Campylobacter

 

Literature Recommendations

Exclusion-Case in SOS*
(Symptomatic)

Yes [1,4-6,8, 9,12, 13,15, 16]
Grade III-A

Exclusion-Case in SOS*
(Asymptomatic or previously symptomatic but now recovered)

No [1,4,6a, 13, 17]
Grade III-A

Clearance-Case in SOS*

No clearance. Exclude until 48 hours after first normal stool. [1,4,5,6]
Grade III-A

Exclusion of Contact
(Symptomatic)

Yes [1,4-6,8, 12, 13, 16]
Grade III-A

Exclusion of Contact
(Asymptomatic)

Specific recommendation exclude asymptomatic contacts unavailable in literature reviewed

Exclusion-Case in Children
(Group setting with children ≤ 5 years of age)
(Symptomatic)

Yes [1,8,13]
Grade III-A

Exclusion-Case in Children
(Group setting with children ≤ 5 years of age)
(Asymptomatic or previously symptomatic but now recovered)

No [1]
Grade III-B

◊ Applicable Code

None

* SOS (Sensitive Occupations or Situations) is not defined precisely in either the Code of Regulations or Health & Safety Code. See Attachment 2 for the definition of food workers.
◊ See California Code of Regulations, Attachment 1, for details.
+ Local health departments may elect to follow more restrictive exclusion and clearance criteria

a This is the only reference with an exclusion recommendation; it is a generalized guideline for diarrhea illnesses.

Disease Trends in the U.S.:

Between 1978 and 1986, 57 outbreaks of Campylobacter infections were reported; they included 11 waterborne outbreaks, 45 foodborne outbreaks, and one outbreak in a tourist group for which the source was unclear. A vehicle for transmission was identified in 80% of the outbreaks during this time period. 70% of the outbreaks were caused by raw milk and 8% were link to poultry. The identified waterborne outbreaks were linked to drinking untreated water or to water supplies with inadequate chlorination [7].
In 1997, an outbreak of Campylobacter jejuni was reported among 106 guardsmen of the Minnesota Army National Guard following a training exercise in Greece. The source of the outbreak was bottled water consumed during international field exercises. The water was bottled in Greece [10].
During 1996-1999, 12,701 cases of culture confirmed Campylobacter infections were ascertained [23].
Campylobacter jejuni is a food-borne disease that can also be acquired through water-bone outbreaks and direct contact with animals or their products [14]. It is the most common cause of bacteria foodborne illness, causing over 2.4 million illnesses and about 124 deaths each year. Over 80% of these illnesses are thought to be foodborne [12].
Organism: Campylobacter jejuni and campylobacter coli—less common [16]. It belongs to a group of specialized gram-negative bacteria designated rRNA superfamily VI [14].
Reservoir of infection: Campylobacter inhabits the intestinal tracts of a wide range of animal hosts; most notably chicken [15]. Campylobacter is found in natural water sources [11].

Modes of Transmission:
Modes of transmission of Campylobacter to humans include contacting animals, handling raw chicken, person-to-person spread, and consumption of contaminated food, raw milk, and water [3, 16, 17, 20]. The most consistent finding in studies of campylobacter infection etiology has been an association with eating chicken [21]. A study of Campylobacter infections in rural Michigan, found that farm animals were a significant risk factor; caring for poultry greatly increased your odds of contracting Campylobacter [2].
Person-to-person transmission appears to be uncommon with C. jejuni. Neither outbreaks nor large numbers of sporadic cases have been reported in situations where person-to-person transmission of other enteric diseases is common [7].
Attack rates: In an outbreak of Campylobacter from poultry consumption among company employees in Copenhagen a caterer food handler was a suspected to be the cause of the outbreak. In this outbreak, Campylobacter had an overall attack rate of 32% [19].
Sacks et al (1986) reported an outbreak with 865 cases of campylobacter in Greenville, Florida. A survey was administered to compare the difference in attack rate between those who inside town limits and those who live outside town limits. The researcher found that the attack rate among the survey respondents for those inside the city limits was 56% versus 9% for those living outside town limits. Among family members, it was 49 % and 19% for campylobacter [ 20].
Attack rates from these studies range from 9 to 56 percent; although it is closer to 32% to 50%.
Infectious dose: volunteer studies established that the infective dose could be as low as 500 bacteria; however a dose of 9000 bacteria was needed to produce illness in 50 percent of the subjects [14]. Campylobacter organisms have a relatively low infectious dose. However, they do not survive well or multiply on foods that are exposed to oxygen [12].

Incubation Period: 1 to 10 days--usually 2-5 days [16]. An evidence-based summary on existing literature listed an average incubation period of three days, with a range of one to seven days [15].
Infectious Period: Shedding of campylobacter normally lasts 2-3 weeks (and up to 7 weeks for individuals not treated with antibiotics) [14, 16].
Asymptomatic carrier state: Evidence is lacking in reviewed literature regarding carrier state.
Diagnosis: Campylobacter can be isolated from stool samples using filtration and antibiotic-free culture medium [14]. Whole stool or rectal swab specimens placed in Cary-Blair media were collected from ill and well nursing-home residents, ill community residents, and outbreak-related hospitalized persons [20]. The ProSpecT microplate assay correctly characterized 48 of 50 campylobacter culture-positive stool specimens [22]. Pulsed-Field Gel Electrophoresis (PFGE) is useful in identifying the source of an outbreak. Used regularly, it can aid in the rapid identification of the cause of future Campylobacter outbreaks [12].

Preventive Measures
Exclusions:
Symptomatic

  1. According to Communicable Disease Report (1995), Exclusion “ Cases in risk groups 1 to 4 (Food handlers, Staff of health care facilities, children aged less than 5 years and older children who may find it difficult to implement good personal hygiene) be excluded until 48 hours after first normal stool [1]. Guidelines and Consensus Document {Grade III-A}
  2. A consensus document by the APHA, AAP and NRCHS (2002) recommends, “Children with diarrheal illness of infectious origin generally may be allowed to return to child care once the diarrhea has resolved” [8].  Guidelines and Consensus Document {Grade III-A}
  3. According to Allos (2007), “Patients with Campylobacter enteritis need not be isolated, as person-to-person spread of infection is unusual. Simple excretion precautions (dedicated gloves and gown for handling bedpans) are adequate to prevent the spread of infection. The low infectivity of the disease is well illustrated by the case of a man who developed severe campylobacter enteritis and hepatitis A after falling into a tank of concentrated sewage. Despite 19 days of profuse diarrhea, none of his caregivers got campylobacter infection, while seven of them contracted hepatitis A” [9, 15]. Infants and younger children in diapers with gastroenteritis caused by C. jejuni should be excluded from routine childcare centers until diarrhea has resolved” [15]. Evidence Based Literature {Grade III-A}
  4. Recommended 2 consecutive negative stool samples 24 hours apart and at least 48 hours after symptoms resolve [6]. Evidence based reviews with guidelines formed out of reviewed literary sources {Grade III-A}
  5. Recommendation cited in the article was that cases may return to work if no longer symptomatic (diarrhea free) [5]. Evidence based reviews with guidelines formed out of reviewed literary sources {Grade III-A}
  6.  For clearance, cases are allowed to return 48 hours after first normal stool [4]. Guidelines and Consensus Document {Grade III-A}
  7. Tauxe et al (1987) states that “The rarity of sustained person-to-person transmission suggests that, in the context of sporadic cases of C. jejuni infections, there is little need for public health measures such as tracing contacts, screening food handlers, or closing day-care centers” [7]. Review of Outbreaks and Epidemiology {Grade III-A}
  8. According to Olsen et al (2001) “One staff member, a food handler, was at school on 14 September and reported having severe abdominal cramps and profuse diarrhea and making numerous trips to the bathroom while serving lunch that day. The diarrhea was so severe that the person wore a protective pad to absorb any stool incontinence. Although kitchen duties are shared, the primary responsibilities of this person were filling condiment containers (e.g., dressing) between lunch periods, assisting children when needed (e.g., opening utensils or food wrapped in plastic), and cleaning tables” [12].
    “To our knowledge, this is only the second published report of an ill food handler identified as the likely source of a Campylobacter outbreak. The other food handler–associated outbreak occurred in an Israeli military base in 1982” [12].
    “Kansas State regulations require that food handlers with diarrhea be excluded from work; however, these regulations were not followed. Despite years of efforts to educate food handlers about the risks of pathogen transmission, ill food handlers continue to play a role in foodborne disease outbreaks…although Campylobacter outbreaks resulting from food handler contamination are rare, they do occur” [12]. Review of Outbreaks and Epidemiology {Grade III-A}
  9. Division of Environmental Health and Communicable Disease Prevention (2003) “Because of the known risk of transmission of enteric pathogens from individuals with diarrhea, food handlers and symptomatic health care personnel with patient care responsibilities should not be permitted to work until the diarrhea has ended” [13]. Guidelines and Consensus Document {Grade III-A}
  10. Division of Environmental Health and Communicable Disease Prevention (2003) “In child care settings where children are not toilet-trained, it is prudent to treat with antibiotics. Symptomatic children should be excluded from child care for two days after beginning antibiotics or until the child is asymptomatic, whichever is the shorter period of time” [13]. Guidelines and Consensus Document {Grade III-A}
  11. Heymann (2004) states, “exclude all symptomatic individuals from handling food, or caring for individuals in hospitals, custodial institutions or day care centers… [16].” Guidelines and Consensus Document {Grade III-A}

Asymptomatic

  1. According to Cowden (1992) “Asymptomatic excretion of campylobacter is unusual, and infected food handlers do not seem to present a risk” [17]. Evidence Based Literature {Grade III-A}
  2. The Communicable Disease Report states that (1995) “Contacts in risk groups 1 to 4 (Food handlers, Staff of healthcare facilities, children under the age of 5 and older children who may have problems implement proper personal hygiene) should be screened microbiologically” [1]. Guidelines and Consensus Document {Grade III-A}
  3. According to Division of Environmental Health and Communicable Disease Prevention (2003) “Asymptomatically infected food handlers or health care personnel need not be excluded from work, but the need for handwashing after defecation should be stressed. Exclusion of asymptomatic, convalescent, stool-positive individuals is indicated only for those with questionable handwashing habits” [13]. Guidelines and Consensus Document {Grade III-A}
  4. According to Guerrant et al (2001), “because food-handlers and health care workers can transmit bacterial and parasitic disease even if they are asymptomatic, it is recommended that before returning to their jobs these persons have 2 consecutive negative stool samples taken 24 h apart and at least 48 h after resolution of symptoms” [6]. Evidence based reviews with guidelines formed out of reviewed literary sources {Grade III-A}

 

References

    1. Communicable Disease Report. The Prevention of Human Transmission of Gastrointestinal infections, infestations, and bacterial infestations. A Guide to Public Health Physicians and Environmental Health Officers in England and Wales. 1995; Volume 5 Number 11: R157-72. Guidelines and Consensus Document
    2. Potter R, Kaneene J, and Hall W. (2003).  Risk Factor for Sporadic Campylobacter jejuni Infections in Rural Michigan: A prospective Case Control Study. American Journal of Public Health, 93, 2118-23. Review of Outbreaks and Epidemiology
    3. Hopkins R S, Olmsted R, and Istre G. (1984). Endemic Campylobacter jejuni Infection in Colorado: Identified Risk Factors. American Journal of  Public Health, 74, 249-250.  Evidence Based Literature
    4. Public Health Laboratory Service, Advisory Committee on Gastrointestinal Infections. (2004). Preventing Person-to-Person Spread Following Gastrointestinal Infections: Guidelines for Public Health Physicians and Environmental Health Officers. Communicable Disease and Public Health , 7 (4), 362-384. Guidelines and Consensus Document 
    5. Bolyard EA, Ofelia CT, Water WW et al. (1998). Guidelines for Infection Control in Health Care Personnel. America Journal of Infectious Disease, 26(3): 307-308. Evidence based reviews with guidelines formed out of reviewed literary sources
    6. Guerrant R L., Van Gilder T, Steiner T S. et al. (2001).  Practical Guideline for Management of Infectious Diarrhea. Clinical Infectious Diseases, 32, 331-350. Evidence based reviews with guidelines formed out of reviewed literary sources
    7. Tauxe RV, Hargrett-Bean N and Patton C M. (1987). Campylobacter Isolates in the United States, 1982-1986. Morbidity and Mortality Weekly Report, 1-10.  Review of Outbreaks and Epidemiology
    8. APHA, AAP, & NRCHS (2002). Exclusion and Inclusion of Ill Children in Child Care Facilities and Care of Ill Children in Child Care. Standards from CFOC, 2nd ed. Child Care Providers' Health and Well Being. Second Edition. A Joint Collaborative Project of The American Academy of Pediatrics, The American Public Health Association, and The National Resource Center for Health and Safety in Child Care.  Guidelines and Consensus Document
    9. Sumathipala RW and Morrison GW. Campylobacter enteritis after falling into sewage. British Medical Journal (Clinical Research Edition) 1983; 286:1356. Review of Outbreaks and Epidemiology
    10. Center for Disease Control and Prevention. (2000). Surveillance for Waterborne-Disease Outbreaks—United States, 1997-1998. Morbidity and Mortality Weekly Report, 49, 1-44.  Review of Outbreaks and Epidemiology
    11. Altekruse SF, Stern NJ, Fields PI, and Swerdlow DL. (1999). Campylobacter jejuni—An Emerging Foodborne Pathogen. Emerging Infectious Diseases, 5(1), 28-35. Evidence Based Literature
    12. Olsen SJ, Hansen GR, and Bartlett L. (2001). An Outbreak of Campylobacter jejuni Infections Associated with Food Handler Contamination: The use of Pulsed-Field Gel Electrophoresis. The Journal of Infectious Diseases, 183, 164-7. Review of Outbreaks and Epidemiology
    13. Division of Environmental Health and Communicable Disease Prevention. (2003). Campylobacteriosis. Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual, 1-4. Guidelines  and Consensus Document
    14. Allos, B. (2007).  Microbiology, pathogenesis, and epidemiology of Campylobacter infection. UpToDate.com, 1-11. Evidence Based Literature
    15. Allos, B. (2007).  Clinical Features and Treatment of Campylobacter Infection. UpToDate.com, 1-11. Evidence Based Literature
    16. Heymann, D. (2004). Control of Communicable Disease Manual 18th ed. Washington D.C.: American Public Health Association, 81-84. Guidelines and Consensus Document
    17. Cowden, J. (1993). Campylobacter: Epidemiological Paradoxes. The vehicles for most cases of infection remain unknown. British Medical Journal, 305, 132-133.  Evidence Based Literature
    18. Peterson M. (1994). Clinical aspects of Campylobacter jejuni infections. The Western Journal of Medicine, 161, 148-152. Evidence Based Literature
    19. Mazick A, Ethelberg S, Nielsen K and Lisby M. (2006). An Outbreak of Campylobacter jejuni Associated with Consumption of Chicken, Copenhagen, 2005. Euro Surveill, 11(5), 137-139. Review of Outbreaks and Epidemiology (retrospective cohort study)
    20. Sacks JJ, Lieb S, Baldy LM et al. (1986). Epidemic Campylobacteriosis Associated with a Community Water Supply. American Journal Public Health, 76(4), 424-428. Review of Outbreaks and Epidemiology
    21. Evans MR, Ribeiro D and Salmon R. (2003). Hazards of Healthy Living: Bottled Water and Salad Vegetables as Risk Factors for Campylobacter Infection. Emerging Infectious Diseases, 9(10), 1219-1225. Review of Outbreaks and Epidemiology
    22. Tolcin R, LaSalvia M, Kirkley B et al. (2000).  Evaluation of the Alexon-Trend Prospect Campylobacter Microplate Assay. Journal of Clinical Microbiology, 38(10): 3853-3855. Evidence Based Literature
    23. Samuel MC, Vugia D, Shallow S et al. (2004). Epidemiology of Sporadic Campylobacter Infection in the United States and Declining Trend in Incidence, FoodNet 1996-1999. Clinical Infectious Diseases, 38 (Suppl 3), S165-74. Review of Outbreaks and Epidemiology