Gastroentiritis in summer camps

Dr Wim Flipse (Zorg en Gezondheid Agentschap) Dr Carole Schirvel (AViQ)

A few questions

• How many children go to summer camp every year?

Summer Camp: - Different settings - Organised for young people by young people - Not at all exceptional: > 5000 camps organised each

year in Belgium and abroad

Kitchen

Bathroom

Water supply

Outbreak of gastro-entiritis in summer camps

Transmission: • person-to-person spread • Waterborne (drinking water, taking showers, washing dishes) • Foodborne • Environemental • [Animal to person (leptospirosis)]

• Gastroenteritis may be caused by a variety of different bacteria, viruses or parasites.

• Symptoms: Diarrhoea, nausea, vomiting and abdominal pains may be experienced over several hours, days or weeks, and may also be accompanied by fever, headache. • Incubation time can vary from a few hours to several days (after the closure of the camp).

Outbreak of gastro-entiritis in summer camps

Outbreak of gastroentiritis in summer camps

Pathogens -> Most frequent : NOROVIRUS (!! Aerosol transmission, person-to-person, environmental, water and foodborne) • Bacteria (salmonella, campylobacter, E. Coli, shigella, C. perfringens) • Virus (norovirus, rotavirus, hepatitis A, …) • Parasites (giardia, cryptosporidium,…)

Focus on NOROVIRUS • Highly infectious (transmitted from person to person

by faecal-oral spread, via aerosolised vomit and by consuming contaminated food or water, touching contaminated surfaces)

• Can survive in the environment for weeks • Incubation period : 12-48 hours • Symptoms : vomiting, diarrhea and abdominal pain,

only 24–72 hours.

When/why it’s important to notify GE outbreak to public health authorities? • To help prevent further spread of illness • To eliminate sources of infection such as contaminated products

• AFSCA/FAVV notifications

• Sick staff/Huge number of sick people • Gravity (112 call, hospitalisations) • Responsabilities (local authorities/GP) • Following camps • Closure?

And about notifications in Belgium?

• Few declarations compared to the number of camps organised • Camps already finished when outbreak is notified • Difficulty to have human samples • Collaboration with local authorities (local delegate)

Start camp on Thirsday (day 1)

155 participants of whom 30 supervisors

Summer camp in Geel in 2016

Day 3 How?

drilling the participants

running through this ditch

Saturday night “fever” (day 3)

First child diarrea and vomitting

Trip to Zilvermeer in Mol

Theusday (day 6) Activity swimming

2 leaders and one cook got sick

More got sick (day 7)

A general practitioner was consulted

He collected 3 stool samples

Results of 3 samples (day 9)

1 blastocistus hominus 1 giardia lamblia

all rapid norovirustests negative

Contact with the camp leader day 9 Friday morning

More participants got sick Information on activities, exposure and

how hygiene was maintained He wondered the camp should be closed

A quick decision on Friday morning

We decided to visit the camp and to collect some data Also we wanted to take some additional samples

We designed a questionnaire in one hour

Inclusion of some exposure risks and printed 120 copies We packed some bottles for stool samples

We informed our headquarter and went off

The results

Impression Stone houses as dormitoirs The eldest group used tents Sanitation room spacy with rows of toilets and showers Sufficient taps available with each having a bottle of Dettol. Corvée groups were cleaning sanitary space On different places activities in the open air were going on The cooking group preparing meals under a stone roof Sick-bay with about 10 beds some were bunk beds

Problems mentionned Because the place often was used for campingactivities of groups, places to drop waist were considered too few. This caused some odour nuissance.

Many of the supervisors were tired because of the cleaning of the dormitoirs when someone got sick, transfers to the sick-bay, caring for the sick, seeking medical help, contact home etc. No agreement within the staff of the camp to end the camp.

Actions We provided about 8 people with a bundle of questionnaires and asked them to get them dispersed under the participants (including staff). Another supervisor was responsible to collect 6 stool samples of sick persons Inspection of the premisis Handhygiene and hygiene education

I visited the sick-bay

questionnaire

102 questionnaires returned (=85% of 120) 47 had gastroenteritis (=46,1%) male/female ratio equal over agegroups equal percentage

symptoms

0 10 20 30 40 50 60 70 80 90 100

tiredness

headache

fever > 37,5°

nausea

stomach-ache

vomitting

diarrea

%

Epicurve outbreak

0

2

4

6

8

10

12

14

16

18

Coun

ts

weekend

Association gastroenteritis with exposure

exposure OR 95% BI 95% BI

number exposed number GE N p-value

LL BL

lake swimming 1,29 0,54 3,1 60 45 102 0,55

ingested water lake 1,9 0,84 4,26 39 45 102 0,12

ditch running 1,75 0,72 4,27 73 45 102 0,22

ditch water ingested 0,94 0,33 2,71 17 42 99 0,91

wild berries eaten 0,24 0,01 2,25 4 45 100 0,22

contact with animals 1,05 0,39 2,79 20 45 102 0,93

Results 6 samples

3 tested positive norovirus of which 1 also aeromonas species

conclusion • Giardia and blastocystis most likely not acquired but already present • Saturday night “fever” probably the introduction of the norovirus • Activities probably related to disease but multifocal • Quick and “dirty” research too “dirty” to get significant results • Hygenic circumstances obvious not very good • Isolation probably not effective

In addition age by years camp experience

y = 0,3953x - 0,3296 R² = 0,29181

0

2

4

6

8

10

12

14

16

7 9 11 13 15 17 19 21 23 25

Thank you for

your attention