Documente Academic
Documente Profesional
Documente Cultură
Infectious Diseases
THE
BLUE
BOOK
Acknowledgements
Editorial Committee
Dr John Carnie
Dr Kath Taylor
Dr Rosemary Lester
Dr Sally Ng
Ms Sheila Beaton
Ms Pam Norris
Sr Anne Murphy
Dr Graham Rouch
(040AP96)
ii
Disclaimer
iii
Contents
Anthrax 15 Hepatitis A 71
Botulism 23 Hepatitis E 87
Cholera 35 Influenza 95
Cryptosporidiosis 41 Legionellosis 99
v
Malaria 113 Rubella 173
Information Sheet 117
Salmonellosis 177
Measles 119
Scabies 181
Meningococcal Infections 123 Information Sheets 183
Information Sheet 127
Shigellosis 185
Meningoencephalitis 129
Streptococcal Disease Caused by
Mumps 131 Group A Beta-Haemolytic
Streptococcus 187
Mycobacterial Infections 133
Tuberculosis 133 Ta e n i a s i s 189
Atypical (Non-Tuberculosis) 139
Te t a n u s 191
Pediculosis/Headlice 141 NH&MRC Recommendations 192
Information Sheet 143
To x o p l a s m o s i s 193
Pertussis 145
Typhoid/Paratyphoid 195
Plague 149
Ty p h u s 199
Pneumonia due to Chlamydia
pneumoniae 153 Verotoxin Producing E. coli 201
vi
Appendix 3: Outbreak
Investigation 221
Appendix 6: Management of
Needlestick Injury and Exposure
to Blood or Body Fluids 227
Appendix 8: Infections in
Children’s Services Centres 237
vii
Introduction
Infectious diseases still occur frequently throughout the A case of any of these diseases should be notified to
world and constant vigilance is required to prevent the Human Services, Victoria, by telephone or facsimile upon
reappearance of diseases thought to have been con- initial diagnosis (presumptive or confirmed) and written
quered. Changes in lifestyle have also led to the emer- notification should follow within seven days. Notification
gence of new threats to public health from infections. forms are available from the Department:
Telephone (03) 9616 7777.
Health authorities depend on medical practitioners for
information on the incidence of infectious diseases and The telephone numbers for notification of diseases are:
notification is vital in efforts to prevent or control the Infectious Diseases Unit (03) 9616 7777 or 1800 034 280.
spread of infection. Fax: (03) 9616 8329 (Attention: Chief Health Officer).
After hours, contact the duty medical officer.
Telephone the paging service on (03) 9625 5000 and
The Health (Infectious Diseases) Regulations 1990
give pager number 46870.
replaced the outdated legislative provisions relating to
such diseases.
Group B Diseases
Notifiable infectious diseases are to be found in schedule
Amoebiasis.
2 of the Regulations and are divided into four groups on
Arbovirus infections (except for Australian
the basis of the method of notification and the information
Arboencephalitis and Yellow Fever).
required.
Brucellosis.
Campylobacter infection.
Group A Diseases Giardiasis.
Anthrax. Hepatitis B.
Botulism. Hepatitis C.
Hepatitis non-A non-B.
Cholera.
Hepatitis (viral, unspecified).
Diphtheria.
Hydatid disease.
Food-borne and water-borne illness (two or more related
Leprosy.
cases).
Leptospirosis.
Legionellosis.
Listeriosis.
Measles.
Malaria.
Meningitis or epiglottitis due to Haemophilus influenzae.
Mumps.
Meningococcal infection.
Pertussis.
Plague.
Psittacosis (Ornithosis).
Poliomyelitis.
Q Fever.
Primary amoebic meningo-encephalitis.
Rubella (including congenital Rubella).
Rabies.
Salmonellosis.
Typhoid and Paratyphoid fevers.
Shigellosis.
Typhus.
Taeniasis (tape worm infections).
Viral haemorrhagic fevers.
Tetanus.
Yellow Fever.
Tuberculosis.
Yersiniosis.
1
Note Laboratory Notification
For these, written notification only is sufficient, within
Around Australia and overseas, it has been recognised
seven days of confirmation of diagnosis.
that laboratory notification of infectious diseases should
be an integral part of any disease surveillance system.
Group C Diseases
Chancroid. The Health (Infectious Diseases) Regulations 1990
Donovanosis. require notification from laboratories under the
Gonorrhoea (all forms). circumstanceslisted below.
Lymphogranuloma venereum.
Other Chlamydial infections. A. Food and Water Supplies
Syphilis (all forms).
Isolate the following pathogens from food for human
consumption or from water supplies:
Note
• Campylobacter jejuni.
These sexually transmissible diseases should be notified
• Listeria monocytogenes.
using the same notification form but, to preclude identifi-
• Salmonella species.
cation of the patient, only the first two letters of the given
name and surname of the patient are required.
Isolate the following pathogens from water supplies:
• Campylobacter coli.
Not all chlamydial diseases are STDs.
• Campylobacter lari.
• Vibrio cholerae.
Group D Diseases • Giardia cysts.
Acquired lmmunodeficiency Syndrome. • Cryptosporidium oocysts.
HIV was made notifiable in September 1996.
Detection of any of the above organisms should be
Note notified in writing to Human Services within seven days,
Written notification is required within seven days of stating the pathogen isolated, the source, the date of
confirmation of diagnosis. isolation, and any batch identification (if appropriate).
Send all notifications to: If the disease is in Group A, the notification should be
Freepost 547 made by telephone or other rapid transmission.
Infectious Diseases Unit
Public Health Branch If the disease is in Groups B or C, Human Services
GPO Box 4057 should be notified in writing within seven days.
Melbourne 3001
and mark them Confidential.
2
The notification from the laboratory should state the
laboratory finding, the family name and given name of
the patient (except for Group C diseases); the age, sex
and postcode of the patient; and the name, address and
telephone number of the doctor requesting the test.
3
Abbreviations Used
5
Acquired Immunodeficiency Syndrome
7
Mode of Transmission Presence of other sexually transmitted diseases, espe-
cially those causing genital ulceration, increases suscep-
HIV can be transmitted by:
tibility for sexual transmission.
• Unprotected sexual intercourse with an infected
person.
• Inoculation with infected blood, blood products and Control of Case
through transplantation of infected organs, bone graft,
Standard fluid precautions apply to all patients.
tissue or semen.
• From infected woman to the foetus during pregnancy
Additional precautions apply for specific infections that
or breastfeeding. Approximately 15 to 30 per cent of
occur in AIDS patients.
infants from HIV positive mothers are infected, but
treatment during pregnancy can result in a marked
Concurrent disinfection of equipment, contaminated with
reduction in infections.
blood or body fluids.
• Needle-stick injuries or other exposure to blood and
body fluids by health care or emergency workers. The
Patients and their sexual partners should not donate:
rate of seroconversion following a needle stick injury
• Blood.
involving HIV infected blood is said to be less than 0.5
• Plasma.
per cent.
• Organs for transplantation.
• Tissues.
Note
• Cells.
Social contact with HIV infected person carries no risk of
• Semen for artificial insemination.
transmission.
• Breast milk for human breast banks.
Incubation Period All HIV positive persons should be evaluated for the
presence of tuberculosis.
From infection to primary illness, three weeks to three
months.
Tre a t m e n t
The time from HIV infection to the diagnosis of AIDS
Zidovudine (AZT), dideoxycytidine (DDC) and
ranges from about two months to 20 years or longer, with
dideoxyinosine (DDI) are the current anti-retroviral drugs
a median of 10 years.
available in Australia specifically indicated for HIV
infection.
Treatment lengthens the incubation period.
8
Control of Contacts Epidemic Measures
If a person is diagnosed as having HIV infection, the HIV infection is usually pandemic.
diagnosing practitioner has a responsibility to ensure that
sexual and needle-sharing contacts are followed up.
Assistance with partner notification may be provided by
International Measures
Human Services through its partner notification officers: A global prevention and control program coordinated by
telephone (03) 9482 5700. WHO was initiated in 1987.
Pre- and post-test counselling should be provided for all Currently all countries have developed AIDS prevention
contacts who seek HIV testing. and control programs.
Preventive Measures
Personal:
• Public education on the use of condoms and safer sex
practices.
• Public education should stress that having unprotected
sex with multiple sexual partners and sharing needles
(drug users) increases the risk of infection with HIV.
• Sexual intercourse with persons with known or sus-
pected HIV should be avoided.
• HIV-infected persons should be offered confidential
counselling.
• Care sould be taken when handling, using and dispos-
ing of needles or other sharp instruments.
• Use of needle exchange programs by injecting drug
users.
Institutional:
• Use of appropriate infection control measures by all
health care and emergency workers.
• Use of appropriate infection control measures in all
premises where skin penetration is carried out; for
example, by tattooists or beauty therapists carrying out
electrolysis.
• Blood and blood products for transfusion and tissues
for donation should be tested for HIV infection.
• Needle-stick/sharps injuries and parenteral exposure
to laboratory specimens containing high titre of virus
should be dealt with according to the Australian
National Council on AIDS guidelines.
9
Acute Bacterial Conjunctivitis
Infectious Agent
Haemophilus influenzae, Streptococcus pneumoniae. Incubation Period
Usually 24–72 hours.
Other organisms include:
• Staphylococcus aureus, Pseudomonas aeruginosa.
Period of Communicability
• Neisseria gonorrhoeae in neonates.
It is infectious while there is discharge.
Clinical Features
Susceptibility and Resistance
Excessive tears, irritation and redness of eyes, followed
Children under five years are most often affected.
by oedema of lids, photophobia and mucopurulent
Incidence decreases with age.
discharge which usually lasts from two days to two to
Immunity after attack is low-grade.
three weeks.
Oc c u r re n c e
A common communicable disease, frequently epidemic, Tre a t m e n t
affecting children under five years of age. Local application of antibiotic ointment or drops.
Occurrence is worldwide.
Control of Contacts
Investigation of contacts and source of infection not
Method of Diagnosis practicable.
Microscopic examination of a smear or bacteriologic
culture of the discharge.
Preventive Measures
Personal hygiene and proper treatment of infected eyes.
Reservoir
Human.
Epidemic Measures
Not applicable.
11
Amoebiasis
Incubation Period
High-risk groups include:
Average incubation period is two to four weeks.
• Patients in institutions for the intellectually disabled.
• Male homosexuals.
Patients may present months after the initial infection.
• People living in areas with poor sanitation.
• Travellers returning from developing countries.
13
Period of Communicability • Educate the public about the possibility of transmitting
the disease via sexual contact.
Cases are infectious as long as cysts are present in the
• Protect public water supplies from faecal contamina-
faeces.
tion.
Tre a t m e n t
For acute amoebic dysentery, use metronidazole. After
initial treatment of invasive amoebiasis with metronida-
zole, cyst eradication with furamide may be indicated.
Control of Contacts
Routine investigation of contacts is not indicated. How-
ever, in residential institutions or in the case of fellow
travellers, microscopic examination of faeces is advis-
able.
Preventive Measures
• Educate the public in personal hygiene.
• Provide information to intending travellers about the
risk involved in eating uncooked vegetables and fruits
and drinking contaminated water.
14
Anthrax
16
Arbovirus Infections
17
Reservoir All family members should be questioned about symp-
toms and evaluate serologically if appropriate.
Probably macropods (for example, kangaroos); possibly
other marsupials and wild rodents.
Preventive Measures
Transovarian transmission in the mosquito Aedes vigilax Ross River virus can be prevented by:
has been demonstrated in the laboratory, making an • Mosquito control measures (see local municipality).
insect reservoir a possibility. • Personal protection measures (long sleeves and
mosquito repellents).
Mode of Transmission • Avoidance of mosquito-prone areas. Vectors usually
bite at dusk and dawn.
It is transmitted by mosquitoes Culex annulirostris, Ae.
camptorhynchus. Ae. vigilax, Ae. polynesiensis and other
Aedes spp. of mosquitoes. Epidemic Measures
• Conduct a community survey to determine species of
Incubation Period vector mosquitoes. Identify their breeding places and
promote their elimination.
Usually three to 11 days.
• Use mosquito repellents for persons exposed because
of occupation or otherwise to mosquito bites.
Period of Communicability
• Identify the infection among animal reservoirs; for
There is no evidence of transmission from person to
example, kangaroos, small marsupials, farm and
person.
domestic animals.
Control of Contacts
Unreported or undiagnosed cases should be searched
for in the region where the patient had been during the
incubation period of their illness.
18
Australian Arboencephalitis (AE) During the 1974 epidemic, of those affected, one-third
died, one-third were left with residual brain damage, and
Infectious Agent
one-third recovered completely.
Murray Valley Encephalitis (MVE) virus. Kunjin virus may
also cause an encephalitic illness indistinguishable from
Method of Diagnosis
AE.
Serology: Two blood specimens are required seven to10
days apart. Sera for diagnosis should be sent to the
Clinical Features
Director of Virology, VIDRL, preceded by telephone
Fever, headache and sometimes nausea and vomiting, contact via the Royal Melbourne Hospital on (03) 9342
followed by the features of encephalitis. 7000.
19
Investigate the source of infection. Search for unreported
or undiagnosed cases of encephalitis from the
Murray-Darling drainage basin.
Control of Contacts
Not applicable.
Preventive Measures
• Apply mosquito control measures (local municipalities).
• Use personal protection measures (long sleeves, long
trousers, mosquito repellents and so on).
• Avoid mosquito-prone areas; vectors usually bite at
dusk and dawn.
Epidemic Measures
See the Victorian Arbovirus Task Force Contingency Plan
for outbreaks of AE for details.
20
Dengue Method of Diagnosis
Infectious Agent Serology: Rising titre to Dengue virus antibodies.
Dengue virus 1, 2, 3 and 4 (flavivirus).
Reservoir
Clinical Features Humans and monkeys (in most cases monkeys play no
Dengue Fever (Break Bone Fever) role).
Classically, dengue fever presents as an acute febrile
illness of sudden onset. Mode of Transmission
It is transmitted by the bite of an infected mosquito
It is characterised by fever (three to five days), myalgia, usually Ae. aegypti and Ae. albopictus. (Other Aedes
arthralgia, retro-orbital pain, anorexia, gastrointestinal species are involved in the enzootic monkey complex).
disturbance, rash and increased vascular permeability
(see below).
Incubation Period
Usually three to 14 days; commonly seven to 10 days.
Dengue Haemorrhagic Fever (Dengue
Shock Syndrome)
Susceptibility and Resistance
In contrast to classic dengue, myalgia and bone pains
are unusual in dengue haemorrhagic fever which is a There is universal susceptibility but children usually have
disease of abrupt onset characterised by fever, palpable a milder primary disease than adults.
O c c u r re n c e
Outbreaks of this disease have occurred throughout the Control of Case
tropics and over the past 40 years. • Isolate patient and prevent mosquito access until fever
subsides.
A complication, dengue shock syndrome, is believed to • Investigate source of infection.
be caused by immune enhancement of infection, in
which dengue antibodies from prior infections appear to Preventive Measures
promote the infection of other serotypes.
• Search for and eliminate breeding sites of Aedes aegypti.
• Use mosquito repellents, mosquito nets and other
Outbreaks of dengue have occurred in Northern Australia
methods of personal protection.
but have been limited by the distribution of Aedes aegypti.
• Control Aedes aegypti near airports.
• Prevent importation of new vectors; for example, Aedes
The detection of larvae of Aedes albopictus (a potential
albopictus.
vector overseas) on one occasion in South Australia in
imported car tyres is cause for concern.
21
Kunjin Incubation Period
Infectious Agent Uncertain, probably weeks.
Mode of Transmission
Culex annulirostris is the major vector of the Kunjin virus.
22
Botulism
botulism are due to colonisation by the causative organ- scribed in the US literature as a source of infection but
ism. never implicated in Australia, nor have surveys of Aus-
tralian honey shown C. botulinum.
23
Incubation Period Investigation of contacts and source of toxin and search
for other cases of botulism to rule out food-borne botu-
Within 12–36 hours (sometimes several days) after eating
lism.
contaminated food.
In general, the shorter the incubation period, the more Specific Treatment
severe the disease and the higher the case fatality rate.
Intravenous and intramuscular administration as soon as
possible of trivalent botulinum antitoxin (types A,B,E).
Period of Communicability This is available from Centers for Disease Control,
Atlanta. Limited supply is available from Commonwealth
There are no instances of secondary person-to-person
Serum Laboratories for use in hospitalised patients.
transmission have been documented.
24
Epidemic Measures
• Investigate home-preserved foods as prime source of
single case or suspect group outbreak (for example,
family).
• Recall any food implicated by epidemiologic or labora-
tory findings immediately.
• Submit food for laboratory examination.
• Take sera and faeces from cases (and exposed but not
ill persons) for reference laboratory examination,
before administration of antitoxin.
• Undertake international efforts, if necessary, to recover
and test implicated foods.
• This should be coordinated through the:
Australia New Zealand Food Authority
PO Box 7186
Canberra MC
ACT 2610
Tel: (06) 271 2222
25
B r u c ello sis
Method of Diagnosis
Subclinical and unrecognised infections are frequent.
Laboratory diagnosis is made by either isolating the
infectious agent from blood, bone marrow or other
Fever is the most common symptom and may be associ-
tissues or discharges of the patient, or by a specific
ated with a variety of other complaints.
antibody response.
Oc c u r re n c e
Since the success of the national eradication campaign Incubation Period
for B. abortus in cattle herds in 1989, only an occasional Variable and difficult to ascertain.
case of brucellosis is now seen which is usually acquired
overseas. In 1992, 29 cases were reported in Australia. Usually five to 60 days; can be several months.
The majority of these (25) were due to B. suis, contracted
in Queensland, often by people hunting or butchering
feral pigs. Mode of Transmission
Brucellosis can be transmitted by contact with infected
In Victoria in 1991, two cases of B. abortus were re- tissues, blood, urine, vaginal discharges, aborted animal
ported, and both were believed to be long-standing foetuses and especially placentae; also by ingestion of
infections. One case notified in 1992 was an imported raw milk and dairy products from infected animals.
case due to B. melitensis.
27
Epidemics are generally attributed to inhalation of Epidemic Measures
aerosols.
Trace source of infection.
Period of Communicability
There is no evidence of communicability from person to
person.
Control of Case
• Treat with rifampicin and doxycycline for at least six
weeks.
• Inform the Department of Agriculture.
Preventive Measures
• Educate the public against drinking untreated/unpas-
teurised milk or eating dairy products produced from
such milk. Boiling milk is effective when pasteurisation
is not available.
• Educate farmers and handlers of potentially infected
animals (for example, feral pigs) to reduce exposure
and exercise care in handling placentae, discharges
and foetuses.
• Search for and investigate livestock at risk of infection.
28
Campylobacter Infection
Victorian Statutory All age groups are affected, most commonly children
less than five years of age and young adults. In devel-
Re quirem ent
oped countries, asymptomatic carriage is probably rare.
Group B notification.
29
Period of Communicability Control of Contacts
Cases are infectious throughout their illness. The diagnosis should be considered in symptomatic
contacts.
Excretion of organisms may continue for some weeks
after symptoms resolve.
Preventive Measures
• Ensure scrupulous hand washing and hygiene, espe-
Susceptibility and Resistance cially in food handlers.
Most persons in the developed world are susceptible. • Thoroughly cook all meat and, particularly, poultry and
avoid recontamination after cooking.
Immunity to serologically related strains may follow • Thoroughly wash utensils used to prepare raw meats
infection. and poultry before using them to prepare non-cooked
food such as salads.
• Pasteurise milk and chlorinate water.
Control of Case • Recognise pets as sources of infection and encourage
• Report case to Department of Human Services. hand washing after handling animals.
• Immediately report clusters of cases by telephone or • Minimise contact with poultry and their faeces.
fax.
• Investigate related cases or outbreaks to identify a
common source.
• Use Standard Precautions for hospitalised patients.
• Exclude infected children from child care centres until
diarrhoea has ceased.
• Exclude symptomatic persons from food handling, care
of patients in hospitals, or care of infants in child care
centres.
• Exclude asymptomatic convalescent stool-positive
individuals if strict attention to personal hygiene cannot
be assured.
• Stress hand washing/personal hygiene education.
• Do not share towels, washers or personal items such
as toys that may be contaminated.
Tre a t m e n t
Antibiotics (for example, erythromycin) are indicated for
severe illness or where prompt termination of faecal
excretion of organisms is desired.
30
Chicken Pox/Herpes Zoster
A common complication in children with chicken pox is Public Health Significance and
bacterial superinfection of the skin. Other complications O c c u r re n c e
include aseptic meningitis, encephalitis and Reye’s Chicken pox is a highly contagious but generally mild
syndrome. Varicella pneumonia may be a complication in disease and is endemic in the population. It becomes
adults. Those at risk of a more severe form of infection epidemic among susceptible individuals mainly during
are children who have acute leukaemia and those in winter and early spring. More than 90 per cent of cases
remission following chemotherapy. are children aged one to 14 years.
Herpes zoster in the immunosuppressed host is more Herpes zoster, a sporadic disease, is the consequence
severe and prolonged than in the normal individual; for of reactivation of a latent virus from the dorsal root
example, those who have received a bone marrow ganglia. It is most commonly seen in the elderly.
transplant, those with Hodgkins disease, non-Hodgkins
lymphoma or HIV infection.
Method of Diagnosis
A most debilitating complication of herpes zoster in all Clinical: Isolation of the virus in cell cultures or visualisa-
patients is pain associated with acute neuritis and post- tion by electron microscopy (EM) is not routinely re-
herpetic neuralgia and hyperaesthesia; the latter persists quired.
for months after resolution of the disease.
31
Serological: Susceptibility
• Complement fixation tests showing detectable IgM
Universal among those not previously infected but the
antibody.
disease is more severe in adults. Infection remains latent
• Immunofluorescence on lesion swab/fluid.
and may occur years later as shingles in some older
• ELISA (kit) now more commonly used.
adults.
32
Preventive Measures
Immunosuppressed individuals should be protected from
exposure.
Epidemic Measures
Not applicable aside from protection of
immunosuppressed.
33
Cholera
35
Reservoir Infection results in a rise in agglutinating, vibriocidal and
antitoxic antibodies with increased resistance to reinfec-
Water and humans.
tion.
Incubation Period Terminal cleaning of the room and articles used by the
From a few hours to five days; usually two to three days. patient is required.
By the end of the first week, 70 per cent of patients are Patients with severe dehydration require urgent intrave-
non-infectious, and by the end of the third week 98 per nous fluid therapy with Hartmann’s solution or WHO
cent are non-infectious. solution (NaCl 4.0 g/l, KCl 1.0 g/l, Sod acetate 6.5 g/l and
glucose 8.0 g/l), or other similar fluid.
Occasionally the carrier state may persist for months,
and exceptionally chronic biliary infection with intermit- Antimicrobial agents (to which the strain is sensitive)
tent shedding of organisms may last for years. shorten the duration of diarrhoea and the duration of
vibrio excretion:
• Adults: Tetracycline drugs (if strain sensitive).
Susceptibility and Resistance • Children: Co-trimoxazole (if strain sensitive).
Even in severe epidemics, attack rates of overt disease
rarely exceed 2 per cent.
36
Control of Contacts Epidemic Measures
Contacts should be observed for five days from the date • Immediately notify Communicable Diseases Network,
of last exposure. Australia and New Zealand (CDN-ANZ) and WHO.
• Initiate thorough investigation to determine the vehicle
This may include, for example, all air travellers on a flight and circumstances of transmission and plan control
from overseas. measures accordingly.
• Educate the population at risk about the need to seek
Stool culture of any contacts with symptoms of diarrhoea appropriate treatment without delay.
and stool culture of all household contacts, even if • Adopt emergency measures to assure a safe water
asymptomatic, should be underaken. supply.
• Assure careful supervision of food and drink prepara-
Cases should also be looked for among those possibly tion.
exposed to a common source.
Note
Immunisation of contacts is not indicated. Immunisation of contacts is not indicated, even in the
epidemic situation.
Preventive Measures
Cholera vaccine is a heat-killed suspension of the Inaba
and Ogawa serotypes of the classical biotype of V.
cholerae O1.
37
Cryptococcal Infection
Method of Diagnosis
Persons with AIDS are particularly prone and now
HIV-infected persons may have cryptococcal meningitis, constitute a majority of cryptococcal infection cases.
even in the absence of inflammatory cells in the cerebro-
spinal fluid (CSF).
39
Control of Case
The diagnosis should be established.
Control of Contacts
Contacts of cases need no specific follow-up.
Preventive Measures
Remove large accumulations of bird droppings.
Epidemic Measures
Clusters have not been reported.
40
Cryptosporidiosis
Period of Communicability
Public Health Significance and Cases may be infectious for as long as oocysts are
Oc c u r re n c e excreted in the stool: from the onset of symptoms until
Cryptosporidiosis occurs worldwide. Young children, the several weeks after symptoms resolve.
families of infected persons, homosexual men, travellers,
health care workers and people in close contact with Under suitable conditions, oocysts may survive in soil
animals comprise most reported cases. and be infective for up to six months.
41
Control of Case
• Exclude symptomatic persons from food handling and
direct care of hospitalised and institutionalised patients
until asymptomatic.
• Stress the importance of hand washing.
• Disinfect soiled articles.
• Exclude symptomatic persons from direct care of
children in child care centres.
• Exclude children with diarrhoea from child care centres
until their diarrhoea has ceased.
Tre a t m e n t
Symptomatic. Supportive care with fluid and electrolyte
replacement and anti-diarrhoeal agents may be needed
by severely affected cases, particularly those with
underlying immune deficiency.
Control of Contacts
The diagnosis should be considered in symptomatic
contacts.
Preventive Measures
• Educate the public in personal hygiene.
• Dispose of faeces in a sanitary manner.
• Insist on careful hand washing by persons in contact
with animals.
• Filter or boil contaminated drinking water (chemical
disinfectants such as chlorine are not effective against
oocysts at the concentrations used in water treatment).
Epidemic Measures
Investigate clustered cases. Look for sources of infection
such as water or raw milk supplies.
42
Cytomegalovirus (CMV) Infection
43
Modes of Transmission Control of Case
CMV may be transmitted by: • Use standard precautions for hospitalised and acute
• Transplacental infection of the foetus of a mother with cases.
primary or reactivated infection. • Do not need exclude cases from school or child care.
• Perinatal infection of neonates via infective maternal • Seek specialist advice if CMV infection is suspected
cervical secretions or breast milk or infective secre- during pregnancy.
tions of attendants or siblings.
• Blood transfusion or organ transplantation.
• Close personal contact with infective secretions of
Tre a t m e n t
infected persons: There is no specific treatment for primary CMV infection
– Children: peers and siblings. of normal hosts.
– Adults: peers, sexual partners and young children.
Immunosuppressed persons with severe CMV infection
are treated in specialist centres with ganciclovir and/or
Incubation Period foscarnet.
The incubation period of cases of sporadic cases of CMV
usually cannot be determined.
Preventive Measures
Perinatal infection develops three to 12 weeks after • Wash hands after handling nappies or exposure to the
delivery. In adults, illness usually occurs three to eight secretions of young children.
weeks after blood transfusion, and between four weeks • Educate persons working in hospitals, child care
and four months after organ transplantation. centres and centres for the disabled to adhere to
infection control precautions and to regard all body
fluids as potentially infectious.
Period of Communicability • Advise women of childbearing age of the risk which
CMV is excreted in urine and saliva for months to years CMV infection may pose.
after primary infection. • Avoid transfusing neonates with CMV seropositive
blood or transplanting organs from CMV seropositive
Neonatal infection in particular is associated with pro- donors to seronegative recipients.
longed excretion.
44
Diphtheria
Presumptive Diagnosis
School exclusion.
Whitish membrane on tonsils, especially if extending to
uvula and soft palate with cervical lymphadenopathy or a
Infectious Agent serosanguinous nasal discharge. If strong suspicion of
Corynebacterium diphtheriae. diphtheria, give antitoxin immediately and commence
antibiotic treatment after bacteriological specimens are
taken without waiting for results.
Clinical Features
Acute bacterial disease of tonsils, pharynx, larynx, nose
and occasionally other mucous membranes, skin,
Bacteriological Investigations
conjunctivae and genitalia. The throat is sore in faucial or • Verify diagnosis.
pharyngotonsillar diphtheria with cervical lymph nodes • Determine toxigenicity of C. diphtheriae. Non-toxigenic
enlarged and tender. In severe cases, there is marked strains can sometimes be associated with disease: skin
swelling and oedema of the neck. lesions, pharyngitis, bacteraemia, arthritis and endo-
carditis.
Cutaneous diphtheria also occurs, generally without
systemic symptoms. Collection of Specimens
For cases:
Laryngeal disease is serious in infants and young
• Nasopharyngeal cultures should be obtained with a
children.
flexible alginate swab that reaches deep into the
posterior nares.
Case fatality rate is 5–10 per cent for non-cutaneous
• Throat cultures should be taken with a cotton swab that
diphtheria.
is firmly applied to any area with a membrane or
inflammation.
Public Health Significance • Any chronic crusting lesion should also be swabbed.
Cases are now rare since widespread immunisation. Before cultures of wounds are taken, lesions should be
They occur mainly in winter, generally in unimmunised cleansed with sterile normal saline and crusted mate-
children under 15 years, but also in unimmunised adults. rial removed. A cotton-tipped applicator is then firmly
applied to the base of the wound.
Case fatality rate is high, especially if there is delay in
diagnosis and treatment with antitoxin. For contacts:
• Ideally the nasopharynx, the tonsillar fossae, posterior
Outbreaks have occurred in Europe among non-immu- pharynx and retrouvular areas should be sampled as
45
For transport: Control of Case
• If no extended delays in culture setup are anticipated,
• Isolate until two cultures taken more than 24–48 hours
ordinary semi-solid transport medium, such as Amies
apart are clear (the first to be taken more than 24
or Stuarts, is adequate.
• When longer transit times (greater than 24 hours) are hours after the cessation of antibiotics).
unavoidable, swabs should be shipped in silica gel. • Isolate for l4 days, if no culture available. Disinfect
contact articles.
Reservoir
Specific Treatment
Humans only.
If strong suspicion of diphtheria:
• Make bacteriological diagnosis, take cultures.
Mode of Transmission • Give Antitoxin without delay:
Transmission occurs by droplet spread through contact – First test for hypersensitivity.
with a patient or carrier, or articles soiled with discharges – Dose (Equine) Antitoxin (20,000–100,000 units) IM.
from infected lesions. Dose depends on assessed clinical severity.
– May need IV antitoxin in addition if very severe
infection (diluted and given as IV infusion).
Incubation Period
Usually two to five days. Administration of antitoxin is the most important facet of
treatment and must not be delayed until bacteriological
confirmation.
Period of Communicability
It is variable, until virulent bacilli disappear from dis-
Antibiotics are commonly used. These are used to
charges (usually more than two weeks; seldom more
eradicate C. diphtheriae from disease sites:
than four weeks).
• Oral erythromycin (preferred to penicillins).
• IM procaine penicillin.
Rarely chronic carriage.
• Benzathine penicillin (single dose).
46
Household contacts should be excluded from schools
and children’s services centres until investigated by the
Medical Officer of Health or a health officer of Human
Services and shown to be clear of infection.
Preventive Measures
Diphtheria toxoid is recommended for all persons at two,
four, six, 18 months and five years (given as DTP (Triple
Antigen)) and at 15 years and every 10 years thereafter
(given as ADT).
Epidemic Measures
• Define population groups at special risk.
• Immunise the largest possible proportion of the popula-
tion group involved, especially infants and
preschoolers.
• Repeat immunisation efforts one month later to provide
at least two doses to recipients.
47
Erythema Infectiosum
(also known as ‘Slapped Cheek Disease’
and ‘Fifth Disease’)
In adults, the rash is often atypical or absent but pain, Other diagnostic techniques may be available in some
inflammation and swelling of joints may occur and, rarely, specialised centres.
persist for months.
49
Mode of Transmission Pregnant Women
The infection is transmitted by contact with infected A pregnant woman who believes she has been in
respiratory secretions. It may be spread vertically from contact with a case of parvovirus infection should
mother to foetus and, rarely, by transfusion of blood or consult the doctor supervising her pregnancy.
blood products.
Antibody testing is available at VIDRL and this may
assist doctors advising women who are pregnant or
Incubation Period
contemplating pregnancy of the risk, if any, which
Usually one to two weeks. parvovirus infection poses.
Control of Case
Persons with parvovirus infection need not be excluded
from child care or schools.
50
Information Sheet
Erythema Infectiosum
(also known as ‘Slapped Cheek Disease’ and ‘Fifth Disease’)
one to four days later by a lace-like rash on the trunk and contact with a case of parvovirus infection should
limbs that fades but may recur over several weeks on consult the doctor supervising her pregnancy.
exposure to heat. There is no specific treatment for the • School/child care exclusion is not required.
infection. Adults often have little rash, but may experi-
ence joint pains and swelling that are sometimes pro- If you require further information, telephone the
longed. Many cases experience no symptoms at all. Infectious Diseases Unit, Human Services, Victoria on
(03) 9616 7777.
The diagnosis can usually be made on clinical grounds,
but blood tests to confirm current or past infection are For specific advice relating to infection and pregnancy,
available. consult the Genetic Clinic, Royal Women’s Hospital or
the Foetal Diagnostic Unit, Monash Medical Centre.
Several groups of people are at particular risk from the
effects of parvovirus infection on developing red blood
cells. People with impaired immunity and/or chronic
blood disorders may develop severe anaemia after
parvovirus infection.
Spread of Infection
Parvovirus infection is spread by contact with infected
respiratory secretions and can spread rapidly in child
care centres and schools.
51
Food- or Water-Borne Illness
Parasites:
School exclusion.
• Cryptosporidium spp.
• Entamoeba histolytica.
Infectious Agent • Giardia lamblia.
53
Public Health Significance and Water is rendered unsafe by human or animal faecal
contamination.
Oc c u r re n c e
Occurrence is worldwide with sporadic cases and
Food may be contaminated by contact with raw materi-
common source outbreaks reported. Incidence varies
als, including animal products, environmental pathogens
from country to country.
or carrier humans or animals.
54
• Obtain clinical specimens of: Avoidance of contamination of food. This can be
– Faeces. Forward to MDU. achieved by:
– Blood (if collected). Forward to VIDRL. • Providing raw materials of better microbiological
– Suspected food/water. Forward to MDU. quality.
• Investigate place where foods are produced or pre- • Educating food handlers about proper food processing,
pared. preparation, storage and in personal hygiene.
• Trace source of contamination. • Adopting the following ‘Ten Golden Rules for Safe Food
Preparation’ developed by WHO:
– Choose food processed for safety.
Control of Case – Cook food thoroughly.
As appropriate, ranging from supportive treatment and – Eat cooked food immediately.
rehydration, to hospitalisation. – Store cooked food carefully.
– Reheat cooked food thoroughly.
Exclusion from food handling and schools and children’s – Avoid contact between raw foods and cooked
services centres. foods.
– Wash hands repeatedly.
Exclusion from nursing duties if employed in an area with – Keep all kitchen surfaces meticulously clean.
high-risk patients such as special care nurseries or – Protect food from insects, rodents, and other
nursing homes. animals.
– Use pure water.
Note
Cases are excluded until diarrhoea has ceased. Incorporation of HACCP (Hazard Analysis Critical Control
Point) system into good manufacturing practices for food
industries.
Control of Contacts/
En v i ro n m e n t
Contacts who are food handlers may require surveil- Epidemic Measures
lance. • Withdraw implicated food from sale.
• Close implicated source of water or issue boiling order
Implicated food (if in retail outlets) to be withdrawn from on water supplies.
sale. • Issue closing order on food establishments if neces-
sary.
Investigation of place of manufacture/preparation of • Issue public warning if necessary.
incriminated food and institute corrective action.
Preventive Measures
Prevention of the contamination of potable water. Con-
taminated water should be treated by adequate filtration
and disinfection, or by boiling.
55
Common Food- or Water-Borne Pathogens
Incubation Duration of Predominant Foods
Causative Agent Period Illness Symptoms Commonly Implicated
Bacteria
Campylobacter jejuni 3–5 days 2–5 days occ. Sudden onset of Raw or undercooked
>10 days diarrhoea, abdominal poultry, raw milk,
pain, nausea, vomit- meat, untreated
ing. water.
E. coli enteropatho- 12–72 hrs 3–14 days Severe colic, watery Many raw foods,
genic, enterotoxigenic, (enterotoxigenic) to profuse diarrhoea, unpasteurised milk,
enteroinvasive, longer in others sometimes bloody. contaminated water,
enterohaemorrhagic See also Haemolytic minced beef.
Uraemic Syndrome.
Salmonella serovars 6–72 hrs 3–5 days Abdominal pain, Meat, chicken, eggs
diarrhoea, chills, and egg products.
fever, malaise.
S. Typhi/Paratyphi Typhoid 1–3 weeks Days–weeks (chronic Sustained fever, Raw shellfish, salads,
Paratyphoid 1–10 carriers occur) headache, constipa- contaminated water,
days tion rather than foods from unsafe
diarrhoea—systemic sources.
illness.
Shigella spp. 12–96 hrs 4–7 days Malaise, fever, Any contaminated
vomiting, diarrhoea food or water.
(blood and mucus).
Yersinia enterocolitica 3–7 days 1–21 days Acute diarrhoea Raw meat and
sometimes bloody, poultry, milk and milk
fever, vomiting. products.
V. cholerae Few hours to 5 days 3–4 days Asymptomatic to Raw seafood, con-
profuse dehydrating taminated water.
diarrhoea.
V. parahaemolyticus 12–24 hrs 1–7 days Abdominal pain Raw and cooked fish,
diarrhoea/vomiting of shellfish, other
moderate severity. seafoods.
56
Common Food- or Water-Borne Pathogens (continued)
Incubation Duration of Predominant Foods
Causative Agent Period Illness Symptoms Commonly Implicated
Viruses
Norwalk and other 24–48 hrs 12–48 hrs Severe vomiting, Oysters, clams, other
SRSV diarrhoea. food contaminated by
human excreta.
Parasites
G. lamblia 1–3 weeks 1–2 weeks to months Loose pale greasy Contaminated water,
stools, abdominal food contaminated by
pain. infected food han-
dlers.
E. histolytica 2–4 weeks Weeks-months Colic, mucous or Contaminated water
bloody diarrhoea. and food.
B. cereus 1–6 hours < 24 hours Nausea, vomiting, Cereals, rice, meat
(toxin in food) diarrhoea, cramps. products, soups,
vegetables.
C. perfringens 8–20 hours 24 hours Sudden onset colic, Meats poultry, stews,
(toxin in gut) diarrhoea. gravies, (often
reheated).
57
Giardiasis
Incubation Period
Public Health Significance and Usually one to three weeks or longer; on average seven
Oc c u r re n c e to 10 days.
Giardiasis is a common infection that affects children
more frequently than adults.
Period of Communicability
It is communicable for the entire period of cyst excretion.
It spreads very easily in institutions such as day care
centres among children who are not toilet trained.
Susceptibility and Resistance
The rate of asymptomatic carriage may be high.
Susceptibility is general.
Asymptomatic carrier rate is high.
Occurrence is worldwide.
59
Control of Case
• Dispose of faeces in a sanitary manner.
• Disinfect Soiled clothing and other articles concur-
rently.
Tre a t m e n t
Metronidazole for seven days or tinidazole.
Control of Contacts
Microscopic examination of faeces of household mem-
bers and other suspected contacts only if they are
symptomatic.
Preventive Measures
• Educate families, and adult personnel of day care
centres in personal hygiene such as the need for hand
washing before meals, after toilet use and changing
nappies.
• Protect public water supplies against faecal contami-
nation.
• Exclude a child from attending school or a day care
centre until diarrhoea has ceased.
Epidemic Measures
Epidemic investigation of outbreaks of disease, espe-
cially in day care centres and institutions, must be based
upon documented microbiological diagnosis and consid-
eration of the phenomenon of asymptomatic carriage.
60
Haemophilus influenzae Infections
Victorian Statutory Since the introduction of Hib vaccines, there has been a
dramatic fall in the number of invasive cases in children
Re quirem ent
under five years.
Group A notification for meningitis or epiglottitis.
Note Reservoir
H. influenzae type b (Hib) may cause other conditions,
Humans. It is estimated that approximately 5 per cent of
such as pneumonia, septic arthritis, cellulitis, osteomyeli-
children under six years are colonised with Hib. It is
tis and so on. These are not notifiable, but the Depart-
generally carried in the nasopharynx without causing
ment of Human Services would appreciate information
symptoms for a period of months before it disappears.
on cases to increase its knowledge of the epidemiology
of these infections.
Carriage rates decline with age, though they are higher
in household and other contacts of children with estab-
Public Health Significance lished Hib infections.
61
Period of Communicability Control of Contacts
It is communicable for as long as the organisms are All contacts under the age of six years should be placed
present in the nasopharynx. under surveillance for the earliest signs of illness so that
prompt medical attention can be sought.
It is non-communicable within 24–48 hours after starting
effective antibiotic therapy. A surveillance letter should be provided as soon as
possible to the parents of contacts in a kindergarten or
day care centre.
Susceptibility and Resistance
Prior to the introduction of vaccine, the risk of secondary
cases in household contacts within 30 days of the index Antibiotic Prophylaxis
case has been estimated to be 3.3 per cent for children Rifampicin is the drug of choice. It is given in a dose of
under two years, 1.4 per cent for children two to three 20 mg/kg/day once daily for four days (up to a maximum
years, 0.06 per cent for children four to five years, and nil of 600 mg daily). Note that the dose used is different
over the age of six years. from that used in meningococcal infections. (For adverse
effects and contraindications to rifampicin, see section
Most secondary cases among close contacts occur on meningococcal infections.) For infants less than one
within the first week after exposure, though late second- month old, reduce the dose to 10 mg/kg once daily for
ary cases are reported. four days.
The patient should be given a course of rifampicin prior Chemoprophylaxis for household contacts is useful up to
to discharge from hospital to ensure elimination of the one month after the index case has been diagnosed,
organism from the nasopharynx (for dosage see below). though ideally it should be commenced as soon as
possible after diagnosis.
If the treated patient is less than two years of age and
has not been immunised, a course of Hib vaccine should In day care centres, kindergartens and so on, all room
be given after discharge from hospital. contacts, teachers and children should be offered
prophylaxis if two or more cases of Hib disease have
Respiratory isolation is recommended for 24 hours after occurred within a period of 120 days.
the start of treatment. Concurrent or terminal disinfection
is not required. Note
Chemoprophylaxis does not eliminate the need for
surveillance, and parents of contacts should be advised
of the risk of late secondary cases despite prophylaxis.
62
Investigative Procedures
In households with siblings under four years of age,
determine if household contacts have been offered
chemoprophylaxis and ensure that this is done by
treating doctor. Any missed immunisations should be
brought up to date.
Note
Nose and throat swabs are not routinely recommended.
Preventive Measures
All children should receive Hib immunisation, usually at
two, four and six months of age, and a booster dose at
18 months.
Note
Vaccination may be recommended for older persons
who are immune suppressed.
Epidemic Measures
Increased surveillance and chemoprophylaxis for all
household and day care centre contacts as detailed
above. Throat swabs may be indicated in the epidemic
situation to assess carriage rates.
63
Information Sheet
Haemophilus influenzae type b Infection
(Epiglottitis)
64
Information Sheet
Haemophilus influenzae type b Infection
(Meningitis)
65
Information Sheet
Rifadin (Rifampicin)
Warning
• Should not be taken in cases of impaired liver function.
• Should not be taken in pregnancy.
• Can interrupt the effectiveness of oral contraception.
• May produce a reddish colour of the urine, sputum and
tears and so discolour contact lenses.
• May increase the requirement for anticoagulant drugs.
• This medication will usually eliminate the bacterium
from the nose/throat.
66
Hand, Foot and Mouth Disease
(Enteroviral Vesicular Stomatitis with
Exanthem)
Infectious Agent
Coxsackievirus group A, mainly type 16.
Mode of Transmission
It is transmitted by:
• Direct contact with fluid from the vesicular lesions.
Clinical Features • Direct contact with nose and throat discharges and
This viral infection occurs mainly in children under 10 faeces of an infected person.
years of age and in young adults. It lasts seven to 10 • Aerosol droplet spread.
days.
Incubation Period
The clinical picture consists of sore throat, fever and
Usually three to seven days.
vesicular lesions on the buccal surfaces of the cheeks,
gums and sides of the tongue.
Period of Communicability
Papulovesicular lesions of the palms, fingers and soles
It is communicable during the acute stage of disease
commonly occur; occasionally maculopapular lesions
from nose and throat secretions, and as long as there is
appear on the buttocks.
fluid in the lesions. Viruses persist in the stools for
several weeks.
Public Health Significance and
Oc c u r re n c e Susceptibility and Resistance
Hand, foot and mouth disease occurs worldwide sporadi- Immunity to the specific virus may be acquired due to
cally and in epidemics; the greatest incidence is in previous infection.
summer and early autumn.
Second attacks may occur with group A coxsackievirus
Outbreaks occur frequently among groups of children in of a different serotype.
child care centres and schools.
Control of Case
Method of Diagnosis • Do not exclude children with hand, foot and mouth
Usually clinical (viral isolation from nasopharyngeal or disease as the virus is present in the faeces for many
stool specimens is rarely indicated). weeks.
• Cover lesions on hands and feet if possible and allow
to dry naturally.
• Avoid piercing lesions.
• Take care with hand washing and disposing of soiled
articles.
67
Tre a t m e n t
Usually none required. Paracetamol may be used for
fever and discomfort.
Control of Contacts
Of no practical value.
Preventive Measures
Use of hand washing and other hygienic measures at
home and at child care centres.
Epidemic Measures
General practitioners should be informed about periods
of increased incidence of the disease.
68
Information Sheet
Hand, Foot and Mouth Disease
This is a viral disease that usually lasts seven to 10 days. • Exclusion from school and child care centres is not
usually recommended because the virus may be
The incubation period is between three to seven days. present in the faeces for many weeks.
Symptoms
• Fever.
• Sore throat.
• Small, blister-like lesions that may occur on the inside of
the mouth, sides of the tongue, palms of the hands,
fingers and soles of the feet and nappy area.
Infectious Period
• As long as there is fluid in the blisters.
• The faeces can remain infectious for several weeks.
Tre a t m e n t
• Usually none is required.
• Use paracetamol for fever and any discomfort. Do not
use aspirin where there is fever.
• The disease itself is not serious. If the child complains
of severe headache and fever persists, consult your
local doctor immediately.
69
Hepatitis A
Clinical Features
Adults usually experience a distinct illness with acute
Illness due to hepatitis A typically causes acute fever,
onset of symptoms and jaundice, but a high index of
malaise, anorexia, nausea and abdominal discomfort,
suspicion is needed to diagnose young children with few
followed a few days later by dark urine and jaundice.
symptoms. Related adult cases are a clue.
71
Period of Communicability IG is rarely given to persons exposed to a potential
common source of hepatitis A (such as food or water)
Cases are most infectious from the latter half of the
because cases related to such a source are usually
incubation period until a few days after the onset of
recognised too long after the exposure for IG to be
jaundice (corresponding to a peak in transaminase levels
effective for the co-exposed persons.
in anicteric cases).
72
Control of Environment The dose is one ml (720 ELISA units) administered
intramuscularly into the deltoid. A second dose must be
A source of infection should always be sought. For
given two to four weeks after the first dose, and a third
apparently sporadic cases, consider contact with an-
dose should be given six to 12 months after the first
other known case and recent travel to an area where the
dose.
disease is endemic. If these do not provide an answer,
acquisition from young children, particularly those in
Protective immunity is acquired approximately two weeks
child care, should be considered.
after the second dose, and long-term immunity (up to 10
years) is expected to follow the third dose.
A number of cases occurring at the one time should
prompt a search for a common source, particularly food
Alternatively, if ‘Havrix 1440’ is used (one ml contains
or water.
1440 ELISA units), then a single dose followed by a
booster dose at six to 12 months provides long-term
Special attention should be given to toilet hygiene in
immunity.
schools and child care centres. Ensure soap and water
are available and are used.
Travellers to countries where hepatitis A is common (for
example, Asia, Africa, Central and South America), have
Clusters of cases, possibly related to a single source,
previously been offered short-term protection with
may require epidemiologic investigation, including case
immunoglobulin, but should now be offered active
finding and surveillance, and public health measures to
vaccination with inactivated hepatitis A vaccine, particu-
prevent further cases.
larly if their stay is long or ‘rough’.
Active Immunisation
Inactivated hepatitis A vaccine (‘Havrix’, SmithKline
Beecham) is licensed for use for persons aged more
than five years.
73
Passive Immunisation When cases occur in three or more staff, attendees or
families with members at the centre, or new cases occur
In most instances where prophylactic immunisation is
more than three weeks after the onset of the first case,
undertaken, vaccine should be used.
consider giving IG to all family contacts of all children
aged two years or less at the centre, and all attendees,
However, when immunoglobulin is used to provide
staff and family contacts of cases.
passive protection, the following dosages are recom-
mended:
Food- and Water-Borne Outbreaks
Dosage of Immunoglobulin The source of such outbreaks is usually recognised too
late for IG to be usefully given to persons exposed to the
Dosage source.
Person’s Short-Term Long-Term
Weight (Kg) Prophylaxis Prophylaxis
Contacts of acutely ill cases should be given IG accord-
(six weeks) (ml) (5 months) (ml)
ing to the usual guidelines.
Under 25 0.5 1.0
25 to 50 1.0 2.5
Over 50 2.0 5.0
Epidemic Measures
Outbreaks Associated with Child
Care Centres
Clusters of cases of hepatitis A associated with child
care centres are not uncommon. When centre staff and/
or family of attendees develop hepatitis A, it usually
reflects an outbreak of hepatitis among young children at
the centre.
74
Hepatitis B
Infectious Agent The prevalence of the carrier state varies widely between
Hepatitis B virus (HBV) ( a DNA hepadnavirus). populations with parts of Africa, Oceania and Asia having
carrier rates of approximately 10 per cent.
Clinical Features
The onset is usually insidious with anorexia, abdominal
Method of Diagnosis
discomfort, nausea, vomiting, dark urine and jaundice. The diagnosis is established by a blood test and clinical
features. (See Case Definition.)
Rarely, arthralgia, rashes and renal disease may occur.
Reservoir
The severity ranges from inapparent cases to fatal cases
Humans.
of acute hepatic necrosis.
75
Period of Communicability
Blood from infected persons is infective many weeks
before the onset of symptoms and remains infective
through the acute clinical course of the disease and
during the chronic carrier state, which may persist for
life.
76
Serology of Hepatitis B Infection
Acute
Hepatits Resolution
Titre
HBsAg Anti-HBcIgM Anti-HBs Anti-HBcIgG
HBeAg Anti-HBe
77
Recommendations for Hepatitis B Prophylaxis Following
Percutaneous or Permucosal Exposure
Unknown sero-conversion Test exposed for anti-HBs. No treatment. Test exposed for anti-HBs.
1. IG inadequate, 1. If inadequate, HB
HBIG x1 plus HB vaccine vaccine booster dose
booster dose. plus HBIG x1.
2. If adequate, no 2. If adequate, no
treatment. treatment.
** An adequate antibody level is greater than 10 milli International Units per ml, approximately equivalent to 10 sample ratio units (SRU) by radio-
immune-assay (RIA) or positive by enzyme-immuno-assay (EIA).
78
Control of Case Paediatric hepatitis B vaccine is given for:
• Infants of HBsAg positive mothers (as discussed
Exclusion from school and work until the diagnosis is
above).
confirmed. Blood and body fluid precautions should be
• Infants in ethnic groups of high HBsAg endemicity,
observed until the disappearance of HBsAg and the
whether the mother is a carrier or not.
appearance of anti-HBs.
• Children up to 10 years of age in both of the above
groups.
Control of Contacts
Household contacts should be tested for anti-HBc and WHO recommends that hepatitis B vaccine should be
HBsAg and offered vaccination if susceptible. included in all childhood immunisation protocols.
Preventive Measures
Pre-exposure vaccination is recommended for:
• Health care workers. Individual risk depends on HBsAg
carrier rate in the population served, degree of blood
(not patient) exposure, and thoroughness of hygiene
measures in dealing with blood.
• Haemodialysis patients and recipients of blood prod-
ucts such as factors VIII and IX.
• Residents and staff in institutions for the intellectually
disabled.
• Those with multiple sexual contacts.
• Injecting drug users.
• Household and sexual contacts of hepatitis B virus
carriers.
• Inmates of long-term correctional facilities.
79
Hepatitis C
Infectious Agent There are at least six major genotypes of HCV and it is
thought that some are more pathogenic than others. It is
Hepatitis C virus (HCV), a small RNA virus, is closely
also believed that repeat infection of a HCV carrier with a
related to the flaviviruses and animal pestiviruses.
different strain may exacerbate underlying liver disease.
81
Mode of Transmission Incubation Period
It is primarily transmitted by blood-to-blood contact. Ranges from two weeks to six months—most commonly
six to nine weeks after which serum ALT levels rise.
In Australia and other Western countries, sharing inject- Current HCV antibody tests become positive two to three
ing equipment by drug users is the most common mode months after exposure.
of transmission.
82
Counselling of the patient is a very important part of the Preventive Measures
management. This counselling should include:
• Use standard precautions by all health care providers
• Likely source of the infection.
with potential contact with blood or body fluids.
• Current knowledge of the natural history.
• Use disposable equipment for all skin penetration
• Possible symptoms.
procedures, or use adequate sterilisation methods
• Advice on prevention of further transmission of infec-
when reusable needles are used for any procedure.
tion.
• Lifestyle issues, such as immunisation against hepatitis
B, minimisation of alcohol intake, cessation of smoking,
healthy diet.
Control of Contacts
There is no vaccine available for hepatitis C.
83
Hepatitis D
Oc c u r re n c e
Two general epidemiological patterns are recognised:
• Endemic infection occurs in Italy, the Middle East,
some areas of Africa and South America, although the
ratio of the two infections varies widely with location.
Transmission occurs primarily within the household
setting.
• Non-endemic infection occurs in Australia, North
America and Western Europe, where HDV occurs
sporadically in the HBsAg population and is largely
confined to the risk group of injecting drug users.
Method of Diagnosis
Identification of HDV antigen or anti-HDV in the serum.
Mode of Transmission
The mode of transmission is similar to hepatitis B (see
Public Health Significance).
85
Hepatitis E
Method of Diagnosis
Immune electron microscopy of faeces.
Reservoir
Humans, transmissible to some other primates.
Mode of Transmission
Hepatitis D can be transmitted:
• From contaminated water.
• Person-to-person by the faecal-oral route.
87
Herpes Simplex
Clinical Features
Vaginal delivery in pregnant women with active genital
This viral infection is characterised by a localised primary
infection carries a high risk to the newborn. It can cause
lesion, latency and a tendency to local recurrence.
disseminated visceral infection, encephalitis and death.
89
Transmission of HSV type 2 to non-immune adults is Preventive Measures
usually by sexual contact.
• Emphasise personal hygiene to minimise the transfer of
infectious material.
Incubation Period • Avoid contamination of the skin of patients with ec-
zema.
Usually two to 12 days.
• Wear gloves when in direct contact with infectious
lesions and wash hands with soap and water after-
Period of Communicability ward.
Secretion of virus in the saliva may occur up to seven • Advise cesarean section before membranes rupture
weeks after recovery from stomatitis. when primary or recurrent genital infections occur in
late pregnancy because of the risk of neonatal infec-
Patients with primary genital lesions are infective for tion.
seven to 10 days. Those with recurrent disease are
infective for four to seven days.
Epidemic Measures
Not applicable.
Susceptibility and Resistance
Severe extensive disease may occur in
immunosuppressed individuals.
Control of Case
The patient should be kept away from newborns, children
with burns or eczema, and immunosuppressed patients.
Tre a t m e n t
Treatment includes:
• Idoxuridine (Stoxil) for cutaneous lesions.
• Povidone-iodine ointment and paint (Betadine).
• Acyclovir (Zovirax tablets) for initial and recurrent
genital herpes.
• Acyclovir intravenous infusion for H. simplex encephali-
tis and immunosuppressed patients.
Control of Contacts
Contact isolation is necessary only for neonatal or severe
primary lesions.
No immunisation is available.
90
Hydatid Disease
The most common site for the cysts is the liver; less
If a cyst ruptures, examine for protoscolices, brood
commonly brain, lungs, kidneys, and uncommonly the
capsules and cyst wall in sputum, vomitus, faeces and
heart, thyroid and bone.
urine.
91
Mode of Transmission Tre a t m e n t
Infection occurs by hand-to-mouth transfer of tapeworm Surgery is the treatment of choice.
eggs from dog faeces. The larvae penetrate the intestinal
mucosa, enter the portal system and are carried to Mebendazole (Vermox) is used when surgery is contrain-
various organs where they produce cysts in which dicated.
infectious protoscolices develop.
Albendazole (special access scheme) has been used
The important life cycle is dog-sheep-dog. A successfully.
dingo-wallaby-dingo (or wild dog) sylvatic cycle also
occurs. A dog-wild pig-dog cycle has recently been
recognised with risks for hunters from urban areas.
Control of Contacts
Household contacts should be examined for evidence of
infection.
Incubation Period
Variable: from months to years. Dogs in contact with the patient should be investigated
(obtain advice from the Department of Natural Resources
and Energy).
Period of Communicability
It is not communicable through person-to-person trans-
mission. Preventive Measures
• Educate the public on the danger of close association
Dogs pass eggs approximately seven weeks after with dogs and on the need to wash hands after contact
infection. with dogs.
• Treat infected dogs and destroy unwanted dogs.
In the absence of reinfection, this ends in about one • Control the slaughter of animals, particularly sheep.
year. The area should be enclosed to prevent access by
dogs and have adequate drainage, an incinerator and/
or disposal pit.
Susceptibility and Resistance • Do not allow children to play with strange dogs,
Children are more often infected than adults. especially in rural areas.
• Dispose of animal carcasses as soon as possible.
92
Impetigo
Infectious Agent
Streptococcus pyogenes (Group A streptococci).
Period of Communicability
It is communicable while active lesions persist.
Staphylococcus aureus.
Control of Case
It begins as a papule that vesiculates and then breaks
Local treatment-crusts should be bathed with cetrimide
leaving a denuded area covered by a honey-coloured
0.1 per cent lotion or saline or water.
crust.
Method of Diagnosis The child should be excluded from child care settings
Culture taken from active skin lesions. until sores have fully healed.
93
Preventive Measures
Personal hygiene.
Epidemic Measures
• Investigate if a cluster of two or more concurrent cases
occur in a hospital nursery or maternity ward.
• Take swabs from all patients, care personnel and
search for active lesions.
• Investigate if a a large number of cases occur in
schools and community settings.
• See attached sheet of investigative procedures for
protocol.
Epidemic Investigative
Procedures for Impetigo
Case:
• Obtain swab of discharging lesion.
• Obtain nasal swab.
• Instruct patient to cover active lesion with dressings.
• Dispose of soiled dressings appropriately.
• Educate regarding personal hygiene. Emphasise hand
washing, especially after changing dressings, and the
importance of avoiding sharing toilet articles, towels or
clothing.
• Instruct on the use of anti-bacterial soap for bathing for
two to three weeks (Gamophen soap).
Contacts:
• Obtain nasal swabs.
• Educate about modes of transmission.
Environment:
• Trace source of infection.
• Swab communal laundry facilities if applicable.
• Educate public in modes of infection and personal
hygiene.
94
I n fl u en z a
Oc c u r re n c e
Influenza occurs as pandemics, epidemics and as Mode of Transmission
sporadic cases. It is predominately transmitted by airborne spread.
Transmission also occurs by direct contact through
Type A viruses cause most epidemics. Mixed A and B droplet spread.
epidemics also occur.
95
Susceptibility and Resistance • Aboriginal and Torres Strait Islander adults over 50
years of age, partly because of the greatly increased
When a new subtype appears, all are susceptible except
risk of premature death from respiratory disease.
those who have lived through earlier epidemics caused
• Children with cyanotic congenital heart disease.
by a related subtype.
• Staff caring for immunosuppressed patients.
• Staff and residents of nursing homes and other chronic
Infection produces immunity to the specific infecting
care facilities.
virus, but the duration and breadth of immunity depends
• Adults and children receiving immuosuppressive
on the degree of antigenic drift and the number of
therapy.
previous infections.
Control of Contacts
No routine measures.
Preventive Measures
Inactivated influenza vaccine is formulated annually so
that changes in composition can be made to counter
antigenic shifts and antigenic drift.
96
Infectious Mononucleosis
(Glandular Fever)
Clinical Features
Serological
It is an acute viral infection affecting mainly young adults.
ELISA IgG and IgM for viral capsid antigen.
97
Susceptibility and Resistance
Infection confers a high degree of resistance.
Control of Case
Isolation is not necessary.
Tre a t m e n t
None. Steroids may be of some value in severe, toxic
cases.
Control of Contacts
Investigation of contacts is not necessary. No immunisa-
tion is available.
Preventive Measures
• Use hygienic measures including hand washing to help
prevent spread.
• Disinfect articles soiled with nose and throat dis-
charges.
Epidemic Measures
None.
98
Legionellosis
99
In 1988–1989, an outbreak, where L. longbeachae SG1 Reservoir
was implicated, occurred in South Australia. Epidemio- The bacterium is water-associated and ubiquitous.
logical investigations found an association with the use of
potting mix. Further work by the Institute of Medical and It is often isolated from natural habitats (rivers, creeks,
Veterinary Science, Adelaide (IMVS) found L. hot springs) and from artificial equipment such as
longbeachae to be present in approximately 70 per cent cooling towers associated with airconditioning and
of samples of commercial potting mix tested. industrial processes, and in warm water systems where
the temperature is maintained around 43˚C favouring
Case fatality in the Victorian cases is around 20 per cent. proliferation of the bacteria.
Control of Case Where necessary, meetings should take place with staff,
Specific antibiotic treatment includes erythromycin and occupational health and safety representatives, union
rifampicin. representatives to:
• Discuss the presentation of disease.
Supportive treatment is needed if there is respiratory • Allay fears.
failure.
To help identify a common source, serology should be
Dialysis may be required if there is renal failure. considered for work colleagues. Tests are generally
offered to those who have been away four or more
consecutive days with a respiratory illness.
Investigation
After estimating the onset of illness, the patient’s move- These tests are, however, of limited value as 13 to 35 per
ments during the incubation period should be estab- cent of the normal population (WA) and 30 per cent (SA)
lished. have been found to have antibodies to L. pneumophila
serogroup 1.
Inspection should be underatken of places where the
following aerosol generating equipment may be present: Clotted blood, 10 ml should be sent to Legionella Refer-
• Cooling towers. ence Laboratory, VIDRL. Ample warning should be given
• Fountains or sprinklers. of expected numbers of specimens.
• Spas.
• Humidifiers. Potential sources should be sampled, and the tempera-
• Showers, especially associated with warm water ture of water recorded.
systems (temperature especially ranging from 35˚C to
43˚C). Water sample (100 ml) should be collected in containers
• Oxygen nebulizers. (available from MDU) and sent to MDU.
• Others (be suspicious).
Potting Mix
To minimise the risk of infection, gardeners should:
• Open the bag with care to avoid inhalation of airborne
potting mix.
• Moisten the contents to avoid creating dust.
• Wear gloves to avoid transferring the potting mix from
hand to mouth.
• Wash hands after handling potting mix, even if gloves
have been worn.
• Adopt the same measures when handling other gar-
dening material such as compost.
102
Leprosy (Hansen’s Disease)
Clinical Features Africa, Central and South America, Pacific regions and
the USA (Hawaii, Texas, California, Louisiana, Puerto
It is a chronic bacterial infection involving the cooler
Rico).
body tissues, skin, superficial nerves, nose, pharynx,
larynx, eyes and testicles.
Method of Diagnosis
Skin lesions may occur as pale, anaesthetic macular Clinical examination.
lesions or erythematous infiltrated nodules.
Laboratory tests which show:
Neurologic disturbances are manifested by nerve • The demonstration of acid-fast bacilli in scrapings from
infiltration and thickening with anaesthesia, neuritis, skin or the nasal septum.
paraesthesia and trophic ulcers. • A typical histologic picture in a biopsy of skin or of a
thickened involved nerve.
The disease is divided clinically and by laboratory tests
into two overlapping types: lepromatous and tuberculoid.
Reservoir
The lepromatous type is progressive with nodular skin Humans.
lesions, slow symmetric nerve involvement, numerous
acid-fast bacilli in the skin lesions and a negative lep-
romin skin test.
Mode of Transmission
The mode of transmission is not clearly established. The
The tuberculoid type is benign and non-progressive with disease is probably transmitted by aerosol with a high
103
Incubation Period For tuberculoid leprosy, the recommended regimen is
rifampicin and dapsone for a period of six months (for
The incubation period is difficult to determine.
detailed treatment see Control of Communicable Dis-
eases in Man by Benenson).
It probably ranges from nine months to 20 years; on
average four years, for tuberculoid leprosy and eight
years for lepromatous leprosy. Control of Contacts
Investigation of contacts and source of infection.
Period of Communicability
Early detection and treatment of new cases.
Leprosy is not infectious after three months of continuous
treatment with dapsone or clofazimine, or after two to
Prophylactic BCG has resulted in a considerable reduc-
three weeks of treatment with rifampicin.
tion in the incidence of tuberculoid leprosy among
contacts in some trials.
Susceptibility and Resistance
Infection among close contacts of leprosy patients is
Epidemic Measures
frequent, but clinical disease occurs only in a small
Not applicable.
proportion.
Control of Case
No isolation is required for cases of tuberculoid leprosy;
contact isolation is required for cases of lepromatous
leprosy.
Tre a t m e n t
The minimal regimen recommended by WHO for lepro-
matous leprosy is rifampicin, dapsone and clofazimine
and, recently, ofloxacin.
104
Leptospirosis
105
Susceptibility and Resistance • Consult the Department of Natural Resources and
Energy on herd immunisation.
Immunity to the specific serovar follows infection, but
• Prevent the contamination of accommodation, working
may not protect against infection with a different serovar.
and recreational areas.
Control of Case
Epidemic Measures
• Isolate the case with blood/body fluid precautions.
• Seek source of infections and eliminate contamination
• Disinfect articles soiled with urine.
or prohibit use of infected waters.
• Use antibiotic treatment: penicillin, doxycycline or
• Search for industrial and occupational source.
amoxycillin.
Investigation
• Ascertain occupational exposure.
• Seek the source of the infection; for example, contact
with contaminated water, farm or domestic animals,
rodent infestations.
• Inform the Department of Natural Resources and
Energy.
Control of Contacts
No human vaccine is available.
Control of Environment
Recognise potentially contaminated waters and soil, and
drain such waters when possible.
Preventive Measures
• Educate the public on modes of transmission to avoid
swimming or wading in potentially contaminated
waters, and to use proper protection when work
requires such exposure.
• Protect workers in hazardous occupations with boots
and gloves.
• Control rodents.
• Segregate infected domestic animals.
106
Diagnosis of Leptospirosis in Humans
This checklist is designed for those who deal directly with the patient. To use the list, note the main clinical features
listed, mark Yes or No, and write the appropriate score in the right-hand column.
A presumptive diagnosis of leptospirosis may be made if:
• Part A, or Parts A and B score: 26 or more.
• Parts A, B and C total: 25 or more.
B. Epidemiological factors:
• Has there been contact with animals at home, work, leisure, or
in travel, or contact with known (or possibly) contaminated water? Yes = 10 No = 0 ____
Total ______________
107
L i s t e rio sis
Group B notification.
Infection of healthy adults is usually transient with mild to
moderate flu-like symptoms, but in pregnant women,
Note
foetal infection through the placenta can result in abor-
Also isolation of L. monocytogenes from food is notifiable
tion, stillbirth or premature birth of severely affected
under the Health (Infectious Diseases) Regulations 1990.
babies (early-onset neonatal listeriosis).
109
These three outbreaks in the Maritime Provinces (1981), Incubation Period
Massachusetts (1983) and Los Angeles County (1985)
Unknown and may be up to 90 days.
involved a total of 232 cases. The overall case fatality
rate was 36 per cent.
In pregnancy, the foetus is infected within a few days of
the mother’s illness.
The implicated foods were coleslaw, pasteurised milk
and Mexican-style soft cheese.
Period of Communicability
Mothers of infected newborns may shed the infectious
Method of Diagnosis
agent in vaginal discharges and urine for seven to 10
Culture of the organism from blood, CSF, placenta,
days.
meconium and other sites of infection.
Susceptibility
Reservoir
Although healthy people can be infected, the disease
L. monocytogenes is widespread in the environment and
generally affects vulnerable groups in the community,
is commonly isolated from sewage, silage, sludge, birds,
such as:
wild and domestic animals.
• Neonates.
• Elderly, diabetics, alcoholics.
It has caused infection in many animals and resulted in
• The immunosuppressed.
abortion in sheep and cattle. The bacteria are commonly
• Pregnant women, with their foetuses most affected.
isolated from poultry.
110
Control of Contacts/ • Utilising a multidisciplinary approach to the investiga-
tion of cases.
En v i ro n m e n t
The significance of vaginal and faecal carriers is un-
New regulations for the control of Listeria approved by
known.
the National Food Standards Council became effective
from September 1994. These regulations require that
When implicated, food is to be withdrawn from sale.
pâté, soft cheese, smoked fish and smoked seafood
have zero Listeria at the point of wholesale distribution.
Preventive Measures
A surveillance program should be estblished to monitor: Epidemic Measures
• The epidemiological aspects of the disease.
• Epidemiological investigation of cases should be used
• The presence of Listeria in food and its public health
to detect outbreaks and to determine source.
importance.
• Molecular subtyping should be used to determine the
association between isolates from cases and food
This is achieved through notification and surveys of at-
samples.
risk foods.
• If a common source is detected, implicated food
should be withdrawn from sale.
Dairy products should be withheld from sale should
Listeria be isolated.
111
Malaria
Victorian Statutory Individuals who are partially immune or have been taking
Re quirem ent anti-malarial chemoprophylaxis may show an atypical
Group B notification. clinical picture with wide variations in incubation period.
Most antibiotics also can modify the course of malaria.
Infection is most commonly caused by P. vivax and/or P. Public Health Significance and
falciparum. O c c u r re n c e
The malaria situation worldwide is deteriorating. There
Mixed infections may occur in endemic areas.
are increasing levels of transmission, and it has returned
to areas where it had been previously eradicated. Drug
Clinical Features resistance has increased and there has been a spread of
The features include indefinite malaise and slowly rising resistance of the vector to insecticides.
fever of several days duration. This is followed by shak-
ing chills and rapidly rising temperature, that ends with There are said to be over 220 million new infections a
profuse sweating. year worldwide, and the disease is endemic in areas of
Asia, Africa and Central and South America.
The fever is usually accompanied by headache and
nausea. Australia was certified by WHO as being free of endemic
malaria in 1981, but several hundred imported cases are
While, classically, fever due to malaria may occur every recorded each year. However, the region lying north of a
second or third day, in practice, the fever may have no line joining Townsville on the east coast and Port
specific pattern. Hedland on the west remains receptive and vulnerable to
the re-establishment of the disease due to the presence
Falciparum malaria (malignant tertian) may present a of known or suspected vectors, suitable environmental
varied clinical picture with an atypical onset including conditions, and the continual arrival of malaria-infected
diarrhoea. travellers.
The above features may progress to jaundice, coagula- Many cases occur among migrants returning to their
tion defects, shock, renal and hepatic failure, acute native country for holidays after many years, when they
encephalopathy, pulmonary and cerebral oedema, coma may have lost their immunity.
and death.
A large percentage of Australian cases originate in
Every year, Australians die of falciparum malaria when Papua New Guinea.
diagnosis or treatment has been delayed. Any person
returning from an endemic area who develops a fever
should be promptly investigated.
113
Method of Diagnosis reach the lumen of these glands that communicates with
the salivary ducts and are then passed into a skin wound
Malaria can be diagnosed by demonstration of malaria
in the salivary fluid when the insect next bites a human.
parasites in blood films. Blood samples should be sent to
a laboratory with experience in the diagnosis of malaria
The cycle in the mosquito takes eight to 35 days, de-
by the use of thick and thin films. Repeated examination
pending on the species and the temperature.
may be necessary due to variations in density of para-
sites.
In the human host, the period between the infective bite
and the appearance of parasites in the blood is called
Confirmation of the species should be sought from a
the pre-patent period. This period varies from six to nine
reference laboratory.
days for P. falciparum, P. vivax and P. ovale, and 12 to
16 days for P. malariae.
Reservoir
Humans are the only important reservoir of human Malaria can also be transmitted by transfusion of blood
malaria, although other Plasmodium species may natu- of infected persons, or by using contaminated needles or
rally infect non-human primates. syringes.
114
Infected mosquitoes remain infective for life. Control of Contacts
The diagnosis of malaria in travelling companions should
Transmission by transfusion may occur as long as
be considered.
asexual forms remain in the circulating blood; with P.
malariae, this can continue for over 40 years.
In transfusion-induced malaria, all donors must be
located and their blood tested for malaria parasites and
Stored blood can remain infective for 16 days.
anti-malarial antibodies.
115
Malaria poses a serious threat to pregnant women as it International Measures
can compromise foetal development, possibly resulting
Aircraft, ships and other vehicles should be sprayed with
in premature labour or miscarriage.
insecticides on arrival if there is reason to suspect
importation of malaria vectors.
Pregnant women should be advised to avoid travel to
malarious areas if possible.
Anti-mosquito sanitation should take place within the
mosquito flight range of all ports and airports.
Similarly, malaria presents considerable risks for chil-
dren, particularly the very young, and the choice of
WHO should be notified by national health administra-
suitable drugs is limited. Mosquito avoidance measures
tions of details of cases twice yearly for the WHO Malarial
should be emphasised.
Surveillance Program.
Chemoprophylaxis
Drugs used for this purpose include chloroquine,
mefloquine and doxycycline.
116
Information Sheet
Malaria
117
Further Information
• For up-to-date recorded advice, telephone the Interna-
tional Travel Health Info Line on (06) 269 7815.
• The following publications:
– Health Information for International Travel, 1995,
fourth edition, Australian Government Publishing
Service, Canberra.
– International Travel and Health, Vaccination Require-
ments and Health Advice, World Health Organisa-
tion, Geneva. (published annually).
• Any travel health clinic. The address of the nearest
clinic may be obtained by ringing Infectious Diseases
Unit (03) 9616 7777.
118
Measles
Complications can include otitis media, pneumonia and Death is rare but does occur.
encephalitis.
Method of Diagnosis
Subacute sclerosing panencephalitis (SSPE) develops
See Case Definition.
very rarely as a late sequel.
119
Period of Communicability Classroom contacts without a valid school entry immuni-
sation certificate must be excluded for 13 days from the
From slightly before the beginning of the prodromal
first appearance of rash in the last occurring case,
period to four days after the appearance of the rash.
unless they are immunised within 72 hours of first con-
tact.
Susceptibility and Resistance
Vaccination at 12 months produces antibody in approxi-
Preventive Measures
mately 95 per cent of recipients. It is not yet clear
Live attenuated measles vaccine is recommended for all
whether vaccine-induced immunity is lost over time, but
persons born after 1970 unless specific contraindications
the majority of evidence suggests that this is uncommon.
to live vaccines exist.
Epidemic Measures
Control of Contacts A measles outbreak exists whenever one case of mea-
Household and other general contacts should be sles is confirmed.
checked for documentation of measles immunisation. If
non-immune, immunisation should be given within 72 The diagnosis should establish that the disease is
hours of contact. actually measles (see clinical or laboratory case
definition).
Persons born before 1970 are generally regarded as
immune as they would have contracted measles in Nasopharyngeal aspirates may be collected and rapidly
childhood. transported to Royal Childrens Hospital or VIDRL for
immunofluorescent identification of measles antigen. This
Children aged between six to 12 months should be given is a rapid method of virus identification. The specimen is
a measles-containing vaccine, but should be then cultured for virus.
revaccinated at 12 months or three months after the last
dose, whichever is later. It is also acceptable to give Alternatively, a blood sample (10 ml in a plain tube)
normal immunoglobulin to children in this age group in a should be collected immediately after the child presents
dose of 0.2 ml/kg then to vaccinate them at 12 months with the rash, and sent to VIDRL to look for measles-
(or three months after the administration of immuno- specific IgM.
globulin).
A second specimen 10 days later is useful if the IgM
In school, immunisation status of close contacts should result is equivocal.
be checked. This refers to classroom contacts of the
child, not the whole school.
120
For school-based outbreaks: class levels involved should
be revaccinated, for all children who do not have docu-
mented evidence of two doses of measles-containing
vaccine.
121
Meningococcal Infections
123
Detection of meningococcal antigen in CSF and/or serum Patients deficient in certain complement components in
can be obtained by techniques such as counter-current the blood are prone to recurrent meningococcal infec-
immuno-electrophoresis (CIE). This is particularly useful tions.
in partially treated cases where both smear and culture
may be negative. There is an increased and prolonged risk of secondary
infections in close contacts. In one series, the incidence
of such infection was 0.5 per cent with a median interval
Reservoir of seven weeks between the index and secondary cases.
Humans. Asymptomatic naso-pharyngeal carriers of the
organism can spread infection, but there is no consistent Secondary cases have been reported up to five months
relationship between the carrier rate in a given commu- later. The risk in household contacts is 500 to 800 times
nity and the incidence of disease. higher than in the general population.
Susceptibility decreases with age. However, a secondary If ceftriaxone is used in treatment, rifampicin need not be
peak of meningococcal meningitis occurs in adolescents given.
and young adults in the age group of 15 to 24 years.
124
Contacts When indicated, chemoprophylaxis should be instituted
All household and other contacts should be placed as soon as possible, preferably within 24 to 48 hours of
under close surveillance for the earliest signs of infection diagnosis of the index case.
letter should be provided as soon as possible to the Antibiotic prophylaxis does not eliminate the need for
parents of all children in a class, school or day care close surveillance of contacts.
centre where a case has occurred.
In a school class, only the patient’s close friends would Itching, rashes and gastro-intestinal reactions may
require antibiotic treatment. However in a day care occur. It should be used with caution in patients with liver
centre, because of the high risk in young children, damage, and is contraindicated in pregnant or lactating
everybody (including staff) should be offered antibiotic women. Patients on oral contraceptives should be
treatment unless groups of children are kept quite advised to use other contraceptive methods during
separate, in which case only children in the patient’s treatment with this drug and for the remainder of the
group need treatment. cycle.
Special circumstances may justify wider use of antibiotic Patients receiving anticoagulants may need to increase
prophylaxis, such as attendance of the index case in the their prescribed dose.
10 days before onset at a party where young children
and teenagers were present. Alternatives to rifampicin include:
• Ceftriaxone. 5.0 mg/kg to a maximum of 250 mg IM as
Health care personnel do not usually require antibiotic a single dose (safe in pregnancy), reduce to 125 mg in
treatment except where intimate contact (such as mouth- children under 15 years of age.
to-mouth resuscitation) has occurred. • Ciprofloxacin. 500 mg orally as a single dose. It should
not be prescribed to children under 12 years of age or
40 kg body weight, or to pregnant women.
125
Note Preventive Measures
Antibiotic prophylaxis of family and household contacts
A quadrivalent vaccine is available in Australia against
is the responsibility of the treating hospital while the
Groups A, C, Y and W135. Group C vaccine does not
Department of Human Services will take responsibility for
induce a reliable antibody response under two years of
follow-up of other contacts. Rifampicin supplies are
age, but Group A vaccine can elicit a response in
available through the Public Health nurses or through the
children as young as three months.
Department. Written consent should be obtained prior to
administration of any antibiotic prophylaxis to children.
However, in children aged three months to two years,
two doses are given three months apart instead of a
Throat or Nasopharyngeal single dose as in older children and adults. The vaccine
provides effective immunity one to two weeks after
Swabs
administration which lasts for more than one year (though
Obtaining such swabs prior to chemoprophylaxis is
the duration of protection is limited in young children).
unnecessary, of no value in control and therefore not
routinely recommended. They may be of some value
It is recommended for travellers to epidemic and highly
during epidemics to estimate the prevalence of carriage
endemic areas such as Brazil, Mongolia, Vietnam, India,
of the causative strain.
Nepal and sub-Saharan Africa and is a requirement for
visits to Mecca. There is, at present, no effective vaccine
Routine post-prophylaxis swabs are also not cost-
against Group B available.
effective as rifampicin is effective in eliminating carrier
status in 90 to 95 per cent of patients.
Epidemic Measures
The major emphasis is on surveillance and early detec-
Investigative Procedures
tion of cases.
• Determine if household and other close contacts have
been offered chemoprophylaxis by the treating doctor.
Individuals should be separated and living and sleeping
Ensure that this is done.
quarters of those in crowded conditions ventilated.
• Determine if there is a school, kindergarten, child care
centre, baby sitter and so on involved, and ensure that
Rifampicin is not recommended for mass prophylaxis
all close contacts in such situations are offered chemo-
because of the danger of producing drug-resistant
prophylaxis.
strains.
• Ensure that surveillance letters are distributed to all
close contacts or their parents.
If the epidemic is due to Groups A or C, vaccination of
persons in a given area should be considered.
126
Information Sheet
Meningococcal Septicaemia/Meningitis
127
Meningoencephalitis (Primary Amoebic)
Victorian Statutory Two cases notified in Victoria in 1992 and one in 1996
were caused by a free-living amoeba hitherto regarded
Re quirem ent
as an innocuous soil organism incapable of infecting
Group A notification.
mammals. This is the Balamuthia mandrillaris. It is a rare
cause of meningoencephalitis.
Infectious Agent
Naegleria fowleri, Acanthamoeba culbertsoni and other Method of Diagnosis
species of Acanthamoeba, Balamuthia mandrillaris.
It can be diagnosed by:
• Microscopic examination of fresh CSF.
Clinical Features • Culture on non-nutrient agar plates spread with bacte-
ria (for example, E. coli).
It is a serious disease of brain and meninges.
• Culture on cell cultures of monkey kidney (Balamuthia
spp).
Naegleria spp enter the brain via the nasal mucosa and
olfactory nerve and causes a syndrome of fulminating
pyogenic meningoencephalitis with sore throat, severe Reservoir
headache, neck stiffness and death within 10 days,
The amoebae are free-living in water, soil and vegetation.
usually on the fifth or sixth day.
Period of Communicability
Cases caused by Acanthamoeba spp have been re-
ported from Africa, India, Korea, Japan, Peru, Venezuela, There is no person-to-person transmission.
129
Control of Case
No isolation, concurrent disinfection or quarantine is
necessary.
Tre a t m e n t
Amphotericin B, miconazole and rifampicin. Recovery
from infection is rare.
Control of Contacts
Investigation of contacts and source of infection should
take place.
Preventive Measures
• Educate the public on the danger of swimming in lakes
and ponds where the infection has been acquired.
• Maintain a residual chlorine of 1 to 2 ppm in swimming
pools.
• Chlorinate public water supplies that are naturally
warm.
Epidemic Measures
Any grouping of cases needs proper epidemiological
investigation.
130
Mumps
Group B notification.
Serologic tests (CF, HAI, EIA) are useful in confirming the
School exclusion.
diagnosis.
Infectious Agent The virus can be isolated in duck embryo or cell cultures
Mumps virus (paramyxovirus). from saliva, blood, urine and CSF during the acute phase
of the disease.
Clinical Features
Reservoir
Mumps is an acute viral disease characterised by fever,
Humans.
swelling and tenderness of one or more salivary glands,
usually the parotid.
Mode of Transmission
Orchitis occurs in 20–30 per cent of postpubertal males, It is transmitted by droplet spread and by direct contact
and oophoritis in about 5 per cent of females. Involve- with saliva of an infected person.
ment of the CNS results in meningitis, encephalitis or
meningoencephalitis in up to 15 per cent of cases but
permanent sequelae are rare.
Incubation Period
Usually 12–25 days; commonly 18 days.
Public Health Significance and Maximum infectivity occurs 48 hours before onset of
illness.
Oc c u r re n c e
Occurrence is worldwide. Serologic studies show 85 per Inapparent infection can be communicable.
cent or more people have had mumps infection by adult
life.
Susceptibility and Resistance
Most infections in children less than two years of age are Immunity is lifelong and develops after inapparent and
subclinical. clinical infections.
No specific treatment.
131
Control of Contacts
Isolation is unnecessary.
Susceptible contacts should be offered immunisation.
Preventive Measures
Live attenuated vaccine is available singly or combined
with rubella and measles.
Epidemic Measures
Susceptible persons should be immunised, especially
those at risk of exposure.
132
Mycobacterial Infections
Tubercu l o si s
133
Recovery and identification of mycobacteria from speci- In practice, the greatest risk of transmitting infection is in
mens has been made more rapid with test procedures the period prior to diagnosis of an open case; a sputum
such as the Bactec Systems and DNA probes. Further smear positive case is more infectious than a case only
information on these tests can be obtained from the positive on culture.
Mycobacterium Reference Laboratory, VIDRL.
The risk of transmitting the infection is significantly
reduced within days to two weeks after commencing
Reservoir appropriate chemotherapy.
Primarily humans; rarely diseased cattle.
Extrapulmonary tuberculosis, other than laryngeal, is The risk of developing the disease is highest in children
generally not communicable. under three years of age, lowest in later childhood, but
rises again for adolescents, young adults and the very
Urine is infectious in cases of renal tuberculosis. old.
134
Control of Case There is, however, a potential risk of MDRTB in Victoria
as most of the patients notified each year are foreign-
Tre a t m e n t
born and developing countries have high rates of drug
Adequate anti-TB chemotherapy for an appropriate resistance.
period of time will result in almost 100 per cent cure rate.
Short treatment regimes have been in use for some Control of Contacts
years. These involve the use initially of three or four Contact tracing and surveillance is the responsibility of
drugs (isoniazid, rifampicin, pyrazinamide and ethambu- the Department and is managed by the TB Program.
tol) for two months, and continuing with isoniazid and Anyone identified by health care workers as a contact of
rifampicin for a further four months. a case of TB should be referred to the TB Program on
(03) 9616 7777.
Where there is evidence of drug resistance to INH or
rifampicin or to both, short course anti-TB chemotherapy Contact investigation consists of:
would be inappropriate. • History taking.
• Tuberculin testing.
With the introduction of potent anti-TB drugs, hospitalisa- • Radiographic examination.
tion of tuberculous patients is no longer mandatory
unless social conditions or coexisting medical conditions The extent of investigation is governed by the character-
dictate otherwise. istics of the source case.
The success of treatment relies heavily on patient The scope of investigation is extended when the follow-
compliance and direct supervision should be the aim of ing factors in the source case are present:
any treatment program. • AFB in sputum smear.
• Cavitation on chest X-ray.
Compliance is important to prevent the development of • Laryngeal TB.
drug resistance. • Cough.
• High volume and reduced viscosity of respiratory
For drugs used in treatment of tuberculosis, see TB in secretions.
Australia and New Zealand into the 1990s, Australian • Where there is evidence of tuberculin conversion in
Government Publishing Services, Canberra. Telephone: any of the contacts.
(06) 289 7646, or fax (06) 289 6957.
Note
Multi-Drug Resistant TB (MDRTB) Tuberculosis testing should never be omitted for child
135
Following tuberculin testing, contacts can be grouped See Management, Control and Prevention of
as: Tuberculosis,Guidelines for Health Care Providers
• Initial negative reactors: published by Human Services and available from Infor-
– Tuberculin conversion takes a few weeks and may mation Services, Human Services, telephone: (03) 9616
not have occurred yet in these contacts. 7333.
– Testing should be repeated in eight to 12 weeks after
a break of contact or in some cases, initial testing
may be delayed for eight weeks.
Preventive Measures
– Chest X-rays may be indicated. The public should be educated about the mode of
spread and methods of control and the importance of
Initial positive reactors: early diagnosis.
• Definition of a positive tuberculin reactor.
Chemoprophylaxis should be given to persons with a
Dimension of Induration
Conditions (greater than or equal to)
positive tuberculin reaction without any clinical or radio-
logical evidence of active tuberculosis including those
No BCG, adult 10 mm
Past BCG, adult 15 mm who are HIV sero-positive.
HIV-infected individual 5 mm
No BCG, child 5 mm
The only drug currently used for routine chemoprophy-
BCG <5 years ago—child 15 mm
BCG >5 years ago—child 10 mm laxis is isoniazid given for six to 12 months as a single
daily dose of 5.0 mg/kg bodyweight up to a maximum of
Contacts identified by the TB Program as requiring ers, and contacts who react strongly to the tuberculin
When X-ray and physical examination are normal, Chemoprophylaxis is not usually recommended for
contacts with positive reaction should be offered isoni- people over 35 years of age because of the hepatotoxic-
Treatment should be for a minimum period of six months. age (over 35), should be considered for chemoprophy-
laxis.
chest X-rays taken at six months and 12 months. receiving corticosteroids, on immunosuppressive drugs,
insulin-dependent diabetics, persons following gastrec-
tomy and persons with silicosis.
136
Epidemic Measures
• Recognise and treat new cases.
• Search for the sources of infection.
International Measures
Individuals from high-prevalence countries should be X-
ray screened upon immigration.
137
Mycobacterial Infections
Atypical (Non-Tuberculosis)
139
Mode of Transmission Disseminated and pulmonary infections are treated with
combinations of antimycobacterial drugs. The clinical
The mode of transmission can rarely be determined for
outcome is strongly influenced by the underlying health
individual cases. Atypical mycobacteria are probably
of the host.
transmitted by aerosol from soil, dust or water, by
ingestion, or by skin inoculation.
No specific measures are needed for contacts of cases.
Incubation Period
The incubation periods of atypical mycobacterial infec-
tions can rarely be determined, but are probably weeks
to several months.
Period of Communicability
Communicability of human cases is usually not a practi-
cal concern. Localised foci of disease due to atypical
mycobacteria suggest that an established environmental
focus of organisms may remain the source of infections
for years.
Control of Case
Cases of atypical mycobacterial infection usually require
specialist management.
140
P e d ic ulo sis/ Headlice
141
Susceptibility and Resistance Note
Pregnant women, people with sensitive skin, and parents
Lice are host-specific.
with children less than 12 months old should consult a
doctor before using pediculicides.
Those that live on animals will not infest humans, al-
though they may be present transiently.
Preventive Measures
Repeated infestations often result in dermal hypersensi-
• Exclude infested children until treated.
tivity.
• Educate children, child care workers and parents
about headlice and the importance of regular inspec-
Control of Case tion of heads, and discourage sharing of personal
items such as combs and hats.
• Exclude confirmed or suspected case from school or
• Promote grooming and general hygiene.
child care facility.
• Educate the public.
• Readmit the day after appropriate treatment has
commenced.
• Do not preclude readmission because of the presence
of a few remaining nits.
• Treat with an appropriate lotion that kills louse and
egg.
• Use products containing maldison or permethrin as the
first line of treatment.
• Apply again seven to 10 days after treatment if using a
product that does not kill the egg, such as pyrethrins.
• Take care to avoid contact with the eyes, nose and
throat.
• Wash clothes, linen and towels on a hot water cycle,
and soak combs and brushes in hot water and deter-
gent for 10 minutes.
Note
To prevent unnecessary or repeated exposure to
pediculicides, the person applying the chemical should
wear protective gloves.
Control of Contacts
All household contacts should be treated simultaneously.
142
Information Sheet
H e a d lic e/ Pedic ulosis
What are Head Lice? Transmission may occur indirectly by sharing personal
items such as combs, brushes and hats but is far less
Head lice are tiny insects that live on the human scalp
common.
and feed on blood.
Nits found more than 12 mm out from the scalp are dead What is the Incubation Period?
or are only empty casings since human hair grows
Nits usually hatch in seven to 10 days.
approximately 1 cm/month.
Large numbers of nits resemble dandruff, except that What is the Contagious Period?
nits cannot be brushed out. As long as lice or nits (eggs) remain alive on the infested
person.
143
• Treat with an appropriate lotion that kills louse and nits. Note
• Use a fine metal comb or fingernails to remove nits. The whole family should be treated if one member is
• Treat all household contacts simultaneously. found to have head lice.
• Wash clothes, bed linen and towels on a hot water
cycle. Compliance with product instructions eliminates the need
• Wash combs and brushes in hot water and detergent. for nit removal after treatment.
• Never share combs, brushes or hats.
• Inspect close contacts regularly for signs of infestation. For children less than 12 months of age, the recom-
mended treatment is Lyban Foam or Pyrifoam.
How To Treat Head Lice
• Lyban Foam, Pyrifoam and Banlice Mousse are also
• There are a number of effective products available for
recommended as safe preparations in pregnancy.
the treatment of head lice. These products can be
obtained from a chemist without prescription.
• Resistant head lice can be eradicated by switching to If Lice Are Found Following
a different product. Tre a t m e n t
• The most effective products contain maldison or The lotion may have been inadequately applied.
permethrins: 0.5 per cent Malathion or Maldison Lotion
(Lice Rid or Cleensheen). The person may have been in contact with another
• The lotion should be applied to dry hair and left for 12 infected person.
hours. Care should be taken to protect the eyes.
• The hair is then washed and combed with a fine-tooth
Prevention
comb.
• Permethrins (Nix Creme Rinse, Quellada Creme Rinse, • Ordinary hair care is the best way to discourage head
Quellada Head Lice Treatment, Pyrifoam Shampoo). lice.
These liquids are applied to clean, damp hair for 10 • Daily brushing is likely to damage the lice.
minutes, then rinsed out. An application of Nix may be • To obtain effective control of head lice, the whole
repeated in two weeks if necessary. The other applica- community should be involved.
tions may be repeated after one week. • Parents should be encouraged to screen themselves
• Pyrethrins (Lyban Foam, Banlice Mousse) should be and their children regularly in the home, and to treat
applied according to directions. themselves only when necessary.
144
Pertussis
(Whooping Cough)
Victorian Statutory • An illness lasting two weeks or more with one of the
following:
Re quirem ent
– Paroxysms of coughing.
Group B notification.
or
– Inspiratory ‘whoop’ without other apparent causes.
School exclusion.
or
– Post-tussive vomiting.
Infectious Agent
Bordetella pertussis. Public Health Significance and
O c c u r re n c e
Clinical Features It is a distressing and often serious illness, particularly in
The catarrhal state may be indistinguishable from a viral children under one year of age.
upper respiratory tract infection.
The mortality rate is 0.5 per cent in infants under six
The infection damages respiratory epithelium, producing months.
respiratory obstruction and paroxysmal coughing, often
with a characteristic whoop. High immunisation levels reduce cases, and good
nutrition and medical care reduce case fatality.
There is little fever.
Infants aged less than six months and adults often do not
have the characteristic whoop. Method of Diagnosis
It can be diagnosed by:
Paroxysms frequently end with the expulsion of clear, • Elevated B. pertussis-specific IgA in serum.
tenacious mucus, often followed by vomiting. • DFA identification of B. pertussis in nasopharyngeal
specimens.
Pneumonia is the most common cause of death. Fatal • Culture:
encephalopathy, probably hypoxic, and inanition from – The definitive diagnosis of B. pertussis infection relies
repeated vomiting occasionally occur. on the culture of the organism from nasopharyngeal
swabs.
– Unfortunately, the organism is fastidious and slow
Case Definition growing and its culture is usually complicated by
The case can be defined by: contamination and overgrowth of other nasopharyn-
• Isolation of Bordetella pertussis from a clinical speci- geal organisms.
men. – Nasopharyngeal (not anterior nares) specimens
or should be taken with Dacron or calcium alginate
• Elevated Bordella pertussis-specific IgA in serum, or B. swabs rather than cotton swabs.
pertussis antigen in a nasopharyngeal specimen using – Patient specimens should be directly plated on
immunofluorescence with a history of clinically compat- selective transport media; for example, Charcoal
ible illness. agar, Regan-Lowe, Modified Stainer-Scholte agar,
or Fresh Bordet-Gengou medium.
145
– Isolation rates are highest in the first three to four Thereafter, communicability decreases and becomes
weeks of illness. Prior antibiotic treatment will mark- negligible in about three weeks.
edly decrease the detection rate.
• Fluorescent antibody tests: When treated with erythromycin, the period of infectivity
– Direct fluorescent antibody identification of B. pertus- usually lasts five days or less after commencement of
sis in nasopharyngeal specimens is a useful tech- therapy.
nique.
– This needs good reagents and experienced person-
nel.
Susceptibility and Resistance
– False negative and false positive results occur. Young infants are at risk of disease as there is poor
– These tests are particularly useful in situations later in placental transfer of immunity.
disease or during antimicrobial therapy when viable
organisms are no longer present. Severity is greatest in young infants; milder and atypical
• Other tests: cases occur in all age groups.
– Polymerase Chain Reaction (PCR).
– Serology, anti-B. pertussis IgA, IgG or IgM may be Incomplete immunisation or waning immunity results in
utilised in diagnosis. The role of these studies in cases occurring in older children and adults.
clinical practice remains to be clarified.
There may not be lifelong immunity, even after clinical
disease.
Reservoir
Humans only.
Control of Case
The suspected case should be excluded from the
Mode of Transmission presence of others outside the home (especially young
It is transmitted primarily by direct contact with dis- children and infants) until the patient has received more
charges from respiratory mucous membranes of infected than five days of a minimum 14-day course of antibiotics.
persons by the airborne route, probably droplet spread.
Antibiotics: Erythromycin shortens the period of commu-
Adults and older siblings may be infected despite nicability. Antibiotics do not reduce symptoms unless
adequate vaccination, and may transmit infection without they are given during the incubation period or early in the
clinical disease. catarrhal stage of the disease. (A 14-day course of co-
trimoxazole should be given if erythromycin is contraindi-
cated.)
Incubation Period
It is commonly seven to 10 days; rarely more than 14 Antibiotics should be given if case has been coughing
days. less than three weeks.
Period of Communicability Exclusion from school should take place until a medical
certificate of recovery from infection has been received.
It is highly communicable in the early catarrhal stage
This certificate is issued when the case has received at
before the onset of paroxysmal cough.
least five days of 14-day course of erythromycin.
146
Note Preventive Measures
This is in accordance with NH&MRC guidelines for
• Educate the public to the dangers of whooping cough
school exclusion. The Infectious Diseases Regulations in
and the advantages of initiating immunisation at two
Victoria will be amended accordingly.
months of age and adhering to the immunisation
schedule (DTP at two, four, six and 18 months and five
Control of Contacts years).
• Delay immunisation only for significant intercurrent
Vaccination:
infection or evolving neurological disorder. Minor URTI
• Protection is not afforded by passive immunisation.
is not a contraindication to immunisation.
• Close contacts under eight years of age who have not
received five doses of DTP should be given a DTP
dose as soon after exposure as possible. Health Care Workers
When there is an outbreak, consider protection of health
Antibiotics: A 14-day course of erythromycin for house- workers at high risk of exposure by using a 14-day
hold or other close contacts, regardless of immunisation course of erythromycin.
status, is recommended. Erythromycin should be given
as soon as possible. It should be given no later than 14
Epidemic Measures
days after the recipient’s first contact with the primary
case during the infectious period (in high-risk household • Search for unrecognised and unreported cases and
exposure settings, chemoprophylaxis may be considered ensure their exclusion from schools and child care
under eight years old should be excluded from school • Consider accelerated immunisation with the first dose
and child care centres until cases and contacts have at two weeks of age and the second and third doses at
received a minimum of five days of a 14-day course of four-week intervals. Complete immunisation for those
Note
Close contacts may include all children in a child care
centre, or all children in the same school classroom.
Please contact the Department of Human Services for
further advice.
147
Plague
Clinical Features America, Africa, Central and South East Asia. Human
plague has occurred recently in several countries in
It is an acute, severe infection appearing in a bubonic or
Africa and in India.
pneumonic form.
149
Mode of Transmission effective therapy. For patients with pneumonic plague,
isolate the case to prevent airborne spread until the
It is transmitted from rodent to human by the bite of an
completion of three days of appropriate antibiotic
infected flea vector.
therapy with clinical improvement.
• Disinfect sputum, purulent discharges and soiled
Human-to-human transmission comes from inhalation of
articles concurrently.
infected droplets spread by coughing patients with
• Clean terminally.
plague pneumonia or pharyngitis.
• Handle bodies of plague victims with strict aseptic
precautions.
It can also be transmitted by handling tissues of infected
• Use streptomycin, tetracyclines, chloramphenicol early
animals.
when they are highly effective.
Incubation Period
Control of Contacts
Usually one to six days.
Contacts and sources of infection should be investi-
gated.
Period of Communicability
It is communicable as long as fleas remain infective. Close contacts of confirmed or suspected plague
pneumonia cases should be offered chemoprophylaxis
Fleas may remain infective for months under suitable with tetracycline or sulphonamides and placed under
conditions of temperature and humidity. surveillance for seven days.
150
Epidemic Measures
• Investigate all possible plague deaths by autopsy and
laboratory examination.
• Inform the public through the press and news media
(but avoid panic).
• Destroy all rodents within affected areas, after satisfac-
tory flea control has been achieved.
• Protect field workers against fleas by using insecticide
powders and insect repellents.
International Measures
Within 24 hours, government should notify WHO and
adjacent countries of the first cases of plague in any area
previously free of the disease according to the Interna-
tional Health Regulations.
151
Pneumonia Due to Chlamydia pneumoniae
Clinical Features
Diagnosis by PCR methodology is under development.
These are similar to psittacosis with headache, fever,
myalgia and the development of a dry cough on days
three to five. Reservoir
Humans.
Sore throat and sinusitis are occasionally seen.
Patients who have died usually have had underlying Incubation Period
disease or additional bacterial infections.
Usually five to 10 days.
153
Control of Case
• Apply personal hygiene measures.
• Cover mouth when coughing.
• Dispose of discharges from mouth and nose in a
sanitary manner and wash hands.
Tre a t m e n t
Doxycycline for 14 days.
Preventive Measures
• Avoid crowding in living and sleeping quarters.
• Educate the public in hygiene measures.
Epidemic Measures
Case finding and treatment.
154
Poliomyelitis
155
Control of Case Epidemic Measures
• Obtain details of vaccine history, lot number, virus After a single case of paralytic poliomyelitis from wild
type, severity and persistence of residual paralysis 60 poliovirus, a dose of OPV should be given to all persons
days after onset (if vaccine-associated). in the immediate neighbourhood of the case, regardless
• Isolate patient with Standard Precautions in hospital. of their previous immunisation history.
Exclude from schools and children’s settings until at
least 14 days after onset of illness and until receipt of a All suspected cases of polio must have appropriate
medical certificate of recovery from infection. faecal specimens sent to the National Polio Reference
• Disinfect throat discharges, faeces and soiled articles. Laboratory.
• Determine whether the patient’s disease represents an
indigenous or imported case.
International Measures
National health administrations are expected to promptly
Control of Contacts inform WHO of outbreaks.
Vaccination of families and other close contacts contrib-
utes little to immediate control because susceptible The notification should be supplemented with details of
contacts are generally already infected by the time the source, nature, extent of the epidemic and virus identity
first case is recognised. type.
Preventive Measures
OPV (Sabin) is recommended at two, four and six
months, five years and 15 years.
156
Psittacosis (Ornithosis)
Method of Diagnosis
Humans:
Period of Communicability
• Infection is also generally diagnosed by serology using Infected birds may shed the agent for a prolonged
paired acute and convalescent phase sera. period.
• Culture of the organism from sputum, blood or biopsy
material (spleen, liver) is generally not performed
(because of danger to laboratory workers).
157
Susceptibility and Resistance Wearing gloves and dust masks are recommended when
cleaning areas where bird nests are found.
Immunity following infection is incomplete and transitory.
Control of Contacts
The diagnosis in symptomatic contacts should be
considered.
Control of Environment
The origin of suspected birds should be traced.
158
Q Fever
Scheduled WorkCover compensable disease for certain Preferably, blood samples are collected 14 days apart.
occupations.
Acute Q Fever:
Infectious Agent • Fourfold rise in CFT antibodies to phase II antigen that
can be confirmed with phase II IgM ELISA.
Coxiella burnetii.
Chronic Q Fever:
Clinical Features • High CFT antibody titre to phase I and II, and low or
The onset is usually acute and characterised by fever, absent IgM antibody.
chills, sweats, severe headache (especially behind the • An alternative and improved serological test for diag-
eyes), weakness, anorexia, myalgia and cough. Transient nosis is based on direct immunofluorescence (IF)
mild rashes are an occasional feature. testing.
159
Period of Communicability Epidemic Measures
Person-to-person spread occurs rarely, if ever. All notified cases should be investigated to ascertain if
other associated cases are likely to have occurred.
Susceptibility and Resistance If two or more related cases are evident in the same
Infection usually confers lifelong immunity. workplace, staff should be assessed for immune status
(if not already known) with CFT levels and skin testing.
Control of Case
Non-immune staff should be offered vaccination.
The notification details required are:
• Occupation.
The Department of Natural Resources and Energy and
• Possible source of infection (for example, batch of
the Occupational Health and Safety Organisation should
stock from endemic areas).
be notified.
• Any other known recent cases (for example, at
workplace).
• Immunisation status for Q Fever. Q Fever Guidelines
Persons who wish to be vaccinated should first complete
Specific treatments are: a questionnaire to elicit the type and duration of their
• Tetracycline for two to three weeks. When endocarditis work (abattoir, shearer, farmer, veterinary surgeon),
occurs, treatment should be prolonged and rifampicin previous Q Fever infection, previous Q Fever vaccination,
may be used in combination with tetracycline. egg allergy and current medications such as cortisone.
• Isolation is not necessary.
• Articles contaminated with blood, sputum and excreta
Skin Testing
should be disinfected.
Vaccine dilution:
• Immunisation of household contacts is not necessary.
• The required dilution of vaccine for a skin-testing
solution can be achieved by diluting 0.1 ml of vaccine
Preventive Measures in 30 ml normal saline.
• Eliminate source of infection if known.
• Disinfect incriminated stock-holding facilities if practi- Skin-test procedure:
cable; for example, 0.05 per cent hypochlorite (500 • Prepare the skin with methylated spirits.
• Dry well before injecting.
ppm available chlorine) or 5 per cent peroxide.
• Inject 0.1 ml of the diluted vaccine solution
• Immunise high-risk occupational groups.
intradermally into the volar surface of the left forearm.
Choose a smooth, unblemished area of skin.
Note
• Cover with a bandaid if returning to work.
Prevaccination assessment with CFT levels and skin • Instruct the patient to remove the bandaid when
testing is essential to reduce risk of severe local reac- showering then leave uncovered.
tions in those already immune. A certain degree of
training is required to recognise positive skin tests.
160
Reading Note
Where a history of Q Fever infection or previous vaccina-
The skin test can be read between three to 10 days
tion is given, confirm results through the admitting
(optimum seven days). After 10 days, it is unreliable. A
hospital, laboratory or LMO. If the results are negative,
positive reaction is indicated by induration at the site of
vaccination is recommended. In immunosuppressed
the injection.
individuals and in pregnancy, the risk-benefit ratio should
be evaluated before use.
Serology (CF):
• Positive titre: 1:2.5 and above.
• Negative titre: <1: 2.5. Side Effects
• Doubtful: A.C. (Anti-Complementary) <1:5 or <1:10. A localised redness/soreness around the injection site for
three to four days post-vaccination occurs in approxi-
Vaccination mately 45 per cent.
Note
Approximately 10 per cent experience a general reaction
Vaccination must be given subcutaneously. such as slight fever, headache and ‘flu-like’ symptoms 14
hours post-vaccination.
Retest
Australian vaccine induces protective immunity and in-
If a person with no previous history of Q Fever infection
vitro cell mediated immune responses within two to three
or Q Fever vaccination presents with the following:
weeks in over 90 per cent of individuals. Seroconversion
• Negative skin reaction and doubtful A.C. serology
rates are lower (50–60 per cent) when measured as
<1:10.
complement fixing or immunofluorescent antibody
• Doubtful skin reaction and negative serology.
responses.
161
Information Sheet
Q Fever
The Illness To detect immunity, two tests are done, a blood test and
a skin test:
Q Fever is an acute illness with fever, chills, headache
• For the blood test, 5–10 ml of blood is taken and tested
and muscle pains similar to severe influenza. Some
for Q Fever antibodies.
people become infected without any illness being
• For the skin test, a very small dose of diluted vaccine is
apparent, and a few develop a long-lasting illness with
injected into the skin. A previous history of infection
liver and heart complications. It is an infectious disease
with Q Fever or having recent Q Fever vaccine is a
caught from infected animals.
contraindication to vaccination.
The Germ The skin test is read seven days later. If both the skin test
The germ is a very small organism that is carried by and the blood test are negative and the person is not
cattle, sheep and goats and particularly by feral (wild) allergic to eggs, they are offered the vaccine which is
goats. Humans may occasionally become infected after given by injection under the skin.
drinking unpasteurised milk or, more usually, from
inhaling dust from infected premises. Animal faeces,
urine, blood and pregnancy fluids may contain large
numbers of organisms that are not killed by sunlight or
drying.
Pre ve n t i o n
The Commonwealth Serum Laboratories have prepared a
vaccine, Q-Vax, which gives a very high level of protec-
tion, except if given after a person has already been
infected. Some reddening and tenderness at the injection
site is common.
162
Rabies
To date, rabies has been excluded from this country by Person-to-person transmission via saliva is theoretically
animal quarantine measures and rapid destruction and possible but has never been documented.
investigation of suspect cases of rabies in animals.
163
The virus is comparatively fragile and does not survive • Implement the AUSVETPLAN rabies control proce-
for long periods outside the host. dures. In designated areas, animal owners may be
required to have susceptible animals vaccinated with
It is readily inactivated by heat and direct sunlight. rabies vaccine. Animal movements will be restricted
and stray animals destroyed.
• Take contact precautions (gloves, gown and mask)
Incubation Period when nursing a case of rabies in view of the potential
The incubation period is variable, usually two to eight hazard of saliva.
weeks, but can occur from five days to over a year
depending on factors such as severity, site of wound and
infective dose. Control of Contacts
Rabies immunoglobulin should be given and contacts
Very long incubation periods of up to six years or more immunised who report possibly infectious exposure to
have been reported. the case; for example, through bites, scratches, open
wounds or mucous membranes contaminated with saliva
or other infectious material.
Period of Communicability
Dogs and cats may transmit virus for three to 10 days Human Diploid Cell rabies Vaccine (HDCV) is available
(rarely over three days) prior to onset of their own clinical from Pasteur Merieux. (See NH& MRC Immunisation
signs and throughout the course of the disease. Procedures for details.)
164
The same prophylaxis should also be given to those
people with open wounds or mucous membranes that
have been contaminated with saliva or other potentially
infectious material (brain tissue) from a rabid animal.
Epidemic Measures
Control of rabies in the animal population, if relevant, will
be carried out according to the AUSVETPLAN rabies
procedures as described under Control of Case.
165
Ringwor m/Tinea
Tinea capitis (Head), Tinea corporis (Body), Tinea pedis
(Feet), Tinea unguium (Nails)
167
Method of Diagnosis Incubation Period
Tinea capitis: Tinea corporis: four to 10 days.
• Microscopic examination of hair. Tinea capitis: 10–14 days.
• Examination of hair with a Wood’s lamp. Tinea pedis and Tinea unguium: unknown.
• Fungal culture.
Tinea corporis:
Period of Communicability
• Microscopic examination of skin scrapings. The fungus persists on contaminated materials as long
• Fungal culture. as lesions or animal hair harbour viable spores.
It can be transmitted indirectly through contaminated • It can be treated effectively with topical medications.
168
Tinea capitis: Tinea pedis:
• Oral griseofulvin is the treatment of choice for resistant • Gymnasiums, showers and similar sources of infection
infection; for example, T. tonsurans. should be thoroughly cleaned and washed.
• Topical antifungal medication may be used concur- • Shower areas should be frequently hosed and rapidly
rently. drained.
Tinea pedis:
• Topical fungicides, oral griseofulvin may be indicated
Epidemic Measures
in severe protracted disease. Children and parents should be eduated about modes of
• Feet should be exposed to air by wearing sandals. spread, prevention, and the necessity of maintaining a
• Socks of heavily infected individuals should be boiled high standard of personal hygiene.
to prevent reinfection.
Tinea unguium:
• Oral terbinafine hydrochloride should be given until
nails grow: six months for fingernails and 18 months for
toenails.
Note
M. canis infection is self-limiting in children before
puberty and griseofulvin may not be necessary. Consult
a specialist about treatment.
Control of Contacts
• Investigate household contacts, pets and farm animals
for evidence of infection.
• Treat infected contacts, human or animal.
Preventive Measures
Tinea capitis:
• Parents should be educated about modes of spread
from infected children and animals.
• In case of epidemics, consider examination of all
children to identify cases. Disinfect contaminated
articles.
Tinea corporis:
• Shower bases, mats and floors adjacent to showers
should be disinfected.
• Infected animals should be avoided.
169
Information Sheet
Tinea (Ringworm)
170
Rotaviral Gastroenteritis
In temperate climates, outbreaks of rotavirus gastroen- Immunosuppressed infants are at increased risk of
teritis occur mostly in the cooler months. infection.
Infection in adults is usually subclinical, although out- By three years of age, most children have rotavirus
breaks have been reported among parents of children antibodies.
with rotavirus gastroenteritis, and travellers.
171
Control of Case
Cases should be excluded from school and child care
until diarrhoea has ceased.
Tre a t m e n t
Oral rehydration therapy.
Control of Contacts
The diagnosis should be considered in symptomatic
contacts.
Preventive Measures
In child care centres, hospitals and family settings,
exposure of infants and young children to persons with
acute gastroenteritis should be prevented.
Epidemic Measures
• Investigate outbreaks to determine the source of
infection and mode/s of transmission.
• Do not enrol new children at child care centres during
an outbreak.
172
Rubella
Children usually experience few or no constitutional • Isolation of rubella virus from a clinical specimen.
Exposure of Pregnant Women to The case should be excluded from school for at least five
days after onset of the rash.
Rubella
All women should be routinely tested for the presence of
Adults should be excluded from work for the same time.
rubella antibodies early in every pregnancy. If this result
is available and the woman is known to be immune, she
If the case is pregnant, the diagnosis should be con-
may be reassured that her foetus is at little risk.
firmed serologically, then the patient referred to her
obstetrician for specialist advice.
Pregnant women, in whom immunity to rubella has not
been confirmed for the current pregnancy, and who may
have been exposed to rubella, must be investigated Control of Contacts
serologically—irrespective of a history of vaccination, School contacts should not be excluded from school
clinical rubella or previous positive rubella antibody. regardless of immunisation status.
174
Preventive Measures
MMR vaccine is recommended for all infants at 12
months, and at 10–16 years (Year 6 in Victoria).
Epidemic Measures
All suspected outbreaks should be reported promptly to
Human Services.
175
Salmonellosis
Clinical Features Pets such as dogs and cats, tortoises, turtles and
It is a bacterial disease that commonly presents as an reptiles.
acute gastroenterocolitis with fever, vomiting, nausea,
abdominal pain and diarrhoea. Chronic carriers are rare among humans but common
among birds and animals.
Dehydration may occur, especially among infants and
the elderly.
Mode of Transmission
Salmonellosis may be complicated by septicaemia or It can be transmitted by:
focal infection. • Ingestion of the organisms in food derived from in-
fected food animals or contaminated by human or
animal faeces:
Public Health Significance and – Raw and undercooked eggs and egg products.
O c c u r re n c e – Raw milk and raw milk products.
Occurrence is worldwide. – Poultry and poultry products.
– Raw red meats.
The prevalence of infection is highest in infants and • Faecal-oral transmission from person to person,
young children. especially when diarrhoea is present.
• Contaminated utensils or tables used for food process-
Outbreaks occur in hospitals, institutions for children and ing and preparation.
nursing homes. • Pet turtles and chickens.
177
Period of Communicability Patients at high risk (for example, infants under two
months of age, the elderly and the immunosuppressed),
It is communicable through the course of infection—
may need antibiotic therapy.
usually several days to several weeks.
Tre a t m e n t
Epidemic Measures
No antibiotic treatment is indicated in uncomplicated
Sources of contamination, such as use of uncooked
enterocolitis. Antibiotics, given in the acute illness, may
products and inadequate cooking should be investi-
prolong the carrier state.
gated.
178
Attention should be paid to environmental cleaning,
particularly in institutions, child care centres and food
premises.
179
Scabies
Infectious Agent Outbreaks may occur in child care centres and kinder-
Sarcoptes scabiei (mite). gartens, and not infrequently are reported in nursing
homes and institutions.
Clinical Features
It is a highly contagious parasitic skin infestation, charac- Method of Diagnosis
terised by thin, slightly elevated wavy greyish-white See Clinical Features.
burrows that contain the mites and eggs. Multiple
papules and vesicles soon appear. Diagnosis is confirmed by scraping the burrows with a
needle or scalpel blade and identifying the mites or eggs
The most common sites for burrows are between the under the microscope.
fingers and toes, anterior surfaces of the wrists and
elbows, axillae, lower abdomen, beneath female breasts
and genitalia. The face, head, palms and soles are
Reservoir
seldom involved in adults, but in infants any area of skin Human. Other species of mite can also live on humans
may be infected. but do not reproduce in the skin.
Itching varies from person to person but may be severe. • Contact with infected towels, bedclothes and under-
It tends to be more marked at night or after a hot bath. garments only if these have been contaminated by
Scratching frequently leads to secondary infection. infested persons within the last four to five days.
181
Period of Communicability
It is communicable until mites and eggs are destroyed .
Control of Case
Infested patients should be excluded from school or
workplace until the day following the first application of
appropriate treatment.
Control of Contacts
• Investigate contacts and source of infestation.
• Treat all household contacts prophylactically and
simultaneously.
Preventive Measures
• Educate the public about the mode of spread, early
diagnosis and treatment.
• Promote good personal hygiene.
• Isolate the case until appropriate treatment has com-
menced.
• Treat patients and their contacts simultaneously.
Epidemic Measures
In an institution, ensure that investigations, screening,
treatment and education are undertaken on a coordi-
nated basis.
182
Information Sheet
Scabies
183
Information Sheet
Treatment of Scabies
184
Shigellosis
Clinical Features Sh. boydii, Sh. dysenteriae and Sh. flexneri occur mostly
in developing countries. Sh. sonnei is the most common
It is an acute bacterial disease characterised by diar-
and Sh. dysenteriae is uncommon in developed coun-
rhoea, fever, nausea, vomiting and abdominal cramps.
tries, but may be imported by travellers.
185
Period of Communicability
It is communicable during acute infection and while the
infectious agent is present in faeces (usually no longer
than four weeks).
Control of Contacts
Symptomatic contacts of shigellosis patients should be
excluded from food handling and the care of children or
patients until investigated.
Epidemic Measures
• Investigate food, water and milk supplies.
• Stress the importance of hand washing after toilet use.
• Pay attention to cleaning, particularly in toilet areas.
186
Streptococcal Disease Caused by Group A
Beta-Haemolytic Streptococcus
Streptococcal Sore Throat, Scarlet Fever (see also impetigo)
School exclusion.
Reservoir
Human.
Infectious Agent
Streptococcus pyogenes. Modes of Transmission
It is transmitted by direct contact with patient or carriers.
Clinical Features
Streptococcal sore throat in its typical form is manifested Outbreaks of streptococcal infection may also occur as a
by sore throat, fever, red pharynx and tonsillar exudate. result of ingestion of contaminated foods such as milk,
This form occurs in about 20 per cent of patients. In its milk products and eggs.
atypical form in children, convulsions may occur. Cervi-
cal and submaxillary nodes may enlarge and become
Incubation Period
tender. In children younger than four years of age,
Usually one to three days.
rhinorrhoea may be the sole manifestation of the infec-
tion.
Period of Communicability
The clinical manifestation of scarlet fever consists of
With adequate penicillin therapy, it is communicable for
streptococcal pharyngitis and a diffuse pink-red cutane-
24–48 hours; in untreated cases, for 10–21 days.
ous flush that blanches on pressure. The rash is seen
best on the abdomen, lateral chest and in cutaneous
Patients with untreated streptococcal infection with
folds. Characteristic manifestations of the disease
purulent discharges may spread the infection for weeks
include ‘strawberry tongue’ and circumoral pallor.
or months.
187
Control of Case Necrotising Fasciitis
Secretion precautions may be terminated after 24–48 Necrotising fasciitis due to Streptococcus pyogenes
hours of treatment with penicillin or other effective (Group A streptococcus) is an acute infection of the
antibiotics. subcutaneous fascia resulting in its necrosis and gan-
grene of the overlying skin. It is associated with severe
There should be concurrent disinfection of purulent malaise, fever, prostration and prolonged morbidity. The
discharges and other soiled articles. fatality rate is high in spite of prompt treatment with
penicillin and surgical excision. The speed with which
such infections develop is matched by few other infec-
Tre a t m e n t tious organisms.
Penicillin IM or oral for 10 days. For penicillin-sensitive
patients, use erythromycin. If the above antibiotics are Between February and May 1994, a cluster of seven
contraindicated, clindamycin or a cephalosporin may be people living in Gloucestershire, UK developed
used. necrotising fasciitis and three died. The isolates were
typed by the PHLS Streptococcus Reference Laboratory
Control of Contacts and found to be four different M types (M1(2), M3, M5,
untypable). There was no increase in reports of systemic
Not required for sporadic cases.
infection with Group A streptococci elsewhere in Britain.
The cluster in Gloucestershire, although unusual, was
Preventive Measures probably a chance occurrence.
188
Ta e n i a s i s
Taenia saginata (beef tapeworm). In the case of T. saginata, infection eggs can be de-
tected with perianal swabs.
Clinical Features
Taeniasis is the intestinal infection with the adult stage of Reservoir
either of the large tapeworms, and follows ingestion of Humans are the definitive host for both species.
viable larval forms in undercooked meat.
Cattle are the intermediate host for T. saginata and pigs
Cysticercosis results from infection with the larval stages for T. solium and certain Asian strains of T. saginata.
of T. solium and results from the ingestion of eggs.
Incubation Period
Both diseases are usually imported to Australia, but
T. saginata: eight to 10 weeks.
sporadic locally acquired cases of T. saginata infection
have been reported.
T. solium: eight to 12 weeks.
189
Period of Communicability Use of raw sewage for irrigation of soil should be
avoided.
It is communicable as long as infectious ova are
passed—sometimes for years.
Beef and pork, should be adequately cooked; for exam-
ple, at 56˚C for five minutes.
Eggs may remain viable in the environment for months.
Control of Case
Isolation is indicated only for persons infected with T.
Epidemic Measures
solium until treated. Not applicable.
Tre a t m e n t
Praziquantel (Biltricide) or niclosamide (Yomesan) are
used for treatment of beef and pork tapeworm.
Control of Contacts
• Investigate contacts and source of infection.
• Evaluate symptomatic contacts.
Preventive Measures
Proper public education should be undertaken.
190
Te t a n u s
Clostridium tetani.
Method of Diagnosis
Clinical Features Attempts at laboratory confirmation are of little help.
Period of Communicability
Public Health Significance and It is not directly transmitted from person to person.
Oc c u r re n c e
Tetanus is now rare in this community and usually Spores may remain viable for many years in the environ-
reflects waning immunity in the elderly. ment.
Occurrence is worldwide.
191
Susceptibility and Resistance Control of Contacts
Active immunity is produced by immunisation with There is no need for quarantine, disinfection or immuni-
tetanus toxoid and persists for at least 10 years after full sation of contacts.
immunisation.
Three doses or more: – If less than five years Clean, minor wound No No
since last dose All other wounds No No
* If child less than eight years old, use DTP in preference to tetanus toxoid alone.
If the person is eight years of age or older, use ADT in preference to tetanus toxoid alone.
192
To x o p l a s m o s i s
Infectious Agent
Toxoplasma gondii, an intracellular coccidian protozoan Method of Diagnosis
of cats. It is diagnosed by:
• Clinical signs and supportive laboratory results.
• Visualisation of the protozoa in body tissues or isolation
Clinical Features in animals.
Toxoplasmosis is a systemic disease that is contracted • Serology: rising antibody titres, or specific IgM anti-
by eating raw or undercooked meat, or through contact bodies in infants and rising titres in sequential sera are
with cat faeces. evidence of congenital infection.
193
Transplacental infection occurs when a woman has a Common exposure to cat faeces, soil, raw meat or
primary infection. infected animals should be determined.
Apart from transmission from mother to unborn child, Treatment is not usually indicated except in an initial
person-to-person spread does not occur. infection during pregnancy, presence of active chorio-
retinitis, myocarditis or other organ involvement.
Incubation Period
Uncertain, but probably ranges from several days to Preventive Measures
months. Pregnant women should:
• Cook meat thoroughly.
• Avoid cleaning litter trays and contact with cats.
Period of Communicability
Oocysts spread by cats may remain infective in water or Cats should be fed with dry, canned or boiled food. Cats
moist soil for about a year. should be discouraged from hunting and scavaging.
Cysts in the flesh of infected animals remains infective as Cat faeces and litter should be disposed of daily, as it
long as the meat is uncooked. becomes infectious after 24 hours.
Susceptibility and Resistance Hands should be washed thoroughly before eating, and
after handling raw meat or having contact with soil and
Susceptibility to infection is general, but immunity is
cat litter/faeces.
readily acquired and most infections are asymptomatic.
Control of Case
School exclusion is not required as person-to-person
spread does not occur.
194
Typhoid and Paratyphoid Fevers
Incubation Period
Complications such as intestinal haemorrhage or perfo-
Typhoid fever: Usually one to three weeks (depending on
ration can develop in untreated patients or when treat-
the infective dose, from three days to three months).
ment is delayed.
Method of Diagnosis
It can diagnosed by the demonstration of typhoid bacilli
Control of Case
in the blood, urine and/or faeces. Repeated sampling Hospitalisation is required for an acute infection.
may be necessary. Serology (that is, the Widal test), is no
longer routinely used. Ciprofloxacin, ceftriaxone, chloramphenicol, amoxycillin
or co-trimoxazole are used in treatment.
195
However, strains resistant to chloramphenicol, • Collect urine samples in addition to faeces if the
amoxycillin and co-trimoxazole are common in south patient:
Asia. Failure to respond to ciprofloxacin has been – Was initially diagnosed with a positive urine culture.
reported from Vietnam. – Has a past history of urinary tract disease, especially
with stone formation.
– Has a history of schistomiasis.
Investigative Procedures
Establish:
• Occupation and whether the case is a food handler. Control of Contacts
• Recent overseas travel (dates, localities). Surveillance of all contacts for four weeks is advised from
• Contact with recent overseas traveller (dates and the last date of contact with a case.
places of travel).
• Food history. For household contacts of patient who has been an
• Clinical history such as: overseas traveller:
– Date of onset and symptoms. • Obtain one specimen of faeces after four weeks if the
– Hospital admission and discharge. contact is a food handler. If a not a food handler, no
– Therapy provided. investigation is necessary.
– Criteria used in diagnosis. • Obtain one specimen of faeces after four weeks for
– Date of pre-travel immunisation (oral or injection). children under the age of 10 years.
196
Typhoid Carrier purging with 15 grams of magnesium sulphate dis-
solved in 250 ml of water.
The following is an extract from the Health (Infectious
• Repeat the above procedure two months later.
Diseases) Regulations 1990. S.R. No. 85/1990.
• Repeat the above procedure after an interval of one
month, if any of these specimens are positive, until two
Division 2—Prevention of Typhoid.
sets of three consecutive negative specimens are
Definition obtained.
‘22. In this Division—
‘Typhoid carrier’ means any person who continues to
excrete Salmonella Typhi organisms in their excre- Specimen Collection
tion or discharges 90 days or longer after cessation See appendix 7.
of a course of antibiotics or other treatment although
presenting no signs or symptoms of typhoid fever.
Transport of Specimens
Duties of Chief General Manager See appendix 7.
197
Vaccination does not offer full protection from infection,
and travellers should be advised to exercise care in
selecting food and drink.
It is important to provide a:
• Pure water supply.
• Pasteurised milk supply.
• Proper sewerage system.
Epidemic Measures
• Look for sources of infection such as chronic carriers,
and/or contaminated water or food supplies.
• Boil or pasteurise milk.
• Chlorinate or boil drinking water before use.
198
Typhus (Epidemic Louse-Borne Typhus)
The louse is infective for two to six days after the infected
blood meal.
199
Susceptibility and Resistance Epidemic Measures
Susceptibility is general. Typhus can be rapidly controlled by applying an insecti-
cide with residual effect to all contacts.
There is long-lasting Immunity following infection.
In case of a widespread infection, systematic application
of residual insecticide to all persons in the community is
Control of Case indicated.
Isolation is not required after proper delousing of patient,
clothing, living quarters and household contacts.
International Measures
There should be concurrent disinfection of clothing and Government should notify WHO and neighbouring
bedding of patient and contacts, and laundering of countries of the occurrence of disease in an area previ-
clothing and bedding of patient and contacts. ously free of the disease.
Control of Contacts
• Investigate all contacts.
• Look for a source of infection.
• Keep all immediate contacts under surveillance for two
weeks.
Preventive Measures
• Apply an effective residual insecticide powder (Carba-
ryl) to population at risk.
• Improve living conditions and standard of hygiene.
• Immunise susceptible persons or groups of persons
entering typhus area (two doses of 1 ml for children
over 10 years of age and adults, with intervals of four
weeks between doses).
200
Verotoxin-Producing E. coli
Common strains are E. coli O157: H7, E. coli O111: H8, Humans may also serve as a reservoir for person-to-
E. coli O26: H11. person transmission.
201
Susceptibility and Resistance • Heat beef adequately during cooking to at least 68oC.
• Chlorinate water supplies and swimming pools.
The infectious dose is very low. Little is known about
• Ensure adequate hygiene in child care centres, espe-
susceptibility and immunity.
cially hand washing.
Preventive Measures
• Identify source.
• Instruct family members in hand washing, disposal of
waste, and prevention of contamination of food and
beverages.
• Pasteurise milk and dairy products.
• Manage abattoir operations to minimise contamination
of meat by animal faeces.
202
Viral Gastroenteritis Caused by Agents
Other than Rotavirus
203
Period of Communicability Epidemic Measures
It is communicable during the acute phase of the dis- • Investigate outbreaks to determine the source/s and
ease and up to 48 hours after the diarrhoea ceases. route/s of transmission.
• Institute control measures.
• Clean exposed environmental surfaces.
Susceptibility and Resistance • Exclude cases from work, school and gatherings until
Short-term immunity lasts several weeks after infection. 48 hours after symptoms cease.
• Consider cohorting exposed persons within institutions.
Control of Case
In most cases the illness is self-limited.
Control of Contacts
Secondary cases should be anticipated in household
contacts and persons exposed to the faeces or vomitus
of cases.
Control of Environment
Environmental surfaces exposed to infectious faecal
matter or vomitus should be thoroughly cleaned.
Preventive Measures
Attention should be paid to hygiene and Standard
Precautions taken to reduce transmission of enteric
viruses.
204
Viral Haemorrhagic Fevers
Victorian Statutory plained fever who has been exposed to the infection in
an area with endemic VHF during the preceding three
Re quirem ent
weeks.
Group A notification.
Method of Diagnosis
Infectious Agents
Lassa Fever (LF):
Lassa fever virus (LF) (Arenavirus); Crimean-Congo
• Isolation of the virus from blood, urine, or throat wash-
Haemorrhagic fever (CCHF) virus (Nairovirus); Ebola
ing.
virus (EV); Marburg virus (MV) (Filoviridae).
• Presence of IgM antibodies to LF.
• Fourfold rise in IgG antibody titre, between acute and
Clinical Features convalescent sera.
205
Crimean Congo HF: Control of Case
• Bite of infective adult tick.
The Infectious Diseases Unit, Department of Human
• Nosocomial transmission from patients to medical
Services should be immediately contacted (03) 9616
workers by accidental inoculation of blood.
7777, or duty medical officer: (03) 9625 5000, pager
• Butchering infected animals.
number 46870.
206
In addition, specimens should be collected in tightly Tre a t m e n t
sealed, screw-top plastic containers labelled with the
Supportive care with viral haemorrhagic fevers may save
patient’s details. The outside of each container should be
lives.
swabbed with disinfectant.
207
Surveillance should continue for three weeks after the
person’s last contact with the patient.
Preventive Measures
Not applicable in Australia.
Epidemic Measures
Not determined.
International Measures
Government should notify WHO, source country and
receiving countries of possible exposures by infected
travellers.
208
Yellow Fever
Clinical Features
The case fatality is 5 per cent in indigenous populations
Yellow fever is an acute viral disease of short duration
in endemic areas. In non-indigenous individuals or
with a wide variation in intensity.
during epidemics it may be 50 per cent.
cardia: high temperature, slow pulse) that appear on the by the Aedes aegypti mosquito.
second day. On the third day, the fever falls by crisis and
patient enters remission. Jungle yellow fever is a zoonosis transmitted among non-
human hosts (mainly monkeys) by various forest mosqui-
Stage two: Remission that may last several hours to toes that may also bite and infect humans.
several days but haemorrhages, anuria and delirium may
occur without remission. If these humans are subsequently bitten by Aedes
aegypti mosquitoes, they become the source of out-
Stage three: Development of the classic symptoms of breaks of the urban form of the disease.
209
Period of Communicability Insect quarantine should be used to prevent the intro-
duction of Ae. albopictus.
Human blood is infective for mosquitoes shortly before
the onset of fever. For three to five days thereafter,
Certification of yellow fever vaccination should be
mosquitoes require nine to 12 days after a blood meal to
required for travellers over one year of age entering
become infectious and remain so for life.
Australia within six days of leaving an infected country.
Susceptibility and Resistance Unimmunised contacts who visit or stay in the northern
Mild infections are common in endemic areas. part of Australia are subject to quarantine.
Previous infection with dengue gives some degree of A yellow fever vaccination certificate is valid for 10 years
immunity, and passive immunity in infants born to im- and begins 10 days after vaccination.
mune mothers may last for six months.
Epidemic Measures
Recovery from yellow fever gives lifelong immunity.
Epidemic measures include:
• Using mass vaccination.
Control of Case • Spraying all houses with insecticide.
Access of mosquitoes should be prevented (with mos- • Controlling Ae.aegypti near airports.
quito nets and residual sprays) for at least five days after
onset of disease.
International Measures
The Commonwealth Department of Health and Family
Control of Contacts and the Services and WHO should be notiifed.
En v i ro n m e n t
• Investige contacts and source of infection.
• Investigate places visited three to six days before
onset.
• Investigate mild febrile illness.
• Immunise population at risk.
• Determine presence and source of vector mosquitoes.
Preventive Measures
All travellers to endemic areas in Africa and South
America should be immunised.
210
Yellow Fever Vaccine Outlets in Victoria
Name of Vaccine Outlet Telephone Number Facsimile Number
211
Yellow Fever Vaccine Outlets in Victoria
Name of Vaccine Outlet Telephone Number Facsimile Number
212
Yellow Fever Vaccine Outlets in Victoria
Name of Vaccine Outlet Telephone Number Facsimile Number
213
Yellow Fever Vaccine Outlets in Victoria
Name of Vaccine Outlet Telephone Number Facsimile Number
214
Ye r s i n i o s i s
216
Appendix 1: Telephone and Facsimile
Numbers
Laboratories
Microbiological Diagnostic Unit (03) 9344 5713 (03) 9344 7833 –
Victorian Infectious Diseases Reference (03) 9280 2222 (03) 9280 2898 24-hour switchboard
Laboratory
Victorian Institute of Animal Science: Attwood (03) 9217 4200 (03) 9217 4299 Night message on
switchboard
Australian National Animal Health Laboratory: (03) 5275 5000
Geelong –
217
Appendix 2: Glossary
Endemic Isolation
The constant presence of a disease or infectious agent Represents separation for the period of communicability,
within a given geographic area. of infected persons or animals from others in such places
and under such conditions as to prevent or limit the
Epidemic direct or indirect transmission of the infectious agent.
The occurrence of a number of cases of a disease (or Categories of isolation include:
condition) in excess of a number expected in a given • Strict isolation: for highly contagious infections spread
time and place. In some instances a single case will by air and contact.
constitute such an unusual occurrence.
219
• Contact isolation: for diseases spread primarily by School exclusion
close or direct contact. Exclusion from school under Health (Infectious Diseases)
• Respiratory isolation: to prevent transmission over short Regulations 1990.
distances through the air.
Source of infection
Drainage/secretion precautions are defined elsewhere in The person, animal or substance from which an infec-
this appendix. For blood and body substance precau- tious agent passes to a host.
tions, see appendix 4.
Surveillance
Nosocomial infection Personal surveillance is the practice of close medical or
Hospital-acquired infection. other supervision of contacts to permit prompt recogni-
tion of infection or illness but without restricting the
Notification movements of the individual.
The process of reporting a notifiable infectious disease.
Susceptibility
Outbreak Lack of resistance to a particular pathogenic agent.
See epidemic.
Transmission
Period of communicability In terms of infection, it relates to any mechanism by
The time during which an infectious agent may be which an infectious agent is spread from a source or
transferred directly or indirectly from an infected person reservoir to a person. This may be direct, indirect (that is,
or animal to a susceptible host. vehicle-borne, vector-borne, or airborne).
Resistance
The natural ability of an organism to resist micro-organ-
isms or toxins produced in disease.
220
Appendix 3: Outbreak Investigation
This section contains a brief summary of the principles of Characterise the Data
disease outbreak investigation. Any outbreak (or sus- Time: Determine date and/or hour of onset. Construct
pected outbreak) should be reported promptly to the epidemic curve of cases.
Infectious Diseases Unit. Personnel from the unit will then
conduct the investigation assisted by public health Place: Prepare spot map of cases with respect to home,
personnel from local government. work, recreational places and special meetings.
An outbreak (or epidemic) is when the number of cases Person: Determine age, sex, occupation and ethnic
of a disease (or condition) exceeds the number expected groups.
in a given time and place. In some instances, a single
case will constitute such an unusual occurrence.
Formulate a Working
The following steps are a guide only and the later steps Hypothesis of the Source and
will not necessarily be followed in sequence. Complete- Manner of Spread
ness and accuracy of data may be less than ideal in the Test hypothesis:
situation of a field investigation. • Determine infection and/or illness rates in persons
exposed and not exposed to the putative source/s by
questionnaire, interviews or laboratory tests.
Determine the Existence of an • Try to isolate the agent from the putative source/s.
Outbreak
• Check the diagnosis and compare with previous data Analyse data: On the basis of the data analysis, initiate
on the disease. short- and long-term control measures.
• Remember to allow for causes of spurious ‘outbreaks’,
such as new or improved laboratory tests, better Disseminate information: Inform physicians, other health
reporting, or a change in the size or structure of the officials and departments, as appropriate, on the nature
population. of the outbreak and the control measures being imple-
mented.
221
Appendix 4: Standard Precautions
Standard Precautions also apply to dried blood and between patient contacts and when otherwise indi-
other body substances, including saliva. cated to avoid transfer of micro-organisms to other
patients or environments.
• An antimicrobial agent or waterless antiseptic agent
may be used in an outbreak.
223
Gloves
• Wear gloves (clean non sterile gloves are adequate)
when touching blood, body fluids, secretions,
excretions and contaminated items; put on clean
gloves just before touching mucous membrane and
non-intact skin.
• Change gloves between tasks and procedures on the
same patients after contact with material that may
contain a high concentration of micro-organisms.
• Remove gloves promptly after use, before touching
non-contaminated items and environmental surfaces
and before going to another patient and wash hands
immediately to avoid transfer of micro-organisms to
other patients or environments.
Gowns
• Wear a gown (a clean non sterile gown is adequate) to
protect skin and prevent soiling of clothing during
procedures and patient care activities that are likely to
generate splashing or sprays of blood, body fluids,
secretions, or excretions or cause soiling of clothing.
• Select a gown that is appropriate for the activity and
the amount of fluid likely to be encountered.
• Remove a soiled gown as promptly as possible and
wash hands to avoid transfer of micro-organisms to
other patients and environments.
Environmental Control
• Ensure that the health care establishment has ad-
equate procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bedrails,
bedside equipment, and other frequently touched
surfaces and that these procedures are being followed.
224
Appendix 5: Procedure for Dealing with
Spills of Blood and Body Fluids
Equipment • Clean the area with warm water and detergent using
disposable cleaning cloth or sponge.
A spills kit should contain a large (10 litre) reusable
• Where contact with bare skin is likely, disinfect area by
plastic container or bucket with fitted lid, containing:
wiping with sodium hypochlorite 1,000 ppm available
• A 5 litre impervious container (treated cardboard or
chlorine (or other suitable disinfectant solution) and
plastic) with fitted lid for waste material.
allow to dry.
• Two large (10 litre) zip-seal plastic bags for waste
• Discard contaminated materials (absorbent towelling,
material.
cleaning cloths, disposable gloves and plastic apron)
• A disposable, sturdy cardboard scraper and pan
in accordance with State/Territory regulations.
(similar to a ‘pooper scooper’).
• Wash hands.
• Five granular disinfectant sachets containing 10,000
• Reusable eyewear should be cleaned and disinfected
ppm available chlorine or equivalent. (Each sachet
before reuse.
should contain sufficient granules to cover a 10 cm
diameter spill.)
Large Spills (greater than 10 cm diameter):
• Disposable rubber gloves that are suitable for clean-
• Collect cleaning materials and equipment (‘Spills kit
ing.
optional’).
• Eye protection (disposable or reusable).
• Wear disposable cleaning gloves, eyewear, mask and
• A plastic apron.
plastic apron.
• A mask (for protection against inhalation of powder
• Cover area of the spill with granular chlorine releasing
from the disinfection granules, or aerosols from high-
agent (10,000 ppm available chlorine) or other equiva-
risk spills that may be generated during the cleaning
lent-acting granular disinfectant and leave for three to
process).
10 minutes, depending on formulation and labelling
instructions.
Pr o c e d u re s • Use disposable (for example, cardboard) scraper and
Spot Cleaning: pan to scoop up granular disinfectant and any
• Wipe up spot immediately with a damp cloth, tissue or unabsorbed blood or body substances. Place all
paper towel. An alcohol wipe may be used. contaminated items into impervious container or plastic
• Discard contaminated materials (tissue, paper towel- bag for disposal.
ling, alcohol wipe) in accordance with State/Territory • Wipe area with absorbent paper towelling to remove
regulations. any remaining blood and place in container for dis-
• Wash hands. posal.
• Discard contaminated materials (absorbent towelling,
Small Spills (up to 10 cm diameter): cleaning cloths, disposable gloves and plastic apron)
• Collect cleaning materials and equipment (‘Spills kit in accordance with State/Territory regulations.
optional’). • Wash hands.
• Wear disposable cleaning gloves. Eyewear and plastic • Use ward cleaning materials to mop with warm water
apron should be worn where there is a risk of splashing and detergent.
occurring. • Where contact with bare skin is likely, disinfect area by
• Wipe up spill immediately with absorbent material (for wiping with sodium hypochlorite 1,000 ppm available
example, paper hand towelling). Place contaminated chlorine (or other suitable disinfectant solution) and
absorbent material into impervious container or plastic allow to dry.
bag for disposal.
225
• Clean and disinfect bucket and mop. Dry and store
appropriately.
• Reusable eyewear should be cleaned and disinfected
before reuse.
Notes:
1. Spill = a spill of blood or body substances.
2. * Spills kit (see above).
3. Where a spill occurs on a carpet, shampoo as soon as
possible. Do not use disinfectant.
4. Hypochlorites are corrosive to metals. Sodium
dichloroisocyanurates are less corrosive to metals, but
it may be difficult or impossible to prepare concen-
trated solutions above 1,000 ppm.
5. Wash hands thoroughly after cleaning is completed.
226
Appendix 6: Management of Needlestick
Injury and Exposure to Blood or Body
Fluids
227
The risk of zidovudine to mother and foetus should be Source HBV positive (HBsAg
carefully considered against the benefit of this antiviral
positive)
drug in a pregnant woman who has had a significant
The approach to investigation is modified according to
exposure. Prophylaxis should be commenced only after
whether or not the affected person has received a course
counselling the affected person and informing them of
of hepatitis B vaccine.
the absence of data regarding the efficacy, toxicity and
safety of zidovudine for this purpose.
If the affected person has been vaccinated, take blood
for estimation of hepatitis B surface antibody (Anti-HBs)
Prophylactic zidovudine should be at no cost to the
to confirm that vaccine immunity is being maintained.
affected person. Treatment should begin as soon as
Antibody titres may fall below protective levels some
possible after exposure (preferably within two hours).
years after vaccination (non-protective levels less than
10 IU/l).
The suggested dose of zidovudine is 200 mg orally five
times per day, or 250 mg four times a day for six weeks.
If the affected person has not been previously vacci-
nated for hepatitis B, take blood for estimation for hepati-
Doctors should emphasise the importance of strict
tis B core antibody (Anti-HBc), Anti-HBs or other such
compliance with the treatment regimen. They should
test such as HBsAg that is available in your local labora-
describe the potential side effects and the appropriate
tory to determine previous infection.
course of action if these are experienced.
Source Unknown
Reasonable efforts should be made to identify source
persons or syringes. If the source remains unknown,
appropriate follow-up should be determined on an
individual basis depending on:
• Type of exposure.
• Likelihood of source being positive for a blood patho-
gen.
• Prevalence of HIV, HBV and HCV in the community
from which the instrument or needle comes.
229
Appendix 7: Specimen Collection and
Transport Guidelines
231
• Moisten a charcoal swab and insert it into rectum 2 cm • Explain the procedure to patient and ask them to:
to 3 cm. Gently rotate it so that faeces cover the swab. – Wash, rinse and thoroughly dry hands.
Place it in transport medium, break off the top portion – Uncap specimen jar, handling only the outside of
of swab stick and discard. the jar and lid.
• Label the specimen and place it in a plastic hazard – Wash external genitalia with warm tap water and
bag with the appropriate request slip attached. discard swabs onto a tray.
Male:
Early morning specimens are more concentrated, and
• Draw back the foreskin.
therefore more likely to be positive for culture.
• Clean the area underneath thoroughly using cotton
wool dipped in saline.
• Instruct the patient to collect a 10 ml to 20 ml specimen
• Stand or sit over the toilet bowl.
of urine in the sterile container on the morning of the
required day.
• Collect a specimen of 10 ml to 20 ml, when urine flow
• Clearly label container. Place it in a sealed plastic
is established, then complete the flow in the toilet.
hazard bag and attach the request form.
• Take care not to touch the inside of the specimen jar or
• Send it to MDU on the day of collection.
cap. Screw cap on firmly.
• Return the specimen container and kidney dish to
Infants and Young Children
nurse.
Plastic collection bags are available for this purpose. The
• Place the specimen in a plastic hazard bag with a
adhesive bag is attached over the genitalia and 4 ml to 5
request slip, and send to the laboratory within 24 hours
ml collected in one voiding. The specimen should be
of collection.
transferred to a sterile container by removing the tab and
draining the urine into the container.
Throat Swabs
If the specimen is inadequate, a new bag must be Stuart’s transport medium kits should be used for trans-
applied and the procedure repeated. porting throat swabs to the laboratory.
232
The tongue should be gently pressed down with the • Pass the perinasal swab horizontally along the floor of
depressor. The two tonsillar areas, pillars of the fauces the nasal passage under the lower turbinate until it
and the posterior pharyngeal wall behind the uvula reaches the posterior nasopharyngeal wall. Rotate and
should be rapidly swabbed with slight pressure . gently remove it. Place it in transport medium.
• Collect material behind the soft palate through the
It is an advantage to sit a child on an adult’s knee. The mouth with a swab on a bent wire stalk.
adult should hold the child’s hands with one hand. Their • Label specimens for identification.
other hand should firmly hold the child’s forehead • Place them in a hazard bag and attach a request slip.
against the adult’s chest. This prevents the child from • Forward them to laboratory, preferably within 24 hours
retracting their head. of collection.
233
Quantity: • Ensure the request slip also identifies the cases/s and/
• Adults 8 ml to 10 ml. or incident by name/s and location and circumstances
• Children 3 ml to 4 ml. of the incident. Please also include clinical details of
illnesses attributed to the food.
The samples should be collected in plain tubes and
stored at 4oC. Water
• Collect a minimum of 200 ml if testing water for potabil-
Whole blood samples must not be frozen. ity.
• Collect a minimum of one litre if samples are required
Blood specimens shuold be delivered to the laboratory for investigation of possible contamination by Salmo-
within six hours of sampling. If a delay of more than six nella or Campylobacter.
hours is likely, the specimens should be stored in a • Collect water in sterile bottles provided by laboratory.
refrigerator (but do not freeze whole blood samples). • Label samples carefully. The request slip should
identify the cases/s and/or incident by name/s, and
Centrifuged specimens of separated serum can be location and circumstances of the incident. Please also
frozen and transported on dry ice. If this process is include clinical details of illnesses attributed to the
considered, please discuss it with the laboratory. water. Store and transport water samples chilled,
ideally at 4˚C.
Food and Water Samples
Specimens of food, water or ice can be submitted for Water must be examined within 24 hours of collection.
testing if they are considered to be possibly implicated The laboratory should be notified before samples are
as a vehicle of the disease or outbreak. collected.
234
Specimen Transport Guidelines Specimens related to investigation of outbreaks and
public health screening are routinely sent to:
Packaging
• Place specimen containers in sealed plastic bags in an
Microbiological Diagnostic Unit
insulated container (Esky) containing frozen icepacks.
Department of Microbiology
Do not use paper bags. Do not use ice cubes.
The University of Melbourne
• Keep the specimen container upright to reduce the risk
Royal Parade
of leakage and cross-contamination of other speci-
Parkville 3052
mens.
Telephone: (03) 9344 5713
• Place trays of blood tubes from mass screening
Facsimile: (03) 9344 7833
surveys in a sealed plastic bag and maintain in an
upright position.
Hours: 8.30 a.m. to 5.00 p.m., Monday to Friday.
• Keep chilled but not frozen and deliver them to the
laboratory as soon as possible. If frozen samples of
Please notify laboratory if specimens to arrive out of
separated serum are to be transported, please discuss
normal hours.
this process with the laboratory. If specimens have to
be transported by rail, ensure the insulated container
The entrance is at Gate 11, Royal Parade (approximately
has several icepacks to maintain the temperature as
100 metres from Grattan Street, traffic lights) through the
close to 4oC for as long as possible.
loading bay on ground floor; or via Gate 12 (200 metres
• Seal all containers well.
from Grattan Street). Turn right to reach the car park in
• Label the insulated container clearly with the address
front of MDU.
and telephone numbers of the laboratory and the
submitting authority.
After hours:
• Notify the laboratory of impending specimen delivery.
• An overnight box for specimens is located on northern
side of MDU adjacent to Royal Parade.
Transport • The area is well-lit and clearly signposted. Place the
The preferred method of transport is door-to-door bagged specimens with the request slips in the hatch.
delivery by courier. • Always give laboratory staff prior notification if out-of-
hours delivery of specimens is anticipated.
If specimens have to be delivered by rail, ensure that the • Saturdays and Sundays: place specimens in the
package contains sufficient icepacks to keep the con- overnight box (emergency only).
tents chilled. Seal containers well.
235
Instructions for Collecting Faeces
236
Appendix 8: Infections in Children’s
Services Centres
237
Appendix 9: School Exclusion Table
Conjunctivitis (Acute infectious) Until discharge from eyes has Not excluded.
ceased.
Impetigo (School sores) Until sores have fully healed. The Not excluded.
child may be allowed to return
earlier provided that appropriate
treatment has commenced, and that
sores on exposed surfaces (such as
scalp, face, hands or legs) are
properly covered with occlusive
dressings.
Measles Until at least five days from the Non-immunised contacts must be
appearance of rash, or until receipt excluded for 13 days from the first
of a medical certificate of recovery day of appearance of rash in the last
from infection. case unless immunised within 72
hours of first contact.
239
School Exclusion Table (continued)
Disease or Condition Exclusion of Cases Exclusion of Contacts
Pertussis (Whooping cough) Until two weeks after the onset of Domiciliary contacts must be
illness and until receipt of a medical excluded from attending a children’s
certificate of recovery from infec- services centre for 21 days after the
tion. last exposure to infection if the
contacts have not previously had
whooping cough or immunisation
against whooping cough.
Typhoid and paratyphoid fevers Until receipt of a medical certificate Not excluded unless the medical
of recovery from infection. officer of health or a health officer of
the Department considers exclusion
to be necessary.
240