Abstract
BackgroundIn Norway, it is recommended that children with Shiga-Toxin producing Escherichia coli (STEC) infections are excluded from daycare centers until up to five consecutive negative stool cultures are obtained. Children with gastrointestinal illness of unknown etiology are asked to remain home for 48 hours after symptoms subside. On 16 October 2012, two cases of STEC infection were reported from a daycare center, where other children were also symptomatic. Local health authorities temporarily closed the daycare center and all children and staff were screened for pathogenic E. coli. We present the results of the outbreak investigation in order to discuss the implications of screening and the exclusion policies for children attending daycare in Norway.MethodsStool specimens for all children (n = 91) and employees at the daycare center (n = 40) were tested for pathogenic E. coli. Information on demographics, symptoms and potential exposures was collected from parents through trawling interviews and a web-based questionnaire. Cases were monitored to determine the duration of shedding and the resulting exclusion period from daycare.ResultsWe identified five children with stx1- and eae-positive STEC O103:H2 infections, and one staff member and one child with STEC O91:H- infections. Three additional children who tested positive for stx1 and eae genes were considered probable STEC cases. Three cases were asymptomatic. Median length of time of exclusion from daycare for STEC cases was 53 days (range 9 days – 108 days). Survey responses for 75 children revealed mild gastrointestinal symptoms among both children with STEC infections and children with negative microbiological results. There was no evidence of common exposures; person-to-person transmission was likely.ConclusionsThe results of screening indicate that E. coli infections can spread in daycare centres, reflected in the proportion of children with STEC and EPEC infections. While screening can identify asymptomatic cases, the implications should be carefully considered as it can produce unanticipated results and have significant socioeconomic consequences. Daycare exclusion policies should be reviewed to address the management of prolonged asymptomatic shedders.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-014-0673-2) contains supplementary material, which is available to authorized users.
Highlights
In Norway, it is recommended that children with Shiga-Toxin producing Escherichia coli (STEC) infections are excluded from daycare centers until up to five consecutive negative stool cultures are obtained
Six children were classified as confirmed cases: specimens from five children were positive for E. coli O103:H2, eae and stx1a with identical or similar multiple-locus variable number of tandem repeat analysis (MLVA) profiles, while one child had a specimen that was positive for STEC O91:H- and was stx1a- and stx2b-positive
Three additional children tested positive for eae and stx1 at the local laboratory in mixed fecal culture but the National Reference Laboratory (NRL) was unable to isolate STEC for two of the children and the third child did not have a specimen provided to the NRL
Summary
In Norway, it is recommended that children with Shiga-Toxin producing Escherichia coli (STEC) infections are excluded from daycare centers until up to five consecutive negative stool cultures are obtained. On 16 October 2012, two cases of STEC infection were reported from a daycare center, where other children were symptomatic. Local health authorities temporarily closed the daycare center and all children and staff were screened for pathogenic E. coli. Shiga-toxin producing Escherichia coli (STEC) is a leading cause of gastrointestinal illness, ranging in severity from mild diarrhea to hemorrhagic colitis. Outbreaks of STEC infections in childcare facilities [3,4,5,6,7] pose a particular threat to public health, as children under 5 years old are most frequently diagnosed with infection and are at greatest risk of developing HUS [2]. Epidemiological studies have shown that STEC isolates producing Stx, or both Stx and Stx, are more commonly associated with HUS than isolates producing only Stx1 [8]
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