Shigella Outbreak in Santa Cruz County

  • Shigellosis is a highly infectious intestinal disease caused by a family of bacteria called Shigella.
  • The incubation period is 12 hours to 4 days, meaning that illness usually starts between 12 hours and 4 days after shigella bacteria enter the body.
  • The main sign of shigella infection is diarrhea, which can be watery, bloody, or both. Many people with shigella also get fever, stomach aches, and nausea. Vomiting can occur but is not common.
  • Symptoms typically last 4-7 days. People with mild illness usually get better without specific treatment.
  • With more severe shigella infection, patients can get diarrhea so severe they become dehydrated. Occasionally, shigellosis causes seizures, bloodstream infection, or arthritis, and can rarely result in death.
  • Shigella is often diagnosed by health professionals by collecting a sample of stool or diarrhea, and sending it to a microbiology laboratory for culture.
  • Most laboratories are also able to test for antibiotic sensitivities (to find out which antibiotic will be effective in killing the Shigella bacteria).
  • People with mild illness usually get better on their own, with no specific treatment.
  • However, a course of effective antibiotics can be helpful by shortening the length of illness
  • Effective treatment also makes the patient less infectious to others by reducing diarrhea and the bacterial count. Continued attention to hand hygiene remains an important step in protecting others from infection even after symptoms have resolved.
  • Handwashing! Thoroughly clean your hands using soap and water for at least 20 seconds, or use hand sanitizer followed by hand washing at earliest opportunity. Do this frequently, and before eating, drinking, or touching your face. Make sure to clean under your nails.
  • Creeks, rivers, lagoons, and ocean water may be contaminated with bacteria that can result in gastrointestinal illness. Protect yourself and your pets by not swimming or bathing in creeks, rivers, lagoons, and ocean water known or suspected of being contaminated. Some waterways have signage posted, if testing has shown they contain elevated levels of bacteria.
  • Avoid all waterways for at least 2-3 days after rain. If you come in contact with contaminated water, bathe yourself and/ or your pet as soon as possible. Avoid eating, drinking or smoking before you've washed your hands.
  • Children should be supervised when washing their hands in day care centers and at home.
  • When possible, young children with a Shigella infection who are still in diapers should not come into contact with uninfected children.
  • In traveling to the developing world where Shigella infection is more common: drink only treated or boiled water, and eat only cooked hot foods or fruits/vegetables you peel yourself after thorough washing.
  • During sexual contact, avoid unprotected direct oral-anal contact and be sure to wash hands, other body parts, and any objects thoroughly after sex.

Prevention Tips and Resources for Employers

  • Read the Shigella Prevention and Control Guidelines Factsheet to implement healthy practices that can help prevent the spread of Shigella in the workplace.
  • Consider posting notices about Handwashing and other Shigella prevention tips in break areas, janitorial areas and restrooms.  (Scroll down to the main Resources section at the bottom of this page to view/print flyers in multiple languages).
  • Per CDC returning to work guidance, cases in sensitive occupations or situations such as Food Service and Childcare, should be excluded from these settings while symptomatic and until Public Health restrictions are lifted. By State law, California Retail Food Code requires that food service workers be excluded until cleared.
     

Please follow CDC guidance for the following occupations:

Food Service Workers

Childcare Providers

>Direct Caregivers for Adults

Shelter and Street Outreach Workers

  • People who have shigellosis usually get better without antibiotic treatment in 5 to 7 days. People with mild shigellosis may need only fluids and rest. Bismuth subsalicylate (for example, Pepto-Bismol) may be helpful, but people sick with shigellosis should not use medications that cause the gut to slow down and interfere with the way the body digests food, such as loperamide (for example, Imodium) or diphenoxylate with atropine (for example, Lomotil).
  • Healthcare providers may prescribe antibiotics for people with severe cases of shigellosis to help them get better faster. However, some antibiotics are not effective against certain types of Shigella. Healthcare providers can order laboratory tests to determine which antibiotics are likely to work. Tell your healthcare provider if you do not get better within a couple of days after starting antibiotics. They can do more tests to learn whether your type of Shigella bacteria can be treated effectively with the antibiotic you are taking. If not, your doctor may prescribe another type of antibiotic.
  • CDC recommends the following precautions be taken by adult patients and those who take care of children who are recovering from Shigella. 

Adults:

  • Wash your hands carefully and frequently with soap and water, especially after using the bathroom.
  • Do not prepare food for others while you are sick. After you get better, wash your hands carefully with soap and water before preparing food for others.
  • Stay home from childcare, school and food service facilities while sick.
  • Avoid swimming until you have fully recovered.
  • Wait to have sex (vaginal, anal, and oral) for 2 weeks after you no longer have diarrhea. Because Shigella bacteria (germs) may be in stool for several weeks, follow safe sexual practices, or ideally avoid having sex, for several weeks after you have recovered.

Caregivers/Parents:

  • Supervise handwashing of toddlers and small children after they use the bathroom. Wash your hands and your infant’s hands with soap and water after diaper changes.
  • Throw away soiled diapers in a covered, lined garbage can. Clean diaper changing areas after using them. (Safe & Healthy Diapering in the Home)  
  • Keep your child out of childcare and group play settings while sick with diarrhea.

Actions Requested of Healthcare Providers

  1. SUSPECT shigellosis in patients with compatible symptoms.
  2. TEST by obtaining stool cultures and antimicrobial susceptibility testing. PCR testing does not replace stool culture.
  • Consider testing stool specimens with rapid enteric panel PCR testing followed by reflex cultures for bacterial enteritis, as may be necessary in some settings.
  • Test shigellosis patients for HIV and STIs (particularly syphilis), as co-infections are common. Substance use disorders may present as co-morbidities.
  1. TREAT appropriately, considering local resistance patterns and individual susceptibility results.
    • Empiric antibiotic treatment with fluoroquinolones (Ciprofloxacin or Levofloxacin). Based on recently isolated samples, this strain of Shigella sonnei is susceptible only to Ciprofloxacin and Levofloxacin (fluoroquinolones) and resistant to Ampicillin, Ceftriaxone, and Trimethoprim-Sulfamethoxazole.
    • Subsequently tailor antibiotic treatment when individual susceptibility results are available.
  2. REPORT suspected and confirmed shigellosis cases to the Communicable Disease Unit:
    • Call 831-454-4114 or submit a Confidential Morbidity Report (CMR) by faxing 831-454-5049 or via the CalREDIE Provider Portal.
    • It is especially important to report cases in sensitive occupations and situations (i.e. food handlers, direct care givers in health care facilities or group settings, or persons attending daycare, etc.). Cases in sensitive situations should be excluded from these settings while symptomatic and until Public Health restrictions are lifted.
  3. COUNSEL patients on hand hygiene practices and avoiding activities while symptomatic that could pose.
  • As per general guidance for enteric illnesses such as Shigella/Shigellosis, we recommend that patients wait 48 hours without diarrhea before resuming use of shared living spaces. Symptomatic sheltered persons should be provided separate sleeping accommodations and dedicated restroom facilities, whenever possible, and all symptomatic persons should be provided testing for Shigella and other enteric pathogens, including norovirus. 

Provider Resources

Health Alerts:

Disease Reporting Information: www.santacruzhealth.org/CDUnit

Centers for Disease Control (CDC) Shigellosis Treatment Guidance: www.cdc.gov/shigella/audience-medical-professionals.html