Haemolytic uraemic syndrome (HUS) and shigatoxigenic E. coli infections (STEC) control guideline

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David Harris, MP</a> </li> </ul> <div class="clearfix"></div> </div> <div class="five columns omega"> <ul /> <div class="clearfix"></div> </div> </div> </div> </li> </ul></div></div> </nav>  </div> </header> <div id="printHeader"> <div id="mediaHeader"> <h1 class="mediaHeading">Factsheet</h1> <div class="mediaLogoContainer"> <img src="/Style%20Library/Design/NSWHealth-logo.png" class="mediaLogo" alt="New South Wales Health" /> </div> </div> </div>  <div class="clearfix"></div> <div id="maincontent" role="main">   <nav class="breadwrapper twelve columns offset-by-four" aria-label="breadcrumb"> <ul id="ctl00_PlaceHolderTitleBreadcrumbInner_SimpleSiteMapPath1" class="breadcrumbs"> <li><a title="Home" href="/Pages/default.aspx">Home</a></li><li><img src='/Style%20Library/Design/NSWHealth-bullet-breadcrumb.gif' alt='arrow' /></li><li><a href="/Infectious/Pages/default.aspx">Infectious diseases</a></li><li><img src='/Style%20Library/Design/NSWHealth-bullet-breadcrumb.gif' alt='arrow' /></li><li><a href="/Infectious/controlguideline/Pages/default.aspx">Control guidelines</a></li><li><img src='/Style%20Library/Design/NSWHealth-bullet-breadcrumb.gif' alt='arrow' /></li><li>Haemolytic uraemic syndrome (HUS) and shigatoxigenic E. coli infections (STEC) control guideline</li> </ul> </nav>   <div class="four columns leftnavwrapper"> <nav aria-label="section"> <div id="zz1_QuickLaunchMenu" class="leftnav noindex ms-core-listMenu-verticalBox"> <ul id="zz2_RootAspMenu" class="root ms-core-listMenu-root depth-0"> <li class="selected first even"> <a class="selected menu-item ms-core-listMenu-item ms-displayInline ms-core-listMenu-selected ms-navedit-linkNode" href="/Infectious/controlguideline"> <span class="additional-background ms-navedit-flyoutArrow"> <span class="menu-item-text">Control guidelines</span> <span class="ms-hidden">Currently selected</span> </span> </a> </li> <li class="odd nav-hidden"> <a class="menu-item ms-core-listMenu-item ms-displayInline ms-navedit-linkNode" href="/Infectious/factsheets"> <span class="additional-background ms-navedit-flyoutArrow"> <span class="menu-item-text">Fact sheets</span> </span> </a> </li> <li class="last even nav-hidden"> <a class="menu-item ms-core-listMenu-item ms-displayInline ms-navedit-linkNode" href="/Infectious/diseases/Pages/default.aspx"> <span class="additional-background ms-navedit-flyoutArrow"> <span class="menu-item-text">A-Z of infectious diseases</span> </span> </a> </li> </ul> </div> </nav> </div>   <h1 class="pagetitle"> Haemolytic uraemic syndrome (HUS) and shigatoxigenic E. coli infections (STEC) control guideline </h1>    <div class="twelve columns maincontent"> <div class="factsummarybox"> <div class="ms-rtestate-field"><h2 class="moh-rteElement-H2"><a name="top" id="top"></a>Control Guideline for Public Health Units</h2> <p>Public health priority: High.</p> <p>PHU response time: Respond to reported cases within 1 working day of notification. Enter confirmed cases on NCIMS within 1 working day. </p> <p>Case management: Notify the Communicable Diseases Branch. Obtain stool, and identify the serogroup. Determine and control likely source. Recommend that cases avoid preparing food for others for at least 48 hours after diarrhoea has ceased. </p> <p style="margin-bottom:0px;">Contact management: Contacts with diarrhoea should be investigated for possible STEC infections and be excluded from food handling and care of patients, children or elderly until 48 hours after diarrhoea has ceased. </p> <p style="margin-bottom:0px;"> </p> <div>Revision History</div> <table width="100%" class="ms-rteTable-default" cellspacing="0" style="font-size:1em;"><tbody><tr class="ms-rteTableOddRow-default"><th class="ms-rteTableFirstCol-default">Version</th> <td class="ms-rteTableOddCol-default">Date</td> <td class="ms-rteTableEvenCol-default">Revised by</td> <td class="ms-rteTableOddCol-default">Changes</td> <td class="ms-rteTableLastCol-default">Approval</td></tr> <tr class="ms-rteTableEvenRow-default"><th class="ms-rteTableFirstCol-default">1.0</th> <td class="ms-rteTableOddCol-default">01 July 2012</td> <td class="ms-rteTableEvenCol-default">Enterics</td> <td class="ms-rteTableOddCol-default">Revision</td> <td class="ms-rteTableLastCol-default">Director Health Protection</td></tr> <tr class="ms-rteTableFooterRow-default"><th class="ms-rteTableFooterFirstCol-default">1.1</th> <td class="ms-rteTableFooterOddCol-default">01 July 2016</td> <td class="ms-rteTableFooterEvenCol-default">CDWG</td> <td class="ms-rteTableFooterOddCol-default">Case definition</td> <td class="ms-rteTableFooterLastCol-default">CDNA</td></tr></tbody></table></div> </div> <div> <div class="lastupdated factlastupdated"> Last updated: 05 September 2016 </div> <div class="factdownload"> <a href="/Infectious/controlguideline/Documents/hus-stec.PDF"><img src="/Style%20Library/Design/NSWHealth-icon-pdf24.png" alt="Download" /></a> </div> </div> <div id="ctl00_PlaceHolderMain_contentc1_label" style='display:none'>Content 1</div><div id="ctl00_PlaceHolderMain_contentc1__ControlWrapper_RichHtmlField" class="ms-rtestate-field" style="display:inline" aria-labelledby="ctl00_PlaceHolderMain_contentc1_label"><ol><li><a href="#1">Reason for surveillance</a><br></li> <li><a href="#2">Case definition</a></li> <li><a href="#3">Notification criteria and procedure</a></li> <li><a href="#4">The disease</a></li> <li><a href="#5">Managing single notifications</a></li> <li><a href="#6">Managing special situations</a></li></ol> <h2 class="moh-rteElement-H2"><a name="1" id="1"></a>1. Reason for surveillance</h2> <ul><li>To identify the source of the infection and to prevent further cases </li> <li>To monitor the epidemiology to inform the development of better prevention strategies.</li></ul> <h2 class="moh-rteElement-H2"><a name="2" id="2"></a>2. Case definition</h2> <h3 class="moh-rteElement-H3">Shiatoxogenic/verotoxigenic Escherichia coli infections (STEC/VTEC)</h3> <p>A confirmed case requires laboratory definitive evidence only.</p> <h4 class="moh-rteElement-H4">Laboratory evidence</h4> <ul><li>Isolation of Shigatoxigenic/verotoxigenic <em>E. coli </em>from faeces, <strong>or</strong> </li> <li>Detection of the gene(s) associated with the production of shiga toxin or vero toxin in <em>E. coli</em> by nucleic acid testing on isolate or faeces.</li></ul> <h3 class="moh-rteElement-H3">Haemolytic uraemic syndrome</h3> <p>A confirmed cases requires clinical evidence only.</p> <h4 class="moh-rteElement-H4">Clinical evidence</h4> <p>Acute microangiopathic anaemia on peripheral blood smear (schistocytes, burr cells or helmet cells), and at least one of the following: </p> <ul><li>Acute renal impairment (haematuria, proteinuria or elevated creatinine level), <strong>or</strong> </li> <li>Thrombocytopenia, particularly during the first seven days of illness.</li></ul> <h2 class="moh-rteElement-H2"><a name="3" id="3"></a>3. Notification criteria and procedure</h2> <p>HUS is to be notified by hospital CEOs on clinical diagnosis (ideal reporting by telephone on same day of diagnosis). </p> STEC infection is to be notified by laboratories on microbiological or toxicological confirmation (ideal reporting by telephone on same day of diagnosis). <p>Only confirmed cases should be entered onto NCIMS. Where STEC is isolated is the context of HUS, it should be entered into NCIMS as both HUS and STEC. HUS is notifiable whether STEC is present or not.</p> <h2 class="moh-rteElement-H2"><a name="4" id="4"></a>4. The disease</h2> <h3 class="moh-rteElement-H3">Infectious agent</h3> <p>STEC particularly serotypes O111 and O157 or O26 can cause HUS. Occasionally other organisms such as <em>Shigella</em> can cause HUS. HUS may also occur with any evidence of diarrhoeal illness.</p> <h3 class="moh-rteElement-H3">Mode of transmission</h3> <p>STEC is transmitted by ingesting contaminated food, water, milk or particularly under-cooked or fermented meats and raw food which may have been contaminated by animal manure. Person to person transmission can also occur, particularly in families and child care centres. Outbreaks have been linked to contaminated swimming areas.</p> <h3 class="moh-rteElement-H3">Timeline</h3> <p>The typical incubation period is 2 to 10 days, more commonly 3 to 4 days. </p> <p>STECs are infectious for the duration of excretion of the organism, which is usually up to a week for adults but up to 3 weeks for children.</p> <h3 class="moh-rteElement-H3">Clinical presentation</h3> <p>The usual clinical presentation following infection is diarrhoea (which ranges from mild to severe) which can be either bloody or non-bloody. In a small percentage of infections this can progress within days to microangiopathic haemolytic anaemia, thrombocytopenia and renal failure. Children <5 years old are at greatest risk of developing HUS. A laboratory diagnosis of STEC may not always be made.<br></p> <div style="text-align:right;"><a title="Return to top of page" href="#top">[back to top]</a></div> <h2 class="moh-rteElement-H2"><a name="5" id="5"></a>5. Managing single notifications</h2> <h3 class="moh-rteElement-H3">Response times</h3> <h4 class="moh-rteElement-H4">Investigation</h4> <p>Within one working day of notification of any case begin follow-up investigation and notify the Communicable Diseases Branch (CDB) of the case details.</p> <h4 class="moh-rteElement-H4">Data entry</h4> <p>Enter confirmed cases on NCIMS within 1 working day of notification. Within 1 working day of notification of the serogroup of the organism update NCIMS.</p> <h3 class="moh-rteElement-H3">Response procedure</h3> <p>The response to a notification will normally be carried out in collaboration with the case's health carers. But regardless of who does the follow-up, PHU staff should ensure that action has been taken to: </p> <ul><li>Confirm the onset date and symptoms of the illness </li> <li>Confirm results of relevant pathology tests, or recommend the tests be done </li> <li>Find out if the case or relevant care-giver has been told what the diagnosis is before beginning the interview </li> <li>Seek the doctor's permission to contact the case or relevant care-giver </li> <li>Review case and contact management </li> <li>Investigate the possible source of infection.</li></ul> <h3 class="moh-rteElement-H3">Case management</h3> <h4 class="moh-rteElement-H4">Investigation and treatment</h4> <p>All cases of HUS should have stool samples (or failing that, rectal swabs) collected and examined for evidence of STEC; suspicious <em>E. coli</em> isolates should be sent to ICPMR for serotyping and PCR. </p> <p>Antibiotic therapy is not recommended for the treatment STEC infections. Information should be sought from the case or relevant care-giver about foods ingested, in particular: </p> <ul><li>Ingestion of raw or undercooked meat or meat products </li> <li>ingestion of unpasteurised milk, milk products and fruit juices </li> <li>Ingestion of untreated water </li> <li>Exposure to farm animals and manure </li> <li>Swimming </li> <li>Contact with other persons with diarrhoea.</li></ul> <p>Because a single case of HUS or STEC is unusual and could represent a larger cluster, the PHU should call laboratories and renal services in the area to ask them to report other possible cases.</p> <h4 class="moh-rteElement-H4">Education</h4> <p>The case or relevant care-giver should be informed about the nature of the infection and the mode of transmission. Emphasise the importance of hygienic practices, particularly hand washing before eating and preparing food and after handling animals or animal manure and after going to the toilet.</p> <h4 class="moh-rteElement-H4">Isolation and restriction</h4> <p>Strict isolation of cases is not necessary, provided good hygiene is observed. Cases who are food handlers or care for young children, the elderly or debilitated persons should be advised not to attend work until 48 hours after the resolution of symptoms. Children in child care should not attend until 24 hours after diarrhoea has stopped.</p> <h4 class="moh-rteElement-H4">Environmental evaluation</h4> <p>In a cluster, if the epidemiological investigation suggests that food may be the source of illness, contact the NSW Food Authority to assess and correct food handling procedures, and to arrange tracing, collection and testing of suspected foods.</p> <h3 class="moh-rteElement-H3">Contact management</h3> <h4 class="moh-rteElement-H4">Identification of contacts</h4> <p>Contacts are defined as those people who may have eaten contaminated food or drink causally linked to a human case, or were exposed to an infectious case in the same household, childcare or similar setting.</p> <h4 class="moh-rteElement-H4">Investigation and treatment</h4> <p>Contacts with diarrhoea should be investigated for possible STEC infection, and be excluded from food handling and care of children or patients until at least 48 hours after diarrhoea has ceased. Contacts should be counselled about the importance of hygienic practices, particularly hand washing before eating and preparing food, after handling animal manure and after going to the toilet. Contacts should be advised to seek medical attention early if symptoms develop.</p> <h2 class="moh-rteElement-H2"><a name="6" id="6"></a>6. Managing special situations</h2> <p>Where a cluster is identified, it is important that a thorough epidemiological investigation be done without delay. 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Haemolytic uraemic syndrome (HUS) and shigatoxigenic E. coli infections (STEC) control guideline