The EpiNotes Newsletter | Page
Winter 2014
Cover: Colonial morphology displayed by Shigella
boydii bacteria cultivated on a Hektoen enteric
(HE) agar surface. CDC.
The Shigellosis outbreak response toolkit 2
Carbon Monoxide 5
Elevated lead levels in private well water 7
Isolation and Quarantine workshops 8
Employee of the Quarter 9
Contact Us 9
Your moment of Zen 10
PAGE
The
EpiNotes
Newsletter
North Carolina Department of
Health and Human Services
The EpiNotes Newsletter | Page 2
S higellosis is an acute gastrointestinal
illness caused by a species of bacteria in
the genus Shigella. There are four
species of Shigella, including S.
dysenteriae, S. flexneri, S. boydii, and S. sonnei.
Almost all cases reported in North Carolina are
caused by S. sonnei. According to the CDC, there
are approximately 450,000 cases of shigellosis
(72% due to S. sonnei) that occur in the United
States each year, but only 14,000 of these are
laboratory confirmed. Because of the low
infectious dose and significant outbreak
potential, single or multiple cases of Shigella
infection necessitate a prompt and aggressive
response and strict application of control
measures. Outbreaks are known to persist for
weeks or months without appropriate control
measures. This article provides relevant
background information and NC Department of
Public Health guidance for case identification,
management and outbreak control.
Transmission: Shigella bacteria are spread by
fecal-oral transmission. While contamination of a
vehicle (e.g., food or water) by an infected food
handler or bather can happen, the majority of
cases are caused by person-to-person
transmission. Humans are the only reservoir for
Shigella bacteria. The infectious dose for
shigellosis is very small; less than 200 organisms
(Figure 2). As a result, even seemingly minor
breaches in hygiene can result in outbreaks.
Clinical signs and symptoms : Infection with S.
sonnei and S. boydii usually cause relatively mild
illness in which diarrhea may be watery or bloody.
Signs and symptoms of shigellosis range from
asymptomatic or mild symptoms to abdominal
cramping, fever and mild or severe diarrhea.
Diagnosis and Case Classification: Isolation of
Shigella from feces or rectal swabs using
bacterial culture methods is confirmatory. Non-culture
based methods such as PCR, fluorescent
antibody, and enzyme-linked microassay testing
are becoming more common. Non-culture based
diagnostics provide laboratory evidence of
infection, but from a surveillance standpoint,
these cases are classified as suspect cases.
A person with a clinically compatible illness with
direct contact with a confirmed case or a
member of a risk group during an outbreak
meets case definition criteria as a probable case.
Incubation period: The symptoms of shigellosis
usually appear within one to three days of
infection, but may range from 1 to 7 days
between exposure and illness onset.
The Shigellosis Outbreak Response Toolkit
By Nicole Lee, MPH and Carl Williams, DVM
Figure 1
The EpiNotes Newsletter | Page 3
Risk Factors: Anyone can get shigellosis, but it is recognized more often in young children and
frequently associated with children in group settings, including individuals who work at or attend
child care centers. A lack of appropriate hand washing and diapering practice is associated with
an increased risk of transmission of shigellosis in childcare centers. [1]
Period of infectivity: Shigella can be spread for as long as the organism can be isolated from a
person's stool, which is up to four weeks. Certain antibiotics may shorten the shedding phase;
however, Shigellae are frequently resistant to one or more antibiotics.
Preventive measures: Good personal hygiene is the single most important preventive measure.
Frequent and thorough hand washing is essential before
handling food, before eating and after toilet use, especially in
young children who may not be completely toilet trained.
Control of cases: Exclusion until appropriate for re-admission.
Treatment if indicated by clinician; best supported by antibiotic
susceptibility testing. Re-admission based on applicable
regulations, negative testing, or resolution of symptoms
depending on the type of facility attended. Historically, culture
has been required in certain circumstances, but PCR testing is
becoming more widely used and is adequate in some
situations. Education on the importance of personal hygiene,
particularly after using the toilet, and before and after food
handling.
Control of contacts: Identification and testing of symptomatic contacts to identify additional cases
and apply control measures. In situations with 2 or more cases, test all direct contacts of cases
regardless of illness status.
Control of environment: Strict attention should be paid to maintaining environmental cleanliness
and sanitation in childcare centers, institutions and food premises.
Intervention to control or prevent a shigellosis outbreak is dependent on community
collaboration. If an outbreak is beginning or expanding, it is recommended that local health
departments develop a task force to identify the necessary control measures and ensure their
application throughout the community. This has been demonstrated to be an effective means of
addressing and controlling outbreaks. [2] The task force should include, at a minimum:
  Communicable disease nursing staff
  Environmental health staff
  NC Division of Child Development and Early Education staff
  Clinicians
SHIGELLOSIS TOOLKIT|NICOLE LEE
Figure 2
Table 1
The EpiNotes Newsletter | Page 4
  Childcare operators
  School district administrators & nurses
  Public Information Officer
Historical Incidence of Shigellosis Outbreaks in North Carolina
In North Carolina, there have been various outbreaks of Shigella. It has
been established that outbreaks usually cycle every 7 – 9 years.
However, a decreasing trend in disease incidence has been observed
during the past 10 years in North Carolina (Figure 1). The large
outbreak of 1993-1994 primarily affected children and staff at
childcare centers and their household contacts statewide. During that
period, 43% of 4271 reported cases were aged less than 5, and 68%
less than 9 years. Similarly, an outbreak in 2002 also began in
childcare centers and persisted for approximately 18 months, though it
was mostly limited to Mecklenburg County. These outbreaks led to the
development of a toolkit to assist local health departments with
Shigella outbreak response. Childcare centers were the primary type of
facility associated with illness and became the focus of controlling
transmission. The toolkit concentrated on exclusion of the ill,
environmental cleaning, and cohorting.
2013 Shigellosis Outbreak
The most recent outbreak of shigellosis began in September 2013.
Initial cases were reported in an elementary school in Cabarrus County
and quickly spread into the community. By the end of the outbreak,
185 confirmed and probable cases were identified, affecting multiple
schools and childcare facilities in five counties (Figure 3). An additional
116 symptomatic contacts were investigated. Most of the 185 cases
were children and the majority were female. Approximately 5% of cases
were hospitalized; the median duration of illness was 5 days (Table 1).
The shigellosis outbreak toolkit was updated in 2013 based on
activities stemming from the 2013 outbreak, collaboration with CDC,
and updated scientific studies regarding exclusion criteria [3]. The
updated guidance includes the following new recommendations (see
Toolkit for complete list of updates at epi.publichealth.nc.gov):
• Response should be adapted based on whether a community-wide
outbreak is occurring or not.
• Ill childcare attendees who become asymptomatic require one
negative stool instead of two before they can be allowed to return
to childcare.
• A childcare center should be temporarily closed to new admissions after
the report of one positive case. Surveillance for additional cases should
occur for one week, after which normal activities may resume if no
additional cases are identified.
• Ill staff epi-linked to a lab-identified case cannot return to a childcare
facility where one case has been identified until he/she tests negative
according to the testing protocol in the toolkit, per APHA manual. [4]
• Children who are not yet of kindergarten age should be excluded until
one negative stool is obtained.
• A task force should convene before an outbreak to ensure all necessary
partners are on the same page regarding response.
Impact of Shigellosis: Shigellosis cases and outbreaks can last for months
and have a big impact on business operations for childcare centers, schools
and parents. It is essential to communicate a clear and succinct plan to all
community members to foster cooperation and understanding. Outbreaks of
shigellosis are difficult to control and may persist for months, and community
members must be prepared for their impact.
References
1. Shane A, Crump J, Tucker N, Painter J, Mintz E. Sharing Shigella: risk factors and costs of a multi-community
outbreak of shigellosis. Archives Pediatrics and Adolescent Med 2003; 157 601-603.
2. Heymann, D (2008). Control of Communicable Disease Manual. Washington: American Public Health
Association.
3. Shane A, Crump J, Tucker N, Painter J, Mintz E. Sharing Shigella: risk factors and costs of a multi-community
outbreak of shigellosis. Archives Pediatrics and Adolescent Med 2003; 157 601-603.
4. Heymann, D (2008). Control of Communicable Disease Manual. Washington: American Public Health
Association.
SHIGELLOSIS TOOLKIT|NICOLE LEE
Figure 3
The EpiNotes Newsletter | Page 5
T he Occupational and Environmental
Epidemiology Branch (OEEB) provides
routine consultation on exposure
investigations as well as methods to
prevent carbon monoxide (CO) poisonings.
Recently, however, OEEB implemented a
statewide CO-related surveillance system using
near real-time emergency
department and poison
center call data.
Specifically, ED visits
suggestive of CO
poisoning are monitored
using chief complaints as
well as clinical and
exposure information from
calls made to the
Carolinas Poison Center.
These data are
aggregated and compiled
monthly. Reports are
being posted to the OEEB
website (Figure 1).
During 1999-2010, the
CDC reported that 5,149
deaths from unintentional
CO poisonings occurred in
the U.S. (an average of
430 deaths per year). In
addition, each year
approximately 21,000 persons are evaluated in
EDs, and between 2,500 and 4,000 patients are
hospitalized.
CO is produced from the incomplete combustion
of fuels such as gasoline, diesel fuel, liquefied
natural gas, kerosene, propane, wood, and
charcoal. Equipment that uses these fuels
include, but are not limited to, forklifts, power
washers, concrete saws, gas-powered floor
buffers, small gasoline engines, grills, cook
stoves, water heaters and dryers, portable
generators, and unvented heaters, all of which
generate CO. Prior use of the equipment without
any problems may provide a false sense of
safety. It is important to follow basic safety
precautions when working with or around these
types of equipment, especially in enclosed
spaces. More detailed prevention guidance can
be found on both the OEEB and CDC websites
(see resource section at the end of this article).
Exposure to CO may cause the following
symptoms: headache, dizziness, weakness,
nausea, vomiting, chest pain, and confusion.
Exposure to high levels of CO can quickly cause
unconsciousness and can result in death.
Carbon monoxide alarms are life safety devices,
intended to provide
additional warning beyond
smoke detectors about
potentially hazardous
conditions. Carbon
monoxide alarms should be
installed and maintained in
every residential dwelling
following manufacturer’s
instructions. North Carolina
General Statute Chapter 42
Article 42 requires that
owners install a carbon
monoxide alarm in every
residential rental dwelling
containing fuel burning
appliances or equipment.
The North Carolina Building
Code requires carbon
monoxide alarms in all
residences built after
2009. Effective October 1,
2013, the General
Assembly amended North
Carolina General Statute 143-138 to require
carbon monoxide alarms if combustion sources
are present in lodging establishments. Industrial
grade CO monitors should be installed where
combustion powered equipment or power tools
are used indoors or in confined spaces.
Carbon Monoxide: From the Basics to Syndromic Surveillance
By David Lipton, MSPH CIH and Ricky Langley, MD MPH
Figure 1. ED visits related to unintentional non-fire related
CO poisoning by month/year, North Carolina. An increase in
ED visits from May to June 2013 was largely due to a CO leak
at a production plant resulting in 28 ED visits.
The EpiNotes Newsletter | Page 6
To prevent overexposure to CO
• Keep combustion equipment properly maintained.
• Combustion products from fixed equipment should be
properly vented to the outside and away from
buildings, especially doors, windows, or air intakes.
• Do not use fuel-burning mobile or portable equipment
in enclosed spaces without adequate ventilation.
• Substitute electric-powered or alternative (using non-combustible
fuel) equipment if possible.
• Limit the amount of time combustion equipment is
operated indoors.
• Industrial grade CO monitors should be installed where
combustion powered equipment or power tools are
used indoors or in confined spaces.
• Every residential dwelling should have a carbon
monoxide alarm meeting current UL™ standards.
Steps for people responding to an emergency
• If a person has symptoms or is unconscious, be aware
that hazardous gases such as CO may be present. Do
NOT make yourself a victim!
• Use appropriate personal protective equipment (see
CDC website).
• Use ventilation to remove possible toxic gases.
• Remove victim to a safe area with fresh air.
• Transport victim to an emergency facility for further
medical evaluation.
Resources:
  Occupational and Environmental Epidemiology Branch,
CO Poisoning webpage: http://epi.publichealth.nc.gov/
OEE/A_Z/CO.HTML
  CDC, Carbon Monoxide webpage: http://www.cdc.gov/
CO/FAQS.HTM
  Consumer Products Safety Division, Guidelines for
Responding to Carbon Monoxide Incidents. Available
at: http://www.cpsc.gov/PAGEFILES/117067/
COGUIDE.PDF & Questions and Answers available at:
http://www.cpsc.gov/en/Safety-Education/Safety-
Education-Centers/Carbon-Monoxide-Information-
Center/Carbon-Monoxide-Questions-and-Answers-/.
CARBON MONOXIDE|DAVID LIPTON & RICKY LANGLEY
The EpiNotes Newsletter | Page 7
I n December 2012, the North Carolina
Division of Public Health (NC DPH) received
a report from a western North Carolina
county health department of elevated lead
levels (ELLs) in water samples from 55 (14%) of
398 private wells installed between 2008 and
2012. ELL is defined as a lead level greater than
or equal to the U.S. Environmental Protection
Agency’s (EPA) Action Level (AL) for Treatment
Technique of 15 parts per billion (ppb) for lead
in drinking water. All 55 wells therefore had
initial lead levels above EPA’s Maximum
Contaminant Level Goal (MCLG) of zero ppb (a
non-enforceable health goal). New wells in NC
are tested for microbial and inorganic
contaminants within 30 days of being newly
constructed pursuant to legislation adopted by
the NC General Assembly in 2008. Of the 55
wells with ELLs, 41 (75%) were above the AL
(range, 16 – 191 ppb), while the remaining wells
had lead levels at or near the AL. NC DPH and
the county health department began an
investigation to 1) re-sample the wells with ELLs
constructed since 2008, and 2) determine the
source of potential lead contamination.
These ELLs were brought to our agency’s
attention by this county after a resident
requested well water testing after elevated iron
levels were noted soon after the well was
constructed in 2010. The initial lead level was
191 ppb. The well water was re-sampled in June
2012 and the lead level (34 ppb) was found to
be more than twice the AL. The water from the
well was sampled again a month later and found
to have an even higher lead level (55 ppb). The
county then began an examination of lead levels
in well water around this locale.
During April–May 2013, 41 (75%) of the 55
wells with initial ELLs were re-sampled. Twenty
(49%) of 41 wells continued to demonstrate
ELLs at the well head. However, only three of 20
wells had ELLs at the well head after flushing
the system by allowing the water to run for five
minutes. Thirteen (32%) of the 41 well water
samples still had lead levels greater than the
MCLG after the water had been allowed to run
for one minute at the kitchen tap and 5 (38%) of
these 13 samples had ELLs. However, when the
water had been allowed to run for more than
one minute at the kitchen tap, none of the 41
samples were above the AL and only two wells
continued to have lead levels greater than the
MCLG.
All households using wells with initial ELLs were
advised to consult their health care providers for
testing of blood lead levels in children.
Households with ELLs at the well head or
kitchen tap re-sampling were advised to let the
water run in the morning for a specified period
of time as determined by the level of lead
detected in their water before drawing water for
drinking. The two households with lead levels
that continued to be greater than zero even
after flushing at the kitchen tap were advised to
drink bottled water and obtain information from
their county health department about other
measures to reduce lead in their drinking water
(e.g., filters, piping replacement).
Potential sources of lead contamination in well
water include plumbing at the well (e.g., the
“drop pipe” that carries water from the
submersible pump in a well up to the surface),
well pumps, solder, wells casings, and indoor
plumbing fixtures. Lead may enter the water as
a result of corrosion of these plumbing systems.
The water’s acidity may influence the amount of
lead in the water (US EPA, 2012) and cause
piping corrosion; however, we did not observe
any considerable trends of low pH among re-sampled
wells. Five wells had lead levels greater
than the MCLG at the kitchen tap, but no lead
was found at the well head, indicating that lead
may be leaching from the plumbing fixture
dispensing the water from the tap.
Elevated Lead Levels in Private Wells, Western NC, 2013
By Nirmalla Barros, PhD MPH
The EpiNotes Newsletter | Page 8
While no existing wells were disassembled and tested, drop piping from
a local drill yard was sampled to represent piping used for wells in this
county. Four samples of imported galvanized steel pipes and one
sample of U.S.-made galvanized steel pipes were tested. Two of the
imported drop pipe samples had lead levels ranging from 8 to 7,800
mg/kg with more than 300 times the lead level of 20 mg/kg in the U.S.-
manufactured drop pipe. Although the imported piping met the definition
of “lead-free” for piping providing water for human consumption as
required by the Safe Drinking Water Act, there were visible differences in
integrity of the galvanic coating between the imported and domestic
sources of piping, suggesting that lead could potentially be leaching
from the drop piping.
Building code rules in NC do not cover plumbing at the well. For
example, continuous plumbing from the well pump to within 5 feet of the
house or other structure is not subject to any inspection or regulatory
oversight. Therefore, in NC, inspections of construction quality and well
piping integrity are not conducted. Local health departments in NC
permit and inspect private drinking water wells based on state well
construction rules. Discussions with state agencies have been ongoing
to add well plumbing specifications to the state’s building code rules.
Reference
US EPA (US Environmental Protection Agency). Basic information about
lead in drinking water. Last updated on March 6, 2012. Available at
http://water.epa.gov/drink/contaminants/basicinformation/lead.cfm.
Accessed on October 8, 2013.
Regional Isolation and
Quarantine Workshops
By Aaron Fleischauer, PhD MSPH
D uring November and December 2013, the Public Health
Preparedness and Response branch facilitated four regional
isolation & quarantine (I&Q) workshops for local health departments.
The goals for these workshops were to 1) describe the legal authorities
and jurisdictional responsibilities for isolation and quarantine; 2)
understand the state mass I&Q template and how to adapt it to local
jurisdictions’ needs and requirements; and 3) define the partners
involved in supporting mass I&Q and draft a local plan to engage those
partners.
I&Q methods have been
used throughout history to
control disease spread. In
the U.S., I&Q authority is
derived from the police
powers granted to states in
Article 6 of the U.S.
Constitution. In North
Carolina, General Stature
§130A-145 empowers both
the state and local health
directors to exercise their
authorities to isolate and/or
quarantine individuals “only
when and so long as the
public health is endangered,
all other reasonable means
for correcting the problem
have been exhausted, and
no less restrictive
alternative exists.”
NC DPH and local health departments routinely exercise their isolation
and, to a lesser extent, quarantine authority. Most commonly this occurs
in TB case investigations and treatment management.
I&Q has also been employed during recent outbreaks to control disease
transmission. During the 2013 measles outbreak, approximately 72
quarantine orders were issued to susceptible contacts. Developing
county-level mass I&Q plans will further enhance our capacity to respond
to future outbreaks and pandemics.
Reference
Moore J. THE NORTH CAROLINA PUBLIC HEALTH SYSTEM’S ISOLATION AND
QUARANTINE AUTHORITY. Health Law Bulletin. 2006; No. 84. Available at: http://
sogpubs.unc.edu//electronicversions/pdfs/hlb84.pdf?
LEAD|NIRMALLA BARROS
The difference between
quarantine and isolation is:
Isolation applies to people
who are known to be ill with
a contagious disease.
Quarantine applies to
people who have been
exposed to a contagious
disease, but who may or may
not become ill.
The EpiNotes Newsletter | Page 9
Employee of the Quarter: Eric Davis
E ric Davis coordinates the STD/TB drug shipment program for the Communicable
Disease Branch and has worked tirelessly over the last eight months to improve
this program and make it more efficient. During this time period, Mr. Davis
1) Surveyed all local health departments to get appropriate contact information to
prepare them to register appropriately with HRSA; 2) Conducted research to answer
many questions from LHDs about the availability of 340 B pricing on STD/TB drugs
to enable them to use these drugs as allowed by HRSA; and 3) Worked with a
contract pharmacy to ensure that all LHDs have the ability to order 340 B pricing to
allow drugs to be purchased at a discount.
Mr. Davis’ work with Cardinal Health enabled the CD Branch to save thousands of
dollars in drug costs by ensuring that we can receive discount pricing on all STD and
TB drugs ordered. His work with HRSA to appropriately register all local health
departments in NC with HRSA will enable them to take control of their own STD/TB
drug orders in the future.
Pictured from L-R: John Peebles, Pete Moore, Recipient Eric Davis, and Dr. Davies
Epidemiology Section Offices
Communicable Disease Branch
(24/7 on-call)
919-733-3419
HIV/STD Program
919-733-7301
TB Program
919-733-7286
Occupational & Environmental
Epidemiology Branch
919-707-5900
Public Health Preparedness
and Response
919-715-0919
PHPR Emergency 24/7
919-820-0520
Rabies Emergency
(Nights, Weekends, Holidays)
919-733-3419
State Laboratory of Public Health
919-733-7834
The EpiNotes Newsletter | Page 10
The EpiNotes Newsletter Editorial Team
Lead Editor: Aaron Fleischauer, PhD MSPH
Co-editors: Jean-Marie Maillard, MD MSc and Megan Davies, MD
Editorial Board: Julie Casani, MD MPH; Jean-Marie Maillard, MD MSc; Evelyn Foust, MPH; and Mina Shehee, PhD
State of North Carolina │ North Carolina Department of Health and Human Services
North Carolina Division of Public Health │ Epidemiology Section
www.ncdhhs.gov
N.C. DHHS is an equal opportunity employer and provider. 7/13