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When a case of enterohemorrhagic E. coli gastroenteris is reported to SRHD, an Epidemiology Investigator (EI)

follows the General Disease Investigation Guidelines at the beginning of this section, with special attention

to the notes below:

MANAGEMENT OF CASE

1. Verifies the diagnosis with the laboratory that performed the test. 2. Contacts the clinical care provider(s) who made the diagnosis to:

a. Assure they are aware of the test results.

b. Assure they have had the opportunity to inform the patient.

c. Obtain the demographic information necessary to determine whether the case is a Spokane County resident and to make contact with the case.

Note: Although this disease is commonly diagnosed, it potentially may be a bioterrorism (BT) issue. If there is a cluster of cases with an unusual distribution or presentation, or a reason to suspect intentional

dissemination, EI should notify the SRHD Duty Officer, Emergency Response Coordinator, Health Officer, and WA State CD Epidemiology immediately.

3. If the case is a resident of another county or state, refers the case to the appropriate local health jurisdiction or to WA State CD Epidemiology as necessary. Assists other investigators if the case is hospitalized in Spokane.

4. Attempts to make contact with the case. If the case cannot be reached by telephone, a message is left (if possible) requesting the case, case guardian or household member to return the call without specifying the reason for the call. If the case cannot be reached by telephone, sends a letter requesting the case or case guardian make contact with the EI.

5. As information to complete the CD case report is gathered, it is entered into the PHIMS electronic database system. If PHIMS is not available, Epidemiology staff records information on the appropriate form available at Disease Reporting Forms.

6. Stresses to case that all information collected is kept confidential. 7. Questions case about:

a. Food history.

b. Contact with infected pets, livestock, or other animals.

c. Contacts with other people with suspected or confirmed cases of diarrheal disease. d. Water supply.

8. Inquires about water and sewage systems:

a. Single-family well, community well, city water, any problems (off odors, taste), repairs to system; is it functional, when was water last tested?

b. On-site septic system, community sewer or city sewer; how is it functioning, any surfacing sewage?

c. If any concerns, contact SRHD EPH Liquid Waste program staff. 9. Informs case of the disease:

Symptoms: Diarrhea (often bloody), cramping, abdominal pain, malaise, nausea and vomiting. Complications may include Hemolytic Uremic Syndrome (HUS) and Thrombotic Thrombocytopenic Purpura (TTP).

Transmission: Ingestion of the organisms in food, most often undercooked or raw beef (especially ground beef) and raw milk products. Outbreaks have been linked to contaminated drinking water and recreational water, juices, fruits, vegetables, and other food items as well. Person-to-person transmission

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Incubation period: 2-8 days, usually 3-4 days.

Period of communicability: Duration of excretion of pathogen is usually short, but may be prolonged in young children.

Prevention: Thoroughly cooking all foodstuffs derived from animal sources, particularly beef products, and thoroughly washing vegetable foodstuffs consumed raw. Other preventive strategies are not consuming raw/unpasteurized milk or milk products, and carefully handling raw meat to avoid cross- contamination.

Isolation: Standard precautions as well as contact precautions for diapered and incontinent persons. 10. Stresses the importance of thorough hand washing with soap and warm water and safe food handling

practices.

11. In conjunction with SRHD EPH Food Program staff and others as needed, excludes symptomatic cases or symptomatic contacts from sensitive occupations including: food handling, care of people in hospitals, custodial institutions and day-care centers until fecal bacterial shedding is confirmed absent by two consecutive negative stool samples collected 24 hours apart.

12. Refers to APHA ―Control of Communicable Diseases‖ for specific treatment recommendations. 13. Refers case to their personal health care provider if cases have questions regarding treatment. If clinical

care providers request information regarding standard treatment regimens, an epidemiologist can provide them with such general information.

14. When a complete CD case report has been entered into PHIMS (or it is determined that one is not obtainable), the record is submitted electronically to DOH CD Epidemiology. If electronic transmission is not possible, staff sends a hardcopy of the completed report to the DOH Data Compiler. (See Appendix D for address.)

MANAGEMENT OF CONTACTS

1. Obtains a list from the case of all contacts from 10 days before onset of diarrhea until diarrhea is resolved.

2. Interviews contacts to identify possible contaminated food, water, raw milk, or other sources. 3. Informs contacts regarding the disease as above.

4. Advises contacts to seek care immediately through their personal health care provider if they currently are symptomatic or if they become ill.

5. In conjunction with EPH Food Program staff and others, may exclude symptomatic individuals from sensitive occupations including: food handling, care of people in hospitals, custodial institutions and day care centers until fecal bacterial shedding is confirmed absent by two consecutive negative stool samples collected 24 hours apart.

MANAGEMENT OF COMMUNITY (in an Outbreak)

1. Notifies the ERC if indicated, who will coordinate agency-wide activities including any or all of the following as appropriate:

a. Contacts the appropriate EPH staff to assist in investigating the source of infection and mode of transmission.

b. Consults with the SRHD Health Officer to initiate control measures if a common mode of transmission is indicated (i.e. water or food).

c. Initiates an ERNIE Team meeting if indicated.

d. Informs the Department of Health, Washington State Department of Agriculture, FDA, and/or USDA as indicated, if a water supply or food product is indicated as source.

e. Collaborates with the SRHD Public Information Officer to draft a Public Health Press Release if indicated, and submits it to the SRHD Health Officer for approval.

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f. Coordinates with the SRHD Public Information Officer to distribute the Public Health Press Release as outlined in this manual.

g. Coordinates with SRHD Health Officer to issue Provider Alerts to ERs/Urgent Care facilities, primary care facilities, hospitals, labs, nursing homes, or other care providers, if indicated.

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