ENTERIC DISEASES

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Cases = 702

Crude rate (per 100,000 population) = 12.7

Age-adjusted race-specific rates (per 100,000 population)

White = 6.9

Nonwhite = 4.8

Sex-specific rates (per 100,000 population)

Female = 11.7

Male = 13.2

Campylobacteriosis is a bacterial disease usually transmitted through raw or undercooked foods of animal origin, or through foods cross contaminated by animal products. It can also be transmitted person-to-person or by handling infected domestic animals.

The incidence of campylobacteriosis in Indiana has remained fairly constant over the past five years (Campylobacteriosis-1).

The incidence of disease was greatest during the summer months, as shown in Campylobacteriosis-2.

There was little difference in rates of campylobacteriosis by race or sex. Age-specific rates, however, were greatest among infants (24.0) followed by preschoolers (Campylobacteriosis-3).

Cases = 59

Crude rate (per 100,000 population) = 1.1

Age-adjusted race-specific rates (per 100,000 population)

White = 0.9

Nonwhite = 0.7

Sex-specific rates (per 100,000 population)

Female = 1.0

Male = 1.0

Cryptosporidiosis is caused by Cryptosporidium parvum, a coccidial protozoa. The parasite is transmitted by ingestion of oocysts excreted in the feces of infected humans or animals. Transmission is also common from ingestion of food or water contaminated with stool, including water in recreational settings such as pools, lakes, etc. The organism can cause watery diarrhea in an immunocompetent host, but usually resolves spontaneously several days after onset. In the immunocompromised host, such as a person with HIV infection, cryptosporidiosis can be severe, lasting several months and eventually causing death in some patients. Other than supportive care and rehydration, there is no effective therapy for cryptosporidiosis.

Reported cases of cryptosporidiosis declined markedly in 1996 (Cryptosporidiosis-1).

The incidence of cryptosporidiosis was greatest during the summer and early autumn months as shown in Cryptosporidiosis-2.

There was little difference in the rates of cryptosporidiosis by race or sex. The greatest age-specific rate was among children less than one year of age (4.2) followed by children aged one to four years (3.4). These rates are summarized in Cryptosporidiosis-3. Because of the high risk among pre-school aged children, transmission is common in the day care center setting. High-risk activities in child care settings include poor hygiene and toilet habits by children, diaper changing, and failure of staff to wash hands thoroughly before preparing or serving food. Supervised handwashing after using the toilet and before meals is recommended for young children.

Most cases of cryptosporidiosis are reported from the northern part of the state. In fact, fifty-four per cent of all cryptosporidiosis cases were reported from three northern Indiana counties: St. Joseph (32%), Elkhart (14%), and Allen (8%).

Cases = 84

Crude rate (per 100,000 population) = 1.5

Age-adjusted race-specific rates (per 100,000 population)

White = 1.3

Nonwhite = unable to calculate

Sex-specific rates (per 100,000 population)

Female = 1.7

Male = 1.4

Escherichia coli O157:H7 infection is a bacterial disease usually transmitted through raw or undercooked foods of animal origin, or through foods cross contaminated by animal products. It has most commonly been associated with raw or undercooked hamburger. It can also be transmitted person-to-person and is a special concern in the day care center setting.

Reported incidence in Indiana has increased markedly over the last five years (E. coli-1). This trend probably reflects a steady increase in testing for E. coli O157:H7, rather than a true increase in incidence. Due to increased awareness, more laboratories are routinely testing all stool specimens for sorbitol-negative E. coli. Lack of sorbitol fermentation in E. coli is a biochemical marker for the O157:H7 type. The ISDH Laboratory provides free confirmation services for all sorbitol-negative E. coli isolates.

E. coli-1

Generally, incidence was greatest during the summer months as shown in E. coli-2.

E. coli-2

There was little difference in rates of E. coli O157:H7 infection by sex. Differences by race could not be calculated due to small numbers of cases reported in the non-white population. Age-specific rates were greatest among children aged one to four (4.9) (See E. coli-3). Younger children are more likely to show poor personal hygiene and are often more susceptible to serious infection and complications, and may be more likely to be seen by a physician when they have a diarrheal illness.

E. coli-3

Indiana recorded its first documented outbreak of E. coli O157:H7 in 1996, which occurred in Blackford County. The outbreak, which occurred primarily among students in an elementary/middle school complex is described in more detail in the Appendix.

Prevention of gastroenteritis due to E. coli O157:H7 is achieved through adequate cooking of meat (especially hamburger) and pasteurization of milk, good hand washing practices during food handling, as well as avoidance of cross contamination of foods with raw animal products. Transmission in day care centers can be avoided through exclusion of children with diarrhea and good everyday hand washing practices.

Three cases of hemolytic uremic syndrome (HUS) associated with E. coli O157:H7 infections were reported in Indiana during 1996. All three cases occurred in children under the age of five and all survived. HUS afflicts mostly children of preschool age and can cause kidney failure and death.

Cases = 871

Crude rate (per 100,000 population) = 15.7

Age-adjusted race-specific rates (per 100,000 population)

White = 10.4

Nonwhite = 5.7

Sex-specific rates (per 100,000 population)

Female = 14.9

Male = 16.1

Giardiasis is a flagellate protozoan infection transmitted most commonly by ingestion of cysts in fecally contaminated water and from person-to-person by hand-to-mouth transfer of cysts from the feces of infected individuals.

Incidence has been steady during the past five years (Giardiasis-1).

The number of reported cases was highest during the summer and autumn months as shown in Giardiasis-2. The increase during warm weather months may indicate increased exposure to contaminated surface water during outdoor activities.

While the rate of giardiasis infection by sex was similar, the age-adjusted race-specific rate of giardiasis for whites was more than 1.8 times that for nonwhites.

Giardiasis-3 shows the age-specific rates were highest among children aged one to four years (41.8), followed by children age five to nine (16.8). Nationally, outbreaks of giardiasis have been occurring with more frequency in day care centers. Adults aged 30-39 years may have a higher incidence of disease than other adults because they are more likely to be parents of infected children.

Crude incidence rates of giardiasis were highest in Tipton (62.0), St. Joseph (55.9), and Steuben (43.7) counties.

In 1996, there was one outbreak of giardiasis reported in a St. Joseph County day care center which was attributed to person-to-person transmission.

Cases = 377

Crude rate (per 100,000 population) = 6.8

Age-adjusted race-specific rates (per 100,000 population)

White = 5.7

Nonwhite = 5.3

Sex-specific rates (per 100,000 population)

Female = 5.3

Male = 8.3

Hepatitis A is a viral disease most commonly transmitted from person to person via fecally-contaminated hands, food, water, or other objects.

In 1996, hepatitis A incidence in Indiana increased to its highest level in two years as shown in Hepatitis A-1.

There was little difference in the rate of hepatitis A infections by race. Men were 1.6 times more likely to become infected than females. The age-specific incidence was highest among adults aged 30 to 39 years (10.2) and adults aged 20 to 29 (8.9) (Hepatitis A-2). Children under the age of five are less likely to be reported than adults because they are less likely to be symptomatic. In November, an outbreak in a Sullivan County elementary school accounted for the elevated rate in children aged 5 to 9. A single point source was not identified; the outbreak was exacerbated by person-to-person transmission.

There was no clear seasonal trend although the number of reported cases was greatest during the winter months of November (14%) and February (12%) (Hepatitis A-3).

Sullivan (121.1), Bartholomew (67.6), and Vanderburgh (30.3) counties had the highest crude incidence rates of Hepatitis A in 1996. Both Bartholomew and Vanderburgh counties were still experiencing propagated community outbreaks which had begun in 1995. Sullivan County, in addition to the outbreak mentioned above, also experienced a propagated community outbreak which began during the summer of 1996. One foodborne outbreak of hepatitis A occurred in Hamilton County. This outbreak is summarized in Appendix D.

Approximately one-third of the interviewed cases had been in contact with a known case of hepatitis A. Of the more common risk factors for hepatitis A, exposures to day care centers, international travel, having multiple sexual partners, and male homosexual contact were more common among cases than intravenous drug use, and eating raw shellfish. Twenty-two (7%) of the interviewed cases were employed as food handlers during their infections. Reported Risk Factors for hepatitis A are shown in Hepatitis A-4.

Risk factor for infection/ transmission of hepatitis A Number (%*)

* Percent of 298 cases who were interviewed. Multiple risk factors possible.

Cases = 593

Crude rate (per 100,000 population) = 10.7

Age-adjusted race-specific rates (per 100,000 population)

White = 7.2

Nonwhite = 7.6

Sex-specific rates (per 100,000 population)

Female = 10.6

Male = 10.6

Salmonellosis is a bacterial disease usually transmitted through raw or undercooked foods of animal origin or foods cross contaminated by animal products or feces. It can also be transmitted person-to-person.

Salmonellosis-1 shows the distribution of serotypes of Salmonella cultured from initial and reference specimens submitted to ISDH Enterics Laboratory.

There are over 2300 different Salmonella serotypes that differ in somatic and flagellar antigens. During 1996, serotype was determined for 90% of the reported Salmonella cases. Of the 531 Salmonella isolates of known serotype, 140 (26%) were typhimurium, 116 (22%) enteritidis, 37 (7%) heidelberg, 21 (4%), java, and 217 (41%) were other serotypes.

Incidence of salmonellosis in Indiana decreased slightly in 1996 with 593 cases being reported (Salmonellosis-2).

The incidence was greatest during the summer months as shown in Salmonellosis-3.

There was little difference in the rates of salmonellosis by race or sex. Overall age-specific rates were greatest among infants (66.3) followed by preschoolers (15.6) as illustrated in Salmonellosis-4.

Among counties with at least 5 reported cases, crude incidence rates of salmonellosis were greatest in Jasper (32.1), LaPorte (23.4), and Knox (22.6) counties.

One outbreak of Salmonella Group C was reported in 1996. The Knox County outbreak occurred in May and was associated with VFW dinner. At least three cases were identified, but no food source ever implicated.

During the summer of 1996, at least one reported case of reptile-associated salmonellosis occurred in a two week old Johnson County infant who contracted the illness from an iguana which had been awarded as a prize at a county fair. The parents of the child received no precautionary information along with their prize to warn them of the potential health hazards associated with their new pet. Though legal, the ISDH strongly discourages the practice of awarding reptiles as prizes. At the very least, information should be distributed to every new reptile owner detailing the potential for Salmonella transmission and precautions which should be taken to prevent disease transmission.

Cases = 161

Crude rate (per 100,000 population) = 2.9

Age-adjusted race-specific rates (per 100,000 population)

White = 1.7

Nonwhite = 3.3

Sex-specific rates (per 100,000 population)

Female = 3.4

Male = 2.5

Shigellosis is a bacterial disease usually transmitted from person-to person through hands contaminated with feces. It can also be transmitted through food and water contaminated with human feces, or oral-anal sexual practices.

There are four Shigella species, all of which infect only humans. Only 10-100 organisms must be ingested to establish an infection. Of the 131 Shigella isolates of known serotype, 112 (85%) were S. sonnei and 19 (15%) were S. flexnerii.

Shigellosis incidence in Indiana has been decreasing steadily for the past three years following 1993, a year in which the incidence of shigellosis was particularly high (Shigellosis-1).

Incidence of shigellosis followed no particular seasonal pattern but most cases occurred during the summer and winter months (Shigellosis-2).

The incidence rate was higher for females (3.3) than for males (2.4). The age-adjusted race-specific rate of shigellosis was almost two times greater for nonwhites than whites.

Age-specific rates were highest among children aged one to four years (7.6), followed by children aged five to nine years (5.6) as shown in Shigellosis-3. These high age-specific rates of shigellosis among preschool-aged and elementary school aged children represent the increasing problem of shigellosis outbreaks in day care centers and certain segments of elementary schools, primarily up through first graders.

Crude incidence rates of shigellosis were greatest in Clark (23.9), and Monroe (11.9) counties.

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