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Cryptosporidiosis

Cryptosporidiosis. What is Cryptosporidiosis?. Caused by a parasite, Cryptosporidium parvum Healthy people recover on their own In those with AIDS or with weak immune systems, it can cause serious illness and may even cause death. Etiologic Agent.

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Cryptosporidiosis

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  1. Cryptosporidiosis

  2. What is Cryptosporidiosis? • Caused by a parasite, Cryptosporidium parvum • Healthy people recover on their own • In those with AIDS or with weak immune systems, it can cause serious illness and may even cause death

  3. Etiologic Agent • Infected animals and people excrete large numbers of oocysts (infectious form) in stool • Oocysts relatively hardy • May be excreted for up to 5 weeks after diarrheal illness ends • Can survive in the environment for weeks/months • Resistant to chlorine & other disinfectants used to treat water • They can be killed by heat (bringing water to a rolling boil) or removed by adequate filtration

  4. Transmission • It may also be spread by touching others with unwashed hands • Outbreaks have occurred when people swallow water • An outbreak has also occurred from consumption of unpasteurized cider

  5. Symptoms • Watery diarrhea (can be several times a day) • Stomach cramps • Upset stomach • Slight fever • Weight loss

  6. Incubation Period & Duration • Incubation Period • 1-12 days • Duration • In healthy people, symptoms usually last about two weeks or less • Some people may not get sick but can still pass the disease to others. • After infection, people can pass cryptosporidiosis in their stool for months. • People with weak immune systems may have the disease for a longer time.

  7. Treatment • There is no drug to cure cryptosporidiosis • Since diarrhea can cause dehydration, drink plenty of fluids.

  8. Prevention • Always wash hands with soap and water: • after using the bathroom • after touching children in diapers • after touching anything soiled with stool • after touching pets or other animals • after gardening • and before eating and preparing food • Supervise young children when they are washing their hands • Wash or peel all uncooked vegetables and fruits • Do not eat or drink unpasteurized milk, dairy products, juice or cider

  9. Prevention • Persons with diarrhea should not: • swim or bathe with others • prepare food that will be eaten by others • attend daycare • Practice safe sex • People with AIDS or weak immune systems should consider using bottled or filtered water

  10. A Massive Outbreak in Milwaukee of Cryptosporidium Infection Transmitted Through The Public Water SupplyNEJM, Volume 331:161-167, July 21,1994 • April 5,1993 Wisconsin Division of Health was contacted by Milwaukee Department of Health • Numerous cases of GI illness • Hospital employees • Students • School teachers • April 7th • 2 labs identified Cryptosporidium oocysts in stool samples of 7 adults

  11. Milwaukee Outbreak NEJM, Volume 331:161-167, July 21,1994 • Milwaukee Water Works (MWW) • Obtained water from Lake Michigan • Examination of Untreated and Treated Water • Revealed an increase in the turbidity of treated water beginning on March 21 • Unprecedented levels of turbidity from 3/23/-4/5 • April 7th advisory to all MWW customers to boil water. • Plant closed on 4/9

  12. Figure 1. Maximal turbidity of treated water in the northern and southern

  13. Milwaukee OutbreakNEJM, Volume 331:161-167, July 21,1994 • 14 Clinical Laboratories • Surveillance • Retrospectively (3/1-4/6) • Prospectively (4/7-4/16) • Before April 7th 12 of 14 laboratories tested for Crypto, only at the request of a physician • 739 lab confirmed cases from 3/1-5/30 • 567 had telephone numbers • 312 interviewed • 285 (91%) onset 3/1-5/15

  14. Milwaukee OutbreakNEJM, Volume 331:161-167, July 21,1994 • Laboratory Surveillance • 3/1-4/6 • 12 of 42 (29%) specimens positive for Cryptosporidium • 4/8-4/16 • 331 of 1009 (33%)specimens positive for Cryptosporidium

  15. Milwaukee OutbreakNEJM, Volume 331:161-167, July 21,1994 • Lab confirmed cases • 285 confirmed cases • 170 (60%) female • 130 (46%) hospitalized • 48 (17%) immunocompromised • Mean age 41 years (2 months- 93 years) • All had diarrhea • 265 (93%) watery • Median duration of diarrhea 9 days (1-55) • Onset of illness 3/1-5/15

  16. Figure 2. Reported Date of Onset of Illness In cases of laboratory confirmed or clinically defined cryptosporidium infection during the period from March 1 through April 15, 1993 Clinically defined cases were identified during a telephone survey begun on April 9 of residents in the area served by the Milwaukee Water Works

  17. Figure 3. Reported date of onset of watery diarrhea during the period of March 1 through April 28, 1993, in 436 cases of infection identified by a random digit telephone survey of the greater Milwaukee area

  18. Milwaukee OutbreakNEJM, Volume 331:161-167, July 21,1994 • Rate of Watery Diarrhea • MWW Southern region (52%) • MWW Middle zone (33%) • MWW Northern region (26%) • Outside of MWW service area (15%)

  19. Milwaukee OutbreakNEJM, Volume 331:161-167, July 21,1994 • Estimate of the Magnitude of the Outbreak • Rate of watery diarrhea among survey participants to the total of greater Milwaukee area (1,610,000) • Estimate of 419,000 people had watery diarrhea

  20. Milwaukee OutbreakNEJM, Volume 331:161-167, July 21,1994 • Recognition of outbreak was delayed • GI symptoms • Constitutional signs (fatigue, low grade fever, muscle aches, and headaches) • Diagnosed as “intestinal flu” • Infrequent testing

  21. An Outbreak of Cryptosporidiosis From Fresh Apple Cider (JAMA , 11/23/1994, 272 (20) 1592-1596) • October 1993 • Elementary school principal • Outbreak of enteric illness • Maine BPH • 2 Elementary schools • 1 High school – rural farming community • Elementary schools • High absenteeism in classes that attended 1 day agricultural fair 8 days ago

  22. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Fair • Organized & Staffed by High School Students • Elementary students attended either morning or afternoon session- but not both • Consisted of: • Agricultural demonstrations • Petting zoo of farm animals • Hayride • Cider-pressing demonstration • Light refreshments

  23. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Cryptosporidium • Found in 3 ill students attending the fair • Cohort & Environmental/Lab Study • Identify Source • Characterize natural history of Cryptosporidium • Determine risk of secondary household transmission

  24. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Study Population • Students and staff attending the fair • Household members of primary case patients • Clinical Cryptosporidiosis • 3 days of diarrhea or vomiting with abdominal cramps • Laboratory Cryptosporidiosis • GI Illness with lab confirmed Cryptosporidium oocysts • Primary cases • Lab or Clinical Cryptosporidiosis following fair attendance • Secondary • household members of primary case patients who did attend the fair but who became ill within 1 month of onset of illness in the primary case patient

  25. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Epidemiological Investigation • Questionnaire • Possible exposures • All 6 food & drink items • Petting of farm animals • Participation in the hayride • Dates of Onset • Date of Recovery • Symptoms • Underlying medical conditions

  26. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Environmental Investigation • High school student had taken a gallon of leftover cider • Interviewed 3 high school students & supervisor who pressed the cider • Pre-existing illness • Source of apples • Details of cider making process • Possible sources of contamination during pressing operation • Obtained stool: • 2 calves that had been at the petting zoo • 6 of 14 cows & 2 of 8 calves from farm that supplied the apples

  27. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Results • 611 of 759 (81%) completed survey • 230 (38%) GI symptoms • 160 primary cases identified • 33 Laboratory confirmed • Primary cases patients • 5 to 66 years • 54% males • 56% younger than 10 years

  28. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Clinical Illness – 160 primary case patients • 106 (66%) both vomiting & diarrhea • 19 (12%) diarrhea w/o vomiting • 26 (16%) vomiting w/o diarrhea • Median incubation period • 6 days (Range 10 hours-13 days) • Median duration of illness • 6 days (Range 1 to 16 days)

  29. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Exposures • 576 answered if they had drank cider at the fair • 284 drank in the afternoon • 154 (54%) met case definition • 6 (2%) who did not drink in the afternoon met case definition • All laboratory confirmed primary case patients & 121 (95%) of 127 clinically defined primary case patients • Reported drinking cider in the afternoon

  30. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Household transmission • 53 secondary cases • 17 lab confirmed • 37 (33%) of 112 households with one primary case and four (36%) of 11 households with 2 primary cases reported one or more secondary cases • Impact of outbreak • 14 (31%) of 45 missed work • 13 (29%) visited private medical office

  31. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Environmental Investigation • 5 bushels of apples used for morning pressing • Purchased from commercial producer • 5 bushels of apples used in afternoon pressing • Collected from uncultivated trees of edge of pasture • Students harvested apples- shaking trees • Apples were sprayed with municipal water from a hose in the morning of the fair • Municipal water supplied by surface water source that was chlorinated but not filtered

  32. Apple Cider Outbreak(JAMA , 11/23/1994, 272 (20) 1592-1596) • Environmental & Laboratory Investigation • Cryptosporidium detected • Leftover apple cider • Swabs from surface of the portable cider press • 2 calves from farm that supplied implicated apples • Not detected in calves at the petting zoo

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