Rapport hebdomadaire des Canada Diseases maladies au Canada

Rapport  hebdomadaire  des Canada Diseases maladies  au  Canada
Rapport hebdomadaire des f)J
.J/\N 11 1904
maladies au Canada
Canada Diseases
Weekly Report
Date of publication:
Date de publication:
ISSN 0382-232X
An Outbreak of Salmonella typhimurium
Gastroenteritis in a Hospital Staff - Ontario •
Salmonella typhimurium Outbreak in an Acute
Care Hospital - British Columbia
Annoucement. • • • • • • • • • • . • • •
December 24, 1983
24 decembre 1983
Une poussee de gastro-enterite a Salmonella
typhimurium parmi le personnel d'un hopital ·ontario • . • • • • • • • • , • • •
Poussee de Salmonella typhimurium dans un
Mpital d'aigus - Colombie-Britannique
Avis • . • • • • • • . • • • . • •
From 17 June to 25 June 1983, an outbreak of
Salmonella typhimurium gastroenteritis occurred on the
Westminster Campus, Victoria Hospital Corporation,
London, Ontario.
Although the number of confirmed
cases was small, 9 in total, the way in which this outbreak
was detected emphasizes the importance of close communication with the local Medical Officer of Health.
Du 17 au 25 juin 1983, une poussee de gastro-enterite a
Salmonella typhimurium est survenue sur le campus
Westminster, de la Victoria Hospital Corporation a London,
en Ontario. Meme si le nombre de cas confirmes a ete faible,
9 au total, la fai;on dont cette poussee a ete decel8e illustre
!'importance d'une liaison etroite avec le medecin-hygieniste
On 17 June, a laboratory technologist from the
microbiology department developed crampy abdominal
pain and diarrhea. A stool sample submitted at that time
was positive for Salmonella typhimurium. Because this
was an isolated incident no action was taken. On 22 June,
a patient in the hospital developed diarrhea; her stool
specimen was also positive for Salmonella typhimurium.
This patient was on the rehabilitation ward and frequently
left the hospital on day passes. On these days she would
obtain her meals at fast-food outlets; in the hospital she
ate in the cafeteria. No other patients were symptomatic
so this was considered another isolated incident and no
action was taken.
Le 17 juin, un technologue du laboratoire du service de
microbiologie eprouve une douleur abdominale crampo"ide et
fait de la diarrhee. Un specimen coprologique soumis a ce
moment se revele positif a l'egard de Salmonella
typhimurium. Comme ii s'agit d'un incident isole, aucune
mesure n'est prise. Le 22 juin, une patiente de l'h8pital
presente de la diarrhee; son specimen coprologique est egalement positif a l'egard de Salmonella typhimurium. Cette.
malade est traitee dans la· section de readaptation et quitte
souvent l'hOpital munie d'une permission de jour. Lorsqu'elle
sort, elle prend ses repas dans des restaurants-minute; a
l'h8pital, elle frequente la cafeteria. Aucun autre malade
n'etant symptomatique, on conclut qu'il s'agit d'un autre
incident isole et aucune mesure n'est prise.
On the morning of 28 June, a nursing orderly was
informed by hi.s physician that a stool culture obtained
l week previously was positive for Salmonella.
orderly notified the Employee Health Services stating
that the onset of his symptoms had been on 18 June. He
had been off sick since that time with the exception of 22
and 23 June when he worked the evening shift, He had
not had any contact with the positive patient during these
2 shifts.
Le matin du 28 juin, un aide-infirmier apprend de son
medecin que sa coproculture obtenue une semaine auparavant
est positive a l'egard de Salmonella. L'aide previent !es
Services de sante des employes en · precisant que ses
symptomes ant commence a se manifester le 18 juin. II a ete
absent depuis !ors a !'exception des 22 et 23 juin lorsqu'il a
travaille avec l'equipe du soir. 11 n'a pas eu de contact avec
la patiente positive pendant ces deux pastes.
Later that morning, another employee from administration reported that he had developed diarrhea on 18
June, and that he had just been notified that his stool
culture was also positive for Salmonella.
Plus tard ce matin-la, un autre employe de !'administration signale avoir fait de la diarrhee le 18 juin et declare
qu'on vient de la prevenir que sa coproculture est positive a
l'egard de Salmonella.
Because all of the cases had occurred in people at l
Campus and at about the same time, a check was made.of
the hospital staff sick leave records to search for more
cases. Two (2) other possible cases were identified:
Comme taus ces cas surviennent chez des gens du meme
campus, a environ la meme periode, on verifie les registres
des conges de maladie du personnel hospitalier pour y deceler
d'autres cas. On decouvre 2 autres cas possibles: une
- 205 Health and Welfare
Sante et Bien-et re social
administrative secretary who had been off work for 1 week
and a secretary from a different area of the hospital who
, had been sick with diarrhea but had not sought medical
attention. The administrative secretary had consulted her
physician but despite the fact that her presenting complaint
had been diarrhea, he had not ordered a stool culture. Both
of these people ate lunch together the day before onset of
symptoms. Neither had informed Employee Health Services
of the nature of their illness.
secretaire de !'administration qui s'est absentee pendant une
semaine et une secretaire d'une autre partie de l'hllpital, qui a fait
de la diarrhee mais n'a pas consulte de medecin. La premiere a vu
son medecin qui n'a pas demande de coproculture meme si elle s'est
plainte de diarrhee. Ces deux personnes avaient dejeune ensemble
le jour precedent !'apparition des symptllmes. Ni l'une ni l'autre
n'avaient prevenu les Services de sante des employes de la nature de
leur maladie.
Because many of these cases had not submitted
specimens to the hospital laboratory for analysis, the
Medical Officer of Health was informed and a search was
made of the Health Unit's records for any other hospital
employees who had been reported as positive for Salmonella
from other laboratories. Two (2) additional cases were
discovered; 1 was a part-time physiotherapist and the other
was a man whose wife worked on the Westminster Campus
where he often joined her for lunch. Although asymptomatic, the wife was asked to submit a stool sample which
was positive for Salmonella typhimurium. One other
employee who had been off sick reported back to work. He
had had diarrhea and his stool culture was positive for
Comme plusieurs de ces cas n'ont pas soumis de specimens au
laboratoire de l'hllpital a des fins d'analyse, on previent le medecinhygieniste et les dossiers de l'unite sanitaire sont passes en revue
afin de deceler tout autre employs d'hllpital qui aurait ete diagnostique positif a l'egard de Salmonella par d'autres laboratoires. On
decouvre 2 cas supplementaires: l'un est physiotherapeute a temps
partiel et l'autre, un homme dont la femme travaille sur le campus
Westminster ou it la rejoint souvent pour dejeuner. Meme si elle est
asymptomatique, on demande a celle-ci de soumettre un
prelevement coprologique qui se revele positif a l'egard de
Salmonella typhimurium. Un autre employs qui s'est absents pour
cause de maladie revient au travail. Il a fait de la diarrhee et sa
coproculture est positive a l'egard de Salmonella.
From the information gathered, it was apparent that
the onset was clustered around a short time period. The
only common factor was that all cases had been eating in
the cafeteria. Further investigation revealed that the food
prepared and served in the cafeteria is all done by 1 staff
group. Food for the patients is not prepared by this group.
11 ressort de !'information recueilli que Jes symptllmes ant
commence a se manifester sur une tres courte periode. Le seul
facteur commun etait la consommation, par taus les cas, d'aliments
a la cafeteria. D'autres recherches ont revel8 que la nourriture
preparee et servie a la cafeteria relevait d'un groupe d'employes qui
ne preparai t pas !es rep as des malades.
All storage, preparation and handling of cafeteria food
was being carried out using standard protocols. An ice
cream refrigerator was found to be malfunctioning and the
contents were removed to prevent cafeteria users from
eating potentially spoiled material. The ice cream was
found negative for Salmonella; however, not all of the cases
had eaten ice cream. Some food items available in the
cafeteria are purchased from commercial caterers.
Moreover, there was no one food that had been eaten by all
of the infected individuals.
Toutes !es operations d'entreposage, de preparation et de manipulation de la nourriture de la cafeteria se faisaient selon des
methodes normalisees. Un r8frigerateur a creme glacee qui ne
fonctionnait pas a ete vide pour ne pas que Jes usagers de la
cafeteria consomment d'aliments possiblement avaries. La creme
glacee etait negative a l'egard de Salmonella mais les malades n'en
avaient pas taus consommee.
Certains aliments vendus a la
cafeteria sont achetes de traiteurs de l'exterieur. De plus, les
personnes contaminees n'avaient pas consomme d'aliment commun.
When the outbreak was confirmed on 30 June, several
measures were instituted based on the assumption that the
common source of infection was the hospital cafeteria.
These measures included the following: only hot food was to
be prepared and served in the cafeteria until further notice,
all cafeteria staff were to submit 3 consecutive stool
samples for culturing, any other staff members becoming ill
with gastroenteritis were to report to the Employee Health
Services to have stool cultures done, there was to be
continued close communication between the Medical Officer
of Health and the hospital to identify any cases in
employees whose samples were submitted to other laboratories, all positive cases or suspected cases were to submit
samples to the hospital laboratory to allow isolation and
typing of the Salmonella and subsequent follow-up on
positives to identify any persistent carriers, and an
education program reinforcing proper food handling and
handwashing techniques was to be provided for dietary
The stools from the dietary staff were all
negative for Salmonella. There were no new cases found
and no chronic carriage occurred in the identified positive
cases. All of the isolates were S. typhirnurium.
Lorsque la poussee a ete confirmee le 30 juin, plusieurs mesures
ant ete prises en supposant que la source commune de !'infection
etait la cafeteria de l'Mpital. Voici certaines des dispositions qui
ant ete prises: la cafeteria ne devait preparer et servir que de la
nourriture chaude jusqu'a nouvel ordre; tout le personnel de la
cafeteria devait soumettre 3 specimens coprologiques consecutifs a
des fins de culture, tout autre membre du personnel souffrant de
gastro-enterite devait prevenir les Services de sante des employes
pour faire analyser ses selles, le medecin-hygieniste et l'hllpital
devaient demeurer en etroite liaison pour reperer !es cas chez !es
employes dont !es prelevements avaient ete soumis a d'autres
laboratoires, taus les cas positifs ou soupi;:onnes de l'etre devaient
soumettre des specimens au laboratoire de l'hopital en vue de
l'isolement et du typage de Salmonella et du suivi subsequent des
sujets positifs pour reperer tout porteur persistant et enfin, un
programme d'education visant a insister sur les methodes correctes
de manipulation des aliments et !'importance de bien se !aver les
mains devait etre fourni au personnel des services de dietetique. Les
setles des employes de ce groupe etaient toutes negatives a l'egard
de ·salmonella. Aucun nouveau cas n'a ete decele et aucun cas
positif identifie n'est devenu porteur permanent. Taus !es isolats
etaient de s. typhimurium.
It is not unusual for small outbreaks of salmonellosis to
occur and in many instances a common source is implicated
by epidemiological data. However, frequently the actual
source cannot be found as was the case in this outbreak.
De petites poussees de salmonellose surviennent couramment et
ii arrive souvent que !es donnees epidemiologiques reve!ent une
source commune. It arrive cependant frequemment que la source
reetle ne puisse 13tre decelee comme ce fut le cas pour cette
- 206 -
This report indicates that outbreaks of Salmonella ·
Ce rapport indique que Jes poussees de gastro-enterite a
gastroenteritis in institutions which would normally go unno- Salmonella qui surviennent dans Jes institutions et qui passeraient
ticed can be documented even though the infected individual normalement inapergues peuvent etre documentees meme si la
may be seen by different health care providers. Close personne touchee est vue par differents specialistes de Ia sante.
communication with the Medical Officer of Health, the Dans ces cas, une liaison etroite entre le medecin-hygieniste, le
Infection Control Officer and Employee Health Services is responsable de la lutte contre !'infection hospitaliere et !es Services
very important in such instances.
de sante des employes peut etre tres importante.
R Lannigan, MDC M, Director, Clinical Microbiology, Z Hussain, MD, Assistant Medical
Microbiologist, D Kingdom, RN, Occupational
Health and Safety Officer, Victoria Hospital
Corporation; N Tuttle, MD, Associate Medical
Officer of Health, Middlesex-London District
Health Unit, London, Ontario.
Dr R Lannigan, MC, Directeur de la microbiologie
clinique, Dr Z Hussain, Microbiologiste medical adjoint,
D Kingdom, IA, Responsable de l 1hygiene et de la securite du travail, Victoria Hospital Corporation;
Dr N Tuttle, Medecin-hygiemste ad1omt, Omte samtaire du district de Middlesex-London, London
On 27 Decer:nber 1982, the infection control nurse at
Le 27 decembre 1982, l'infirmiere responsable de la lutte contre
St. Paul's Hospital, an acute care tertiary referral teaching !'infection hospitaliere de l'ht'lpital Saint-Paul, ht'lpital tertiaire d'enhospital in Vancouver, was informed that there were 3 seignement et de recours pour aigus a Vancouver, apprend que trois
patients on l medical ward who were positive for patients d'une section medicate sont positifs a l'egard de Salmonella.
Salmonella. Surveillance and laboratory reports promptly Les rapports de surveillance et de laboratoire etab!issent sans tarder
established that there were no other cases in the hospital. qu'il n'y a pas d'autres cas dans l'hi'lpital. Cependant, les dossiers de
However, laboratory records revealed that there had been laboratoire revelent qu'une autre patiente de Ia section avait
another patient on that ward with a Salmonella typhimurium souffert d'une infection a Salmonella typhimurium des voies uriurinary tract infection.
This particular patient was a naires. II s'agit d'une diabetique qui a ete admise le 13 decembre et
diabetic who had been admitted on 13 December with qui presentait des sympti'lmes de confusion et d'incontinence uriconfusion and urinary incontinence and discharged on 21 naire. Elle est sortie le 21 decembre sans que le medecin traitant
December without the attending physician or the nursing ou le personnel infirmier ne connaisse la nature de l'iso!at. Elle a
staff being aware of the nature of the isolate. She had partage une chambre avec l'un des trois sujets positifs et est
shared a room with 1 of the 3 positive patients and is consideree etre le cas de reference.
considered to be the index case.
Measures to contain the outbreak were immediately
taken. The 3 positive patients were placed in private rooms
on enteric precautions. The importance of using proper
handwashing techniques was re-emphasized. Admission to
the ward was restricted to exclude diabetics, patients who
required antibiotics especially ampicillin or penicillin, and
patients with marked arteriovascular disease. Nurses were
asked to send stools for culturing from all patients with
diarrhea. The next day the private duty nurse who had
attended the roommate of the index case reported that she
had been ill for 1 week with diarrhea and vomiting. A stool
specimen from this nurse yielded Salmonella. Two (2) more
patients were found with diarrhea and Salmonella was
isolated from their stools. Both of these patients are
believed to have acquired the infection before precautions
were instituted.
Des mesures sont prises aussitt'.lt pour contenir la poussee. Les
3 patients positifs sont places en charilbres privees sous surveillance
intestinale. On insiste de nouveau sur !'importance de bien se !aver
!es mains en Iimitant !'admission dans la section de maniere a
exclure les diabetiques, !es malades qui ant besoin d'antibiotiques,
surtout d'ampicilline ou de penicillins, et !es malades souffrant de
troubles arterio-vasculaires importants. On demande au personnel
infirmier d'envoyer a des fins de culture, les specimens coprologiques de tous !es malades qui font de la diarrhee. Le jour suivant,
l'infirmiere de service prive qui a pris soin de la compagne de
chambre du cas de reference signale avoir ete malade pendant une
semaine et avoir presents de Ia diarrhee et des vomissements. Un
specimen coprologique de cette infirmiere met en evidence
Salmonella. On decouvre 2 patients de plus qui font de la diarrhee
et on isole Salmonella de leurs selles. On croit que ces patients
auraient contracts !'infection avant la prise des mesures speciales.
Taus les iso!ats sont resistants a l'ampicilline (40 µg). II sont
All isolates were resistant to ampicillin 40 µg. They
were all identified as S. typhimurium with 1 exception: taus, a une exception pres, identifies comme etant S. typhimurium:
S. saint-paul had been initially isolated from the urine of 1 S. saint-paul est isole, au debut, de l'urine d'un des trois sujets
of the first 3 positive patients. This indicated the co- positifs, II y a done eu coexistence d'une autre espece de Salmonella
existence of another species of Salmonella which was not qui ne s'est pas propagee pendant la poussee. Taus les patients sauf
disseminated in the outbreak. All patients except the index le cas de reference avaient regu de l'ampicilline (4) ou de la
case had received ampicillin (4) or penicillin (1) prior to the penicilline (1) avant !'apparition des symptomes. Dans le cas de la
development of symptoms. In the case of the S. saint-paul patiente contaminee par s. saint-paul, ses cultures d'urine precepatient, preceding urine cultures had been positive for dentes avaient ete positives a l'egard de Streptococcus faecalis; !ors
Streptococcus faecalis; on ampicillin therapy this was repla- de la therapie a l'ampicilline, cette souche a ete remplacee par
Escherichia coli
later Escherichia coli resistant a l'ampicilline accompagne plus tard de
accompanied by Salmonella. S. saint-paul was subsequently Salmonella. S. saint-paul a ete identifie par la suite dans ses selles;
recovered from her stool; she must have entered the cette patiente a dQ entrer a l'hi'lpital comme porteuse tecale.
hospital as a fecal carrier. Four (4) of the 6 patients had Quatre (4) des 6 patients souffraient de diabete. Un des deux
diabetes. One of the 2 non-diabetic patients was seriously malades non diabetiques etait gravement malade et etait traits a
ill and on multiple antibiotics for prosthetic valve !'aide d'antibiotiques multiples pour une endocardite liee a une valve
endocarditis and pneumonia; the other was the roommate of prothetique et une pneumonie; l'autre etait la compagne de chambre
the index case whose nurse was also infected.
Most du cas de reference dont l'infirmiere avait aussi ete contaminee. II
probably these 2 close contacts of the index case had est fort probable que ces deux contacts etroits du cas de reference
received a large infective dose. Four (4) of the 6 patients avaient regu une dose infectieuse importante. Quatre (4) des 6
patients et l'infirmiere ont fait de la diarrhee pendant environ une
and the nurse had diarrhea for approximately 1 week.
- 207 -
Negative stool cultures were obtained from 2 patients
and the nurse within l month. One patient, an elderly
diabetic, was discharged home after being free of diarrhea
for 3 weeks but her stools were still positive for Salmonella.
The roa°mmate of the index case was to be transferred to a
nursing home but this could not be done until her stools were
negative for Salmonella which took 7 months (stool specimens were tested weekly). The last patient died. At
autopsy Candida and Salmonella were isolated from the
heart valve, lungs, kidneys, and CFS despite the fact that
the patient had been on tobramycin to which the Salmonella
had been susceptible in vitro.
Des cultures coprologiques negatives ant ete obtenues de 2
malades et de l'infirmiere dans le mois qui a suivi. Une patiente,
une personne €!gee diabetique, est sortie de l'hopital 3 semaines
apres avoir cesse de faire de la diarrhee mais ses selles etaient
encore posi~ives a l'egard de Salmonella. La compagne de chambre
du cas de reference devait l?ltre transferee dans une maison de repos
mais ii ne pouvait €ltre question de le faire tant que ses selles ne
devenaient pas negatives a l'egard de Salmonella, ce qui pris 7 mois
(on a verifie ses prelevements coprologiques toutes !es semaines).
Le dernier patient est decede. A l'autopsie, Candida et Salmonella
ant ete isoles des valvules cardiaques, des poumons, des reins et du
LCR en depit du fait qu'il avait ete traite a la tobramycine a
laquelle !es Salmonella etaient sensibles in vitro.
This outbreak which involved 6 patients and a private
duty nurse was fortunately confined to l ward. Cross
infection probably occurred before the index case was
discovered. It is unusual to have an outbreak like this on a
medical ward in an acute-care hospital.
No doubt, a
combination of circumstances such as breaks in hospital
techniques because of Christmas celebrations and staff
shortages, and susceptible patients with diabetes on antimicrobial therapy contributed to the outbreak. It was the first
and only incident to date of nosocomial salmonellosis in this
ins ti tu ti on.
Cette poussee qui a atteint 6 patients et une infirmiere du
service prive s'est heur('lusement limitee a une section de l'hopital.
L'infection croisee est probablement survenue avant la decouverte
du cas de reference. II est rare qu'une poussee comme celle-la se
produise dans une section medicale d'un hopital d'aigus. Nu! doute
qu'un ensemble de circonstances comme des interruptions de l'activite hospitaliere a cause des celebrations de No!!! et du manque de
personnel, et la presence de diabetiques receptifs faisant l'objet
d'une therapie antimicrobienne ant contribute a la poussee. II s'agit
du premier incident de salmonellose nosocomiale a survenir dans cet
E Crichton,
St. Paul's
Dr E Crichton, Microbiologie medicale,
Saint-Paul, Vancouver (Colombie-Britannique).
19-20 JLL Y, 1984
LES 19 ET 20 JUILLET 1984
This symposium will have a broad scope and will include
an international review of the Salmonella situation from all
major aspects of food-animal production and meat and
poultry processing as well as public health. Objectives will
include the identification of practical methods and approaches to prevent or reduce infections in the major foodanimal populations and contamination of food products
derived from them, an assessment of the usefulness of
various national and regional regulatory programs for controlling Salmonella and the impact of Salmonella on world
trade, and the development of an international understanding of the approaches that are useful to contain the
worldwide problem posed by Salmonella.
Ce symposium d'une vaste portee fera le tour d'horizon de la
situation internationale en matiere de salmonellose; on y traitera de
taus [es principaux aspects de ce probleme touchant a la production
des animaux de boucherie et au· traitement des viandes et de la
volaille aussi bien qu'a !'hygiene publique.
Les objectifs fixes
porteront notamment sur l'etablissement de methodes et d'approches
pratiques Visant a empl3cher OU a redt!ire Jes infections dans les
populations importantes d'animaux de boucherie et la contamination
des produits qui en sont tires, sur !'evaluation de l'efficacite de
diffe::ents programmes nationaux et regionaux de reglementation
destines a enrayer la salmonellose et des repercussions de la maladie
sur le commerce international, et enfin, sur !'elaboration d'une
entente internationale concernant !es approches qui permettraient
de limiter Jes problemes que cause la salmonellose a !'echelon
A limited number of papers will be accepted based on
abstracts submitted to the general chairman by 30 January
Le nombre des exposes etant limite, veuillez faire parvenir vos
resumes au president general avant le 30 janvier 1984.
For further information contact Dr. G.H. Snoeyenbos,
General Chairman, ISOS, Paige Laboratory, University of
Massachusets, Amherst, MA 01003 U.S.A.
Pour plus ample information, n'hesitez pas a contacter le
or G.H. Snoeyenbos, President general du colloque international sur
la salmonellose, Laboratoire Paige, Universite du Massachusets,
Amherst, MA 01003, E:.-U.
The Canada Diseases Weekly Report presents current information on Infectious
and other diseases for surveillance purposes and is available free of charge upon
request. Many of the articles contain preliminary information and further
confirmation may be obtained from the sources quoted, The Department of
National Health and Welfare does not assume responsibility for accuracy or
authenticity. Contributions are welcome (in the official language of your
choice) from anyone working in the health field and will not preclude
publication elsewhere.
Le Rapport hebdomadaire des maladies au Canada, qui fournlt des dannees pertinentes sur
les maladies infectieuses et les autres maladies dans le but de faciliter leur surveillance,
peut Atre obtenu gratuitem~nt sur demande. Un grand nombre d'articles ne cqntlennent
que des donn~es sommaires mais des renseignements complementaires peuvent @tre
obtenus en s'adressant aux sources citees. Le minist~re de la Sant~ nationale et du BienBtre social ne peut etre tenu responsable de !'exactitude, ni de Pauthentlcite des articles.
Toute personne oeuvrant dans le dornaine de la sante est invitee ·a collaborer (dens Ja
langue officielle de son choix) et la publication d'un article dans le present RappQrt n'en
empQche pas la publication ailleurs.
Editor: Dr. S.E. Acres
Managing Editor: Eleanor Paulson
Assistant Editor: Jo-Anne Doherty
Redacteur en chef: Dr S.E. Acres
Redacteur administratif: Eleanor Paulson
Redacteur adjoint: Jo-Anne Doherty
Bureau of Epidemiology,
Laboratory Centre for Disease Control,
Tunney1s Pasture,
OTTAWA, Ontario.
Canada. KlA OL2
(613) 996-4041
Bureau d'epidemiologie
Laboratoire de lutte contre la maladie
Pare Tunney
Ottawa (Ontario)
Canada Kl A OL 2
(613) 996-4041
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