Shigellosis importance of hygiene in prevention

Preventive measures (communications of the RKI)

The basis of prevention is hygienically impeccable conditions (personal hygiene, drinking water and food hygiene, hygiene in communal facilities, prevention of fly infestation). Since transmission usually occurs through direct person-to-person contact, effective hand hygiene to avoid faecal-oral smear infections is the decisive preventive measure. To avoid further spread of the pathogens via sexual contact, sex (vaginal, anal, oral) should be avoided as long as the diarrhea persists and for at least one week after the diarrhea has subsided. Protective measures that can reduce the risk of fecal-oral transmission of the pathogen should also be followed during sexual contact in subsequent weeks.

Measures for patients and contacts

• Early diagnosis and treatment is of great importance to avoid secondary infections. During the entire duration of the disease, continuous disinfection of all objects and surfaces that may have come into contact with infectious excretions of the patient should be carried out. Excreta that cannot be disposed of through a regular sewage system should also be disinfected. Ongoing disinfection also applies to excreta. Body and bed linen, handkerchiefs and towels are to be washed on the boil wash cycle, but at least at 60°C. In the case of non-heat-resistant linen or if machine washing is not possible, the linen should be soaked in suitable disinfectant solutions for 12 hours and then washed as normal household linen. Toilet seat, toilet lid as well as bed frame, wash basin and bath tub are to be disinfected daily in health care facilities.
• In hand hygiene, thorough hand washing with soap and water is supplemented by hand disinfection, which requires intensive wetting of the hands with an alcohol-based disinfectant (the manufacturer's instructions for use must be observed). In domestic areas, hand and toilet hygiene are sufficient.

Protective measures concerning schools, other community facilities and food establishments are laid down in §§ 34 and 42 IfSG:

• Teachers, pupils, school staff, employees and visitors to children's communal facilities who are ill with shigellosis or are suspected of having it, are not allowed to use school facilities and similar facilities and not to take part in their events in accordance with § 34 of the Infection Protection Act (IfSG) until, according to medical judgement, a further spread of the disease through them is no longer to be feared. These regulations also apply to persons in whose residential community, according to medical judgement, an illness with or a suspicion of shigellosis has occurred (§34 Para. 3).

Persons who have contracted or are suspected of having contracted shigellosis, or persons who are excretors of shigella, may not work or be employed in accordance with Section 42 (1) IfSG:

a) in the production, treatment or marketing of the foodstuffs mentioned in § 42 Para. 2 (see following list), if they come into contact with them, or

b) in kitchens of restaurants and other establishments with or for communal catering. Foods referred to in section 42(2) are:

• meat, poultry meat and products thereof
• milk and milk-based products
• fish, crustaceans or molluscs and products thereof
• Egg products
• food for infants and young children
• Ice cream and semi-ice cream products
• Bread, pastry, cakes, biscuits and other bakers' wares with fillings or toppings that are not baked or heated through
• Delicatessen, raw vegetable and potato salads, marinades, mayonnaises, other emulsified sauces, nutritional yeasts
• Sprouts and germ buds for raw consumption and seeds for the production of sprouts and germ buds for raw consumption

Reference to EU Regulation 852/2004 on the hygiene of foodstuffs

According to Annex 2, Chapter VIII ("Personal Hygiene") No. 2, first sentence of Regulation (EC) No. 852/2004, which lays down general food hygiene rules for food business operators, persons suffering from or carrying a food-borne disease, as well as persons with, for example, infected wounds, skin infections or lesions, or diarrhoea, are generally prohibited from handling food and from entering areas where food is handled if there is a possibility of direct or indirect contamination.

Re-admission to community facilities is possible after clinical recovery from shigellosis or after shigella has been excreted if there are two negative results of a bacteriological stool examination (stool samples 1-2 days apart). The first stool sample should be taken at the earliest 24 hours after the diarrhoea symptoms have subsided or 48 hours after the end of antibiotic therapy. In the case of prolonged excretion of the pathogen, an individual solution should be found together with the public health department in order to allow approval if necessary (§ 34 Para. 2 No. 5 IfSG).

Persons who were temporarily not allowed to work on the basis of § 42 IfSG because they were ill with shigellosis or had excreted shigella may resume work if the attending physician has received three negative results of a bacteriological stool examination (stool samples at intervals of 1-2 days) and there is agreement with the health authority.

Contact persons (especially from the domestic community of the infected person) must maintain particularly thorough hand hygiene for the duration of the incubation period. Re-admission is possible after a negative stool sample (to be taken 96 hours after the last contact with the infected/suspected person) is available. This rule can be deviated from as long as no suspicious symptoms occur and compliance with the required hygiene measures is safely ensured (§ 34 Para. 3 in conjunction with Para. 7 IfSG). For further information, see the recommendations of the RKI for re-admission to community facilities according to § 34 IfSG.

The restriction of the activity or the visit to the communal facility applies until, according to medical judgement, a further spread of the disease is no longer to be feared. The medical judgement can be the judgement of the attending physician or a physician of the responsible public health department. The medical opinion may be given orally. Section 34 IfSG does not require a written certificate of the medical judgement, but this may be useful for the assurance of all parties involved.

3 Measures to be taken in the event of an outbreak

Because of the relatively easy transmissibility of the pathogens, shigellosis can easily spread in the case of close personal contact and deficiencies in hygiene, especially in communal facilities of all kinds. If there are indications of an outbreak, it is necessary to quickly identify the source(s) of infection and the transmission factors involved (e.g. food) in order to be able to initiate targeted measures to prevent further spread. The competent public health authority should be informed at the earliest possible stage if there is any suspicion. If there is a suspicion of transmission through certain foodstuffs, the public health department is obliged under Section 27 IfSG to inform the competent food monitoring authority without delay.

1. RKI guide - Shigellosis - RKI