Cluster of diarrhoea at a long day care centre
You are one of three GPs in a town of 8,000. Over 11 days you and your partners have seen 14 children and 3 staff from the same long day care centre with diarrhoea, and 6 with fever and vomiting. A stool culture from a 3-year-old grew Campylobacter jejuni. The centre's director phones your practice asking what she should do; she has already sent home four children and two parents are demanding a clearance stool test before their children return. One of the affected staff is a food handler at the town's hospital kitchen. The local newspaper has rung the practice asking for a comment. Your practice nurse is 12 weeks pregnant and asks whether she is at risk. The practice has no written outbreak protocol.
1. What immediate actions do you take, and who do you notify?
Read the worked answer
Campylobacteriosis is notifiable in most jurisdictions. The stool result is laboratory-confirmed, but do not assume the laboratory has notified - contact the local public health unit the same day and give the case details, the cluster (14 children, 3 staff, one centre), and the food handler. Ask them to take the lead on the outbreak investigation and to advise on exclusion.
In parallel, ring the director back with clear written advice: exclude symptomatic cases until 48 hours symptom-free, reinforce hand hygiene and nappy-changing protocols, deep clean, and keep a line list of affected children and staff with dates of onset. Ask her to suspend water play and shared food activities in the meantime.
Do not order clearance stool tests. Convalescent shedding can persist for weeks, so a negative test is not a reliable return-to-work criterion, and testing asymptomatic contacts generates anxiety and cost without changing management. Tell the parents this explicitly, and explain the 48-hour rule.
Practice side: put a sign on the door asking patients with diarrhoea to phone ahead, use the side room, and reassure the nurse that campylobacter is not a specific pregnancy risk, though she should not handle specimens; offer her a discussion rather than an unnecessary test.
2. What advice do you give the director about exclusion, stool testing and hygiene, and what information do you ask her to collect?
Read the worked answer
Give the director a one-page written protocol, because verbal advice gets diluted by the third retelling. Key elements: exclusion of children and staff until at least 48 hours after the last loose stool; hand hygiene with soap and water (alcohol gel is unreliable against campylobacter); gloves and a dedicated nappy-changing area; cleaning of shared toys and surfaces; no sharing of food, cups or water bottles; and exclusion of anyone who cannot maintain hygiene, such as a child still in nappies with diarrhoea.
Be explicit about why stool testing is not required: it does not shorten exclusion, it can remain positive for weeks after recovery, and it may keep children out unnecessarily. Parents who insist should be given the public health advice in writing and the public health unit's number so that the message comes from a second source.
Ask for a line list: name, room, date of onset, symptoms, whether they saw a doctor, and stool results. This is what public health will want and what identifies a continuing source.
Ask specifically about a common exposure in the two to five days before the first case - shared food, water play, an excursion, a petting zoo, or an unwell food handler. That question often finds the answer.
3. How do you handle the food handler, the pregnant practice nurse, and the newspaper?
Read the worked answer
Food handler: this is the highest-risk element. Campylobacter is not usually transmitted by food handlers, but the principle holds - anyone with diarrhoea who handles food must be excluded until 48 hours symptom-free, and the hospital's infection control team and the public health unit should be told directly. Do not rely on the director to make that call.
Pregnant nurse: campylobacter is not a specific risk in pregnancy the way listeria or CMV are, but she should avoid handling specimens and practise careful hygiene. Reassure her with facts rather than a vague instruction to 'be careful', and document the conversation.
Media: do not comment on individual cases. Agree a single spokesperson - usually the public health unit. A brief statement that the practice is working with the public health unit and the centre is enough; anything more risks breaching privacy and inflaming the situation, and a doorstop comment is hard to retract.
Practice level: write the outbreak protocol now, while the details are fresh - who calls public health, who speaks to the media, where the line list is kept, and who covers after hours.