoms of trichinosis include: Nausea Diarrhea Vomiting Stomach pain Symptoms may also include: Fever Chills Eye swelling Aching joints and muscle pains In severe cases, patients may have heart and breathing problems. In severe cases, death can occur.

There are drugs that your health care provider can give you to help treat trichinosis. If you suspect that you have eaten infected meat, you should see your doctor immediately.
How Can You Prevent Trichinellosis?

Cook meat products until the juices run clear or to an internal temperature 71 C (160F). Freeze pork less than 15 cm (6 inches) thick for 30 days at -15 C (5 F) to kill any worms. Cook wild game meat thoroughly. Freezing wild game meats, unlike freezing pork products, even for long periods of time, may not effectively kill all worms. Cook all meat fed to pigs or other wild animals. Clean meat grinders thoroughly if you prepare your own ground meats. Curing (salting), drying, smoking, or microwaving meat does not consistently kill worms.
TYPHOID & PARATYPHOID FEVER

1. Information
1.1 Case definition
Typhoid:
Clinical illness with laboratory confirmation of infection: isolation of Salmonella typhi from an appropriate clinical specimen.
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.
1.2 Causative agent

Salmonella typhi and Salmonella paratyphi.
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.

2.1.2 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
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.

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food handlers Criteria for Exclusion Until 2 negative stool samples have been obtained at least 24 hours apart and at least 48 hours after discontinuance of antibiotics.
Health care, nursery or other Until 2 negative stool samples have been staff who have contact with obtained at least 24 hours apart and at least susceptible persons 48 hours after discontinuance of antibiotics. Children < 5 years attending Until 2 negative stool samples have been day care etc. obtained at least 24 hours apart and at least 48 hours after discontinuance of antibiotics. Case contacts who are in special risk groups Symptomatic: Exclude and have stool samples cultured for confirmation. If positive, handle as a case. If negative, exclude until symptoms have cleared and stools are well formed. Asymptomatic: This must be evaluated on a case by case basis.

If a person remains positive for more than 12 months, they may be considered a chronic carrier. 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.

No action is indicated for a single case (except for exclusion as noted above). If more than one case occurs in a child care attendee or staff, all other staff and attendees of the day care should be cultured. Staff and attendees with positive
cultures should be excluded and investigated as a case of typhoid or paratyphoid fever. The MOH may grant or deny readmission to the child care centre based on the likelihood of transmission. Parents should be educated about typhoid and paratyphoid fever and instructed to watch for symptoms of diarrhea.

For residents of an institution with a case of typhoid or paratyphoid fever, institute enteric precautions for the case until the case has 2 negative stool cultures. No action is recommended for other residents. If there are 2 or more cases in the institution, residents, employees, food and handlers should be screened.
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/ccdrrmtc/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.
Who Can Get Typhoid Fever?

Anyone can get typhoid fever if they: Eat or drink contaminated food or liquids. Are in close contact with another child or adult who has typhoid fever, such as a family member, daycare or a residential institution. 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.

Fever Headache Red spots on the trunk of the body Slow heart rate Constipation more often than diarrhea

Your doctor can prescribe an antibiotic to treat the disease. Persons given antibiotics usually begin to feel better within 2 to 3 days. People who do not get treatment may continue to have a fever for weeks or months, and as many as 20% may die.
How Can You Prevent Typhoid Fever?

This disease is seen mostly in travellers. Wash hands with soap and water after using the toilet, changing diapers, touching pets, and before and after handling foods.
Avoid unpasteurised milk or cheese. Eat only well-cooked shellfish, wash hands after touching these uncooked foods. Keep salads and cold foods refrigerated after preparation. Do not let food stand at room temperature. Typhoid vaccine is recommended for people travelling to countries where there is a high risk of the disease. When travelling to affected areas, take precautions to avoid contaminated food and water.
VIRAL GASTROENTERITIS
1. Information
1.1 Case definition
Laboratory isolation of a small round structured virus or Norwalk-like virus, rotavirus, astrovirus or enteric adenovirus.
1.2 Causative agent

Small round structured virus or Norwalk-like virus, rotavirus, astrovirus or enteric adenovirus.
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
2.1.4 Laboratory

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements:
Risk Group Food handlers
Criteria for Exclusion General guideline.
Health care, nursery or other staff who have General guideline. contact with susceptible persons Children < 5 years attending day care etc. Case contacts who are in special risk groups General guideline. Symptomatic: General guideline. Asymptomatic: No exclusion required.

None.

Staff and attendees should wash hands upon arrival at the centre, after using the toilet and after a diaper change. Shared surfaces, such as toys should be disinfected on a daily basis.

Enteric precautions for the 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/ccdrrmtc/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.
Who Can Get Viral Gastroenteritis?

Viral gastroenteritis affects people in all parts of the world. Viral gastroenteritis outbreaks can occur in institutional settings, such as schools, child care facilities, and nursing homes. Or in other group settings, such as banquet halls, cruise ships, dormitories, and campgrounds. Food can be contaminated by infected food handlers especially if they do not wash their hands after using the toilet. Shellfish and drinking water can be contaminated by sewage. The viruses are also spread by close contact with infected people.

The symptoms of viral gastroenteritis may include: Diarrhea (non-bloody) Nausea Vomiting Stomach cramps Headache Fever Chills Muscle ache Symptoms begin 1 to 2 days following infection with a virus. The illness usually lasts between 12 and 60 hours.

There are no drugs to cure viral gastroenteritis. It is important to drink plenty of fluids to prevent dehydration.
How Can You Prevent Viral Gastroenteritis?

You can reduce your chance of getting infected by: Frequent hand washing after using the toilet and before preparing or eating food. Avoid eating raw or undercooked shellfish. Avoid drinking water from lakes, streams and rivers. Keep household surfaces clean, such as sinks, countertops, etc.
YERSINIOSIS
1. Information
1.1 Case definition
Clinical findings consistent with enterocolitis and isolation of Yersinia enterocolitica, usually from a stool culture but may be from throat swab, blood, peritoneal fluid, synovial fluid, bile, urine, cerebrospinal fluid, sputum, wounds and/or mesenteric lymph nodes. Clinical findings consistent with pseudotuberculosis and isolation of Yersinia pseudotuberculosis from stool cultures, and also from throat swabs, mesenteric lymph nodes, blood and/or peritoneal fluid.
1.2 Causative agent

Yersinia enterocolitica or Yersinia pseudotuberculosis; both are Gram-negative rod bacteria.
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.

2.1.2 Investigator
2.1.3 Physician
2.1.4 Laboratory

Exclude clients in the risk groups below according to the general guideline as well as any additional noted requirements: Risk Group Food handlers Health care, nursery or other staff who have contact with susceptible persons Children < 5 years attending day care etc. Case contacts who are in special risk groups Criteria for Exclusion General guideline. General guideline.
General guideline. Symptomatic: General guideline. Asymptomatic: No exclusion required.

None.

None.

Enteric precautions for the 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/ccdrrmtc/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.
Who Can Get Yersiniosis?

Anyone can get Yersiniosis. However, children are infected more often than adults.

Symptoms in young children include: Fever Stomach pain Diarrhea, which is often bloody In older children and adults, symptoms include: Right-sided pain in the stomach area that may be confused with appendicitis. Fever. In some cases, people will get a skin rash or joint pain.

Most mild cases do not need any special treatment. In more serious cases, your doctor can prescribe antibiotics.
How Can You Prevent Yersiniosis?

Avoid eating raw or undercooked pork. Consume only pasteurised milk or milk products. Wash hands with soap and water before eating and preparing food, after contact with animals, and after handling raw meat. Use separate cutting boards for meat and other foods. Carefully clean all cutting boards, counter-tops, and utensils with soap and hot water after preparing raw meat. Dispose of animal feces in a sanitary manner.
BLOOD BORNE PATHOGENS

List of Section Contents
Principles General Guidelines Hepatitis B Hepatitis C HIV/AIDS Management of Occupational Exposures to HBV, HCV, & HIV Lookback/Traceback Protocol
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.

1.1. Role of the Medical Officer of Health
1.1.1. Determine investigative responsibility
It is the responsibility of the Medical Officer of Health (MOH) to ensure that reports of cases of blood borne pathogens once received are disseminated in a timely manner to the appropriate personnel for investigation within each district.
1.1.2. Ensure confidentiality

It is the role of the MOH to ensure that confidentiality is maintained for all records of exposures to blood borne pathogens.
1.1.3. Review high-risk situations.

MOH reviews high-risk situations to determine if further investigations or interventions are required.
1.2. Role of the Investigator:

Effective follow-up will occur as a result of a collaborative working relationship developed between the investigator and the physician, clinician or nurse practitioner working in the physician's office. It is useful, where possible, to discuss and negotiate procedure and protocol responsibilities with all physicians in the community to ensure consistent and effective case management.
1.2.1. Contact physician named on lab report.

Inform the physician about the reporting system. Discuss the status of the case. It may be useful to supply the physician with a fact sheet on the related disease to facilitate contact between the physicians office and the client. A call is not necessary when the physician refers a case to PHS and provides information regarding the case.
1.2.2. Discuss investigators responsibilities.

Inform the physician that HIV follow-up is done with the physician only. The client will not be contacted by the investigator unless assistance is requested by the physician or the individual requests assistance with partner notification, or the individual donated or received blood, organs or other tissue since 1977. Inform the physician that hepatitis B follow-up is done by Public Health. The individual and their partners are contacted by Public Health. Inform the physician that hepatitis C follow-up is done by Public health. The partners are not followed-up. If the physician asks that you do not become involved with hepatitis B or hepatitis C follow-up (or has already completed education and partner notification), stress that it is crucial that the physician complete these two components with the individual. If the investigator has concerns about the extent to which partner notification has taken place, this concern should be discussed with the MOH.
1.2.3. Contact individual.

Telephone from a caller ID blocked phone or visit the individual to begin investigation. a) Ensure the confidentiality of the case. Do not relate that you are calling from PHS if someone else answers the phone. When you reach the individual by phone, ask if the individual is alone and comfortable talking. If phone contact is unsuccessful, make a home visit. If there is no response when the visit is made, leave a message in the mailbox in a plain envelope for individual to call investigator. If there is no response to
this message, registered letter should be sent. Do not include information about the disease in letters. If the individual is a teenager, contact at school. Arrange to meet the individual at their home, at a PHS office or other convenient location where confidential discussion can occur. The interview may be done over the phone depending on what is best for the individual and the investigator. b) Set the tone for the conversation. Do not appear judgemental. Be supportive and accepting and inform the individual that everything is confidential. Use appropriate fact sheets. Discussion of various sexual activities and preferences should be open and comfortable, so that the individual feels free to ask questions. Attempt to determine the route of infection. In cases where transmission by receipt of blood products may be a risk or where the infected individual has donated blood a lookback or traceback may need to take place (see Blood Borne Pathogens Appendix 1). Educate the individual about the disease and prevention. Educate the individual about blood borne pathogens. Discuss symptoms to look for, post-exposure prophylaxis for partners, long-term outcomes, risk factors, and prevention of transmission. High-risk behaviours include unprotected sex and/or multiple partners and sharing needles, paraphernalia and wash. Determine responsibility for partner notification. Definitions related to partner notification are included in Blood Borne Pathogens Appendix 1. Explain the importance of partner notification to the client. Inform the client that he/she may contact their partners to notify them of potential infection, or PHS can conduct partner notification on their behalf. Present partner notification as a service that PHS provides to assist the individual in possibly uncomfortable situations. Make it clear to the client that partner notification by PHS will not involve his or her own identification to the partners. If the client chooses to notify his/her own partners, request that the client inform you about their success in informing partners. For Hepatitis B follow up, the Public Health Nurse should also contact partners to ensure post-exposure prophylaxis is completed.
c)
d)
1.2.4 Conduct partner notification.

Notification of partners should be started as soon as names are obtained. Refer to Section 1.2.2.
1.2.5 Follow-up testing and post-exposure prophylaxis.

Regardless of who conducts partner notification (client or PHS) partners should be advised of options for follow-up testing and post-exposure prophylaxis if appropriate (see specific disease section). The name and work phone number of the investigator should be provided in case the individual has questions.
1.2.6 Alert MOH to high-risk situation.

A high-risk situation is any situation where: there is reason to suspect that a client has not or may not notify partners, or a situation where it is highly suspicious that the individual is taking part in high risk behaviours without informing their sexual or injection drug use partner(s). injection drug users or sex trade workers. individual has received or donated blood or blood product, semen or body tissue.
1.2.7. If a report is received by PHS of a sexually transmitted disease in a child younger than 16 years, the investigator must call the family physician.
Nova Scotia Law states that any suspicion of sexual abuse in a child under the age of sixteen must be reported immediately to local Child Protection Agency. (Ref: Children and Family Services Act, 1991. C.5.-Mandatory Reporting Provisions, Section 23). Procedure for Potential Cases of Child Abuse In speaking with the physician, mention reporting under the law and ask if the physician, clinician and/or nurse practitioner are suspicious of abuse and what has been done about this. If the physician is certain that the disease is not a result of sexual abuse then reporting is unnecessary.
However, if the physician is uncertain and has not reported the possible case, discuss the case and your reporting responsibilities with the physician and ensure that one of you will take responsibility to report it immediately to the local child protection agency (in the blue pages of your local telephone book) if deemed necessary. After working hours report to the local police or RCMP; they will put you in touch with the caseworker on call at that time. If you have any doubt about the physician reporting the case, then call, The Childrens Aid Society and report it again. Never should the situation be handled within the family.
1.2.8. Complete surveillance forms.

1.3. Role of the Family Physician:

1.3.1. Report.
It is the responsibility of the physician to report all blood borne pathogens to the Medical Officer of Health as follows: Within 1 working day by telephone: Hepatitis B Within 5 working days by reporting form: Hepatitis C Contact PHS for special case reporting guidelines: HIV
1.3.2. Patient treatment, education and follow-up.

Collaborate with Public Health Services in the districts. Where possible, be aware of the information provided to the patient by the PHS investigator or the attending physician if different than the family physician. It is useful to discuss and negotiate procedure and protocol responsibilities with the MOH or PHS investigator and all physicians in the community to ensure consistent and effective case management.
1.3.3. Partner notification.

Public Health does the follow-up for hepatitis B. No partner notification is done for hepatitis C. If the physician's office staff or the HIV positive client cannot provide timely partner notification for HIV, the physician should contact PHS for
assistance. Confidentiality will be maintained throughout the partner notification procedure.
1.3.4. Any suspicion of sexual abuse in a child under the age of sixteen must be reported as soon as possible.
Report to the local child protection agency (in the blue pages of your local telephone book). After working hours, contact the local police or RCMP to reach the after hours authorities on call.
1.4 Role of the Laboratory:

It is the responsibility of the laboratory to report in writing to PHS all laboratory results of confirmed HIV, HBV and HCV. All new cases of HBV require telephone reporting as soon as possible.
2. Criteria for Exclusion

In general, there is no need for exclusion from work provided that individuals are informed and are able to minimize high-risk activities.
2.1. Special case for food handlers.

HBV, HCV, and HIV positive food handlers may continue to handle food. For all situations when food handlers cut themselves while handling food, the food must be disposed of and the preparation area cleaned and disinfected. The wound itself should be cleansed and bandaged after the bleeding has stopped. Following an incident, the food handler should wear gloves for a minimum of 24 hours and until the cut is healed well enough so that the risk of spontaneous bleeding is minimal.
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 Clearance of HBsAg in a person who was documented to be HBsAg positive within the last six months in the context of a compatible clinical history 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
1.2. Causative agent:

Hepatitis B virus (HBV), a DNA virus.
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 2550% of children infected at age 15 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. Hepatitis B vaccination is recommended in three doses at 0, 1 and 6 month intervals. Consult the latest edition of the Canadian Immunization Guide for details about specific dosages, booster dose, post vaccination serologic testing, etc. Refer to Table 3 (after the post-exposure prophylaxis component of this section) for details about the availability of publicly funded pre-exposure immunization. Vaccines produced by different manufacturers may be used interchangeably.
1.10.2 Post-exposure
a. Percutaneous or permucosal exposure Refer to Management of Occupational Exposures later in this section of the manual. b. Contacts of a HbsAg+ case All sexual contacts of acute cases and all household and sexual contacts of carriers should be vaccinated.
If prophylaxis can be started within 14 days of the last sexual contact with the HBV infected person, a single dose of HBIG (0.06 mL/kg) should also be given. Sexual assault victims should be managed in the same manner if the HbsAg status of the assailant cannot be determined. HBIG is not indicated for nonsexual household contacts, with the exception of infants <12 months whose mother or primary care giver is acutely or chronically infected and persons with identifiable exposure to the blood of an infected person (e.g. through sharing of razors). Table 1: Interpretation of HBV Serological Results Note that IgM class antibodies rise at the onset of symptoms and indicate acute infection. IgG antibodies appear at recovery and indicate immunity. HBsAg HBcAb IgM (antiHBc IgM) + + + + or HBc Ab (anti HBc) + + + + + + HBsAb (antiHBs) HBeAg HBeAb (antiHbe)
+ + + + + -
+ or + + +
+ + or -
+ or + + or + or + or -
Incubation period Acute hepatitis B Early convalescent period Late convalescent period Chronic persistent hepatitis HBsAg carrier state Past infection Vaccine
Definition of terms: HBsAg: hepatitis B surface antigen HBcAb IgM: IgM antibody to hepatitis B core antigen HBcAb (anti- HBc): IgG antibody to hepatitis B core antigen HBsAb (anti-HBs): antibody to hepatitis B surface antigen HBeAg: hepatitis B eantigen (denotes high infectivity) HBeAb (anti-Hbe): antibody to hepatitis B eantigen
Table 2: Funding for Hepatitis B Vaccine Adapted from the Canadian Immunization Publicly Funded Guide A. Universal immunization grade 4 Yes B. High risk pre-exposure prophylaxis* No 1. Persons with occupational risk, including health care workers and others who are exposed to blood or blood products or at increased risk of injury by blood contaminated instruments. 2. Residents and staff of institutions for the developmentally challenged. 3. Sexually active homosexual or bisexual men. 4. Heterosexual males or females with multiple sexual partners or a history of STD. 5. Injection drug users. 6. Hemophiliacs or others receiving repeated infusions of blood or products. 7. Hemodialysis patients. 8. Inmates of long term correctional facilities 9. Household and sexual partners of HBV carriers (HBsAg+) . 10. Children below the age of 7 whose families have immigrated to Canada from areas where there is a high prevalence of hepatitis B and who may be exposed to HBV carriers through their extended families. 11.International travellers to hepatitis B endemic areas who will reside in the area for longer than 6 months, or shorter term travellers who are likely to have contact with blood from or sexual partner with in areas with high levels of endemic disease. 12. HCV positive individuals. Situation dependent* No* No* Yes Yes Yes No Yes No
No
Yes
13. HIV positive individuals. C. Post exposure prophylaxis 1. Infants born to HBsAg+ mothers.
Yes Yes
2. Infants less than 12 months of age who are Yes exposed to a household case of acute HBV infection.
3. Sexual contacts of an acute case.
Yes
4. Persons with occupational or accidental Yes percutaneous or permusocal exposure to HbsAg+ blood *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.

2.1.1. Medical Officer of Health:
Use general guidelines. Also use the following guidelines re: a. Assessing high-risk situations. Assess high-risk situations where the use of publicly funded vaccine for hepatitis B may be appropriate.
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). In addition to the general guidelines, also use the following re: a. Educating the Client. Educate clients about the following: Range of clinical presentation from no symptoms to very ill. Incubation period. Routes of transmission, risk behaviours and prevention outlined in the general guidelines section. High infectivity of HBV. Low infective dose.
Long-term prognosis and concept of carrier status. 5-10% of HBVinfected adults become carriers, and 10-20% of carriers have problems later in life with cirrhosis or liver cancer. Reassure and support clients when discussing long-term prognosis. Perinatal transmission and the importance of identifying any contacts who may be pregnant. Children have a much greater chance of becoming carriers. Suspicion of HBV in a pregnant woman warrants action to confirm diagnosis. If positive, ensure appropriate follow-up.
b. Educating and Following-Up Carriers. In addition to the education provided to persons with acute Hepatitis B infection as described above, education for carriers should also include: The carrier (and the investigator) should encourage household contacts and existing or new sexual partners to be vaccinated. The carrier should be encouraged to inform their dentist and physician of their carrier status. One follow-up visit with clients when they are determined to be carriers is warranted to review information about the carrier state and proper prevention. Once the carrier has been educated, the carriers name and address should be added to the district database in order to avoid repeated follow-up of this person.
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). b. Following individuals who are HBsAg+. In discussion with PHS, do follow-up testing in six months to determine if the individual becomes a carrier.
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.
2.3. Guidelines for Child Care Centres

Hepatitis B infected children do not need to be excluded from childcare. If the child is known to bite, this should be discussed with the MOH.
3.0 SURVEILLANCE 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.phacaspc.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 Childs Best Shot: A Parents 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.
How Do You Get Hepatitis B?

The virus can be spread during sex, by sharing dirty needles to inject drugs, or by getting blood or other infected body fluids in a mucous membrane (mouth or eyes) or on broken skin. It may be sexually transmitted through genital or anal contact with an infected person. The virus also can be passed from mother to baby, usually at the time of birth. The virus is not spread by casual contact. It takes 2-6 months from the time of exposure to onset of symptoms.

The virus is in the body for several weeks before symptoms start until several months after. Up to 50% of people who have hepatitis B have no symptoms. Of adults who get hepatitis B, 5-10 % will go on to carry the virus for the rest of their lives. Symptoms may include: Tiredness Loss of appetite Fever Vomiting Yellow skin and eyes (jaundice) Urine dark in colour, stool light in colour A blood test is needed for the diagnosis of hepatitis B.

There is no special treatment for hepatitis B. People with hepatitis B need rest and a proper diet. Some people need to be hospitalized, and some will need to take a medication prescribed by their doctor. Alcohol should be avoided. Talk to your doctor before taking any over the counter medication.
How Can You Prevent Hepatitis B?

Practice safer sex. Do not share needles, razors, toothbrushes, sexual toys etc. Clean up spills of body fluids or blood of an infected person with a 1:10 solution of household bleach. If you are at high risk of contracting hepatitis B, you should receive hepatitis B vaccination. Use only professional tattoo artists and body piercing artists working in legitimate, reputable salons.
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)
1. INFORMATION
1.1. Case Definition
JULY 07
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 manufacturers 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.
1.2. Causative Agent

Hepatitis C virus, a RNA virus. Genotype 1 is the predominant type of hepatitis C in Canada, but all types have been seen.
1.3. Laboratory Testing

HCV screening tests are performed at regional laboratories in Nova Scotia. All screen positive HCV screening tests are sent to the QEII Health Sciences Center virology laboratory for confirmatory testing. a. Nominal Testing Nominal testing means that the clients 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 clients 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.
1.10. Core Prevention Messages

Use the general guidelines in the Blood Borne Pathogens chapter (section 4.0 Core Messages for Prevention). In addition use standard precautions in settings where there is a risk of exposure and at home where there is a known HCV infected person. (See manual section on standard precautions.)
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.
2.1 General Guidelines

Refer to the General Guidelines at the front of the Blood Borne Pathogens chapter of the Communicable Disease Control Manual.
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 cases 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/ccdrrmtc/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

What is Hepatitis C?
FEBRUARY 2008
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.
How Do You Get Hepatitis C?

Exposure to blood and body fluids; Injection drug use. The virus can be spread by sharing or re-using needles; Receiving a transfusion or blood products. Blood products have been tested for hepatitis C since 1990. The risk of receiving hepatitis C from a transfusion is very low; An infected mother can pass the infection to her newborn child; Having sex with someone who has hepatitis C (rare).

Many people with hepatitis C have no symptoms. Symptoms may include: Tiredness Loss of appetite Abdominal pain Fever Vomiting Yellow skin and eyes (jaundice)

Treatment is available for hepatitis C, but it is lengthy, has side effects and may not be suitable for all patients. People with hepatitis C need rest and a proper diet. Alcohol should be avoided. Talk to your doctor before taking any over the counter medication. Ask your doctor or Public Health Services about immunization against hepatitis A and B.
How Can You Prevent Hepatitis C?

Do not share needles, razors, toothbrushes, nail clippers, sexual toys, etc Clean up spills of blood of an infected person with a 1:10 solution of household bleach Use only professional tattoo artists and body piercing artists working in legitimate, reputable salons Practice safer sex
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
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 Children < 18 months (on two separate samples collected at different times): 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

Human immunodeficiency virus (HIV-1 and HIV-2), a retrovirus HIV-1 is the predominant strain in Canada and worldwide.
1.3. Laboratory Testing

HIV screening tests are performed at regional laboratories in Nova Scotia. All positive HIV screening tests are sent to the QEII Health Sciences Centre virology laboratory for confirmatory testing. 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 clients 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 clients 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 clients 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. Persons are then asymptomatic for months to years.
1.5. Incubation
Antibodies can typically be detected in the blood 3 to 6 weeks after infection but in some cases it can take up to 6 months before antibodies are detectable.
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
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.

Use the general guidelines in the Blood Borne Pathogens chapter (section 4.0 Core Messages for Prevention). In addition, use standard precautions in settings where there is a risk of exposure and at home where there is a known HIV infected person. (See manual section on standard precautions).

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.

Refer to the General Guidelines at the front of the Blood Borne Pathogens chapter of the Communicable Disease Control Manual.
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 cases 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.
2.3.1. Definition of Contacts

An individual who has had contact with blood, body fluids, cells, organs and tissues from an HIV infected individual.
2.3.2. Susceptibility
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 ongoing basis.
2.3.5. Follow-Up
No follow up is necessary.
2.3.6. Education
See Section 4, Core Prevention Messages.

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/ccdrrmtc/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=CHNRCS%2FPage%2FGTPageTemplate&c=Page&lang=En http://www.cdc.gov/hiv/
HIV FACT SHEET

What is HIV?
JUNE 2008
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).
How do you get HIV?

You can get HIV by: having sex without a condom or oral dam with someone who has HIV exposure to blood and body fluids contaminated with HIV injection drug use ( the virus can be spread by sharing or re-using needles and other injection equipment) receiving a transfusion of blood products (blood products have been tested for HIV since 1985) 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.

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.
How can you prevent HIV infection?

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.
1.2. Occupational Transmission of HBV

1.2.1. Risk
HBV infection is a well-recognized occupational risk for HCP (25). The risk of HBV infection is primarily related to the degree of contact with blood in the work place and also to the hepatitis B e antigen (HBeAg) status of the source person. In studies of HCP who sustained injuries from needles contaminated with blood containing HBV, the risk of developing clinical hepatitis if the blood was both hepatitis B surface antigen (HBsAg)- and HBeAg-positive was 22%-31%; the risk of developing serologic evidence of HBV infection was 37%-62%. By comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAgpositive, HBeAg-negative blood was 1%-6%, and the risk of developing serologic evidence of HBV infection, 23%-37% (26).
1.2.2. Efficacy of Post Exposure Prophylaxis for HBV

Prospective studies have evaluated the effectiveness of HBV immune globulin (HBIG) and/or HBV vaccine in various settings. In occupational settings, multiple doses of HBIG initiated within one week after a percutaneous exposure to HBsAg-positive blood provides 75% protection from HBV infection. Although the efficacy of the combination of HBIG with the HBV vaccine series has not been evaluated in comparison to the HBIG alone, the increased efficacy of this regimen in the perinatal setting is assumed to apply in the occupational setting as well (combining HBIG and the HBV vaccine series at birth for infants exposed to a HBsAg and HbeAg positive mother is 85%-95% effective in preventing HBV infection). Anyone who requires post-exposure prophylaxis who is at continued risk for HBV exposure should receive the HBV vaccine series.
1.3. Occupational Transmission of HCV

1.3.1. Risk
The risk of transmission of HCV in occupational settings is low. The incidence of seroconversion after percutaneous exposure is estimated to be 1.8%. Mucous membrane exposures have rarely resulted in transmission of HCV and no occupational transmission has been documented from intact or non-intact skin exposures. Unlike HBV, data suggest that environmental contamination with blood containing HCV is not a significant risk in the health care setting (with the possible exception of the hemodialysis setting where environmental contamination and poor infection control practices have been implicated in HCV transmission). The risk for transmission from exposure to fluids or tissues other than HCV-infected blood also has not been quantified but is expected to be low.
1.3.2. Efficacy of Post Exposure Prophylaxis for HCV

The use of IG following HCV exposure is not recommended. No clinical trials have been conducted to assess post-exposure use of antiviral agents to prevent HCV infection and therefore post-exposure use of antiviral agents is not recommended.
1.4. Occupational Transmission of HIV

1.4.1. Risk
The risk of HIV transmission after percutaneous exposure to HIV-infected blood is estimated to be approximately 0.3% and approximately 0.09% after a mucous membrane exposure. The risk for transmission after non-intact skin exposure is expected to be less than for mucous membrane exposure. The risk of transmission after exposure to fluids other than HIV-infected blood is probably considerably lower than for blood exposure.
1.4.2. Efficacy of Post Exposure Prophylaxis for HIV

Little information exists about the efficacy of HIV post-exposure prophylaxis in humans, due in large part to the infrequency of seroconversion following exposure (studies would need to involve sample sizes of several thousands in order to achieve sufficient statistical power). Information about primary HIV infection suggests that systemic infection does not occur immediately, which provides a brief interval during which post- exposure antiretroviral therapy may
modify or prevent viral replication. Animal studies suggest that antiretroviral therapy administered within 48 hours of exposure may prevent infection. Decisions regarding post-exposure prophylaxis for HIV must take into consideration the serious side effects associated with antiretrovirals. It is important that an infectious disease physician is consulted if antiretrovirals are being considered following an exposure.
1.5. General Guidelines for the Management of Occupational Exposures:

1.5.1. Treatment of an Exposure Site
Allow immediate bleeding of the wound. Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water.
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. The circumstances and post-exposure management should be recorded in the exposed persons medical record. Recommended contents of the exposure report include: Date and time of exposure. Details of the procedure being performed, including where and how the exposure occurred; if related to a sharp device, the type and brand of device and how and when in the course of handling the device the exposure occurred. Details of the exposure, including the type and amount of fluid or material and the severity of the exposure (e.g. for a percutaneous exposure: depth of injury and whether fluid was injected; for a skin or mucous membrane exposure, the estimated amount of material and the condition of the skin [e.g. chapped, abraded, intact]).
Details about the exposure source (e.g. whether the source material contained HBV, HCV or HIV; if the source is HIV-infected, the stage of disease, viral load, history of antiretroviral therapy and antiretroviral resistance information if known). Details about the exposed person (e.g. hepatitis B vaccination and vaccine response status). Details about counseling, post-exposure management, and follow-up.
1.5.3. Evaluation of the Exposure

The exposure must be evaluated for the potential to transmit HBV, HCV, or HIV based on the severity of the injury and the type of fluid involved. Exposure to any of the fluids described in section 1.1 via percutaneous injury or a mucous membrane pose a risk of transmission and requires further evaluation. Any direct contact with concentrated virus in a research lab or production facility (in which personal protective equipment was absent or deficient) is an exposure requiring further evaluation. Follow up of skin exposures is only required if one of the named body fluids contacted an area where skin integrity is compromised (e.g. open wound, dermatitis, abrasion). 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. Summary of factors to consider in assessing the need for followup of occupational exposures include: a. Type of exposure Percutaneous injury Mucous membrane exposure Non-intact skin exposure Bites resulting in blood exposure to either person involved b. Type and amount of fluid/tissue Blood Fluids containing blood Potentially infectious fluid or tissue (semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids) Direct contact with concentrated virus
c. Infectious status of source Presence of HBsAg Presence of HCV antibody Presence of HIV antibody d. Susceptibility of exposed person Hepatitis B vaccine and vaccine response status HBV, HCV, and HIV status
1.5.4 Evaluation of the Exposure Source

The person whose blood or body fluid is the source of an occupational exposure should be evaluated for HBV, HCV or HIV infection. Every reasonable effort should be made to obtain permission to test the source. Obtaining informed consent is an integral part of all post-exposure testing procedures, as is maintaining confidentiality of all information. Testing the source without consent is unethical. When consent is given to draw blood for all three viruses, the appropriate pre- and post- test counseling for all three blood borne pathogens should be done. Testing to determine the HBV, HCV and HIV infection status of the source should be carried out as soon as possible. If the source is unknown or cannot be tested, information about where and under what circumstances the exposure occurred should be assessed for the likelihood of transmission of HBV, HCV, or HIV. Summary - Evaluation of Occupational exposure sources: a. Known Sources Test known sources for HBsAg, anti-HCV and HIV antibody. If the source person is not infected with a blood borne pathogen, baseline testing is not necessary. For sources whose infection status remains unknown (e.g. the source person refuses testing), consider medical diagnoses, clinical symptoms, and history of risk behaviours. Do not test discarded needles for blood borne pathogens (reliability and interpretation of findings is unknown and testing might be hazardous to persons handling the sharp instrument).
b. Unknown sources For unknown sources, evaluate the likelihood of exposure to a source at high risk for infection. Consider likelihood of blood borne pathogens infection among patients in the exposure setting.
1.6 Disease Specific Management Guidelines

1.6.1 Management of Exposures to HBV
For percutaneous or mucosal exposures, the decision to provide prophylaxis should be based on the HBV vaccination status and vaccine response status of the exposed person. In cases where the possibility of exposure exists, (refer to the latest Canadian Immunization Guide): Post Exposure Immunoprophylaxis for Hepatitis B refer to the latest Canadian Immunization Guide.
1.6.2. Management of Exposures to HCV

IG and antiviral agents are not recommended for post-exposure prophylaxis after exposure to HCV. Management of exposures to HCV includes the following: Perform anti-HCV testing for the source. For the person exposed to HCV, perform baseline testing for anti-HCV and ALT activity, and perform follow-up testing (e.g. at 4-6 months) for anti-HCV and ALT activity. If earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4-6 weeks. Confirm all anti-HCV results reported positive by enzyme immunoassay using supplemental anti-HCV testing.
1.6.3. Management of Exposures to HIV

It is important that persons exposed to HIV be evaluated and tested for HIV at baseline within hours (rather than days) after the exposure. If the source person is seronegative for HIV, baseline testing or further follow-up of the exposed person is not necessary. For the purpose of considering HIV post-exposure prophylaxis, the evaluation of the exposed person should include information about medications currently being taken by the exposed person and any current health conditions (e.g. pregnancy).
The following recommendations apply to situations when a person has been exposed to a source person with HIV infection or when information suggests that the likelihood that the source person is HIV-infected. Potential toxicity must be carefully considered in decisions regarding post-exposure prophylaxis for HIV. Because current therapies for post-exposure prophylaxis change rapidly, when HIV post-exposure prophylaxis is being considered, an infectious diseases physician must be consulted regarding appropriate therapies and monitoring. Post Exposure Prophylaxis for HIV For percutaneous injuries, mucous membrane and non-intact skin exposures: When the source is known to be HIV positive, post-exposure prophylaxis is recommended (consult infectious disease specialist). When the HIV status of source is unknown, post-exposure prophylaxis is generally not warranted, except in the case where the source is known to have HIV risk factors (in this case consult infectious disease specialist). If source is later determined to be HIV-negative then discontinue postexposure prophylaxis. When the source is HIV-negative, no post-exposure prophylaxis is warranted.
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.
1.7.1 Counseling for Persons Exposed to HBV and HCV

Counseling for persons exposed to HBV and HCV should include the following information: 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.)
1.7.2. Counseling for Persons Exposed to HIV

Counseling for persons exposed to HIV should include the following information: 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.) When post-exposure prophylaxis is considered, the exposed person should be informed about the limited knowledge of efficacy of postexposure prophylaxis, potential toxicity of the drugs and potential serious adverse events associated with the regimen.
Even though HIV infection following exposure occurs infrequently, the emotional effect of an exposure is often substantial. It is important for the exposed person to have access to a person knowledgeable about issues associated with occupational exposures throughout the follow-up period.

These guidelines should be used for all community exposures as well as occupational exposures.
2.1. Role of the Medical Officer of Health:

2.1.1. Determine investigative responsibility.
It is the responsibility of the Medical Officer of Health (MOH) to ensure that reports of exposures to blood/body fluids are received and disseminated in a timely manner, to the appropriate personnel for investigation within each district. The MOH may designate the CDC Coordinator/Manager to receive and disseminate these reports. It is not necessary to report all exposures. Only those exposures that require Public Health consultation need to be reported and investigated by Public Health.

It is the role of the MOH to ensure that confidentiality is maintained for all records of exposures to potentially infected blood and body fluids.

Effective follow-up will occur in discussion between the investigator and the physician, clinician or nurse practitioner working in the physician's office. It is useful, where possible to discuss and negotiate procedure and protocol responsibilities with all physicians in the community to ensure consistent and effective case management. In cases where there may be questions regarding whether follow-up is being done by physicians, upon receipt of the report, the investigator should:
2.2.1. Contact person who reported the case and discuss investigative responsibilities.
Contact the person who reported the case to discuss the status of the case, confirm if a significant exposure has occurred (see section 3.5.3) and if so,
determine who will do follow-up. Inform the contact of the consultative role offered by Public Health Services. Confirm who will conduct assessment, counseling and follow-up, and advise this person as appropriate for the situation. Inform them how to obtain HBIG and/or HBV vaccine if a decision is made that they should be given. Provide contact information for an appropriate infectious disease physician if antiretrovirals are being considered for HIV post- exposure prophylaxis. In cases where it is agreed that the investigator will conduct assessment, counseling and follow-up, follow the guidelines below.
2.2.2. Contact individual.

It is important to make every effort to contact the individual quickly because of the potential for post-exposure prophylaxis. Telephone or visit the individual to begin investigation. a. Ensure the confidentiality of the case. Do not relate that you are calling from PHS if someone else answers the phone; ask if the individual is alone and comfortable talking. This interview may be done over the phone or in person depending on what is best for the investigator and the client. 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. If contact cannot be made with the source in a timely manner, or if the source is unknown or refuses to be tested, determine appropriate followup interventions based on existing knowledge about the exposure.
2.3. Role of the Physician

2.3.1. Report
Exposures do not have to be reported to PHS. If the physicians office staff cannot provide effective education and follow-up, the physician may contact PHS for assistance.
2.3.2. Patient treatment and follow-up

It is important that the individual who does the initial assessment and counseling ensures that education and follow- up take place.
2.4. Role of the Laboratory

It is the responsibility of the laboratory to report the results of the blood tests to the individuals requesting the tests.
References: Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phacaspc.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 2. CMOH provides this information to CBS-Halifax and copies this to relevant MO 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. 4. The hospital blood bank reports disposition of components and information on recipients to CBS-Halifax and the Chief Medical Officer of Health.
5. Chief Medical Officer of Health reviews recipients names against administrative databases to see if any positive individuals are identified. CBS-Halifax is responsible for the follow-up of out of province recipients. If no information on the recipient is obtained from the database, the lookback form will be forwarded to the provincial CDC Coordinator.
Role of Provincial Coordinator/Office of CMOH

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.
Role of Regional CDC Coordinator/Manager

1. 2. 3. 4. Receives the lookback form and other pertinent information. Assigns case to CDC Nurse (case manager). Monitors progress of follow-up periodically with CDC Nurse. Ensures all reports are received from the CDC Nurses according to schedule and such reports are complete and accurate.
5. Sends completed tracking form and a report containing all the details of the investigation to the Provincial CDC Coordinator. 6. Keeps record of when information received, when forwarded to CDC Nurse and when returned to Provincial CDC Coordinator.
Role of CDC Nurse

1. Upon receipt of lookback information, notes date file received. 2. Contact recipients physician by phone and follow-up letter to ascertain if status is known and to request that the physician provide counseling and testing if it has not already been done. Uses the content of the follow-up letter to indicate reason for call and follow-up actions required. Seeks physicians cooperation in completing follow-up within 30 days. 3. Prepares a package of information to send to physicians. This package should include: (a) Letter to doctor. Put clients file number (number on tracking form), name, address and other pertinent information on the letter. (b) Lookback investigation form. Put case managers name and date sent. (c) Self addressed envelope for physician to return results. (d) Appropriate educational material if applicable. 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.
If Physician Could Not be Found for a Client

1. Contact MSI by phone or letter (copy attached) requesting a physicians name. MSI provides the name of a physician that the client saw last. 2. If a physician refuses to do follow-up, unable to contact client or could not be found, then the CDC Nurse should make a home visit and explain reason for visit and actions required.
File No: 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. In this particular case, the patient ____________ , has expired. You may wish to counsel his/her partner on the risks of infection so they can decide if they wish to be tested for ______________________________. Please contact me if you have any questions or concerns about this investigation. Sincerely,
Robert Strang, MD, MHSc, FRCP(C) Chief Public Health Officer
File No: Dear Doctor: Your patient (Name) transfusion of (Component) (Hospital) has now been found to be positive for __________________. (Component) 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 902Sincerely, Public Health Nurse - and Robert Strang, MD, MHSc, FRCP(C) if you have any questions or concerns about this investigation. , (DOB) on while at . The individual who donated the , received a
Chief Public Health Officer Enclosure
Lookback: Public Health

Infected Donor MOH or CBS-Halifax initiates Lookback Previous Donations Reviewed by CBS-Halifax Components/Products located by CBS-Halifax
Hospitals Notified by CBS-Halifax CBS-Halifax and Public Health Notified of Recipient Identification/Product Disposition by Hospital Databases Queried
Not on Database On Database

Central Case Manager distributes recipients to regions
No contact with Individual
Recipients Physician is Contacted** Recipient notified, counselled and offered testing Public Health notified of result CBS-Halifax Public Health compiles results of all Contacts and summarizes investigation. CBS-Halifax sent a Summary of Lookback 30 days
**if physician is unable to contact or no physician is identified then Public Health contacts recipients.
NOVA SCOTIA TRACEBACK PROTOCOL BLOOD BORNE PATHOGEN (BBP) INFECTION

Definition:
Traceback is the process of investigating a report of a transfusion-associated infection. The purpose of the investigation is to identify the associated/implicated donors and to retrieve untransfused blood components related to this donor.
Protocol:
Notification of positive individual received by Public Health Services (PHS). 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. PHS is notified of associated donors with unknown status in the case. DOH reviews available administrative and reporting databases for information on testing, vital status and current address. If any donors are found to be positive, CBS-Halifax opens a lookback investigation. This investigation will be investigated as per Nova Scotias lookback protocol. CBS-Halifax provides MOH and transfusion hospital with a summary of their investigation.
Appendix 1: Partner Notification Definitions

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 persons 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 clients 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
SEXUALLY TRANSMITTED DISEASES

Principles
The principles for case management of STDs are: 1. All STDs are followed-up in a timely manner while PPNG and primary and secondary syphilis require urgent response. 2. All identified contacts of STDs will be followed-up in a timely manner while PPNG and primary and secondary syphilis require urgent response. 3. All new cases of STDs will be added to the provincial database for notifiable diseases. 4. All cases and contacts followed up by Public Health Services are counseled and educated about prevention, treatment and transmission.
GENERAL GUIDELINES FOR SEXUALLY TRANSMITTED DISEASES (STD)

These guidelines aim to define general control measures for sexually transmitted diseases in Nova Scotia. Specific procedures for each of the STDs may be found under each disease. Note: Hepatitis B, C, and HIV/AIDS are covered in the Blood Borne Diseases Section. The following STDs require follow-up by Public Health staff: Name of STD PHS Response Time as At A Glance (mandated) (Case Management Issue) Within 2 working days Within 4 working days Public Health Follow-up (needs to be flexible as per PHSSA abilities) Yes, with physician and client Yes, with physician and client or followup with physician only*
PPNG Chlamydia Chancroid
Receive for information Yes, with physician and client and may provide advice and assistance if asked Within 4 working days Within 4 working days Passive Yes, with physician and client Yes, with physician and client Yes, with physician and client, or followup with physician only, or no follow-up*
Gonorrhea Syphilis Genital Herpes
*The decision to devote time and resources to these follow-ups is decided at the Public Health Services level, and all options should be available. To eliminate an option is too restrictive. Use the following general guidelines for follow-up on referred cases.

1.1. Role of the Medical Officer of Health:
It is the responsibility of the Medical Officer of Health (MOH) or designate to ensure that reports of sexually transmitted diseases once received are disseminated in a timely manner, to the appropriate personnel for investigation within each district.

It is the role of the MOH or designate to ensure that confidentiality is maintained for all records of STD cases and information.
1.1.3. Ensure consistent follow-up of STD cases on the part of physicians in the community
The MOH or designate is responsible for contacting physicians to encourage timely follow-up where and when necessary and to offer Public Health Services (PHS) assistance with these procedures.

Effective follow-up will occur in discussion between the investigator and the physician or designate. A helpful document for the management of sexually transmitted diseases that is useful for both physicians and Public Health Services (PHS) staff is Canadian STD Guidelines, 1998 Edition, Health Canada.
1.2.1. Contact physician named in lab report.

Discuss the status of the case. Ask the following questions: Has the individual been informed? Has treatment (if appropriate) been initiated? Has education been done? Have partners been notified? If no to any of the above, assistance is offered.
It may be useful to supply the physician with a fact sheet about the related disease to facilitate contact between the physicians office and the client. A call is not necessary when the physician refers a case to PHS.
1.2.2. Discuss investigators responsibilities.

Inform the physician that you will contact the individual for all cases of syphilis, chancroid, gonorrhea and PPNG. Explain your role in interviewing the client, partner notification and education. If the physician asks that you do not become involved, stress that it is the role of Public Health and that if the physician insists on doing the follow-up, it is crucial that the physician complete the education and partner notification. 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. Herpes is not actively followed-up by Public Health.
1.2.3. Contact individual

Telephone or visit the individual to begin investigation. a) Ensure the confidentiality of the case. Do not relate that you are calling from PHS if someone else answers the phone. Ask if the individual is alone and comfortable talking. This interview may be done over the phone or in person depending on what is appropriate for the investigator and the client. b) Set the tone for the conversation. Do not appear judgmental. Be supportive and accepting and inform the individual that everything is confidential. Discussion of various sexual activities and preferences should be open and comfortable, so that the individual feels free to ask questions regarding modes of transmission and risks of future sexual practices.
c) Ascertain if the individual is aware of the diagnosis. Is he or she receiving treatment (if relevant)? Discuss treatment regimen and answer questions for clarification. d) Educate the individual about the STD. Provide information on the specific STD, including how it is transmitted, treated and prevented. e) Stress the need for partner notification. There are disease specific guidelines in terms of how far back to go in sexual history for contact tracing which are included in Canadian STD Guidelines, 1998 Edition, Health Canada. Ascertain whether all partners have been notified. f) Explain how confidential partner notification works and offer assistance in notifying partners. You may need to discuss concerns about and strategies for talking to past sexual or other partners. It should be made clear to the individuals that notification will not involve their own identification. Indicate that partner notification is a service that PHS provides to assist the individual in possibly uncomfortable situations, instead of as a method of policing the case. Be sure that the individual understands that confidentiality is maintained. If the individual is very reluctant to name his/her partners, instruct the individual that they are now responsible for reaching their contacts. Stress the importance of this for future health and fertility of contacts, especially for partners who may be pregnant. g) Encourage the individual to go for another test after treatment. Encourage the individual to go for another test as appropriate for the specific STD. h) Give your name and work telephone number. Give your name and work telephone number in case the individual wishes to contact you with/for more information.
1.2.4 Notify sexual partners

Notification of past and present sexual partners should be started as soon as the names are obtained, except in the event that an individual asks the investigator to wait so that he or she may inform the partners first. a) Keep the partner notification confidential. Partners may be reached by telephone, through confidential, registered letter, or in person at the discretion of the investigator. Sample letters are attached at the end of these general guidelines. Letters designed to reach individual partners should be in a plain envelope. Ensure that phone calls to partners are made using a telephone for which call display has been blocked. Telephone messages should be discreet, and the investigator should only leave their first name and telephone number. Use professional judgment. Other procedures may also be used (i.e. visiting the school). b) Educate each individual partner. Educate each individual partner about the STD, transmission, symptoms, testing, treatment, long-term outcomes and further prevention. Use fact sheets where appropriate. It is important to be sensitive to the issues that may surround a positive test result in a relationship that has been monogamous. Issues such as fidelity and vulnerability may be of concern to clients and their partners. Stress the need for testing and treatment in terms of future health and fertility. c) Partner notification may stop at the first round. There is no need to do partner notification on the partners of the partners unless an individual is confirmed for the STD, or unless the partner is considered high risk (e.g. injection drug user). d) Never fax information on STDs. All information for infected individuals or partners must leave PHS in envelopes marked Medical Confidential or Personal and Confidential to ensure privacy. Letters sent by registered mail may help to ensure that the individual has been contacted. Envelopes sent or left for an individual or contact should be in plain envelopes and the letter should not contain information as to the specific disease. Information about contacting PHS
because of the possibility of infection may be included (sample letter is attached at the end of these general guidelines). e) If a report is received in PHS of an STD in a child younger than 16 years, the investigator must call the family physician. Nova Scotia Law states that any suspicion of sexual abuse in a child under the age of sixteen must be reported immediately to local Childrens Aid Society or Child and Family Services Department of the Provincial Community Services Office. (Children and Family Services Act 1991. C.5. Mandatory Reporting Provisions section 23).
1.2.5 Procedure for Potential Cases of Child Abuse

In speaking with the physician mention the law and the report and ask if the physician, clinician and/or nurse practitioner are suspicious of abuse and what has been done about this. If the physician is certain that the STD is not a result of sexual abuse then reporting is unnecessary. However, if the physician is uncertain and has not reported the possible case, discuss the case and your reporting responsibilities with the physician and ensure that one of you will take responsibility to report it immediately to the Child Protection (in the provincial blue pages under child/family benefits of your local telephone book), if deemed necessary. After working hours report to the local police or RCMP; they will put you in touch with the caseworker on call at that time. If you have any doubt about the physician reporting the case, then call Child Protection and report it again. The situation should never be handled within the family.
1.3. Role of the Family Physician

Reference has been made previously in this manual to the document, Canadian STD Guidelines, 1998 Edition, Health Canada. Use of this document ensures consistent management of STDs in the community, and its use is recommended when dealing with individuals, partners, and families in cooperation with PHS staff.
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.
1.3.2. Client treatment and follow-up.

It is useful to discuss roles and responsibilities with the PHS staff so that there is consistent and effective management of STD cases.
1.3.3. Client education and partner notification.

If the physicians office staff cannot provide effective partner notification within 4-5 days of report, the physician should contact PHS for assistance. Even if completed by the physician, PHS may still follow-up with the individual and his or her partners unless specifically asked not to do so by the physician. Confidentiality will be maintained throughout the partner notification procedure. Only in extreme cases should the physician request that PHS not become involved. It is important to discuss these kinds of situations beforehand, in order to facilitate effective testing, treatment and follow up of each case and to ensure responsibility is designated and clarified in each case.
1.3.4. Encourage the individual to be retested.

The family physician should encourage the individual to be tested at the end of the treatment or course of the illness (when relevant) to determine if the infection has cleared.
1.3.5. Any suspicion of sexual abuse in a child under the age of sixteen must be reported immediately.
Report to the local Child Protection Agency (in the blue pages). After working hours, contact the local police or RCMP to reach the afterhours authorities on call.
1.4. Role of the Laboratory:

It is the responsibility of the laboratory to report STDS to the Medical Officer of Health or designate as follows: Within 1 working day by telephone: gonorrhea (PPNG).
Within 5 working days by reporting form: chancroid, chlamydia, genital herpes, gonorrhea and syphilis.
3. Safer Sex Practices

3.1. Counseling about Safer Sex
The following is produced from the Safer Sex Guidelines published by the Royal Adelaide Hospital (www.stdservices.on.net/std/prevention/safersex_guidelines.htm) At present there are no absolute guidelines for some sex practices. Recommendations are necessarily based on epidemiologic investigations and as new evidence becomes known there can be alterations in the advice which should be given. This of course can complicate the education and counseling of clients especially when some people expect precise information about what to do or what to avoid. 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 factorsbut 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 usedfor 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.
Some Examples of safer sex guidelines: Safe Mutual Masturbation (male or female) Social kissing (dry) Body Massage, hugging Body-to-Body rubbing (frottage) Light S/M activities (without bruising or bleeding) Using ones own sex toys Possibly Safe Anal intercourse with a condom Fellatio interruptus Mouth-to-Mouth kissing Urine contact Vaginal intercourse with a condom Oral-vaginal contact (cunnilingus) Unsafe Receptive anal intercourse without a condom Insertive anal intercourse without a condom Manual-anal intercourse Fellatio Oral-anal contact Vaginal intercourse without a condom
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.
Additional prevention messages are included in the specific disease sections.
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
Clinically compatible symptoms and a culture taken from an ulcerated lesion in the genital area, positive for Haemophilus.ducreyi.

Haemophilus ducreyi (H. ducreyi), a gram-negative coccobacillus.
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.
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.

Use core messages in general guidelines (section 3.2). Other messages include: Refrain from sexual contact if ulcers/lesions are observed in the genital area.
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.

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:
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/ccdrrmtc/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.
Who Can Get Chancroid?

Chancroid is transmitted from person to person through sexual contact. The infection starts usually 3-5 days after contact with an infected person (sometimes it takes up to 14 days).

Symptoms include: Tender blisters in the genital area that become ulcers. Redness around the area of the ulcers. Tenderness and swelling in the glands surrounding the pubic area. The symptoms may be confused with syphilis. It is important to be tested by your doctor. Some individuals will be carriers of this infection though they may not have symptoms of the disease. These carriers may infect others.

Chancroid can be treated with antibiotics, taken either by an injection or by mouth. Your doctor can prescribe the best treatment for you.
How Can You Prevent Chancroid?

You can reduce your risk of getting chancroid by: Limiting the number of sexual partners you have. Using condoms and rubber dams for all sexual contact. Seeing your doctor if you have any of the above symptoms. Having no sexual contact if there are ulcers in your or your partners genital area. Learning about prevention and control of sexually transmitted diseases.
CHLAMYDIA
1. Information
Confirmed case----Genital
Laboratory evidence of infection in genitourinary specimens: detection of Chlamydia trachomatis by culture OR detection of C. trachomatis nucleic acid OR detection of C. trachomatis antigen
Confirmed CaseExtra-genital infections

Laboratory evidence of infection in rectum, conjunctiva, pharynx and other extra-genital sites: detection of C. trachomatis by culture OR detection of C. trachomatis nucleic acid OR detection of C. trachomatis antigen
Confirmed CasePerinatally Acquired Infections

Laboratory evidence of infection: detection and confirmation of C. trachomatis in nasopharyngeal or other respiratory tract specimens from an infant in whom pneumonia developed in the first six months of life: isolation of C. trachomatis by culture OR demonstration of C. trachomatis nucleic acid OR demonstration of C. trachomatis antigen OR
OR OR
detection and confirmation of C. trachomatis in conjunctival specimens from an infant who developed conjunctivitis in the first month of life: isolation of C. trachomatis by culture demonstration of C. trachomatis nucleic acid demonstration of C. trachomatis antigen

Chlamydia trachomatis, a bacterium with many serologic variants.
1.3. Symptoms:
More than 50% of males and 70% of females are asymptomatic. Symptoms may include: Females Genital discharge Dysuria Abdominal pain Abnormal vaginal bleeding Dyspareunia Males Urethral discharge Dysuria Urethral itch Epididymal pain Neonates & Infants Conjunctivitis (neonates) Pneumonia (infants < 6mo.)
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, Reiters 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.
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.

Chlamydia is currently the most common sexually transmitted disease in Canada and has the potential to affect the fertility of each individual who becomes exposed. Education of those populations that are at risk is important, i.e.: adolescents and young adults 15-25 yrs. of age or anyone with multiple sexual partners. Use core messages in general guidelines (section 3.2).
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.

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:
2.1.4. Laboratory:
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/ccdrrmtc/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.
Who Can Get Chlamydia?

Chlamydia is only spread through oral, vaginal or anal intercourse. Babies can also get infected during vaginal delivery when a mother has Chlamydia.

More than 50% of males and 70% of females have no symptoms. For those people who get symptoms, the symptoms may appear 2-6 weeks after the person has had sexual contact with anyone with Chlamydia. Symptoms may include: Females Discharge from vagina Pain in the lower abdomen Bleeding after intercourse Pain when urinating Pain during sex Males Discharge from penis Pain when urinating

A doctor will test you for chlamydia and prescribe an antibiotic if positive. The doctor may retest you after the treatment stops. If chlamydia is not treated, it may cause an inflammation in a womans pelvis. This is called Pelvic Inflammatory Disease (PID). PID can be very serious and may later affect a womans ability to get pregnant.
How Can You Prevent Chlamydia?

You can reduce your risk of getting chlamydia by practising safer sex.
How Can I Practice Safer Sex?

You can practice safer sex by: Limiting the number of sexual partners you have. Learning all about prevention and control of sexually transmitted diseases. If you are having sex, remember: Use a latex condom every timeits the most important thing you can do. IT TAKES TWO! The birth control pill prevents pregnancy, and the condom prevents STDs. Consider doing other things with your partner, like kissing, caressing and touching, instead of having intercourse The riskiest way of having sex in terms of catching an STD is anal sex (for both males and females).
GENITAL HERPES
1. Information
Positive HSV type I or II from a genital lesion.

Herpes simplex virus type 1 (HSV-1) or herpes simplex virus type 2 (HSV-2).
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, genitalrectal, 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 elses 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.
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.

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.

Genital herpes is not actively followed up unless assistance is required. Use general guidelines. Also use additional guidelines re:
a) Educating the Client. It is important to allow individuals to vent feelings of shame, anger, and resentment about contracting herpes. 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. All clients should be informed about the risk of autoinoculation as well as putting others at risk if there is any spread of the secretions. General cleanliness is required, especially hand washing to prevent spread of the infection.
2.1.3. Physician:
2.1.4. Laboratory:
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/ccdrrmtc/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.
Who Can Get Genital Herpes?

HSV-1
About 70-90 % of adults have had a HSV-1 infection, a small cold sore on the lip or some other site on the body. Herpes is passed on to others through direct contact, because the virus lives in the fluid in the sore or blister. Activities like kissing someone or touching the blister and then touching some other part of your body or someone elses body can spread the disease.
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.
What are the Symptoms of Genital Herpes?

Symptoms include: Painful blisters on the genitals of women and on the penis in men. Pain during urination. 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.

A drug called Acyclovir (Zovirax) is often used to decrease the pain and symptoms of herpes and to decrease the healing time. This drug is available from your doctor.
How Can You Prevent Genital Herpes?

You can reduce your risk of getting herpes by: Limiting the number of sexual partners you have. Using condoms and rubber dams for all sexual contact. Learning about prevention and control of sexually transmitted diseases. Seeing your doctor if you have any of the above symptoms. 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
Visible lesions of hyperkeratotic exophytic papules on genital or anal area or in the oral cavity of men and women.

Human papillomavirus [HPV], a small DNA virus, usually type 6,11,16,18 or 31. There is evidence that these DNA viruses, especially types 16 and 18 figure prominently in the development of cervical dysplasias.
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.
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.

Use core messages in general guidelines (section 3.2). Other messages include: Refrain from sexual contact if lesions are observed in the genital area. Condoms may not prevent transmission of genital warts (although the use of condoms should be encouraged during all sexual contacts with new sex partners).
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/ccdrrmtc/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.
Who Can Get Genital Warts?

The virus is spread through skin-to-skin contact. That means that any genital contact, even without having intercourse can spread the virus. The virus can be present from a month to a year or more before the wart appears. It is difficult to know who has the virus and who does not. Usually the warts are found on routine tests like a Pap smear. The warts may cause some tenderness but usually no pain.

Like other kinds of warts, genital warts look like a raised small cauliflower attached to the skin of the genital area. They may also be hidden and seen only inside the vagina or on the cervix for females, and inside the urethra for males.

There are different ways to treat genital warts. Warts on the cervix are treated with cryotherapy to freeze them off. A cream to put on the warts is sometimes used for warts on the outside of the body. Other kinds of treatments can be used if the warts continue. Your doctor will prescribe the best treatment for you.
How Can You Prevent the Spread of Genital Warts?

You can reduce your risk of getting genital warts by: Limiting the number of sexual partners you have. Condoms may not prevent the spread of genital warts, so it is important to avoid sexual contact if you or your partner has warts in the genital area. Using a condom is still important to reduce the risk of transmission of other sexually transmitted diseases.
Seeing your doctor if you have any of the above symptoms. Learning all about prevention and control of sexually transmitted diseases.
GONORRHEA/PENICILLINASE-PRODUCING NEISSERIA GONORRHEA (PPNG)

1. Information
Gonorrhea:
Confirmed caseGenital Infections Laboratory evidence of infection in genitourinary specimens: detection of Neisseria gonorrhoeae by culture OR detection of N. gonorrhoeae nucleic acid
Confirmed CaseExtra-genital infections

Laboratory confirmation of infection from pharynx, rectum, joint, conjunctiva, blood and other extra-genital sites: detection of N. gonorrhoeae by culture OR detection of N. gonorrhoeae nucleic acid
Confirmed CasePerinatally Acquired Infections

Laboratory confirmation of infection from a neonate in the first four weeks of life leading to the diagnosis of gonococcal conjunctivitis, scalp abscess, vaginitis, bacteremia, arthritis, meningitis or endocarditis: detection of N. gonorrhoeae by culture OR detection of N. gonorrhoeae nucleic acid

Neisseria gonorrhoea (N. gonorrhea), a Gram-negative diplococci.
1.3. Symptoms:
More than 50% of males and females have asymptomatic infection. Females Vaginal discharge Dysuria Abdominal pain Abnormal vaginal bleeding Dyspareunia Rectal pain and discharge if proctitis Males Urethral discharge Dysuria Urethral itch Epididymal pain 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). Occasionally the infection can be spread to infants if the mother is infected at the time of birth. Infection in the newborn usually involves the eye. If genital, rectal or oral infections are diagnosed in prepubescent children, sexual abuse must be considered.
The infection may extend for months as long as the bacteria are present in the body, even if the individual is asymptomatic. Effective therapy ends communicability within hours.
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. Repeat diagnostic testing is not recommended when a recommended treatment has been given and symptoms disappear. Follow-up testing by culture must be completed if: A previous treatment has failed. Antimicrobial resistance has been documented. Patient compliance with treatment is uncertain. Pharyngeal or rectal gonorrhea is suspected. There is re-exposure to an untreated partner. There is concern over a false-positive non-culture test. Infection occurs during pregnancy. PID or disseminated gonococcal infection is diagnosed. Client is a child and there is a concern about ongoing exposure.
2. Procedures
Use the General Guidelines for Sexually Transmitted Diseases at the beginning of this section. The following are additional guidelines for gonorrhea/PPNG.

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:
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/ccdrrmtc/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.
Who Can Get Gonorrhea?

Gonorrhea is passed on through sexual contact. The infection passes from one person to another through body fluids from the penis, vagina, mouth or rectum. Babies can get the infection in their eyes at the time of birth if the mother is infected.

Many people can have gonorrhea without any symptoms at all. Symptoms usually start from 2-7 days after contact with a person who has been infected. There may be other sexually transmitted diseases present, so individuals should be checked for other diseases when they see the doctor. Symptoms to look for are: Unusual discharge from the penis, vagina or rectum. Pain or burning when urinating. Pain or cramping in the lower abdominal area for women. Sore throat or difficulty swallowing. Pain in the testicles for men.

Gonorrhea can be treated with antibiotics. A swab is taken and antibiotics are prescribed for the infected individual and their partner(s). In the past, penicillin was the only antibiotic used to treat gonorrhea; now other antibiotics are used against the resistant strains like PPNG (see PPNG Fact Sheet). While on antibiotics the individual should refrain from sexual contact. If you have gonorrhea you should inform all your sexual partners so that they can be tested.
How Can You Prevent Gonorrhea?

You can reduce your risk of getting gonorrhea by: Limiting the number of sexual partners you have.
Seeing your doctor if you have any of the above symptoms. Learning about prevention and control of sexually transmitted diseases. Practicing safer sex.
PPNG FACT SHEET

What is PPNG?
PPNG or penicillinase-producing neisseria gonorrhea is a strain of gonorrhea. These bacteria have become resistant to the antibiotic penicillin. They must be treated with a different antibiotic.
Who Can Get PPNG?

PPNG is transmitted by sexual contact, in the same way that gonorrhea is transmitted. The infection passes from one person to another through body fluids from the penis, vagina, mouth or rectum. Because it is more difficult to treat than gonorrhea, it is important that sexual partners know that a person has PPNG and that they may need a special antibiotic.

Many people can have PPNG without any symptoms at all. Symptoms usually start from 2-7 days after contact with a person who has been infected. There may be other sexually transmitted diseases present, so individuals should be checked for other diseases when they see the doctor. Symptoms to look for are: Unusual discharge from the penis, vagina or rectum. Pain or burning when urinating. Pain or cramping in the lower abdominal area for women. Sore throat or difficulty swallowing. Pain in the testicles for men.

A swab is taken and a laboratory report will clarify if the infection is gonorrhea and if the strain of gonorrhea is PPNG or not. If the report is positive for PPNG, a special antibiotic will be prescribed for the infected individual and their partner(s). While on antibiotics the individual should not have any sexual contact.
How Can You Prevent PPNG?

You can reduce your risk of getting PPNG by: Limiting the number of sexual partners you have. Using condoms and rubber dams for all sexual contact. Learning about prevention and control of sexually transmitted diseases. Practicing safer sex. Seeing your doctor if you have any of the above symptoms.
LYMPHOGRANULOMA VENEREUM (LGV)

1. Information
Confirmed Case:
Presence of C. trachomatis serotype L1, L2, L3 confirmed by DNA sequencing or Restriction Fragment Length Polymorphism (RFLP)
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.

Chlamydia trachomatis, a bacterium, serotypes L1, L2 and L3. The serotypes are related to but distinct from the serotypes causing trachoma and oculogenita chlamydial infections.
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 Primary
Incubation Period 3-30 days
Manifestation/Comments 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 Often accompanied by significant 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 More common in females than males Chronic inflammatory lesions lead to scarring: - Lymphatic obstruction causing genital elephantiasis - Rectal strictures and fistulae Possible extensive destruction of genitalia (esthiomene) Surgery may be required to repair genital/rectal damage of tertiary LGV.
Secondary Within 2-6 weeks of primary lesion
Tertiary (chronic LGV occurring in 10-20% of untreated cases)
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
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.

Abstinence is the best way to avoid getting an STI Limit the number of sexual partners Avoid anonymous or casual sexual activity Use latex condoms with oral, vaginal or anal sex Avoid sharing sex toys Clean toys prior to use Minimize or avoid sexual activities associated with mucosal damage, such as fisting Seek medical attention if an infection is suspected (with or without symptoms)

Refer to General Guidelines at the front of the STI Section 5 of the Communicable Disease Control Manual.
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. Immunization for hepatitis B should be offered to non-immune cases.
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, genitalanal or oral-anal) with the case in the past sixty days.
2.3.2. Susceptibility
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

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.
Who Can Get LGV?

A person can become infected if he/she engages in genital-genital sex, genital-oral sex, genital- anal sex or oral-anal sex with an infected person. The bacteria are present in small, painless lesions often found on the genitalia, anus or in the mouth of an infected person. An infected person may not show any symptoms.

The LGV infection passes through three stages with each stage having different symptoms. The infection will remain in the body until it is cured. The symptoms to look for are: A small painless lesion on the genitals, anus or mouth. It may become ulcerated or go unnoticed Low grade fever, chills, malaise, painful muscles and joints Painful lymph nodes, especially in the groin area Bloody, purulent (pus) or mucous discharge from the anus The final stages of the infection can cause significant scarring and possible destruction of the genitalia

LGV can be treated with an antibiotic. It is important to take all the medication until it is gone. It is also important to have follow-up visit with a doctor to make sure the
antibiotic was effective. All sexual partners within the previous 60 days should also be treated.
How Can You Prevent LGV?

Reduce your risk of LGV infection by: Having monogamous sex or limiting the number of sexual partners Avoiding anonymous or casual sexual activity Practicing safer sex by using latex condoms with oral, vaginal or anal sex Choosing not to engage in sexual activity if you or your partner has a lesion on the genitals, anus or in the mouth Learning about prevention and control of sexually transmitted infections Seeking medical attention if an infection is suspected
SYPHILIS
1.0 Information
1.1. Case definition
JANUARY 2012
Confirmed caseEarly 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.
Confirmed CasePrimary Syphilis

Laboratory confirmation of infection: identification of T. pallidum by dark-field microscopy, fluorescent antibody, nucleic acid testing, or equivalent examination of material from a chancre or a regional lymph node. OR presence of one or more typical lesions (chancres) and reactive treponemal serology, regardless of non-treponemal test reactivity, in individuals with no previous history of syphilis. OR presence of one or more typical lesions (chancres) and a fourfold or greater increase in the titre over the last known non-treponemal test in individuals with a past history of syphilis treatment. 1
Confirmed CaseSecondary 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 (nontreponemal 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.
Confirmed CaseEarly Latent Syphilis (< 1 year after infection)

Laboratory confirmation of infection: an asymptomatic patient with reactive serology (treponemal and/or nontreponemal) who, within the previous 12 months, had one of the following: non-reactive serology. symptoms suggestive of primary or secondary syphilis. exposure to a sexual partner with primary, secondary or early latent syphilis.
Confirmed CaseLate Latent Syphilis (> 1 year after infection or of unknown duration)
Laboratory confirmation of infection: an asymptomatic patient with persistently reactive treponemal serology (regardless of non-treponemal serology reactivity) who does not meet the criteria for early latent disease and who has not been previously treated for syphilis.
Confirmed CaseNeurosyphilis (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.
Non-infectious Neurosyphilis (> 1 year after infection)

Laboratory confirmation of infection: reactive treponemal serology (regardless of non-treponemal serology reactivity) AND one of the following: o reactive CSF-VDRL in non-bloody CSF. o clinical evidence of neurosyphilis AND either elevated CSF leukocytes OR elevated CSF protein in the absence of other known causes.
Confirmed CaseTertiary Syphilis Other than Neurosyphilis

Laboratory confirmation of infection: reactive treponemal serology (regardless of non-treponemal test reactivity) together with characteristic late abnormalities of the cardiovascular system, bone, skin or other structures, in the absence of other known causes of these abnormalities (T. pallidum is rarely seen in these lesions although, when present, it is diagnostic). AND no clinical or laboratory evidence of neurosyphilis.
1.2 Causative agent

Treponema pallidum (T. pallidum), a bacterium of the order spirochaeta. Nonvenereal treponemal infections cause pinta, yaws, and bejel.
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 Primary Secondary Incubation Period 3 weeks (3-90 days) 2 - 12 weeks (2 weeks 6 months) Clinical Manifestations Chancre, regional lymphadenopathy Rash, fever, malaise, lymphadenopathy, mucus lesions, condyloma lata, patchy or diffuse alopecia, meningitis, headaches, uveitis, retinitis Asymptomatic Aortic aneurysm, aortic regurgitation, coronary artery ostial stenosis
Latent Tertiary Cardiovascular syphilis Neurosyphilis
Early: <1 year Late: 1 year 10 - 30 years
<2 years-20 years
Ranges from asymptomatic to symptomatic with headaches, vertigo, personality changes, dementia, ataxia, presence of Argyll Robertson pupil Tissue destruction of any organ; manifestations depend on site involved 2/3 may be asymptomatic Fulminant disseminated infection, mucocutaneous lesions, osteochondritis, anemia, hepatosplenomegaly, neurosyphilis Interstitial keratitis, lymphadenopathy, hepatosplenomegaly, bone involvement, anemia, 4
Gumma
1 - 46 years (most cases 15 years) Onset <2 years
Congential Early
Late
Persistence >2 years after birth
Hutchinsons teeth, neurosyphilis

The interpretation of syphilis serology should be made in conjunction with someone experienced in this area (e.g. microbiologist, infectious disease physician) (see Table 2 and the revised January 2010 syphilis chapter in the 2006 edition of the Canadian Guidelines on Sexually Transmitted Infections). Every attempt should be made to obtain and document prior history of treatment for syphilis and prior serologic results in order to avoid unnecessary retreatment.
Table 2: Diagnostic Testing

Non-treponemal test: VDRL, RPR, ART, TRUST, RST, EIA + + Treponemalspecific test: TP-PA, MHATP, FTA-ABS + + Possible Reason
Syphilis recent or previous. Yaws or pinta. No syphilis false positive. Rarely seen in very early syphilis. Consistent with syphilis, primary or latent. Previously treated or untreated. Yaws, pinta or Lyme disease. No syphilis or incubating disease.
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.
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 All non-pregnant adults Primary Secondary Early latent (<1 year duration) All non-pregnant adults Late latent syphilis Latent syphilis of unknown duration Cardiovascular syphilis and other tertiary syphilis not involving the central nervous system All adults Neurosyphilis Preferred treatment Benzathine penicillin G 2.4 million units IM as a single dose*
Benzathine penicillin G 2.4 million units IM weekly for 3 doses
Pregnant women Primary Secondary Early latent (<1 year duration) Pregnant women Benzathine penicillin G 2.4 million units IM weekly for 3 doses Late latent syphilis 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
Penicillin G 3-4 million units IV q 4 h(16-24 million units/day) for 10-14 days Benzathine penicillin G 2.4 million units IM weekly for 1-2 doses*
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
*Some experts recommend 3 weekly doses (total of 7.2 million units) of benzathine penicillin G in HIV-infected individuals. Given the complexity of accurately staging early syphilis, some experts recommend that primary, secondary and early latent cases in pregnancy be treated with two doses of benzathine penicillin G 2.4 million units 1 week apart; the efficacy of this regimen in preventing fetal syphilis is not known.
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.
1.10 Core Messages for Prevention and Control

Sexual activity of any mucosal type (oral, anal, genital) can be a mode of transmission for syphilis. Since lesions may not be readily apparent (e.g., painless lesions on the internal genital tract in females, intra-anal lesions, etc.) all patients with infectious syphilis should be considered potentially infectious regardless of the presence or absence of obvious lesions.
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. In cases where a child is born to a mother who was diagnosed with syphilis in pregnancy, and where the child is placed under the care of child protection services, medical information about the mothers diagnosis may be critical to the ongoing protection and monitoring of the infants health.

2.1 Case Management
Upon receiving a report of syphilis it is very important to confirm the diagnosis (see case definition and section 1.4 above). The interpretation of syphilis serology should be made in conjunction with a physician experienced in this area. Close collaboration between Public Health and the physician is crucial to ensure there is sufficient information to identify syphilis stage. This will allow PH nurse to identify appropriate trace back period and locate sexual contacts in a timely manner.
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). Also, during the initial conversation with the physician, it is important to determine the clinical plan of action for the case. It is a good time to educate the physician regarding the role of public health and contact tracing/education. Refer the treating physician to the appropriate syphilis sections of the revised January 2010 syphilis chapter in the 2006 edition of the Canadian STI Guidelines (e.g. Management, Follow-up, Special considerations) so they are aware of their role in ongoing monitoring of serologic tests and other follow up which can last up to 2 years. Note: Consultation with a specialist is strongly recommended in syphilis cases who are pregnant or HIV-infected. Note: Consult District MOH for advice/guidance if any questions/discrepancies arise regarding the confirmation of diagnosis and staging. The following tables (4a and 4b) can be used as a guide:
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Table 4a: Monitoring of serologic tests and other follow up

Primary, secondary, early latent Late latent, tertiary (EXCEPT NEUROSYPHILIS) Neurosyphilis (*), 3, 6, 12 months after treatment 12 and 24 months after treatment 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 (*), 3, 6, 12 and 24 months after treatment and yearly thereafter
HIV infected (any stage)
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 syphilis serology See revised January 2010 syphilis chapter in the 2006 edition of the Canadian STI Guidelines
(*) Some experts recommend follow up testing at 1 month after treatment to ensure that non-treponemal test titre is not rising; a rising titre may be indicative of either treatment failure or re-infection.
Table 4b: Adequate serologic response

Primary 4-fold* drop at 6 months, 8-fold drop at 12 months, 16-fold drop at 24 months Secondary 8-fold drop at 6 months and 16-fold drop at 12 months Early latent 4-fold drop at 12 months *A four-fold drop= 2- tube drop (e.g., change from 1:32 dilutions to 1:8 dilutions). Once preliminary information is obtained contact and interview the case. Discuss Public Healths role regarding contact tracing (see section 2.2 below for details on contact tracing for syphilis). 11
Review with the case the importance of adequate treatment and follow up with their physician (see above). Obtain details about current and past symptoms and risk factors. Collect prior history of syphilis and treatment information, if applicable. During the interview it is important to build trust and rapport so that the case feels safe in disclosing sensitive details regarding his/her sexual history and partners. It is very important to reassure the case that their personal information will not be disclosed in any way during the contact tracing process. Take the opportunity to provide education regarding other sexually transmitted infections and prevention measures. Public Health should follow case until treatment is completed and there is an adequate serologic response (refer to 4b). Once Public Health follow up is complete ensure that case understands the importance of ongoing follow up with their physician as mentioned above. Advise the case of community clinics/groups as appropriate (i.e. local STI clinics, AIDS Coaltion, Pride Health, Addiction Services, etc).
2.1.2 Exclusion
In most situations, no exclusion is necessary. If syphilis cases 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 Healths 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. NOTE: The reason the Jarisch-Herxheimer reaction occurs is not clear. It may be caused by the toxins released from the syphilis bacteria as they are destroyed by antibiotics. Other important points about this reaction: More common in secondary syphilis (70-90%), but can occur at any stage of infection. An acute febrile illness with headache, myalgia, chills, rigors which can occur as early as 2 hours after treatment and resolves within 24 hours. Not clinically significant unless there is neurologic or ophthalmic involvement or in pregnancy where it may cause fetal distress and premature labour. Not a drug allergy. Can be treated with antipyretics. Steroids may be indicated for the management of severe reactions consult an expert in this area. Depending on risk factors identified during interview, educate the case regarding prevention and harm reduction measures to prevent exposure to comunicable diseases in the future. Educate the case that reinfection can occur. Having syphilis once does not protect a person from getting it again. Following successful treatment, people are still susceptible to re-infection. It is also important for Public Health to educate Health Care Professionals that: A diagnosis of syphilis should be considered in anyone with signs or symptoms compatible with syphilis and also in the following individuals: Those who have had sexual contact wih a known case of syphilis. MSM Sex workers Those with street involvement/homelessness Those with a history of syphilis, HIV and other STIs Those originating from or having sex with an individual from a country with a high prevalence of syphilis; it should be noted that screening for syphilis (using a non-treponemal test) is routinely performed in all immigration applicants to Canada who are older than 15 years Sexual partners of any of the above 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. Rapid identification and investigation of sexual partners/contacts is essential to locate persons with early (primary, secondary, early latent) or incubating syphilis and provide them with treatment to prevent further transmission.
2.2.1 Definition of Close Contact/Exposure criteria

Primary, secondary, and early latent stages are considered infectious, with an estimated risk of transmission per partner of around 60%. Direct (often intimate) contact with lesions of primary and secondary syphilis poses the greatest risk of transmission. Early latent syphilis is considered infectious because of the 25% chance of relapse to secondary stage. Congenital transmission is most likely during the primary and secondary stage of maternal syphilis, but can occur in the latent period. The risk of transmission from mother to baby in untreated women is 70-100% with primary or secondary syphilis, 40% with early latent syphilis and 10% in late latent stages in pregnancy. About 40% of pregnancies in women with infectious syphilis results in fetal demise. Also, please see above for information regarding transmission and communicability.
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.
2.2.3 Initiate Contact Tracing

During interview with the case, identify contact (s). Discuss public healths role in potentially preventing infection to persons who are exposed (see section 2.2.4). Explain that it is important that the contacts be referred to the appropriate health care provider and public
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 contacts 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.
Table 5: Partner notification

Stage of syphilis Primary syphilis Secondary syphilis Early latent Late latent/ tertiary 3 months* 6 months* 1 year* Assess marital or other long-term partners and children as appropriate; the decision to test these contacts depends on estimated duration of infection in source case. Assess mother and her sexual partner (s) Assess/consult with a specialist experienced in syphilis management Trace-back period
Congenital Stage undetermined
*Trace-back period refers to the time period prior to symptom onset or date of specimen collection (if asymptomatic).
The length of time for the trace-back period should be extended: 1) To include additional time up to the date of treatment. 2) If the index case states that there were no partners during the recommended trace back period, then the last partner should be notified.
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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 contacts 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).
2.2.8 Ongoing Follow up of Public Health Measures

Ensure that all contacts are appropriately referred, tested, and treated when appropriate.

Follow the steps of outbreak management as outlined in Guidelines for Outbreak Management, Chapter 2 of the Nova Scotia Communicable Disease Control Manual.
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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 HealthLink BC. (2009). Antibiotics for syphilis Examples. Retrieved from http://www.healthlinkbc.ca/kb/content/drugdetail/hw195771.html Heymen, DL. (ED.). (2008). Control of Communicable Diseases Manual. (19th ed.). Manitoba Health. (2010). Syphilis Communicable Disease Management Protocol. Retrieved from http://www.gov.mb/health/publichealth/cdc/protocol/syphilis.pdf Public Health Agency of Canada. (2006). Canadian Guidelines on Sexually Transmitted Infections. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/guidelignesdireng.php 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
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Syphilis Fact Sheet

What is Syphilis?
Syphilis is a sexually transmitted infection. It is caused by a kind of bacteria called Treponema pallidum.
How do people get syphilis?

Syphilis is spread by vaginal, anal, or oral sex with someone who has an active syphilis infection. It is passed from person to person through direct contact with a syphilis sore. Most often the sores are found on the genitals, but they can occur on the lips, in the mouth, or anywhere on the body. Babies can get syphilis if their mother is infected because the bacteria can pass through the placenta during pregnancy.

Many people infected with syphilis do not have any symptoms for years. However, with or without symptoms, the syphilis infection will stay in the body until it is cured. If it is not treated it can cause serious complications.
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

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.
If I have syphilis once, can I get it again?

Yes, having syphilis once doesnt protect a person from getting it again. Even after your syphilis has been treated and cured, you can still get it again.
How can you prevent Syphilis?

The surest way to avoid syphilis and other sexually transmitted infections is to: Abstain from sexual contact, OR Have sexual contact with only one partner who you know is having sex only with you. You and your partner should both be tested and know that you are not infected before sexual contact occurs. To reduce your risk of getting syphilis: Limit the number of sexual partners you have. Practice safer sex for all sexual activities including oral sex. Use condoms and dental dams. Do not have sexual contact if there are ulcers in your or your partners genital area. Learn about prevention and control of sexually transmitted diseases. Talk to your doctor about getting tested for syphilis and other sexually transmitted infections. See your doctor if you have any symptoms of syphilis.
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Fiche dinformation sur la Syphilis

Quest-ce que la syphilis?
La syphilis est une maladie transmissible sexuellement. Elle est cause par la bactrie Treponema pallidum.
Comment attrape-t-on la syphilis?

La syphilis sattrape en ayant des relations sexuelles vaginales, anales ou orales avec une personne qui souffre dune syphilis volutive. La bactrie est transmise de personne personne par contact direct avec une lsion syphilitique. Ces lsions sont le plus souvent sur les parties gnitales, mais elles peuvent tre sur les lvres, dans la bouche ou partout ailleurs sur le corps. Comme la bactrie peut traverser le placenta durant la grossesse, une femme qui a la syphilis peut transmettre la maladie son bb.

Beaucoup de personnes infectes par la bactrie de la syphilis nont pas de symptmes pendant des annes. Toutefois, quil y ait des symptmes ou non, linfection est prsente dans le corps et y restera jusqu ce quelle soit traite et que la personne infecte soit gurie. Si linfection nest pas traite, elle peut causer des complications graves. Une fois contracte, l'infection volue par stades. Les symptmes, qui sont diffrents chaque stade, sont : Une lsion indolore, ronde, plate et souleve sur les cts, comme un gros furoncle. Parce que la lsion est indolore et peut se trouver un endroit que vous ne pouvez pas voir, vous pourriez ignorer que vous avez une lsion. Des ruptions cutanes n'importe o 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 cur, le cerveau ou d'autres organes. 20
Les premiers symptmes apparaissent entre 10 et 90 jours aprs un contact avec une personne infecte. La moyenne est de 21 jours.

La syphilis se traite par injections de pnicilline ou par la prise dautres antibiotiques prescrits par un mdecin. Il est important de suivre le traitement jusqu la disparition de linfection. Si vous avez la syphilis, vous devez travailler avec le personnel des Services de la sant publique pour informer vos partenaires sexuels afin que ces derniers puissent se faire examiner et soigner sil y a lieu.
Si je contracte la syphilis une fois, est-ce que je peux la contracter de nouveau?

Oui. Le fait davoir eu la syphilis une fois nempche pas une personne de contracter la maladie de nouveau. Mme si vous avez t soign et guri, vous pouvez tre infect de nouveau.
Comment se protger contre la syphilis?

La meilleure faon dviter de contracter la syphilis et dautres infections transmissibles sexuellement est : de sabstenir davoir des contacts sexuels, ou davoir des contacts sexuels avec seulement une personne qui, votre connaissance, na des contacts sexuels quavec vous. Avant d'avoir des contacts sexuels, vous et votre partenaire devriez passer un test de dpistage et tre srs que vous n'tes pas infects. Pour rduire le risque d'attraper la syphilis : Limitez le nombre de vos partenaires sexuels. Adoptez des pratiques sexuelles protges pour toutes vos activits sexuelles, y compris les relations sexuelles orales. Utilisez des condoms et des digues dentaires. vitez tout contact sexuel si vous ou votre partenaire avez des ulcres dans la rgion gnitale. 21
Renseignez-vous sur la prvention et le contrle des maladies transmissibles sexuellement. Parlez votre mdecin pour savoir si vous devriez passer un test de dpistage de la syphilis et d'autres infections transmissibles sexuellement.
Consultez votre mdecin si vous prsentez lun ou lautre des symptmes de la syphilis.
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VACCINE PREVENTABLE DISEASES

Section Contents
Principles General Guidelines Diphtheria Invasive Haemophilus Influenzae Type b (Hib) Disease Measles Mumps Pertussis Polio Rubella Smallpox Tetanus Varicella
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.

This section explains the general roles and responsibilities of the partners normally involved in the investigation of vaccine preventable illnesses. For some diseases, additional responsibilities are placed on some or all of the partners. In these instances, the specific responsibilities are noted in the procedure section for each disease.
1.1. Medical Officer of Health:

The Medical Officer of Health (MOH) must ensure that all reports of vaccine preventable diseases are received and disseminated to the appropriate personnel for investigation within Public Health Services. The Communicable Disease Control Coordinator/Manager may assume this role in the absence of a MOH.
1.1.2. Approve Public Health Control Measures.

It is the responsibility of the MOH or designate to approve any decisions about exclusions from work, child-care centres or school, or any other required public health control measures.
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. c) Contact and educate individual or family. Discuss your role in the management of the disease and contact tracing. Provide information to the infected individual or the parents using the appropriate fact sheet. Ensure that appropriate treatment is administered (see specific disease sections for guidelines). For diseases where isolation or exclusion is required, educate the individual and family about these requirements. Obtain names and addresses for all contacts. 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 Its the Law for reporting requirements for each disease.
1.3.2. Cooperate in contact tracing

Education and follow-up with the PHS investigator.
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.
2. Procedure for Exclusion

Some vaccine preventable diseases require exclusions from work, school or child-care. Specific disease sections indicate requirements for exclusions. In general, the following procedures apply for implementing exclusions.
2.1. Terms for Exclusions

Follow the recommendations outlined in specific disease sections.
2.2. Inform client

The Investigator will immediately inform the individual or parents of a child about the exclusion.
2.3. Inform place of employment/child care centre

The Investigator will ensure that the employer/child care centre is immediately informed of the exclusion. This may be done by phone.
2.4. Return from Exclusion

Terms for return to work/child care are listed under the specific diseases.
3. Guidelines for Child Care Centres and Schools

When an outbreak of vaccine preventable disease occurs in a childcare setting, the following procedures should be put in place, supplemented by any additional guidelines stated in the specific disease section.
3.1. Report the case

The staff of the childcare centre or school is responsible to report any confirmed case of vaccine preventable disease to PHS.
3.2. Inform parents

The Investigator should provide information to the parents of the children in the centre or school about the case of the disease.
3.3. Case finding

Investigate children and staff including absentees to ensure all cases are found. Refer to family physician as required.
3.4. Exclude any infected individual.

Exclude infected individuals as per section 2 and guidelines for the specific disease.
4. Guidelines for Institutions

Consult specific diseases for guidelines.
DIPHTHERIA
1. Information
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:
Laboratory confirmation of infection:

OR isolation of other toxigenic Corynebacterium species (C. ulcerans or C. pseudotuberculosis) from an appropriate clinical specimen, including the exudative membrane histopathologic diagnosis of diphtheria Epidemiologic link (contact within two weeks prior to onset of symptoms) to a laboratory-confirmed case isolation of Corynebacterium diphtheriae with confirmation of toxin from an appropriate clinical specimen, including the exudative membrane
OR OR
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

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 onesided 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.
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. Contact the Biological Coordinator at 481-5865 to obtain diphtheria antitoxin.

Immunize according to the Nova Scotia Immunization schedule. Adolescents and adults should receive a booster every 10 years that includes vaccine for diphtheria and tetanus (Td).
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 nonimmunized 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
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 followup 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:
2.1.4. Laboratory:

Individuals with diagnosed diphtheria are to be excluded from school, childcare centres and work until 2 cultures from nose and throat are negative. These cultures must be taken at least 24 hours apart and taken 24 hours after the completion of antibiotic therapy. All close contacts should have cultures taken from the nose and throat and kept under surveillance for 7 days. A single dose of benzathine penicillin or a 7-10 day course of erythromycin is recommended for all persons with household exposure to diphtheria, regardless of their immunization status. Those who handle food or work with children should be excluded from work until nose/throat swabs demonstrate they are not carriers.
2.3. Guidelines for Long Term Carriers

If carrier status is determined, antibiotic therapy should be administered. Penicillin G (IM) or a 7-10 day course of oral erythromycin should be prescribed.
2.4. Guidelines for Child Care Centres and Schools

Although an outbreak of diphtheria would be a rare occurrence in a childcare setting, if it occurs follow the procedures outlined in section 2 of the general guidelines. Also, follow the guidelines below re:
2.4.1. Immunizing contacts.

Children who have not begun their primary series of immunization against diphtheria should begin this series and be followed closely by the physician. Children over 7 years of age will be given the adult-type tetanus and diphtheria toxoid in a series of three doses.
2.4.2. Exclude any infected individual.

Exclude infected individuals as per section 2.2.
2.5. Guidelines for Institutions

In addition to standard precautions, droplet precautions and strict isolation are also recommended for pharyngeal and laryngeal diphtheria until 2 negative cultures are obtained. Contact precautions are recommended for cutaneous diphtheria until 2 cultures of skin lesions are negative.
2.6. Surveillance 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/ccdrrmtc/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,
Public Health Nurse 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.
Who Can Get Diphtheria?

Anyone who comes in contact with the droplets of fluid from the nose or mouth of an infected person can get diphtheria. The disease can be spread to others for up to several months after a person becomes ill. With treatment they will not be able to spread the disease to others. It is important for people to be retested after treatment to make sure they have not become carriers.

Symptoms can include: Low fever. Sore throat. Yellow discharge over the back of the throat, which may become grey and thick and cover the throat. Swelling of the neck. 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.

Diphtheria is treated with an antitoxin that will help to decrease the illness and the symptoms. Antibiotics will be prescribed by your doctor to help to treat the disease and to stop the spread of the disease. Children with diphtheria cannot attend school or day care until their throat swab tests show that they have no signs of the disease.
How Can You Prevent Diphtheria?

Every child should get diphtheria vaccine as part of childhood immunization. Every adolescent should be given diphtheria-tetanus vaccine as part of the school-based immunization program Every adult should have diphtheria-tetanus vaccine every 10 years.
INVASIVE HAEMOPHILUS INFLUENZAE TYPE B DISEASE (HIB)

Confirmed case
Clinical evidence of invasive disease with laboratory confirmation of infection: isolation of H. influenzae (serotype b) (Hib) from a normally sterile site OR isolation of H. influenzae (serotype b) from the epiglottis in a person with epiglottitis
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

The bacteria Haemophilus influenzae, serotype B.
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.
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.

Immunize according to the Nova Scotia Immunization schedule. Reduce direct contact and exposure to droplets. Good hand washing technique using soap and warm running water. Careful observation of exposed household contacts and childcare centre contacts. Exposed individuals who develop a febrile illness should receive prompt medical evaluation.
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. Childcare centre contact: a child who has attended a childcare centre where an infected individual has been identified. Complete immunization: Immunization is complete when the individual has had at least 1 dose of conjugate vaccine at 15 months of age or older, 2 doses between 12 and 14 months, or a 2 or 3 dose primary series when younger than 12 months with a booster dose at 12 months of age or older.
1.10.2. Prophylaxis for Household Contacts

Chemoprophylaxis is not recommended for occupants of households when all household contacts younger than 48 months of age have completed their Hib immunization. In households with at least 1 contact younger than 48 months of age who is unimmunized or incompletely immunized against Hib, rifampin prophylaxis is recommended for all household contacts irrespective of age. The exception to the above recommendation is that all members of households with a fully immunized but immunocompromised child, regardless of age, should receive rifampin because of concern that the immunization series may not have been effective. Although the risk of secondary disease is low in an infant who has completed the primary 2 or 3 dose series, all members of a household with a child younger than 12 months of age (i.e., who has not yet received the booster vaccine dose) should receive rifampin prophylaxis. Dosage of rifampin is as follows: Rifampin should be given orally once a day for 4 days (in a dose of 20 mg/kg, maximum dose 600 mg/day). For adults each dose is 600 mg. For infants younger than 1 month of age, give, 10mg/kg. Chemoprophylaxis is not recommended for pregnant women
1.10.3. Prophylaxis for Child Care Center Contacts

When two or more cases of invasive disease have occurred within 60 days and unimmunized or incompletely immunized children attend the childcare facility, administration of rifampin to all attendees and supervisory staff is indicated.
1.10.4. Timing of Prophylaxis

The majority of secondary cases occur within 7 days of hospitalization of the index case.
2. Procedure
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. b) Investigating contacts and administering prophylaxis. Definitions of contacts and recommended prophylaxis for Hib are defined in section 1.10. Advise contacts to consult with their physician immediately to obtain prophylaxis. 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). e) Information for pharmacists. See the Invasive Haemophilus Influenzae type b Disease Appendix 2 for instructions for preparing an oral suspension of rifampin.
2.1.3. Physician:
2.1.4. Laboratory:

Children and staff who have Hib should be excluded from childcare centres until they are well enough to return and appropriate prophylaxis measures have been completed.

2.3.1. When 1 case of Hib occurs
Notify all parents of the occurrence of one case (see sample letter in Invasive Haemophilus Influenzae type b Disease Appendix 4). Educate parents and staff to watch for signs and symptoms in children and staff (use fact sheet in the Invasive Haemophilus Influenzae type b Disease Appendix 3), and to seek prompt medical attention for any ill children. Require the director of the childcare centre to notify PHS if additional children become ill.
2.3.2. When 2 cases of Hib occur within 60 days

Notify all parents of the occurrence of cases (see sample letter in Invasive Haemophilus Influenzae type b Disease Appendix 4).
If unimmunized or incompletely immunized children attend the childcare centre, recommend prophylaxis for all attendees and staff. Recommend that unimmunized or incompletely immunized children receive a dose of vaccine and be scheduled for completion of the vaccine series. Educate parents and staff to watch for signs and symptoms in children and staff (use fact sheet in the Invasive Haemophilus Influenzae type b Disease Appendix 3), and to seek prompt medical attention for any ill children. Require the director of the childcare centre to notify PHS if additional children become ill.

Prophylaxis is recommended for individuals younger than 12 months. Provide prophylaxis to those who are 1-3 years of age and inadequately immunized, who share a room with an infected 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/ccdrrmtc/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.
Who Can Get Hib?

Hib is carried in the nose and throat of children and adults who may be healthy or have mild symptoms. It is then spread to another person through contact with discharges or droplets from the nose or mouth through activities such as kissing, sharing food, utensils or glasses. Hib disease usually occurs most seriously in children 2 months to five years of age.

Symptoms include: Fever Vomiting Excessive drowsiness Stiff neck or upper back

Hib can be treated with antibiotics prescribed by your doctor. It is important to get treatment immediately.
How Can You Prevent Hib?

Hib vaccine is recommended for all children starting at 2 months of age. Children need a total of 4 immunizations, given at 2, 4, 6 and 18 months. This
vaccine is included in routine childhood immunization. Make sure your childs immunizations are up-to-date. Practice good hygiene. Cover nose and mouth when coughing and sneezing and dont share eating utensils. In some cases, children and employees in childcare settings where a child has been diagnosed with Hib may also need an antibiotic. Check with your doctor or Public Health Services for advice.
APPENDIX 1: INFORMATION FOR PHYSICIANS

The following information is provided by Public Health Services to assist you in managing patients with Hib and prophylaxis for contacts. If you have any questions please call Public Health Services.
Definition of Contacts for Hib

The following definitions apply to the prophylaxis guidelines listed below: Household contact: an individual residing with the infected person or a nonresident who spent four or more hours with the index case for at least 5 of the 7 days preceding the day of diagnosis of the index case (not school contact). This includes people who share sleeping arrangements, such as military personnel in a barracks setting. Childcare centre contact: a child who has attended a childcare centre where an infected individual has been identified. Complete immunization: Immunization is complete when the individual has had at least 1 dose of conjugate vaccine at 15 months of age or older, 2 doses between 12 and 14 months, or a 2 or 3 dose primary series when younger than 12 months with a booster dose at 12 months of age or older.
Guidelines for Prophylaxis

The majority of secondary cases occur within 7 days of hospitalization of the index case. Prophylaxis for Household Contacts Chemoprophylaxis is not recommended for occupants of households when all household contacts younger than 48 months of age have completed their Hib immunization. In households with at least 1 contact younger than 48 months of age who is unimmunized or incompletely immunized against Hib, rifampin prophylaxis is recommended for all household contacts irrespective of age.
The exception to the above recommendation is that all members of households with a fully immunized but immunocompromised child, regardless of age, should receive rifampin because of concern that the immunization series may not have been effective. Although the risk of secondary disease is low in an infant who has completed the primary 2 or 3 dose series, all members of a household with a child younger than 12 months of age (i.e., who has not yet received the booster vaccine dose) should receive rifampin prophylaxis. Dosage of rifampin is as follows: Rifampin should be given orally once a day for 4 days (in a dose of 20 mg/kg, maximum dose 600 mg/day). For adults each dose is 600 mg. For infants younger than 1 month of age, give 10mg/kg. Chemoprophylaxis is not recommended for pregnant women. Prophylaxis for Child Care Center Contacts When two or more cases of invasive disease have occurred within 60 days and unimmunized or incompletely immunized children attend the childcare facility, administration of rifampin to all attendees and staff is indicated.
Information about Rifampin

Pregnant women should not take rifampin Rifampin may reduce the effectiveness of oral contraceptives Possible side effects include: Orange discoloration of secretions or urine Potential staining of contact lenses Vomiting Influenza-like reaction Hepatitis
APPENDIX 2: INFORMATION FOR PHARMACISTS

Information about Rifampin
Pregnant women should not take rifampin. Rifampin may reduce the effectiveness of oral contraceptives. Possible side effects include: Orange discoloration of secretions or urine Potential staining of contact lenses Vomiting Influenza-like reaction Hepatitis
Preparation of an Oral Suspension of Rifampin

To prepare 120 ml (4 oz.) of rifampin (10 mg/ml): 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 2-8C. (36-46F) for no more than 6 weeks. Because this is a suspension, shake vigorously before administration of each dose.
Sample Letter to Parents for One Case of Hib in Childcare Centre

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 childs immunizations are up to date. If either you or your doctor needs more information, please contact Public Health Services. Sincerely,
Public Health Nurse Phone: __________________
Sample Letter to Parents for Two Cases of Hib in Childcare Centre Within 60 Days
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 childs 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,
Public Health Nurse Phone: __________________
MEASLES
1. Information
Confirmed case
Laboratory confirmation of infection in the absence of recent immunization with measles-containing vaccine: isolation of measles virus from an appropriate clinical specimen OR detection of measles virus RNA OR seroconversion or a significant (e.g. fourfold or greater) rise in measles IgG titre, by any standard serologic assay, between acute and convalescent sera OR positive serologic test for measles IgM antibody using a recommended assay in a person who is either epidemiologically linked to a laboratoryconfirmed case or has recently travelled to an area of known measles activity OR Clinical illness in a person with an epidemiologic link to a laboratoryconfirmed 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 OR in a person who has recently travelled to an area of known measles activity

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.
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.

Vaccination of all infants at one year of age, and again at school-entry age.
Vaccination of all susceptible persons who meet the following requirements: born after 1970, no previous documentation of live measles vaccine on or after 1 year of age, without contraindication to the vaccine.
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.

Use general guidelines. Also use additional guidelines re: a) Determining case status. In discussion with physician, determine if the case meets the case definition. If the suspect case meets the case definition all appropriate control measures should be undertaken. Confirm or rule out the suspect case. Arrange to have the blood drawn for measles IgM between 3 and 7 days after onset of rash. Arrange for a visit to the lab and notify the lab to take the client into a room immediately upon arrival because the client may be infectious. Notify the lab that the results are required immediately. b) Educating the client. Educate the client about measles including the infectious period (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) and the need for isolation from susceptible contacts and public places during the period of communicability. Determine if client was vaccinated and date of vaccination(s). 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. e) Immunize or provide vaccine or IG as in Section 1.10. f) Exclude susceptible contacts as per section 2.2 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:
2.1.4. Laboratory:

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.
2.2.2. Contacts who refuse vaccination and IG.

Susceptible contacts that have not received IG or vaccine should be considered for exclusion from childcare, work or school (including university). Discuss with the MOH.
2.2.3. Return from exclusion.

PHS will inform the school or childcare centre when it is permissible for the case or contact to return (4 days after the rash, 2 weeks after the last case or after vaccine/IG as per recommended timelines).

Use general guidelines. Also use additional guidelines re: 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. Students 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.

Health Care Facilities (HCFs) may handle their own contacts with regard to immunization, follow-up and education. Contacts are to be instructed by the HCF to call PHS if symptoms develop. The PHS investigator should call the HCF after 3 days to verify receipt of vaccine in susceptible contacts, and after 14 days to confirm that no cases have called the HCF to report illness. Exclusion should be in accordance with the facilitys occupational health guidelines.

MEASLES FACT SHEET

What is Measles?
MAY 2008
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.
Who can get Measles?

Anyone who has been in close contact with someone who has measles can get the disease. The chance of getting measles is reduced if you have been immunized against

Symptoms start about 10 days after a person is infected with the virus. Infants and adults are usually sicker than children and teenagers. Symptoms include: Fever runny nose red watery eyes, often sensitive to light cough small, white spots may appear on the inside of the mouth (Koplik spots) rash that starts on the face and neck and then spreads 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.
What are the Complications?

Most people recover from measles. Measles can cause serious complications in 20 percent of cases including ear infections, pneumonia, encephalitis (swelling or inflammation of the brain), seizures, and deafness. In Canada, measles causes death in approximately 1 out of every 3,000 cases.

There is no treatment for measles. Sometimes the measles vaccine is given to people who have been in contact with a person with measles. If the vaccine is given early enough, it may prevent the person from getting the disease. If you have been in contact with someone you know has measles, call your doctor or Public Health Services right away. If you suspect that you have measles, advise your doctor or health care provider before you visit their office.
Should pregnant women worry about the measles?

When measles occurs in pregnant women, the illness is generally not any more severe than in other women. However, measles infection during pregnancy has an increased risk of premature labour, miscarriage, and low birth weight infants. There is no evidence that measles during pregnancy causes birth defects.
How can you prevent measles?

The best way to prevent measles is to make sure that you and your children have been vaccinated. Children should have the measles vaccine at 1 year of age, and again before they enter school. The vaccine is given at the same time as the mumps and rubella vaccine (MMR). Avoid close contact with someone who has measles if you have not had measles or measles vaccine. Generally, measles-mumps-rubella (MMR) vaccine should not be given during pregnancy, as there may be a risk to the fetus. To date, there is no proof that this vaccine actually causes harm to a fetus. Immune Globulin (IG) is recommended for pregnant women who have not had measles or measles vaccine. IG is given by needle and can provide quick, short-term protection against measles, or reduces the severity of illness of those who become ill. The MMR vaccine is safe for breastfeeding mothers and their babies. You can still get MMR vaccine if you are in close contact or live with a pregnant woman.
What should I do if I think I have measles?

Limit contact with others until you speak with a health-care provider. Do not go to school, work, or any public places. Do not take part in social activities. Call your healthcare provider immediately. Tell them that you may have measles and make an appointment. It is important you are seen and that proper testing is done. If you are diagnosed with measles, you should stay home from work, school, public places and other social settings. Avoid close contact with others for 4 days after the rash appears.
The illness can be spread to others from 4 days before to four days after the start of the rash. To avoid spreading disease: wash your hands often or use hand sanitizer do not share drinking glasses or eating utensils cover your coughs and sneezes with a tissue or your elbow stay home when you are sick make sure your vaccines are up-to-date
APPENDIX 1: INFORMATION FOR PHYSICIANS

Diagnosis
Think measles in a patient with fever, cough, coryza and conjunctivitis followed by a maculopapular rash 2 to 4 days after prodromal symptoms. If not linked to another case of measles confirm with measles IgM antibody test. Exclude suspect cases from day care and school while being evaluated. Report confirmed or suspected cases to Public Health Services.
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, doctors office, Emergency room, etc. Family physicians should deal with family members with assistance from Public Health Services. Public Health will deal with other contacts. A susceptible contact is a person who meets one of the following: Infants less than one year. Born after 1970 with no past history of measles (either documented clinical or lab confirmed case) No documented record of MMR after 12 months
Follow up of Contacts
All susceptible contacts should receive measles vaccine within 72 hours of last contact with infectious case if there are no medical contraindications, or Immune globulin (IG) if: more than 72 hours but less than 6 days after contact or if they have medical contraindications to measles vaccine. Infants 6 to 12 months; give measles vaccine and revaccinate at 12 months. Susceptible individuals who refuse IG or measles vaccine are excluded from school, day care, or college until receipt of measles vaccine or IG, or until two weeks after last case in the area.
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
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 laboratoryconfirmed 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.

Mumps virus, a member of the genus Paramyxovirus.
1.3. Symptoms:
Fever, swelling and tenderness of one or more salivary glands; this can involve other glands and organs of the body. Orchitis can occur in as many as 20-50% of post-pubertal males and mastitis can occur in up to 31% of females over the age of 15. 40-60% of mumps cases have been associated with respiratory symptoms, particularly in children younger than 5 years of age.
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.
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.

Vaccination of all infants at one year of age, and again at school-entry age with MMR. Vaccination of all susceptible persons without contraindication to the vaccine. Individuals should be considered susceptible unless they have documentation of at least one mumps vaccination on or after their first birthday, documentation of physician-diagnosed mumps, serologic evidence of immunity or born before 1970.
1.10. Prophylaxis:
None.
2. Procedure
2.1.3. Physician:
2.1.4. Laboratory:

2.2.1. Persons infected with mumps.
Cases should be excluded from school, childcare, university or workplace for 9 days from onset of parotid gland swelling.
2.2.2. Contacts who refuse vaccination.

Susceptible, unimmunized contacts may be considered for exclusion from school, childcare or university until at least 26 days after the onset of parotitis in the last person with mumps in the affected school or childcare centre. Excluded contacts may return immediately after vaccination.
2.2.3. Other potential exclusions.

Other circumstances may also require exclusion such as in the circumstance of a susceptible contact that is a patient care provider and refuses mumps vaccination. These cases are up to the discretion of the MOH.
2.2.4. Return from exclusion.

PHS will inform the school or childcare centre when it is permissible for the case or contact to return.


Respiratory isolation and private room for 9 days after onset of swelling.

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.
Who Can Get Mumps?

Mumps is usually seen in school age children, but young adults may also get the disease.

Symptoms may include: Fever Swollen and tender glands at angle of the jaw Swollen and tender testicles in teenage and adult men Some people may not have any symptoms at all.

There is no treatment for mumps.
How Can You Prevent Mumps?

The best protection against mumps is vaccination. All children should receive a mumps vaccine at one year of age and again when they start school. The vaccine is given at the same time as the measles and rubella vaccine. Avoid close contact with someone who has mumps if you have not had mumps or mumps vaccine. Children should not attend school while they can spread the virus.
PERTUSSIS
1. Information
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

Bordetella pertussis, a gram-negative bacillus.
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.
1.9.Core messages for Prevention

Immunization of all infants at 2, 4, 6, and 18 months followed by boosters given at 4-6 years, in adolescence, and once as an adult.
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 Prophylaxis should be implemented as soon as possible and is unlikely to be of any benefit if started more than 21 days since the first contact with the case.
Antibiotics
The same antimicrobials and schedule should be used for prophylaxis and treatment of symptomatic cases. Public Health will pay for prophylactic antibiotics in situations where the individuals requiring the medication do not have third party payment.
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 2.2. Medical Officer of Health
Recommend exclusion in high-risk situations.
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 childrens 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-todate
2.4. Physician
Use general guidelines. No additional guidelines
2.5. Laboratory
Use general guidelines. No additional guidelines

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 childs 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
2.7. Guidelines for schools

Use general guidelines. Also use the following guidelines regarding: 1. Informing parents: Send a letter (see Appendix A) to parents of classmates of the case to inform them of the case of pertussis and the possible risk 2. Identifying cases: Discuss with staff the signs and symptoms of the disease Following the identification of a pertussis case in a school, the school should be monitored for a three-week period to determine if there are any other ill children. If additional children are diagnosed with pertussis, the school should be monitored until there has been a 3-week period with no additional cases 3. 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/ccdrrmtc/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.
Who Can Get Pertussis?

Anyone can get pertussis, though most severe cases occur in children less than one year of age. Older children and adults may get and spread the disease, but they usually only have mild symptoms.

Symptoms may include: Low fever. Cough, mild at first and then a deep rapid coughing and a whoop. Vomiting after coughing. Coughing is worse at night. 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.

Pertussis is treated with an antibiotic prescribed by your doctor. Some children who have not had their childhood immunization will need the vaccine. Check with your doctor. Some older children and adults who are in contact with the person with pertussis may also need to take an antibiotic.
How Can You Prevent Pertussis?

Every child should get pertussis vaccine at 2, 4, 6 and 18 months. A booster Doses are recommended at 4-6 years, in adolescence and once as an adult. 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 physicians 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.)
Role of the Physician

Report cases of pertussis whether confirmed or suspect to Public Health Services. The physician should indicate whether the case is confirmed, clinical or suspect. In coordination with Public Health, the physician should educate and follow up as follows: FAMILY: Public Health Services should investigate and refer to family physician. The treating physician is responsible for ensuring that the case and all family (household) contacts regardless of age and immunization status, are offered appropriate chemoprophylaxis and have their immunizations updated.
FAMILY DAYCARE: Public Health Services should investigate and refer to family physician. The physician is responsible for ensuring that all contacts and caregivers regardless of age and immunization status are offered chemoprophylaxis and have their immunization status updated.
APPENDIX 1: INFORMATION FOR THE PHYSICIAN

Information for Daycare
On referral from Public Health, the physician is responsible for ensuring that contacts under 1 year of age are offered chemoprophylaxis regardless of immunization status and that they have their immunizations updated.
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: Re: Pertussis Contact This letter is to advise you that a case of whooping cough (pertussis) has been identified in your childs 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, Public Health Nurse
SAMPLE LETTER TO PHYSICIAN

Date: Dear Doctor: Re: Pertussis Contact
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. 3. Immunization: Immunizations following exposure will not provide protection from current infection nor eradicate the organism but it is important that, unless contraindicated, all children be upto-date with scheduled pertussis vaccine even if they have had pertussis disease. Please review the immunization status of the child and provide vaccines as required. 4. Exclusion: Exclusion of cases and contacts has not been shown to be an effective strategy for pertussis control. However, it may be recommended by the Medical Officer of Health in specific high-risk situations. 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,
Public Health Nurse
POLIOMYELITIS (PARALYTIC)
1. Information
Confirmed case
Clinical illness with laboratory confirmation of infection: isolation of polio virus (vaccine or wild-type) from an appropriate clinical specimen OR detection of polio virus RNA OR Clinical illness in a person who is epidemiologically linked to a laboratoryconfirmed case
Confirmed case categories

Confirmed cases of poliomyelitis can be further subdivided into the following two categories: 1. Wild virus Laboratory investigation implicates wild-type virus. This group is further subdivided as follows: Imported: travel in or residence in a polio-endemic area 30 days or less before onset of symptoms Import-related: epidemiologic link to someone who has travelled in or resided in a polio-endemic area within 30 days of onset of symptoms Indigenous: no travel or contact as described above 2. Vaccine-associated virus Laboratory investigation implicates vaccine-type virus. This group is further subdivided as follows: Recipient: the illness began 7-30 days after the patient received oral polio vaccine (OPV)
Contact: the patient was shown to have been in contact with an OPV-recipient and became ill 7-60 days after the contact was vaccinated Possible contact: the patient had no known direct contact with an OPV-recipient and no history of receiving OPV, but the paralysis occurred in an area in which a mass vaccination campaign using OPV had been in progress 7-60 days before the onset of paralysis No known contact: the patient had no known contact with an OPV-recipient and no history of receiving OPV, and the paralysis occurred in an area where no routine or intensive OPV vaccination had been in progress. In Canada, this would include all provinces and territories.
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

Poliovirus, of the genus Enterovirus. It is subdivided into three types; Types 1, 2 and 3. All types can cause paralysis, though Type 1 is most often associated with poliomyelitis.
1.3. Symptoms:
Severity of symptoms may vary. Fever, malaise, headache, nausea and vomiting may appear in the early stages of the disease or in a minor case. If the disease progresses, severe muscle pain and stiffness of the neck and back, with or without flaccid paralysis, may be present. Often a limb is paralysed, but usually only one side is affected. The area of nerve cell destruction will affect them degree and site of paralysis. Paralysis of the muscles used in respiration and swallowing may threaten life.
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).
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.

Immunization of all infants according to the N.S. immunization schedule. Individuals travelling to countries where poliomyelitis is prevalent should be immunized.
1.10. Prophylaxis:
None. Monitor anyone who has been a contact of the infected individual for early signs of disease.
2. Procedure
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.
2.1.3. Role of Physician

2.1.4. Role of Laboratory


Individuals with polio should be excluded from school, work, day care, etc. No exclusions for contacts unless there are symptoms.
2.3. Guidelines for Long Term Care

If there is a case in long-term care the individual should be placed on enteric precautions in a private room.
2.4. Guidelines for Child Care Centres and Schools

The individual with polio would be excluded and an investigation by public health would be done to identify additional cases and contacts of the case. All close contacts would have vaccine status reviewed and updated if necessary.

The individual with polio would be isolated with enteric precautions.

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/ccdrrmtc/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.
Who Can Get Polio?

Polio mainly affects children under three years of age. Unimmunized individuals are at highest risk for polio.

The symptoms may include: Fever. Headache. Vomiting. Stiffness in the neck. Pain in the limbs. Fatigue.

Although there is no cure for polio, medical procedures are available to manage symptoms.
How Can You Prevent Polio?

Every child should get a polio vaccine injection at 2, 4 and 6 months and at 18 months of age. A booster dose at 4-6 years completes the series. This vaccine is given at the same time as diphtheria, pertussis, and tetanus vaccine [DaPTP]. Individuals travelling to countries where polio is prevalent should be immunized. Consult a travel clinic.
RUBELLA
1. Information
Confirmed case
Laboratory confirmation of infection in the absence of recent immunization with rubella- containing vaccine: isolation of rubella virus from an appropriate clinical specimen OR detection of rubella virus RNA OR seroconversion or a significant (e.g. fourfold or greater) rise in rubella IgG titre, by any standard serologic assay, between acute and convalescent sera OR positive serologic test for rubella IgM antibody using a recommended assay in a person with an epidemiologic link to a laboratory-confirmed case or who has recently travelled to an area of known rubella activity OR Clinical illness in a person with an epidemiologic link to a laboratoryconfirmed 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 OR in a person who has recently travelled to an area of known rubella activity

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.
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.

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 nonimmune 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
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:
2.1.4. Laboratory:

2.2.1. Individuals infected with the disease
Excluded from school, childcare or work until 7 days after the appearance of the rash. Isolation of each individual is important so as not to infect those who may be susceptible. PHS will inform the school, childcare centre or employer about the exclusion.
2.2.2. Return from Exclusion

PHS will inform the school, childcare centre, or employer when it is permissible for the infected individual to return.

Use general guidelines. Also use the following guidelines re: 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).

A health care worker should be excluded. Health care facilities may wish to handle the investigation. Public Health Services should be involved as well. In hospitals and institutions, patients suspected of having rubella should be managed under contact isolation precautions and placed in a private room; attempts should be made to prevent exposure of non-immune pregnant women. Immunization of contacts, while not contraindicated (except during pregnancy) will not necessarily prevent infection or illness. Passive immunization with immune globulin is not indicated. Identify pregnant female contacts, especially those in their first trimester. Such contacts should be tested serologically for susceptibility (if not known) or for early infection and advised accordingly. All cases of rubella must be reported to PHS.

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.
Who Can Get Rubella?

Anyone can get rubella, except those people who have had it before or those people who have had a rubella immunization.

Symptoms may include: Low fever. A mild rash that lasts one to three days. Aches in the joints. Swollen glands, behind the ears and the back of the neck. These symptoms start about 2-3 weeks after contact with someone with the disease. Half of the people who get rubella dont get any symptoms at all.

There is no treatment for rubella. Most children and adults can recover from rubella without any problems. However, if a pregnant woman gets the rubella infection her baby can be born with deafness, eye and heart problems and/or mental retardation. Every woman should get a blood test before she becomes pregnant to see if she has protection against rubella infection. If a pregnant woman has been in contact with someone with rubella, she should contact her family doctor for a blood test and to discuss the dangers to her baby.
How Can You Prevent Rubella?

Rubella can be prevented by immunization. Children should have a rubella immunization at 12 months of age and again when they reach school age. This vaccine is given at the same time as the measles and mumps vaccine. Adults can get rubella vaccine if they do not have protection against the disease. Women should not get the vaccine if they are already pregnant or if they plan to get pregnant within one month of the immunization.
To prevent rubella infection:

Immunize all children against rubella. If pregnant or planning to get pregnant, get blood tests to check for rubella protection. Avoid close contact with anyone who has rubella infection. Anyone with rubella should stay home until non infectious.
SAMPLE LETTER TO PARENTS

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 childs 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,
SMALLPOX
1. Information
Confirmed case
Laboratory confirmation of infection: isolation of variola virus from an appropriate clinical specimen OR detection of variola virus nucleic acid
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

Variola virus.
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 trunkthe 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 freezerspotential for bioterrorism.
1.6. Transmission:
Person to person. If used in biowarfare, the agent would most likely be disseminated in an aerosol cloud.
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

In 1980, the World Health Organization confirmed the global eradication of smallpox.
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.

TETANUS
1. Information
Confirmed case
Clinical evidence of illness without other apparent medical cause with or without isolation of Clostridium tetani and with or without history of injury

Clostridium tetani (C. tetani), the tetanus bacillus, is a gram-positive sporeforming bacillus that produces a potent exotoxin.
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.
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.

Immunization of all infants and adults as per the N.S immunization schedule. Any individual who sustains a wound may be at risk if their tetanus immunization is not up to date.
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.

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/ccdrrmtc/09pdf/35s2-eng.pdf Control of Communicable Diseases Manual, 17th edition. 2000. James Chin, editor. American Public Health Association.
TETANUS FACT SHEET

What is Tetanus?
Tetanus is a serious, sometimes fatal, disease of the central nervous system. It is caused by infection of a wound with spores of the bacterium Clostridium tetani.
Who Can Get Tetanus?

Anyone can get tetanus. The spores live in the soil. If they enter the body through a wound, they can multiply and produce a poison that affects the nerves controlling muscle activity.

The symptoms may include: Stiffness of the jaw, commonly known as lockjaw. This makes it difficult to open the mouth. Stiffness of stomach and back muscles and contraction of facial muscles. Rapid pulse, slight fever, and severe sweating. Painful muscle spasms as the disease progresses. If they affect the chest and airways, the person can suffocate.

For treatment, see your doctor immediately.
How Can You Prevent Tetanus?

Tetanus can be prevented with routine immunization. All children and adults should be immunized according to the N.S. immunization schedule. Tetanus can also be prevented by thorough cleaning of cuts and wounds. Wash carefully with lots of soap and water and apply disinfectant. If you are injured, you may need tetanus vaccine or tetanus immune globulin. See your physician for an assessment. If your tetanus vaccine is not up to date, see your physician for an assessment.
VARICELLA
1. Information
Confirmed case
Clinical evidence of illness and laboratory confirmation of infection: isolation or direct antigen detection of varicella-zoster virus (VZV) from an appropriate clinical specimen OR detection of VZV DNA OR seroconversion or a significant rise (e.g. fourfold or greater) by any standard serologic assay in varicella-zoster IgG titre between acute and convalescent sera OR positive serologic test for varicella-zoster IgM antibody OR Clinical evidence of illness in a person with an epidemiologic link to a laboratory-confirmed case of chickenpox or VZV infection
Probable case
Clinical evidence of illness in the absence of laboratory confirmation or epidemiologic link to a laboratory confirmed case

Human (alpha) herpes virus 3, Varicella-Zoster Virus (VZV).
1.3. Symptoms:
Generalized, pruritic, vesicular rash which leaves a granular scab. There is usually an accompanying mild fever and other systemic symptoms. The vesicles appear in crops and may cover the whole body. In adults these symptoms may be more severe.
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.
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 Reyes syndrome.

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
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:

Exclude from school, work (especially maternity care workers in hospitals) or childcare anyone who has been diagnosed with chickenpox until 5 days after the rash appears or sooner, if vesicles crust over. Exclude susceptible health care workers from day 10 to day 21 following last exposure.

Use general guidelines. Also use additional guidelines re: a) Following up susceptible contacts. Children with evidence of the disease should be sent home and parents contacted. Send home letter and fact sheet to parents/guardians. Inform parents of immunocompromised children to contact their physician.

Health care facilities should deal with confirmed cases of chickenpox based on their own guidelines. Airborne and droplet precautions are recommended for patients with varicella for a minimum of 5 days after the onset of the rash and as long as the rash remains vesicular.

Refer to the Nova Scotia Surveillance Guidelines for Notifiable Diseases and Conditions at http://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/ccdrrmtc/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.
Who Can Get Chickenpox?

Children most often get Chickenpox, however adults can get it too if they havent had it as a child. When adults get it, they can be very sick.

The chickenpox virus lives in the nose and throat and in the blisters on the skin. It is spread by direct contact with infected fluids from these areas. The virus can be spread for about 1-2 days before a rash appears and up until the blisters are crusted over. The symptoms may include: Fever. Itchy rash that begins as small fluid filled blisters that dry and form scabs Tiredness These symptoms may start 2-3 weeks after the individual has been in contact with someone with the chickenpox.

There is no treatment for chickenpox. People at high risk and pregnant women can get varicella zoster immune globulin. DO NOT give any ASA or aspirin to children or adolescents with chickenpox. ASA may increase the chance that a child gets Reyes syndrome. Children with chickenpox will be kept out of school or childcare until 5 days after the rash has disappeared or until the blisters have crusted over.
How Can You Prevent Chickenpox?

There is a vaccine that can prevent chickenpox. Contact your local Public Health Services Office to get more information about the vaccine and to find out if you or your child should receive the vaccine. Your doctor may discuss the use of varicella immune globulin in order to help prevent disease.
SAMPLE LETTER TO PARENT

Date: Dear Parent, This is to inform you that someone in your childs 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 childs condition. Please feel free to contact this office if you have any questions or concerns. Sincerely,
APPENDIX 1: CANDIDATES FOR VZIG AND VARICELLA

Candidates for VZIG
1. Significant Exposure
Persons with chickenpox are considered contagious from 2 days before onset of the rash to 5 days thereafter or until crusting of lesions. Skin lesions of zoster or shingles are infectious only until the eruption has crusted and dried. The following contact situations are considered significant exposures to varicella: continuous household contact (living in the same dwelling) playing indoors for more than 1 hour with a contagious case sharing the same hospital room with a contagious patient prolonged face-to-face contact of a worker or staff member with an individual with chickenpox.
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 Verify diagnosis of Varicella (ask questions)
Is exposed individual a candidate for VZIG
Determine susceptibility of exposed individual past history or record of antibody testing
Not susceptible (immune)
Susceptible
Unsure
Varicella IgG result. Available in 96 hours of exposure NO YES Varicella IgG result
Give Varicella Zoster Immune Globulin within 96 hours of exposure
Not immune
Immune
No further action
TUBERCULOSIS
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
1. Follow-up all persons with infectious tuberculosis. 2. Initiate contact tracing of all persons (contacts) exposed to infectious cases and provide appropriate education, evaluation and management for TB. 3. Identify infected persons and those high risk for developing TB and provide appropriate education, evaluation and treatment. 4. All cases of pulmonary and extrapulmonary TB will be reported to the office of the Chief Medical Officer of Health and added to the surveillance database. 5. Complete all Health Canada reports of new tuberculosis cases and treatment outcome forms and forward to the office of the Chief Medical Officer of Health.
GENERAL GUIDELINES FOR TUBERCULOSIS

1. Information
Confirmed case A confirmed case can be either of the following: Laboratory confirmed case Cases with Mycobacterium tuberculosis complex demonstrated on culture, specifically M. tuberculosis, M. africanum, M. canetti, M. caprae, M. microti, M. pinnipedii or M. bovis (excluding M. bovis BCG strain). OR Clinically confirmed case In the absence of culture proof, cases clinically compatible with active tuberculosis that have, for example: chest radiographic changes compatible with active tuberculosis; active nonrespiratory tuberculosis (meningeal, bone, kidney, peripheral lymph nodes, etc.); pathologic or post-mortem evidence of active tuberculosis; favourable response to therapeutic trial of antituberculosis drugs.

The mycobacteria are rod-shaped bacteria which do not stain readily but once stained, resist decolorization by acid alcohol and are therefore called acid-fast bacilli.
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.
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
2.1.1. 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 noninfectious 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.
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. a. Initiate Contact Tracing. Upon notification from the Medical Officer of Health, the Investigator will attempt to identify those at risk of being infected by the index case and determine if there are any other sources of infection in the community. 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.
b. Visit clients home, and if necessary, place of work. c. Take a detailed history. Take a detailed history from the index case identifying possible contacts. By definition household contacts are at high risk but there may be a large number of non-household contacts.
d. List all possible contacts and start a Tuberculosis Survey Sheet. Contacts are all those who may have been infected by a case of active TB. Contacts may be classified as close, casual or community contacts Close household contacts are those that live in the same household as the infectious case. Household contacts are considered by definition to share breathing space on a daily basis with the source case. Close non-household contacts are those that have regular, prolonged contact with the source case and share breathing space daily but do not live in the same household. These include regular sexual partners and close friends. Casual contacts are others who spend time regularly but less frequently with the infectious case. These may include classmates, colleagues at work or members of a club or team. Community contacts are those who have infrequent, occasional contact with the infectious case. These may include, for example, those who attend the same school or workplace, but are not in regular contact with the case. 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. e. Begin examination, starting with the high-risk contacts. Interview all close contacts for history of previous TB infection or diseases and tuberculin tests status. Follow the contacts according to flow charts. Meet regularly to discuss contact follow up with the MOH.
Examination of the contacts should follow the procedure indicated in the Flow Charts (see Appendix 6). Based on the flow charts, one of two procedures will need to be performed on the close contacts. 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 ordering of Chest X-rays is the responsibility of the clients personal physician. The investigator should ensure that the physician is aware of the recommendation for a Chest X-Ray and of the Contact Tracing protocol required by PHS. The Request for Chest X-Ray may be sent to the physician if required (see Request form in Appendix 5). 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 TSTs. 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. f. Discuss with Medical Officer of Health After initial investigation of high-risk contacts, discuss the completed Tuberculosis Survey Sheet with the Medical Officer of Health g. Decide extent of contact tracing and management of individual contacts. The Medical Officer of Health will discuss with the investigator the results of the contact tracing to date in order to decide how far to extend the contact tracing and to provide advice on the management of individual contacts as per the flow charts. 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. Tuberculin reactivity tends to be decreased in the following: Poor injection technique. Immune suppression due to advanced age, corticosteroids, cancer therapy agents, or HIV infection, especially if advanced (CD4 count< 500). Malnutrition, particularly when there has been recent weight loss. Severe illness, which can include tuberculosis. Viral illness or vaccination with live virus vaccine such as MMR vaccine. If vaccination or viral illness has occurred recently, tuberculin testing should be delayed by at least 1 month. Cross-reaction with many mycobacteria, other than tuberculosis, (including BCG) may produce a false positive tuberculin reaction. The general rule is that the larger the reaction size, the greater chance that infection has been caused by Mycobacterium tuberculosis. h. Continue updating Tuberculosis Survey Sheet. Continue to update the Tuberculosis Survey Sheet with Chest X-Ray results, PPD reports and chemoprophylaxis initiation as repeated testing of contacts occurs
and keep the Medical Officer of Health informed of the results as each testing cycle is completed (see flowcharts in Appendix 6). 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 c. Evaluate all referred contacts. Evaluate all contacts referred for medical opinion and decide on the need for preventive therapy with INH. The physician is also responsible for monitoring patients on chemoprophylaxis and informing the PHS of the degree of compliance with the medication.
d. Notify PHS about the outcome of the medical evaluation. Notify PHS about the outcome of the medical evaluation of those contacts referred for medical assessment.
3. Protocol for Follow-up of Individuals Placed Under Surveillance for Inactive TB

3.1. Background
All immigrant applicants, refugees and certain visitors to Canada are required to undergo an immigration medical examination (IME). 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. Persons identified as requiring medical surveillance are required to sign a Medical Surveillance Undertaking Form (IMM 0535). Upon entry to Canada, they are required to report to Public Health authorities within 30 days. All entrants subject to medical surveillance will, in addition to the Medical Surveillance Undertaking Form (IMM 0535), receive a handout which instructs the entrant must telephone the public health authority in their area of residence in Canada within 30 days of entry. The handouts include a list of provincial/territorial public health authority contact telephone numbers for each condition. The activities of CICs 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 entrants declared destination in Canada.
3.2. Follow up by Public Health

1. Upon receiving a Medical Surveillance Form (IMM 0535), a Public Health nurse initiates follow-up, checking form for complete address and S code.
(a) Address if incomplete or not present contact CIC officer. If address unobtainable, contact: Ottawa Medical Surveillance (613) 946-0941 (Health 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: 2.01 active tuberculosis 2.04 adequately treated positive syphilis serology If code not checked off or clearly indicated contact CIC Officer, for clarification or Ottawa Medical Surveillance. (c) Box 10 Serial No. indicates status of immigration applicant: F = student; U = work permit; W = immigrant; C = visitor. 2. Once address and code is complete and confirmed 2.02 for inactive TB surveillance, contact client either by phone or home visit. If clients English language fluency is inadequate a home visit may be appropriate, particularly if a family member can interpret. 3. Complete the Immigration Follow-up Inactive Tuberculosis form. Indicate demographic data, ethnicity and date of entry to Canada, health history related to tuberculosis, date and place of last chest x-ray, and present health status. 4. Advise client to arrange a medical evaluation, including a chest x-ray. Client must be assessed by a family physician from which client will be receiving ongoing medical care.
5. Prior to clients medical assessment, the Public Health Nurse contacts clients 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. 6. Once the Immigration Follow-up Inactive TB form is completed and physician notified, forward form to CDC coordinator who will contact Ottawa for the immigration medical chest x-ray film. 7. Once both chest x-ray reports are available, the MOH will arrange for the Hospitals 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. PHS has two responsibilities. To assist the attending physician in adequately treating cases to ensure that they become and remain non-infectious. To assist the attending physician to monitor and improve the compliance of contacts who have been prescribed INH chemoprophylaxis in order that their chance of becoming infectious in the future can be significantly reduced.
1.1 The Index Case

1.1.1. Management
The index cases attending physician should be contacted in order to discuss monitoring of compliance. It is important that the duration of each prescription for antituberculosis therapy not be too long in order that problems with compliance can be recognised early. A monthly prescription is the maximum length that should be recommended.
The attending physician should be provided with the package of information for physicians and clients. If the physician has any concerns that compliance is poor or unknown it is important that the investigator be informed as soon as possible. In situations where medication has to be discontinued either because of side effects or because of problems with drug resistance the investigator must be informed as soon as possible.
1.1.2. Non-compliant index cases.

If an index case is referred to PHS by a physician as being non-compliant in picking up or taking the medication, the Investigator will communicate with the client to: Ensure that the case is educated regarding the risks of inadequate treatment of tuberculosis; Ensure that the patient is aware of the benefits from treatment. Determine what factors are decreasing the chance of compliance. If the cases compliance cannot be achieved after the above, the Medical Officer of Health must be informed.
1.1.3. Medication Change

If a physician changes the index cases medication, he or she must notify the Medical Officer of Health.
1.2. The Contact on Chemoprophylaxis

Physicians are primarily responsible for monitoring the compliance of contacts for which they prescribe Isoniazid chemoprophylaxis.
1.2.1. Send documents to physician.

The Investigator should send the appropriate TB Chemoprophylaxis Sheet, a copy of Chemoprophylaxis Information, a copy of the INH Follow Up Record and a copy of the Patient Isoniazid Information to the physicians of contacts for whom Isoniazid is being considered. If the physician has any concerns that compliance is poor or unknown and cannot improve this or if the contact has to stop chemoprophylaxis because of side effects, it is important that the MOH be informed as soon as possible.
1.2.2. Non-compliant contacts.

Non-compliant contacts should be managed in the same manner as noncompliant index cases as outlined above in 1.1.2. The Medical Officer of Health should be informed of contacts that cannot achieve compliance.
1.3. Direct Observed Therapy

Poor compliance with prescribed antituberculous therapy is the most common reason for treatment failure. Directly observed therapy (DOT), i.e. watching the patient swallow each dose of medication, is an effective way to monitor adherence with therapy. TB drug regimens utilizing DOT have been shown to significantly reduce the rate of drug resistance and the rate of relapse when compared with self-administered therapy. DOT may be given daily, or 2 or 3 times a week. Intermittent regimens are clinically effective and have similar toxicity to daily regimens, however, all intermittent regimens must be DOT. If self-administered therapy is the only option for drug delivery, the drugs must be taken daily. 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. For patients in whom this is not possible or in whom compliance is difficult to predict, the most effective method of drug delivery is DOT rather than selfadministered therapy. DOT allows the total number of doses to be reduced and importantly, allows patient defaulting to be quickly identified. DOT should be considered for patients with the following features: Intermittent dosing regimens Suspected or known drug-resistant organisms Documented relapse disease Injection drug-users (IDU)/homeless patients HIV/AIDS Suspected inadequate compliance Psychopathology
APPENDIX 2: TREATMENT OF L ATENT TUBERCULOSIS

Infection
Chemoprophylaxis or preventive treatment refers to the treatment after tuberculosis infection has occurred but before tuberculosis disease is present. Treatment of latent TB infection (LTBI) is started only after TB disease has been excluded. 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. Indications*for Treatment of LTBI in High-Risk Groups Tuberculin reaction size
5 mm
Indication
HIV infection Recent contact of infectious TB Presence of lung scar (compatible with old healed TB but not previously treated) Converters (within 2 years) Immunosuppression: Organ transplantation Chronic renal failure Prolonged corticosteroid or immune suppressive drug therapy Hematologic malignancies leukemia, lymphoma Silicosis Diabetes mellitus < 90% of ideal body weight
10 mm
*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. A high index of suspicion for tuberculosis should be maintained in the elderly. The disease is more common and more atypical in the elderly. 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. Primary progressive tuberculosis occurs in 5% of those infected. Extension of the infection occurs in the site of primary invasion and at sites of distant spread including lung apices, renal cortex, vascular bone and lymph nodes. Although only 5% of primary infections are immediately symptomatic, the organism remains viable in the inactive fibrotic lesion and in 10-15%, reactivation occurs years or decades later.
3. Adult pulmonary tuberculosis (post primary) or reactivation tuberculosis

The result of late reactivation of organisms harboured since the primary infection is socalled adult or post primary tuberculosis. It rarely occurs in childhood but is occasionally seen in adolescence. The usual site of the lesion is in the apical or posterior segment of an upper lobe or the superior segment of a lower lobe. It is there that the highest tissue oxygen (O2) levels are found (130 mm Hg). The optimum PO2 for mycobacterial growth is 140 mm Hg. Although the usual site is in the upper lobes, up to 30% present atypically in other parts of the lung. Such atypical presentations are common in elderly and in immunocompromised patients. Clinical symptoms may be absent (20%) or may range from mild to severe. Cough may be dry or associated with sputum production depending on the size and nature of the lesion. Chest pain is uncommon but may be pleuritic in nature. Systemic symptoms include fever, chills, night sweats, weight loss and general malaise.
The earliest lesion is a parenchymal infiltrate. Gradual extension occurs with central necrosis and cavitation. Healing results in fibrotic scarring and loss of volume. Spontaneous healing may occur. X-ray changes are slow. Clinical signs and symptoms depend on extent and duration of involvement. 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.
4.1. Renal tuberculosis.

The origin of renal tuberculosis is via haematogenous dissemination from the primary lung infection. The Mycobacterium tuberculosis is believed to produce a small focus of infection within the glomerulus. If the infection is not contained, rupture into the tubule is postulated, carrying the organism to the medullary portion of the kidney. Proliferation, extension and eventual necrosis of the papilla is recognized radiologically as blunting of the calyces. Subsequent downward spread may involve the infundibulum, the pelvis, the ureter, bladder, urethra and male genital organs. As in the pulmonary lesion, healing is associated with fibrosis and scarring. Close observation during the treatment period is important to detect obstructive lesions before hydronephrosis and loss of function occurs. About 10% of patients with pulmonary tuberculosis have asymptomatic renal tuberculosis which may be indicated by the finding of sterile pyuria. Follow up is necessary to detect obstructive lesions that remain one of the few indications for surgery in renal tuberculosis.
4.2. Lymph node tuberculosis.

Involvement of lymph nodes is most often seen in the cervical region but is second in incidence to hilar and paratracheal involvement associated with primary infection. It was once believed that scrofula (bull neck) was due to ingestion of unpasteurized milk contaminated with bovine strain of tubercle bacilli. However, it is now recognized that the human strain of Mycobacterium tuberculosis reaches cervical nodes via the haematogenous route. Surgery may be necessary to establish the diagnosis of tuberculous lymph node disease or to drain abscesses. It is essential to culture any specimens obtained at surgery to distinguish disease caused by Mycobacterium tuberculosis from similar disease caused by other mycobacteria such as Mycobacterium avium-intracellulare. Tuberculosis lymph node disease is treated with the usual antituberculosis chemotherapy. It is not unusual for the lymph node enlargement to increase when treatment is commenced and sometimes again after several months of treatment. Such a development does not necessarily indicate that the treatment is not effective.
4.3. Bone and joint tuberculosis.

Haematogenous spread may seed Mycobacterium tuberculosis in vascular bone, growing ends of long bones in children and vertebral bodies in adults. Vertebral lesions account for about one-third of all osseous tuberculosis and are most common in the lumbar region. Extension through the intervertebral disc space and into the next vertebral body occurs. Extension posterior may create and intracanalicular abscess with subsequent compression of the spinal cord (Potts Disease). Surgery is indicated to relieve progressive neurological sequelae of cord compression. In the early phases of healing, avoidance of weight- bearing and lifting is important because of the risk of compression fractures. Extension laterally into the paravertebral soft tissue spaces occurs and tuberculosis abscesses have been seen to track for long distances in any direction. 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.
4.3. Bone and joint tuberculosis.

Haematogenous spread may seed Mycobacterium tuberculosis in vascular bone, growing ends of long bones in children and vertebral bodies in adults. Vertebral lesions account for about one-third of all osseous tuberculosis and are most common in the lumbar region. Extension through the intervertebral disc space and into the next vertebral body occurs. Extension posterior may create and intracanalicular abscess with subsequent compression of the spinal cord (Potts Disease). Surgery is indicated to relieve progressive neurological sequelae of cord compression. In the early phases of healing, avoidance of weight- bearing and lifting is important because of the risk of compression fractures. Extension laterally into the paravertebral soft tissue spaces occurs and tuberculosis abscesses have been seen to track for long distances in any direction. 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.
4.4. Tuberculosis meningitis

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. Treatment must include INH, Rifampin, Pyrazinamide. INH and Pyrazinamide cross the blood/brain barrier without impediment. 20% of Rifampin crosses under normal circumstances. During the inflammatory response higher levels can be achieved. 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.)
4.5. Gastrointestinal tuberculosis.

Gastrointestinal tuberculosis accounts for less than 1% of active disease. Peritonitis requires tissue for diagnosis because of the low yield of ascitic fluid culture. Intestinal tissue should also be submitted for culture as Crohns disease produces lesions in the bowel wall which are indistinguishable pathologically from tuberculosis.
4.6. Female genital tuberculosis.

Female genital tuberculosis accounts for 1.5% of active tuberculosis. It is believed that the vascular Fallopian tubes are the site of haematogenous seeding in the adult. Spread to ovary and endometrium occurs. Patients commonly present with infertility. Menstrual irregularities are common.
4.7. Disseminated (or miliary) tuberculosis.

The term miliary comes from millet seed and refers to the small, diffuse infiltrates seen radiologically in lungs but occurring in all body tissues to which Mycobacterium tuberculosis is disseminated when massive haematogenous dissemination occurs. Disseminated tuberculosis accounts for 2% to 3% of cases. The bacilli enter the bloodstream during the initial stages of primary infection, before the hosts 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. Failure to take your medication as prescribed may lead to the medication no longer working.
INH (ISONIAZID) PROPHYLAXIS

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. Failure to take your medication as prescribed may lead to the medication no longer working.
ETHAMBUTOL TREATMENT
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. Failure to take your medication as prescribed may lead to the medication no longer working.
RIFAMPIN
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. Failure to take your medication as prescribed may lead to the medication no longer working.
PYRAZINAMIDE (PZA)
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. Failure to take your medication as prescribed may lead to the medication no longer working.
Tuberculin Skin Test

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. Who Should Not Have the Test? In some cases the tuberculin test may not be useful or should not be done. If any of the following apply to you please tell the nurse or doctor before the test is done: Severe blistering in reaction to a previous TB test. Active TB or history of treatment for TB infection or disease. Extensive burns or eczema. Major viral infections or immunization. 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: Past History:
Result:
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. Public Health Nurse: Phone: Date:
APPENDIX 7: GUIDELINES FOR TUBERCULIN TESTING IN LONG TERM CARE

Developed by: Partners for Infection Control Approved by: Nova Scotia Department of Health
Tuberculin Skin Testing (Mantoux) in Long Term Care

Introduction
Long term care facilities (nursing homes and homes for special care residents) should ensure that all new residents tuberculin skin test status is known and record maintained. 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. The rate of transmission can be measured by the percentage of close contacts (household and non-household) whose tuberculin responses are converted from negative to significant reactive, or in whom active tuberculosis disease develops.
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. With appropriate treatment the prognosis for pulmonary tuberculosis is excellent.
Tuberculin Skin Testing (Mantoux)

The tuberculin skin test involves the injection into the skin of a small amount of purified protein derived from tubercle bacilli. In a person who has previously developed cell-mediated immunity to these tuberculin antigens, this will elicit a delayed cell-mediated reaction (delayed hypersensitivity type) within 48 hours. The reaction will cause localized swelling, manifested as induration of skin at the injection site.
In persons who are exposed to an active case of tuberculosis, the delayed cellmediated reaction to tuberculin will not be manifested immediately. It will develop between 2 and 10 weeks after the acquisition of infection.
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.
Who needs a tuberculin skin test in LTC?

All new admissions to LTC (except for those contraindicated). Persons with signs and/or symptoms of current tuberculosis disease. Recent contacts of known tuberculosis cases. All health care workers who are in contact with residents (refer to Guidelines For Tuberculin Skin (Mantoux) Testing In The Community, Nova Scotia Department of Health, Oct. 1999).
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 If little resistance is felt and there is no bleb or the appearance of a shallow diffused bulge, the needle has been placed too deeply. This may result in induration which will be difficult to measure and impossible to interpret. Or If a substantial portion of the dose leaks out, the needle has not been placed deeply enough and the test result will not be reliable. Then
Repeat test at least 5 cm (2 inches) from original site or in the other arm.
withdraw needle and without recapping dispose of the syringe and needle in a puncture resistant container according to your agencys policy wipe drop of blood that may appear at injection site with a gauze sponge record administration date on client record including date, antigen, lot #, dose, route and site.
How to Read the Tuberculin Skin Test

Read test 48-72 hours after administration The presence or absence of induration is measured. If blistering present, document it. The site should be inspected from a side view against the light, as well as by direct light and by palpation. If induration is present only the transverse diameter is measured i.e., measure across the arm parallel to the watch band.
Use a flexible ruler to measure size of induration in mm. Redness without induration is probably allergic reaction and does not indicate tuberculous infection.
What do the Results Mean?

The interpretation of the test depends on the reason for testing. 0 - 4 mm of induration is negative 5 - 9 mm of induration is positive if: contact of an active case abnormal chest x-ray with fibronodular disease HIV positive 10 mm or more of induration is positive. 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 2step 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 8C. 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 residents 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. The tuberculin skin testing (mantoux) is an excellent screening tool to assess residents exposure to TB.
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/ccdrrmtc/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 subjects 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
BACTERIAL CONJUNCTIVITIS (PINK EYE)

1. Information
1.1 Case definition
Clinical findings including purulent exudate, lacrimation and irritation of the palpebral and bulbar conjunctiva of one or both eyes.
1.2 Causative agent

Haemophilus influenzae (H. influenzae) and Streptococcus pneumonia (S pneumoniae) are the most important. Staphylococci, streptococci and Pseudomonas aeuginosa (P. aeruginosa) may cause disease in newborns.
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.

Wash hands frequently in the presence of any active upper respiratory disease. Avoid sharing of any articles that are used near or on the eyes, such as make-up etc. Launder articles of clothing, washcloths and bed linen of anyone who is infected. Prompt treatment of infected eye to prevent transmission to other eye or other sites. Children should be excluded for 24 hours after antibiotic treatment has been initiated. Avoid hand to eye contact.
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.
Who Can Get Conjunctivitis?

Children are most likely to get pink eye but adults can get it too. The viruses or bacteria are found in the discharge from the infected eye. Hands become contaminated by touching\rubbing the infected eye or coming in contact with the drainage from the eye.

Symptoms include: Redness of the whites of the eye(s) and inside the eyelids. Itchiness and tearing. Scratchy feeling or pain in the eye. Discharge at the corners of the eye, which may crust over during sleep causing the eyelids to stick together.

Most cases are caused by a virus, and will get better without treatment. Some cases are caused by bacteria, and can be treated with eye drops or ointment prescribed by your doctor. If there is pus or discharge from the eye(s), see your doctor. 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.
How Can You Prevent Conjunctivitis?

Wash hands often, especially before and after treatment. Separate the hand and face towels of the infected person from all others in the house.
Do not share personal articles used near or on the eyes such as make-up applicators. Wash in hot water all clothing and personal articles (e.g. pillow cases) of the infected person. Teach children good hand washing practices. Avoid hand to eye contact.
CLOSTRIDIUM DIFFICILE
1.0 Information
1.1 Case Definition
MARCH 2012
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: A laboratory confirmation of a positive toxin assay for C. difficile OR A diagnosis of pseudomembranes on sigmoidoscopy or colonoscopy or histological/pathological diagnosis of C. difficile OR A diagnosis of toxic megacolon
1.2 Causative Agent

Clostridium difficile (C. difficile) is a spore-forming, obligate anaerobic, grampositive bacillus. Disease is related to the action of toxin(s) produced by these organisms. Although other toxins exist, toxins A and B have been associated most strongly with human disease.
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.

The laboratory diagnosis of C. difficile can be accomplished by a variety of testing methods which include: Detection of toxins by enzyme-linked immunoassays (EIAs)
Cytotoxicity assay using tissue culture Nucleic acid amplification techniques Bacterial culture to isolate the organism with subsequent testing of the ability of the isolate to produce toxin Histological examination of the colon. 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: Metronidazole (30 mg/kg per day in 4 divided doses, max 2 g/day) is the drug of choice for the initial treatment of most children and adolescents with colitis. Oral vancomycin (40 mg/kg per day, orally, in 4 divided doses, to a maximum of 125 mg, orally, 4 times/day) for initial therapy for patients with severe disease (hospitalized in an intensive care unit, pseudomembranous colitis on endoscopy, underlying intestinal tract disease).
1.6 Incubation Period

The incubation period is unknown. However; the onset of clinical disease is typically 5-10 days after initiation of antimicrobial treatment.
1.7 Source
The reservoir is mainly humans; however, spores are also present in soil and water. The source of C. difficile may be endogeneous (colonized patient flora) or exogeneous, such as hospital environment and equipment that have been contaminated with stool (commodes, bedrails, and bedpans).
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.

A collaborative approach to communication starts with the timely identification of C. difficile. Exercising meticulous hand hygiene with soap and water. Alcohol-based hygiene products do not inactivate C. difficile spores Proper waste handling (including diapers). Cleaning and disinfecting of surfaces contaminated with vomitus and feces. Limiting the use of antimicrobial and proton pump inhibitor agents. Thorough cleaning and disinfecting of hospital rooms and bathrooms of patients with C. difficile.

2.1 Case Management
Individual cases of C. difficile are not followed by Public Health. ** For additional information and procedures related to C. difficile in Long Term Care Facilities and Community settings, refer to Guidelines-Partners for Infection Control available in all district Public Health Offices and at: http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infection_Control_Guidelines .pdf

There will be no Public Health follow-up unless there is an outbreak.
2.2 Contact Tracing

Not available at this time.

Refer to Chapter 2 on Outbreak Management of the CD manual.
2.4 Guidelines
The CDPC nurse is typically the lead in investigations of communicable disease outbreaks. Upon request of the CDPC lead/MOH, a Public Health Inspector with the Department of Agriculture may complete an on-site inspection of the facility to ensure compliance with outbreak management directives. 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 Residents 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 Guidelines-Partners for Infection Control at: http://www.gov.ns.ca/health/ccs/ltc/IPC_Partners_Infection_Control_Guidelines .pdf.
2.4.2 Guidelines for Childcare Centres

Children and ill staff with C. difficile diarrhea should be excluded from child care settings for the duration of diarrhea, and infection control measures should be enforced. Contact the Department of Agriculture as necessary. Food Safety Specialists (FSS) are able to provide advice and resources regarding environmental sanitation. 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.na.ca/hpp/cdpc/CDCManual.
4.0 Communication Plan

Develop as needed
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.phacaspc.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. Testing, Surveillance and Management of Clostridium Difficile (May 2010). Retrieved from: http://www.oahpp.ca/resources/documents/pidac/RPAP%20Annex%20C%20Testing%2 0Surveillance%20Management%20of%20C%20diff.pdf 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 (pseudomembranous colitis). of the colon
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.
Who can get C. difficile?

Any patient receiving antibiotics is at risk for C. difficile. Heres why: Many different kinds of bacteria live in our gut and bowel. Most of these are good bacteriathat is, they help us to stay healthy. Antibiotics can change the mix of bacteria in the bowel and may decrease the amount of good bacteria. This allows C. difficile to take over. When this happens, the C. difficile bacteria produce toxins that can irritate the bowel and cause diarrhea. The elderly, people who have other illnesses, and people who are already taking antibiotics are at a greater risk of infection. Healthy people do not usually get C. difficile infections.

Symptoms include: watery diarrhea fever loss of appetite nausea abdominal pain/tenderness.
It is possible to be infected with C. difficile and not show any symptoms.
How is it spread?
C. difficile is most often spread through direct contactfor 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.
How can you prevent C. difficile infection?

Hand washing with soap and water is the most effective way of preventing the spread of infections like C. difficile. Alcohol-based hand sanitizers are less effective than washing with soap and water because they do not destroy all of the C. difficile. C. difficile can also be limited by: Careful use of antibiotics Strictly following infection prevention and control measures in hospitals, longterm care facilities and other healthcare facilities.
FICHE DINFORMATION SUR CLOSTRIDIUM DIFFICILE

Qu'est que Clostridium difficile?
Clostridium difficile, communment appel C. difficile, est une bactrie. Il cause : une diarrhe qui peut tre de lgre grave, des conditions intestinales plus graves comme une inflammation du colon (colite pseudo-membraneuse). C. difficile est prsent dans le sol et dautres environnements naturels. Il peut aussi vivre dans nos intestins. Cest la cause la plus commune de la diarrhe infectieuse dans les hpitaux et les tablissements de soins de longue dure au Canada.
Qui peut tre infect par C. difficile?

Tout patient qui prend des antibiotiques court le risque d'une infection au C. difficile. Voici pourquoi. De nombreux types de bactries vivent dans nos intestins. La plupart de ces bactries sont de bonnes bactries qui nous aident rester en sant. Les antibiotiques peuvent modifier la varit de bactries prsentes dans les intestins et rduire le nombre de bonnes bactries. Cela permet au C. difficile de prendre le dessus. Quand cela arrive, C. difficile produit des toxines qui peuvent irriter les intestins et causer la diarrhe. Les personnes ges, celles qui souffrent dautres maladies et les personnes qui prennent des antibiotiques courent un plus grand risque dinfection. En gnral, les personnes en sant ne font pas dinfection au C. difficile.

Les symptmes sont : une diarrhe aqueuse de la fivre la perte de l'apptit
des nauses une sensibilit ou des douleurs abdominales. Il est possible dtre infect par C. difficile et de navoir aucun symptme.
Comment C. difficile se propage-t-il?

C. difficile se propage le plus souvent par contact direct, par exemple avec des mains ou des gants souills. Il se propage aussi par lutilisation dobjets contamins comme des thermomtres ou des chaises daisance.
Comment traite-t-on C. difficile?

Les personnes qui montrent des symptmes lgers pourraient ne pas avoir besoin de traitement. Pour les cas plus graves, un fournisseur de soins de sant prescrira un mdicament (p. ex. des antibiotiques) prendre pendant dix jours. Les mdicaments pour traiter C. difficile sont efficaces et ont peu deffets secondaires.
Comment prvenir une infection au C. difficile?

La faon la plus efficace de prvenir la propagation des infections comme celle au C. difficile est de se laver les mains avec de leau et du savon. Les dsinfectants pour les mains base d'alcool sont moins efficaces que le lavage des mains leau et au savon parce qu'ils ne dtruisent pas toutes les bactries C. difficile. Voici dautres faons de limiter la propagation de C. difficile : une utilisation prudente des antibiotiques une adhsion stricte aux mesures de prvention et de contrle des infections dans les hpitaux, les tablissements de soins de longue dure et les autres tablissements de soins de sant.
CREUTZFELDT-JAKOB DISEASE (CJD), CLASSIC

APRIL 2006 1. Information
This section describes the three etiologic subtypes of classic Creutzfeldt-Jakob disease (CJD) (sporadic CJD, iatrogenic CJD and genetic prion diseases)
1.1 Case definition

Creutzfeldt - Jakob disease, Classic Sporadic Creutzfeldt-Jakob Disease (sCJD) 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
III. IV. List 2: I A. B. C. D. II
transfer from paraffin-embedded tissue (PET) to secondary support (PET blot) Presence of scrapie-associated fibrils (SAF) by electron microscopy Presence of protease-resistant PrP by Western blot
Myoclonus Visual disturbances or cerebellar dysfunction (ataxia) Pyramidal or extrapyramidal features Akinetic mutism
Typical EEG pattern: period sharp-wave complexes ca. 1HZ
Iatrogenic Creutzfeldt Jakob Disease (iCJD) 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.
I.
Treatment with human cadaveric pituitary growth hormone, human pituitary gonadotrophin or human dura mater graft
II. III.
Corneal graft in which the corneal donor has been classified as having a definite or probable prion disease Neurosurgical exposure to instruments previously used on a patient classified as having definite or probable prion disease
Genetic Prion Diseases 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-Strussler-Scheinker disease (GSS)* *Presence of multicentric PrP-immunoreactive plaques in cerebral and/or cerebellar cortex, with neuron loss and spongiosis. Other large amorphic plaques or neurofibrillary tangles immunoreactive for PrP have been described in subsets of GSS, but these are associated with less frequent PRNP mutations (A117V and F198S). Florid or Kuru plaques are not considered diagnostic for 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) II. PRNP mutations associated with a neuropathologic phenotype of GSS (see previous footnote above): P102L, P105L, A117V, G131V, A133V,
III. IV.
Y145Stop, H187R, F198S, D202N, Q212P, Q217R, M232T; octapeptide repeat insertions (various lengths) PRNP mutations associated with a neuropathologic phenotype of Familial Fatal Insomnia (FFI): D178N PRNP mutations associated with other neuropathologic phenotypes: I138M, G142S, Q160Stop, T188K, T188R, P238S, M232R; octapeptide repeat insertions (various lengths)
1.2 Causative agent

Thought to be a unique, self-replicating protein called a prion that replicates by a poorly understood mechanism
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
include any medical or surgical procedures involving tissues with high infectivity such as the brain, spinal cord, and eyes.
1.7 Communicability
Central nervous system (CNS) tissues are infectious throughout symptomatic illness. Other tissues and cerebral spinal fluids (CSF) are sometimes infectious.
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.
1.9 Core messages for prevention

In health care settings, great care must be taken to follow infection control guidelines for CJD Any persons who spent six or more cumulative months between January 1, 1980 and December 31, 1996 in the United Kingdom should not donate blood, organs or other body tissues or fluids
1.10 Prophylaxis
None
1.11 Surveillance
2. Procedures
2.1.1 Medical Officer of Health (MOH)
a. Determine investigative responsibility. The MOH must ensure that all reports of CJD (including those classified as possible, probable and confirmed) are received within the appropriate timeframe (i.e. 3 to 5 days) and disseminated to the appropriate personnel for investigation. In the absence of the MOH, the communicable disease control manager may assume this role.
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). b. Discuss the case with the MOH. c. Initial follow-up procedures include: Contact and interview the client or an immediate family member Obtain the clients medical history including symptoms, date of onset, treatment, surgical procedures of concern, and/or hospitalization and any potential sources of exposure, particularly a history of any receipt or donation of blood, blood products, cells, tissues or organs If necessary, contact the clients physician to obtain further information and clarification of the clients history, especially with respect to past surgical procedures and blood/tissue/organ receipt and/or donation If the client has a history of receipt or donation of blood, cells, tissues or organs, inform the MOH immediately and fax the CJD Case Report Form to the OCMOH so that appropriate lookback and traceback procedures may be initiated immediately If client has a history of surgical procedures of concern when symptomatic, inform infection control program in hospital where procedure occurred Discuss the role of PHS and provide information to the client or family (i.e., fact sheets) Complete the CJD/vCJD Case Report Form and update as new information becomes available If client is deceased, ensure that attending physician has notified the funeral director of CJD diagnosis so appropriate infection control precautions can be taken (refer to, Infection Control Guidance for Handling of Human Remains of Individuals with Communicable Diseases, currently in draft form).
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
2.1.6 Provincial Blood Program

Work with PHS, CBS and hospital blood banks on CJD related blood safety
2.1.7. Regional Tissue Bank and Multi-Organ Transplant Program

Work with PHS on CJD related issues on a case-by-case basis
See Figure 1: Flow chart for public health follow-up of CJD
3. Lookbacks & Tracebacks

3.1. Nova Scotia Lookback/Traceback Protocols for CJD
If case has ever received or donated blood or blood products, follow the general Lookback and/or Traceback Protocols located in the Blood Borne Pathogens section of the Nova Scotia Communicable Disease Manual.
4. Follow-up of Organ/Tissue Donors who Test Positive for CJD

4.1 Follow up of Organ/Tissue Donors
If case has received or donated cells, tissue or organs, work with the Regional Tissue Bank and the Multi-Organ Transplant Program on a case-by-case basis to ensure appropriate follow-up.
CLASSIC CREUTZFELDT-JAKOB DISEASE FACT SHEET DECEMBER 2006

What is Classic Creutzfeldt-Jakob Disease?
Classic Creutzfeldt-Jakob disease (CJD) is a rare and fatal disease that causes rapid and progressive damage to the brain and nervous system.
Who can get Classic Creutzfeldt-Jakob Disease?

Classic CJD is extremely rare, affecting on average only one person per million each year worldwide. Approximately 30 Canadians will be diagnosed with CJD each year; of these, only 1-2 cases will occur in Nova Scotia. The majority of persons with classic CJD are between 50 to 70 years of age. 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).

Early symptoms of classic CJD include confusion, difficulty concentrating, tiredness and lack of coordination. As the disease progresses, individuals with classic CJD will develop loss of muscle control, difficulty speaking and may enter a comatose state.

There is no known effective treatment for classic CJD. Current treatment is therefore aimed at controlling symptoms and making the person as comfortable as possible.
How can you prevent Classic Creutzfeldt-Jakob Disease?

Classic CJD cannot be spread from person-to-person and the risk to the general population is extremely low.
VARIANT CREUTZFELDT-JAKOB DISEASE (VCJD)

APRIL 2006 1. Information
1.1 Case definition
Confirmed case: Definite vCJD:
IA (see List 5) and neuropathologic confirmation as per pathologic features (see footnote a, List 5)
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. B. C. D. E. II A. B. C. D. E. Early psychiatric symptoms b Persistent painful sensory symptoms c Ataxia Myoclonus or chorea or dystonia Dementia
Progressive neuropsychiatric disorder Duration > 6 months Routine investigations do not suggest alternative diagnosis No history of potential iatrogenic exposure No evidence of genetic prion disease
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 A. Spongiform change, extensive PrP deposition, florid plaques throughout the cerebrum & cerebellum B. Depression, anxiety, apathy, withdrawal, delusions C. Frank pain and/or dysaesthesia D. Generalized triphasic period complexes at ca. 1 Hz. Rarely, these may occur in the late stages of vCJD E. Relative to the signal intensity of other deep grey matter nuclei & cortical grey matter F. Tonsil biopsy is not recommended routinely or in cases with EEG appearance typical of sporadic CJD, but may be useful in suspect cases in which the clinical features are compatible with vCJD and MRI does not show bilateral pulvinar high signal
1.2 Causative agent

Thought to be a unique, self-replicating protein called a prion that replicates by a poorly understood mechanism
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.
1.9 Core messages for prevention

In health care settings, great care must be taken to follow infection control guidelines for vCJD. Person who spent 6 or more cumulative months between January 1, 1980 and December 31, 1996 in the United Kingdom should not donate blood, organs, or other body tissues or fluids.
1.10 Prophylaxis
None
1.11 Surveillance
2. Procedures
2.1 Roles and responsibilities 2.1.1 Medical Officer of Health (MOH)
a. Determine investigative responsibility The MOH must ensure that all reports of vCJD (including those classified as possible, probable and confirmed) are received within the appropriate timeframe (i.e. 3 to 5 days) and disseminated to the appropriate personnel for investigation. In the absence of the MOH, the communicable disease control manager may assume this role.
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). b. Discuss the case with the MOH. Note, DHW Surveillance Team should be informed immediately of all reports that meet the case definitions for possible, probable and/or confirmed vCJD. c. Initial follow-up procedures include: Contact and interview the client or an immediate family member Obtain the clients medical history including symptoms, date of onset, treatment, surgical procedures of concern, and/or hospitalization and any potential sources of exposure, particularly a history of any receipt or donation of blood, blood products, cells, tissues or organs If necessary, contact the clients physician to obtain further information and clarification of the clients history, especially with respect to past surgical procedures and blood/tissue/organ receipt and/or donation If the client has a history of receipt or donation of blood, cells, tissues or organs, inform the MOH immediately and fax the CJD Case Report Form to the OCMOH so that appropriate lookback and traceback procedures may be initiated immediately If client has a history of surgical procedures of concern when symptomatic, inform infection control program in hospital where procedure occurred
Discuss the role of PHS and provide information to the individual or family (i.e., fact sheets) Complete the CJD/vCJD Case Report Form and update as new information becomes available If client is deceased, ensure that attending physician has notified the funeral director of vCJD diagnosis so appropriate infection control precautions can be taken (see Infection Control Guidance for Handling of Human Remains of Individuals with Communicable Diseases currently in draft form)
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
2.1.5 Canadian Blood Services (CBS)

Work with PHS, the Provincial Blood Program and hospital blood banks on traceback and lookback procedures for vCJD
2.1.6 Provincial Blood Program

Work with PHS, CBS and hospital blood banks on vCJD related blood safety issues
2.1.7 Regional Tissue Bank and Multi-Organ Transplant Program

Work with PHS on vCJD related issues on a case-by-case basis
3. Lookbacks and Tracebacks

3.1 Nova Scotia Lookback / Traceback Protocols for vCJD
If case has received or donated blood or blood products, follow the general Lookback and/or Traceback Protocols located in the Blood Borne Pathogens section of the Nova Scotia Communicable Disease Manual.
4. Follow-up of Cell / Tissue / Organ Donors with vCJD

4.1 Follow-up
If case has received or donated cells, tissue or organs, work with the Regional Tissue Bank and the Multi-Organ Transplant Program on a case-by-case basis to ensure appropriate follow-up.
VARIANT CREUTZFELDT-JAKOB DISEASE FACT SHEET DECEMBER 2006

What is variant Creutzfeldt-Jakob Disease?
Variant Creutzfeldt-Jakob disease (vCJD) is a rare and fatal disease that causes rapid and progressive damage to the brain and nervous system. It was first identified in the United Kingdom in the early 1990s and has since been linked to the consumption of beef products that have been contaminated with bovine spongiform encephalopathy (or mad cow disease).
Who can get Variant Creutzfeldt-Jakob Disease?

Variant CJD is extremely rare with less than 200 cases having been reported worldwide. Compared to the classic form of CJD, variant CJD typically affects younger patients with the average age being less than 30 years.

Persons with vCJD usually experience psychiatric symptoms such as depression or a schizophrenic-like psychosis early in the illness. As the disease progresses, neurological symptoms include unsteadiness, difficulty walking and involuntary muscle movements.

There is no known effective treatment for variant CJD. Current treatment is therefore aimed at controlling symptoms and making the person as comfortable as possible.
How can you prevent Variant Creutzfeldt-Jakob Disease?

Since 1996, strict measures have been put in place in the United Kingdom and other European countries to control the spread of BSE (i.e., mad cow disease) among cattle. In addition, Canada has banned the importation of beef and beef products from countries that are not designated as being free of BSE.
Persons who have spent six months or more in the United Kingdom between 1980 and 1996 should not donate blood, organs or other body tissues or fluids.
FIFTH DISEASE (HUMAN PARVOVIRUS INFECTION)

1. Information
1.1 Case definition
Compatible clinical illness and laboratory evidence of infection.
1.2 Causative agent

Human parvovirus B19, a member of the Parvoviridae family.
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 immunosuppressed individual, IG therapy is effective. infection in an

Routine attention to good hygienic practices such as frequent and thorough hand washing can help control the spread of the disease. Individuals with underlying anemias, immunodeficiencies and non immune pregnant women may choose to avoid exposure to potentially infectious people in hospitals or outbreak situations.
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.
Who Can Get Fifth Disease?

It usually affects school age children. Many people get fifth disease before they reach adulthood and are then protected for life. In children and most adults the disease does not cause problems. Pregnant women may be in danger of miscarriage or stillbirth if they get fifth disease in the first half of their pregnancy.

Symptoms usually occur within 1-2 weeks after a person has been in contact with someone with the disease. Symptoms may include: Red patchy rash on the face, looks like a slapped cheek. Lace-like rash, which may become more noticeable after a bath or physical exertion. Fever. Headache and body ache. Sore throat. Cough, congestion and runny nose.

There is no treatment or vaccine for fifth disease. It is not recommended that children stay home from school. Once the rash appears they are no longer contagious.
How Can You Prevent Fifth Disease?

Practice good hand washing, especially if working with children in a school, childcare or health care setting. Individuals who have any immune disease should avoid contact with anyone with fifth disease.
GROUP A STREPTOCOCCUS INVASIVE

NOVEMBER 2006 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
1.2 Causative Agent

Streptococcus pyogenes, Group A Streptococcus
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. Clinical evidence of disease may manifest as several conditions including: Streptococcal Toxic Shock Syndrome (STSS) Necrotizing Fasciitis (NF) Necrotizing Myositis (NM STSS is the most serious manifestation of invasive GAS disease. It comprises a primary site of GAS infection together with hypotension, adult respiratory distress syndrome, renal impairment, rapid onset of shock and multi-organ failure. The most common primary site of invasive GAS infections is soft tissue, but pneumonia, septic arthritis and primary bacteremia may also occur. Pneumonia with isolation of GAS from a sterile site, or from a bronchoalveolar lavage (BAL) non-sterile site when no other cause has been identified, should be regarded as a form of invasive disease for the purposes of public health management. 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-toperson 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.
1.9 Core Prevention Messages

Practice proper hand-hygiene, especially after coughing or sneezing, and before preparing or eating foods and before and after each completed patient contact. Ensure all wounds are kept clean and watch for possible signs of infection such as redness, swelling, drainage and pain at the wound site. A person with signs of an infected wound, especially if fever occurs, should seek medical care immediately.

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. Index Case: The first identified in an organization or community-based outbreak. Identifying the index case in an outbreak is important for the characterization and matching of GAS isolate strains. 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: Contact with a common, specific individual (including confirmed or probable cases) Presence in the same location (e.g. school, long-term care facility, child care centre) at or around the same time 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. The public health response to a sporadic case of invasive GAS include: Case Management
Contact tracing Maintenance of surveillance for further cases
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 Contact Tracing

The cornerstone of prevention of secondary cases of invasive GAS is aggressive contact tracing to identify people at increased risk for disease (e.g. close contacts).
2.2.1. Definition of Close Contacts

Household contacts of a case who have spent at least 4 hours/day on average in the previous 7 days or 20 hours/week with the case Non-household persons who share sleeping arrangements with the case or had sexual relations with case Persons who have had direct mucous membrane contact with the oral or nasal secretions of a case (e.g. mouth-to-mouth resuscitation, open mouth kissing) or unprotected direct contact with an open skin lesion of the case Injection drug users who have shared needles with the case Selected LTCF contacts (See Section 2.4) Selected child care and nursery school contacts (See Section 2.4.2) Selected hospital contacts (Infection Control responsibility in respective hospitals)
Note: School classmates (kindergarten and older), work colleagues, as well as social or sports contacts of a case are usually not considered close contacts unless they fit into one of the above categories.
The risk of invasive GAS is significantly associated with the following underlying conditions: Age >65 years Heart disease Diabetes Mellitus Cancer Alcohol abuse Chronic lung disease HIV infection Injection drug use (IDU) High dose steroid use (immunosuppressive doses) Presence of varicella infection in the 2-week period following the onset of symptoms Skin trauma

Obtain names and information for all contacts who meet the definition outlined in Section 2.2.1
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. Chemoprophylaxis should only be offered: 1) to close contacts (Section 2.2.1.) of a confirmed severe case. A confirmed severe case is defined as a 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; AND 2) if close contacts have been exposed to the case during the period from 7 days prior to onset of symptoms in the case to 24 hours after the cases initiation of antimicrobial therapy.
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 7 days after the last contact with an infectious case. Table 1: Chemoprophylaxis for Close Contacts of Invasive GAS Drug
First generation cephalosporins: C cephalexin, u cephadroxill, rcephradine
Dosage
First line: Children and adults: 25 50 mg/kg/day, to a maximum of 1 g/day in 2 to 4 divided doses x 10 days
Comments
Recommended drug for pregnant and lactating women. Should be used with caution in patients with allergy to pencillin. Use of cephalosporins with nephrotoxic drugs (e.g. aminoglycosides, vancomycin) may increase the risk of cephalosporin-induced nephrotoxicity. Erythromycin estolate is contraindicated in persons with pre-existing liver disease or dysfunction and during pregnancy. Sensitivity testing is recommended in areas where macrolide resistance is unknown or known to be 10%.
r e n t Erythromycin l y t h e r e a r e
Clarithromycin
Second line: Children: 5 to 7.5 mg/kg every 6 hours or 10 to 15 mg/kg every 12 hours (base) x 10 days (Not to exceed maximum adult dose) Adults: 500 mg every 12 hours (base) x 10 days
n o
Clindamycin
Second line: Children: 15 mg /kilogram /day in divided doses every 12 hours to a maximum of 250 mg PO BID x 10 days Adults: 250 mg PO BID x 10 days Second line: Children: 8 to 16 mg/kg/day divided into 3 or 4 equal does x 10 days (Not to exceed maximum of adult dose) Adults: 150 mg every 6 hours x 10 days
Contraindicated in pregnancy. Sensitivity testing is recommended in areas where macrolide resistance is unknown or known to be 10%.
Alternative for persons who are unable to tolerate beta-lactam anitibiotics.
2.2.5 Immunization
Exclusion of contracts is not necessary
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

An outbreak is defined as increased transmission of GAS causing invasive disease in a population. Community outbreaks of invasive GAS rarely occur and usually involve two cases who have had close contact. Criteria outlining the impetus for action for organization-based outbreaks or clusters are found in Table 2.
Table 2: Impetus for Action for Organization-based Outbreaks or Clusters Organization

Long-Term Care Facility
Inpetus for Action

An incidence rate of culture-confirmed invasive GAS infections Facility >1 per 100 residents per month or at least 2 cases of culture- confirmed invasive GAS infection in one month in facilities with less than 200 residents or an incidence rate of suggested invasive or non-invasive GAS infections > 4 per 100 residents per month. One severe case of invasive GAS disease in a child attending a child care centre. One or more linked invasive or non-invasive GAS cases in either patients or staff occurring within one month of an invasive GAS case.
Child Centre Hospital
Care
Refer to Section 2.4 for specific guidelines for the management of invasive GAS in long-term care facilities (LTCF) and child care centre (CCC). Management of invasive GAS in a hospital setting is the responsibility of the Infection Control Department within that organization
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. In addition to strict enforcement of standard infection control practices, the following approach may be useful in the investigation and control of invasive GAS disease in LTCF: When a confirmed case of invasive GAS disease (as described in Section 1.1.) occurs in a LTCF such as a nursing home, the facility should: Report the case to the Public Health Units within the District Conduct a retrospective chart review of the entire facilitys residents over the previous 4 6 weeks, for culture-confirmed cases of GAS disease and any suggested cases of invasive or non-invasive GAS infection, including skin and soft tissue infections (e.g. pharyngitis and cellulites) and excluding non-culture- confirmed pneumonia and conjunctivitis. An excess of GAS infection, or LTCF outbreak, is defined in Table 2 Assess the potential for a source of infection from outside the facility (e.g. regular visits from children who have recently been ill) If an excess of GAS infection is identified, the following actions should be considered: All patient care staff should be screened for GAS with throat, nose and skin lesion cultures. In LTCF with <100 beds, all residents should be screened for GAS. In LTCF with 100 beds or greater, screening can be limited to all residents within the same care unit as the infected case and contacts of the case if necessary, unless patient and care staff movement patterns or epidemiologic evidence (e.g. from the chart review) suggest that screening should be conducted more broadly
Anyone colonized with GAS should receive chemoprophylaxis (see Section 2.2.4.) Non-patient care staff should be asked about possible recent GAS infections. Those with a positive history should be screened for GAS and persons positive should be treated with antibiotics as per recommended regimen All GAS isolates should have further typing (see Section 2.5 Public Health laboratory Role). Culturing for a test of cure is recommended for individuals found to have the outbreak-related strain, particularly if there is epidemiologic evidence indicating that contact with the individual is significantly related to illness. Culturing for a test of cure is not necessary for individuals infected with a non- outbreak-related strain of GAS. Re-screen all GAS positive residents and staff including their throat and skin lesion(s) 14 days after chemoprophalaxis has been started. Follow by screening at two weeks and at four weeks after the first rescreening. If the person is found to be positive, a second course of chemoprophalaxis should be offered. If the person is still colonized after the second treatment, discontinue chemoprophalaxis unless the facility has an ongoing problem with GAS infection Active surveillance for GAS infection should be initiated and continued for 1 to 2 months Appropriate specimens should be taken for culture to rule out GAS when suspected infections are detected by active surveillance If no excess is identified, especially if there is evidence of an outside source of infection for the index case, then active surveillance alone for two to four weeks to ensure the absence of additional cases is warranted.
2.4.2 Guidelines for Child Care Centres (CCC)

Child care centres include groups or institutional child care centres (day cares), family or home day care and preschools. 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 strainrelatedness 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.
2.5 Public Health Laboratory Role

The provincial Public Health Laboratory may perform specific molecular analysis in support of outbreak investigations. 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 During an investigation of clusters or outbreaks of invasive GAS, the local Public Health Outbreak team must coordinate the shipment of isolates and required information along with a brief description of the event to the NCS through the provincial laboratory or designate laboratory.
3.0 SURVEILLANCE
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.
Who Can Get Necrotizing Fasciitis?

NF is very rare but may be associated with the persons ability to fight off the infection because of a chronic illness or an illness that affects the immune system. The illness is often related to injury or trauma.

Symptoms include: Fever Severe pain Red painful swelling that spreads rapidly

NF can be treated with antibiotics and surgical intervention if necessary. Early treatment may reduce the risk of serious complications.
How Can You Prevent Necrotizing Fasciitis?

Good hand washing practices All wounds should be kept clean and watched for possible signs of infection such as redness, swelling, drainage, and pain at the wound site. Seek medical attention if a wound gets infected.
APPENDIX 2: STREPTOCOCCAL TOXIC SHOCK SYNDROME (STSS) FACT SHEET

What is STSS?
Streptococcal Toxic Shock Syndrome (STSS) is a serious infection caused by a bacteria called group A streptococcus (GAS). Some strains of GAS are more likely to cause severe illness than others.
Who Can Get STSS?

STSS is a rare disease. It can occur in individuals who have soft tissue infection. It may also occur in people with invasive infections such as pneumonia. It occurs when the bacteria overcome the bodys defenses or when the persons ability to fight off infections is decreased because of chronic illness or an illness that affects the immune system.

Symptoms include: Fever Severe pain Tiredness Breathing difficulty

Antibiotics are used to treat STSS. The sooner antibiotics are started the better the chance for the individual to recover.
How Can You Prevent STSS?

Wash hands well with soap and water Seek medical attention if a wound gets infected
GROUP A STREPTOCOCCUS NON-INVASIVE

1. Information
1.1 Case definition
Laboratory identification of group A streptococcus.
1.2 Causative agent

Streptococcus pyogenes.
1.3 Symptoms
Streptococcal sore throat typically exhibits sudden onset of fever, sore throat, exudative tonsillitis or pharyngitis. Streptococcal skin infections (impetigo) refer to section on impetigo. Scarlet fever is a form of streptococcal disease characterized by a skin rash. It occurs when the infecting strain of streptococcus produces a pyogenic exotoxin and the individual is sensitized but not immune to the toxin. The symptoms may include the symptoms of streptococcal sore throat as well as a rash and a strawberry tongue.
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.

Good hand washing practices, especially after coughing or sneezing, and before preparing or eating foods.
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.

Strept Throat: Fever. Sore throat. Swollen glands (usually at the neck). Headache.

If you suspect strep throat, your child should be seen by a doctor for diagnosis and treatment. An antibiotic may be prescribed. Children with strep throat should not attend school until they have been taking antibiotics for 24 hours.
How Can You Prevent Strept Throat?

Wash your hands often. Discard used tissues in the garbage. Avoid direct contact with anyone who has the disease.
SCARLET FEVER FACT SHEET

What is Scarlet Fever?
Scarlet fever is caused by a bacteria called Group A streptococci. The same bacteria can cause other diseases such as impetigo. 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.

Fever. Sore throat. Swollen glands (usually at the neck). Headache. A fine rash with a sandpaper feel covering the chest, neck, back, arms, legs and stomach. Peeling of the skin at the tips of the fingers and toes, palms of hands and soles of feet. This usually occurs a few days to a few weeks after other symptoms appear.

If you suspect scarlet fever, your child should be seen by a doctor for diagnosis and treatment. An antibiotic may be prescribed. Children with scarlet fever should not attend school until they have been taking antibiotics for 24 hours.
How Can You Prevent Scarlet Fever?

Wash your hands often. Discard used tissues in the garbage. Avoid direct contact with anyone who has the disease.
Group B Streptococcal Infection of the Newborn 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
1.2 Causative agent

Streptococcus agalactiae.
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.

Any pregnant woman who has previously had a baby with GBS disease should discuss this with her physician.
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/ccdrrmtc/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.
1.2 Causative agent

Coxsackievirus group A, type A16 predominantly and types 4,5,9 and 10; group B, types 2 and 5.
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.

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.
Who Can Get Hand, Foot and Mouth Disease?

Anyone can get this disease, however, people who work with diapered infants and young children are more at risk of getting the virus.

It could take 3-6 days before symptoms appear. Symptoms may include: Sores inside the mouth (tongue and gums). Blisters on the hands and feet. Sometimes there may be blisters on the buttocks as well.

There is no specific treatment for this disease. A mild pain medication may be helpful. It is not necessary for children with this disease to stay home from school.
How Can You Prevent Hand, Foot and Mouth Disease?

Wash hands after using the toilet or changing diapers and follow good basic hygiene.
IMPETIGO
1.1 Case definition
Compatible clinical illness or isolation of Staphylococcus aureus or, group A beta hemolytic streptococci (GABS), from the site of a lesion of the skin.
1.2 Causative agent

Staphylococcus aureus (S aureus) and/or group A beta hemolytic streptococci (GABS).
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.

Keep cuts, scratches or bites clean by washing with hot water and soap. Avoid contact with lesions that may be infectious. Avoid contact with any personal articles, like face cloths or towels or clothing of an infected person.
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.
Who Can Get Impetigo?

Children and adults can get impetigo, though children get it more often. It is spread through direct contact with anyone who is infected with these bacteria. Using towels or other personal articles of anyone who is infected may also spread impetigo.

Symptoms include: Small blisters on the face around the nose, mouth, chin or other part of the body. Redness and a honey coloured discharge may ooze out of the blister. Itching around the sore. Scabbing over the blister site with a yellowish crust. Stays longer than an ordinary pimple.

Your doctor can diagnose and treat impetigo. The doctor may prescribe an antibiotic cream or ointment. Your child will have to stay home from school until 24 hours after the treatment begins.
How Can You Prevent Impetigo?

Wash your hands often, especially after touching or treating the sores. If someone in the family has impetigo, each member of the family should have their own personal articles such as face cloths, towels and soap. Keep cuts, scratches and bites clean.
INFLUENZA
1.0 INFORMATION
1.1 Case Definition
Confirmed case:
SEPTEMBER 2011
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
1.2 Causative Agent

Influenza viruses belong to the family Orthomyxoviridae and are classified into three distinct types on the basis of major antigenic differences: influenza A, B and C. Influenza A and B are routinely associated with regional and widespread epidemics whereas influenza C is more commonly responsible for sporadic cases and minor localized outbreaks. Influenza A is further categorized into subtypes based on the presence of two surface antigens: hemagglutinin (H) and neuraminidase (N).
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. Nausea, vomiting and diarrhea are uncommon; however, such symptoms may accompany the respiratory phase of the disease in children under 5. In some cases it will be difficult to distinguish influenza from other respiratory illnesses. *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.
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 elses 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, amantadine and 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. Amantadine is effective against influenza A/H1 (but not most A/H3). It is not effective against influenza B or Pandemic H1N1 ; 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. To be effective in treating influenza, antivirals must be started within 48 hours of developing symptoms. The use of antivirals for the treatment and/or prevention (i.e., prophylaxis) of influenza is typically reserved for controlling outbreaks among residents and staff of long-term care facilities and other residential institutions. For further instructions regarding the use of antivirals in outbreak settings, please refer to Guide to Influenza Control for Long-Term Care Facilities and Adult Residential Centres (revised and distributed annually).
http://www.gov.ns.ca/hpp/cdpc/resources/professionals.asp

Basic personal hygiene is important in reducing transmission (i.e., covering nose and mouth when coughing or sneezing and regular hand washing). Immunization is the best protection against Influenza. Individuals at high risk of influenza-related complications and people capable of transmitting influenza to those at high risk* (e.g. health care workers) should receive annual immunization for influenza. * For high risk groups please refer to the following document annually: National Advisory Committee on Immunization (NACI) - Statement on Influenza Vaccination 2011-2012: http://www.phac-aspc.gc.ca/naci-ccni/
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 care for them.
2.1 Cases
Follow-up of individuals with laboratory-confirmed influenza is only necessary for cases who are hospitalized, residents of long-term care facilities (LTCF) or adult residential centres (ARC) or other residential institutions (i.e., settings with an elevated risk for rapid transmission and outbreaks of influenza). Upon receipt of a laboratory-confirmed influenza case (either by a faxed report or through the Electronic Lab Reporting (ELR) system), the following steps should be taken: Determine if the case is a hospitalized case, a resident of a LTCF/ARC or residential institution. This may be evident based on the lab report (i.e., the name and/or address of the ordering physician). If not evident, contact the physician to obtain the relevant information and if necessary, interview the case. If the case does not reside in a LTCF/ARC or residential institution or is not hospitalized, no further follow-up is required. If the case does reside in a LTCF/ARC or residential institution: Contact the facility and determine if there is an outbreak occurring. Refer to Section 2.3 for the definition of an outbreak and for outbreak management guidelines. If the facility is not experiencing an outbreak, no further action is required. If the case is hospitalized- see Section 3.3.4 (ii)
a)
b) c)
d)
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: 1. until 7 days after onset of symptoms with the first day of symptoms being counted as day 1, OR 2. they have been immunized at least two weeks previously and have started on antiviral therapy.
If the second criterion is met, a fitness-for-work assessment shall first be conducted through the Occupational Health department.
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.

2.3.1 Definition of an Outbreak
Refer to the guide to Influenza Control for Long-Term Care Facilities and Adult Residential Centres (revised and distributed annually) http://www.gov.ns.ca/hpp/cdpc/resources/professionals.asp and the Guidelines for Outbreak Management section of the CDC Manual http://www.govn.ns.ca/hpp/cdpc/cdcmanual
2.3.2. Guidelines for Investigation and Management

Refer to Guide to Influenza Control for Long-Term Care Facilities and Adult Residential Centres (revised and distributed annually). http://www.gov.ns.ca/hpp/cdpc/resources/professionals.asp
2.3.3 Reporting of Outbreaks

Refer to Section 3.5.3 for the outbreak reporting procedure.
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.
2.4.2 Specimen Collection

Appropriate specimen types: - Nasophayngeal swab and aspirate - Endotracheal aspirate - Bronchial Wash/Lavage - CSF - Tissue Non-appropriate specimen types (will be rejected by lab): - Nose - Throat and throat washings 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 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. Sampling beyond 5 days may be considered in patients with persisting or worsening symptoms regardless of age, in younger 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.
2.4.3 Specimen Labeling Requirements

All specimens must be appropriately labeled with 2 unique patient identifiers and accompanied by a completed requisition with corresponding information. One identifier must be the patient's legal name and the other can be the medical record number for in-patient and ambulatory care patients or the provincial health card number for referred in patients. If the patient does not have either the medical record or health card number, other unique identifiers associated with the patient should be used: registered health card equivalent passport number Capital Health invoice number private insurance policy number immigration number physician offices patient chart number
Outbreak numbers are provided by public health services and should be clearly identified on the laboratory requisition. The patient/resident setting should be clearly indicated on the laboratory requisition LTC facility name Inpatient facility name and location (ICU, Floor, etc).
2.4.4 Specimen Transport Conditions

Patient specimens should be kept at 4C and received for testing at the CDHA laboratory within 72 hours. If swabs are to be delayed in transit longer than this, they should be frozen at -70oC. or colder.
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. Public Health Surveillance Subtyping of Influenza virus type A positive samples will be performed. Testing during the season will determine the strains which are circulating. The CDHA Anchor Microbiology laboratory also participates in the WHO Influenza Program offered through the National Microbiology Laboratory (NML) in Winnipeg. This program provides valuable reference / surveillance services for influenza strain characterization, antiviral susceptibility and molecular typing. Testing frequency (weekday/weekend) is assessed on an ongoing basis by CDHA Microbiology. Please note that turn around time may be further impacted by transportation from local/ regional labs to CDHA microbiology testing facility. IWK Health IWK Health Microbiology (PPHLN Paediatric Anchor Lab) performs viral respiratory testing for its facility. This service is under the guidance of the Chief of IWK Laboratories.
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 (RIDT) 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). 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.
2.4.7 Reporting of Results

Positive Influenza reports including subtyping will be phoned for acute care and LTCF/ARC settings. Positive Influenza results will be reported to the District Health Authority Public Health Services. Reports for identifiable outbreaks will be followed up with Public Health Services. All other results will be sent to the referring entity via regular reporting mechanisms. Sentinel results will be treated in the same way as routine specimens, except for reporting to DHW by PPHLN.
2.4.8 To Access Results

Results are available at 902-473-2266 (CDHA Central Lab Reporting) after completion. Public Health Services can contact Janice Pettipas (PPHLN Program Coordinator) 902-473-8280 for questions about results.
For other questions contact the laboratory director.
2.4.9 After Hours

The Microbiologist on call is accessible through QE II HSC Locating 902-473-2222.
3.0 SURVEILLANCE
3.1 Introduction
Both laboratory-confirmed influenza and influenza of pandemic potential are notifiable diseases in Nova Scotia as mandated under the regulations of the Health Protection Act. Physicians and managers of laboratories must report positive influenza test results to the medical officer of health with jurisdiction in the locality in which the reporting person works. Outbreaks of respiratory illness in long-term care facilities are also notifiable. Monitoring influenza is an ongoing activity in Nova Scotia and the capacity of the influenza surveillance system is assessed at the beginning of each influenza season. The system monitors seasonal influenza in addition to other respiratory viruses, such as parainfluenza, adenovirus, and respiratory syncytial virus (RSV). The components of the current influenza surveillance system and the approach for the 20102011 influenza season are described here.
3.2 Influenza Surveillance Guidelines 20112012

It is important to note that this document refers to influenza, regardless of type. All types of influenza (e.g. influenza A, influenza B and pH1N1) are under surveillance in Nova Scotia.
3.2.1 Objectives of Influenza Surveillance in the 20112012 Influenza Season

To monitor the trend of influenza-like illness (ILI) in the community in order to determine waning, re-emergence and activity levels of disease. To monitor the geographic spread of influenza viruses across Nova Scotia and Canada. To monitor the severity of illness. To monitor for changes in the antigenicity and antiviral sensitivity of the virus (lab-based).
3.2.2 Surveillance Systems and Sources of Data

The objectives of influenza surveillance will be met through the implementation of a number of different surveillance systems. The majority of surveillance systems are created and maintained by Nova Scotia, while a few are federal initiatives. They include: Nova Scotia (Figure 1) o Laboratory-confirmed cases of influenza o Influenza-like illness ILI in emergency departments Outbreaks of influenza and ILI o LTCF/ARC and acute care facilities Reporting of absenteeism and potential outbreaks in schools and daycare facilities Federal surveillance initiatives and special studies o Severe Outcome Surveillance (SOS) o Canadian Nosocomial Infection Surveillance Program (CNISP) o Immunization Program Monitoring-Active (IMPACT) o National Research Systems (NaReS) FluWatch sentinel physicians
3.3 Surveillance of Laboratory-Confirmed Influenza

3.3.1 Introduction
Influenza is a notifiable disease in Nova Scotia, regardless of type. All laboratoryconfirmed cases of influenza must be reported to Public Health Services, who in turn report to Department of Health and Wellness (DHW).
3.3.2 Objectives of Surveillance of Laboratory-Confirmed Influenza

To detect, in a timely manner, cases of influenza To detect clusters of influenza in long-term care, acute care facilities, schools and daycares To detect types of respiratory pathogens circulating within the community To monitor the severity of influenza through case follow-up
3.3.3 Laboratory Testing and Reporting

Laboratory testing for influenza in Nova Scotia is conducted according to that described in Figure 1. Confirmed cases are reported by the CDHA laboratory to Public Health Services in the DHAs and to DHW on a daily basis through the Electronic Laboratory Reporting System (ELR).
Figure 2: Influenza Testing Algorithm, Nova Scotia 2011 2012 (CDHA based testing)
Source: PPHLN, August 2011
Important Points for Laboratory Testing in the 20112012 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 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 Table 1: ANDS Influenza Entry Summary
Influenza Result on Lab Report Influenza A; Seasonal Influenza H1N1 detected by PCR Influenza A detected; Further report to follow Influenza A; Pandemic H1N1 detected by PCR Influenza B Disease Name in ANDS Influenza (lab-confirmed) Seasonal Influenza A Influenza A; Preliminary report Influenza (lab-confirmed) Pandemic Strain Influenza (lab-confirmed) Influenza B Case Status in ANDS Confirmed Confirmed Confirmed Confirmed Agent Sub/Serotype in ANDS H1N1 Not yet typed pH1N1
Cases should be entered using the ANDS date hierarchy, to reflect the earliest episode date available (refer to ANDS Quick Reference: Influenza Case Entry in Appendix B) It is expected that all fields are updated in ANDS where possible as new information becomes available. This is standard procedure for all notifiable conditions. For example, if through public health follow-up the outcome of a case (ie: hospitalized, deceased) is determined, this knowledge should be reflected in ANDS. ANDS Cognos reports are available to DHAs and include: an influenza report for each influenza season by DHA and type of influenza (named Reported Influenza Cases Week Ending), type of influenza by selected DHA(s) for a selected time period (named Notifiable Diseases by DHA),
and type of influenza by age group and sex for selected DHA(s) over a selected time period (named Notifiable Diseases by Sex & Age).
ii) Case Follow-up for Surveillance Purposes

Public Health Services should conduct a case investigation for all confirmed cases of influenza, regardless of type, to determine if the case resides in a LTCF/ARC, is hospitalized or is in the community (refer to Table 2) Table 2: Influenza Case Management Summary Community LTCF Case Hospitalized Case* Case Report via ANDS Yes Yes Yes Case follow-up No Yes** Yes Fax case report form No No Yes to DHW * Defined as any person admitted to hospital with laboratory confirmed influenza. **As outlined in Guidelines for Influenza Control in LTCF/ARC If case follow-up is required (as shown in Table 2), use the Influenza Case Report Form (Appendix C) If the case is determined to be from a LTCF/ARC, contact the facility to determine if there is an Influenza outbreak. Refer to the Guidelines for Influenza Control in LTCF/ARC http://www.gov.ns.ca/hpp/cdpc/resources/professionals.asp If it is determined that the case is hospitalized, complete the Influenza Case Report Form, fax to DHW (902-424-0550) and then follow the case once a week until discharge or death (maximum follow-up of 4 weeks). The weekly follow up is noted on case report form and the updated case information should be provided to DHW, and ANDS must be modified accordingly. If a hospitalized case is determined to be part of an outbreak in an acute care facility (refer to Section 2.3), complete the initial/final outbreak report summaries on CNPHI.
Important notes regarding hospitalized cases:

Case follow-up is required for all hospitalized cases of influenza, regardless of type Hospitalized cases should be followed by Public Health Services until discharge, or death (maximum follow-up of 4 weeks). Cases hospitalized at the QEII or Dartmouth General will be reported to CDHA by the Severe Outcome Surveillance Study (SOS) (refer to section 3.6.1)
b) Department of Health and Wellness

DHW will obtain data on laboratory-confirmed cases through the following surveillance systems: Data on all lab-confirmed cases reported via ANDS Enhanced data on hospitalized cases faxed to DHW (using the influenza case report form) Data on laboratory-confirmed cases will be reported weekly in Respiratory Watch (refer to section 3.7) DHW will report data on laboratory-confirmed cases to the Public Health Agency of Canada (PHAC) in accordance with current PHAC reporting practices
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 ofthefollowing: 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.
3.4.2 ILI in Sentinel Primary Health Care Settings Introduction

Sentinel physicians participate in surveillance for ILI in Nova Scotia through FluWatch, a federal surveillance program that has been in place since 1996. Sentinel physicians are recruited by the College of Physicians and Surgeons of Canada and report directly to FluWatch.
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)
3.4.3 ILI in Emergency Departments 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 D) for patients seen in the Emergency Dept (ED). Data are collected daily and reported to DHW weekly. 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.
Role of Department of Health and Wellness

DHW will coordinate and maintain the ED surveillance network DHW will analyze and summarize aggregate data and include this information in Respiratory Watch (refer to section 3.7)
3.5 Surveillance of Outbreaks of Influenza and ILI

Table 3: Summary of ILI Outbreak/Absenteeism Reporting Flu Watch Report CIOSC Report Email/Fax Form to DHW LTC/ARC School Daycare Yes Yes Yes Yes No No No No No
3.5.1 School / Daycare Absenteeism Introduction

School and daycare-based surveillance for ILI is ongoing in Nova Scotia. Schools are requested to report absenteeism that may be due to ILI directly to their local public health service.
Procedures a) District Health Authority

Schools and daycares should report to Public Health Services absenteeism according to the criteria below: Schools: greater than 10% absenteeism OR absenteeism that is 10% higher than baseline levels determined by schools or surveillance region which is likely due to Influenza. Daycares: staff or children absenteeism, which is likely due to ILI, that are higher than baseline levels, as determined by daycare. 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 surveillance region 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 E) 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 F)

DHW uses this information to validate influenza activity levels for FluWatch
3.5.2 Influenza / ILI Outbreaks in Long Term Care/ARC and Acute Care Facilities Introduction
LTCF/ARC and acute care facilities are required to report outbreaks or suspected outbreaks of influenza and/or ILI to District Public Health Services. Please refer to the Guidelines for Influenza Control in LTCF/ARC for more detailed information. The document is available at: http://www.gov.ns.ca/hpp/cdpc/resources/professionals.asp
Important note regarding reporting of influenza/ILI outbreaks in LTCF/ARC and acute care facilities: As of October 1, 2009, all outbreak reporting of the above to DHW will be done through the CNPHI website (https://www.cnphi-rcrsp.ca (see Table 4)
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 o 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) o 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.: 200909-001 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 o When applicable, provide the final number of residents/patients/staff who received treatment, received post-exposure propylaxis, were hospitalized, and the number who died.
Table 4: Influenza/ILI LTCF/ARC Reporting through Outbreak Summaries Initial Report Update Report Final Report Comprehensive Final Report Outbreak of Required As new Required Only if influenza/ILI in information requested LTCF/ARC becomes available (ie: lab results) Report the outbreak through normal FluWatch procedures (Appendix F)

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)
3.5.4 Public Health Alerts

Although outbreak reporting in LTCF/ARC will be done in Nova Scotia using CNPHI, Public Health Alerts will not be used routinely to report school absenteeism or outbreaks in LTCF/ARC. However, Public Health Services may consider the use of a Public Health Alert to notify other jurisdictions of certain outbreaks or unusual events (note that the definition of unusual is subjective and may require a certain level of public health professional discretion). Please refer to the Outbreak Chapter of the Nova Scotia CDC Manual for further detail.
3.6 Federal Surveillance Initiatives and Special Studies

3.6.1 Severe Outcome Surveillance (SOS)
The Severe Outcomes Surveillance Network is a key component of the Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) research plan. Sentinel hospitals participating in this surveillance in Nova Scotia include: the Queen Elizabeth II Health Sciences Center and Dartmouth General Hospital in Halifax, NS. The SOS Network Coordinating Centre is located at the Canadian Center for Vaccinology (CCfV), Halifax, NS. The objectives of SOS are: 1) to describe the incidence, clinical features and outcomes of laboratory-confirmed influenza illness requiring hospitalization in Canadian adults 2) to conduct ongoing assessment of the effectiveness of influenza vaccination in preventing influenza-associated hospitalization and
death in adults 3) to examine clinical and immunologic factors impacting on influenza vaccine effectiveness in adults. Physicians will be requested to order nasopharyngeal swabs for the following diagnoses on admission: Community-acquired pneumonia or other respiratory tract infection Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or asthma Any cardiac or respiratory diagnosis or unexplained sepsis with a triage temperature of 37.5oC or higher The SOS Study will enhance, within participating hospitals, the active surveillance in place for detection of hospitalized cases of influenza in Nova Scotia.
Procedures a) District Health Authority-CDHA only

If lab-confirmed influenza cases are detected at the Halifax Infirmary or Dartmouth General hospital, SOS researchers will forward case reports to local public health services Public Health Services will report to DHW in accordance with usual practice
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 Severity of influenza (hospitalizations and deaths) Percentage of patients from FluWatch sentinel physicians (one day/week reporting) that met ILI case definition 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 Director 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 (http://www.gov.ns.ca/hpp/cdpc/respiratory-watch.asp).
4.0 COMMUNICATION PLAN

Communications Objectives:
To launch the 2011-2012 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 the benefits of the influenza vaccine To associate the influenza campaign with Better Care Sooner, governments overall plan to improve health care for Nova Scotians To inform Nova Scotians on effective steps to prevent influenza 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 lifethreatening 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 morbidity and mortality 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 2011-2012, the H1N1 strain will be included in the influenza vaccine. In 2011-2012, the Department of Health and Wellness is providing 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: people 65 years of age and older; children 6 months to 5 years of age; pregnant women; persons with morbid obesity (BMI 40); aboriginals peoples; residents of long-term care and other chronic care facilities; 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. In 2011-2012, Nova Scotia will order 410,000 doses of vaccine. Target Audiences: Health care professionals Health care students Parents/children/families Seniors Pregnant women First Nations and Inuit Employers General Population Talking Points and Media Lines: 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 defence 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. 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. To learn more, we invite you to visit the Department of Health and Wellness website at www.gov.ns.ca/DHW .
Potential impact on other departments, agencies: Department of Community Services Department of Labour and Workforce Development Health Care Education Organizations Long-Term Care Facilities Home Care and Support Agencies District Health Authorities Service Nova Scotia Strategic Actions/Roll-Out plan: Minister of Health and Wellness Maureen MacDonald and Chief Public Health Officer Robert Strang will hold a press conference at Northwood Centre in Halifax to launch the 2011-2012 Influenza Vaccination Campaign. This will occur on October 13, 2011. The press conference will be followed by a photo opportunity of Minister MacDonald and CPHO, Dr. Robert Strang, 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. DHW will likely be engaging in a comprehensive marketing campaign to promote the influenza vaccine as part of Better Care Sooner. Communications Materials: Note to Editors Media Kit News Release Flu Website Posters Questions and Answers
Recommended spokespersons for 2011-2012: Minister of Health and Wellness Maureen MacDonald Chief Public Health Officer Robert Strang
References Canada Communicable Disease Report. (2011). NACI Statement on Seasonal Trivalent Inactivated Influenza Vaccine 2011-2012. 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/newnouv/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. Health Canada. (2002). Prevention and control of occupational infections in health care. An infection control guideline. CCDR 2002;28S1:1-264. Public Health Agency of Canada. (2009). Case Definitions for Communicable Diseases under National Surveillance. CCDR 2009; 3552, 1-123. Retrieved from http://www.phacaspc.gc.ca/publicat/ccdr-rmtc/09pdf/35s2-eng.pdf Public Health Agency of Canada. (2011). FluWatch. Retrieved from http://www.phacaspc.gc.ca/fluwatch/index-eng.php
5.0 APPENDICES
Appendix A: 2011-2012 Seasonal Influenza Vaccine Information for Immunizers
Appendix B: ANDS Quick Reference: Influenza Case Entry
Appendix C: Case Report Form for Reporting Influenza in Nova Scotia
Appendix D: ILI in Emergency Departments/Outpatient Centres
Appendix E: School and Daycare Absenteeism
Appendix F: FluWatch Reporting Procedure through CNPHI
Appendix G: Influenza Vaccine Coverage and Reporting: Procedures
APPENDIX A: 2011-2012
Seasonal Influenza Vaccine Information for Immunization Providers
2011-2012 Seasonal Influenza Vaccine Information for Immunization Providers
1. What are my accountabilities as an immunization provider?

A. Reporting to Public Health Adverse Events Following Immunization (AEFI) are to be reported to local Public Health Services as per Its the Law Reporting Adverse Events Following Immunization (see Q 17) Physicians are to use MSI billing codes that are specific to the 2011-2012 seasonal influenza vaccine (see Q 24) Other immunization providers are to complete aggregate data collection forms provided by Public Health (see Q 16) Management of Vaccine/Cold Chain Vaccine must be stored between +2 and +8C at all times Report all cold chain breaks to local Public Health Services and follow their directions on use of affected vaccines Attention must be paid to the duration of stability of vaccine once it has been opened or reconstituted Competency Immunizers 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. Its therefore critical for Public Health to manage the supply to ensure equitable distribution to all immunization providers.
Immunization providers should not order the whole seasons 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. Role Model/ Duty of Care Annual influenza immunization of health care workers is very important for reducing influenza-related morbidity and mortality among high risk groups. All immunization providers are encouraged to receive an annual influenza immunization.
2. Who is eligible to receive publicly funded seasonal influenza vaccine?

A. Immunization against influenza is publicly funded and advised for all Nova Scotians 6 months of age, but is strongly recommended for people at high risk of influenza related complications and for those people who live with or care for them. The vaccine will be free of charge. As in previous years, NS Dept of Health and Wellness does not fund the costs of administration or supplies.
3. Which groups are considered high risk for influenza related complications?
A. The following groups are considered high risk : Persons with morbid obesity (BMI 40) Aboriginal peoples Adults (including pregnant women) and children with the following chronic health conditions: cardiac or pulmonary disorders (including bronchopulmonary dysplasia, cystic fibrosis and asthma); diabetes mellitus and other metabolic diseases; cancer, immunodeficiency, immunosuppression (due to underlying disease and/or therapy); renal disease; 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 nursing homes and other chronic care facilities.
People 65 years of age. Healthy children 6 to 23 months of age. Healthy 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).
4. What are the components of the seasonal influenza vaccines?

A. The antigenic strains included in the 2011-2012 influenza seasonal vaccine (northern hemisphere) are: A/California/7/2009 (H1N1)-like virus; A/Perth/16/2009 (H3N2)-like virus; B/Brisbane/60/2008-like virus.
The only two products being used in Nova Scotia for the publicly funded influenza immunization program are Fluviral and Vaxigrip 5. Who should NOT routinely be given seasonal influenza vaccine?
A. The following people people should not receive seasonal influenza vaccine: Infants less than 6 months of age; People who have had a serious allergic reaction to a previous dose of any influenza vaccine; People who have had a serious allergic reaction to any of the components of influenza vaccine; People with an egg allergy who are at higher risk for a severe allergic reaction, defined by the Canadian Society of Allergy and Clinical Immunology as: previous respiratory or cardiovascular reaction, generalized hives or those with poorly controlled asthma; People who have a severe febrile illness; People known to have had Guillain- Barr Syndrome within 8 weeks of a previous influenza vaccine.
6. Should people who have experienced Ocular Respiratory Syndrome (ORS) following receipt of a previous seasonal influenza vaccine be immunized with the seasonal influenza vaccine?
A. There is no evidence to suggest that ORS will be a concern following immunization. Individuals who have experienced the oculorespiratory syndrome (ORS), including those with a severe presentation (bilateral red eyes, cough, sore throat, hoarseness, facial swelling) but without lower respiratory tract symptoms, may be safely reimmunized with influenza vaccine. Persons who
experienced ORS with lower respiratory tract symptoms should have a consultation with an allergist.
7. Should people who are allergic to eggs, components of the vaccine, or a previous dose receive the seasonal influenza vaccine?
A. Influenza vaccination for those with egg allergy is no longer considered a contraindication provided appropriate monitoring and support is available; prior vaccine skin testing is not recommended. Egg-allergic individuals at lower risk for a severe allergic reaction defined by the Canadian Society of Allergy and Clinical Immunology (CSACI) as: mild gastrointestinal or mild local skin reactions and able to tolerate ingestion of small amounts of egg can be vaccinated with a full age-appropriate dose followed by a waiting period of 30 minutes. Persons with an egg allergy who are at higher risk for a severe allergic reaction, defined by CSACI as: previous respiratory or cardiovascular reaction, generalized hives or those with poorly controlled asthma should only be vaccinated if recommended by an allergist. (NACI Statement on Seasonal Influenza Vaccine for 2011-2012) Expert review of the risks and benefits of vaccination should be sought for those who have previously experienced severe lower respiratory symptoms (wheeze, chest tightness, difficulty breathing) within 24 hours of influenza vaccination, an apparent allergic reaction to the vaccine or any other symptoms (e.g., throat constriction, difficulty swallowing) that raise concern regarding the safety of reimmunization.
8. Should pregnant women receive the seasonal influenza vaccine?

A. Yes. Pregnant women should receive seasonal influenza vaccine as evidence demonstrates they are at higher risk of complications from influenza.
9. Is seasonal influenza vaccine safe for breastfeeding mothers?

A. Yes. Seasonal influenza vaccine is safe for breastfeeding mothers.
10. How should the seasonal influenza vaccines be stored?

A. Vaccine Cold Chain should be maintained at all times (2C to 8C). The vaccine should not be frozen and must be protected from light.
11. 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. An opened vial of Vaxigrip (Sanofi Pasteur) should be used within 7 days from the date it was opened.
12. How is the seasonal influenza vaccine administered?

A. The publicly funded seasonal influenza vaccine is administered intramuscularly.
The deltoid muscle is the recommended site in adults/ older children and the anterolateral thigh in infants (1 year old and under).
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.
14. 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.
15. What are the side effects of the seasonal influenza vaccine?
A. One third of those vaccinated report soreness at the 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.
16. What immunization information needs to be reported Public Health Services?

A. Physicians will use MSI billing codes that are specific to the influenza vaccine. (See billing code information sheet at end of this document)
All other providers will submit aggregate influenza information at the end of the influenza season to their local Public Health office on forms provided by Public Health.
17. What adverse events need to be reported to Public Health Services?

A. All adverse events not normally expected as detailed in the product monograph that are temporally related to the administration of the vaccine need to be reported in accordance with the Its the Law: Reporting Adverse Events Following Immunization (AEFI) Poster: http://www.gov.ns.ca/hpp/publications/13087_AdverseEventsPoster_Mar09_En.pd f
18. Can the seasonal influenza vaccine cause influenza illness?

A. No. The seasonal influenza vaccine does not contain live virus and therefore cannot
cause influenza.
19. Can you receive seasonal influenza vaccine before or after having donated/received blood or Immune Globulin?
A. Yes.
20. Can seasonal vaccine and pneumococcal vaccine be given at the same time?
A. Yes they can be administered at the same time but they should be administered via separate syringes in different sites. Pneumococcal vaccination is recommended once in a lifetime, except in certain high risk individuals as specified in the Canadian Immunization Guide. Pertussis vaccine is recommended in childhood and adolescence and once as an adult.
21. Can you receive seasonal influenza vaccine if you have received other vaccines recently? Does there need to be an interval of time between receiving other vaccines and seasonal influenza vaccine?
A. Yes, you can receive seasonal influenza vaccine if you have received other vaccines recently. No, there is no interval of time between receiving other vaccines and seasonal influenza vaccine and any other vaccines.
22. Where can I get more information on seasonal influenza vaccine?

A. For more information on influenza vaccine, contact your local Public Health office: http://www.gov.ns.ca/hpp/contacts/phs-offices.asp. You may also check the following websites: a. Nova Scotia Department of Health and Wellness web site at: www.gov.ns.ca/hpp/flu b. Public Health Agency of Canada: Statement on Seasonal Trivalent Inactivated Influenza vaccine for 2011-2012: http://www.phac-aspc.gc.ca/naciccni/index-eng.php c. Canadian Public Health Association: www.immunize.ca
23. What is the dosage and frequency of the seasonal influenza vaccines?
A. The National Advisory Committee on Immunization (NACI) Statement on Seasonal Influenza Vaccine for 2011-12 recommends a change in the dose of influenza vaccine for children ages 6-35 months. The recommended dosage is now 0.5ml of vaccine (not 0.25 ml as in previous years), based on evidence of moderate increase in immunogenicity and no evidence of increased adverse events. N. S. has made the decision to adopt the NACI recommendation. Recommended Influenza Vaccine Dosage by Age, 2011-2012
Age Group Dose No. of Doses
9 years and older 6 months-8 years**
0.5 ml 0.5 ml
1 1 or 2*
*Previously unvaccinated children less than 9 years of age require two doses
of Seasonal Influenza Vaccine, with a minimum interval of 4 weeks between doses. Children less than 9 years of age who have received one or more doses of Seasonal Influenza Vaccine in the past only need to receive one dose per season thereafter. The seasonal influenza vaccine is not licensed or recommended for infants less than 6 months of age. **The recommended dosage for influenza vaccine for children age 6-35 months has increased from 0.25 ml (half dose) to 0.50 ml (full dose)
24. How do physicians bill for influenza immunization?

A. MSI Billing Information for Administration of Seasonal Influenza (Flu) and Polysaccharide Pneumococcal (PC) Vaccines 2011-2012 Billing requires a health service code, a modifier, and a diagnostic code Immunization Health Service Modifier MSUs Diagnostic Code Code Influenza 13.59L RO=INFL 6.0 Select diagnostic code from the table below Pneumococcal 13.59L RO=PNEU 6.0
Patient Status Pregnant Males & non-pregnant females
Diagnostic Codes FLU
PC and FLU
V221 V048
N/A V066
Refer to the following table when billing for a provincial immunization tray fee. Health Services Code Description MSUs 13.59M Provincial immunization tray fee 1.5 per multiple (max 4/visit)
Notes: 1. If one vaccine is administered but no associated office visit is billed (i.e. the sole
purpose for the visit is the immunization), claim the immunization at a full fee of 6.0 MSUs. 2. If two vaccines are administered at the same visit but no associated office visit is billed (i.e. the sole purpose for the visit is the immunization), claim for each immunization at a full fee of 6.0 MSUs each. 3. If one vaccine is administered in conjunction with a billed office visit, claim both the office visit and the immunization at full fee. 4. If two vaccines are administered in conjunction with a billed office visit, claim the office visit and the first injection can be claimed at full fee. All subsequent injections will be paid at 50%.
5. For children less than 12 months of age, if a vaccine is administered in conjunction
with a well baby care visit, claim the well baby care visit and the immunization.
2011 September 19
APPENDIX B
ANDS Quick Reference: Influenza Case Entry
ANDS Quick Reference: Influenza Case Entry

This table outlines data entry for cases of influenza in ANDS. Note important points in boxes with bold borders.
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. 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 complete, all investigations should be closed in ANDS. The date the investigation was completed. 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 ANDS. Enter influenza type as appropriate from lab result (see Table 1). Please note that ANDS entry will vary according to lab result and Table 2 is essential. Free text field. Enter influenza subtype as indicated in Table 1 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 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 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). Do Not Use The outcome of the case. Note that if deceased is selected, a date of death must be entered. Do Not Use If known, enter information.
Case Status*
Investigation Status* Investigation Closed Date Date Reported* DHA* Disease Name* Agent Sub/Serotype Other lab Info
Episode Date*
Episode Date Type*
Clinical Presentation Outcome Risk Factors for STIs Only Where was cases illness most likely acquired? Associated with an outbreak?
Indicate whether the case is associated with an existing outbreak.
Outbreak Number
Received Vaccine Vaccine Date 1 (& 2) Vaccine Name Do Not Use Comments Free text. Use as appropriate for case management. *Indicates a mandatory field in the ANDS application
The outbreak number of the associated outbreak, if applicable. (Follow outbreak numbering system described in Section 3.5.3). Do Not Use Do Not Use
APPENDIX C
Case Report Form for Reporting Influenza in Nova Scotia
Available at the following website: http://www.gov.ns.ca/hpp/populationhealth/surveillanceguidelines/Influenza_Case_Re port_Form_with_Data_Dictionary.pdf
APPENDIX D
ILI in Emergency Departments (ED)/Outpatient Centres form available at the following website:
http://www.gov.ns.ca/hpp/populationhealth/surveillanceguidelines/ER_ICP_ILI_Surveilla nce_Weekly_Report_Form.pdf
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 If you have any questions, please call 902-424-6567.
APPENDIX E
School and Daycare Absenteeism
forms available at the following websites:
School Reporting Tool

http://www.gov.ns.ca/hpp/populationhealth/surveillanceguidelines/School_Surveillance_ Reporting_Tool.pdf
Daycare Reporting Tool

http://www.gov.ns.ca/hpp/populationhealth/surveillanceguidelines/Daycare_Surveillance _Reporting_Tool.pdf
APPENDIX F
FluWatch Reporting Procedure through CNPHI
FluWatch Reporting using CNPHI Please note that the submission deadline is Tuesday at noon Entering a Sub-Regional Report The data must be manually entered. After the data has been entered, click Submit to send the data to Regional and Provincial/Territorial Reviewers and to make the report viewable to other users within the same region. 1. In CNPHI site, select Sub-Regional Reports from the menu as shown:
2. Select the appropriate DHA from the drop-down menu:
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 HPP:
6. Submitted data will appear as Published in the application:
Entering a Regional Report Please note that the submission deadline is TUESDAY at NOON. A regional report computes a summary of influenza activity levels for the region including detailed information from the sub-regional level reports. Creating a Regional Report after Sub-Regional data has been entered: 1. Select Regional Reports from the menu as shown:
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 HPP:
5. Submitted data will appear as Published in the application:
APPENDIX G
INFLUENZA VACCINE COVERAGE AND REPORTING NOVA SCOTIA, 20112012
(forms available at following link:

http://www.gov.ns.ca/hpp/populationhealth/surveillanceguidelines/APP ENDIX_C_Surveillance_Forms.pdf
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.
1.2 Causative agent

Legionella pneumophila, serogroup 1 is most commonly associated with disease, however there are 18 serogroups. Related organisms have been isolated, including L. micdadei, L. bozemanii, L. longbeachae and L. dumoffi. In total, 35 species of Legionella with at least 45 serogroups are currently recognized.
1.3 Symptoms
There are two distinct clinical and epidemiological manifestations of legionellosis: Legionnaires Disease. Pontiac Fever. The early symptoms of both diseases include anorexia, malaise, myalgia, headache, and rapidly rising fever with chills (temperatures commonly reach 39 C to 40.5 C). Non-productive cough, abdominal pain and diarrhea are common. For Legionnaires disease, chest x-rays often show pneumonia that may progress to bilateral involvement and ultimately respiratory failure. Case fatality rates for Legionnaires disease have reached as high as 39%. Pontiac fever is a milder illness, which is not associated with pneumonia or death. Clients with Pontiac fever usually recover spontaneously in 2-5 days.
1.4 Incubation
Legionnaires 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 Legionnaires 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.

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
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
2.1.3 Role of the Physician

Report all cases to Public Health Services.
2.1.4 Role of the Laboratory

Report all cases to Public Health Services
2.2. Guidelines for Childcare Institutions

Investigate potential water source and air conditioners.

Investigate whether there are any other cases or anyone with symptoms (case find) indicating nosocomial transmission.

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/ccdrrmtc/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.
Who Can Get Legionellosis?

People of any age may get Legionnaires disease, but the illness most often affects middle-aged and older persons, particularly those who smoke cigarettes or have chronic lung disease. Also at increased risk are persons whose immune system is suppressed by diseases such as cancer, kidney failure requiring dialysis, diabetes, or AIDS. People who take drugs that suppress the immune system are also at higher risk. Pontiac Fever most commonly occurs in persons who are otherwise healthy.

Symptoms of Legionnaires disease may include: Fever. Chills. Dry cough. Muscle aches. Headache. Loss of appetite. Diarrhea. Pneumonia.
Symptoms of Pontiac Fever may include the symptoms above except for pneumonia.

Antibiotics are prescribed for people with Legionnaires disease, and hospitalization is often required. People with Pontiac fever usually recover without treatment in 2 to 5 days.
MENINGOCOCCAL DISEASE INVASIVE

JANUARY 2007 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 disease with purpura fulminans or petechiae, with no other apparent cause and with non-confirmatory laboratory evidence: detection of N. meningitidis antigen in the CSF Note: Meningococcal DNA can be found in the CSF up to 90 hours after antibiotics have been started Further to Case Definitions in this section, please note the description of cases in the footnotes that may be useful for epidemiological purposes.3
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

Reduce direct contact and exposure to discharge from nose and mouth (e.g. coughing, kissing, sharing utensils, drinking glasses, cigarettes, etc.)
Reduce overcrowding in living quarters and workplaces (e.g. barracks, dormitories, sleep-away camps and ships) Immunize following the Nova Scotia Immunization Schedule Consult travel health clinics if traveling to countries where disease is endemic Follow hand hygiene practices using plain or antimicrobial soap with running water or an alcohol-based hand sanitizer

2.1 Case
Follow-up of meningococcal disease is a priority and the following steps must be taken immediately: a) Contact physician to obtain clinical information on case b) Record age, gender, address of case c) Interview parent or guardian to determine if case: i. has had recent travel ii. attends or is employed at a childcare centre or school iii. participated in recent athletic or recreational events and/or gatherings
2.1.1 Exclusion
No exclusion required.
2.1.2 Education
See Section 1.9, Core Prevention Messages.
2.2 Contact Tracing

The cornerstone of prevention of secondary cases of invasive meningococcal disease (IMD) is aggressive contact tracing to identify people at increased risk for disease (e.g. close contacts) and providing chemoprophylaxis to this group of susceptible individuals. Chemoprophylaxis is necessary to eliminate nasopharyngeal carriage of meningococci from any carrier within the network of close contacts.
2.2.1 Definition of Close Contacts

Household contacts of a case Persons who share sleeping arrangements with the case Persons who have direct contamination of their nose or mouth with the oral/nasal secretions of a case (e.g. kissing on the mouth, shared cigarettes, shared drinking bottles, etc.) Health care workers (HCWs) who have had intensive unprotected contact (without wearing a mask) with infected patients (e.g. intubating, resuscitating or closely examining the oropharynx) Children and staff in child care and nursery school facilities Airline passengers sitting immediately on either side of the case (but not across the aisle) when the total time spent aboard the aircraft was at least 8 hours
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.

Obtain names and information for all contacts who meet the definition outlined in Section 2.2.1. If the case traveled within the last 10 days on a flight of 8 hours or more (including ground time on the tarmac) during the infectious period (7 days before onset of symptoms to 24 hours after the onset of effective treatment), then a decision must be made in consultation with the MOH to obtain the passenger manifest. It is important to note that aircraft passenger manifests are rarely kept after 48 hours. Contacts do not need to be excluded from any activities.
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. Chemoprophylaxis should be considered for close contacts of a case that is strongly suspected to be IMD, even if laboratory confirmation cannot be obtained within 24 hours. Provide primary care physicians with Guidelines for Prophylaxis of Contacts of Meningococcal Disease (Appendix 1).
Table 1: Chemoprophylaxis for Close Contacts of IMD Cases DruDrug DODosage Comments Ciprofloxacin Adults >18 years of age: Contraindicated during pregnancy 500 mg x 1 dose PO and lactation Only approved for persons >18 years of age. Not recommended for prepubertal children. Rifampin Adults: Contraindicated in pregnancy. 600 mg PO q12h x 4 doses Urine and tears may be stained Children >1 month of age: red. Advise against wear of soft 10 mg/kg (maximum 600 contact lenses as they can also be mg) per dose PO q12h x 4 stained. doses Can reduce effectiveness of oral Infants <1 month of age: contraceptives. 5 mg/kg per dose PO q12h Advise use of alternative X 4 doses contraceptive measures. Ceftrixone Adults: Recommended drug for pregnant 250 mg IM x 1 dose women. Children <12 years: Alternative for persons who 125 mg IM x 1 dose cannot tolerate oral medication. Dilute in 1% lidocaine to reduce pain at injection site.
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.

An outbreak is defined as increased transmission of N. meningitidis in a population, manifested by an increase in cases in the same serogroup. Outbreaks can be subdivided into organization-based or community-based using the following criteria:
Organization-Based:
Increased transmission of N. meningitidis in an organization or institution with two or more cases of the same serogroup occurring within a 4-week interval. This includes restricted populations such as schools, day care centers, sports or social groups, as well as nursing homes or long-term care facilities.
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.
2.4.2 Guidelines for Child Care

Attendees and staff should be evaluated as to whether they meet the definition of a contact. See Section 2.4.1. If the index case attended a childcare centre or school, all parents of children within the centre/school must be notified and given information regarding signs and symptoms of IMD and whether or not their child(ren) are considered to be contacts of the case. See sample letters in Appendix 2. Consider providing education sessions to staff of the childcare centre or school regarding signs and symptoms of IMD and the necessity of prompt medical attention should symptoms develop in the children or staff.
2.5 Public Health Laboratory Role

Contact Laboratory: Meningococcal isolates from all IMD should routinely be sent to the provincial laboratory (located at the QEII Health Sciences Centre, Halifax) to ensure appropriate and timely monitoring of serogroups and for antibiotic susceptibility testing. consider requesting provincial laboratory to forward isolates to the Public Health Agency of Canadas National Microbiology Laboratory (NML) for further phenotypic typing and genetic analysis.
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, Borle-Grime I, et al. Meningococcal disease in Belgium. Secondary attack rate among household, day-care nursery and preelementary 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. Close contacts are defined as: household contacts of a case persons who share sleeping arrangements with the case persons who have direct contamination of their nose or mouth with the oral/nasal secretions of a case (e.g. kissing on the mouth, shared cigarettes, shared drinking bottles) health care workers who have had intensive unprotected contact (without wearing a mask) with infected patients (e.g. intubating, resuscitating or closely examining the oropharynx) children and staff in child care and nursery school facilities airline passengers sitting immediately on either side of the case (but not across the aisle) when the total time spent aboard the aircraft was at least 8 hours
Chemoprophylaxis for Close Contacts of IMD Cases DruDrug DODosage Comments Ciprofloxacin Adults >18 years of age: Contraindicated during pregnancy 500 mg x 1 dose PO and lactation Only approved for persons >18 years of age. Not recommended for prepubertal children. Rifampin Adults: Contraindicated in pregnancy. 600 mg PO q12h x 4 doses Urine and tears may be stained Children >1 month of age: red. Advise against wear of soft 10 mg/kg (max 600 mg) per contact lenses as they can also be dose PO q12h x 4 doses stained. Infants <1 month of age: Can reduce effectiveness of oral 5 mg/kg per dose PO q12h contraceptives. X 4 doses Advise use of alternative contraceptive measures. Ceftrixone Adults: Recommended drug for pregnant 250 mg IM x 1 dose women. Children <12 years: Alternative for persons who 125 mg IM x 1 dose cannot tolerate oral medication. Dilute in 1% lidocaine to reduce pain at injection site.
APPENDIX 2: SAMPLE LETTERS
APPENDIX 3: MENINGOCOCCAL DISEASE FACT SHEET

What is Meningococcal Disease?
Meningococcal disease is a bacterial infection that is spread by direct contact with secretions from the nose and mouth. The infection can be in the blood (meningococcemia) or in the lining of the brain and spinal cord (meningitis).
Who Can Get Meningococcal Disease

Anyone can get meningococcal disease. It is spread by direct contact with secretions from the nose and mouth through activities such as kissing, sharing food, drinks, water bottles, toothbrushes, eating utensils or cigarettes.

Symptoms may include: fever headache change in the level of alertness stiff neck small, purplish rash may develop on the upper body nausea vomiting

Meningococcal disease can be treated with antibiotics. Early diagnosis and treatment are important. If symptoms occur, contact your family doctor or visit the nearest emergency department to you immediately.
How Can Meningococcal Disease be prevented?

Reduce direct contact and exposure to discharges from nose and mouth (e.g. coughing, kissing, sharing utensils, drinking glasses, cigarettes, etc.)
Reduce overcrowding in living quarters and workplaces (e.g. barracks, dormitories, sleep away camps, ships, etc.) Immunize following the Nova Scotia Immunization Schedule Consult a travel health clinic if traveling to countries where meningococcal disease is endemic Follow hand hygiene practices using plain or antimicrobial soap with running water or an alcohol-based hand sanitizer
MRSA / VRE
1. Information
JANUARY 2007
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 (CAMRSA) 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).
What is the Difference between Being Colonized and Being Infected?

MRSA is a germ that lives on the skin and in the nose of about 25 per cent of us. This is called colonization, and occurs with other germs all over our bodies. It does not normally cause a problem. MRSA, however, can cause infections such as boils and abscesses. In the hospital, it can cause more serious infections in those patients who are already ill.
How do you get CA-MRSA?

Most MRSA infections happen to people in hospitals or nursing homes who have weak immune systems. MRSA can also cause infections in people who have not been in the hospital or a nursing home, and these infections are called community-associated MRSA (CA-MRSA). You can get this infection from: skin-to-skin contact with someone who has this infection. touching things (e.g., towels) or surfaces (e.g., benches) that have drainage or pus on them. openings in your skin, like cuts or scrapes. not washing your hands or not washing them well enough.

Most people with CA-MRSA have skin infections. Symptoms on the skin may include: a pimple or boil
redness or swelling pain pus or other drainage More serious infections can cause pneumonia or bloodstream infections.

Many of these infections can be treated by draining the abscess or boil and may not need antibiotics. Drainage should only be done by a health-care provider. Contact your doctor if the infection is not getting better after a few days following drainage. At that point, you may need to be treated with an antibiotic for a period of time. If you are given an antibiotic, take all of the doses, even if the infection is getting better, unless your doctor tells you to stop taking it. Do not share or save your antibiotics. If other people you know or live with get the same kind of infection, tell them to go to their doctor.
How can you Prevent CA-MRSA?

Practice good general hygiene (e.g., take regular baths or showers). Keep your hands clean by washing them often with soap and water. If there is no soap or water available, you can use an alcohol-based hand sanitizer. Keep cuts and scrapes clean and covered with a bandage or dressing until healed. Do not touch other peoples cuts or bandages. Do not share personal items such as towels, razors, creams, lotions, and soaps. Clean sports equipment that touches the skin with detergents/disinfectants (e.g., Lysol). Its very important that gym equipment be cleaned before and after each use. Make sure that your family and others in close contact with you wash their hands often with soap and water or use an alcohol-based hand sanitizer if theres no soap and water available.
PEDICULOSIS (LICE)
This is not an infectious disease. Lice are a nuisance.
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.
1.2 Causative agent

Three species of lice: Pediculosis humanus capitis (head louse), P. humanus corporis (body louse), and Pthirus pubis (pubic or crab louse).
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.

Avoid contact with the personal belongings such as hats, brushes etc. of individuals known to have lice or nits. Launder clothing, bedding and other personal belongings in hot water (55 degrees C or 131 degrees F for 20 minutes). Educate the public especially children about lending combs, brushes, hats and other personal belongings.
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
1.2 Causative agent

Streptococcus pneumoniae (pneumococcus). 23 of the most common types account for about 90% of infections.
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.

Avoid crowded living conditions wherever possible. Vaccinate high-risk populations with pneumococcal vaccine: People 65 years of age or older. Residents of nursing homes and homes for the aged. All persons, 2 years of age or older with chronic: Cardiac diseases Pulmonary diseases Asthma (only if associated with chronic bronchitis, emphysema or long term use of systemic corticosteroids) Diabetes and other metabolic disorders Renal diseases Liver diseases Sickle cell disease or sickle cell anaemia, splenectomy Immunosuppression (Hodgkins disease, lymphoma, organ transplantation, cancers)
Human Immunodeficiency Virus Alcoholism Routine revaccination is not recommended, however, revaccination should be considered for those of 2 years of age or older at highest risk of invasive infection, including those with functional or anatomic asplenia, or sickle-cell disease, debilitating cardio-respiratory disease, hepatic cirrhosis, chronic renal failure or nephrotic syndrome, HIV infection and other conditions associated with immunosuppression. A single revaccination is recommended after 5 years in those over 10 years of age and after 3 years in those younger than 10 years. Experience with revaccination is still limited and there are no data on the relative effectiveness of a second dose.
1.10 Prophlyaxis
None.
2.0 Procedure
No Public Health follow-up required. This disease is notifiable.

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 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.
Who Can Get Pneumococcal Disease?

Anyone can get Pneumococcal disease. However, some people are at greater risk from the disease. These include: People 65 years or older. Children less than 2 years old. People with problems such as alcoholism, heart or lung disease, kidney failure, diabetes, HIV infection or certain types of cancer. People who have had their spleen removed. People with sickle cell disease.

Symptoms may include: Fever Difficult or rapid breathing Cough that may produce rusty-coloured mucous If pneumococcal meningitis, symptoms may include: Fever Loss of appetite Stiff neck Severe headache Tiredness Vomiting
What is the Treatment

Drugs such as penicillin were once effective in treating these infections, but the disease has become more resistant to these drugs, making treatment more difficult. Your doctor will decide which antibiotic is best to treat the disease.
How Can You Prevent Pneumococcal Disease?

There is a vaccine to prevent most types of pneumococcal infections. People who are at greater risk from the disease (see above) should talk to their doctor or Public Health Services about getting the vaccine.
SCABIES
1. Information
1.1 Case definition
Identification of the itch mites eggs or scybaia (feces) from skin scrapings of unexcoriated lesions. Intensely pruritic papular eruptions and linear burrows on the finger webs, wrists, elbows, axillary folds, knee folds, belt line, thighs, navel, abdomen, genitals and buttocks, in adults. In infants, the head and neck as well as the palms and soles are often affected.
1.2 Causative agent

The mite Sarcoptes scabiei.
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.

Avoid skin-to-skin contact with those who are known to have or suspected of having scabies. Avoid sharing personal belongings of those who are known to have or are suspected of having scabies. Launder bedding and clothing of infected individuals and all those who are in close contact with the infected individual. Wash clothes in hot water or dry in hot drying cycle. For heavy blankets, jackets, etc., put in dryer on high for 15 minutes. Exclude from school or childcare anyone who has been diagnosed with scabies until 24 hours after treatment has been completed.
1.10 Prophylaxis
None.
2. Procedure
Refer to Partners for Infection Control manual for management in long term care facilities.

2.1.1 Investigator
Follow-up is optional. Follow up cases of scabies from either physicians or school with a phone call or visit if the individual needs education or help with treatment. a. Discuss treatment regimen with the individual, parent or guardian.
Permethrin containing products are recommended in the treatment of scabies. However, the family physician may have prescribed another medication. It is important to make sure that the treatment regimen is understood. Stress that the individual follow the instructions enclosed with the product. Discuss the need for lotion to be used only for 8-12 hour period and then washed off. Tell individuals to keep fingernails short and clean in order to minimize the risk of secondary infection from scratching. Educate about the need for laundering of bedclothes of infected individuals and other close contacts in the household. 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. c. Exclusion and return to work Tell the individual, parent or guardian that they or their children may return to work, childcare or school the day after treatment is completed.

Exclude infected individuals from work, school and childcare until 24 hours after treatment is completed.

Exclude until child has been treated.

Scabies outbreaks in chronic care facilities are not unusual. It may also be necessary to treat staff and their families when care involves skin-to-skin contact. Accurate diagnosis, timely treatment and supportive therapy of continuous outbreaks are recommended. Refer to the document Partners for Infection Control manual available from Public Health Services.
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
1.2 Causative agent

A wide variety of agents, many of which are associated with other diseases. Many viruses are capable of producing features of meningeal irritation. Half of all cases have no etiology demonstrated. In Canada, enteroviruses cause most cases of known etiology, particularly coxsackievirus and echovirus. In addition, arboviruses, measles, herpes simplex and varicella viruses, adenovirus and others are responsible for sporadic cases.
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.
Who Can Get Viral Meningitis?

Anyone can get viral meningitis. It can be caused by any of the common viruses such as the common cold, or chicken pox, mumps, etc.

Symptoms may include: Headache Nausea Vomiting Fever Stiff Neck Chills

There is no specific treatment but the symptoms may be treated.
How Can You Prevent Viral Meningitis?

Practice good hand washing. Cover your mouth when coughing or sneezing.
VECTORBORNE AND OTHER ZOONOTIC DISEASES

Anthrax Hantavirus Pulmonary Syndrome Lyme Disease Malaria Plague Q Fever Rabies Toxoplasmosis West Nile Virus
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

Bacillus anthracis is an aerobic, gram positive, encapsulated, spore forming, nonmotile rod that produces toxins.
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 Inhalation: Upper-respiratory flu-like syndrome that, after a few days, takes a fulminant course, manifested by dyspnea, cough, tachycardia, chills and a highgrade bacteremia
Gastrointestinal: Abdominal pain, nausea, vomiting, , bloody diarrhea, fever & signs of septicaemia
1.4. Incubation:
Inhalation: 2-60 days Cutaneous: 1-7 days Gastrointestinal: 1-7 days
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.
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:

Use general guidelines
Immediately or within a few hours of receipt of the report, the investigator should begin the investigation. Use general guidelines. Also use additional guidelines: a. Educating the individual. If the infection is cutaneous, educate the client on how to handle discharges or any dressings. 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:
2.1.4. Laboratory:
Use general guidelines

Individuals do not have to be excluded, as anthrax is not transmitted person to person.
2.3. Guidelines for Long Term Carriers

There is no carrier state.
2.4. Guidelines for Childcare Centres and Schools

Educate the staff if a case of anthrax occurs in a childcare centre or school.

ANTHRAX FACT SHEET

What is anthrax?
Anthrax is an infection caused by the bacterium Bacillus anthracis. The bacteria form spores that live in the soil for many years. The spores are extremely tiny and are invisible to the naked eye. In large quantities, the spores are usually brown and powdery and may look like cinnamon or cocoa. However, the colour may be different if the spores are mixed with another substance. They do not have an odour and you cannot smell them. The infection is spread by the spores. Anthrax usually occurs in farm animals such as cows and sheep. It is uncommon in humans.
Can anthrax spread from person-to-person?

No, anthrax cannot spread from one person to another.
What are the signs of anthrax?

Anthrax spores can affect the skin (cutaneous infection), the stomach (gastrointestinal infection) or the lungs (inhalational infection). 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.
Can anthrax be treated?

Anthrax can be treated with several common antibiotics. It is important that antibiotics be started right away. Only those recommended to receive antibiotics should take them. Antibiotics should not be taken just in case.
How do I get anthrax?

Usually, the people who get anthrax are those who work with infected animals. Spores from infected animal hides may get into broken skin and cause skin infections. Eating meat contaminated with spores can cause stomach infections. Breathing in a large quantity of spores can cause a lung 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
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 hantavirusspecific IgG OR Detection of hantavirus RNA in an appropriate clinical specimen OR Detection of hantavirus antigen by immunohistochemistry

Four hantavirus species have been implicated as causative agents for Hantavirus Pulmonary Syndrome (HPS) in North America. The largest proportion of HPS cases has been associated with the Sin Nombre virus.
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.
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.

Prevent rodent infestations (see fact sheet). Use precautions when cleaning up rodent droppings (see fact sheet).
1.10. Prophylaxis:
None.
2. Procedure
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.
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 recent activities, and travel and where the individual has been living. Explore whether there has been contact with rodents. Inquire about type of housing and any evidence of rodent infestation. Educate other household members on how to avoid contact with rodents.
2.1.3. Role of the Physician

2.1.4. Role of the Laboratory


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/ccdrrmtc/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.
Who Can Get Hantavirus Pulmonary Syndrome?

People who live in areas where the virus is present, and who come in close contact with rodent burrows, or are exposed to the saliva, urine or droppings of rodents, are at some risk of catching the virus, although the chances of this happening are extremely low.
How Is Hantavirus Pulmonary Syndrome Spread?

The virus is normally found only in rodents, especially Deer Mice, but also rats and other kinds of mice. People get HPS when they breathe in the virus that is found in the urine, saliva or droppings of infected rodents. Always wash your hands after touching any rodents or their droppings. 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.

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.

Most people require hospitalization and get intensive care. Some people may be given anti-viral drugs.
How Can You Protect Yourself?

For most people, the risk of catching HPS is very low. However, in areas where the virus is thought to be present, certain activities have been connected with HPS infection. These activities include: Cleaning vacant cabins, barns, and other outbuildings, especially if they are known to be infested with rodents. Trapping or handling rodents. Planting field crops. 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.
Getting Rid of Rats and Mice

What Harm Can Rodents Cause?
Rats and mice can pose a threat to property and health. They cause building damage by chewing on insulation, sidings, wallboard, etc. They will eat a wide variety of stored food. As well as leaving a mess in your cupboards, rodents will also often contaminate food. Rodents can also transmit disease.
Whats the Best Way to Get Rid of Rodents?

Rats and mice breed rapidly, so it is important not to let them get established on your property. The best way to get rid of rodents is by using traps. Buy snap traps and bait with dried fruit or peanut butter mixed with oats or cheese. Be sure that the bait is securely attached to the trap pedal, otherwise the trap may not spring when the food is removed. Set the traps at right angles to the walls where the rodents are known to travel, with the bait side of the trap toward the wall. Wear gloves when disposing of the body of the trapped animal. They should be wrapped in plastic and placed in the garbage.
What If I Really Need Help?

If you have problems, either due to the severity of the infestation or because your rodents prove too clever to catch, then you should hire a pest control company (see the Yellow Pages).
LYME DISEASE
1. Information
Confirmed case
JULY 2010 DRAFT
Clinical evidence of illness with laboratory confirmation: isolation of Borrelia burgdorferi from an appropriate clinical specimen OR detection of B. burgdorferi DNA by PCR OR Clinical evidence of illness with 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
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 * An endemic area is a locality where a reproducing population of I. scapularis or I. pacificus ticks is known to exist and the transmission of B. burgdorferi is supported, as demonstrated by molecular methods

A spirochete, Borrelia burgdorferi (B Burgdorferi).
1.3. Symptoms:
The clinical information presented below is not intended to describe the complete range of signs and symptoms that may be used in a clinical diagnosis of Lyme disease. Symptoms of early or late disseminated Lyme disease are described in the 2006 clinical practice guidelines of the Infectious Diseases Society of America. Other symptoms that are, or have been suggested to be, associated with Lyme disease (including those of so-called "chronic" Lyme disease and post Lyme disease syndromes) are considered too non-specific to define cases for surveillance purposes, whether or not they may be caused by B. burgdorferi infection.
Early Lyme disease:

With or without EM other symptoms may include fever, malaise, headache, fatigue, stiff neck, and myalgia and arthralgias. Erythema migrans: a round or oval expanding erythematous area of the skin greater than 5 cm in diameter and enlarging slowly over a period of several days to weeks. It appears one to two weeks (range 3-30 days) after infection and persists for up to eight weeks. Some lesions are homogeneously erythematous, whereas others have prominent central clearing or a distinctive targetlike appearance. On the lower extremities, the lesion may be partially purpuric. Signs of acute or chronic inflammation are not prominent. There is usually little pain, itching, swelling, scaling, exudation or crusting, erosion or ulceration, except that some inflammation associated with the tick bite itself may be present at the very centre of the lesion. 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: Dermatological In early disseminated disease, approximately 15% of patients may present with multiple erythema migrans. It can occur several weeks after a tick bite and consists of secdary annular, reflect spirochetemia with cutaneous dissemination. Early neurological Lyme disease: acute peripheral nervous system involvement, including radiculopathy, cranial neuropathy and mononeuropathy multiplex (multifocal involvement of anatomically unrelated nerves), and CNS involvement, including l lymphocytic meningitis and, rarely, encephalomyelitis (parenchymal inflammation of brain and/ or spinal cord with focal abnormalities). Late neurologic Lyme disease may present as encephalomyelitis, peripheral neuropathy or encephalopathy. Lyme arthritis is a monoarticular or oligoarticular form of arthritis most commonly involving the knee, but other large joints or the tempero-mandibular joint may be involved. Large effusions that are out of proportion to the pain are typical. Lyme arthritis is often intermittent if untreated, with episodes of joint inflammation spontaneously resolving after a few weeks to a few months. Persistent swelling of the same joint for 12 months or more is not a usual presentation. Cardiac involvement associated with Lyme disease includes intermittent atrioventricular heart block often involving the atrioventricular node (although heart block may occur at multiple levels) and sometimes associated with myopericarditis. Carditis can occur in the early stages of the disease
Neurological
Musculoskeletal
Cardiac
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). Relapsed or refractory Lyme arthritis and cardiac Lyme may require IV antibiotics. An infectious diseases specialist should be consulted to assist in the management of disseminated or late Lyme disease. Routine use of prophylactic antimicrobials following a tick bite is not recommended.
1.9 Core Prevention Messages:

Protecting yourself from ticks: 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, your children and pets after walking in grassy or wooded area, particularly where Blacklegged ticks have become endemic. Check clothing and inspect skin including arm pits, groin and scalp. Remove ticks as soon as you find them. Carefully grasp the tick with tweezers as close to the skin as possible and slowly pull the tick straight out. Clean the area where the tick was attached to the skin. See a physician if symptoms of Lyme disease develop after exposure to the Blacklegged tick. Use simple landscaping techniques (available on the DHW website) to reduce the number of Blacklegged ticks around your home. Please see the Department of Health of Wellness (DHW) website for more information at: www.gov.ns.ca/hpp/cdpc/lyme.asp
2.0 Public Health Management and Control Measures____

2.1. Case
Follow-up cases as soon as possible and take the following steps: 1. Contact the physician to obtain clinical information on the case. 2. Review clinical information, mode of transmission, exploring in particular tick exposures, travel, areas of work and recreational activity, donation or receipt of blood products, tissue/organs. 3. Educate the client and/or family about Lyme disease and prevention measures, providing access to fact sheets, brochures, website, as indicated. 4. Document information on Lyme disease case report form.
2.2. Contact Tracing

No contact tracing is required.
2.3. Outbreak Management

N/A
2.4. Tick Guidelines

See NS Tick Borne Diseases Response Plan for information regarding tick surveillance and affiliate agency roles and responsibilities (see Appendix 6).
2.5. Laboratory Procedures

Serum specimens submitted for Lyme are tested in Nova Scotia using an enzyme immunoassay (EIA). Positive specimens will be forwarded to the National Microbiology lab for further confirmation. Recommended testing includes a 2 tier approach involving an approved screening enzyme immunoassay (EIA) and more specific confirmatory testing by Western Blot. NS employs testing recommended by the Canadian National Microbiology Laboratory in Winnipeg, the Canadian Public Health Laboratory Network (CPHLN) and the U.S. Centres for Disease Control. Other UNVALIDATED, unapproved tests may be unreliable and are NOT recommended. 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 postinfection. 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. Important caveats to Lyme testing: a) In the absence of objective clinical signs, the value of serologic testing is limited. The diagnosis should NOT be based on positive serologic tests in the absence of -objective findings and a credible epidemiologic link. b) IgM may be falsely negative if the serum is collected within the first two weeks of infection. Thus there is no point in testing at the time the tick is identified/removed before symptoms begin. Follow up serum will be required. c) Patients that are treated early for Lyme disease may have delayed seroconversion or never seroconvert (develop a positive IgG Western blot). d) Patients who have had symptoms for greater than 4 weeks should have a positive IgG Western Blot. If the patient's symptoms have been present for greater than 4 weeks, a negative Lyme IgG Western Blot suggests the symptoms the patient is experiencing are not due to Lyme disease. e) Testing cannot be used to determine "cure". f) Diagnosis of repeat infection is often difficult as IgM Western blots can remain positive for years despite appropriate treatment. Suspected repeat infections requiring serology should be discussed with a medical microbiologist. g) The Borrelia species that cause Lyme disease in Europe can be different that those in North America. Confirmation testing may require the use of a Western blot specific for those species. If the history suggests exposure in Europe, this should be documented on the requisition so that appropriate types of confirmatory testing can be done. h) EM in Lyme season (a period when ticks are active, usually above 4 degrees Celsius) with a documented tick exposure from an endemic area (the prevalence of B. Burgdorferi infection in the Ixodes ticks should exceed 20% should be considered an indication for antibiotic treatment and does not warrant serologic testing. i) EM like rash out of season (regardless of exposure in an endemic area or not) should have antibody testing. If serology is negative, repeat in 4 weeks.
For further information on laboratory methods please refer to the Provincial Public Health Lab Network: Users Manual. 2009

4.0 Communications Guidelines

4.1 Strategies:
DHW Lyme disease pamphlet DHW Lyme disease poster (general awareness) DHW Lyme disease poster (Blacklegged tick endemic areas) Annual letter to NS physicians regarding awareness of Lyme disease (included in a general Zoonosis letter) DHW links with Doctors NS to provide website information Media articles and press releases as necessary DHW website regular updates Others as appropriate Public Health in DHAs work with communities where endemic Blacklegged ticks have been identified (residential letters, school letters, etc.) Templates are included in Appendices 3, 4 and 5
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). Communication strategies can be implemented at any time as necessary with an emphasis on the early spring/summer season when vector become more active up to and including the fall (usually until there is consistent frost). Additional messaging can be implemented as needed depending upon climate, season, activity of vectors, or other.
4.2 Key Messages:

Self protection (use of protective clothing, DEET, tick checks on skin Symptoms of Lyme disease Know areas of endemic Blacklegged tick populations Landscaping techniques to reduce Blacklegged tick populations Importance of submitting ticks for identification Lyme disease is not fatal
5.0 Tick Surveillance

See the NS Tick Borne Diseases Response Plan (Appendix 6)
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.

Symptoms may include: Rash (may look like a bulls eye target) may appear three to thirty days after tick extended contact with a tick ie. attached for over twenty-four hours. Rash occurs in 70-80% of infected people. Fever, chills Headache Tiredness, fatigue Stiff neck or soreness all over Pain or swelling in the joints Swollen lymph nodes

Early antibiotic treatment prescribed by your doctor is the best way to prevent serious illness. If not treated early, the infection could progress and cause chronic arthritis, cardiac abnormalities, etc.
How Can You Prevent Lyme Disease?

Avoid tick-infested areas when possible. Walk on well-travelled paths. Avoid areas with high grass. Wear light-coloured, long pants and long sleeved shirt in tick infested areas and tuck pants into socks. Cover arms, legs and other exposed areas of the body Wear shoes that cover your entire foot Check frequently for ticks on the skin, especially children Use insect repellent containing DEET when in tick infested areas Remove ticks from skin as soon as possible See a doctor is symptoms of Lyme disease are noted Use landscaping techniques to reduce the number of ticks around yards Check out the Department of Health and Wellness website at: http://www.gov.ns.ca/hpp/cdpc/lyme.asp Check out the Public Health Agency of Canada website at: http://www.phac-aspc.gc.ca/id-mi/lyme-eng.php
LYME DISEASE FACT SHEET (FRENCH)

Fiche de renseignements sur la maladie de Lyme Qu'est-ce que la maladie de Lyme?
La maladie de Lyme est une infection bactrienne transmise par une certaine espce de tique appele tique pattes noires, parfois appele tique du chevreuil. La tique, que lon aperoit surtout pendant les mois dt, est un petit insecte qui colle la peau des animaux, y compris les humains, pour sucer leur sang. La tique est brune ou noire et peut tre aussi petite que le point la fin de cette phrase. Avant quelle se nourrisse, elle peut mesurer de trois cinq millimtres. La bactrie qui cause la maladie de Lyme peut tre porte par des souris, des cureuils, des oiseaux et dautres petits animaux. Elle peut tre transmise aux humains quand des tiques se nourrissent du sang danimaux infects, deviennent elles-mmes infectes, puis mordent un humain. Le risque dattraper la maladie de Lyme est habituellement faible. Une tique met 24 heures transmettre la maladie. Enlever la tique peut aider prvenir la propagation de la maladie de Lyme dans le corps. Utilisez une pince piler ou vos doigts pour prendre le corps de la tique et lenlever dlicatement. Aprs avoir enlev la tique, lavez bien lendroit de la morsure et vos mains.

Les symptmes peuvent comprendre : une ruption cutane qui peut ressembler une cible et qui peut apparatre de trois trente jours aprs un contact prolong avec la tique (cest--dire si la tique est reste attache pendant plus de 24 heures). De 70 80 % des personnes infectes ont une ruption cutane. de la fivre et des frissons; des maux de tte; de la fatigue; une raideur dans le cou ou des douleurs gnralises; des douleurs ou un gonflement des articulations; une enflure des ganglions lymphatiques.

Un traitement antibiotique prcoce prescrit par votre mdecin est la meilleure faon de prvenir une maladie grave. Si linfection nest pas traite immdiatement, elle pourrait progresser et causer larthrite chronique, des anomalies cardiaques, etc.
Comment pouvez-vous prvenir la maladie de Lyme?

vitez, dans la mesure du possible, les endroits infests de tiques. Empruntez des sentiers bien frquents. vitez les endroits recouverts de hautes herbes. Dans des endroits infests de tiques, portez des pantalons de couleur ple avec les jambes rentres dans vos chaussettes et une chemise manches longues. Couvrez vos bras, vos jambes et dautres parties exposes de votre corps. Portez des chaussures qui couvrent votre pied en entier. Examinez souvent la peau la recherch de tiques, surtout la peau des enfants. Utilisez un insectifuge qui contient du DEET quand vous tes dans des endroits infests de tiques. Enlevez les tiques de la peau aussitt que possible. Consultez votre mdecin si des symptmes de la maladie de Lyme se manifestent. Utilisez des techniques damnagement paysager pour rduire le nombre de tiques dans votre jardin. Visitez le site Web de Promotion et Protection de la sant : http://www.gov.ns.ca/hpp/cdpc/lyme.asp. Visitez le site Web de lAgence de la sant publique du Canada : http://www.phac-aspc.gc.ca/id-mi/lyme-fra.php.
APPENDIX 3: LETTER FOR USE IN SCHOOLS (ENGLISH)

Re: Blacklegged ticks and Lyme disease Dear Parent, Guardian, Student: 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 Admirals 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). Lyme disease can be prevented by: applying insect repellents containing DEET to exposed skin and clothing wearing long sleeved shirts and pants, closed shoes and tucking pant legs into socks checking skin and scalp for attached ticks is important since blacklegged ticks have to stay attached for at least 24 hours to cause infection with Lyme disease stay in the middle of paths away from grass and shrubs 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 pattes noires et la maladie de Lyme Aux parents, tuteurs, lves, mesure que la temprature augmente et que les jours rallongent, nous sommes plus enclins participer des activits de plein air. En ce temps de lanne, il est important de se protger dans les endroits o il pourrait y avoir beaucoup de tiques pattes noires. Les tiques peuvent tres porteuses du germe qui cause la maladie de Lyme. Ces endroits comprennent le parc Admiral's Cove Bedford, la campagne dans la rgion de Lunenburg et la rgion de Gunning Cove, dans le comt de Shelburne (de Churchover Roseway). Il est possible de prvenir la maladie de Lyme : en appliquant un insectifuge contenant du DEET sur la peau expose et les vtements; en portant des pantalons, des manches longues et des souliers ferms et en rentrant vos jambes de pantalon dans vos chaussettes; en examinant la peau et le cuir chevelu pour voir s'il y a des tiques puisque les tiques pattes noires doivent rester attaches la peau pendant au moins 24 heures pour causer la maladie de Lyme; en restant au milieu des sentiers et loin des herbes et des buissons. Ces prcautions sont recommandes si vous ou les membres de votre famille passez du temps dans les broussailles ou les forts des rgions ci-dessus. Pour obtenir plus d'information, consultez le dpliant et le site Web du ministre de la Promotion et de la Protection de la sant de la Nouvelle-cosse (http://www.gov.ns.ca/hpp/cdpc/lyme.asp) ou le bureau des Services de la sant publique de votre rgion.
APPENDIX 5: LETTER FOR USE WITH RESIDENTS OF BLT AREAS

Dear Resident: Public Health Services would like to remind you that Blacklegged (deer) ticks are established / endemic (consistently found) in the area around Admirals 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 A REMINDER FROM PUBLIC HEALTH SERVICES... LYME DISEASE SEASON IS NOT OVER!!
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. More information can be found at www.gov.ns.ca/hpp/cdpc/lyme.asp or contact Public Health Services to speak with a Public Health Nurse.
ENJOY THE OUTDOORS SAFELY!!
APPENDIX 6:
Nova Scotia Tick Borne Diseases Response Plan

1.0 INTRODUCTION
The NS Tick Borne Diseases Response Plan was developed in order to respond to evidence that Lyme disease (Ld) and its vector, Ixodes scapularis or Blacklegged ticks (BLTs) are present in the province. BLTs have been confirmed to be established/endemic in 3 areas of the province. Isolated BLTs that have tested positive for Borrelia Burgdorferi (bacteria that can cause Lyme disease) have been found in many other areas of Nova Scotia. Lyme disease is caused by infection with the spirochete Borrelia burgdorferi (Bb). 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. An interagency, interdisciplinary group, the Nova Scotia Vector Borne Diseases Working Group (NSVBDWG), was set up and is chaired by Department of Health and Wellness (DHW). The Working Group developed, maintains and implements the plan with support from Department of Health and Wellness and other partners. The key components of the plan include: Surveillance for human tick borne illnesses Surveillance of distribution and infection of vectors for tick borne diseases Prevention and control of human infection of tick borne diseases Communication to public, media and health care professionals
2.0 GOALS AND OBJECTIVES OF PLAN

Goal: To monitor and reduce the risk of infection with tick borne diseases (Lyme disease, Human Granulocytic Anaplasmosis and other tick borne diseases) in Nova Scotia. 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 (HCPs) about where, in NS, the risk for being infected with a tick borne disease is increased. To increase awareness of the public and HCPs about typical symptoms and signs of tick borne diseases. To provide information to the public and HCPs 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 BLTs 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. BLTs 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 BLTs 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 BLTs to humans usually occurs after the infected nymphal, larval or adult BLT has been attached for 24 hours or more.
3.1 Lyme Disease Clinical Picture

The symptoms are manifested in stages: early localized, early disseminated and late disease.
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. People with underlying immuno-suppression are at a greater risk of severe disease. Antibiotic therapy can reduce the risk for developing serious illness or death. 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 BLTs submitted by the public, veterinarians and health care professionals has sporadically shown the presence of isolated BLTs that test positive for tick borne diseases, in several locations in the province. However, it does not appear that BLTs 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, Admirals Cove area in Bedford, and Gunning Cove in Shelburne county. BLTs 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 BLTs. 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 BLTs 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.
4.0 KEY ELEMENTS OF TICK BORNE DISEASES RESPONSE PLAN 4.1 Nova Scotia Vector Borne Diseases Working Group
The Nova Scotia Vector Borne Diseases working group was established in 2010 but originated from the Tick Borne Diseases working group which initiated in 2002. The group consists of experts in vectors and human health related to vector borne diseases. The group works together to ensure a consistent and coordinated approach to protecting Nova Scotians from vector borne diseases, including those transmitted by ticks. This group of experts is responsible for developing and implementing this Tick Borne Diseases Response Plan and for the ongoing assessment of risk to Nova Scotians. Members represented on the working group have different roles and responsibilities. The working group meets regularly to monitor all activities related to the response plan.
4.2 Human Surveillance

Objectives:
To assess the incidence of infection of humans with tick borne disease in NS.
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.
4.3 Vector/Other surveillance

PASSIVE SURVEILLANCE Objectives:
To monitor geographic location and spread of black legged ticks (BLTs) in NS over time. To identify the percentage of BLTs 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 BLTs and Ld are established.
Dragging for Blacklegged ticks (a process to collect BLTs) to assess the presence of various life stages of BLTs 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 BLTs Lyme or Ap may be prevalent. Suspicion about establishment may be based on clusters of BLTs submitted as part of the passive surveillance system, the reporting of confirmed human cases in an area, surveillance for BLTs 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 BLTs are tested for, Borrelia burgdorferi, Ap and Babesia microti at the NML in Winnipeg. BLTs are determined to be established/endemic in an area when all three feeding stages of the tick (larva, nymph, adult) are present on resident animals or in the environment for at least two consecutive years.
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 BLTs. Samples of deer killed by hunters have been inspected in the Lunenburg area for the presence of BLTs. 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.
4.4 Public Awareness and Education Campaign

Actions taken by the general public play an important role in preventing human cases of Lyme disease, HGA and other vector borne diseases. The public is provided information on Lyme disease and other vector borne diseases including risks, symptoms and how to prevent the spread of tick borne and vector borne diseases. Key messages include: 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 BLTs 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 BLTs 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. The Department of Health and Wellness website is continually updated to include information on Lyme disease. The public can receive further information from their local Public Health Services. Press releases and media interviews will keep the public updated during the spring, summer and fall months as needed.
4.5 Information for Health Professionals

Physicians and health care providers are informed that human cases of specific vector borne diseases are reportable in Nova Scotia under the Health Protection Act. In addition, physicians and other health professionals are provided with information on the risk assessment for Lyme disease (and other vector borne diseases as needed) and the need to contact public health services when suspecting human cases. This is done through letters, newsletter articles, webinars and videoconferences. Please refer to section 8.0.
4.6 Diagnostic Testing for Human Illness

Testing in humans for Lyme disease is performed at the Queen Elizabeth Health Sciences Centre in Halifax. Positive specimens will be forwarded to the National Microbiology laboratory (NML) for further confirmation. Recommended testing for Lyme disease includes a 2 tier approach involving an approved screening enzyme immunoassay (EIA) and more specific confirmatory testing by Western Blot. NS employs testing recommended by the Canadian National Microbiology Laboratory in Winnipeg, the Canadian Public Health Laboratory Network (CPHLN) and the U.S. Centers for Disease Control. Other UNVALIDATED, unapproved tests may be unreliable and are NOT recommended. Specimens submitted for Anaplasmosis diagnostic testing are sent directly to the NML.
For further information on testing please refer to the Nova Scotia Communicable Disease Prevention and Control Manual Chapter 9 Lyme Disease http://www.gov.ns.ca/hpp/publications/cdc_section_9.pdf
For further information on laboratory please refer to the Provincial Public Health Lab Network: Users Manual. - 2009
4.7 Vector Control Measures

There are various landscaping techniques that can be recommended to reduce the number of ticks around homes. References for landscaping techniques can be found on the DHW website at: http://www.gov.ns.ca/hpp/cdpc/lyme.asp Currently there are no approved acaracides available in Canada to use to reduce Blacklegged ticks. The Public Health Agency is working in conjunction with the Pest Management Regulatory Agency of Canada to establish regulation for use of acaracides used in reduction of Blacklegged ticks in Canada.
5.0 ROLES AND RESONSIBILITIES OF ORGANIZATIONS AND AGENCIES RELATED TO TICK BORNE DISEASES 5.1 Department of Health and Wellness
Conducts surveillance for human infection with Ld. Provides program response to public health case management of humans with tick borne diseases. Assesses risk of tick and vector borne diseases to the health of Nova Scotians. Recommends interventions based on health risk assessment in consultation with other NS government departments, Vector Borne Diseases Working Group, and PHAC. Provides support to those involved in the provincial response plan. Provides communication support for provincial vector borne diseases prevention initiatives, media, news releases, issue management, print materials and others as required. Assesses environmental health issues as related to control of vectors Coordinates and chairs the NS Vector borne Diseases Working Group.
Receives the data from DNR and NML regarding Blacklegged tick passive surveillance in NS and disseminates the results to Public Health Services in each District Health Authority. In conjunction with PHAC, reviews and analyzes Blacklegged passive tick surveillance data and recommend active surveillance initiatives.
5.2 Nova Scotia Department of Natural Resources (DNR)

Conducts active tick surveillance in collaboration with PHAC as required. Conducts surveillance for ticks from road and hunter killed deer as required. Receives ticks submitted by the public, health care workers and veterinarians and identifies species. Forwards BLTs to the National Microbiology Laboratory (NML) in Winnipeg for testing for infection with Bb and Ap. Sends BLT data (those ticks sent to the NML for testing) to DHW. Works in collaboration with DHW and NML to analyze tick data.
5.3 Public Health Agency of Canada/National Microbiology Laboratory

Conducts active tick surveillance in collaboration with DNR as required. Tests BLTs and other ticks submitted from DNR and Museum of Natural History for Borrelia burgdorferi, Anaplasma phagocytophilium and Babesiosis. In conjunction with DHW, reviews and analyzes Blacklegged passive tick surveillance data and recommends active surveillance initiatives. Provides laboratory confirmation testing of human EIA positive or indeterminate samples sent from QEII laboratory. Provides Anaplasmosis testing on human samples. Sends reports on human diagnostics to QEII lab (QEII lab sends final results to appropriate provincial health professionals). Provides direction on standards for laboratory testing of suspect Ld cases. Coordinates and chairs the National Non Enteric Zoonosis Issue Group and Tick Borne Diseases Sub Issue Group.
5.4 Public Health Services

Investigates all reported probable and confirmed cases of Lyme disease and Anaplasmosis (as per the National case definitions) and submits reports to DHW. Determines area where infection most likely occurred. Educates about vector borne diseases and measures to prevent disease. Provides advice to the public and health care professionals regarding tick borne diseases. Establishes links with local communities where established/endemic Blacklegged tick populations occur and work with communities to promote awareness to decrease the risk of vector borne diseases. Provides communication support for local public health Lyme disease and other tick borne diseases prevention initiatives, media, news releases, issue management, print materials and others as required. Provides information to individuals who submitted ticks for ticks that test positive for a tick borne disease or those that are negative from human exposures, as soon as possible once the tick surveillance data is received (can be weeks to months after tick was first submitted to DNR).
5.5 Nova Scotia Museum of Natural History

Receives ticks submitted by public, health care workers and veterinarians. Forwards BLTs to DNR for shipment to the National Microbiology Lab for testing for tick borne diseases.
5.6 Nova Scotia Department of Agriculture

Provides link to veterinarian community. Works with NML in following up reports of dogs infected with Ld. Provides education information to veterinarians.
5.7 First Nations and Inuit Health (FNIH)

Provides link to First Nations communities.
5.8 QEII Health Sciences Centre

Provides expertise in human infectious diseases and link to infectious diseases specialist group. Provides timely and appropriate human diagnostic laboratory services for Lyme disease.
Works in collaboration with the National Microbiology Lab (NML) for human diagnostic testing and reports results from the NML to appropriate District Health Authority. Reports all confirmed positive tests to the MOH in the District Health Authority where the physician who orders the test, works. Responds to questions from physicians and public health staff on laboratory diagnosis issues.
5.9 Nova Scotia Department of Environment

Provides recommendations and advice on the use of tick control measures
6.0 RISK ASSESSMENT

The NSVBDWG and DHW support surveillance for BLTs and the presence of Borrelia burgdorferi (Lyme), Ap and Babesiosis in ticks throughout the province. The distribution and prevalence of the tick vectors and the agents that cause Ld, HGA and Babesiosis are monitored by the surveillance system. While BLTs 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 BLTs 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. BLTs have been found to be established/endemic in the general area around Lunenburg, and Gunning Cove in Shelburne County. Additionally, BLTs have become established/endemic in the vicinity of Admirals Cove in Bedford. BLTs 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 BLTs, 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: Maintain a surveillance system for vectors (Blacklegged ticks), mammals and human illness to detect the level of activity in NS. Educate the public on measures to reduce exposure to Blacklegged ticks Reduce BLT habitat in and around homes by recommending key landscaping techniques. Educate health care professionals and veterinarians to be aware and recognize symptoms of tick borne diseases. Consider Blacklegged tick control measures as regulated within NS and Canada, as necessary.
8.0 COMMUNICATION STRATEGY

Objectives
To raise awareness of Lyme disease within Nova Scotia. Provide Nova Scotians with consistent, up to date and reliable information about tick borne diseases including Lyme disease. Ensure health care providers and the public have access to information regarding Lyme disease. Counter misinformation provided in media reports on Lyme disease and other tick borne diseases as required. Emphasize the importance of individual responsibility in preventing the spread of tick borne diseases such as Lyme disease.
Target Audiences
General public Media Health care professionals Municipalities Tourists/Outdoor recreationalists
DHW provides information and resources about the presence of Ld in NS as well as recommendations to prevent exposure to BLTs and infection with Ld and Ap
to the public, media and health care workers. The tools used to provide information include: DHW Ld pamphlet DHW Ld poster (intended for areas where BLTs 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.). Communication strategies can be implemented at any time as necessary with an emphasis on the early spring/summer season when vectors become more active. Additional messaging can be implemented as needed depending upon climate, season and activity of vectors. The key messages provided include: Information about where BLTs and Ld are known or suspected to be established/endemic. Common symptoms and signs of Ld and importance of obtaining medical advice. Inspection of people for attached BLTs and advice about prompt removal (infection is unlikely if BLT attached for < 24 hours). Use of protective clothing and insect repellants. Maintenance of property to reduce BLT infestation. Recommendation to submit ticks for identification and testing. Local meeting with District Health Authorities (Public health services) and communities as required.
Information provided on DHW vector borne disease website: General information about tick borne diseases and their prevention. Updated information on the location of areas where tick borne diseases are established/endemic in Nova Scotia. Updated information on the prevalence, distribution and risk of exposure to tickborne disease in areas where BLTs are established/endemic.
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. 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.
MALARIA
1. Information
Confirmed case
Laboratory confirmation of infection with or without clinical evidence of infection: demonstration of Plasmodium sp. in a blood smear/film (thick and thin)
Probable case
Laboratory confirmation of infection with or without clinical evidence of infection: detection of Plasmodium sp. antigen in an appropriate clinical specimen

Plasmodium vivax, P. malariae, P. falciparum and P. ovale, sporozoan parasites.
1.3. Symptoms:
There are four human malarias that present similar symptoms, making laboratory differentiation necessary. Falciparum malaria symptoms include fever, chills, sweats, diarrhea, respiratory distress and headache, and other non specific symptoms and may progress to splenomegaly, anemia, thrombocytopenia. Acute encephalopathy, severe anemia, icterus, renal failure, hypoglycemia, respiratory distress, lactic acidosis and more rarely, coagulation defects and shock may develop if not treated early. Severe malaria is a possible cause of coma and other CNS symtpoms in any partially immune or non-immune person recently returned from an endemic tropical area. 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.
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.

Reduce the risk of mosquito bites when travelling in a malarious area (see specific suggestions on attached fact sheet).
Discuss prophylaxis with a travel clinic before travelling to malarious areas. Discuss with a travel clinic the necessity for stand-by treatment if travelling to a malarious area where competent medical attention is more than 12 hours away. Individuals who have had malaria should consult Canadian Blood Service if they wish to donate blood.
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 antimalarial 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
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/ccdrrmtc/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.
Who Can Get Malaria?

Travelers to over 100 countries and territories may get malaria if bitten by a malariainfected mosquito. More than 40% of the people in the world are at risk. Large areas of Central and South America, Hispaniola (Haiti and the Dominican Republic), Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania are considered malaria-risk areas (an area of the world that has malaria).

The symptoms of malaria may include: Fever. Chills. Headache. Muscle aches. Tiredness. Nausea, vomiting, and diarrhea may also occur. Kidney failure, seizures, mental confusion, coma.

Malaria can be treated with prescription drugs. The type of drugs and length of treatment will vary depending on the type of malaria and other factors.
How Can You Prevent Malaria?

Visit your health care provider or Travel Clinic 4-6 weeks before foreign travel for advice on required anti-malarial drugs and mosquito protection. Take your antimalarial drug exactly on schedule without missing doses.
Prevent mosquito and other insect bites. Use DEET insect repellent on exposed skin. Spray for flying insects where you sleep. Use 10% or less concentration of DEET for children. Wear light coloured long pants and long-sleeved shirts, especially from dusk to dawn. This is the time when mosquitoes that spread malaria bite. Sleep under a mosquito bed net that has been impregnated with permethrin insecticide if you are not living in screened or air-conditioned housing. Avoid wearing scented products.
PLAGUE
1. Information
Confirmed case
Clinical evidence of illness with laboratory confirmation of infection: isolation of Yersinia pestis from body fluids OR a significant (i.e. fourfold or greater) rise in serum antibody titre to Y. pestis fraction 1 (F1) antigen by EIA or passive emagglutination/inhibition titre
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

Yersinia pestis, a bacillus.
1.3. Symptoms:
Characterized by fever, chills, headache, malaise, prostration, and is manifest in one or more of the following 3 principal forms: Bubonic plague: Regional lymphadenitis Septicemic plague: Less common and results in hypotension, acute respiratory distress and disseminated intravascular coagulation. Septicemia with or without an evident bubo Primary pneumonic plague: inhalation of infectious droplets Secondary pneumonic plague: Pneumonia, resulting from hematogenous spread in bubonic or septicemic cases Pharyngeal plague: Less common and involves cough, fever, dyspnea and hemoptysis, pharyngitis and cervical lymphadenitis resulting from exposure to larger infectious droplets or ingestion of infected tissues
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.
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).

If you live in areas where rodent plague occurs, homes should be rodentproof. 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
a. Determine investigative responsibility. Ensure that reports of plague are received and disseminated to the appropriate personnel for investigation within Public Health Services. b. Approve Public Health control measures. When required, approve control measures.
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/ccdrrmtc/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.
Who Can Get Plague?

Bubonic plague is spread when the fleas of infected rodents bite humans. Respiratory droplets from infected humans or cats spread pneumonic plague. People who handle infected tissues or fluids from infected animals are at increased risk of getting plague (e.g. veterinarians, researchers).

Symptoms may include: Fever, chills, headache. Weakness. People with bubonic plague may have swollen tender lymph nodes. People with pneumonic plague may have a cough, fever, and difficulty breathing.

Antibiotics prescribed by a doctor can treat plague. Treatment is most successful if it is started as early as possible.
How Can You Prevent Plague?

If you live in an area where plague occurs: 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. Make your home rodent-proof. 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.
Treat pet dogs and cats for flea control regularly and do not allow these animals to roam freely. To avoid potential risk of exposure: Safely clean up rodent-infested areas. Air out infested spaces before cleanup. Spray areas of infestation and all excreta, nesting, and other materials with household disinfectant or 10% bleach solution then clean up, seal in bags, and dispose. Avoid sweeping, vacuuming, or stirring dust until the area is thoroughly wet with disinfectant. Wear rubber gloves; disinfect gloves before removal, and wash hands afterwards.
Q FEVER
1. Information
Demonstration of a rise in specific serum antibodies between acute and convalescent stages or recovery of the infectious agent.

Coxiella burnetti, a bacterium.
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.
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.

Appropriately dispose of placenta, birth products, fetal membranes, and aborted fetuses from animals. Restrict access to barns and laboratories used in housing potentially infected animals. Use only pasteurized milk and milk products.
1.10. Prophylaxis:
None.
2. Procedure
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.
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/ccdrrmtc/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.
Who Can Get Q Fever?

People most at risk for getting Q fever include veterinarians, meat processing plant workers, sheep and dairy workers, livestock farmers, and researchers at facilities housing sheep.

Symptoms may include: Fever. Chills. Headache. Weakness. Weight loss Sweats.

Q fever can be treated by antibiotics.
How Can You Prevent Q Fever?

Use only pasteurized milk and milk products. Carefully dispose of placentas, birthing fluids and aborted fetuses.
RABIES
1. Information
Confirmed case
AUGUST 2010
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

Rabies virus, a rhabdovirus of the genus Lyssavirus.
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.
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.
1.9. Core Messages for Prevention

Individuals in high-risk groups including, veterinarians, lab workers, wild life workers and conservationists, hikers or cave explorers and individuals traveling to areas where rabies is endemic should be immunized pre exposure. 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.
1.10 Prophylaxis
1.10.1 Post-exposure prophylaxis a. Categories of exposure.
Two broad categories of exposure are recognized as warranting postexposure prophylaxis
Bite:
A bite includes any penetration of skin by teeth. Bites inflicted by most animals are readily apparent. Post exposure prophylaxis should be initiated in situations where 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. Direct contact is defined as the bat touching or landing on a person (NACI, November 2009). 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.
b. Post-exposure prophylaxis for persons not previously immunized against rabies.

Post-exposure prophylaxis should be started as soon as possible after the exposure and may be started as late as six or more months after exposure. 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. Four additional doses of HDCV are administered IM on each of days 3, 7, 14 and 28 after the first dose. 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). For further information on administration of Rabies immune globulin and/or Rabies vaccine please review the Canadian Immunization Guide (CIG), the CIG Errata and the Product Monographs.
2. Public Health Management and Control Measures

2.1. Case
Follow up cases as soon as possible and take the following steps: 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 animals (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. 2. Interview the client, review clinical information, mode of transmission, exploring the details of the exposure (bite, lick, scratch, contact, etc).
The nature of the exposure (including bite or non-bite, severity and location of the wound). The type of animal (wild animal versus domestic animal or livestock), including the risk of rabies in the animal species involved Behaviour of the animal (provoked or unprovoked attack) at the time of the bite The availability of the animal for observation and /or laboratory testing of the animal brain Rabies immunization status of the client and the animal, if known Also Refer to the NS Rabies Response Plan 2010 Appendix 4
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 animals 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 owners 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. 10. Document the information.
2.2 Contact tracing

Not applicable

If a suspect outbreak is involved in animals the provincial Rabies Working Group will review and provide recommendations
2.4 Rabies Response Plan

See the NS Rabies Response Plan for information regarding affiliate agency roles and responsibilities, Appendix 4.
2.5 Laboratory Procedures

Rabies testing for a suspected human case would be coordinated through the laboratory network in the province. Animal testing for those involved in an exposure to a human will be facilitated through the CFIA.

4.0 Communications Guidelines

Strategies
DHW Rabies pamphlet DHW Bats and Rabies pamphlet Annual letter to NS physicians regarding awareness of zoonotic diseases including Rabies DHW poster Hitchhiking Critters Media articles and press releases as necessary DHW website regular updates Others as appropriate Public Health in DHAs work with community partners to promote awareness and prevention of Rabies (use of fact sheets, pamphlets, etc.). DHW distributes print resources to other provincial government agencies (such as, Department of Natural Resources, Department of Tourism)
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/ccdrrmtc/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. National Advisory Committee on Immunization (2009). Recommendations Regarding the Management of Bat Exposures to Prevent Human Rabies. CCDR, Volume 35, November 2009. 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 1: Rabies Letter to Health Care Provider Regarding Post Exposure Prophylaxis Administration Template
APPENDIX 2: RABIES POST EXPOSURE FACT SHEET FOR THE PUBLIC

Important Information about Rabies and Rabies Treatment 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.
What is the treatment for Rabies?

The treatment for people exposed to rabies requires injections (shots) with 2 different medications - Rabies Immune Globulin and Rabies Vaccine. This works best when people are treated as soon as possible after the bite/scratch/lick.
What is Rabies Immune Globulin (RIG)?

RIG is a medication that contains antibodies. These antibodies can give protection against rabies within 24 hours but it is not long lasting. It is made from the blood of people who have had shots against rabies. The blood has been screened for certain diseases and treated to destroy some viruses like HIV and Hepatitis B. Not all types of viruses may be detected or destroyed. It is given only once as a shot. Some of the RIG may be given in and around the bite/scratch and the rest may be given in the buttocks.
The amount of RIG depends on the persons weight.
CAUTION
Before you receive RIG, tell your doctor/nurse if: you have an allergy to any ingredient in the RIG (human proteins, glycine and sodium chloride) you have received RIG in the past you have already received more than one dose of rabies vaccine you have received a live vaccine in the last 2 weeks you are pregnant or breastfeeding
What to expect after receiving RIG

Side effects from RIG may include: soreness at the site of the shot that may last a few hours (the most common side effect) stiff muscles in the area where the shot was given that may last for one or two days fever that may last for one or two days
What is Rabies Vaccine?

Rabies Vaccine is a medication that triggers the body to make its own antibodies that give long lasting protection. The vaccine will not give you the disease. It is given in the muscle of the upper arm. It must be given on a strict schedule which must be finished in order for the vaccine to work.
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
What to expect after getting Rabies Vaccine

Side effects from the vaccine may include: soreness, redness and/or swelling at the site of the shot that may last for one or two days mild flu-like symptoms such as headache, fever, nausea, fatigue or muscle aches that may last for one or two days 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".
Rabies can cause death.

The virus affects humans when a "rabid" animal bites a person or scratches an open wound. The virus is spread from the animal's saliva to the person's blood stream. If anyone is bitten by a wild animal (such as a fox, coyote, bat or a raccoon), they should contact a doctor immediately.
What is Treatment for a Bite?

Immediate first aid after a bite: Clean the bite area thoroughly with soap and water. Flush the wound area again and again with water. Apply an antiseptic or alcohol to the area See a doctor or go to the emergency room at a local hospital immediately. 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
Nova Scotia Rabies Post-Exposure Prophylaxis Guidelines

1.0 INTRODUCTION
The prevention and control of human exposure to rabies in Nova Scotia is the responsibility of multiple government agencies. Department of Health and Wellness, Public Health Services (PHS), Canadian Food Inspection Agency (CFIA), Department of Agriculture and the Department of Natural Resources (DNR) are the primary agencies that collaborate and share a mandate to control rabies in the province. Other organizations and agencies may also be involved as required. This document provides background information on rabies in Nova Scotia. The main element includes the collaboration and co-ordination of various agencies in the control and prevention of rabies. These guidelines may also be used to supplement other agencies rabies prevention policies. The guidelines were developed in consultation with and by an interdepartmental provincial rabies working group. The members of the working group represent various government agencies. The document provides further guidelines on risk assessment, risk reduction and management of animals and humans with potential and confirmed cases of rabies. It also outlines the procedures for authorization of dispensing Rabies Post Exposure Prophylaxis (RPEP) biologicals, obtaining additional RPEP biologicals during "after-hours" situations, and reporting requirements for Department of Health and Wellness.
2.0 GOAL AND OBJECTIVES OF THE RESPONSE PLAN

Goal: To reduce the risk of rabies infection to humans and animals in Nova Scotia. Objectives of the Response Plan: 1. To ensure that a working group with the necessary expertise and representation from the appropriate departments is in place to plan for and respond to rabies virus related issues in Nova Scotia. 2. To maintain a surveillance system to detect Rabies virus in Nova Scotia in animals and humans.
3. To increase the knowledge of the public regarding Rabies and to change behaviour towards personal protection against animal bites and exposures that increase the risk of rabies. 4. To increase knowledge of health professionals regarding rabies. 5. To keep Nova Scotians informed about rabies activity in Nova Scotia. 6. To recommend rabies control measures, as needed, based on assessment of risk and the many other factors related to rabies control.
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.
3.1 Clinical Picture

Rabies almost always causes death. The incubation period after being bitten by an infected animal is usually 3-8 weeks. The incubation period is often influenced by the intensity and site of the wound. 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 from 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 5 lab confirmed cases of rabies in animals in Nova Scotia. 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 cases of raccoon rabies. There have been no lab confirmed human cases of rabies in NS.
4.0 KEY ELEMENTS RABIES RESPONSE PLAN

The key elements of the Nova Scotia Response Plan for rabies virus are noted below. Activities for the start of each season are outlined along with a response if rabies activity is detected.
4.1 Nova Scotia Rabies Working Group

The Rabies Working Group consists of experts in wildlife, and human health who are working together to ensure a consistent and co-coordinated approach to protecting Nova Scotians from rabies virus. This group of experts is responsible for developing and implementing this rabies virus response plan and for the ongoing assessment of risk to Nova Scotians. Members represented on the working group have different roles and responsibilities. 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 Nova Scotia Rabies Working Group has representatives on the National Rabies virus Human Sub-Committee cocoordinated by the Public Health Agency of Canada.
4.2 Human Illness Surveillance

National case definitions for rabies are available in http://www.phacaspc.gc.ca/publicat/ccdr-rmtc/09vol35/35s2/index-eng.php Rabies virus is on the list of Notifiable Diseases in Nova Scotia. Physicians and laboratories are required to notify the Medical Officer of Health of all cases of Rabies illness. The Medical Officer of 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 rabies investigation report forms, are found in the Communicable Disease Prevention and Control Manual at http://www.gov.ns.ca/hpp/publications/cdc_manual.pdf Also, please refer to section 4.6 for information on laboratory diagnostics.
4.3 Other Animal Surveillance

Rabies in animals is a reportable disease to CFIA. All veterinary laboratories diagnosing positive rabies virus samples or suspect of rabies in domestic animals must immediately notify CFIA. CFIA will notify DHW (chair of Rabies working group) of any positive rabies tests. Veterinary practitioners clinically suspecting/diagnosing rabies are to also contact their nearest CFIA Animal Health Veterinarian for a possible farm or premises visit and subsequent inspection or investigation. 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.
4.4 Public Awareness and Education Campaign

Actions taken by the general public play an important role in preventing human cases of rabies. The public will be provided with information on rabies including symptoms and how to avoid unprovoked animal encounters. Key messages include: Individuals in high-risk groups including, veterinarians, lab workers, wild life workers and conservationists, hikers or cave explorers and individuals traveling 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
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.
4.5 Information for Health Professionals

Physicians and health care providers are informed that rabies virus illness is reportable in Nova Scotia under the Health Protection Act. In addition, physicians and other health professionals are provided with information on the risk assessment for rabies and the need to contact public health services when treating bites and wounds related to animal exposures. This is done through letters, newsletter articles and videoconferences. Please refer to section 9.0.
4.6 Diagnostic Testing for Human Illness

Rabies testing for a suspected human case would be coordinated through the laboratory network in the province.
4.7 Rabies Control Measures in Animals

A number of factors need to be weighed for consideration of wildlife rabies vaccination programs. probability of human cases of rabies time of the year, i.e. mobility and habitat of animals relative size of the wildlife population wildlife species composition probability that abatement will work in that area density of human population If necessary, the Nova Scotia rabies working group will make a recommendation regarding wildlife vaccine programs after discussing the circumstances with help from outside experts as needed The recommendation for such an initiative would require joint approval by all working group representatives departments.
The Department of Natural Resources will assist Department of Health and Wellness in any wild life rabies vaccination program.
5.0 ROLES AND RESPONSIBILITIES

All potential rabies exposures should be reported immediately to the local Public Health Services (PHS) office within the District Health Authority (DHA). In some cases, exposures involving farm animals are first reported to the nearest CFIA Animal Health Office, or Department of Agriculture who will then inform local PHS. 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.
5.1 Role of Public Health Services (PHS)

Ensure that all human exposures to an animal which have a potential to transmit rabies to humans are identified, assessed (investigated), and provided education. Provide advice on the need for rabies Post Exposure Prophylaxis (RPEP) and for ensuring that required RPEP biologicals are provided and administered. Inform those in the community who might "hear" about animal bites (physicians, emergency department staff, police, veterinarians, animal control staff, SPCA, DNR, etc.) to contact PHS immediately. Bites or other exposures that could pose a risk should be promptly reported to PHS. They should be informed of the process for contacting PHS (both during and after normal working hours). Establish protocols for reaching the local CFIA veterinarian, DNR staff and local animal control officers during and after normal working hours. Liaise with First Nations Health Centre or Health Canada EHO if incident involves First Nation individual. Complete the reporting requirements (investigation forms, biological forms, if necessary) for DHW. Provide communication support for local public health rabies prevention initiative, media, news releases, issue management, print materials and others as required.
5.2 Role of Canadian Food Inspection Agency (CFIA)

Receive reports of suspect rabid domestic animals and wildlife as well as human exposures. Promptly inform the appropriate local Medical Officer of Health (MOH) or designate of any confirmed or suspect rabid animals and any potential human exposure to a suspect animal. Make arrangements (in cooperation with PHS) to ensure that suspect domestic, farm, or wild animals are assessed, confined and observed or sacrificed for rabies testing as appropriate. Notify DHW (chair of Rabies working group) of any positive specimens for rabies virus. See Appendix A for contact information for CFIA Animal Health Offices.
5.3 Role of NS Department of Natural Resources (DNR)

Report all human exposures to suspect rabid animals to the local PHS office. 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, will coordinate the required actions. Upon request from PHS, assist with location and capture of feral domestic animals when there has been human contact and potential transmission of rabies. If the suspect animal has escaped after the initial contact, it may not be possible to locate it or positively identify that it was the same animal that had been involved in the human contact incident. Assist in the shipping of specimens to the nearest CFIA Animal Health Office for rabies testing as required. Provide assistance (as able) to Health Canada EHO for capture and arrangement of testing of animals involved with cases from First Nations and Inuit Health. See Appendix B for contact information for Department of Natural Resources staff.
5.4 Role of NS Department of Agriculture (NSDA)

Assist in arranging for testing of farm animals for rabies virus.
Promptly inform the appropriate local Medical Officer of Health (MOH) or designate of any confirmed or suspect rabid animals and any potential human exposure to a suspect animal. Notify DHW (chair of Rabies working group) of any specimens in NS positive for rabies virus.
5.5 Role of First Nations and Inuit Health (FNIH)

If a First Nations client is exposed to an animal that may be infected with rabies, they should report the incident to: the local First Nations Health Centre or nearest Emergency Department
The First Nations Health Centre will notify the local PHS office of the exposure. PHS will follow up the exposure as outlined in this document. Community Health Nurses at First Nations Health Centres cannot provide treatment for wounds inflicted by animals with suspect rabies infection. However, they may be able to provide RPEP (likely doses 2 5) if necessary.
5.6 Role of Department of Health and Wellness (DHW)

Review and analyze data regarding exposures to possible and positive rabies virus Secure biological procurement of provincial Rabies Immune Globulin and Rabies Vaccines and manage provincial supply Provide program response to public health case management of humans with rabies and investigation of suspect possible exposures to rabies Provide support to those involved in the provincial rabies program Coordinate and chair the provincial rabies working group Provide communication support for provincial rabies prevention initiative, media, news releases, issue management, print materials and others as required
5.7 Role of Municipalities

If a municipality employs animal control staff, then Public Health Services may request their assistance in following up suspect rabies exposures from stray and domestic animals.
6.0 RISK ASSESSMENT OF NEED FOR RPEP

Overall, in Nova Scotia, the risk is low for exposures to rabies infected animals but the potential is present. Additionally, inter-provincial and international transport of goods and products via rail, air, boat, and truck into the province can potentially introduce animals with rabies virus into the province. PHS must be promptly notified of all incidents where transmission of rabies to humans may be possible. PHS staff will determine whether rabies Post Exposure Prophylaxis should be provided after careful examination of all the risk factors in a particular exposure situation. The assessment of all suspect rabies exposures by PHS should include the evaluation of all the following risk factors: 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. 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 The Nature of Exposure

Rabies is a viral infection transmitted in the saliva of infected mammals. Transmission occurs when virus-laden saliva of a rabid animal is introduced by a bite or scratch through intact skin or onto mucous membranes. If there is no such exposure, postexposure prophylaxis is not indicated.
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 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.
6.1.2 Non-Bite Exposures

"Non-bite" contamination of scratches, abrasions and open wounds or mucous membranes by saliva or other potentially infectious material, such as the brain tissue of a rabid animal, can transfer the virus. When direct contact between a human and a bat has occurred and the bat is not available for testing, RPEP should be considered, when both of the following conditions apply: 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
Direct contact is defined as the bat touching or landing on a person. NACI no longer recommends RPEP when this is no contact involved. Any direct contact of a bat with skin or mucous membranes is considered a reason for intervention
unless a bite, scratch, or saliva exposure into a wound or mucous membrane can be ruled out. In an adult, a bat landing on clothing would be considered reason for an intervention 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 a 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. Intervention is defined as testing the bat for rabies, if it is available, and/or RPEP as indicated. If possible, the bat involved in the exposure should be captured and tested to determine whether it is infected and if RPEP is required.
6.1.3 Non-Risk Exposures

Petting a rabid animal or handling its blood, urine or feces does not constitute an exposure (Human Rabies Prevention - United States, 1999, MMWR January 8, 1999/Vol.48/No. RR-1), Being sprayed by a skunk is not considered to be an exposure, Rabies virus is inactivated by desiccation and ultraviolet irradiation. In general, if the material containing the virus is dry, the virus can be considered noninfectious.
6.2 Type of Animal (domestic animal or pet versus wild animal)

PHS staff must determine whether the animal is a domestic animal (horses, cattle, etc.), pet (dog, cat, ferret, etc.) or a wild animal. The wild animal category for this purpose includes stray dogs/cats/ferrets, wild animals (such as coyotes, raccoons, skunk, etc.) and exotic animals. The species of animal, the risk of rabies infection in the species and the geographical location where the exposure occurred, all need to be considered. The CFIA Animal Health Office can provide PHS staff with information about the likely risk of infection in various species. The likelihood of rabies in wildlife and domestic animals in Nova Scotia is considered low.
6.2.1 Domestic Pets (cats, dogs, ferrets) and Other Domestic Animals
If the exposed person owns the animal or knows the owner of the animal well, PHS staff should advise the person to observe the animal for ten days. The owner must be instructed to have the animal assessed by a veterinarian and immediately inform PHS if the animal becomes unwell during the observation period. PHS staff must inform and consult with the MOH and the nearest CFIA Animal Health Office if the animal becomes unwell. The exposed individual should also be advised to seek medical treatment for the wound if necessary. If the exposed person does not know the owner of the animal or requests assistance, PHS staff will contact the owner of the animal and advise the owner to observe the animal for ten days. The owner must be instructed to have the animal assessed by a veterinarian and immediately inform PHS if the animal becomes unwell during the observation period. The CFIA Animal Health Office and/or local animal control staff should be contacted if assistance is required. The exposed individual should also be advised to seek medical treatment for the wound if necessary. PHS staff must inform and consult with the MOH and the nearest CFIA Animal Health Office if the animal becomes unwell. PHS staff will assess whether the exposure was provoked, the animal is clinically normal, will determine its rabies immunization status and will ensure that the animal will be assessed, observed and confined (as required) for ten days. If the animal's behavior during the 10-day observation period remains normal, the client need not receive post-exposure prophylaxis beyond proper wound care. The nearest CFIA Animal Health Office should be consulted to assist with the assessment as necessary. PHS staff should contact their nearest CFIA Animal Health Office immediately if illness develops in the animal during the observation period. If signs and symptoms suggestive of rabies develop, the CFIA Animal Health Office will ensure that the animal is euthanized and tested for rabies infection. An animal's history of up-to-date rabies immunization makes the chance of rabies much less, but does not eliminate risk. The vaccination history
in itself should not solely influence the need for prophylaxis or the need to sacrifice the animal for testing. An up-to date rabies immunization for pets varies with the product used so it is important to inquire details on all rabies vaccine. Some products are administered yearly and others are every 3 years. Missed doses can lead to decreased immunity. Recent studies regarding rabies pathogenesis and viral shedding patterns, and evidence of the efficacy of the IMRAB3 vaccine in ferrets has led to the recommendation of including domestic (pet) ferrets with domestic cats and dogs rather than with wild animals.
6.2.2 Other Domestic Animals (horses, cattle, swine, etc.)

PHS staff should consult with the nearest CFIA Animal Health Office to determine whether sacrifice and testing are needed when rabies is suspected as part of the differential diagnosis.
6.2.3 Wild and Stray Animals

All wild and stray animal (foxes, raccoons, skunks, bats, etc.) bites and hazardous non-bite exposures are of concern and PHS should be immediately notified (by person bitten, their parent or guardian, health care professional, local animal control officer, DNR staff, etc.). PHS staff may consult the nearest CFIA Animal Health Office as required to help determine the risk of rabies in the species to which a person was exposed. Bites from rabbits or small rodents (such as squirrels, rats, gerbils, mice, and chipmunks) seldom, if ever, call for rabies prophylaxis (only if the behavior is highly unusual). Exotic animals (lions, monkeys, etc.) in captivity should be treated as wild animals in terms of risk but may be confined and observed depending on the animal and the circumstances. The nearest CFIA Animal Health Office must be consulted. Risk assessment would include an examination by a veterinarian. Sacrifice and testing should be done if rabies is part of the veterinarian's differential diagnosis and/or the CFIA Animal Health Office recommends it. Monkey bites should be reported to the District MOH and the CFIA Animal Health Office due to risk of B-virus infection.
PHS staff should request whether a local animal control officer or staff from DNR could locate and confine a stray dog, cat, or ferret. A veterinarian should assess the animal. If it is clinically normal and the suspicion of rabies is low, it should be held and observed for ten days in a secure facility. If this is not feasible or if there is any suspicion of rabies illness, the animal should be euthanized and the head submitted for rabies testing.
6.2.4 Animal Exposures outside Nova Scotia

The nearest CFIA Animal Health Office should be consulted for current information about the risk posed by the animal species where the exposure occurred.
6.3 Behaviour of Animal

The behaviour of the animal in relation to the human behaviour (provoked attack or unprovoked attack) at the time of the bite must be considered. The CFIA Animal Health Office can provide advice to PHS staff about this assessment if required. An unprovoked attack is one where the person did not surprise, antagonize or threaten the animal or enter its territory. A provoked attack is one where the human did something to incite the animal (even if the action was unintentional) and the attack would be the animal's normal response to such a human action. Examples of such human actions could include: Attempting to corner or trap an animal Entering an area that the animal considers its territory (dog in a yard) or approaching the animal's litter Coming too close to an injured animal Trying to break up a fight between two animals Picking up an animal and attempting to take it elsewhere Petting an unfamiliar animal Interfering with an animal's food Interfering/wrestling with an animal's owner Signs of rabies cannot be reliably interpreted in wild animals. An unprovoked attack may indicate that the animal is rabid. Rabid cats and dogs may, however, become uncharacteristically quiet.
The symptoms in different animal species can vary considerably, but almost always there is a change of temperament and evidence of paralysis, with death ensuing within a few days of the onset of symptoms. The overall period from onset of clinical symptoms to death rarely exceeds ten days in dogs, cats, and ferrets. In the earlier stages, a common factor is that the animal undergoes a change of temperament so that a normal friendly animal may become snappy and seek to avoid his owner's company. Timid, shy animals may become less restrained and unnaturally approachable. PHS staff should consider recommending RPEP while awaiting the results of rabies testing or the outcome of an animal confinement if the behaviour of the animal is highly suspicious of rabies. The CFIA Animal Health Officer can provide advice about interpretation of animal symptoms and the MOH should be consulted.
6.4 Availability of Animal (for observation and/or laboratory testing) (Also refer to Section 7.0 Management of Animals Involved in Biting Incidents)
6.4.1 Animal is available for Observation
PHS staff should ensure that every effort has been made to locate pet dogs, cats, and ferrets before recommending RPEP. Local animal control officers (where available) can assist PHS staff in ensuring that the animal is located and assessed. An apparently healthy pet dog, cat or ferret that bites a person should be confined and observed for ten days (the day of the bite would be day one). This may eliminate the need for RPEP and unnecessary laboratory testing of the animal brain for rabies. The nearest CFIA Animal Health Office may be consulted as needed to ensure that this occurs. PHS staff should contact DNR staff and local animal control officers (where available) to attempt to locate and capture a stray dog/cat/ferret. If clinically normal and the suspicion of rabies is low, the animal should be held in a secure facility and observed for ten days. If the animal remains clinically normal throughout this ten-day period, then rabies can be ruled out.
Circumstances of the exposure as well as the location and severity of the bite may, however, may justify early initiation of RPEP.
6.4.2 Animal available for Laboratory Testing of the Brain

PHS staff should ensure than any wild animal that has bitten a person, is captured if possible, sacrificed and tested for rabies infection. PHS staff should contact their nearest CFIA Animal Health Office to make arrangements for the testing of the animal. PHS staff should contact the local office of DNR to request that a wild animal be captured if possible. DNR can also pick up a dead animal that has exposed a person after normal working hours (evenings, weekends, and holidays) and store it until the CFIA Animal Health Office can be reached. It may not be possible to reach the CFIA Animal Health Office outside of regular office hours. DNR will notify PHS whether capture of the wild animal has been possible. PHS should contact their nearest CFIA Animal Health Office on next business day if after hours or on a weekend. The CFIA Animal Health Office will make arrangements with DNR staff for the animal to be euthanized and for the head to be sent for testing. A bat should be safely collected and the entire bat can be submitted for rabies diagnosis. If a person brings a dead animal to which they or another person has been exposed (most likely a bat) directly to a PHS office, PHS staff should make arrangements with the nearest CFIA Animal Health Office for testing of the animal. Dogs, cats, ferrets and other domestic animals and stray pets that exhibit any signs of illness during an observation period should be sacrificed and submitted for rabies testing (in consultation with the CFIA Animal Health Office ). RPEP may be started pending animal examination results if the exposure is felt to be high risk. Factors to consider include the severity and location of bites (head and neck of greatest concern), the health and behavior of the biting animal, availability of test results and the reliability of victim to recognize or report the nature of the exposure. In high-risk situations, PHS may recommend that prophylaxis be started. The need for completion of RPEP will be determined by the animal test results.
Negative test results obtained by appropriate and systematic examination of specimens can be interpreted reliably so that no RPEP is required or RPEP that was initiated can be stopped.
6.4.3 Animal not available for Observation or Laboratory Testing

PHS staff can obtain advice on the risk of rabies exposure when the animal is not available for testing or observation from the CFIA Animal Health Office. Such situations should be discussed with the local MOH. 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: 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 7.1 Risk Reduction
To reduce the risk of rabies virus illness in general, a number of steps can be considered: Maintain a surveillance system for animals and human illness in order to detect rabies Educate the public on ways to reduce exposures to wild animals including not feeding wildlife and ensuring homes are sealed from bats Encourage vaccination of domestic pets and farm animals 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.
7.2 Management of Animals

The management of animals that have bitten/exposed a human depends on whether the animal is a pet or other domestic animal or a wild animal. PHS staff should ensure that all possible effort is made to locate animals that have exposed humans to the risk of rabies (bite or non-bite exposures). Locating the animal for observation or testing, as appropriate, can reduce unnecessary RPEP. PHS staff should notify the nearest CFIA Animal Health Office of any animal suspected of being rabid, regardless of whether it has been involved in a biting incident. If the MOH and CFIA Animal Health Office agree that the animal should be euthanized, CFIA will make arrangements for this.
PHS staff must consult with the MOH and the CFIA Animal Health Office about the need to euthanize any domestic animal for rabies testing.
7.2.1 Domestic Animals

PHS staff should ensure that domestic animals are located and observed. The nearest CFIA Animal Health Office and local animal control services (if available) should be contacted to provide assistance if necessary. Apparently healthy, non-stray dogs/cats/ferrets, and if feasible, clinically normal strays, should not be euthanized before a ten-day observation period. PHS staff must discuss the destruction and testing of an animal before the end of the observation period with the MOH and the CFIA Animal Health Office. Rarely, I the animal is indeed rabid, but is not exhibiting signs of rabies, the virus may not have reached the brain and the test results may be falsely negative. If the animal remains clinically normal throughout this ten-day period, then exposure to rabies can be ruled out. If an attack by a domestic non-stray dog/cat/ferret was provoked and there are no clinical signs of rabies in the animal, the animal can be confined at home. It should be confined in a building or secured area so that it cannot run away. Local animal control officers (if available) can provide assistance to ensure that the necessary arrangements are made. If the owner refuses to quarantine an animal, the CFIA Animal Health Office can issue an order for the animal to be secured alive and uninjured and confined in a secure place at the owner's expense for up to ten days.
Municipalities, PHS and/or the CFIA Animal Health Office should develop a list of kennels where pet dogs/cats/ferrets under observation could be detained (at the owner's expense) if the owners refuse to confine them at home. If the animal is euthanized, PHS and the CFIA Animal Health Office should ensure that the head is tested in order to rule out rabies. At the first sign of illness during confinement, PHS staff must be immediately notified by the owner or the persons responsible for confining and observing the animal. PHS staff will immediately contact their nearest CFIA Animal Health Office who will ensure that the animal is examined and will arrange for euthanization and testing as required. If signs suggestive of rabies develop, the animal should be euthanized and its head removed and shipped for testing. In cases where a domestic dog/cat/ferret does not appear to be clinically normal, is dangerous or has inflicted a facial bite, the MOH and/or the CFIA Animal Health office can decide whether immediate euthanasia and testing is warranted. Stray domestic pets (cats, dogs, ferrets) should be confined for observation instead of being immediately euthanized if possible and appropriate. PHS staff should make this decision in consultation with the MOH and the CFIA Animal Health Office. A stray dog, cat, or ferret that bites/exposes a person and is aggressive or displaying abnormal clinical signs may be euthanized immediately and have its head sent for testing. Otherwise, euthanize only if observation for ten days in a secure facility is not feasible. Sacrifice and testing of non-feline/non-canine domestic animals such as horses, cattle and swine should be done if rabies is part of the CFIA Animal Health Offices differential diagnosis.
7.2.2 Wild Animals

PHS staff should contact DNR officers to request assistance for capturing stray or wild suspect animals. DNR officers can attempt to locate/euthanize the suspect animal (if not already done) and will collect the head to submit it to the CFIA Animal Health Office for testing. DNR will only provide assistance when resources are available and if the suspect animal is identifiable (trapped in a closed area).
If the wild animal is captured, it should be euthanized and the head sent by DNR staff to the CFIA Animal Health Office for testing. A bat should be safely collected, if possible, and the entire bat submitted for testing. Sacrifice and testing of exotic animals should be done if rabies is part of the veterinarian's differential diagnosis and only in consultation with the nearest CFIA Animal Health Office.
7.2.3 Laboratory Testing of Animals

Testing of animal specimens for rabies in Nova Scotia is done at the Animal Disease Research Institute (ADRI) in Nepean, Ontario. The CFIA Animal Health Office will ensure the collection and shipping of appropriate specimens for diagnosis. The specimen must be shipped appropriately and classified as "dangerous goods". Rabies diagnosis is based on the observation that, in all mammals, the rabies virus reaches the salivary glands and is excreted in saliva only after replication in the central nervous system. Absence of the rabies virus antigen in the brain of the animal essentially precludes the presence of virus in saliva, the risk for rabies transmission, and the need for RPEP. Clinical signs leading to a suspicion of rabies occur only after substantial virus replication. At that time, most tests for rabies reveal considerable amounts of viral antigen in all areas of the brain. The fluorescent antibody test (FAT) for detection of rabies virus antigen in brain tissue is used as the primary diagnostic test. The test has a sensitivity approaching 100%. Results are usually available within 24hours of receipt of the specimen at the ADRI. When there has been human exposure, positive results are immediately phoned to the nearest CFIA Animal Health Office who will ensure that PHS is also immediately notified. If the FAT is negative, a rabies tissue culture test is performed. The results of this test are available in four to five days. A positive tissue test culture result is always phoned-in as well. If the animal has already been euthanized, burned or buried, there may still be enough matter suitable for testing. PHS staff should discuss such situations with the local MOH and the nearest CFIA Animal Health Office.
7.2.4 Quarantine of Exposed Animals

In some cases, a pet or domestic animal may have been attacked by or fought with a suspected or confirmed rabid animal. Consequently, the
animal may remain at risk for developing rabies in the future. PHS staff should consult with the nearest CFIA Animal Health Office for direction on the assessment and any required quarantine and observation of the animal.
7.3 Management of Exposed People

Rabies RPEP must be considered in every incident in which potential exposure to the rabies virus has occurred. In evaluating each case, PHS staff must be consulted. Rabies in humans can be prevented by providing exposed clients with prompt local treatment of wounds combined with appropriate passive and active immunization.
7.3.1 Treatment of Wounds

Immediate and thorough cleaning of all wounds is one of the most important aspects of rabies prevention. Wounds should be thoroughly washed, flushed with running water and then treated with an antiseptic. At the time medical attention is sought, if the wound is caused by a known rabid or highly suspect rabid animal, suturing of the wound should not be done, and RIG should be infiltrated in the area around and into the wound. If suturing is unavoidable, it should be done after local infiltration of RIG. If at the time medical attention is sought, the animal is being held for observation to rule out rabies, suturing can proceed. Tetanus prophylaxis should be given as indicated. There should be an assessment by a physician regarding measures to control bacterial infection (antibiotic therapy).
7.3.2 Immunizing Agents

There are two types of immunizing products: Rabies vaccine, HDCV (Human Diploid Cell Vaccine), available in 1ml vials, contains inactivated virus and induces an active immune response beginning in seven to ten days and persisting for at least one year. Rabies Immune Globulin (RIG), available in 300 IU/ 2ml vials, provides rapid protection that persists for only a short period of time (half-life is about 21 days).
7.3.3 Post-Exposure Immunization

When post-exposure rabies prophylaxis is recommended: PHS staff must determine the immunization status of the client.
Refer to Section 7.3.6, "Post-Exposure Immunization of Previously Immunized Clients", if applicable. RPEP started in another country requires individual assessment and consultation with the MOH. PHS staff must discuss with the client their willingness and commitment to accept and complete rabies prophylaxis. If PHS staff administers RPEP, informed consent for immunization must always be obtained from the client. PHS staff should plan the immunization schedule with the client and confirm the identity and location of the health care provider who will give RPEP. Rabies vaccine and RIG must be used concurrently for optimum RPEP except in certain previously immunized clients. Pregnancy is not a contraindication to post-exposure prophylaxis, if it has been determined that the client is at risk of infection. If notification of an exposure is delayed, RPEP may be started as late as 6 months or more after exposure. The combination of RIG and rabies vaccine is recommended regardless of the interval between exposure and initiation of treatment. If the client needs to complete the post-exposure series outside of the PHS area, PHS staff should ensure that arrangements are made to complete the series.
7.3.4 Administering RIG

The recommended dose is 20 IU/kg (0.133ml/kg) of body weight. Excessive dosages can interfere with active antibody production and should be avoided. If anatomically feasible, the full dose should be infiltrated in the area around and into the wound. If not anatomically feasible, any remaining volume of RIG should be injected, using a separate needle and syringe, intramuscularly at a site distant from vaccine administration. (Canadian Immunization Guide, Seventh Edition, 2006). When more than one wound exists, each should be locally infiltrated with a portion of the RIG. Since vaccine-induced antibodies begin to appear within one week, there is no value in administering RIG more than eight days after initiating a vaccine course.
RIG and rabies vaccine must never be given at the same site, or delivered through the same syringe and needle.
7.3.5 Administering Rabies Vaccine (HDCV)

The history of any previous hypersensitivity reaction to rabies vaccine (HDCV) should be elicited. Hypersensitive individuals should be vaccinated only under strict medical supervision. A series of five doses (1ml each) of rabies vaccine is provided intramuscularly (at a site separate from RIG) on each of days 0, 3, 7, 14, and 28. Rabies vaccine should never be given in the gluteal region as administration in this area results in lower neutralizing antibody titres (gluteal injections may miss the muscle). For adults the vaccination should be administered intramuscularly in the deltoid area. For younger children, the anterolateral aspect of the thigh is also acceptable. A course of vaccine started before rabies-testing results are available may be discontinued if the direct fluorescent antibody test of the brain of the animal responsible for an attack proves to be negative unless the client is at continue risk of rabies exposure and requires pre-exposure prophylaxis. Rabies antibody titer determination is not usually necessary following treatment. However, clients receiving steroids or immunosuppressive therapy should have a rabies antibody determination (two weeks after completion of a post-exposure course of rabies vaccine) to ensure that an adequate response has developed. Immunosuppressive agents should not be administered during post-exposure prophylaxis unless essential for the treatment of other conditions.
For additional information please refer to the Canadian Immunization Guide, (Seventh Edition, 2006) and the product insert.
7.3.6 Post-Exposure Immunization of Previously Immunized Clients

RPEP for clients who have previously received rabies vaccine depends on what preparation of rabies vaccine was previously received (please refer to the Canadian Immunization Guide, Seventh Edition, 2006 and the Errata/Clarification of the CIG, 2008).
Two doses of rabies vaccine (HDCV), one injected immediately and the other three days later without RIG, are recommended for exposed individuals with the following rabies immunization history: Completion of an approved course of pre- or post-exposure prophylaxis with HDCV or PCECV; or Completion of immunization with other types of rabies vaccine or with HDCV according to unapproved schedules so long as neutralizing rabies antibody has been demonstrated in serum. If vaccine other than HDCV was used for pre-exposure immunization and the client's immune status is not known, a full course of treatment, including RIG, should be initiated. A serum sample may be collected before vaccine is given, and if antibody is demonstrated, the course may be discontinued, provided at least two doses of HDCV have been administered. (Canadian Immunization Guide, Seventh Edition, 2006 and Errata/Clarification of the CIG, 2008).
8.0 OBTAINING RABIES BIOLOGICALS

A limited supply of RIG and rabies vaccine is kept in each PHS district. Only the MOH or delegate can authorize the release of RIG and vaccine for a client.
8.1 Authorization of Biologicals

Only the District MOH (or MOH on-call after-hours) or delegate can authorize release of Rabies Immune Globulin (RIG) and rabies vaccine for a client. The Chief Medical Officer and Deputy Chief Medical Officer of Health are available for consultation if required by the MOH. RIG and Rabies vaccine should be stocked within the PHS district where it can be accessed by appropriate staff when authorized by the MOH.
8.2 Requirements for Additional Biologicals

If more RIG and vaccine is needed than what is available in the stock supply (multiple cases occurring at a time, or more RIG being required), then
During regular business hours:

PHS staff should contact the Provincial Biological Depot Coordinator to arrange the shipment of the required biologicals.
Outside of regular business hours:

If necessary, the MOH (or on call CD PHN) should page the Provincial Biological Coordinator, or delegate, to arrange for the release and delivery of additional vaccine or RIG. The Provincial Biological Depot Coordinator will check to ensure that the release of the vaccine has been authorized by the MOH on-call before releasing it.
9.0 COMMUNICATION STRATEGY

Objectives:
To raise awareness of and prevent Rabies within Nova Scotia Provide Nova Scotians with consistent, up to date and reliable information about Rabies Ensure health care providers have access to information regarding Rabies including legislature regarding disease reporting Emphasize the importance of individual responsibility in preventing the spread of Rabies
Target Audiences:
General public Media Health care professionals Tourists/Outdoor recreationalists DHW provides information and resources about the risk of Rabies in NS 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: DHW Rabies pamphlets DHW Rabies poster (to create awareness of potential hitchhiking critters ) 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.). The key messages provided include: Individuals in high-risk groups including, veterinarians, lab workers, wild life workers and conservationists, hikers or cave explorers and individuals traveling 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.
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. National Advisory Committee on Immunization (2009). Recommendations Regarding the Management of Bat Exposures to Prevent Human Rabies. CCDR, Volume 35, November 2009. 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
TOXOPLASMOSIS
1. Information
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.

Toxoplasma gondii, a protozoan.
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. Transmission of T gondii has been documented to result from blood or blood product transfusion and organ or bone marrow transplantation from a seropositive donor with latent infection.
Not directly transmitted from person-to-person except in utero. Oocysts shed by cats sporulate and become infective 1-5 days later, and remain infective in water or moist soil for over 1 year.
1.8. Treatment:
Treatment is not normally required in an immunocompetent client. For treatment consult appropriate specialist.

Wash or peel fruits and vegetables. Order or cook meat well done (refer to meat temperature chart in the general guidelines of the Enteric Disease Section). Wash hands, utensils, and cutting boards with hot soapy water after handling raw meat to prevent contamination of other foods. Freezing foods, as most cysts are destroyed at -20C Do not drink unpasteurized milk from any animal (cow, goat, etc). Wear gloves when gardening or any contact with soil or sand, and then wash your hands. Unless they are known to have antibodies to T. gondii, pregnant women should avoid cleaning litter boxes. Dispose of cat feces and litter daily before sporocysts become infective.
1.10. Prophylaxis:
Chemoprophylaxis is recommended for HIV-infected adults who are T. gondii seropositive. Appropriate specialists should be consulted.
1.11. Surveillance
2. Procedure
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. b. Approve Public Health control measures. When required, approve control measures.
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.
2.1.3 Role of Physician

a. Report cases to Public Health Services. b. Treat client as required.
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/ccdrrmtc/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.
What are the symptoms of toxoplasmosis?

Most people who are infected do not show any signs of the disease. Those who do get sick usually have flu-like symptoms such as fever, sore throat, sore muscles and tiredness. Glands in the neck, armpits or groin can become swollen, but are usually not sore. In some cases the infection can also cause temporary blurred vision or loss of vision.
Who is at high risk from toxoplasmosis?

Pregnant women and persons with a suppressed immune system due to AIDS, cancer or following organ transplants should reduce their risk of toxoplasmosis by following the advice in this fact sheet.
Pregnancy and toxoplasmosis

If you are pregnant or are thinking of becoming pregnant soon, avoiding infection is very important as it can cause harm to your unborn baby. 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.
How is toxoplasmosis spread?

All animals (including humans) and birds can be infected with the toxoplasmosis parasite. However, cats are the primary source of the parasite. Food animals are
thought to be infected by eating food stuffs and water contaminated by cat feces. The parasite enters the muscles of a bird or animal when it eats raw meat or drinks the milk of another animal that is infected. Cats can spread the parasite in their feces. Common ways for people to become infected with toxoplasmosis include: Eating raw or undercooked meats; Drinking unpasteurized milk; Cleaning cat litter boxes; Working in gardens or playing in sandboxes that contain cat feces; Eating unwashed fruits and vegetables.
Is there a treatment for toxoplasmosis?

Most people will recover from toxoplasmosis without treatment. However, medication is available from your family doctor to treat the infection. Treatment may be needed if the eyes or heart are affected or if the infection occurs in persons with weak immune systems or long lasting diseases (e.g. AIDS or cancer). 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.
How can I avoid getting toxoplasmosis?

Fruits and vegetables should be peeled or washed thoroughly; Order or cook your meat well done (food thermometer: beef, lamb, veal = 71C; pork, ground meat and wild game = 71C whole poultry = 82C); Wash your hands, utensils, and cutting boards with hot soapy water after handling raw meat to prevent contamination of other foods; Do not drink unpasteurized milk from any animal (cow, goat, etc); Wear gloves when gardening, or any contact with soil or sand, then wash your hands; Follow the advice below regarding cats.
Cats and You

Just like other family members, your pet cat can pass disease on to you. Most cats infected with toxoplasmosis do not appear sick. The cats feces contain the parasites
for only 4 weeks after the cat is infected. However, the feces may remain infectious for well over a year. 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; Dont feed raw meat to your cat; See a vet if there are any signs of illness in your cat.
Food handling and You

There are four main things you can do to reduce your risk of foodborne illness: clean, separate, cook and chill. 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 dont 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 4C (40F), and keep the freezer at -18C (0F).
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
Case Classification-West Nile Virus Neurological Syndrome (WNNS) Confirmed case-West Nile Virus Neurological Syndrome (WNNS)
Clinical criteria AND at least one of the confirmed case diagnostic test criteria (see below)
Probable case-West Nile Virus Neurological Syndrome (WNNS)

Clinical criteria AND at least one of the probable case diagnostic test criteria (see below)
Suspect case-West Nile Virus Neurological Syndrome (WNNS)

Clinical criteria in the absence of or pending diagnostic test criteria (see below) AND in the absence of any other obvious cause
Clinical Criteria-West Nile Virus Neurological Syndrome (WNNS)

History of exposure in an area where West Nile virus (WNV) activity is occurring OR history of exposure to an alternative mode of transmission AND onset of fever AND recent onset of at least one of the following: encephalitis (acute signs of central or peripheral neurologic dysfunction) OR viral meningitis (pleocytosis and signs of infection, e.g. headache, nuchal rigidity) OR
acute flaccid paralysis (e.g. poliomyelitis like syndrome or Guillain-Barrlike syndrome) OR movement disorders (e.g. tremor, myoclonus) OR Parkinsonism or Parkinsonian-like conditions (e.g. cogwheel rigidity, brad0ykinesia, postural instability) OR other neurological syndromes
Case Classification-West Nile Virus Non-Neurological Syndrome (WN Non-NS) Confirmed case-West Nile Virus Non-Neurological Syndrome (WN Non-NS)
Clinical criteria AND at least one of the confirmed case diagnostic test criteria (see below)
Probable case-West Nile Virus Non-Neurological Syndrome (WN Non-NS)

Clinical criteria AND at least one of the probable case diagnostic test criteria (see below)
Suspect case-West Nile Virus Non-Neurological Syndrome (WN Non-NS)

Clinical criteria in the absence of or pending diagnostic test criteria (see below) AND in the absence of any other obvious cause
Clinical Criteria-West Nile Virus Non-Neurological Syndrome (WN Non-NS)

History of exposure in an area where WN virus (WNV) activity is occurring OR history of exposure to an alternative mode of transmission AND at least two of the following: fever
myalgia anthralgia headache fatigue lymphadenopathy maculopapular rash
Case Classification-West Nile Virus Asymptomatic Infection (WNAI) Confirmed case-West Nile Virus Asymptomatic Infection (WNAI)
Confirmed case diagnostic test criteria (see below) in the absence of clinical criteria
Probable case-West Nile Virus Asymptomatic Infection (WNAI)

Probable case diagnostic test criteria (see below) in the absence of clinical criteria
Clinical Evidence West Nile Virus Asymptomatic Infection (WNAI)

This category could include, for example, asymptomatic blood donors.
Case Diagnostic Test Criteria-West Nile Virus

It is currently recommended that health jurisdictions/authorities use the Confirmed Case Diagnostic Test Criteria to confirm index cases (locally acquired) in their area each year; for subsequent cases, health jurisdictions/ authorities could use the Probable Case Diagnostic Test Criteria to classify cases in their area as "confirmed", for the purposes of surveillance. Throughout the remainder of the transmission season health jurisdictions/ authorities may wish to document PRN antibody titres to West Nile virus in a proportion of cases, to be determined by that health jurisdiction/authority, in order to rule out the possibility of concurrent activity by other flaviviruses. (For further information on diagnostic testing algorithms for West Nile virus, see the section entitled Laboratory Specimen Diagnostic Testing Algorithm in Appendix 4 of the National Guidelines for Response to West Nile virus.)
Confirmed Case Diagnostic Test Criteria-West Nile Virus

AT LEAST ONE of the following: a significant (e.g. fourfold or greater) change in WN virus neutralizing antibody titres (using a PRN or other kind of neutralization assay) in paired acute and convalescent sera, or CSF OR isolation of WN virus from, or demonstration of WN virus-specific genomic sequences in, tissue, blood, CSF or other body fluids OR demonstration of WN virus antigen in tissue OR demonstration of flavivirus antibodies in a single serum or CSF sample using a WN virus IgM EIA, confirmed by the detection of WN virus specific antibodies using a PRN (acute or convalescent specimen) OR a significant (e.g. fourfold or greater) change in flavivirus haemagglutination inhibition (HI) titres in paired acute and convalescent sera or demonstration of a seroconversion using a WN virus IgG EIA AND the detection of WN specific antibodies using a PRN (acute or convalescent serum sample)
Probable Case Diagnostic Test Criteria-West Nile Virus

AT LEAST ONE of the following: detection of flavivirus antibodies in a single serum or CSF sample using a WN virus IgM EIA without confirmatory neutralization serology (e.g. PRN) OR a significant (e.g. fourfold or greater) change in flavivirus HI titres in paired acute and convalescent sera or demonstration of a seroconversion using a WN virus IgG EIA OR a titre of > 1:320 in a single WN virus HI test or an elevated titre in a WN virus IgG EIA, with a confirmatory PRN result (Note: a confirmatory PRN or other kind of neutralization assay is not required in a health
jurisdiction/authority where cases have already been confirmed in the current year.) OR demonstration of Japanese encephalitis (JE) serocomplex-specific genomic sequences in blood by NAT screening on donor blood, by Blood Operators in Canada
The Public Health Laboratory at the Queen Elizabeth II Health Sciences Centre will be consulted on appropriate specimens etc.

West Nile virus, which is an arbovirus of the family Flaviviridae, genus Flavivirus.
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.
Clinical Evidence-West Nile Neurological Syndrome (WNNS)

A significant feature of West Nile viral neurologic illness may be marked muscle weakness that is more frequently unilateral but can be bilateral. WNV should be considered in the differential diagnosis of all suspected cases of acute flaccid paralysis with or without sensory deficit. WNV-associated weakness typically affects one or more limbs (sometimes affecting one limb only). Muscle weakness may be the sole presenting feature of WNV illness (in the absence of other neurologic features) or may develop in the setting of fever, altered reflexes, meningitis or encephalitis. Weakness typically develops early in the course of clinical infection. Patients should be carefully monitored for evolving weakness and in particular for acute neuromuscular respiratory failure, which is a severe manifestation associated with high morbidity and mortality. For the purpose of WNV Neurologic Syndrome Classification, muscle weakness is characterized by severe (polio-like), non-transient and prolonged symptoms. Electromyography (EMG) and lumbar puncture should be performed to differentiate WNVassociated paralysis from acute demyelinating polyneuropathy (e.g. GuillainBarr syndrome). Lymphocytic pleocytosis (an increase in white blood cells with a predominance of lymphocytes in the CSF) is commonly seen in acute flaccid paralysis because of WNV, whereas pleocytosis is not a feature of Guillain- Barr
syndrome. Other emerging clinical syndromes, identified during 2002, included, but were not limited to, the following: myelopathy, rhabdomyolysis (acute destruction of skeletal muscle cells), peripheral neuropathy; polyradiculoneuropathy; optic neuritis; and acute demyelinating encephalomyelitis (ADEM). Ophthalmologic conditions, including chorioretinitis and vitritis, were also reported. As well, facial weakness was reported. Myocarditis, pancreatitis and fulminant hepatitis have not been identified in North America but were reported in outbreaks of WNV in South Africa. "Aseptic" meningitis without encephalitis or acute flaccid paralysis occurring in August and September when WNV is circulating may be due to non-polio enteroviruses circulating at the same time. This should be considered in the differential diagnosis(2-4). A person with WNV-associated acute flaccid paralysis may present with or without fever or mental status changes. Altered mental status could range from confusion to coma with or without additional signs of brain dysfunction (e.g. paralysis, cranial nerve palsies, sensory deficits, abnormal reflexes, generalized convulsions and abnormal movements). Acute flaccid paralysis with respiratory failure is also a problem.
Clinical Evidence-West Nile Virus Non-Neurological Syndrome (WN Non-NS)

It is possible that other clinical signs and symptoms could be identified that have not been listed and may accompany probable case or confirmed case diagnostic test criteria. For example, gastrointestinal symptoms were seen in many WNV patients in Canada and the USA in 2003 and 2004. Muscle weakness may be a presenting feature of WNV illness. For the purpose of WNV Non- Neurological Syndrome classification, muscle weakness or myalgia (muscle aches and pains) is characterized by mild, transient, unlikely prolonged symptoms that are not associated with motor neuropathy.
Clinical Evidence-West Nile Virus Asymptomatic Infection (WNAI)

This category could include asymptomatic blood donors whose blood is screened using a nucleic acid amplification test (NAT) by Blood Operators (i.e. Canadian Blood Services or Hma-Qubec) and is subsequently brought to the attention of public health officials. The NAT that will be used by Blood Operators in Canada is designed to detect all viruses in the Japanese encephalitis (JE) serocomplex. The JE serocomplex includes WN virus and nine other viruses, although from this group only WN virus and St Louis encephalitis virus are currently endemic to
parts of North America. Blood Operators in Canada perform a supplementary WN virus-specific NAT following any positive result from donor screening.
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.
Not transmitted from person to person. Infected mosquitoes probably remain infected for life.
1.8. Treatment:
Supportive therapy.

Reduce risk for mosquito bites (see fact sheet for specific suggestions). Reduce mosquito habitat around your home
1.10. Prophylaxis:
None.
2. Procedure
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. 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. Educate on mosquito protection to avoid mosquito bites including repellents (DEET) and protective clothing. Educate on mosquito control. Inquire about travel. Inquire about areas of work/ activities ,where the individual resides. Inquire about mosquito bites. Inquire about donation or receipt of blood products, tissue or organs. Obtain any additional clinical information to complete the special surveillance form.



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/ccdrrmtc/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.

Most people who are infected with WNV have no symptoms. Some people will have a fever, headache, muscle weakness and body aches. A few people will experience more severe forms of WNV such as encephalitis or meningitis (swelling of the brain or the lining of the brain). The symptoms of encephalitis/meningitis may include a rapid onset of severe headache, high fever, stiff neck and disorientation.

There is no specific treatment for WNV infection. Therefore, prevention is very important.
How Can You Prevent West Nile Virus?

Avoiding mosquito bites is the most important way of preventing WNV infection. Stay indoors at dawn, dusk, and in the early evening. Wear long-sleeved shirts and long pants whenever you are outdoors. Spray clothing with repellents containing permethrin or DEET since mosquitoes may bite through thin clothing. Apply insect repellent sparingly to exposed skin. An effective repellent will contain 35% DEET). DEET in high concentrations (greater than 35%) provides no additional protection. Repellents may irritate the eyes and mouth, so avoid applying repellent to the hands of children. Do not apply DEET repellants more than 3 times per day for children aged 2 to 12 years old. Use DEET on children aged 6 months to 2 years only when there is a high risk of infections from mosquito bites, and only apply once daily. Do not use DEET on children less than 6 months of age.
Whenever you use an insecticide or insect repellent, be sure to read and follow the manufacturers DIRECTIONS FOR USE, as printed on the product. Eliminate potential mosquito breeding sites around your home. Eliminate standing water in such things as pool covers, flower pots, childrens toys, old tires etc. Clean clogged roof gutters on an annual basis, particularly if the leaves from surrounding trees have a tendency to plug up the drains. Roof gutters are easily overlooked but can produce millions of mosquitoes each season. Turn over plastic wading pools when not in use. A wading pool becomes a mosquito producer if it is not used on a regular basis. Turn over wheelbarrows and change water in bird baths at least twice weekly. Both provide breeding habitat for domestic mosquitoes. Aerate ornamental pools or stock them with fish. Water gardens may become major mosquito producers if they are allowed to stagnate. Clean and chlorinate swimming pools that are not being used. Use landscaping to eliminate standing water that collects on your property. Mosquitoes can develop in any puddle that lasts more than 4 - 8 days. Mosquito breeding around the home can be reduced significantly by reducing the amount of standing water available for mosquito breeding.
Mosquitoes and You

There are steps you can take to decrease your chances of being bit by mosquitoes. Steps to reduce mosquito bites include: Make sure that door and window screens do not have holes and fit tightly. Avoid exposing skin at dawn, dusk and in the evenings when mosquitoes are most active. If you must be outdoors during peak mosquito times, wear long-sleeved shirts and pants.
Wearing light coloured clothing is recommended as mosquitoes are attracted to darker colours. Special screen mesh clothing is available in the form of screen jackets, suits and head nets. These are available at most hardware and department stores, as well as camping and outdoor supply shops. There are many insect repellents available. Be sure to read and follow the manufacturers DIRECTIONS FOR USE whenever you use these products. Do not apply insect repellents to children under 2 years of age. Avoid applying repellent to the hands of older children. Spray clothing with repellents containing DEET or permethrin, as mosquitoes may bite through thin clothing.
More information can be obtained at the Health Canada web site: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/info/repell_e.html
POLICIES
Section Contents
Communicable Disease Record Retention Policy Guidelines for Notification of Laboratory Results Payment of Latent Tuberculosis Infection (LBTI) Medication
Chapter 10 Policies NOVA SCOTIA COMMUNICABLE DISEASES MANUAL
Policy: Communicable Disease Records Retention Schedule
Originating Branch: Communicable Disease Prevention and Control Approval Date: October 13, 2011 Review Date: October 2013 Approved by: Provincial Communicable Prevention and Control Committee Chief Medical Officer of Health
POLICY STATEMENT Public Health in the District Health Authorities (DHAs) 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 DHAs 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 DHAs who are involved in filing and maintaining communicable disease and immunization records.
POLICY DIRECTIVES 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 DHAs 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 DHAs are informed about this policy. MONITORING The Public Health Services director or delegate is responsible for monitoring of the implementation of this policy. INQUIRIES Branch/Section: Communicable Disease Prevention and Control Nova Scotia Department of Health and Wellness Email: CDPCRC@gov.ns.ca Tel: (902) 424-6550 Fax: (902) 428-3313
00000
COMMUNICABLE DISEASE
00000
Records documenting outbreaks and individual client identifiable case management information relating to the Notifiable Diseases and Conditions as well as immunization and treatment.
00000 -01 -30 -31 -32 Hepatitis C Case Files -33 -34 -35 -36 -37 -40 -41 -42 -50 -51 Communicable Disease Communicable Disease - General Tuberculosis Case Files Hepatitis B Case Files HIV Case Files Syphilis Case Files Lymphogranuloma Venerum (LGV) Case Files Creutzfeldt-Jakob Disease (CJD) Sexually Transmitted Infection Other Than Hepatitis B, HIV, Syphilis and LGV Case Files CDC Enteric Disease Case Files Food-Borne Disease Outbreak Case Files Disease Outbreak Other Than Food-Borne Case Files Immunization Case Files Adverse Effects Following Immunization (AEFI) Case Files ACT FY+1 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SO+0 SA 2 0 0 0 0 0 0 0 7 7 7 7 0 0 DIS D D D D D D D D D D D D D D
Superseded/Obsolete Definition [File closed / Retention triggered / Deactivation begun]: -30 Infected person dies -31 Infected person dies -32 Infected person dies -33 Infected person dies -34 Infected person dies -35 Infected person dies -36 Infected person dies -37 Infection successfully treated or infected person recovered -40 Disease successfully treated or affected person recovered -41 Outbreak contained or mitigated -42 Outbreak contained or mitigated -50 Inoculated person dies -51 Affected person re-immunized without negative impact
Secondary Scope Notes 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 vaccinepreventable diseases, diseases transmitted through direct contact or respiratory route, and zoonotic disease materials. OPR (Office of Primary Responsibility) [Owner/Custodian/Controller]: Manager for the Communicable Disease Program District
00000-30
Tuberculosis Case Files

Records documenting individual client identifiable case management information relating to tuberculosis. Examples: case report forms (provincial and national); nursing progress notes; contact tracing line list form; lab report (s); chest x-ray report (s), e-mail correspondence; letter(s) to pharmacy regarding billing for medication (s); letter (s) to physician regarding PH recommendations; monthly medication compliance and side effect assessment form; TB skin test result form; ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
00000-31
Hepatitis B Case Files

Records documenting individual client identifiable case management information relating to hepatitis B. Examples: case report form; nursing progress notes; lab report (s); e-mail correspondence; Immune Globulin/Vaccine release form; Immune Globulin/Vaccine reciprocal form; ER reports and other medical documentation (i.e. consult letters), look-back/trace-back forms and nursing notes. OPR: District Manager for the Communicable Disease Program
00000-32
Hepatitis C Case Files

Records documenting individual client identifiable case management information related to Hepatitis C. Examples: case report form; nursing progress notes; lab report (s); e-mail correspondence; vaccine release form; vaccine reciprocal form; ER reports and other medical documentation (i.e. consult letters), look-back/trace-back forms and nursing notes. OPR: District Manager for the Communicable Disease Program
00000-33
HIV Case Files

Records documenting individual client identifiable case management information related to HIV. Examples: case report form (provincial and national); nursing progress notes; lab report (s); e-mail correspondence; HIV strain and drug resistance surveillance form; ER reports and other medical documentation (i.e. consult letters), look-back/traceback forms and nursing notes. OPR: District Manager for the Communicable Disease Program
00000-34
Syphilis Case Files

Records documenting individual client identifiable case management information related to syphilis. Examples: case report form; nursing progress notes; lab report (s); e-mail correspondence; ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
00000-35
Lymphogranuloma Venerum (LGV) Case Files

Records documenting individual client identifiable case management information related to LGV. Examples: case report forms (provincial and national); nursing progress notes; lab report (s); e-mail correspondence; ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
00000-36
Creutzfeldt-Jakob Disease
Records documenting individual client identifiable case management information related to CJD. Examples: case report forms; nursing notes; lab reports; e-mail correspondence; other medical documentation. OPR: District Manager for the Communicable Disease Program
00000-37
Sexually Transmitted Infection Other Than Hepatitis B, HIV, Syphilis and LGV Case Files
Records documenting individual client identifiable case management information related to sexually transmitted infection other than Hepatitis B, HIV, Syphilis and LGV case files. Examples: case report form; nursing progress notes; lab report (s); e-mail
correspondence; letter (s) to pharmacy regarding billing for medication; ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
00000-40
CDC Enteric Disease Case Files

Records documenting individual client identifiable case management information related to CDC enteric disease. Examples: case report forms; nursing progress notes; lab report (s); e-mail correspondence; exclusion and return to work letter (s) to employer; exclusion and return to work letter (s) to employee; notification letter to daycare/school; sporadic communicable disease in returning travelers form; referral form to department of agriculture; national questionnaire (e.g. listeriosis); ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
00000-41
Food-Borne Disease Outbreak Case Files
Records documenting individual client identifiable case management information related to food-borne disease outbreak case files. Examples: case report forms; nursing progress notes; lab report (s); e-mail correspondence; exclusion and return to work letter (s) to employer; exclusion and return to work letter (s) to employee; notification letter to daycare/school; sporadic communicable disease in returning travelers form; referral form to department of agriculture; contact line list form; letter(s) to contacts; epidemiology analysis document (s); ER reports and other medical documentation (i.e. consult letters)
OPR:
District Manager for the Communicable Disease Program
00000-42
Disease Outbreak Other Than Food-Borne Case Files

Records documenting individual client identification case management information relating to outbreaks. Examples: case report forms; nursing progress notes; lab report (s); e-mail correspondence; exclusion and return to work letter (s) to employer; exclusion and return to work letter (s) to employee; notification letter to daycare/school; sporadic communicable disease in returning travelers form; referral form to department of agriculture; contact line list form; letter(s) to contacts; epidemiology analysis document (s); ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
00000-50
Immunization Case Files

Records documenting individual client identifiable case management information related to immunization. Examples: Immunization reciprocal form, MCH9 cards, line listings from HINI clinics and seasonal influenza clinics Immunization consent form, nursing progress notes, email correspondence OPR: District Manager for the Communicable Disease Program
00000-51
Adverse Effects Following Immunization (AEFI) Case Files

Chapter 10 Policies
NOVA SCOTIA COMMUNICABLE DISEASES MANUAL
Records documenting individual client identification case management information relating to an adverse event following an immunization. Examples: AEFI report form, email correspondence, immunization reciprocal form, nursing notes, ER reports and other medical documentation (i.e. consult letters) OPR: District Manager for the Communicable Disease Program
Policy: Payment of Latent Tuberculosis Infection (LTBI) Medication
Originating Branch: Communicable Disease Prevention and Control Approval Date: January 12, 2012 Review Date: January 2015 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. II. POLICY OBJECTIVES To provide Nova Scotians equitable access to LTBI medications. To ensure Public Health within the DHAs have consistent payment processes in place that are both reasonable and cost effective for the public health system. III. POLICY APPLICATION 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.
IV. POLICY DIRECTIVES

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 Payment of LTBI Medication Policy as outlined in the NS Communicable Disease Manual.
V. ACCOUNTABILITY Public Health staff within the DHAs 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 DHAs 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 Branch/Section: Communicable Disease Prevention and Control Nova Scotia Department of Health and Wellness Email: CDPCRC@gov.ns.ca Tel: (902) 424-6550 Fax: (902) 428-3313

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Communicable Disease Control Manual

STANDARD PRECAUTION GUIDELINES

Through the skin.

Through the mucous membranes.

GUIDELINES FOR OUTBREAK MANAGEMENT

GUIDELINES FOR OUTBREAK MANAGEMENT

3. Principles of Outbreak Management

Core Outbreak Team Members

Supplemental Outbreak Team Members

5. Roles and Responsibilities of the Outbreak Team Members

5.2 Role of the CD District/SSA Manager

5.3 Role of the Investigator

5.4 Role of Administrative Support

5.5 Role of the Provincial Public Health Laboratory Network

5.6 Role of the District/Anchor Laboratory

5.7 Role of Communications

5.8 Role of Public Health Services in the District Health Authority

5.9 Role of Nova Scotia Health and Wellness Responsibility Centres

NSDHW Environmental Health Responsibility Centre

NSDHW PHAS Responsibility Centre

Health Service Emergency Management Responsibility Centre

Support the coordination of the response to logistical demands as necessary

Department of Health and Wellness Outbreak Working Group

Role of Other Members

6. Steps in Outbreak Investigation and Management

6.1 Confirm the diagnosis

6.2 Establish an Outbreak Team

6.3 Establish a case definition

6.4 Notify NSDHW

6.5 Develop an interview tool

6.6 Collect information/data

contact with animals, pets, vectors, as appropriate.

6.7 Complete preliminary and ongoing analysis of information

6.8 Develop notifications/alerts

6.9 Develop a communication plan/education

6.10 Implement control measures based on findings

6.11 Document the outbreak as it progresses

6.13 Consider further studies or special investigations

6.14 Determine when the outbreak is over

6.15 Evaluate the outbreak control and management

6.16 Complete final report

6.17 Complete comprehensive final outbreak report

Table 1: Reports Required for Outbreaks

Only if requested Only if requested

6.18 Review reports

7.1 Procedures in the District Health Authority

7.2 Procedures in the Department of Health and Wellness

APPENDIX 1: RECOMMENDED OUTBREAK RESPONSE KIT COMPONENTS

APPENDIX 3: COMPREHENSIVE FINAL OUTBREAK REPORT

V. VI. VII. VIII. IX. X.

II. Introduction and Background

APPENDIX 4: OUTBREAK EVALUATION GUIDE

Interview Document Review

Clinical Services Evaluation Questions

Interview Document Review

Interview Document Review

Interview Document Review

Interview Document Review

Interview Document Review

Challenges in implementing community measures?

Interview Document Review