Epidemiologic Notes and Reports Cryptosporidiosis among Children Attending Day-Care Centers -- Georgia, Pennsylvania, Michigan, California, New Mexico

During 1984, CDC has received several reports of cryptosporidiosis among children attending day-care centers. Seven investigations conducted in five states are summarized below.

Georgia: Investigation 1: Two sisters, aged 2 years and 4 years, who attended an Atlanta day-care center, developed watery diarrhea in late February, and stool specimens showed Cryptosporidium oocysts. An investigation in April found that 27 (51%) of 53 persons had recent histories of diarrhea. Stool examinations of 50 children and 11 adult staff members revealed three other children with Cryptosporidium; all had recent histories of afebrile, diarrheal illness without nausea or vomiting. No asymptomatic children had cryptosporidiosis. One infected child also had Giardia lamblia cysts. Eight of 27 symptomatic and six of 26 asymptomatic persons had Giardia. Symptomatic persons had mild-to-moderate diarrhea, and most sought medical attention. No one was hospitalized.

Investigation 2: On August 27, a 2-year-old day-care center attendee in Atlanta developed severe, watery diarrhea. Stool examination on September 6 showed Cryptosporidium. Thus far, four (17%) of 23 children from the same room who were examined have had Cryptosporidium. Two of 12 children tested in other rooms at the day-care center had Cryptosporidium; both children were siblings of infected children in the original room. Two of the six infected children had no histories of diarrhea and were asypmtomatic at the time of the investigation; the others had mild-to-moderate diarrhea without fever. None required hospitalization, and two children were seen by physicians.

Pennsylvania: Beginning in June, the rate of diarrheal illness increased at a day-care center in Philadelphia, where 20 (34%) of 59 children were symptomatic. Stool specimens obtained from 45 children were examined for enteropathogenic bacteria, viruses, and parasites. Eleven (65%) of 17 symptomatic children and three (11%) of 28 asymptomatic children had Cryptosporidium. Enteropathogenic bacteria and viruses were not implicated in the outbreak (1).

Michigan: In September, an investigation of day-care-center-associated diarrhea in Ann Arbor found a 2-year-old with cryptosporidiosis. Review of the day-care center's records showed an increase of diarrhea among children from three rooms--two for toddler-aged children, and one for infants. Stool specimens were obtained from 38 (70%) of the 54 children in the three affected rooms and examined for parasites, Salmonella, Shigella, Campylobacter, and rotavirus; 21 (55%) had Cryptosporidium. One of these children also had Salmonella; another also had Giardia. Infected children generally had mild-to-moderate diarrhea without fever; none required hospitalization, and three children saw physicians.

California: On September 14, a 2-year-old child with a diarrheal illness who regularly attends a day-care center in San Carlos was found to have cryptosporidiosis. A survey showed that children with recent histories of diarrhea were limited to the classroom with the index child, where 10 of 11 classmates had been symptomatic. Stool specimens from all 11 children were examined for Salmonella, Shigella, Campylobacter, Yersinia, Vibrio, Aeromonas, Edwardsiella, Plesiomonas, and parasites. Six of 10 specimens from symptomatic children were positive for Cryptosporidium. Yersinia enterocolitica serotype 5,27 was recovered from one currently asymptomatic child who had symptoms earlier. No other bacterial pathogens were isolated. The asymptomatic child had a negative stool examination. Three parents (including both parents of the index patient), who later developed diarrhea, were positive for Cryptosporidium. Parents of children reported mild-to-moderate diarrhea, and most persons required medical care. No one was hospitalized.

New Mexico: During September, investigation of giardiasis in two children led to the discovery of widespread diarrheal disease in two day-care centers in Albuquerque.

Investigation 1: Eighteen (47%) of 38 children attending a day-care center had recently had diarrhea. Stool specimens from 17 symptomatic and one asymptomatic child were examined for parasites. Cryptosporidium alone was found in specimens from four symptomatic children. Five children had Giardia only; one child was infected with both parasites. Only two of six specimens with Giardia were examined for Cryptosporidium. Stool specimens were submitted by 11 household members of symptomatic children. Of seven household members reporting recent diarrheal illness, one had Cryptosporidium, and two had Giardia; one asymptomatic adult had Giardia. Children and adults reported mild but sometimes prolonged diarrhea, and no one was hospitalized.

Investigation 2: In this day-care center, diarrheal illness was limited to the classroom for toddler-aged children. Thirteen (81%) of 16 children and one of three adults reported recent diarrhea. Of stool specimens from 13 children examined so far, five have shown Cryptosporidium only, and four, Giardia only. Two additional children had both parasites. Two of the specimens with Giardia were not examined for Cryptosporidium. Reported by G Bohan, MD, DeKalb County Health Dept, RK Sikes, DVM, State Epidemiologist, Georgia Dept of Human Resources; G Alpert, MD, L Bell, MD, CE Kirkpatrick, MD, JM Campos, PhD, HM Friedman, MD, SA Plotkin, MD, Children's Hospital of Philadelphia, LD Budnick, MD, RG Sharrar, MD, Philadelphia Dept of Health; ML Collinge, PhD, CL Combee, PhD, JA Gardner, MS, EM Britt, PhD, St Joseph Mercy Hospital, Ann Arbor, KR Wilcox, MD, State Epidemiologist, Michigan Dept of Health; J Bodie, MD, San Mateo County Health Dept, K Hadley, MD, San Francisco General Hospital, C Taclindo, MS, RR Roberto, MD, J Chin, MD, State Epidemiologist, California State Dept of Health Svcs; L Nims, MS, A Salas, HF Hull, MD, State Epidemiologist, New Mexico Health and Environment Dept; Protozoal Diseases Br, Div of Parasitic Diseases, Center for Infectious Diseases, Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Outbreaks caused by a number of important infectious agents (including Giardia, Shigella, Haemophilus influenza, hepatitis A, rotavirus, and respiratory-tract viruses) have been documented in day-care centers (2). The investigations reported here suggest that the intestinal parasite Cryptosporidium should be added to this list. Although a few children had moderately severe diarrhea, none required hospitalization.

Cryptosporidium is a well-known cause of diarrhea in animals but has been recognized only recently as a cause of human disease. The first case of human cryptosporidiosis was reported in 1976; before 1982, literature exists on only seven human cases of cryptosporidiosis. Since 1982, the number of reported cases increased markedly (3). Initially, this increase was noted in patients with acquired immunodeficiency syndrome (AIDS), but recent reports indicate that cryptosporidiosis is common in immunologically normal persons (4-6). Patients with AIDS and cryptosporidiosis usually have severe, irreversible diarrhea, but persons with normal immunologic function have self-limited, although at times severe, diarrhea. The spectrum of illness caused by Cryptosporodium has yet to be clearly defined, and no satisfactory treatment is currently available.

Public health workers, physicians, parents, and day-care providers need to be alert to cryptospordiosis as a potential cause of outbreaks of diarrhea in day-care centers. Special concentration and staining techniques for the recovery and isolation of Cryptosporodium are required (7,8), and investigators should notify laboratory personnel that Cryptosporodium is considered a possible pathogen in outbreaks. Knowledge of how Cryptosporidium is transmitted in the day-care setting is presently lacking, and only general guildelines for the prevention and control of enteric infections are available. Cryptosporidiosis outbreaks in day-care centers should be reported to state and local health departments. CDC would also like to be notified so that the spectrum of illness of this organism in this setting can be further defined.

References

1. Alpert G, Bell LM, Kirkpatrick CE, et al. Cryptosporidiosis in a day-care center. N Engl J Med 1984;311:860-1.

2. Pickering LK, Woodward WE. Diarrhea in day care centers. Peditr Infect Dis 1982;1:47-52.

3. Navin TR, Juranek DD. Cryptosporidiosis: clinical, epidemiologic, and parasitologic review. Rev Infect Dis 1984;6:313-27.

4. Tzipori S, Smith M, Birch C, et al. Cryptosporidiosis in hospitalized patients with gastroenteritis. Am J Trop Med Hyg 1983;32:931-4.

5. Jokipii L, Pohjola S, Jokipii AM. Cryptosporidium: a frequent finding in patients with gastrointestinal symptoms. Lancet 1983;II:358-61.

6. Current WL, Reese NC, Ernst JV, Bailey WS, Heyman MB, Weinstein WM. Human cryptosporidiosis in immunocompetent and immunodeficient persons. Studies of an outbreak and experimental transmission. N Engl J Med 1983; 308:1252-7.

7. Ma P, Soave R. Three-step stool examination for cryptosporidiosis

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