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Antimicrobial prophylaxis halts GAS outbreak in children’s shelter
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ATLANTA — Research presented at the CDC’s Epidemic Intelligence Service Conference showed that an outbreak of group A Streptococcus, or GAS, in a shelter for unaccompanied migrant children that lasted more than 6 months and was stopped by the mass administration of antimicrobial prophylaxis to both children and staff members.
“This outbreak was unique because of the setting and the persistence of the infection,” Carla P. Bezold, ScD, MPH, an Epidemic Intelligence Service officer working with the Arizona Department of Health Services and the Maricopa County Department of Public Health, told Infectious Diseases in Children. “Successfully stopping this outbreak required a shelter-wide approach that involved multiple government agencies and the shelter staff.”
In January 2018, the local health department and the Office of Refugee Resettlement were notified about a GAS pharyngitis outbreak in the shelter. According to the researchers, transmission continued through July despite the fact that they implemented screening, targeted treatments and infection control interventions.
Bezold and colleagues assessed ORR surveillance to identify confirmed cases, which were identified as pharyngitis or lymphadenopathy with GAS isolation or a positive rapid test in children residing in the shelter. Infections occurring more than 5 days after arrival were considered to be acquired in the shelter.
Additionally, to identify cases among approximately 500 staff, the researchers conducted an anonymous survey about GAS symptoms in the past 6 months.
All children and staff were asked to begin antimicrobial therapy with either cephalexin or azithromycin.
During the outbreak, 195 cases of GAS were confirmed among children in the shelter. Nearly all (93%) children acquired the infection in the shelter. Most of the infected children (73%) were from Guatemala, with a median age of 16 years.
According to the researchers, 403 staff members completed the survey. Suspected GAS pharyngitis was identified in 36% of the staff. More than half (69%) of these staff members worked while ill.
The Maricopa County Department of Public Health administered 961 antibiotic courses for children (n = 423) and staff (n = 538). The outbreak ended on Aug. 7.
“Engaging staff as essential partners in the response was key to stopping this outbreak and should be done as early as possible,” Bezold said. “Regular education and engagement with staff about handwashing, identifying symptoms of GAS and staying home when ill can help prevent future outbreaks.” – by Katherine Bortz
Reference:
Bezold CP, et al. Use of mass antimicrobial prophylaxis to stop a group A Streptococcus outbreak among unaccompanied children in a shelter, Maricopa County, Arizona, January-August 2018. Presented at: Epidemic Intelligence Service Conference; April 29-May 2, 2019; Atlanta.
Disclosure: Bezold reports no relevant financial disclosures.
Perspective
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Anisa Ibrahim, MD, FAAP
Unaccompanied immigrant children are among the most high-risk populations for whom pediatricians and family physicians provide care. The conditions that unaccompanied immigrant children face in their country of origin, during their journeys and in Customs and Border Protection processing centers can threaten their health and wellbeing. Subsequently, living in shelter housing may increase both the frequency and severity of exposure to communicable disease.
This study shows us that microbial infections can spread for a long period of time and can be difficult to control. Outbreaks in shelters may require interventions such as mass treatment, which is outside of the normal screening and treatment protocol recommended by the Office of Refugee Resettlement (ORR). The study also highlights that addressing outbreaks in shelters for unaccompanied minors requires partnership between multiple organizations, including local public health officials and the ORR.
Lessons learned from the provision of care to populations living in homeless shelters or jails may provide guidance in supporting youth living in ORR shelters. Furthermore, studies that compare the health of unaccompanied immigrant children who are reunited with family members in the community vs. those kept in shelters for prolonged periods of time are warranted. Further thoughtful research would inform evidence-based guidelines, protocols and policies.
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