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The blue book: Guidelines for the control of infectious diseases i

The blue book

Guidelines for the control of infectious diseases


ii The blue book: Guidelines for the control of infectious diseases

Acknowledgements Disclaimer
These guidelines have been developed These guidelines have been prepared
by the Communicable Diseases Section, following consultation with experts in the
Public Health Group. The Blue Book – field of infectious diseases and are based
Guidelines for the control of infectious on information available at the time of
diseases first edition (1996) was used as their preparation.
the basis for this update. Practitioners should have regard to any
We would like to acknowledge and thank information on these matters which may
those who contributed to the become available subsequent to the
development of the original guidelines preparation of these guidelines.
including various past and present staff Neither the Department of Human
of the Communicable Diseases Section. Services, Victoria, nor any person
We would also like to acknowledge and associated with the preparation of these
thank the following contributors for their guidelines accept any contractual,
assistance: tortious or other liability whatsoever in
A/Prof Heath Kelly, Victorian Infectious respect of their contents or any
Diseases Reference Laboratory consequences arising from their use.

Dr Noel Bennett, content editor While all advice and recommendations


are made in good faith, neither the
Dr Sally Murray, content editor Department of Human Services, Victoria,
Ms Kerry Ann O’Grady, content editor nor any other person associated with the
preparation of these guidelines accepts
legal liability or responsibility for such
advice or recommendations.
Published by the Communicable Diseases
Section
Victorian Government Department of Human
Services
Melbourne Victoria

May 2005

© Copyright State of Victoria, Department of


Human Services 2005

This publication is copyright. No part may be


reproduced by any process except in
accordance with the provisions of the Copyright
Act 1968.

Authorised by the State Government of Victoria,


555 Collins St, Melbourne.

Printed by

This document may also be downloaded from


the Department of Human Services web site at:
www.health.vic.gov.au/ideas/bluebook
The blue book: Guidelines for the control of infectious diseases iii

Contents
Acknowledgements ii Hepatitis C 79 Ringworm or tinea 181
Disclaimer ii Hepatitis D (delta hepatitis) 83 Ringworm (tinea) information sheet 183
Introduction 1 Hepatitis E 85 Ross River virus disease 185
Notification of infectious diseases 2 Herpes simplex infections 87 Rotaviral gastroenteritis 187
Abbreviations used 4 Human immunodeficiency Rubella (German measles) 189
Acute bacterial conjunctivitis 6 virus or acquired Salmonellosis 191
Amoebiasis 7 immunodeficiency syndrome 89 Scabies 193
Anthrax 8 Hydatid disease (echinococcosis) 93 Scabies information sheet 195
Ascariasis (round worm infection) 13 Impetigo (school sores) 95 Guide to scabies management
Barmah Forest virus disease 15 Impetigo (school sores) in residential care facilities 197
Botulism 17 information sheet 97 Severe acute respiratory
Brucellosis (undulant fever, Infectious mononucleosis syndrome (SARS) 199
Malta fever) 19 (glandular fever) 99 Shigellosis 207
Campylobacter infection 21 Influenza 101 Smallpox (variola) 209
Chickenpox or shingles Invasive pneumococcal disease 105 Staphylococcal infections 215
(varicella /herpes zoster) 23 Japanese encephalitis 107 Streptococcal disease
Chlamydia (genital infection) 27 Kunjin virus disease 109 (Group A beta-haemolytic
Chlamydophila pneumoniae 29 Legionellosis (Legionnaires’ streptococcus) 217
Cholera 31 disease) 111 Syphilis 219
Creutzfeldt-Jakob disease (CJD) 33 Leprosy (Hansen’s disease) 115 Taeniasis 223
Croup or bronchiolitis 37 Leptospirosis 117 Tetanus 225
Cryptococcal infection Listeriosis 119 Toxoplasmosis 227
(cryptococcosis) 39 Malaria 123 Typhoid and paratyphoid fever 229
Cryptosporidiosis 41 Measles (rubeola) 127 Verotoxin producing E. coli
Cytomegalovirus infection 43 Melioidosis 131 (VTEC) 231
Dengue virus disease 45 Meningococcal disease 133 Viral gastroenteritis
Diphtheria 47 Molluscum contagiosum 137 (not rotavirus) 233
Donovanosis 51 Molluscum contagiosum Viral haemorrhagic fevers 235
Erythema infectiosum (human information sheet 138 Yellow fever 239
parvovirus infection or Mumps 139 Appendix 1: Contacts 243
slapped cheek disease) 53 Murray Valley encephalitis virus 141 Appendix 2: Glossary 245
Slapped cheek infection Mycobacterial infections Appendix 3: Standard and
information sheet for (non-tuberculosis) 145 additional precautions 247
pregnant women 55 Mycobacterial infections Appendix 4: Procedure for
Slapped cheek infection (tuberculosis) 147 managing an exposure to
information sheet 56 Mycobacterium ulcerans 151 blood/body fluids/
Food or water-borne illness 57 Pediculosis or head lice 153 substances 253
Common food or water-borne Pertussis (whooping cough) 155 Appendix 5: Procedure for
pathogens 60 Pinworm infection (threadworm) 157 managing spills of blood
Giardiasis 63 Plague 161 and body fluids/substances 257
Gonorrhoea 65 Poliomyelitis 163 Appendix 6: Cleaning and
Haemophilus influenzae Psittacosis (ornithosis) 167 waste disposal procedures 259
infections 67 Psittacosis information sheet 169 Appendix 7: Infections in
Hand, foot and mouth disease 69 Q fever 171 children’s services centres 263
Hand, foot and mouth disease Rabies and Australian bat Appendix 8: School exclusion
information sheet 70 lyssavirus 174 table 265
Hendra and Nipah viruses 71 Rabies and Australian bat lyssavirus
Hepatitis A 73 exposure information sheet 176
Hepatitis B 75 Rickettsial infections 179
iv The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 1

Introduction
The blue book: guidelines for the control The first edition of The blue book: • Health Translations Directory, links to
of infectious diseases has been published guidelines for the control of infectious health information that has been
by the Communicable Diseases Section, diseases (1996) was used as the basis translated into various different languages,
Public Health Group, Victorian for this second edition. As treatments www.healthtranslations.vic.gov.au
Department of Human Services, to assist change over time health care workers • Victorian Department of Human
public health practitioners in the should consult the current version of Services 1998, Guidelines for the
prevention and control of infectious Therapeutic guidelines: antibiotic investigation of gastrointestinal illness,
diseases. (Therapeutic Guidelines Limited) for up to http://www.health.vic.gov.au/ideas/
The Department of Human Services is date information. The blue book is not
intended to replace appropriate referral Other sources
committed to enhancing and protecting • Australian Government Department of
the health and well-being of all or the need to seek further professional
advice. Health and Ageing 2004, Infection
Victorians. Our challenge, together with control guidelines for the prevention of
public health practitioners, is to reduce transmission of infectious diseases in
References
community risk from communicable the health care setting,
The following sources were used in the
disease in Victoria through the http://www.icg.health.gov.au/
preparation of the guidelines:
implementation of patient focused and
population focused control strategies • Therapeutic Guidelines Limited 2003, • Centers for Disease Control and
based on surveillance and risk Therapeutic guidelines – antibiotic, Prevention, Atlanta USA, www.cdc.gov
assessment. version 12. • Food Standards Australia New Zealand,
Information for each disease in this • Heymann D, 2004 Control of http://www.foodstandards.gov.au/
edition covers: communicable diseases manual, 18th • National Health and Medical Research
edn, American Public Health Council 2003, The Australian
• Victorian statutory requirement for
Association (the 17th edition, Chin J immunisation handbook, 8th edn,
notification and exclusion
ed. 2000, was used in compiling The www.immunise.health.gov.au
• infectious agent(s) blue book).
• National Health and Medical Research
• identification Council 2001, Staying healthy in child
Further information
• incubation period Together with the references above, the care, 3rd edn, Australian Government
• public health significance and following resources provide further Department of Health and Aged Care,
occurrence information. http://www.health.gov.au/nhmrc/

• reservoir Victorian Department of Human


Services
• mode of transmission
Fact sheets, surveillance reports,
• period of communicability Departmental policies and guidelines,
• susceptibility and resistance and online ordering of resources can be
• control measures for patients and accessed at
contacts http://www.health.vic.gov.au/ideas/

• outbreak measures • Better Health Channel, information for


the public, www.betterhealth.vic.gov.au
• international measures if applicable
• Clinicians Health Channel,
• sources of further information if www.health.vic.gov.au/clinicians
applicable
2 The blue book: Guidelines for the control of infectious diseases

Notification of
infectious diseases
Notifiable infectious diseases are Group A diseases Group B diseases
included in Schedule 3 of the Health Group A diseases require notification to Group B diseases require written
(Infectious Diseases) Regulations 2001 the Department of Human Services by notification only within five days of
and are divided into four groups on the telephone or fax upon initial diagnosis diagnosis.
basis of the method of notification and (presumptive or confirmed) with written • Arbovirus infections
the information required. notification to follow within five days.
• Ross River virus
Notification forms are available from the • Anthrax
Department: • Barmah Forest virus
• Arbovirus infections
Telephone 1300 651 160 • Dengue virus
– Japanese encephalitis virus
Or print or order online at • Kunjin virus
– Murray Valley encephalitis virus
www.health.vic.gov.au/ideas • other Arbovirus infections
• Botulism
All notifications and related inquiries • Brucellosis
should be directed to: • Cholera
• Campylobacter infection
Communicable Diseases Section • Diphtheria
• Creutzfeldt-Jakob disease (CJD)
Public Health Group • Food-borne and water-borne illness
Department of Human Services (two or more related cases). • Cryptosporidiosis
Reply Paid 65937 • Haemolytic uraemic syndrome (HUS) • Giardiasis
Melbourne VIC 8060 • Hepatitis A
• Legionellosis
Telephone 1300 651 160 • Hepatitis B
Facsimile 1300 651 170 • Measles
• Hemophilus influenzae, type B • Hepatitis C
For urgent notifications after hours:
infection (meningitis, epiglottitis, other • Hepatitis D
Contact the Duty Medical Officer invasive infections) • Hepatitis E
via pager service 13 22 22
and quote pager number 46870 • Meningococcal infection (meningitis or • Hepatitis viral (not further specified)
meningococcaemia)
• Influenza (laboratory confirmed)
• Plague
• Leprosy
• Poliomyelitis
• Leptospirosis
• Rabies
• Listeriosis
• Severe acute respiratory syndrome
• Lyssavirus – Australian bat lyssavirus
(SARS)
• Lyssavirus – other (specify)
• Smallpox
• Malaria
• Tularaemia
• Mumps
• Typhoid and paratyphoid fevers
• Mycobacterium ulcerans
• Viral haemorrhagic fevers
• Pneumococcal infection (invasive)
• Yellow fever
• Psittacosis (ornithosis)
• Pertussis
• Q Fever
The blue book: Guidelines for the control of infectious diseases 3

• Rubella (including congenital rubella) • Acquired immunodeficiency syndrome Immediate notification must be made by
• Salmonellosis (AIDS) telephone followed by notice in writing
• Human immunodeficiency virus (HIV) within 5 days specifying the micro-
• Shigellosis organism isolated or detected, date of
infection
• Tetanus isolation or detection, source (food or
• Tuberculosis Laboratory notification water) and any batch identification (if
Around Australia and overseas it has appropriate).
• variant Creutzfeldt-Jakob disease
been recognised that laboratory
(vCJD)
notification of infectious diseases should
• Verotoxin-producing Escherichia coli be an integral part of any disease
(VTEC) surveillance system.

Group C diseases The Health (Infectious Diseases)


Group C diseases include the sexually Regulations 2001 require laboratories to
transmissible diseases and should be notify tests indicating the probable
notified using the same form. To preclude presence of a human pathogenic
identification of the patient, only the first organism associated with an infectious
two letters of the given and family name disease listed above. The notification
of the patient are required. should state the laboratory finding, the
family name and given name of the
• Chlamydia trachomatis genital
patient (except for Group C diseases),
infection
the age, sex and postcode of the patient,
• Donovanosis and the name, address and telephone
• Gonococcal infection number of the doctor requesting the test.

• Syphilis/congenital syphilis In addition to the above, the Health


(Infectious Diseases) Regulations 2001
Group D diseases require notification from laboratories of
Group D diseases include HIV infection the following micro-organisms isolated or
(human immunodeficiency virus) and detected in food or water supplies:
AIDS (acquired immunodeficiency
• Campylobacter spp
syndrome) and written notification is
required within five days of confirmation • Cryptosporidium spp
of diagnosis. A separate form is used for • Salmonella spp
this purpose due to the need to have • Verotoxin producing Escherichia coli
national uniformity in collection of data. (VTEC)
Copies of this form are available from the
Communicable Diseases Section, • Vibrio spp
telephone 1300 651 160. • Giardia cysts
• Listeria monocytogenes
• Cyclospora spp
4 The blue book: Guidelines for the control of infectious diseases

Abbreviations used
ADT adult diphtheria tetanus HIV human immunodeficiency
vaccine virus
ALT alanine aminotransferase IG immune globulin
anti-HBc hepatitis B core antibody IHA indirect haemagglutination
anti HBs hepatitis B surface antibody IM intramuscular
CF/CFT complement fixation test IV intravenous
CNS central nervous system MDU Microbiological Diagnostic
CSF cerebro-spinal fluid Unit

CT Scan computerised MIF micro immunofluorescent


tomography test

DTP diphtheria tetanus pertussis MMR measles-mumps-rubella


vaccine vaccine

DTPa diphtheria tetanus acellular MRI magnetic resonance


pertussis vaccine imaging

dTpa adult/adolescent NHMRC National Health and Medical


formulation diphtheria Research Council
tetanus acellular pertussis PCR polymerase chain reaction
vaccine VIDRL Victorian Infectious
EBV Epstein-Barr virus Diseases Reference
EEG electroencephalogram Laboratory

EIA enzyme immunoassay WHO World Health Organization

ELISA enzyme-linked
immunosorbent assay
EM electron microscopy
FA direct fluorescent or
immunofluorescent antibody
test
HAV hepatitis A virus
HBIG hepatitis B immune globulin
HbsAg hepatitis B surface antigen
HbeAg hepatitis B e antigen
HBV hepatitis B virus
HCV hepatitis C virus
HDV hepatitis D virus
Hib Haemophilus influenzae
type b
The blue book: Guidelines for the control of infectious diseases 5

Acute bacterial
conjunctivitis
Victorian statutory requirement Method of diagnosis Period of communicability
Infections with Neisseria meningitidis Mild conjunctivitis is rarely investigated It is infectious while there is discharge.
(Group A disease) must be notified and is usually treated empirically.
immediately by telephone or fax followed Microscopic examination of a stained Susceptibility and resistance
by written notification within five days. smear or culture of the discharge is Everyone is susceptible to infection and
required to differentiate bacterial from repeated attacks due to the same or
Infections with Chlamydia trachomatis
viral or allergic conjunctivitis. different bacteria are possible. Maternal
(Group C disease) must be notified in
infection does not confer immunity to the
writing within five days of diagnosis. Incubation period child.
Infections with Neisseria gonorrhoeae The incubation period is usually 24–72
(Group C disease) must be notified in hours. In the case of trachoma Control measures
writing within five days of diagnosis. incubation is 5–12 days. Preventive measures
Preventative measures include careful
Other pathogens are not notifiable.
Public health significance treatment of affected eyes and personal
School exclusion: exclude until discharge and occurrence hygiene, particularly hand washing.
from the eyes has ceased. Acute bacterial conjunctivitis is
Control of case
widespread throughout the world.
Infectious agent Conjunctivitis due to bacterial infection
Outbreaks of gonococcal conjunctivitis
Haemophilus influenzae and may be difficult to distinguish clinically
have occurred in northern and central
Streptococcus pneumoniae are the most from allergic or viral conjunctivitis or that
Australia. Infection due to Chlamydia
common causes but Staphylococcus due to physical irritation. Therefore,
trachomatis (trachoma) continues to be a
aureus, Pseudomonas aeruginosa, empirical antibiotic therapy is often used.
significant public health concern in
Neisseria gonorrhoeae, Neisseria Patients with significant eye pain, loss of
Aboriginal communities and is a major
meningitidis and Chlamydia trachomatis vision or photophobia require immediate
cause of preventable blindness
(trachoma serovars A-C) can referral to an ophthalmologist.
worldwide.
occasionally be implicated. In mild cases propamidine eye drops are
The epidemiology of acute bacterial
the usual treatment.
Identification conjunctivitis in Australia due to causes
Clinical features other than trachoma and gonococcal In moderate and severe cases a
The clinical syndrome ranges from mild infection is not well documented. combination of treatments may be used.
redness of the conjunctivae to corneal Infections are most common in children Consult the current version of
infiltration and visual disturbances in under five years of age and incidence Therapeutic guidelines: antibiotic
neglected cases. A purulent exudate is decreases with age. (Therapeutic Guidelines Limited). An eye
almost always present. Trachoma should ointment may be used at bedtime. Soiled
be suspected in the presence of Reservoir articles should be discarded or
lymphoid follicles and diffuse Humans. disinfected. Rigorous hand washing
conjunctival inflammation or trichiasis before and after eye examinations and
Mode of transmission toilets is important in preventing further
(inturned eyelashes). Specialist
Infection is transmitted via contact with transmission. Children should not attend
ophthalmological advice should be
the discharge from the conjunctivae or school and child care settings until
sought in this case.
upper respiratory tract of infected discharge from the eyes has ceased.
persons. Neonates may acquire infection
during vaginal delivery. In some areas
flies have been suggested as possible
vectors.
6 The blue book: Guidelines for the control of infectious diseases

Control of contacts
With the exception of gonococcal or
meningococcal conjunctivitis, contact
tracing is not applicable in most
situations in Victoria. Refer to the
relevant sections for the management of
persons in contact with these infections.
Control of environment
Dispose of contaminated articles
carefully.

Outbreak measures
Public health action in an outbreak is
dependent on the type of infection and
the setting in which it has occurred.
The blue book: Guidelines for the control of infectious diseases 7

Amoebiasis
Victorian statutory requirement Method of diagnosis Public health significance
Notification is not required. Diagnosis is confirmed by microscopic and occurrence
examination for trophozoites or cysts in: Occurrence is worldwide. Prevalence
School exclusion: exclude until diarrhoea
has ceased. • fresh or suitably preserved faecal rates tend to be higher in:
specimens • areas with poor sanitation
Infectious agent
• smears of aspirates or scrapings • institutions for the intellectually
Entamoeba histolytica is a protozoan
obtained by proctoscopy disabled
parasite that exists in two forms: an
infective cyst and a potentially • aspirates of abscesses or other tissue • men who have sex with men
pathogenic trophozoite. It should not be specimens.
• travellers returning from developing
confused with the morphologically Repeated stool specimens may be countries.
identical non-pathogenic Entamoeba needed to establish a diagnosis as cysts
Amoebiasis most commonly affects
dispar. are shed intermittently in asymptomatic
young adults and is rare below the age of
and mild infections. The presence of
Identification five years. Amoebic dysentery is very
trophozoites containing red blood cells is
Clinical features rare under the age of two years when
indicative of invasive amoebiasis.
Most infections are asymptomatic but dysentery is more commonly due to
occasionally clinically important Serology using indirect Shigella.
intestinal or extra-intestinal disease may haemagglutination (IHA) and enzyme
immunoassays (EIA) is useful in the Reservoir
result.
diagnosis of extra-intestinal disease such Humans are often asymptomatic
Intestinal disease varies from an acute carriers.
as liver abscesses, when stool
form with diarrhoea which may be bloody
examination is often negative. Serology is
and associated fever and abdominal Mode of transmission
also important in the differentiation
discomfort (amoebic dysentery) to mild Amoebiasis can be transmitted by:
between strains of the pathogenic
abdominal discomfort with diarrhoea • ingestion of water contaminated with
E. histolytica and strains of the non-
containing blood or mucus alternating faeces containing amoebic cysts
pathogenic E. dispar.
with periods of constipation or remission.
X-ray, ultrasound and CT scans are also • ingestion after faecal contamination of
Intestinal amoebiasis may rarely be hands
useful in the identification of amoebic
complicated by:
abscesses and can be considered • contaminated raw vegetables
• granuloma of the large intestine diagnostic in the presence of a specific
• unprotected oral-anal sexual contact.
• colonic perforation and haemorrhage antibody response to E. histolytica.

• perianal ulceration. Period of communicability


Incubation period
Cases are infectious as long as cysts are
Dissemination via the bloodstream may The average incubation period is two to
present in the faeces. In some instances
lead to extra-intestinal amoebiasis. This four weeks. Patients may present months
cyst excretion may persist for years.
is most commonly manifested as to years after the initial infection.
abscess formation in the liver. This can Susceptibility and resistance
occur less commonly in the brain or All non immune people are susceptible
lungs. to infection. People with E. dispar do not
develop symptoms. Reinfection is
possible but rare.
8 The blue book: Guidelines for the control of infectious diseases

Control measures Control of contacts


Preventive measures Consider faecal screening for household
General public health measures to members and institutional contacts.
prevent disease transmission focus on: Faecal screening is advised for fellow
travellers of a confirmed case. Confirmed
• public education on the importance of
carriers should also be treated.
personal hygiene
Control of environment
• providing information to intending
Environmental measures to control
travellers about the risk involved in
disease transmission focus on:
eating uncooked vegetables and fruits
and drinking contaminated water • protecting public water supplies from
faecal contamination
• public education about the possibility
of transmitting the disease via sexual • investigation of the food preparation
contact. practices of any implicated local food
premises.
Control of case
Treating clinicians should consult the Outbreak measures
current version of Therapeutic guidelines: In the event of a cluster of cases, public
antibiotic (Therapeutic Guidelines health measures involve:
Limited) and seek expert advice.
Metronidazole and either diloxanide • confirmation of laboratory results
furoate or paramomycin are the usual • undertaking an epidemiological
treatment. Neither diloxanide furoate or investigation to determine source of
paramomycin are registered for use in infection and common mode of
Australia - contact the NPS Therapeutic transmission
Advice and Information Service on • taking appropriate measures to
1300 138 677. eliminate any common vehicles of
For amoebic liver abscess metronidazole transmission, such as contaminated
should be continued for 14 days and food or water, to prevent further cases.
specialist advice should be sought. Special settings
Passage of Entamoeba cysts or Persons who are suspected of having
trophozoites in the absence of acute acquired their infection in an institutional
dysenteric illness does not warrant setting should be investigated as
antimicrobial therapy. appropriate by the Department of
Surgical aspiration of abscesses may be Human Services.
necessary. Cyst eradication with
diloxanide furoate may be indicated in Additional sources of information
cyst carriers. Seek expert advice. • Centers for Disease Prevention and
Control, Atlanta USA,
http://www.cdc.gov/ncidod/
The blue book: Guidelines for the control of infectious diseases 9

Anthrax
Victorian statutory requirement Untreated cutaneous anthrax has a case Method of diagnosis
Anthrax infection (Group A disease) must fatality rate of 5–20% but death is rare Laboratory confirmation of anthrax is
be notified immediately by telephone or with early appropriate treatment. by demonstrating the presence of
fax followed by written notification within Pulmonary (inhalational) anthrax B. anthracis in blood, lesions or discharges
five days. This is very rare and often presents with by direct staining of smears using Gram or
mild and non-specific symptoms other special stains, or by isolation of the
School exclusion is not required.
including fever, malaise and mild cough organism by culture or animal inoculation.
Infectious agent or chest pain (upper respiratory tract Serological and nucleic acid testing are
Bacillus anthracis is a gram-positive, symptoms are rare). Early symptoms may likely to be available in the near future
aerobic rod-shaped bacterium that is be confused with a flu-like illness. from reference laboratories.
encapsulated, spore-forming and non-
This is followed within three to six days Incubation period
motile.
by rapid onset of hypoxia, dyspnoea and The incubation period is typically one day
Identification high temperature, with radiological for cutaneous anthrax and one to seven
Clinical features evidence of mediastinal widening. days for pulmonary anthrax. Evidence from
Anthrax is an acute bacterial disease that Meningitis frequently occurs. mass exposures indicates incubation
usually affects the skin. It may rarely The mortality rate approaches 100% with periods up to 60 days are possible for
involve the lungs after inhalation or the delayed or no treatment. pulmonary anthrax, related to delayed
intestinal tract after ingestion. Commencement of appropriate activation of inhaled spores. The
antibiotics during the prodrome incubation is typically three to seven days
Cutaneous anthrax
significantly decreases the mortality rate. for the gastrointestinal form.
This form accounts for over 95% of
anthrax cases. Lesions usually occur on Intestinal/oropharyngeal anthrax Public health significance
exposed skin and often commence with These are very rare forms of anthrax in and occurrence
itchiness. They pass through several developed countries but may occur in Anthrax is primarily a disease of
stages: large outbreaks in developing countries herbivores. Humans usually become
• papular stage following ingestion of meat from infected infected when they come into contact
animals. with infected animals or their products.
• vesicular stage with a blister that often
becomes haemorrhagic In intestinal anthrax, gastro-intestinal Anthrax is primarily an occupational
symptoms may be followed by fever, hazard for handlers of processed hides,
• eschar stage that appears two to six
septicaemia and death. Case fatality goat hair, bone products, wool and
days after the haemorrhagic vesicle
rates of 25–75% have been reported. infected wildlife. It can also be
dries to become a depressed black
scab (malignant pustule) which may In oropharyngeal anthrax, fever, neck contracted by contact with infected
have surrounding redness and swelling due to lymphadenopathy, throat meat, for example in abattoir workers.
extensive oedema (swelling). pain, oral ulcers and dysphagia may be New areas of infection in livestock may
followed by severe local ulcers and develop through introducing animal feed
Anthrax lesions are usually painless but
swelling, septicaemia and death. Case containing bone meal. Cutaneous
pain may result due to surrounding
fatality rates are similar to the intestinal outbreaks sometimes occur in knackery
oedema. Untreated lesions can progress
form. workers and those handling pet meat.
to involve regional lymph nodes. An
overwhelming septicaemia can occur in Anthrax spores can persist in the soil of
severe cases. certain tracts of land for years such as
areas where carcasses of animals dying
of anthrax are buried.
10 The blue book: Guidelines for the control of infectious diseases

Anthrax can also be used as a bio- • by intentional release of spores using a • Sterilise hair, wool or hides, bone meal
warfare or bio-terrorism agent, most likely variety of aerosol devices including or other feed of animal origin prior to
spread as an aerosol. Any new case mail-items. processing.
should be assessed with this possibility Intestinal or oropharyngeal anthrax is Control of case
in mind, particularly but not exclusively in caused by ingestion of anthrax The following treatment advice is to be
cases of pulmonary anthrax. contaminated undercooked meat. There used as a guide only. Always consult the
is no evidence of transmission through current version of Therapeutic guidelines:
Reservoir
the milk of an infected animal. antibiotic (Therapeutic Guidelines
Spores may remain viable in
The deliberate release of anthrax spores Limited) and seek expert advice from an
contaminated soil for many years. Dried
through contaminated letters in the USA infectious diseases physician.
or processed skins and hides of infected
animals may also harbour spores for in October 2001 resulted in 22 cases of Cutaneous/gastrointestinal anthrax
years. anthrax, of which half were cutaneous • Ciprofloxacin, penicillin or doxycycline
and half were pulmonary anthrax. are the drugs of choice, usually given
Mode of transmission for 7–10 days in cutaneous anthrax.
Cutaneous anthrax is usually Period of communicability The duration of therapy for
introduced through a skin injury. It can There is no evidence of direct spread gastrointestinal anthrax is not well
occur: from person to person. Articles and soil defined.
contaminated with spores may remain
• by contact with tissues of animals such • If the case is associated with a bio-
infective for years.
as cattle, horses, pigs and others dying terrorist attack involving aerosolised
of the disease, or in processing after Susceptibility and resistance anthrax where the risk is high,
death Recovery is usually followed by ciprofloxacin or doxycycline are
• by contact with contaminated hair, prolonged immunity. recommended and should be given for
wool, hides or products made from at least 60 days.
them (Hide-porter’s disease) Control measures • For patients with signs of systemic
Preventive measures
• by contact with soil associated with involvement, extensive oedema, or
• Immunise high risk persons, usually
infected animals and contaminated lesions on the head or neck, antibiotics
laboratory workers who are liable to
bone meal used in some gardening should be administered intravenously,
handle B. anthracis, with the cell-free
products as for patients with pulmonary disease.
vaccine giving annual boosters as
• possibly by biting flies that have fed on recommended. Protection is likely to Pulmonary anthrax
infected animals in some parts of the be greater against cutaneous The following recommendations were
world but not seen in Australia. exposures than pulmonary exposures. developed in the USA following
The vaccine is not currently licensed experience during the deliberate release
Pulmonary anthrax (‘woolsorter’s
for use in the general community. of anthrax through the postal system in
disease’) can occur:
2001.
• by inhalation of aerosolised spores in • Educate employees who are handlers
of potentially infected articles in the • Recommended initial treatment of
industries that inadvertently may deal
proper care of skin abrasions. pulmonary anthrax is an intravenous
with contaminated tissues or products
multi-drug regimen of either
such as tanning hides, processing wool • Ensure proper ventilation in hazardous
ciprofloxacin or doxycycline along with
or bone products, or by accident in industries and the use of protective
one or more agents to which the
laboratory workers clothing.
organism is typically sensitive.
The blue book: Guidelines for the control of infectious diseases 11

• Ciprofloxacin has been recommended farm is suspended. Appropriate samples Outbreak measures
on the basis of in vivo (animal) are collected and tested at a laboratory. A single case of anthrax should be
findings. It should be used in This can take 12–24 hours. If the case considered an outbreak and should be
preference to doxycycline in cases occurs on a dairy farm, the dairy factory managed with great urgency. If one or
where meningitis is suspected because is advised to suspend collection of milk more patients seem to have been
of the lack of adequate central nervous until the case is investigated and Dairy infected in an unusual way, such as no
system penetration by the latter. Food Safety Victoria is advised. evidence of exposure to infected animals
• Bacteremic patients are often initially If an animal anthrax case is confirmed, or their products, a deliberate release of
treated with an empiric multi-drug the affected property is quarantined, anthrax organisms must be considered.
regimen which provides adequate potentially exposed stock vaccinated, If a focus of infection was identified or a
therapy for B. anthracis and other dead animals buried and contaminated deliberate release of organisms is
possible pathogens. sites disinfected. The quarantine is not suspected, outbreak control measures
• After susceptibility testing and clinical released until occurrences of anthrax would include:
improvement, the empiric regimen may cases have ceased and at least six
• coordination with appropriate
be altered. A penicillin-based antibiotic, weeks have elapsed since the last round
emergency services including the
such as amoxycillin or amoxycillin/ of vaccinations on the property. DPI staff
police force if required
clavulanic acid may then be used to will liaise with knackeries, local veterinary
practitioners, the dairy industry, health • active case finding
complete the course.
authorities, local government and • alerts for medical practitioners and
• Treatment should be continued for 60 regional emergency services staff. hospitals
days in all cases of pulmonary anthrax.
Decontamination of environments • release of appropriate public
Keys to successful management appear contaminated after a deliberate release information
to be early institution of antibiotics and of anthrax spores requires full HAZMAT
aggressive supportive care. Chest tube • control of contacts including field
decontamination by appropriately workers involved in environmental
drainage of the recurrent pleural protected trained personnel using strong
effusions, which are typically control measures
chlorine-based disinfectants. The risk of
hemorrhagic, often leads to dramatic secondary aerosolisation is generally • environmental control measures.
clinical improvement. thought to be very low, although spores
Additional sources of information
Control of contacts produced for bioterrorism may be
• Australian Government Department of
Although there is no person to person deliberately prepared to increase this
Health and Ageing fact sheet,
transmission, the Department of Human risk. Although the risk of anthrax can be
http://www.health.gov.au
Services will trace and follow-up anyone significantly reduced by environmental
who may have been exposed to the decontamination measures, evidence • Centers for Disease Control and
same source as the case, and it may be from deliberate release of anthrax spores Prevention, Atlanta USA, Public health
recommended that they take in other countries suggests that emergency preparedness and
prophylactic antibiotics. complete environmental response, http://www.bt.cdc.gov

Control of environment decontamination of anthrax spores is


If an animal anthrax case is suspected, it extremely difficult.
should be reported to the Department of
Primary Industries (DPI). Movement of
animals and animal products from the
12 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 13

Ascariasis
(round worm infection)
Victorian statutory requirement A. lumbricoides are often diagnosed on Mode of transmission
Notification is not required. radiography either as worm shaped Transmission occurs when eggs are
radiolucent areas in a barium filled swallowed from soil contaminated with
School exclusion: exclude from school or
intestine or in cholangiograms. human faeces or from uncooked produce
children’s services centre if diarrhoea is
Significant eosinophilia is noted in only contaminated with soil containing
present.
about 10% of cases. infective eggs. The eggs remain viable in
Infectious agent moist soil for several months or years.
The infective agents are Ascaris
Incubation period
The lifecycle requires four to eight weeks Transmission does not occur from direct
lumbricoides, a large intestinal person to person contact or from fresh
to complete. Ascaris eggs are
roundworm (the female measuring up to faeces. The eggs hatch in the small
unsegmented when passed and require a
30 cm in length) and Ascaris suum, a intestine and larvae pass through the
period of two or three weeks outside the
similar parasite primarily affecting pigs intestinal wall into the blood. They then
host to develop to the infective stage.
and occasionally humans. pass to the liver and heart and to the
Mature female worms have been
estimated to produce an average of 200 lungs. In the lungs they have a further
Identification
000 eggs per day. period of development. Larvae then
Clinical features
penetrate through the alveoli into the
Many people have no symptoms and the
first indication of ascariasis may be the
Public health significance airways and migrate up to the pharynx to
passage of a worm by the anus, mouth or
and occurrence be swallowed and reach their final
Ascariasis infects an estimated one destination in the small intestine. This
nostril. The usual life cycle of the worm is
billion people around the world, more occurs about 14–20 days after egg
described below. Migration of the larval
than any other parasitic infection. ingestion. Larvae then mature into adult
forms of the worm can cause symptoms
worms which mate. Females begin to lay
due to various types of pneumonitis, liver Roundworm infections are common in
eggs 45–60 days after initial egg
damage or allergy. temperate or tropical regions of the world
ingestion.
including Australia. In communities
Adult worms can cause a variety of
where poor sanitary conditions exist Period of communicability
abdominal symptoms and occasionally
often 100% of the population will harbour Ascariasis is communicable as long as
serious complications such as intestinal
the parasite. the mature fertilised female worm lives in
obstruction or biliary disease. Ascariasis
aggravates malnutrition in The prevalence and intensity of infection the intestine. The usual life span is 12
underdeveloped countries. is usually highest in children aged three months however it has been reported to
to eight years. Ascaris eggs are able to be as long as 24 months.
Method of diagnosis
survive for months in faecal matter,
Diagnosis can be made by the Susceptibility and resistance
sewage or even in a 10% formalin
identification of eggs or the presence of Infection does not infer immunity.
solution.
adult worms in faeces. Pulmonary
involvement may be confirmed by Reservoir Control measures
identifying ascarid larvae in the sputum Ascaris eggs in soil or infected humans Preventive measures
or gastric washings. act as reservoirs. Promote effective hand washing,
particularly prior to preparing or
consuming food.
14 The blue book: Guidelines for the control of infectious diseases

Control of case
The usual treatment is albendazole,
pyrantel or mebendazole. In mixed
infections with Ascaris and other
parasites it is important to initially use a
drug that is effective against Ascaris,
thereby reducing the chances of
stimulating the worm into untoward
activity. Consult the current version of
Therapeutic guidelines: antibiotic
(Therapeutic Guidelines Limited).
When worms obstruct the pancreatic
duct or migrate up the biliary tree,
surgical or endoscopic removal of the
worm may be necessary.
Students with ascariasis should be
excluded from school or child care if
diarrhoea is present.
Control of contacts
Consider faecal screening of household
members to determine if they also
require treatment. No school or child
care exclusion is required for contacts.
Control of environment
Environmental sources of infection
should be investigated.

Outbreak measures
Not applicable.

Additional sources of information


Markell, E, John, D, Krotoski, W 1999,
Markell and Voge’s medical parasitology,
8th edn, ed. Saunders.
The blue book: Guidelines for the control of infectious diseases 15

Barmah Forest virus


disease
Arboviruses are viruses which are spread most parts of mainland Australia, and Northern Territory and Victoria.
by the bite of arthropods, particularly serological surveys indicate that it Outbreaks have been reported in Victoria
mosquitoes. They are divided into causes widespread human infection. throughout the Murray Valley and the
alphaviruses and flaviviruses. Gippsland areas.
Identification
Three infective alphaviruses include Ross
Clinical features Reservoir
River, Barmah Forest and Sindbis viruses.
Features include fever, arthritis, arthralgia Like RRV, BFV disease appears after
These all have the capacity to cause a and rash which are clinically heavy rains encourage the breeding of
similar disease in humans characterised indistinguishable from RRV disease. Like mosquito vectors. It is not established,
by fever, joint involvement and a rash. RRV disease there is a high subclinical but it is likely, that macropods and other
Molecular studies of epidemiologically rate of infection and a low disease rate in marsupials are the principal hosts for the
distinct isolates of Ross River and Sindbis children. Recovery usually occurs within virus. BFV antibodies have been found in
viruses have shown changes in isolates several weeks but lethargy, arthralgia and kangaroos, cattle, horses and sheep on
from different areas (distinct topotypes). myalgia can persist for over six months. the south coast of New South Wales.
This may explain varying disease patterns Outbreaks of BFV disease sometimes
which sometimes occur in certain occur concurrently with RRV disease Mode of transmission
geographic locations and the differing making diagnosis difficult. BFV is transmitted by mosquitoes. Culex
transmissibility of some strains by annulirostris is the major vector in inland
Method of diagnosis
different vector mosquitoes. areas and Ochlerotatus vigilax (New
Serology shows a significant rise in
South Wales) and Ochlerotatus
Victorian statutory requirement antibody titre to the BFV. The virus may
camptorhynchus in southern parts of
Barmah Forest virus infection (Group B be isolated from the blood of acutely ill
Victoria and Tasmania are the vectors in
disease) requires notification in writing patients. Virological tests are necessary
coastal regions.
within five days of diagnosis. to distinguish BFV disease from other
causes of arthritis. Period of communicability
School exclusion is not required.
Laboratory evidence requires one of the There is no evidence of transmission
Infectious agent following: from person to person.
Barmah Forest virus (BFV) was first • isolation of BFV from clinical material Susceptibility and resistance
isolated in 1974 from Culex annulirostris
• detection of BFV by nucleic acid Infection with BFV confers lifelong
mosquitoes collected in the Barmah
testing immunity.
Forest near the Murray River in northern
Victoria, and simultaneously from • a significant rise in IgG to BFV
mosquitoes collected in southwest • detection of BFV-specific IgM.
Queensland. It has also been isolated
from numerous other mosquitoes Incubation period
including the coastal species The incubation period appears to be
Ochlerotatus vigilax (New South Wales) seven to ten days.
and Ochlerotatus camptorhynchus
(Victoria), which enjoy a salt marsh Public health significance
habitat, and from the midge Culicoides and occurrence
marksi in the Northern Territory. Since 1988, BFV disease has been
Subsequently, BFV has been detected in reported in Western Australia,
Queensland, New South Wales, the
16 The blue book: Guidelines for the control of infectious diseases

Control measures Outbreak measures


Preventive measures • Conduct a community survey to
BFV infection can be prevented by: determine the species of the vector
• mosquito control measures mosquito involved. Identify their
breeding places and promote their
• personal protection measures such as elimination.
long sleeves and mosquito repellents
• Use mosquito repellents for persons
• avoidance of mosquito-prone areas exposed to bites because of their
and vector biting times at dusk and occupation, or other reasons.
dawn.
• Identify the infection among animal
Control of case reservoirs, for example kangaroos, farm
Second attacks are unknown. Treatment and domestic animals.
is symptomatic with rest advisable in the
acute stages of the disease. Presently, International measures
there is no vaccine available Airport vector control in Australia and
commercially to protect against BFV Papua New Guinea may be necessary to
disease. prevent spread from endemic areas to
Control of contacts other countries where local vectors such
Unreported or undiagnosed cases should as Aedes polynesiensis may transmit the
be sought in the region where the patient disease.
had been staying during the incubation
Additional sources of information
period of their illness. All family members
• Boughton C R 1996, Australian
should be questioned about symptoms
Arboviruses of Medical Importance, A
and evaluated serologically if necessary.
handbook for general practitioners and
Control of environment other clinicians, RACGP Services.
To reduce or prevent virus transmission,
interruption of human-mosquito contact
is required by:
• suppression of the vector mosquito
population
• avoidance of vector contact through
personal protection and education.
The blue book: Guidelines for the control of infectious diseases 17

Botulism
Victorian statutory requirement Method of diagnosis Mode of transmission
Clostridium botulinum infection (Group A Diagnosis is made by culture of Classical botulism is acquired by
disease) must be notified immediately by C. botulinum or demonstration of specific ingestion of inadequately cooked food or
telephone or fax followed by written toxin in serum, gastric aspirate, faeces, processed or refrigerated foods in which
notification within five days. implicated food or wounds. toxin has formed, particularly canned and
Electromyography may be useful in alkaline foods. Most cases of wound
School exclusion is not required.
corroborating the clinical diagnosis. botulism are due to ground-in soil or
Infectious agent gravel. Several cases have been reported
Clostridium botulinum is a spore-forming
Incubation period amongst chronic drug users.
Classical botulism occurs within 12–36
anaerobic bacillus. Several serotypes Infant botulism arises from ingestion of
hours (sometimes several days) after
exist, however types A, B and E cause spores rather than pre-formed toxin.
eating contaminated food. The
most human disease. Sources of spores include foods such as
incubation period for infant botulism is
unknown due to difficulty in determining honey and dust. Honey has been
Identification
the precise time of ingestion. Shorter described in the US literature as a source
Clinical features
incubation periods are associated with of infection but never implicated in
There are three forms of botulism:
more severe disease and higher case- Australia and surveys of Australian honey
• Classical botulism is a severe and have failed to identify C. botulinum.
fatality rates.
often fatal infection resulting from
ingestion of contaminated food. Public health significance Period of communicability
Symptoms include double vision, and occurrence Secondary transmission has not been
dysphagia and dry mouth. It can be Botulism is a rare disease internationally. documented.
followed by descending flaccid However missed diagnoses particularly
paralysis which may be associated Susceptibility and resistance
for intestinal botulism are likely due to
with respiratory paralysis and result in Everyone is susceptible to infection.
low clinician suspicion and limited
death. Fever is absent unless a laboratory diagnostic capacity in many Control measures
complicating infection occurs. areas. Preventive measures
• Intestinal botulism is the most There have been only six cases of Ensure effective control of processing
common form and usually affects botulism reported in Australia between and preparation of commercially canned
infants under one year of age. It can 1991 and 2003. Two of these occurred in and preserved foods.
affect adults who have altered Victoria in 2000 and 2001 Educate people undertaking home
gastrointestinal anatomy and (Communicable Diseases Network canning and other food preservation
microflora. The illness typically begins Australia - National Notifiable Diseases techniques about cooking time, pressure,
with constipation followed by lethargy, Surveillance System). temperature, adequate refrigeration and
listlessness, poor feeding, ptosis,
C. botulinum has been identified as a storage. The absence of a bulging lid on
difficulty in swallowing and generalised
potential bioterrorist agent. tinned food does not preclude C.
muscle weak-ness (‘floppy baby’).
botulinum contamination.
• Wound botulism is rare but has been Reservoir
seen after contamination of wounds It is most commonly found in soil and
where anaerobic conditions developed. agricultural products. Spores have been
found in marine sediments and the
intestinal tracts of animals, including fish.
18 The blue book: Guidelines for the control of infectious diseases

Control of case Control of environment


Botulism is a medical emergency. Environmental health officers and food
Suspected cases should immediately be safety officers should coordinate the
referred for specialist care and trivalent appropriate disposal of implicated food.
botulinum antitoxin (types A, B, E)
administered as soon as possible. A Outbreak measures
limited supply is available from CSL An outbreak of botulism is defined as
Limited. Antitoxin is not used in infant one or more cases of disease. The
botulism due to the risk of anaphylaxis. immediate aim is to identify possible
Antibiotics do not affect the course of sources of the disease and other people
the disease. possibly exposed. Recall any implicated
food immediately and send samples to
For wound botulism, in addition to
the Microbiological Diagnostic Unit for
antitoxin the wound should be debrided
analysis. Take sera and faeces from
or drained, and appropriate antibiotic
cases as well as exposed but
prophylaxis against other potential
asymptomatic persons for analysis,
infections should be administered.
before administration of antitoxin.
Isolation or quarantine is not needed but
Undertake efforts to recover and test
hand washing is indicated after handling
implicated foods. This should be
soiled nappies. Usual sanitary disposal of
coordinated through Food Standards
faeces from infant cases is acceptable.
Australia New Zealand (02) 6271 2222.
Any implicated food should be retained
for collection and investigation by public
health authorities. Contaminated utensils
should be cleaned by boiling or with
household bleach.
Control of contacts
Those who have eaten incriminated food
should be purged with emetics, gastric
lavage or high enemas. Administration of
polyvalent antitoxin to asymptomatic
individuals should be considered
carefully, assessing potential protection
against the risk of sensitisation and
severe reactions to horse serum.
The blue book: Guidelines for the control of infectious diseases 19

Brucellosis (undulant
fever, Malta fever)
Victorian statutory requirement test (Rose Bengal and seroagglutination) Mode of transmission
Brucellosis (Group B disease) must be detecting agglutinating antibodies (IgM, Brucellosis can be transmitted by
notified in writing within five days of IgG and IgA) with others detecting non- contact with infected tissues, blood,
diagnosis. agglutinating antibodies (Coombs-IgG or urine, vaginal discharges, aborted animal
ELISA-IgG) developing in later stages. foetuses and especially placentae. It can
School exclusion is not required.
Except in the case of B. canis, where also be transmitted by ingestion of raw
Infectious agent diagnosis requires tests detecting milk and dairy products from infected
The following infectious agents cause antibodies to rough-lipolysaccharide animals.
brucellosis: antigens.
Outbreaks are generally attributed to
• Brucella abortus (biovars 1–6 and 9) Incubation period inhalation of aerosols which may occur in
• Brucella melitensis (biovars 1–3) The incubation period is highly variable. It animal pens and stables, abattoirs and
is most commonly one to two months laboratories, or through ingestion of
• Brucella suis (biovars 1–5) unpasteurised milk products. A small
but ranges from five to sixty days.
• Brucella canis number of cases have occurred following
Public health significance accidental self-inoculation of the strain
Identification and occurrence 19 animal Brucella vaccine.
Clinical features B. abortus was successfully eradicated
Brucellosis is a systemic bacterial from Australian cattle herds during the Period of communicability
disease with acute or insidious onset. national eradication campaign in 1989. There is no evidence of communicability
Localised suppurative infections may B. suis is still isolated occasionally from from person to person.
occur. Subclinical and unrecognised feral pigs in Queensland and represents
infections are frequent. Susceptibility and resistance
a risk to people who hunt and butcher
Everyone is susceptible to infection.
Fever is the most common symptom and feral pigs. Notifications of brucellosis in
Severity and duration of clinical illness
may be associated with a variety of other Victoria are now rare and generally
are subject to wide variation. Duration of
complaints. represent imported infections or
acquired immunity is uncertain.
Osteoarticular complications are undiagnosed chronic infections.
common. Orchitis, epididymitis, Brucellosis occurs worldwide. The Control measures
osteomyelitis and endocarditis are less sources of infection and responsible Preventive measures
common. The case-fatality rate in organism vary according to geographic Educate the public, particularly travellers,
untreated brucellosis is approximately area. Affected regions include the against drinking unpasteurised milk or
2%, mostly due to endocarditis from Mediterranean countries, North and East eating dairy products produced from
B. melitensis infections. Africa, Western Africa, the Middle East, such milk. Boiling milk is effective in
India and Central and South America. killing the organisms when pasteurisation
Method of diagnosis
is not available.
Laboratory confirmation of the diagnosis
Reservoir Educate farmers and handlers of
is made by isolating the infectious agent
The most important reservoirs for human
from blood, bone marrow, other tissues or potentially infected animals such as feral
infection are cattle, swine, goats, sheep
discharges of the patient. Serological pigs to reduce exposure and exercise
and dogs. Infections may also occur in
testing for Brucella is useful but often care in handling placentae, discharges
other wild ungulates.
difficult to interpret. Current serological and foetuses. Search for and investigate
B. canis has occasionally been identified
tests allow a precise diagnosis in over 95% livestock at risk of infection.
in laboratory dogs.
of cases, but it is necessary to combine a
20 The blue book: Guidelines for the control of infectious diseases

Control of case
Treatment should be age appropriate.
Consult the current version of
Therapeutic guidelines: antibiotic
(Therapeutic Guidelines Limited) and
seek expert infectious diseases.
Control of contacts
Although there is no person to person
transmission of brucellosis, contact
tracing is done as part of the case
investigation to identify those people
who have been exposed to the same
implicated source of Brucella infection as
the case. These people are advised of
the early signs and symptoms of
brucellosis to aid early diagnosis and
treatment.
Control of environment
The Department of Primary Industries is
notified of any new, non-imported case
of brucellosis so that appropriate animal
investigations and control measures can
commence.
All incriminated products are recalled.
Restriction on the distribution of
unpasteurised milk and milk products is
enforced.

Outbreak measures
Trace source of infection such as
contaminated unpasteurised milk
products and institute appropriate
control measures.

Additional sources of information


• Australian Quarantine and Inspection
Service, www.aqis.gov.au
• Victorian Department of Primary
Industries, phone 136 186,
www.dpi.vic.gov.au
The blue book: Guidelines for the control of infectious diseases 21

Campylobacter
infection
Victorian statutory requirement Incubation period Period of communicability
Campylobacter infection (Group B The incubation period is usually two to Cases are infectious throughout their
disease) must be notified in writing five days, with a range of one to ten days. illness. Excretion of organisms may
within five days of diagnosis. continue for some weeks after symptoms
Public health significance resolve.
School exclusion: exclude cases from
and occurrence
child care and school until after
Campylobacter infections are now the Susceptibility and resistance
diarrhoea has ceased.
most commonly notified of the enteric All non immune people are susceptible
Laboratories are required to notify pathogens in Victoria and over 14 900 to infection. Immunity to serologically
C. jejuni, C. coli or C. lari isolated from cases were reported Australia-wide in related strains may follow infection and
water supplies or C. jejuni detected in 2003 (Communicable Diseases Network may be more common in high incidence
food. Australia – National Notifiable Diseases regions.
Surveillance System). The incidence of
Infectious agent infection appears to be increasing, a Control measures
The most common types of trend observed internationally. All age Preventive measures
Campylobacter species that cause groups are affected. The most commonly Prevention is dependent on good
infection are C. jejuni, C. coli, C. fetus, C. affected are children less than five years personal and food hygiene. Raw meats
lari, and C. upsaliensis. of age and young adults. Most cases in should be cooked thoroughly and
Australia appear sporadic but food and refrigerated after cooking, especially
Identification poultry. Wash utensils used to prepare
Clinical features water-borne outbreaks occur and it is
likely that many outbreaks are not raw meats and poultry in hot soapy
Campylobacter infection may be water before using them to prepare non-
subclinical or cause disease of variable detected.
cooked food such as salads.
severity. C. jejuni infection typically Reservoir Unpasteurised milk and dairy products
results in abdominal pain, fever and Many animals, especially birds, are should not be consumed. Recognise
diarrhoea which may be mucopurulent or carriers of Campylobacter spp. Domestic pets as sources of infection and
bloody. Symptoms usually last two to five animals are another possible source of encourage hand washing after handling
days. infection. animals.
Campylobacter infection has been Control of case
associated with rare sequelae including Mode of transmission
Treatment is largely symptomatic.
reactive arthritis and Guillain-Barré Infection occurs most commonly by
However, antibiotics may be indicated for
syndrome (polyneuritis). Human infection ingestion of the organism via
severe illness or where prompt
with C. fetus may cause localised contaminated foods, particularly raw or
termination of faecal excretion is desired.
abscesses or generalised sepsis undercooked meats (especially poultry).
Antibiotics are not indicated for
particularly in immunosuppressed Person to person transmission via the
diarrhoeal disease in which the causative
persons. faecal-oral route is common. Infection
pathogen is not known, except in some
may also occur through contact with
Method of diagnosis very severe illnesses when empirical
infected animals.
Infection is diagnosed by culture of treatment may be considered.
Campylobacter spp. from faeces, blood
or other clinical specimens.
22 The blue book: Guidelines for the control of infectious diseases

To prevent further transmission the


importance of hand washing and
personal hygiene should be stressed,
particularly with respect to food
preparation. Health care workers, child
care workers, food handlers and children
in school and child care centres should
be excluded from work or school until
diarrhoea has ceased. As asymptomatic
excretion may persist, diligent personal
hygiene is required.
Isolation is not required for hospitalised
patients and standard precautions apply.
Control of contacts
The diagnosis should be considered in
symptomatic contacts. Investigate
related cases to identify a common
source.
Control of environment
Isolation is not required for hospitalised
patients and standard precautions apply.

Outbreak measures
Two or more related cases should be
reported immediately, particularly in
institutions. Obtain food histories and
investigate other recognised vehicles of
infection such as pets or farm animals to
identify a common source.
The blue book: Guidelines for the control of infectious diseases 23

Chickenpox or shingles
(varicella/herpes zoster)
Victorian statutory requirement Complications include secondary Method of diagnosis
Notification is not required. bacterial infection of the skin lesions, Confirmation of the diagnosis is generally
primary varicella pneumonia, aseptic only required when the clinical picture is
School exclusion differs according to
meningitis, encephalitis and Reye’s atypical. It is made by:
case or contact status:
syndrome (acute encephalopathy with
• cases should be excluded until full • isolation of the virus in cell cultures
fatty infiltration and dysfunction of the
recovery or for at least five days after liver). • visualisation by electron microscopy
the first eruption appears. Some • serological tests for antibodies
Newborns and immunosuppressed
remaining scabs are not a reason for
patients are at greatly increased risk of • immunofluorescence on lesion swab or
continued exclusion
severe chickenpox. fluid
• any child with an immune deficiency or
Herpes zoster (shingles) • nucleic acid testing or PCR.
receiving chemotherapy should be
Herpes zoster or shingles is characterised
excluded for their own protection. Incubation period
by a predominantly unilateral vesicular
Otherwise contacts are not excluded. The incubation period is from two to
eruption within a dermatome. It is often
Infectious agent associated with severe pain that may three weeks and is usually 14–16 days.
Human herpesvirus 3 (alpha) or varicella precede lesions by 48–72 hours. The This may be prolonged in
zoster virus (VZV) is the causative agent. rash lasts up to several weeks depending immunosuppressed persons or following
on severity. The rash is often more immunoglobulin administration as
Identification widespread and persistent in passive immunisation against varicella.
Clinical features immunosuppressed patients.
Varicella (chickenpox) Public health significance
Patients must be carefully evaluated to and occurrence
Chickenpox generally presents with a
ensure that there is no eye involvement Chickenpox is a highly contagious but
low-grade fever, malaise and a rash. The
when the rash involves the ophthalmic generally mild disease and is endemic in
rash is firstly maculopapular then
area of the face. Specialist treatment is the population. It becomes epidemic
becomes vesicular (blistered) and
mandatory in this case as blindness can among susceptible individuals mainly
progresses to crusted lesions over about
result. during winter and early spring. More than
five days. Lesions appear in three or four
crops. They are most numerous on the Incidence increases with age and 90% of cases are children under 15 years
trunk and less so on the face, scalp, children under 12 are rarely affected of age.
limbs and mucous membranes of the unless immunosuppressed or infected as Herpes zoster (shingles) occurs in 20% of
mouth. Some cases (about 5%) are infants. people, mostly when they are elderly due
subclinical or exceedingly mild in nature. A debilitating complication of herpes to the reactivation of latent virus from the
Adults tend to suffer with more severe zoster in many (especially elderly) dorsal root ganglia.
disease than children. Rarely, the disease patients is prolonged pain (post-herpetic
neuralgia) which may persist for months
Reservoir
may be fatal. Humans.
after resolution of the skin lesions.
24 The blue book: Guidelines for the control of infectious diseases

Mode of transmission • immunosuppressed individuals Control of case


Chickenpox transmission is mainly including those with haematological Varicella (chickenpox)
person to person by airborne respiratory malignancies, on chemotherapy, high In the non-hospitalised patient with a
droplets but also by direct contact with dose steroids or with HIV infection. normal immune system and
vesicle fluid of chickenpox cases, or uncomplicated varicella, aciclovir is not
contact with the vesicle fluid of patients Control measures recommended because the benefits are
with herpes zoster. Indirect contact Preventive measures only marginal. In immunocompromised
occurs through articles freshly soiled by In Australia, the varicella vaccine is patients with severe disease and in
discharges from vesicles of infected recommended for non-immune, healthy normal patients with complications of
persons. Scabs are not infective. individuals aged 12 months or older. varicella (such as pneumonitis or
It provides protection against infection in encephalitis) aciclovir may be used.
Period of communicability 70–90% of individuals. Consult the current version of
It is usually communicable for one to two Therapeutic guidelines: antibiotic
Non-immune individuals who should be
days (up to five days) before the onset of (Therapeutic Guidelines Limited).
specifically targeted for vaccination
the rash, continuing until all the lesions
include: General measures include:
are crusted. Communicability may be
prolonged in patients with altered • household contacts of • tepid bathing or cool compresses may
immunity. immunosuppressed people help to alleviate itching

Those with zoster are considered • health care workers • exclude from school until fully
infectious for a week after lesions appear • those working with young children recovered, or at least five days after
when they are moist. eruption first appears. Some remaining
• women contemplating pregnancy scabs are not a reason for continued
Susceptibility and resistance • parents of young children. exclusion
Chickenpox is highly infectious, herpes
Vaccination is contraindicated in • advise adults to stay away from work
zoster much less so. Over 80% of non-
immunosuppressed people and pregnant for the same period
immune household contacts of a case of
women. For further details see the • avoid contact with high risk susceptible
chickenpox will become infected. Non-
current edition of the Australian persons.
immune people exposed to shingles
immunisation handbook (National Health
cases will develop chickenpox (not Aspirin should never be given to children
and Medical Research Council).
zoster) if they become infected. with varicella due to a strong association
Immunosuppressed people and with the development of Reye’s
Second attacks of chickenpox are rare
newborns should be protected from syndrome.
but do occur.
exposure. If exposure has occurred in
Infection remains latent and can recur these persons varicella zoster immune
years later as shingles. globulin (VZIG) is effective in modifying
Patients who are at high risk of severe or preventing the disease if given within
disease/complications if they do not 96 hours of exposure. VZIG is available
have immunity include: from the Australian Red Cross.

• infants less than one month old


• pregnant women
The blue book: Guidelines for the control of infectious diseases 25

Herpes zoster (shingles) Any non-immune person admitted to limb hypoplasia and cortical atrophy of
Some antiviral medications (famciclovir, hospital who has a known exposure to the brain.
valaciclovir or aciclovir) have been shown varicella should be isolated during days Intrauterine infection can also result in
to be effective for treatment of varicella 10–21 after exposure or up to 28 days if herpes zoster in infancy. This occurs in
zoster infections in patients with a rash immune globulin given to reduce the risk less than 2% of infants. The highest risk is
less than 72 hours old. It gives pain relief, of spread to immunosuppressed associated with infection in late
accelerates healing and may be of patients. pregnancy.
benefit in reducing the incidence of post- Special settings
herpetic neuralgia. The addition of In the third trimester, maternal varicella
School may precipitate the onset of premature
corticosteroids in selected patients may Children with chickenpox are excluded
also speed resolution. labour.
for at least five days after the rash
More intensive treatment is warranted in appears. A few remaining scabs are not a Severe maternal varicella and pneumonia
high risk patients. Consultation with an reason for continued exclusion. Children at any stage of pregnancy can cause
infectious diseases physician is advised. with shingles can attend school if the foetal death.
Adequate analgesia should not be lesions can be covered adequately Susceptible pregnant women who have
forgotten. however exclusion from swimming and been exposed during pregnancy should
Control of contacts contact sports should be advised for seek specialist obstetric advice. They
Significant contact is defined as face-to seven days after the rash appears. may be offered zoster immune globulin
face contact for at least five minutes, Parents of children with (VZIG) and antivirals (famciclovir,
being in the same room for greater than immunosuppressive diseases should be valaciclovir or aciclovir), especially where
one hour or household contact. advised of cases of chickenpox in the delivery is imminent.

Varicella vaccination school as they may wish to voluntarily Where chickenpox develops in
Vaccination may be used to prevent or exclude their own child. pregnancy, early medical review within
attenuate illness if given to susceptible Immunosuppressed and their 24 hours of rash onset is indicated to
contacts within five days (preferably 72 household contacts consider treatment options.
hours) of first exposure. Immunosuppressed people, in particular Newborns
Varicella zoster immunoglobulin (VZIG) those with haematological malignancies, Where newborns develop varicella before
High risk susceptible contacts where are at high risk of more severe infection. ten days of age or when maternal
vaccination is not indicated such as VZIG should be offered to these patients chickenpox develops within seven days
neonates, pregnancy and if exposed. Recommend vaccination of prior to delivery and up to 48 hours
immunosuppressed persons should be susceptible household contacts of these postpartum, the neonatal fatality rate is
offered varicella-zoster immune globulin patients. up to 30% without treatment. Treatment
(VZIG) within 96 hours of exposure. If Pregnancy of mothers and of babies once born is
vaccination is not contraindicated this Varicella infection during the first vital.
should follow at least 3 months later. trimester of pregnancy confers a small Premature babies and infants less than
(See the current edition of the Australian risk of miscarriage. Maternal infection one month old who develop varicella
immunisation handbook, National Health before 20 weeks may rarely result in the may require specific treatment. Seek
and Medical Research Council, for foetal varicella zoster syndrome, with the expert advice.
further details and supply.) highest risk (2%) occurring at 13–20
Contacts should not be excluded from weeks. Clinical manifestations include
school. growth retardation, cutaneous scarring,
26 The blue book: Guidelines for the control of infectious diseases

Health care workers Outbreak measures


On commencement at a new workplace Timely vaccination of susceptible
all health care workers with an uncertain contacts is indicated to contain an
history of varicella infection should be outbreak.
serotested and offered immunisation if
susceptible. Additional sources of information
• Australasian Society for Infectious
If a rash develops in the three weeks
Diseases 2001, ‘Position statement on
after immunisation, the worker should be
management of varicella-zoster virus
removed from patient contact until
exposure and infection in pregnancy
varicella is excluded or lesions have
and the newborn period’, Medical
crusted over.
Journal of Australia, vol. 174, pp.
If a health care worker is exposed to a 288–291.
confirmed case of varicella or herpes
zoster they may continue working with
patient contact if they have a history of
previous infection or immunisation. They
should be advised to report any febrile
symptoms or rash developing within
three weeks of exposure and then avoid
patient contact until varicella is
confidently excluded.
If the worker is susceptible and has been
exposed, vaccination within five days of
exposure is indicated. They should report
rash occurring within six weeks of
vaccination and avoid patient contact as
above. If vaccination is refused, no
patient contact should take place
between days 10–21 after first exposure.
Shingles in a health care worker
Workers should not care for high risk
patients until lesions have crusted over.
Other patients can be cared for as long
as lesions can be adequately covered.
The blue book: Guidelines for the control of infectious diseases 27

Chlamydia (genital
infection)
Victorian statutory requirement Complications and sequelae may result The choice of test depends on the
Chlamydia (Group C disease) must be in chronic pelvic pain, infertility and specimen type submitted, the cost of the
notified in writing within five days of ectopic pregnancy. Infections during test, the sensitivity and specificity of the
diagnosis. pregnancy may cause preterm rupture of test and the expertise and size of the
the membranes and preterm delivery. It laboratory.
Specific information must be notified
can also cause conjunctivitis in the
under the Health (Infectious Diseases) Incubation period
newborn and pneumonitis in the young
Regulations 2001. To maintain The incubation period is poorly defined
infant.
confidentiality, only the name code (first but is probably 7–14 days or longer.
two letters of the surname followed by The primary presentation of chlamydial
the first two letters of the first name) is infection in males is urethritis but Public health significance
required. A questionnaire is sent to the infection may be asymptomatic. Possible and occurrence
diagnosing doctor to collect additional sequelae and complications of male Infection with C. trachomatis has
information on the case that is essential urethral infection are epididymitis, become a major public health problem
for detecting disease trends and infertility, Reiter’s syndrome and because of the long term consequences
informing policy development. conjunctivitis. Receptive anal intercourse of infection experienced predominantly
in men who have sex with men (MSM) by women. These include chronic pelvic
Medical practitioners have a statutory
may result in chlamydial proctitis. pain, ectopic pregnancy and infertility.
obligation under the Children and Young
Person’s Act 1989 to notify the Method of diagnosis Rarely males may also become infertile.
Department of Human Services’ Child Testing individuals at high risk of Chlamydia is the most commonly
Protection Service if they believe a child chlamydial infection is recommended. notified sexually transmissible bacterial
is in need of protection on the basis of High risk individuals include those with a disease in Victoria. It affects both
sexual abuse. clinical presentation suggestive of genders. The annual number of notified
chlamydial infection, individuals cases has more than doubled since the
Infectious agent attending general practitioners for testing early 1990s. Approximately 75% of
Chlamydia trachomatis serogroups D–K of sexually acquired infection (STI), those infections are notified from individuals
cause disease. attending STI and family planning clinics aged less than 30 years.
and gay men’s health centres and
Identification The prevalence of chlamydial genital
partners of those already diagnosed with
Clinical features infections in Australia has not been
an STI.
Most women with urethral or comprehensively established but it has
endocervical chlamydial infection are Laboratory investigations currently been estimated to be 2.5 –14% in STD
asymptomatic. Clinical manifestations available are: clinic patients, 5% in family planning
may include vaginal discharge, dysuria • cell culture (only in specialised clients and up to 15% in commercial sex
and post-coital or intermenstrual laboratories) workers.
bleeding. Less frequent manifestations While the spontaneous cure rate has
• antigen assays including direct
include urethral syndrome (dysuria and been estimated at 7.4%, immunity
immunofluorescence or enzyme
pyuria), bartholinitis, perihepatitis and following infection is thought to be type-
immunoassay
proctitis. specific and only partially protective. As
• hybridisation assays such as the DNA
a result recurrent infections are common.
probe
• amplification assays including PCR and
ligase chain reaction (LCR).
28 The blue book: Guidelines for the control of infectious diseases

Risk factors for chlamydial infections Control of case sequelae’, American Journal of
include a relatively high number of sexual Azithromycin or doxycycline are used as Obstetrics and Gynecology, vol. 164,
partners, a new sexual partner and lack first line antimicrobials to treat no. 6, pt. 2, pp. 1771–81.
of use of barrier contraceptive measures. chlamydial infection. Advice on the • Centers for Disease Control and
Endocervical C. trachomatis infection treatment of chlamydial infections can Prevention 2002, ‘Sexually transmitted
has also been associated with an be found in Therapeutic guidelines: diseases treatment guidelines 2002,
increased risk of acquiring human antibiotic (Therapeutic Guidelines Morbidity and Mortality Weekly Report,
immunodeficiency virus (HIV) infection Limited) and the National management vol. 51 (RR06), pp.1–80,
and may also increase HIV guidelines for sexually transmissible http://www.cdc.gov/mmwr
infectiousness. infections (Venereology Society of
Victoria, 2002). • Garland, SM, Gertig, DM & McInnes, JA
1993, ‘Genital Chlamydia trachomatis
Reservoir Specialist consultation should be sought infection in Australia’, Medical Journal
Humans. for complicated or disseminated of Australia, vol. 159, pp. 90–6.
infections.
Mode of transmission • Genc, M & Mardh, A 1996, ‘A cost-
Transmission of C. trachomatis occurs Control of contacts effectiveness analysis of screening and
primarily by sexual contact. Mother to Sexual partners of individuals with treatment for Chlamydia trachomatis
baby transmission occurs when mothers chlamydial infection should be examined infection in asymptomatic women’,
colonised with C. trachomatis infect and investigated then treated empirically. Annals of Internal Medicine, vol. 124,
their babies as they are born vaginally. Contact tracing assistance can be no. 1, pt. 1, pp. 1–7.
A high proportion of infections in women provided by the Department’s partner • Pearlman, MD & McNeeley, SG 1992,
are asymptomatic resulting in untreated notification officers (03) 9347 1899. ‘A review of the microbiology,
disease, ongoing transmission and an Control of environment immunology, and clinical implications
increased risk of sequelae. Not applicable. of Chlamydia trachomatis infections’,
Obstetrical and Gynecological Survey,
Period of communicability Outbreak measures vol. 47, no. 7, pp. 448–61.
The period of communicability is Not applicable.
unknown but may be months to years. • Venereology Society of Victoria 2002,
Additional sources of information National management guidelines for
Susceptibility and resistance • Australian Government Department of sexually transmissible diseases,
Everyone is susceptible to infection. Health and Family Services 1997, Venereology Society of Victoria,
Contact tracing manual – a practical http://www.mshc.org.au
Control measures handbook for health care providers • Victorian Department of Human
Preventive measures
managing people with HIV, viral Services 2001, Chlamydia strategy for
Preventive measures include education
hepatitis, other STDs and HIV-related Victoria 2001–2004, Victorian
about safe sex practices including use of
tuberculosis, Australian Government Department of Human Services.
condoms and early detection of infection
Department of Health and Family
by testing of those at risk. • Weinstock, H, Dean, D & Bolan, G
Services.
1994, ‘Chlamydia trachomatis
• Cates, W & Wasserheit, JN 1991, infections’, Infectious Disease Clinics of
‘Genital chlamydia infections: North America, vol. 8, no. 4, pp.
epidemiology and reproductive 797–819.
The blue book: Guidelines for the control of infectious diseases 29

Chlamydophila
pneumoniae
Victorian statutory requirement chlamydial species. A single antibody Asymptomatic carriage occurs in 2–5%
Notification and school exclusion are not titre is of little diagnostic value on its of the population. Only about 10% of
required. own as the seroprevalence of infections result in pneumonia.
antibodies to C. pneumoniae Epidemics of respiratory illness can
Infectious agent approaches 50% in the adult occur and these usually occur in
The infectious agent is Chlamydophila population. Seroconversion may take institutional settings such as military
pneumoniae, an obligate intracellular up to eight weeks in an initial infection barracks or nursing homes.
bacterium (previously named Chlamydia but it tends to occur much more Speculation regarding the bacteria’s
pneumoniae). quickly in reinfection (one to two involvement in the pathogenesis of
weeks). False positive antibody tests atherosclerotic arterial disease
Identification
can occur in the presence of a positive continues. Seroepidemiologic studies
Clinical features
rheumatoid factor. have shown an association between
Chlamydophila pneumoniae infection is
often mild. The initial infection appears to • Culture of nasopharyngeal aspirates, evidence of C. pneumoniae infection and
be the most severe with reinfection often throat swabs or bronchial lavage fluid is atherosclerosis but the significance of
asymptomatic. A spectrum of illness possible. Swabs should be placed in this is not yet established. Studies are
from pharyngitis and sinusitis to chlamydia transport medium whilst ongoing into the effect of prophylactic
pneumonia and bronchitis may occur. other specimens can be collected in antibiotic treatment on prevention of
Sometimes there is a biphasic illness the usual containers. All samples atherogenesis.
with initial upper respiratory tract should be kept refrigerated. Possible links with Alzheimer’s disease,
infection symptoms which resolve and Diagnosis by PCR is available through the arthritis and asthma are also postulated.
then a dry cough and low grade fever. Victorian Infectious Diseases Reference
Laboratory (VIDRL) but it is currently only Reservoir
The organism may be an infectious
being used in investigation of outbreaks Humans.
precipitant of asthma and is implicated in
about 5% of episodes of acute bronchitis. of respiratory illness where conventional
Mode of transmission
Cough occasionally persists for some testing has not revealed the cause of
Transmission occurs person to person
weeks despite appropriate antibiotic infection.
via respiratory secretions.
therapy.
Incubation period
Method of diagnosis Period of communicability
The incubation period is approximately
Chest X-ray may show small infiltrates. Asymptomatic carriers may be an
21 days.
Most cases of pneumonia are mild but important source of infection.
the illness can be severe in otherwise Public health significance Symptomatic patients can carry the
debilitated patients. C. pneumoniae is emerging as a frequent bacteria in the nasopharynx for months
cause of both upper and lower after illness.
Laboratory diagnosis is made with
respiratory tract infections. It appears to
serology or culture:
be a common cause of mild pneumonia,
• Serological diagnosis is made by especially in school age children. Up to
detecting a four fold rise in antibody 10% of cases of community-acquired
titre using microimmunofluorescence pneumonia can be attributed to this
(MIF). MIF is the only serological test organism.
that can reliably differentiate
30 The blue book: Guidelines for the control of infectious diseases

Susceptibility and resistance


Everyone is susceptible to infection, with
the risk of clinical disease increasing in
patients with a chronic medical
condition. Immunosuppressed patients
do not seem to be more susceptible, but
older debilitated patients may develop
severe disease.
Initial infection occurs in school-age
children with up to 50% of the population
becoming seropositive by 20 years of
age. Infection does not produce
complete immunity and reinfection can
occur.

Control methods
Control of case
Mild to moderate infections are generally
treated with roxithromycin or
doxycycline. Consult the current version
of Therapeutic guidelines: antibiotic
(Therapeutic Guidelines Limited).
Patients being managed in the
community should be reviewed after 24
hours to assess treatment response.
Therapy may need to be continued for up
to 14 days.
Isolation is not necessary, but the patient
should be counselled on good respiratory
hygiene, such as coughing into
disposable tissues.
Special settings
Institutions
Avoid crowding in living and sleeping
quarters.
The blue book: Guidelines for the control of infectious diseases 31

Cholera
Victorian statutory requirement Method of diagnosis person to person contact is rare.
Cholera (Group A disease) must be The diagnosis is confirmed by the
notified immediately by telephone or fax isolation of V. cholerae serogroup O1 or Period of communicability
followed by written notification within five O139 from faeces. A presumptive Persons are infectious during the acute
days. diagnosis can be made by visualisation stage and for a few days after recovery.
by dark field or phase microscopy of By the end of the first week 70% of
Cholera is subject to Australian patients are non-infectious. By the end
V. cholerae’s characteristic motility,
quarantine. of the third week 98% are non-infectious.
specifically inhibited by preservative-free
serotype-specific antiserum. Occasionally the carrier state may persist
Infectious agent
for months and chronic biliary infection
Vibrio cholerae serogroups O1 or O139
cause cholera.
Incubation period with intermittent shedding of organisms
The incubation period is from a few may last for years.
Note hours to five days. It is usually two to
Non-O1 Vibrios, formerly known as non- three days. Susceptibility and resistance
agglutinable Vibrios (NAG) or non-cholera Even in severe epidemics, clinically
Vibrios (NCV) are now included in the Public health significance apparent disease rarely occurs in more
species Vibrio cholerae, but the reporting and occurrence than two per cent of those at risk.
of Non-O1 or O139 infections as ‘cholera’ Cholera can occur in epidemics or Gastric achlorhydria increases risk of
is inaccurate. pandemics. In any single epidemic one disease. There is some evidence that
Most non-O1/O139 strains do not particular biovar tends to predominate. breastfeeding reduces the risk of
secrete enterotoxin but can cause Endemic cholera occurs in parts of infection. Infection results in a rise in
sporadic disease. The term non-Vibrio Africa, Central Europe and Asia. Cholera antibodies with increased resistance to
cholera (NVC) refers to cases of cholera- appears to be increasing worldwide in reinfection. Infection with an O1 strain
like illness caused by organisms other both the number of cases and their does not confer immunity against O139
than the 01 or 0139 Vibrio species. These distribution. Only sporadic imported strains and vice-versa.
infections are not notifiable. cases in returned travellers occur in
Victoria. V. cholerae O1 is established in Control measures
Identification the riverine environment in some parts of Preventive measures
Clinical features Queensland and New South Wales Travellers to endemic areas should be
Asymptomatic infection with however human disease is rare. advised on careful food and water
V. cholerae is more frequent than clinical consumption and personal hygiene.
illness and bacteria may be present in Reservoir Travellers to endemic areas should carry
faeces for 7–14 days. Mild cases of V. cholerae is often part of the normal oral rehydration powder available from
diarrhoea are common especially among flora of brackish water and estuaries and pharmacies which must be reconstituted
children. can be associated with algal blooms with boiled or sterilised water.
(plankton). Humans are one of the Cholera vaccine is a heat-killed
In severe cases disease is characterised
reservoirs of the pathogenic form of V. suspension of the Inaba and Ogawa
by a sudden onset of symptoms with
cholerae. serotypes of V. cholerae O1. It provides
profuse painless watery (rice water)
stools, occasional vomiting, rapid partial protection (approximately 50%) for
Mode of transmission
dehydration, acidosis and circulatory three to six months. It is not routinely
Transmission occurs through ingestion of
collapse. In untreated cases, death may recommended and advice to overseas
contaminated water and food. Sudden
occur in a few hours and the case fatality travellers should emphasise careful
large outbreaks are usually caused by a
rate may exceed 50%. selection of food and water rather than
contaminated water supply. Direct
32 The blue book: Guidelines for the control of infectious diseases

immunisation. Officially, cholera Control of contacts Outbreak measures


vaccination certificates are no longer Contacts should be observed for five A single case of cholera in a person with
required by any country or territory. days from the date of last exposure. This a history of no overseas travel is
Unofficially, some countries may still may include all fellow travellers of a case. considered an outbreak. Initiate a
require such a certificate, in which case Stool culture of any contacts with thorough investigation to determine the
a single dose of cholera vaccine would symptoms of diarrhoea and stool culture vehicle and circumstances of
satisfy this requirement. of all household contacts, even if transmission and plan control measures
Control of case asymptomatic, should be undertaken. accordingly. Educate the population at
Cholera is subject to quarantine Cases should also be looked for among risk about the need to seek appropriate
conditions under the Commonwealth those possibly exposed to a common treatment without delay. Adopt
Quarantine Act 1908. source. Immunisation of contacts is not emergency measures to assure a safe
indicated. water supply. Ensure careful supervision
Prompt fluid therapy with adequate
Control of environment of food and drink preparation.
volumes of electrolyte solution such as
Gastrolyte is critical as life-threatening Severely ill patients should be isolated in Immunisation of contacts is not
dehydration may rapidly occur. This is hospital, with standard precautions. Less indicated, even in the epidemic situation.
usually all that is required for mild to severe cases can be managed at home.
Disinfection of linen and articles used by International measures
moderate illness. Patients with severe
the patient is required. Faeces and Reporting of cholera to the World Health
dehydration require urgent intravenous
vomitus can be disposed of into the toilet Organization is mandatory under
fluid. Antimicrobial agents to which the
without preliminary disinfection, except in international health regulations. This will
strain is sensitive shorten the duration of
areas with an inadequate sewage be done by the Department of Human
diarrhoea and the duration of Vibrio
disposal system. Terminal cleaning of Services through the Australian
excretion.
hospital rooms and equipment is Government.
Investigate possible sources of infection, required.
particularly if there is no history of travel Additional sources of information
to an endemic region. In cases with no history of overseas • Quarantine Act 1908,
travel, urgent investigation of potentially http://www.austlii.edu.au
contaminated food and water supplies is
• World Health Organization,
indicated.
http://www.who.int/csr
The blue book: Guidelines for the control of infectious diseases 33

Creutzfeldt-Jakob
disease (CJD)
Victorian statutory requirement symptoms such as dysarthria. With Public health significance
CJD (Group B disease) must be notified disease progression there may be and occurrence
in writing within five days of diagnosis. pyramidal or spinal cord involvement, Since 1986 over 180 000 cases of BSE in
muscle atrophy or fasciculations and cattle have been reported in the UK.
School exclusion is not applicable.
frequently myoclonus. Survival beyond Other countries have reported BSE in
Infectious agent one year is unusual with death ensuing cattle imported from the UK. The rates of
The infectious agent is a unique after a median of 4.5 months. BSE are now decreasing. BSE has not
abnormal prion protein, designated as Variant CJD been reported in Australian cattle. Over
PrP. This protein is an insoluble, protease- Variant CJD (vCJD) was first described in 100 cases of human vCJD have now
resistant amyloid form of a normal the United Kingdom in 1996. The disease been reported in Britain.
cellular protein designated PrPc. PrP acts is strongly linked to the consumption of No cases of vCJD have been reported in
on normal prions, causing them to cattle products infected with the prion Australia. Classical CJD continues to
change into the abnormal infectious form protein that causes bovine spongiform occur, with about 20 cases reported
in a cascade like manner. encephalopathy (BSE), or mad cow annually.
disease. There are clinical differences
Identification Reservoir
between vCJD and cCJD. vCJD affects
Clinical features Prion disease is present in cattle (BSE),
younger people (average 29 years) and
CJD belongs to a group of rare diseases sheep, goats, mink, mule deer and elk,
the duration of illness is longer (median
known to affect humans and animals cats and exotic zoo animals.
14 months). Unlike cCJD, it commonly
called transmissible spongiform Transmission of variant CJD in humans
begins with psychiatric symptoms such
encephalopathies (TSE). CJD presents in has only been linked to the consumption
as depression and anxiety. Involuntary
humans in either a classical or a variant of meat and meat products from cattle
movements and sensory symptoms such
form. with BSE.
as pain are usually present.
Classical CJD Infected humans with variant CJD and
Method of diagnosis
Classical CJD (cCJD) is one of four rare classical CJD are potential sources of
Diagnosis is suspected by the clinical
prion diseases that affect humans. The infection for other humans by iatrogenic
presentation, disease progression and
others are Kuru, Gerstmann-Straussler- means.
exclusion of other causes. EEG and MRI
Scheinker disease and fatal familial
scans yield distinct results between
insomnia. Mode of transmission
classical and variant CJD. CSF tests
Classical CJD occurs in sporadic, familial The majority of cases of cCJD appear to
assist diagnosis. Definitive diagnosis is
and iatrogenic forms. Sporadic cases occur spontaneously with no source
usually made by brain biopsy or at
account for 85–90% of CJD cases and identified. In very rare cases
autopsy by detection of the PrP and
have an unknown cause. Familial cases transmission of cCJD has occurred
demonstration of the typical pathological
make up 5–10% and are associated with through iatrogenic means. This has
spongiform changes in the brain.
a genetic mutation. Less than 5% are included direct or indirect contact with
However, the diagnosis can also be
iatrogenic. brain tissue and cerebrospinal fluid.
confirmed by the detection of PrP in
The symptoms of classical CJD usually other human tissue such as tonsillar For example, corneal or dural grafts or
begin at an average age of 65 years. tissue by biopsy. injections of contaminated pituitary
Most cases occur between 45 and 75 hormone obtained from cadavers.
Incubation period Growth hormone is now made artificially.
years. The onset is commonly a rapidly
The incubation period is difficult to There is no evidence of risk to people in
progressing dementia, however one third
ascertain and varies from 15 months up close casual contact with a person
of people may present with cerebellar
to 30 years in iatrogenic cases. infected with CJD.
34 The blue book: Guidelines for the control of infectious diseases

Variant CJD is believed to be transmitted • a ban on blood products from people Control of contacts
to humans through consumption of who have lived in the UK for six months Individuals who have may have shared a
cattle infected with BSE. or more since 1980 until 1996, common exposure with a case or who
There have been no cases of vCJD linked commenced in 2000 may have been exposed to infected
to the receipt of infected blood products. • surveillance for vCJD by the Australian material from a case, such as
As there is a theoretical risk of infection National CJD Registry based at the transplanted tissue, should be counselled
from blood products, blood donors are University of Melbourne by a specialist infectious diseases
screened with respect to their possible physician.
• active surveillance of cattle for BSE by
exposure in areas affected by vCJD, the Australian Government Control of environment
particularly the United Kingdom. Department of Agriculture, Fisheries All wound drainage, tissues and surgical
and Forestry. equipment should be considered to be
Period of communicability contaminated. See also Control of case,
The central nervous system tissues are Control of case above. These should be terminally
infectious during symptomatic illness of There is no specific treatment except for disposed of or inactivated
CJD. supportive care. (see Appendix 3).
Animal studies suggest that the lymphoid Hospitalised patients should be managed The World Health Organization has
and other organs are probably infectious using standard precautions. Tissues, advised that no part or product of any
long before symptoms develop. surgical instruments and all wound animal which has shown signs of a TSE
drainage should be considered should enter a human or animal food
Susceptibility and resistance contaminated and must be inactivated. chain.
Genetic mutations have been found in The PrP is very resistant to destruction
familial CJD. Genetic susceptibility also by normal methods including standard Outbreak measures
occurs for vCJD for humans who are sterilisation and because of this In the event of cases of vCJD being
homozygous for methionine at codon129 instruments used on CJD patients, detected in Australia the Australian
of the prion gene. particularly in surgery involving the brain, Government Department of Health and
spine or eye, may need to be destroyed. Ageing with the Chief Medical Officer will
Control measures
It is important to obtain an accurate coordinate the national response in
Preventive measures
history of travel, any previous surgical or consultation with the State and Territory
Precautionary measures instituted in
dental procedures, and any history of health departments, and in consultation
Australia to reduce the risk of vCJD
exposure to human growth hormone or with animal health authorities.
importation include:
transplanted tissue.
• a ban on the importation of beef and International measures
beef products from the UK since 1996. If there is no travel history, obtain details See Outbreak measures, above.
Extended to other affected European of any past procedure or surgery. International advisories and human and
countries Inform the Australian Government animal quarantine issues are the
• monitoring and restriction by the Department of Agriculture, Fisheries and responsibility of various Australian and
Therapeutic Goods Administration Forestry to monitor Australian cattle if de State Government departments.
(TGA) of the source of materials of novo vCJD occurs.
animal origin used in the manufacture
of medicines and medical devices
The blue book: Guidelines for the control of infectious diseases 35

Additional sources of information • Turner, M 2001, ‘Variant Creutzfeldt-


• Australian Government Department of Jakob disease and blood transfusion’,
Health and Ageing 2003, ‘How Current Opinion in Hematology, vol. 8,
Australia will respond to our first case of no. 6, pp. 372–379.
vCJD. A guide for the public’, • World Health Organization 2002,
www.health.gov.au Variant Creutzfeld-Jakob Disease -
• Australian Government Department of fact sheet 180, www.who.int
Agriculture, Forestry and Fisheries,
www.affa.gov.au
• Brown, P 2001, ‘Bovine spongiform
encephalopathy and variant Creutzfeld-
Jakob disease’, British Medical Journal,
vol. 322, no. 7290, pp841–844.
• Creutzfeld-Jakob Disease Foundation
Inc, www.cjdfoundation.org
• Coulthart, M, Cashman N 2001,
‘Variant Creutzfeldt-Jakob disease: a
summary of current scientific
knowledge in relation to public health’,
Canadian Medical Association, vol. 165.
• Health Canada Online 2003, Classical
Creutzfeld-Jakob disease,
www.hc-sc.gc.ca
• National Institute of Neurological
Disorders and Stroke 2003,
Creutzfeldt-Jakob disease fact sheet,
Bethesda USA, www.ninds.nih.gov
• Smith, P 2003, ‘The epidemics of
bovine spongiform encephalopathy and
variant Creutzfeld-Jakob disease:
current status and future prospects’,
Public Health Reviews, Bulletin of the
World Health Organization, vol. 81, no. 2.
• Therapeutic Goods Administration (for
specific TGA measures to minimise the
risk of exposure to TSEs through
medicines and medical devices),
www.tga.health.gov.au
36 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 37

Croup or bronchiolitis
Victorian statutory requirement Bronchiolitis underlying cardiac or pulmonary disease
Notification and school exclusion are not A one to seven day prodrome of mild or compromised immune systems are at
required. fever, coryza and cough is common with increased risk for serious complications
bronchiolitis. Disease can rapidly of RSV infection, such as pneumonia and
Infectious agent progress to deepening cough, death. RSV infection among recipients of
Respiratory syncytial virus (RSV), tachypnoea, restlessness, chest wall bone marrow transplants has resulted in
parainfluenza viruses and adenoviruses retraction, nasal flaring and grunting. high mortality rates. Symptomatic RSV
are the causative agents. Audible wheezing is a characteristic disease can recur throughout life
Parainfluenza type 1 virus is the most feature. It can be accompanied by because of limited protective immunity
common cause of croup and RSV the paroxysms of coughing, vomiting, induced by natural infection.
most common cause of bronchiolitis. dehydration, otitis media and diarrhoea.
Reservoir
Method of diagnosis
Identification Humans.
The diagnosis of croup and bronchiolitis
Clinical features
is usually based on characteristic clinical Mode of transmission
Disease is generally characterised by
findings. Serologic diagnosis can be RSV is transmitted via oral contact,
fever and one or more systemic reactions
unreliable. Identification of the specific droplet spread or by contact with hands
such as chills, headaches, generalised
viral agent may be accomplished by or fomites soiled by respiratory
aches, malaise and anorexia.
isolation in tissue culture from throat, discharges from an infected person.
Gastrointestinal disturbances may also
tracheal and nasal wash specimens, or
occur. In babies and young children Period of communicability
by multiplex PCR.
general features are often not apparent RSV is communicable shortly prior to and
and disease presents with localising Incubation period for the duration of active disease.
signs at various sites in the respiratory The incubation period varies from one to Prolonged shedding of RSV has been
tract. ten days. documented.
Croup
Croup (laryngotracheobronchitis) has a
Public health significance Susceptibility and resistance
prodrome of fever, runny nose and sore
and occurrence Everyone is susceptible to infection.
There is limited data on the epidemiology Reinfection with the agents that cause
throat. Cough is also common.
of croup and bronchiolitis in Australia. croup is common but the infection is
Inflammation at the subglottic level
Croup is more common in autumn and generally milder.
produces a classic high-pitched
affects children aged three months to
inspiratory stridor and a hoarse voice.
three years. It peaks in the second year Control measures
The larger airways are narrowed by
of life. Bronchiolitis is more common in Preventive measures
inflammation resulting in various degrees
winter and predominantly affects children There is no vaccine available. Basic
of shortness of breath and increased
in the first year of life. hygiene can help limit the spread of
respiratory rate. Airway obstruction can
many diseases including croup and
progress with in-drawing of the Lower respiratory tract infections due to
bronchiolitis.
intercostal spaces and the soft tissues of viral agents are significant causes of
the neck, cyanosis and death without infant and childhood morbidity and
urgent treatment. mortality worldwide. Persons with
38 The blue book: Guidelines for the control of infectious diseases

Control of case
Children with these diseases should not
attend school or child care centres while
unwell. Investigations are generally not
indicated but may be useful in outbreak
situations.
Control of contacts
Investigation of contacts is not
necessary but the diagnosis in other
family or close contacts should be
considered if they are symptomatic.
Control of environment
Not applicable.

Outbreak measures
Public health action is dependant on the
setting in which the case has occurred
and is based on an assessment of
ongoing risk. The risk for nosocomial
transmission of RSV increases during
community outbreaks. Nosocomial
outbreaks of RSV can be controlled by
adhering to contact and respiratory
precautions.

Additional sources of information


• Centers for Disease Control and
Prevention, Atlanta USA, Respiratory
syncytial virus infection,
http://www.cdc.gov/ncidod
The blue book: Guidelines for the control of infectious diseases 39

Cryptococcal infection
(cryptococcosis)
Victorian statutory requirement Public health significance and disorders of the reticuloendothelial
Notification and school exclusion are not and occurrence system, particularly Hodgkin’s disease
required. Human infection is rare in the absence of and sarcoidosis.
immunosuppression. Persons at
Infectious agent increased risk of infection include Control measures
Cryptococcus neoformans, an patients with impaired immunity due to Preventive measures
encapsulated yeast-like fungus. There are HIV/AIDS infection, corticosteroid No vaccine is available. Some patients
two principal variants: therapy, lymphoma or sarcoidosis. may require maintenance antibiotics to
C. neoformans var. neoformans prevent repeat infections (see below).
Cryptococcal infections occur
(serotypes A & D) and C. neoformans var. Control of case
sporadically in all parts of the world.
gattii (serotypes B & C). Clinicians should consider referral to a
Adults are more commonly infected with
males more commonly infected than specialist centre for treatment. Typical
Identification
females. treatment often involves amphotericin or
Clinical features
flucytosine.
Cryptococcal infection usually presents
as sub-acute or chronic
Reservoir Patients with HIV/AIDS may require
Cryptococcus has saprophytic growth in continuing maintenance therapy
meningoencephalitis with headache and
the external environment. (secondary prophylaxis), typically
altered mental state. Lung involvement
C. neoformans var. neoformans occurs fluconazole orally daily.
may cause symptoms of lower respiratory
worldwide, frequently in association with
tract infection or may be asymptomatic. Control of contacts
pigeon or other bird droppings.
Skin, bone and other organs are less No action required.
C. neoformans var. gattii occurs in
frequently infected.
endemic foci in the tropics and sub- Control of environment
Method of diagnosis tropics where certain eucalypts provide Large accumulations of bird droppings
Encapsulated budding forms of the an ecological niche. should be removed after first being
fungus may be seen in the CSF, urine or wetted or chemically disinfected to
pus using Indian ink staining. Mode of transmission reduce aerosolisation.
Cryptococcal antigens may also be Transmission is presumed to be by
detected in the CSF and serum. inhalation. Outbreak measures
Case clusters are rare. Environmental
The diagnosis is confirmed by culture
Period of communicability investigations focus on potential
(CSF, blood, sputum or andurine) or by
Not spread directly from person to reservoirs of infection such as bird
histopathology (Mayer’s mucicarmine
person, nor spread between animals and droppings, although a definitive source is
staining).
people. rarely found.
Pulmonary cryptococcosis in non-HIV
Susceptibility and resistance Special settings
infected persons usually manifests as a
Human resistance is presumed to be Where nosocomial transmission is
nodule which must be distinguished from
considerable given the widespread suspected in single cases or clusters, the
a malignancy. Malignancies may co-exist.
distribution of the organism and the risk of further infections should be
Incubation period rarity of infection. It is not known reduced through appropriate control of
The incubation period is unknown. whether infection confers immunity. the external environment, with
Pulmonary infection may precede investigation of the internal environment
Susceptibility is increased during
infection in other sites by months or within facilities as appropriate.
corticosteroid therapy, immune
years.
deficiency disorders (especially AIDS),
40 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 41

Cryptosporidiosis
Victorian statutory requirement Oocysts may be identified by microscopy Mode of transmission
Cryptosporidial infection (Group B of faecal smears treated with a modified Transmission occurs by the faecal-oral
disease) must be notified in writing acid-fast stain. A monoclonal antibody route (person to person and animal to
within five days of diagnosis. test is useful for detecting oocysts in person), and via ingestion of
faecal and environmental samples. contaminated foods and water.
School exclusion: exclude cases from
child care and school until diarrhoea has Oocyst excretion is most intense during
Period of communicability
ceased or until a medical certificate of the first days of illness. Oocysts are
Cases may be infectious for as long as
recovery is produced. rarely recovered from solid faeces.
oocysts are excreted in the stool.
Notification is required if Cryptosporidium ELISA assays have been developed for Asymptomatic excretion may persist for
spp are isolated from water supplies. the detection of antibodies but these are several weeks after symptoms resolve.
not in routine use.
Infectious agent Under suitable conditions oocysts may
Cryptosporidium parvum is a coccidian Incubation period survive in soil and be infective for up to
protozoon. The incubation period is estimated to be six months.
one to twelve days, with an average of
Identification Susceptibility and resistance
seven days.
Clinical features Everyone is susceptible to infection.
Cryptosporidiosis is a parasitic infection Public health significance People with normal immune systems
that commonly presents as and occurrence usually have asymptomatic or self-limited
gastroenteritis. Enteric symptoms usually Cryptosporidiosis occurs worldwide. gastrointestinal disease.
include watery diarrhoea associated with Young children, the families of infected People with impaired immunity may
cramping abdominal pain, bloating, persons, men who have sex with men, experience prolonged illness.
vomiting and fever. The disease is usually travelers, health care workers and people
mild and self-limiting. In persons with in close contact with farm animals Control measures
impaired immunity, particularly those comprise most reported cases. Preventive measures
with AIDS, it may be prolonged and life- Substantial outbreaks linked to public Encourage good personal hygiene,
threatening. Cryptosporidiosis infection water supplies have been reported in the particularly following contact with
may less commonly involve the lungs United States. Multiple outbreaks animals or infected persons. Particular
(bronchitis or pneumonia), gall bladder associated with public swimming pools attention to hand washing is required
(cholecystitis) or pancreas (pancreatitis). and spas have been reported in Australia during calving seasons on cattle
Symptoms usually last four to twenty-one and worldwide. The risk of infection for properties.
days. Melbourne residents has been greater for Filter or boil contaminated drinking water,
people exposed to public swimming as chemical disinfectants such as
Method of diagnosis
pools and household contacts of infected chlorine are not effective against oocysts
As tests for Cryptosporidium are not
persons. at the concentrations used in water
routinely conducted in some facilities
laboratories should be informed if treatment.
Reservoir
cryptosporidiosis is suspected. Reservoirs include humans, cattle and
other domestic animals.
42 The blue book: Guidelines for the control of infectious diseases

Control of case Outbreak measures


Treatment is symptomatic and An outbreak investigation is required if
particularly involves rehydration. two or more cases are clustered in a
Antibiotics are not indicated. geographic area or institution. Investigate
Exclude symptomatic persons from food potential common sources such as
handling, direct care of hospitalised and contact with farm animals, consumption
institutionalised patients and care of of contaminated water or unpasteurised
children in child care centres until milk or exposure to a common
asymptomatic. recreational swimming area.

Disinfect soiled articles. The Department of Human Services


considers cases may be linked to a
As oocyst excretion may persist for
public swimming facility if two or more
extended periods it is not advisable for
people with Cryptosporidium infection
adults to swim in public pools for a
(confirmed by a pathology laboratory)
period of seven days and children for a
have used the same pool within two
period of four weeks after their diarrhoea
weeks of their illness. In this situation
has ceased. Showering before swimming
pool owners may need to close the
is recommended at all times.
affected swimming pool until it has been
Control of contacts treated and superchlorinated with at
The diagnosis should be considered in least 14 mg/L free chlorine for at least 12
symptomatic contacts. hours.
Control of environment It is important to ensure that the total
Faecal contamination of pools requires chlorine level in a treated pool is less
prompt action by the pool operator than 8 mg/L before re-opening it to the
including disinfection, but oocysts resist public. If an outbreak is particularly large,
standard chlorination. Refer to the the Department may request additional
Department of Human Services’ Pool steps to be undertaken.
operators’ handbook.
Additional sources of information
• Victorian Department of Human
Services 2000, Pool operators’
handbook, http://www.health.vic.
gov.au/environment
The blue book: Guidelines for the control of infectious diseases 43

Cytomegalovirus
infection
Victorian statutory requirement When infected with CMV, most pregnant Method of diagnosis
Notification and school exclusion are not women have no symptoms while a very CMV may be detected by virus isolation
required. few have a disease resembling or PCR, usually from urine. Virus may also
mononucleosis. However, for those be detected in saliva, breast milk, semen
Infectious agent women who are infected for the first time and cervical secretions during primary
Cytomegalovirus (CMV) also designated during their pregnancy, one in three will and reactivated infection.
as Human herpesvirus 5, is a member of pass the CMV infection on to their CMV causes typical ‘cytomegalic’ cells in
the subfamily betaherpesvirus of the developing unborn child. tissue culture and characteristic histologic
family herpesviridae. Other members of
CMV remains the most important cause features in affected tissues. CMV antigens
the herpesvirus group include herpes
of congenital viral infections in Australia. may be detected using rapid antigen
simplex virus types 1 and 2, varicella
For infants who are infected by their tests. Serology is also available where
zoster virus (which causes chickenpox),
mothers before birth, two potential recent infection is suggested by the
and Epstein-Barr virus (which causes
problems exist: identification of CMV IgM or a fourfold or
infectious mononucleosis/glandular
Generalised infection may occur with greater rise in serum IgG titres to CMV
fever). These viruses share a
symptoms ranging from moderate from paired sera.
characteristic ability to remain dormant
within the body over a long period. enlargement of the liver and spleen with Isolation of CMV from culture does not
jaundice, to a fatal illness. With necessarily imply recent infection as
Identification supportive treatment most infants with CMV may be excreted for months to
Clinical features CMV disease survive. However 80% to years following infection. Positive results
Primary CMV infection of children and 90% will have complications within the for CMV from laboratory investigations
adults may cause a mononucleosis first few years of life that may include should always be considered with clinical
syndrome clinically indistinguishable hearing loss, vision impairment and findings.
from that caused by the Epstein-Barr varying degrees of mental retardation.
virus (glandular fever). Features include Incubation period
Another 5% to 10% of infants who are
fever, lymphadenopathy and mild The incubation period of sporadic cases
infected but without symptoms at birth
hepatitis. More rare features include of CMV usually cannot be determined.
will subsequently have varying degrees of
anaemia, thrombocytopaenia, Perinatal infection develops three to
hearing and mental or coordination
pneumonitis, meningoencephalitis and twelve weeks after delivery. In adults,
problems.
Guillain-Barrè syndrome. Many infections illness usually occurs three to eight
are asymptomatic, particularly those in Immunosuppression weeks after blood transfusion and
young children. Other people at increased risk of severe between four weeks and four months
infection include patients with impaired after organ transplantation.
Pregnancy
immunity due to HIV/AIDS infection,
Healthy pregnant women are not at Public health significance
corticosteroid therapy, lymphoma or
special risk for disease from CMV and occurrence
sarcoidosis. In these people, disease is
infection but between 1% and 5% are Although infection with CMV is very
usually due to reactivation of previous
infected for the first time during their common around the world, symptomatic
infection. Manifestations include sight-
pregnancy. Many women will already disease is rare. The risk of severe or
threatening retinitis, pneumonitis,
have been exposed to CMV and so are complicated CMV infection is increased
gastrointestinal ulceration and
not at risk of a new infection during their in some groups including:
inflammation, and neurological disease
pregnancy.
particularly affecting the brain and spinal
cord.
44 The blue book: Guidelines for the control of infectious diseases

• the developing infant during pregnancy CMV is not readily spread by casual Women of childbearing age working in
• people with immunosuppression such contact but requires prolonged, intimate hospitals (especially obstetric and
as organ transplant recipients, people exposure for transmission. This can occur paediatric wards), child care centres and
infected with human immunodeficiency in settings such as child care centres preschools should practice strict
virus (HIV) and those being treated for where toddlers shed the virus in saliva infection control precautions and regard
cancer. and urine and thereby spread the all body fluids as potentially infectious.
infection among them. The CMV status of blood and organ
Serosurveys of adult populations
worldwide have shown wide-spread donors should be matched to that of
Period of communicability
evidence of previous CMV infection with recipients wherever possible. If CMV
CMV may be shed in the bodily fluids of
seropositivity rates ranging from 40% in seropositive donors must be used for
any previously infected person, and thus
highly developed countries to 100% in CMV seronegative recipients,
may be found in urine, saliva, blood,
developing countries. prophylactic use of hyperimmune
tears, semen and breast milk. The
immunoglobulin or antiviral drugs may be
The incidence peaks during the perinatal shedding of virus may take place
considered.
period with a secondary peak among intermittently for months to years after
young adults in areas where perinatal primary infection without any detectable Control of case
infection is less common. signs, and without causing symptoms. There is no specific treatment
recommended for primary CMV infection
Neonatal infection in particular is
Reservoir associated with prolonged excretion. The
of normal hosts.
Humans. period of excretion seems to be shorter Immunosuppressed persons with CMV
in adults. retinitis or pneumonitis are usually
Mode of transmission
treated in specialist centres with
CMV is excreted in urine, saliva, breast Susceptibility and resistance ganciclovir, foscarnet, or
milk, cervical secretions and semen Once a person becomes infected, the cidofovir/probenecid. These drugs may
during primary and reactivated infections. virus may remain dormant in their body also be of benefit for other complications
CMV may be transmitted by: for life (latent infection). Recurrent of CMV infection.
• transplacental infection of the foetus disease rarely occurs unless the person’s
Control of contacts
of a mother with primary or reactivated immune system is suppressed due to
None required because of the high
infection therapeutic drugs or disease.
prevalence of asymptomatic virus
• perinatal infection of neonates via shedders in the community.
Control measures
infective maternal cervical secretions
Preventive measures Control of environment
or breast milk
There is no vaccine available to protect Not applicable.
• blood transfusion or organ against CMV infection.
transplantation Outbreak measures
Public health measures focus on
• intimate exposure by mucosal contact Not applicable.
reducing the risk of CMV transmission to
with infective tissues, secretions or pregnant women, women of childbearing Additional sources of information
excretions. age and other people at risk of more • Centers for Disease Control and
serious infections. Prevention, Atlanta USA,
Cytomegalovirus infection,
http://www.cdc.gov/ncidod
The blue book: Guidelines for the control of infectious diseases 45

Dengue virus disease


Victorian statutory requirement Identification Laboratory evidence requires one of the
Dengue virus infection (Group B disease) Clinical features following:
requires notification within five days of Dengue fever (break bone fever) • isolation of dengue virus from clinical
diagnosis. Dengue fever classically presents as an material
School exclusion: case should be acute febrile illness of sudden onset. It is
• detection of dengue viral RNA in
isolated until the fever subsides to extremely debilitating with fever lasting
clinical material
prevent further mosquito bites. three to five days, myalgia (particularly
backache), arthralgia, retro-orbital pain, • a significant rise in the level of dengue
Infectious agent anorexia, gastrointestinal disturbance, virus specific IgG proven by
Dengue virus (DENV) has four related but rash and increased vascular permeability. neutralisation or another specific test
distinct serotypes: 1, 2, 3 and 4. There is a high subclinical rate of milder • dengue virus specific IgM in the CSF in
Dengue virus has been recognised since disease in children compared to adults the absence of IgM to Murray Valley
the latter part of the 18th century as and a low fatality rate. Recovery from encephalitis, Kunjin or Japanese
causing epidemics in tropical and infection with one serotype of the encephalitis viruses
subtropical parts throughout the world. dengue virus results in homologous
• dengue virus specific IgM in serum,
Dengue was first recognised in Townsville immunity but does not provide protection
except in north Queensland. In north
late in the 19th century and early in the against infection with other serotypes.
Queensland dengue virus specific IgM
20th century. Outbreaks occurred in an Dengue haemorrhagic fever in serum is acceptable evidence only
area from the coast of Western Australia Dengue haemorrhagic fever (DHF) is a when this occurs during a proven
to the Northern Territory and down severe complication of dengue virus outbreak.
through high rainfall areas of Queensland infection. It occurs mainly in children and
Confirmation of laboratory results by a
and New South Wales. At that time is characterised by abrupt onset of fever,
second arbovirus reference laboratory is
Aedes aegypti mosquitoes were widely haemorrhagic phenomena and
required if the case occurs in previously
distributed in northern Australia and thrombocytopaenia. In its severest form
unaffected areas of Australia. North
occurred as far south as the Victorian it may result in shock (dengue shock
Queensland is currently the only area
border in eastern Australia and south of syndrome [DSS]), which has a high
with the potential for indigenous
Perth in Western Australia. By the 1970s fatality rate. The rate of death from DHF
(epidemic) dengue fever in Australia.
Aedes aegypti were restricted to a small without DSS is usually quoted at 1–5%.
area of northern Queensland. Epidemic This is believed to be caused by immune Incubation period
dengue returned to north Queensland in enhancement when a person with The incubation period is usually short but
1981–82. Other outbreaks occurred dengue antibodies due to a previous varies from three to fourteen days.
there in the 1990s, a time when Aedes infection is subsequently infected by a
aegypti mosquitoes were spreading dengue virus of a different serotype. Public health significance
westwards from Queensland to the and occurrence
Northern Territory border and towards Method of diagnosis Dengue is not an endemic disease in
the New South Wales border. Dengue virus infection is diagnosed by a Australia and the outbreaks which have
significant rise in antibodies to the occurred have been due to importations
dengue virus serotype. of the virus by a viraemic tourist or
returning resident. It is important to
46 The blue book: Guidelines for the control of infectious diseases

rapidly diagnose the disease in returning Mode of transmission Control of case


residents and tourists to prevent local Dengue is transmitted by the bite of an Isolate the patient and prevent mosquito
spread in receptive areas. Spread or infected mosquito, particularly Aedes access until fever subsides.
introduction of Aedes aegypti from its aegypti. This was first recognised by Investigate the source of infection.
present distribution in Queensland must workers in Queensland early in the 20th
be closely monitored. Control of contacts
century. Aedes aegypti breeds in fresh
Not applicable.
Of great concern has been the repeated water and particularly in man made
detection of imported Aedes albopictus containers such as old tyres, pot plant Control of environment
mosquitoes into various parts of Australia holders, buckets and tree hollows in • Search for and eliminate breeding sites
dating from 1975 in Townsville. Since urban areas. Aedes albopictus is a of Aedes aegypti in the urban area.
then it has been detected at various mosquito common in South East Asia • Use mosquito repellents, mosquito
times and in various carriers on ships, in and Papua New Guinea and can also be nets and other methods of personal
machinery and in car tyres in South an important vector. Other Aedes species protection.
Australia, Perth and Darwin. In 1998 it are involved in the enzootic monkey
• Control Aedes aegypti near airports.
was trapped on a wharf in Cairns and cycle.
• Prevent importation of new vectors, for
similarly at West Melbourne in 2002.
Period of communicability example Aedes albopictus.
Preventing the introduction and
There is no evidence of person to person
establishment of Aedes albopictus Outbreak measures
transmission.
remains a high priority because this Not applicable.
mosquito has the potential to spread Susceptibility and resistance
widely over Australia including southern Infection with a serotype of dengue virus
areas. It can also transmit dengue and does not necessarily confer immunity.
other arboviruses.
Control measures
Reservoir Preventive measures
Humans are the only vertebrate hosts of There are effective vaccines available
the virus. There is a jungle cycle between against a number of the dengue virus
monkeys and mosquitoes, but this plays serotypes.
no role in human disease.
Dengue fever can be prevented by:
• mosquito control measures
• personal protection measures such as
long sleeves and mosquito repellents
• avoidance of mosquito-prone areas.
The blue book: Guidelines for the control of infectious diseases 47

Diphtheria
Victorian statutory requirement The characteristic lesion in the throat is Specimens for C. diphtheriae culture
Diphtheria (Group A disease) must be an adherent greyish-white membrane should be obtained from the nose and
notified immediately by telephone or fax that first occurs on the tonsils, but may throat and from any other suspicious
followed by written notification within five spread up onto the palate and involve lesions. Swabs should be obtained from
days. the pharynx and result in respiratory the pharyngeal membrane, or a portion
obstruction. of the membrane itself could be
School exclusion is relevant for cases
The onset is insidious with early submitted for culture.
and contacts:
symptoms of malaise, sore throat, Selective medium is required to culture
• Cases should be excluded until a
anorexia and low-grade fever. Patients C. diphtheriae so the testing laboratory
medical certificate of recovery is
with severe pharyngeal disease may should be notified that the disease is
received following at least two negative
develop neck swelling giving a clinically suspected. All isolates should
throat swabs. The first should be 24
characteristic ‘bull neck appearance’. be sent to a public health reference
hours or more after finishing a course
Systemic absorption of the toxin can laboratory for C. diphtheriae toxin
of antibiotics and the second 48 hours
result in neuropathy and cardiomyopathy, detection by polymerase chain reaction
later.
resulting in early death or later (PCR).
• Contacts should be excluded until neurological complications.
cleared to return by the Department of Incubation period
Laryngeal diphtheria can present as a
Human Services. The incubation period is two to five days
slowly progressive croup which can
but occasionally longer.
Infectious agent result in death if the airway obstruction is
Corynebacterium diphtheriae of the not relieved. Public health significance
gravis, mitis or intermedius biotypes is an Non-toxigenic strains of C. diphtheriae and occurrence
aerobic gram-positive bacillus. Toxin rarely cause local lesions but may cause Diphtheria occurs worldwide and is more
production results when the bacteria are infective endocarditis. prevalent in winter months in temperate
infected by a bacteriophage containing zones. Illness is now rare in highly
Cutaneous diphtheria presents with
the diphtheria toxin gene tox. immunised communities.
lesions of variable appearance but which
may resemble impetigo. An epidemic began in the Russian
Identification
Federation in 1990 involving all of the
Clinical features Non-cutaneous diphtheria has a case
countries of the former Soviet Union and
Diphtheria is an acute bacterial infection fatality rate of 5–10% with higher rates in
Mongolia. The epidemic has declined
caused by toxigenic strains of children under five years and adults over
after a peak in 1995 but was responsible
Corynebacterium diphtheriae. It primarily 40 years of age.
for over 140 000 cases and over 4000
affects the tonsils, pharynx, nose and
Method of diagnosis deaths. Over 70% of cases were aged 15
larynx. Other mucous membranes, skin,
Diagnosis is usually based on years or older.
and rarely the vagina or conjunctivae can
observation of the classical greyish-white
also be involved. The toxin causes local Diphtheria is now a very rare infection in
membrane overlying the tonsils or
tissue destruction and membrane Australia but may occur in unimmunised
pharynx.
formation. people who are recent travellers, or their
contacts. The last reported case in
48 The blue book: Guidelines for the control of infectious diseases

Victoria occurred in 1991. Importation of Control measures Diphtheria antitoxin should be given if
the infection from other affected Preventive measures there is strong clinical suspicion,
countries remains a concern in Australia Diphtheria vaccination is part of the immediately after specimens are taken
with the potential to affect unimmunised Australian Standard Vaccination and without waiting for laboratory
children and adults as well as adults with Schedule. Primary vaccination is confirmation. The dosage will depend on
waning immunity post-vaccination. achieved with three doses of a severity which is assessed by the extent
diphtheria-toxoid containing vaccine at of the pharyngeal membrane and
Reservoir two, four and six months of age. Booster duration of disease. Antitoxin can be
Humans are the usual reservoir and doses are currently recommended. They obtained from CSL Limited. Patients
carriers are usually asymptomatic. are given as DTPa at four years of age must be tested for hypersensitivity prior
and as adult/adolescent formulation to administration. Co-administration of
Mode of transmission
DTPa at 15 to 17 years of age. Prior to the antitoxin with corticosteroids may be
Transmission is droplet spread from the
8th birthday, DTP-containing vaccines recommended for patients with
respiratory tract. More rarely
should be used. After the eighth birthday, hypersensitivity to antitoxin.
transmission can occur from contact
smaller doses of toxoid Parenteral antibiotic treatment is usually
with articles soiled with discharges from
(adult/adolescent formulation DTPa or required initially and can be either
infected lesions.
DT-containing vaccines) should be given. erythromycin or benzathine penicillin.
Period of communicability Refer to the current edition of The These can be substituted for by
Transmission may occur as long as Australian immunisation handbook equivalent oral formulations once the
virulent bacilli are present in discharges (National Health and Medical Research patient can swallow comfortably. These
and lesions. The time is variable but is Council). should be continued to complete a total
usually two weeks or less and seldom Adults who have been fully vaccinated in of 14 days of treatment.
more than four weeks without antibiotics. the past should receive a booster dose of Natural infection with diphtheria does
Appropriate antibiotic therapy promptly adult tetanus-diphtheria vaccine (Td, not guarantee ongoing immunity. The
terminates shedding. The rare chronic ‘ADT’) at the age of 50 years unless a patient should begin or complete active
carrier may shed organisms for six booster dose has been documented in immunisation with an age-appropriate
months or more. the previous ten years. diphtheria toxoid-containing vaccine
Susceptibility and resistance For ‘catch-up’ diphtheria immunisation during convalescence.
Infants born of immune mothers are schedules for children and adults refer to Use standard precautions with additional
relatively immune, but passive immunity the current edition of The Australian respiratory precautions for pharyngeal
is usually lost by six months of age. immunisation handbook (National Health diphtheria and standard precautions with
and Medical Research Council). additional contact precautions for
Lifelong immunity is usually, but not
always, acquired after disease or Control of case cutaneous diphtheria, until the case is
inapparent infection. The management of cases involves shown to be clear of carriage.
diphtheria antitoxin, antibiotic therapy The disease is usually not highly
A primary course of toxoid vaccination
and infection control. Consult the current contagious after 48 hours of antibiotic
provides long lasting but not lifelong
version of Therapeutic guidelines: therapy.
immunity. Vaccinated individuals may
antibiotic (Therapeutic Guidelines
become colonised by C. diphtheriae in
Limited). Specialist infectious diseases
the nasopharynx while still being
advice should always be sought on
protected from clinical disease.
clinical suspicion of a case of diphtheria.
The blue book: Guidelines for the control of infectious diseases 49

Control of contacts For close contacts identified as diphtheria Additional sources of information
All close contacts of the case including carriers: • Gidding, HF, Burgess, MA, Gilbert, GL
all household contacts and other persons • ensure that prophylactic antibiotic 2000, ‘Diphtheria in Australia, recent
directly exposed to oral secretions from therapy has been given (as above for trends and future prevention
the case, should have swabs taken for close contacts) strategies’, Communicable Diseases
culture from their throat and nose. Intelligence, vol. 24, no. 6.
• exclude until two negative swabs, the
A prophylactic course of seven days of first not less than 24 hours after
oral erythromycin or a single dose of finishing the antibiotics and the other
procaine penicillin IM is recommended 48 hours later.
for close contacts. Such contacts should
If either of the repeat cultures is positive
also be kept under surveillance for seven
then an additional ten day course of
days, regardless of their immunisation
erythromycin or penicillin is
status.
recommended, followed by two repeat
Contacts are excluded from childcare cultures.
and school until cleared by the
Extensive swabbing to detect diphtheria
Department of Human Services. Other
carriers apart from close contacts is not
contacts are advised to exclude
recommended.
themselves from work and particularly
food handling, until bacteriologic Outbreak measures
examination shows they are not carriers Outbreaks of diphtheria require
of the organism. immunising the largest possible
Unvaccinated contacts should be proportion of the population involved,
commenced on their primary course of emphasising the need for protection of
vaccine. infants and preschool children. In
Vaccinated contacts should be given a outbreaks amongst adults immunise
booster injection of vaccine if more than groups that are most affected and at high
five years have elapsed since their last risk. Repeat immunisations may be
dose. recommended after one month.
Outbreak investigations involve
enhanced case surveillance with
laboratory confirmation of all suspected
cases, as well as the identification and
appropriate management of close
contacts and asymptomatic carriers (see
Control of contacts, above).
50 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 51

Donovanosis
Victorian statutory requirement Method of diagnosis Control of case
Donovanosis (Group C disease) requires The diagnosis is confirmed by First-line treatment for donovanosis is
written notification within five days of the demonstrating ‘Donovan bodies’ in azithromycin. Treatment should be
initial diagnosis. Wright or Giemsa-stained smears of directly observed. Follow-up is important
granulation tissue or by histological as resolution may be slow and
Specific information must be notified
examination of biopsy specimens. recurrence may occur.
under the Health (Infectious Diseases)
Regulations 2001. To maintain Control of contacts
Incubation period
confidentiality, only the name code (first Sexual contacts should be examined for
The incubation period is weeks to
two letters of the surname followed by possible infection. The likelihood of
months.
the first two letters of the first name) is transmission per act of unprotected
required. Public health significance intercourse is considered to be low and
and occurrence the likelihood of a long term partner
Medical practitioners have a statutory
Donovanosis is rare in industrialised being infected is low to moderate.
obligation under the Children and Young
countries but endemic in some tropical Contacts dating back weeks or months
Person’s Act 1989 to notify the
and subtropical countries and areas should be traced according to the sexual
Department of Human Services Child
including northern Australia. history.
Protection Service if they believe that a
child is in need of protection on the basis There have been no cases of Control of environment
of sexual abuse. donovanosis notified in Victoria since at Not applicable.
least 1992.
Infectious agent Outbreak measures
Previously known as Reservoir Not applicable.
Calymmatobacterium granulomatis, a Humans.
gram-negative bacillus, the causative Additional sources of information
agents is now named Klebsiella Mode of transmission • Australian Government Department of
granulomatis. Transmission is primarily sexual. It is Health and Family Services 1998,
possible that some cases are transmitted Contact tracing manual – a practical
Identification non-sexually. handbook for health care providers
Clinical features managing people with HIV, viral
Donovanosis is a chronic, progressively Period of communicability hepatitis, other STDs and HIV-related
destructive infection which affects the The period of communicability is tuberculosis.
skin and mucous membranes of the unknown but may be months to years.
• Carter, JS, Bowden, FJ, Bastian, I,
external genitalia, inguinal and anal Myers, GM, Sriprakash, KS, Kemp, DJ
Susceptibility and resistance
regions. Disseminated disease is 1999, ‘Phylogenetic evidence for
Everyone is susceptible to infection.
uncommon but may be life threatening reclassification of Calymmatobacterium
and so should be considered in patients Control measures granulomatis as Klebsiella
from endemic areas. It presents initially Preventive measures granulomatis’, International Journal of
as raised, ‘beefy’ nodules or sores. Preventative measures include education Systemic Bacteriology, vol. 49, pp.
Lesions may extend peripherally with about safe sex practices including use of 1695–700.
characteristic rolled edges. Local spread condoms and early detection of infection • Venereology Society of Victoria 2002,
to pelvic and abdominal structures by testing of people at risk. National management guidelines for
occurs and dissemination to distant sites
sexually transmissible infections,
can also occur.
Venereology Society of Victoria,
http://www.msch.org.au
52 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 53

Erythema infectiosum
(human parvovirus
infection or slapped
cheek disease)
Victorian statutory requirement Method of diagnosis Period of communicability
Notification and school exclusion are not Diagnosis can be suspected on clinical Children with erythema infectiosum are
required. grounds, particularly during outbreaks. most infectious before the onset of the
However, confirmation depends on rash and are probably not infectious after
Infectious agent demonstrating the presence of specific the rash appears.
The causative agent is human parvovirus IgM antibodies or seroconversion to
Patients with an aplastic crisis are
B19. specific IgG antibodies. Comparison of
infectious for a week after the onset of
the current antibody status against pre-
Identification symptoms.
natal screening serology for parvovirus is
Clinical features Immunosuppressed persons with chronic
often useful in pregnancy.
Asymptomatic infection with human anaemia due to infection may excrete
parvovirus B19 is common. Specific IgM antibody titres decline two
virus for years.
to three months after infection while IgG
In children it causes a mild illness with
levels, which appear two weeks after Susceptibility and resistance
little or no fever but a striking redness of
infection, can persist indefinitely. Infection generally confers immunity.
the cheeks, hence the alternative name
Nucleic acid (PCR) testing and electron Serological surveys suggest 5–15% of
of ‘slapped cheek disease’. There may
microscopy can also be used to confirm preschool children and 50–60% of all
also be a lacy pink rash on the trunk and
foetal infection. adults are immune.
limbs that fades within a week, but which
may recur over several weeks on Control measures
Incubation period
exposure to heat or sunlight. Headache, Preventive measures
The incubation period varies from four to
itch or common cold-type symptoms There is no vaccine available.
twenty days.
may also occur. In adults the rash is
often absent or atypical. They may have All people who are non-immune to
Public health significance parvovirus, immunosuppressed, have
cold-type symptoms and sometimes and occurrence
painful or swollen joints lasting two or chronic haemolytic disorders, or who are
Human parvovirus infection occurs
three days. pregnant are at increased risk of
worldwide and is a common childhood
complications.
Parvovirus affects the development of disease. Outbreaks occur during winter
red blood cells. As a result several and spring with epidemics occurring These people should be advised of the
groups of people are at increased risk of every three to four years. risk that parvovirus infection may pose to
developing complications: them. They should avoid close contact
Up to 50% of susceptible household
with children or adults in settings where
• infection in the first half of pregnancy contacts and 10–60% of child care or
parvovirus infection may occur such as
can cause foetal anaemia with hydrops school contacts may be infected during
schools, child care centres and health
foetalis. Foetal death occurs in less outbreaks.
care facilities.
than ten per cent of these cases
Reservoir Strict hand washing and separate eating
• persons with haemolytic anaemia may Humans. utensils are also advised for these
develop transient aplastic crises, often people.
in the absence of a rash Mode of transmission
• immunosuppressed persons may The virus is transmitted by contact with
develop severe chronic anaemia. infected respiratory secretions. It may be
spread vertically from mother to foetus
and rarely by transfusion of blood
products.
54 The blue book: Guidelines for the control of infectious diseases

Control of case
There is no specific treatment required
for uncomplicated infection.
Specialist advice should be sought if a
patient with immunodeficiency or a blood
disorder contracts parvovirus infection.
Control of contacts
Intrauterine infection may rarely result in
foetal hydrops or death if infection
occurs within the first 20 weeks of
pregnancy. Medical advice should be
sought for pregnant women who have
been in close contact with a case of
parvovirus infection. Specific antibody
testing should be performed to
determine the woman’s immune status
to parvovirus.
Control of environment
Not applicable.
Special settings
Patients and health care workers with
acute parvovirus infection should not
have contact with high risk hospitalised
patients such as pregnant women, the
immunosuppressed and those with a
chronic haemolytic anaemia.

Outbreak measures
General public health measures include:
• advising high risk persons of relevant
outbreaks
• advising patients and contacts to
observe strict hand washing after
coughing, sneezing and before eating.
Slapped cheek infection information sheet
for pregnant women
Also known as human parvovirus infection or erythema infectiosum

What is slapped cheek infection? How is it spread? How can I protect myself and my
Erythema infectiosum is also known as Parvovirus infection is spread by infected baby?
‘slapped cheek disease’ or ‘fifth disease’ respiratory secretions through coughing, Washing hands before eating or touching
and is a common childhood viral sneezing or touching something that has your face can help prevent infection.
infection caused by human parvovirus been coughed or sneezed on. About 50% Avoid sharing cutlery, cups and plates.
B19. Fifty to sixty percent of women are of non-immune people will become
immune to the virus by the time they infected if there is a case in their What action should I take if I
reach childbearing age. Occasionally, an household, less if the case is at school or think I have been exposed?
unborn baby of a non-immune mother child care. Cases are infectious before A pregnant woman who believes she has
can develop problems if infected before the onset of the rash and are probably been in contact with a case of parvovirus
the 20th week of pregnancy. not infectious after the rash appears. infection should consult the doctor
supervising her pregnancy even if she
The incubation period of the infection is
What are the symptoms? has no symptoms. Blood testing can
1 to 2 weeks.
Most cases experience no symptoms at assist doctors advising women who are
all. How can it affect my baby? pregnant of the risk, if any, which
In children the infection causes a mild The risk to unborn babies is low. Spread parvovirus infection poses. There is no
illness with little or no fever but a striking from mother to baby can only occur if the risk to a woman (or her baby) that already
redness of the cheeks (hence ‘slapped mother is not immune. Even if the has immunity.
cheek disease’). This may be mother is affected only one-third of If active infection is diagnosed,
accompanied by a lacy looking rash that babies will develop the infection ultrasound is performed every 1–2
fades within a week but can re-occur (generally about a month after the weeks to monitor the health of the baby.
over several weeks on exposure to heat mother’s illness). If there are signs the baby is having
or sunlight. Infection during the first 20 weeks of difficulty with severe anemia a blood
Adults often do not have a rash but may pregnancy can rarely cause a form of transfusion while the baby is still in the
have cold-type symptoms and/or painful anaemia (low blood count) in the baby. In womb may be considered.
or swollen joints over two to three days. many cases this resolves by itself but in
Further information
some instances it may require treatment.
• Your local doctor
Very rarely it can be fatal. Parvovirus
infection does not cause congenital • Better Health Channel,
abnormalities. www.betterhealth.vic.gov.au
• Victorian Department of Human
Services, 1300 651 160

Department of Human Services


www.health.vic.gov.au/ideas
Slapped cheek infection information sheet
Also known as human parvovirus infection or erythema infectiosum

What is slapped cheek infection? Who is at risk? Can my child attend day care or
Erythema infectiosum, also known as Several groups of people are at risk from school?
‘slapped cheek disease’ or ‘fifth disease’ the effects of parvovirus infection on Yes. As cases are infectious before the
is a common childhood viral infection developing red blood cells: onset of the rash and are probably not
caused by human parvovirus B19. Five to • people with chronic blood disorders infectious after the rash occurs there is
15% of preschool children and 50–60% of (for example, sickle cell disease) may no reason to exclude the child from
all adults are immune. develop severe anaemia (low blood school or day care once the rash
count) appears.
What are the symptoms?
Most cases experience no symptoms at • immunosuppressed people (for Further information
all. example those on chemotherapy, • Your local doctor
organ transplant recipients) may
In children the infection causes a mild • Better Health Channel,
develop chronic anaemia
illness with little or no fever but a striking www.betterhealth.vic.gov.au
redness of the cheeks (hence ‘slapped • occasionally, an unborn baby of a non-
• Victorian Department of Human
cheek disease’). This may be immune mother can develop problems
Services, 1300 651 160
accompanied by a lacy looking rash that if infected before the 20th week of
fades within a week but can re-occur pregnancy.
over several weeks on exposure to heat
or sunlight. Adults often do not have a How can I protect myself?
rash but may have cold-type symptoms Washing hands before eating or touching
and sometimes painful or swollen joints your face can help prevent infection.
over two to three days. Avoid sharing cutlery or cups and plates
with others.
How is it spread?
Parvovirus infection is spread by infected What action should I take if I
respiratory secretions (coughing, think I have been exposed?
sneezing, or touching something that has There is no specific treatment required
been coughed or sneezed on). About for uncomplicated infection. Specialist
50% of non-immune people will become advice should be sought if a person with
infected if there is a case in their immunodeficiency or a blood disorder
household, less if the case is at school or suffers parvovirus infection. A pregnant
child care. The incubation period of the woman who believes she has been in
infection is one to two weeks. Cases are contact with a case of parvovirus
infectious before the onset of the rash infection should consult the doctor
and are probably not infectious after the supervising her pregnancy even if she
rash appears. has no symptoms.

Department of Human Services


www.health.vic.gov.au/ideas
The blue book: Guidelines for the control of infectious diseases 57

Food or water-borne
illness
Victorian statutory requirement – Clostridium perfringens shellfish poisoning, botulism).
Two or more related cases of suspected – Campylobacter spp. Severity depends on host and agent
food or water-borne illness must be characteristics and the infectious dose.
– E. coli.
notified within 24 hours of diagnosis. Hospitalisation and death may occur due
– Helicobacter pylori to acute dehydration, metabolic acidosis
School exclusion: for most
gastrointestinal illnesses children should – Vibrio cholerae/V. parahaemolyticus and subsequent organ failure.
be excluded from school or childcare – Yersinia enterocolitica The duration of illness varies from hours
until at least the diarrhoea has ceased. (24–48 hours in viral and staphylococcal
– S.typhi/Paratyphi
infections) to days and even weeks in
Infectious and other causative – Brucella spp.
salmonellosis and campylobacteriosis.
agents – Listeria monocytogenes
The most frequent causes of food or Method of diagnosis
water-borne illnesses are various Diagnostic methods vary according to
bacteria, viruses and parasites. Refer to Viruses: the type of infective agent:
specific sections for detail on the more • Hepatitis A and E viruses • bacteria can be isolated from faeces or
common agents. blood or by detection of toxin
• Noroviruses and other small round
Non-infective agents: structured viruses (SRSV) • parasites can be isolated by
• heavy metal poisoning, including, microscopy of fresh or appropriately
• Rotavirus
cadmium, copper, lead, tin and zinc preserved faeces

• fish toxins that are present in some • viruses can be isolated by stool
shellfish or fish like paralytic shellfish Parasites: electron microscopy (EM), immune EM
poisoning or ciguatera • Cryptosporidium spp. or paired sera from patients to detect
seroconversion to a virus
• plant toxins which occur naturally in • Entamoeba histolytica
some foods such as toxic fungi and • chemicals can be isolated by
• Giardia lamblia
green potato skins serological detection of implicated
Identification compounds.
• toxic cyanobacteria (blue green algae)
overgrowth in water. Clinical features Advice regarding specific tests should be
Symptoms vary with the causative agent sought from laboratories with expertise
and range from slight abdominal pain and in the identification of gastrointestinal
Bacteria: nausea to retching, vomiting, abdominal pathogens and chemical agents.
• toxin produced in food: cramps, fever and diarrhoea. Fever, chills,
headache, malaise and muscular pains Incubation period
– Staphylococcus aureus Incubation periods are typically short for
may accompany gastrointestinal
– Clostridium botulinum symptoms. Vomiting, with or without toxin-producing bacteria and longer for
– Bacillus cereus diarrhoea, abdominal cramps and fever others.
are common symptoms of viral disease or
• damage to gut wall and/or systemic
staphylococcal intoxication. Certain food-
infection:
borne illnesses can present with
– Salmonella spp. meningitis or septicaemia (listeriosis) or
– Shigella spp. with neurological symptoms (paralytic
58 The blue book: Guidelines for the control of infectious diseases

Public health significance Susceptibility and resistance – protect food from insects, rodents,
and occurrence With most infections everyone is and other animals
Food and water-borne diseases are susceptible, however sporadic disease is – use pure water
thought to be the most common of all more often detected in young children,
Incorporation of HACCP (Hazard Analysis
acute illnesses. However a large the elderly or immunocompromised
Critical Control Point) systems is
proportion of disease is not detected, as people. This is in some part due to the
important for good manufacturing
many people will not seek health care health care seeking behaviours of those
practices for food industries.
with mild illness. Occurrence is caring for patients in these categories.
worldwide and the incidence varies from Vaccines are currently available for
country to country. In recent years the Control measures cholera and hepatitis A (refer to relevant
detection of outbreaks of viral origin, Preventive measures sections).
especially noroviruses, has been Prevention of the contamination of
Control of case
increasing. potable water is very important.
Control of the case ranges from
Contaminated water should be treated by
supportive treatment and rehydration to
Reservoir adequate filtration and disinfection or by
hospitalisation.
• Soil, dust, cereals boiling.
Cases due to infection need exclusion
• Bacteria and parasites: fish, birds, Avoiding contamination of food is also
from food handling, schools and
reptiles, wild and domestic animals important. This can be achieved by:
children’s services centres until after the
• Viruses: humans • providing raw materials of better diarrhoea has ceased.
microbiological quality
Mode of transmission Health care workers need exclusion if
• educating food handlers about proper employed in an area with high risk
Transmission is predominantly via the
food processing, preparation, storage patients, such as special care nurseries
faecal-oral route or ingestion of
and in personal hygiene or nursing homes, until after the
contaminated food and water sources.
Transmission via aerosols (produced • adopting the following ‘Ten golden diarrhoea has ceased.
during profuse vomiting) has been rules for safe food preparation’ Control of contacts
implicated in outbreaks involving viral developed by WHO: Control of contacts includes:
pathogens. – choose food processed for safety • prevention of further ingestion of
– cook food thoroughly contaminated food or water
Period of communicability
Communicable periods for food and – eat cooked food immediately • surveillance of contacts who are food
water-borne illnesses depend on the handlers if required
– store cooked food carefully
causative agents. Viruses are generally • withdrawal of implicated food (if in
communicable during the acute phase – reheat cooked food thoroughly
retail outlets) from sale.
and up to two days after recovery while – avoid contact between raw foods
Control of environment
bacteria are generally communicable and cooked foods
Investigate water sources or place of
during the acute diarrhoeal stage. For – wash hands repeatedly manufacture or preparation of
parasites refer to relevant sections in this
– keep all kitchen surfaces incriminated food and institute corrective
book.
meticulously clean action.
The blue book: Guidelines for the control of infectious diseases 59

Outbreak measures
Food and water-borne outbreaks are
usually detected following the onset of
illness in a group of people who have
shared a common meal. The primary
objectives of outbreak control are the
rapid identification of the causative agent
through epidemiological, environmental
and laboratory investigations and
prevention of further disease by
destruction or denaturation of the
source.
International measures
International outbreaks are increasingly
being recognised, primarily due to the
increased trade in food and agricultural
products worldwide. Food and water-
borne pathogens and contaminants have
been identified as potential biological
terrorism agents. Cases of rare diseases
like botulism should be investigated
immediately. Some diseases require
notification to the World Health
Organization, like cholera.
Quarantine of suspected sources or
halting international trade should be
coordinated through Food Standards
Australia New Zealand.

Additional sources of information


Food Standards Australia New Zealand,
http://www.foodstandards.gov.au
60 The blue book: Guidelines for the control of infectious diseases

Common food- or water-borne pathogens

Causative agent Incubation Duration of Predominant symptoms Foods commonly implicated


period illness
Bacteria
Campylobacter jejuni 1–10 days 2–5 days Sudden onset of diarrhoea, Raw or undercooked poultry, raw milk,
(usually 2–5 days) occasionally >10 days abdominal pain, nausea, vomiting raw or undercooked meat, untreated
water
E. coli 2–10 days 5–10 days Severe colic, mild to profuse bloody Many raw foods (especially minced
enterohaemorrhagic diarrhoea can lead to haemolytic beef), unpasteurised milk, contaminated
(STEC, VTEC) uraemic syndrome water
E. coli 12–72 hrs 3–14 days Severe colic, watery to profuse Many raw foods, food contaminated by
enteropathogenic (enterotoxigenic) diarrhoea, sometimes bloody faecal matter, contaminated water
enterotoxigenic
enteroinvasive
Salmonella serovars 6–72 hrs 3–5 days Abdominal pain, diarrhoea, chills, Raw or undercooked meat and chicken,
(non-typhoid) fever, malaise raw or undercooked eggs and egg
products
Salmonella Typhi/ Typhoid Days-weeks Systemic illness - sustained fever, Raw shellfish, salads, contaminated
paratyphi 8–14 days (chronic headache and constipation rather water
Paratyphoid asymptomatic than diarrhoea
1–10 days carriers can occur)
Shigella spp. 12–96 hrs 4–7 days Malaise, fever, vomiting, diarrhoea Foods contaminated by infected food
(blood & mucus) handlers and untreated water
contaminated by human faeces
Yersinia 3–7 days 1–21 days Acute diarrhoea sometimes bloody, Raw meat especially pork, raw or
enterocolitica fever, vomiting undercooked poultry, milk and milk
products
Vibrio cholerae A few hours to 3–4 days Asymptomatic to profuse painless Raw seafood, contaminated water
5 days watery diarrhoea, dehydration
Vibrio 4–30 hours 1–7 days Abdominal pain, diarrhoea, vomiting Raw and lightly cooked fish, shellfish,
parahaemolyticus (usually 12–24 hrs) and sometimes fever. Illness of other seafoods
moderate severity
Listeria 3–70 days Varies Gastrointestinal symptoms rare; Unpasteurised milk, soft cheese, pate,
monocytogenes flu-like symptoms to meningitis/ coleslaw, salads, ready to eat seafood,
septicaemia; infection in pregnancy cold meats, fresh fruit drinks
can result in abortions, neonatal
infection
Viruses
Norovirus (and 24–48 hrs 12–60 hrs Severe vomiting, diarrhoea Oysters, clams, foods contaminated by
other viral infected food handlers and untreated
gastroenteritis) water contaminated by human faeces
Rotaviruses 24–72 hrs Up to 7 days Malaise, headache, fever, vomiting, Foods contaminated by infected food
diarrhoea handlers and untreated water
contaminated by human faeces
Hepatitis A 15–50 days Usually 1–2 weeks Fever, nausea, abdominal Shellfish, foods contaminated by
discomfort, possibly jaundice infected food handlers and untreated
water contaminated by human faeces
The blue book: Guidelines for the control of infectious diseases 61

Common food- or water-borne pathogens continued

Causative agent Incubation Duration of Predominant symptoms Foods commonly implicated


period illness
Parasites
Cryptosporidium 1–12 days 4–21 days Profuse watery diarrhoea, Foods contaminated by infected food
abdominal pain handlers and untreated water
contaminated by human faeces
Giardia lamblia 1–3 weeks 1–2 weeks to months Loose pale greasy stools, Foods contaminated by infected food
abdominal pain handlers and untreated water
contaminated by human faeces
Entamoeba histolytica 2–4 weeks Weeks to months Colic, mucous or bloody diarrhoea Foods contaminated by infected food
handlers and untreated water
contaminated by human faeces
Toxin producing bacteria
B. cereus 1–6 hrs (vomiting) < 24 hrs Two known toxins causing nausea Cereals, rice, meat products, soups,
(toxin in food) or and vomiting or diarrhoea and vegetables
6–24 hrs cramps
(diarrhoea)
Clostridium 12–36 hrs Variable (Neurotoxin) Canned food, often home canned food
botulinum Blurred or double vision, difficulty (low acid)
swallowing, respiratory paralysis,
muscle weakness and lethargy
C. perfringens 6–24 hrs 24 hrs Sudden onset colic, diarrhoea Meats, poultry, stews, gravies, (often
(toxin in gut) inadequately reheated or held warm)
Staphylococcus 30 min – 8 hrs 24 hrs Acute vomiting, and cramps, may Cold foods (much handled during
aureus lead to collapse preparation) milk products, salted meats
(toxin in food)
Fish / shellfish toxins
Scombroid fish Few hours Up to 12 hours Tingling and burning around mouth, Fish such as tuna, mackerel, skipjack,
poisoning sweating, diarrhoea, vomiting, bonito, herring and sardines. Fish stored
(histamine poisoning) headache, dizziness at >5°C for extended periods
Ciguatera poisoning Less than 24 hours Weeks to months Numbness and tingling around Large tropical reef fish
mouth, diarrhoea, vomiting and
nausea followed by neurological
symptoms such as dizziness,
blurred vision and temperature
reversal.
Paralytic shellfish Minutes to Several days Burning and tingling around the Bivalve molluscs
poisoning (PSP) several hours mouth and extremities, nausea
dizziness, potentially muscle and
respiratory paralysis
Diarrhetic shellfish 30 mins – 2 hrs Hours to 3 days Diarrhoea, nausea, vomiting and Mussels, scallops and clams
poisoning (DSP) abdominal pain
62 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 63

Giardiasis
Victorian statutory requirement Public health significance Control measures
Giardiasis (Group B disease) must be and occurrence Preventive measures
notified in writing within five days of Occurrence is worldwide and endemic in Preventative measures include:
diagnosis. most regions. Over 800 cases are • educating families and personnel of
School exclusion: exclude cases from reported in Victoria each year. Infection day care centres in personal hygiene
child care and school until diarrhoea has is detected more frequently in children such as the need for hand washing
ceased or until a medical certificate of than adults. It is readily transmitted in before meals, after toilet use and
recovery is produced. institutions such as day care centres changing nappies
among children who are not toilet
• protecting public water supplies
Infectious agent trained. Other risk factors for infection
include travel to high risk areas, against faecal contamination
Giardia lamblia is a flagellate protozoan
which lives in the duodenum and immunosuppression, male to male sexual • educating travellers about the need for
jejunum. intercourse and achlorhydria. safe food and water consumption.
Control of case
Identification Reservoir
Symptomatic cases are usually treated
Clinical features Reservoirs include humans and animals
with metronidazole or tinidazole. Consult
Giardia infection is usually asymptomatic as well as contaminated waters.
the current version of Therapeutic
but may present as acute or chronic
Mode of transmission guidelines: antibiotic (Therapeutic
diarrhoea associated with abdominal
Transmission occurs person to person Guidelines Limited). Treatment of
cramps, bloating, nausea, vomiting, fever,
and animal to person via hand to mouth asymptomatic carriers is rarely
fatigue and weight loss. Fat
transfer of cysts from infected faeces or warranted.
malabsorption may lead to steatorrhoea.
Symptoms usually last one to two weeks faecally contaminated surfaces. Water- Dispose of faeces in a sanitary and
or months. The rate of asymptomatic borne outbreaks may occur due to faecal hygienic manner and disinfect soiled
carriage may be high. contamination of public water supplies or clothing and other articles concurrently.
recreational swimming areas.
Method of diagnosis School exclusion criteria apply until
Stool microscopy for cysts or Period of communicability diarrhoea has ceased or until a medical
trophozoites can be used for diagnosis of It is communicable for the entire period certificate of recovery is produced. Food
Giardia however a negative test does not of cyst excretion. handlers should not attend work until
preclude infection. diarrhoea has ceased and strict hygienic
Susceptibility and resistance food preparation practices should be
Incubation period Everyone is susceptible to infection. maintained.
The incubation period is usually one to Relapses may occur. It is also recommended that health care
three weeks but it can be longer. It is on workers or child care workers do not
average seven to ten days. attend work until diarrhoea has ceased.
64 The blue book: Guidelines for the control of infectious diseases

Control of contacts
The diagnosis should be considered in
symptomatic contacts. Active case
finding among contacts is rarely
indicated.
Control of environment
Disinfection of contaminated areas or
water sources is required. Particular
attention should be paid to potentially
contaminated surfaces in child care
centres.

Outbreak measures
Two or more related cases may indicate
an outbreak and requires prompt
reporting to the Department of Human
Services. Attempt to identify a potentially
common exposure such as child care
attendance or exposure to farm animals
and recreational swimming areas.
Epidemiological, environmental and
laboratory investigations may be
warranted as per the Department’s
Guidelines for the investigation of
gastrointestinal illness.
The blue book: Guidelines for the control of infectious diseases 65

Gonorrhoea
Victorian statutory requirement In females, an initial urethritis or cervicitis Co-infection with Chlamydia trachomatis
Gonorrhoea (Group C disease) must be occurs a few days after exposure. It is sometimes occurs, particularly in
notified in writing within five days of frequently mild and passes unnoticed. imported cases. Screening for other
diagnosis. Females may have abnormal vaginal sexually transmissible infections such as
discharge and post-coital bleeding. Later, chlamydia should be considered when
Specific information must be notified
pelvic inflammatory disease may testing for N. gonorrhoeae.
under the Health (Infectious Diseases)
develop. Pelvic inflammatory disease
Regulations 2001. To maintain Incubation period
may cause ectopic pregnancy, infertility
confidentiality, only the name code (first The incubation period is usually two to
or chronic pelvic pain.
two letters of the surname followed by seven days.
the first two letters of the first name) is Conjunctivitis can occur in neonates and
required. A questionnaire is sent to the rarely in adults. It may cause blindness if Public health significance
diagnosing doctor to collect additional not rapidly and adequately treated. and occurrence
information on the case that is essential Septicaemia and septic arthritis are rare Gonorrhoea is common worldwide and
for detecting disease trends and complications. affects both sexes. Infection may be
informing policy development. symptomatic or asymptomatic. Infections
Method of diagnosis
Medical practitioners have a statutory of the cervix, anus and throat usually
Swabs taken from the urethra, cervix,
obligation under the Children and Young cause no symptoms. Gonorrhoea can
pharynx, rectum or other site should be
Person’s Act 1989 to notify the have acute and chronic sequelae.
rolled onto a slide first and then sent to
Department of Human Services Child the laboratory in an appropriate Strains of gonococci resistant to
Protection Service if they believe that a transport medium. penicillin are common and widespread.
child is in need of protection on the basis Resistance to fluoroquinolone antibiotics
The following tests can be performed on
of sexual abuse. such as ciprofloxacin is common among
swabs and smears taken from the site of
isolates from infections acquired in Asia.
Infectious agent infection:
Ciprofloxacin resistance in gonococcal
Neisseria gonorrhoeae • Gram stain on discharges smeared on isolates in Victoria is increasing.
the slide.
Identification Gonorrhoea may increase susceptibility
Clinical features • culture on both selective and non- to the sexual acquisition of HIV infection
Infections with N. gonorrhoeae may selective media should be used. and increase HIV infectiousness.
present with a number of clinical Culture of N. gonorrhoeae provides
Other serious complications such as
syndromes. definitive diagnosis, and isolates
blindness from neonatal conjunctival
provide valuable information on
The most common presenting symptom infection and the various complications
patterns of antibiotic resistance and
in males is a painful purulent urethral of pelvic inflammatory disease are
other epidemiological markers.
discharge. If left untreated, complications currently rare in Victoria. The rate of
may include epididymitis, prostatitis and • nucleic acid testing can be performed notified cases of gonorrhoea increased in
urethral stricture. Anorectal infection is on cervical and urethral swabs and Victoria in the late 1990s to a level not
more common in homosexual males and urine. In women, PCR testing of urine is seen since the mid 1980s. The increase
is usually asymptomatic. It may cause less sensitive than PCR testing on involved men who have sex with men
pruritis, tenesmus and discharge. endocervical swab specimens. In who comprised approximately two thirds
Pharyngeal infection is usually cases diagnosed by PCR, further of cases, and also heterosexual men. A
asymptomatic. specimens should be obtained if similar phenomenon was noted
possible for culture to allow monitoring elsewhere in Australia and overseas. This
of antibiotic resistance. increase has been sustained in Victoria.
66 The blue book: Guidelines for the control of infectious diseases

Reservoir Control of case Additional sources of information


Humans. Ceftriaxone plus azithromycin or • Australian Government Department of
doxycycline (to cover co-existing Health and Family Services 1997,
Mode of transmission chlamydial infection), are used to treat Contact tracing manual – a practical
Gonorrhoea is transmitted by contact gonorrhoea. Ciprofloxacin can be used handbook for health care providers
with exudates from mucous membranes as an alternative to ceftriaxone when a managing people with HIV, viral
of infected people, almost always as the sensitive strain has been identified. hepatitis, other STDs and HIV-related
result of sexual activity. Advice on the clinical management of tuberculosis.
Gonococcal conjunctivitis can occur in patients with gonococcal infection can
• Centers for Disease Control and
neonates who have had contact with the be found in Therapeutic guidelines:
Prevention 2002, ‘Sexually transmitted
mother’s infected birth canal during antibiotic (Therapeutic Guidelines
diseases treatment guidelines 2002’,
childbirth. Limited) and the National management
Morbidity and Mortality Weekly Report,
guidelines for sexually transmissible
vol. 51 (RR06), pp.1–80,
Period of communicability infections (Venereology Society of
http://www.cdc.gov/mmwr
Communicability may extend for months Victoria, 2002).
in untreated individuals. • Crotchfelt, KA, Welsh, LE, DeBonville,
Specialist consultation should be sought
D, Rosenstraus, M & Quinn, TC 1997,
Susceptibility and resistance for complicated or disseminated
‘Detection of Neisseria gonorrhoeae
Everyone is susceptible to infection. infections and for infection during
and Chlamydia trachomatis in
pregnancy.
genitourinary specimens form men and
Control measures Control of contacts women by a co-amplification PCR
Preventive measures Sexual partners of individuals with assay’, Journal of Clinical Microbiology,
Preventative measures include education gonorrhoea should be examined and vol. 35, no. 6, pp. 1536–40.
about safe sex practices including use of investigated then treated empirically.
condoms and early detection of infection • Fleming, DT & Wasserheit, JN 1999,
Contact tracing assistance can be ‘From epidemiological synergy to
by testing of those at risk.
provided by the Department’s partner public health policy and practice: the
notification officers (03) 9347 1899. contribution of other sexually
Control of environment transmitted diseases to sexual
Not applicable. transmission of HIV infection,’ Sexually
Transmissible Infections, vol. 73, pp.
Outbreak measures 3–17.
Not applicable. • Venereology Society of Victoria 2002,
National management guidelines for
sexually transmissible infections,
Venereology Society of Victoria,
http://www.msch.org.au
The blue book: Guidelines for the control of infectious diseases 67

Haemophilus influenzae
infections
Victorian statutory requirement • detection of Hib antigen in CSF when obstruction resembling croup. Other
Suspected and confirmed Haemophilus other laboratory parameters are previously rare bacterial causes of
influenzae type B (Hib) infections (Group consistent with bacterial meningitis, epiglottitis may now be more likely
A disease) must be notified immediately and when there has been no Hib diagnoses.
by telephone followed by written vaccination within 21 days of onset. Immunosuppressed individuals of any
notification within five days. • Body fluids and urine may give positive age remain at risk from Hib infection.
antigen reactions for Hib for up to 21 Asplenic patients are at greater risk of
Infectious agent
days after vaccination. infection if they have not been
Haemophilus influenzae is a gram-
appropriately immunised.
negative coccobacillus. Invasive Incubation period
infections are commonly caused by The incubation period is uncertain. It is Reservoir
serotype B. probably two to four days. Humans.

Identification Public health significance Mode of transmission


Clinical features and occurrence Hib is transmitted person to person
Meningitis Prior to the introduction of Hib vaccine to through respiratory droplet spread and
The onset can be sub-acute or sudden the routine immunisation schedule in may also be rarely acquired through
with fever, vomiting, lethargy and 1993, Hib disease was the most common contact with infected respiratory
meningeal irritation with a bulging serious invasive bacterial infection in discharges.
fontanelle in infants and stiff neck and children. At this time at least 500 cases
back in older children. of Hib disease annually in Australian in Period of communicability
Epiglottitis children less than six years of age. There Hib is communicable for as long as the
The patient is usually a child and were 10–15 deaths per year and 20–40% organisms are present in the
presents with signs of upper respiratory of survivors were left with permanent nasopharynx. Patients are no longer
tract obstruction and a characteristic neurological damage. infectious once they have received 24 to
expiratory snore, difficulty in swallowing 48 hours of appropriate antibiotic
Indigenous children were at five to six
with drooling of saliva, irritability, therapy.
times greater risk of developing Hib
restlessness and fever. Progression of disease and acquired it at a much Susceptibility and resistance
the infection can lead to complete younger age than non-indigenous Sustained immunity is conferred through
respiratory obstruction. children. immunisation or prior infection. Maternal
H. influenzae type b infection may also By 1998 the number of notified cases in antibody provides passive immunity for a
cause other diseases such as Australia had reduced by more than 90%. variable time period after birth.
pneumonia, septic arthritis, cellulitis and The number of notified cases has Infection does not always result in
osteomyelitis. continued to fall. Invasive Hib disease is immunity. This is particularly evident in
Method of diagnosis now only very rarely seen in Victorian children less than two years of age who
Clinical diagnosis is confirmed in the children. There has been no evidence of are unable to mount an antibody response
laboratory by: a shift in Hib cases to older age groups. to the type b capsular polysaccharide,
• isolation of Hib from a normally sterile Hib epiglottitis may still occur, even following invasive disease.
site such as blood or cerebrospinal particularly in adults and unimmunised Most secondary cases among close
fluid, typing should be confirmed by an children. This diagnosis should still be contacts occur within the first week after
approved reference laboratory considered when a person presents with exposure, though late secondary cases
fever and signs of upper respiratory have been reported.
68 The blue book: Guidelines for the control of infectious diseases

Control measures These antibiotics do not clear Hib from In either setting, all persons in the same
Preventive measures the nasopharynx. Rifampicin should be household should receive
Routine childhood immunisation remains given to cases prior to discharge from chemoprophylaxis and inadequately
the most important preventive measure hospital to ensure clearance of the vaccinated children should receive age
against Hib disease. Hib vaccine is organism. If the treated patient is less appropriate Hib vaccination.
recommended as part of the Australian than two years of age and has not been Child care
Standard Vaccination Schedule for all immunised, a course of Hib vaccine If the case attends a child care facility for
children at two, four and 12 months of should still be given after discharge from more than 18 hours a week and other
age and for older persons with asplenia. hospital. children less than two years of age in this
Refer to the current edition of the Respiratory isolation procedures are facility are in close contact,
Australian immunisation handbook recommended for 24 hours after the start chemoprophylaxis should be given to all
(National Health and Medical Research of treatment. contacts including staff if any of the
Council) for further details. close contacts are inadequately
Concurrent or terminal disinfection of
Before and after splenectomy possibly contaminated items is not vaccinated.
Hib is an uncommon cause of post- generally required. Chemoprophylaxis does not eliminate
splenectomy sepsis in adults and the need for surveillance and parents of
Control of contacts
children. Children over two years of age contacts should be advised of the risk of
Unvaccinated contacts less than five
who are fully immunised do not require a late secondary cases despite
years of age should be immunised as
Hib booster following splenectomy. A prophylaxis.
soon as possible.
single dose is recommended for any
Household contacts Chemoprophylaxis
other individuals (regardless of age) if
Parents of confirmed cases should be Decisions about the use and advice
incompletely or unvaccinated who have
educated about the risks of secondary about contra-indications, dosing and
close contact with children less than five
cases in siblings and other close supply of rifampicin for chemoprophylaxis
years. No booster doses are required.
contacts under five years of age, and should always be made in consultation
If possible the vaccine should be given at with the Department of Human Services.
seek early medical review if any close
least two weeks before splenectomy. For adverse effects and contra-
contacts develop symptoms consistent
Control of case with Hib disease. indications to rifampicin, see section on
Intravenous cefotaxime or ceftriaxone meningococcal disease.
Chemoprophylaxis (see below) is
may be used for empirical therapy until Control of environment
indicated for household contacts only if:
antibiotic sensitivities are known. See Outbreak measures, below.
Consult the current version of • the household of a case contains one
Therapeutic guidelines: antibiotic or more infants under seven months of Outbreak measures
(Therapeutic Guidelines Limited) and age regardless of vaccination status, or Outbreaks of Hib are now rare. The
seek expert infectious disease advice. • the household of a case contains one public health response to a cluster of Hib
or more children aged seven months to cases is based on the control principles
five years who are not age- outlined above in Control of contacts,
appropriately immunised against Hib which may require expansion in the
according to the current Australian extent of contact surveillance,
Standard Vaccination Schedule. chemoprophylaxis and vaccination.
The blue book: Guidelines for the control of infectious diseases 69

Hand, foot and mouth


disease
Victorian statutory requirement Public health significance Control of case
Notification is not required. and occurrence Control of the case includes:
School exclusion is required until all Hand, foot and mouth disease occurs • exclusion from school of children with
blisters have dried. worldwide sporadically and in epidemics. hand, foot and mouth disease until all
The greatest incidence is in summer and blisters have dried
Infectious agent early autumn. Outbreaks occur
• covering lesions on hands and feet if
Coxsackievirus group A, mainly type 16, frequently among groups of children in
possible and allowing to dry naturally
is the infectious agent. child care centres and schools.
• avoiding piercing lesions as the fluid
Human hand, foot and mouth disease is Reservoir within the blisters is infectious
unrelated to the foot and mouth disease Humans.
of animals (caused by members of the • good hand washing, cleaning and
family Picornaviridae). Mode of transmission disposal of soiled articles.
HFMD is transmitted by direct contact Control of contacts
Identification with fluid from the vesicular lesions, Not applicable.
Clinical features direct contact with nose and throat
Hand, foot and mouth disease (HFMD) discharges and faeces of an infected Outbreak measures
occurs mainly in children under ten years person, and aerosol droplet spread. Not applicable.
of age and in young adults. Symptoms
and lesions usually persist for seven to Period of communicability
ten days. It is communicable during the acute
The clinical picture consists of sore stage of disease from nose and throat
throat, fever and vesicular lesions on the secretions and as long as there is fluid in
buccal surfaces of the cheeks, gums and the lesions. Viruses persist in the stools
sides of the tongue. for several weeks.

Papulovesicular lesions of the palms, Susceptibility and resistance


fingers and soles commonly occur. Everyone is susceptible to infection.
Occasionally maculopapular lesions Immunity to the specific virus may be
appear on the buttocks. acquired due to previous infection.
Method of diagnosis Second attacks may occur with group A
Diagnosis of HFMD is usually clinical. coxsackievirus of a different serotype.
Viral isolation from nasopharyngeal or
stool specimens is possible but rarely Control measures
indicated. Preventive measures
Not applicable.
Incubation period
The incubation period is from three to
seven days.
Hand, foot and mouth disease information sheet
What is hand food and mouth Signs and symptoms • using separate eating and drinking
disease? People usually develop symptoms utensils.
Hand foot and mouth disease is caused between three to seven days after being Children with hand, foot and mouth
by a virus (usually coxsackie virus A16). infected. disease should be excluded from school
It causes blisters on the hands and feet, The most common signs and symptoms and child care centres until all the
in the mouth and often in the ‘nappy’ are: blisters have dried.
area. • a high temperature (fever) How do you treat hand foot and
It is generally only a mild disease that • a sore throat mouth disease?
lasts seven to ten days. There is no specific treatment for hand,
• small, blister-like lesions that may
It is more common during warmer occur on the inside of the mouth, sides foot and mouth disease.
weather and tends to spread easily of the tongue, palms of the hands, Use paracetamol (not aspirin) as directed
between children. fingers, soles of the feet and ‘nappy’ for fever and any discomfort.
This infection is spread by direct contact area. The disease itself is generally mild. If a
with fluid from the skin blisters, nose and child with hand, foot and mouth disease
throat discharges, droplets (sneezing, How long is it infectious?
complains of severe headache, if fever
coughing) and faeces (stools). Good The skin blisters of hand, foot and mouth
persists, or if there are any other
personal hygiene is important to prevent disease are infectious until they become
worrying symptoms consult your local
spread of the infection to others. crusty and there is no fluid in the blisters.
doctor immediately.
The virus may also be shed in the faeces
There is no connection between this
for several weeks after the blisters Further information
disease and the foot and mouth disease
resolve. • Your local doctor
that affects cattle and some other
animals. Good personal hygiene is essential to • Better Health Channel,
prevent the spread of hand, foot and www.betterhealth.vic.gov.au
Who gets hand, foot and mouth mouth disease to others, both for those
disease? infected and their carers. This includes: • Victorian Department of Human
Most people have been infected with the Services, 1300 651 160
• washing hands carefully after contact
virus which causes this disease by the with the blister-like lesions, after
time they are adults. So it is generally handling nose and throat discharges,
just a small percentage of children who and after contact with faeces such as
get features of disease after infection. with nappy changing
• allowing blisters to dry naturally. Do
not pierce blisters, as the fluid within is
infectious

Department of Human Services


www.health.vic.gov.au/ideas
The blue book: Guidelines for the control of infectious diseases 71

Hendra and Nipah


viruses
Victorian statutory requirement Incubation period Malaysia and Singapore.
Notification is not required however any The incubation period varies from four No human or animal cases of Hendra or
new case of these emerging infections to18 days and rarely up to three months Nipah viral disease have been detected
should be discussed with the (Hendra virus). in Victoria.
Department of Human Services as a
matter of urgency. Public health significance Reservoir
and occurrence Fruit bats (Pteropus spp.) are the primary
School exclusion is not required.
Hendra and Nipah viruses are recently reservoir for both viruses and appear to be
Infectious agent recognised zoonotic viral diseases. asymptomatic carriers. Horses are the
Two distinct, but closely related RNA Hendra virus appears to have emerged most likely intermediary host in human
viruses of the family Paramyxoviridae: from fruit bats in Australia. Horses are infection for Hendra virus although other
Hendra virus which has so far only been the intermediary host most commonly species such as cats show serological
detected in Queensland, and Nipah virus associated with human infection. The evidence of exposure.
which has been confined to the Malay first described outbreak of Hendra virus
Pigs are the most likely intermediary host
Peninsula. infection occurred in the Brisbane
for Nipah virus although seropositive
suburb of Hendra in 1994, involving 21
horses and dogs have been identified.
Identification horses (14 fatal cases) and two of their
Clinical features human handlers (one fatal case). A Mode of transmission
Both viral diseases may cause acute smaller outbreak occurred in 1995 The mode of transmission is unknown
infection with a variety of symptoms involving two horses and a farmer from although a respiratory route is
including fever, headache, shortness of the northern Queensland town of suspected. Human infection has been
breath, dizziness, drowsiness and Mackay. most commonly associated with direct
confusion. Two of the three recorded The presumed reservoir for Hendra virus is contact with infected horses (Hendra) or
cases of Hendra virus in humans were the fruit bat, the Australian flying fox infected pigs (Nipah). Symptomatic
fatal. One death was due to septic (Pteropus spp.), which appears to be an infections also occur in cats and other
pneumonia while the other was due to asymptomatic host. A 20% seropositive animals. Both viruses have been isolated
severe encephalitis. rate to Hendra virus has been found from the urine of infected bats and other
In clinical cases of Nipah virus infection among Pteropus bats in Queensland. infected animals.
encephalitis is the major manifestation, Wildlife workers who frequently come in to
often leading to coma and death in three contact with Australian bats have very low Period of communicability
to thirty days. The case fatality rate for seropositive rates. There is no evidence of person to person
clinical cases approaches 50%. The transmission.
Nipah virus (named after the Baru Sungai
frequency of subclinical infections is Nipa village in Malaysia) is closely related Susceptibility and resistance
unknown. to Hendra virus. Nipah virus may also Unknown.
Method of diagnosis have emerged from fruit bats. Pigs are
The diagnosis can be made by the the most common intermediary host Control measures
detection of specific neutralising IgM and associated with human infection. The Preventive measures
IgG antibodies to either virus. Testing is virus was first identified in 1999 during In an outbreak setting the public should
available through the CSIRO Australian the investigation of an outbreak in be advised to avoid contact with possible
Animal Health Laboratory at Geelong. several pig-farming provinces on the animal sources, particularly bats.
The diagnosis can also be confirmed by Malay Peninsula. The outbreak began in Control of case
virus isolation from infected tissues. 1998 and resulted in 265 confirmed Treatment is primarily supportive as
human cases with 105 deaths in there is no proven specific treatment. An
72 The blue book: Guidelines for the control of infectious diseases

uncontrolled trial of the antiviral drug Measures could include:


ribavirin has suggested it may reduce the • appropriate protective equipment and
mortality in Nipah virus encephalitis. hygiene practices for animal handlers
Expert treatment advice should be and investigators on implicated farms
sought from an infectious diseases or properties
physician.
• slaughter of infected horses, pigs, or
Control of contacts other animals with burial or
No person to person transmission has incineration of carcasses
been observed.
restriction of movement of horses or pigs
Control of environment from infected farms or designated areas.
See Outbreak measures, below.
International measures
Outbreak measures Prohibition of export of animal products
A single confirmed case of either of from affected areas.
these emerging viral infections would
constitute an outbreak. Additional sources of information
Case investigation determines the likely • McCormack, JG, Allworth, MA 2002,
source of infection through a detailed ‘Emerging viral infections in Australia,’
history of the patient’s work and travel Med J Aust, vol. 177, pp. 45–49.
history. • Patterson, DL, Murray, PK,
Further cases may be identified through McCormack, JG 2000, ‘Zoonotic
active case finding amongst close disease in Australia caused by a novel
contacts with similar exposure, as well as member of the Paramyxoviridae’, Clin
animal source detection if the infection Infect Dis, vol. 27, pp. 112–8.
was acquired in Australia.
In the event of a case being linked to
exposure in Victoria or elsewhere in
Australia, the Department would work
closely with relevant animal health
authorities and scientists to control
possible sources of infection.
The blue book: Guidelines for the control of infectious diseases 73

Hepatitis A
Victorian statutory requirement Incubation period Period of communicability
Hepatitis A infection (Group B disease) The incubation period is fifteen to fifty Cases are most infectious from the latter
must be notified in writing within five days, with an average of 28–30 days. half of the incubation period until a few
days of diagnosis. days after the onset of jaundice,
Public health significance corresponding to a peak in transaminase
School and child care exclusion are
and occurrence levels in cases without jaundice. Most
outlined below (see Control measures).
Hepatitis A occurs worldwide. In cases are not infectious after the first
Infectious agent developing countries most people are week of jaundice. Long term carriage or
Hepatitis A virus (HAV) is the causative infected during childhood. With good excretion of the virus does not occur.
agent. sanitation and hygiene in the developed
world, most people now reach adulthood Susceptibility and resistance
Identification without experiencing infection. There are All non immune people are susceptible
Clinical features about 70–200 cases per year in Victoria. to infection. Immunity after infection is
Illness due to hepatitis A typically causes Notifications have been declining probably lifelong.
acute fever, malaise, anorexia, nausea nationally since the late 1990s. Infection
and abdominal discomfort. This is is more common in travelers to endemic Control measures
followed a few days later by dark urine areas, injecting drug users, children in Preventive measures
and jaundice. Symptoms usually last childcare and men who have sex with Education about good hygiene is
several weeks although convalescence men. important, particularly hand washing
may sometimes be prolonged. Severe before handling food and eating and after
Common source outbreaks due to
illness may rarely occur when hepatitis A using the toilet. Inadequate sanitation
contaminated food are rare.
infection complicates pre-existing liver and housing may contribute to endemic
disease. Infants and young children Reservoir illness.
infected with HAV may have a mild Humans. Inactivated hepatitis A vaccines are
illness with few or no symptoms, with available for use in persons two years of
jaundice often being absent. Mode of transmission age and over. Protection begins within
Infection is transmitted by the faecal-oral 14–21 days after the first dose. A second
Method of diagnosis
route from person to person or via dose is required for long term protection.
A blood test indicating IgM anti-HAV
fomites. Infectious food handlers may The vaccine is recommended for
antibodies confirms recent infection.
contaminate non-cooked foods such as travellers to high risk areas, persons in
These antibodies are present for two to
salads. high risk occupations such as childcare
four months after infection. IgG
antibodies alone are evidence of past Infection can also occur through workers and emergency services
infection. ingestion of contaminated food or water. personnel, injecting drug users and men
Filter-feeding shellfish such as oysters who have sex with men.
In the acute stage of the illness, blood
raised in contaminated waters may Control of case
biochemistry shows elevated
harbour the virus. Treatment is generally supportive.
transaminase levels indicating
hepatocellular damage. The pattern of The precise timing and mode of Exclude from childcare, school or work
liver function tests may be non-specific transmission are often difficult to define. for at least one week after the onset of
in later illness. illness or jaundice and until they are well.
74 The blue book: Guidelines for the control of infectious diseases

Children must have a medical certificate Surveillance of contacts in a household and consideration given to the provision
of recovery before returning to school or or workplace should be maintained. of IG prophylaxis for co-workers and
child care. Live vaccines such as Measles Mumps patients in their direct care whilst
Educate the patient and their family on Rubella (MMR) should not be infectious. Surveillance of contacts in the
the need for strict hygiene practices. administered for three months after a health care facility should be maintained.

Infected persons should not prepare dose of IG, and may also be ineffective if Control of environment
meals for others while infectious, nor given in the 14 days prior to IG. A source of infection should always be
share utensils, toothbrushes, towels and Reschedule such routine vaccinations. sought. For apparently sporadic cases,
face washers. When the case is a food handler: consider contact with another known
case and recent travel to an area where
Dispose of or thoroughly wash nappies of • consider serological testing of co- the disease is endemic. Acquisition of
infants that have hepatitis A. workers to determine whether they infection from young children, particularly
Control of contacts have been infected or are susceptible those in childcare should be considered.
Normal immunoglobulin (IG) 0.02 mL/kg • place uninfected susceptible co- Special attention should be given to
body weight intramuscularly is workers under surveillance and give toilet hygiene in schools and childcare
recommended for: them IG prophylaxis. These persons centres. Ensure that soap and water are
• household and sexual contacts of the remain at a risk of developing mild available and are used regularly to wash
case illness modified by IG but can generally hands.
continue to work provided good
• staff and children in close contact with personal hygiene and food handling Food premises, health care facilities or
a case in a childcare centre. practices are maintained child care centres where a case has
IG is not recommended for usual office, worked whilst potentially infective should
• undertake surveillance for hepatitis A be requested to carry out a clean up in
school or factory contacts. IG must be in patrons by seeking a history of
given within seven to ten days of accordance with the Department’s
exposure to the food premises from Guidelines for the investigation of
exposure to be effective. IG is rarely cases notified over the next two to
given to persons exposed to a potential gastrointestinal illness.
three months
common source of hepatitis A such as
• carefully consider the role of the Outbreak measures
food or water because cases related to
infected food handler. If transmission to Clusters of cases possibly related to a
such a source are usually recognised too
patrons appears likely, consider urgent single source will require epidemiological
long after the exposure for IG to be
follow-up of exposed patrons to offer and environmental investigation,
effective. Timely administration of IG will
them IG prophylaxis. Note that when including case finding and surveillance
prevent or modify clinical illness for
the index case is a patron, it is usually and public health measures to prevent
approximately six weeks after the dose.
too late to offer IG prophylaxis to other further cases.
However, people exposed and infected
before the administration of IG may still diners, although personal contacts of Use of the hepatitis A vaccine in an
experience a mild infection, and may the patron case should be offered IG outbreak setting is dependent on rapid
have the potential to infect others if strict according to the usual protocol. identification of the outbreak and
personal hygiene is not maintained. When the case is a health care worker, persons at risk, and the ability to achieve
the role of the case should be assessed high vaccine coverage levels.
The blue book: Guidelines for the control of infectious diseases 75

Hepatitis B
Victorian statutory requirement Serology for newly acquired infections • detection of HBV DNA and high levels
Hepatitis B infection (Group B disease) requires one of the following: of specific IgM to hepatitis B core
must be notified in writing within five • detection of HBsAg in a patient shown antigen (IgM HBcAg) in the absence of
days of diagnosis. to be negative within the last 24 prior evidence of HBV infection.
School exclusion is not applicable. months Serology for chronic carriers requires:
• detection of HBsAg and high levels of • detection of HBsAg or HBV DNA in the
Infectious agent
specific IgM to hepatitis B core antigen serum of a patient on two occasions at
Hepatitis B virus (HBV) is the causative
(IgM HBcAg) in the absence of prior least six months apart.
agent.
evidence of HBV infection The following table summarises the
Identification interpretation of hepatitis B virus
Clinical features serology.
Less than 10% of children and only
30–50% of adults with acute HBV Tests Results Interpretation

infections will have icteric disease. The HbsAg negative


onset is usually insidious with anorexia, anti-HBc negative susceptible – discuss vaccination
anti-HBs negative
abdominal discomfort, nausea, vomiting,
lethargy and occasional rash and HbsAg negative
arthralgia. It often progresses to dark anti-HBc positive immune due to infection
anti-HBs positive
urine and jaundice. The severity of
infection ranges from asymptomatic HbsAg negative
cases detected only after further anti-HBc negative immune due to hepatitis B vaccination
anti-HBs positive
investigation of abnormal liver function
tests, to fulminating and often fatal case HbsAg positive
with extensive acute hepatic necrosis. anti-HBc positive acutely infected
IgM anti-HBc positive
Method of diagnosis anti-HBs negative
HBV infection is confirmed by the
HbsAg positive
detection of hepatitis B surface antigen anti-HBc positive chronic carrier
(HBsAg) or of HBV DNA in serum. IgM anti-HBc negative
Serology determines whether infections anti-HBs negative
are newly acquired or reflect chronic HbsAg negative
carriage. anti-HBc positive * five interpretations possible (see below)
anti-HBs negative

Source: Centers for Disease Control and Prevention (CDC).


*1. May be recovering from acute HBV infection
2. May be distantly immune and test not sensitive enough to detect very low level of anti-HBs
in serum
3. May be susceptible with a false positive anti-HBc
4. May be undetectable level of HbsAg present in the serum and the person is actually a carrier
5. Maternal antibody
76 The blue book: Guidelines for the control of infectious diseases

Incubation period Mode of transmission Susceptibility and resistance


The incubation period is 45–180 days Although hepatitis B surface antigen All non immune people are susceptible
with an average of 60–90 days. (HBsAg) has been found in virtually all to infection. Immunity conferred through
body secretions and excretions, only infection confers lifelong immunity in
Public health significance and blood (serum or plasma), semen and those who do not become chronic
occurrence vaginal fluids have been shown to be carriers.
Hepatitis B virus is a major cause of infectious.
chronic hepatitis, cirrhosis and Control measures
Transmission occurs via percutaneous
hepatocellular carcinoma. Preventive measures
and permucosal exposure to
An estimated two billion people have Universal vaccination for hepatitis B is
contaminated blood and body fluids. This
been infected with HBV worldwide, 350 part of the Australian Standard
may occur during:
million of whom are chronic carriers. Vaccination Schedule. All children are
• sexual contact offered a birth dose which should be
Each year an estimated one million
people die as a result of HBV infections • birth given within the first seven days after
and over four million new acute clinical birth and thereafter the infant should
• injecting drug use
cases occur. receive hepatitis B vaccine at 2, 4 and 12
• some household activities such as months of age.
In countries with low endemicity (HBsAg sharing razors or toothbrushes
prevalence less than 2%) most infections For those not immunised in childhood,
• invasive procedures in the community the ASVS recommends all pre-
occur in young adults and especially
such as tattooing or body-piercing, if adolescent children aged 10–13 years
among persons who belong to known
there has been inadequate infection receive hepatitis B vaccine. This is
high risk groups. Risk of HBV infection
control carried out in Year 7 of school. These
increases with:
• invasive medical or dental procedures children receive two doses of adult
• unprotected sexual contact formulation hepatitis B vaccine.
if there has been inadequate infection
• injecting drug use control. Health care workers should ascertain
• household and sexual contact with All blood and blood products produced their HBV immune status, particularly
known HBV infected persons for medical purposes in Australia are those engaging in invasive procedures. If
• incarceration carefully screened for HBV and other infected, health care workers should
blood-borne viruses using nucleic acid consult with a medical practitioner to
• workplace exposure to blood.
testing. review and consider modifications to
In higher endemicity areas (HBsAg their work practices to reduce the risk of
prevalence 2%) most infections occur as Period of communicability transmission to others in accordance
a result of perinatal transmission from The blood of infected persons is infective with the guidelines of their relevant
HBsAg-positive mothers or early many weeks before the onset of professional registration boards. Non-
horizontal transmission via close contact symptoms and remains infective through immune health care workers should be
in the household family setting. the acute clinical course of the disease vaccinated against HBV.
and during the chronic carrier state,
Reservoir which may persist for life. The proportion
Humans. of infected individuals who become
carriers is inversely related to their age at
infection. Persons who are HBV DNA
positive are highly infectious.
The blue book: Guidelines for the control of infectious diseases 77

Control of case Control of environment


All newly acquired cases should be Appendix 5 outlines procedures for
interviewed to identify likely risk factors dealing with spills of blood and body
for their infection and to identify others fluids.
who may be at risk of infection. If the
patient’s history suggests nosocomial Outbreak measures
transmission such as a surgical Special settings
procedure, or other possible source of Health care workers
infection that may put the general public Registration boards should be consulted
at risk such as a commercial tattoo, the in relation to their policies regarding
Department of Human Services should health care workers with blood-borne
be contacted for further advice and viruses. For example, the Medical
investigation. Practitioners Board of Victoria has a
policy on medical practitioners and
Isolation of HBV positive patients is not
medical students who carry a blood-
required. The infected person should be
borne virus which is available at
educated about transmission routes, safe
http://medicalboardvic.org.au.
injecting and sexual practises, blood and
Recommendations are also included in
body fluid precautions, and not donating
Infection control guidelines for the
organs or blood.
prevention of transmission of infectious
Control of contacts diseases in the health care setting,
Non-immune sexual contacts should be http://www.icg.health.gov.au
offered hepatitis B immunoglobulin
(HBIG) 400 IU IM within 14 days of
contact and commence hepatitis B
vaccination.
Household contacts should be tested for
HBsAg and anti-HBc and offered
vaccination if susceptible.
Infants born to HBsAg positive mothers
should be given a single dose of HBIG
and vaccine within 12 hours of birth, at
different sites. The remaining doses of
vaccine should be given at 2, 4 and 12
months of age.
Recipients of needle-stick injuries should
be considered for hepatitis B
immunoglobulin (see Appendix 4).
78 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 79

Hepatitis C
Victorian statutory requirement Method of diagnosis Public health significance
Hepatitis C infection (Group B disease) HCV infection is confirmed by using the and occurrence
must be notified in writing within five combination of a HCV antibody test and Hepatitis C occurs worldwide. Current
days of diagnosis. PCR to detect HCV RNA. A positive estimates suggest that more than 200
antibody test implies previous infection 000 Australians have been infected with
Specific information is required to be
by the virus and a positive HCV RNA this virus and that 11 000 new infections
notified under the Health (Infectious
implies ongoing infection. are occurring each year. Specific groups
Diseases) Regulations 2001. In certain
circumstances the attending doctor and Antibodies are directed against the such as injecting drug users are at
patient may be asked to complete a products of expressed clones or peptides greater risk of HCV infection.
questionnaire to collect additional of the HCV. First generation enzyme Three quarters of people infected with
information. All information collected by immunoassay (EIA) for antibody HCV become chronic carriers of the
the Department of Human Services is detection became available in Australia virus. Of those chronically infected,
treated as confidential. It is used for in 1990 and since then second and third approximately 10–20% will develop liver
reasons such as detecting disease generation EIA tests with improved cirrhosis over a period of 15–40 years
trends and to inform public health action sensitivity and specificity have been and an estimated 5% will develop
and policy development. developed. hepatocellular carcinoma after 40 years
School exclusion is not required. Supplemental tests are also available in of infection.
the form of recombinant immunoblot There are at least six major genotypes of
Infectious agent assays (RIBA). The significance of HCV. At present the main genotypes
Hepatitis C virus (HCV) is a small RNA equivocal reactivity detected by EIA tests found in the Australian population are 1
virus that is closely related to the and indeterminate reactivity detected by (54%), 3 (36%) and 2 (6%).
flaviviruses and animal pestiviruses. RIBA testing remains problematic in low
risk groups. Reservoir
Identification Humans.
Clinical features A positive HCV RNA test is a marker for
Most infections with HCV are viraemia and ongoing infection. A single Mode of transmission
asymptomatic and acute infection may negative PCR does not exclude infection Hepatitis C is primarily transmitted by
only be detected in patients by the as viraemia may be intermittent. The blood-to-blood contact.
development of elevated serum alanine patient should be retested in six to 12
In Australia and other Western countries
aminotransferase (ALT) levels. When months time.
the sharing of injecting equipment by
symptoms and signs do occur, they are Current EIA tests cannot distinguish intravenous drug users is the most
similar to other forms of viral hepatitis between patients who are currently common mode of transmission.
but usually milder. Estimates vary but infectious and those who have recovered Tattooing, ear piercing and body piercing
between 10% and 50% of people infected from infection and developed immunity. using unsterile equipment are other
with HCV completely recover and are potential sources. There is a high
clear of the virus in the subsequent few Incubation period
prevalence of HCV in people who have
years. Community based studies report a The incubation period ranges from two
been in prison because of the high
greater likelihood of viral clearance weeks to six months. It is most
likelihood of injecting drug use and
compared with hospital-based studies. If commonly six to nine weeks after which
tattooing.
symptoms of ongoing disease occur they serum ALT levels rise. Current HCV
may be non-specific and include fatigue, antibody tests become positive two to
headaches and nausea. three months after exposure.
80 The blue book: Guidelines for the control of infectious diseases

Health care and laboratory staff who Period of communicability genotype and sometimes whether
handle blood and blood products are at Communicability occurs during the acute previous treatment has failed. Combined
increased risk. The Centers for Disease clinical stage of HCV infection and therapy with alpha interferon and
Control and Prevention report that the indefinitely in the chronic carrier stage. ribavirin or pegylated interferon and
risk of contracting hepatitis C after All HCV positive individuals should be ribavirin are possible treatment
percutaneous exposure such as needle considered potentially infectious regimens.
stick or sharps injury from the blood of a although the risk is minimal in the non- Counselling of the patient is a very
person with hepatitis C antibody has viraemic (PCR negative) individual. important part of the management. This
been estimated at 0–7% (average 1.8%). counselling should include:
The risk of transmission is negligible if Susceptibility and resistance
the source is HCV RNA-negative. All non immune people are susceptible • exploring the likely source of the
to infection. The degree of immunity infection
Sexual transmission rates of HCV
following infection is uncertain. If • current knowledge of the natural
infection are very low. The risk is
infection resolves and the virus is history
increased if the HCV positive partner is
cleared, the person can be re-infected
immunocompromised as the viral blood • possible symptoms
with the same and other genotypes.
titre may be increased, or when there is • advice on prevention of further
However there is some evidence from
the possibility of blood-to-blood contact transmission of infection
cohort studies that the likelihood of
for example sex during menstruation and
reinfection is reduced after the first HCV • lifestyle issues such as immunisation
traumatic sexual practices.
infection. against hepatitis A and B, minimisation
Mother to baby transmission is of alcohol intake, cessation of smoking
approximately 5–6% and is thought to Control measures and healthy diet.
occur only when the mother is HCV RNA Preventive measures
All health care providers with potential The patient should be advised not to:
positive. The likelihood of transmission is
increased if the mother is also infected contact with blood or body fluids should • donate blood or body organs
with HIV. Although HCV has occasionally use standard precautions. • share injecting equipment
been detected in breast milk there is no Use single-use equipment for all skin • share personal items such as
evidence that HCV is transmitted from penetration procedures or use toothbrushes or razors.
mother to child by breast feeding. appropriate cleaning, disinfection or
They should also be advised to:
Community or household transmission of sterilisation methods when reusable
HCV is considered rare. instruments are used for any procedure. • consider discussing their condition
This includes needles. with their health care provider when
A proportion of HCV positive individuals
undergoing any dental or medical
do not fall into any known risk subgroup. Control of case
procedure
They may have forgotten that they had All people diagnosed with HCV infection
exposure to injecting drugs many years should be reviewed by a hepatitis • wipe up any blood spills with single
ago or they may be unwilling to discuss specialist (either a gastroenterologist or use disposable paper towels and clean
the possibility. an infectious diseases physician) and an area with detergent and warm water
assessment made of the likelihood of • cover any cuts or wounds with an
Re-use of poorly cleaned needles by
disease progression. Treatment is offered occlusive waterproof dressing
medical practitioners and others in some
based on the presence of liver fibrosis.
countries and cultural practices that • place blood-stained paper tissues,
involve skin piercing are other potential Length of treatment and type of sanitary towels or dressings in a plastic
sources of infection. treatment depends mainly on the bag before disposal
The blue book: Guidelines for the control of infectious diseases 81

• use safer sex practices. People in long Other settings • Dore, G, Grulich, A, Kidd, M, Hoy, J
term stable relationships will need to All workplaces should have policies and McCoy, R, Mijch, A & Strasser, S 2001,
discuss condom use with their health procedures in place regarding action to HIV/Viral hepatitis – a guide for primary
care provider. Safe sex is not routinely be taken in the event of a blood spill or care, Australasian Society for HIV
recommended among long term sharps injury. Further information can be Medicine, http://www.ashm.org.au
monogamous couples. found in Infection control guidelines for • Mehta, SH, Cox, A, Hoover, DR, Wang,
Control of contacts the prevention of transmission of XH, Mao, Q, Ray, S, et al. 2002,
There is no vaccine available for the infectious diseases in the health care ‘Protection against persistence of
prevention of hepatitis C. http://www.icg.health.gov.au/ hepatitis C’, Lancet, vol. 359, no. 9316,
Prophylactic immunoglobulin for contacts pp. 1478–1483.
Additional sources of information
has no role. • Centers for Disease Control 1997, • Victorian Department of Human
Control of environment ‘Notice to readers – Services 2002, Hepatitis C Strategy
Not applicable. Recommendations for follow-up of 2002–2004,
health-care workers after occupational http://www.health.vic.gov.au/ideas
Special settings
exposure to hepatitis C’, Morbidity and
Health care workers
Mortality Weekly Report, vol. 46, no. 26,
Registration boards should be consulted
pp. 603–606.
in relation to their policies regarding
health care workers with blood-borne • Centers for Disease Control 2001,
viruses. For example, the Medical ‘Updated US public health service
Practitioners Board of Victoria has a guidelines for the management of
policy on medical practitioners and occupational exposures to HBV, HCV
medical students who carry a blood- and HIV and recommendations for
borne virus which is available at postexposure prophylaxis, Morbidity
http://medicalboardvic.org.au. and Mortality Weekly, vol. 50, RR –11,
Recommendations are also included in pp. 1–42.
Infection control guidelines for the • Charles, PG, Angus, PW, Sasadeusz, JJ
prevention of transmission of infectious & Grayson, LM 2003, ‘Management of
diseases in the health care setting, healthcare workers after occupational
http://www.icg.health.gov.au exposure to hepatitis C’, Medical
Antenatal care Journal of Australia, vol. 179, no. 3, pp.
Antenatal care should include a 153–157.
comprehensive assessment of hepatitis • Crofts, N, Dore, G & Locarnini, S (eds.)
C risk factors. Women found to be at 2001, Hepatitis C – An Australian
higher risk of hepatitis C infection or perspective, IP Communications.
exposure should be encouraged to
undergo hepatitis C antibody screening.
82 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 83

Hepatitis D
(delta hepatitis)
Victorian statutory requirement Incubation period Period of communicability
Hepatitis D infection (Group B disease) Approximately two to eight weeks. This is similar to that of HBV. Persons
must be notified in writing within five infected with the HDV are thought to be
days of diagnosis. Public health significance most infectious before the onset of
and occurrence symptoms. All persons with
School exclusion is not applicable.
Hepatitis D occurs worldwide and is asymptomatic infection, persons with
Infectious agent most prevalent in countries that have a acute disease and those with chronic
Hepatitis D virus (HDV) is a virus-like high incidence of hepatitis B. The highest carriage of the virus are infectious to
particle consisting of a coat of hepatitis incidence occurs in parts of Russia, others.
B virus (HBV) surface antigen and a Romania, southern Italy, Africa, pockets
unique internal antigen, the delta of South America and the islands of the Susceptibility and resistance
antigen. Western Pacific. All people susceptible to hepatitis B
Despite high rates of hepatitis B in Asian infection or those who have chronic
Identification countries the incidence of hepatitis D is hepatitis B can be infected with HDV.
Clinical features lower. Hepatitis D is uncommon in
Onset of disease is usually abrupt, with Control measures
Australia. Three to twelve cases are
signs and symptoms resembling those of Preventive measures
reported per year in Victoria.
hepatitis B infection. It may be severe Prevention of hepatitis B infection with
and is always associated with a Reservoir hepatitis B vaccine prevents infection
coexistent HBV infection. Co-infection HDV is unable to infect a cell by itself with HDV. For persons with chronic
(simultaneous infection with HBV and and requires co-infection with HBV to hepatitis B infections, the only preventive
HDV) or superinfection (infection with undergo complete replication. Therefore measure is avoidance of exposure to
HDV in a person who already has HBV) humans with HBV infection act as potential sources of HDV. This means
with HDV is usually more severe than reservoirs. always using a new needle and syringe
HBV infection alone and more likely to when injecting drugs and practising safe
result in fulminant disease. Co-infection Mode of transmission sex.
has a lower risk of severe chronic disease This virus is transmitted by the same Control of case
than does superinfection. methods as HBV: exposure to infected There is no specific treatment for
blood and serous body fluids, hepatitis D, although alpha-interferon has
Method of diagnosis
contaminated needles, syringes or blood been shown to be of some benefit.
Serological diagnosis is made by:
and plasma product transfusions. Sexual Expert advice for ongoing management
• detection of total antibody to HDV transmission may also occur but is less should be sought.
(anti-HDV). A positive HDV IgM result common than with hepatitis B. Perinatal
indicates ongoing replication Isolation is not required.
infection is rare. Infection may occur at
• detection of HDV-specific RNA by the same time as a new HBV infection Educate patient about safe injecting, safe
polymerase chain reaction (PCR) (co-infection) or after someone has been sex and blood and body fluid
testing. PCR is the most sensitive infected with HBV and become a chronic precautions.
assay for assessing HDV viraemia. HBV carrier (super-infection).
84 The blue book: Guidelines for the control of infectious diseases

Control of contacts
Initiate contact tracing with patient.
Susceptible sexual, injecting and
household contacts should be offered
hepatitis B vaccine.
Vaccination against hepatitis B prevents
HDV infection.
Control of environment
Not applicable.

Outbreak measures
Not applicable.
The blue book: Guidelines for the control of infectious diseases 85

Hepatitis E
Victorian statutory requirement Public health significance Control measures
Hepatitis E infection (Group B disease) and occurrence Preventive measures
must be notified in writing within five Sporadic cases and epidemics in adults Good personal hygiene is important,
days of diagnosis. have occurred in India, areas of the particularly after defecation. Travellers to
School exclusion is not applicable. former Soviet Union, some African endemic areas should be advised of the
countries, Mexico and parts of Asia. The risk and avoid ingestion of potentially
Infectious agent disease is not endemic in Australia and contaminated water. There are no
Hepatitis E virus (HEV) is the causative cases reported to date have occurred in vaccines against HEV.
agent. travellers, with the exception of one Control of case
patient with no history of overseas travel Treatment is supportive only, particularly
Identification who was diagnosed in the Northern the maintenance of hydration.
Clinical features Territory in 1995.
The clinical course of disease due to HEV Food handlers must not work for at least
is similar to that of hepatitis A. It is a self- Reservoir seven days after the onset of jaundice and
limiting disease of adults aged 15–40 Humans and some primates act as until well.
years. A high case fatality rate (up to reservoirs. It is recommended that health care
20%) has been described in pregnant workers and child care workers remain
women affected in their third trimester of Mode of transmission
away from work for at least seven days
pregnancy. Hepatitis E is transmitted via
after the onset of illness and until well.
contaminated water and possibly through
Method of diagnosis Children should not attend school or child
person to person transmission via the
Exclusion of other causes of acute care for seven days after the onset of
faecal-oral route. Evidence of infection in
hepatitis, particularly hepatitis A is symtoms.
rats and other rodents in some endemic
important. HEV may be detected by countries suggests other mechanisms of Control of contacts
immune electron microscopy of faeces transmission are likely. Consider the diagnosis in symptomatic
collected during the acute phase. contacts. Immunoglobulin prepared from
Serological tests to confirm HEV Period of communicability donors in non-endemic countries will not
infection are available through the The period of communicability is prevent infection or disease.
Victorian Infectious Diseases Reference unknown. HEV has been detected in If the case has worked as a food handler,
Laboratory. stools 14 days after the onset of child care worker or health care worker,
jaundice. surveillance for further cases in the work
Incubation period
The incubation period varies from two Susceptibility and resistance place should be carried out.
weeks to two months. In different Susceptibility is unknown, however Control of environment
epidemics the average incubation period disease tends to occur in adults and Infected persons should be advised to
has varied from 26 to 42 days. pregnant women are at particular risk of maintain strict personal hygiene and
fulminating disease. avoid preparing meals for others unless
adequate food safety can be guaranteed.
86 The blue book: Guidelines for the control of infectious diseases

Food premises, child care centres or Additional sources of information


health care facilities where a case has • Heath, TC, Burrow, JN, Currie, BJ,
worked whilst potentially infective should Bowden, FJ, Fishe,r DA, Demediuk, BH,
be requested to complete a clean up in Locarnini, SA, Anderson, DA 1995,
accordance with the Department’s ‘Locally acquired hepatitis E in the
Guidelines for the Investigation of Northern Territory of Australia’, Med J
gastrointestinal illness. Aust., vol. 162, no. 6, pp. 318–9.

Outbreak measures • World Health Organization,


A case with no history of overseas travel http://www.who.int/csr
would constitute an outbreak in Victoria.
Immediate notification is critical to
identify the source and prevent further
disease. A detailed epidemiological,
environmental and laboratory
investigation of common exposures,
particularly water, amongst cases is
necessary.
The blue book: Guidelines for the control of infectious diseases 87

Herpes simplex
infections
Victorian statutory requirement per cent of primary infections cause a depending on sexual practices.
Notification is not required. more severe form of disease manifested HSV 2 infections are rarely associated
by fever and malaise. This may last a with aseptic meningitis and radiculitis.
School exclusion: young children with
week or more and can be associated
cold sores who are unable to comply
with good hygiene practices should be
with vesicular lesions leading to ulcers in Method of diagnosis
and around the mouth The diagnosis may be suggested by
excluded while the lesion is weeping.
(gingivostomatitis), eye infection cytologic changes in tissue scrapings or
Lesions should be covered by a dressing
(keratoconjunctivitis), a generalised biopsy. Confirmation is made by direct
where possible.
vesicular skin eruption complicating fluorescent antibody tests, by isolation of
Infectious agent chronic eczema or more rarely the virus from oral or genital lesions or
Human herpes simplex virus (HSV) types encephalitis. other sites, or by detection of HSV DNA
1 and 2 cause disease. Features of gingivostomatitis include by nucleic acid testing in lesion or spinal
ulceration of the tongue, gums, lips and fluid. Techniques are also available to
Identification differentiate type 1 from type 2 antibody
anterior buccal mucosa, severe systemic
Clinical features if required.
toxicity and lymphadenopathy.
Cold sores are the most common
manifestation of herpetic infection and Reactivation of latent viral infection in the Incubation period
are characterised by a localised primary dorsal root ganglia results in cold sores The incubation period varies from two to
lesion, latency and a tendency to local appearing as clear vesicles on an twelve days.
recurrence. erythematous base. These usually occur
on the face and lips and crust and heal in Public health significance
In children with atopic dermatitis and and occurrence
a few days. This reactivation may be
immunosuppressed patients, herpes Asymptomatic infections with HSV type 1
precipitated by trauma, fever,
simplex virus may disseminate causing a virus are common. Seventy to ninety per
environmental conditions such as windy
generalised eruption that requires cent of adults have circulating antibodies
days, sunburn or intercurrent disease.
hospitalisation for intravenous antiviral to HSV type 1 virus indicating previous
therapy. Herpes simplex may become HSV type 2
infection.
chronic in patients with HIV infection This virus is the usual cause of genital
with recalcitrant crusted lesions and herpes although this can also be caused HSV type 1 is a common cause of
ulceration. Herpes simplex may be by type 1 virus. Genital herpes occurs meningoencephalitis. Vaginal delivery in
complicated by erythema multiforme mainly in adults and is sexually pregnant women with active genital
which is often more disabling than the transmitted. Primary and recurrent infection carries a high risk of
infection itself. Herpes simplex virus infections occur, with or without disseminated visceral infection,
infection may cause severe extensive symptoms. encephalitis and death to the newborn.
disease in immunosuppressed The principal sites of primary disease in HSV type 2 is frequently associated with
individuals. women are the cervix and vulva. sexually transmitted infections and
HSV types 1 and 2 generally produce Recurrent disease generally involves the 20–30% of adults have antibody
distinct clinical syndromes depending on vulva, perineal skin, legs and buttocks. In evidence of exposure. The prevalence is
the portal of entry. men, lesions appear on the glans penis greater in socio-economically
or prepuce, and in the anus or rectum of disadvantaged groups and those with
HSV type 1 multiple sexual partners.
those engaging in anal sex. Other genital
The primary infection may be mild and
or perineal sites as well as the mouth
generally occurs in early childhood
may also be involved in either gender
Reservoir
before the age of five years. About ten Humans.
88 The blue book: Guidelines for the control of infectious diseases

Mode of transmission Emphasise personal hygiene to minimise Contact isolation is required for
Contact with HSV type 1 in the saliva of the transfer of infectious material. Wear disseminated severe infections and for
carriers is the most important mode of gloves when in direct contact with infected neonates because of the risk to
spread. Contact of health care workers infectious lesions and wash hands with other neonates or pregnant women.
with patients who are shedding HSV may soap and water afterwards. Anogenital herpes
result in an infection of the tip of the Use of latex condoms during sexual Patients should be fully screened for
finger (herpetic whitlow). It begins with intercourse decreases the risk of other STIs, including HIV infection, on
intense itching and pain and is followed infection. their first presentation.
by vesicle formation and then ulceration.
Control of case For initial attack or infrequent recurrent
Transmission of HSV type 2 to non- Non-genital herpes attacks treatment usually consists of
immune adults is usually by sexual For symptomatic treatment of minor valaciclovir, famciclovir or aciclovir. For
contact. attacks, use povidone iodine 10% paint suppression of frequent recurrent attacks
applied three times daily. Also consider aciclovir or valaciclovir are generally
Period of communicability
topical antiviral therapy. Therapy should used. Consult the current version of
Secretion of virus in the saliva may occur
be self-initiated and commenced at the Therapeutic guidelines: antibiotic
up to seven weeks after recovery from
earliest sign of onset. Consult the current (Therapeutic Guidelines Limited).
stomatitis.
version of Therapeutic guidelines: If there is breakthrough during
Patients with primary genital lesions are antibiotic (Therapeutic Guidelines prophylaxis, higher doses may be
infective for seven to ten days. Those Limited). successful. Relapse may occur at the
with recurrent disease are infectious for
Sun protection is important in preventing cessation of prophylaxis.
four to seven days with each episode.
recurrences of facial herpes simplex. Control of contacts
Susceptibility and resistance Specialist advice on systemic antiviral None applicable.
Everyone is susceptible to infection. The treatment should be sought for: Control of environment
disease does not usually confer
• severe primary or severe recurrent None applicable.
protective immunity because the virus
attacks
tends to become latent in dorsal root Outbreak measures
ganglia of the spine where it may • attacks complicated by erythema
None applicable.
become reactivated at a later date. multiforme
• primary or recurrent attacks in HIV-
Control measures infected patients or the
Preventive measures immunosuppressed.
No vaccine is currently available.
Patients with active lesions should have
Health education and personal hygiene no contact with newborns, children with
should be directed toward minimising burns or eczema and immunosuppressed
transfer of infectious material and patients. Consider caesarean section
reducing the risk of exposure to high risk before the membranes rupture when
groups. primary or recurrent genital infections
occur in late pregnancy to minimise the
risk of neonatal infection.
The blue book: Guidelines for the control of infectious diseases 89

Human
immunodeficiency virus
or acquired
immunodeficiency
syndrome
Victorian statutory requirement • Pneumocystis carinii pneumonia The interval from HIV infection to the
Both HIV infection and AIDS are Group D • oesophageal candidiasis diagnosis of AIDS ranges from about nine
notifications. A separate notification form months to 20 years or longer, with a
• Kaposi’s sarcoma median of 12 years. There is a group of
is required for HIV and AIDS diagnoses.
Written notification is required within five • chronic herpes simplex infection people with a more rapid onset of
days of the initial diagnosis. • cryptococcosis disease who develop AIDS within three
to five years of infection. Treatment with
School exclusion is not required unless • cryptosporidiosis
antiretroviral drugs and disease-specific
the child has a secondary infection.
• toxoplasmosis prophylaxis has resulted in an 80%
Infectious agent • cytomegalovirus infection reduction in AIDS-associated illnesses.
Human immunodeficiency virus (HIV)
• mycobacteriosis Public health significance
types 1 and 2 are a member of family
retroviridae. A number of subtypes exist • lymphoma and occurrence
Occurrence is worldwide. There were 40
within HIV–1 and HIV–2. • HIV encephalopathy
million people living with HIV/AIDS by
• HIV wasting disease the end of 2001 and in 2000 three
Identification
Clinical features Method of diagnosis million people died from HIV-related
AIDS is a severe, life-threatening disease Careful history and physical examination illnesses. The vast majority of HIV
that represents the late clinical stage of looking for risk factors and clinical infections occur in developing countries.
infection with the HIV. Several weeks manifestations of immunodeficiency are For the period 1983 to 2003 there was a
after infection with HIV, a number of necessary. cumulative total of 4680 HIV diagnoses
infected individuals will develop a self- Diagnostic testing includes: in Victoria. This represents about 21% of
limited glandular fever-like illness lasting Australia’s total. Males accounted for
• detection of HIV antibody by the ELISA
for a week or two. Infected persons may 94% of the diagnoses. Male to male
screening test and confirmation by
then be free of clinical signs or sexual contact including homosexual and
Western blot analysis
symptoms for months or years. bisexual contact accounts for the
• detection of the viral p24 antigen in majority of new diagnoses in men. In
Treatment with antiretroviral medication
serum females, heterosexual contact and
has resulted in fewer cases of AIDS. The
burden of illness is now increasingly due • PCR tests to detect pro-viral DNA injecting drug use are the most common
to non-AIDS infections, toxicities related sequences risk factors.
to antiretroviral therapy including • HIV culture, although this is only
changes in body shape and metabolic
Reservoir
performed in certain special clinical
Humans.
markers such as diabetes and high situations.
cholesterol, and neurological and Mode of transmission
psychiatric manifestations of HIV. Incubation period
HIV can be transmitted from an infected
The period from infection to the primary
Untreated individuals are at risk of person by:
seroconversion illness is three to eight
specific opportunistic infections and • Sexual exposure to infected semen,
weeks. The period from infection to
malignancies and a range of other AIDS vaginal fluids and other infected body
development of anti-HIV antibodies is
indicative diseases. Major diseases that fluids during unprotected sexual
three weeks to three months.
may be indicative of AIDS include: intercourse with an infected person.
This includes oral sex.
90 The blue book: Guidelines for the control of infectious diseases

• Inoculation with infected blood, blood Susceptibility and resistance • use of appropriate infection control
products and through transplantation Everyone is susceptible to infection. measures in all premises where skin
of infected organs such as bone grafts penetration is carried out, for example
The presence of other sexually
or other tissues, or by artificial electrolysis, tattooing or body piercing
transmitted infections, especially those
insemination with infected semen. • blood and blood products for
with skin or mucosal ulceration, may
• Breastfeeding of an uninfected infant increase susceptibility. transfusion and the donors of tissues
by an HIV-positive mother. and body fluids such as semen should
Interventions that decrease the risk of Control measures be tested for the presence of markers
vertical transmission from an infected Preventive measures of HIV
woman to her child include Preventive measures for HIV centre on
• sharps injuries, including needle stick
antiretroviral therapy during pregnancy personal and institutional factors.
injuries, and parenteral exposure to
and caesarean section. Avoiding Personal factors include: laboratory specimens containing HIV
breastfeeding also decreases should be dealt with according to
• public education on the use of
transmission. With these interventions Infection control guidelines for the
condoms and safer sex practices
the risk of mother to child transmission prevention of transmission of infectious
is less than 5%. If there is no • public education should stress that
diseases in the health care setting
intervention, the risk of mother to child having unprotected sex with unknown
http://www.icg.health.gov.au/
HIV transmission has been estimated or multiple sexual partners and sharing
to be 20–45%. needles (drug users) increases the risk • non-occupational exposure to infected
of infection with HIV blood or body fluids should be assessed
• Sharps injuries including needle stick and managed according to Australian
injuries or other exposure to blood and • unprotected sexual intercourse with
National Council on AIDS, Hepatitis C
body fluids. The rate of seroconversion persons with known or suspected HIV
and related diseases guidelines,
following a needle stick injury involving infection should be avoided
http://www.ancahrd.org/pubs/
HIV infected blood is said to be less • HIV-infected persons should be offered
than 0.5%, but this is dependent on the Control of case
confidential counselling and access to
type of needle stick injury (deep versus Standard precautions (see Appendix 3)
screening and treatment for sexually
shallow) and the viral load of the apply to all patients.
transmissible infections and
infected person. appropriate antiviral therapy for HIV Additional transmission-based
precautions apply for specific infections
Period of communicability • care should be taken when handling,
that occur in AIDS patients such as
All antibody positive persons carry the using and disposing of needles or other
tuberculosis. Equipment contaminated
HIV virus. sharp items
with blood or body fluids should be
Infectivity is presumed to be life long, • use of needle exchange programs by cleaned and then disinfected or sterilised
although successful therapy with injecting drug users should be as appropriate.
antiretroviral drugs can lower the viral facilitated.
Patients and their sexual partners should
load in blood and semen to undetectable Institutional factors include: not donate blood, organs or other human
levels. • use of appropriate infection control tissue.
measures by all health care and All HIV positive persons should be
emergency workers evaluated for the presence of
tuberculosis.
The blue book: Guidelines for the control of infectious diseases 91

Treatment Special settings Additional sources of information


Anti-retroviral drug therapy is used to Health care workers • Australian Government Department of
treat established HIV infection. As such Registration boards should be consulted Health and Family Services 1997,
treatment is specialised and constantly in relation to their policies regarding Contact tracing manual – A practical
changing, only those doctors health care workers with blood-borne handbook for health care providers
experienced in HIV management should viruses. For example, the Medical managing people with HIV, viral
prescribe antiretroviral therapy. For Practitioners Board of Victoria has a hepatitis, other STDs and HIV-related
further information, see the current policy on medical practitioners and tuberculosis, Australian Government
edition of the Therapeutic guidelines: medical students who carry a blood- Department of Health and Family
antibiotic (Therapeutic Guidelines borne virus, which is available at Services.
Limited). Other treatment includes http://medicalboardvic.org.au.
• Australian Government Department of
specific treatment or prophylaxis for the Recommendations are also included in
Health and Aged Care 2000, National
opportunistic infectious diseases that Infection control guidelines for the
HIV/AIDS strategy 1999–2000 to
result from HIV infection. prevention of transmission of infectious
2003–2004 – changes and challenges,
Control of contacts diseases in the health care setting,
Australian Government Department of
If a person is diagnosed as having HIV http://www.icg.health.gov.au
Health and Aged Care,
infection, the diagnosing practitioner has Antenatal care http://www.health.gov.au
a responsibility to ensure that sexual and Antenatal care should include a
• Australian National Council on AIDS,
needle-sharing contacts are followed up comprehensive assessment of HIV risk
Hepatitis C and Related Diseases,
where possible. factors. Women found to be at higher risk
www.ancahrd.org
Assistance with partner notification may of HIV infection or exposure should be
encouraged to undergo HIV antibody • Australasian Society for HIV Medicine Inc
be provided by Department of Human
screening. 2001, HIV/Viral hepatitis – A guide for
Services through its partner notification
primary care, http://www.ashm.org.au/
officers. Other settings
All workplaces should have policies and • Centers for Disease Control 2001,
Pre and post-test counselling must be
procedures in place regarding action to ‘Updated U.S. Public health service
provided for all contacts seeking HIV
be taken in the event of a blood spill or guidelines for the management of
testing.
sharps injury. Further information can be occupational exposures to HBV, HCV,
Control of environment found in Infection Control Guidelines: for and HIV and recommendations for
The procedure for dealing with spills of the prevention of transmission of postexposure prophylaxis’, MMWR, vol.
blood and body fluids is in Appendix 5. infectious diseases in the health care 50, RR11, pp. 1–42,
setting. http://www.icg.health.gov.au http://www.cdc.gov/mmwr
Outbreak measures
The epidemiology of HIV is closely • Fleming, DT & Wasserheit, JN 1999,
International measures ‘From epidemiological synergy to
monitored in Victoria and public health WHO initiated a global prevention and
action is informed by enhanced public health policy and practice: the
control program in 1987. Since 1995, the contribution of other sexually
epidemiological information notified to global AIDS program has been
the Department. transmitted diseases to sexual
coordinated by UNAIDS. Nearly all transmission of HIV infection’, Sexually
countries have developed an AIDS transmissible infections, vol. 73, pp.
prevention and care program. 3–17.
92 The blue book: Guidelines for the control of infectious diseases

• Venereology Society of Victoria 2002,


National management guidelines for
sexually transmissible infections,
Venereology Society of Victoria,
http://www.mshc.org.au
• Victorian Department of Human
Services 2002, Victorian HIV/AIDS
strategy 2002–2004,
http://www.health.vic.gov.au/ideas
• Working Group of the UK Chief Medical
Officer’s Expert Advisory Group on
AIDS 2000, Review of the evidence on
risk of HIV transmission associated with
oral sex – report of a working group of
the UK Chief Medical Officer’s Expert
Advisory Group on AIDS, Department
of Health, London.
The blue book: Guidelines for the control of infectious diseases 93

Hydatid disease
(echinococcosis)
Victorian statutory requirement The Casoni skin test has now been are the major intermediate hosts. Sheep
Notification and school exclusion are not replaced by serological tests for hydatid eat the worm eggs from pasture
required. disease. These include fluorescent contaminated with dog faeces. These
antibody (FA) and indirect hatch inside the sheep, forming cysts.
Infectious agent haemagglutination antibody testing. The life cycle is completed when dogs
Echinococcus granulosus (dog tapeworm) are infected through eating the offal of
is the causative agent. Incubation period infected livestock or wild animals,
The incubation period varies from particularly the liver and lung.
Identification months to years.
Clinical features Mode of transmission
Hydatid disease in humans is produced Public health significance Human infection occurs by hand-to-
by cysts that are the larval stages of the and occurrence mouth transfer of tapeworm eggs from
tapeworm Echinococcus. Brood capsules Hydatid disease occurs worldwide and is dog faeces. The larvae penetrate the
are formed within cysts,cysts containing mainly associated with sheep farming. intestinal mucosa, enter the portal
30–40 protoscoleces. Each of these is Notification of hydatid infection ceased system and are carried to various organs
capable of developing into a single in Victoria earlyVictoria early in 2001. In where they produce cysts in which
tapeworm. Symptoms depend on the the decade prior to 2001 there was an infectious protoscoleces develop.
location of the cyst within the body and average of 16 notifications per year. Most The important life cycle is dog-sheep-
develop as a result of pressure, leakage of these represented infections acquired dog. A dingo-wallaby-dingo (or wild dog)
or rupture. The most common site for the overseas. Occasional cases of recently sylvatic cycle also occurs. A dog-wild
cysts is the liver. Less commonly brain, acquired hydatid infection have been pig-dog cycle has been recognised and
lungs and kidneys are affected. The identified in visitors to rural areas in poses a special risk for wild pig-hunters.
heart, thyroid and bone are uncommonly Victoria where there are infected sheep
affected. or dingoes. Urban dogs which Period of communicability
Cysts in the body may remain viable or accompany travellers are often Hydatid disease is not transmitted from
die and calcify. They may be detected on suspected of being an intermediary of person to person.
routine X-rays. The prognosis is generally the cycle of transmission to humans. Dogs pass eggs approximately seven
good and depends on the site and People who trap wild dogs are similarly weeks after infection. In the absence of
potential for rupture and spread. Sudden at risk. reinfection this ends within one year.
rupture of the brood capsules and
liberation of the daughter cysts may Reservoir Susceptibility and resistance
cause fatal anaphylaxis. Persons who The domestic dog and other canids, Young children are more likely to be
have a calcified cyst detected on X-ray definitive hosts for E. granulosus, may infected as they are more likely to have
may still have active infection. harbour thousands of adult tapeworms closer contact withcontact with infected
without being symptomatic. dogs and they are less likely to have
Method of diagnosis
Diagnosis may be made plain X-ray, Felines and most other carnivores are appropriate hygiene habits. There is no
ultrasound or CT scan. If a cyst ruptures, normally not suitable hosts for the evidence to suggest children are more
appropriate examination for parasite. susceptible to infection than adults.
protoscoleces, brood capsules and cyst Intermediate hosts include herbivores,
wall in sputum, vomitus, faeces or urine sheep, cattle, goats, pigs, horses,
should be undertaken. kangaroos, wallabies and camels. Sheep
94 The blue book: Guidelines for the control of infectious diseases

Control measures Control of environment


Preventive measures Dogs kept in and around the case’s
Basic hygiene such as washing hands house may require veterinary screening
with soap after gardening or touching the for hydatid infection.
dog and washing vegetables that may In general, dogs should be treated with
have been contaminated by dog faeces, an anti-tapeworm medication such as
are are important in prevention of this praziquantel every six weeks in rotation
disease. with a broad spectrumbroad-spectrum
Control of case de-worming preparation to prevent
Surgery is often the treatment of choice disease in dogs and break the life cycle
for infection with Echinococcus of the parasite.
granulosus, sometimes combined with Review practices that may have led to
prolonged high-doses of the drug infection. In particular, restrict dog
albendazole. Percutaneous drainage with access to raw offal from infected sheep
ultrasound guidance plus prolonged high- or kangaroos to prevent the life cycle
dose albendazole theraphytherapy has continuing. Incinerate or deeply bury
been effective for liver cysts. Praziquantel infected organs from dead intermediate
followed by prolonged high-dose animal hosts.
albendazole theraphytherapy is used if
there is cyst spillage from trauma or Outbreak measures
surgery. Consult the current version of Not applicable.
Therapeutic guidelines: antibiotic
(Therapeutic Guidelines Limited). Additional sources of information
Specialist infectious disease advice • Victorian Department of Primary
should be sought. Industries, www.dpi.vic.gov.au

Control of contacts • Victorian Department of Sustainability


Persons carrying the infection are not and Environment, www.dse.vic.gov.au
contagious to others. Encourage
contacts to practice appropriate hygiene
and to report early any compatible
symptoms.
The blue book: Guidelines for the control of infectious diseases 95

Impetigo (school sores)


Victorian statutory requirement common in the nappy area. Most cases are no longer infectious after
Notification is not required. Complications are rare. 24 hours of appropriate antibiotic
Staphylococcal skin infections rarely therapy.
School exclusion: exclude until
appropriate treatment has commenced. result in the more severe ‘scalded skin
Susceptibility and resistance
Sores on exposed surfaces must be syndrome’ which varies from a diffuse
Everyone is susceptible to streptococcal
covered with a watertight dressing. scarlatiniform erythema to a generalised
and staphylococcal skin infection.
bullous desquamation of the skin.
Infectious agent Persons suffering from chronic
Method of diagnosis
Various strains of Streptococcus conditions producing breaks in the skin,
Diagnosis should be confirmed by
pyogenes, group A streptococci (GAS) such as eczema or atopic dermatitis, may
isolation of the organism from skin
and Staphylococcus aureus cause be at greater risk of impetigo.
swabs. This also allows confirmation of
disease.
antibiotic susceptibility. Control measures
Identification Preventive measures
Incubation period Good personal hygiene practices
Clinical features
The incubation period is one to three
Impetigo is a contagious superficial skin including a daily bath or shower.
days for S. pyogenes and four to ten days
infection seen mainly in children but it Emphasise the importance of not sharing
for S. aureus.
may occur at any age. The infection may toilet articles and of suitably covering
present with mildly irritating blisters that Public health significance cuts and abrasions.
become pustular and erode rapidly and occurrence Educate on modes of transmission and
leaving a honey-coloured crust. It often Occurrence is worldwide. Impetigo is a possible complications of impetigo and
appears around the nose and mouth. rapidly spreading, highly contagious skin reinforce the importance of treating
Local lymph nodes may be enlarged and infection that frequently occurs in cases promptly.
the affected child may occasionally be children’s settings such as day care Control of case
acutely ill. centres, kindergartens and schools. General therapy may consist of saline or
Impetigo due to S. pyogenes is not soap and water or aluminium acetate
Reservoir
generally associated with scarlet fever solution or potassium permanganate
Humans.
but may rarely cause a solution to remove crusts.
glomerulonephritis. This usually occurs Mode of transmission For cases where Streptococcus pyogenes
three to eight weeks after the skin The organisms enter through damaged is suspected or confirmed treatment is
infection. Skin GAS infections may be an skin and are transmitted through direct generally phenoxymethylpenicillin or
important risk factor for rheumatic heart contact with patients or asymptomatic benzathine penicillin.
disease, independent of throat GAS carriers. Nasal carriers are particularly
Patients with penicillin hypersensitivity
carriage. likely to transmit disease. It is rarely
are generally given roxithromycin.
Impetigo in the neonate often follows S. transmitted by indirect contact with
objects. For cases where Staphylococcal aureus is
aureus colonisation of the nose,
suspected or confirmed mupirocin
umbilicus, rectum or conjunctivae. The
Period of communicability ointment is the usual treatment.
lesions are initially vesicular and become
If untreated, purulent discharges may
seropustular and may develop bullae
remain infectious for weeks to months.
(bullous impetigo). Lesions are most
96 The blue book: Guidelines for the control of infectious diseases

For severe, widespread or longstanding • avoiding direct contact with lesions on Treat confirmed cases with appropriate
infections flucloxacillin, cephalexin or the affected person if possible antibiotics.
roxithromycin may be used as each of • remembering to wash hands regularly • Draining lesions should be covered at
these drugs is active against both S. particularly after touching the lesions all times with a dressing.
aureus and S. pyogenes. or scabs of the infected person and • Trace and determine source of
In all cases see the current edition of the use gloves where possible infection. Consider:
Therapeutic guidelines: antibiotic • refer symptomatic contacts for
(Therapeutic Guidelines Limited). – examining staff for active lesions
appropriate treatment. anywhere on the body
General advice for patients with impetigo Control of environment
includes: – obtaining nasal swabs from staff to
See Control of contacts, above. detect asymptomatic carriers and
• consider using anti-bacterial soap for treating accordingly.
bathing for two to three weeks Outbreak measures
Child care settings and schools • Promote the need for good hand
• dispose of soiled dressings washing and hygiene practices among
• Exclude all confirmed cases and refer
appropriately staff and visitors to the unit where the
suspected cases for appropriate
• emphasise the need for hand washing, treatment and management. outbreak has occurred.
especially after changing dressings, • Investigate adequacy of infection
• Emphasise the need for good hand
and the importance of avoiding sharing control procedures and the availability
washing procedures for all staff and
toilet articles, towels, clothing or bed of hand washing facilities including
children.
linen antiseptic hand solutions.
• Advise parents of other children and
• avoid scratching or touching the
staff who may have had contact with Additional sources of information
lesions to prevent spread to other
the cases to remain vigilant for signs of • Centers for Disease Control and
areas of the body
impetigo and seek treatment if Prevention, Group A Streptococcal
• advise on the importance of symptoms develop. (GAS) Disease, www.cdc.gov/ncidod
completing the recommended
• Ensure that sores on exposed skin • Shelby-James, TM, Leach, AJ,
antibiotic course.
surfaces of confirmed cases are Carapetis, JR, Currie, BJ, Mathews, JD
Patients must be excluded from school covered with a watertight dressing 2002, ‘Impact of single dose
or child care services until antibiotic while at school. azithromycin on group A streptococci
treatment has commenced. Sores on
Hospital nursery or maternity ward in the upper respiratory tract and skin
exposed surfaces such as scalp, face,
• Cohort cases and contacts until all of Aboriginal children’, Pediatr Infect Dis
hands or legs must be covered with a
have been discharged. Staff working J, vol. 21, no. 5, pp. 375–80.
watertight dressing.
with colonised infants should not work
Control of contacts with non-colonised newborns.
Advice to household members should
• Obtain swabs from discharging lesions
include:
to determine organism.
• education about the mode of
transmission
Impetigo (school sores) information sheet
What is impetigo? How long does it take until When can children return to
Impetigo is a contagious skin infection symptoms start? school or child care?
usually caused by either Staphylococcus The incubation period will vary Children can return to school or child
or Streptococcus bacteria. It is most depending on the particular bacteria. care after treatment has started and the
commonly found in children although it It is usually 1–3 days for streptococcal sores are completely covered with a
may also occur in adults. and 4–10 days for staphylococcal watertight dressing.
Impetigo may affect skin anywhere on infections.
How can impetigo be prevented?
the body but commonly occurs in the
How is impetigo treated? • Encourage children to wash their
area around the nose and mouth. It first
• Impetigo is most often treated with hands regularly and always use their
appears as a small itchy, inflamed area of
antibiotics, either orally or with own towel and facecloth.
skin which blisters. The blisters rupture,
release a yellow fluid and develop honey- bactericidal ointment. It is important to • Cut your child’s nails short and
coloured crusts and form scabs. New follow the recommended treatment encourage them not to scratch scabs
blisters develop in the same area or in and complete the course of antibiotics. or pick their nose.
different parts of the body and may ooze • Treatment involves washing the sores • Keep injured areas of skin clean and
fluid which is highly contagious. and crusts every 12 hours or as covered to minimise the chance of any
Impetigo is easily diagnosed by the directed with the prescribed soap or bacterial infection, including impetigo.
doctor. Occasionally a skin swab may be lotion. After each wash pat dry. • Always wash your hands after touching
taken to identify the bacteria responsible • Healing should begin within 3 days and sores or scabs and use gloves if
for the infection. the infection eliminated in 7–10 days. possible when treating infected
• If the sores spread and get worse children.
How is impetigo spread?
Impetigo is extremely contagious. It can despite treatment or the child • Keep children with impetigo away from
be spread from one person to another becomes unwell with fever, see your other children for the period of
through touch or shared items such as doctor. exclusion. This is until antibiotic
clothes and towels. However, a person • Cover the sores with an airtight treatment has commenced and the
can also spread it to another part of their dressing if the child is returning to sores are covered with a watertight
own body through scratching or picking school in order to reduce the risk of dressing.
at the blisters and scabs. spreading the infection.
Further information
• The child’s clothes, towels and • Your local doctor
Who is most at risk of
bedclothes should be changed at least
developing impetigo? • Better Health Channel,
once a day.
Children are most at risk of developing www.betterhealth.vic.gov.au
impetigo. Children and adolescents may • Always remember to wash your hands
• Victorian Department of Human
be more likely to develop impetigo if the after touching scabs or sores or
Services, 1300 651 160
skin has already been irritated or injured handling infected clothing.
by other skin problems such as eczema,
insect bites, skin allergy or recent cuts or
How long does impetigo remain
abrasions.
infectious?
If untreated, oozing sores remain
infectious for as long as they persist.

Department of Human Services


www.health.vic.gov.au/ideas
98 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 99

Infectious
mononucleosis
(glandular fever)
Victorian statutory requirement ELISA IgG for nuclear antigen,antigen Period of communicability
Notification and school exclusion are not takes two to three months to become The period of communicability is
required. positive. prolonged. Pharyngeal excretion may
persist for a year or more after infection.
Infectious agent Incubation period Twenty per cent or more of EBV antibody
Epstein-Barr virus (EBV) is the causative The incubation period is from four to six positive healthy adults are long term
agent. weeks. oropharyngeal carriers.
Identification Public health significance Susceptibility and resistance
Clinical features and occurrence Everyone is susceptible to infection.
EBV is an acute viral infection affecting Occurrence is worldwide and widespread Infection confers a high degree of
mainly young adults. Clinical features in early childhood in developing resistance. Reactivation of EBV may
include fever, generalised countries. In developed countries the occur in immunosuppressed individuals.
lymphadenopathy and a sore throat that age of infection is delayed until older
usually is an exudative childhood or young adulthood and is Control measures
pharyngotonsillitis. most commonly seen in high school and Preventive measures
university students. Only 50% of those There is no vaccine available. Basic
Splenomegaly occurs in 50% of patients
infected will develop clinical disease. hygiene can help prevent many diseases
and jaundice in 4%. In young children the
disease is mild or asymptomatic. The Epstein-Barr virus appears to play a including glandular fever. Teach children
duration of symptoms varies from one to causative rolecausative role in: not to share spoons, forks, cups, soft
several weeks. A variety of uncommon drink cans or sports water bottles. Adults
• Burkett’s lymphoma which is a
complications have been described and should not share personal items such as
monoclonal tumor of B cells
fatalities are exceedingly rare. A chronic glasses, cigarettes, lipstick or other items
hyperendemic in highly malarious
form of the disease is suggested as one that may be covered in saliva.
zones of the world
of the causes of the chronic fatigue Control of case
• nasopharyngeal carcinoma, particularly
syndrome. Isolation is not necessary. There is no
among groups from China and Taiwan
Herpes virus 6, cytomegalovirus or treatment and antibiotics are not
• hairy cell leukemia. indicated.
toxoplasmosis may cause a syndrome
resembling glandular fever, both both Reservoir Control of contacts
clinically and haematologically. Humans. Not applicable.
Method of diagnosis Control of environment
Diagnostic ELISA IgG and IgM antibody Mode of transmission Not applicable.
testing can be conducted on sera. A full EBV is transmitted by person to person
Special settings
blood examination characteristically spread by the oropharyngeal route via
People with active EBV infection should
shows mononucleosis and a lymphocyte saliva, classically by ‘tongue-kissing’.
not visit people receiving organ
count of 50% or more. PCR testing is Young children may be infected by saliva
transplants including bone marrow.
available foravailable for CSF or tissue on the hands of attendants or on toys.
specimens through VIDRL. Virus can also Outbreak measures
be isolatedbe isolated from throatfrom Not applicable.
throat swabs or nasopharyngealor
nasopharyngeal aspirates.
100 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 101

Influenza
Victorian statutory requirement performed on blood specimens taken Most human infections are caused by
Influenza (Group B disease) must be during the acute and convalescent either type A or B influenza viruses. Type
notified in writing within five days of stages. A has been associated with widespread
laboratory confirmation. The diagnosis can be confirmed in the epidemics and pandemics, while type B
laboratory by one or more of the has been infrequently associated with
School exclusion: exclude until well.
following: regional epidemics, and type C is only
Infectious agent rarely associated with human infection.
• detection of influenza virus by culture
Influenza virus (types A, B and C) is the Influenza A is sub-typed further. It has
or nucleic acid testing, most commonly
causative agent. two surface antigens (proteins) that are
polymerase chain reaction (PCR)
testing used for sub-typing: haemagglutinin (H)
Identification
and neuraminidase (N). Since 1918 the
Clinical features • demonstration of a significant rise, only three influenza A sub-types known
Influenza is an acute respiratory disease. i.e. fourfold increase in the influenza- to usually cause human disease are
Symptoms include fever, headache, specific antibody titre between a H1N1, H2N2 and H3N2. Other subtypes
myalgia, lethargy, coryza, sore throat and serum sample collected in the acute such as HSN1 are very rare.
cough. Infections in children, particularly phase and another sample collected in
type A and B (H1N1) may also be the convalescent phase two to three Influenza viruses are formally named
associated with gastrointestinal weeks after onset of symptoms according to their type (A, B or C), their
symptoms such as nausea, vomiting and sub-type antigenic characterisation and
• a single high influenza-specific location of first isolation; for example,
diarrhoea. Croup is a common
antibody titre of five dilutions or influenza A (H1N1) or New Caledonia.
presentation in children.
greater. This means a titre of 160 or
Most symptoms resolve within two to greater, or 128 or greater, depending The emergence of completely new sub-
seven days although the cough may upon the titration method. types of type A virus (antigenic shift)
persist longer. Complications of influenza occurs at irregular intervals and is
include middle ear infections, secondary Incubation period responsible for pandemics. Minor
bacterial pneumonia and exacerbation of The incubation period is one to four days. antigenic changes (antigenic drift) are
underlying chronic health conditions. responsible for annual epidemics and
Public health significance regional outbreaks.
During influenza epidemics, patients with and occurrence
early influenza symptoms (fever >38ºC, Influenza occurs as pandemics, Reservoir
plus at least one systemic symptom such epidemics, outbreaks and as sporadic Humans are the primary reservoir.
as myalgia, and one respiratory cases. Animal reservoirs are suspected as
symptom) have a 60–70% chance of sources of new human subtypes and
Severe disease and complications such
having influenza infection. may occur particularly when people and
as viral and bacterial pneumonia occur
Method of diagnosis primarily among the elderly and those livestock (for example pigs and poultry)
A clinical diagnosis can be confirmed by debilitated by a chronic disease. live closely together. In 2004 an outbreak
culture or antigen testing of appropriate of avian influenza (influenza A H5N1)
In temperate zones outbreaks tend to caused a number of human infections in
respiratory specimens such as
occur in winter. In the tropics they often South East Asia.
nasopharyngeal aspirate or nose and
occur in the rainy season but outbreaks
throat swabs, taken within five days of
or sporadic cases may occur at any time.
onset. Or it can be confirmed by serology
102 The blue book: Guidelines for the control of infectious diseases

Mode of transmission Hemisphere winter. It normally includes For sporadic cases isolation is often
Influenza viruses are predominately representatives of both major influenza A unrealistic due to the delay in diagnosis.
transmitted by airborne spread in subtypes (H1N1, H3N2) and B strain. If cases are still symptomatic they should
aerosols but can also be transferred by Influenza vaccine is recommended on be advised to remain at home until well
direct contact with droplets. Nasal the Australian Standard Vaccination and to avoid contact with high risk
inoculation after hand contamination Schedule annually for all persons 65 persons.
with the virus is also an important mode years and older. Control of contacts
of transmission. Control of contacts may be of benefit in
Free annual influenza vaccine is provided
Direct contact is important, as the virus and recommended for the following high risk populations who should be
will survive some hours in dried mucus groups in Victoria: advised to seek medical advice on
particularly in cold and dry prophylaxis and to seek early medical
• all people aged 65 years and older review if symptoms develop.
environments.
• all Aboriginal and Torres Strait Chemoprophylaxis with amantadine or a
Period of communicability Islanders aged 50 years and older, and neuraminidase inhibitor may be
It is probably communicable for three to those aged 15–49 years who are at considered in special circumstances
five days from clinical onset in adults and high risk for the complications of against influenza A strains, for example in
up to seven days and occasionally longer influenza including those with: residential institutions. The potential
in young children.
– chronic disease such as diabetes, value of chemoprophylactic drugs must
Susceptibility and resistance heart, lung, kidney or liver disease be assessed against their side effects.
When a new subtype appears, all people – decreased immunity Control of environment
are susceptible except those who have – living in chronic care facilities Cases and carers should be advised
lived through earlier epidemics caused by about the importance of hand washing,
a related subtype. • all public hospital staff in both
covering the mouth when coughing,
outpatient and ward settings who
Infection produces immunity to the sneezing into disposable tissues, and the
provide direct care to patients, to
specific infecting virus, but the duration appropriate cleaning or disposal of
protect themselves and their patients.
and breadth of immunity varies widely. contaminated objects.
This is partly dependent on host factors, Annual influenza vaccination is also
recommended for staff working in Outbreak measures
the degree of antigenic drift in the virus
nursing homes and other chronic care The most important control measure to
and the period of time since the previous
facilities to protect themselves and their prevent serious morbidity and mortality
infection.
patients. from influenza epidemics is appropriate
Control measures immunisation. Investigations are generally
Control of case
Preventive measures restricted to outbreaks in groups at
Symptomatic treatment alone or with the
The influenza vaccine in Australia is higher risk of complications (see Special
addition of a neuraminidase inhibitor, if
developed in time for the annual winter settings, below).
commenced within the first 36 hours of
rise in ‘flu’ activity. The strains that are the onset of the illness, can shorten the An influenza pandemic results when
contained in the vaccine are based on duration by two to three days. Consult antigenic shift leads to a new highly
the circulating strains in the previous the current version of Therapeutic virulent influenza subtype for which there
couple of years as well as those guidelines: antibiotic (Therapeutic is little or no immunity in the population.
circulating in the previous Northern Guidelines Limited). Public health action in this setting may
The blue book: Guidelines for the control of infectious diseases 103

involve a variety of measures to control Additional sources of information


spread in the community. Victorian Infectious Disease Reference
Special settings Laboratory, The flu report,
Aged care facilities, health care facilities http://www.vidrl.org.au
and child care centres are all special (during flu season).
areas at high risk of influenza outbreaks.
Aged care facilities
Specific infection control measures
should be implemented in the event of:
• a laboratory-confirmed case of
influenza
• two or more cases of an acute
respiratory illness consistent with
influenza (’influenza-like illness’).
Infection control measures include
vaccination of any unvaccinated staff
and residents, exclusion of sick staff
members, cohorting of resident cases,
active case finding and, in some settings,
the use of antiviral treatment and
prophylaxis.
Health care facilities
Outbreaks of an unidentified respiratory
illness in a hospital setting including
outbreaks of influenza-like illness are
investigated jointly by the Department of
Human Services and the hospital’s
infection control unit.
Child care centres
Outbreaks of influenza or influenza-like
illness in child care require exclusion of
cases and may warrant prophylaxis for
high risk contacts. The Department of
Human Services can advise on
prophylaxis and infection control
procedures.
104 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 105

Invasive pneumococcal
disease
Victorian statutory requirement Public health significance Susceptibility and resistance
Invasive pneumococcal disease (Group B and occurrence Everyone is susceptible to infection,
disease) requires notification in writing S. pneumoniae is one of the most however the risk of invasive disease is
within five days of diagnosis. common causes of bacterial meningitis, highest for those aged less than two
septicaemia and pneumonia worldwide. years and the elderly. Other risk factors
Infectious agent Indigenous children in central Australia include prematurity and low birth weight,
Streptococcus pneumoniae is a gram- have the highest reported rates of immunosuppressive therapy and
positive Streptococcus of which 90 invasive pneumococcal disease exposure to tobacco smoke. Chronic
serotypes are known to cause disease. worldwide. The overall incidence rate in illness such as asplenia, sickle cell
Worldwide, approximately 23 serotypes Victoria is approximately 9 per 100 000 disease, cardiovascular disease, diabetes
account for the majority of infections. population per year, with an overall case mellitus, cirrhosis, Hodgkin’s disease,
fatality rate approaching eight per cent. lymphoma, multiple myeloma, renal
Identification
Rates of disease are highest in children failure, nephrotic syndrome, HIV infection
Clinical features
aged less than two years and persons and recent organ transplant are also risk
Invasive pneumococcal disease
aged 65 years and over. factors for infection. Immunity is thought
commonly presents as septicaemia,
The prevalence of antibiotic resistance is to be serotype specific.
meningitis and pneumonia. Septicaemia
and meningitis are more common in increasing. Approximately 12% of isolates
Control measures
children (with the exception of Aboriginal in 2001 in Australia were resistant to
Preventive measures
children who present most commonly penicillin and five per cent were resistant
A 7-valent pneumococcal conjugate
with pneumonia), while pneumonia is to third generation cephalosporins. The
vaccine (7vPCV) and a 23-valent
more frequent in adults. Other clinical prevalence of antibiotic resistant differs
polysaccharide pneumococcal (23vPPV)
presentations include septic arthritis, by State and Territory.
vaccine are both available in Australia.
peritonitis, pleurisy and pericardial Approximately 86% of serotypes causing
abscess.
Reservoir
S. pneumoniae are commonly found in disease in non-Indigenous children in
Method of diagnosis the upper respiratory tract of humans. Australia (55% in indigenous children) are
Identification of the organism by contained in the 7vPCV, and 93% of
culturing it from a normally sterile site Mode of transmission those causing adult disease are
like blood or cerebrospinal fluid or by Respiratory droplets, direct oral contact contained in the 23vPPV.
nucleic acid tests such as PCR. Rapid or indirect contact through articles In Australia the 23vPCV is recommended
antigen detection tests are available but freshly soiled with respiratory discharges. on the Australian Standard Vaccnation
they are of limited use in the diagnosis of Schedule for all persons aged 65 years
invasive disease in children due to the Period of communicability
and over, those in high risk groups and all
frequency of pharyngeal pneumococcal Bacteria are communicable in respiratory
Indigenous persons aged 50 years or
carriage. infections, until discharge from the
more. The vaccine is funded for all
mouth and nose no longer contain
persons aged 65 years and over and
Incubation period virulent pneumococci in significant
indigenous persons aged 50 years or
The incubation period is one to three numbers. Penicillin renders patients with
more, and those aged 15–49 years in
days. susceptible strains non-infectious within
certain high risk groups.
24–48 hours.
106 The blue book: Guidelines for the control of infectious diseases

The 7vPCV is recommended on the Outbreak measures


ASVS for all children at two, four and six In outbreaks in institutions or in other
months of age. From 1 January 2005 this closed population groups immunisation
vaccine will be funded under the National could be considered.
Immunisation Program. Refer to The
Australian immunisation handbook Additional sources of information
(National Health and Medical Research • Australian Government Department of
Council). Health and Ageing, National Indigenous
Pneumococcal and Influenza Program,
Control of case
http://www.health.gov.au
Penicillin remains the treatment of
choice until antibiotic sensitivities are • MJA 2000 ‘Pneumococcal disease in
obtained. Patients who are allergic to Australia’, Medical Journal of Australia,
penicillin may be given cephalosporins or vol. 173, Supplement.
erythromycin for pneumonia and • Roche P & Krause V. ‘Invasive
chloramphenicol for meningitis. Attempt pneumococcal disease in Australia’
to obtain blood or CSF specimens prior Comm Dis Intell, 2001, 24 (4);
to commencing therapy however 505–519.
treatment should not be delayed in
• Victorian Department of Human
children and infants, particularly if the
Services, Victorian Pneumococcal and
clinical presentation suggests
Influenza Program,
septicaemia or meningitis. Consult the
http://www.health.vic.gov.au/
current version of Therapeutic guidelines:
immunisation
antibiotic (Therapeutic Guidelines
Limited).
Respiratory isolation may be warranted
in hospitals for patients with infection
due to an antibiotic resistant strain to
reduce the risk of transmitting it to other
patients at high risk of pneumococcal
disease.
Control of contacts
Investigation of contacts is of no
practical value.
Control of environment
Disinfect or destroy articles
contaminated with discharges from the
nose and throat or from other infected
sites.
The blue book: Guidelines for the control of infectious diseases 107

Japanese encephalitis
Victorian statutory requirement Method of diagnosis Incubation period
Japanese encephalitis (Group A disease) Confirmation of JEV infection is made by The incubation period is usually six to
must be notified immediately by either isolating the virus or by a rising sixteen days.
telephone or fax followed by written antibody titre.
notification within five days. Public health significance
Laboratory evidence requires one of the
and occurrence
School exclusion: case should be following:
The occurrence of JEV disease in Papua
isolated until the fever subsides to • isolation of JEV from clinical material New Guinea and probable spread from
prevent further mosquito bites.
• detection of JEV viral RNA in clinical there to cause disease in the Torres
Infectious agent material Strait Islands poses a significant threat to
Japanese encephalitis virus (JEV) was Australia. Suitable vector mosquitoes
• IgG seroconversion or a significant
first isolated in Japan in 1935. However, such as Culex annulirostris and
increase in antibody level or a fourfold
the disease Japanese encephalitis had vertebrate hosts in the form of water
rise in titre of JEV specific IgG proven
been first described in Japan as early as birds are widespread across the
by neutralisation or another specific
1871, and since then has been found in mainland. There are also many wild pigs
test, with no history of recent JE or
Russia, most of the Far East and South in north eastern Australia to act as
yellow fever vaccination
East Asia, and more recently it has amplifiers for the virus. There is a
• JEV specific IgM in the CSF, in the theoretical concern that migratory birds
spread to the Indian subcontinent and
absence of IgM to Murray Valley could carry the virus southwards in
Nepal. It is the principal cause of
encephalitis, Kunjin and dengue Australia, even as far as Victoria.
epidemic viral encephalitis in the world,
viruses
resulting in of the order of 50 000 clinical
• JEV specific IgM detected in serum in Reservoir
cases annually.
the absence of IgM to Murray Valley Infection is maintained in enzootic cycles
Of great concern to Australia was the between birds and pigs: water birds
encephalitis, Kunjin and dengue
introduction of the JEV into the Torres (herons and egrets) are the main
viruses, with no history of recent JEV or
Strait islands (1995) with two fatal cases reservoir for disseminating the virus
yellow fever vaccination.
of encephalitis and on to the mainland of whilst pigs are important amplifier hosts.
Australia (Cape York) in 1998. Confirmation by a second arbovirus Pigs do not show signs of infection other
Seropositive pigs were also detected on reference laboratory is required if the than abortion and stillbirth, but have
the mainland. The most likely source of case appears to have been acquired in continuing viremia allowing transmission
the outbreak in the Torres Strait islands Australia. to man via mosquitoes. Humans and
was Papua New Guinea, where the first Clinical evidence other large vertebrates such as horses
human cases were detected in 1997. Febrile illness of variable severity are not efficient amplifying hosts, and are
associated with neurological symptoms therefore ‘dead-end’ hosts for the JEV.
Identification ranging from headache to meningitis or
Clinical features encephalitis. Symptoms may include Mode of transmission
Over 90% of Japanese encephalitis virus headache, fever, meningeal signs, stupor, In Asia the rice field breeding mosquitoes,
infections are subclinical. Encephalitis is disorientation, coma, tremors, mainly Culex tritaeniorhynchus, usually
its serious manifestation. This is clinically generalised paresis, hypertonia and loss transmit JEV. In the Torres Strait Islands
indistinguishable from other viral of coordination. The encephalitis cannot outbreak virus was isolated from Culex
encephalilitides and has a mortality of be distinguished clinically from other annulirostris mosquitoes which were
20–50%. Up to 50% of patients have central nervous system infections. considered to be the main vector
serious sequelae. involved. Culex gelidus is a new potential
vector in Australia if introduced from Asia.
108 The blue book: Guidelines for the control of infectious diseases

Period of communicability
There is no evidence of transmission
from person to person.

Susceptibility and resistance


Infection with JEV confers lifelong
immunity.

Control measures
Preventive measures
There is an effective vaccine available. It
requires three doses on days zero, seven
and 28 with a booster every three years.
Control of case
• Isolate patient and prevent mosquito
access until fever subsides.
• Investigate source of infection.
Control of contacts
Not applicable.
Control of environment
Search for and eliminate breeding sites
of mosquito vectors in the urban area.
Use mosquito repellents, mosquito nets
and other methods of personal
protection.

Outbreak measures
Not applicable.
The blue book: Guidelines for the control of infectious diseases 109

Kunjin virus disease


Arboviruses are viruses which are spread Fatalities are rare or absent. Very few Non-encephalitic illness
by the bite of arthropods, particularly epidemiological studies have been Acute febrile illness with headache,
mosquitoes. They are divided into carried out to determine the life cycle, myalgia and/or rash.
alphaviruses and flaviviruses. nature and frequency of Kunjin virus Encephalitic disease
infection in Australia. Acute febrile meningoencephalitis
Victorian statutory requirement
Method of diagnosis characterised by one or more of the
Kunjin virus infection (Group B disease)
Infection is confirmed by a significant following:
requires notification within five days of
rise in antibody titre to the virus in two • focal neurological disease or clearly
diagnosis.
blood specimens taken seven to ten days impaired level of consciousness
School exclusion is not required. apart.
• abnormal CT, MRI scan or EEG
Infectious agent Laboratory evidence requires one of the
following: • presence of pleocytosis in the CSF.
Kunjin virus (KUNV) is a flavivirus and
was first isolated from Culex annulirostris • isolation of Kunjin virus from clinical Incubation period
mosquitoes collected in north material The incubation period is probably similar
Queensland in 1960 and given the name to Murray Valley encephalitis virus
• detection of Kunjin virus RNA in clinical
of a nearby aboriginal clan living on the (MVEV) disease.
material
Mitchell River. It is closely related to the
West Nile virus which was probably • IgG seroconversion or a significant Public health significance
exported from the Middle East to New increase in antibody level or a fourfold and occurrence
York in 1999 where it caused thousands rise in titre of Kunjin virus specific IgG Kunjin virus has many similarities to MVE
of deaths in birds and horses and human proven by neutralisation or another virus and disease due to these two
disease including fatal encephalitis. specific test viruses can only be distinguished by
• Kunjin virus specific IgM detected in virological tests. This distinction is
Identification the CSF important in periods when weather
Clinical features patterns and other portends suggest that
Serological surveys indicate that • Kunjin virus specific IgM detected in
an outbreak of MVE virus may be
subclinical infection is common. Two serum in the absence of IgM to Murray
imminent in southeast Australia. This has
main clinical forms of disease have been Valley encephalitis, Japanese
a higher mortality rate and can be more
reported: mild disease and encephalitis. encephalitis or dengue viruses. This is
prevalent.
Mild disease consisting of only accepted as laboratory evidence
for encephalitic illnesses. Serological surveys have shown that
lymphadenopathy, fever, lethargy and
Kunjin virus infection has occurred over
rash was first noted when two laboratory Confirmation of laboratory results by a
wide areas of Australia infecting humans,
workers acquired the infection in second arbovirus reference laboratory is
and wild and domestic animals including
Queensland in 1963. A few other similar required if the case occurs in areas of
cattle, sheep and horses. Similarly to
cases have been described in Australia Australia not known to have established
MVE virus, Kunjin virus occasionally
including some with additional muscle enzootic, endemic or regular epidemic
spreads southward from the tropical
weakness and fatigue. There has been a activity.
north to central and southeastern
comparatively small number (about six) Clinical evidence Australia after heavy rains. Kunjin virus
of reported cases of encephalitis due to Clinical evidence may present as non- has been detected in Victoria on several
Kunjin virus but one source quoted that a encephalitic, encephalitic and occasions since 1974, most recently in
total of 15 cases occurred prior to 2000. asymptomatic disease. 2001.
110 The blue book: Guidelines for the control of infectious diseases

Reservoir The patient with suspected infection or Outbreak measures


The virus is endemic in the tropical north friend or relative, should be asked to Search for unreported or undiagnosed
of Australia and Sarawak where it has recall if in the month prior to onset of cases of encephalitis from the Murray-
cycles of infection between birds and symptoms he or she had: Darling drainage basin.
mosquitoes in enzootic foci. • been bitten by mosquitoes

Mode of transmission • visited regions where arboviruses are


Transmission occurs via mosquitoes, endemic
particularly Culex annulirostris. • participated in recreational or other
activities involving exposure to
Period of communicability bushland or other mosquito habitat
There is no evidence of person to person
such as gardening, bushwalking,
transmission.
camping and picnicking.
Susceptibility and resistance Control of contacts
Infection confers lifelong immunity. Not applicable.
Control of environment
Control measures
To reduce or prevent virus transmission,
Preventive measures
interruption of human-mosquito contact
There is no vaccine available.
is required by:
Kunjin virus infection can be prevented
• suppression of the vector mosquito
by:
population
• mosquito control measures
• avoidance of vector contact and biting
• personal protection measures such as times at dusk and dawn
long sleeves and mosquito repellents
• applying mosquito control measures in
• avoidance of mosquito-prone areas local municipalities
and vector biting times at dusk and
• using personal protection measures
dawn.
such as long sleeves, long trousers,
Control of case mosquito repellents
Investigate the source of infection.
• avoiding mosquito-prone areas.
Search for unreported or undiagnosed
cases of encephalitis from the Murray-
Darling drainage basin.
The blue book: Guidelines for the control of infectious diseases 111

Legionellosis
(Legionnaires’ disease)
Victorian statutory requirement Pontiac fever suspected. Culture is the gold standard
Legionellosis (Group A disease) must be A non-pneumonic form of the infection and the only method by which human
notified immediately by telephone or fax has been reported in other countries, specimens can be compared to
followed by written notification within five presenting as a flu-like illness with fever environmental samples. Sputum samples
days. and malaise lasting two to three days. for culture should be attempted for public
Although there is said to be a high attack health reasons even if there are already
School exclusion is not required.
rate (95%), recovery is rapid with no positive serological or urinary antigen
Infectious agent reported deaths. results.
Legionellae are gram-negative bacilli. Method of diagnosis Nucleic acid testing
There are currently more than 45 known Various methods of diagnosis for Detection of Legionella bacteria DNA in
species of Legionellae. Those that are Legionellae infection include urinary clinical specimens using polymerase
known to cause disease in Australia antigen testing, serology, culture and chain reaction (PCR) techniques is now
include L. pneumophila, nucleic acid testing. available in some reference laboratories.
L. longbeachae, L. micdadei and The sensitivities and specificities of such
Urinary antigen testing
L. bozemanii. L. pneumophila has 16 tests are variable. Legionella PCR
The Legionella urinary antigen test is the
identified serogroups. L. pneumophila requests should be discussed with the
most rapid and sensitive test currently
serogroup 1 has been identified as the Department of Human Services.
available but will only detect the most
cause of over 80% of cases in Victoria.
common serogroup,
Incubation period
Identification L. pneumophila serogroup 1. The antigen
The incubation period for Legionnaires’
Clinical features test may not become positive for up to
disease is two to ten days. For Pontiac
Legionellosis has two recognised five days into the illness and should be
fever it is 24 to 48 hours.
presentations: Legionnaires’ disease and repeated if the specimen was taken early
Pontiac fever. Only Legionnaires’ disease in the illness and legionellosis is still Public health significance
has been reported in Australia. strongly suspected. and occurrence
Serology Sporadic and epidemic forms of
Legionnaires’ disease
Positive Legionella antibody results (both Legionnaires’ disease occur in Australia.
This is the pneumonic form of the illness.
IgG and IgM) are common in healthy Legionella infections are believed to
There is often a severe flu-like prodrome
adult populations. The presence of account for 5–15% of community-
with anorexia, malaise, myalgia and fever.
antibodies is not necessarily indicative of acquired pneumonias.
Upper respiratory tract symptoms such
as runny nose and sore throat are rare. recent infection, especially in acute Outbreaks in Australia are generally
phase sera. Diagnosis is made by the associated with man-made water
Patients may present with any form of
observation of a significant four fold systems including water-cooling towers
pneumonia. As a group they are more
increase in antibody titre between sera and spa baths. Home and institutional
likely than other community acquired
taken in the acute phase and during warm water systems are potential
pneumonias to fulfill criteria for severe
convalescence three to six weeks later. sources of Legionella infection but are
disease. There are nearly always
The two samples should be tested only rarely implicated in Australia.
radiographic changes on CXR at the time
concurrently (in parallel). Legionella outbreaks due to
of presentation.
Culture contaminated warm water systems are
Other features commonly include regularly reported from other countries.
Legionellae are fastidious organisms and
hyponatraemia, fever greater than 40˚C,
will not grow on conventional culture Legionellosis in hospitalised and severely
renal impairment, diarrhoea and
media. Culture for Legionellae must be immunosuppressed patients carries a
confusion.
specifically requested if the illness is much higher case fatality rate.
112 The blue book: Guidelines for the control of infectious diseases

Reservoir Susceptibility and resistance To minimise the risk of infection through


Legionellae are ubiquitous in the There is a greater risk of more severe potting mix gardeners should be advised
environment. They are often isolated legionellosis in persons aged 50 years to:
from water and wet areas in the natural and over, regular smokers, and the • open the bag with care to avoid
environment such as creeks, hot springs, immunosuppressed. More than 70% of inhalation of airborne potting mix
seawater, woodchips, mulch and soil. infections in Victoria occur in patients
• moisten the contents to avoid creating
Potting mix is often colonised with over 50 years of age. The disease is
dust
Legionella species, particularly extremely rare in children.
L. longbeachae. • wear gloves
Nosocomial infections and infections in
Legionellae also thrive in man-made severely immunosuppressed patients • wash hands after handling potting mix
water systems if the water temperature is have a much higher case fatality rate (up even if gloves have been worn.
maintained at 20°C–43°C, which favours to 40%) when compared to the 7% overall The same measures are also advisable
the proliferation of the bacteria. These mortality rate in Victoria. when handling other gardening material
may include cooling water towers Serological surveys identify Legionella- such as compost.
associated with air-conditioning and specific antibody in 10–20% of healthy Only sterile water should be used in the
industrial processes, spa baths and adults with no history of clinical cleaning of nebuliser medication
household warm water systems for legionellosis. It is unclear whether this chambers and in the preparation of
bathing. Shower-heads, nebulisers, antibody confers protective immunity. aerosol solutions for use in nebulisers or
humidifiers, ultrasonic misting systems
humidifiers. Flushing and instillation of
and fountains have also been implicated. Control measures
drinking water through nasogastric tubes
Evaporative air conditioners like those Preventive measures
in intubated or immunosuppressed
commonly used for domestic cooling are Smoking is an important risk factor for
patients should also only be performed
not associated with Legionella infections. developing symptomatic infection in
with sterile water.
those exposed to Legionella bacteria, and
Mode of transmission it is presumed cessation of smoking Control of case
Legionellosis is generally transmitted reduces an individual’s risk of infection. Early antibiotic treatment improves
through inhalation of contaminated survival. Empirical treatment of severe
Although total eradication of Legionellae
aerosols of water or of dust. pneumonia with erythromycin to cover
from all artificial systems is not possible,
Microaspiration of contaminated water the possibility of legionellosis is
the risk of legionellosis can be minimised
may be an important mode of recommended.
through diligent maintenance of aerosol
transmission in certain subgroups, such generating equipment and ensuring The patient’s environmental exposures
as intubated patients and those receiving appropriate placement, design and during their incubation period are
nasogastric feeding. compliance with legislation requirements established by interview and compared
No human-to-human transmission has by owners. to other cases.
been recorded.
The blue book: Guidelines for the control of infectious diseases 113

Exposures of particular concern include: Outbreak measures


• contact with hospitals and other health When two or more cases are linked in
care facilities as a nosocomial source time and place an investigation is
presents the greatest risk to others generally undertaken to identify likely
Legionellae sources in the common area.
• exposure to cooling towers
Environmental sources sampled during
• use of spas the Department of Human Services’
• use of potting mix. investigations such as cooling towers
and spa baths are generally requested to
The Department of Human Services
be disinfected as a precaution while
routinely investigates workplaces of
laboratory testing is conducted.
confirmed cases.
Special settings
Control of contacts
Health care facilities
Although there is no risk of person to
When a nosocomial source is suspected,
person transmission,amongs an active
immediate testing and disinfection of
search for other people who may have
possible sources is undertaken and
been exposed to the same
active case finding is conducted
environmental source is commonly
throughout the institution.
undertaken as part of the investigation of
cases. Additional sources of information
Control of environment • Victorian Department of Human
After sampling of suspected Services Legionella Risk Management
environmental Legionellae sources, an Program (including relevant
immediate precautionary disinfection regulations),
with an oxidizing biocide is undertaken. http://www.health.vic.gov.au/
Disinfection may be impractical and environment
omitted if the source is organic such as
garden potting mix.
All cooling towers in Victoria are required
by law to be registered and to undergo
regular maintenance and water testing.
Records of treatment may be sought and
further disinfection may be required
depending on the circumstances of the
case, and in accordance with
regulations.
114 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 115

Leprosy
(Hansen’s disease)
Victorian statutory requirement Method of diagnosis endemic in tropical and subtropical Asia,
Leprosy (Group B disease) must be Clinical suspicion is the crucial factor in Africa, Central and South America,
notified in writing within five days of making an early diagnosis of leprosy in Pacific regions and the USA (Hawaii,
diagnosis. non-endemic parts of Australia, like Texas, California, Louisiana, Puerto Rico).
Victoria. Leprosy should always be
School exclusion: exclude until approval Reservoir
considered in any undiagnosed patient
to return has been given by the Humans.
with chronic skin lesions or a peripheral
Secretary. Contacts are not excluded.
neuropathy. This is particularly important
Mode of transmission
Infectious agent if they have spent more than brief
The mode of transmission is not clearly
Mycobacterium leprae is the causative periods in areas where the disease is
established. The disease is probably
agent. endemic, or they have been a contact of
transmitted from person to person by
a patient known to have leprosy.
aerosol with a high subclinical rate of
Identification
Confirmation of diagnosis depends on infection. Household and prolonged
Clinical features
the form: close contact seem important. There is
Leprosy is a slowly progressive bacterial
• lepromatous disease requires anecdotal evidence that rarely it may be
infection involving the cooler body
demonstration of plentiful acid-fast transmitted by inoculation, such as by
tissues, skin, superficial nerves, nose,
bacilli in skin or nasal smears. Skin contaminated tattoo needles.
pharynx, larynx, eyes and testicles. Skin
lesions may occur as pale, anaesthetic smears are made by scraping a small
amount of tissue fluid from a
Period of communicability
macules, papules or erythematous Leprosy is not usually infectious after
infiltrated nodules. superficial scalpel cut over a lesion and
three months of continuous treatment
smearing it on a glass slide.
Neurological disturbances are with dapsone or clofazimine, or after two
manifested by nerve infiltration and • tuberculoid disease requires to three weeks of treatment with
thickening with anaesthesia, neuritis, demonstration of typical granulomata rifampicin.
paraesthesia and trophic ulcers. with sparse acid-fast bacilli, in biopsies
of either skin or nerve lesions. Susceptibility and resistance
The disease is divided clinically and by
Everyone is susceptible to infection,
laboratory tests into two overlapping Incubation period however study results have suggested a
types: lepromatous and tuberculoid. The The incubation period is difficult to strong age-related susceptibility to being
lepromatous type (multibacillary or non- determine. It probably ranges from nine infected or developing disease following
immune form) is progressive with nodular months to 20 years with an average of close contact with a multi-bacillary case.
skin lesions, slow symmetric nerve four years for tuberculoid leprosy and Children aged between five and nine
involvement, numerous acid-fast bacilli in eight years for lepromatous leprosy. years are at greatest risk. The risk of
skin lesions and a negative lepromin skin
progression to leprosy disease following
test. The tuberculoid type (paucibacillary Public health significance
infection is considered to be
or immune form) is benign and non- and occurrence
approximately the same as tuberculosis
progressive with localised skin lesions, Leprosy is occasionally detected on
which is approximately a 10% lifetime
asymmetric nerve involvement, few routine refugee screening. The world
risk.
bacilli present in the lesions and a prevalence is estimated to be between
positive lepromin skin test. ten to 12 million cases. The disease is
116 The blue book: Guidelines for the control of infectious diseases

Control measures Control of contacts


Preventive measures Investigation of contacts and source of
BCG vaccination has some protective infection, and early detection and
efficacy and is recommended for treatment of new cases is required.
neonates born to a person diagnosed Prophylactic BCG has resulted in a
with leprosy. considerable reduction in the incidence
of tuberculoid leprosy among contacts in
Control of case
some trials. Other studies are currently in
Isolation of tuberculoid (paucibacillary)
progress using a single dose of rifampicin
cases is unnecessary. Isolation of
as prophylaxis following leprosy
lepromatous (multibacillary) cases is
exposure. Currently, treatment of
indicated until treatment is initiated,
contacts in Australia is not
particularly if nasal smears are positive.
recommended.
Nasal discharges of infectious patients
should be disinfected or disposed of as Control of environment
infectious waste. Not applicable.
Rifampicin is the key to early control of Outbreak measures
disease and rapid elimination of the risk Not applicable.
of further transmission of infection to
contacts. Minocycline can be used as an Additional sources of information
alternative. • Fine, PE, Sterne, JA, Ponnighaus, JM et
The minimal regimen recommended by al. 1997, ‘Household and dwelling
WHO for lepromatous leprosy is triple contact as risk factors for leprosy in
therapy with rifampicin, dapsone and northern Malawi’, Am J Epidemiol, vol.
clofazimine for twelve months. 146, no. 1, pp. 91–102.

For tuberculoid leprosy, the • World Health Organization,


recommended regimen is rifampicin and http://www.who.int/topics/en/
dapsone for a period of six months (for
detailed treatment regimens and
duration, see current WHO
recommendations).
The blue book: Guidelines for the control of infectious diseases 117

Leptospirosis
Victorian statutory requirement The diagnosis is more commonly Mode of transmission
Leptospirosis (Group B disease) must be confirmed serologically by the Primarily through contact of skin with
notified in writing within five days of demonstration of a fourfold or greater water, moist soil or vegetation
diagnosis. rise in Leptospira antibody in paired sera contaminated with the urine of infected
taken in the acute phase and at least two animals. The infection may also be
School exclusion is not applicable.
weeks later. A single Leptospira micro transmitted through direct contact with
Infectious agent agglutination titre of 400 or greater is urine or tissues of infected animals or by
Leptospires are members of the order of also highly suggestive of acute infection. the inhalation of aerosols of
Spirochaetes. Pathogenic leptospires contaminated fluids, such as may occur
belong to the species Leptospira
Incubation period in abattoirs. Ingestion of foods
Typically 10 to 12 days, with a range of contaminated with urine of infected rats
interrogans which is subdivided into
four to 19 days. is an occasional route of infection.
serovars. In Australia, the most common
serovar is Public health significance
L. interrogans serovar hardjo. Period of communicability
and occurrence Direct transmission from person to
Leptospirosis occurs worldwide in
Identification person is rare. Leptospires may be
developed and developing countries in excreted in the urine for a month, but
Clinical features
both rural and urban settings. The urinary excretion in humans and animals
This group of zoonotic bacterial diseases
disease is an occupational hazard for for up to 11 months has been reported.
may present in a variety of
farmers, sewer workers, miners, dairy and
manifestations. Common clinical features
abattoir workers and fish workers. It is a Susceptibility and resistance
include fever (which may be biphasic),
recreational hazard to bathers, campers Immunity to the specific serovar follows
headache, chills, a rash, myalgia and
and some sportspeople in infected infection, but may not protect against
inflamed conjunctivae. In endemic areas,
areas. infection with a different serovar.
many infections are either asymptomatic
or too mild to be diagnosed. Farmers, farm workers and meat industry
Control measures
workers in Victoria are the occupational
More severe manifestations occur rarely Preventive measures
groups most commonly affected by
and include, meningitis, haemolytic There is no human vaccine available.
leptospirosis.
anaemia, haemorrhage into skin and
General preventive measures include:
mucous membranes, hepatorenal failure, Reservoir
jaundice, mental confusion, respiratory • education for the public on modes of
Serovars vary with the wild and domestic
distress and haemoptysis. transmission, for example advise to
animal affected. Animal hosts in Victoria
avoid swimming or wading in
The acute illness may lasts from a few include rats, cows and pigs.
potentially contaminated waters and to
days to three weeks or more, with full Asymptomatic kidney infections in carrier
use appropriate personal protection
recovery often taking several months. animals can lead to prolonged and
when work requires such exposure
Method of diagnosis sometime lifelong excretion of
leptospires in the urine. • protecting workers in hazardous
Leptospires may be isolated from the
occupations with boots and gloves
blood (days 0 to 7), CSF (days 4 to 10)
during the acute illness, and from the • rodent control around human
urine after 10th day. habitations
• prompt treatment and isolation of
infected domestic animals
118 The blue book: Guidelines for the control of infectious diseases

The Department of Primary Industries Outbreak measures


can be consulted for advice on herd See Control measures, above.
immunisation.
Additional sources of information
Control of case
• Victorian Department of Primary
The usual treatment is doxycycline or
Industries, www.dpi.vic.gov.au,
benzylpenicillin. Consult the current
(03) 9296 4606 or 13 6186
version of the Therapeutic guidelines:
antibiotic (Therapeutic Guidelines • WHO/FAO/OIE Collaborating Centre
Limited) or seek specialist infectious for Reference and Research on
disease advice. Leptospirosis, Australia and Western
Pacific Region, Queensland Health,
Although person to person transmission
http://www.health.qld.gov.au/qhpss
is rare, cases should be nursed with
blood and body fluid precautions. Any
articles soiled with urine should be
disinfected and the patient should be
advised that they may continue to
excrete leptospires in the urine for a
month or more after the acute infection.
Control of contacts
Not applicable.
Control of environment
The exposure history of each case should
be investigated to identify and control
possible sources of infection such as
exposure to infected animals and
potentially contaminated bodies of water.
Environmental control measures may
include environmental clean-ups, and
draining or restricting access to
potentially contaminated water bodies.
The Department of Primary Industries
investigates suspected animal industry
sources such as dairies and piggeries,
and may recommend animal vaccination
or other disease control measures.
The blue book: Guidelines for the control of infectious diseases 119

Listeriosis
Victorian statutory requirement Late onset neonatal listeriosis generally Public health significance
Listeriosis (Group B disease) must be affects full-term babies who are usually and occurrence
notified in writing within five days of healthy at birth. Listeriosis is an uncommon disease in
diagnosis. The onset of symptoms in these babies humans. In Australia in 2003 the rate
Laboratories are required to notify occurs several days to weeks after birth was three infections per million
Listeria monocytogenes isolated from (a mean of 14 days), possibly as a result population for non-pregnancy Listeriosis
food or water. of infection acquired from the mother’s cases and 4.6 infections per 100 000
genital tract during delivery or postnatally births per year for maternal-foetal
Infectious agent through cross-infection. infections.
L. monocytogenes is a gram-positive Although most human cases appear to
In non-pregnant cases listeriosis usually
bacterium belonging to the genus be sporadic, three large outbreaks
presents as an acute
Listeria. Of the seven recognised species reported overseas have clearly
meningoencephalitis or septicaemia.
it is currently the only one implicated in established L. monocytogenes to be a
Focal infections such as pneumonia,
human cases. food-borne pathogen. These three
endocarditis, infected prosthetic joints,
localised internal abscesses and outbreaks in the Maritime Provinces
Identification
granulomatous lesions in the liver and (1981), Massachusetts (1983) and Los
Clinical features
other organs have been described. Angeles County (1985) involved a total of
Listeriosis predominantly affects:
Symptoms may have a sudden onset. 232 cases. The overall case fatality rate
• people who have was 36%. The implicated foods were
Fever, severe headache, nausea and
immunocompromising illnesses such coleslaw, pasteurised milk and Mexican-
vomiting can lead to prostration and
as leukaemia, diabetes and cancer style soft cheese.
shock.
• the elderly
The reported case fatality rate has been Reservoir
• pregnant women and their foetuses around 30% in both pregnancy and non- L. monocytogenes is widespread in the
• newborn babies pregnancy related groups. environment and commonly isolated
• people on immunosuppressive drugs Method of diagnosis from sewage, silage, sludge, birds, and
such as prednisone or cortisone. Listeriosis is diagnosed by isolation of wild and domestic animals. It has caused
Listeria monocytogenes from blood, CSF, infection in many animals and resulted in
Healthy adults are usually not affected
placenta, meconium, foetal abortion in sheep and cattle. The
but may experience transient, mild to
gastrointestinal contents and other bacteria are commonly isolated from
moderate flu-like symptoms.
normally sterile sites. poultry. It is a common contaminant of
Infection in pregnant women may be raw food.
mild and a temperature before or during Incubation period
Asymptomatic vaginal carriage occurs in
birth may be the only sign. However the The incubation period is mostly
humans and faecal carriage of up to five
infection can be transmitted to the unknown. Outbreak cases have occurred
per cent in the general population has
foetus through the placenta, which can 3–70 days after a single exposure to an
been reported. The significance of these
result in stillbirth or premature birth. implicated product. Median incubation is
carriers in the epidemiology of listeriosis
Babies may be severely affected with estimated to be three weeks.
is unknown.
conditions such as septicaemia or
meningitis (early-onset neonatal
listeriosis).
120 The blue book: Guidelines for the control of infectious diseases

Mode of transmission Control measures Safe foods include:


The main route of transmission is oral Preventive measures • freshly prepared foods
through ingestion of contaminated food. It is important to educate people in high
• freshly cooked foods, to be eaten
Other routes include mother to foetus via risk groups about the foods likely to be
immediately
the placenta or at birth. The infectious contaminated and about safe food
dose is unknown. handling and storage. • hard cheeses, cheese spreads,
processed cheese
People in high risk groups for
Period of communicability
listeriosis should avoid the following • milk- freshly pasteurised and UHT
Mothers of infected newborns may shed
high risk foods: • yoghurt
the infectious agent in vaginal discharges
and urine for seven to ten days after • ready to eat seafood such as smoked • canned and pickled food.
delivery. Infected individuals can shed fish and smoked mussels, oysters or
the organisms in their stools for several raw seafood such as sashimi or sushi
months. Safe food handling and storage:
• pre-prepared or stored salads,
including coleslaw and fresh fruit salad • wash your hands before preparing food
Susceptibility and resistance and between handling raw and ready
Although healthy people can be infected, • drinks made from fresh fruit or
to eat foods
the disease generally affects vulnerable vegetables where washing procedures
are unknown (excluding canned or • keep all food covered during storage
groups in the community such as:
pasteurised juices) • place all cooked food in the refrigerator
• people who have
• pre-cooked meat products which are within one hour of cooking
immunocompromising illnesses (such
as leukaemia, diabetes, cancer) eaten without further cooking or • store raw meat, raw poultry and raw
heating, such as pate, sliced deli meat fish on the lowest shelves of your
• the elderly
including ham, strassburg and salami refrigerator to prevent them from
• pregnant women and their foetuses and cooked diced chicken (as used in dripping onto cooked and ready to eat
• newborn babies sandwich shops) foods
• people on immunosuppressive drugs • any unpasteurised milk or foods made • keep your refrigerator clean and the
(such as prednisone or cortisone). from unpasteurised milk temperature below 5°C
There is little evidence of acquired • soft serve ice creams • strictly observe use-by and best before
immunity even after prolonged severe • soft cheeses, such as brie, camembert, dates on refrigerated foods
infection. ricotta and feta (these are safe if • do not handle cooked foods with the
cooked and served hot) same utensils (tongs, knives, cutting
• ready-to-eat foods, including leftover boards) used for raw foods, unless they
meats which have been refrigerated for have been thoroughly washed with hot
more than one day soapy water between uses

• dips and salad dressings in which • all raw vegetables, salads and fruits
vegetables may have been dipped should be well washed before eating or
juicing and consumed fresh
• raw vegetable garnishes.
The blue book: Guidelines for the control of infectious diseases 121

• defrost food by placing it on the lower Investigation/outbreak measures


shelves of a refrigerator or use a • Obtain medical history from treating
microwave oven doctor.
• thoroughly cook all food of animal • Obtain a food history from patient.
origin
• Test any available suspected foods.
• keep hot foods hot (above 60°C) and
• Assess the possibility of common
cold foods cold (at or below 5°C)
source outbreaks if there is a cluster of
• reheat food until the internal cases.
temperature of the food reaches at
• Epidemiological investigation of cases
least 70°C (piping hot)
should be used to detect outbreaks
• reheat left overs until piping hot and to determine source.
• when using a microwave oven, read • Molecular subtyping should be used to
the manufacture’s instructions determine the association between
carefully and observe the isolates from cases and any foods
recommended standing times, to positive for L. monocytogenes.
ensure the food attains an even
• Investigate the source of any foods found
temperature before it is eaten.
to be positive for L. monocytogenes to
Foods are regularly tested for the determine at what point they became
presence of L. monocytogenes. contaminated.
Processed, packaged ready to eat foods
• Recall contaminated food if necessary.
found to be contaminated with
L. monocytogenes are recalled from sale.
Control of case
Treatment is usually with penicillin or
amoxyl/ampicillin either alone or in
combination with trimethoprim+
sulfamethoxazole. For penicillin sensitive
patients trimethoprim+
sulfamethoxazole may be used alone
(see the current edition of Therapeutic
guidelines: antibiotic, Therapeutic
Guidelines Limited).
122 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 123

Malaria
Victorian statutory requirement The rapidly rising temperature is thick and thin films. Repeated
Malaria (Group B disease) must be commonly associated with shaking chills, examination may be necessary due to
notified in writing within five days of muscle pains, back pain, nausea and variations in density of parasites.
diagnosis. headache, and the episode frequently Confirmation of the species should be
ends with profuse sweating. Other sought from a reference laboratory.
School exclusion is not required.
symptoms may include confusion or
Infectious agent other neurological signs, diarrhoea, dark Incubation period
urine, jaundice, cough and respiratory The time between an infectious mosquito
Malaria is caused by parasites of the
distress. bite and the first detection of parasites in
Plasmodium spp. Four species of
a blood smear is generally 6–16 days.
Plasmodium (P.) can infect humans: The following severe complications may
Symptoms may not occur at that time
P. vivax, P. ovale, P. malariae and occur, usually with P. falciparum
and the first presentation of the infection
P. falciparum. Infection is most commonly infections: coma, acute encephalopathy,
may be delayed for weeks or months.
caused by P. vivax or P. falciparum, the cerebral oedema, vomiting, renal failure,
Commonly, clinical symptoms occur after
latter causing the most severe form of severe anaemia, thrombocytopenia,
7–14 days for P. falciparum, 7–30 days
malaria. Mixed infections may occur. pulmonary oedema, shock, acidosis,
for P. malariae and 8–14 days for P. vivax
coagulation defects, respiratory failure,
Identification and P. ovale.
liver failure and death. Case fatality rates
Clinical features Suboptimal suppression with
in non-immune people may be 10–40%.
The most prominent feature of malaria is prophylactic drugs may delay the clinical
fever. Classic descriptions of fever with a Atypical presentations can occur which
presentation and transmission by blood
regular recurring pattern every two or predominantly involve a diarrhoeal illness
transfusion usually results in a shorter
three days is not usually present when the and have resulted in delayed diagnosis
incubation period.
disease begins. Irregular fever also may and death. Other infections such as the
occur due to mixed infections, ineffective bacterial infection typhoid fever may Public health significance
use of prophylactic drugs and partial occur concurrently. These should be and occurrence
treatment. Patients commonly feel well on looked for, especially if the patient fails to The malaria situation worldwide is
the days when fever is absent. respond well to appropriate treatment. deteriorating. There are increasing levels
A presumptive diagnosis of malaria should Individuals who are partially immune or of transmission and it has returned to
be made for any person with a high fever have been taking anti-malarial areas where it had previously been
who has been to a malarious area until chemoprophylaxis, may show an atypical eradicated. Drug resistance has
proved otherwise, particularly with recent clinical picture with wide variations in the increased and there has been a spread
travel. incubation period. Malaria due to species of vector resistance to insecticides.
Early diagnosis with prompt appropriate other than P. falciparum is generally not life An estimated 220 million new infections
treatment is essential as malaria can be threatening except in the very young, very a year occur worldwide. The disease is
a fatal disease. If the initial blood film is old and those with immunodeficiency or endemic in areas of Asia, Africa and
negative for malarial parasites it should other concurrent disease. Central and South America.
be repeated within 12–24 hours and Method of diagnosis
preferably when the temperature is Malaria can be diagnosed by
rising. One negative test does not demonstration of malaria parasites in
exclude the diagnosis, particularly if the blood films. Blood samples should be
patient has taken antibiotics which may sent to a laboratory with experience in
result in partial treatment of the infection. the diagnosis of malaria by the use of
124 The blue book: Guidelines for the control of infectious diseases

The World Health Organization certified Period of communicability • using knock-down sprays, mosquito
Australia free of endemic malaria in 1981 Infected cases may remain infectious for coils, or plug-in vaporising devices
but several hundred imported cases are years if untreated or inadequately treated indoors
recorded each year. However the region so that gametocytes persist. The infected • using mosquito nets, preferably pre-
lying north of a line joining Townsville on mosquito remains infected for life. treated with an appropriate insect
the east coast and Port Hedland on the repellent.
west coast remains receptive and Susceptibility and resistance
vulnerable to the re-establishment of the People traveling to malarious areas are at There is no drug that is completely safe
disease. This is due to the presence of risk. and completely effective for prophylaxis
known or suspected vectors, suitable against malaria. The decision to
Control measures recommend chemoprophylaxis and the
environmental conditions and the
Preventive measures choice of drug(s) must involve an analysis
continual arrival of malaria-infected
Travellers should be advised of the four of the risks and benefits based on the
travellers.
principles of malaria protection: following considerations:
Many cases occur among migrants who
• be aware of the risk, the incubation • prevalence and type of resistance of
become infected after re-visiting their
period, and the main symptoms the malarial parasite to the available
native country after a delay of many
years when they may have lost their • avoid being bitten by mosquitoes, drugs
immunity. In Victoria, all malarial patients especially between dusk and dawn • level of malaria transmission
in recent times have provided travel • take antimalarial drugs • duration and place of stay, particularly
histories which include countries with (chemoprophylaxis) to suppress in rural areas
endemic malaria. Recently, the countries infection where appropriate
• intensity of vector mosquito contact
most commonly associated with
• immediately seek diagnosis and
imported malaria have been Papua New • availability of adequate health care
treatment if a fever develops one week
Guinea, East Timor and Indonesia. • age
or more after entering an area where
Reservoir there is a malaria risk. • traveller’s current health and medical
Humans. Personal protection against mosquito history
bites remains the first line of defence • risk of traveller not complying with
Mode of transmission against malaria. Measures to recommend recommendations.
A female Anopheles mosquito ingests include:
gametocytes from an infected human. All prophylactic drugs should be taken
The parasite must undergo 8–35 days of • avoiding outdoor exposure between with unfailing regularity for the duration
development within the mosquito before dusk and dawn of the stay in the malaria risk area and
the infective sporozoites are formed. The • wearing long, loose clothing after dusk, should be continued for four weeks after
sporozoites are transmitted to another preferably in light colours the last possible exposure to infection as
person via the bite of an infected parasites may still emerge from the liver
• avoiding perfumes and colognes
mosquito. and cause disease during this period.
• using effective insect repellents, for The single exception is atovaquone/
The disease may also be transmitted by example products containing up to 20% proguanil, which can be stopped one
blood or congenitally in untreated or DEET week after return. Over-reliance on
inadequately treated cases. chemoprophylaxis is ill-advised as drug
resistance by the malaria parasite
continues to change.
The blue book: Guidelines for the control of infectious diseases 125

Malaria poses a serious threat to If the species cannot be identified with


pregnant women as it can compromise confidence, the patient should be treated
foetal development, possibly resulting in as for the most serious infection with P.
premature labour or miscarriage. falciparum. Although primaquine reduces
Pregnant women should be advised to the risk of relapses of disease, relapses
avoid travel to malarious areas if can occur.
possible. Similarly, malaria presents Control of contacts
considerable risks for children, Travelling companions or recipients of
particularly the very young, and the any blood transfusion from the case
choice of suitable drugs is limited. should be warned that they may also be
Mosquito avoidance measures should be at risk of developing the disease and
emphasised. should seek help promptly if suggestive
There is no vaccine available. symptoms develop.
Control of case Control of environment
Isolation of the case is not required. Not applicable as Victoria’s ecology is
Mosquito contact with the patient should unlikely to sustain endemic malaria,
be prevented, especially in tropical areas although this is possible in northern
of Australia where mosquitoes capable of areas of Australia.
transmitting the disease are present. The
country of acquisition of the disease Outbreak measures
should be determined. It is important to Any outbreaks of malaria in Australia
exclude acquisition within Australia or require immediate public health
from an unusual source, such as a blood interventions.
transfusion, that would need further
Additional sources of information
investigation.
• Australian Government Department of
Treatment is complex and advice should Foreign Affairs and Trade,
be sought from an infectious disease http://www.smartraveller.gov.au/
physician. Most strains of
• Centers for Disease Control and
P. falciparum today are resistant to
Prevention, www.cdc.gov/travel
chloroquine. Only P. falciparum
contracted in some parts of China, • World Health Organization,
Central America and the Middle East are International Travel and Health booklet,
still sensitive to chloroquine. www.who.int/ith
P. vivax, P. ovale, and P. malariae are
sensitive to chloroquine but P. vivax
resistant to chloroquine has been found
in Irian Jaya, Myanmar, Papua New
Guinea and Vanuatu.
126 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 127

Measles (rubeola)
Victorian statutory requirement • cough, coryza, conjunctivitis and Serodiagnosis is not possible between
Measles (Group A disease) must be Koplik’s spots. eight days and eight weeks after measles
notified immediately by telephone or fax The characteristic red, blotchy rash vaccination. Suspected measles cases
followed by a written notification within appears on the third to seventh day. It who have been recently vaccinated prior
five days. begins on the face before becoming to their illness onset can only be
generalised and generally lasts four to confirmed as cases if they have an
School exclusion for cases and contacts
seven days. epidemiological link to a confirmed
is:
measles case or if a non-vaccine strain is
• cases should be excluded for at least Complications can include otitis media, identified in a clinical specimen by
four days after rash onset pneumonia and encephalitis. Sub-acute culture or molecular methods.
sclerosing panencephalitis (SSPE)
• immunised contacts do not need
develops very rarely as a late sequela. Incubation period
exclusion
Persons who have been previously The incubation period is approximately
• unimmunised contacts should be
immunised may present with non- ten days, but varies from seven to 18
excluded until 14 days after the first
classical features. days from exposure to the onset of fever.
day of appearance of rash in the last
It is usually 14 days until the rash
case. If unimmunised contacts are Measles infection (confirmed virologically)
appears.
vaccinated within 72 hours of their first may rarely occur without a rash.
contact with the first case or if they Method of diagnosis Public health significance
receive immunoglobulin within seven The diagnosis should be confirmed by and occurrence
days of the contact they may return to demonstration of anti-measles IgM The use of measles vaccine in infant
school. antibody, detection of measles RNA by immunisation programs globally has led
polymerase chain reaction (PCR) to a significant reduction in measles
Infectious agent cases and deaths. In addition to
techniques (if available) or by viral
Measles virus is a member of the genus
culture. The latter is particularly useful for providing direct protection to the vaccine
Morbillivirus.
epidemiological purposes. recipient immunisation against measles
Identification results in the indirect protection of
Suspected cases should be bled at the
Clinical features unimmunised persons (herd immunity) if
time of clinical diagnosis. The detection
Clinical features of measles include high enough coverage is achieved.
of anti-measles IgM increases to 100% for
prodromal fever, a severe cough, Measles vaccine has several major
samples taken 4–14 days after rash
conjunctivitis, coryza and Koplik’s spots effects on measles epidemiology. These
onset. If testing is negative for anti-
on the buccal mucosa. These are present include achieving an increase of the
measles IgM on a sample collected three
for three to four days prior to rash onset. mean age of infection and an increase in
days or less after rash onset, it should be
the time between epidemics.
The most important clinical predictors repeated between 4–14 days after rash
are included in the clinical case onset. Despite the availability of an effective
definition for measles which is an illness measles vaccine for almost 40 years the
The diagnosis can also be confirmed by
characterised by all the following disease still causes a considerable
demonstration of a fourfold or greater
features: burden in many countries. This is
change in measles antibody titre
primarily because of underutilisation of
• generalised maculopapular rash, between acute and convalescent-phase
the vaccine. In 2001 it was estimated
usually lasting three or more days, AND sera. These should be obtained at least
that there were 30 million measles cases
two weeks apart, with the tests
• fever (at least 38°C if measured) and 777 000 deaths. Most deaths
preferably conducted in parallel at the
present at the time of rash onset, AND occurred in developing countries,
same laboratory.
128 The blue book: Guidelines for the control of infectious diseases

principally in Africa and Asia. Thirteen who have not been vaccinated are most Control measures
countries reported that routine measles at risk along with the small numbers of Preventive measures
vaccine coverage was below 50%. Large unimmunised children. Live attenuated measles vaccine is
measles outbreaks continue to occur. recommended for all persons born after
These occur especially in areas of Reservoir 1966 unless specific contra-indications
developing countries with low vaccine Humans. to live vaccines exist.
coverage and among children living in
Mode of transmission It is recommended that this vaccine be
countries where there are unstable social
Measles transmission is airborne by given as measles-mumps-rubella (MMR)
conditions. These outbreaks frequently
respiratory droplet nuclei spread or it can vaccine at 12 months of age and a
have high case-fatality rates.
be transmitted by direct contact with second dose at four years of age (prior to
In Australia, live attenuated measles infected nasal or throat secretions. The school entry). The second dose is not a
vaccine was licensed in 1968 and virus can persist in the environment for booster but is designed to vaccinate the
included in childhood vaccination up to two hours. Transmission has been approximately five per cent of children
schedules in 1971. Even after the first reported to people whose only apparent who do not seroconvert to measles after
national measles campaign in 1988, source of infection was a room the first dose of vaccine.
coverage remained too low (85%) to presumably contaminated with measles Older children and adults born after 1966
achieve herd immunity. This allowed virus when it had been occupied by a who are unimmunised and those with
major measles outbreaks in many areas patient with measles up to two hours serological evidence of non-immunity
in 1993–94. In 1994 a second dose of earlier. should be given at least one dose of
measles-mumps-rubella (MMR) vaccine
MMR and ideally a second dose of MMR
was introduced for a year’s cohort of Period of communicability
one month later.
children aged between 10 and 16 years. Cases are infectious from slightly before
Although the incidence of measles the beginning of the prodromal period, A dose of MMR should also be given
declined, seroprevalence studies usually five days prior to rash onset. They postpartum for non-immune women,
indicated that further measles outbreaks continue to be infectious until four days followed a month later with a repeat
were likely. after the onset of the rash. dose. Pregnancy should be avoided for
28 days after vaccination.
In July 1998 a ‘catch-up’ campaign was Susceptibility and resistance
conducted to give a dose of MMR Unimmunised health care workers,
Natural infection provides lifelong
vaccine to all primary school children including medical practice staff, born
immunity. A history of prior measles
before lowering the recommended age after 1966 are at high risk of measles
infection should be confirmed
for the second dose of MMR vaccine to infection. The measles vaccination status
serologically before vaccination is
four years in 1999. After the measles of all health care workers measles should
deferred as reports of clinical measles
control campaign an estimated 96% of be assessed prior to commencing work
infection are not always accurate.
children aged five to 12 years had and non-immune workers should be
Vaccination at 12 months of age vaccinated with two doses of MMR
received two doses of MMR.
produces a protective antibody in vaccine.
Although the endemic spread of measles approximately 95% of recipients. The
has now been interrupted in Australia, second dose of vaccine, recommended
small outbreaks have continued to occur at 4 years, increases protection to
following importation of measles cases approximately 99% of recipients.
from overseas. Adults born after 1966
The blue book: Guidelines for the control of infectious diseases 129

Control of case • determine which of the contacts are • Infants six to nine months of age
There is no specific treatment for likely to be susceptible to measles (see should not be given MMR but should
measles. Treatment is supportive with below). be offered immunoglobulin if within
particular attention to the possible 2.Protection of susceptible contacts of a seven days from first contact with a
complications of measles, particularly measles patient with: case.
pneumonia and encephalitis. • Infants between nine and twelve
• MMR if within 72 hours of first contact
The case should be immediately isolated with the patient months of age should be offered early
to minimise any possible ongoing MMR if within 72 hours of first contact
transmission. If the case requires • immunoglobulin if longer than 72 hours with a case, and receive a further dose
hospitalisation they should be nursed in but within seven days from contact at 12 months of age or four weeks after
an isolation room, preferably with (see below); then offer MMR three the first dose, whichever is later. This
negative pressure ventilation, using months later. second dose does not replace the
respiratory and standard precautions. Susceptible contacts are best identified routine dose of MMR at four years but
Cases not requiring hospitalisation by excluding contacts not considered to is given because children under 12
should be advised to stay at home until be at risk. These are: months have a lower likelihood of
they are no longer infectious, usually the • children aged one to four years who becoming immune (seroconverting)
fifth day after rash onset. Children are have documented evidence of having after measles vaccination.
excluded from school or child care for at had one measles vaccine dose If contact with the infectious case
least four days after the onset of the • persons born after 1966 who have had occurred between 72 hours and seven
rash. two measles vaccine doses days, immunoglobulin should be offered
The Department of Human Services (see below).
– susceptible contacts who have
actively investigates all suspected documented evidence of having had Immunoglobulin prophylaxis
measles cases to confirm the diagnosis, at least one measles vaccine dose The recommended dose of
identify the source of infection, identify do not require immunoglobulin but immunoglobulin is 0.2 mL/kg body
other cases, and to identify and protect should be offered a second MMR weight (maximum dose = 15 mL) given
susceptible contacts in the community. dose by deep intramuscular injection. Children
Control of contacts who have immunodeficiency diseases
• persons born before 1966, as they are
The Department of Human Services will such as leukaemia, lymphoma, or HIV
likely to have natural immunity
trace and manage susceptible community infection require a higher dose (0.5
• persons with documented evidence of mL/kg body weight, maximum dose = 15
contacts of cases. The responsibility of
immunity through vaccination or mL).
identifying and protecting susceptible
natural infection.
contacts exposed in health care Control of environment
institutions, such as medical practices or Prophylaxis for contacts under 12 Any room visited by a patient while
emergency departments, is the months of age infectious should be left vacant for at
responsibility of the individual institution. • Infants less than six months of age least two hours after the patient has left.
should not be given MMR and should This includes medical consulting rooms.
Control measures require:
not be offered immunoglobulin unless Environmental clean-up is not generally
1. Identification of susceptible contacts: the mother is a case, or the mother has recommended, although items
• make a list of other people who been tested and found to have no contaminated with nasal and throat
attended the same area at the same measles immunity. discharges should be disposed of
time or within two hours after the visit carefully.
of the measles patient, including staff
130 The blue book: Guidelines for the control of infectious diseases

Outbreak measures During an outbreak, children and their


Outbreaks in the community setting siblings who are aged between one and
occur sporadically as a result of imported four years should receive their routine
measles cases exposing local second dose of MMR early (but not less
susceptible people. The epidemiology of than four weeks after their first dose).
outbreaks has changed with the They are then considered to have
introduction of childhood vaccination, completed their MMR vaccination
with young adults now at highest risk. schedule and so do not need a further
Outbreaks in schools may still occur if dose at four years of age.
there are significant numbers of Child care
unvaccinated students. If there is a case of measles in a child
The Department of Human Services care setting where infants between six to
conducts detailed investigations of twelve months of age are present, they
clusters of cases. should be excluded from attendance for
14 days to interrupt local transmission:
Special settings
Infants can return if they receive MMR
Schools
vaccination (9 –12 months) within 72
Although outbreaks mainly affect
hours of their first contact or if they
unvaccinated children, highly vaccinated
receive immunoglobulin (6–12 months)
school populations have also been
within seven days.
affected.
It is not necessary for infants under six
Cases are excluded from school and
months to be excluded unless the
child care for at least four days after rash
mother is a case, or where the mother is
onset.
aware she has no protective immunity.
Immunised contacts are not excluded.
Unimmunised contacts should be Additional sources of information
excluded until 14 days after the first day • Communicable Diseases Network
of appearance of the rash in the last Australia New Zealand 2000,
case. Guidelines for the control of measles
If unimmunised contacts are vaccinated outbreaks in Australia, Communicable
within 72 hours of their first contact with Diseases Intelligence technical report
the first case or if they receive series, www.cda.gov.au
immunoglobulin within seven days of the
contact they may return to school.
The blue book: Guidelines for the control of infectious diseases 131

Melioidosis
Victorian statutory requirement Incubation period Period of communicability
Notification is not required although it is Australian data suggests an incubation The disease is only very rarely
recommended that cases of melioidosis period of 1–21 days. This can be transmitted person to person.
with a history of travel to northern prolonged in infections which initially
Australia be reported to public health become latent. Susceptibility and resistance
units in the relevant state or territory. Disease in humans is uncommon even
Public health significance among people in epidemic areas who
School exclusion is not required.
and occurrence have close contact with soil or water
Infectious agent Melioidosis is endemic in South East Asia containing the infectious agent.
Burkholderia pseudomallei are small and northern Australia. It is now Approximately two thirds of cases have a
gram-negative, aerobic bacillus. It was recognised in the northern areas of the predisposing medical or recrudescence
previously named Pseudomonas Northern Territory as the most common in asymptomatic infected individuals.
pseudomallei or Whitmore’s bacillus. cause of fatal community-acquired
bacteraemic pneumonia and as the most Control measures
Identification common cause of severe community Preventive measures
Clinical features acquired sepsis in Thailand. The There is no vaccine available. Basic
Pneumonia is the most common clinical incidence of disease in Victorian hygiene can help limit the spread of
presentation of melioidosis, ranging from residents is unknown. many diseases including melioidosis and
a mild respiratory illness to a severe measures such as wearing shoes outside
In a 10-year prospective study in the
pneumonia with septicaemia, with a may prevent transmission.
Northern Territory 252 cases were
mortality rate often over 50%. Other identified, with a case fatality rate of 19%. Control of case
presentations include skin abscesses or The majority of cases in northern A history of travel to northern Australia or
ulcers, internal abscesses of the prostate, Australia occur during the wet season in tropical regions of South East Asia should
kidney, spleen and liver, fulminant November to April. Disease can affect all be determined.
septicaemia, and neurological illnesses ages but is more common in adults and Initial intensive antibiotic therapy usually
such as brainstem encephalitis and acute predominantly occurs in males and consists of trimethoprim/
flaccid paralysis. Asymptomatic infection Australian Aboriginals. Risk factors for sulfamethoxazole with ceftazidime,
can occur and in a small proportion of disease include diabetes, chronic lung meropenem, or imipenem. The
these people the infection can re-activate and renal disease and excess alcohol trimethoprim/sulfamethoxazole
from a latent form many years later. consumption. component is usually continued for three
Method of diagnosis months to ensure eradication. Consult
A definitive diagnosis of melioidosis can Reservoir the current version of Therapeutic
only be made by isolation of the Burkholderia pseudomallei have been guidelines: antibiotic (Therapeutic
organism from the respiratory tract, lung, found in soil and water in tropical regions Guidelines Limited). Specialist infectious
blood or other sites. of northern Australia and South East disease advice should be sought for all
Asia. cases.
The likelihood of a bacterial diagnosis is
increased by using selective culture Mode of transmission Follow-up of cases and adherence to
media (modified Ashbrown’s broth), Infection is thought to be acquired eradication therapy are critical to prevent
frequent sampling (sputum, throat, rectal through percutaneous inoculation, relapse, which can be fatal.
and ulcer swabs) and collection of blood although inhalation and ingestion are
cultures. also possible.
132 The blue book: Guidelines for the control of infectious diseases

Control of contacts
Investigation of potential sources is
important. Human carriers are not
known.
Control of environment
Not applicable.

Outbreak measures
Melioidosis has been identified as a
potential bioterrorism agent. Any case or
cases presenting without a clear history
of exposure in an endemic area should
be reported to the Department of Human
Services for further investigation.

Additional sources of information


• Currie, BJ, Fisher, DA, Howard, DM,
Burrow, JNC et al. 2000, ‘Endemic
melioidosis in tropical northern
Australia; a ten year prospective study
and review of the literature’, Clin Infect
Dis, vol. 31, pp. 981–986.
• Currie, BJ 2000 ‘Melioidosis: an
Australian perspective of an emerging
infectious disease’, Recent Adv
Microbiol, vol. 8, pp. 1–75.
• Currie, BJ, Fisher, DA, Howard, DM,
Burrow, JNC et al. 2000, ‘The
epidemiology of melioidosis in
Australia and Papua New Guinea’, Acta
Tropica, vol. 74, pp. 121–127.
• Northern Territory Centre for Disease
Control, http://www.nt.gov.au/health
The blue book: Guidelines for the control of infectious diseases 133

Meningococcal disease
Victorian statutory requirement Method of diagnosis incidence in the winter and spring
Suspected or confirmed meningococcal Diagnosis is usually made on clinical months. Although the reasons for this
infection (Group A disease) must be grounds confirmed by laboratory tests. seasonality are not clear, there is
notified immediately by telephone or fax Laboratory tests include: evidence that influenza virus or
followed by a written notification within • gram stain of cerebrospinal fluid, skin Mycoplasma pneumoniae infections may
five days. lesion smear or joint fluid predispose to invasive disease and that
closer personal contact or lack of
School exclusion: cases should be • culture of blood, CSF or other sterile ventilation may facilitate transmission of
excluded until adequate carrier site meningococci.
eradication therapy has been completed.
• polymerase chain reaction (PCR). The three major serogroups of
Contacts do not need to be excluded if
receiving carrier eradication therapy. Meningococcal isolates from all cases of meningococci cause different patterns of
invasive disease should be sent to MDU disease. Serogroup A meningococci
Infectious agent at the University of Melbourne to ensure cause outbreaks of infection in areas
Neisseria meningitidis (the appropriate monitoring of serogroups such as the meningitis belt of Africa
meningococcus) is a gram-negative and to perform susceptibility testing. This where the incidence of meningococcal
diplococcus. Various serogroups have needs to be authorised by the infection rises sharply towards the end of
been recognised including groups A, B, Communicable Diseases Section of the the dry season and declines rapidly with
C, 29E, H, I, K, L, W135, X, Y and Z. Within Department of Human Services. the onset of rains. The epidemics occur
these groups, certain serotypes have in 8–14 year cycles. Since 1990 New
been identified, for example, group B Incubation period Zealand has been experiencing an
serotypes 2b and 15. In 2004 groups B The incubation period is commonly three epidemic of serogroup B meningococcal
and C were the most common in to four days, but can vary from two to disease. Age-standardised rates for Maori
Victoria. seven days. People who do not develop and Pacific Island people were three and
the disease in the seven days after six times higher respectively than for the
Identification colonisation may become asymptomatic European population. Serogroup C
Clinical features carriers. meningococci are usually associated
Clinical features of meningococcal
with sporadic disease but can cause
infection include an acute onset of Public health significance
small or large outbreaks. Attack rates for
meningitis or septicaemia. Typical and occurrence
serogroup C are between those seen
features of these include fever, intense Invasive meningococcal infections occur
with serogroups A and B.
headache, nausea, vomiting and neck in endemic and epidemic forms. In
stiffness. There may be a petechial or Australia epidemic disease has not Meningococcal disease has had cyclical
purpuric rash on the trunk and limbs occurred for many years. Endemic peaks of incidence. Notification of
that may sometimes cover large areas of disease is at low levels of incidence and ‘meningitis’ reached a peak of 33.1 cases
the body. In fulminating cases there is cases are generally unrelated to each per 100 000 in 1942 (2371 cases) as part
sudden prostration and shock other. Despite this, invasive of a pandemic of serogroup A disease
associated with the characteristic rash meningococcal disease is of public during World War II. Apart from another
and this condition has a high fatality health importance and is frequently a peak of activity in the early 1950s, there
rate. Chronic meningococcal cause of public alarm and receives a high was a steady decline of notifications to
septicaemia can also occur with febrile level of media attention. less than 0.5 cases per 100 000 in 1987.
episodes, skin rashes and fleeting joint The notification rate for meningococcal
Meningococcal disease characteristically
pains. disease to the National Notifiable
has a seasonal pattern with a peak of
Diseases Surveillance System (NNDSS)
134 The blue book: Guidelines for the control of infectious diseases

has been slowly increasing over the past Period of communicability There is no evidence to suggest carriers
10 years from 1.6 per 100 000 in 1991 to It is communicable until the organisms will suddenly become cases after weeks
3.1 per 100 000 in 2000. In 2002 there are no longer present in discharges from or months of carriage.
were 129 notifications in Victoria (1/3 of the nose and mouth. Conjugate vaccines are available that
the national total) of which 47 were can give long lasting protection against
serogroup B and 72 were serogroup C. Susceptibility and resistance
meningococcal serogroup C disease.
Susceptibility to clinical disease is low as
There is no vaccine for meningococcal
Reservoir evidenced by the usual high ratio of
serogroup B disease. There is
Human. carriers to cases. Susceptibility
polysaccharide quadrivalent vaccine
decreases with age although a
Mode of transmission available in Australia against groups A, C,
secondary peak of meningococcal
Respiratory droplets shed from the upper Y and W135 however it cannot be given
meningitis occurs in adolescents and
respiratory tract transmit meningococci under two years of age and only protects
young adults in the age group of 15–24
from one person to another. Humans are for one to five years. This vaccine is
years. Patients deficient in certain
the only natural hosts for meningococci considered a ‘travel’ vaccine for travellers
complement components in the blood
and the organism dies quickly outside to epidemic and highly endemic areas
are prone to recurrent meningococcal
the human host. It is not able to be such as Brazil, Mongolia, Vietnam, India,
infections. There is an increased and
isolated from environmental surfaces or Nepal and sub-Saharan Africa and is a
prolonged risk of secondary infections in
samples. requirement for visits to Mecca.
close contacts. In one series, the
Salivary contact has in the past been incidence of such infection was 0.5% There are different brands of (conjugate)
regarded as a means of transmission of with a median interval of seven weeks meningococcal serogroup C vaccine
meningococci. There is little evidence to between the index and secondary cases. available. The vaccines contain
support this view. Available evidence Secondary cases have been reported up meningococcal serogroup C ‘sugars’
indicates that neither saliva nor salivary to five months later. The risk in joined with an inactive protein of either
contact is important in the transmission household contacts is 500 to 800 times diphtheria or tetanus toxoid and additives
of meningococci. Saliva has been shown higher than in the general population. aluminium phosphate or hydroxide.
to inhibit the growth of meningococci. There is no maternal immunity. Under the National Immunisation
Carriage of meningococci has not been Program, a single dose of meningococcal
convincingly shown to be associated with Control measures serogroup C vaccine is given at 12
saliva contact. A case-control study of Preventive measures months of age. If parents wish to
United Kingdom university students Note that most strains of meningococci purchase vaccine to immunise their child
found no association between carriage of do not cause disease, but instead prior to 12 months of age, infants from six
meningococci and sharing of drinks or provide protection. Other protective weeks to four months of age at the
cigarettes and a weak association with bacteria such as Lactamicas (Neisseria commencement of vaccination receive
‘intimate kissing’ (OR = 1.4 & 95% CI, lactamica spp) also colonise the three doses one to two months apart.
1.0–1.8%). nasopharynx. By giving Babies from four months to 11 months at
It is unclear whether carriage in these chemoprophylaxis when it is not needed the commencement of vaccination
circumstances is due to saliva contact these bacteria, which are protective, are receive two doses one to two months
rather than to droplets shed during also eradicated. People can carry apart.
household-like (close and prolonged) meningococci with no ill effects for many
contact. months. Carriage produces protection.
The blue book: Guidelines for the control of infectious diseases 135

The National Meningococcal C Clearance antibiotics should only be Clearance antibiotics should only be
Vaccination Program is a four year given to the following people (see below) given to those people who are at risk of
program from 2003–2006 in which all who have had contact with the case either being the source of disease in the
persons aged 1–19 years in 2003 are seven days prior to the onset of the case, or of having acquired the invading
eligible for a dose of meningococcal C case’s illness. They should be organism from the case. The aim of
vaccine. commenced as soon as possible after clearance antibiotics is to prevent further
Control of case diagnosis. transmission.
Prompt treatment with parenteral Contacts include: There are three antibiotics currently used
penicillin in adequate doses should begin • household contacts are defined as for the chemoprophylaxis of
when a presumptive clinical diagnosis is those people living in the same house meningococcal disease. Each agent has
made prior to laboratory confirmation. In and include recent visitors who stayed advantages and disadvantages and each
cases with a very acute onset, such overnight in the seven days preceding is the preferred agent in specific
treatment should commence prior to the onset of the case’s illness circumstances.
transfer of the patient to hospital even Clearance antibiotic for contacts of
though there may be some interference • dormitory contacts in boarding
schools, military barracks, school meningococcal disease:
with laboratory confirmation by culture. Rifampicin can be dispensed for
Suitable alternatives for patients who are camps, and hostels in the seven days
preceding the onset of the case’s meningococcal prophylaxis as syrup for
allergic to penicillin include ceftriaxone, children or in capsules for older children
cefotaxime or chloramphenicol. illness
and adults. The product information
Since penicillin only temporarily • sexual (intimate) contacts should be consulted for the adverse
suppresses but does not eradicate the • medical, nursing, or paramedical events and side effects of rifampicin,
organisms in the nasopharynx, all staff that have performed mouth-to- although it should be noted that the
patients should be treated with a drug mouth resuscitation or intubation or product information recommends a
such as rifampicin prior to discharge from suction or similar intimate treatment once-daily four-day regimen of rifampicin
hospital. If ceftriaxone is used in with a case of meningococcal disease for the chemoprophylaxis of
treatment rifampicin need not be given. prior to being started on therapeutic meningococcal disease. The two-day
Consult the current version of antibiotics. regimen (below) is recommended by the
Therapeutic guidelines: antibiotic The risk of meningococcal disease in Communicable Diseases Network
(Therapeutic Guidelines Limited). close contacts, whilst higher than the Australia.
Control of contacts general population, is still very low. The Age Dose
Meningococci are likely to have been risk is highest in the first seven days after 0–2 months 1 mL syrup* Twice daily
acquired from an asymptomatic person a case and falls rapidly during the for 2 days
(carrier) who either lives in the same following weeks. If antibiotic prophylaxis 3–11 months 2 mL syrup*
household or is a sexual partner of the is not given, the absolute risk to an
1–5 years 7.5 mL syrup*
sick person. Children tend to acquire individual in the same household one to
their disease from adults (in their 30 days after an index case is about one 6–12 years 300 mg capsule
household) whereas teenagers and in 300. The increased risk in household > 12 years 600 mg capsule
adults are more likely to acquire their members may be due to a combination
*Rifampicin syrup contains 100 mg/5 mL
disease from close friends. of genetic susceptibility in the family,
increased exposure to virulent
meningococci and environmental factors.
136 The blue book: Guidelines for the control of infectious diseases

Ciprofloxacin: Adults 500 mg orally, Clusters of invasive meningococcal


single dose (minimum age 12 years and disease in people who have had a low
weight >40 kg). This is preferred in level of salivary contact like footballers
women taking the oral contraceptive pill. who have shared drink bottles or
Although ciprofloxacin is not registered churchgoers who have shared a
for chemoprophylaxis of meningococcal communion cup appear to be very rare.
disease in Australia the Communicable Although clusters have been described,
Diseases Network Australia recommends for example, in association with sporting
it for that purpose. events and sports clubs, the reported
Ceftriaxone: Adults 250 mg IM details indicate that point-source salivary
(recommended for pregnant contacts). transmission was not involved.
This may be dissolved in lignocaine 1% Secondary cases in situations where
solution to reduce pain at the injection dribbling of saliva is common such as
site. Dosage for children (<12yrs) is 125 child day-care centres are also rare.
mg IM. Not for infants under 1 month of
Additional sources of information
age.
• Australian Government Department of
Control of environment Health and Ageing 2003, ‘Annual
Respiratory isolation is recommended for report of the Australian Meningococcal
24 hours after commencing treatment. Surveillance Programme’,
There should be concurrent disinfection Communicable Diseases Intelligence,
of discharges from nose or throat and vol. 27, no. 2.
articles soiled with such discharges.
• Communicable Diseases Network
Articles used by the patient should be
Australia 2001, Guidelines for the early
terminally cleaned.
clinical and public health management
Outbreak measures of meningococcal disease in Australia.
When there are two or more cases in four • Public Health Laboratory Service 2002,
weeks of exactly the same strain in a Meningococcus forum: Guidelines for
childcare centre, school or university, all public health management of
students and staff in the same class or in meningococcal disease in the UK,
the same group as the case will be given http://www.hpa.org.uk/infections
clearance antibiotics. If serogroup C • Victorian Department of Human
disease is identified a vaccination Services, Advice for medical practitioners,
campaign may be instituted. http://www.health.vic.gov.au/ideas
The blue book: Guidelines for the control of infectious diseases 137

Molluscum
contagiosum
Victorian statutory requirement Public health significance Control of case
Notification and school exclusion are not and occurrence Isolation of case is not required. Infected
required. Molluscum contagiosum infection occurs children should either avoid contact
worldwide. Surveys in other countries sports or ensure lesions are adequately
Infectious agent suggest peak incidence occurs during covered during play. No school exclusion
Molluscipoxvirus is a member of the pox childhood. is required.
virus (Poxviridae) family.
Lesions typically resolve without Transmission through warm water is only
Identification complication. Molluscum contagiosum very rarely observed. The risk of
Clinical features may be more severe and more persistent transmission through public swimming
This is a viral disease of the skin that in immunosuppressed patients and pool contact is very low and exclusion is
produces firm, smooth, spherical, pearly particularly in patients with HIV/AIDS. rarely if ever necessary.
white papules with a central dimple. Many treatments are cited in the
Most papules are 2–5 mm in diameter,
Reservoir
literature with destruction of the lesions
Humans.
although papules may coalesce to form as their common goal but there is
larger lesions. Mode of transmission minimal evidence to support them.
Lesions in adults are more common on Molluscum is transmitted by direct Watchful waiting may still be the best
the lower abdomen, genitalia or inner contact, fomites or sexual contact. option for many patients. Phenol ablation
thighs. In children lesions are more Autoinoculation through scratching is may produce significant scarring. Other
common on the face, trunk, and limbs. also suspected. topical preparations are under
Lesions may disseminate more widely in investigation.
patients with HIV infection. Period of communicability Control of contacts
The period of communicability is Not required.
Molluscum contagiosum may persist for
unknown but probably as long as the
six months to two years without Control of environment
lesions persist.
treatment. Lesions may resolve Not required.
spontaneously or possibly as a result of Susceptibility and resistance
inflammatory responses secondary to Any age may be affected although Outbreak measures
bacterial infection or trauma. infection is more common in children. Consider suspending direct contact and
Infection is more common and more sporting activities.
Method of diagnosis
The virus has not yet been cultivated. severe in the immunosuppressed.
Additional sources of information
Diagnosis can be confirmed by It is unknown whether prior infection • Australian College of Dermatologists,
microscopy (the core of the lesion is confers any protection against http://www.dermcoll.asn.au/
expressed onto a slide then stained), by subsequent exposures.
histology or by visualisation of the vesicle
fluid by electron microscopy. Control measures
Preventive measures
Incubation period Avoid close contact with the lesions of
The incubation period is unknown. affected persons. Avoid sharing baths
Clinical reports suggest a range from and spas with patients with lesions, and
seven days to six months. do not share face or bath towels.
Molluscum contagiosum information sheet
What is molluscum Can it become a serious Further information
contagiosum? disease? • Your local doctor
It is a viral disease caused by the Bacterial infections can complicate • Better Health Channel
molluscum contagiosum virus (MCV). molluscum contagiosum, causing the http://www.betterhealth.vic.gov.au
lumps to become red and sore. However,
How is it transmitted? these symptoms may also be signs that • Melbourne Sexual Health Centre
It is transmitted by skin-to-skin contact, the lumps are about to disappear http://www.mshc.org.au
which is usually sexual in adults and non- naturally. If symptoms don’t resolve • Victorian Department of Human
sexual in children. Towels and other quickly, consult your doctor in case you Services, 1300 651 160
objects might transmit occasional cases. need antibiotic treatment.
Spots appear one week to six months
(usually two to three months) after How is it treated?
contact. Although molluscum contagiosum
eventually resolves, freezing the lumps
Signs and symptoms with liquid nitrogen can shorten the
Molluscum contagiosum may cause a duration of symptoms.
variable number of skin lumps,
A single treatment is all that is usually
sometimes even ten or twenty. The
required. However, it may take a couple
lumps may be located on or around the
of weeks for the lumps to disappear.
genitals. This includes the pubic area, the
inner thighs and the abdomen. They are Imiquimod cream 0.1% applied three
painless, but may be slightly itchy and times daily is also effective.
often pearly white in appearance with a Do not scratch any irritated areas after
tiny central indentation. treatment, as this may spread the
Molluscum contagiosum can be infection. If no treatment is provided it is
mistaken for genital warts or pimples. If a mild, self-limiting disease. It can persist
you think you have molluscum for six months to two years. However,
contagiosum, it is recommended that any one lump will usually clear up in two
you see your doctor or other experienced to three months.
health professional.

Department of Human Services


The blue book: Guidelines for the control of infectious diseases 139

Mumps
Victorian statutory requirement Method of diagnosis Period of communicability
Mumps (Group B disease) must be The predictive value of parotitis in the Mumps is communicable from six to
notified in writing within five days of diagnosis of mumps is reduced in seven days before to nine days after the
diagnosis. countries with high immunisation rates onset of parotitis. Asymptomatic and
such as Australia. The diagnosis should inapparent cases can also be infectious.
School exclusion: exclude for nine days
be confirmed serologically by the
or until swelling goes down, whichever is
detection of mumps specific IgM Susceptibility and resistance
sooner.
antibody, or a significant rise in mumps Immunity is generally life long and
Infectious agent IgG antibody in acute and convalescent develops after either inapparent or
Mumps virus is a member of the family sera. Mumps virus can also be cultured clinical infections. Individuals born prior
Paramyxoviridae. from swabs of the buccal mucosa and to 1970 have a high likelihood of natural
from urine. immunity even if they have had no
Identification history of clinical infection.
Clinical features Incubation period
Mumps is an acute febrile disease The incubation period ranges from 14 to Control measures
characterised by swelling and tenderness 25 days. It is commonly 15–18 days. Preventive measures
of one or more of the salivary glands, Live attenuated mumps vaccine is
usually the parotid and occasionally the
Public health significance available combined with rubella and
sublingual or submaxillary glands.
and occurrence measles vaccine (MMR). Vaccination
Occurrence is worldwide. There is with this vaccine results in
Respiratory symptoms can occur,
generalised spread of the infection in seroconversion to all three viruses in
particularly in children under five years.
communities with low immunisation over 95% of recipients. Since the MMR
Epididymo-orchitis occurs in up to a third
rates; serologic studies show 85% or vaccine viruses are not transmissible,
of postpuberal males and is most
more of individuals in these communities there is no risk of infection originating
commonly unilateral: sterility is an
have evidence of previous mumps from vaccines.
uncommon complication. Oophoritis
infection by adult life. High childhood
occurs in up to 31% of females aged over MMR vaccination is recommended for all
immunisation rates in Australia have
15 years and may cause lower abdominal children at 12 months of age, unless
resulted in a dramatic reduction in rates
or back pain. Many infections in children specific contra-indications to the vaccine
of mumps infection. Unimmunised
less than two years of age are exist. A second dose is recommended at
children and adults, especially males, are
subclinical. Mumps meningitis is a fairly four years of age, prior to school entry.
the groups at highest risk of infection.
common complication. It usually occurs Control of case
two to ten days after the onset of Reservoir There is no specific treatment. Cases
parotitis and is self-limited with Humans. requiring hospitalisation should be
symptoms lasting three to five days. nursed in an isolation room using
Mumps very rarely causes sensorineural Mode of transmission respiratory precautions until nine days
deafness, encephalitis and pancreatitis. Transmission occurs through via after the onset of glandular swelling.
Mumps during the first trimester may respiratory aerosols and respiratory
Exclude cases from school, child care or
increase the risk of spontaneous abortion droplet spread or by direct contact with
workplace until nine days after the onset
but there is no evidence that mumps contaminated saliva.
of glandular swelling. Advise parents to
during pregnancy results in congenital keep the child away from other children
malformations. and susceptible adults for the period of
exclusion.
140 The blue book: Guidelines for the control of infectious diseases

Control of contacts
Susceptible contacts should be offered
immunisation with MMR vaccine.
Immunoglobulin is not effective in
preventing mumps. Contact isolation is
not required.
Control of environment
Concurrent disinfection of articles soiled
with nose and throat secretions.

Outbreak measures
Susceptible persons should be
immunised, especially those at risk of
exposure. Those who are not certain of
their immunity can be vaccinated if no
specific contra-indications to live
vaccines exist.
The blue book: Guidelines for the control of infectious diseases 141

Murray Valley
encephalitis virus
Arboviruses are viruses which are spread confusion, fitting, weakness or ataxia viruses. This is only accepted as
by the bite of arthropods, particularly indicate the onset of encephalitis. laboratory evidence for encephalitic
mosquitoes. They are divided into Method of diagnosis illnesses.
alphaviruses and flaviviruses. Infection is confirmed by a significant Confirmation of the laboratory result by a
Victorian statutory requirement rise in antibody titre to the virus in two second arbovirus reference laboratory is
Murray Valley encephalitis (Group A blood specimens taken seven to ten days required if the case occurs in areas of
disease) must be notified immediately by apart. Sera for diagnosis should be sent Australia not known to have established
telephone or fax followed by written to the Director of Virology, Victorian enzootic, endemic or regular epidemic
notification within five days. Infectious Diseases Reference activity.
Laboratory (VIDRL), preceded by Clinical evidence
School exclusion is not required. telephone contact via the Royal Clinical evidence may be present as non-
Infectious agent Melbourne Hospital on (03) 9342 7000 encephalitic illness, encephalitic illness
Murray Valley encephalitis virus is a advising the on-call Virologist that sera or asymptomatic disease.
flavivirus. It has the capacity to cause has been sent for urgent testing.
Non-encephalitic illness
severe human disease, with encephalitis A diagnosis of MVEV encephalitis should Acute febrile illness with headache,
being the most notable clinical feature. be considered in any patient who myalgia and/or rash
Murray Valley encephalitis virus (MVEV) presents with encephalitis and who has
been in the Murray Valley area within the Encephalitic disease
was first isolated from patients who died Acute febrile meningoencephalitis
from encephalitis in the Murray Valley in incubation period of the disease,
especially in the period between characterised by one or more of the
Victoria and South Australia in 1951. It following:
was previously included as one of the November and March. The disease may
also be acquired at any time in northern • focal neurological disease or clearly
causative agents in the disease called
parts of Australia or Papua New Guinea. impaired level of consciousness
Australian encephalitis, which also
included disease caused by Kunjin virus, Laboratory evidence requires one of the • an abnormal CT, MRI scan or EEG
another flavivirus. These viruses are now following: • presence of pleocytosis in the CSF.
accepted as causing two separate • isolation of MVEV from clinical material
diseases. Incubation period
• detection of MVEV RNA in clinical The incubation period is usually 7–28
Identification material days.
Clinical features • IgG seroconversion or a significant
The MVE virus commonly infects humans increase in antibody level or a fourfold Public health significance
without producing apparent disease rise in titre of MVEV specific IgG and occurrence
(subclinical infection). It may also cause proven by neutralisation or another Serological studies show that only one
a comparatively mild disease with specific test person in about every 800 of those
features such as fever, headache, nausea infected with MVE virus develops clinical
• MVEV-specific IgM detected in the
and vomiting. In a small percentage of all disease. Of those presenting with
CSF in the absence of IgM to Kunjin,
people infected, mild disease may be a encephalitis in Victoria in the 1974
Japanese encephalitis or dengue
prodrome to disease progression and epidemic, approximately one-third died,
viruses
involvement of the central nervous one-third were left with residual brain
system. This can result in meningitis or • MVEV-specific IgM detected in serum damage and one-third recovered
encephalitis of variable severity. Signs of in the absence of IgM to Kunjin, completely.
brain dysfunction such as drowsiness, Japanese encephalitis or dengue
142 The blue book: Guidelines for the control of infectious diseases

MVE virus is endemic in northern Reservoir The patient with suspected infection or
Australia and Papua New Guinea where The primary hosts in Victoria of MVE friend or relative, should be asked to
sporadic cases or small outbreaks of virus during years of high virus activity recall if in the month prior to onset of
MVE virus encephalitis occur every few are water birds. Ardeiformes (herons), symptoms he or she had:
years. This is usually at the end of the particularly the Rufous night-heron and • been bitten by mosquitoes
wet season. Seven outbreaks of MVE the Pelicaniformes (cormorants/
virus encephalitis have occurred at • visited regions where arboviruses are
darters) are the most commonly
irregular intervals in southeastern endemic
infected.
Australia since 1917. The last of these • participated in recreational or other
was in 1974. During these times there Mode of transmission activities involving exposure to
was heavy rainfall leading to widespread The primary mosquito vector during bushland or other mosquito habitat
flooding which promoted large increases epidemics is Culex annulirostris. Other such as gardening, bushwalking,
in water bird and vector mosquito mosquitoes such as Culex australicus camping and picnicking.
populations. The MVE virus numbers and some Aedes and Ochlerotatus
Control of contacts
were amplified in the bird-mosquito-bird species may be involved in other aspects
Not applicable.
cycle and humans became infected of MVE virus ecology.
Control of environment
when bitten by mosquitoes carrying the
Period of communicability To reduce or prevent virus transmission,
virus.
There is no evidence of person to person interruption of human-mosquito contact
MVE virus encephalitis seems to occur in transmission. is required by:
people who receive large numbers of
• suppression of the vector mosquito
mosquito bites during a single exposure. Susceptibility and resistance
population
There are two theories as to how the Infection with MVE virus confers lifelong
MVE virus appears and causes outbreaks immunity. • avoidance of vector contact at biting
of MVE virus encephalitis in southeastern times at dusk and dawn
Australia; both may be correct. The first Control measures
• applying mosquito control measures in
one postulates that the virus is carried Preventive measures
local municipalities
from northern parts of Australia by birds Patients can be managed at any hospital,
but facilities for providing intensive care • using personal protection measures
migrating south in search of food after
and artificial respiration must be such as long sleeves, long trousers and
heavy rainfall down the southeastern
available. There is no preventative mosquito repellents
parts of the continent. This occurs in
repeated mosquito-bird-mosquito vaccine available. • avoiding mosquito-prone areas.
amplification cycles. The other suggests Control of case
that the virus persists during inter- Investigate the source of infection.
epidemic periods in cryptic foci along the Search for unreported or undiagnosed
Murray River and the MVE virus only cases of encephalitis from the Murray-
amplifies and becomes evident when Darling drainage basin.
weather conditions are conducive to
massive local mosquito and bird
multiplication.
The blue book: Guidelines for the control of infectious diseases 143

Outbreak measures
Following notification of a seroconversion
to MVE virus or information of human
notification:
• an emergency meeting of the Victorian
Arbovirus Task Force (VATF) will be
convened by the Department of
Human Services
• the presence of MVE virus in the area
will be notified to relevant regional
offices and local health council
personnel
• suitable media releases will be made
available
• appropriate VATF members will visit the
area to consult and advise local
councils, health and tourism
authorities
• depending on the actual or potential
severity of the epidemic, meetings of
relevant personnel will be arranged in
the affected area to consider control
measures.

Additional sources of information


Victorian Department of Human
Services, Victorian Arbovirus Task Force
contingency plan for outbreaks of MVE.
144 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 145

Mycobacterial
infections
(non-tuberculosis)
Victorian statutory requirement Clinicians who suspect infection with Reservoir
Notification and school exclusion are not atypical mycobacteria should liaise with Mycobacteria are ubiquitous in the
required. a pathology laboratory to ensure that environment, including many that are
clinical specimens are appropriately non-pathogenic to humans.
Infectious agent collected and transported. Mycobacteria have been cultured from
Mycobacterial agents include various environmental sources including
To establish a definite diagnosis of
M. avium-intracellulare complex (MAC), ground waters, dust and soil. The
atypical mycobacterial infection,
M. kansasii, M. scrofulaceum, environmental niches of many others
organisms must be cultured from a case
M. fortuitum, M. marinum and remain unknown.
with clinically compatible disease.
M. chelonae.
Identification of acid-fast bacilli by direct
For infections due to M. ulcerans see Mode of transmission
smear on at least two occasions is highly
separate chapter. The mode of transmission can rarely be
suggestive of a mycobacterial infection.
determined for individual cases. Atypical
Histological examination of biopsies of
Identification mycobacteria are probably transmitted
clinical lesions may also assist in the
Clinical features by aerosol from soil, dust or water, by
diagnosis. Recent advances in gene
MAC and M. kansasii are rare causes of ingestion, or in
probes and nucleic acid amplification
lung disease in humans, and mainly M. marinum and infections by skin
procedures such as polymerase chain
affect middle-aged and elderly persons inoculation.
reaction (PCR) have allowed more rapid
with underlying chronic lung conditions. Person to person spread of atypical
diagnosis of mycobacterial infections
Disseminated MAC infection frequently mycobacteria is rare except in people
such as DNA probes for MAC and M.
occurs in people with advanced HIV who are immunosuppressed.
kansasii.
infection, but is rare in M. avium-intracellulare causes disease in
immunocompetent hosts. Incubation period poultry and pigs but animal to human
Cervical and submandibular The incubation period of atypical transmission is rare.
lymphadenitis due to MAC, mycobacterial infections can rarely be
M. scrofulaceum and M. kansasii may determined, but is probably weeks to Period of communicability
occur in otherwise healthy young several months. Communicability of human cases is
children. usually not a practical concern except in
Public health significance cases of co-existing HIV infection.
M. fortuitum and M. chelonae cause skin and occurrence Localised foci of disease due to some
and wound infections and abscesses. Disease due to atypical mycobacterial atypical mycobacteria suggest that an
They are frequently associated with infection is relatively rare. Cases of established environmental focus of
trauma or surgery. M. kansasii lung infection have occurred in organisms may remain the source of
M. marinum causes ‘swimming pool western Victoria in recent years. Infection infections for years.
granuloma’, a nodular lesion that may with M. marinum is associated with
ulcerate and is usually located on an contact with swimming pools, aquariums Susceptibility and resistance
extremity. and other bodies of water. With the exception of M. marinum
infections, atypical mycobacterial
Method of diagnosis Atypical mycobacteria may colonise and
infections (in particular MAC) are more
Persons with immunodeficiencies or infect persons without causing clinical
common in patients who are
tissue damage such as skin trauma and disease. Skin tests to tuberculin and
immunocompromised or in those with
pulmonary disease may be at increased other mycobacterial derivatives may be
chronic respiratory disease.
risk of atypical mycobacterial infection. positive in such people.
146 The blue book: Guidelines for the control of infectious diseases

Control measures
Preventive measures
As little information is known about their
mode of transmission, prevention of
atypical mycobacterial infections is
difficult. Environmental contamination of
skin lesions may be reduced by some
measures, including the wearing of
gloves and thorough hand washing when
cleaning aquarium equipment (for M.
marinum). Early medical advice should
be sought in the event of skin lesions
that do not heal.
Control of case
Cases of atypical mycobacterial
infection usually require specialist
management. Skin lesions and
childhood lymphadenopathy are usually
cured by surgery, sometimes in
combination with anti-mycobacterial
drugs.
Disseminated and pulmonary infections
are treated with combinations of anti-
mycobacterial drugs. The clinical
outcome is strongly influenced by the
underlying health of the host.
Control of contacts
No specific measures are needed for
contacts of cases.
Control of environment
If infections can be linked with a specific
environmental source it may be possible
to modify the environment or practices to
minimise further transmission.

Outbreak measures
Not applicable.
The blue book: Guidelines for the control of infectious diseases 147

Mycobacterial
infections (tuberculosis)
Victorian statutory requirement positive tuberculin reactions, and those Incubation period
Tuberculosis (Group B disease) must be with a history of inadequately treated Infection to the primary lesion or
notified in writing within five days of active tuberculosis. Positive tuberculin significant tuberculin reaction is about
diagnosis including clinical suspicion. reactors with inactive tuberculosis on four to twelve weeks.
chest X-ray without a previous diagnosis
School exclusion: exclude until receipt of
of active tuberculosis remain at some risk. Public health significance
a medical certificate from the treating
The risk of developing the disease is and occurrence
physician stating that the child is not
highest in children under three years of Tuberculosis occurs worldwide and had
considered to be infectious.
age, lowest in later childhood, but rises been decreasing steadily over past
Contacts are not excluded. again for adolescents, young adults and decades in developed countries. This
the very old. pattern was reversed with the arrival of
Infectious agent HIV and increased mobility of the world’s
Mycobacterium tuberculosis (human Method of diagnosis
population. Tuberculosis in the USA was
tuberculosis) and Mycobacterium bovis TB is diagnosed by a consideration of the
on the increase in the early 1990s.
(cattle tuberculosis) are the infective following:
agents. A combination of factors is thought to be
• clinical presentation
responsible for this increase including
Identification • tuberculin skin test using the Mantoux the high rate of HIV infection,
Clinical features procedure overcrowding, limited health care
Tuberculosis (TB) is an acute or chronic • radiographic examination, sometimes resources and falling living standards. In
infection caused by the tubercle bacillus including CT scans the USA, large outbreaks of TB have
Mycobacterium tuberculosis, and rarely occurred in institutions, particularly
• bacteriology, direct staining and culture
by M. bovis or M. africanum. The initial prisons and hospitals. These outbreaks
of sputum or other specimens for the
pulmonary infection usually goes have predominantly affected HIV-infected
presence of M. tuberculosis
unnoticed with lesions healing, persons. The increasing trend in the US
sometimes leaving traces of calcified • molecular amplification (PCR) and has now been reversed and the
scar tissue. The infection may however gene probes assist in rapid diagnosis. incidence rate is once again declining.
progress to pulmonary tuberculosis, or Definitive diagnosis of TB rests on The World Health Organization (WHO)
through blood or lymphatic spread isolation of M. tuberculosis (or estimated that a third of the world’s
produce miliary, meningeal or other M. bovis) from sputum, urine, biopsy population is infected and tuberculosis
extrapulmonary involvement. material, CSF or other clinical specimens. accounts for three million deaths
Common symptoms include: A negative sputum test does not rule out annually. One-fifth of all deaths in adults
a diagnosis of TB. Recovery and in developing countries relate to TB. Two-
• a chronic cough sometimes
identification of mycobacteria from thirds of the world’s tuberculosis-infected
accompanied by haemoptysis
specimens has become more rapid with people reside in Asia and this will have a
• fevers and night sweats test procedures such as liquid medium significant impact on the control of TB in
• loss of weight systems and DNA probes. Further Australia as a result of increased
information on these tests can be immigration.
• feeling generally unwell.
obtained from the Mycobacterium
Clinical suspicion of active disease should Reference Laboratory at Victorian
be high in those who have a newly Infectious Diseases Reference
positive tuberculin reaction, juveniles with Laboratory.
148 The blue book: Guidelines for the control of infectious diseases

Notified cases of TB in Victoria have Period of communicability The disease does not always confer
dropped dramatically from 1000 cases in In theory, the patient is infectious as long protective immunity as reinfection can
1954 to 292 in 2000. However, the rate as viable bacilli are being discharged occur.
of decline in the incidence of TB has from the sputum. In practice, the
reached a plateau with an average greatest risk of transmitting infection is in Control measures
incidence rate of 6.2/100 000 over the the period prior to diagnosis of an open Preventive measures
last five years (range 5.1/100 000 in case. A sputum smear positive case is BCG vaccination has limited application
1998 to 7.0/100 000 in 1999). more infectious than a case only positive in developed countries where the
on culture. The risk of transmitting the incidence of TB is low. It is an effective
The proportion of notified cases that
infection is significantly reduced within vaccine in reducing TB meningitis and
were overseas-born has also increased
days to two weeks after commencing death in babies and children less than
from 37% in 1970 to 86% in 2000. In
appropriate chemotherapy. five years in countries of high TB
Victoria the highest country-specific
prevalence. It is not recommended for
incidence rates are in the Vietnamese,
Susceptibility and resistance general use in the Australian community
Indian, Filipino and African born
Everyone is susceptible to infection, but should be considered for specific
populations. This reflects the pattern of
however some groups are more high risk groups such as infants and
disease in their countries of birth. Of the
susceptible to infection and progression young children travelling for extended
overseas-born patients, almost 50%
to active disease than others. Special periods to countries with a high
present with disease within five years
groups at risk are: incidence of TB. (Refer to The Australian
and 30% present within two years of their
immunisation handbook, National Health
arrival in Australia. • recent immigrants and refugees from
and Medical Research Council).
countries with a high incidence of
Reservoir tuberculosis including Vietnam, India, Control of case
Humans are the primary reservoir. China, Africa and the Philippines With the introduction of potent anti-TB
Diseased cattle rarely act as reservoirs. drugs, hospitalisation of tuberculosis
• those in close contact with a case of
patients is no longer mandatory unless
Mode of transmission active TB
social conditions or coexisting medical
TB is transmitted mainly by inhalation of • Aboriginal people and Torres Strait conditions dictate otherwise.
infectious droplets produced by persons Islanders in some parts of Australia
Patients with pulmonary TB should be
with pulmonary or laryngeal tuberculosis • immunosuppressed patients isolated either at home or in hospital until
during coughing, laughing, shouting or
• those with HIV infection and AIDS they have been on adequate anti-TB
sneezing.
• the elderly therapy for 14 days and sputum smears
Invasion may occur through mucous are negative. Appropriate education and
membranes or damaged skin. • diabetics counseling about minimising the risk of
Extrapulmonary tuberculosis, other than • drug and alcohol-dependent people transmission of infection should be
laryngeal infection, is generally not • people living in substandard, provided to all patients, particularly those
communicable. Urine is infectious in overcrowded conditions with pulmonary TB. There is no restriction
cases of renal tuberculosis. Bovine on the movement of patients with non-
• institutionalised people including
tuberculosis results mainly from pulmonary disease.
prisoners
ingestion of unpasteurised milk and dairy
products. Aerosol transmission has been • health professionals.
reported among abattoir workers.
The blue book: Guidelines for the control of infectious diseases 149

Written notification of tuberculosis is Control of contacts – Chest X-rays may be considered on


required within five days of diagnosis. Exclusion of contacts is not necessary, an individual basis.
On receipt of a notification, a public unless they have signs and symptoms • Positive reactors
health nurse is allocated to the patient consistent with pulmonary TB.
to provide support, assist with treatment – Initial positive reactors should be
Contact tracing and surveillance are the evaluated to exclude active disease.
compliance and to assess the responsibility of the Department of
requirements and extent of contact The positive tuberculin test may
Human Services and are managed by the signify recent tuberculin conversion
tracing. TB Program. Anyone identified by health or an incidental finding.
Adequate anti-TB chemotherapy for an care workers as a contact of a case of TB
appropriate period of time will result in should be referred to the TB Program. – Contacts identified by the TB
almost 100% cure rate. Short treatment Program as requiring further
Contact investigation consists of: assessment are referred to specialist
regimens have been in use for some
years. These involve the use initially of • history taking physicians for exclusion of active
three or four drugs (isoniazid [INH], • tuberculin testing disease or consideration for
rifampicin, pyrazinamide and may include treatment of latent infection.
• radiographic examination.
ethambutol) for two months, and – When X-ray and physical
The extent of investigation is governed by examination are normal, contacts
continuing with isoniazid and rifampicin
the characteristics of the source case. with positive reaction may be offered
for a further four months. Where there is
The scope of investigation is extended isoniazid treatment of latent
evidence of drug resistance to isoniazid
when the following factors in the source infection, given once daily at a
or rifampicin or to both, short course
case are present: dosage of 5 mg/kg body weight to a
anti-TB chemotherapy is inappropriate.
• acid fast bacilli (AFB) in sputum smear maximum of 300 mg daily. Treatment
The success of treatment relies heavily
on patient compliance and direct • cavitation on chest X-ray should be for a minimum period of
supervision should be the aim of any nine months with appropriate
• laryngeal TB
treatment program. Compliance is monitoring for liver toxicity.
• cough, particularly if productive of
important to prevent the development of – Contacts with positive reactions,
sputum, or
drug resistance. who do not undertake treatment of
• evidence of tuberculin conversion in latent infection, should be kept under
Multi-drug resistant TB (MDRTB)
any of the contacts. surveillance and followed up with
Resistance to at least isoniazid and
rifampicin (whether or not it is also Note: Tuberculosis testing should never chest X-rays taken at six months and
resistant to other drugs) is classified as be omitted for child contacts. 12 months.
multi-drug resistant. MDRTB is rare in Following tuberculin testing contacts can Control of environment
Australia. It has remained at less than be grouped as: There are no specific environmental
two percent per year in the past 15 controls as the greatest risk of
• Negative reactors
years. There is however a potential risk of transmission of infection is prior to
MDRTB in Victoria as most of the – Tuberculin conversion takes a few diagnosis. However, a patient with
patients notified each year are overseas weeks and may not have occurred pulmonary tuberculosis should be
born, many from countries with high yet in these contacts. isolated from any new contacts and
rates of drug resistant TB. – Testing should be repeated in eight young children (either in hospital or at
to 12 weeks after a break of contact home) until at least 14 days after
or in some cases initial testing may commencing appropriate anti-
be delayed for eight weeks. tuberculosis treatment.
150 The blue book: Guidelines for the control of infectious diseases

Fresh air, sunlight and covering the Health care facilities are required to have
mouth and nose when coughing are all protocols and guidelines for tuberculosis
appropriate patient education and prevention and management in place,
environmental control measures. including a tuberculin skin test screening
policy (refer to Management, control and
Outbreak measures prevention of tuberculosis guidelines for
It is unusual for an outbreak of TB to health care providers, Department of
occur due to the chronic nature of the Human Services 2002).
disease and the extended incubation
International measures
period. In the event of two or more cases
All countries are required to report TB
occurring concurrently in a single setting,
surveillance data to the World Health
contact tracing and investigation would
Organization. This data informs policies
be extended to identify a possible
and strategies aimed at the global
unknown source case.
control of TB. Migrants and long term
Special settings visitors to Australia are screened for
Nosocomial transmission of tuberculosis evidence of TB prior to being granted a
does occur, particularly in cases where visa.
diagnosis is delayed. It is important that
a high index of suspicion for tuberculosis Additional sources of information
is maintained, particularly in patients • Victorian Department of Human
with respiratory symptoms and belonging Services 2002, Management, control and
to a high risk group for TB such as prevention of tuberculosis. Guidelines for
overseas born from high prevalence health care providers (2002–2005),
countries, immunosuppressed patients http://www.health.vic.gov.au/ideas
and the elderly (both Australian and • World Health Organization,
overseas born). http://www.who.int
All suspected and active cases of
tuberculosis must be placed in
respiratory isolation and appropriate
infection control measures implemented,
including use of submicron or particulate
filter masks for health care workers and
surgical masks for patients during
transport within the hospital. In the event
of a health care worker being exposed to
an undiagnosed case of tuberculosis,
appropriate contact tracing and
screening measures must be
implemented. Investigation and
management will be as for contacts
(above).
The blue book: Guidelines for the control of infectious diseases 151

Mycobacterium
ulcerans
Victorian statutory requirement Method of diagnosis Incubation period
Mycobacterium ulcerans infection (Group Swabs from beneath the undermined This has not been clearly defined but is
B disease) must be notified in writing edges of the lesion or a biopsy should be thought to be quite long, i.e. weeks to a
within five days of diagnosis. sent for staining for acid-fast bacilli couple of months.
(AFBs). Two other swabs should be
School exclusion is not required.
taken; a dry swab for a polymerase chain Public health significance
Infectious agent reaction (PCR test) and another for and occurrence
Mycobacterium ulcerans is a member of culture should be placed in transport Although this is not a common cause of
the mycobacterium family. Tuberculosis, medium. Bacterial culture or a specific ulcers in Australia, it is important that it
leprosy and many other environmental PCR should be performed to confirm the be considered in the focal areas in which
mycobacteria belong to this family. diagnosis. It should be stated on the it occurs as early diagnosis and
Mycobacterium ulcerans causes skin request form that treatment is advisable to minimise tissue
ulcers, variously known as the Bairnsdale M. ulcerans is suspected. damage.
,Bairnsdale, Buruli, or Daintree ulcer. A positive smear for AFBs makes the After tuberculosis and leprosy this is the
diagnosis likely. Culture or PCR is most common mycobacterial disease. The
Identification disease exists or is suspected in 31
required for confirmation. A negative
Clinical features countries. The majority of the cases occur
smear does not exclude the diagnosis.
The first sign of M. ulcerans is usually a in foci in west and central Africa, where
painless, non-tender nodule or papule. It The PCR test is performed at the
large, severe disabling ulcers may result in
is often thought to be an insect bite. The Victorian Infectious Diseases Reference
severe contractures or death from
lesion may occur anywhere on the body Laboratory (VIDRL). This test can give
extensive skin loss.
but it is most common on exposed areas rapid confirmation of the diagnosis within
a few days. Culture of the organism In Australia the disease exists in Far
of the limbs. Some patients complain
usually takes 8–12 weeks. North Queensland around the Mossman
that the lesion is itchy. In one or two
area and in parts of coastal Victoria
months the nodule may become A biopsy of suspicious lesions which
including East Gippsland (where it was
fluctuant and ulcerate, forming a have not ulcerated can be sent for
first described in Bairnsdale and so
characteristic ulcer with undermined histology. The suspected diagnosis
named), Cowes on Phillip Island,
edges. Ordinarily there is no regional should be mentioned and a request
Mornington Peninsula and most recently
lymphadenopathy, fever or systemic made for AFB staining, specific PCR and
Bellarine Peninsula.
manifestations associated with the bacterial culture. Biopsy specimens
disease. If left untreated extensive usually show extensive necrosis, Reservoir
ulceration can occur. especially of fat. Granulomatous The organism appears to be associated
Occasionally the disease may present as inflammation is usually present in more with usually swampy or stagnant water.
a firm, painless elevated plaque with chronic lesions. AFBs are frequently seen The exact reservoir remains unclear.
irregular edges. Or an entire limb or area in large numbers.
may be indurated by oedema without an
ulcer being present. The oedematous
form may be associated with fever.
152 The blue book: Guidelines for the control of infectious diseases

Mode of transmission Control of case Control of environment


The exact method of transmission of M. Isolation is not required. The ulcers do Not applicable.
ulcerans infection is unclear. Exposure to however contain large numbers of
contaminated water, soil, or vegetation in organisms and it is possible that person Outbreak measures
areas where the disease is known to to person infection could occur through Clusters of cases are investigated looking
occur is thought to be required. The breaks in the skin. Thus, it is for a common source where an
bacteria may enter through a breakage in recommended that ulcers be kept intervention may be feasible and
the skin. Exposure to aerosols of covered and thorough hand washing be advisable, including health or public
contaminated water has been performed following dressing changes. alerts.
hypothesised to be a method of Safe disposal of infected material should
Additional sources of information
acquisition. Recently, some insects that also occur.
• World Health Organization,
live in water have been shown to contain The current mainstay of treatment is www.who.int/topics
the bacteria and they may play a role in surgery with adequate (but not
transmission. excessive) clearance of the undermined
edges of the ulcer. Primary closure may
Period of communicability
be possible with small lesions but skin
M. ulcerans infection is not (or is rarely)
grafting of the area may be required for
transmitted from one person to another.
larger areas. Other forms of treatment
Susceptibility and resistance that may be used, often as an adjunct to
Everyone is susceptible to infection. surgery, include:
• Heat treatment. Continuous local
Control measures heating promotes healing but care
Preventive measures must be taken to prevent burning. The
Early recognition and diagnosis is organism grows at 32˚C and heat up
important to minimise the disabling and to 40˚C has been used with some
disfiguring effects of this disease. effect.
Referral for treatment by doctors
experienced in the management of this • Antibiotic treatment. A number of
condition is recommended. Simple antibiotics have been found to be
precautionary measures such as wearing active against the organism in vitro.
appropriate protective clothing when These include clarithromycin,
gardening and undertaking recreational rifampicin, azithromycin and amikacin.
activities in identified risk areas may Combinations of these have been
assist in preventing infection. Cuts and used, often to mop up residual
abrasions should be cleaned promptly organisms after surgery in an attempt
and exposed skin contaminated by to prevent recurrence.
suspect soil or water should be washed Occasionally small lesions have been
following outdoor activities. reported to heal spontaneously.
BCG vaccination is not used for Control of contacts
prophylaxis. Not applicable.
The blue book: Guidelines for the control of infectious diseases 153

Pediculosis or
head lice
Victorian statutory requirement Incubation period Mode of transmission
Notification is not required. The life cycle consists of three stages: Pediculosis is transmitted through direct
School exclusion: readmit the day after egg, nymph and adult. The eggs are head to head contact with a person with
appropriate treatment has been known as nits and hatch in six to seven head lice. Nymphal and adult lice survive,
commenced. days. There are three nymphal forms that dependent on the humidity of the
each last one to eight days. environment, and according to
Infectious agent The female lays the first egg one or two Queensland research usually die within
Pediculus humanus var. capitus is the days after mating and can lay 24 hours of being stranded away from
infective agent. approximately three to eight eggs per day the head. There is no significant risk of
for the next 16 days. After a life span of transmission from the environment.
Identification
32–35 days the louse dies.
Clinical features Period of communicability
Pediculosis is commonly said to be Public health significance Communicability continues as long as
associated with an itchy scalp however and occurrence lice or their nymphs remain alive.
this is an unreliable sign. Itching is only Head lice have been associated with
experienced in 14–50% of people with Susceptibility and resistance
humans for 10 000 years. Head lice
head lice. Head lice can be present for Everyone is susceptible to infection.
occur worldwide. Anyone can get lice
weeks or even months without causing and given the opportunity head lice will Control measures
an itch. Secondary scalp infections move from head to head without Preventive measures
resulting from scratching can occur but discrimination. They are frequently Regular checking using the method
are rare. associated with children. known as ‘conditioner and combing’
Method of diagnosis Information on the prevalence of head allows early detection of head lice and
Early detection makes treatment and lice varies around the world. In 2002 the will limit the establishment of large
control of head lice easier. Traditional prevalence of head lice among primary outbreaks.
scalp inspection is a poor method of school children in Victoria was found to Control of case
detecting lice. It can result in 30% false be 13%. Females were more than twice Treatment should concentrate on the
positive and 10% false negative findings. as likely to have head lice as males. head. There is no evidence that the
The technique known as ‘conditioner and The prevalence of head lice in primary environment is a significant cause of
combing’ is the most effective method school aged children in other parts of reinfection.
for detection. This involves combing Australia is reported to be up to 60%. The conditioner and combing method
white hair conditioner through dry,
Head lice are not vectors of infectious can be repeated every second day until
brushed hair. The next step is to divide
disease. Louse-borne relapsing fever, no lice are found for ten days.
the hair into smaller sections and to
trench fever and typhus, none of which If using an insecticidal product it is
comb each section using a head lice
occur in Australia, are all associated with important to use a ’registered’ or ’listed’
comb. After each combing the comb is
the body louse Pediculus humanus var. product which should have two
wiped on to a tissue. This allows lice and
corporis. applications seven days apart. Applying
eggs to be easily seen. The aim is to
cylindrically coat each hair in conditioner with the least amount of water possible
Reservoir and the removal of as many eggs as
and continue to comb hair until the Humans are the only reservoir. The lice
majority of conditioner is removed. possible will optimise the treatment.
of other animals are not transmissible to
humans.
154 The blue book: Guidelines for the control of infectious diseases

Increasing resistance to the products has Outbreak measures Additional sources of information
been reported and each head lice Schools • De Maeseneer, J, Blokland, I, Willems, S
product should be tested after 20 While head lice are often associated with et al. 2000, ‘Wet combing versus
minutes to ensure it has killed the lice. schools they are not necessarily spread traditional scalp inspection to detect
Control of contacts in schools. Schools experiencing head lice in school children:
Contact tracing is recommended. difficulty should encourage families to observational study’, BMJ, vol. 321, no.
check for lice using the combing and 7270, pp. 1187–8.
All household members or people who
conditioner method on a weekly basis, or • Spear, R, Thomas, G, Cahill, C 2002,
have had head to head contact with the
more often during an outbreak. Even on ‘Head lice are not found on floors in
case should be examined for head lice.
receipt of a single case report of head primary school classrooms’, Aust N Z J
Preferably this should be done using the
lice, parents or guardians of all children Public Health, vol. 26, no. 3, pp.
conditioner and combing detection
from the class should be asked to screen 208–11.
method and repeated every two days for
their child at home utilising the
ten days. • Victorian Department of Human
conditioner and comb method. Parents
Special settings or guardians should then report any Services, http://www.health.vic.gov.au/
Hairdressing salons active head lice following the headlice/
Head lice rarely fall from the head. Data synchronised home screening.
from James Cook University show head
If there is a cluster of cases in a class, for
lice on combs and brushes are easily
example 10% of pupils, a further school
killed by immersion in hot water at 60ºC
wide management program could be
for one minute. There is then no
considered (see resources for schools,
subsequent risk of transmission from the
www.health.vic.gov.au/headlice)
comb or brush to the next client.
The blue book: Guidelines for the control of infectious diseases 155

Pertussis
(whooping cough)
Victorian statutory requirement from repeated vomiting, occasionally for younger children. Australia
Pertussis infection (Group B disease) occur. experiences an epidemic of whooping
requires written notification within five Method of diagnosis cough about every three or four years.
days of diagnosis. Pertussis can be diagnosed on a clinical As it is not possible to completely control
School exclusion for cases and contacts basis if the patient has an acute illness pertussis with the current vaccine, the
is: lasting more than 14 days without highest priority should be given to
another apparent cause, a classical protecting infants under 12 months of
• cases should be excluded for five days
paroxysmal cough with whooping and age.
after commencing antibiotic treatment
post-tussive vomiting. However bouts of The World Health Organization (WHO)
• unimmunised sibling contacts under coughing may occur without whoops or estimates there were 40 million cases of
seven years of age and unimmunised vomiting and the disease may only be pertussis in 1994 and 360 000 deaths.
close child care contacts must be suspected if the patient is a contact of a WHO believes only one to two per cent
excluded from school and children’s known case. Apnoea may be the only of cases are reported. In industrialised
services centres for 14 days from the manifestation in infants. Laboratory countries four children out of every 10
last exposure to infection, or until they confirmation can be problematic but 000 infected die from pertussis and its
have taken five days of a ten day should be sought where possible. A complications. In Australia the first
course of antibiotics. nasopharyngeal aspirate or swab is the pertussis vaccine was manufactured in
best specimen to obtain to culture the the 1920s. There is a clear seasonal
Infectious agent
bacterium. The likelihood of such cultures pattern with 65% of notifications
Bordetella pertussis.
being positive is reduced 21 days after occurring over the spring and summer
Identification the cough onset or if effective months.
Clinical features antimicrobial therapy has commenced
The catarrhal state may be against Reservoir
indistinguishable from a viral upper B. pertussis. Serology using B. pertussis Humans are the only known natural
respiratory tract infection. The infection specific IgA may be falsely negative but a reservoir of B. pertussis.
damages respiratory epithelium, positive result is highly reliable in the
producing respiratory obstruction and presence of appropriate symptoms. Mode of transmission
B. pertussis is highly infectious. It may be
paroxysmal coughing. There is often a
Incubation period spread from person to person by close
characteristic whoop. This is a crowing
The incubation period is usually between contact, usually by respiratory aerosols,
sound during inspiration preceding a
six and 20 days. It is most commonly infecting 70–100% of household
bout of coughing.
about 14 days. contacts.
There is little fever. Apnoea, seizures and
encephalopathy may occur in very Public health significance Period of communicability
severe cases. Infants aged less than six and occurrence It is highly communicable in the early
months and adults often do not have the It is a distressing and often serious catarrhal stage before the onset of
characteristic whoop. Paroxysms illness particularly in children under one paroxysmal cough. Thereafter
frequently end with the expulsion of year of age. The mortality rate is 0.5% in communicability decreases and
clear, tenacious mucus. This is often infants under six months. High becomes negligible in about three
followed by vomiting. immunisation levels reduce the number weeks. When treated with a macrolide
Pneumonia is the most common cause of cases and good nutrition and medical antibiotic the period of infectivity usually
of death. Fatal encephalopathy, which is care reduce case fatality. Many lasts five days or less after
probably hypoxic, and severe weakness vaccinated adults may have mild commencement of therapy.
infection and act as a source of infection
156 The blue book: Guidelines for the control of infectious diseases

Susceptibility and resistance days is no longer infectious and antibiotic Outbreak measures
Maternal antibodies do not protect treatment and school exclusion are not See Control of contacts, above.
newborns against infection. Severity is needed. Antibiotic treatment is required
Clusters of infection are managed on a
greatest in young infants while milder and if there is complicating pneumonia.
case-by-case basis. Contact the
atypical cases occur in all age groups. Consult the current version of
Department of Human Services for
Incomplete immunisation, waning Therapeutic guidelines: antibiotic
further advice.
immunity and the fact that vaccine (Therapeutic Guidelines Limited).
efficacy is 70–80%, results in cases Control of contacts Additional sources of information
occurring in older children and adults. Erythromycin should not be given if more • Communicable Diseases Network
Lifelong immunity is not guaranteed, than 14 days have elapsed since the first Australia 1997, Guidelines for the
even after clinical disease. contact with the infectious case (doses control of pertussis in Australia,
and duration as for cases). In special Communicable Diseases Intelligence
Control measures Technical Report Series,
circumstances, such as a high risk
Preventive measures http://www.health.gov.au
exposure for an infant contact, antibiotics
Educate the public to the dangers of
may be given within 21 days of first • PHLS Communicable Disease
whooping cough and the advantages of
contact with an infectious case. Surveillance Centre 2002, ‘UK
initiating immunisation at two months of
Antibiotics rarely prevent secondary guidelines for use of erythromycin
age and adhering to the immunisation
transmission and should be limited to chemoprophylaxis in persons exposed
schedule (DTPa at two, four and six
household or child care contacts at high to pertussis’, Journal of Public Health
months and four and fifteen years of
risk of severe complications that have Medicine, vol. 24, pp. 200–206.
age). Delay immunisation only for
had direct contact with an infectious
significant intercurrent infection or an
case:
evolving neurological disorder. Minor
respiratory infections are not a contra- • infants <12 months of age regardless
indication for immunisation. of vaccination status

Control of case • any child aged between 12 and 24


Antibiotics will have little effect on the months who has received less than
clinical course of disease but can reduce three doses of pertussis vaccine
the risk of transmission if commenced • any women in the last month of
within 21 days of cough onset. Treatment pregnancy
generally consists of erythromycin or
• any child or adult who attends or works
clarithromycin. If it is not tolerated
at a child care facility.
alternative macrolides with fewer side
effects may be considered. A patient Control of environment
who has been coughing for more than 21 Not applicable.
The blue book: Guidelines for the control of infectious diseases 157

Pinworm infection
(threadworm)
Victorian statutory requirement Incubation period Period of communicability
Notification and school exclusion are not The lifecycle requires two to six weeks to Communicability continues as long as
required. complete. The eggs are fully embryonated the eggs are being discharged on the
and are infective within a few hours of perianal area. The eggs can survive for
Infectious agent being deposited. Male and female several days in the right conditions.
Enterobius vermicularis is an intestinal pinworms vary in size ranging between Reinfection from contaminated hands is
nematode. 2–13mm in length, up to 0.5mm wide common.
and are yellowish white in colour. A long,
Identification Susceptibility and resistance
thin and sharply pointed tail distinguishes
Clinical features Infection does not confer immunity.
the female worm.
In the majority of children and adults
infection is asymptomatic. Migration of Public health significance Control measures
the female worm from the rectum then and occurrence Preventive measures
anus to lay eggs on the perianal skin The pinworm is the most common • Effective hand washing, particularly
during the night can lead to perianal helminth parasite of temperate regions. before eating or preparing food.
pruritus or disturbed sleep or irritability. These infections are found worldwide • Keep nails short, discourage scratching
Sometimes secondary infection of the and affect all socio-economic groups. bare anal area and nail biting.
scratched skin occurs. In children the
Less attention is paid to the pinworm in • Daily bathing or showering.
pinworm can cause vulvovaginitis during
tropical regions of the world presumably • Change to clean underwear,
its migration from the anus.
because of the prevalence of more nightclothes and bed sheets frequently
Pinworms or their eggs have occasionally important parasites. Pinworm infections
been detected at other sites such as the preferably after bathing.
predominantly affect paediatric
liver and lung. Rarer clinical populations where the prevalence is Control of case
manifestations include salpingitis, pelvic reported to between 10–50% in some There are a number of drugs available for
pain and the formation of granulomas in groups. treatment including pyrantel pamoate,
the peritoneal cavity. mebendazole or albendazole. Consult the
Method of diagnosis Reservoir current version of Therapeutic guidelines:
The diagnosis should be suspected in Humans are the only reservoir. Pinworms antibiotic (Therapeutic Guidelines
children with a perianal itch and this is of other animals are not transmissible to Limited).
confirmed by detection of their humans. Care should be taken to change linen
characteristic eggs. Applying clear sticky and underwear of infected person daily
Mode of transmission
tape ({with sticky side outward) to the for several days after treatment with care
Pinworms are transmitted by direct
perianal skin and examining it for eggs is to avoid dispersing the eggs into the air.
transfer of infected eggs by hand from
the best way to make the diagnosis. This Control of contacts
anus to mouth of the same or another
is best done in the morning prior to Not applicable.
person. It can also be transmitted
bathing, as the worms migrate during
indirectly through bedding, clothing, food Special settings
resting periods. Microscopy on faeces
or other articles. Spread is facilitated by Public health education on the
can be conducted although finding eggs
conditions of overcrowding. importance of hand washing may assist.
is exceptional.
Outbreak measures
Not applicable.
158 The blue book: Guidelines for the control of infectious diseases

Additional sources of information


• Markell, E, John, D, Krotoski, W 1999,
Markell and Voge’s medical
parasitology, 8th edn, ed Saunders.
The blue book: Guidelines for the control of infectious diseases 159

Plague
Victorian statutory requirement All forms of plague infection may Untreated bubonic plague has a case
Plague (Group A disease) must be progress to septicaemic plague with fatality rate of about 50–60%. Case
notified immediately by telephone or fax bloodstream spread around the body, fatality rates are significantly higher for
followed by written notification within five including to the meninges. This includes pneumonic and septicaemic plague.
days. some with no preceding localising signs Given that techniques for mass
or buboes. Sepsis may lead to production and aerosol dissemination
Plague is subject to Australian
disseminated intravascular coagulation are well described the threat of a bio-
quarantine.
(DIC). terrorist attack using plague is a potential
Infectious agent Method of diagnosis public health concern.
Yersinia pestis is the plague bacillus. Visualisation of characteristic ‘safety-pin’
ovoid gram-negative organisms in Reservoir
Identification No enzootic (animal) reservoir exists in
material aspirated from buboes, sputum
Clinical features Australia. In affected countries wild rats
or CSF is highly suggestive of plague
Plague is an acute, severe bacterial and other rodents are the natural
infection.
infection usually transmitted through a reservoir. Other animal reservoirs include
flea bite and most commonly presents as Fluorescent antibody (FA) testing or
ground squirrels (especially in North
bubonic, pneumonic or septicaemic antigen capture ELISA is more specific and
America), rabbits, hares and domestic
forms. particularly useful in sporadic cases.
cats.
Initial symptoms are often non-specific Seroconversion using the passive
Plague bacteria are killed within a few
and may include fever, chills, muscle haemagglutination (PHA) test is also
hours of exposure to sunlight although
aches, nausea and lethargy. highly suggestive of recent infection.
they may persist for several weeks in
Bubonic plague is the most common The diagnosis is confirmed by culture water and on moist grains and pulses.
form. It is characterised by swelling and and identification of the organism from
inflammation of the local lymph nodes bubo aspirates, the blood, CSF or Mode of transmission
sputum. Plague is most commonly transmitted
(buboes) draining the site of the flea bite
from rodent to human by the bite of an
or elsewhere. The nodes are tender, firm
Incubation period infected flea, especially the oriental rat
and fixed, and may suppurate in the
The incubation period is from one to flea Xenopsylla cheopis.
second week.
seven days. For primary plague
Respiratory droplets from people or
Pneumonic plague may be primary due pneumonia it is one to four days.
domestic pets with plague pharyngitis or
to respiratory transmission from an
Public health significance pneumonia may also transmit plague.
external source, or secondary as a
and occurrence Unprotected handling of plague infected
complication of bubonic plague. Onset of
Y. pestis is not endemic in Australia but it animal tissues or laboratory specimens
primary plague pneumonia is usually
is widely distributed around the world. are also possible aerosol routes for
abrupt with high fever, tachycardia and
plague transmission.
headache. Cough develops within 24 The World Health Organization (WHO)
hours. Sputum is mucoid at first and reports 1000 to 3000 cases of plague If plague bacteria were to be used as a
then becomes bright red and foamy. every year. Plague is endemic in some bioterrorist agent, it would most likely be
Chest X-rays show a rapidly progressing parts of South East Asia including parts spread in the form of an aerosol or an
pneumonia. of Indonesia, Burma and Vietnam. Wild aerosolised powder. This would result
rodent plague exists in areas of the USA, primarily in pneumonic plague. A
South America, Africa, Central and South deliberate release of infected fleas is also
East Asia. possible.
160 The blue book: Guidelines for the control of infectious diseases

Period of communicability For cases with bubonic plague, if there Special settings
Infected fleas may remain infectious for are no respiratory symptoms contact The control measures described above
months. precautions are indicated until the apply to all settings.
completion of at least three days of
Bubonic plague is not usually transmitted Outbreak measures
appropriate antibiotic therapy with
from person to person unless there is A single case of plague constitutes an
clinical improvement.
direct contact with pus from suppurating outbreak and should be considered as a
buboes. For patients with pneumonic plague,
public health emergency.
isolate the case to prevent droplet
Pneumonic plague may be highly If one or more cases are found with no
spread and use respiratory precautions
communicable under appropriate history of travel to an endemic plague
until the completion of at least three
climatic conditions. area, a deliberate release of plague
days of appropriate antibiotic therapy
Patients are usually no longer infectious with clinical improvement. bacteria must be considered.
after receiving 48–72 hours of If a focus of infection is identified,
Disinfect all sputum and purulent
appropriate antibiotic treatment. outbreak control measures should
discharges and soiled articles
concurrently. include:
Susceptibility and resistance
Everyone is susceptible to infection. The Use respiratory and contact precautions • active case finding
disease does not always confer during the handling, and autopsy, of • alerting medical practitioners
protective immunity. bodies of patients suspected, or • alerting specialist treatment centres
confirmed of dying from plague.
Control measures • release of appropriate public
Preventive measures Control of contacts information
A vaccine is available against plague that Contacts of the case should be
identified, examined for and, if • instigation of intensive flea control
provides some short term protection. It
appropriate, disinfested of fleas. around the focus in expanding circles
may be recommended for laboratory
Contacts are placed under surveillance of control
workers handling plague specimens and
visitors to epidemic areas but should not to detect symptoms of early infection for • destruction of rodents within affected
be relied upon as the sole prevention six days from the last exposure. areas
measure. Close contacts of confirmed or • control of contacts (as described
The vaccine is not protective against suspected pneumonic plague cases above) including field workers involved
primary pneumonic plague. should also be given chemoprophylaxis in environmental control measures.
(doxycycline or ciprofloxacin) supervised
Control of case International measures
by an experienced physician.
Hospitalise the case in a single room. Governments are required to notify WHO
Control of environment
Treatment usually consists of gentamicin and adjacent countries of the first cases
As currently there is no enzootic plague in
or doxycycline. Consult the current of plague in any area previously free of
Australia, the greatest risk of infection is
version of Therapeutic guidelines: the disease within 24 hours of diagnosis,
associated with overseas travel.
antibiotic (Therapeutic Guidelines in accordance with International Health
Limited). Any suspected local sources of infection Regulations.
should be investigated and managed as a
Use an appropriate insecticide to rid the
public health emergency (see Outbreak
patient (including clothing and baggage)
measures, below).
of fleas.
The blue book: Guidelines for the control of infectious diseases 161

Measures applicable to ships, aircraft,


land transport and international travellers
arriving from plague areas are specified
in the International Health Regulations
1969, third annotated edition 1983,
WHO, Geneva.
Prior to departure from an area where
there is an epidemic of pulmonary
plague, those suspected of significant
exposure should be placed under
surveillance to detect symptoms of early
infection for six days from the last
exposure.
On arrival of a suspected infected ship or
aircraft, travellers should be disinfested
of fleas and kept under symptom
surveillance for six days from the date of
arrival.

Additional sources of information


• Australian Government Department of
Health and Ageing fact sheet,
http://www.health.gov.au
• Centers for Disease Control and
Prevention, Atlanta USA, Public health
emergency preparedness and response,
http://www.bt.cdc.gov
162 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 163

Poliomyelitis
Victorian statutory requirement After 60 days the degree of existing by the Victorian Infectious Diseases
Poliomyelitis (Group A disease) must be paralysis is likely to be permanent. Reference Laboratory. The NPRL can also
notified immediately by telephone or fax Sensory loss is very rare and its differentiate between ‘wild-type’ and
followed by written notification within five occurrence should strongly suggest vaccine-associated strains.
days. some other diagnosis such as Guillain- The Department coordinates with
Barré syndrome. clinicians and the NPRL to ensure that
School exclusion: applicable for at least 14
days from onset. Re-admit after receiving Post-polio syndrome is an infrequent appropriate infection control procedures
medical certificate of recovery. recurrence of muscle weakness that may are followed in the collection, transfer
occur many years after initial infection. It and analysis of all clinical specimens
Infectious agent is thought to be due to progressive from patients with suspected polio.
Poliovirus is an enterovirus; types 1, 2 dysfunction and loss of motor neurons
and 3 cause disease. that compensated for the neurons lost Incubation period
during the original infection, not to The range is between three to 35 days
Identification with seven to 14 days for paralytic cases.
persistent or reactivated poliovirus
Clinical features
infection.
The majority of polio infections are either Public health significance
inapparent or present as a non-specific Vaccine-associated paralytic and occurrence
febrile illness. Flaccid paralysis occurs in poliomyelitis (VAPP) is a very rare Prior to vaccination programs polio
less than 1% of poliovirus infections. complication in recipients of oral polio occurred worldwide. Since the Global
vaccine or their contacts, with Polio Eradication Initiative was launched
Symptoms of minor illness include fever,
approximately one case per 2.4 million in 1988, three WHO regions have been
malaise, headache, nausea and vomiting.
doses of vaccine. The risk is greater for certified polio-free: the Americas in
If the disease progresses to major illness,
the first dose than subsequent doses 1994, the Western Pacific (of which
severe muscle pain and stiffness of the
and is slightly greater for adults than Australia is a member) in 2000, and
neck and back with flaccid paralysis may
children. Europe in 2002. Polio cases have
occur.
Method of diagnosis dropped from an estimated 350 000 in
The most characteristic feature of polio 125 countries in 1988 to just 480
A clinical history including vaccination
paralysis is its asymmetric distribution, reported cases in only ten polio-endemic
status of case and household contacts
which affects some muscle groups while countries in 2001.
and any recent travel is important.
sparing others. Fever and muscle pain
Diagnosis is made by isolation of virus By 2003, six countries were still
are generally present at onset with the
from cerebrospinal fluid (CSF), faecal reporting new polio cases: India, Niger,
maximum extent of paralysis usually
specimens or oropharyngeal secretions. Pakistan, Afghanistan, Egypt, and Nigeria.
reached within three to four days.
Progression of paralysis almost invariably Two separate faecal specimens taken at In endemic areas, cases of polio occur
halts when the patient becomes afebrile. least 24 hours apart and within 14 days both sporadically and in epidemics. In
The site of paralysis depends upon the of onset of symptoms give the best temperate climates an increase in cases
location of nerve cell destruction in the chance of diagnosis. CSF usually reveals occurs during the late summer and
spinal cord or brain stem. Proximal a mild elevation in protein and a autumn, in tropical countries an increase
muscles of the extremities tend to be lymphocytosis. is less pronounced but can occur as a
more involved than distal. The legs are The Department requires that all seasonal peak in the rainy season.
more often affected than the arms. suspected cases of polio have In countries where polio has been
Paralysis of the respiratory and appropriate faecal specimens sent for eradicated, importation from non-
swallowing muscles is life threatening. analysis by the National Poliovirus vaccinated individuals remains a threat.
Reference Laboratory (NPRL), managed
164 The blue book: Guidelines for the control of infectious diseases

Polio remains a predominantly childhood Susceptibility and resistance Under the National Immunisation
illness with 80% to 90% of cases All non-immune people are susceptible Program, polio immunisation consists of
occurring in children less than five years to infection. a primary course of OPV given as two
old. drops by mouth at 2, 4 and 6 months of
After infection from both clinically
age with a booster at four years of age.
Reservoir recognisable and inapparent infections,
IPV is given for individuals with
Humans. type specific lifelong immunity occurs.
immunosuppression from disease or
Reinfection is rare but can occur if
chemotherapy and for their siblings and
Mode of transmission infected with poliovirus of a different
household contacts.
Wild poliovirus is spread through faeces type.
and saliva. It is primarily transmitted Both IPV and OPV give mucosal and
Vaccine efficacy of OPV and Inactivated
through faecal-oral spread and is an humoral protection, however IPV
Polio Vaccine (IPV) after a primary course
important consideration where sanitation produces considerably lower levels of
is 95% and thought to be life long. Both
is poor. intestinal immunity than OPV.
vaccines give protection against all three
‘Live’ oral polio vaccine (OPV) virus can types of poliovirus. Due to the successful elimination of polio
be shed in the faeces for six weeks and in some regions and the concern with
Infants born of immune mothers have
may lead to infection in unvaccinated OPV of Vaccine Associated Paralytic
transient passive immunity.
contacts. Unvaccinated household Poliomyelitis (VAPP), many industrialised
contacts of a case should be vaccinated Control measures countries have now changed to IPV alone
at the same time. Stressing the Preventive measures for routine immunisations. IPV is the
importance of hand washing for parents Universal vaccination in early childhood vaccine recommended on the ASVS
following nappy changing and disposal is is the most effective means of preventing subject to the availability of further
important. and eradicating poliomyelitis. Catch-up combination vaccines. The Australian
immunisation is also recommended for Government is currently reviewing this
Period of communicability unimmunised or partially immunised funding decision.
The risk of transmission of infection is adults at risk of exposure such as those OPV is still recommended in developing
greatest for the seven to ten days prior to travelling overseas and health care countries because of the higher risk of
and following the onset of symptoms. workers in possible contact with polio exposure to wild poliovirus, the low cost
The virus persists in the pharynx for cases. of the vaccine, the ease of its
approximately one week and in the Immunisation can be given as an administration and its excellent capacity
faeces for up to six weeks, or longer in intramuscular IPV, or as a live OPV. to provide population-level immunity.
the immunosuppressed.
Transmission of the virus is possible for
as long as the virus is excreted.
The blue book: Guidelines for the control of infectious diseases 165

Control of case Control of environment


There is no specific treatment against In communities with modern sewerage
poliovirus. Cases require expert systems, faeces and urine can be
supervision and may need ventilation disposed of directly into the system
support. Early physiotherapy may without preliminary disinfection.
increase the level of function and reduce Cases and carers should be advised
the risk of physical deformities as a result about the importance of strict hand
of paralytic polio. washing, covering the mouth when
Enteric precautions should be initiated in coughing, sneezing into disposable
hospital settings. These are often of little tissues, and the appropriate cleaning or
benefit in household settings as disposal of contaminated objects.
susceptible contacts are likely to have
been exposed prior to diagnosis. Outbreak measures
In countries such as Australia where
In communities with appropriate modern
polio has been eradicated a single case
sewerage systems, faeces and urine from
of polio is considered a public health
infected patients can be disposed of
emergency and the Department of
directly into sewers without preliminary
Human Services must be notified
disinfection. Terminal disinfection is
immediately. The Department
required for all other potentially
investigates to:
contaminated items.
• determine whether the patient’s
Control of contacts
disease represents an indigenous,
Vaccination of families and other close
imported or VAPP case
contacts is recommended but may not
contribute to immediate control due to • if believed to be a VAPP case, obtain
susceptible contacts often being infected details of vaccine history, batch
by the time the first case is recognised. number, virus type, severity and
persistence of residual paralysis 60
Active case finding, especially among
days after onset
children, ensures early detection of
related cases and facilitates control. supervise all appropriate case and
contact control measures, as outlined
above.
166 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 167

Psittacosis (ornithosis)
Victorian statutory requirement positives may occur in C. pneumoniae, C Mode of transmission
Psittacosis (Group B disease) must be trachomatis and occasionally in Infection is generally acquired by inhaling
notified in writing within five days of Legionella infections. dust from dried faeces or fresh or dried
diagnosis. Antibiotic treatment may delay or ocular and nasal secretions from infected
School exclusion is not applicable. attenuate antibody formation so birds. Direct contact with birds is not
convalescent sera should be taken at required for infection. Rare person to
Infectious agent least two weeks after the acute person transmission has occurred.
Chlamydia psittaci is an obligate specimen.
intracellular bacterium. Period of communicability
Culture of the organism is generally not Infected birds may shed the agent
Identification performed because of danger to intermittently for a prolonged period.
Clinical features laboratory workers. Shedding may be precipitated by stress
The onset of psittacosis is usually abrupt Birds on the birds such as cold, crowding or
with fever, prominent headache, Birds suspected of being infected should shipping. Dried secretions may remain
photophobia, myalgia, and upper or lower be referred to a veterinarian for diagnosis infectious for many months.
respiratory tract symptoms. Dry cough is and treatment as required. The Avian
a common feature. Pulse-temperature Medicine Section at Primary Industries
Susceptibility and resistance
dissociation, splenomegaly and rash may Chlamydia psittaci is highly infectious. At
Research Victoria, Attwood (03) 9217
occur. In association with pneumonia risk groups include bird owners, pet shop
4200 has further details of specimen
these are said to be suggestive of the employees, veterinarians, poultry-
collection and transport requirements.
diagnosis. Chest X-rays may show patchy processing workers, zoo workers and
or focal consolidation. Incubation period taxidermists.
The incubation period is four days to four Older adults and pregnant women may
The illness usually lasts for seven to ten
weeks, commonly ten days. have a more severe illness. Immunity
days and is mild or moderate. It may be
severe in pregnant or older, untreated following infection may be incomplete
Public health significance
patients. Asymptomatic infection or mild and reinfection occurs occasionally.
and occurrence
flu-like illness may also occur. Most cases are sporadic but outbreaks Control measures
Complications include encephalitis, of infection may occur rarely within Preventive measures
endocarditis, myocarditis and individual households or through contact Educate the public about the danger of
thrombophlebitis. Relapses may occur, with affected pet shops or poultry household or occupational exposure to
especially when there has been processing plants. infected pet birds.
inadequate treatment.
Reservoir Wearing gloves and dust masks is
Method of diagnosis Birds of all types act as a reservoir. This recommended when cleaning areas with
Humans is especially common for psittacine birds which birds have frequent contact such
Infection is generally diagnosed by (parrots, lorikeets, cockatiels, as cages and bird feeders.
seroconversion on paired acute and budgerigars) but also pigeons, turkeys, Prevent or eliminate infections of birds by
convalescent phase sera, although a ducks and occasionally chickens. quarantine and antibiotic treatment.
single high acute phase titre in the Healthy birds may be carriers. Cats,
setting of clinically-compatible illness is Appropriate surveillance of commercial
dogs, goats or sheep may be infected but
significant. Low positive titres are flocks, pet shops and aviaries should be
this is rare.
common in high risk groups. False instituted.
168 The blue book: Guidelines for the control of infectious diseases

Destroy or treat infected birds and Outbreak measures


disinfect premises. All cases should be thoroughly
Control of case investigated in order to identify more
Isolation is not necessary, but instruct extensive outbreaks.
the patient to cough into disposable Outbreaks should be reported to the
tissues. Treatment with tetracyclines Department of Human Services, Victoria.
should be continued for 10–14 days after
fever settles. If tetracyclines are Additional sources of information
contraindicated erythromycin can be • Centers for Disease Control and
used. Consult the current version of Prevention 2000, ‘Compendium of
Therapeutic guidelines: antibiotic measures to control Chlamydia psittaci
(Therapeutic Guidelines Limited). infection among humans and pet
birds’, Morbidity and Mortality Weekly
Control of contacts
Report, vol. 49, RR08, pp. 3–17,
A diagnosis of psittacosis should be
http://www.cdc.gov/mmwr
considered in symptomatic contacts.
Control of environment
If birds were recently purchased the
origin of suspected birds should be
traced. This is the responsibility of the
Department of Human Services in liaison
with the Department of Primary
Industries.
Prophylactic use of tetracyclines can
suppress, but not eliminate, infection in
flocks and may complicate
investigations.
For disinfection of floors and cages use a
1:100 dilution of household bleach in
water or 70% isopropyl alcohol.
Psittacosis information sheet
What is psittacosis? What about my pet bird? Further information
Psittacosis is bacterial disease of both Sick birds may have eye or nasal • Your local doctor
wild and domestic birds that can affect discharge or ruffled feathers, and may • Better Health Channel,
people. In birds it is also known as avian feed poorly. If your bird is ill seek advice www.betterhealth.vic.gov.au
chlamydiosis (AC). from your vet. Stop wild birds getting
close to your pet bird’s cage as they can • Victorian Department of Human
What are the symptoms in spread disease. Services, 1300 651 160
humans?
Psittacosis in humans may cause a flu- I think I may be infected - what
like illness or pneumonia. Symptoms may should I do?
include fever, headache, aching muscles See your local doctor and tell them about
and chills, while cough is your contact with birds. This disease can
characteristically dry or may be absent. If be readily treated with antibiotics.
pneumonia occurs, symptoms such as
shortness of breath or chest pain may How can I avoid getting
occur. psittacosis?
Avoid contact with wild birds and do not
Where is psittacosis found? feed wild birds.
Birds, especially parrots, can carry the Try to avoid stressing birds by crowding
disease. Birds do not have to be sick to or cold conditions and do not buy birds
spread the disease. Rarely ill cats, dogs, which appear ill.
goats or sheep can spread infection.
Wear gloves and a dust mask when
How is psittacosis spread? cleaning cages and wet down the area
The disease is spread by breathing in the prior to cleaning to prevent dust
bacteria which is present in the infected formation. Don’t use an ordinary vacuum
bird’s droppings, nose or eye secretions. cleaner as it can throw infectious dust
Dried secretions can remain infectious into the air.
for many months. The risk of getting the Clean cages, food and water bowls daily
disease is greater when the birds are and use litter which creates dust such as
under stress, for example just after being newspaper.
bought. You may unknowingly come into
Use a 1:100 diluted solution of household
contact with infected birds while feeding
bleach to disinfect any ill bird’s cage,
wild birds, cleaning feeding stations or
bowl etc. Throw away material which
cleaning contaminated aviaries. The
cannot be disinfected and rinse all
spread of psittacosis from person to
disinfected items before replacing them.
person is rare.
Do not allow birds to get close to your
face and wash hands thoroughly after
contact with birds.

Department of Human Services


170 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 171

Q fever
Victorian statutory requirement The diagnosis is supported by the Reservoir
Q fever infection (Group B disease) must detection of phase II IgM by ELISA testing There is no known endemic reservoir in
be notified in writing within five days of but this may not appear until 10 days Victoria. The organism is commonly
diagnosis. after the onset of symptoms. Q fever IgM introduced in stock from interstate from
may persist for many months after animals including goats, cattle, sheep,
School exclusion is not applicable.
infection; hence its presence does not other farm and domestic animals and
Infectious agent necessarily confirm the diagnosis. some wild animals (including kangaroos
The rickettsia-like bacterium Coxiella If Q fever antibodies are present within and bandicoots).
burnetii is the causative agent. three to four days of the onset of
Mode of transmission
symptoms it is more likely to indicate
Identification Q fever is contracted through the
past exposure rather than recent
Clinical features respiratory route after inhalation of
infection.
The onset of Q fever infection is usually Coxiellae-contaminated dust or aerosols.
acute and characterised by fever, chills, Chronic Q fever is suggested by a high This most commonly occurs as a result
sweats, severe headache (especially CF antibody titre( 320) to phase I and II of:
behind the eyes), weakness, anorexia, antigens and low or absent IgM antibody.
• inhaling water droplets and dust
myalgia and cough. Transient mild rashes IgA class antibody to phase I antigen is contaminated by placental tissues,
are an occasional feature. Orchitis occurs highly suggestive of Q fever endocarditis. birth fluids or excreta of infected
rarely. Abnormal liver function tests are animals. Contaminated dust particles
common. Incubation period
may occasionally be carried downwind
The incubation period is typically 19–21
Chronic complications include for a considerable distance from the
days although the range is from two
granulomatous hepatitis and source
weeks to two months.
endocarditis. The latter is the most • direct contact with contaminated
serious concern as it usually involves the Public health significance materials in establishments processing
aortic valve and occurs months to years and occurrence infected animals or their by-products,
after the acute illness. A relapsing fatigue It is an acute febrile rickettsial disease of contact with contaminated straw, wool
syndrome may occur in 20–40% of low mortality but significant morbidity. It or hides, or the contaminated clothing
cases. is most commonly found in abattoir of workers.
Method of diagnosis workers who have recently handled Although Q fever is occasionally
Acute and some chronic manifestations contaminated stock such as feral goats transmitted sexually, there is no evidence
of Q fever can be diagnosed by serology. or sheep from interstate endemic areas. of person to person transmission through
It is an occupational hazard for tannery other routes. Direct transmission through
Acute Q fever can be diagnosed by a
and knackery workers, shearers, meat blood and bone marrow transfusion has
fourfold rise in specific complement
inspectors, dairy workers, animal-farm also been reported.
fixation (CF}) antibodies or by direct
workers, animal transporters, wool
immunofluorescence (IF) antibody Drinking non-pasteurised milk from an
sorters and veterinary personnel. It also
testing between acute and convalescent infected animal has been suggested as a
occurs in others handling fomites such
sera collected at least 14 days apart. possible route but this has not been
as those laundering contaminated
clothing. proven.

Outbreaks are usually of short duration.


172 The blue book: Guidelines for the control of infectious diseases

Period of communicability Access to high risk environments such as Outbreak measures


Person to person spread occurs very rarely abattoirs and meat-processing plants All notified cases are investigated to
by the sexual route. Contaminated clothing should be restricted to immunised ascertain the most likely source of
may also be a source. persons. This includes visitors, exposure and to identify any other linked
contractors and delivery drivers. Workers cases. If two or more cases are linked in
Susceptibility and resistance in these environments should also be time and place to a workplace, other
All non immune people are susceptible educated about the nature of the staff should be assessed for immune
to infection. Most cases are in male disease. status (if not already known) with
adults but this is probably due to their antibody levels and skin testing.
Control of case
higher frequency of exposure to high risk
Acute cases of Q fever generally require Non-immune staff should be excluded
environments, rather than differential
treatment with doxycycline or from the worksite until vaccinated.
susceptibility.
chloramphenicol. Consult the current
Infection usually confers lifelong version of Therapeutic guidelines:
immunity. antibiotic (Therapeutic Guidelines
Limited).
Control measures
Preventive measures In chronic disease or endocarditis,
Immunisation of those in high risk prolonged combination therapy together
occupational groups is the primary with cardiac surgery may be required.
preventive measure against Q fever. Consultation with an infectious diseases
There is a risk of severe local reactions to physician should be sought.
the vaccine in those people previously Isolation is not necessary. Articles
exposed to Q fever or the vaccine. To contaminated with blood, sputum and
assess prior exposure to Q fever or the excreta should be disinfected using
vaccine, pre-vaccination screening is standard precautions.
necessary and involves:
Control of contacts
• checking for a clinical history of Q No specific measures are required for
fever or Q fever vaccination household contacts.
• antibody testing Vaccination during the incubation period
• an intradermal skin test, read after does not prevent the disease. Post-
seven days. exposure prophylaxis is not
recommended.
Any positive result on screening
precludes vaccination. Vaccination Control of environment
induces lifelong immunity in most If a clear source is identified, disinfection
vaccinees. Training is recommended for can be performed using 0.05%
medical practitioners intending to hypochlorite (500 ppm available
conduct Q fever screening and chlorine) or 5% peroxide.
vaccination.
The blue book: Guidelines for the control of infectious diseases 173

Rabies and Australian


bat lyssavirus
Victorian statutory requirement The criteria for a confirmed case are a Incubation period
Rabies (Group A disease) must be clinically compatible neurological illness The incubation period for rabies is usually
notified immediately by telephone or fax and one or more positive results from the three to eight weeks. It is rarely as short
followed by written notification within five three laboratory tests described below. as nine days or as long as seven years. It
days. Symptoms of encephalitis due to ABL tends to be shorter for wounds in areas
Australian bat lyssavirus (Group B include numbness, muscle weakness, of the body with rich nerve supply and
disease) must be notified in writing collapse and coma. A confirmed case close to the head.
within five days of diagnosis. requires laboratory definitive evidence The incubation period for ABL is not well
only. characterised but it is assumed to be
Rabies is subject to Australian
quarantine. Method of diagnosis similar to rabies. The first case, reported
The Australian Animal Health Laboratory in 1996, is believed to have had an
Infectious agents at Geelong is the reference laboratory for incubation period of at least several
Rabies virus and Australian bat lyssavirus the diagnosis of rabies and ABL. The weeks. In the second patient the
(ABL) are closely related members of the State Chief Quarantine Medical Officer at incubation period was greater than two
genus Lyssavirus. the Department of Human Services years.
should also be advised at the time of
Identification Public health significance
submitting any specimen. Transfer of
Clinical features and occurrence
human and animal specimens is
Rabies is an acute viral disease of the Rabies is endemic in Asia, India, Africa,
coordinated by the State Chief
central nervous system (CNS). CNS North and South America and parts of
Quarantine Medical Officer in
symptoms are preceded by a non- Europe. High rates of rabies are reported
consultation with the chief veterinary
specific prodrome of fever, headache, from the Philippines, Thailand and
officer.
malaise, anorexia, nausea and vomiting Indonesia with the exception of Bali,
lasting one to four days. This is followed Rabies and ABL can be diagnosed by: which is rabies-free.
by signs of encephalitis manifested by • detection of virus antigen by direct Australia is currently rabies-free. Rabies
periods of excitation and agitation fluorescent antibody of a clinical is a very rare infection of travellers to
leading to delirium, confusion, specimen such as neural tissue endemic areas outside of Australia. Only
hallucinations and convulsions. Signs of (preferred), skin snips from the nape of two imported human cases were
brain stem dysfunction begin shortly the neck, saliva or CSF reported between 1900 and 1995 (1987
after with excessive salivation and and 1990).
• isolation in cell culture or laboratory
difficulty in swallowing. This produces the
animal of the virus from saliva, CSF or Two human cases of ABL infection have
classical picture of ‘foaming at the
CNS tissue been reported. One of these was from
mouth’.
• identification of rabies-neutralising Northern New South Wales (1996) and
Even with medical intervention the the other from Rockhampton in
antibody in the serum or CSF of
disease is almost invariably fatal. Death Queensland (1998). Both patients had a
unvaccinated persons.
from respiratory paralysis generally history of bites and scratches from a bat
occurs within two to six days of the Confirmation by all the above methods is
and both died from their infections.
onset of symptoms. recommended.

The criterion for a suspect rabies case is


progressive encephalitis with a past
history of exposure in a rabies endemic
area.
174 The blue book: Guidelines for the control of infectious diseases

Rabies is subject to human quarantine ABL is known to infect all four faeces does not constitute a likely
controls under the Commonwealth Megachiroptera (fruit bats and flying exposure to ABL, although bat urine and
Quarantine Act 1908. Rabies is a foxes) species in Australia and at least faeces may carry other human
quarantinable disease because of three species of Microchiroptera pathogens.
Australia’s freedom from this disease. It (insectivorous bats). Ongoing serological Transmission from person to person is
is also reportable to the World Health testing and virus studies suggest that this theoretically possible but it has only ever
Organization. lyssavirus is widely distributed in been documented through corneal
The primary quarantine concern is the Australia. It is therefore assumed that all transplantation.
prevention of the introduction of rabies Australian bats have the potential to
virus to local dog and wildlife carry and transmit ABL. Period of communicability
populations. There is no evidence that lyssaviruses in In dogs and cats rabies is usually
bats can establish and spread amongst communicable three to seven days
ABL is an emerging infectious disease
terrestrial animals, although isolated before onset of clinical signs and
which has much in common with rabies.
cases in humans may occur on rare throughout the course of the illness. Viral
The risk of human exposure increases
occasions. excretion up to 14 days prior to clinical
with increasing human contact with
signs has been observed in some animal
Australian bat environments. This risk Mode of transmission
species. Similar communicability can be
would increase significantly if ABL Rabies virus and other lyssaviruses are assumed for human cases.
became established in terrestrial animal usually transmitted to humans via bites
populations, particularly dogs. Communicability for ABL is not known
or scratches which provide direct access
but assumed to be similar to rabies.
of the virus in saliva to exposed tissue
Reservoir
and nerve endings. It can also occur Susceptibility and resistance
Rabies is a disease primarily of animals.
where mucous membrane exposure to All mammals are susceptible to varying
Most wild and domesticated dog-species
bat saliva has occurred such as eyes, degrees. In one case series, only 40% of
(including foxes, coyotes, wolves and
nose or mouth. children bitten by known rabid dogs
jackals) are susceptible to infection.
Infected dogs remain the highest risk The most frequent way that humans developed the disease.
source for human transmission. Other become infected with rabies is through
the bite of infected dogs, cats, wild
Control measures
species include skunks, racoons and
Preventive measures
bats. carnivorous species like foxes, raccoons,
Pre-exposure vaccination is
skunks, jackals and wolves, and
In developed countries rabies is mainly recommended for people whose
insectivorous and vampire bats. Cattle,
found in wild animal hosts. Disease is occupation or recreational activities
horses, deer and other herbivores can
spread from wild hosts to domestic place them at increased risk of being
become infected with rabies but rarely
animals and humans. In contrast dogs bitten or scratched by a bat. It is also
transmit the virus to other animals,
continue to be the main hosts in most recommended for travellers who will be
although they may transmit the disease
African, Asian and Latin American spending prolonged periods (i.e. more
to humans.
countries, and are responsible for most than one month) in rural parts of rabies
of the rabies deaths that occur People are not exposed to ABL through endemic areas (see rabies/ABL
worldwide. tactile contact with bats where vaccination information sheet below).
parenteral or mucous membrane
Australia is one of a growing number of The World Health Organization maintains
exposure does not occur. Contact such
countries in the world where the animal data on rabies infected countries – see
as patting bats or exposure to urine and
population is free of rabies. www.who.int/csr
The blue book: Guidelines for the control of infectious diseases 175

Control of case The decision to offer post-exposure Additional sources of information


There is no specific treatment available. prophylaxis (rabies vaccine and rabies • Animal Health Australia 1996,
Intensive supportive treatment is immunoglobulin) to a potentially exposed AUSVETPLAN,
required. person should be made in consultation http://www.aahc.com.au/
The patient should be placed in a private with the Communicable Diseases ausvetplan/
room with standard isolation precautions Section of the Department of Human
• Communicable Diseases Network of
implemented for respiratory secretions Services (see rabies/ABL vaccination
Australia 2001, Australian bat lyssavirus
for the duration of the illness. There information sheet below).
– Information for medical practitioners.
should be concurrent disinfection of all Control of environment
saliva-contaminated articles. Although See Outbreak measures, below.
transmission from a patient to attending
carers has not been documented, health Outbreak measures
care workers should be advised to wear If the source of the ABL infection is likely
gowns, gloves and masks while attending to be in Australia, a search should be
patients. Blood and urine are not made for the infected animal in
considered infectious. collaboration with animal health
authorities. Where possible, without
Control of contacts
placing other persons at risk of exposure,
Other individuals exposed to the source
the bat should be kept and the
animal are identified and offered post-
Department of Human Services
exposure prophylaxis. Contacts that have
consulted about arranging testing of the
open wound or mucous membrane
bat for virus carriage.
exposure to a patient’s saliva should be
offered full post-exposure prophylaxis. If a rabies case, human or animal, is
believed to have been locally acquired,
Post-exposure treatment
the AUSVETPLAN rabies control
Proper cleansing of the wound is the
procedures should be implemented. In
single most effective measure for
designated areas animal owners may be
reducing the transmission of rabies virus
required to have susceptible animals
and this is likely to be also true for ABL.
vaccinated with rabies vaccine. Animal
When a person has been injured by a movements are restricted and stray
potentially infected animal overseas, or animals destroyed.
any Australian bat, the wound should be
ABL is unique to Australia and currently it
washed thoroughly for approximately five
is only found in Australian bat species. If
minutes as soon as possible with soap
a human case of ABL is diagnosed in
and water. If available, a virucidal
Victoria or ABL is found in another animal
antiseptic such as povidone-iodine,
species such as a dog or cat,
iodine tincture, aqueous iodine solution
investigation and control measures
or alcohol (ethanol) should be applied
similar to those for a rabies case, should
after washing. Exposed mucous
be instigated.
membranes such as eyes, nose or mouth
should be flushed well with water.
Rabies and Australian bat lyssavirus exposure
information sheet
Pre-exposure prophylaxis Post-exposure treatment for If the exposure is connected to an
Pre-exposure vaccination should be persons bitten or scratched Australian bat, where possible without
recommended to those people whose The decision to offer post-exposure placing other persons at risk of exposure,
occupation or recreational activities prophylaxis to a potentially exposed the bat should be kept so that the
place them at increased risk of being person should be made in consultation Department of Human Services can
bitten or scratched by a bat. For with the Department of Human Services. arrange for testing of the bat.
example: If post-exposure prophylaxis is indicated, First aid
• bat carers, bat handlers, researchers the Department of Human Services will Proper cleansing of the wound is the
and students arrange for rapid delivery of vaccine and single most effective measure for
immunoglobulin as required. reducing the transmission of classic
• veterinarians and veterinary assistants
Post-exposure treatment should be rabies virus.
• veterinary laboratory staff considered in the following scenarios: Where a person has been injured by a
• fruit pickers • person bitten or scratched by bats in potentially infected animal, the wound
• wildlife officers (including local Australia should be washed thoroughly for
government officers) approximately five minutes as soon as
• person bitten or scratched by any
• managers of display or research possible with soap and water. If available,
animal in a country with endemic
colonies of bats a virucidal antiseptic such as povidone-
rabies.
iodine, iodine tincture, aqueous iodine
• power line workers who frequently Assessment solution or alcohol (ethanol) should be
remove bats from power lines. Rabies virus and other lyssaviruses are applied after washing. Exposed mucous
Pre-exposure vaccination should also usually transmitted to humans via bites membranes such as eyes, nose or mouth
be recommended for travellers who or scratches which provide direct access should be flushed well with water.
will be spending prolonged periods of the virus in saliva to exposed tissue
(i.e. more than one month) in rural parts and nerve endings, or where mucous Post-exposure treatment – not
of rabies endemic areas. The World membrane such as eyes, nose or mouth previously vaccinated against
Health Organization maintains data on exposure to bat saliva has occurred. This rabies
rabies infected countries – see means that people would not be exposed Rabies vaccine
www.who.int/csr to lyssavirus through tactile contact with Post-exposure prophylaxis for persons
bats alone or other animals where not previously immunised against rabies
Pre-exposure prophylaxis consists of three
parenteral or mucous membrane consists of five doses of 1.0 mL of rabies
deep subcutaneous or intramuscular
exposure does not occur. Contact such vaccine given as deep subcutaneous or
doses of 1.0 mL rabies vaccine given on
as patting bats (Australia) or other intramuscular injection, on days 0, 3, 7,
days 0, 7 and 28. Doses should be given
animals or exposure to their urine and 14 and 28. Doses should be given in the
in the deltoid area, as rabies neutralising
faeces does not constitute a possible deltoid area, as rabies neutralising
antibody titres may be reduced after
exposure to ABL, although bat urine and antibody titres may be reduced after
administration in other sites. In children,
faeces may carry other human administration in other sites. In children,
administration into the anterolateral
pathogens. Pre-exposure vaccination administration into the anterolateral
aspect of the thigh is also acceptable.
should however be offered if the person aspect of the thigh is also acceptable.
The vaccine should not be administered has ongoing contact with bats. The vaccine should not be administered
by the intradermal route. by the intradermal route.

Department of Human Services


Rabies immunoglobulin Post-exposure treatment - Further information
Rabies immunoglobulin (RIG) should be previously vaccinated against • Your local doctor
given as a single dose at the same time rabies • Better Health Channel,
as the first dose of the post-exposure Post-exposure prophylaxis for persons www.betterhealth.vic.gov.au
vaccination course. The dose for RIG is who have previously completed the
20 International Units (IU) per kilogram recommended course of either pre- • Victorian Department of Human
of body mass. RIG should be infiltrated in exposure vaccination or post-exposure Services, 1300 651 160
and around all wounds using as much of prophylaxis or who have documented • Australian Immunisation Handbook,
the calculated dose as possible, and the rabies neutralising antibodies, comprises www.immunise.health.gov.au
remainder administered intramuscularly. a total of two doses of rabies vaccine
It should not be given at the same site as (1.0 mL each) given by either deep
the vaccine, and if administered in the subcutaneous or intramuscular injection
buttock, care should be taken to ensure on day 0 and day 3. In cases where prior
that the dose is given intramuscularly vaccination status is uncertain, or the
and not into adipose tissue. person has been vaccinated by
Although the RIG and first dose of rabies inappropriate intradermal injection, a full
vaccine should preferably be given on course of post-exposure prophylaxis (RIG
the same day, if necessary the RIG can plus five doses of vaccine) should be
be given up to seven days after the first offered. It is therefore advisable to
dose of vaccine, but not thereafter. ensure that people are given adequate
written documentation as to any RIG and
RIG should be infiltrated into finger
vaccines administered.
wounds using a 25 or 26 gauge needle,
and to avoid a compartment (Note that product information
compression syndrome the RIG should recommends a routine 6th dose at 90
be infiltrated very slowly, and should not days. This dose is not considered
cause the adjacent finger tissue to go necessary, except for immunosuppressed
pale or white. If necessary a ring-block persons. See the current edition of the
using local anaesthesia may be required. Australian immunisation handbook,
If the wounds are severe and the National Health and Medical Research
calculated volume of RIG is inadequate Council, for more information).
for complete infiltration, the RIG may be
diluted in saline to make up an adequate
volume for the infiltration of all wounds,
but as most bat bites are small and fine,
this should not be necessary.
178 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 179

Rickettsial infections
Includes scrub typhus and
Queensland tick typhus (spotted
fever)

Victorian statutory requirement Fever may persist for 14 days without distribution in the rest of Australia is less
Notification and school exclusion are not antibiotic treatment. The fatality rate in clear (Odorico, Graves et al 1998). The
required. untreated cases is 1–40%. This increases public health impact on lives or
with age and depends on the infection productivity lost is largely unmeasured
Infectious agents site, the type of Rickettsiae involved and but it is suspected to be high.
Numerous species of Rickettsiae are of previous exposure.
concern to humans. Rickettsiae (and Reservoir
Method of diagnosis
their associated diseases) of particular Humans are incidental hosts and are not
In endemic areas the clinical picture is
importance in Australia are R. australis useful in propagating the organism in
sufficiently distinctive for a clinical
(Queensland tick typhus, Spotted fever), nature. Scrub typhus is transmitted by
diagnosis. A biopsy of the eschar can be
R. tsutsugamushi (Scrub typhus), R. honei rodent mites. It occurs in a large area
used to demonstrate rickettsiae by
(Flinders Island spotted fever) and R. from the Indian subcontinent to Australia
immunofluorescence. Specific diagnosis
typhi (murine typhus). and in much of Asia including Japan,
is seldom possible early enough to help
China, Korea and parts of Russia. The
Identification in the management.
reservoir also includes rats, mice and
Clinical features Definitive diagnosis can be made by other small mammals. An exception is
There is great variation in the severity of isolation of the rickettsia after inoculation louse-borne typhus
illness produced by each organism. of the patient’s blood into mice. (R. prowazekii), which does not occur in
Infection most commonly begins with a Serological methods are also available Australia. Humans are the principal
papule forming at the site of the bite although these need to be interpreted reservoir for louse-borne typhus and the
where the infection was introduced. This with caution because of cross-reactivity human body louse (pediculosis humanus
usually becomes necrotic and forms a between strains. var humanus) is the vector.
typical black eschar (scab). Four days to
two weeks after the bite symptoms begin Incubation period Mode of transmission
with fever and malaise followed by The incubation is from two to 14 days. The disease is not directly transmitted
adenitis in the lymph glands draining the The variation in incubation may be in from person to person. Humans are
bite site. As the organisms spread part related to the inoculum size. infected by the bite of an infected larval
throughout the body, fever, malaise and mite or in the case of scrub typhus, a rat.
Public health significance
headache increase and general
and occurrence Period of communicability
lymphadenopathy occurs in most cases.
The epidemiology varies in different parts The person is infective for lice during the
About a week after onset the main
of the world. Disease occurrence is often febrile illness and probably two or three
features are continuous fever, cough and
associated with the modification of days after the temperature returns to
signs of bronchitis or pneumonia,
natural habitats by humans such as normal. People are at risk of infection for
photophobia, conjunctivitis, generalised
when a forest is felled and replaced by a as long as they remain in infected areas.
adenopathy, delirium, deafness and a
secondary growth of scrub. R. australis
maculopapular rash most commonly over
occurs along the eastern side of Susceptibility and resistance
the trunk and proximal limb parts.
Australia, R. honei has been recognised All non immune people are susceptible
Splenomegaly occurs in some cases.
on Flinders Island near Tasmania and R. to infection and according to
typhi occurs throughout many states of environmental exposure. Long-lasting
Australia. Scrub typhus occurs in immunity probably follows infection.
Queensland but its geographic
180 The blue book: Guidelines for the control of infectious diseases

Control measures Outbreak measures


Preventive measures Except in the case of an epidemic of
There is no vaccine available. People who louse borne typhus, no outbreak
enter infected areas can be protected by measures are necessary.
impregnating their clothing with dimethyl
phthalate and renewing the repellent International measures
frequently. Chemoprophylaxis can be In the event of an epidemic of louse
successfully used short term and for this borne typhus occurring in Australia, the
a consultation with an infectious Department of Human Services will
diseases specialist is recommended. notify the World Health Organization
People camping can also help prevent (WHO) and neighbouring countries of this
tick bites by using camp beds for occurrence in an area previously free of
elevation from the floor. the disease.

Control of case Additional sources of information


Treatment is generally doxycycline or • Bell, D 1995, Tropical Medicine, 4th
chloramphenicol. Consult the current edn, Blackwell Science.
version of Therapeutic guidelines:
• Odorico, D, Graves, S, Currie, B,
antibiotic (Therapeutic Guidelines
Catmull, J, Zoltan, N, Ellis, S, Wang, L
Limited).
and Miller, D 1998, ‘New Oriental
In severe disease, consultation with an tsutsugamushi Strain from Scrub
infectious diseases specialist is Typhus in Australia’. Emerging
recommended. Infectious Diseases, vol. 4, no. 4.
Control of contacts
Consider active case finding if other
people were exposed to the same setting
as the case such as a camping holiday or
military exercise.
Control of environment
Not applicable. The mites themselves act
as reservoirs so no immediate effect is
achieved by rodent control.
Special settings
Not applicable.
The blue book: Guidelines for the control of infectious diseases 181

Ringworm or tinea
Tinea capitis (head), tinea
corporis (body), tinea pedis
(feet), tinea unguium (nails)

Victorian statutory requirement Method of diagnosis Tinea unguium occurs commonly but
Notification is not required. Diagnosis can be made by microscopic there are low rates of transmission, even
examination of material from the affected to close family associates. It is spread by
School exclusion: readmit the day after
area or by fungal culture. direct contact with skin or nail lesions of
appropriate treatment has commenced.
infected persons or indirectly through
Infectious agent Incubation period contact with contaminated floors or
The incubation period differs: showers.
Microsporum spp. includes Microsporum
canis as the primary causative agent in • tinea corporis has an incubation period
Australia of tinea capitis and corporis. of four to ten days Reservoir
Reservoirs for tinea are:
Trichophyton spp. also cause disease for • tinea capitis has an incubation period
example T. rubrum, T.mentagrophytes and of 10–14 days • tinea capitis: humans and animals
Epidermophyton floccosum. including dogs, cats and cattle
• the incubation period of tinea pedis
and tinea unguium is probably weeks • tinea corporis: humans, soil and
Identification
but exact limits are unknown. animals including cattle, kittens,
Clinical features
puppies, guinea pigs, mice and horses
The clinical features of tinea infections
Public health significance • tinea pedis: humans
are those of superficial fungal infection of
and occurrence
the skin, nails or hair: • tinea unguium: humans and rarely
Tinea capitis mainly affects children.
• tinea capitis results in a small papule animals or soil.
M. canis is usually contracted from
that spreads peripherally leaving fine,
infected kittens or puppies. Mode of transmission
scaly patches of temporary baldness.
The highly contagious M. audouinii Direct transmission occurs through
Infected hairs become brittle and
spreads from person to person and does human to human contact, for example
break off easily.
not occur in Australia. T. rubrum and T.mentagrophytes. Animal-
• tinea corporis appears as a flat, red, to-human contact also occurs, for
ring-shaped lesion of the skin. It is Tinea capitis may extend to tinea example M. canis and T. verrucosum.
usually dry and scaly or moist and corporis. It occurs worldwide. Tinea can be transmitted indirectly
crusted but sometimes contains fluid Tinea corporis occurs worldwide and through contaminated soil, for example M.
or pus. The lesion tends to heal relatively frequent. Males are infected gypseum.
centrally. more than females. Infection can occur
• tinea pedis is commonly known as from direct or indirect contact with skin Period of communicability
‘athlete’s foot’. It occurs as itchy, and scalp lesions of infected persons or The fungus persists on contaminated
scaling, cracking of the skin or blisters animals. materials as long as lesions or animal
containing a thin watery fluid. This hair harbour viable spores.
Tinea pedis occurs in children and adults
occurs commonly between the toes. and is spread by using communal Susceptibility and resistance
• tinea unguium is a chronic fungal facilities such as showers at swimming Young children are particularly
disease involving one or more nails of pools. Adults are affected more often susceptible to tinea capitis (Microsporum
the hands or feet. The nail gradually than children and males more than canis). All ages are susceptible to
thickens and becomes discoloured and females. Infection is more frequent and infections particularly those caused by
brittle. Caseous-looking material forms severe in hot weather. Trichophyton spp.
beneath the nail or the nail becomes
chalky and disintegrates.
182 The blue book: Guidelines for the control of infectious diseases

Susceptibility to tinea corporis is • for tinea capitis oral griseofulvin is the


widespread. It is aggravated by friction treatment of choice for resistant
and excessive perspiration in axillary and infection, for example T. tonsurans.
inguinal regions, and when environmental Topical anti-fungal medication may be
temperatures and humidity are high. used concurrently
Susceptibility is variable for tinea pedis • for tinea pedis topical fungicides are
and infection may be inapparent. recommended but oral griseofulvin
Repeated attacks are frequent. may be indicated in severe protracted
An injury to the nail predisposes to tinea disease. Feet should be kept dry as
unguium infection. Reinfection is possible and exposed to air by wearing
frequent. sandals. Socks of heavily infected
individuals should be boiled or
Control measures discarded to prevent reinfection
Preventive measures • for tinea unguium oral terbinafine
Measures differ according to cause: should be given daily for six weeks for
• for tinea capitis parents should be finger nails and twelve weeks for toe
educated about modes of spread from nails.
infected children and animals Consult the current version of
• for tinea corporis shower bases, mats Therapeutic guidelines: antibiotic
and floors adjacent to showers should (Therapeutic Guidelines Limited).
be disinfected. Infected animals should Note: M. canis infection is self-limiting in
be avoided children before puberty and griseofulvin
• for tinea pedis gymnasiums, showers may not be necessary. Consult a
and similar sources of infection should specialist about treatment.
be thoroughly cleaned and washed. Control of contacts
Shower areas should be frequently Investigate household contacts, pets and
hosed and rapidly drained. Users of farm animals for evidence of infection.
such areas should be encouraged to Treat infected contacts, human or animal.
carefully dry (and perhaps powder)
Control of environment
between their toes.
See Preventative measures, above.
Control of case
Control depends on the cause: Outbreak measures
• for tinea corporis infected children Children and parents should be educated
should be excluded from schools and about modes of spread, prevention and
swimming pools until at least 24 hours the necessity of maintaining a high
following the commencement of standard of personal hygiene. In case of
appropriate treatment. It can be epidemics, consider examination of all
treated effectively with topical children to identify cases. Disinfect
medications contaminated articles.
Ringworm (tinea) information sheet
What is ringworm? Ringworm of the foot (commonly known Further information
Ringworm is a fungal infection that can as tinea or athlete’s foot) - The • Your local doctor
affect any part of the body. characteristics of this common condition
• Better Health Channel,
are itchy scaling or cracking of the skin,
www.betterhealth.vic.gov.au
How do you get ringworm? especially between the toes, or blisters
Ringworm is spread by direct and containing a thin watery fluid. • Victorian Department of Human
indirect contact with humans, animals, Services, 1300 651 160
Ringworm of the nail - This condition
and soil.
tends to be a long term fungal disease
Humans get infections through skin and and is difficult to treat. It usually affects
scalp lesions of infected persons, one or more nails of the hands or feet.
contaminated clothing, bath mats, The nail gradually thickens and becomes
towels, floors and showers. discoloured and brittle. Cheesy-looking
Animals get infections through cats, material forms beneath the nail, or the
dogs, mice, and guinea pigs. Cattle and nail becomes chalky and disintegrates.
horses may be infected.
How do you control ringworm?
How long is the incubation Seek medical advice to confirm diagnosis
period? and receive appropriate treatment.
The incubation period lasts from one to Exclude infected persons from
three weeks. It varies with the site of communal swimming and bathing
infection. facilities until appropriate treatment has
commenced.
How do you recognise
Maintain hygiene by regular, thorough
ringworm?
bathing with soap and water and special
Ringworm of the skin - This appears as a
attention to drying moist areas.
flat, spreading, circular lesion with a
reddish outer edge. It is usually dry and • Do not share clothing or personal
scaly or moist and crusted, but it may linen.
contain fluid or pus. Single or multiple • Frequently launder clothing and linen in
rings may appear. The centre of the hot water.
patch may appear to be healing.
• Wash pets with anti-fungal solution.
Ringworm of the scalp and beard - This
• Dry carefully between toes.
condition begins as a small pimple. It
spreads outward leaving fine, scaly
patches of temporary baldness. Infected
hairs become brittle and break off easily.

Department of Human Services


184 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 185

Ross River virus


disease
Arboviruses are viruses which are spread Identification Incubation period
by the bite of arthropods, particularly Clinical features The incubation period is usually three to
mosquitoes. They are divided into Pyrexia and other constitutional eleven days.
alphaviruses and flaviviruses. symptoms are usually slight. A rash can
occur up to two weeks before or after Public health significance
Three infective alphaviruses include Ross
other symptoms. It can be absent in and occurrence
River, Barmah Forest and Sindbis viruses.
about one–third of cases. The rash is Infection is subclinical in up to 60% of
These all have the capacity to cause a cases. Clinical features of infection are
variable in distribution, character and
similar disease in humans characterised rare before puberty after which the
duration and may be associated with
by fever, joint involvement and a rash. disease has a similar pattern at all ages.
buccal and palatal enanthems.
Molecular studies of epidemiologically The disease can cause incapacity and
Rheumatic symptoms are present in
distinct isolates of Ross River and Sindbis inability to work for two to three months.
most patients except for the few who
viruses have shown changes in isolates About one quarter of patients have
present with rash alone: these consist of
from different areas (distinct topotypes). rheumatic symptoms which persist for a
arthritis or arthralgia primarily affecting
This may explain varying disease year or more.
the wrist, knee, ankle and small joints of
patterns which sometimes occur in
the extremities. Prolonged symptoms are RRV disease is the commonest and most
certain geographic locations and the
common. In some cases there may be widespread arboviral disease in Australia,
differing transmissibility of some strains
remissions and exacerbations of sometimes thousands of clinical cases
by different vector mosquitoes.
decreasing intensity for years. Cervical occur in epidemics. Disease notifications
Victorian statutory requirement lymphadenopathy occurs frequently and in Australia average about 4800 per year.
Ross River virus infection (Group B paraesthesiae and tenderness of the Major outbreaks have occurred in all
disease) requires notification within five palms and soles are present in a small parts of Australia. These occur chiefly in
days of diagnosis. percentage of cases. the period from January to May. RRV has
Method of diagnosis been detected and probably transmitted
School exclusion is not required.
Serology shows a significant rise in to humans in most major metropolitan
Infectious agent antibody titre to RRV. The virus may be areas of Australia including Perth,
First isolated in 1959 from Aedes vigilax isolated from the blood of acutely ill Brisbane, Sydney and Melbourne. In
mosquitoes collected near the Ross River patients. Virological tests are necessary 1993, 1216 cases of RRV disease were
in Townsville, the causative role of Ross to distinguish RRV disease from other notified in Victoria. Epidemics usually
River virus (RRV) was confirmed in 1971 causes of arthritis. In the event of a local follow heavy rains or after high tides
by its isolation from the blood of an outbreak clinical diagnosis may be which inundate salt marshes or coastal
indigenous child with the disease. Some sufficient, but outbreaks of RRV disease wetlands. Sporadic cases occur in
Aedes species have recently been sometimes occur concurrently with BFV mainland and coastal regions of Australia
renamed Ochlerotatus spp. mosquitoes. disease making diagnosis difficult. and Papua New Guinea at other times of
the year. In 1979, a major outbreak of
Laboratory evidence requires one of the
RRV disease which was probably
following:
exported from Australia occurred in Fiji
• isolation of RRV from clinical material and spread to other Pacific islands,
• detection of RRV by nucleic acid including Tonga and the Cook Islands.
testing
• a significant rise in IgG to RRV
• detection of RRV-specific IgM.
186 The blue book: Guidelines for the control of infectious diseases

Reservoir Susceptibility and resistance Outbreak measures


The virus is maintained in a primary Infection with the RRV confers lifelong Conduct a community survey to
mosquito–mammal cycle involving immunity. determine the species of the vector
macropods (particularly the Western mosquito involved. Identify their breeding
Grey kangaroo) and possibly other Control measures places and promote their elimination.
marsupials and wild rodents. A Preventive measures
Use mosquito repellents for persons
man–mosquito cycle may occur in RRV infection can be prevented by:
exposed to bites because of their
explosive outbreaks. Horses can act as • mosquito control measures occupation, or other reasons.
amplifier hosts and appear to develop • personal protection measures such as
joint and nervous system disease after Identify the infection among animal
wearing long sleeves and mosquito reservoirs, for example kangaroos, small
infection with RRV. Fruit bats might act repellents
as vertebrate hosts in some areas. marsupials, farm and domestic animals.
Vertical transmission in desiccation- • avoidance of mosquito-prone areas
and exposure during biting times at International measures
resistant eggs of Ochlerotatus spp. Airport vector control in Australia and
mosquitoes may be a mechanism to dusk and dawn.
Papua New Guinea may be necessary to
enable the virus to persist in the Control of case prevent spread from endemic areas to
environment for long periods. This could Second attacks are unknown. Treatment other countries where local vectors such
explain the rapid appearance of cases of is symptomatic with rest advisable in the as Aedes polynesiensis may transmit the
RRV disease after heavy rains. RRV is acute stages of the disease. There is no disease.
endemic throughout Australia, Papua vaccine currently available commercially
New Guinea, adjacent Indonesia and the to protect against RRV disease.
Solomon islands Control of contacts
Unreported or undiagnosed cases should
Mode of transmission
be sought in the region where the patient
RRV is transmitted by mosquitoes. Culex
had been staying during the incubation
annulirostris is the major vector in inland
period of their illness. All family members
areas whilst Ochlerotatus vigilax in New
should be questioned about symptoms
South Wales and Ochlerotatus
and evaluated serologically if necessary.
camptorhynchus in southern parts of
Victoria and Tasmania are the vectors in Control of environment
coastal regions. To reduce or prevent virus transmission,
interruption of human-mosquito contact
Period of communicability is required by:
There is no evidence of transmission
• suppression of the vector mosquito
from person to person.
population
• avoidance of vector contact through
personal protection and education.
The blue book: Guidelines for the control of infectious diseases 187

Rotaviral
gastroenteritis
Victorian statutory requirement Reservoir Control of environment
Isolated cases are not notifiable. Humans. Rigorous attention to clean-up
procedures and personal and home
School exclusion: exclude from school or
Mode of transmission hygiene is essential to prevent further
child care centre until at least 48 hours
Rotavirus is transmitted predominantly transmission.
after symptoms have ceased.
via the faecal-oral route. Rotavirus has
Infectious agent been detected in respiratory secretions. Outbreak measures
Because the virus is stable in the An outbreak is defined as two or more
Rotavirus, predominantly Group A, is the
environment transmission can occur related cases of gastroenteritis. The
causative agent.
through ingestion of contaminated water primary aim is to prevent further disease
Identification or food and contact with contaminated by identifying the source, cleaning
Clinical features surfaces. contaminated environments and isolating
The disease is characterised by vomiting cases.
and watery diarrhoea lasting for three to Period of communicability
Special settings
eight days. Fever and abdominal pain Rotavirus is communicable during the
Specific protocols for the management of
occur frequently. Treatment is acute stage of disease and while viral
outbreaks in special settings are
symptomatic. Maintenance of hydration shedding continues. Excretion of virus for
available from the Communicable
is the most important measure. greater than 30 days has been
Diseases Section of the Department of
documented.
Method of diagnosis Human Services, phone 9637 4126.
Diagnosis may be made by rapid antigen Susceptibility and resistance
detection of rotavirus in stool specimens.
Additional sources of information
Everyone is susceptible to infection.
• Centers for Disease Control and
Strains may be further characterised by Immunity after infection is incomplete,
Prevention, Atlanta USA, Viral
enzyme immunoassay or reverse but repeat infections tend to be less
gastroenteritis, http://www.cdc.gov/
transcriptase polymerase chain reaction. severe than the original infection.
ncidod
Stools for these tests should be collected
in the acute phase of illness. Control measures
Preventive measures
Incubation period Prevention is primarily through good
The incubation period is approximately personal, food and home hygiene.
24–72 hours.
Control of case
Public health significance Provide advice regarding personal
and occurrence hygiene, exclusion from work or school or
Disease usually occurs in infants and child care and attempt to identify source
young children, particularly under two of infection. Health care workers and
years of age. Adults can also be infected food handlers should be excluded from
although their resultant disease tends to work until at least 48 hours after
be mild. In temperate climates it is more diarrhoea has ceased.
common in the winter months. Rotavirus Control of contacts
gastroenteritis is the leading cause of Identify whether any contacts are ill.
infant viral gastroenteritis worldwide. The Provide advice about strict personal, food
cost of managing rotavirus disease in and home hygiene.
Australia is estimated at $26 million
annually.
188 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 189

Rubella
(German measles)
Victorian statutory requirement Differential diagnosis includes measles, Routine serological testing of reported
Rubella and congenital rubella syndrome human parvovirus (‘slapped cheek’) clinical cases of rubella in Victoria has
(Group B disease) must be notified in infection, human herpesvirus 6 (roseola) revealed that only a small proportion of
writing within five days of diagnosis. infection and a large number of other these cases can be confirmed in the
rashes of varied aetiology. laboratory. The remainder are likely to be
School exclusion: excluded until fully
Method of diagnosis due to other causes.
recovered or at least four days after the
onset of the rash. Clinical diagnosis should be confirmed Unimmunised travellers and their
by one or more of the following: unimmunised contacts remain at risk of
Infectious agent infection.
• demonstration of rubella-specific IgM
Rubella virus of the Togaviridae family is
antibody, except following rubella Congenital rubella syndrome (CRS) was a
the infective agent.
immunisation major cause of congenital abnormalities
Identification • fourfold or greater rise in rubella including deafness prior to the infant
Clinical features antibody titre between acute and immunisation program. Although CRS is
Rubella is a mild febrile viral illness convalescent-phase sera obtained at • now rare, the risk of infection remains for
characterised by a diffuse punctate and least two weeks apart unimmunised pregnant women. Such
maculopapular rash. Children usually women have been infected primarily by
• isolation of rubella virus from a clinical persons who have not been included in
experience few or no constitutional
specimen. rubella vaccine programs.
symptoms but adults may experience a
one to five day prodrome of low-grade Consider also testing for other similar
exanthems such as measles and human Reservoir
fever, headache, malaise, mild coryza
parvovirus. Humans.
and conjunctivitis. Postauricular, occipital
and posterior cervical lymphadenopathy Mode of transmission
Incubation period
is common and precedes the rash by five Rubella is transmitted by droplet spread
The incubation period is usually 14 to 17
to ten days. or direct contact with infectious patients.
days. It ranges from 14 to 21 days.
Complications include arthralgia and less Infants with CRS shed the rubella virus in
commonly arthritis, particularly among Public health significance their nose, pharyngeal secretions and
adult females. Encephalitis is a rare and occurrence urine for months or even years.
complication. Rubella occurs worldwide and is
universally endemic except in remote Period of communicability
Congenital rubella syndrome (CRS)
and isolated communities. It is most Rubella is communicable approximately
occurs in less than 25% of infants born to
prevalent in winter and spring. one week before and for at least four
women who acquire rubella during the
first trimester of pregnancy. The risk of a A combined measles-mumps vaccine days after the onset of the rash.
single congenital defect falls to was first added to the routine childhood CRS infants may shed the virus for
approximately 10–20% by the 16th week immunisation schedule in 1983. months or longer after birth.
of pregnancy. Defects are rare when the Although this has clearly led to a
maternal infection occurs after the 20th dramatic reduction in the number of
week of gestation. reported cases the epidemiology of
rubella infection in Australia is not clear
because of the acceptance of clinical
diagnoses without laboratory
confirmation.
190 The blue book: Guidelines for the control of infectious diseases

Susceptibility and resistance Control of case Immunoglobulin should be considered


Immunity after natural disease is usually There is no specific treatment. after exposure to rubella in early
life long. Immunity after vaccination is The case should be excluded from pregnancy. It may not prevent infection
long term and usually lifelong, although school and childcare for at least four days or viraemia, but may modify
reinfection of vaccinees has been after onset of the rash. Adults should not abnormalities in the baby.
observed. go to work for the same period of time. Control of environment
Passive maternal immunity is acquired Patients with rubella should avoid Not applicable.
transplacentally. Infants born to immune contact with other people while
mothers are ordinarily protected for six to Outbreak measures
infectious, particularly pregnant women.
nine months depending on the amount All suspected outbreaks should be
If a person with suspected rubella is reported promptly to the Department of
of maternal antibodies transferred.
pregnant, the diagnosis should be Human Services.
Control measures confirmed serologically and the patient
Mass immunisation may be
Preventive measures referred to a specialist obstetrician for
recommended during an outbreak of
MMR vaccine is recommended in the advice, taking care not to expose other
rubella in a school regardless of immune
ASVS for all infants at the age of 12 pregnant women to possible infection in
status.
months and at again at four years of age. the process.

Women of childbearing age should be Control of contacts


tested for immunity to rubella prior to School contacts should not be excluded
pregnancy if possible. All non-pregnant from school regardless of immunisation
seronegative women should be offered status.
rubella vaccine. Although immunisation is generally
Women receiving rubella vaccine should recommended for non-immune contacts
be instructed to avoid pregnancy for 28 (except pregnant women) it is unlikely to
days after vaccination. Inadvertent reduce the risk of infection or illness.
rubella vaccination during pregnancy has Immunoglobulin is not generally
not been associated with any CRS-like recommended, except for pregnant
defects; it is not necessary to consider contacts.
termination. Pregnant women in whom immunity to
Women attending for antenatal care who rubella has not been confirmed for the
are unaware of their immune status current pregnancy and who may have
should be tested for rubella antibodies been exposed to rubella must be
and if negative, be vaccinated investigated serologically. This should
immediately post partum. occur irrespective of a history of
vaccination, clinical rubella or previous
All health care workers should receive
positive rubella antibody.
MMR vaccine if not immune.
The blue book: Guidelines for the control of infectious diseases 191

Salmonellosis
Victorian statutory requirement Public health significance foods also occurs. This occurs
Salmonellosis (Group B disease) must be and occurrence particularly with:
notified in writing within five days of Salmonella infection occurs worldwide • raw and undercooked eggs and egg
diagnosis. and only a small proportion of cases are products
Laboratories are required to notify detected and reported. The incidence of
• raw milk and raw milk products
Salmonellae isolated from food or water. infection is highest in infants and young
children. Mortality is low however it may • poultry and poultry products
School exclusion: exclude cases from be increased in the elderly and • raw red meats
child care and school until after the immunocompromised people.
diarrhoea has ceased. • unwashed salads, fruits and
Salmonellosis may incur significant social
vegetables, grains, seeds and nuts
Infectious agent and economic costs due to lost
productivity and the impact on industry • some shellfish and filter feeders such
Approximately 2000 known serotypes
and agriculture. as oysters
exist of Salmonella spp, a small number
of which usually account for the majority There are approximately 1000 cases of Period of communicability
of infections. salmonellosis reported in Victoria each Salmonellosis is communicable through
year. The most common serovar is the course of infection, usually several
Identification S. typhimurium. The majority of cases are days to several weeks. One per cent of
Clinical features sporadic, but outbreaks in institutions infected adults and five per cent of
Salmonellosis commonly presents as an and child care centres and those children under the age of five years
acute gastroenteritis with fever, vomiting, associated with retail food premises are excrete the organism for more than one
nausea, abdominal pain, headache and not uncommon. The emergence of year. Antibiotics given in the acute illness
diarrhoea. Dehydration may occur, strains resistant to single or multiple can prolong the carrier state.
especially among infants and the elderly. antibiotics is of increasing concern
Infection may also present as septicaemia worldwide. Susceptibility and resistance
and occasionally may be localised in other Susceptibility may be increased by some
body tissues resulting in endocarditis, Reservoir medical conditions and treatments
pneumonia, septic arthritis, cholecystitis Domestic and wild animals including including immunosuppressant therapy,
and abscesses. Symptoms usually last poultry and reptiles act as reservoirs. prior or concurrent broad-spectrum
three to five days. Patients and convalescent carriers antibiotic therapy, gastrointestinal surgery,
Method of diagnosis including mild and unrecognised cases antacid use, achlorhydria and
Infection is diagnosed by isolation of can also act as reservoirs. malnutrition.
Salmonella spp. from faeces, blood or Mode of transmission Severity of the disease varies with:
other clinical specimen. Transmission is via person to person or • the serotype
Incubation period animal to person spread via the faecal-
• the numbers of organisms ingested
The incubation period is usually 6–72 oral route.
• the vehicle of transmission
hours with an average of 12–36 hours. Ingestion of the organisms via
contaminated or improperly cooked • host factors.
192 The blue book: Guidelines for the control of infectious diseases

Control measures Use standard enteric precautions when the Microbiological Diagnostic
Preventive measures handling faeces, contaminated clothing Laboratory. Staff of the Communicable
Thoroughly cook all food derived from and bed linen from hospitalised patients. Diseases Section, the Department’s
animals sources, particularly poultry, Exclude symptomatic cases from food Food Safety Unit, and Local Government
pork, egg products and meat dishes. handling and direct care of children, the Environmental Health Units usually
Inadequate temperature control and elderly and immunosuppressed patients conduct environmental investigations.
incorrect storage of food during and after until after the diarrhoea has ceased. Refer to the Department’s Guidelines for
the cooking process facilitates bacterial Children are excluded from school and the investigation of gastrointestinal illness
multiplication and are important risk child care until diarrhoea has ceased. for specific details.
factors.
Instruct asymptomatic individuals in
• Avoid recontamination from raw food International measures
strict personal hygiene. Stress proper
within the kitchen or refrigerator, after International outbreaks are increasingly
hand washing.
cooking is completed. being recognised, primarily due to the
Control of contacts increased dissemination of food and
• Emphasise the importance of Consider the diagnosis in symptomatic agricultural products worldwide.
refrigerating food and maintaining a contacts. Active case finding is not Investigation of imported products
sanitary kitchen. routinely undertaken in sporadic cases. should be coordinated through Food
• Avoid consuming raw or incompletely Control of environment Standards Australia New Zealand.
cooked eggs, or using dirty or cracked Sources of contamination such as use of
eggs. uncooked products and inadequate
• Pasteurise all milk and egg products. cooking should be investigated. Attention
should be paid to environmental
• Educate food handlers on the
cleaning, particularly in institutions, child
importance of hand washing and
care centres and food premises.
separating raw and cooked foods.
• Inspect and supervise abattoirs, Outbreak measures
butcher shops, food-processing plants Two or more related cases of
and egg-grading stations. gastroenteritis are suggestive of an
Control of case outbreak and should be reported to the
Treatment is supportive and antibiotics are Department of Human Services
not indicated in uncomplicated immediately. The aims of an outbreak
gastroenteritis as they may prolong the investigation are to rapidly identify the
carrier state and promote antibiotic source and prevent further cases.
resistance. The exceptions are patients at Epidemiological, environmental and
high risk of more severe disease including laboratory investigations will be
infants under two months of age, the elderly implemented immediately.
and immunocompromised (particularly Stools should be collected from cases
those with HIV), and food handlers who are and attempts made to identify a
chronic carriers. For systemic disease, the common source by obtaining food
choice of antibiotic should be based on the histories and potentially relevant
antibiograms of the relevant serovar and environmental exposures. Any implicated
local antibiotic guidelines. foods should be retained for analysis at
The blue book: Guidelines for the control of infectious diseases 193

Scabies
Victorian statutory requirement Immunosuppressed people, those living Symptoms develop much more quickly if
Notification is not required. in institutions and the elderly may also a person is re-exposed, often within one
show a clinical pattern of infestation to four days.
School exclusion: exclude until the day
similar to that in infants. The incubation period may be shorter if
after appropriate treatment has
commenced. Itching varies from person to person but infestation is acquired from a person
may be severe. It tends to be more with crusted (Norwegian) scabies. In this
Infectious agent marked at night or after a hot bath. case it is between 10 to 14 days.
The Sarcoptes scabiei mite is a tiny eight Scratching may lead to secondary
legged creature barely visible to the bacterial infections. Public health significance and
naked eye. Females are 0.3 to 0.4mm occurrence
Crusted (Norwegian) scabies
long and 0.25 to 0.35 mm wide. Males Scabies occurs worldwide regardless of
This is a particularly virulent infestation
are less than half the size of the female. age, sex, race, socio-economic status or
that can occur in the elderly, debilitated
standards of personal hygiene.
Scabies life cycle or immunosuppressed patients including
The mite undergoes four stages in its life those with HIV infection. These patients Cyclical epidemics occur at intervals of
cycle: egg, larva, nymph and adult. The are highly infective and difficult to treat. 10 to 15 years.
female mite burrows into the skin, lays Large areas of the body may appear Outbreaks may occur in childcare
eggs, larvae travel to the skin surface scaly and crusted with thousands of centres and kindergartens, and are
where they moult into nymphs and mites and eggs. Treatment applied frequently reported in nursing homes and
become adult mites. The period from directly to the skin such as creams and institutions. Scabies is more likely to
fertilization to adult mite ranges from 10 lotions may not penetrate the crusted spread in situations of overcrowding.
to 14 days. Female mites live about two thickened skin and result in treatment
months, laying three eggs a day and failure. Reservoir
travel up to three centimetres a minute. Humans are the primary reservoir. Other
Crusted scabies may be misdiagnosed
species of mite from animals or birds can
Identification as psoriasis or eczema.
also live on humans but do not
Clinical features Method of diagnosis reproduce in the skin.
Scabies is a highly contagious parasitic Diagnosis is commonly made clinically
skin infestation characterised by thin, by examining the burrows or rash. The Mode of transmission
slightly elevated, wavy grey-white diagnosis may be confirmed by scraping Scabies is transmitted by:
burrows that contain the mites and eggs. the burrows with a needle or scalpel • skin contact with an infected person
Multiple papules and vesicles soon blade and identifying the mites or eggs
• contact with towels, bedclothes and
appear. under a microscope. A negative result on
under-garments if these have been
The most common sites for burrows are skin scraping is not always conclusive as
contaminated by infested persons
between the fingers and toes, anterior the infested person may have few mites
within the last four to five days.
surfaces of the wrists and elbows, axillae, (on average 10 to 15) and these can
easily be missed on skin scraping. The mites cannot jump or fly. Adult
lower abdomen, beneath female breasts
scabies mites may survive off the skin for
and genitalia. The face, head, palms and
Incubation period up to 48 hours in room conditions.
soles are seldom involved in adults but in
It may take two to six weeks before
infants any area of skin may be infected.
itching occurs in a person not previously
exposed to scabies.
194 The blue book: Guidelines for the control of infectious diseases

Period of communicability For moderate and severe infections, treatment. Treat all those who have had
Scabies is communicable until mites and repeat scabicide treatment in 14 days. close skin to skin contact with the case,
eggs are destroyed by treatment, usually Infested persons should be excluded this includes family members, playmates
two courses one week apart. Itching may from school or workplace until the day and staff. Treatment should occur
persist for two or more weeks after following the first application of simultaneously to reduce the risk of
successful eradication of the mite. appropriate treatment. reinfestation. Generally, prolonged close
contact is required for transmission.
Susceptibility and resistance For hospitalised patients or patients in
nursing homes contact isolation should Nursing homes, aged care and other
Fewer mites succeed in establishing
be used until appropriate treatment has residential facilities
themselves in persons previously
commenced. In order to prevent See below, Guide to scabies
infested than in those with no prior
nosocomial infection, affected staff management in residential care facilities.
exposure. Diminished resistance to
infestation is also suggested by the should be excluded until appropriate
Additional sources of information
observation that immunologically treatment has commenced.
• Centres for Disease Control and
compromised persons are most Control of contacts Prevention, Scabies fact sheet,
susceptible to severe infestations. Investigate contacts and source of http://www.cdc.gov/ncidod
infestation.
Control measures • Centres for Disease Control and
Preventive measures Treat all household contacts, sexual Prevention 1988, ‘Epidemiologic notes
Educate the public about the mode of contacts, and those considered ‘at risk’ and reports scabies in health-care
spread, early diagnosis and treatment, by virtue of close contact in nursing facilities – Iowa’, MMR Weekly, vol. 37,
and promote good personal hygiene. homes and institutions simultaneously. no. 11, pp. 178–9.

Control of case Control of environment • Degelau J 1992, ‘Scabies in long-term


For simple scabies the usual treatment is Clothing, towels and bedclothes used by care facilities’, Infection Control and
permethrin applied topically to the whole the infested person in the 48 hours prior to Hospital Epidemiology, vol. 13, no. 7.
body including face and hair (avoid eyes treatment should be laundered using the pp 421–425.
and mucous membranes) and left hot cycle or dry cleaned. Alternatively,
• Lemmon, J 1998, ‘Scabies outbreak
overnight, or benzyl benzoate 25% items may be placed in a plastic bag and
among nursing staff’, 1998 Nursing
emulsion applied topically, including face sealed for one week before laundering as
monograph, St Vincents Hospital &
and hair (avoid eyes and mucous mite cannot survive lengthy periods off the
Sacred Heart Hospice NSW,
membranes) and left for 24 hours. human body.
http://www.clininfo.health.nsw.gov.au
For children less than two months of age Outbreak measures
sulfur 5% cream or crotamiton 10% cream Special settings
are alternatives (see the current edition School and childcare facilities
of Therapeutic guidelines: antibiotic). Exclude the case until the day after
For crusted (Norwegian) scabies, the appropriate treatment has been given.
addition of oral ivermectin may also be Advise staff and parents of other children
considered. Seek specialist infectious who may have had direct contact with
disease or dermatological advice. the infested person and may require
Scabies information sheet
What is scabies? How do you get scabies? How long does it take until
Scabies is an infestation caused by the By direct, prolonged, skin-to-skin contact symptoms start?
microscopic mite Sarcoptes scabiei. It is with a person already infested with It may take 4 to 6 weeks for symptoms to
found worldwide and affects people of all scabies. Contact must be prolonged (a develop in people who haven’t had
races and social classes. Scabies quick handshake or hug will usually not scabies before. People who have had
spreads rapidly in conditions where there spread infestation). Infestation is easily scabies before usually develop
is frequent skin-to-skin contact between spread to sexual partners and household symptoms much more quickly if they are
people, such as aged care facilities, members. Infestation may also occur by exposed again, usually within one to four
childcare centres and residential sharing clothing, towels, and bedding. days.
facilities. Anyone can get scabies regardless of
age, sex, race or standards of personal How long are people with
The female mite, which is only a few
hygiene. scabies infectious to others?
millimetres long, burrows into the top
People with scabies can pass on the
layer of the skin where she lays her eggs.
Did my pet spread scabies to scabies mite until the day after they have
The eggs hatch into larvae after 10 to 14
me? commenced their treatment for scabies.
days and travel back up to the surface of
No. Pets become infested with a different The scabies mite can live for two to three
the skin. Female mites live for about two
kind of scabies mite. If your pet is days on the clothes, bed linen and other
months, laying three eggs a day and
infested with scabies, (also called personal items of people who have
travel up to three centimetres a minute.
mange) and they have close contact with scabies.
What are the symptoms of you, the mite can get under your skin and
cause itching and skin irritation. How is scabies diagnosed?
scabies? Diagnosis is commonly made by
The main symptoms are: However, the mite dies in a couple of
days and does not reproduce. The mites examining the characteristic burrows or
• pimple-like irritations, burrows or rash may cause you to itch for several days rash. The diagnosis may be confirmed by
of the skin, especially the webbing but you do not need to be treated with scraping the burrows with a needle or
between the fingers; the skin folds on special medication to kill the mites. Until scalpel blade and identifying the mites or
the wrist, elbow, or knee; the penis, the your pet is successfully treated, mites eggs under a microscope. A negative
breast, or shoulder blades. can continue to burrow into your skin result on skin scraping is not always
• intense itching, especially at night and and cause you to have symptoms. conclusive as the infested person may
over most of the body. have few mites (on average 10 to 15) and
Who is at risk for severe these can easily be missed on skin
• sores on the body caused by
infestation? scraping.
scratching. These sores can
People with weakened immune systems
sometimes become infected by
and the elderly are at risk for a more
bacteria.
severe form of scabies, called crusted or
Norwegian scabies.

Department of Human Services


Can scabies be treated? The lotions or creams are applied to the As the scabies mite can live on the bed
Yes. A number of effective anti-scabies whole body from the neck to the toes. linen, clothes, towels and other personal
lotions or creams are available from your The treatment may also need to be used by the person with scabies prior to
local pharmacist. A prescription from applied to the face and scalp if these starting their treatment, these items
your doctor is not required. areas are clearly involved. Avoid contact should be machine washed in hot water.
with the eyes, nose and mouth. Blankets can be dry cleaned or placed in
Recommended treatments include
People will no longer be infectious within a tumble dryer on a hot setting for half an
permethrin preparations (e.g. Lyclear
24 hours of treatment, but it can take up hour. Alternatively, scabies mites can be
cream or Quellada lotion) or benzyl
to two months until the skin lesions and killed by sealing these items in a plastic
benzoate 25% preparations (e.g. Ascabiol,
itch to disappear completely. bag for one week before laundering, as
Benzemul 25%).
the mite cannot survive lengthy periods
Note that: A repeat treatment may be advised 14 off the human body.
days after the first treatment, particularly
• Lyclear cream or Quellada lotion should
for moderate to severe infestations. Further information
not be used during pregnancy,
lactation, for children less than two or Antihistamines, calamine lotion and • Your local doctor
in those with extensive dermatitis Eurax are sometimes useful to • Better Health Channel,
counteract itchiness. Antibiotics may be www.betterhealth.vic.gov.au
• for children under 2 months of age
needed if there is secondary bacterial
sulfur 5% cream or crotamiton 10% • Victorian Department of Human
infection from scratching.
cream (e.g. Eurax) are alternatives Services, 1300 651 160
• Ascabiol and Benzemul 25% What else should I do to stop
preparations should be diluted for the spread of scabies?
children less than 2 years of age (dilute Preventing the spread of scabies
with 3 parts water) and for children 2 requires:
to 12 years of age and adults with • maintaining good personal hygiene
sensitive skin (dilute with equal parts
water) • not sharing clothes, towels or bed linen
with others
• the anti-scabies preparations should
be used according to the • excluding affected children from
manufacturer’s directions school and child care centres until
treatment has commenced
• ensure that all household members are
treated simultaneously. • limiting close physical contact with
others until appropriate treatment has
commenced.
The blue book: Guidelines for the control of infectious diseases 197

Guide to scabies
management in
residential care
facilities
Contact precautions should be employed When crusted (Norwegian) scabies is Scabies infection control
for suspected cases until the diagnosis is suspected, a single oral dose of measures
excluded by skin scraping, and, if ivermectin is often prescribed in addition Linen and bed linen should be hot
confirmed, until the day after appropriate to the scabicide. Specialist infectious washed while the treatment application
therapy has been commenced. As skin disease or dermatological advice should is on and linen used during the
scraping is not always positive in true be sought. application period hot washed after the
cases, therapy may need to be treatment is washed off.
commenced if the clinical suspicion Treating contacts
Close contacts without symptoms who Clothes and towels used by the affected
remains high.
have had recent close contact with persons in the 48 hours prior to
Treating cases cases should be advised of their possible treatment should be machine washed in
Residents and/or staff should be treated exposure to scabies and be treated hot water. Linen, blankets and clothing
with Permethrin 5% cream (e.g. Lyclear, simultaneously as above, but with no can also be dry cleaned or placed in a
Quellada) topically, to the whole body repeat treatment required. Close tumble dryer on a hot setting for half an
including face, hair, behind ears and contacts include: hour, or sealed in a plastic bag for one
fingernails (avoid eyes and mucous week before laundering.
• residents with recent close contact,
membranes), leave 8 to 12 hours (e.g. including those who share the same
overnight) or Benzyl benzoate 25% room
emulsion (e.g. Ascabiol, Benzemul 25%)
topically, to the whole body including • family members and regular visitors
face, hair, behind ears and fingernails with recent close contact with the
(avoid eyes and mucous membranes), case
leave for 24 hours. For adults with • staff members with recent close
sensitive skin, dilute with equal parts contact, including staff handling
water. Consult the current version of laundry items.
Therapeutic guidelines: antibiotic Close contacts with symptoms
(Therapeutic Guidelines Limited). consistent with scabies, such as itch or
A repeat treatment is advised 14 days rash, should be treated as if they were a
after the first treatment, particularly for case (see Treating cases, above).
moderate to severe infestations. Any agency staff should be notified as
Occasionally large nodular lesions they will also need treatment, especially
(scabies nodules) can develop in the as many attend different health care
elderly. These can remain itchy for facilities. If necessary notify the Agency in
several months after successful order to trace staff.
treatment. In these circumstances the Everyone identified as needing treatment
use of topical steroids (e.g. Betnovate should ideally be treated within the same
cream, Elecon cream) may be necessary. 24 to 48 hour period. Itch may persist for
over 2 weeks after successful treatment
and this does not signify treatment
failure.
198 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 199

Severe acute
respiratory syndrome
(SARS)
Victorian statutory requirement Any specific testing for SARS should only • stool samples if diarrhoea is present
SARS – CoV infection (Group A disease) be performed after consultation with the • serum for antibody titres and, where
must be notified immediately by Communicable Diseases Section of the appropriate, convalescent serum for
telephone or fax followed by written Department of Human Services (DHS), parallel testing.
notification within five days. (see Guidance for recognition,
investigation and infection control of Testing is only performed at the Victorian
Infectious agent SARS and avian influenza, Infectious Diseases Reference
SARS-associated coronavirus (SARS- http://www.health.gov.au/ Laboratory (VIDRL) and all tests should
CoV). At that time the status of any outbreak be clearly labelled ‘For urgent SARS
can be ascertained, the exposure and testing at VIDRL’.
Identification Suspect case
epidemiological links clarified, the case
Clinical features
may be notified, appropriate infection A person presenting after 1 November
Severe Acute Respiratory Syndrome
control processes confirmed, and 2002 with history of:
(SARS) is a recently recognised lower
suitable patient transfer arranged. • high fever (>38°C) AND
respiratory tract infection. In the first
week of illness the patient develops The testing algorithm for SARS is heavily • cough or breathing difficulty AND
influenza-like symptoms, which include dependent upon the prevalence of the
• one or more of the following exposures
fever, malaise, myalgia, headache, and disease worldwide and locally, and this
during the 10 days prior to onset of
rigors. No individual symptom or cluster can be found on Department of Health
symptoms:
of symptoms has proven specific, and Ageing web site
however a history of fever is the one http://www.health.gov.au – close contact with a person who is a
most frequently reported. suspect or probable case of SARS
The microbiological investigation of a
The patient progresses to develop a possible SARS infected patient will – history of travel, to an area with
cough (initially dry), dyspnoea and often include the concurrent testing for other recent local transmission of SARS
diarrhoea (large volume and watery) more common and likely respiratory (http://www.health.gov.au)
usually in the second week of illness, pathogens through normal means – residing in an area with recent local
although these features may occur (sputum, blood, nasal swabs, urine) as transmission of SARS
earlier. well as specific tests aimed to detect
OR
SARS-CoV.
Severe cases progress to a rapidly A person with an unexplained acute
increasing respiratory distress and The samples to be collected for SARS
respiratory illness resulting in death after
oxygen desaturation of which CoV specifically include:
1 November 2002, but on whom no
approximately 20% require intensive care. • a left and right nasal swab and a autopsy has been performed AND one or
Upper respiratory symptoms such as posterior pharyngeal wall swab all more of the following exposures during to
rhinorrhea and sore throat may occur but placed into the same viral transport 10 days prior to onset of symptoms:
are uncommon. medium. These can have PCR testing
• close contact with a person who is a
for many different respiratory viruses
Method of diagnosis and case suspect or probable case of SARS
(respiratory multiplex) as well as for
definition • history of travel to an area with recent
SARS-CoV if that is considered
appropriate. An alternative to this is a local transmission of SARS
nasopharyngeal aspirate • residing in an area with recent local
transmission of SARS
200 The blue book: Guidelines for the control of infectious diseases

Close contact: having cared for, lived A suspect case should be excluded if c)Virus isolation
with, or had direct contact with they have had a mild self limiting illness • Isolation in cell culture of SARS-CoV
respiratory secretions or body fluids of a however, persons are not to be from any specimen AND
suspect or probable case of SARS. downgraded should signs of clinical
• PCR confirmation using a validated
Probable case illness remain.
method.
A suspect case with Laboratory confirmed SARS
Reclassification of cases
• radiographic evidence of infiltrates A person with symptoms and signs that
A suspect case who, after investigation,
consistent with pneumonia or are clinically suggestive of SARS
fulfils the probable case definition should
respiratory distress syndrome (RDS) on AND be reclassified as ‘probable’. A suspect
chest X-ray (CXR) With positive laboratory findings for case with a normal CXR should be
OR SARS-CoV, based on one or more of the treated, as deemed appropriate, and
A suspect case with following diagnostic criteria: monitored for 7 days. Those cases in
a)PCR positive for SARS-CoV whom recovery is inadequate should be
• autopsy findings consistent with the re-evaluated by CXR.
pathology of RDS without an PCR positive using a validated method
identifiable cause. from: A suspect case who dies, on whom no
autopsy is conducted, should remain
Exclusion criteria • at least two different clinical classified as ‘suspect’. However, if this
A probable or suspect case should be specimens (e.g. nasopharyngeal and case is identified as being part of a chain
excluded if: stool) OR of transmission of SARS, the case should
1. No convincing possibility of exposure • the same clinical specimen collected be reclassified as ‘probable’. If an
Visited a SARS affected area, but was in on two or more occasions during the autopsy is conducted and no
transit for less than 8 hours (in total, if course of the illness (e.g. sequential pathological evidence of RDS is found,
multiple stopovers) and remained within nasopharyngeal aspirates) OR the case should be ‘discarded’.
the airport. • two different assays or repeat PCR Maintaining vigilance and SARS alert
2. An alternative diagnosis is made using a new RNA extract from the clusters
original clinical sample on each If SARS does reemerge, it is unlikely but
e.g. a clinical diagnosis of probable occasion of testing. not impossible, that the first place it is
bacterial pneumonia, which could be
b)Seroconversion by ELISA or IFA recognised will be Australia. The most
defined by X-ray findings of lobar
likely scenario is that this will occur in
consolidation and clinical response to • Negative antibody test on acute serum
another country or countries (particularly
antibiotics. A case initially classified as followed by positive antibody test on
Southern China, the source of the
suspect or probable, for whom an convalescent phase serum tested in
original outbreak), providing time for
alternative diagnosis can fully explain the parallel OR
Australia to institute targeted surveillance
illness, should be discarded after • Fourfold or greater rise in antibody titre and investigation of illness in travelers
carefully considering the possibility of co- between acute and convalescent from defined outbreak areas, as was
infection. phase sera tested in parallel. undertaken in the initial outbreak period.
The blue book: Guidelines for the control of infectious diseases 201

Although both WHO and Australian health b) One or more symptoms of lower The pathogen emerged out of Southern
authorities regard Australia as a low respiratory tract illness (cough, difficulty China creating a local outbreak of
likelihood country to first recognise a new breathing, atypical pneumonia and subsequent
SARS outbreak, a cautious approach is shortness of breath) infection of international travellers
being taken. Maintaining vigilance for SARS resulted in the importation of possible
(www.health.gov.au/sars) is a surveillance AND SARS cases to 29 other countries around
protocol that seeks to ensure that c) Radiographic evidence of lung the world. Hong Kong, Hanoi, Singapore
Australian health authorities will detect any infiltrates consistent with pneumonia or and Toronto received such infected
new SARS outbreak by the detection of acute respiratory distress syndrome travellers early in the outbreak and
‘alert’ clusters of cases. These are clusters (ARDS) OR autopsy findings consistent further transmission within these cities
of apparent hospital-acquired cases in staff, with the pathology of pneumonia or RDS resulted in local outbreaks, affecting
patients, and visitors to the same health- without an identifiable cause. many hundreds of people.
care facility, and that meet the new WHO AND The overall case fatality rate was
post outbreak clinical case definition for approximately 10% and was highest
d) No alternative diagnosis can fully
SARS. (>50%) in those over 60 years of age. A
explain the illness.
Definition of a SARS alert characteristic feature of the SARS
If ‘alert’ clusters are detected from one
a) Two or more health care workers in the outbreak was its unprecedented degree
institution then those cases should be
same health care facility fulfilling the of nosocomial spread, which resulted in
urgently isolated and the situation
clinical case definition of SARS (see 21% of all cases involving health care
immediately discussed with an infectious
below) and with onset of illness in the workers. This has resulted in a
disease physician AND with the
same ten day period. requirement for heath care staff to adopt
Communicable Disease Section, DHS.
OR a new standard of infection control and
This is likely to lead to testing for SARS-
personal protection.
b) Apparent hospital-acquired illness in coronavirus and the adoption of
three or more persons (health care enhanced infection control measures. WHO declared the outbreak interrupted
workers and/or other hospital staff on 5 July 2003 at which time there were
and/or patients and/or visitors) in the Incubation period more than 8400 cases and
same health-care facility fulfilling the The mean incubation period is five days approximately 900 deaths. Mainland
clinical case definition of SARS (see with the range of 2–10 days although China reported over 5300 cases and 349
below) and with onset of illness in the there are infrequent isolated reports of deaths. Australia had a single confirmed
same 10-day period. longer incubation periods. case of SARS who had visited NSW prior
to the global alert and was detected in
Clinical case definition of SARS alert Public health significance retrospect by authorities in her home
cases (post-outbreak period) and occurrence country. She did not transmit the illness
The following clinical case definition has SARS came to the world’s attention in to any of her close contacts.
been developed for public health early 2003 when WHO declared a global
purposes. Five international flights were associated
public health alert in response to a
with the transmission of SARS however
A person with a history of: severe respiratory illness due to an
there has been no evidence of confirmed
unidentified communicable pathogen.
a) Fever (≥ 38°C) transmission on any flights after WHO
AND recommended control measures, which
included border exit screening.
202 The blue book: Guidelines for the control of infectious diseases

Reservoir Maximum excretion of the virus from the During the 2003 outbreaks, infants and
There has been much interest in respiratory tract seems to occur near day children accounted for only a small
determining the source of this new virus, 10 of illness and then declines. The percentage of patients and had much
with particular focus on the animal efficiency of transmission appears to be milder disease with better outcomes.
species involved and animal husbandry greatest following exposure to severely ill There have been two reported cases of
methods seen in Southern China. Early patients or those experiencing rapid transmission from children to adults and
investigations have pointed in the clinical deterioration, both of which no reports of transmission from children
direction of certain animal species (palm usually occur during the second week of to other children. Three separate
civet, racoon dog) however these are not illness. epidemiological investigations have
conclusive and more work in this area On reviewing cases of SARS it was found found no evidence of SARS transmission
needs to be completed. that when symptomatic cases were in schools. Furthermore, no evidence of
isolated within 5 days following onset of SARS has been found in infants of
Mode of transmission mothers who were infected during
illness, few cases of secondary
During the SARS outbreak, the pregnancy. Further investigation is
transmission occurred.
predominant mode of transmission of the required to determine whether children
SARS CoV appeared to be by direct Period of communicability may have asymptomatic or mild
mucus membrane contact with SARS-CoV is not thought to be infections.
respiratory droplets from either infected transmissible during the asymptomatic
persons or fomites. incubation period and there has been no Control measures
evidence that the virus has been spread Preventive measures
The evidence to date suggests that
ten days after fever has resolved. There are no vaccines available for SARS-
spread is predominantly through direct
CoV.
contact or exposure to larger virus-laden
droplets that are thought to travel only Susceptibility and resistance As a result of the global outbreak of
one to two metres, than by lighter The elderly are more prone to severe SARS there has been resurgence in
airborne particles. It has been postulated disease and pose a particular challenge interest and prominence of respiratory
that these lighter and smaller aerosols in the recognition of SARS as they may hygiene and cough etiquette as an
may have been generated by procedures present with an afebrile illness or with a attempt to reduce transmission of all
such as nebulisers or intubations, concurrent bacterial sepsis or forms of respiratory pathogens, including
resulting in episodes where significant pneumonia. SARS-CoV.
amplification of transmission was In the setting of a SARS outbreak the This includes encouraging all persons
observed. diagnosis should be considered for with signs and symptoms of a respiratory
Infective stool may also pose a almost any change in health status, even infection to:
transmission risk but the risks associated in the absence of typical clinical features
• cover the nose and mouth when
with this are not yet clear. of SARS-CoV disease, when such
coughing or sneezing
patients have epidemiologic risk factors
New cases occurred primarily in persons for SARS-CoV disease (e.g. close contact • use tissues to contain respiratory
with close contact to those very ill with with someone suspected to have SARS- secretions
SARS, which was seen in health care and CoV disease or exposure to a location • dispose of tissues in the nearest waste
household settings. Less frequently, [domestic or international] with receptacle after use
transmission occurred to casual and documented or suspected recent
social contacts after intense exposure to • wash hands after contact with
transmission of SARS-CoV).
a case of SARS (in workplaces, airplanes respiratory secretions and
or taxis). contaminated objects and materials.
The blue book: Guidelines for the control of infectious diseases 203

Health care facilities should ensure the • use of airborne precautions that • if seen in the practice the clinician
availability of materials for adhering to include the use of a P2 (N95 should close the door, open a window,
respiratory hygiene/cough etiquette in equivalent) mask (respirator) for all turn off the air-conditioning, put on a
waiting areas for patients and visitors: persons entering the room and where mask (N2 if possible), gown, gloves and
• provide tissues and no-touch available, a negative pressure eye protection
receptacles for used tissue disposal respiratory isolation room (with en- • wash hands after consultation
suite)
• provide conveniently located • do not self contaminate by touching
dispensers for alcohol-based hand rub • restriction of patient movement (and ones own mucus membranes with
fitting of a surgical mask if they must contaminated hands
• provide soap and disposable leave their room)
towels/hand driers for hand washing • make an assessment and call the
where sinks are available. • avoiding the use of nebulisers, chest Communicable Diseases Section,
physiotherapy, bronchoscopy, DHS, for an update of the SARS
During periods of increased respiratory gastroscopy or any intervention that
infection in the community, it may be situation and to develop a suitable
may disrupt the respiratory tract management strategy
possible for healthcare facilities to offer
surgical masks to persons who are • placing surgical masks over nasal • where possible any cases of concern
coughing and encourage coughing oxygen prongs. should be seen at home with the
persons to sit at least three feet away It will become increasingly important for appropriate PPE.
from others in waiting areas. clinicians to elicit epidemiological For further details see the Australian
Healthcare workers should practice information from their patients as part of interim control guidelines,
droplet precautions, in addition to normal history taking. Travel history, http://www.health.gov.au
standard precautions, when examining a recent attendance to hospitals or
exposure to others who are ill, may assist Control of case
patient with symptoms of a respiratory Suspected cases will be managed on
infection. in the refinement of a patient’s
differential diagnosis and associated risk. their clinical merits with home care
=Once there exists an index of suspicion regarded as a suitable option if the
of SARS then the appropriate infection The following points may become domestic situation, including its
control measures need to be activated appropriate to consider in the primary suitability in terms of infection control, is
and suitable PPE worn, (see care setting as a means of managing the judged to be adequate. In such
http://www.icg.health.gov.au). These issues of SARS: circumstances, cases will be advised to
will dependent on the specific facility • signage at the reception desk may voluntarily restrict their movements.
involved and the resources available at advise potential cases to report their Probable and confirmed cases will
the time. They include: concerns to the practice as early as require hospitalisation and isolation in a
• use of standard precautions (ie hand possible suitable health facility, which will be
hygiene) and contact and droplet • any case that could be reasonably determined by the Communicable
precautions (ie use of long-sleeved regarded as possibly SARS should be Diseases Section DHS in consultation
gowns, gloves and protective eyewear discretely offered a mask and diverted with the treating clinician. The receiving
for contact with patient or out of the waiting room and into a hospital will activate its SARS protocol to
environment) single room (e.g. returned travellers suitably manage such a patient.
from affected region with SARS like
symptoms)
204 The blue book: Guidelines for the control of infectious diseases

All suspected, probable and confirmed Contact tracing will be undertaken for Close contacts of cases or returned
cases will be excluded from school and those close contacts of probable cases of travellers from regions of SARS outbreak
work until clearance is obtained from SARS who were exposed after the patient as defined by DoHA will be allowed to
DHS. became symptomatic (see details in the attend school on the provision that they
There are no specific treatment Recommendations for tracing & managing remain completely asymptomatic. Such
recommendations for SARS. The contacts of SARS cases persons should measure their
application of intensive supportive http://www.health.gov.au temperatures daily to ensure that fever is
therapy and empirical antimicrobial Contact tracing will not be undertaken not present during the ten days
therapy, to cover other infective agents, is for suspected cases of SARS while SARS incubation period.
the usual approach. Antiviral and pulse has not been locally transmitted in
Australia. Cleaning and disinfection
steroid therapy have been used in the
Early studies of SARS-CoV show that if
past, in different countries with varying The aims of contact tracing is to find,
uninterrupted by cleaning or disinfectants it
degree of success. provide information to and manage
can survive on surfaces in the
Discontinuation of SARS isolation persons those who may have been
environment, such as on stainless steel
precautions exposed to the SARS CoV and who may
benches, plastic, wood or cotton, for
SARS isolation precautions should be be incubating or have early signs of the
between 12 and 72 hours. However, the
discontinued only after consultation with disease. Management of these contacts
virus is not difficult to kill. It is important to
the local public health authorities and depends on who they were exposed to
clean surfaces with detergent and water
the evaluating clinician. and the circumstances surrounding the
and then to disinfect them. Remember that
exposure.
Control of contacts disinfectants need the appropriate time at
Only people who have been close to an Well close contacts will be placed under the appropriate concentration to be
unwell person with SARS are at any either passive or active surveillance, effective.
significant risk of acquiring infection. For whilst all unwell close contacts of
The different methods available for
this reason only close contacts are probable cases will be placed under
disinfecting include:
sought to implement public health active surveillance and isolated in an
appropriate setting. Heat (56 degrees Celsius) is very
contact tracing measures and control
effective, so dishes, linen and other
disease spread. A close contact is a It should be remembered that one of the
washable items can be disinfected by
person who has lived, worked or had most important available measures to
washing in hot water and detergent.
other dealings with a SARS case that prevent the spread of SARS CoV is the
have caused them to be within a meter application of respiratory precautions Alcohol is effective. Tests show that 75%
of the case or who has had direct and scrupulous hand washing. Contacts ethanol kills the virus at room
contact with respiratory secretions from should be advised of such and also for temperature in less than 5 minutes.
a case while not wearing personal the need to seek immediate medical Slightly lower concentrations of alcohol
protective equipment. attention if they develop the initial would take a slightly longer time. Alcohol
symptoms of SARS. Daily temperature can be found in alcohol rubs (for hands),
monitoring for ten days after a break in alcohol impregnated wipes and swabs
exposure from the SARS case is such as used to disinfect skin, and
advisable. methylated spirits.
The blue book: Guidelines for the control of infectious diseases 205

Acetone is effective. 10% acetone will kill • Centres for Disease Control and
the virus in less than 5 minutes. Prevention 2004, In the absence of
Phenol (2%) is effective and may be SARS-CoV transmission worldwide:
found in some hospital grade guidance for surveillance, clinical and
disinfectants. laboratory evaluation, and reporting,
Version 2, http://www.cdc.gov/
Bleach has not yet been tested against ncidod
the SARS coronavirus. However bleach is
an effective disinfectant for many other • Communicable Diseases Network
viruses and is likely to be effective. Australia 2003, Recommendations for
Surfaces to be disinfected with bleach tracing and managing contacts of SARS
must first be cleaned with detergent and cases, Australian Government
water. An appropriate dilution of 1 in 100 Department of Health and Ageing,
of most household bleach provides http://www.health.gov.au
sodium hypochlorite at 500 ppm. • World Health Organization
http://www.who.int/csr
Additional sources of information
• World Health Organization 2003, Alert,
• Australian Government Department of
verification and public health
Health and Ageing,
management of SARS in the post-
http://www.health.gov.au
outbreak period, http://www.who.int/
• Australian Government Department of csr
Health and Ageing 2004, Severe acute
• World Health Organization 2003,
respiratory syndrome (SARS) case
Consensus document on the
definitions,
epidemiology of severe acute
http://www.health.gov.au
respiratory syndrome (SARS),
• Centres for Disease Control and http://www.who.int/csr
Prevention, Atlanta USA see
http://www.cdc.gov/ncidod/sars/
• Centres for Disease Control and
Prevention 2004, Clinical guidance on
the identification and evaluation of
possible SARS-CoV disease among
persons presenting with community-
acquired illness Version 2,
http://www.cdc.gov/ncidod
206 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 207

Shigellosis
Victorian statutory requirement associated with serious disease and a Period of communicability
Shigellosis (Group B disease) must be high case fatality rate. Shigella is communicable during the
notified in writing within five days of Asymptomatic infections occur and acute phase and while the infectious
diagnosis. carriage may persist for months. agent is present in faeces which is
School exclusion: exclude until after usually no longer than four weeks.
Method of diagnosis
diarrhoea has ceased. Asymptomatic carriage and excretion
Diagnosis is made by isolation of Shigella
may persist for months.
spp. from a clinical specimen.
Infectious agent
The genus Shigella consists of four Susceptibility and resistance
Incubation period
species: Everyone is susceptible to infection, with
The incubation period depends on the
infection following ingestion of a small
• Group A: Sh. dysenteriae serotype. It varies from twelve hours to
number of organisms. In endemic areas
seven days but is usually one to three
• Group B: Sh. flexneri the disease is usually more severe in
days.
• Group C: Sh. boydii young children. The risk of infection is
Public health significance increased in men who have sex with
• Group D: Sh. sonnei
and occurrence men, those with immune deficiency
Groups A, B and C are further divided disorders, by attendance at child care or
Shigella infection occurs worldwide
into approximately 40 serotypes, contact with a child in child care, and in
however the incidence of specific
designated by numbers. international travellers who do not take
serotypes varies by country. Sh. sonnei is
the most common type reported in adequate food and water safety
Identification precautions.
Clinical features Victoria and Australia. Sh. dysenteriae
Shigellosis is characterised by an acute and Sh. flexneri are usually acquired
Control measures
onset of diarrhoea, fever, nausea, overseas and are often resistant to
Preventive measures
vomiting and abdominal cramps. multiple antibiotics. In Victoria outbreaks
Good personal hygiene is the single most
Typically the stools contain blood, mucus have occurred in child care centres and
important preventive measure. Frequent
and pus, although some persons will amongst men who have sex with men.
and thorough hand washing is important
present with watery diarrhoea. Two-thirds of the cases and most of the before eating and food handling and after
Complications include toxic megacolon deaths worldwide are in children less toilet use, especially in young children
and reactive arthritis. Rarely haemolytic than ten years. The disease is rare in who may not be completely toilet trained.
uraemic syndrome can occur. The infants under six months of age,
Educate travellers on the need for safe
infectious dose required to produce particularly those who are breastfed.
food and water consumption.
disease is low and may be as few as ten Secondary attack rates in households
organisms. Control of case
may be as high as 40%.
Treatment is usually supportive for mild
Illness is usually self-limited and lasts
Reservoir illnesses. Antibiotics may shorten the
from several days to weeks with an
Humans. duration and severity of illness however
average of four to seven days. The
their use should be based on the
severity of infection depends on host
Mode of transmission serotype, severity of illness and host
factors such as age and nutritional status
Faecal-oral transmission is the most characteristics, for example if they are a
and the serotype. Infections with Sh.
important mode of transmission of child in child care, food handler or suffer
sonnei usually result in a short clinical
Shigella however infection may be spread chronic illness. Multi-drug resistance is
course and low case fatality rate. In
via contaminated food, water, milk or by common, particularly for overseas-
contrast, Sh. dysenteriae is often
flies. acquired strains. The choice of antibiotic
208 The blue book: Guidelines for the control of infectious diseases

should be based on the antibiogram of Control of environment


the serotype. Anti-motility drugs are Remove contaminated food and/or
thought to increase the risk of prolonged water sources. Strict attention should be
carriage. paid to environmental hygiene in child
Cases should be educated on the care centres, institutions and food
importance of personal hygiene, premises.
particularly after using the toilet and
Outbreak measures
before and after food handling.
Two or more related cases should be
Food handlers should be excluded from considered indicative of an outbreak and
work until two negative stools have been require investigation. These cases should
obtained, or until at least 48 hours after be reported immediately to the
the diarrhoea has ceased and rigid Department of Human Services. Attempt
personal hygiene measures can be to determine a common source of
assured. infection and identify those at risk of
Cases in institutions should be separated infection.
from non-infected residents if possible. Refer to the Guidelines for the
Control of contacts investigation of gastrointestinal illness for
The diagnosis should be considered in further advice and management of
symptomatic contacts however stool outbreaks.
cultures may be confined to food
handlers and those in situations where
the spread of infection is particularly
likely (child care centres, hospitals,
institutions).
Symptomatic contacts of shigellosis
patients should be excluded from food
handling and the care of children or
patients until investigated.
The blue book: Guidelines for the control of infectious diseases 209

Smallpox (variola)
Victorian statutory requirement prodromal phase. This occurs rarely as a A patient is no longer infectious once all
Smallpox (Group A disease) must be petechial rash. This may be the scabs have separated from the skin
notified immediately by telephone or fax misdiagnosed as meningococcal disease, which is usually three to four weeks after
followed by written notification within five erythema multiforme or measles. the onset of the rash. Recovery results in
days. By the second or third day fever begins the complete clearing of the virus from
to descend from its peak (40.5 to the body and prolonged immunity.
Smallpox is included on the
Commonwealth Quarantine List and all 38.5 C) and the eruptive phase begins The major differential diagnosis is
cases will need to be notified immediately with the development of rash lesions. chickenpox and disseminated herpes
to the State Chief Quarantine Officer. These lesions first appear on the buccal simplex infections.
and pharyngeal mucosa and then Smallpox may be complicated by
Smallpox is subject to Australian
emerge on the face, forearms and hands. secondary bacterial skin infection,
quarantine.
The rash spreads down, and within a day corneal scaring, keratitis, arthritis,
Infectious agent the trunk and lower limbs are involved. osteomyelitis, bronchitis, pneumonitis,
Variola virus is a DNA virus of the genus Smallpox produces a single crop of pulmonary oedema and encephalitis.
Orthopoxvirus. lesions which are distributed in a Method of diagnosis
The virus used in the live smallpox centrifugal pattern: most profuse on the The diagnosis of smallpox will be made
vaccine is known as the vaccinia virus face, more abundant on the forearms on the basis of a consistent clinical
and is also a member of the genus and lower legs than the upper arms and presentation combined with the results
Orthopoxvirus. thighs, and often involve palms and of electron microscopy and PCR testing
soles. which will be performed at the National
Identification
Prominent surfaces and areas most High Security Quarantine Laboratory at
Clinical features
exposed to irritation are more heavily Victorian Infectious Diseases Reference
Smallpox is a severe prostrating illness
involved by the rash. Protected surfaces Laboratory in Melbourne.
characterised by fever and a macular,
such as flexures and depressions (axilla)
papular, vesicular and pustular rash with Incubation period
are usually spared.
an observed mortality rate of 30%. There The incubation period is regarded to be
are three major forms. The most The eruptive lesions appear as flat
seven to 17 days, with a median of 12
common form described below occurs in discoloured macules that progress to
days.
90% of cases. The remaining two are firm papules on the second day of the
known as haemorrhagic and malignant rash. These are typically described as Public health significance
(flat) variants. These both have ‘shotty’. They become clearly identifiable and occurrence
significantly higher mortality (greater than as vesicles on the fourth or fifth day of In 1980 the World Health Organization
95%) and seem to be related to the rash and progress to pustules on day (WHO) declared smallpox the first
alterations in immune status. seven. communicable disease ever to be
Day ten commonly sees the pustules at globally eradicated. This was a direct
Common smallpox begins with
maximal size and the lesions then consequence of the Global Smallpox
symptoms of fever (100%), headache
commence to flatten. Approximately 14 Eradication Program which was achieved
(90%), backache (90%), chills (60%),
days after rash onset the pustules begin by a population based smallpox
vomiting (50%), malaise, prostration and
to dry up and crust. Most pustules begin vaccination strategy.
cough. Less commonly pharyngitis and
severe abdominal pain are observed. In to scab and separate at day 19. Lesions The virus has been retained legally under
pale-skinned patients an erythematous on the palms and soles separate last and strict security in two World Health
rash sometimes accompanies the typically leave pitted scars. Organization collaborating centres in the
USA and the Russian Federation.
210 The blue book: Guidelines for the control of infectious diseases

The virus is believed to have been part of and air-conditioning systems. Such Susceptibility and resistance
the bio-weapons research of certain spread is most likely in instances where Resolved infection confers lifetime
countries and there have been recent the case has a significant cough. immunity.
concerns that non-state actors may Cases may contaminate objects in their Pregnant women and those who are
obtain access to the virus for deliberate environment including their clothing and immunocompromised are more
release. linen with the large droplets or aerosols susceptible to variant forms of smallpox.
A single confirmed case of smallpox during sneezing or coughing and these
It is unclear how long the smallpox
would prompt a global public health alert fomites may serve as a further route of
vaccine will provide effective immunity
from the World Health Organization and transmission.
but it is unlikely to be more than 10
would raise the spectre of an intentional Physical contact with a smallpox pustule years. As a result essentially all persons
release. or crusted scab may also transmit the in Victoria and Australia will be regarded
Historically variola major has a significant virus. The virus has been found to survive as susceptible to smallpox.
mortality and it would be reasonable to in scabs for many years, however
expect a greater impact upon today’s encased in this form it is not considered Control measures
unimmunised and older populations. It is to represent a significant infectious risk. Preventive measures
clear that an outbreak would be of The Australian Government Department
Body fluids are also infectious and care is
extreme public concern requiring action of Health and Ageing has stockpiled a
needed for the disposal of clinical waste.
at the highest level of government and certain amount of smallpox vaccine
involving the mobilisation of significant The variola virus is thought to be unlikely which will be accessed under appropriate
resources. to survive on its own for more than 48 situations.
hours when exposed to normal
In the event of an outbreak, there will be
Reservoir environmental conditions (ambient
a stepwise process to vaccinate persons
Smallpox is a disease only of humans temperature, usual humidity and sunlight
who will be required to assist in its
and there are no non-human hosts. exposure).
containment such as doctors, nurses and
During the smallpox era the disease had ambulance personnel.
Mode of transmission
secondary household or close contact
The variola virus is most frequently All others will be offered vaccination only
attack rates of up to 80%.
transmitted from an infectious person via if they have had contact with a case or
direct deposition of large, infective, Period of communicability form part of a ‘ring vaccination’ control
airborne droplets of saliva onto the nasal, Patients are not infectious during the strategy.
oral or pharyngeal mucosal membranes asymptomatic incubation period. They Control of case
during close, face to face contact with a become increasingly infectious after Any patient that raises a concern of
susceptible individual. onset of fever and this usually results smallpox must be notified to the
The generation of infectious fine-particle from the release of virus from Communicable Diseases Section of the
aerosols provides a possible albeit less oropharyngeal lesions. Department of Human Services as soon
common means of smallpox For the purpose of contact tracing, cases as possible such that a mobile smallpox
transmission. This may result in the are regarded as infectious 24 hours prior care team can be dispatched to provide
infection of persons involved in non-face to the recognition of fever, and any a swift and expert provisional diagnosis,
to face contact with the case, with the contacts identified from this time on and to implement suitable patient care
virus carried in aerosols spread by drafts need suitable management. and public health management.
The blue book: Guidelines for the control of infectious diseases 211

All such patients (and their possessions) Those who meet the possible or • Active surveillance for 17 days after the
should be placed in the best available suspected criteria will be placed in the last exposure
form of isolation as soon as possible. observation ward of the smallpox care – Daily reporting of the contact by
They should have limited contact with centre. phone to the Department of Human
any persons other than those directly Control of contacts Services will be required
involved in their care, who must wear The strategy of ring vaccination will be
personal protective equipment. Any air – Details of oral temperature and
used in the control of any smallpox presence of constitutional symptoms
conditioning should be turned off outbreak. This means that all contacts of
immediately. a case will be immunised (category A – If there is failure to contact, the
All persons in contact with the case or and B, see below) and as an extra Department will actively follow up
those sharing the same airspace precaution, those persons with ongoing cases by phone or in person.
(hospital or practice staff, other patients household contact with category A • Restriction of movement from seven
etc) should be requested to remain in a contacts, during the formal monitoring days after first exposure until 17 days
safe area until the smallpox care team period, will also be offered access to the after last exposure.
arrives and makes an assessment. They vaccine. – Avoid contact with unvaccinated
may need to be given access to smallpox Category A, primary contacts persons
immunisation in the short term and their These are persons who are likely to be – During this time contact must stay
details, including contact numbers, will exposed to the virus through large away from school and work
be essential to collect. This should be droplets or contaminated fomites. They
commenced as soon as practicable. The – Remain within local area as defined
include:
smallpox care team will advise about by the Department
infection control matters including • Household contacts. All usual
• If symptomatic, category A cases need
disinfection and provide information to residents and any visitors who had
to stay at home and immediately
those present. spent more that one hour at the
contact the Department.
address during the infectious period.
Cases will be categorised as possible, – A category A contact who develops
suspected, probable or confirmed, • Face to face contacts (within two
fever will be regarded as a possible
depending upon the epidemiology, metres) during the infectious period.
case and transferred immediately to
clinical presentation and the results of This will include work and social
the observation ward of the smallpox
electron microscopy and PCR testing of settings as well as unvaccinated health
care centre
vesicular fluid. care and emergency services
personnel. – A category A contact who develops
All confirmed and probable cases will be fever and rash will be regarded as a
managed in the treatment ward of the • Fomite contact. All persons with direct
probable case and transferred
smallpox care centre where they will contact with clothing or articles that
immediately to the treatment ward of
receive optimal health care by staff who have been used by infectious cases of
the smallpox care centre.
have been successfully immunised, smallpox.
• Outside the restricted period category
whilst maintaining appropriate isolation Actions required
A contacts will need to stay within the
precautions for the community. • Urgent vaccination, preferably before
local area until their vaccination site is
day three but up to day seven.
completely healed and their formal
monitoring period is over.
212 The blue book: Guidelines for the control of infectious diseases

Category B, primary contacts • Restricted movement: • Passive surveillance and no restriction


These contacts are less likely to have – Category B contacts will not be of movement:
been exposed to the virus than Category allowed to travel abroad until their – There are no monitoring or
A contacts. They include: vaccination site is completely healed restriction requirements necessary
• All persons who have shared a room or and their formal surveillance period unless the primary contact becomes
other enclosed spaces with the case is over. symptomatic. If they become
whilst infective and not meeting the – No other restrictions of activity are confirmed with smallpox, then the
criteria of category A contacts required unless the case is unwell. secondary contacts will be
– These may include those who have reclassified as a category A contact
• If symptomatic they will be admitted to and will need to be managed
visited the same premises or the smallpox care centre:
travelled on the same public accordingly.
transport (trains, planes or buses) or – Category B contacts who develop Unimmunised primary contacts
who have shared the same floors of fever will be classified as possible Definition
buildings or the same air cases and transferred to observation These are primary contacts (both
conditioning space with an infectious ward of the smallpox care centre. category A and B) who fail to respond to
case. – Category B contacts who develop the vaccine after three days, who are
Action required for category B contacts fever and vesicular rash will be vaccinated later than three days after
classified as probable cases and first exposure to the virus, or who refuse
• Vaccinate unless contraindicated transferred to the treatment ward. to be vaccinated.
• Commence passive surveillance: Secondary contacts Action
– Details will be taken by the These are persons who will have ongoing • Limited options are available for the
Department of Human Services and household contact with category A pharmacological management of
information provided as to nature of contacts during the formal monitoring persons vaccinated late. The smallpox
smallpox and actions to be taken if period. As such they are at risk of response team’s infectious disease
symptoms develop (fever, rash or exposure to the virus if the primary specialist may suggest the use of
constitutional symptoms). contact becomes symptomatic. vaccinia immune globulin or cidofovir in
– If symptoms develop they must Secondary contacts would be expected very limited circumstances.
immediately contact the Department to include usual household residence of
category A contacts, together with any • Category A primary contacts who are
and remain at home, avoiding categorised as unimmunised, will be
contact with all unvaccinated visitors to the household who expect to
spend extended periods of time there, required to remain in isolation
persons. accommodation until the incubation
during the formal monitoring period.
– Surveillance will continue until 17 period has elapsed.
days after the last exposure to the Actions required for secondary
contacts • Category B primary contacts will be
virus. managed as if they were a category A
• Vaccinate unless contraindicated:
contact (active surveillance, restricted
– If immunisation is contraindicated movement from day seven after first
then the secondary contact will need exposure to day 17 after last exposure,
to avoid contact with the primary see above).
contact until the vaccination site is
completely healed.
The blue book: Guidelines for the control of infectious diseases 213

Control of environment remain there until disinfected or disposed


All persons in contact with a case of of appropriately. This includes all linen,
smallpox must wear the appropriate dressings and disposable eating utensils
personal protective equipment (PPE) and and medical notes.
in order to limit any further spread, this
will be removed and the person required Outbreak measures
to shower on leaving the infected area. Smallpox management will be framed in
This PPE includes gloves, theatre cottons one of the five Australia response codes
with head cover, disposable apron, eye detailed below.
protection, foot wear such as overshoes,
Australian response codes for smallpox
and a P2 respiratory mask.
• Response code 0: Smallpox remains eradicated – no credible threat of a
Until the smallpox care team arrives, the
release
possibly infected area should be
cordoned off and access limited to those • Response code 1: Imminent threat or a case overseas
already present and those required for • Response code 2: One case or a cluster of related cases in Australia
urgent medial care. The case of concern
• Response code 3: Unrelated cases or unrelated clusters occurring in Australia
should be isolated as best as possible
and all others should remain within a • Response code 4: Outbreak controlled – no further cases occurring
safe distance of the cordoned off area.
Information and all care should be Emergency plans would be activated in However if a case does present to an ED,
afforded all persons involved, with sequence with these codes as outlined then activation of the ED infection
particular attention being made to advise in the Australian Government’s control procedures should be instituted,
that the earliest possible access to the Guidelines for the smallpox outbreak, such that appropriate action is taken to
vaccine will provide the best possible preparedness, response and limit any spread into the broader
outcome if the case in fact proves to be management. This would include alerts to hospital.
smallpox. the community and health providers, roll
out of the smallpox vaccination strategy, International measures
The smallpox care team will advise on If there are smallpox cases overseas
mobilisation and augmentation of the
suitable decontamination processes and then the Australian Government may
smallpox care teams, and commissioning
the disposal of possibly infectious divert all aircraft from that country, to a
of the smallpox care centre.
materials. This will be in accordance with limited number of airports where
the Guidelines for the smallpox outbreak, Special settings screening, immunisation and the
preparedness, response and General hospital wards and their appropriate isolation and quarantine
management. emergency department (ED) may be at measures will be applied as required.
increased risk of attending to smallpox
As the virus is transmitted through
cases. In order to limit this, all Additional sources of information
infectious respiratory droplets and bodily
community concerns regarding smallpox • Australian Government Department of
fluids or contaminated clothing,
need to be notified to the Department of Health and Ageing 2004, Guidelines for
dressings, linen, towels or clinical waste,
Human Services immediately. The smallpox outbreak, preparedness,
every effort must be made by relevant
Department will dispatch a smallpox care response and management.
staff to limit spread through these routes.
team to make an urgent assessment. In • Fenner, F 1988, Smallpox and its
Air conditioning must be isolated or
this way, cases will be diverted to eradication, World Health Organization.
turned off and the time documented. Any
smallpox care centres without disrupting
object that enters the infected area must
the working of any hospitals.
214 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 215

Staphylococcal
infections
Victorian statutory requirement • food poisoning by releasing toxins into Reservoir
Notification is not required. food Human carriers are a major source of
School exclusion: for impetigo due to • toxic shock syndrome by releasing infection. Staphylococci have prolonged
staphylococcal infection exclude until toxins into the blood stream. survival in the hospital environment due
appropriate treatment has commenced. to resistance to antiseptics and
Method of diagnosis
disinfectants.
Diagnosis is confirmed by isolation of the
Infectious agent
organism from relevant specimens. Their Mode of transmission
There are nineteen species of
antibiotic resistance profile is important Staphylococci are most often transmitted
staphylococci. The most significant
in management. by direct or indirect contact with a
human pathogens are Staphylococcus
aureus and Staphylococcus epidermidis. person who has a discharging would, a
Incubation period
Methicillin resistant clinical infection of the respiratory or
The incubation period is variable and
S. aureus (MRSA) and vancomycin- urinary tract, or one who is colonised
indefinite. It is most commonly four to
resistant S. aureus (h-VISA, VISA and with the organism. MRSA can be carried
ten days.
VRSA) are significant pathogens in on the hands of healthcare personnel
hospital-acquired disease. Virulence Public health significance and is a likely mode of transmission
varies greatly amongst the bacterial and occurrence between patients and staff.
strains. Staphylococcal infections are frequent Contaminated surfaces and medical
but are usually contained by immune equipment are also possible sources of
Identification mechanisms to the site of entry. MRSA.
Clinical features Approximately 20–30% of the population
Staphylococcal infection presents with a Period of communicability
are colonised with S. aureus in the
variety of different clinical and Communicability exists as long as
anterior nasal passages. The highest
epidemiological patterns amongst the purulent lesions continue to drain, or the
incidence of disease usually occurs in
general community, newborns, carrier state persists.
people with poor personal hygiene,
hospitalised patients and menstruating overcrowding and in children. However Susceptibility and resistance
women. It may cause: anyone can develop a serious People who are most susceptible to
• purulent skin infections such as a staphylococcal infection including fit infection are the chronically ill and
boils, abscesses, styes, impetigo and young people. newborns.
scalded skin syndrome Since the late 1970s MRSA strains have Mechanisms of immunity are not well
• systemic infections such as been identified in Victoria as a major understood. An experimental vaccine
pneumonia, osteomyelitis or cause of nosocomial infections and with a short duration of immunity has
endocarditis outbreaks. MRSA accounts for been developed to assist patients with
approximately 30–50% of hospital- end-stage renal disease.
• urinary tract infections due to
acquired S. aureus isolated from
S. saprophyticus in young women or Resistance to penicillin-related
normally sterile sites. Vancomycin
S. epidermidis with indwelling catheters antibiotics in the hospital setting is
resistant strains have been reported.
• hospital-acquired (nosocomial) common and includes MRSA. Two
Health care employees and other carers
infection of surgical wounds or specific types of vancomycin
may develop intermittent colonisation
treatment lines antimicrobial resistant S. aureus called
with MRSA. These workers rarely develop
VISA and VRSA have recently emerged.
infection.
216 The blue book: Guidelines for the control of infectious diseases

Control measures Outbreak measures


Preventive measures The Department of Human Services may
General measures: investigate unusual clusters of
• maintain good hygiene through public staphylococcal infection in the
education in relation to hand washing, community, particularly those associated
food preparation and avoiding sharing with antibiotic resistant strains.
toilet articles This may include:
• cover purulent lesions with a • investigation of the source of infection
waterproof dressing. including microbiological screening of
In the health care setting: contacts

• educate hospital staff regarding the • advising on added infection control


importance of hand washing precautions for cases and carriers

• use common narrow spectrum • treatment recommendations for cases


antibiotics where possible. and carriers.

Control of case Special settings


Advise isolation until treatment of the Hospital nursery workers with minor
infection has commenced. Search for lesions such as boils or abscesses
and cover draining lesions. Infected should not have direct contact with
persons should avoid contact with infants until the lesion has healed.
infants and chronically ill patients. Added All known or suspected cases in a
infection control precautions may be nursery should be isolated.
recommended for cases with infections In school settings, the child should be
due to multi-resistant organisms. excluded from school until specific
Control of contacts treatment begins. Lesions must be
Routine contact tracing is not usually covered with a watertight dressing.
required. Contacts do not need to be excluded.
Determining the carrier status amongst
family members of a pathogenic strain
may be occasionally useful, in which
carriers might be recommended
antibiotics to eliminate the bacteria such
as mupirocin.
Control of environment
Encourage hand washing, especially in
the hospital setting.
The blue book: Guidelines for the control of infectious diseases 217

Streptococcal disease
(Group A beta-haemolytic
streptococcus)
Victorian statutory requirement Antigen detection tests are available for Mode of transmission
Notification is not required. rapid identification. A rise in serum GAS is usually transmitted via large
antibody titres (anti-streptolysin O, anti- respiratory droplets or direct contact with
School exclusion: exclude until the child
hyaluronidase, anti-DNAase B) may also infected persons or carriers. It is rarely
has received antibiotic treatment for at
be demonstrated in sera taken in the transmitted by indirect contact through
least 24 hours and the child feels well.
acute and convalescent phases of the objects. Outbreaks of streptococcal
Infectious agent disease. infection may occur as a result of
Streptococcus pyogenes or Group A ingestion of contaminated foods such as
streptococci (GAS) has approximately 80
Incubation period milk, milk products and eggs.
The incubation period is usually one to
serologically distinct types. Those
three days. Period of communicability
producing skin infections are usually of
different serological types to those that With appropriate antibiotic therapy GAS
Public health significance is communicable for 24–48 hours. In
cause throat infections. and occurrence untreated uncomplicated cases
The incidence of GAS infections and their
Identification communicability can last for 10–21 days.
sequelae are not well documented in Communicability can be prolonged in
Clinical features
Australia except in Aboriginal untreated complicated cases.
The spectrum of disease caused by GAS
communities in northern Australia. In the
includes:
USA, acute pharyngitis is one of the Susceptibility and resistance
• superficial infections such as most common reasons for seeking Pharyngitis and tonsillitis are common in
pharyngitis, impetigo and pyoderma medical advice and GAS is thought to be children aged 5–15 years, whereas
• scarlet and puerperal fever responsible for 15–30% of pharyngitis in pyoderma occurs more frequently in
• severe invasive disease such as children and 5–10% in adults. The children aged less than five years. Most
necrotising fasciitis, toxic shock community burden of pyoderma in people in their lifetime will develop a GAS
syndrome and septicaemia industrialised countries in not well throat or skin infection and many of the
documented. throat infections may be subclinical.
• post-streptococcal immunological
Preliminary data from a voluntary People with chronic illnesses like cancer
sequelae include acute rheumatic fever
surveillance system implemented in and diabetes, those on kidney dialysis, or
and acute glomerulonephritis.
Victoria in 2002 suggests the incidence those who use medications such as
Method of diagnosis of invasive GAS disease may be greater steroids, have a higher risk than healthy
Superficial infection is diagnosed by than 4 per 100 000 per year, with a case- persons. There is an increased risk of
isolation of the organism from infected fatality rate of approximately 11%. infection in varicella (chickenpox).
tissues. Invasive infection can be
confirmed by isolation of the organism Outbreaks occur in childcare settings, Control measures
from a normally sterile site such as institutions, and in remote communities Preventive measures
blood. Throat swabs are of limited value in northern and central Australia. There are currently no vaccines available
due to the frequency of inapparent but candidate vaccines are being used in
Reservoir
Streptococcal carriage. Definitive clinical trials. Food-borne disease can be
Humans.
identification depends on specific prevented by pasteurising milk and milk
serogrouping procedures. products and careful preparation and
storage of high risk foods, particularly
eggs.
218 The blue book: Guidelines for the control of infectious diseases

Control of case Outbreak measures


Treatment is dependent on the clinical Outbreak management is dependent on
presentation and severity of disease. the setting and specific disease. Seek
Evidence has accumulated that advice from the Department of Human
antibiotics may not always be indicated Services.
in pharyngitis or tonsillitis. The current
version of Therapeutic guidelines: Additional sources of information
antibiotics (Therapeutic Guidelines • Passmore, J, Kelpie, L & Carapetis, J
Limited) should be consulted prior to 2003, ‘Surveillance for invasive group A
treatment. streptococcal disease in Victoria-the
first 12 months’, Vic Infect Dis Bulletin,
Infected children should be excluded
vol. 6, no. 2, p. 30,
from schools and children’s services
www.health.vic.gov.au/ideas
centres until they have received
antibiotics for at least 24 hours and the
child feels well. People with skin lesions
should be excluded from food handling
until infection has resolved.
Control of contacts
Consider the diagnosis in symptomatic
contacts. Few people who come in
contact with GAS will develop invasive
GAS disease. At present, the role of
antibiotic prophylaxis for close contacts
of cases of invasive GAS infection is
uncertain. However in certain
circumstances, antibiotic therapy may be
appropriate for those at higher risk of
infection.
Control of environment
Standard infection control procedures
should be applied.
The blue book: Guidelines for the control of infectious diseases 219

Syphilis
Victorian statutory requirement • late latent syphilis where latent syphilis • Treponemal tests measure specific
Syphilis (Group C disease) must be has existed for two or more years or of treponemal antibodies in serum. These
notified in writing within five days of indeterminate duration, in the absence include Treponema pallidum particle
diagnosis. of neurosyphilis and other symptoms agglutination, enzyme immunoassay
and signs of disease and fluorescent Treponemal antibody
Specific information must be notified
• tertiary syphilis where cardiovascular absorption tests. Once these tests are
under the Health (Infectious Diseases)
involvement and neurosyphilis is reactive they usually remain so for life
Regulations 2001. To maintain
present. and give no indication of current
confidentiality, only the name code (first
disease activity. Enzyme
two letters of the surname followed by Syphilis in pregnancy immunoassays with highly purified
the first two letters of first name) is Foetal infection may result in abortion, Treponema pallidum antigens are
required. A questionnaire is sent to the stillbirth, premature delivery and becoming more commonly used for
diagnosing doctor to collect additional perinatal death. In congenital syphilis, screening for syphilis. These assays
information on the case that is essential generalised systemic disease in a live have a high specificity and sensitivity.
for detecting disease trends and born infant is present. IgM enzyme immunoassay for the
informing policy development.
Method of diagnosis detection of IgM antibodies to
Medical practitioners have a statutory Syphilis can be diagnosed by the Treponema pallidum is a useful assay
obligation under the Children and Young demonstration of spirochaetes in the for the diagnosis of congenital syphilis.
Person’s Act 1989 to notify the exudate from primary chancres or from • Non-treponemal tests such as rapid
Department of Human Services’ Child the mucous membrane lesions of plasma reagin (RPR) and venereal
Protection service if they believe that a secondary syphilis, using dark field diseases research laboratory test
child is in need of protection on the basis microscopy or immunofluorescence. measure antibodies that are produced
of sexual abuse.
Dark field microscopy is a difficult in response to syphilis and also to a
Infectious agent technique and requires an experienced relatively large number of other
The spirochaete Treponema pallidum, operator for reliable results. The test is conditions. This results in biological
subspecies pallidum is the infective unreliable on mucous membrane lesions false positives. The non-treponemal
agent. due to the presence of morphologically test gives an indication of current
similar saprophytic spirochaetes. Dark disease activity.
Identification field is also best done on site, as drying All sera showing reactive serology on
Clinical features of the exudate during transport to the screening tests should be forwarded to a
Syphilis is characterised by a primary laboratory renders the specimen reference laboratory for confirmatory
lesion, a secondary eruption involving unsuitable for microscopy. testing.
skin and mucous membranes, long Immunofluorescence is more sensitive
periods of latency, and late lesions of and does not have to be performed It is necessary to interpret syphilis
skin, bone, viscera, cardiovascular and immediately. It is suitable for use with serology in the context of:
central nervous systems. mucous membrane lesions but it is not • clinical history and examination
The stages of syphilis can be divided currently performed by the Victorian • serial RPR titres tested in parallel
into: Infectious Diseases Reference where possible (results obtained from
Laboratory. different laboratories are not directly
• early syphilis where primary (chancre),
secondary (rash or condylomata lata) More commonly syphilis is diagnosed comparable)
or latent syphilis (asymptomatic) of less using a combination of treponemal and • treponemal test results
than two years duration exist based on non-treponemal serological tests:
• a past record of treatment.
serology results
220 The blue book: Guidelines for the control of infectious diseases

It is essential that all cases of syphilis outbreaks. Imported infectious cases Control of case
receive close clinical and laboratory could result in syphilis re-emerging as a Penicillin is the drug of choice to treat
follow-up. significant public health issue. syphilis.
Lumbar puncture is advised when there Further information on the clinical
Reservoir
are: management of patients with syphilis can
Humans are the only reservoir.
• neurological or ophthalmic signs or be found in the latest editions of the
symptoms Mode of transmission Therapeutic guidelines: antibiotic
Transmission occurs primarily by sexual (Therapeutic Guidelines Limited) and the
• evidence of active tertiary syphilis National management guidelines for
contact. Transplacental infection of a
• treatment failure foetus may occur during the pregnancy sexually transmissible infections
• HIV infection with late latent syphilis or of an infected woman. Foetal infection (Venereology Society of Victoria, 2002).
syphilis of unknown duration. occurs with high frequency in untreated The necessity for long term follow-up
early infections of pregnant women and with repeat serology and the frequent
Note that other sexually transmissible
with lower frequency later in the disease presence of complicating factors makes
infections may be present in addition to
or in late latency. Syphilis may also be it desirable to seek specialist advice.
syphilis. Patients in whom syphilis is
transmitted by transfusion of blood from
diagnosed should be encouraged to be Control of contacts
infected individuals, however this risk is
tested for HIV infection. Sexual contacts should be identified. The
minimised by the screening of all
extent of contact tracing depends on the
Incubation period donated blood in Australia.
clinical stage of infection.
The incubation period is from ten days to
three months and is usually three weeks.
Period of communicability For primary syphilis, all persons having
A case is considered sexually infectious sexual contact with the index case during
Public health significance until the end of the early latent period the three months preceding onset should
and occurrence which is approximately two years after be evaluated. Such contacts should be
This is a complex disease. Sequelae infection. Infectious moist treated as for the case, even if their
include neurosyphilis, cardiovascular mucocutaneous lesions are present in serology is negative.
syphilis and congenital infection with the primary and secondary stages of For secondary syphilis, this period should
foetal death, stillbirth and abortion. syphilis and may reoccur intermittently in be extended to six months and for early
Testing and effective treatment are the early latent period. These lesions may latent syphilis, to twelve months.
available to facilitate the interruption of not be apparent to the infected
individual. For late latent syphilis, any sexual
disease transmission. Immune responses
partners and also children of infected
are only partially protective and
reinfection may occur following
Susceptibility and resistance women should be evaluated.
Everyone is susceptible to infection. For congenital syphilis, all members of
treatment. Syphilis enhances the
transmission of HIV, like other diseases the immediate family should be
Control measures
that cause genital ulcers. evaluated.
Preventive measures
The number of notifications of infectious Education about safe sex practices Contact tracing assistance can be
syphilis in Victoria is currently relatively including the use of condoms and early provided by the Department’s partner
small. However, syphilis occurs detection of infection by testing of notification officers (phone 9347 1899).
worldwide and has a high incidence in people at risk are the main prevention All newborns of mothers with syphilis
other parts of Australia. Other developed measures. should be investigated and treated in
countries have experienced recent consultation with a specialist.
The blue book: Guidelines for the control of infectious diseases 221

Control of environment • Larsen, SA et al 1995, ‘Laboratory


Not applicable. diagnosis and interpretation of tests for
syphilis’, Clin Micro Revs, vol. 8, no. 1,
Outbreak measures pp. 1–21.
Not applicable.
• Nganampa Health Council 1999, How
Additional sources of information to interpret syphilis results – A manual
• Australian Government Department of for nursing and medical staff in remote
Health and Family Services 1997, area clinics, 2nd ed.
Contact tracing manual – a practical • Singh, AE et al 1999, ‘Syphilis: Review
handbook for health care providers with emphasis on clinical,
managing people with HIV, viral epidemiologic and some biologic
hepatitis, other STDs and HIV-related features’, Clin Micro reviews vol. 12, no.
tuberculosis, Australian Government 2, pp. 187–209.
Department of Health and Family
• Venereology Society of Victoria 2002,
Services.
National management guidelines for
• Centers for Disease Control and sexually transmissible infections,
Prevention 2002, ‘Sexually transmitted http://www.mshc.org.au
diseases treatment guidelines 2002’,
Morbidity and Mortality Weekly Report,
vol. 51, RR06, pp.1–80.
http://www.cdc.gov/mmwr
• Egglestone, SI et al 2000, ‘Serological
diagnosis of syphilis,’ Communicable
Diseases & Public Health, vol. 3, no. 3,
pp. 158–62.
222 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 223

Taeniasis
Victorian statutory requirement Subcutaneous cysticerci may be visible tapeworm develops in the intestine over
Notification and school exclusion are not or palpable. Calcified cysticerci may be two to three months. The cycle of
required. visualised using ultrasound, CT scan or infection repeats when infectious eggs
MRI. are passed in the faeces and later
Infectious agent ingested by cattle, slowly migrating into
Taenia solium (pork tapeworm) causes Incubation period the flesh and transforming into the larval
both intestinal infection with the adult Symptoms of cysticercosis may appear stage.
tapeworm and somatic infections with from weeks to years after infection. Eggs
Infections by T. solium may follow a
the larvae (cysticerci). appear in the faeces 8–12 weeks after
similar cycle with consumption of
infection with the adult T. saginata
Taenia saginata (beef tapeworm) causes infected pork leading to the subsequent
tapeworm and after 10–14 weeks with T.
only intestinal infection with the adult development of adult tapeworms.
solium.
tapeworm in humans. However human infection may also occur
Public health significance through the consumption of T. solium
Identification
and occurrence eggs. This occurs by direct transfer from
Clinical features
Taeniasis occurs worldwide. It is the faeces of an infected person or
Taenia saginata infections are often
commonly seen in parts of Latin through the ingestion of contaminated
asymptomatic apart from the anal
America, Africa, South East Asia and food or water. When the eggs of
passage of tapeworm segments.
Eastern Europe. Both forms are usually T. solium are ingested by either humans
Infection may be associated with
imported to Australia but sporadic locally or pigs the embryos escape the shells
epigastric pain, diarrhoea and weight
acquired cases of T. saginata infection and penetrate the intestinal wall, with
loss.
have been reported. subsequent spread of larvae to various
Taenia solium adult worm infections are tissues to produce cysticercosis.
Many infections are largely
also usually asymptomatic. Many tissues
asymptomatic, but the larval stage of Period of communicability
and organs may be infected by the larval
T. solium may cause fatal cysticercosis. T. saginata is not directly transmissible
form (cysticercosis). Neurocysticercosis
Chronic tapeworm infections contribute from person to person although
is a serious but rarely fatal complication
to malnutrition for developing T. solium may be. Adult tapeworms may
which may be manifest as headaches,
communities in many parts of the world. persist in the intestines for up to 30
epileptiform seizures and visual or
psychiatric disturbances. years and are able to disseminate eggs
Reservoir
for all of this time. Eggs may remain
Method of diagnosis Humans are the definitive host for both
viable in the environment for months.
Infection with an adult tapeworm can be species. Cattle are the intermediate host
diagnosed through the identification of for T. saginata and pigs for T. solium. Susceptibility and resistance
segments, eggs or the head of the Everyone is susceptible to infection.
parasite in faeces or perianal swabs. Mode of transmission
Infection does not appear to confer
Microscopic examination of the eggs Eggs of T. saginata passed in the faeces
immunity.
cannot differentiate between the two of an infected person are only infectious
species. to cattle. Humans are infected by
ingestion of raw or undercooked beef
Specific serological tests are available to
infected with cysticerci bovis, the larval
support the clinical diagnosis of
stage of T. saginata. In humans the adult
taeniasis.
224 The blue book: Guidelines for the control of infectious diseases

Control measures Control of contacts


Preventive measures Symptomatic patients exposed to a
The public should be advised to avoid suspected source of infection should be
faecal contamination of soil, and human evaluated for evidence of taeniasis.
and animal food; avoid the use of raw Control of environment
sewage for irrigation of pasture soil; and If the history is consistent with local
to cook beef and pork thoroughly. infection the source of the infection
Beef and pork, should be adequately should be investigated, often with the
cooked, for example at 60°C for five assistance of the local government.
minutes.
Outbreak measures
Freezing meat below –5°C for more than Not applicable.
four days will kill cysticerci.
Meat should be routinely inspected for Additional sources of information
evidence of taeniasis at slaughter. • Centers for Disease Control and
Prevention, http://www.dpd.cdc.gov
Control of case
Praziquantel or niclosamide are used for
treatment of beef and pork tapeworm
infections. Consult the current version of
Therapeutic guidelines: antibiotic
(Therapeutic Guidelines Limited).
Persons harbouring adult T. solium
should be immediately identified and
treated to prevent human cysticercosis.
For cysticercosis surgical intervention
may relieve symptoms. For CNS
cysticercosis, praziquantel or albendazole
may be used, with corticosteroids if
indicated.
Isolation is not required. The case and
relevant caregivers should be advised
that the case’s faeces may be infectious
and advised on sanitary disposal of
wastes.
The blue book: Guidelines for the control of infectious diseases 225

Tetanus
Victorian statutory requirement Laryngeal spasm is a very serious Tetanus is still common in developing
Tetanus (Group B disease) must be complication which may occur at any countries with low immunisation rates
notified in writing within five days of stage and can cause sudden asphyxia. and where contact with animal excreta is
diagnosis. Exhaustion and inability to swallow are more common. Tetanus, particularly
also associated with severe disease. neonatal tetanus, is a significant cause of
School exclusion is not applicable.
Case fatality rates vary from 10–90% and death in these settings.
Infectious agent are highest in infants and the elderly. Intravenous drug use is an independent
Clostridium tetani, the tetanus bacillus is risk factor for tetanus in the absence of
Method of diagnosis
the causative agent. acute injuries and may be linked to
Clinical features of severe classical
tetanus are virtually diagnostic. localised case clusters.
Identification
Clinical features Laboratory confirmation of tetanus Reservoir
Tetanus is an acute, potentially fatal infection is often difficult. C. tetani is widely distributed in cultivated
disease caused by tetanus bacilli soil and in the gut of humans and
C. tetani antibodies are sometimes
multiplying at the site of an injury. These animals. Spores can usually be found
detectable in serum samples but may
produce an exotoxin that reaches the wherever there is contamination with
result from waning past immunisation.
central nervous system and causes soil.
Cultures from the site of infection should
muscle stimulation.
be attempted although the organism is
Initial features are increased muscle
Mode of transmission
often not recovered.
Tetanus is not directly transmitted from
rigidity. This may be restricted to and
Incubation period person to person.
most pronounced in muscles near the
injury (localised tetanus). Depending on The incubation period is usually three to Spores may be introduced through
severity, muscle rigidity usually affects 21 days although it may range from one contaminated puncture wounds,
most parts of the body and is associated day to several months depending upon lacerations, burns or contaminated
with hyperreflexia. As a result, features the nature of exposure. Most cases injected ‘street drugs’. Tetanus can result
such as neck, back and limb stiffness, occur within14 days. from minor wounds considered too trivial
stiff jaw or ‘lock jaw’ (trismus) and a Cases with shorter incubation periods for medical consultation.
sardonic smile (risus sardonicus) may tend to have more severe disease and The presence of necrotic tissue or
occur. thereby a greater risk of death. foreign bodies encourages the growth of
With progression, superimposed painful anaerobic organism such as
Public health significance C. tetani. Tetanus rarely follows surgical
muscle spasms can appear anywhere or
and occurrence procedures today.
involve most body muscles
Tetanus occurs worldwide but is now
simultaneously. Opisthotonos can result.
rare in developed countries due to high Period of communicability
This is when spasm is most marked in
immunisation rates. Infection is most Spores may remain viable for many years
the back muscles causing the head and
likely in older people who have never in the environment.
heels to bend backward and the body to
been immunised or who have waning and
bow forward. Painful spasms may
inadequate immunity.
become very frequent and together with
background rigidity cause life-threatening
interference with respiration.
226 The blue book: Guidelines for the control of infectious diseases

Susceptibility and resistance Control of case


Active immunity is produced by Refer the patient immediately to a
immunisation with tetanus toxoid and specialised centre with intensive care
persists for at least ten years after full facilities. The principles of treatment
immunisation. include:
Transient passive immunity follows • tetanus immunoglobulin (TIG) by
injection of tetanus immune globulin intramuscular injection
(TIG) or tetanus antitoxin. • IV penicillin in large doses for 10 to 14
Recovery from tetanus is not necessarily days. Intravenous metronidazole is a
associated with immunity. reasonable alternative for patients with
immediate penicillin hypersensitivity
Control Measures
• adequate wound debridement
Preventive measures
Tetanus toxoid is part of the Australian • careful attention to provide an
Standard Vaccination Schedule. Primary adequate airway and to control muscle
immunisation for children begins at two spasm
months of age and requires three doses • case investigation to determine the
of tetanus toxoid-containing vaccine at circumstances of injury
two-monthly intervals. Children should
• completion of course of active
be given a booster at four years of age. A
immunisation after recovery.
further booster dose is given prior to
leaving school (15–17 years of age) and Control of contacts
again at 50 years of age. Not required.

For further information on tetanus Control of environment


vaccination, particularly with respect to Not required.
the management of children who have
Outbreak measures
missed doses, consult the current edition
Not applicable.
of The Australian immunisation handbook
(National Health and Medical Research
Council).
The use of tetanus toxoid in the
management of wounds, with or without
tetanus immunoglobulin, is determined
by considering the vaccination history of
the person and the nature of the wound.
For further information on the
management of bites and other tetanus-
prone wounds, consult the current
edition of Therapeutic guidelines:
antibiotic (Therapeutic Guidelines
Limited).
The blue book: Guidelines for the control of infectious diseases 227

Toxoplasmosis
Victorian statutory requirement Serological results require careful Reservoir
Notification and school exclusion are not interpretation and should preferably be The main host in Australia is the
required. performed and discussed with a domestic cat. Cats acquire the infection
reference laboratory. In general, mainly through eating small infected
Infectious agent toxoplasma-specific IgG antibody mammals including rodents and birds,
Toxoplasma gondii is a protozoal disease. appears two to three weeks after acute and rarely from the ingestion of infected
infection, peaks in six to eight weeks and cat faeces. Only young felines harbor the
Identification
often persists lifelong. parasite in the intestinal tract, where the
Clinical features
Presence of toxoplasma-specific IgM sexual stage of the life-cycle takes place
Toxoplasmosis infection is asymptomatic
antibody suggests infection within the resulting in the excretion of oocysts in
in 80% of people. The most common sign
last two years. False positive IgM results faeces for 10–20 days.
in symptomatic patients is enlarged
lymph nodes, especially around the neck. are common and should always be Many other intermediate hosts including
The illness may mimic glandular fever repeated before final interpretation. They sheep, goats, rodents, cattle, swine,
with other symptoms of muscle pain, are common in autoimmune disease. chicken and birds may carry an infective
intermittent fever and malaise. Presence of IgA antibodies is said to stage of T. gondii encysted in their
correlate with acute infection. tissues. This occurs more commonly in
Dormant infection persists for life and
muscle and brain. Tissue cysts remain
can reactivate in the immunosuppressed Testing paired sera taken two weeks
viable for long periods.
person. apart is often helpful as is IgG antibody
More serious disease can develop or avidity testing. Mode of transmission
reactivate in immunosuppressed patients A specific PCR performed on amniotic Adults most commonly acquire
with brain, heart or eye involvement, fluid may determine if a foetus has toxoplasmosis by eating raw or
pneumonia and occasionally death. become infected. undercooked meat infected with tissue
Cerebral toxoplasmosis or chorioretinitis cysts. Consumption of contaminated,
Incubation period unpasteurised milk has also been
are frequent complications of AIDS when
The incubation period is uncertain but implicated.
the lymphocyte CD4 cell count drops
probably ranges from 5–23 days.
below 100 / cu mm. Children may become infected by
Acute toxoplasmosis in pregnant women Public health significance ingestion of oocysts in dirt or sandpit
can affect the unborn child. In early and occurrence sand after faecal contamination by cats,
pregnancy brain damage as well as liver, Toxoplasmosis occurs worldwide in particularly kittens, or other animals.
spleen and eye disorders may occur. mammals and birds. Infection in humans The infection may also be transmitted
Infection in late pregnancy may result in is common. through blood transfusion and organ
persistent eye infection through life. Infections during pregnancy may lead to transplantation. Transplacental
Toxoplasmosis acquired after birth severe complications for the foetus. transmission may occur when a woman
usually results in no symptoms or only a Primary or reactivated lesions may lead has a primary infection during
mild illness. to severe complications in pregnancy.
Method of diagnosis immunosuppressed patients.
Period of communicability
Infection may be diagnosed by Toxoplasmosis is not transmitted from
visualisation of the protozoa in biopsy person to person spread except in-utero.
material or serology.
228 The blue book: Guidelines for the control of infectious diseases

Oocysts spread by cats sporulate and • cat litter trays should be emptied daily Primary infection in pregnancy can cause
become infective one to five days later. and regularly disinfected with boiling serious foetal disease. Infection in the
They may remain infective in water or water to dispose of the oocysts before first trimester results in a low foetal
moist soil for over a year. they become infective. infection rate (15%) but a higher risk of
Tissue cysts in meat remain infective for Cats should only be fed with dry, canned serious disease. Infection later in
as long as the meat is edible and under- or boiled food and should be discouraged pregnancy results in a higher infection
cooked. from hunting and scavenging. However, rate but generally less severe disease.
direct contact with cats is rarely the Diagnosis and treatment during
Susceptibility and resistance cause of infection. Cats are generally pregnancy appears to reduce the effects
Everyone is susceptible to infection. infected as kittens and only excrete the on the baby.
About 75% of women of childbearing age oocysts for two weeks after their original False positive IgM antibody test (and less
are susceptible. infection. commonly IgG) results do occur and
Immunity is thought to be life long Sandpits should be covered when not in treatment should never begin without
however patients undergoing use to stop cats defecating in the pit. further testing. Where infection of the
immunosuppressive therapy, in particular mother is confirmed, treatment is
Control of case
for haematological malignancies, or indicated.
Isolation of patient is not required.
patients with AIDS, are at high risk of
Specific anti-protozoal treatment may be Amniocentesis with PCR testing can be
developing illness from reactivated
indicated in immunosuppressed persons, carried out to determine whether
infection.
infections during pregnancy, or where transmission to the foetus has occurred.
Control measures there is eye or other organ involvement. Newborns
Preventive measures Specialist advice should be sought. Newborns of mothers with primary
No immunisation is available. Immunosuppressed persons may also infection during pregnancy or active
Pregnant women and require prophylactic treatment for the infection, and immunosuppressed
immunosuppressed people should be duration of their immunosuppression. patients are treated empirically until
advised to: Infants who acquire an infection before congenital disease is ruled out. Where
birth may require prolonged treatment to infection is confirmed, treatment is
• cook meat thoroughly (until no longer
reduce the risk of ongoing active continued for 12 months to help reduce
pink) and avoid uncooked cured meat
infection. long term effects.
products
• not consume unpasteurised milk or its Control of contacts Outbreak measures
products Not applicable. Not applicable.
• wash all raw fruit and vegetables Special settings
Additional sources of information
carefully before eating Pregnancy
• Gilbert, G 2002, ‘Infections in pregnant
Children of mothers with evidence of
• wash hands thoroughly before meals women’ MJA, vol. 176, pp. 229–236.
previous immunity more than six months
and after handling raw meat
prior to conception are not at risk.
• delegate the cleaning of cat litter trays Primary infection in pregnancy is rare
to others wherever possible and if this although up to one third of these
is not possible, gloves should be worn infections result in transplacental spread
during cleaning and hands washed well to the developing foetus.
afterward
The blue book: Guidelines for the control of infectious diseases 229

Typhoid and
paratyphoid fever
Victorian statutory requirement Phage typing is used for characterising S. travellers. The disease commonly occurs
Salmonella (Group A disease) must be typhi and S. paratyphi isolates for in association with poor standards of
notified immediately by telephone or fax epidemiological purposes and in hygiene in food preparation and handling.
followed by written notification within five outbreak settings. A number of phage
days. types are recognised. Period of communicability
It is communicable as long as typhoid or
School exclusion: exclude until approved Incubation period paratyphoid bacilli are present in excreta.
to return by the Department of Human The incubation differs for typhoid and Some patients become permanent
Services. paratyphoid fever: carriers.
Work exclusion: exclusions apply to food- • typhoid fever is usually 8–14 days but
handlers and some health care workers Susceptibility and resistance
this depends on the infective dose and
(see below). Everyone is susceptible to infection.
can vary from three days to one month
Immunity following clinical disease or
Infectious agent • paratyphoid fever is usually one to ten immunisation is insufficient to protect
Salmonella typhi, the typhoid bacillus and days. against a large infectious dose of
Salmonella paratyphi, with three organisms.
recognised serovars A, B and C are the Public health significance
infectious agents. and occurrence Control measures
Typhoid and paratyphoid infections occur Preventive measures
Identification worldwide. Outbreaks occur in areas with Vaccination is not routinely
Clinical features poor sanitation and inadequate sewerage recommended, except for travellers who
Typhoid fever (enteric fever) is a systems. Approximately 30–35 cases of will be exposed to potentially
septicaemic illness characterised initially enteric fever occur in Victoria each year. contaminated food and water in
by fever, bradycardia, splenomegaly, The majority of these are returned countries such as in Asia, the Middle
abdominal symptoms and ‘rose spots’ travellers, especially from the Indian East, Africa, Latin America and the
which are clusters of pink macules on subcontinent. Pacific Islands.
the skin. Vaccination should be considered for
Reservoir
Complications such as intestinal Reservoirs for typhoid and paratyphoid laboratory workers in potential contact
haemorrhage or perforation can develop fever are: with Salmonella typhi.
in untreated patients or when treatment Three typhoid vaccines are currently
is delayed. • typhoid fever: Human gallbladder
carriers and rarely human urinary available in Australia. The live oral
Paratyphoid fever presents a similar carriers vaccine and Vi capsular polysaccharide
clinical picture but is usually milder, injectable vaccine generally cause few
shorter in duration and with fewer • paratyphoid fever: Humans and rarely adverse reactions.
complications. domestic animals.
A combination hepatitis A and typhoid
Method of diagnosis Mode of transmission injectable vaccine is also available. All
Diagnosis is made by culture of typhoid or Salmonella is transmitted by formulations are equally effective.
paratyphoid bacilli from the blood, urine or contaminated water and food and rarely Vaccination does not offer full protection
faeces. Repeated sampling may be by direct contact. Water, ice (if unboiled from infection and travellers should be
necessary. Serology in the form of the water used), raw vegetables, salads and advised to exercise care in selecting food
Widal test is no longer routinely used. shellfish are important sources for and drink.
230 The blue book: Guidelines for the control of infectious diseases

No vaccine is available against If the patient is a food-handler or works in a Control of environment


paratyphoid fever. profession that poses a high risk of A public health investigation is carried
The community should be educated transferring infection to others, such as out to determine the most likely source
about personal hygiene, especially health care workers, or child care workers, of infection. A history of travel to an
thorough hand washing after toilet use they should be advised to cease work until endemic area is usually found.
and before food preparation. advised by the Department. If there is no history of travel, local
Control of case The Department arranges the collection sources of infection are investigated to
Hospitalisation is usually required for and testing of weekly faecal specimens identify further cases, asymptomatic
acute infections. for S. typhi or S. paratyphi to be taken over carriers, and contaminated food items.
three consecutive weeks, commencing no Food industry
Antibiotic therapy may include one or sooner than at least 48 hours after
more to the following agents: If a case is involved in commercial food
cessation of antibiotic treatment. Food preparation, the Department will
ciprofloxacin, ceftriaxone, handlers and workers in high risk
chloramphenicol, amoxycillin or co- determine the appropriate management
professions are generally excluded from of the workplace on an individual basis.
trimoxazole. However, strains resistant to high risk work or patient care until they
chloramphenicol, amoxycillin and co- have had three consecutive negative Outbreak measures
trimoxazole are common in south Asia. faecal specimens. All cases are intensively investigated,
Failure to respond to ciprofloxacin has
Control of contacts whether sporadic or part of a cluster.
been reported from Vietnam. In the UK
Contacts should be educated about the Further actions to reduce the risk of
decreased susceptibility to ciprofloxacin
disease so as to reduce the risk of infection during an outbreak may include:
has been exhibited with increasing
numbers of treatment failures particularly transmission and to allow for early • selective elimination of suspected
in patients with a travel history to India identification if they develop symptoms. contaminated food
and Pakistan. A similar picture is The decision to screen contacts of cases • ensuring pasteurisation of milk
emerging in Victoria with ongoing S. typhi is dependent upon the extent of contact • ensuring appropriate chlorination or
and S. paratyphi after treatment being and the likely source of the patient’s boiling of drinking water prior to
noted. Consult the current version of infection. Faecal screening is generally consumption
Therapeutic guidelines: antibiotic arranged for:
(Therapeutic Guidelines Limited). • reviewing the integrity of waste and
• Household contacts of a case who are sewerage systems.
Education should be given to the patient food-handlers or in a high risk
regarding the importance of completing profession. Screening is more intensive Widespread use of typhoid vaccine is not
the course of antibiotics, the possibility and includes the entire household if generally recommended.
of relapse, persisting excretion, the need the patient has no history of travel to a
International measures
for good personal hygiene and typhoid-endemic area.
Typhoid vaccination is recommended for
precautions in food preparation. • Fellow travellers. prolonged travel to endemic areas.
Follow-up of all patients is conducted by Use of typhoid vaccine for contacts is
the Department of Human Services to Additional sources of information
not generally recommended. Typhoid
identify possible sources of infection, • Skull, SA, Tallis, G 2001, ‘An evidence-
vaccination is only recommended for
other cases, and to manage ongoing based review of current guidelines for
persons with intimate exposure to a
risks. the public health control of typhoid in
documented typhoid fever carrier, such
Australia: a case for simplification and
as occurs with continued household
resource savings’, Aust N Z J Public
contact.
Health, vol. 25, no. 6, pp. 539–42.
The blue book: Guidelines for the control of infectious diseases 231

Verotoxin producing E.
coli (VTEC)
(Enterohaemorrhagic
E. coli [ETEC], Shiga-like
toxin producing E. coli
[STEC])
Victorian statutory requirement Method of diagnosis Since then several large outbreaks have
Haemolytic uraemic syndrome (Group A Diagnosis is confirmed by isolation of the been reported worldwide and over
disease) must be notified immediately by organism from faeces. Other diagnostic 70,000 cases are reported in the US
telephone followed by written notification methods may be required including: each year. A particular brand of
within five days. • demonstrating the presence of Shiga- fermented salami was implicated in a
like toxins large outbreak in South Australia in 1995.
VTEC and STEC (Group B disease) must
be notified in writing within five days of • serotyping An average of five cases of VTEC and
diagnosis. three cases of HUS are reported in
• DNA probes that identify the toxin Victoria each year. This is likely to be a
School exclusion: exclude if required by producing genes or the presence of significant underestimate of the true
the Secretary and only for the period the VTEC virulence plasmid. burden of disease related to VTEC due to
specified by the Secretary. Contacts are
As screening for VTEC is not routine in the lack of routine screening of bloody
not excluded.
Victorian laboratories the test should be diarrhoea.
Infectious agent specifically requested for persons with
Escherichia coli serotypes capable of bloody diarrhoea. Reservoir
The gastrointestinal tracts of cattle and
producing toxins (Shiga-like or Vero- As a negative stool culture is not
possibly other domesticated animals act
toxins) similar to those of Shigella exclusionary, HUS should be considered
as reservoirs. Humans serve as
dysenteriae type 1 are the causative in the presence of the following:
reservoirs for person to person
agents. The most important are E. coli
• acute microangiopathic anaemia on transmission. Prolonged carriage is
O157:H7, E. coli O111:H8 and E. coli
peripheral blood smear uncommon.
O26:H11.
• acute renal impairment (haematuria,
Identification proteinuria or elevated creatinine level)
Mode of transmission
Ingestion of contaminated food and
Clinical features • thrombocytopaenia, particularly during water and person to person and animal
Illness is characterised by severe the first seven days of illness. to person transmission by the faecal-oral
abdominal pain and cramping and watery
route are responsible for VTEC infection.
diarrhoea which becomes grossly bloody Incubation period
Undercooked meat, especially ground
and lasts five to ten days. Fever is usually The incubation period is two to eight
meat or mince, is a source of infection.
mild or absent. Asymptomatic infection days, with an average of three to four
Other known food sources have included
can occur. days.
lettuce, sprouts, salami, unpasteurised
In children aged less than five years and milk and fruit juices. The infectious dose
Public health significance
the elderly, infection may lead to necessary to cause disease is thought to
and occurrence
haemolytic uraemic syndrome (HUS). be as low as ten organisms.
Recognition of VTEC as an important
This is a disease characterised by renal
cause of food-borne illness is relatively
failure, a high mortality rate and Period of communicability
recent. The first outbreaks of O157:H7
thrombotic thrombocytopaenic purpura VTEC is communicable for as long as the
were reported in the United Kingdom and
(TTP). HUS and TTP are complications of organism is present in faeces which is
United States in the early 1980s.
infection with serotype O157:H7. approximately one week for adults but
may be as long as three weeks in
children.
232 The blue book: Guidelines for the control of infectious diseases

Susceptibility and resistance Children must not attend school or child Additional sources of information
Everyone is susceptible to infection. care until diarrhoea has ceased. Any • Bettelheim, KA, Hornitzky, MA,
Children and the elderly are at higher risk ongoing exclusion is at the discretion of Djordjevic, SP, Kuzevski, A 2003,
for severe disease. Antibiotic resistance the Secretary of the Department of ‘Antibiotic resistance among
is of increasing concern. A study recently Human Services. verocytotoxigenic Escherichia coli
conducted in Melbourne found that 28% Control of contacts (VTEC) and non-VTEC isolated from
of VTEC strains isolated from healthy The diagnosis should be considered in domestic animals and humans’, J Med
babies, who had neither contact with symptomatic contacts. As for cases, Microbiol, vol. 52, pt 2, pp. 155–62.
antibiotics nor had gastrointestinal work and school exclusion apply to • Karmali, MA 1989, ‘Infection by
symptoms for at least two weeks prior to contacts with diarrhoea. verocytotoxin-producing Escherichia
the specimen being taken, were resistant coli’, Clinical Microbiological Review,
Control of environment
to one or more of the antibiotics tested. vol. 2, no. 1, pp. 15–38.
Environmental surfaces exposed to
Control measures infectious material should be thoroughly • Subcommittee of the PHLS Advisory
Preventive measures cleaned. Implicated food should be Committee on Gastrointestinal
Avoid ingestion of inadequately cooked destroyed and contaminated water Infections 2000, ‘Guidelines for the
meat and meat products, unpasteurised sources treated. control of infection with Vero cytotoxin
milk and fruit juices, unwashed salad Particular attention to personal and producing Escherichia coli (VTEC)’,
ingredients and untreated water. Hand environmental hygiene should be Commun Dis Public Health, vol. 3, no.
washing before and after using the toilet observed in food premises, institutions 1, pp. 14–23.
and preparing or eating food is critical. and child care centres.
Control of case
Outbreak measures
Treatment is generally supportive,
A single case of EHEC or HUS is
particularly maintenance of hydration.
potentially indicative of an outbreak.
The role of antibiotics in the
Search for other cases and identify
management of VTEC is unclear and
persons at risk of infection. A source of
there is some concern that they may
infection should be sought for all cases
precipitate the onset of HUS. Specialist
of EHEC and HUS. Obtain detailed food
medical advice should be sought for
and environmental exposure histories
cases of HUS and TTP. Enteric
from cases. Collect samples of
precautions should be strictly observed
potentially implicated food and send to
in the management of hospitalised
the Microbiological Diagnostic Unit for
cases.
analysis. Antibiotic prophylaxis has
Food handlers, child care workers and neither been proven to be efficacious nor
health care workers must not work until safe for the prevention of secondary
symptoms have stopped and two cases during VTEC outbreaks.
consecutive faecal specimens taken at
Refer to the Department’s Guidelines for
least 24 hours apart are negative for
the investigation of gastrointestinal illness
VTEC.
for more detailed on the investigation
and management of outbreaks.
The blue book: Guidelines for the control of infectious diseases 233

Viral gastroenteritis
(not rotavirus)
Victorian statutory requirement Incubation period person to person contact. Aerosols are
Isolated cases are not notifiable. The incubation period is usually 24–48 thought to be important in the
hours. The known range for norovirus is transmission of norovirus and it is also
School exclusion: exclude from school or
10–50 hours. known to persist on certain
childcare centres until after symptoms
contaminated surfaces such as carpets
have ceased or a medical certificate of
Public health significance for weeks.
recovery is produced.
and occurrence
Infectious agents The endemic burden of gastroenteritis of Period of communicability
viral causes is not known however Communicability continues during the
Small round structured viruses (SRSVs)
norovirus is recognised as the major acute phase and for as long as viral
including noroviruses and other
cause of outbreaks of non-bacterial shedding persists. Cases should be
caliciviruses, astroviruses and
gastroenteritis. Explosive outbreaks have considered infectious until at least 48
adenoviruses are the infective agents.
occurred in institutions, camps, childcare hours after diarrhoea has ceased.
Identification centres, cruise ships, restaurants and Shedding of norovirus in the absence of
Clinical features following catered functions. clinical illness can persist for up to two
Illness is characterised by an acute onset Approximately 50% of gastroenteritis weeks and is of concern in food-handler
of fever, myalgia, headache, nausea, outbreaks investigated each year in related transmission.
vomiting, abdominal cramps and watery Victoria are attributed to viral pathogens.
diarrhoea lasting 12–60 hours. Vomiting High secondary attack rates result in Susceptibility and resistance
outbreaks that are often prolonged and Everyone is susceptible to infection and
is relatively more prevalent among
difficult to contain. infection is not known to confer lifelong
children. Forceful vomiting as a
immunity.
predominant symptom and a significant Disease occurs in all age groups and
secondary attack rate in an outbreak of predominantly affects infants and young Control measures
gastroenteritis are suggestive of children. In Australia, viruses can be Preventive measures
norovirus infection. Although rare, severe detected throughout the year but are Prevention is dependent on attention to
dehydration caused by viral more common in the period from late good food and personal hygiene,
gastroenteritis can be fatal in persons winter to early summer. Norovirus has particularly hand washing.
with debilitating health conditions. been reported to account for between
Control of case
Method of diagnosis 5–17% of cases of diarrhoea in the
Treatment is symptomatic and should be
Diagnosis is predominantly based on community and 5–7% of cases requiring
focussed on maintaining hydration.
clinical presentation. Virus in stool can treatment by physicians.
be visualised and distinguished by Healthcare workers and food handlers
electron microscopy. Nucleic acid Reservoir should be excluded from work until at
hybridisation assays and RT-PCR assays The reservoir is thought to be primarily least 48 hours after diarrhoea and
to detect norovirus genome are a humans. vomiting has ceased. Children should be
sensitive and specific tool for outbreak excluded from school or childcare
Mode of transmission centres until after symptoms have
investigations. Nucleotide sequencing
Viral gastroenteritis is predominantly ceased or a medical certificate of
provides a classification of the viruses n
spread via the faecal-oral route. recovery is produced. Residents of
observed,and is an important tool in
Transmission is facilitated through institutions should be isolated until
establishing links to contaminated
contaminated food (particularly raw diarrhoea has ceased.
vehicles of infection in outbreak settings.
shellfish), water (including ice) and
234 The blue book: Guidelines for the control of infectious diseases

Control of contacts
Advise case to maintain strict personal
hygiene and hand washing in the home.
Determine if others are ill. If so, report to
Local Government environmental health
officers or the Department’s
Communicable Diseases Section so that
outbreak investigation and control can
occur.
Control of environment
The ability of norovirus to survive
relatively high levels of chlorine and
varying temperatures (from freezing to
60°C) means rigorous attention to clean-
up procedures and personal and home
hygiene is essential in preventing further
transmission.

Outbreak measures
An outbreak is defined as two or more
related cases of gastroenteritis. The
primary aim is to prevent further disease
by identifying the source, cleaning
contaminated environments and isolating
cases.
Special settings
Specific protocols for the management of
outbreaks in special settings are
available from the Communicable
Diseases Section of the Department of
Human Services.

Additional sources of information


Centres for Disease Control and
Prevention 2001, ‘Norwalk-like viruses:
public health consequences and
outbreak management’, MMWR, vol. 50,
RR9, pp. 1–18.
The blue book: Guidelines for the control of infectious diseases 235

Viral haemorrhagic
fevers
Victorian statutory requirement infections are complicated by massive • Marburg virus is usually three to nine
Viral haemorrhagic fever (Group A haemorrhage and multi-organ failure. days
disease) must be notified immediately by Case fatality rates vary greatly: • Ebola virus is usually 2–21 days.
telephone or fax followed by written
• Lassa fever virus has a case fatality
notification within five days. Public health significance
rate of 1% of infected cases but 25% of
School exclusion: until medical and occurrence
hospitalised cases.
clearance. The term viral hemorrhagic fever (VHF)
• Crimean-Congo haemorrhagic fever refers to a group of rare illnesses that are
Crimean-Congo, Ebola, Lassa and virus has a case fatality rate of 2–50%. caused by several distinct families of
Marburg viral haemorrhagic fevers are viruses. While some types of
• Marburg virus has a case fatality rate
subject to Australian quarantine. hemorrhagic fever viruses can cause
of 25% and Ebola virus is 50–90%.
relatively mild illnesses, many of these
Infectious agent Method of diagnosis
viruses cause severe life-threatening
Four viral haemorrhagic fevers (VHFs) are The Department of Human Services and
disease.
of particular concern because they could the Victorian Infectious Diseases
be imported into Australia and be Reference Laboratory (VIDRL) should be Lassa, Marburg and Ebola viruses are
transmitted to other people, particularly consulted prior to the collection and restricted to sub-Saharan Africa.
health care personnel by blood or body transport of any clinical specimens from Crimean-Congo haemorrhagic fever virus
fluid inoculation. These quarantinable suspected VHF patients for diagnostic is more widely distributed in Africa, the
VHFs are: testing. Mediterranean region, the Middle East,
Eastern Europe, Central Asia and China.
• Lassa fever (LF) virus - an arenavirus All suspected VHF clinical specimens are
The origins of the Marburg and Ebola
• Crimean-Congo haemorrhagic fever tested under the highest bio-security
viruses are still unclear but most cases
(CCHF) virus - a Bunyavirus level (BSL–4) laboratory conditions.
appear to have arisen in Africa.
Diagnosis is typically made using specific
• Ebola virus (EV) and Marburg virus The high case fatality rate means that it
PCR tests supported by viral isolation
(MV) - filoviruses. is important that the diagnosis is made
and serology. Appropriate specimens
Dengue haemorrhagic fever and yellow are: and treatment is commenced as early as
fever are discussed elsewhere. possible. Viral haemorrhagic fevers
• unclotted blood, tissue or nose and
should be considered in the differential
Identification throat swabs for viral PCR
diagnosis of every patient with an
Clinical features • unclotted blood, urine, tissue or nose unexplained fever who has been exposed
Clinically apparent infections with any of and throat swabs for virus isolation to the infection in an area with endemic
these viruses may present with similar VHF during the preceding three weeks.
• clotted blood for serology.
symptoms. Fever is typically insidious in
onset and accompanied by severe Incubation period Reservoir
headache, myalgia and malaise. Other The incubation period varies according to The reservoir for Lassa fever virus is a
symptoms include retrosternal chest pain, the causative agent: rodent known as the multimammate rat
cough, abdominal pain, diarrhoea, of the genus Mastomys spp.
• Lassa fever virus is usually 6–21 days
conjunctivitis, facial swelling, proteinuria The reservoirs for Crimean-Congo
and jaundice. A bleeding diathesis leads • Crimean-Congo haemorrhagic fever
haemorrhagic fever virus are hares, birds
to mucosal bleeding, haematemesis, virus is usually one to three days
and Hyalomma spp. of ticks. Domestic
melaena and haematuria. Severe (range 1–12 days)
animals such as sheep, goats and cattle
236 The blue book: Guidelines for the control of infectious diseases

may act as amplifying hosts. Period of communicability All patients should be cared for at the
The natural reservoir of Ebola virus Communicability of viral haemorrhagic hospital where they are first seen (if
remains unknown. Current evidence fevers depends on the infective agent: possible), or transferred to the Victorian
suggests that the virus is zoonotic Infectious Diseases Service at the Royal
• Lassa fever virus is communicable via
(animal-borne) and is normally Melbourne Hospital, the designated VHF
person to person spread during the
maintained in animal hosts native to the treatment centre forVictoria, or similarly
acute febrile phase. Virus is excreted in
African continent. This could include equipped tertiary hospital.
the urine for up to three to nine weeks
other primates such as gorillas. from the onset of the illness. Intravenous ribavirin may be useful for
treatment purposes; a stock of this drug
Mode of transmission • Crimean-Congo haemorrhagic fever
is maintained at a number of tertiary
Transmission for the viral haemorrhagic virus communicability is unknown. The
hospitals including the Royal Melbourne
fevers depends on the type of virus: virus is highly infectious in the hospital
Hospital.
setting where it has been transmitted
• The Mastomys rodents shed Lassa to health care personnel by accidental Cases should be cared for in an isolation
fever virus in urine and droppings. The needle stick injury. room, preferably with negative pressure
virus can be transmitted through direct ventilation, and non-essential staff and
contact with these materials, touching • Marburg and Ebola virus are
visitors should be restricted. The highest
objects or eating food contaminated communicable as long as blood and
level of barrier infection control
with these materials, or through cuts or secretions contain virus. Virus has
precautions should be instituted
sores. Person to person transmission been isolated in seminal fluid 60 days
including gowns, gloves, face shields and
may occur through sexual contact or after the onset of infection.
masks.
inoculation with blood.
Susceptibility and resistance No airborne transmission has been
• Crimean-Congo haemorrhagic fever All ages are susceptible. The duration of reported so personal and room HEPA
virus is transmitted by the bite of immunity after infection is unknown. filtration is not an absolute requirement
infective Hyalomma spp. ticks. Ticks are but should be used if available. An
believed to acquire the virus by Control measures
anteroom for putting on and discarding
transovarian transmission or from Preventive measures
clothing and storing supplies is
animal hosts. Nosocomial spread to Not applicable in Australia. No vaccines
advisable.
medical workers in contact with infected are available.
The obligatory period of isolation for a
blood or secretions has been observed. Intending travellers to LF and CCHF
proven case of viral haemorrhagic fever
Slaughtering of infected animals is also endemic areas should avoid contact with
is a minimum of two days without fever
linked to some infections. ticks and rodents.
and a total of 21 days from onset of
• The source of infection for the index Control of case illness.
human for Ebola and Marburg viruses All travellers who arrive in Australia with
Convalescent patients and their contacts
is usually unknown. Secondary human any risk of contracting quarantinable VHF
should be informed that VHF viruses may
infections occur by person to person should be immediately notified to the
be excreted for many weeks in semen
spread through direct contact with Department of Human Services.
(MV and EV) and in urine (LF).
infected blood or secretions, including
The Department of Human Services Meticulous personal hygiene is
semen. Nosocomial transmission has
state chief quarantine officer will make necessary. Abstinence from sexual
also been reported through
any decisions concerning patient’s intercourse is advised until genital fluids
contaminated needles and syringes.
assessment, transport and quarantine. have been shown to be free of the virus.
The blue book: Guidelines for the control of infectious diseases 237

Post-mortem is discouraged. Bodies of self-surveillance as soon as VHF is immediately notify the Commonwealth
deceased patients should preferably be considered to be a likely diagnosis in the Chief Medical Officer who would in turn
cremated. index patient. notify WHO according to International
Control of contacts Any close or high risk contact that Health Regulations, as well as notify the
Active case and contact surveillance is develops a fever (> 38°C) or any other source country and other countries who
conducted by the Department to identify symptoms of illness should be may receive possible exposure by
any fellow cases and all contacts with immediately isolated and treated as a infected travellers.
the patient from the 21 days after the VHF patient. Close and high risk contacts should be
onset of symptoms. A contact is a Ribavirin may be prescribed as post- discouraged from travel during their
person who has been exposed to an exposure prophylaxis for high risk period of surveillance.
infected person or to an infected contacts of patients.
person’s secretions or tissues within Additional sources of information
three weeks of the patient’s onset of Control of environment • Australian Government Department of
illness. All potentially contaminated personal Health and Ageing, quarantine and
items and items used in the treatment of travel health information,
Contacts are further classified as casual the patient should be disinfected with an http://www.health.gov.au
contacts, close contacts or high risk appropriate viricide such as 0.5%
contacts. • Centers for Disease Control and
hypochlorite or 0.5% phenol with
Prevention, Atlanta USA, Public health
Casual contacts are those people with detergent, and as far as possible,
emergency preparedness and response,
no direct contact with the patient but subjected to heating by incineration,
http://www.bt.cdc.gov
who have been in the near vicinity, such autoclaving or boiling by appropriately
as on the same aeroplane or in the same protected staff. Room disinfection should
hotel. No special surveillance is required be performed using the same virucidal
although information on the disease and disinfectants.
symptoms may be distributed. These disinfection measures may apply
Close contacts are defined as those to the patient’s place of residence and
living with the patient, nursing and other environments where the patient
hugging the patient, or handling the has spent a significant period of time
patient’s laboratory specimens. If the while symptomatic, such as aircraft and
diagnosis is confirmed, close contacts hotel rooms.
are placed under self-surveillance with
twice daily recording of body Outbreak measures
temperature. A single case of any of these viral
haemorrhagic fevers in any setting would
High risk contacts are those with a
constitute an outbreak and requires the
history of either mucous membrane
clinical and public health control
contact with the patient (kissing, sexual
measures as outlined above.
intercourse), or needle-stick or other
penetrating injuries contaminated with International measures
blood or other body fluids from the In the event of a suspected or confirmed
patient during their infectious period. case of any of these viral haemorrhagic
These contacts should be placed under fevers, the Department would
238 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 239

Yellow fever
Victorian statutory requirement • stage three shows development of the Clinical evidence
Yellow fever virus (Group A disease) must classic features of jaundice and Clinical evidence includes acute onset
be notified immediately by telephone or haemorrhagic manifestations such as with fever and jaundice and other
fax followed by written notification within epistaxis, haematemesis, melaena and possible manifestations of the disease.
five days. uterine bleeding followed by Epidemiological evidence
albuminuria, coma and death two to Epidemiological evidence includes a history
Any health care provider who suspects
three days later. of travel to a yellow fever endemic country
yellow fever should immediately contact
the Chief Quarantine Medical Officer. Method of diagnosis in the preceding six days and no history of
The diagnosis is based on the presence vaccination with yellow fever vaccine in the
School exclusion is not applicable.
of laboratory, clinical and epidemiological preceding two months.
Yellow fever is subject to Australian evidence. A person with a febrile illness who has
quarantine.
Laboratory evidence includes one of the been in a yellow fever area within the
Infectious agent following: previous six days is considered a
Yellow fever virus (YFV) is a member of • isolation of YFV from clinical material suspected case and should be reported
the flavivirus group. immediately.
• detection of YF viral RNA in clinical
Identification material Incubation period
Clinical features • seroconversion with a significant rise The incubation period is three to six
Yellow fever is an acute viral disease of in IgG level to YFV days.
short duration. In mild cases, the only
• YFV specific IgM detected in the Public health significance
symptoms may be headache and fever or
absence of IgM to other flaviviruses. and occurrence
a ‘dengue-like’ illness with fever, chills
Yellow fever virus specific IgG on a single Yellow fever is endemic in tropical areas
and myalgia. Sometimes the infection
specimen confirmed by neutralisation and of South America and Central Africa.
may be inapparent.
where cross-reactions with other Outbreaks may occur in unaffected areas
More severe disease occurs in a small if mosquitoes are infected by migrating
flaviviruses have been excluded is
percentage of cases and is characterised humans or monkeys infected with the
suggestive of infection and should be
by three stages: virus.
viewed in the context of clinical and
• stage one has fever, chills, backache, epidemiological evidence. Ae. aegypti is widely distributed in
myalgia, nausea, vomiting and Queensland. The introduction of yellow
All clinical specimens should be
epistaxis. Faget’s sign of relative fever virus to the Australian mosquito
transferred immediately to the National
bradycardia with a high temperature population could theoretically result in an
High Security Quarantine Laboratory
with a slow pulse appears on the urban outbreak of human disease. No
(NHSQL) at Victorian Infectious Diseases
second day. On the third day the fever other mosquito species in Australia are
Reference Laboratory (VIDRL) as per
falls and the patient enters remission. considered likely to be competent
national quarantine guidelines. VIDRL
• stage two is a remission that may last should be contacted on (03) 9342 2600 vectors.
several hours to several days. to discuss requirements for confirmatory
Haemorrhages, anuria and delirium tests or for interpretation of laboratory
may occur without remission. results. Cross-reactivity with other
flaviviruses can occur.
240 The blue book: Guidelines for the control of infectious diseases

Reservoir Control measures Control of contacts


In urban areas of endemic countries the Preventive measures If a traveller to Australia is diagnosed
reservoirs are humans and Aedes All travellers to endemic areas in Africa with yellow fever and has been
mosquitoes. In forest areas, invertebrates and South America should be potentially exposed to Australian Ae.
(other than humans), mainly monkeys immunised. Certification of yellow fever aegypti mosquitoes during the period of
and possibly marsupials, and forest vaccination is required for travellers over viraemia or if the first recognised case is
mosquitoes are the reservoir. The one year of age entering Australia within indigenous, then the following measures
viraemic period in monkeys and man is six days of leaving an infected country. should be considered:
too short for monkeys to act as a A yellow fever vaccination certificate is Spray inside and around the home of the
reservoir. valid for ten years and begins ten days patient, and all houses within a half a
Humans have no essential role in after vaccination. Vaccine providers in kilometre radius, with an effective
transmission of jungle yellow fever but Victoria must be accredited with the insecticide to eliminate vectors. Potential
are the primary amplifying host (in the Department of Human Services. vector breeding sites should be
urban cycle). Control of case destroyed, emptied or sprayed within this
In Victoria suspected or confirmed cases area.
Mode of transmission that require inpatient treatment should Contacts of the patient who have not
Yellow fever is transmitted via infected be referred to the Victorian Infectious previously been immunised should be
mosquitoes. Mosquitoes become Diseases Service at the Royal Melbourne offered yellow fever vaccine. Other cases
infectious 9–12 days after a blood meal Hospital where adequate facilities for of mild febrile illness and any
from a viraemic host. Human to human isolation are available if required. This is unexplained deaths possibly consistent
transmission has not been documented. of particular concern in suspected cases with yellow fever should be investigated.
where the differential diagnosis may
Period of communicability Australian Quarantine and Inspection
include other viral or haemorrhagic fevers
Human blood is infective for mosquitoes Service officers routinely place travel
with greater potential for person to
shortly before the onset of fever and for companions of the case under
person spread.
three to five days after. Mosquitoes quarantine surveillance on entry into
require nine to 12 days after a blood meal There are no endemic foci of yellow fever Australia for six days since last staying
to become infectious and remain so for vectors in Victoria however infection of over night in a country where yellow
life. Victorian mosquitoes is a theoretical risk. fever may be present. During this period
Therefore, the case should be protected they are required to notify the Chief
Susceptibility and resistance from exposure to mosquitoes for greater Quarantine Medical Officer if suffering
Mild infections are common in endemic than five days after onset of infection. from a febrile illness.
areas. Previous infection with dengue The case should be cared for in an
gives some degree of immunity, and Control of environment
isolation room or in a screened room
passive immunity in infants born to Ae. aegypti mosquitoes should be
with use of a mosquito net and a suitable
immune mothers may last for six months. eliminated near airports. Insect
knock down spray for mosquitoes if not
Infections confer lifelong immunity. quarantine should be maintained to
in hospital.
prevent the introduction of Ae.
albopictus, a prevalent Asian species
which is capable of transmitting yellow
fever.
The blue book: Guidelines for the control of infectious diseases 241

Outbreak measures
A single case of indigenous transmission
constitutes an outbreak. In the event of
an epidemic of yellow fever in an urban
area, all persons living in the area
infested with Ae. aegypti should be
offered yellow fever vaccine and a wider
mosquito spraying and breeding site
elimination program implemented.

International measures
Yellow fever must be notified to the World
Health Organization under the
International Health Regulations (1969).

Additional sources of information


• Australian Government Department of
Health and Aged Care 1999, Guidelines
for the management of human
quarantine disease in Australia.
• Victorian Department of Human
Services, for information on yellow
fever vaccination clinics in Victoria
phone the Immunisation Unit
1300 882 008 or go to
www.health.vic.gov.au/ideas.
• World Health Organization,
http://www.who.int/emc/topics
242 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 243

Appendix 1: Contacts

Organisation Telephone Fax Internet After hours


contact

Department of Human Services, Victoria

Communicable Diseases Section 1300 651 160 (03) 9637 4477 www.health.vic.gov.au/ideas 132222
(03) 9637 4126 general www.betterhealth.vic.gov.au pager no. 46870
1300 651 170
for notifications

Melbourne Sexual Health Centre (03) 9347 0244 (03) 9347 2230 www.mshc.org.au

Laboratories

Microbiological Diagnostic Unit (03) 9344 5713 (03) 9344 7833 www.microbiol.unimelb.edu.au

Victorian Infectious Diseases (03) 9342 2600 (03) 9342 2666 www.vidrl.org.au (03) 9342 2600
Reference Laboratory

Interstate health departments

Australian Capital Territory: (02) 6205 2155 (02) 6205 0711 www.health.act.gov.au Pager
Communicable Disease Control (02) 6269 0495

New South Wales (02) 9391 9000 (02) 9391 9101 www.health.nsw.gov.au

Northern Territory: Disease Control (08) 8922 8044 (08) 8922 8310 www.nt.gov.au/health Hospital switchboard
(08) 8922 8888

Queensland: Communicable (07) 3234 1155 (07) 3234 0057 www.health.qld.gov.au


Diseases Unit

South Australia: Communicable (08) 8226 7177 (08) 8226 7187 www.health.sa.gov.au (08) 8226 7177
Disease Control

Tasmania: Public and Environmental 1800 671 738 (03) 6222 7407 www.dhhs.tas.gov.au 1800 671 738
Health Services (03) 6233 3203

Western Australia: Communicable (08) 9388 4999 (08) 9388 4888 www.population.health.wa.gov.au (08) 9388 4999
Disease Control

Other government departments

Food Standards Australia (02) 6271 2222 (02) 6271 2278 www.foodstandards.gov.au
New Zealand

Australian Government Department (02) 6289 1555 (02) 6281 6946 www.health.gov.au (02) 6122 2747
of Health and Ageing

Victorian Department of 136 186 www.dpi.vic.gov.au


Primary Industries
244 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 245

Appendix 2: Glossary
airborne transmission droplet transmission infectious agent
Transmission by air of infectious agents Transmission of infectious agents in An organism that is capable of producing
from respiratory secretions. droplets from respiratory secretions. infection or infectious disease.
asymptomatic infection endemic infestation
Infection that does not display any The constant presence of a disease or The lodgement, development and
clinical symptoms, but may still be infectious agent within a given reproduction of arthropods on the
capable of transmitting disease. geographic area. surface of the body of persons or animals
carrier epidemic or in clothing.
A person or animal that harbours a The occurrence of a number of cases of isolation
specific infectious agent in the absence a disease (or condition) in excess of a Represents separation for the period of
of clinical disease and serves as a number expected in a given time and communicability, of infected persons or
potential source of infection. place. In some instances a single case animals from others in such places and
communicable disease will constitute such an unusual under such conditions as to prevent or
A disease capable of being transmitted occurrence. limit the direct or indirect transmission of
from an infected person or species to a fomes (plural fomites) the infectious agent. Categories of
susceptible host, either directly or An object such as a book, wooden isolation include:
indirectly. object, or an article of clothing that is not • strict isolation: for highly contagious
concurrent disinfection harmful in itself, but is able to harbour infections spread by air and contact
Immediate disinfection and disposal of pathogenic microorganisms and thus • contact isolation: for diseases spread
discharges and infective matter all may serve as an agent of transmission of primarily by close or direct contact
through the course of a disease. an infection.
• respiratory isolation: to prevent
contact immunity transmission over short distances
A person or animal that has associated The protection against infectious disease through the air.
with an infected person or animal that generated by immunisation, previous
infection or by other nonimmunologic For drainage/secretion precautions see
might provide an opportunity to acquire separate entry. For blood and body
the infection. factors.
substance precautions, see appendix 3.
disinfection inapparent infection
The presence of infection in a host nosocomial infection
Killing of infectious agents outside the Hospital-acquired infection.
body by direct exposure to chemical or without recognisable clinical signs or
physical agents. High level disinfection symptoms. notifiable disease
refers to the inactivation of all incubation period Disease or condition that is required by
microorganisms except some bacterial The time interval between initial contact law to be notified to the State health
spores. with an infectious agent and the department.

drainage/secretion precautions appearance of clinical signs and notification


Precautions used to prevent infections symptoms. The process of reporting a notifiable
transmitted by direct or indirect contact infection infectious disease.
with purulent material or drainage from Invasion and multiplication of micro- outbreak
an infected body site. organisms in body tissues. See epidemic.
246 The blue book: Guidelines for the control of infectious diseases

period of communicability surveillance


The time during which an infectious Personal surveillance is the practice of
agent may be transferred directly or close medical or other supervision of
indirectly from an infected person or contacts to permit prompt recognition of
animal to a susceptible host. infection or illness but without restricting
personal hygiene the movements of the individual.
The protective measures within the susceptibility
responsibility of the individual that limit Lack of resistance to a particular
the spread of infectious diseases. pathogenic agent.
personal protective equipment transmission
The equipment to be worn when In terms of infection, it relates to any
performing duties that may involve mechanism by which an infectious agent
possible occupational exposure to blood, is spread from a source or reservoir to a
splashing or aerosols from cleaning person. This may be direct or indirect
processes – for example, masks, goggles, (that is, vehicle-borne, vector-borne, or
gloves and aprons. airborne).
quarantine standard precautions
The restriction of freedom of movement Work practices that require everyone to
of apparently healthy individuals who assume that all blood and body fluids are
have been exposed to infectious disease. potential sources of infection,
reservoir of infectious agents independent of perceived risk. Such
Any person, animal, or substance in precautions involve the use of safe work
which an infectious agent normally lives practices and protective barriers, and the
and multiplies in such a manner that it safe disposal of body substances and
can be transmitted to a susceptible host. soiled material. See appendix 3.

resistance vector
The natural ability of an organism to A carrier, especially the animal (usually
resist micro-organisms or toxins an arthropod) that transfers an infective
produced in disease. agent from one host to another.

school exclusion zoonosis


Exclusion from school or children’s A disease of animals that may be
services centre under Health (Infectious transmitted to humans under natural
Diseases) Regulations 2001. conditions.

source of infection
The person, animal or substance from
which an infectious agent passes to a
host.
The blue book: Guidelines for the control of infectious diseases 247

Appendix 3: Standard
and additional
precautions
General Standard precautions should be Standard precautions for infection
Infection control and prevention uses a implemented at all times particularly control in health care settings consist of
risk management approach to minimise when patients are undergoing invasive the following work practices:
or prevent the transmission of infection. procedures, including catheterisation, • aseptic technique for all invasive
Standard and additional precautions cannulation or intubation. Health procedures, including appropriate use
principles and practice are based on the services that offer these procedures of skin disinfectants
mode of transmission of an infectious should provide detailed protocols for
patient management in their infection • personal hygiene practices, particularly
agent.
control procedures manuals. hand washing and drying before and
Standard precautions are work practices after all significant patient contacts
required for the basic level of infection Additional precautions are work practices
that should be applied in a health care • the use of 70% alcohol-based
control. They include good hygiene
setting for patients known, or suspected, chlorhexidine (0.5%) hand rub solutions
practices, particularly washing and
to be infected or colonised with as an adjunct to hand washing
drying hands before and after patient
contact, the use of protective barriers infectious agents that may not be • use of personal protective equipment,
which may include gloves, gowns, plastic contained using standard precautions which may include gloves,
aprons, masks, eye shields or goggles, alone. impermeable gowns, plastic aprons,
appropriate handling and disposal of masks/face shields and eye protection
sharps and other contaminated or clinical Standard precautions
• appropriate handling and disposal of
(infectious) waste, and use of aseptic The use of standard precautions is
sharps and other clinical (infectious)
techniques. essential as the primary strategy for the
waste
successful minimisation of transmission
Standard precautions apply to all of health care associated infection • appropriate reprocessing of reusable
patients regardless of their diagnosis or because: equipment and instruments, including
presumed infection status, and in the appropriate use of disinfectants
handling of: • infectious patients may not show any
signs or symptoms of infection that • environmental controls, including
• blood may be detected in a routine history design and maintenance of premises,
• all other body fluids, secretions and and medical assessment cleaning and spills management
excretions (except sweat), regardless including appropriate use of
• a patient’s infectious status is often
of whether they contain visible blood disinfectants
determined by laboratory tests that
• non-intact skin may not be completed in time to • appropriate provision of support
provide emergency care services such as laundry and food
• mucous membranes (mouth and eyes)
services.
• standard precautions also apply to • patients may be infectious before
dried blood and other body laboratory tests are positive or Additional precautions
substances, including saliva. symptoms of disease are recognised Additional Precautions are used for
(the window period of disease) patients known or suspected to be
Standard precautions should be
considered minimum requirements for • people may be placed at risk of infected or colonised with
infection control. Implementing standard infection from those who are epidemiologically important or highly
precautions minimises the risk of asymptomatic but infectious. transmissible pathogens that can
transmission of infection from person to transmit/cause infection by the following
person even in high-risk situations. means:
248 The blue book: Guidelines for the control of infectious diseases

• airborne transmission (e.g. pulmonary Additional precautions should be tailored Additional precautions are not required
tuberculosis, chickenpox, measles) to the particular infectious agent involved for patients with bloodborne viruses,
• droplet transmission of respiratory and the mode of transmission, and may such as HIV, hepatitis B virus or hepatitis
secretions (e.g. rubella, pertussis, include one or any combination of the C virus, unless there are complicating
influenza) following: infections, such as pulmonary
• allocation of a single room with ensuite tuberculosis.
• contact transmission (direct or indirect)
with patients who may be facilities To minimise the exposure time of other
disseminators of infectious agents of • a dedicated toilet (to prevent people in office practices or hospital
special concern (e.g. the dry skin of transmission of infections that are waiting rooms, people identified as ‘at
those colonised with Multi-resistant transmitted primarily by contact with risk’ of transmitting droplet or airborne
Staphylococcus aureus [MRSA], faecal faecal material, such as for patients diseases (e.g. a child with suspected
contamination from carriers of with infectious diarrhoea or chicken pox) should be subject to
vancomycin-resistant enterococci gastroenteritis caused by enteric additional precautions including isolation
[VRE] or contaminated surfaces) bacteria or viruses) and should be attended to before other
people waiting for treatment.
• inherent resistance to standard • cohorting (room sharing by people with
sterilisation procedures or other the same infection) may be an An outline of the application of additional
disease-specific means of transmission alternative if single rooms are not precautions for infections with airborne,
where standard precautions are not available droplet or contact transmission is shown
sufficient (e.g. patients with known or in the following table.
• special ventilation requirements (e.g.
suspected Creutzfeldt-Jakob disease) monitored negative air pressure in
• any combination of these routes. relation to surrounding areas)
Additional precautions are designed to • additional use of personal protective
interrupt transmission of infection by equipment (e.g. health care workers
these routes and should be used, in attending to patients in respiratory
addition to standard precautions, when isolation should wear a well-fitting
standard precautions alone might not mask: a 0.3-mm particulate filter mask
contain transmission of infection. (P2 or N95 mask) is recommended for
Additional precautions may be specific to tuberculosis)
the situation for which they are required, • rostering of immune health care
or may be combined where workers to care for certain classes of
microorganisms have multiple routes of infectious patients (eg chickenpox)
transmission.
• dedicated patient equipment
• restricted movement of both patients
and health care workers.
The blue book: Guidelines for the control of infectious diseases 249

Outline of requirements for specified categories of additional precautions


Requirement Additional precautions by transmission route
Airborne Droplet Contact
Gloves Nil Nil For all manual contact with patient,
associated devices and immediate
environmental surfaces
Impermeable apron/gown Nil Nil When health care worker’s clothing
is in substantial contact with the
patient, items in contact with the
patient, and their immediate
environment
Respirator or mask. P2/N95 particulate Yes —mask* Protect face if splash likely
respirator for
Refer to AS 4381:2000 for tuberculosis only.
additional information All others, use face
mask suited to the
purpose such as a mask
that filters to o.1 microns
and has a splash resistant
shield.
Goggles/face-shields Protect face if splash likely Protect face if splash likely Protect face if splash likely
Special handling of equipment As per standard precautions As per standard precautions Single use or reprocess before
reuse on next patient (includes all
equipment in contact with patient)
Single room Yes Yes If possible, or cohort with patient
or or with the same infection (eg
Cohort patients with Cohort patients methicillin-resistant Staphylococcus
same infection. with same infection. aureus)

Door closed. Door closed.


Negative pressure Essential for pulmonary TB No No
Transport of patients Appropriate mask* Appropriate mask* Notify area receiving patient
for patient for patient
Notify area receiving patient Notify area receiving patient
Other Encourage patients to cover Provide one metre of Remove gloves and gown, and
nose and mouth when separation between patients wash hands before leaving
coughing or sneezing and in ward accommodation patient’s room
wash their hands after
blowing nose.

Provide one metre of


separation between patients
in ward accommodation
* Refer to Australian Standards:
AS 4381:2000 Single-use face masks for use in health care, for additional information
AS/NZS 1715 Selection, use and maintenance of respiratory protective devices
AS/NZS 1716:1994 Respiratory protective devices
250 The blue book: Guidelines for the control of infectious diseases

Handwashing Gloves • Remove the used gown as promptly as


• Wash and dry hands after touching • Wear gloves (clean non sterile gloves possible using gloved hands, roll up
blood, body fluids, secretions, are adequate) when touching blood, carefully and place in a linen
excretions and contaminated items body fluids, secretions, excretions and receptacle for laundering.
such as equipment or instruments, contaminated items; put on clean • Wash and dry hands to avoid transfer
regardless of whether gloves are worn gloves just before touching mucous of microorganisms to other patients
or not. membrane and non-intact skin. Sterile and environments.
• Wash and dry hands immediately after gloves are required for invasive
gloves are removed, after significant procedures. Masks, eye protection,
patient contact such as contact with or • Change gloves between tasks and faceshields
physical examination, emptying procedures on the same patient after Wear a mask and eye protection or a
drainage bags, undertaking contact with material that may contain faceshield to protect mucous
venepuncture or delivery of an a high concentration of membranes of the eyes, nose and
injection or going to the toilet. microorganisms. mouth:

• Wash and dry hands following any • Remove gloves promptly after use, • during procedures and patient-care
activities that may transfer before touching non-contaminated activities that are likely to generate
microorganisms to other patients or items and environmental surfaces and splashes or sprays of blood, body
environments. before going to another patient. fluids, secretions and excretions

• Use plain liquid soap for routine hand Dispose of gloves in the clinical • during cleaning activities.
washing. Antimicrobial liquid soap (infectious) waste or place in a plastic Remove the mask by holding the ties
solutions are required for invasive bag and tie before disposing of it in the only and dispose of the mask into a
procedures and in some situations general household waste. clinical waste bin.
such as those patients with VRE and • Wash and dry hands immediately after Reusable face shields or goggles should
MRSA. removing gloves to avoid transfer of be removed carefully and placed in a
• A 70% alcohol-based chlorhexidine microorganisms to other patients or receptacle for cleaning.
(0.5%) hand rub solution may be used environments.
as an adjunct to handwashing and in Waterproof aprons
Gowns Wear waterproof aprons when splashes
situations where water is not readily
• Wear a gown (a clean non-sterile gown or sprays of blood or body fluids/
available.
is adequate) to protect skin and substances are likely such as during
Personal protective equipment prevent soiling of clothing during cleaning activities.
The use of personal protective procedures and patient care activities
Remove the used apron as promptly as
equipment (PPE) protects the health care that are likely to generate splashing or
possible using gloved hands, roll up
worker and others from exposure to sprays of blood, body fluids,
carefully and place in a clinical waste bin.
blood and body fluids/substances. PPE secretions, or excretions or cause
that complies with relevant Australian soiling of clothing.
Standards should be readily available • Select a gown (long- or short –sleeved)
and accessible in all health services. that is appropriate for the activity and
the amount of fluid likely to be
encountered.
The blue book: Guidelines for the control of infectious diseases 251

Environmental control Further information


Ensure that the health service has • Australian Government Department of
adequate procedures for the routine Health and Ageing 2004, Infection
care, cleaning, and disinfection of control guidelines for the prevention of
environmental surfaces, beds, bedrails, transmission of infectious diseases in
bedside equipment, and other frequently the health care setting,
touched surfaces and that these http://www.icg.health.gov.au/
procedures are being followed. See • Victorian Department of Human
Appendix 6 for cleaning and waste Services 2000, Sure protection against
disposal. infection, www.health.vic.gov.au/ideas
252 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 253

Appendix 4: Procedure
for managing an exposure
to blood/body
fluids/substances
These include sharps injuries (including incidents involving either patients or Patients or others exposed to blood or
needlestick) and splashes into/onto health care workers, including: other body fluids/substances must be
mucous membranes or bare intact skin. • the physician, medical officer or other informed of the exposure by a
Occupational hazards for health care suitably qualified professional to be designated professional, while
workers from sharps injuries (including contacted maintaining confidentiality about the
needlestick injury) and other blood or source of the blood. Baseline serum
• the laboratory which will process should be collected from the patient and
body fluid incidents include human emergency specimens
immunodeficiency virus (HIV), hepatitis B expert counselling provided on the
virus (HBV) and hepatitis C virus. • the pharmacy which stocks implications of what has happened.
prophylactic medication Postexposure prophylaxis (PEP and N-
Exposure is an injury that involves direct PEP) and appropriate long-term follow-up
skin contact with a body fluid listed above • procedures for investigating the
circumstances of the incident and should be offered where applicable.
and there is compromised skin integrity Patient or source refusal for testing and
such as an open wound, abrasion or measures to prevent recurrence (this
may include changes to work serum storage should be documented.
dermatitis, or if there is direct mucous
membrane contact. For exposure to skin, practices, changes to equipment, Australian National Council for AIDS,
the larger the area of skin exposed and the and/or training) Hepatitis C and Related Diseases
longer the time of contact, the more • details for prompt reporting, evaluation, (ANCAHRD) has published a
important it is to verify that all the relevant counselling, treatment and follow-up of comprehensive bulletin entitled
skin area is intact. occupational exposures to bloodborne Management of exposure to blood/body
viruses. fluids in a health care setting, available at
Exposure to blood and body http://www.ancahrd.org/.
fluids/substances Immediate action Document the incident and include:
The following body fluids pose a risk for Treatment protocols should include
removal of contaminated clothing and • date, time and type of exposure
bloodborne virus transmission:
thorough washing of the injured area • how the incident occurred
• blood, serum, plasma and all biological
fluids visibly contaminated with blood with soap and water. Affected mucous • name of the source individual
membranes should be flushed with large (if known)
• laboratory specimens that contain amounts of water. Eyes should be
concentrated virus Exposure incidents that do not occur in a
flushed gently.
health service should be reported to a
• pleural, amniotic, pericardial, The exposed person must report any general medical practitioner or the
peritoneal, synovial and cerebrospinal occupational exposures immediately. Emergency Department at the nearest
fluids
The exposed person should have a hospital.
• uterine/vaginal secretions or semen. medical evaluation, including information
about medications they are taking and Management of the source
Infection control protocols individual
underlying medical conditions or
All health services must develop their The person whose blood or body fluids
circumstances. Postexposure prophylaxis
own infection control protocols for are the source of an occupational/
(PEP and N-PEP) and counselling should
communicable diseases, including clear non-occupational exposure or other
be available and offered. Treatment
written instructions on the appropriate injury should be evaluated for infection
should be available during all working
action to take in the event of an with HIV, HBV and HCV. Information
hours, and on call after hours (e.g.
exposure to blood or body available in the medical record or from
through an on-call infectious diseases
fluids/substances including needlestick the source person may suggest or rule
physician).
injuries and other blood or body fluid
254 The blue book: Guidelines for the control of infectious diseases

out infection with each virus. If the Source individual unknown Depending on the circumstances of the
source is known to have HIV infection, Reasonable efforts should be made to exposure, the following may need to be
then information on stage of infection identify the source. If the source remains considered:
and current and previous antiretroviral unknown, appropriate follow-up should • tetanus immunoglobulin
therapy should be gathered and used in be determined on an individual basis
deciding the most appropriate regimen of • a course of adsorbed diphtheria
depending on:
post exposure prophylaxis (PEP). tetanus vaccine, adult formulation (Td)
• the type of exposure vaccine
If the HIV, HBV or HCV status of the
• the likelihood of the source being • Td booster.
source person is unknown, then the
positive for a blood pathogen
source person should be informed of the The current edition of The Australian
incident, and their consent sought to test • the prevalence of HIV, HBV and HCV in immunisation handbook should be
for these viruses, with appropriate pre- the community of the likely source on consulted for further details.
and post-test counselling. Their consent whom the instrument or needle was
The exposed person would normally be
to having the information in their patient used.
tested for HIV antibody, HCV antibody
record used should be sought also. If and antibody to HBV surface antigen
Management of the exposed
consent cannot be obtained, for example (HBsAg) at the time of the injury, to
person
if the patient is unconscious or unwilling establish their serostatus at the time of
Immediate care of the exposure site
to consent, then procedures should be the exposure. Expert counselling on the
Contaminated clothing should be
followed which comply with legislation in implications of the event, PEP (post
removed, and the injured area should be
Victoria. exposure prophylaxis) and appropriate
washed well with soap and water (an
The source individual should be tested as antiseptic could also be applied). Any long-term follow-up should be offered.
follows at the time of injury: affected mucous membranes should be An option that may be offered to health
• HIV antibody flushed with large amounts of water. If care workers who do not wish to undergo
the eyes are contaminated, they should testing at the time of the exposure is to
• HBsAg
be rinsed gently but thoroughly with have blood collected and stored but not
• HCV antibody. water or normal saline, while kept open. tested. Blood that is collected and stored
If the HCV antibody test is positive, then Evaluation of the exposure for this purpose must be retained for a
HCV polymerase chain reaction (PCR) The exposed person should be examined minimum period of 12 months.
should be performed to test for HCV to confirm the nature of exposure and If the source person is found to be HIV,
RNA. Transmission is much less likely to counselled about the possibility of HBV and HCV negative, no further follow-
occur from a source who is PCR transmission of bloodborne disease. up of the exposed person is generally
negative. The status of the source necessary, unless there is reason to
Evaluation and testing of the exposed
individual may be known at the time of suspect the source person is
person
the incident. In this case the affected seroconverting to one of these viruses,
The exposed person should have a
person should be managed as described or was at high risk of bloodborne viral
medical evaluation, including information
below under ‘immediate management’. If infection at the time of the exposure. If
about medications they are taking and
the source is unknown, the case should source is positive for one of these
underlying medical conditions or
be managed as described below. viruses, pregnancy testing should be
circumstances. All exposed people
should be assessed to determine the risk offered to women of child-bearing age
of tetanus. who have been exposed and whose
pregnancy status is unknown.
The blue book: Guidelines for the control of infectious diseases 255

Postexposure counselling Management of exposure to blood/body fluids summary table


A specialist with knowledge of When What
bloodborne infections should undertake
Immediately after exposure First aid
follow-up. If it is demonstrated that a
Relief from duty
person has been exposed to a Risk assessment
bloodborne pathogen, they should not Post exposure prophylaxis (PEP) – if significant injury
donate blood, semen, organs or tissue for
As soon as possible Source assessment
six months, and should not share (same day) Documentation of exposure
implements that may be contaminated Prevention of transmission and exposure/pre-test counselling
with even a small amount of blood (e.g. Baseline serology if agreed to
razors or toothbrushes). Referral to specialist physician - if PEP commenced
Support of significant others
For HIV and HBV, they should be
1-3 weeks Post-test counselling with results of baseline serology
informed of the risk of transmission to
Occupational health and safety review
sexual and injecting partners for a six-
month period, and be counselled about 3 months Pre HIV test counselling
Follow up serology – HIV, HBV, HCV
issues of safe sex and safe injecting. If
PEP is indicated, or there is a risk of 6 months Follow up serology – HBV, HCV
acute infection with HIV, HCV or HBV, – HIV (if PEP taken)

advice should be offered on pregnancy


and breastfeeding based on an individual
risk assessment. In the case of HIV,
patients should be advised of the remote
risk of seroconversion up to 12 months
post-exposure, particularly if specific PEP
was undertaken.
Follow-up for the exposed person
If the source person is seronegative for
HIV, HbsAg and HCV, baseline testing or
further follow-up of the health care
worker normally is not necessary. If the
source person has recently engaged in
behaviours that are associated with a
risk for transmission of these viruses,
baseline and follow-up HIV-antibody
testing of the health care worker should
be considered.
256 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 257

Appendix 5: Procedure
for managing spills of
blood and body
fluids/substances
Health services should have service, in a public location or within a from the disinfectant granules, or
management systems in place for dealing community premises aerosols, which may be generated from
with blood and body substance spills and • whether there is any likelihood of bare high-risk spills during the cleaning
protocols should be included in skin contact with the soiled process).
procedural manuals and emphasised in (contaminated) surface. Single-use items in the spills kit should
ongoing education or training programs. be replaced after each use of the spills
The basic principles of blood and body Equipment kit.
fluid/substance spills management are: Standard cleaning equipment, including
With all spills management protocols, it is
• standard precautions apply, including a mop and cleaning bucket and cleaning
essential that the affected area is left
use of personal protective equipment agents, should be readily available for
clean and dry.
(PPE) as applicable spills management and should be stored
in an area known to all. This is Sodium hydroxide (caustic soda) spills
• spills should be cleared up before the kits should be available for areas at risk
particularly important in clinical areas. To
area is cleaned (adding cleaning liquids for higher-risk CJD spills, such as
facilitate the management of spills in
to spills increases the size of the spill neurosurgery units, mortuaries and
areas where cleaning materials may not
and should be avoided) laboratories.
be readily available, a disposable ‘spills
• generation of aerosols from spilled kit’ could be used, containing the
material should be avoided. following items: Procedures
In clinical areas blood and body
Using these basic principles, the • a large (10 L) reusable plastic fluid/substance spills should be dealt
management of spills should be flexible container or bucket with fitted lid, with as soon as possible. In operating
enough to cope with different types of containing the following items rooms, or in circumstances where
spills, taking into account the following
• appropriate leak proof bags and medical procedures are under way, spills
factors:
containers for disposal of waste should be attended to as soon as it is
• the nature (type) of the spill (e.g. material safe to do so.
sputum, vomit, faeces, urine, blood or
• a designated, sturdy scraper and pan Care should be taken to thoroughly clean
laboratory culture)
for spills (similar to a ‘pooper scooper’) and dry areas where there is any
• the pathogens most likely to be possibility of bare skin contact with the
• about five sachets of a granular
involved in these different types of surface (e.g. on an examination couch).
formulation containing 10,000 ppm
spills (e.g. stool samples may contain
available chlorine or equivalent (each Personal protective equipment (PPE)
viruses, bacteria or protozoan
sachet should contain sufficient should be used for all cleaning
pathogens whereas sputum may
granules to cover a 10-cm diameter procedures and disposed of or sent for
contain Mycobacterium tuberculosis)
spill) cleaning after use. Hands should be
• the size of the spill (e.g. spot [few washed and dried after cleaning.
• disposable rubber gloves suitable for
drops], small [<10cm] or large [>10cm])
cleaning (vinyl gloves are not Where a spill occurs on a carpet,
• the type of surface (e.g. carpet or recommended for handling blood) shampoo as soon as possible. Do not
impervious flooring) use disinfectant. Steam cleaning may be
• eye protection (disposable or reusable)
• the location involved i.e. whether the used instead.
• a plastic apron
spill occurs in a contained area such Wash hands thoroughly after cleaning is
as a microbiology laboratory or in a • a respiratory protection device (for completed.
public or clinical area of a health protection against inhalation of powder
258 The blue book: Guidelines for the control of infectious diseases

Spots or small spills Use of sodium hypochlorite (bleach)


Spots or drops of blood or other small It is generally unnecessary to use sodium
spills (up to 10cms) can easily be hypochlorite for managing spills but it
managed by wiping the area immediately may be used in specific circumstances.
with paper towelling and then cleaning It is recognised, however, that some
with warm water and detergent followed health care workers/members of the
by rinsing and drying the area. Dry the public may feel more reassured that the
area as wet areas attract contaminants. risk of infection is reduced if sodium
A hospital grade disinfectant can be hypochlorite is used. Health care workers
used on the spill area after cleaning. and members of the public should be
aware that there is no evidence of
Large spills benefit from an infection control
Where large spills (over 10cms) have perspective.
occurred in a ‘wet’ area, such as a
bathroom or toilet area, the spill should Hypochlorites are corrosive to metals
be carefully washed off into the and must be rinsed off after 10 minutes
sewerage system using copious amounts and the area dried.
of water and the area flushed with warm Creutzfeldt–Jakob disease (CJD)
water and detergent. If a spill of tissue (potentially) infected
Large blood spills that have occurred in with Creutzfeldt–Jakob disease (CJD)
‘dry’ areas (such as clinical areas) should occurs (eg brain tissue), the
be contained and generation of aerosols contaminated item should either be
should be avoided. destroyed by incineration or immersed in
either sodium hydroxide or sodium
Granular formulations that produce high hypochlorite for one hour, rinsed and
available chlorine concentrations can placed in a pan of clean water and
contain the spilled material and are sterilised on an eighteen minute cycle.
useful for preventing aerosols. A scraper The items should then be cleaned
and pan should be used to remove the following routine cleaning and
absorbed material. The area of the spill sterilisation procedures.
should then be cleaned with a mop and
bucket of warm water and detergent. The Surface spills should be cleaned up using
bucket and mop should be thoroughly paper towels before the surface is wiped
cleaned after use and stored dry. over with either sodium hydroxide or
sodium hypochlorite, left for one hour (if
possible or as long as possible, with the
area cordoned off), the solution wiped
off and the surface cleaned by following
routine cleaning procedures.
The blue book: Guidelines for the control of infectious diseases 259

Appendix 6: Cleaning
and waste disposal
procedures
Cleaning • detergents should not be mixed with dried before, and after, each session or
General other chemicals when visibly soiled. Spills should be
Cleaning is important particularly in work • all cleaning solutions should be cleaned up as soon as practical.
areas because deposits of dust, soil and prepared fresh before use. • When a disinfectant is required for
microbes on surfaces can transmit surface cleaning, the manufacturer’s
Specific
infection. Contaminated areas such as recommendations for use and OH&S
Surface cleaning
operating rooms or isolation rooms must instructions should be followed.
• Floors in hospitals and day care
be cleaned after each session and spot
facilities should be cleaned daily, or as • Buckets should be emptied after use,
cleaned after each case or thoroughly
necessary, with a vacuum cleaner washed with detergent and warm
cleaned as necessary.
fitted with a particulate-retaining filter, water, rinsed in hot water and stored
The following basic principles should be which should be changed in dry - turn upside down.
followed: accordance with the manufacturer’s • Mops should be laundered or cleaned
• written cleaning protocols should be instructions. in detergent and warm water, rinsed in
prepared, including methods and • The exhaust air should be directed hot water then stored dry. Mop heads
frequency of cleaning. These should away from the floor to avoid dust should be detachable or stored with
include policies for the supply of all dispersal. mop head uppermost.
cleaning and disinfectant products
• A ducted vacuum cleaning system can Specialised areas
• standard precautions (including also be used, as long as safe venting of • Isolation rooms and ensuite bathrooms
wearing of personal protective the exhaust air is ensured. should be cleaned at least twice daily
equipment as applicable) should be dependant on the type of organism.
• Damp dusting is essential using a lint
implemented when cleaning surfaces
free cloth. Brooms disperse dust and • Operating rooms and day procedure
and facilities (see appendix 3)
bacteria into the air and should not be rooms including endoscopy rooms
• cleaning methods should avoid used in patient/clinical areas. Dust- should be cleaned after each operating
generation of aerosols retaining mops, which are specially session and when visibly soiled.
• all cleaning items should be changed treated or manufactured to attract and Thorough cleaning of the operating
after each use and cleaned and dried retain dust particles, do not increase suite should be performed daily in
before being used again. They should airborne counts as much as ordinary addition to the cleaning performed
also be changed immediately following brooms and remove more dust from after each operating session.
the cleaning of blood or body surfaces (Ayliffe et al 1999). However, • Obstetric areas, particularly delivery
fluid/substance spills, cleaned and brooms and dust-retaining mops suites should be cleaned after each
dried. Single use cleaning items are should not be used in clinical areas delivery, when visibly soiled and at
preferred where possible such as where there is a high risk of infection least daily.
cleaning cloths which should be lint associated with dust (e.g. burns units).
• Oncology areas should be cleaned
free Procedure for routine surface cleaning twice daily.
• sprays should not be used as they can • All cleaning solutions should be
prepared immediately prior to use. • Sterilising processing departments
become contaminated and are difficult
(SSDs) should be cleaned at least
to clean. Sprays are not effective as • Work surfaces should be cleaned twice daily and when visibly soiled.
they do not touch all parts of the (wiped over) with a neutral detergent
surface to be cleaned and warm water solution, rinsed and
260 The blue book: Guidelines for the control of infectious diseases

Wet areas • These items should be washed in companies licensed with the EPA will
Toilets, sinks, washbasins, baths, shower detergent and warm water, rinsed and collect all clinical and pharmaceutical
cubicles, all fittings attached to showers, stored dry between uses. Mops with waste for disposal in specialised waste
baths and hand basins and surrounding detachable heads should be laundered disposal facilities which are also licensed
floor and wall areas should be cleaned at between uses. by the EPA.
least daily and more frequently as Spills of laboratory cultures of human Waste should be removed from clinical
required. pathogens areas at least three times each day and
Walls and fittings Spills of laboratory cultures should be more frequently as needed such as from
Walls and screens should be cleaned absorbed on to paper towels and specialised areas. Waste bags should be
quarterly or if visibly soiled. Blinds and disposed of as clinical waste. The tied before removing from the area.
curtains should be cleaned quarterly or if contaminated surfaces should be treated General waste
visibly soiled. Carpets should be with 2.0-2.5% sodium hypochlorite, left Place in general waste bin for removal.
vacuumed daily and other floor surfaces for one hour and cleaned again with
washed daily and when soiled. paper towels that are disposed of as Clinical waste
clinical waste. Place in biohazard bags as soon as
Bed and examination screens should be possible. Biohazard bags have a
changed weekly and when visibly soiled. Laboratories should also refer to AS/NZS biohazard symbol and are currently
Cleaning for Creutzfeldt-Jakob disease 2243.3:2002: Safety in laboratories - coloured yellow.
infectious agents Microbiological aspects and containment
facilities. Single use sharps should be placed (by
Spills of central nervous system tissue or the user) into a sharps container that
cerebrospinal fluid should be absorbed meets the Australian and New Zealand
Waste disposal
onto paper towels and disposed of by Standards AS 4031:1992 and AS/NZS
General
incineration. The surface should then be 4261:1994.
All health care facilities should have
soaked with 1 molar sodium hydroxide or
policies and procedures in place for the Pharmaceutical waste
2.0-2.5% sodium hypochlorite, left for one
correct management of all waste When uncertain about how to dispose of
hour and cleaned again with paper towels
generated. The Environmental Protection leftover pharmaceuticals they should be
that are disposed of by incineration.
Authority (EPA) has clear guidelines on returned to pharmacy for correct
Spills of blood or other body fluids and
how waste should be managed. The disposal.
tissues should be cleaned using standard
National Health and Medical Research
spills management procedures. Personal Most disinfectants can be disposed of
Council (NHMRC) also has guidelines on
protective equipment used when through the sewer system by running
the management of waste generated in
cleaning contaminated surfaces should cold water into the sink prior to pouring
health care facilities.
be incinerated after use. Reusable eye the disinfectant into the sink. Leaving the
protection should be cleaned as above. Waste is classified into three main cold water running for a few moments
groups of waste: after the disinfectant has been disposed
Maintenance of cleaning equipment
• Cleaning items (including solutions, • general of as this dilutes the disinfectant.
water, buckets, cleaning cloths and • clinical
mop heads) should be changed after • pharmaceutical
each use. They should also be changed
immediately following the cleaning of All waste should be stored in secure
blood or body substance spills. areas until collected. Waste disposal
The blue book: Guidelines for the control of infectious diseases 261

Further information
• National Health & Medical Research
Council 1999, National guidelines for
waste management in the health
industry, http://www.nhmrc.gov.au
• Environmental Protection Authority
Victoria 1993, Manual for the
management and disposal of
biomedical wastes in Victoria (under
review)
• Australian/New Zealand Standards
AS/NZS 3816:1998, Management of
clinical and related wastes
• Australian/New Zealand Standards AS
4031:1992, Non-reusable containers for
the collection of sharp medical items
used in health care areas
• Australian/New Zealand Standards
AS/NZS 4261:1994, Reusable
containers for the collection of sharp
items used in human and animal
medical applications
262 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 263

Appendix 7: Infections in
children’s services
centres
Children in day care centres and other Infections with the following organisms
children’s services centres and have been shown to be more common in
kindergartens are particularly at risk of these settings, or have been reported as
developing communicable diseases epidemic:
because of: • Respiratory Syncytial virus (RSV)
• Close contact with other children and • Influenza virus
staff
• Haemophilus influenzae type b
• Lack of previous exposure to common
infections • Neisseria meningitidis

• Lack of toilet training • Shigella spp

• Lack of control of other body • Rotavirus


secretions • Giardia lamblia
• Mouthing behaviour • Cryptosporidium
These risk factors may be increased • Hepatitis A
when staff are not appropriately trained, • E. coli
group sizes are large, and mixing of age
• Campylobacter spp
groups occurs.
• Parvovirus B19 (erythema infectiosum)
• Coxsackievirus group A (hand, food
and mouth disease)
• Streptococcus, pyogenes,
Staphylococcus aureus (impetigo)
• Cytomegalovirus
• Scabies
• Head lice
264 The blue book: Guidelines for the control of infectious diseases
The blue book: Guidelines for the control of infectious diseases 265

Appendix 8: School
exclusion table
The following table indicates the minimum period of exclusion from schools and children’s service centres required for infectious
diseases cases and contacts as prescribed under Regulations 13 and 14 of the Health (Infectious Diseases) Regulations 2001 –
Schedule 6. In this Schedule ‘medical certificate’ means a certificate of a registered medical practitioner.

Disease or condition Exclusion of cases Exclusion of contacts

Amoebiasis (Entamoeba histolytica) Exclude until diarrhoea has ceased Not excluded

Campylobacter Exclude until diarrhoea has ceased Not excluded

Chickenpox Exclude until fully recovered or for at least 5 days after the eruption Any child with an immune deficiency
first appears. Note that some remaining scabs are not a reason for (for example, leukaemia) or receiving
continued exclusion chemotherapy should be excluded
for their own protection. Otherwise
not excluded

Conjunctivitis Exclude until discharge from eyes has ceased Not excluded

Diarrhoea Exclude until diarrhoea has ceased or until medical certificate Not excluded
of recovery is produced

Diphtheria Exclude until medical certificate of recovery is received following at Exclude family/household contacts
least two negative throat swabs, the first not less than 24 hours after until cleared to return by the
finishing a course of antibiotics and the other 48 hours later Secretary

Haemophilus type b (Hib) Exclude until medical certificate of recovery is received Not excluded

Hand, foot and mouth disease Until all blisters have dried Not excluded

Hepatitis A Exclude until a medical certificate of recovery is received, but not Not excluded
before 7 days after the onset of jaundice or illness

Herpes (‘cold sores’) Young children unable to comply with good hygiene practices should Not excluded
be excluded while the lesion is weeping. Lesions to be covered by
dressing, where possible

Human immuno-deficiency virus Exclusion is not necessary unless the child has a secondary infection Not excluded
infection (HIV/AIDS)

Impetigo Exclude until appropriate treatment has commenced. Sores on Not excluded
exposed surfaces must be covered with a watertight dressing

Influenza and influenza like illnesses Exclude until well Not excluded

Leprosy Exclude until approval to return has been given by the Secretary Not excluded

Measles Exclude until at least 4 days after the onset of rash Immunised contacts not excluded.
Unimmunised contacts should be
excluded until 14 days after the first
day of appearance of rash in the last
case. If unimmunised contacts are
vaccinated within 72 hours of their
first contact with the first case they
may return to school

Meningitis (bacteria) Exclude until well Not excluded

Meningococcal infection Exclude until adequate carrier eradication therapy has been completed Not excluded if receiving carrier
eradication therapy
266 The blue book: Guidelines for the control of infectious diseases

Disease or condition Exclusion of cases Exclusion of contacts

Mumps Exclude for 9 days or until swelling goes down (whichever is sooner) Not excluded

Poliomyelitis Exclude for at least 14 days from onset. Re-admit after receiving Not excluded
medical certificate of recovery

Ringworm, scabies, Re-admit the day after appropriate treatment has commenced Not excluded
pediculosis (head lice)

Rubella (german measles) Exclude until fully recovered or for at least four days after the onset Not excluded
of rash

Salmonella, Shigella Exclude until diarrhoea ceases Not excluded

Severe Acute Respiratory Syndrome Exclude until medical certificate of recovery is produced Not excluded unless considered
(SARS) necessary by the Secretary

Streptococcal infection Exclude until the child has received antibiotic treatment for at least Not excluded
(including scarlet fever) 24 hours and the child feels well

Trachoma Re-admit the day after appropriate treatment has commenced Not excluded

Tuberculosis Exclude until receipt of a medical certificate from the treating Not excluded
physician stating that the child is not considered to be infectious

Typhoid fever Exclude until approval to return has been given by the Secretary Not excluded unless considered
(including paratyphoid fever) necessary by the Secretary

Verotoxin producing Exclude if required by the Secretary and only for the period Not excluded
Escherichia coli (VTEC) specified by the Secretary

Whooping cough Exclude the child for 5 days after starting antibiotic treatment Exclude unimmunised household
contacts aged less than 7 years and
close child care contacts for 14 days
after the last exposure to infection
or until they have taken 5 days of a
10 day course of antibiotics

Worms (Intestinal) Exclude if diarrhoea present Not excluded

Exclusion cases and contacts is not required for Cytomegalovirus Infection, Glandualr fever (mononucleosis), Hepatitis B or C, Hookworm, Cytofalovirus
Infection, Molluscum contafiosum, or , Parvovirus (erythema infectiosum, fifth disease).

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