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ISSN 1188-4169
Canada Communicable
Disease Report
Date of publication: 31 July 1992
Releve des maladies
transmissibles au Canada
Vol. 18-14
Contained in this issue:
Date de publication: 31 juillet 1992
Contenu du present numero :
Non-01 Vibrio cholerae Enterocolilis In Quebec Tourists Returning
from the Dominican Republic .
. . . . . .
Cholera and International Air Travel
. . . . .
Gastrointestinal Illness Associated with Drinking Well Water
Delivered by Tank Truck During a Period of Drought· Nova Scotia
Enterocollte a Vibrio cholerae non-01 chez des tourlstes Quebecois revenant
de Republlque Dominlcaine . . . . . . . . . . . . .
Cholera et transport aerlen International . . . . . . . . . .
Gastro·enterlte assoclee ala consommatlon d'eau de pulls llvree par
camlon·citeme durant une periods de secheresse • Nouvelle·Ecosse
Non-01 Vibrio cholerae is a known etiological agent of bacterial
enterocolitis0.2>. The clinical spectrum of infections caused by this
bacterium varies from a mild diarrheal syndrome to bloody or febrile
diarrhea to a clinical picture of cholera or extra-intestinal
infection< 1•2•3>. Non-01 Vibrio cholerae is rarely isolated in stool
cultures in Canada. Generally the bacterium is acquired outside of the
country in known endemic areas, such as American and Mexican
states along the Gulf of Mex.ico<l.3l. Only one case presumed
indigenous to Canada appears to have been diagnosed but little
information is currently available to assess this<4>. The following is a
report on 2 cases of severe enterocolitis in Quebec residents who had
travelled to the Dominican Republic.
Vibrio cholerae non-01 est un agent etiologique reconnu de l'enterocolite
bacterienne<1.2>. Le spectre clinique des infections causees par cette bacterie
varie d'un syndrome diarrheique Jeger a une diarrhee sangJante OU febrile et a
un tableau de cholera ou aune infection extra-intestinale< 1•2·3>. Vibrio cholerae
non-01 est rarement isole dans !es coprocultures au Canada. Cette bacterie
s'acquiert habituellement al'exterieur du pays dans des regions endemiques
connues, comme !es etats americains et mexicains bordant le Golfe du
Mexiquel Cl.3>. Un seul cas presume indigene au Canada aurait ete
diagnostique, mais peu d'informations sont presentement disponibles pour
evaluation<4>. Nous presentons 2 cas d'enterocolite severe chez des voyageurs
quebecois ayant sejourne en Republique Dominicaine.
Case 1
A 34-year-old man consulted his physician for diarrhea. His
general health was good and he had no unusual medical or surgical
history. The patient had just spent 2 weeks in the Dominican
Republic. While there he had only eaten well-cooked fish once and
had never eaten any other seafood or raw oysters. Early in the second
week of his stay he developed a spiking fever of 38.5°C accompanied
by anorexia and asthenia. At the same time he developed intense
abdominal cramps preceding each of the 10 or 12 daily stools. He had
no nausea or vomiting, and reported no blood in his stools. The
symptoms had persisted for 17 days when he was referred to the
Wectious Disease Clinic at Sacre-Coeur Hospital in Montreal in
September 1990.
Un homme de 34 ans consulte son medecin pour diarrhee. Il jouit en
general d'une bonne sante et ses antecedents medicaux-chirurgicaux sont sans
particularite. II revient d'un sejour de 2 semaines en Republique Dominicaine
ou ii a consomme du poisson bien cuit a une occasion, mais n'a mange ni
fruits de mer ni huitres crues. Au debut de la deuxieme semaine de son
sejour, ii commence a faire des poussees de fievre a38,5 °C accompagnees
d'anorexie et d'asthenie. En meme temps apparaissent des douleurs
abdominales crampiformes intenses qui precedent chacune des 10 a 12 selles
liquides quotidiennes. n n'a pas de nausee ni de vomissement, et ii ne
remarque pas de sang dans ses selles. Les symptomes persistent depuis 17
jours quand ii est adresse a la clinique de maladies infectieuses de l'Hopital du
Sacre-Coeur, en septembre 1990.
Examination showed a well-hydrated man, with an abdomen that
was diffusely sensitive but with no guarding. There was no
visceromegaly. The rest of the examination was normal. Stool culture
indicated the presence of Vibrio cholerae and the Quebec Public
Health Laboratory later identified this as non-01 Vibrio cholerae. A
disk diffusion test established sensitivity to the following antibiotics:
ampicillin, tetracyline, trimethoprim-sulfamethoxazole and
L' examen montre un homme bien hydrate. L' abdomen est sensible de
diffuse, mais ii n'y a pas de defense de la paroi. II n'y a pas de
visceromegalie. Le reste de I' examen est sans particularite. Une coproculture
montre la presence de Vibrio cholerae et le Laboratoire de sante publique du
Quebec specifie plus tard qu'il s'agit d'un Vibrio cholerae non-OJ. Une
epreuve de diffusion en disque etablit la sensibilite de la bacterie aux
antibiotiques suivants : ampicilline, tetracycline, trimethoprimesulfamethoxazole et ciprofloxacine.
Despite a specific diet for gastroenteritis, the symptoms persisted
and treatment was undertaken with a double dose of
trimethoprim-sulfamethoxazole twice daily. The patient's general
Les symptomes persistant malgre une diete pour gastroenterite, un
traitement est entrepris avec un comprime double dose de
trimethoprime-sulfamethoxazole 2 fois par jour. L'etat general du malade
I second Oass Moll Rogls•al'oo No.
Health and Welfare
I Ca.m1DI' do la daa:IOmo clam · Ervoglstr001ont n° 6670 I
Santa et Bien-etre social
condition improved and he became asymptomatic after 4 days of
antibiotic therapy, which was continued for a total of 7 days.
s'ameliore et ce dernier devient asymptomatique apres 4 jours
d'antibiotherapie, laquelle a dure 7 jours.
Deuxieme cas
This was a 28-year-old man with known HIV-positive status
since 1987. He was on antiretroviral therapy ( AZT 5 times a day)
plus pentamidine in aerosol form. From 22 December, 1990 to 5
January, 1991 he was in the city of Juan Dolios in the Dominican
Republic. Before his departure, he received a dose of diphtheria,
tetanus and polio vaccine in addition to regular gamma globulin for
hepatitis A. He also took 2 tablets once a week of AralenR
(chloroquine), starting the week prior to his departure, during his
stay, and 4 weeks after returning home.
II s'agit d'un homme de 28 ans dont la possitivite a!'anti-VIII est
connue depuis 1987 et qui est sous therapie anti-retrovirale (AZT 5 fois par
jour) et pentarnidine en aerosol. Du 22 decembre 1990 au 5 janvier 1991, ii
sejourne en Republique Dorninicaine dans la ville de Juan Dolios
exclusivement. Avant son depart, il a reyu un rappel des immunisations
contre la poliomyelite, la diphtene et le tetanos, ainsi que de la
gammaglobuline ordinaire contre l'hepatite A. De plus, ii a pris de
l'AralenR (chloroquine), a raison de 2 comprimes une fois par semaine,
commen~ant une semaine avant son depart et continuant durant le sejour et
Jes 4 semaines suivant son retour.
He reported no health problems during his stay except for a
slight sunstroke the first week. Three days after his return to
Canada, he developed marked diarrhea (5-8 stools a day) without
rectal pain and a temperature of 38°C. In response to a
questionnaire, the patient reported having consumed scampi on the
evening of his departure. These had been well cooked but had an
unusual taste. Examination of the patient did not contribute any
new information. Stool culture, investigation for ova and parasites
and for Cryptosporidium was carried out 3 times; hematology was
ordered and an antidiarrheal diet begun. A non-01 Vibrio cholerae
was isolated from the 3 stool cultures by the Saint-Luc Hospital
Laboratory according to a protocol for Aeromonas using an
non-specific medium. Identification was subsequently confirmed by
the Quebec Public Health Laboratory. This strain was sensitive to
ampicillin, trimethoprim-sulfamethoxazole and ciprofloxacin using
the disk diffusion method. Three subsequent stool samples still
demonstrated the presence of this enteric pathogen. A 5-day
treatment course with ciprofloxacin (500 mg twice a day) was
started 5 days after onset of symptoms and stools returned to
normal in less than 48 hours. Three stool cultures a week after the
treatment was stopped were negative.
Le voyageur ne decrit aucun probleme de sante pendant son sejour, si ce
n' est une insolation legere la premiere semaine. Trois jours apres son retour
au Canada, il presente des diarrhees importantes (5-8 par jour), sans
rectorragie, accompagnees d'une temperature de 38 °C. Un questionnaire
nous apprend que, la veille de son depart, le patient aurait consomme des
langoustines bien cuites, mais d'un goOt douteux sans autre particularite
culinaire. L'examen du voyageur est peu informatif. Des cultures de selles
et la recherche d'oeufs, de parasites et de Cryptosporidium sont effectuees
a3 reprises; un bilan sanguin est prescrit et une diete anti-diarrheique,
instauree. Un Vibrio cholerae non-01 est isole des 3 coprocultures par le
laboratoire de l'Hopital Saint-Luc, selon un protocole de recherche
d'Aeromonas sans milieu selectif specifique. L'identification est, par la
suite, confirmee au Laboratoire de sante publique du Quebec. La souche
isolee se revele sensible a I' ampicilline, au trimethoprimesulfamethoxazole et ala ciprofloxacine par Ia technique de diffusion en
disque. Trois echantillons subsequents de selles demontrent toujours la
presence de ce pathogene enterique. Un traitement de 5 jours ala
ciprofloxacine (500 mg BID) est instaure 5 jours apres le debut des
symptomes. On observe la normalisation des selles en moins de 48 heures
et 3 coprocultures faites une semaine apres Ia fin du traitement se revelent
Les Vibrio cholerae non-01 ont ete isoles par Jes 2 laboratoires
hospitaliers selon un protocole de recherche d' Aeromonas a partir de
The non-01 Vibrio cholerae organisms were isolated by the 2
hospital laboratories using a standard stool culture media protocol
for the investigation of Aeromonas. The selective and differential
medium recommended for investigation of vibrios was not used in
the 2 cases reported here. It seems, moreover, that thiosulfate
citrate bile salts sucrose (TCBS) agar is not essential for isolation of
vibrios provided that there is determination of the oxydase reaction
of Gram-negative rod colonies found on the blood agar<5>. Two
strains of non-01 Vibrio cholerae (one of these documented as
being ampicillin-resistant) have recently been isolated from
ampicillin blood agar used for the investigation of Aeromonas<
milieux usuels de culture de selles. Le milieu selectif et differentiel
recommande pour la recherche de vibrio, la gelose thiosulphate, citrate, sel
biliaire, gelose sucrose (TCBS), n'a pas ete utilise dans Jes 2 cas exposes
ici. TI semble d'ailleurs que la gelose TCBS ne soit pas essentielle a
l'isolement des vibrio si toutefois on determine la reaction a 1'oxydase des
colonies de batonnets a Gram negatif retrouvees sur Ia gelose au sang<5>.
Deux souches de Vibrio cholerae non-01 (dont une documentee comme
resistante al'ampicilline) ont recemment ete isolees a partir d'une gelose
sang-ampicilline utilisee pour la recherche d' Aeromonas<4>.
Non-01 Vibrio cholerae represents 27% of vibrio strains
submitted to CDC, Atlanta, and, consequently, is the most
frequently isolated vibrio in the United States<6>. The distribution of
these strains from stool and from extra-intestinal sites (40% from
blood) is roughly equal. The frequency of isolation of this
bacterium seems to be growing in that country<1•3>. Patients from
whom enteric strains of non-01 Vibrio cholerae were isolated in
the U.S. in 1979 had diarrhea lasting an average of 6.4 days,
abdominal cramps (93%), fever (71 %), nausea and vomiting (21 %),
and blood in the stool (25%)0.3>. This bacterium can be isolated
from the water and domestic animals in a number of countries. Raw
oysters are the vehicle most often associated with this enteric
infection when acquired in the U.S.; this is not the case with
infections acquired elsewhere<3>.
Vibrio cholerae non-01 represente 27 % des souches de vibrio
sou mises aux CDC d' Atlanta. II s' agit done du vibrio le plus frequemment
isole aux Etats-Unis<6>. Ces souches proviennent en quantite a peu pres
egale des selles et de sites extra-intestinaux (dont 40 % isolees du sang). La
frequence d'isolement de cette bactene semble etre ala hausse dans ce
pays<1•3>. Les patients chez qui des souches enteriques de Vibrio cholerae
non-01 ont ete isolees en 1979, aux Etats-Unis, presentaient une diarrhee
d'une duree moyenne de 6,4 jours, des crampes abdorninales (93 %), de la
fievre (71 %), des nausees et vomissements (21 %) et du sang dans Jes
selles (25 %)<1.3>. Cette bacterie peut etre isolee de l'eau et des animaux
domestiques dans plusieurs pays. Les huitres crues sont le vehicule le plus
frequemment associe avec cette infection enterique lorsqu'elle est acquise
aux Etats-Unis. Tel n'est pas le cas pour Jes infections acquises ailleursC3>.
There have been 11 strains of non-01 Vibrio cholerae
confirmed by the Quebec Public Health Laboratory in the past 11
years, 7 of these since 1986. The 2 strains reported here were
acquired in the Dominican Republic which has had very few reports
of this infection in the pastCl.3>.
Onze souches de Vibrio cholerae non-01 ont ete confirrnees par le
Laboratoire de sante publique du Quebec depuis 11 ans, dont 7 depuis
1986. Les 2 souches dont ii est question ici ont ete acquises en Republique
Dominicaine, pays ou cette infection a rarement ete signalee dans le
Investigation for oxydase-positive, Gram-negative rods in stool
cultures on blood agar is probably sufficient for vibrio investigation
for most laboratories in non-endemic zones. Most patients suffering
from non-01 Vibrio cholerae recover without specific antibiotic
therapy when fluid and electrolyte loss is replaced. More severe
infections, however, may necessitate antibiotic therapy. Indications
for antibiotic therapy and which one to use remain to be
La recherche de batonnets a Gram negatif, oxydase positifs, sur la
gelose au sang des coprocultures probablement une technique adequate de
mise en evidence de Vibrio pour la majorite des laboratoires en zone non
endemique. La plupart des malades souffrant d'enterocolite a Vibrio
cholerae non-01 guerissent avec le remplacement des pertes en eau et en
electrolytes sans antibiotherapie specifique. Cependant, certaines
infections plus severes peuvent necessiter une antibiotherapie. Les
indications de l'antibiotherapie et l'antibiotique a utiliser sont adeterminer.
1. Holmberg SD. Vibrio and Aeromonas. In: Infectious disease
clinics of North America. Philadelphia: WB Saunders
Company, 1988;2:655-76.
2. Carpenter CCJ. Other pathogenic Vibrios. In: Mandell GL,
Douglas Jr RG, Bennett JE, eds. Principles and practice of
infectious diseases. 3rd ed. New York: Churchill Livingstone,
1990: 1646-9.
3. Morris JG Jr, Wilson R, Davis BR, Wachsmuth IK, Riddle CF,
Wathen HG, et al. Non-0 group J Vibrio clwlerae
gastroenteritis in the United States. Ann Intern Med
1981 ;94:656-8.
4. Dalton MT, Haldane JM, Homer GW. Non-OJ Vibrio cholerae
-Nova Scotia. CDWR 1991;17:115-6.
5. Kelly MT, Hickman-Brenner FW, Farmer llI JJ. Vibrio. In:
Balows A, Hausler Jr WJ, Herrmann KL, Isenberg HD,
Shadomy HJ, eds. Manual of clinical microbiology. 5th ed.
Washington, DC: American Society for Microbiology,
6. Farmer ill JJ, Hickman-Brenner FW, Kelly MT. Vibrio. In:
Lennette EH, Balows A, Hausler Jr WJ, Shadomy HJ, eds.
Manual of clinical microbiology. 4th ed. Washington, DC:
American Society for Microbiology, 1985:282-301.
Source: Y Girouard, MD, Service de mjcrobjologie medicate et
1. Holmberg SD. Vibrio andAeromollas. Dans: Infectious disease clinics
a,fNorth America. Philadelphia: WB Saunders Company,
1988 ;2:655-76.
2. Carpenter CCJ. Other pathogenic Yibrios. Dans: Mandell GL, Douglas
Jr RG, Bennett JE, eds. Principles and practice af infecti@s diseases.
3e ed. New York: Churchill Livingstone, 1990: 1646-9.
infectjolagie. Hovital du Sacre-Coeur C Gaudreau, MD,
Service de microbjologje mt!djca/e et maladies
infectieuses Hovjtal Saint-Luc. G Frechette, MD,
Devar(ement de sante communautaire HOvitat Saint-Luc
et Cljnjque medicate Mont-Canne/, Montreal; M
Lorange-Rodrigues, BSc, Laboratoire de sanre uublique
du Que/Jee, Ste-Anne-de-Bellevue, Quebec.
infectiologie, Hopital du Sacre-Coeur, D' C Gaudreau, Service
de microbiologie medicate et maladies infectieuses, Hopital
Saint-Luc, D' G Frechette Departement de sante communautaire,
Hopital Saint-Luc et Clinique medicate Mont-Carmel, Montreal;
M Lorange-Rodrigues, BSc, Laboratoire de santl publique du
Quebec, Ste-Anne-de-Bellevue (Quebec).
International Notes
3. Morris JG Jr, Wilson R, Davis BR, Wachsmuth IK, Riddle CF, Wathen
HG, et coll. Non-0 '1rDUQ I Vibrio choierae gastroenteritis in the
United States. Ann Intern Med 1981;94:656-8.
4. Dalton MT, Haldane JM, Homer GW. Vibrio cholerae non-OJ Nouvelle-Ecosse. RHMC 1991 ;17:115-6.
5. Kelly MT, Hickman-Brenner FW, Farmer ill JJ. Vibrio In: Balows A,
Hausler Jr WJ, Herrmann KL, Isenberg HD, Shadomy HJ, eds. MiJJ:J1m1.
afclinical microbiology. Se ed. Washington, DC : American Society for
Mjcrobjolo~y. 1991 :384-95.
6. Farmer ill JJ, Hickman-Brenner FW, Kelly MT. Vibrio. Dans: Lennette
EH, Balows A, Ilausler Jr WJ, Shadomy HJ, eds. Manual a,fcljnical
microbiology.4e ed. Washington, DC : American Society for
Microbiolo~. 1985:282-301.
Source : D' Y Girouard, Service de microbiologie medicate et
Notes internationales
In an earlier issue (CCDR 1992;18:60,63), 5 cases of cholera
associated with an international airline flight were reported. The
flight had originated in Buenos Aires, Argentina, on 14 February,
1992, with a stop en route in Lima, Peru, before arriving in Los
Angeles, California. On arrival the flight had 336 passengers and
20 crew members. The following is an update on the investigation
following the identification of these cases on 19 February.
Dans un numero precedent du RMTC (1992; 18:60,63), on a sign ale 5
cas de cholera parmi !es passagers d'u..11 vol international. Parti de Buenos
Aires en Argentine, le 14 fevrier 1992, l'avion est arrive aLos Angeles,
Califomie, apres une escale a Lima, Perou. On comptait al'arrivee 336
passagers et 20 membres d'equipage. L'article qui suit fournit !es resultats
!es plus recents de l'enquete menee apres !'identification de ces cas le 19
Passengers were located through appeals made in the news
media, beginning on the evening of 19 February. Other passengers
were located by review of disembarkation records of the United
States Customs Service. Over the next several days passengers and
1 ground crew member were interviewed regarding symptoms and
foods eaten prior to and during the flight. Menus provided by the
airline aided in the recall of diet. Laboratory confirmation was
necessary to determine case status. Stool and serum specimens
were collected from all consenting passengers who could be
Certains passagers ont ete localises grace ades appels publies dans les
medias des la soiree du 19 fevrier. D'autres passagers ont ete localises
~res examen des cartes de debarquement du service des douanes des
Etats-Unis d' Amerique. Les jours suivants, les passagers et un membre du
personnel au sol ont ete interroges sur Ieurs symptomes et !es aliments
qu'ils avaient consommes avant l'embarquement et pendant la duree du
vol. Les menus fournis par la compagnie aenenne Jes ont aides ase
souvenir de ce qu'ils avaient mange. La confirmation des cas en laboratoire
a ete necessaire. Des echantillons de selles et de serum ont ete recueillis
pour tous Jes pass agers consentants qui avaient pu etre joints.
The data were analyzed in a case-control design. Cases were
defined as passengers on the flight or Los Angeles-based ground
crew who had either a positive stool culture for Vibrio cholerae or
a vibriocidal antihody titre greater than 1:640, whether they had
symptoms or not. Controls were passengers or crew who (1) did
not meet the case definition; (2) denied any symptoms following
the flight; and (3) if serum had been obtained, did not have a
vibriocidal antibody titre greater than 1:20. Excluded from
Les donnees ont ete analysees dans le cadre d'une etude cas-temoins.
Les cas ont ete definis comrne Jes passagers du vol ou !es membres du
personnel au sol aLos Angeles presentant soit une coproculture positive
pour Vibrio cholerae, soit des titres d'anli1.:urps vibriocides superieurs a
1:640, qu'ils aient presente OU non des symptomes. Les temoins etaient des
passagers ou des membres d'equipage qui: 1) ne repondaient pas aux
criteres de la definition de cas; 2) n' avaient presente aucun symptome ala
suite du vol; et 3) sides analyses de serum avaient ete pratiquees, ne
analysis were passengers or crew reporting diarrheal illness in the 3
days before the flight. Also excluded were passengers or crew with
antibody titres between 1:40 and 1:640, and all non-cases who had
reported any symptoms after the flight.
presentaient pas de titres d'anticorps vibriocides superieurs a 1:20. Ont ete
exclus de !'analyse les passagers ou membres d'equipage qui avaient signale
des episodes diarrheiques dans !es 3 jours ayant precede le vol, de meme
que Jes passagers ou membres d' equipage presentant des titres d' anticorps
se situant entre 1:40 et 1:640, ainsi que toutes !es personnes ayant signale
des symptOmes apres le vol qui ne repondaient pas a la definition de cas.
As of 4 March, 76 cases of cholera had been associated with the
outbreak:, 34 determined by stool culture only, 32 determined by
antibody titres only and 10 determined by both. Fifty-one cases
were reported from California, 14 from Nevada, 4 from Hawaii, 2
from Arizona, 4 from Japan and 1 from Argentina.
Le 4 mars, 76 cas de cholera ont ete associes acette flambee : 34 avaient
ete determines uniquement par coproculture, 32 uniquement par titrage des
anticorps et 10 par !es deux ala fois. Cinquante et une personnes etaient
originaires de Californie, 14 du Nevada, 4 d'Hawai·, 2 de I' Arizona, 4 du
Japon et une d' Argentine.
As of 4 March, 172 passengers and 1 ground crew member have
been interviewed for the case-control study. Of these, 48 meet the
case definition, 57 meet the control definition and 68 have been
excluded from the analysis. Thirty-seven cases had reported
diarrheal illness after the flight. Ten were asymptomatic.
Twenty-nine cases (60%) were female and 19 (40%) were male.
The age of cases ranged from 8 to 77 years. Twenty-nine cases
(60%) boarded in Buenos Aires, 18 (38%) boarded in Lima and 1
case was a member of the Los Angeles ground crew. Three cases
had eaten raw seafood in the 3 days prior to the flight, 1 had bought
food from a street vendor in the 3 days prior to the flight, and 2 had
eaten food in the Lima airport.
Le 4 mars, 172 passagers et 1 membre du personnel au sol ont pu etre
interroges aux fins de l'etude cas-temoins. Parrni ceux-ci, 48 repondaient a
la definition de cas, 57 a la definition de temoin et 68 ont ete exclus de
l'etude. Parrni Jes cas, 37 personnes avaient signales un episode diarrMique
apres le vol. Dix etaient asymptomatiques. Vingt-neuf cas (60 %) etaient
des femmes et 19 (40 %) des hommes. Leur age allait de 8 a77 ans.
Vingt-neuf personnes (60 %) avaient embarque aBuenos Aires, 18 (38 %) a
Lima et 1 personne etait membre du personnel au sol a Los Angeles. Trois
personnes avaient consomme des fruits de mer crus dans Jes 3 jours
precedant le vol, une avait achete des aliments a un vendeur ambulant dans
Jes 3 jours precedant le vol et 2 avaient consomme des aliments a l'aeroport
de Lima.
Preliminary analysis shows that the only menu item from the
flight significantly associated with illness was a seafood salad
served between Lima and Los Angeles (odds ratio= 6.18, 95% CI:
2.36 - 16.53). The salad included shrimp, fish, pineapple, pickle,
egg, apples, lemon, olives, asparagus, sweet peppers, mayonnaise,
dill and parsley. The investigation into other menu items is
Les premieres analyses montrent que le seul aliment du menu servi sur le
vol qui puisse etre associe de fa~on significative ala maladie etait une
salade de fruits de mer servie entre Lima et Los Angeles (odds ratio= 6,18,
IC a 95 %: 2,36 - 16,53). La salade etait composee de crevettes, poisson,
ananas, comichons, oeufs, pommes, citron, olives, asperges, poivrons doux,
mayonnaise, aneth et persil. Les recherches sur d'autres aliments du menu
se poursuivent.
The food and ice served between Lima and Los Angeles were
supplied by a caterer in Lima. An investigation of the caterer and
its suppliers by Peruvian health officials has not uncovered a
mechanism of contamination. The results reported in this report are
based on interviews and laboratory data collected until 4 March and
are subject to change as the investigation continues.
Les aliments et la glace servis entre Lima et Los Angeles avaient ete
fournis par une societe de restauration de Lima. Une enquete effectuee dans
cette societe et chez ses fournisseurs par Jes autorites sanitaires peruviennes
n'a pas mis en evidence de mecanisme de contamination. Les resultats dont
il est fait etat dans ce rapport reposent sur !es renseignements et Jes donnees
de Iaboratoire recueillis jusqu' au 4 mars et restent sujets a modification tant
que l'enquete n'est pas terminee.
Source: WHO Weekly Epidemiological Record, Vol 67, No 14,
Source: Releve epidemiologique hebdomadaire de l'OMS, Vol 67, n° 14,
On 5 August, 1991, campers and staff at a youth camp (Camp
A) in Yarmouth County, Nova Scotia, developed symptoms of
gastrointestinal illness. Illness was of short duration (usually 24
hours), and characterized by vomiting and mild diarrhea. Cases
occurred throughout the week, with the number peaking on 6
August. The camp's population consisted of 36 children who had
been present the previous week; 49 new campers who arrived
throughout the day of 4 August; and 29 counsellors and other
workers, 25 of whom had remained at the camp over the weekend
prior to the outbreak. Mean age of those at the camp including those
classified as counsellors and staff was 14.4 years.
Le 5 aoOt 1991, des campeurs et des employes d' une coJonie de
vacances (camp A) dans le comte de Yarmouth, Nouvelle-Ecosse, ont
presente des symptomes de gastro-enterite. En general, la maladie etait de
courte duree (habituellement de moins de 24 heures) et se traduisait par des
vomissements et une diarrhee Mnigne. Des cas se sont declares tout au long
de Ia semaine, Ieur nombre atteignant un sommet le 6 aoOt. Parrni !es
residents de la colonie, on comptait 36 enfants presents depuis une semaine,
49 nouveaux campeurs arrives durant lajournee du 4 aoOt ainsi que
29 moniteurs et autres travailleurs, dont 25 etaient demeures sur place
durant la fin de semaine precedant l'eclosion de cas. L'age moyen des
personnes presentes, y compris Jes moniteurs et Jes membres du personnel,
etait de 14,4 ans.
On 10 August all of the campers and all but 6 of the staff left the
camp. At approximately 1500 hours the following day a group of
85 diabetic children and their counsellors arrived at the camp. They
had been preceded by 5 staff members on 10 August, bringing the
total staff number to 21. Mean age of those at this camp including
both campers and counsellors was 15.9 years. Eighty-three per cent
of those attending this camp (Camp B), including campers and
staff, were diabetic.
Le 10 aoOt, tous Jes campeurs et tous Jes membres du personnel sauf six
ont quitte la colonie. Le Iendemain, a environ 15 h, arrivaient un groupe de
85 enfants diabetiques et leurs moniteurs. Ils avaient ete precedes par 5
employes le 10 aoOt, ce qui portait le nombre d'employes a21. L'age
moyen des campeurs et moniteurs etait de 15,9 ans. Quatre-vingt-trois pour
cent des campeurs et employes presents au camp B etaient diabetiques.
During the early morning of 13 August, gastrointestinal
symptoms similar to those noted during Camp A began. Again,
most of the illness noted was mild and characterized by vomiting
and diarrhea of short duration. Two of the diabetic campers required
intravenous fluids for hydration, and wide fluctuations of blood
sugar levels were noted.
Au debut de la matinee du 13 aout, des symptomes gastro-intestinaux
semblables a ceux releves durant le camp A ont fait leur apparition. Encore
une fois, la plupart des malaises signales etaient benins et prenaient la forme
de vomissements et d'une diarrhee de courte duree. Deux des campeurs
diabetiques ont dO etre rehydrates par voie intraveineuse, et l'on a enregistre
d'importantes fluctuations des taux de glycemie.
By noon of 13 August, the camp medical staff had stopped
consumption of water from any source, and the Department of
Health was notified. The camp kitchen was inspected and water
samples were taken. Storage and preparation of food appeared
adequate. None of the kitchen staff at that time was symptomatic.
There was no specific protocol in place for the identification of
symptomatic kitchen workers reporting for work. Manual sanitizing
of dishes was established, and water was brought to the camp from
a commercial supplier.
A midi le 13 aoOt, le personnel medical de la colonie a interrompu la
consommation d'eau provenant de toute source, et le ministere de la Sante a
ete avise. La cuisine de la colonie a ete inspectee et des echantillons d'eau
preleves. Les methodes d'entreposage et de preparation des aliments
semblaient adequates. De plus, aucun des employes de la cuisine n'etait
symptomatique ace moment-la. Il n'existait cependant aucun protocole
precis perrnettant d'identifier Jes preposes a la cuisine symptomatiques qui
se presentaient au travail. Des methodes manuelles de sterilisation de la
vaisselle ont ete mises en place et un fournisseur commercials' est charge
d' acheminer I' eau a la colonie.
Very few new cases were being reported 48 hours after the
change in water supply. Campers and staff at Camp B left on 18
August around 0900 hours. The Department of Health requested an
investigation into these outbreaks.
Quarante-huit heures apres le changement dans l'approvisionnement en
eau, on signalait un tres petit nombre de nouveaux cas. Les campeurs et le
personnel du camp B ont quitte Jes lieux le 18 aoOt vers 9 h. Le ministere de
la Sante a demande que ces eclosions de cas fassent l'objet d'une enquete.
The camp was visited and inspected on 22 August. Department
of Health records were reviewed for test results of camp water
Une visite et une inspection de la colonie a eu lieu le 22 aoOt. Les
enqueteurs ont passe en revue Jes dossiers du ministere de la Sante ou
etaient Consignes Jes resultats des tests de Ja qualite de l'eau de Ja Colonie.
A telephone questionnaire, initially inquiring about usual water
source, swimming, and date of onset of illness, was administered to
campers and counsellors present at Camp A from 3 to 10 August.
The questionnaire was later modified to include more specific
questions about symptoms as well as sources of drinking water.
Les campeurs et moniteurs presents au camp A du 3 au 10 aoOt ont ete
interroges par telephone, Jes questions portant au depart sur la source
habituelle d' eau, la pratique de la natation et la date d'apparition des
symptOmes. Le questionnaire a ete par la suite modifie pour inclure des
questions plus precises sur Jes symptomes de meme que sur Jes sources
d'eau potable.
A case was defined as an individual present during Camp A or B
who had experienced one episode of vomiting on any occasion
and/or 2 loose stools in any 24-hour period after 2 August. Well
individuals present at both camps were only included once, with the
Camp A group. The period of observation extended to the 3 days
following departure from camp. Due to the self-limiting aspect and
nature of the illness, stool cultures had been obtained on only 2
individuals during the Camp B outbreak; therefore, a positive stool
culture was not included in the case definition.
Les criteres utilises pour definir Jes cas etaient Jes suivants : presence
durant le camp A ou B et un episode de vomissements a un moment
quelconque OU 2 selles liquides a J'interieur d'une periode de 24 heures
apres le 2 aoOt. Les personnes bien portantes presentes aux deux camps
n'etaient incluses qu'une seule fois, soit avec le groupe du camp A. La
penoded' observation s' etendaitjusqu'a la troisieme joumee suivant le
depart de la colonie. En raison du caractere spontanement resolutif de la
maladie, des coprocultures n' ont pu etre effectuees que chez 2 personnes
durant l'eclosion de cas au camp B; c'est la raison pour laquelle, on n'a pas
retenu comme critere nosologique un resultat positif a la coproculture.
Data were analyzed separately for each camp population for
various exposures, and then combined using Mantel-Haentzel
stratified analysis.
Les donnees portant sur la population de chaque camp ont ete analysees
separement pour diverses expositions, puis combinees selon la methode
d'analyse stratifiee de Mantel-Haentzel.
Camp A had been attended by 114 campers and staff, with
information from the less detailed questionnaire available on 108
(95%); the detailed questionnaire was completed on 68 (60%). Of
those on whom information was available there were 79 campers
(32 males, 47 females) ranging in age from 7 to 16 years, and 29
staff (8 male, 21 female) ranging in age from 16 to 54 years.
Cent quatorze campeurs et employes etaient presents au camp A; 108
d'entre eux (95 %) ont rempli le premier questionnaire et 68 (60 %) le
questionnaire plus detaille. On disposait ainsi de renseignements sur 79
campeurs (32 garyons et 47 filles) dont !'age variait entre 7 et 16 ans, ainsi
que sur 29 employes (8 hommes et 21 femmes) de 16 a 54 ans.
Camp B had been attended and staffed by 106 persons;
interviews were completed on 101 (95%). Of these, there were 66
campers (22 male, 44 female) ranging in age from 8 to 16 years,
and 35 staff (13 male, 22 female).
Cent six personnes ont participe au camp B, dont 101 (95 %) ont ete
interrogees. On retrouvait parmi elles 66 campeurs (22 garyons, 44 filles) de
8 a 16 ans et 35 employes (13 hommes, 22 femmes).
The camp had multiple water sources. Lake water was used for
the Director's cabin, hot water in the camp washrooms and toilets.
Water from the well supplied the camp kitchen where it was used in
food preparation and for drinking. It also supplied the cold water
taps in the washrooms and an outside drinking fountain, which was
easily reached by campers. This fountain was available to Camp A
attendees, but was turned off throughout Camp B.
Les sources d'approvisionnement en eau etaient multiples. L'eau du lac
servait a alimenter le chalet du directeur et foumissait l'eau chaude des
salles de bains et toilettes de la colonie, alors que l' eau servant a la
preparation des aliments et l'eau de boisson provenaient du puits. Le puits
alimentait egalement en eau froide Jes robinets des salles de bains et une
fontaine exterieure, a laquelle Jes·campeurs avaient facilement acces. Cette
fontaine a ete utilisee par Jes personnes presentes au camp A, mais l'eau a
ete coupee durant le camp B.
Fi~ure 1
Epidemic Curve: Camp
Outbreaks of
Gastrointestinal Illness,
Nova Scotia, August 1991
Figure 1
Maladie gastro-intestinale
durant des camps : courbe
epidemiq4e des eclosions,
Nouvelle-Ecosse, aout 1991
n = 41
10 -
5 -
8/2 8/3 8/4 8/5 8/6 8/7 8/8 8/98/108/118/128/138/148/168/168/178/188/100/20
Water Delivery
Livraison d'eau
Camp A
~Camp B
• 52 were ill. One case unable to give onset date.
• 52 malades; 1 n'a pu donner la date de debut de l'atteinte .
A large contour sewage bed, located in an area between the
campers' cabins and the swimming area (from which the water to
the Director's cabin was taken) was apparently malfunctioning.
Food sources for the 2 groups of campers were entirely different.
Food had been specially ordered for the diabetic camp and even
common food items had been replaced.
Un champ d'epuration s'etendant sur un large perimetre entre le chalet
des campeurs et l'aire de natation (d'ou provenait l'eau alimentant le chalet
du directeur) fonctionnait mal apparemment. Quant aux aliments, !es
sources d'approvisionnement pour !es 2 groupes de campeurs etaient tout a
fait differentes. Des aliments avaient ete commandes specialement pour le
camp reserve aux diabetiques et meme !es produits alimentaires courants
avaient ete remplaces.
On 21 July, 1991 the camp well, which was about 5 metres in
depth, had gone dry and a local fire department delivered water,
obtained from a river source, in a truck with a stainless steel
interior. The water had been taken from the edge of a river about 40
centimetres in depth and poured from the truck into the camp's well
with the addition of 0.5 L of liquid bleach. The well was filled again
on the evening of 2 August with water from the same source, but no
bleach was added. On later inspection, the truck's interior showed
evidence of pitting and scaling.
Le 21juillet 1991, le puits, dont la profondeur atteignait environ
5 metres, s'etant tari, un service local d'incendie a livre de l'eau dans un
camion a la citerne en acier inoxydable. L' eau avait ete prelevee sur le bord
d'une riviere a environ 40 centimetres de profondeur et versee du camion
dans le puits apres I' ajout de 0,5 L de javellisant liquide. Le puits a ete
rempli a nouveau le soir du 2 aout avec de l'eau provenant de la meme
source, mais aucun javellisant n' a ete ajoute. Lors d'une inspection
ulterieure, on a releve des taches et des depots calcaires a l' interieur du
Water samples from the kitchen were negative for bacterial
growth on 19 June and on 17 July; coliforms had been grown from
samples taken on 31 July from the kitchen tap and the outside water
fountain. On 13 August, coliforms were grown from the kitchen
water and from tap water in the Director's cabin.
Les echantillons d'eau de la cuisine ne presentaient aucune croissance
bacterienne le 19 juin ni le 17 juillet. On a note la presence de coliformes
dans Jes echantillons preleves le 31 juillet au robinet de la cuisine et a la
fontaine exterieure. Le 13 aoOt, des coliformes etaient detectes dans l'eau de
la cuisine et l'eau de robinet du chalet du directeur.
The Camp A outbreak began early in the morning of 5 August
with 6 cases occurring that day, and peaked 6 August with 15 cases
(Figure 1). All of those ill the first day of the outbreak had been at
the camp during week 5 of a 6-week stay and remained over the
weekend into the final week. Cases occurred throughout the week
and after the camp had ended, with the last case noted on 13
August. Fifty-two of 108 people for whom data were available
became ill, an attack rate of 48 .1 %.
L'eclosion de cas durant le camp A a debute au debut de la matinee du 5
aout, 6 cas survenant cette journee-la, et a atteint un point culminant le 6
aout avec !'apparition de 15 cas (figure 1). Toutes Jes personnes malades le
premier jour de la flambee de cas etaient presentes au camp durant la
cinquieme semaine du sejour prevu de 6 semaines et sont demeurees au
camp Jes samedi et dimanche precedant la derniere semaine. Des cas se sont
declares tout au long de la semaine ainsi qu'apres la fin du camp, le dernier
cas ayant ete signale le 13 aoOt. Cinquante-deux des 108 personnes sur
lesquelles on dispose des donnees sont tombees malades, soit un taux
d'attaque de 48,1 %.
The Camp B outbreak began 12 August with 1 case and peaked
the following day with 19 cases. On 13 August exposure to water
L'eclosion de cas durant le camp Ba debute le 12 aout par la survenue
d'un cas et a atteint un sommet le lendemain, oil !'on a recense 19 cas. Le
ended around 1200 hours.
Eleven cases occurred the
following day, but by 15
August the number had
decreased substantially. The
last cases were reported 19
August. In total there were 41
cases in the 101 persons who
completed the questionnaire,
an attack rate of 40.6%.
Table 1/ Tableau 1
Symptoms in those ill at camps A and B
Sympomes signales durant les camps A et B
Camp A (n =35)
Camp 8 (n =41)
13 aoOt, vers 12 h, toute consommation
d'eau a cesse. Onze cas sont survenus
le lendemain, mais le 15 aoOt, le
nombre de cas avait diminue
considerablement. Les derniers cas ont
ete signales le 19 aoOt. On denombre
au total, 41 cas parmi !es 101 personnes
qui ont rempli le questionnaire, soit un
taux d'attaque de 40,6 %.
Table 2 shows odds ratios
Maux de t~te
and confidence intervals for
various water exposures for
camps separately and
combined. Water exposure
was defined as having had water from any source on any occasion.
There is evidence that the kitchen water and washroom water
were causes of the outbreaks. A non-significant elevated odds ratio
for drinking water from the Director's cabin was also noted. The
outside fountain was not operating during the Camp B outbreak, but
showed a non-significant association with illness during the
Camp A outbreak. If those who had also drunk water from the
Director's cabin were eliminated from the analysis, the odds ratio
for kitchen water fell but remained significant (2.07;95% C.I.
1.02-4.20), while that for washroom water was no longer significant.
Certaines donnees montrent que l'eau de la cuisine et des salles de bains
etait al'origine des ec!osions de cas. On a egalement releve un rapport de
cotes eleve non significatif pour l'eau potable du chalet du directeur. La
fontaine exterieure ne fonctionnait pas durant le camp B, mais cette source
etait associee de fa~on non significative al'eclosion de cas du camp A. Si
l'on elimine de !'analyse !es personnes qui ont egalement bu de l'eau du
chalet du directeur, le rapport de cotes pour l'eau de la cuisine baisse mais
demeure significatif (2,07; I.C. de 95 % 1,02-4,20), alors que pour l'eau des
salles de bains, ii n'est plus significatif.
Swimming was not associated with illness during either
outbreak, and frequency of swimming was less in those who were
La natation n'etait pas associee a !'apparition de symptomes dans
aucune des deux eclosions de cas, et cette activite etait pratiquee moins
frequemment par ceux qui etaient malades.
Summary and Discussion
Water delivered to the camp from a river source is implicated as
the cause of these 2 outbreaks.
Resume et analyse
L'eau de riviere qui a ete acheminee ala colonie est mise en cause dans
ces 2 eclosions de cas.
No unexpected amount of gastroenteritis occurred in the camp in
the week prior to that beginning 5 August, and none was reported
from camp organizers in the camp subsequent to Camp B.
On n' a pas releve un nombre imprevu de cas de gastro-enterite dans la
colonie durant la semaine precedant celle du 5 aoOt, et aucun cas n'a ete
signale par Jes organisateurs apres le camp B.
Water consumed at the camp was taken from a questionable
source, delivered in a vehicle in poor repair and consumed without
having been chlorinated. Samples taken from the kitchen tap and
the outside water fountain on 31 July grew coliform organisms. The
well at this point contained water from the same source as that
L'eau bue au camp provenait d'une source de qualite douteuse, etait
livree par un vehicule en pietre condition et consommee sans avoir ete
javellisee. Des echantillons d' eau du robinet de la cuisine et de la fontaine
exterieure preleves le 31 juillet contenaient des coliforrnes. A cette date,
l'eau du puits provenait de la meme source que celle livree le 2 aoOt, bien
Symptoms for the 2
outbreaks were similar (fable
1) indicating that the
outbreaks could have been
due to the same or similar
Les symptomes releves durant les
deux eclosions de cas etaient similaires
(tableau 1), ce qui donne apenser que
celles-ci pourraient etre dues au meme
organisme OU ades organismes
Les rapports de cotes et !es
intervalles de confiance pour diverses
expositions al'eau !ors de chacun des
camps et pour !es deux camps
combines sont indiques au tableau 2.
Etaient considerees comme exposees toutes !es personnes ayant consomme
a un moment ou aun autre de l'eau provenant de n'importe quelle source.
Table 2/Tableau 2
Odds ratios for various water exposures (95% Cl) for each camf and combined
Risque relatif associe a !'exposition a diverses d'eau (IC a 95% pour chacun des camps et les deux combines
Camp A
Salles de bain
(1.11 -6.41)
delivered 2 August, although the first supply had been chlorinated.
A sample taken from the kitchen on 13 August also grew coliforms.
qu'on ait ajoute de l' eau de javel au premier approvisionnement. Un echantillon
d'eau de la cuisine preleve le 13 aoOt contenait egalement des coliformes.
The epidemic curves for the 2 outbreaks are typical of a
continuing source of infection during Camp A and compatible with
an exposure ceasing 13 August during Camp B.
Les courbes epidemiques pour les 2 eclosions de cas sont caracteristiques
d'une source continue d'infection durant le camp A et sont compatibles avec une
exposition cessant le 13 aoOt durant le camp B.
Odds ratios are significantly elevated for exposure to kitchen
water and for washroom water (both supplied by the filled well),
when the 2 outbreaks are combined. Other types of water exposure
also show a tendancy towards implicating the well water.
Discussions with local public health officials indicate that it was
entirely possible that the river source had been contaminated by
sewage from residences upstream.
Lorsqu'on combine les 2 eclosions de cas, on constate que les rapports de
cotes d'exposition a l'eau de la cuisine et a l'eau des salles de bains sont
significativement eleves (les 2 provenant du puits qui a ete rempli). D'autres
types d'exposition a l'eau semblent egalement incriminer l' eau du puits. D'apres
les discussions que nous avons eues avec les responsables locaux de la sante
publique, ii est tout a fait possible que la riviere ait ete contaminee par des eaux
usees provenant de residences en amont.
No causative organism was identified. Three of those ill during
Camp B had negative stool cultures, and one electron microscopic
study was performed, which was negative. Although the outbreak
could have been due to bacterial organisms or other viruses, the
clinical symptoms and the duration of illness observed in these 2
outbreaks are compatible with those seen with Norwalk-type
disease<1>. The termination of the Camp A outbreak after 8 days is
also compatible with what is known about the natural history of
outbreaks caused by Norwalk infection<2>. Viral gastroenteritis is
believed to be caused most often by Norwalk or Norwalk-like
On n'a pas toutefois identifie l'organisme en cause. Trois des personnes
malades durant le camp B ont obtenu des resultats negatifs a la coproculture, et
l' examen au microscope electronique effectue dans un des cas s' est revele
negatif. Bien que l'eclosion de cas puisse etre due a des bacteries OU a d'autres
virus, les symptomes cliniques et la duree de la maladie dans ces 2 flarnbees de
cas sont compatibles avec ceux associes au virus de type NorwalkOl. Le fait que
l'eclosion de cas durant le camp Ase soit terminee apres 8 jours concorde
egalement avec ce que l' on sait de l'histoire naturelle des eclosions de cas
causees par le virus de Norwalk<2>. On croit en outre que la gastro-enterite virale
est le plus souvent causee par le virus de Norwalk ou des virus de ce type<3>.
These outbreaks indicate problematic areas in the management
of both the water shortage at this camp and the response of the
camp staff to the original outbreak. The filling of empty wells is
common practice in Nova Scotia, but there appears to be no clear
guidelines available to such groups to assist them in avoiding
problems resulting in the outbreaks described here. Guidelines
should include advice on the type of tank to be used, addition of
chlorine and its concentration, water sources, and instructions to be
distributed to home owners and others regarding safe usage of such
water. Camp officials and those of other similar gatherings should
be made aware that it is 'obligatory to report outbreaks at the time
of their occurrence. The delay observed here in reporting the Camp
A outbreak no doubt represented a wasted opportunity to prevent
the second outbreak.
Ces flambees de cas mettent en evidence certains problemes dans la fac;:on
dont on a gere les 2 penuries d' eau dans cette colonie de vacances et dont le
personnel du camp a reagi a l'eclosion de cas originale. Le remplissage de puits
a sec est monnaie courante en Nouvelle-Ecosse, mais ii semble n'exister aucune
ligne directrice precise pour aider ces groupes a eviter les problemes al'origine
des eclosions de cas decrites ci-dessus. De telles lignes directrices devraient
comporter des recommandations quant aux types de reservoirs a utiliser, a l'ajout
de chlore, aux concentrations de chlore employees et aux sources d'eau ainsi que
des instructions a distribuer aux proprietaires de maison et ad' autres personnes
concemant la fac;:on d'utiliser cette eau en toute securite. On devrait aviser les
responsables de la colonie et les organisateurs d' autres rassemblements de ce
type qu'il est obligatoire de signaler les eclosions de cas au moment ou elles
surviennent. Nul doute que le retard dans la declaration des cas survenus durant
le camp A n' a pas permis de prevenir la deuxieme eclosion de cas.
1. Be£enson AS, ed. Control of communicable disease in man.
14 ed. Washington, DC: Am Public Health Assoc 1985:154.
2. Kaplan JE, Gary WG, Baron RC, Singh N, Schonberger LB,
Feldman R, et al. Epidemiology of Norwalk gastroenteritis and
3. Kaplan J, Feldman R, Campbell D, Lookabaugh C, Gary WG,
et al. The frequency of Norwalk-like pattern of illness in
outbreaks of acute gastroenteritis. Am J Public Health
1. Benenson AS, ed. Control o,fcommunicable disease jn man. 14e ed.
Washington, DC: Am Public Health Assoc 1985: 154.
2. Kaplan JE, Gary WG, Baron RC, ingh N, Schonberger LB, Feldman R, et
coll. Evidemiology o,fNorwalk gastroenteritis and the role o,fNorwalk vims
in outbreaks o,facute nonbacterial gastroenteritis. Ann Intern Med
l 982;96:756-61.
Kaplan J, Feldman R, Campbell D, Lookabaugh C, Gary WG, et coll. The.
3. frequency o,fNorwalk-like oattern o,fillness in outbreaks o,facute
gastroenteritis. Am J Public Health 1982;72: 1329-32.
Source: DB Langille, MD, LCDC Field Epidemiologist, JC
Source: D' DB Langille, epidemiologiste regional de LLCM, D' JC LeBlanc,
the role of Norwalk virus in outbreaks of acute nonbacterial
gastroenteritis. Ann Intern Med 1982;96:756-61.
epidemiologiste provincial, Halifax; MK Durkee, C/HP(C), Service
de sante Western, Yarmouth (Nouvelle-Ecosse).
LeBlanc, MD, Provincial Epidemiologist, Halifax; MK
Durkee, CPHI(C), Western Health Unit, Yarmouth, Nova
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