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The Somatic Arts and Sciences Institute

3-Hours Continuing Education
Lecture Notes

Controlling Infectious Agents

in the Massage Room

Table of Contents
Instructions.. 3
Educational Objectives.. 3
Chapter 1: Introduction to infectious agent control and modes of transmission....4
Chapter 2: Massage therapy in a health care setting (Universal Precautions Standards)....13
Chapter 3: Bacteria...27
Chapter 4: Viruses ....64
Chapter 5: Fungi ...93
Chapter 6: Parasites ..128
Chapter 7: Massage Environment Hygiene.141
Summary of Controlling Infectious Agents in the Massage Room .....155
Course Completion: Certificate of Completion and Transcript.156
Course Evaluation and Errata...157
Help and Technical Support Line..157
Bibliography (Sources)...158

Controlling Infectious Agents in the Massage Room

Read the lecture notes. Take the quiz on our website when you feel ready.
You can pay for the certificate of completion and transcript by clicking the
blue button underneath the quiz on the website.
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link to it on our webpage.
Target Audience
This continuing education course has been designed to meet the
educational needs of massage therapists.
Degree of Difficulty
Beginner/Entry Level
Course Description
We all know that hygiene and sanitation are important elements of a
massage practice. This course goes into detail explaining why, with a look
at the potential bacteria, fungus and viruses that you can, and probably do,
come into contact with every day.
Educational Objectives
Upon completion of this home study continuing education course, the
massage practitioner should be able to:

List four examples of dangerous fungus.

List the four components of disease.
Identify the classic symptoms of a bacterial infection.
List three types of harmful bacteria.
Name two examples of animal parasites.
Describe the proper hygiene requirements for massage therapy.
Explain how Norovirus and Influenza are transmitted.

Chapter 1: Introduction to infectious agent control

Abbreviations Used in the Course
AIIR Airborne infection isolation room
CDC Centers for Disease Control and Prevention
CF Cystic fibrosis
CJD Creutzfeld-Jakob Disease
CLSI Clinical Laboratory Standards Institute
ESBL Extended spectrum beta-lactamases
FDA Food and Drug Administration
HAI Healthcare-associated infections
HBV Hepatitis B virus
HCV Hepatitis C virus
HEPA High efficiency particulate air [filtration]
HICPAC Healthcare Infection Control Practices Advisory Committee
HIV Human immunodeficiency virus
HCW Healthcare worker
HSCT Hematopoetic stem-cell transplant
ICU Intensive care unit LTCF
Long-term care facility
MDRO Multidrug-resistant organism
MDR-GNB Multidrug-resistant gram-negative bacilli
MRSA Methicillin-resistant Staphylococcus aureus
NCCLS National Committee for Clinical Laboratory Standards
NICU Neonatal intensive care unit
NIOSH National Institute for Occupational Safety and Health, CDC
NNIS National Nosocomial Infection Surveillance
NSSP Nonsusceptible Streptococcus pneumoniae
OSHA Occupational Safety and Health Administration
PICU Pediatric intensive care unit
PPE Personal protective equipment
RSV Respiratory syncytial virus
SARS Severe acquired respiratory syndrome
vCJD variant Creutzfeld-Jakob Disease
VRE Vancomycin-resistant enterococci
WHO World Health Organization

Definition of Terms
Cleaning is the removal of soil through manual or mechanical means, often
in preparation for disinfection or sterilization.
Disinfection is the destruction of pathogenic microorganisms or their toxins
by direct exposure to chemical or physical agents. Disinfectants are
described as low-, intermediate-, and high-level. These interventions can
kill most pathogens, but bacterial spores may be spared.
Sterilization is destruction of all microorganisms in a given field. It is
accomplished through baking, chemicals under pressure, or steam under
Sanitation is use of measures designed to promote health and prevent
disease; it usually refers to creating a clean environment, but does not
specify the level of cleanliness.
Plain soap is any detergent that contains no antimicrobial products or only
small amounts of antimicrobial products that act as preservatives.
Antimicrobial soap is a detergent that contains antimicrobial substances.
Rationale for this course (why its relevant to you)
According to Occupational Safety Health Administration (OSHA) massage
therapists and bodyworkers are not at great risk for occupational exposure
to bloodborne pathogens, but due to the fact that our work is on the human
body it is important that the basics of the Bloodborne Pathogen standard
and Universal precautions as set forth by the Center for Disease Control
and the Occupational and Safety Health Administration are reviewed and
So we study Universal precautions in massage school (and we will be
reviewing it in this course also) but we do not spend nearly enough time on
the other infectious dangers that we are exposed to, in some cases with
alarming frequency.
Bloodborne pathogens are only part of the story; there are also airborn
pathogens (respiratory diseases and infections) and contagious skin
conditions that people can be bringing into your massage room every day.
Theres a very real reason why many states require massage therapists to

get TB (Mycobacterium tuberculosis) tests when they renew their licenses.

In 2013, a total of 9,588 new tuberculosis (TB) cases were reported in the
United States. According to the CDC one of the high risk factors is being in
close confined proximity (like a massage room) with a person that has
recently been out of the country (any of your clients go out of the country
on business?).
The fact is that the human body is a highly efficient conveyance for fungus,
parasites and bacteria that can be spread from person to person by touch
In addition to our hands that touch complete strangers all day every day
there are linens in our massage room that, according to statistics, are not
being washed adequately enough to kill most of these infectious threats.
Modes of Transmission
Transmission of infectious agents within a healthcare setting requires three
elements: a source (or reservoir) of infectious agents, a susceptible host
with a portal of entry receptive to the agent, and a mode of transmission for
the agent.
This section describes the interrelationship of these elements in the
Sources of infectious agents Infectious agents transmitted during
healthcare derive primarily from human sources but inanimate
environmental sources also are implicated in transmission. Human
reservoirs include patients, healthcare personnel, and household members
and other visitors.
Such source individuals may have active infections, may be in the
asymptomatic and/or incubation period of an infectious disease, or may be
transiently or chronically colonized with pathogenic microorganisms,
particularly in the respiratory and gastrointestinal tracts. The endogenous
flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal
tract) also are the source of HAIs
Susceptible hosts Infection is the result of a complex interrelationship
between a potential host and an infectious agent. Most of the factors that
influence infection and the occurrence and severity of disease are related

to the host. However, characteristics of the host-agent interaction as it

relates to pathogenicity, virulence and antigenicity are also important, as
are the infectious dose, mechanisms of disease production and route of
There is a spectrum of possible outcomes following exposure to an
infectious agent.
Some persons exposed to pathogenic microorganisms never develop
symptomatic disease while others become severely ill and even die. Some
individuals are prone to becoming transiently or permanently colonized but
remain asymptomatic. Still others progress from colonization to
symptomatic disease either immediately following exposure, or after a
period of asymptomatic colonization. The immune state at the time of
exposure to an infectious agent, interaction between pathogens, and
virulence factors intrinsic to the agent are important predictors of an
individuals outcome. Host factors such as extremes of age and underlying
disease, human immunodeficiency virus/acquired immune deficiency
syndrome [HIV/AIDS], malignancy, and transplants can increase
susceptibility to infection as do a variety of medications that alter the
normal flora (e.g., antimicrobial agents, gastric acid suppressants,
corticosteroids, antirejection drugs, antineoplastic agents, and
immunosuppressive drugs). Surgical procedures and radiation therapy
impair defenses of the skin and other involved organ systems. Indwelling
devices such as urinary catheters, endotracheal tubes, central venous and
arterial catheters synthetic implants facilitate development of HAIs by
allowing potential pathogens to bypass local defenses that would ordinarily
impede their invasion and by providing surfaces for development of bioflms
that may facilitate adherence of microorganisms and protect from
antimicrobial activity infections associated with invasive procedures result
from transmission within the healthcare facility; others arise from the
patients endogenous flora
Modes of transmission
Several classes of pathogens can cause infection, including bacteria,
viruses, fungi, parasites, and prions. The modes of transmission vary by
type of organism and some infectious agents may be transmitted by more
than one route: some are transmitted primarily by direct or indirect contact,
(e.g., Herpes simplex virus [HSV], respiratory syncytial virus,
Staphylococcus aureus), others by the droplet, (e.g., influenza virus, B.

pertussis) or airborne routes (e.g., M. tuberculosis). Other infectious

agents, such as bloodborne viruses (e.g., hepatitis B and C viruses [HBV,
HCV] and HIV are transmitted rarely in healthcare settings, via
percutaneous or mucous membrane exposure. Importantly, not all
infectious agents are transmitted from person to person. The three principal
routes of transmission are summarized below.
Contact transmission
The most common mode of transmission, contact transmission is divided
into two subgroups: direct contact and indirect contact.
Direct contact transmission
Direct transmission occurs when microorganisms are transferred from one
infected person to another person without a contaminated intermediate
object or person. Opportunities for direct contact transmission between
patients and healthcare personnel have been summarized in the Guideline
for Infection Control in Healthcare Personnel, 1998 and include:
Blood or other blood-containing body fluids from a patient directly enters a
caregivers body through contact with a mucous membrane or breaks (i.e.,
cuts, abrasions) in the skin
Mites from a scabies-infested patient are transferred to the skin of a
caregiver while he/she is having direct ungloved contact with the patients
A healthcare provider develops herpetic whitlow on a finger after contact
with HSV when providing oral care to a patient without using gloves or HSV
is transmitted to a patient from a herpetic whitlow on an ungloved hand of a
healthcare worker (HCW)
Indirect contact transmission involves the transfer of an infectious agent
through a contaminated intermediate object or person. In the absence of a
point-source outbreak, it is difficult to determine how indirect transmission
occurs. However, extensive evidence cited in the Guideline for Hand
Hygiene in Health-Care Settings suggests that the contaminated hands of
healthcare personnel are important contributors to indirect contact

Examples of opportunities for indirect contact transmission include:

Hands of healthcare personnel may transmit pathogens after touching an
infected or colonized body site on one patient or a contaminated inanimate
object, if hand hygiene is not performed before touching another patient.
Patient-care devices (e.g., electronic thermometers, glucose monitoring
devices) may transmit pathogens if devices contaminated with blood or
body fluids are shared between patients without cleaning and disinfecting
between patients.
Shared toys may become a vehicle for transmitting respiratory viruses
(e.g., respiratory syncytial virus or pathogenic bacteria (e.g., Pseudomonas
aeruginosa) among pediatric patients.
Instruments that are inadequately cleaned between patients before
disinfection or sterilization (e.g., endoscopes or surgical instruments) or
that have manufacturing defects that interfere with the effectiveness of
reprocessing may transmit bacterial and viral pathogens.
Clothing, uniforms, laboratory coats, or isolation gowns used as personal
protective equipment (PPE), may become contaminated with potential
pathogens after care of a patient colonized or infected with an infectious
agent, (e.g., MRSA, VRE, and C. difficile
Although contaminated clothing has not been implicated directly in
transmission, the potential exists for soiled garments to transfer infectious
agents to successive patients.
Droplet transmission
Droplet transmission is, technically, a form of contact transmission, and
some infectious agents transmitted by the droplet route also may be
transmitted by the direct and indirect contact routes. However, in contrast
to contact transmission, respiratory droplets carrying infectious pathogens
transmit infection when they travel directly from the respiratory tract of the
infectious individual to susceptible mucosal surfaces of the recipient,
generally over short distances, necessitating facial protection. Respiratory
droplets are generated when an infected person coughs, sneezes, or talks
or during procedures such as suctioning, endotracheal intubation, cough
induction by chest physiotherapy and cardiopulmonary resuscitation.

Evidence for droplet transmission comes from epidemiological studies of

disease outbreaks, experimental studies and from information on aerosol
Studies have shown that the nasal mucosa, conjunctivae and less
frequently the mouth, are susceptible portals of entry for respiratory viruses
The maximum distance for droplet transmission is currently unresolved,
although pathogens transmitted by the droplet route have not been
transmitted through the air over long distances, in contrast to the airborne
pathogens discussed below. Historically, the area of defined risk has been
a distance of <3 feet around the patient and is based on epidemiologic and
simulated studies of selected infections
Using this distance for donning masks has been effective in preventing
transmission of infectious agents via the droplet route. However,
experimental studies with smallpox and investigations during the global
SARS outbreaks of 2003 suggest that droplets from patients with these two
infections could reach persons located 6 feet or more from their source. It is
likely that the distance droplets travel depends on the velocity and
mechanism by which respiratory droplets are propelled from the source, the
density of respiratory secretions, environmental factors such as
temperature and humidity, and the ability of the pathogen to maintain
infectivity over that distance
Thus, a distance of <3 feet around the patient is best viewed as an
example of what is meant by a short distance from a patient and should
not be used as the sole criterion for deciding when a mask should be
donned to protect from droplet exposure. Based on these considerations, it
may be prudent to don a mask when within 6 to 10 feet of the patient or
upon entry into the patients room, especially when exposure to emerging
or highly virulent pathogens is likely. More studies are needed to improve
understanding of droplet transmission under various circumstances.
Droplet size is another variable under discussion. Droplets traditionally
have been defined as being >5 m in size. Droplet nuclei, particles arising
from desiccation of suspended droplets, have been associated with
airborne transmission and defined as <5 m in size, a reflection of the
pathogenesis of pulmonary tuberculosis which is not generalizeable to
other organisms. Observations of particle dynamics have demonstrated

that a range of droplet sizes, including those with diameters of 30m or

greater, can remain suspended in the air. The behavior of droplets and
droplet nuclei affect recommendations for preventing transmission.
Whereas fine airborne particles containing pathogens that are able to
remain infective may transmit infections over long distances, requiring AIIR
to prevent its dissemination within a facility; organisms transmitted by the
droplet route do not remain infective over long distances, and therefore do
not require special air handling and ventilation.
Examples of infectious agents that are transmitted via the droplet route
include Bordetella pertussis, influenza virus, adenovirus, rhinovirus,
Mycoplasma pneumoniae, SARS-associated coronavirus (SARS-CoV),
group A streptococcus, and Neisseria meningitidis. Although respiratory
syncytial virus may be transmitted by the droplet route, direct contact with
infected respiratory secretions is the most important determinant of
transmission and consistent adherence to Standard plus Contact
Precautions prevents transmission in healthcare settings
Rarely, pathogens that are not transmitted routinely by the droplet route are
dispersed into the air over short distances. For example, although S.
aureus is transmitted most frequently by the contact route, viral upper
respiratory tract infection has been associated with increased dispersal of
S. aureus from the nose into the air for a distance of 4 feet under both
outbreak and experimental conditions and is known as the cloud baby
and cloud adult phenomenon
Airborne transmission Airborne transmission occurs by dissemination of
either airborne droplet nuclei or small particles in the respirable size range
containing infectious agents that remain infective over time and distance
(e.g., spores of Aspergillus spp, and Mycobacterium tuberculosis).
Microorganisms carried in this manner may be dispersed over long
distances by air currents and may be inhaled by susceptible individuals
who have not had face-to-face contact with (or been in the same room with)
the infectious individual. Preventing the spread of pathogens that are
transmitted by the airborne route requires the use of special air handling
and ventilation systems (e.g., AIIRs) to contain and then safely remove the
infectious agent.


Infectious agents to which this applies include Mycobacterium tuberculosis,

rubeola virus (measles), and varicella-zoster virus (chickenpox). In addition,
published data suggest the possibility that variola virus (smallpox) may be
transmitted over long distances through the air under unusual
circumstances and AIIRs are recommended for this agent as well;
however, droplet and contact routes are the more frequent routes of
transmission for smallpox. In addition to AIIRs, respiratory protection with
NIOSH certified N95 or higher level respirator is recommended for
healthcare personnel entering the AIIR to prevent acquisition of airborne
infectious agents such as M. tuberculosis.
For certain other respiratory infectious agents, such as influenza and
Rhinovirus , and even some gastrointestinal viruses (e.g., norovirus and
rotavirus) there is some evidence that the pathogen may be transmitted via
small-particle aerosols, under natural and experimental conditions. Such
transmission has occurred over distances longer than 3 feet but within a
defined airspace (e.g., patient room), suggesting that it is unlikely that
these agents remain viable on air currents that travel long distances. AIIRs
are not required routinely to prevent transmission of these agents.


Chapter 2: Massage therapy in a health care setting (Universal

Precautions Standard)
There seems to be a push by certain national massage therapy
organizations to see massage therapy make further inroads into the
mainstream healthcare field.
While there are definitely advantages to this, namely more career
opportunities and greater acceptance of massage therapy as a billable
treatment for insurances, there are some important things to consider
before taking a job in a hospital, nursing home, rehabilitation clinic or long
term care facility. Probably the most important difference, and the reason
why this chapter is in this course, is that Universal Precautions are not
good enough for a health care environment. In a medical setting you need
to be prepared to exercise the Standard Precautions recommended by
the CDC for infection control, and that goes a lot farther than just assuming
all blood is infected. If you are a massage therapist working in a hospital,
you are going to be around people with all kinds of infectious conditions-so
you need to be prepared.
The reality of working in a medical setting
You will not be working in a serene candle it environment anymore. The
sounds of soft music and the gentle murmur of a desk fountain will be
replaced with the occasional intercom announcement and the pitiful
moaning of your clients roommate.
Diseases and medical conditions do not work around schedules, there very
inconsiderate that way. Anyone thats ever been in a hospital has probably
heard a code being announced over the intercom and they may have
witnessed the resulting chaos as doctors, nurses and orderlies stopped
what they were doing and changed direction, either to go toward the new
emergency or to get out of the way of it.
Medical settings are like that; they require flexibility and a different level of
professionalism than any other massage therapy environment.
You will also have to deal with not having a massage table. More than
likely you would be working with someone in a hospital bed, possibly
attached to an IV or even a catheter.


It will also be considerably colder than any environment your used to

working in. We keep our massage rooms nice and warm in consideration
of the fact that our clients are not wearing much and the application of
lotion to the skin has the same effect as sweat for cooling them down.
Hospitals and other healthcare settings tend to keep the temperature a little
cooler to inhibit the growth of bacteria, so you need to keep that in mind,
which brings us to the main reason for this course.
Keep in mind that what follows is an adaptation of the CDC
recommendations for Universal Precautions in a Health Care Environment,
and you may feel much of this is not massage therapy related. I assure
you, if you plan on working on a hospital, it is relevant to you, because they
will expect you to adhere to the same standards. Just because some of the
language refers to techniques and tasks that are outside of our scope of
practice are irrelevant, if you work in a health care setting, you need to
know the Universal Precautions for the control of infectious organisms.
Universal Precautions for health care environments
Precautions to Prevent Transmission of Infectious Agents There are two
tiers of HICPAC/CDC precautions to prevent transmission of infectious
agents, Standard Precautions and Transmission-Based Precautions.
Standard Precautions are intended to be applied to the care of all patients
in all healthcare settings, regardless of the suspected or confirmed
presence of an infectious agent. Implementation of Standard Precautions
constitutes the primary strategy for the prevention of healthcare-associated
transmission of infectious agents among patients and healthcare
Transmission-Based Precautions are for patients who are known or
suspected to be infected or colonized with infectious agents, including
certain epidemiologically important pathogens, which require additional
control measures to effectively prevent transmission. Since the infecting
agent often is not known at the time of admission to a healthcare facility,
Transmission-Based Precautions are used empirically, according to the
clinical syndrome and the likely etiologic agents at the time, and then
modified when the pathogen is identified or a transmissible infectious
etiology is ruled out. The HICPAC/CDC Guidelines also include
recommendations for creating a Protective Environment for allogeneic
HSCT patients.


The specific elements of Standard and Transmission-Based Precautions

are discussed in Part II of this guideline. In Part III, the circumstances in
which Standard Precautions, Transmission-Based Precautions, and a
Protective Environment are applied are discussed.
Standard Precautions Standard Precautions combine the major features of
Universal Precautions (UP) and Body Substance Isolation (BSI) and are
based on the principle that all blood, body fluids, secretions, excretions
except sweat, nonintact skin, and mucous membranes may contain
transmissible infectious agents. Standard Precautions include a group of
infection prevention practices that apply to all patients, regardless of
suspected or confirmed infection status, in any setting in which healthcare
is delivered. These include: hand hygiene; use of gloves, gown, mask, eye
protection, or face shield, depending on the anticipated exposure; and safe
injection practices. Also, equipment or items in the patient environment
likely to have been contaminated with infectious body fluids must be
handled in a manner to prevent transmission of infectious agents (e.g. wear
gloves for direct contact, contain heavily soiled equipment, properly clean
and disinfect or sterilize reusable equipment before use on another
The application of Standard Precautions during patient care is determined
by the nature of the HCW-patient interaction and the extent of anticipated
blood, body fluid, or pathogen exposure. For some interactions (e.g.,
performing venipuncture), only gloves may be needed; during other
interactions (e.g., intubation), use of gloves, gown, and face shield or mask
and goggles is necessary. Education and training on the principles and
rationale for recommended practices are critical elements of Standard
Precautions because they facilitate appropriate decision-making and
promote adherence when HCWs are faced with new circumstances
An example of the importance of the use of Standard Precautions is
intubation, especially under emergency circumstances when infectious
agents may not be suspected, but later are identified (e.g., SARS-CoV, N.
meningitides). The application of Standard
Standard Precautions are also intended to protect patients by ensuring that
healthcare personnel do not carry infectious agents to patients on their
hands or via equipment used during patient care.


New Elements of Standard Precautions Infection control problems that are

identified in the course of outbreak investigations often indicate the need
for new recommendations or reinforcement of existing infection control
recommendations to protect patients. Because such recommendations are
considered a standard of care and may not be included in other guidelines,
they are added here to Standard Precautions. Three such areas of practice
that have been added are: Respiratory Hygiene/Cough Etiquette, safe
injection practices, and use of masks for insertion of catheters or injection
of material into spinal or epidural spaces via lumbar puncture procedures
(e.g., myelogram, spinal or epidural anesthesia). While most elements of
Standard Precautions evolved from
Universal Precautions that were developed for protection of healthcare
personnel, these new elements of Standard Precautions focus on
protection of patients.
Respiratory Hygiene/Cough Etiquette The transmission of SARSCoV in emergency departments by patients and their family members
during the widespread SARS outbreaks in 2003 highlighted the need for
vigilance and prompt implementation of infection control measures at the
first point of encounter within a healthcare setting (e.g., reception and triage
areas in emergency departments, outpatient clinics, and physician offices)
The strategy proposed has been termed Respiratory Hygiene/Cough
Etiquette and is intended to be incorporated into infection control practices
as a new component of Standard Precautions. The strategy is targeted at
patients and accompanying family members and friends with undiagnosed
transmissible respiratory infections, and applies to any person with signs of
illness including cough, congestion, rhinorrhea, or increased production of
respiratory secretions when entering a healthcare facility. The term cough
etiquette is derived from recommended source control measures for M.
The elements of Respiratory Hygiene/Cough Etiquette include 1) education
of healthcare facility staff, patients, and visitors; 2) posted signs, in
language(s) appropriate to the population served, with instructions to
patients and accompanying family members or friends; 3) source control
measures (e.g., covering the mouth/nose with a tissue when coughing and
prompt disposal of used tissues, using surgical masks on the coughing
person when tolerated and appropriate); 4) hand hygiene after contact with

respiratory secretions; and 5) spatial separation, ideally >3 feet, of persons

with respiratory infections in common waiting areas when possible.
Covering sneezes and coughs and placing masks on coughing patients are
proven means of source containment that prevent infected persons from
dispersing respiratory secretions into the air.
Masking may be difficult in some settings, (e.g., pediatrics, in which case,
the emphasis by necessity may be on cough etiquette. Physical proximity
of <3 feet has been associated with an increased risk for transmission of
infections via the droplet route (e.g., N. meningitides and group A
streptococcus and therefore supports the practice of distancing infected
persons from others who are not infected. The effectiveness of good
hygiene practices, especially hand hygiene, in preventing transmission of
viruses and reducing the incidence of respiratory infections both within and
outside healthcare settings is summarized in several reviews.
These measures should be effective in decreasing the risk of transmission
of pathogens contained in large respiratory droplets (e.g., influenza virus
adenovirus, B. pertussis and Mycoplasma pneumoniae. Although fever will
be present in many respiratory infections, patients with pertussis and mild
upper respiratory tract infections are often afebrile. Therefore, the absence
of fever does not always exclude a respiratory infection. Patients who have
asthma, allergic rhinitis, or chronic obstructive lung disease also may be
coughing and sneezing. While these patients often are not infectious,
cough etiquette measures are prudent.
Healthcare personnel are advised to observe Droplet Precautions (i.e.,
wear a mask) and hand hygiene when examining and caring for patients
with signs and symptoms of a respiratory infection. Healthcare personnel
who have a respiratory infection are advised to avoid direct patient contact,
especially with high-risk patients. If this is not possible, then a mask should
be worn while providing patient care.
Transmission-Based Precautions
There are three categories of Transmission-Based Precautions: Contact
Precautions, Droplet Precautions, and Airborne Precautions. TransmissionBased Precautions are used when the route(s) of transmission is (are) not
completely interrupted using Standard Precautions alone. For some
diseases that have multiple routes of transmission (e.g., SARS), more than
one Transmission-Based Precautions category may be used. When used

either singly or in combination, they are always used in addition to

Standard Precautions. When Transmission-Based Precautions are
indicated, efforts must be made to counteract possible adverse effects on
patients (i.e., anxiety, depression and other mood disturbances,
perceptions of stigma, reduced contact with clinical staff, and increases in
preventable adverse events in order to improve acceptance by the patients
and adherence by HCWs.
Contact Precautions
Contact Precautions are intended to prevent transmission of infectious
agents, including epidemiologically important microorganisms, which are
spread by direct or indirect contact with the patient or the patients
Contact Precautions also apply where the presence of excessive wound
drainage, fecal incontinence, or other discharges from the body suggest an
increased potential for extensive environmental contamination and risk of
transmission. A single- patient room is preferred for patients who require
Contact Precautions. When a single-patient room is not available,
consultation with infection control personnel is recommended to assess the
various risks associated with other patient placement options (e.g.,
cohorting, keeping the patient with an existing roommate). In multi-patient
rooms, >3 feet spatial separation between beds is advised to reduce the
opportunities for inadvertent sharing of items between the
infected/colonized patient and other patients. Healthcare personnel caring
for patients on Contact Precautions wear a gown and gloves for all
interactions that may involve contact with the patient or potentially
contaminated areas in the patients environment. Donning PPE upon room
entry and discarding before exiting the patient room is done to contain
pathogens, especially those that have been implicated in transmission
through environmental contamination (e.g., VRE, C. difficile, noroviruses
and other intestinal tract pathogens; RSV).
Droplet Precautions
Droplet Precautions are intended to prevent transmission of pathogens
spread through close respiratory or mucous membrane contact with
respiratory secretions. Because these pathogens do not remain infectious
over long distances in a healthcare facility, special air handling and
ventilation are not required to prevent droplet transmission. Infectious
agents for which Droplet Precautions are indicated are include B. pertussis,

influenza virus, adenovirus, rhinovirus, N. meningitides, and group A

streptococcus (for the first 24 hours of antimicrobial therapy). A single
patient room is preferred for patients who require Droplet Precautions.
When a single-patient room is not available, consultation with infection
control personnel is recommended to assess the various risks associated
with other patient placement options (e.g., cohorting, keeping the patient
with an existing roommate). Spatial separation of > 3 feet and drawing the
curtain between patient beds is especially important for patients in multibed rooms with infections transmitted by the droplet route. Healthcare
personnel wear a mask (a respirator is not necessary) for close contact
with infectious patient; the mask is generally donned upon room entry.
Patients who must be transported outside of the room should wear a mask
if tolerated and follow Respiratory Hygiene/Cough Etiquette.
Airborne Precautions
Airborne Precautions prevent transmission of infectious agents that remain
infectious over long distances when suspended in the air (e.g., rubeola
virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly
The preferred placement for patients who require Airborne Precautions is in
an airborne infection isolation room (AIIR). An AIIR is a single-patient room
that is equipped with special air handling and ventilation capacity that meet
the American Institute of Architects/Facility Guidelines Institute (AIA/FGI)
standards for AIIRs (i.e., monitored negative pressure relative to the
surrounding area, 12 air exchanges per hour for new construction and
renovation and 6 air exchanges per hour for existing facilities, air
exhausted directly to the outside or recirculated through HEPA filtration
before return). Some states require the availability of such rooms in
hospitals, emergency departments, and nursing homes that care for
patients with M. tuberculosis.
A respiratory protection program that includes education about use of
respirators, fit-testing, and user seal checks is required in any facility with
AIIRs. In settings where Airborne Precautions cannot be implemented due
to limited engineering resources (e.g., physician offices), masking the
patient, placing the patient in a private room (e.g., office examination room)
with the door closed, and providing N95 or higher level respirators or
masks if respirators are not available for healthcare personnel will reduce
the likelihood of airborne transmission until the patient is either transferred

to a facility with an AIIR or returned to the home environment, as deemed

medically appropriate. Healthcare personnel caring for patients on Airborne
Precautions wear a mask or respirator, depending on the disease-specific
recommendations (Respiratory Protection, that is donned prior to room
entry. Whenever possible, non-immune HCWs should not care for patients
with vaccine-preventable airborne diseases (e.g., measles, chickenpox,
and smallpox).
Discontinuation of Transmission-Based Precautions
Transmission-Based Precautions remain in effect for limited periods of time
(i.e., while the risk for transmission of the infectious agent persists or for the
duration of the illness. For most infectious diseases, this duration reflects
known patterns of persistence and shedding of infectious agents
associated with the natural history of the infectious process and its
treatment. For some diseases (e.g., pharyngeal or cutaneous diphtheria,
RSV), Transmission-Based Precautions remain in effect until culture or
antigen-detection test results document eradication of the pathogen and,
for RSV, symptomatic disease is resolved. For other diseases, (e.g., M.
tuberculosis) state laws and regulations, and healthcare facility policies,
may dictate the duration of precautions). In immunocompromised patients,
viral shedding can persist for prolonged periods of time (many weeks to
months) and transmission to others may occur during that time; therefore,
the duration of contact and/or droplet precautions may be prolonged for
many weeks.
The duration of Contact Precautions for patients who are colonized or
infected with MDROs remains undefined. MRSA is the only MDRO for
which effective decolonization regimens are available.
However, carriers of MRSA who have negative nasal cultures after a
course of systemic or topical therapy may resume shedding MRSA in the
weeks that follow therapy. Although early guidelines for VRE suggested
discontinuation of Contact Precautions after three stool cultures obtained at
weekly intervals proved negative, subsequent experiences have indicated
that such screening may fail to detect colonization that can persist for >1
year . Likewise, available data indicate that colonization with VRE, MRSA,
and possibly MDR-GNB, can persist for many months, especially in the
presence of severe underlying disease, invasive devices, and recurrent
courses of antimicrobial agents. It may be prudent to assume that MDRO
carriers are colonized permanently and manage them accordingly.

Alternatively, an interval free of hospitalizations, antimicrobial therapy, and

invasive devices (e.g., 6 or 12 months) before reculturing patients to
document clearance of carriage may be used.
Determination of the best strategy awaits the results of additional studies.
Application of Transmission-Based Precautions in ambulatory and
home care settings
Although Transmission-Based Precautions generally apply in all healthcare
settings, exceptions exist. For example, in home care, AIIRs are not
available. Furthermore, family members already exposed to diseases such
as varicella and tuberculosis would not use masks or respiratory protection,
but visiting HCWs would need to use such protection. Similarly,
management of patients colonized or infected with MDROs may
Contact Precautions in acute care hospitals and in some LTCFs when
there is continued transmission, but the risk of transmission in ambulatory
care and home care, has not been defined. Consistent use of Standard
Precautions may suffice in these settings, but more information is needed.
Protective Environment
A Protective Environment is designed for
allogeneic HSCT patients to minimize fungal spore counts in the air and
reduce the risk of invasive environmental fungal infections. The need for
such controls has been demonstrated in studies of aspergillus outbreaks
associated with construction. As defined by the American Insitute of
Architecture and presented in detail in the
CDC Guideline for Environmental Infection Control 2003, air quality for
HSCT patients is improved through a combination of environmental
controls that include
1) HEPA filtration of incoming air;
2) Directed room air flow;
3) Positive room air pressure relative to the corridor
4) Well-sealed rooms (including sealed walls,
5) Floors, ceilings, windows, electrical outlets) to prevent flow of air from
the outside;
6) Ventilation to provide >12 air changes per hour; 6) strategies to
minimize dust (e.g., scrubbable surfaces rather than upholstery).
7) Prohibiting dried and fresh flowers and potted plants in the rooms of
HSCT patients. The latter is based on molecular typing studies that

have found indistinguishable strains of Aspergillus terreus in patients

with hematologic malignancies and in potted plants in the vicinity of
the patients
The desired quality of air may be achieved without incurring the
inconvenience or expense of laminar airflow. To prevent inhalation of
fungal spores during periods when construction, renovation, or other dustgenerating activities that may be ongoing in and around the health-care
facility, it has been advised that severely immunocompromised patients
wear a high-efficiency respiratory-protection device (e.g., an N95
respirator) when they leave the Protective Environment). The use of masks
or respirators by HSCT patients when they are outside of the Protective
Environment for prevention of environmental fungal infections in the
absence of construction has not been evaluated. A Protective Environment
does not include the use of barrier precautions beyond those indicated for
Standard and Transmission-Based Precautions. No published reports
support the benefit of placing solid organ transplants or other
immunocompromised patients in a Protective Environment.
Standard Precautions
Assume that every person is potentially infected or colonized with an
organism that could be transmitted in the healthcare setting and apply the
following infection control practices during the delivery of health care.
Hand Hygiene
During the delivery of healthcare, avoid unnecessary touching of surfaces
in close proximity to the patient to prevent both contamination of clean
hands from environmental surfaces and transmission of pathogens from
contaminated hands to surfaces.
When hands are visibly dirty, contaminated with proteinaceous material, or
visibly soiled with blood or body fluids, wash hands with either a
nonantimicrobial soap and water or an antimicrobial soap and water.
If hands are not visibly soiled, or after removing visible material with
nonantimicrobial soap and water, decontaminate hands in the
clinical situations. The preferred method of hand decontamination is with an
alcohol-based hand rub.


Alternatively, hands may be washed with an antimicrobial soap and

water. Frequent use of alcohol-based hand rub immediately
following handwashing with nonantimicrobial soap may increase
the frequency of dermatitis.
Perform hand hygiene:
Before having direct contact with patients
After contact with blood, body fluids or excretions, mucous membranes,
nonintact skin, or wound dressings
After contact with a patients intact skin.
If hands will be moving from a contaminated-body site to a clean-body site
during patient care.
After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient.
After removing gloves
Wash hands with non-antimicrobial soap and water or with antimicrobial
soap and water if contact with spores (e.g., C. difficile
or Bacillus anthracis) is likely to have occurred. The physical action of
washing and rinsing hands under such circumstances is recommended
because alcohols, chlorhexidine, iodophors, and other antiseptic agents
have poor activity against spores.
Do not wear artificial fingernails or extenders if duties include direct contact
with patients at high risk for infection and associated adverse outcomes
(e.g., those in ICUs).
Develop an organizational policy on the wearing of non-natural nails by
healthcare personnel who have direct contact with patients outside of the
groups specified above.
Personal protective equipment (PPE)
Observe the following principles of use
Wear PPE, as described in,when the nature of the anticipated patient
interaction indicates that contact with blood body fluids may occur.

Prevent contamination of clothing and skin during the process of

removing PPE.
Before leaving the patients room or cubicle, remove and
discard PPE.
Wear gloves when it can be reasonably anticipated that contact with blood
or other potentially infectious materials, mucous membranes, nonintact
skin, or potentially contaminated intact skin (e.g., of a patient incontinent of
stool or urine) could occur.
Wear gloves with fit and durability appropriate to the task
Wear disposable medical examination gloves for providing direct patient
Wear disposable medical examination gloves or reusable utility gloves for
cleaning the environment or medical equipment.
Remove gloves after contact with a patient and/or the surrounding
environment (including medical equipment) using proper technique to
prevent hand contamination.
Do not wear the same pair of gloves for the care of more than
one patient. Do not wash gloves for the purpose of reuse since this practice
has been associated with transmission of pathogens
Change gloves during patient care if the hands will move from a
contaminated body-site (e.g., perineal area) to a clean body-site
(e.g., face).
Wear a gown, that is appropriate to the task, to protect skin and prevent
soiling or contamination of clothing during procedures and patient-care
activities when contact with blood, body fluids, secretions, or excretions is


Wear a gown for direct patient contact if the patient has uncontained
secretions or excretions.
Remove gown and perform hand hygiene before leaving the patients
Do not reuse gowns, even for repeated contacts with the same patient.
Routine donning of gowns upon entrance into a high-risk unit.
Mouth, nose, eye protection
Use PPE to protect the mucous membranes of the eyes, noseand mouth
during procedures and patient-care activities that are likely to generate
splashes or sprays of blood, body fluids, secretions and excretions. Select
masks, goggles, face shields, and combinations of each according to the
need anticipated by the task performed
During aerosol-generating procedures (e.g., bronchoscopy, suctioning of
the respiratory tract [if not using in-line suction catheters], endotracheal
intubation) in patients who are not suspected of being infected with an
agent for which respiratory protection is otherwise recommended (e.g., M.
tuberculosis, SARS or hemorrhagic fever viruses), wear one of the
following: a face shield that fully covers the front and sides of the face, a
mask with attached shield, or a mask and goggles (in addition to gloves
and gown)
Respiratory Hygiene/Cough Etiquette
Educate healthcare personnel on the importance of source control
measures to contain respiratory secretions to prevent droplet and
fomite transmission of respiratory pathogens, especially during seasonal
outbreaks of viral respiratory tract infections (e.g., influenza, RSV,
adenovirus, parainfluenza virus) in communities
Implement the following measures to contain respiratory secretions in
patients and accompanying individuals who have signs and symptoms of a
respiratory infection, beginning at the point of initial encounter in a
healthcare setting (e.g., triage, reception and waiting areas in emergency
departments, outpatient clinics and physician offices)


Post signs at entrances and in strategic places (e.g., elevators, cafeterias)

within ambulatory and inpatient settings with instructions to patients and
other persons with symptoms of a respiratory infection to cover their
mouths/noses when coughing or sneezing, use and dispose of tissues, and
perform hand hygiene after hands have been in contact with respiratory
Provide tissues and no-touch receptacles (e.g.,foot-pedal operated lid or
open, plastic-lined waste basket) for disposal of tissues
Provide resources and instructions for performing hand hygiene in or near
waiting areas in ambulatory and inpatient settings; provide convenientlylocated dispensers of alcohol-based hand rubs and, where sinks are
available, supplies for handwashing
During periods of increased prevalence of respiratory infections
in the community (e.g., as indicated by increased school absenteeism,
increased number of patients seeking care for a respiratory infection), offer
masks to coughing patients and other symptomatic persons (e.g., persons
who accompany ill patients) upon entry into the facility or medical office and
encourage them to maintain special separation, ideally a distance of at
least 3 feet, from others in common waiting areas.


Chapter 3: Bacteria
Bacteria are ubiquitous, present in the soil, air and water all around you.
Some bacteria can be beneficial, while other bacteria causes illness and
even death. Pathogenic bacteria, those organisms that cause disease,
relentlessly bombard your body daily. Your bodys immune system fights off
most of these invaders. Some types of bacteria cause more harm to
humans than others, overwhelming your bodys defenses and frequently
causing death in terrifying ways and at alarming speeds.
Bacteria are a large domain of prokaryotic microorganisms. Unlike the cells
of animals and other eukaryotes, prokaryotic cells do not contain a nucleus
and rarely harbour membrane-bound organelles.
Bacterium are usually only a few micrometres in length and have a wide
range of shapes, ranging from spheres to rods and spirals. They are
present in most habitats on Earth and can be found in the soil, in the Earths
crust, in acidic hot springs, in radioactive waste dumps, deep in the ocean
and of course, in the intestinal tracks of all animals, including us humans.
There are usually 40 million bacterial cells in just one gram of soil and a
million bacterial cells in a millilitre of fresh water; in all, there are
approximately five nonillion (yeah, thats a real number-google it) bacteria
on Earth.
Bacteria are needed to recycle nutrients, with many steps in nutrient cycles
depending on these organisms, such as the fixation of nitrogen from the
atmosphere and putrefaction.
The scientific study of bacteria is known as bacteriology, it is a branch of
microbiology, and since most bacteria on the planet have not been
characterized, and only about half of the phyla of bacteria have species
that can be grown in the laboratory I think they better get cracking.
The vast majority of the bacteria in the human body are rendered harmless
by the awesome protective power of the immune system. Some of the
bacteria in our body is even beneficial, but since this course is about
pathology we are going to skip those.
There are a few species of bacteria that are pathogenic and cause
infectious diseases, including but not limited to cholera, syphilis, anthrax,

leprosy, and bubonic plague. By far the most common fatal bacterial
diseases are respiratory infections, with tuberculosis in the lead with an
astounding 2 million people each year, mostly in sub-Saharan Africa.
In more developed countries antibiotics are used to treat bacterial
infections so antibiotic resistance is becoming common. We use bacteria
in sewage treatment facilities and for the breakdown of oil spills, the
production of yummy cheese and yogurt products, and the recovery of
gold, palladium, copper and other commercial metals in the mining sector.
The word bacteria is the plural of the New Latin bacterium, which is the
latinisation of the Greek baktrion, the diminutive of baktria, meaning
"staff, cane",because the first ones to be discovered were rod-shaped.
Bacteria can be found in a wide variety of shapes and sizes, called
morphologies. Bacterial cells are about one tenth the size of eukaryotic
cells and are typically 0.55.0 micrometres in length.
Most bacterial species are either spherical, called cocci (sing. coccus, from
Greek -kkkos, grain, seed), or rod-shaped, called bacilli (sing. bacillus,
from Latin baculus, stick). Elongation is associated with swimming. Some
rod-shaped bacteria, called vibrio, are slightly curved or comma-shaped;
others, can be spiral-shaped, called spirilla, or tightly coiled, called
The most common household bacteria are described on the following
1. Staphylococcus
Staphylococcus is a genus of Gram-positive bacteria. Under the
microscope, they appear round (cocci), and form in grape-like clusters. The
Staphylococcus genus includes at least 40 species. Most are harmless and
reside normally on the skin and mucous membranes of humans and other
organisms. Found worldwide, they are a small component of soil microbial
Staphylococcus can cause a wide variety of diseases in humans and other
animals through either toxin production or penetration. Staphylococcal

toxins are a common cause of food poisoning, as they can be produced by

bacteria growing in improperly stored food items.The most common form is
sialadenitis, which is caused by staphylococci, as bacterial infections.
Sialadenitis (sialoadenitis) is inflammation of a salivary gland. It may be
subdivided temporally into acute, chronic and recurrent forms.
2. Streptococcus
Cellular division occurs along a single axis in these bacteria, and thus they
grow in chains or pairs, hence the name from Greek streptos, meaning
easily bent or twisted, like a chain (twisted chain). Contrast this with
staphylococci, which divide along multiple axes and generate grape-like
clusters of cells. Most streptococci are oxidase- and catalase-negative, and
many are facultative anaerobes.
In addition to streptococcal pharyngitis (strep throat), certain Streptococcus
species are responsible for many cases of meningitis, bacterial pneumonia,
endocarditis, erysipelas and necrotizing fasciitis (the 'flesh-eating' bacterial
However, many streptococcal species are nonpathogenic. Indeed,
streptococci are a necessary ingredient in Emmentaler ("Swiss") cheese
(making sandwiches more awesome!). Streptococci are also part of the
normal commensal microbiome of the mouth, skin, intestine, and upper
respiratory tract of humans.
3. Bacillus
Bacillus includes both free-living and pathogenic species. Under stressful
environmental conditions, the cells produce oval endospores that can stay
dormant for extended periods. These characteristics originally defined the
genus, but not all such species are closely related, and many have been
moved to other genera.
Many Bacillus species are able to secrete large quantities of enzymes.
Bacillus amyloliquefaciens is the source of a natural antibiotic protein
barnase (a ribonuclease), alpha amylase used in starch hydrolysis, the
protease subtilisin used with detergents, and the BamH1 restriction enzyme
used in DNA research.


A portion of the Bacillus thuringiensis genome was incorporated into corn

(and cotton) crops.
4. Escherichia coli.
Escherichia coli (commonly abbreviated E. coli) is a Gram-negative, rodshaped bacterium that is commonly found in the lower intestine of warmblooded organisms. Most E. coli strains are harmless, but some serotypes
can cause serious food poisoning in humans, and are occasionally
responsible for people making product recalls.
The harmless strains are part of the normal flora of the gut, and can benefit
their hosts by producing vitamin K2, and by preventing the establishment of
pathogenic bacteria within the intestine.
Although most strains of E. coli are harmless, others can make you sick.
Some kinds of E. coli can cause diarrhea, while others cause urinary tract
infections, respiratory illness and pneumonia, and other illnesses. Still other
kinds of E. coli are used as markers for water contaminationso you might
hear about E. coli being found in drinking water, which are not themselves
harmful, but indicate the water is contaminated. It does get a bit
confusingeven to microbiologists.
Shiga toxin-producing E. coli
Some kinds of E. coli cause disease by making a toxin called Shiga toxin.
The bacteria that make these toxins are called Shiga toxin-producing E.
coli, or STEC for short. You might hear these bacteria called verocytotoxic
E. coli (VTEC) or enterohemorrhagic E. coli (EHEC); these all refer
generally to the same group of bacteria. The strain of Shiga toxin-producing
E. coli O104:H4 that caused a large outbreak in Europe in 2011 was
frequently referred to as EHEC. The most commonly identified STEC in
North America is E. coli O157:H7 (often shortened to E. coli O157 or even
just O157). When you hear news reports about outbreaks of E. coli
infections, they are usually talking about E. coli O157.
In addition to E. coli O157, many other kinds (called serogroups) of STEC
cause disease. Other E. coli serogroups in the STEC group, including E.
coli O145, are sometimes called "non-O157 STECs." Currently, there are
limited public health surveillance data on the occurrence of non-O157
STECs, including STEC O145; many STEC O145 infections may go
undiagnosed or unreported.

Compared with STEC O157 infections, identification of non-O157 STEC

infections is more complex. First, clinical laboratories must test stool
samples for the presence of Shiga toxins. Then, the positive samples must
be sent to public health laboratories to look for non-O157 STEC. Clinical
laboratories typically cannot identify non-O157 STEC. Other non-O157
STEC serogroups that often cause illness in people in the United States
include O26, O111, and O103. Some types of STEC frequently cause
severe disease, including bloody diarrhea and hemolytic uremic syndrome
(HUS), which is a type of kidney failure.
Important differences between E. coli O157 and other STEC?
Most of what we know about STEC comes from outbreak investigations
and studies of E. coli O157 infection, which was first identified as a
pathogen in 1982. The non-O157 STEC are not nearly as well understood,
partly because outbreaks due to them are rarely identified. As a whole, the
non-O157 serogroup is less likely to cause severe illness than E. coli O157;
however, some non-O157 STEC serogroups can cause the most severe
manifestations of STEC illness.
People of any age can become infected. Very young children and the
elderly are more likely to develop severe illness and hemolytic uremic
syndrome (HUS) than others, but even healthy older children and young
adults can become seriously ill.
The symptoms of STEC infections vary for each person but often include
severe stomach cramps, diarrhea (often bloody), and vomiting. If there is
fever, it usually is not very high (less than 101F/less than 38.5C). Most
people get better within 57 days. Some infections are very mild, but others
are severe or even life-threatening.
Around 510% of those who are diagnosed with STEC infection develop a
potentially life-threatening complication known as hemolytic uremic
syndrome (HUS). Clues that a person is developing HUS include
decreased frequency of urination, feeling very tired, and losing pink color in
cheeks and inside the lower eyelids. Persons with HUS should be
hospitalized because their kidneys may stop working and they may develop
other serious problems. Most persons with HUS recover within a few
weeks, but some suffer permanent damage or die.


The time between ingesting the STEC bacteria and feeling sick is called the
incubation period. The incubation period is usually 3-4 days after the
exposure, but may be as short as 1 day or as long as 10 days. The
symptoms often begin slowly with mild belly pain or non-bloody diarrhea
that worsens over several days. HUS, if it occurs, develops an average 7
days after the first symptoms, when the diarrhea is improving.
STEC live in the guts of ruminant animals, including cattle, goats, sheep,
deer, and elk. The major source for human illnesses is cattle. STEC that
cause human illness generally do not make animals sick. Other kinds of
animals, including pigs and birds, sometimes pick up STEC from the
environment and may spread it.
Transmission of STEC
Infections start when you swallow STECin other words, when you get tiny
(usually invisible) amounts of human or animal feces in your mouth.
Unfortunately, this happens more often than we would like to think about.
Exposures that result in illness include consumption of contaminated food,
consumption of unpasteurized (raw) milk, consumption of water that has
not been disinfected, contact with cattle, or contact with the feces of
infected people. Some foods are considered to carry such a high risk of
infection with E. coli O157 or another germ that health officials recommend
that people avoid them completely. These foods include unpasteurized
(raw) milk, unpasteurized apple cider, and soft cheeses made from raw
milk. Sometimes the contact is pretty obvious (working with cows at a dairy
or changing diapers, for example), but sometimes it is not (like eating an
undercooked hamburger or a contaminated piece of lettuce). People have
gotten infected by swallowing lake water while swimming, touching the
environment in petting zoos and other animal exhibits, and by eating food
prepared by people who did not wash their hands well after using the toilet.
Almost everyone has some risk of infection.
STEC infections statistics
An estimated 265,000 STEC infections occur each year in the United
States. STEC O157 causes about 36% of these infections, and non-O157
STEC cause the rest. Public health experts rely on estimates rather than
actual numbers of infections because not all STEC infections are
diagnosed, for several reasons. Many infected people do not seek medical
care; many of those who do seek care do not provide a stool specimen for
testing, and many labs do not test for non-O157 STEC. However, this

situation is changing as more labs have begun using newer, simpler tests
that can help detect non-O157 STEC.
STEC infections are usually diagnosed through laboratory testing of stool
specimens (feces). Identifying the specific strain of STEC is essential for
public health purposes, such as finding outbreaks. Many labs can
determine if STEC are present, and most can identify E. coli O157. Labs
that test for the presence of Shiga toxins in stool can detect non-O157
STEC infections. However, for the O group (serogroup) and other
characteristics of non-O157 STEC to be identified, Shiga toxin-positive
specimens must be sent to a state public health laboratory.
Contact your healthcare provider if you have diarrhea that lasts for more
than 3 days, or is accompanied by high fever, blood in the stool, or so
much vomiting that you cannot keep liquids down and you pass very little
STEC typically disappear from the feces by the time the illiness is resolved,
but may be shed for several weeks, even after symptoms go away. Young
children tend to carry STEC longer than adults. A few people keep
shedding these bacteria for several months. Good hand-washing is always
a smart idea to protect yourself, your family, and other persons.
Treatment for STEC infection
Non-specific supportive therapy, including hydration, is important.
Antibiotics should not be used to treat this infection. There is no evidence
that treatment with antibiotics is helpful, and taking antibiotics may increase
the risk of HUS. Antidiarrheal agents like Imodium may also increase that
Should an infected person be excluded from school or work?
School and work exclusion policies differ by local jurisdiction. Check with
your local or state health department to learn more about the laws where
you live. In any case, good hand-washing after changing diapers, after
using the toilet, and before preparing food is essential to prevent the
spread of these and many other infections.
Prevention of STEC infections
WASH YOUR HANDS thoroughly after using the bathroom or changing
diapers and before preparing or eating food.

WASH YOUR HANDS after contact with animals or their environments (at
farms, petting zoos, fairs, even your own backyard).
COOK meats thoroughly. Ground beef and meat that has been needletenderized should be cooked to a temperature of at least 160F/70C. Its
best to use a thermometer, as color is not a very reliable indicator of
AVOID raw milk, unpasteurized dairy products, and unpasteurized juices
(like fresh apple cider).
AVOID swallowing water when swimming or playing in lakes, ponds,
streams, swimming pools, and backyard kiddie pools.
PREVENT cross contamination in food preparation areas by thoroughly
washing hands, counters, cutting boards, and utensils after they touch raw
meat. To learn more about how to protect yourself from E. coli, see CDCs
feature, E. coli Infection.
5. Corynaebacterium
Corynebacterium is a genus of Gram-positive rod-shaped bacteria. They
are widely distributed in nature and are mostly innocuous. Some are useful
in industrial settings such as C. glutamicum.
The most notable human infection is diphtheria, caused by
Corynebacterium diphtheriae. It is an acute and contagious infection
characterized by pseudomembranes of dead epithelial cells, white blood
cells, red blood cells, and fibrin that form around the tonsils and back of the
It is an uncommon illness that tends to occur in unvaccinated individuals,
especially school-aged children, those in developing countries, elderly,
neutropenic or immunocompromised patients, and those with prosthetic
devices such as prosthetic heart valves, shunts, or catheters. It can
occasionally infect wounds, the vulva, the conjunctiva, and the middle ear.
It can be spread within a hospital.


6. Salmonella
Salmonella is found worldwide in cold- and warm-blooded animals
(including humans), and in the environment. They cause illnesses like
typhoid fever, paratyphoid fever, and foodborne illness.
Salmonella infections are zoonotic and can be transferred between humans
and non-human animals. Many infections are due to ingestion of
contaminated food.
A distinction is made between enteritis Salmonella and Salmonella
typhoid/paratyphoid Salmonella, where the latter because of a special
virulence factor and a capsule protein (virulence antigen) can cause
serious illness, such as Salmonella enterica subsp. enterica serovar Typhi.
Salmonella typhi. is adapted to humans and does not occur in other
Bacillus Anthracis
The bacteria Bacillus anthracis, or anthrax, can enter the body via three
avenues: through the skin, into the lungs or down the digestive tract. Of
these three methods, inhalation anthrax is the most deadly, with symptoms
resembling those of the flu or a cold. The Centers for Disease Control and
Prevention (CDC) classify anthrax as a Category A agent, the most
dangerous group of pathogens, or disease-causing organisms.
Animals may spread the anthrax bacteria to humans through contact with
infected animal products, inhalation of spores originating from infected
animals or consumption of infected meat not thoroughly cooked. So far,
human-to-human infections have not occurred. Treatment currently
includes antibiotics. A vaccine does exist, but it is not yet available to the
Anthrax is a serious infectious disease caused by gram-positive, rodshaped bacteria known as Bacillus anthracis. Anthrax can be found
naturally in soil and commonly affects domestic and wild animals around
the world. Although it is rare, people can get sick with anthrax if they come
in contact with infected animals or contaminated animal products.
Contact with anthrax can cause severe illness in both humans and animals.
Anthrax is not contagious, which means you cant catch it like the cold or


Domestic and wild animals such as cattle, sheep, goats, antelope, and deer
can become infected when they breathe in or ingest spores in
contaminated soil, plants, or water. In areas where domestic animals have
had anthrax in the past, routine vaccination can help prevent outbreaks.
People get infected with anthrax when spores get into the body. When
anthrax spores get inside the body, they can be activated. When they
become active, the bacteria can multiply, spread out in the body, produce
toxins (poisons), and cause severe illness.
This can happen when people breathe in spores, eat food or drink water
that is contaminated with spores, or get spores in a cut or scrape in the
skin. It is very uncommon for people in the United States to get infected
with anthrax.
How People Are Infected
People get infected with anthrax when spores get into the body. When this
happens, the spores can be activated and become anthrax bacteria. Then
the bacteria can multiply, spread out in the body, produce toxins (poisons),
and cause severe illness. This can happen when people breathe in spores,
eat food or drink water that is contaminated with spores, or get spores in a
cut or scrape in the skin.
Certain activities (described below) can increase a persons chances of
getting infected.
Working with infected animals or animal products
Most people who get sick from anthrax are exposed while working with
infected animals or animal products such as wool, hides, or hair.
Inhalation anthrax can occur when a person inhales spores that are in the
air (aerosolized) during the industrial processing of contaminated materials,
such as wool, hides, or hair.
Cutaneous anthrax can occur when workers who handle contaminated
animal products get spores in a cut or scrape on their skin.
Eating raw or undercooked meat from infected animals. People who eat
raw or undercooked meat from infected animals may get sick with
gastrointestinal anthrax. This usually occurs in countries where livestock

are not routinely vaccinated against anthrax and food animals are not
inspected prior to slaughter.
In the United States, gastrointestinal anthrax has rarely been reported. This
is because yearly vaccination of livestock is recommended in areas of the
United States where animals have had anthrax in the past, and because of
the examination of all food animals, which ensures that they are healthy at
the time of slaughter.
Injecting heroin
A newly discovered type of anthrax is injection anthrax. This type of anthrax
has been seen in northern Europe in people injecting heroin. So far, no
cases of injection anthrax have been reported in the United States.
Is Anthrax Contagious?
Normally no. You cannot catch anthrax from another person the way you
might catch a cold or the flu, but person-to-person transmission has been
reported with cutaneous anthrax, where discharges from skin lesions might
be infectious.
Anthrax is most common in agricultural regions of Central and South
America, sub-Saharan Africa, central and southwestern Asia, southern and
eastern Europe, and the Caribbean.
Anthrax is rare in the United States, but sporadic outbreaks do occur in wild
and domestic grazing animals such as cattle or deer. Anthrax is more
common in developing countries and countries that do not have veterinary
public health programs that routinely vaccinate animals against anthrax. In
the United States, yearly vaccination of livestock is recommended in areas
where animals have had anthrax in the past.
Types of Anthrax
The type of illness a person develops depends on how anthrax enters the
body. Typically, anthrax gets into the body through the skin, lungs, or
gastrointestinal system. All types of anthrax can eventually spread
throughout the body and cause death if they are not treated with antibiotics.
Cutaneous Anthrax
When anthrax spores get into the skin, usually through a cut or scrape, a
person can develop cutaneous anthrax. This can happen when a person

handles infected animals or contaminated animal products like wool, hides,

or hair. Cutaneous anthrax is most common on the head, neck, forearms,
and hands. It affects the skin and tissue around the site of infection.
Cutaneous anthrax is the most common form of anthrax infection, and it is
also considered to be the least dangerous. Infection usually develops from
1 to 7 days after exposure. Without treatment, up to 20% of people with
cutaneous anthrax may die. However, with proper treatment, almost all
patients with cutaneous anthrax survive.
Inhalation Anthrax
When a person breathes in anthrax spores, they can develop inhalation
anthrax. People who work in places such as wool mills, slaughterhouses,
and tanneries may breathe in the spores when working with infected
animals or contaminated animal products from infected animals. Inhalation
anthrax starts primarily in the lymph nodes in the chest before spreading
throughout the rest of the body, ultimately causing severe breathing
problems and shock.
Inhalation anthrax is considered to be the most deadly form of anthrax.
Infection usually develops within a week after exposure, but it can take up
to 2 months. Without treatment, only about 10 - 15% of patients with
inhalation anthrax survive. However, with aggressive treatment, about 55%
of patients survive.
Gastrointestinal Anthrax
When a person eats raw or undercooked meat from an animal infected with
anthrax, they can develop gastrointestinal anthrax. Once ingested, anthrax
spores can affect the upper gastrointestinal tract (throat and esophagus),
stomach, and intestines.
Gastrointestinal anthrax has rarely been reported in the United States.
Infection usually develops from 1 to 7 days after exposure. Without
treatment, more than half of patients with gastrointestinal anthrax die.
However, with proper treatment, 60% of patients survive.
Injection Anthrax
Recently, another type of anthrax infection has been identified in heroininjecting drug users in northern Europe. This type of infection has never
been reported in the United States.

Symptoms may be similar to those of cutaneous anthrax, but there may be

infection deep under the skin or in the muscle where the drug was injected.
Injection anthrax can spread throughout the body faster and be harder to
recognize and treat. Lots of other more common bacteria can cause skin
and injection site infections, so a skin or injection site infection in a drug
user does not necessarily mean the person has anthrax.
The symptoms of anthrax depend on the type of infection and can take
anywhere from 1 day to more than 2 months to appear. All types of anthrax
have the potential, if untreated, to spread throughout the body and cause
severe illness and even death.
Cutaneous anthrax symptoms can include
 Ulcer on forearm showing cutaneous anthrax
 A group of small blisters or bumps that may itch
 A painless skin sore (ulcer) with a black center that appears after the
small blisters or bumps
 Most often the sore will be on the face, neck, arms, or hands
 Swelling can occur around the sore
Inhalation anthrax symptoms can include
 Fever and chills
 Chest discomfort
 Shortness of breath
 Confusion or dizziness
 Nausea, vomiting, or stomach pains
 Sweats (often drenching)
 Extreme tiredness
 Body aches
Gastrointestinal anthrax symptoms can include
 Fever and chills
 Swelling of neck or neck glands
 Sore throat
 Painful swallowing

Nausea and vomiting, especially bloody vomiting

Diarrhea or bloody diarrhea
Flushing (red face) and red eyes
Stomach pain
Swelling of abdomen (stomach)

Injection anthrax symptoms can include

 Fever and chills
 A group of small blisters or bumps that may itch, appearing where the
drug was injected
 A painless skin sore with a black center that appears after the blisters
or bumps
 Swelling around the sore
 Abscesses deep under the skin or in the muscle where the drug was
Keep in mind
Symptoms are similar to those of cutaneous anthrax, but injection anthrax
can spread throughout the body faster and be harder to recognize and treat
than cutaneous anthrax.
Skin and injection site infections associated with injection drug use are
common and do not necessarily mean the person has anthrax.
Who is at risk
Anyone who has come in contact with anthrax spores could be at risk of
getting sick. Most people will never be exposed to anthrax. However, there
are activities that can put some people at greater risk of exposure than
People with certain jobs may be at an increased risk of coming in contact
with anthrax spores. These include:
 Laboratory professionals
 Livestock producers
 People who handle animal products
 Mail handlers, military personnel, and response workers who may be
exposed during a bioterror event involving anthrax spores.

The anthrax vaccine is currently provided only to people who are at an

increased risk of coming in contact with anthrax spores, such as members
of the U.S. military, certain laboratory workers, and some people who
handle animals or animal products (for example, farmers, veterinarians,
and livestock handlers). The vaccine is not licensed for use in children
under age 18, adults over age 65, or pregnant and nursing women.
Medical Care
All types of anthrax can be prevented and treated with antibiotics. There is
a vaccine licensed to prevent anthrax, but it is only recommended for
routine use in certain groups of at-risk adults. If someone has symptoms of
anthrax, its important to get medical care as quickly as possible to have
the best chances of a full recovery.
bottle of pillsAntibiotics can prevent anthrax from developing in people who
have been exposed but have not developed symptoms. Ciprofloxacin and
doxycycline are two of the antibiotics that could be used to prevent anthrax.
Each of these antibiotics offers the same protection against anthrax.
Anthrax spores typically take 1 to 6 days to be activated, but some spores
can remain inside the body and take up to 60 days or more before they are
activated. Activated spores release toxinsor poisonsthat attack the
body, causing the person to become sick. Thats why people who have
been exposed to anthrax must take antibiotics for 60 days. This will protect
them from any anthrax spores in their body when the spores are activated.
Anthrax Vaccine Adsorbed (AVA)
While there is a vaccine licensed to prevent anthrax, it is not typically
available for the general public. Anthrax Vaccine Adsorbed (AVA) protects
against cutaneous and inhalation anthrax, according to limited but well
researched evidence. The vaccine is approved by the Food and Drug
Administration (FDA) for at-risk adults before exposure to anthrax. The
vaccine does not contain any anthrax bacteria and cannot give people
Currently, FDA has not approved the vaccine for use after exposure for
anyone. However, if there were ever an anthrax emergency, people who
are exposed might be given anthrax vaccine to help prevent disease. This

would be allowed under a special protocol for use of the vaccine in

The Threat of Bioterrorism
We do not know if or when another anthrax attack might occur. However,
federal agencies have worked for years with health departments across the
country to plan and prepare for an anthrax attack. If such an emergency
were to occur in the United States, CDC and other federal agencies would
work closely with local and state partners to coordinate a response.
If a bioterrorist attack were to happen, Bacillus anthracis, the bacteria that
causes anthrax, would be one of the biological agents most likely to be
used. Biological agents are germs that can sicken or kill people, livestock,
or crops. Anthrax is one of the most likely agents to be used because
 Anthrax spores are easily found in nature, can be produced in a lab,
and can last for a long time in the environment.
 Anthrax makes a good weapon because it can be released quietly
and without anyone knowing. The microscopic spores could be put
into powders, sprays, food, and water. Because they are so small,
you may not be able to see, smell, or taste them.
 Anthrax has been used as a weapon before. It has been used as a
weapon around the world for nearly a century. In 2001, powdered
anthrax spores were deliberately put into letters that were mailed
through the U.S. postal system. Twenty-two people, including 12 mail
handlers, got anthrax, and five of these 22 people died.
How Dangerous Is Anthrax?
A subset of select agents and toxins have been designated as Tier 1
because these biological agents and toxins present the greatest risk of
deliberate misuse with significant potential for mass casualties or
devastating effect to the economy, critical infrastructure, or public
confidence, and pose a severe threat to public health and safety. Bacillus
anthracis is a Tier 1 agent.
An Anthrax Terrorist Attack
An anthrax attack could take many forms. For example, it could be placed
in letters and mailed, as was done in 2001, or it could be put into food or
water. Anthrax also could be released into the air from a truck, building, or
plane. This type of attack would mean the anthrax spores could easily be

blown around by the wind or carried on peoples clothes, shoes, and other
It only takes a small amount of anthrax to infect a large number of people.
If anthrax spores were released into the air, people could breathe them in
and get sick with anthrax. Inhalation anthrax is the most serious form and
can kill quickly if not treated immediately. If the attack were not detected by
one of the monitoring systems in place in the United States, it might go
unnoticed until doctors begin to see unusual patterns of illness among sick
people showing up at emergency rooms.
Clostridium Botulinum
Clostridium botulinum causes a severe form of food poisoning, with most
cases arising from improper canning methods. The U.S. Food and Drug
Administration (FDA) notes that acidity or high heat will kill the bacteria.
Once inside the human body, the bacteria start producing toxins, or
poisons. Just a minute amount of toxin can make you ill with botulism.
Botulinum toxin acts on the nervous system, causing trouble with
respiration, swallowing, speaking, vision and overall physical weakness.
Death results from the inability to breathe when the toxin paralyzes
breathing muscles. Early introduction of an antitoxin and respiratory aid can
save a patient.
Clostridium botulinum is the name of a group of bacteria. They can be
found in soil. These rod-shaped organisms grow best in low oxygen
conditions. The bacteria form spores which allow them to survive in a
dormant state until exposed to conditions that can support their growth.
There are seven types of botulism toxin designated by the letters A through
G; only types A, B, E and F cause illness in humans.
Botulism in the United States
In the United States, an average of 145 cases are reported each year. Of
these, approximately 15% are foodborne, 65% are infant botulism, and
20% are wound. Adult intestinal colonization and iatrogenic botulism also
occur, but rarely. Outbreaks of foodborne botulism involving two or more
persons occur most years and are usually caused by home-canned foods.
Most wound botulism cases are associated with black-tar heroin injection,
especially in California.


Symptoms of botulism
The classic symptoms of botulism include double vision, blurred vision,
drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and
muscle weakness. Infants with botulism appear lethargic, feed poorly, are
constipated, and have a weak cry and poor muscle tone. These are all
symptoms of the muscle paralysis caused by the bacterial toxin. If
untreated, these symptoms may progress to cause paralysis of the
respiratory muscles, arms, legs, and trunk. In foodborne botulism,
symptoms generally begin 18 to 36 hours after eating a contaminated food,
but they can occur as early as 6 hours or as late as 10 days.
Physicians may consider the diagnosis if the patient's history and physical
examination suggest botulism. However, these clues are usually not
enough to allow a diagnosis of botulism. Other diseases such as GuillainBarr syndrome, stroke, and myasthenia gravis can appear similar to
botulism, and special tests may be needed to exclude these other
conditions. These tests may include a brain scan, spinal fluid examination,
nerve conduction test (electromyography, or EMG), and a tensilon test for
myasthenia gravis. Tests for botulinum toxin and for bacteria that cause
botulism can be performed at some state health department laboratories
and at CDC.
The respiratory failure and paralysis that occur with severe botulism may
require a patient to be on a breathing machine (ventilator) for weeks or
months, plus intensive medical and nursing care. The paralysis slowly
improves. Botulism can be treated with an antitoxin which blocks the action
of toxin circulating in the blood. Antitoxin for infants is available from the
California Department of Public Health, and antitoxin for older children and
adults is available through CDC.If given before paralysis is complete,
antitoxin can prevent worsening and shorten recovery time. Physicians may
try to remove contaminated food still in the gut by inducing vomiting or by
using enemas. Wounds should be treated, usually surgically, to remove the
source of the toxin-producing bacteria followed by administration of
appropriate antibiotics. Good supportive care in a hospital is the mainstay
of therapy for all forms of botulism.
Complications from botulism
Botulism can result in death due to respiratory failure. However, in the past
50 years the proportion of patients with botulism who die has fallen from

about 50% to 3-5%. A patient with severe botulism may require a breathing
machine as well as intensive medical and nursing care for several months,
and some patients die from infections or other problems related to
remaining paralyzed for weeks or months. Patients who survive an episode
of botulism poisoning may have fatigue and shortness of breath for years
and long-term therapy may be needed to aid recovery.
Preventing botulism
Many cases of botulism are preventable. Foodborne botulism has often
been from home-canned foods with low acid content, such as asparagus,
green beans, beets and corn and is caused by failure to follow proper
canning methods. However, seemingly unlikely or unusual sources are
found every decade, with the common problem of improper handling during
manufacture, at retail, or by consumers; some examples are chopped garlic
in oil, canned cheese sauce, chile peppers, tomatoes, carrot juice, and
baked potatoes wrapped in foil.
In Alaska, foodborne botulism is caused by fermented fish and other
aquatic game foods. Persons who do home canning should follow strict
hygienic procedures to reduce contamination of foods, and carefully follow
instructions on safe home canning including the use of pressure
canners/cookers as recommended through county extension services or
from the US Department of Agriculture. Oils infused with garlic or herbs
should be refrigerated. Potatoes which have been baked while wrapped in
aluminum foil should be kept hot until served or refrigerated.
Because the botulinum toxin is destroyed by high temperatures, persons
who eat home-canned foods should consider boiling the food for 10
minutes before eating it to ensure safety. Wound botulism can be
prevented by promptly seeking medical care for infected wounds and by
not using injectable street drugs. Most infant botulism cases cannot be
prevented because the bacteria that causes this disease is in soil and dust.
The bacteria can be found inside homes on floors, carpet, and countertops
even after cleaning. Honey can contain the bacteria that causes infant
botulism so, children less than 12 months old should not be fed honey.
Honey is safe for persons 1 year of age and older.
Public education about botulism prevention is an ongoing activity.
Information about safe canning is widely available for consumers. Persons
in state health departments and at CDC are knowledgeable about botulism

and available to consult with physicians 24 hours a day. If antitoxin is

needed to treat a patient, it can be quickly delivered to a physician
anywhere in the country. Suspected outbreaks of botulism are quickly
investigated, and if they involve a commercial product, the appropriate
control measures are coordinated among public health and regulatory
agencies. Physicians should immediately report suspected cases of
botulism to their state health department.
Cellulitis is a bacterial infection of the skin and the connective tissues
beneath the skin, specifically the dermal and subcutaneous layers of the
skin. Cellulitis is caused by a type of bacteria entering the skin where it has
been broken either by a cut, abrasion, or fissure.
Group A Streptococcus and Staphylococcus are the most common of these
bacteria, which are normally present on the skin, but generally cause no
actual infection while on the skin's outer surface where it belongs.
Certain factors can predispose a person to cellulites and these include
insect or spider bites, blistering from a an abrasion or burn, any animal bite,
tattoos, pruritic (itchy) skin rash, recent surgery, athlete's foot, chronic dry
skin, eczema, or iv drugs (injecting drugs especially subcutaneous or
intramuscular injections) pregnancy, diabetes and obesity.
Often starting with just a small tender and red area, a client with cellulitis
typically will get a fever and chills as the reddened area enlarges. Without
proper treatment, the fever can get dangerously high. It is also common for
the lymph nodes near the affected area to swell. Cellulitis is associated with
"tracking," which looks like red streaks traveling away from the area of
inflammation though lymphatic system towards the nearest group of nodes.
If you witness this tracking on your client, please advise them to get
medical attention immediately, as this is very serious.
Once in the lymphatic system it can spread rapidly throughout the body.
This can result in influenza-like symptoms with a high temperature and
sweating or feeling very cold with shaking, as the sufferer cannot get warm.
In some rare cases the infection can spread to the deep layer of tissue
called the fascial lining. Necrotizing fasciitis, also called by the media


"flesh-eating bacteria", is an example of a deep-layer infection. It is a

medical emergency and needless to say, is as scary as it sounds.
Necrotizing fasciitis
Necrotizing fasciitis is a rare infection of the deeper layers of skin and
subcutaneous tissues, easily spreading across the fascial plane within the
subcutaneous tissue.
Necrotizing fasciitis is a fast moving and dangerous disease with a rapid
onset and is usually treated immediately with high doses of intravenous
Type I describes a polymicrobial infection, whereas Type II describes a
monomicrobial infection. Many types of bacteria can cause necrotizing
fasciitis (e.g., Group A streptococcus (Streptococcus pyogenes),
Staphylococcus aureus, Vibrio vulnificus, Clostridium perfringens,
Bacteroides fragilis). Such infections are more likely to occur in people with
compromised immune systems, over 70% have at least one of the following
clinical situations: immunosuppression, diabetes, alcoholism/drug abuse,
malignancies, and chronic systemic diseases. It does occasionally occur in
people with an apparently normal general condition and really, really bad
The infection begins locally at a site of the injury (where the skin is
compromised). The severity of the injury itself is not a factor, it can happen
with a condition as minor as a non-venomous spider bite. In the early
stages, signs of inflammation may not be apparent if the bacteria are deep
within the tissue. If they are not deep, signs of inflammation, such as
redness and swollen or hot skin, develop very quickly. Skin color may
progress to violet, and blisters may form, with subsequent necrosis (death)
of the subcutaneous tissues.
Clients with this condition usually complain of intense pain that may seem
out of step with the minor appearance of the injury. With progression of the
disease, often within hours, tissue becomes swollen. Diarrhea and vomiting
are also common symptoms.
Clients with necrotizing fasciitis typically have a fever and appear very ill.
Mortality rates have been noted as high as 73 percent if left untreated.


Without surgery and medical assistance, such as antibiotics, the infection

will rapidly progress and will eventually lead to death.
It should be noted that the expression "Flesh-eating bacteria" is a
misnomer, as the bacteria do not actually "eat" the tissue. They do cause
destruction of skin and muscle by releasing toxins (virulence factors), which
include streptococcal pyogenic exotoxins. S. pyogenes produces an
exotoxin known as a superantigen. This toxin is capable of activating Tcells non-specifically, which causes the overproduction of cytokines and
severe systemic illness (Toxic shock syndrome). So really, it is just a matter
of semantics.
It should go without saying that this condition is contraindicated for
Shigella is a genus of Gram-negative, facultative anaerobic, nonsporeforming, nonmotile, rod-shaped bacteria closely related to Salmonella. The
genus is named after Kiyoshi Shiga, who first discovered it in 1897.
It is the causative agent of a disease called shigellosis. During infection, it
typically causes dysentery. Shigella is one of the leading bacterial causes
of diarrhea worldwide. Insufficient data exist, but conservative estimates
suggest Shigella causes about 90 million cases of severe dysentery, with at
least 100,000 of these resulting in death, each year, mostly among children
in the developing world.
Shigella infection is typically by ingestion (fecaloral contamination);
depending on age and condition of the host, fewer than 100 bacterial cells
can be enough to cause an infection. Shigella causes dysentery that results
in the destruction of the epithelial cells of the intestinal mucosa in the
cecum and rectum. Some strains produce the enterotoxin shiga toxin,
which is similar to the verotoxin of E. coli O157:H7 and other verotoxinproducing E. coli. Both shiga toxin and verotoxin are associated with
causing hemolytic uremic syndrome. As noted above, these supposed E.
coli strains are at least in part actually more closely related to Shigella than
to the "typical" E. coli.
Shigella species invade the host through the M-cells interspersed in the gut
epithelia of the small intestine, as they do not interact with the apical

surface of epithelial cells, preferring the basolateral side. Shigella uses a

type-III secretion system, which acts as a biological syringe to translocate
toxic effector proteins to the target human cell. The effector proteins can
alter the metabolism of the target cell, for instance leading to the lysis of
vacuolar membranes or reorganization of actin polymerization to facilitate
intracellular motility of Shigella bacteria inside the host cell. For instance,
the IcsA effector protein triggers actin reorganization by N-WASP
recruitment of Arp2/3 complexes, helping cell-to-cell spread.
After invasion, Shigella cells multiply intracellularly and spread to
neighboring epithelial cells, resulting in tissue destruction and characteristic
pathology of shigellosis.
The most common symptoms are diarrhea, fever, nausea, vomiting,
stomach cramps, and flatulence. It is also commonly known to cause large
and painful bowel movements. The stool may contain blood, mucus, or pus.
Hence, Shigella cells may cause dysentery. In rare cases, young children
may have seizures. Symptoms can take as long as a week to appear, but
most often begin two to four days after ingestion. Symptoms usually last for
several days, but can last for weeks. Shigella is implicated as one of the
pathogenic causes of reactive arthritis worldwide.
Hand washing before handling food and thoroughly cooking all food before
eating decreases the risk of getting shigellosis.
Severe dysentery can be treated with ampicillin, TMP-SMX, or
fluoroquinolones, such as ciprofloxacin, and of course rehydration. Medical
treatment should only be used in severe cases or for certain populations
with mild symptoms (elderly, immunocompromised, food service industry
workers, child care workers). Antibiotics are usually avoided in mild cases
because some Shigella species are resistant to antibiotics, and their use
may make the germ even more resistant. Antidiarrheal agents may worsen
the sickness, and should be avoided. For Shigella-associated diarrhea,
antibiotics shorten the length of infection.
Currently, no licenced vaccine targeting Shigella exists. Shigella has been
a longstanding World Health Organization target for vaccine development,
and sharp declines in age-specific diarrhea/dysentery attack rates for this
pathogen indicate natural immunity does develop following exposure; thus,


vaccination to prevent the disease should be feasible. Several vaccine

candidates for Shigella are in various stages of development.
Legionnaires' disease (also Legionellosis) is a form of pneumonia caused
by any species of Gram negative aerobic bacteria belonging to the genus
Legionella. Over 90% of cases of Legionnaires' disease are caused by the
bacterium Legionella pneumophila.
Other causative species include Legionella longbeachae, Legionella feeleii,
Legionella micdadei and Legionella anisa. These species cause a less
severe infection known as Pontiac fever, which resembles acute influenza.
These species can be water-borne or present in soil, whereas L.
pneumophila has only been found in aquatic systems, where it is
symbiotically present in aquatic-borne amoebae. It thrives in temperatures
between 25C and 45C (77F and 113F), with an optimum temperature of
35C (95F). During infection, the bacterium invades macrophages and
lung epithelial cells and replicates intracellularly.
Legionnaires' disease acquired its name in July 1976, when an outbreak of
pneumonia occurred among people attending a convention of the American
Legion at the Bellevue-Stratford Hotel in Philadelphia. Of the 182 reported
cases, mostly men, 29 died. On January 18, 1977, the causative agent was
identified as a previously unknown strain of bacteria, subsequently named
Legionella, and the species that caused the outbreak was named
Legionella pneumophila.
Outbreaks of Legionnaires' disease receive significant media attention.
However, this disease usually occurs in single, isolated cases not
associated with any recognized outbreak. When outbreaks do occur, they
are usually in the summer and early autumn, though cases may occur at
any time of year. Most infections occur in those who are middle-aged or
older. Legionella pneumophila was first identified in 1976. National
surveillance systems and research studies were established early, and in
recent years improved ascertainment and changes in clinical methods of
diagnosis have contributed to an upsurge in reported cases in many
countries. Environmental studies continue to identify novel sources of
infection, leading to regular revisions of guidelines and regulations. There
are about 8,000 to 18,000 cases of Legionnaires' disease each year in the
United States, according to the Bureau of Communicable Disease Control.

Between 1995 and 2005 over 32,000 cases of Legionnaires' disease and
more than 600 outbreaks were reported to the European Working Group for
Legionella Infections There is a shortage of data on Legionella in
developing countries and it is likely that Legionella-related illness is
underdiagnosed worldwide. Improvements in diagnosis and surveillance in
developing countries would be expected to reveal far higher levels of
morbidity and mortality than are currently recognised. Similarly, improved
diagnosis of human illness related to legionella species and serogroups
other than Legionella pneumophila would improve knowledge about their
incidence and spread.
A 2011 study successfully used modeling to predict the likely number of
cases during Legionnaires outbreaks based on symptom on-set dates from
past outbreaks. In this way, the eventual likely size of an outbreak can be
predicted, enabling efficient and effective use of public health resources in
managing an outbreak.
Legionella pneumophila thrives in aquatic systems where it is established
within amoeba in a symbiotic relationship. In the built environment, central
air conditioning systems in office buildings, hotels, and hospitals are
sources of contaminated water. Other places it can dwell include cooling
towers used in industrial cooling systems as well as evaporative coolers,
nebulizers, humidifiers, whirlpool spas, hot water systems, showers,
windshield washers, fountains, room-air humidifiers, ice making machines,
and misting systems typically found in grocery store produce sections.
Potential sources of contaminated water include cooling towers (some 40%
to 60% of ones tested) used in industrial cooling water systems as well as
in large central air conditioning systems, evaporative coolers, nebulizers,
humidifiers, whirlpool spas, hot water systems, showers, windshield
washers, architectural fountains, room-air humidifiers, ice making
machines, misting equipment, and similar disseminators that draw upon a
public water supply.
The disease may also be transmitted from contaminated aerosols
generated in hot tubs if the disinfection and maintenance program is not
done rigorously. Freshwater ponds, creeks, and ornamental fountains are
potential sources of Legionella. The disease is particularly associated with


hotels, fountains, cruise ships and hospitals with complex potable water
systems and cooling systems.
Respiratory care devices such as humidifiers and nebulizers used with
contaminated tap water may contain Legionella. Using sterile water is very
important, especially when using respiratory care devices. Other sources
include exposure to potting mix and compost and misting systems in
produce sections of grocery stores.
Signs and symptoms
Patients with Legionnaires' disease usually have fever, chills, and a cough,
which may be dry or may produce sputum. Some patients also have
muscle aches, headache, tiredness, loss of appetite, loss of coordination
(ataxia), and occasionally diarrhea and vomiting. Confusion and impaired
cognition may also occur, as can a so-called 'relative bradycardia', i.e. low
or low normal heart rate despite the presence of a fever. Laboratory tests
may show that patients' renal functions, liver functions and electrolytes are
deranged, including hyponatremia. Chest X-rays often show pneumonia
with bi-basal consolidation. It is difficult to distinguish Legionnaires' disease
from other types of pneumonia by symptoms or radiologic findings alone;
other tests are required for diagnosis.
Persons with Pontiac fever experience fever and muscle aches without
pneumonia. They generally recover in 2 to 5 days without treatment. The
time between the patient's exposure to the bacterium and the onset of
illness for Legionnaires' disease is 2 to 10 days; for Pontiac fever, it is
shorter, generally a few hours to 2 days.
People of any age may suffer from Legionnaires' disease, but the illness
most often affects middle-age and older persons, particularly those who
smoke cigarettes or have chronic lung disease. Immunocompromised
patients are also at elevated risk. Pontiac fever most commonly occurs in
persons who are otherwise healthy.
The most useful diagnostic tests detect the bacteria in sputum, find
Legionella antigens in urine samples (due to renal fibrosis), or the
comparison of Legionella antibody levels in two blood samples taken 3 to 6
weeks apart. A urine antigen test which is simple, quick, and very reliable
will only detect Legionella pneumophila serogroup 1, which accounts for
70% of disease cause by L. pneumophila. This test was developed by

Richard Kohler and described in the Journal of Infectious disease in 1982

while Dr. Kohler was a junior faculty member at the Indiana University
School of Medicine. In addition the urine antigen test will not identify the
specific subtypes; so it cannot be used to match the patient with the
environmental source of infection. Legionella can be isolated on CYE agar
as well.
Legionella stains poorly with Gram stain, stains positive with silver, and is
cultured on charcoal yeast extract with iron and cysteine.
There is a significant under-reporting problem with Legionellosis. Even in
countries with effective health services and readily available diagnostic
testing, about 90% of cases of Legionnaires' disease are missed. This is
partly due to Legionnaire's disease being a relatively rare form of
pneumonia, which many clinicians will not have encountered before and
therefore may mis-diagnose. A further issue is that patients with
Legionellosis can present with a wide range of symptoms some of which
(such as diarrhea) may distract clinicians from making a correct diagnosis.
Current treatments of choice are the respiratory tract quinolones
(levofloxacin, moxifloxacin, gemifloxacin) or newer macrolides
(azithromycin, clarithromycin, roxithromycin). The antibiotics used most
frequently have been levofloxacin and azithromycin. Macrolides are used in
all age groups while tetracyclines are prescribed for children above the age
of 12 and quinolones above the age of 18. Rifampicin can be used in
combination with a quinolone or macrolide. It is uncertain whether
rifampicin is an effective antibiotic to take for treatment.The Infectious
Diseases Society of America does not recommend the usage of rifampicin
with added regimens.
Tetracyclines and erythromycin led to improved outcomes compared to
other antibiotics in the original American Legion outbreak. These antibiotics
are effective because they have excellent intracellular penetration in
Legionella infected cells.
Tuberculosis (TB) is caused by a bacterium called Mycobacterium
tuberculosis. The bacteria usually attack the lungs, but TB bacteria can


attack any part of the body such as the kidney, spine, and brain. If not
treated properly, TB disease can be fatal.
TB is spread through the air from one person to another. The TB bacteria
are put into the air when a person with TB disease of the lungs or throat
coughs, sneezes, speaks, or sings. People nearby may breathe in these
bacteria and become infected.
TB is NOT spread by
Shaking someones hand
Sharing food or drink
Touching bed linens or toilet seats
Sharing toothbrushes
Latent TB Infection and TB Disease
Not everyone infected with TB bacteria becomes sick. As a result, two TBrelated conditions exist: latent TB infection and TB disease.
Latent TB Infection
TB bacteria can live in the body without making you sick. This is called
latent TB infection. In most people who breathe in TB bacteria and become
infected, the body is able to fight the bacteria to stop them from growing.
People with latent TB infection do not feel sick and do not have any
symptoms. People with latent TB infection are not infectious and cannot
spread TB bacteria to others. However, if TB bacteria become active in the
body and multiply, the person will go from having latent TB infection to
being sick with TB disease.
TB Disease
TB bacteria become active if the immune system can't stop them from
growing. When TB bacteria are active (multiplying in your body), this is
called TB disease. People with TB disease are sick. They may also be able
to spread the bacteria to people they spend time with every day.
Many people who have latent TB infection never develop TB disease.
Some people develop TB disease soon after becoming infected (within
weeks) before their immune system can fight the TB bacteria. Other people
may get sick years later when their immune system becomes weak for
another reason.

For people whose immune systems are weak, especially those with HIV
infection, the risk of developing TB disease is much higher than for people
with normal immune systems.
TB Symptoms
Symptoms of TB disease include:
A bad cough that lasts 3 weeks or longer
Pain in the chest
Coughing up blood or sputum
Weakness or fatigue
Weight loss
No appetite
Sweating at night
TB Risk Factors
Once a person is infected with TB bacteria, the chance of developing TB
disease is higher if the person:
 Has HIV infection;
 Has been recently infected with TB bacteria (in the last 2 years);
 Has other health problems, like diabetes, that make it hard for the
body to fight bacteria;
 Abuses alcohol or uses illegal drugs; or
 Was not treated correctly for TB infection in the past
Testing for TB Infection
There are two kinds of tests that are used to detect TB bacteria in the body:
the TB skin test (TST) and TB blood tests. These tests can be given by a
health care provider or local health department. If you have a positive
reaction to either of the tests, you will be given other tests to see if you
have latent TB infection or TB disease.
Exposure to TB
If you think you have been exposed to someone with TB disease, contact
your health care provider or local health department to see if you should be


tested for TB infection. Be sure to tell the doctor or nurse when you spent
time with the person who has TB disease.
Treatment for Latent TB Infection and TB Disease
If you have latent TB infection but not TB disease, your health care provider
may want you be treated to keep you from developing TB disease.
Treatment of latent TB infection reduces the risk that TB infection will
progress to TB disease. Treatment of latent TB infection is essential to
controlling and eliminating TB in the United States. The decision about
taking treatment for latent TB infection will be based on your chances of
developing TB disease.
Treatment for TB Disease
TB disease can be treated by taking several drugs, usually for 6 to 9
months. It is very important to finish the medicine, and take the drugs
exactly as prescribed. If you stop taking the drugs too soon, you can
become sick again. If you do not take the drugs correctly, the germs that
are still alive may become resistant to those drugs. TB that is resistant to
drugs is harder and more expensive to treat.
TB in Specific Populations
Tuberculosis (TB) is a challenging disease to diagnose, treat, and control. It
is critical to target prevention and control efforts to certain populations so
as to reduce disparities related to TB, and further reduce TB rates both in
the United States and worldwide.
High Risk Groups
AfricanAmerican Community
Blacks in the United States continue to have a disproportionate share of
TB. The percentage of TB cases that occur in blacks or African Americans
is higher than expected based on the percentage of blacks in the US
If looking at only people born in the US, the proportion of TB in African
Americans is even greater.
Rates of TB in both blacks and whites have gone down over the past
decade, but the disparity remains.
We must better target our efforts to prevent and control TB in this group.

Tuberculosis (TB) is a disease caused by a bacterium called

Mycobacterium tuberculosis. The disease is spread from person to person
through the air. The bacteria usually attack the lungs, but TB bacteria can
attack any part of the body such as the kidney, spine, and brain. If not
treated properly, TB disease can be fatal.
TB disease was once a leading cause of death in the United States, but
since 1993 the rates of TB in the country have declined in all groups. In
2011, a total of 10,528 TB cases were reported in the United States;
however, blacks continue to have a disproportionate share of TB. The
percentage of TB cases in blacks is higher than expected based on the
percentage of blacks in the U.S. population. If looking at only people born
in the United States, the proportion of TB in blacks is even greater.
Although rates of TB in blacks have declined substantially over the past
decade, the disparity remains. Addressing the TB disparity among blacks is
an important priority; prevention and control efforts should be targeted to
this population.
The Numbers
In 2011, TB disease was reported in 1533 non-Hispanic blacks in the
United States, accounting for 23% of all people reported with TB nationally.
Among U.S.-born people reported with TB disease, 39% were nonHispanic blacks.
The rate of TB disease was 6.3 cases per 100,000 population, which is
over seven times higher than the rate of TB disease in white, non-Hispanic
people (0.8 cases per 100,000 population).
Prevention Challenges
TB is a challenging disease to diagnose, treat, and control. Dwindling
resources and loss of public health capacity, including access to care and
maintaining clinical and public health expertise add to the challenge. It is
critical to reach those at highest risk for TB, and to identify and implement
innovative strategies to improve testing and treatment.
TB rates are higher for some racial and ethnic groups. This relates to a
greater proportion of people in these groups who have other risk factors for


TB. Like other communities, blacks face a number of challenges that

contribute to higher rates of TB. Challenges include:
The duration of treatment for latent TB infection and TB disease is lengthy.
Patients are often unable or reluctant to take medication for several
months. For people with TB disease, inadequate treatment can lead to
treatment failure, relapse, ongoing transmission, and development of drug
resistance. For people with latent TB infection, medication for a condition
with no symptoms of illness is often not a priority.
Socioeconomic factors impact health outcomes and are associated with
poverty, including limited access to quality health care, unemployment,
housing, and transportation. These factors can directly or indirectly
increase the risk for TB disease and present barriers to treatment of this
Language and cultural barriers, including health knowledge, stigma
associated with the disease, values, and beliefs may also place certain
populations at higher risk. Stigma may deter people from seeking medical
care or follow up care.
TB remains a serious threat, especially for people who are infected with
human immunodeficiency virus (HIV). People infected with HIV are more
likely than uninfected people to get sick with other infections and diseases,
including TB.
Blacks have the most severe burden of HIV of all racial/ethnic groups in the
United States. Compared with other races and ethnicities, Blacks account
for a higher proportion of HIV infections at all stages of diseasefrom new
infections to deaths.
Blacks accounted for an estimated 44% of all new HIV infections among
adults and adolescents (aged 13 years or older) in 2010, despite
representing only 12% to 14% of the U.S. population.
Without treatment, as with other opportunistic infections, HIV and TB can
work together to shorten the life of the person infected.
In addition to HIV, other underlying medical conditions may increase the
risk that latent TB infection will progress to TB disease. For example, the
risk is higher in people with diabetes, substance abuse (including injection

of illegal drugs), silicosis, or those undergoing medical treatments with

Delayed detection and diagnosis of TB disease, as well as delayed
reporting of TB disease remains a challenge in TB prevention and
treatment. Because the number of TB cases in the United States is
declining, there is decreased awareness of TB signs and symptoms among
health care providers and at-risk populations. Patients may be less likely to
seek medical care and health care providers may be less likely to consider
TB as the cause.
International Travelers
In many countries, TB is much more common than in the United States. TB
is a serious international public health problem. Although multidrugresistant (MDR) and extensively drug-resistant (XDR) TB are occurring
globally, they are still rare. HIV-infected travelers are at greatest risk if they
come in contact with a person with MDR or XDR TB. All travelers should
avoid high risk settings where there are no infection control measures in
Documented places where transmission has occurred include crowded
hospitals, prisons, homeless shelters, and other settings where susceptible
persons come in contact with persons with TB disease.
Air travel itself carries a relatively low risk of infection with TB of any kind.
Trends in Tuberculosis United States, 2013
A CDC update
Negar Niki Alami, MD1, Courtney M. Yuen, PhD1, Roque Miramontes,
MPH2, Robert Pratt2, Sandy F. Price2,
Thomas R. Navin, MD2 (Author affiliations at end of text)
In 2013, a total of 9,588 new tuberculosis (TB) cases were reported in the
United States, with an incidence rate of 3.0 cases per 100,000 population,
a decrease of 4.2% from 2012 (1). This report summarizes provisional TB
surveillance data reported to CDC in 2013. Although case counts and
incidence rates continue to decline, certain populations are
disproportionately affected. The TB incidence rate among foreign-born
persons in 2013 was approximately 13 times greater than the incidence

rate among U.S.-born persons, and the proportion of TB cases occurring in

foreign-born persons continues to increase, reaching 64.6% in 2013.
Racial/ethnic disparities in TB incidence persist, with TB rates among nonHispanic Asians almost 26 times greater than among non-Hispanic whites.
Four states (California, Texas, New York, and Florida), home to
approximately one third of the U.S. population, accounted for approximately
half the TB cases reported in 2013. The proportion of TB cases occurring in
these four states increased from 49.9% in 2012 to 51.3% in 2013.
Continued progress toward TB elimination in the United States will require
focused TB control efforts among populations and in geographic areas with
disproportionate burdens of TB.
Health departments in the 50 states and the District of Columbia
electronically report to CDC verified cases of disease that meet the CDC
and Council of State and Territorial Epidemiologists surveillance case
definition for TB.* Reports include the patient's country of origin, selfidentified race and ethnicity (i.e., Hispanic or non-Hispanic), information on
(e.g., homelessness
and incarceration), human
immunodeficiency virus (HIV) status, and drug-susceptibility test results.
CDC calculates national and state TB incidence rates overall and by
racial/ethnic group, using U.S. Census Bureau population estimates (2).
The Current Population Survey provides the population denominators used
to calculate TB incidence rates and percentage changes according to
national origin. For TB surveillance, a U.S.-born person is defined as a
person born in the United States or its associated jurisdictions, or a
person born in a foreign country but having at least one U.S.-citizen parent.
In 2013, the country of birth was unknown for 0.4% of patients, and
race/ethnicity was unknown for 0.4%. In this report, persons of Hispanic
ethnicity might be of any race; non-Hispanic persons are categorized as
Asian, black, white, American Indian/Alaska Native, Native Hawaiian or
other Pacific Islander, or of multiple races.
Compared with the national TB incidence rate of 3.0 cases per 100,000
population, the median incidence rate in reporting areas was 2.2 per
100,000 population, ranging from zero in Wyoming to 9.7 per 100,000
population in Alaska (Figure 1). Thirty-three states had lower rates in 2013
than in 2012. Nine states and the District of Columbia had incidence rates
higher than the national rate. In 2013, as in 2012, four states (California,
Texas, New York, and Florida) reported more than 500 cases each.


Combined, these four states accounted for 4,917 TB cases, 51.3% of all TB
cases reported in 2013.
Among U.S.-born persons, the number and rate of TB cases decreased in
2013. The 3,377 TB cases reported among U.S.-born persons (35.4% of all
cases with known national origin) were 7.6% fewer than the number
reported in 2012 and 61.0% fewer than the number reported in 2000
(Figure 2). The rate of 1.2 per 100,000 population among U.S.-born
persons is an 8.4% decrease since 2012 and a 64.7% decrease since
Among foreign-born persons in the United States, the number and rate of
TB cases also decreased in 2013. A total of 6,172 TB cases were reported
among foreign-born persons (64.6% of all cases in persons with known
national origin), a 1.6% decrease since 2012 and a 19.0% decrease since
2000. The 15.6 cases per 100,000 population TB rate among foreign-born
persons is a 2.1% decrease since 2012 and a 41.1% decrease since 2000.
In 2013, 54.2% of foreign-born persons with TB and known country of birth
originated from five countries: 1,233 (20.0%) from Mexico, 776 (12.6%)
from the Philippines, 495 (8.0%) from India, 454 (7.4%) from Vietnam, and
377 (6.1%) from China.
The TB incidence rate among Asians was the highest among all
racial/ethnic groups and was 25.9 times higher than the incidence rate
among whites (Table). Although incidence rates among all racial/ethnic
groups declined in 2013, the decrease was greater among whites (9.2%)
and blacks (7.5%) than among Hispanics (5.3%) and Asians (0.3%).
Among persons with TB, 95% of Asians, 75% of Hispanics, 40% of blacks,
and 23% of whites were foreign-born. Among U.S.-born persons, the
incidence rate among blacks was 6.2 times higher than among whites.
HIV status was known for 85% of TB cases reported in 2013, as in 2012.
Among TB patients with known HIV status, 6.8% had a positive test result
for HIV infection in 2013, compared with 7.4% in 2012.
Among persons aged 15 years with TB, 98.5% had known housing status,
5.7% of whom reported being homeless within the past year. Among
persons aged 15 years with TB, 99.1% had a known incarceration status,
3.9% of whom were confined to a detention or correctional facility at the
time of TB diagnosis.


A total of 86 cases of multidrug-resistant TB (MDR TB) were reported in

2012, the most recent year for which complete drug-susceptibility results
are available. Drug-susceptibility test results for isoniazid and rifampin were
reported for 97.9% and 97.6% of cases with culture results positive for
Mycobacterium tuberculosis in 2011 and 2012, respectively. Among these
cases, the percentage of MDR TB for 2012 (1.2% [86 of 7,426 cases])
decreased from the percentage in 2011 (1.6% [129 of 7,906 cases]). The
percentage of MDR TB cases among persons without a previous history of
TB (1.0%) and the percentage of MDR TB cases among persons with a
previous history of TB (3.4%) were lower in 2012 than in 2011. Foreignborn persons accounted for 88.4% of MDR TB cases in 2012. Two cases of
extensively drug-resistant TB** have been reported so far for 2013,
compared with two cases in 2012 and five cases in 2011.
Despite the continued decline in U.S. TB cases and rates since 1993, the
goal of TB elimination in the United States (i.e., less than one case per
1,000,000) set in 1989 (3) remains unmet. Most states reported fewer
cases of TB in 2013. However, elevated rates of TB in specific populations
remain a major challenge that impedes progress toward TB elimination.
In 2013, four states (California, Texas, New York, and Florida) reported
approximately half of the TB cases in the United States. Their TB burden is
disproportionately greater after population adjustment, and their share of
the national TB case count has increased, from 49.9% in 2012 to 51.3% in
2013. To continue to make significant progress toward TB elimination, TB
control and prevention in the areas with the highest burden will have to
continue to be given priority. One contributing factor to the geographic
disparity is that these four states have populations at elevated risk for TB.
In 2013, 16%26% of the population in each of these four states was
foreign-born (4). In addition, three of these states (California, New York,
and Florida) were among the 15 states with the highest rates of
homelessness in 2013 (5).
The rate of decline in TB incidence among foreign-born persons (2.1%)
lagged behind the rate of decline among the U.S.-born (8.4%) in 2013,
causing the proportion of TB cases in foreign-born persons to continue to
increase. The majority of TB cases among foreign-born persons have been
attributed to reactivation of TB infection acquired previously, with the rate
reflecting TB incidence in their countries of origin (6). Further interventions
aimed at diagnosing and treating latent TB infection (LTBI) among foreign62

born persons are necessary to meet the goal of TB elimination in the

United States.
Persons experiencing homelessness also present a challenge for TB
control. During 20062010, the TB rate among persons experiencing
homelessness was estimated to be 3647 per 100,000 population,
approximately 10 times greater than the overall national TB incidence
during that period (7). In addition, recent outbreaks among persons
experiencing homelessness have underscored the potential for
transmission in homeless shelters (8,9). Effectively addressing TB among
persons experiencing homelessness requires partnerships between TB
control programs and homeless service providers to diagnose and treat
active TB disease and LTBI in this population.
The findings in this report are subject to at least two limitations. First, this
analysis is limited to reporting provisional case counts and incidence rates
for 2013. Second, incidence rates are calculated based on estimated
population denominators from 2013. CDC's annual TB surveillance report,
which is released in September of every year, will provide final TB
incidence rates based on updated denominators.
Although TB rates are declining in the United States, equal progress toward
TB elimination is not being made in all populations. The disparity between
TB rates in different populations defined by factors such as geography,
country of birth, and housing status presents a challenge to TB control
programs, given that strategies and interventions must be tailored to the
population being served. Ongoing surveillance and an ability to translate
surveillance data into public health action will be key to achieving TB
Tuberculosis (TB) incidence has been declining in the United States since
1993, but an increasing proportion of cases have been among foreign-born


Chapter 4: Viruses
Well known to the student of the human body, a virus is a microscopic
infectious agent that can only reproduce itself in the living cell of another
host organism. They have been known to infect all types of organisms,
animals, plants, and even bacteria.
About 5,000 different viruses have been described in detail, but there are
literally millions of different kinds. Viruses can be found in almost every
ecosystem on the planet and are the most abundant type of biological
The study of viruses is a sub-specialty of microbiology called virology.
The basics of Viruses
A virus is made up of particles (known as virions) consisting of the genetic
material made from either DNA or RNA, some long molecules that carry
genetic information; a protein coat that protects the genes; and in some
cases an envelope of lipids that surrounds the protein coat when they are
outside a cell.
The average virus is only about one one-hundredth the size of the average
bacterium, and the average bacterium is not very big at all, so we are
talking tiny here. Most viruses are way too small to be seen directly with a
light microscope. The shapes of a virus can range from a simple helical and
icosahedral forms to more complex structures.
Viral infections in animals are met with an innate immune system response
that generally wipes out the virus. This innate response can also be used
to make a vaccine, which can convey an artificially acquired immunity to
the specific viral infection.
Unfortunately some viruses evade or even overwhelm immune responses
and result in chronic infections. Antibiotics have no effect on viruses, but
several antiviral drugs have been developed.
Viruses spread in different ways. In plants, for example, viruses are often
transmitted from plant to plant by insects that feed on them. In animals
viruses can be carried by blood sucking insects (Fleas, Ticks, Mosquitoes,
etc). We call these disease carrying organism vectors.


The Influenza virus is spread by coughing and sneezing. The Norovirus

and rotavirus, are transmitted by the fecal-oral route and are passed from
person to person by contact, entering the body in food or water. HIV is just
one of the many STDs transmitted through sexual contact and by exposure
to infected blood.
Lets look at some of the fun and exciting viruses we can encounter during
our daily massage routine (in no particular order).
You may hear norovirus illness called "food poisoning" or "stomach flu."
Food poisoning can be caused by noroviruses. But, other germs and
chemicals can also cause food poisoning.
Norovirus illness is not related to the flu (influenza), which is a respiratory
illness caused by influenza virus.
Norovirus is a very contagious virus. You can get norovirus from an
infected person, contaminated food or water, or by touching contaminated
surfaces. The virus causes your stomach or intestines or both to get
inflamed (acute gastroenteritis). This leads you to have stomach pain,
nausea, and diarrhea and to throw up.
Anyone can be infected with norovirus and get sick. Also, you can have
norovirus illness many times in your life. Norovirus illness can be serious,
especially for young children and older adults.
Norovirus is the most common cause of acute gastroenteritis in the United
States. Each year, it causes 19-21 million illnesses and contributes to
56,000-71,000 hospitalizations and 570-800 deaths. Norovirus is also the
most common cause of foodborne-disease outbreaks in the United States.
The best way to help prevent norovirus is to practice proper hand washing
and general cleanliness.


Norovirus causes inflammation of the stomach or intestines or both. This is
called acute gastroenteritis, other common symptoms
 Throwing up
 Stomach pain
 Body aches
If you have norovirus illness, you can feel extremely ill and throw up or
have diarrhea many times a day. This can lead to dehydration, especially in
young children, older adults, and people with other illnesses. Prevent
dehydration by drinking plenty of liquids to replace fluids that are lost from
throwing up and diarrhea.
Sports drinks and other drinks without caffeine or alcohol can help with mild
dehydration. But, these drinks may not replace important nutrients and
minerals. Oral rehydration fluids that you can get over the counter are most
helpful for mild dehydration.
If you think you or someone you are caring for is severely dehydrated, call
a doctor.
Most people with norovirus illness get better within 1 to 3 days.
Symptoms of dehydration
 Decrease in urination
 Dry mouth and throat
 Feeling dizzy when standing up
 Children who are dehydrated may cry with few or no tears and be
unusually sleepy or fussy.
Norovirus is a highly contagious virus. Anyone can get infected with
norovirus and get sick. Also, you can get norovirus illness many times in
your life. One reason for this is that there are many different types of
noroviruses. Being infected with one type of norovirus may not protect you
against other types.


Norovirus can be found in your stool (feces) even before you start feeling
sick. The virus can stay in your stool for 2 weeks or more after you feel
You are most contagious when you are sick with norovirus illness, and
during the first few days after you recover from norovirus illness.
You can become infected with norovirus by accidentally getting stool or
vomit from infected people in your mouth. This usually happens by
Norovirus and food
Norovirus is the leading cause of illness and outbreaks from contaminated
food in the United States. Most of these outbreaks occur in the food service
settings like restaurants. Infected food workers are frequently the source of
the outbreaks, often by touching ready-to-eat foods, such as raw fruits and
vegetables, with their bare hands before serving them. However, any food
served raw or handled after being cooked can get contaminated with
Norovirus outbreaks can also occur from foods, such as oysters, fruits, and
vegetables, that are contaminated at their source.
Eating food or drinking liquids that are contaminated with norovirus,
touching surfaces or objects contaminated with norovirus then putting your
fingers in your mouth, or having contact with someone who is infected with
norovirus (for example, caring for or sharing food or eating utensils with
someone with norovirus illness).
Norovirus can spread quickly in closed places like daycare centers, nursing
homes, schools, and cruise ships. Most norovirus outbreaks happen from
November to April in the United States.
Practice proper hand hygiene
Wash your hands carefully with soap and water especially after using the
toilet and changing diapers, and always before eating, preparing, or
handling food.
Noroviruses can be found in your vomit or stool even before you start
feeling sick. The virus can stay in your stool for 2 weeks or more after you
feel better. So, it is important to continue washing your hands often during
this time.

Alcohol-based hand sanitizers can be used in addition to hand washing.

But, they should not be used as a substitute for washing with soap and
Carefully wash fruits and vegetables before preparing and eating them.
Cook oysters and other shellfish thoroughly before eating them.
Be aware that noroviruses are relatively resistant. They can survive
temperatures as high as 140F and quick steaming processes that are
often used for cooking shellfish.
Food that might be contaminated with norovirus should be thrown out.
Keep sick infants and children out of areas where food is being handled
and prepared.
When you are sick, do not prepare food or care for others who are sick.
You should not prepare food for others or provide healthcare while you are
sick and for at least 3 days after symptoms stop. This also applies to sick
workers in settings such as schools and daycares where they may expose
people to norovirus.
Many local and state health departments require that food workers and
preparers with norovirus illness not work until at least 48 hours after
symptoms stop. If you were recently sick, you can be given different duties
in the restaurant, such as working at a cash register or hosting.
Clean and disinfect contaminated surfaces
After throwing up or having diarrhea, immediately clean and disinfect
contaminated surfaces. Use a chlorine bleach solution with a concentration
of 10005000 ppm (525 tablespoons of household bleach [5.25%] per
gallon of water) or other disinfectant registered as effective against
norovirus by the Environmental Protection Agency (EPA).
Immediately remove and wash clothes or linens that may be contaminated
with vomit or stool (feces).
You should
 Handle soiled items carefully without agitating them,


 Wear rubber or disposable gloves while handling soiled items and

Wash your hands after, and
 Wash the items with detergent at the maximum available cycle length
then machine dry them.
Each year on average in the United States, norovirus causes 1921 million
cases of acute gastroenteritis (inflammation of the stomach or intestines or
both) leads to 1.71.9 million outpatient visits and 400,000 emergency
department visits, primarily in young children
contributes to about 56,00071,000 hospitalizations and 570-800 deaths,
mostly among young children and the elderly.
You can get norovirus illness at any time during the year. But, it is most
common in the winter. Also, there can be 50% more norovirus illness in
years when there is a new strain of the virus going around.
Most outbreaks of norovirus illness happen when infected people spread
the virus to others. But, norovirus can also spread by consuming
contaminated food or water and touching things that have the virus on
Healthcare facilities, including nursing homes and hospitals, are the most
commonly reported places for norovirus outbreaks in the United States and
other industrialized countries. Over half of all norovirus outbreaks reported
in the United States occur in long-term care facilities.
Outbreaks of norovirus illness have also occurred in restaurants, schools,
banquet halls, summer camps, cruise ships, and even at family dinners.
These are all places where people often eat food handled or prepared by
In fact, norovirus is the leading cause of illness and outbreaks from
contaminated food in the United States. About 50% of all outbreaks of foodrelated illness are caused by norovirus.
Foods that are commonly involved in outbreaks of norovirus
Leafy greens (such as lettuce),
Fresh fruits, and

Shellfish (such as oysters).

But, any food that is served raw or handled after being cooked can get
Norovirus outbreaks have also been caused by contaminated water from
wells and recreational settings, such as pools.
Rotavirus is a contagious virus that can cause gastroenteritis (inflammation
of the stomach and intestines). Symptoms include severe watery diarrhea,
often with vomiting, fever, and abdominal pain. Infants and young children
are most likely to get rotavirus disease. They can become severely
dehydrated and need to be hospitalized and can even die.
Rotavirus disease is most common in infants and young children. However,
older children and adults and can also become infected with rotavirus.
Once a person has been exposed to rotavirus, it takes about 2 days for the
symptoms to appear.
Children who get infected may have severe watery diarrhea, often with
vomiting, fever, and abdominal pain. Vomiting and watery diarrhea can last
from 3 to 8 days. Additional symptoms include loss of appetite and
dehydration (loss of body fluids), which can be especially harmful for
infants and young children.
Adults who get rotavirus disease tend to have milder symptoms.
Children, even those that are vaccinated, may develop rotavirus disease
more than once. That is because neither natural infection with rotavirus nor
rotavirus vaccination provides full immunity (protection) from future
infections. Usually a persons first infection with rotavirus causes the most
severe symptoms.
Rotavirus spreads easily among infants and young children. Children can
spread the virus both before and after they become sick with diarrhea.
They can also pass rotavirus to family members and other people with
whom they have close contact.
People who are infected with rotavirus shed rotavirus (passed from a
persons body into the environment) in their feces (stool). They shed the

virus most when they are sick and during the first 3 days after they recover
from rotavirus disease.
The virus spreads by the fecal-oral route; this means that the virus must be
shed by an infected person and then enter a susceptible persons mouth to
cause infection. Rotavirus can be spread by contaminated
Objects (toys, surfaces)
Rotavirus can spread easily. Good hygiene (handwashing) and cleanliness
are important but are not enough to control the spread of the disease.
Rotavirus vaccines are very effective in preventing rotavirus gastroenteritis
and the accompanying diarrhea and other symptoms.
CDC recommends routine vaccination of infants with either of the two
available vaccines: RotaTeq (RV5), which is given in 3 doses at ages 2
months, 4 months, and 6 months; or Rotarix (RV1), which is given in 2
doses at ages 2 months and 4 months.
Both rotavirus vaccines are given orally. The vaccines are very effective
(85% to 98%) in preventing severe rotavirus disease in infants and young
children, including rotavirus infection that requires hospitalization.
Rotavirus vaccines will not prevent diarrhea or vomiting caused by other
viruses or pathogens.


Viral Hepatitis
"Hepatitis" means inflammation of the liver and also refers to a group of
viral infections that affect the liver . The most common types are Hepatitis
A, Hepatitis B, and Hepatitis C.
Viral hepatitis is the leading cause of liver cancer and the most common
reason for liver transplantation. An estimated 4.4 million Americans are
living with chronic hepatitis; most do not know they are infected.
Hepatitis A
Hepatitis A, caused by infection with the Hepatitis A virus (HAV), has an
incubation period of approximately 28 days (range: 1550 days). HAV
replicates in the liver and is shed in high concentrations in feces from 2
weeks before to 1 week after the onset of clinical illness. HAV infection
produces a self-limited disease that does not result in chronic infection or
chronic liver disease.
However, 10%15% of patients might experience a relapse of symptoms
during the 6 months after acute illness. Acute liver failure from Hepatitis A
is rare (overall case-fatality rate: 0.5%). The risk for symptomatic infection
is directly related to age, with >80% of adults having symptoms compatible
with acute viral hepatitis and the majority of children having either
asymptomatic or unrecognized infection. Antibody produced in response to
HAV infection persists for life and confers protection against reinfection.
HAV infection is primarily transmitted by the fecal-oral route, by either
person-to-person contact or consumption of contaminated food or water.
Although viremia occurs early in infection and can persist for several weeks
after onset of symptoms, bloodborne transmission of HAV is uncommon.
HAV occasionally might be detected in saliva in experimentally infected
animals, but transmission by saliva has not been demonstrated.
In the United States, nearly half of all reported Hepatitis A cases have no
specific risk factor identified. Among adults with identified risk factors, the
majority of cases are among men who have sex with other men, persons
who use illegal drugs, and international travelers.
Because transmission of HAV during sexual activity probably occurs
because of fecal-oral contact, measures typically used to prevent the
transmission of other STDs (e.g., use of condoms) do not prevent HAV

transmission. In addition, efforts to promote good personal hygiene have

not been successful in interrupting outbreaks of Hepatitis A. Vaccination is
the most effective means of preventing HAV transmission among persons
at risk for infection. Hepatitis A vaccination is recommended for all children
at age 1 year, for persons who are at increased risk for infection, for
persons who are at increased risk for complications from Hepatitis A, and
for any person wishing to obtain immunity.
How is HAV transmitted?
Person-to-person transmission through the fecal-oral route (i.e., ingestion
of something that has been contaminated with the feces of an infected
person) is the primary means of HAV transmission in the United States.
Most infections result from close personal contact with an infected
household member or sex partner.
Common-source outbreaks and sporadic cases also can occur from
exposure to fecally contaminated food or water. Uncooked HAVcontaminated foods have been recognized as a source of outbreaks.
Cooked foods also can transmit HAV if the temperature during food
preparation is inadequate to kill the virus or if food is contaminated after
cooking, as occurs in outbreaks associated with infected food handlers.
Waterborne outbreaks are infrequent in developed countries with wellmaintained sanitation and water supplies.
Who is at increased risk for acquiring HAV infection?
 Travelers to countries with high or intermediate endemicity of HAV
 Men who have sex with men
 Users of injection and non-injection illegal drugs
 Persons with clotting factor disorders
 Persons working with nonhuman primates
Signs and symptoms of HAV infection
Some persons, particularly young children, are asymptomatic. When
symptoms are present, they usually occur abruptly and can include the
 Loss of appetite

Abdominal pain
Dark urine
Clay-colored bowel movements
Joint pain

In children aged <6 years, 70% of infections are asymptomatic; if illness
does occur, it is typically not accompanied by jaundice. Among older
children and adults, infection is typically symptomatic, with jaundice
occurring in >70% of patients.
When symptoms occur, how long do they usually last?
Symptoms usually last less than 2 months, although 10%15% of
symptomatic persons have prolonged or relapsing disease for up to 6
Incubation period for Hepatitis A
The average incubation period for Hepatitis A is 28 days (range: 1550
The Hepatitis A Virus outside the body
HAV can live outside the body for months, depending on the environmental
conditions. The virus is killed by heating to >185 degrees F (>85 degrees
C) for one minute. However, the virus can still be spread from cooked food
if it is contaminated after cooking. Adequate chlorination of water, as
recommended in the United States, kills HAV that enters the water supply.
Preventing Hepatitis A Infection
Vaccination with the full, two-dose series of Hepatitis A vaccine is the best
way to prevent HAV infection. Hepatitis A vaccine has been licensed in the
United States for use in persons 12 months of age and older. The vaccine
is recommended for persons who are more likely to get HAV infection or
are more likely to get seriously ill if they get Hepatitis A, and for any person
wishing to obtain immunity (see Who should be vaccinated against
Hepatitis A?).
Immune globulin is available for short-term protection (approximately 3
months) against Hepatitis A, both pre- and post-exposure. Immune globulin


must be administered within 2 weeks after exposure for maximum

Good hygiene including handwashing after using the bathroom,
changing diapers, and before preparing or eating food is also integral to
Hepatitis A prevention, given that the virus is transmitted through the fecal
oral route. Environmental surfaces can be cleaned with a freshly prepared
solution of 1:100 dilution of household bleach.
Hepatitis A Vaccination
Who should be vaccinated against Hepatitis A?
Hepatitis A vaccination is recommended for all children at age 1 year, for
persons who are at increased risk for infection, for persons who are at
increased risk for complications from Hepatitis A, and for any person
wishing to obtain immunity. The following groups are recommended to
receive Hepatitis A vaccination:
All children at age 1 year (i.e., 1223 months). Children who have not
been vaccinated by age 2 can be vaccinated at subsequent visits.
Children and adolescents ages 218 who live in states or communities
where routine Hepatitis A vaccination has been implemented because of
high disease incidence. Before 2006, when Hepatitis A vaccination was first
recommended for all children at age 1 year, vaccination had been targeted
to children living in states or communities that had historically high rates of
Hepatitis A. States, counties, and communities with existing Hepatitis A
vaccination programs for children aged 218 years are encouraged to
maintain these programs. In those communities, new efforts focused on
routine vaccination of children at age 1 year should enhance, not replace,
ongoing programs directed at a broader population of children.
Persons traveling to or working in countries that have high or intermediate
rates of Hepatitis A. Persons from developed countries who travel to
developing countries are at high risk for Hepatitis A. The risk for Hepatitis A
exists even for travelers to urban areas, those who stay in luxury hotels,
and those who report that they have good hygiene and that they are careful
about what they drink and eat (see Hepatitis A and International Travel for
more information).


Men who have sex with men. Sexually active men (both adolescents and
adults) who have sex with men should be vaccinated. Hepatitis A outbreaks
among men who have sex with men have been reported frequently. Recent
outbreaks have occurred in urban areas in the United States, Canada, and
Users of illegal injection and noninjection drugs. During the past two
decades, outbreaks of Hepatitis A have been reported with increasing
frequency among users of both injection and noninjection drugs (e.g.,
methamphetamine) in North America, Europe, and Australia.
Persons who have occupational risk for infection. Persons who work with
HAV-infected primates or with HAV in a research laboratory setting should
be vaccinated. No other groups have been shown to be at increased risk
for HAV infection because of occupational exposure.
Persons who have chronic liver disease. Persons with chronic liver disease
who have never had Hepatitis A should be vaccinated, as they have a
higher rate of fulminant Hepatitis A (i.e., rapid onset of liver failure, often
leading to death). Persons who are either awaiting or have received liver
transplants also should be vaccinated.
Persons who have clotting-factor disorders. Persons who have never had
Hepatitis A and who are administered clotting-factor concentrates,
especially solvent detergent-treated preparations, should be vaccinated.
Household members and other close personal contacts of adopted children
newly arriving from countries with high or intermediate hepatitis A
Hepatitis A does not become chronic and IgG antibodies to HAV, which
appear early in the course of infection, provide lifelong protection against
the disease.
Hepatitis B
Hepatitis B is caused by infection with the Hepatitis B virus (HBV). The
incubation period from the time of exposure to onset of symptoms is 6
weeks to 6 months. HBV is found in highest concentrations in blood and in
lower concentrations in other body fluids (e.g., semen, vaginal secretions,
and wound exudates). HBV infection can be self-limited or chronic.

In adults, only approximately half of newly acquired HBV infections are

symptomatic, and approximately 1% of reported cases result in acute liver
failure and death. Risk for chronic infection is inversely related to age at
infection: approximately 90% of infected infants and 30% of infected
children aged <5 years become chronically infected, compared with 2%
6% of adults. Among persons with chronic HBV infection, the risk for
premature death from cirrhosis or hepatocellular carcinoma is 15%25%.
HBV is efficiently transmitted by percutaneous or mucous membrane
exposure to infectious blood or body fluids that contain blood.
The primary risk factors that have been associated with infection are
unprotected sex with an infected partner, birth to an infected mother,
unprotected sex with more than one partner, men who have sex with other
men (MSM), history of other STDs, and illegal injection drug use.
How many new HBV infections occur annually in the United States?
In 2009, 3,374 cases of acute Hepatitis B in the United States were
reported to CDC; the overall incidence of reported acute Hepatitis B was
1.5 per 100,000 population, the lowest ever recorded. However, because
many HBV infections are either asymptomatic or never reported, the actual
number of new infections is estimated to be approximately tenfold higher.
In 2009, an estimated 38,000 persons in the United States were newly
infected with HBV. Rates are highest among adults, particularly males aged
2544 years.
Has the rate of new HBV infections in the United States declined?
The rate of new HBV infections has declined by approximately 82% since
1991, when a national strategy to eliminate HBV infection was implemented
in the United States. The decline has been greatest among children born
since 1991, when routine vaccination of children was first recommended.
How common is chronic HBV infection in the United States?
An estimated 800,0001.4 million persons in the United States have
chronic HBV infection. Chronic infection is an even greater problem
globally, affecting approximately 240 million persons. An estimated 786,000
persons worldwide die from HBV-related liver disease each year.


Transmission, Symptoms, and Treatment

 HBV is transmitted through activities that involve percutaneous (i.e.,
puncture through the skin) or mucosal contact with infectious blood or
body fluids (e.g., semen, saliva), including
 Sex with an infected partner
 Injection drug use that involves sharing needles, syringes, or drugpreparation equipment
 Birth to an infected mother
 Contact with blood or open sores of an infected person
 Needle sticks or sharp instrument exposures
 Sharing items such as razors or toothbrushes with an infected person
HBV is not spread through food or water, sharing eating utensils,
breastfeeding, hugging, kissing, hand holding, coughing, or sneezing.
The Hepatitis B Virus outside the body
HBV can survive outside the body at least 7 days and still be capable of
causing infection.
Any blood spills including dried blood, which can still be infectious
should be cleaned using 1:10 dilution of one part household bleach to 10
parts of water for disinfecting the area. Gloves should be used when
cleaning up any blood spills.
Who is at risk for HBV infection?
The following populations are at increased risk of becoming infected with
 Infants born to infected mothers
 Sex partners of infected persons
 Sexually active persons who are not in a long-term, mutually
monogamous relationship (e.g., >1 sex partner during the previous 6
 Men who have sex with men
 Injection drug users
 Household contacts of persons with chronic HBV infection
 Health care and public safety workers at risk for occupational
exposure to blood or blood-contaminated body fluids
 Hemodialysis patients
 Residents and staff of facilities for developmentally disabled persons

 Travelers to countries with intermediate or high prevalence of HBV

International travelers
The risk for HBV infection in international travelers is generally low, except
for certain travelers to regions where the prevalence of chronic HBV
infection is high or intermediate (i.e., Hepatitis B surface antigen
prevalence of 2%). Hepatitis B vaccination should be administered to
unvaccinated persons traveling to those countries.
Signs and symptoms of HBV infection
The presence of signs and symptoms varies by age. Most children under
age 5 years and newly infected immunosuppressed adults are
asymptomatic, whereas 30%50% of persons aged 5 years have initial
signs and symptoms. When present, signs and symptoms can include
 Loss of appetite
 Abdominal pain
 Dark urine
 Clay-colored bowel movements
 Joint pain
Persons with chronic HBV infection might be asymptomatic, have no
evidence of liver disease, or have a spectrum of disease ranging from
chronic hepatitis to cirrhosis or hepatocellular carcinoma (a type of liver
Incubation period for Hepatitis B
Symptoms begin an average of 90 days (range: 60150 days) after
exposure to HBV.
When symptoms of acute Hepatitis B occur, how long do they usually last?
Symptoms typically last for several weeks but can persist for up to 6


Acute infection ranges from asymptomatic or mild disease to rarely

fulminant hepatitis. Disease is more severe among adults aged >60 years.
The fatality rate among acute cases reported to CDC is 0.5%1%.
Approximately 25% of those who become chronically infected during
childhood and 15% of those who become chronically infected after
childhood die prematurely from cirrhosis or liver cancer, and the majority
remain asymptomatic until onset of cirrhosis or end-stage liver disease. In
the United States, chronic HBV infection results in an estimated 2,000
4,000 deaths per year.
The risk for chronic infection varies according to the age at infection and is
greatest among young children. Approximately 90% of infants and 25%
50% of children aged 15 years will remain chronically infected with HBV.
By contrast, approximately 95% of adults recover completely from HBV
infection and do not become chronically infected.
For acute infection, no medication is available; treatment is supportive.
For chronic infection, several antiviral drugs (adefovir dipivoxil, interferon
alfa-2b, pegylated interferon alfa-2a, lamivudine, entecavir, and telbivudine)
are available. Persons with chronic HBV infection require medical
evaluation and regular monitoring to determine whether disease is
progressing and to identify liver damage or hepatocellular carcinoma.
Hepatitis C
Hepatitis C virus (HCV) infection is the most common chronic bloodborne
infection in the United States; approximately 3.2 million persons are
chronically infected. Although HCV is not efficiently transmitted sexually,
persons at risk for infection through injection drug use might seek care in
STD treatment facilities, HIV counseling and testing facilities, correctional
facilities, drug treatment facilities, and other public health settings where
STD and HIV prevention and control services are available.
Sixty to 70% of persons newly infected with HCV typically are usually
asymptomatic or have a mild clinical illness. HCV RNA can be detected in
blood within 13 weeks after exposure. The average time from exposure to
antibody to HCV (anti-HCV) seroconversion is 89 weeks, and anti-HCV
can be detected in >97% of persons by 6 months after exposure. Chronic
HCV infection develops in 70%85% of HCV-infected persons; 60%70%

of chronically infected persons have evidence of active liver disease. The

majority of infected persons might not be aware of their infection because
they are not clinically ill. However, infected persons serve as a source of
transmission to others and are at risk for chronic liver disease or other
HCV-related chronic diseases decades after infection.
HCV is most efficiently transmitted through large or repeated percutaneous
exposure to infected blood (e.g., through transfusion of blood from
unscreened donors or through use of injecting drugs). Although much less
frequent, occupational, perinatal, and sexual exposures also can result in
transmission of HCV.
The role of sexual activity in the transmission of HCV has been
controversial. Case-control studies have reported an association between
acquiring HCV infection and exposure to a sex contact with HCV infection
or exposure to multiple sex partners. Surveillance data also indicate that
15%20% of persons reported with acute HCV infection have a history of
sexual exposure in the absence of other risk factors. Case reports of acute
HCV infection among HIV-positive MSM who deny injecting-drug use have
indicated that this occurrence is frequently associated with other STDs
(e.g., syphilis). In contrast, a low prevalence (1.5% on average) of HCV
infection has been demonstrated in studies of long-term spouses of
patients with chronic HCV infection who had no other risk factors for
infection. Multiple published studies have demonstrated that the prevalence
of HCV infection among MSM who have not reported a history of injectingdrug use is no higher than that of heterosexuals. Because sexual
transmission of other bloodborne viruses, such as HIV, is more efficient
among homosexual men than in heterosexual men and women, the reason
that HCV infection rates are not substantially higher among MSM is
unclear. Overall, these findings indicate that sexual transmission of HCV is
possible but inefficient.
Incidence of HCV infection in the United States
Although only 849 cases of confirmed acute Hepatitis C were reported in
the United States in 2007, CDC estimates that approximately 17,000 new
HCV infections occurred that year, after adjusting for asymptomatic
infection and underreporting. Persons newly infected with HCV are usually
asymptomatic, so acute Hepatitis C is rarely identified or reported.


Approximately 3.2 million persons in the United States have chronic HCV
infection. Infection is most prevalent among those born during 19451965,
the majority of whom were likely infected during the 1970s and 1980s when
rates were highest.
Who is at risk for HCV infection?
The following persons are at known to be at increased risk for HCV
 Current or former injection drug users, including those who injected
only once many years ago
 Recipients of clotting factor concentrates made before 1987, when
more advanced methods for manufacturing those products were
 Recipients of blood transfusions or solid organ transplants before July
1992, when better testing of blood donors became available
 Chronic hemodialysis patients
 Persons with known exposures to HCV, such as health care workers
after needlesticks involving HCV-positive blood recipients of blood or
organs from a donor who tested HCV-positive
 Persons with HIV infection
 Children born to HCV-positive mothers
HCV infection becomes chronic in approximately 75%85% of cases.
A person infected with HCV mounts an immune response to the virus, but
replication of the virus during infection can result in changes that evade the
immune response. This may explain how the virus establishes and
maintains chronic infection.
Hepatitis C Severity
Of every 100 persons infected with HCV, approximately
7585 will go on to develop chronic infection
6070 will go on to develop chronic liver disease
520 will go on to develop cirrhosis over a period of 2030 years
15 will die from the consequences of chronic infection (liver cancer or

Prior infection with HCV does not protect against later infection with the
same or different genotypes of the virus. This is because persons infected
with HCV typically have an ineffective immune response due to changes in
the virus during infection. For the same reason, no effective pre- or
postexposure prophylaxis (i.e., immune globulin) is available.
Chronic HCV infection is the leading indication for liver transplants in the
United States.
How many deaths can be attributed to chronic HCV infection?
A recent CDC analysis of death certificate data found that HCV-attributable
deaths increased significantly between 1999 and 2007. CDC estimates that
there were 15,106 deaths caused by HCV in 2007. The citation can be
found at "The increasing burden of mortality from viral hepatitis in the
United States between 1999 and 2007." Ly, K., et al. Annals Of Internal
Medicine, 2012. 156(4): p. 271-278External Web Site Icon
No vaccine for Hepatitis C is available. Research into the development of a
vaccine is under way.
Transmission and Symptoms
HCV is transmitted primarily through large or repeated percutaneous (i.e.,
passage through the skin) exposures to infectious blood, such as
Injection drug use (currently the most common means of HCV transmission
in the United States).
Receipt of donated blood, blood products, and organs (once a common
means of transmission but now rare in the United States since blood
screening became available in 1992)
Needlestick injuries in health care settings.
Birth to an HCV-infected mother
HCV can also be spread infrequently through
Sex with an HCV-infected person (an inefficient means of transmission)


Sharing personal items contaminated with infectious blood, such as razors

or toothbrushes (also inefficient vectors of transmission)
Other health care procedures that involve invasive procedures, such as
injections (usually recognized in the context of outbreaks)
The most recent surveys of active IDUs indicate that approximately one
third of young (aged 1830 years) IDUs are HCV-infected. Older and
former IDUs typically have a much higher prevalence (approximately 70%
90%) of HCV infection, reflecting the increased risk of continued injection
drug use. The high HCV prevalence among former IDUs is largely
attributable to needle sharing during the 1970s and 1980s, before the risks
of bloodborne viruses were widely known and before educational initiatives
were implemented.
Now that more advanced screening tests for HCV are used in blood banks,
the risk is considered to be less than 1 chance per 2 million units
transfused. Before 1992, when blood screening for HCV became available,
blood transfusion was a leading means of HCV transmission.
As long as Standard Precautions and other infection control practices are
used consistently, medical and dental procedures performed in the United
States generally do not pose a risk for the spread of HCV. However, HCV
has been spread in health care settings when injection equipment, such as
syringes, was shared between patients or when injectable medications or
intravenous solutions were mishandled and became contaminated with
blood. Health care personnel should understand and adhere to Standard
Precautions, which includes safe injection practices and other guidance
aimed at reducing bloodborne pathogen risks for patients and health care
personnel. If health care-associated HCV infection is suspected, this should
be reported to state and local public health authorities.
What are the signs and symptoms of acute HCV infection?
Persons with newly acquired HCV infection usually are asymptomatic or
have mild symptoms that are unlikely to prompt a visit to a health care
professional. When symptoms occur, they can include
 Dark urine
 Clay-colored stool

Abdominal pain
Loss of appetite
Joint pain

Percentage of persons infected with HCV that develop symptoms of

acute illness
Approximately 20%30% of those newly infected with HCV experience
fatigue, abdominal pain, poor appetite, or jaundice.
In those persons who do develop symptoms, the average time period from
exposure to symptom onset is 412 weeks (range: 224 weeks).
Most persons with chronic HCV infection are asymptomatic. However,
many have chronic liver disease, which can range from mild to severe,
including cirrhosis and liver cancer. Chronic liver disease in HCV-infected
persons is usually insidious, progressing slowly without any signs or
symptoms for several decades. In fact, HCV infection is often not
recognized until asymptomatic persons are identified as HCV-positive when
screened for blood donation or when elevated alanine aminotransferase
(ALT, a liver enzyme) levels are detected during routine examinations.
HCV testing is recommended for anyone at increased risk for HCV
infection, including:
 Persons born from 1945 through 1965
 Persons who have ever injected illegal drugs, including those who
injected only once many years ago
 Recipients of clotting factor concentrates made before 1987
 Recipients of blood transfusions or solid organ transplants before July
 Patients who have ever received long-term hemodialysis treatment
 Persons with known exposures to HCV, such as
 health care workers after needlesticks involving HCV-positive blood
 recipients of blood or organs from a donor who later tested HCVpositive
 All persons with HIV infection


 Patients with signs or symptoms of liver disease (e.g., abnormal liver

enzyme tests)
 Children born to HCV-positive mothers (to avoid detecting maternal
antibody, these children should not be tested before age 18 months)
Hepatitis D
Hepatitis D, also known as "delta hepatitis," is a serious liver disease
caused by infection with the Hepatitis D virus (HDV), which is an RNA virus
structurally unrelated to the Hepatitis A, B, or C viruses.
Hepatitis D, which can be acute or chronic, is uncommon in the United
States. HDV is an incomplete virus that requires the helper function of HBV
to replicate and only occurs among people who are infected with the
Hepatitis B virus (HBV). HDV is transmitted through percutaneous or
mucosal contact with infectious blood and can be acquired either as a
coinfection with HBV or as superinfection in persons with HBV infection.
There is no vaccine for Hepatitis D, but it can be prevented in persons who
are not already HBV-infected by Hepatitis B vaccination.
Hepatitis E
Hepatitis E is a serious liver disease caused by the Hepatitis E virus (HEV)
that usually results in an acute infection. It does not lead to a chronic
infection. While rare in the United States, Hepatitis E is common in many
parts of the world. Transmission: Ingestion of fecal matter, even in
microscopic amounts; outbreaks are usually associated with contaminated
water supply in countries with poor sanitation. Vaccination: There is
currently no FDA-approved vaccine for Hepatitis E.
Since between 3 and 4 million people in this country are infected with either
hepatitis B or hepatitis C (or both), the chances for massage therapists to
have an infected client are relatively high. Clients may or may not know
about their status, or they may choose not to share their status with you.
Genital herpes
Genital herpes is a disease caused by the herpes simplex virus (HSV), of
which there are two types. Type 1 (HSV-1) usually causes oral herpes, an
infection of the lips and mouth. Symptoms are commonly known as cold
sores or fever blisters. In the past, HSV-1 was not known to cause genital
herpes, but that is changing, especially among people who begin having


sex at a young age. Still, in most cases, genital herpes is caused by the
second type of herpes virus (HSV-2).
HSV-2 lives in the nerves. When it's active, it travels to the surface of the
infected area (skin or mucous membrane) and makes copies of itself. This
is called "shedding" because these new viruses can, at this time, rub off on
another person. Then the virus travels back down the nerve to a ganglion
(mass of nerve tissue), usually at the base of the spine, where it lies
dormant for a while.
About one-fifth of all people aged 12 and up in the U.S. are infected with
the HSV-2 virus that causes genital herpes, but as many as 90% don't
know it. (By comparison, experts estimate 50% to 80% of adults have oral
More women than men are infected -- one in four women compared with
one in five men. One reason may be that the virus can infect a woman's
genitals more easily than it can a man's. Genital herpes is more common
among blacks than it is among whites, and it becomes more common as
people age. The more sex partners people have, the more common it is,
Herpes (Oral or Genital) Transmission
HSV-1 is usually passed from person to person by kissing. HSV-1 can also
spread from the mouth to the genitals during oral sex (fellatio, cunnilingus,
analingus). If this happens, it becomes a case of genital herpes.
HSV-2 is most often passed by vaginal sex and anal sex. But just as HSV-1
can infect the genitals and cause genital herpes, HSV-2 can pass from one
person's genitals to another person's mouth, resulting in oral herpes.
Why this matters to massage therapists:
HSV-1 and HSV-2 can survive outside the body, although for how long is a
matter of debate.
This means that the cloth on the face rest of your massage table or even
the linen on the table itself can harbor the virus and pass it on to the next
client, in theory1.

Herpes Simplex Demystified By Ruth Werner, LMP, NCTMB, Massage Therapy Foundation President


The CDC suggests that the virus can only last outside the body for a few
hours and that is only in the right conditions (warm and moist-like the
unchanged sheets of a massage table). It is possible (again, theoretically)
that if a massage therapist failed to change the linens on their table after
working on a client with an active Herpes infection and then had another
client use the same linens within a few minutes (as with back to back
appointments). While experts agree that it is possible, its highly unlikely.
Influenza (flu) is a contagious respiratory illness caused by influenza
viruses. It can cause mild to severe illness. Serious outcomes of flu
infection can result in hospitalization or death.
The flu is a contagious respiratory illness caused by influenza viruses that
infect the nose, throat, and lungs. It can cause mild to severe illness, and at
times can lead to death. The best way to prevent the flu is by getting a flu
vaccine each year.
Signs and symptoms of flu
People who have the flu often feel some or all of these signs and
Fever or feeling feverish/chills
Sore throat
Runny or stuffy nose
Muscle or body aches
Fatigue (very tired)
Some people may have vomiting and diarrhea, though this is more
common in children than adults.
How flu spreads
Most experts believe that flu viruses spread mainly by droplets made when
people with flu cough, sneeze or talk. These droplets can land in the
mouths or noses of people who are nearby. Less often, a person might also
get flu by touching a surface or object that has flu virus on it and then
touching their own mouth, eyes or possibly their nose.


Person to Person
People with flu can spread it to others up to about 6 feet away. Most
experts think that flu viruses are spread mainly by droplets made when
people with flu cough, sneeze or talk. These droplets can land in the
mouths or noses of people who are nearby or possibly be inhaled into the
lungs. Less often, a person might also get flu by touching a surface or
object that has flu virus on it and then touching their own mouth or nose.
To avoid this, people should stay away from sick people and stay home if
sick. It also is important to wash hands often with soap and water. If soap
and water are not available, use an alcohol-based hand rub. Linens, eating
utensils, and dishes belonging to those who are sick should not be shared
without washing thoroughly first. Eating utensils can be washed either in a
dishwasher or by hand with water and soap and do not need to be cleaned
separately. Further, frequently touched surfaces should be cleaned and
disinfected at home, work and school, especially if someone is ill.
The Flu Is Contagious
Most healthy adults may be able to infect other people beginning 1 day
before symptoms develop and up to 5 to 7 days after becoming sick.
Children may pass the virus for longer than 7 days. Symptoms start 1 to 4
days after the virus enters the body. That means that you may be able to
pass on the flu to someone else before you know you are sick, as well as
while you are sick. Some people can be infected with the flu virus but have
no symptoms. During this time, those persons may still spread the virus to
Period of contagiousness
You may be able to pass on the flu to someone else before you know you
are sick, as well as while you are sick. Most healthy adults may be able to
infect others beginning 1 day before symptoms develop and up to 5 to 7
days after becoming sick. Some people, especially young children and
people with weakened immune systems, might be able to infect others for
an even longer time.
Flu is unpredictable and how severe it is can vary widely from one season
to the next depending on many things, including:
 What flu viruses are spreading,
 How much flu vaccine is available
 When vaccine is available

 How many people get vaccinated, and

 How well the flu vaccine is matched to flu viruses that are causing
Certain people are at greater risk for serious complications if they get the
flu. This includes older people, young children, pregnant women and
people with certain health conditions (such as asthma, diabetes, or heart
disease), and persons who live in facilities like nursing homes.
Flu seasons are unpredictable and can be severe. Over a period of 30
years, between 1976 and 2006, estimates of flu-associated deaths in the
United States range from a low of about 3,000 to a high of about 49,000
There are three types of influenza viruses: A, B and C. Human influenza A
and B viruses cause seasonal epidemics of disease almost every winter in
the United States. The emergence of a new and very different influenza
virus to infect people can cause an influenza pandemic. Influenza type C
infections cause a mild respiratory illness and are not thought to cause
Influenza A viruses are divided into subtypes based on two proteins on the
surface of the virus: the hemagglutinin (H) and the neuraminidase (N).
There are 18 different hemagglutinin subtypes and 11 different
neuraminidase subtypes. Influenza A viruses can be further broken down
into different strains. Current subtypes of influenza A viruses found in
people are influenza A (H1N1) and influenza A (H3N2) viruses. In the
spring of 2009, a new influenza A (H1N1) virus (CDC 2009 H1N1 Flu
website) emerged to cause illness in people. This virus was very different
from regular human influenza A (H1N1) viruses and the new virus caused
the first influenza pandemic in more than 40 years. That virus (often called
2009 H1N1) has now mostly replaced the H1N1 virus that was previously
circulating in humans.
Influenza B viruses are not divided into subtypes, but can be further broken
down into different strains.
Flu can be a serious disease, particularly among young children, older
adults, and people with certain chronic health conditions, such as asthma,

heart disease or diabetes. Any flu infection can carry a risk of serious
complications, hospitalization or death, even among otherwise healthy
children and adults. Therefore, getting vaccinated is a safer choice than
risking illness to obtain immune protection. Flu vaccines are readily
available and are a good idea for people that routine have close contact
with the multiple strangers in a confined space (like massage therapists).
CDC recommends a yearly flu vaccine for just about everyone 6 months
and older, even when the viruses the vaccine protects against have not
changed from the previous season. The reason for this is that a person's
immune protection from vaccination declines over time, so an annual
vaccination is needed to get the optimal or best protection against the flu.
Some people report having mild reactions to flu vaccination. Common
reactions to the flu shot and the nasal spray flu vaccine are described
Reactions to the flu shot:
The most common reaction to the flu shot in adults has been soreness,
redness or swelling at the spot where the shot was given. This usually lasts
less than two days. This initial soreness is most likely the result of the
body's early immune response reacting to a foreign substance entering the
body. Other reactions following the flu shot are usually mild and can include
a low grade fever and aches. If these reactions occur, they usually begin
soon after the shot and last 1-2 days. The most common reactions people
have to flu vaccine are considerably less severe than the symptoms
caused by actual flu illness.
Reactions to nasal spray flu vaccine:
People also may have mild reactions to the nasal spray vaccine. Some
children and young adults 2-17 years of age have reported experiencing
mild reactions after receiving nasal spray flu vaccine, including runny nose,
nasal congestion or cough, chills, tiredness/weakness, sore throat and
headache. Some adults 18-49 years of age have reported runny nose or
nasal congestion, cough, chills, tiredness/weakness, sore throat and
headache. These side effects are mild and short-lasting, especially when
compared to symptoms of seasonal flu infection.
What about serious reactions to flu vaccine?


Serious allergic reactions to flu vaccines are very rare. If they do occur, it is
usually within a few minutes to a few hours after the vaccination. While
these reactions can be life-threatening, effective treatments are available.


Chapter 5: Fungi
General Fungus infection information
Anyone can get a fungal infection, even people who are otherwise healthy.
Fungi are common in the environment, and people breathe in or come in
contact with fungal spores every day without getting sick. However, in
people with weak immune systems, these fungi are more likely to cause an
infection in people with weak immune systems
Infections that happen because a persons immune system is weak are
called opportunistic infections. These illnesses can be caused by bacteria,
viruses, or fungi. Many fungal infections are opportunistic infections.
Some people are born with a weak immune system. Others may have an
illness that attacks the immune system such as HIV/AIDS. Some
medications, like corticosteroids or cancer chemotherapy, can also lower
the bodys ability to fight infections.
If you have a weakened immune system, you should be aware that fungal
infections can happen. Learning about fungal infections can help you and
your doctor recognize them early. This may help prevent serious
Medications that Weaken Your Immune System and Fungal Infections
Overall, most serious fungal infections are rare, but they do happen. They
are most common among people with weak immune systems. People with
certain health conditions may need to take medications with side effects
that can weaken your immune system and put you at risk for fungal
Specifically, corticosteroids and TNF (tumor necrosis factor) inhibitors are
two types of medications that can increase your chances of getting a fungal
Corticosteroids are medications that treat conditions including arthritis,
asthma, allergic reactions, and autoimmune diseases such as lupus,
sarcoidosis, or inflammatory bowel disease.
TNF inhibitors are medications that treat autoimmune diseases such as
rheumatoid arthritis, psoriasis, and inflammatory bowel disease.

Some fungal infections can be serious, such as:

Coccidioidomycosis (Valley fever)
Cryptococcosis (neoformans and gattii)
Pneumocystis pneumonia (PCP)
Invasive Candida infection
Invasive aspergillosis
Other fungal infections, such as oral candidiasis (thrush), are usually not
life threatening.
What you need to know about fungal infections
Fungal infections can range from mild to life-threatening. Some fungal
infections are mild skin rashes, but others can have serious complications.
Because of this, its important for you to seek treatment as soon as
possible to avoid serious infection.
Fungal infections can look like bacterial or viral infections. If youre taking
medicine to fight an infection and you arent getting better, ask your doctor
about testing you for a fungal infection.
Where you live (geography) matters. Some disease-causing fungi are more
common in certain parts of the world. If you live in or visit these areas and
are taking medications that weaken the immune system, youre more likely
to get these infections than the general population. 7,8,12 For more
information on travel-related illnesses, please see the CDC Travelers
Health site.
The length of your treatment matters. Your healthcare provider can
prescribe corticosteroids for short-term use (days to weeks) or long-term
use (weeks to months). Long-term corticosteroid use is more likely to
increase your chance of getting a fungal infection.
Amount of medication (dose). Higher doses of medications that weaken
your immune system are more likely to increase your risk of getting a
fungal infection.
Fungal outbreaks have been linked to a variety of sources, including
exposure to disease-causing fungi in the natural environment or injections
with contaminated medication. With systems in place for early identification

for these types of events, CDC and partners can continue to track, test for,
respond to, and better understand emerging fungal health threats.
Some fungal diseases may be more common than previously realized, and
rare but newly-emerging fungi are becoming increasingly problematic.
Some types of fungal infections can be deadly if they are not identified and
treated quickly, so early recognition is essential in order to reduce the risk
of serious complications and save lives.
Aspergillus is a common fungus that can be found in indoor and outdoor
environments. Most people breathe in Aspergillus spores every day without
being affected. Aspergillosis is a disease caused by this fungus and usually
occurs in people with lung diseases or weakened immune systems. The
spectrum of illness includes allergic reactions, lung infections, and
infections in other organs.
What is Aspergillosis?
Aspergillosis is an infection caused by a fungus called Aspergillus. There
are several different kinds of aspergillosis. One kind is allergic
bronchopulmonary aspergillosis (also called ABPA), a condition where the
fungus causes allergic respiratory symptoms, such as wheezing and
coughing, but does not actually invade and destroy tissue in the body.
Another kind of aspergillosis is invasive aspergillosis, a disease that usually
affects people with weakened immune systems. In this condition, the
fungus invades and damages tissues in the body. Invasive aspergillosis
most commonly affects the lungs, but Aspergillus can spread throughout
the body and also cause infection in other organs.
What is Aspergillus?
Aspergillus is a fungus that is common in the environment. It is found in
soil, on plants, and in decaying organic matter. It is also found in household
dust and building materials. There are many different species of
Aspergillus, but the most common species are Aspergillus fumigatus and
Aspergillus flavus. Other species are Aspergillus terreus, Aspergillus
nidulans, and Aspergillus niger.


Symptoms of Aspergillosis
What are the Symptoms of Aspergillosis?
The different kinds of aspergillosis can cause different symptoms.
 Symptoms of allergic bronchopulmonary aspergillosis (ABPA) may
 Fever (in rare cases)
 Symptoms of invasive aspergillosis may include:
 Chest pain
 Shortness of breath
Other symptoms may develop if the infection spreads beyond the lungs.
When invasive aspergillosis spreads outside of the lungs, it can cause
symptoms in almost any organ. If you have symptoms that you think are
related to aspergillosis, contact your doctor.
Allergic bronchopulmonary aspergillosis (ABPA) can affect people who are
otherwise healthy, but it is most common in people with asthma or cystic
fibrosis. Invasive aspergillosis generally affects people who have weakened
immune systems, such as people who have had a bone marrow transplant
or solid organ transplant, people who are taking high doses of
corticosteroids, and people who are getting chemotherapy for cancer.
Rarely, people with advanced HIV infection can also get invasive
Preventing Aspergillosis
It is difficult to avoid breathing in normal levels of Aspergillus spores. For
people with weakened immune systems or severe lung diseases, there are
steps that can be taken to help reduce exposure, including:
Wear an N95 mask when near or in a dusty environment such as
construction sites
Avoid activities that involve close contact to soil or dust, such as yard work
or gardening
Use air quality improvement measures such as HEPA filters
Take prophylactic antifungal medication if deemed necessary by your
healthcare provider


Clean skin injuries well with soap and water, especially if the injury has
been exposed to soil or dust
Aspergillosis Transmission
Aspergillus is common in the environment, so most people breathe in the
fungal spores every day. It is probably impossible to completely avoid
breathing in some Aspergillus spores. For people with healthy immune
systems, this does not cause harm, and the immune system is able to get
rid of the spores. But for people with weakened immune systems, breathing
in Aspergillus spores can lead to infection. Studies have shown that
invasive aspergillosis can occur during building renovation or construction.
Outbreaks of Aspergillus skin infections have been traced to contaminated
biomedical devices. Aspergillosis cannot be spread from person to person
or between people and animals.
Aspergillosis Treatment
Aspergillosis requires treatment with antifungal medication prescribed by a
doctor. Voriconazole is currently the first-line treatment for invasive
aspergillosis. There are other medications that can be used to treat
invasive aspergillosis in patients who cannot take voriconazole or who have
not responded to voriconazole. These include itraconazole, lipid
amphotericin formulations, caspofungin, micafungin, and posaconazole.
Whenever possible, immunosuppressive medications should be
discontinued or decreased.
Blastomycosis is a disease caused by the fungus Blastomyces dermatitidis.
The fungus lives in moist soil and in association with decomposing organic
matter such as wood and leaves. Lung infection can occur after a person
inhales airborne, microscopic fungal spores from the environment;
however, many people who inhale the spores do not get sick. The
symptoms of blastomycosis are similar to flu symptoms, and the infection
can sometimes become serious if it is not treated.
Definition of Blastomycosis
Blastomycosis is a disease caused by the fungus Blastomyces dermatitidis.
The fungus lives in moist soil and in association with decomposing organic
matter such as wood and leaves. Lung infection can occur after a person
inhales airborne, microscopic fungal spores from the environment;
however, many people who inhale the spores do not get sick. The

symptoms of blastomycosis are similar to flu symptoms, and the infection

can sometimes become serious if it is not treated, especially if the infection
spreads from the lungs to other organs.
Symptoms of Blastomycosis
Only with about half of the people who are infected with blastomycosis will
show symptoms. If symptoms occur, they usually appear between 3 and 15
weeks after being exposed to the fungus. The symptoms of blastomycosis
are similar to flu symptoms, and include fever, chills, cough, muscle aches,
joint pain, and chest pain. In very serious cases of blastomycosis, the
fungus can disseminate (spread) to other parts of the body, such as the
skin and bones.
Anyone can get blastomycosis, even people who are otherwise healthy.
However, people who have underlying medical conditions such as diabetes
may be at increased risk for the infection. Blastomyces dermatitidis, the
fungus that causes blastomycosis, can be found throughout the world, but
is most common in parts of North, Central, and South America. In the
United States, the fungus is endemic (native and common) in the
Southeast and the Midwest.
People who live in endemic areas and engage in activities that expose
them to wooded areas may be at a higher risk for getting blastomycosis.
This may include farmers, forestry workers, hunters, and campers.
Prevention of blastomycosis
There is no vaccine to prevent blastomycosis. In endemic regions, such as
the Mississippi and Ohio River valleys, it may not be possible to completely
avoid being exposed to the fungus. However, people who have weakened
immune systems may consider avoiding wooded areas where the fungus is
Sources of Blastomycosis
Blastomyces dermatitidis lives in soil and in association with decaying
organic matter such as leaves and wood. The microscopic fungal spores
can become airborne when the soil is disturbed, and breathing in the
spores can cause infection in the lungs. Blastomycosis cannot be spread
from person to person or from animals to people.


In the environment, Blastomyces dermatitidis exists as mold (1) with

septate aerial hyphae. The hyphae produce conidial spores (2). These
spores are either inhaled, or inoculated into the skin (3) of a susceptible
host. The warmer temperature inside the host signals a transformation (4)
into a broad-based budding yeast. The yeast may continue to colonize the
lungs or disseminate in the bloodstream (5) to other parts of the body, such
as the skin, bones and joints, organs, and central nervous system.
Candidiasis is a fungal infection caused by yeasts that belong to the genus
Candida. There are over 20 species of Candida yeasts that can cause
infection in humans, the most common of which is Candida albicans.
Candida yeasts normally live on the skin and mucous membranes without
causing infection; however, overgrowth of these organisms can cause
symptoms to develop. Symptoms of candidiasis vary depending on the
area of the body that is infected.
Candidiasis that develops in the mouth or throat is called thrush or
oropharyngeal candidiasis. Candidiasis in the vagina is commonly referred
to as a yeast infection. Invasive candidiasis occurs when Candida species
enter the bloodstream and spread throughout the body.
Oropharyngeal / Esophageal Candidiasis ("Thrush")
Candidiasis that develops in the mouth or throat is called "thrush" or
oropharyngeal candidiasis. The most common symptom of oral thrush is
white patches or plaques on the tongue and other oral mucous
membranes. This infection is uncommon among healthy adults.
Candidiasis of the mouth and throat, also known as thrush" or
oropharyngeal candidiasis, is a fungal infection that occurs when there is
overgrowth of a yeast called Candida. Candida yeasts normally live on the
skin or mucous membranes in small amounts. However, if the environment
inside the mouth or throat becomes imbalanced, the yeasts can multiply
and cause symptoms. Candida overgrowth can also develop in the
esophagus, and this is called Candida esophagitis, or esophageal
Candida infections of the mouth and throat can manifest in a variety of
ways. The most common symptom of oral thrush is white patches or


plaques on the tongue and other oral mucous membranes. Other

symptoms include:
 Redness or soreness in the affected areas
 Difficulty swallowing
 Cracking at the corners of the mouth (angular cheilitis)
 It is important to see your doctor if you have any of these symptoms.
Candida infections of the mouth and throat are uncommon among adults
who are otherwise healthy. Oral thrush occurs most frequently among
babies less than one month old, the elderly, and groups of people with
weakened immune systems. Other factors associated with oral and
esophageal candidiasis include:
Cancer treatments
Organ transplantation
Corticosteroid use
Broad-spectrum antibiotic use
Prevention of Oral Candidiasis
Good oral hygiene practices may help to prevent oral thrush in people with
weakened immune systems. Some studies have shown that chlorhexidine
(CHX) mouthwash can help to prevent oral candidiasis in people
undergoing cancer treatment. People who use inhaled corticosteroids may
be able to reduce the risk of developing thrush by washing out the mouth
with water or mouthwash after using an inhaler.
Candida species are normal inhabitants of the mouth, throat, and the rest
of the gastrointestinal tract. Usually, Candida yeasts live in and on the body
in small amounts and do not cause any harm. However, the use of certain
medications or a weakening of the immune system can cause Candida to
multiply, which may cause symptoms of infection.
The infection is not very common in the general population. It is estimated
that between 5% and 7% of babies less than one month old will develop
oral candidiasis. The prevalence of oral candidiasis among AIDS patients
is estimated to be between 9% and 31%, and studies have documented
clinical evidence of oral candidiasis in nearly 20% of cancer patients.


Candida infections of the mouth and throat must be treated with

prescription antifungal medication. The type and duration of treatment
depends on the severity of the infection and patient-specific factors such as
age and immune status. Untreated infections can lead to a more serious
form of invasive candidiasis.
Oral candidiasis usually responds to topical treatments such as
clotrimazole troches and nystatin suspension (nystatin swish and
swallow). Systemic antifungal medication such as fluconazole or
itraconazole may be necessary for oropharyngeal infections that do not
respond to these treatments.
Candida esophagitis is typically treated with oral or intravenous fluconazole
or oral itraconazole. For severe or azole-resistant esophageal candidiasis,
treatment with amphotericin B may be necessary.
Invasive candidiasis
Invasive candidiasis is a fungal infection that can occur when Candida
yeasts enter the bloodstream. Once the fungus is in the bloodstream, it can
spread to other parts of the body and cause infection.
The symptoms of invasive candidiasis are not specific. Fever and chills that
do not improve after antibiotic therapy are the most common symptoms. If
the infection spreads to other organs or parts of the body such as kidneys,
liver, bones, muscles, joints, spleen, or eyes, additional symptoms may
develop, which vary depending on the site of infection. If the infection does
not respond to treatment, the patients organs may stop working.
Candidemia (a bloodstream infection with Candida), is the fourth most
common bloodstream infection among hospitalized patients in the United
States. People at high risk for developing candidemia include:
Intensive care unit (ICU) patients
Surgical patients
Patients with a central venous catheter
People whose immune systems are weakened (such as people with
Very low-birth-weight infants


Preventing Invasive Candidiasis

Antifungal prophylaxis may be appropriate for some groups of people who
are at high risk of developing candidemia, such as low-birth-weight infants.
Doctors and nurses can follow CDC-recommended infection control steps
every time they work with a central line.
Patients and caregivers can ask if a central line is needed and, if so, how
long it should stay in place. They can also make sure that healthcare
professionals wash their hands before they care for the central line.
Patients should speak up if the skin around the central line becomes sore
or red, or if their bandages are wet or dirty.
People at Risk for Invasive Candidiasis
Candidemia (a bloodstream infection with Candida), is the fourth most
common bloodstream infection among hospitalized patients in the United
States. People at high risk for developing candidemia include:
Intensive care unit (ICU) patients
Surgical patients
Patients with a central venous catheter
People whose immune systems are weakened (such as people with
Very low-birth-weight infants
Preventing Invasive Candidiasis
Antifungal prophylaxis may be appropriate for some groups of people who
are at high risk of developing candidemia, such as low-birth-weight infants.
Doctors and nurses can follow CDC-recommended infection control steps
every time they work with a central line.
Patients and caregivers can ask if a central line is needed and, if so, how
long it should stay in place. They can also make sure that healthcare
professionals wash their hands before they care for the central line.
Patients should speak up if the skin around the central line becomes sore
or red, or if their bandages are wet or dirty.
Candida yeasts normally live in and on the body without causing any
symptoms. In people at risk, invasive candidiasis may occur when a
persons own Candida yeasts enter the bloodstream. This can also happen
if medical equipment or devices, particularly intravenous (IV) catheters,

become contaminated with Candida. In either case, the infection may

spread through the bloodstream and infect various organs.
Invasive candidiasis is extremely rare in people without risk factors, but it is
the fourth most common cause of hospital-acquired bloodstream infections
in the U.S. In the general population, the incidence is 8 to 10 cases per
100,000 people. A higher incidence has been observed among
Blacks/African-Americans and babies less than one month old. It is
estimated that between 5% and 20% of newborns that weigh less than
1000 grams (2.2 pounds) at birth develop invasive candidiasis.
Invasive candidiasis requires treatment with oral or intravenous (IV)
antifungal medication for several weeks. The type and duration of
antifungal treatment will depend on patient-specific factors such as age,
immune status, and severity of infection. Treatment of invasive candidiasis
should include prompt removal of catheters.
Neonates with invasive candidiasis should be treated with amphotericin B
for at least 3 weeks. For clinically stable children and adults, fluconazole or
an echinocandin (caspofungin, micafungin, or anidulafungin) is the
recommended form of therapy. In critically ill patients, an echinocandin or a
lipid formulation of amphotericin B is recommended. Treatment should
continue for 2 weeks after signs and symptoms of candidemia have
resolved and the Candida yeasts have been cleared from the bloodstream.
Valley Fever (Coccidioidomycosis)
Valley fever, also called coccidioidomycosis, is an infection caused by the
fungus Coccidioides. The fungus is known to live in the soil in the
southwestern United States and parts of Mexico and Central and South
America. The fungus was also recently found in south-central Washington.
People can get valley fever by breathing in the microscopic fungal spores
from the air, although most people who breathe in the spores dont get sick.
Usually, people who get sick with valley fever will get better on their own
within 2-3 months, but some people will need antifungal medication.
Certain groups of people are at higher risk for becoming severely ill. Its
difficult to prevent exposure to Coccidioides in areas where its common in
the environment, but people who are at higher risk for severe valley fever
should try to avoid breathing in large amounts of dust if theyre in these


Valley fever is an infection caused by the fungus Coccidioides. The

scientific name for valley fever is coccidioidomycosis, and its also
sometimes called San Joaquin Valley fever or desert rheumatism. The
term valley fever usually refers to Coccidioides infection in the lungs, but
the infection can spread to other parts of the body in severe cases (this is
called disseminated coccidioidomycosis).
The fungus is known to live in the soil in the southwestern United States
and parts of Mexico and Central and South America. The fungus was also
recently found in south-central Washington. People can get valley fever by
breathing in the microscopic fungal spores from the air in these areas.
Most people who breathe in the spores dont get sick, but some people do.
Usually, people who get sick with valley fever will get better on their own
within 2-3 months, but some people will need antifungal medication.
Certain groups of people are at higher risk for developing the severe forms
of the infection, and these people typically need antifungal treatment. Its
difficult to prevent exposure to Coccidioides in areas where its common in
the environment, but people who are at higher risk for severe valley fever
should try to avoid breathing in large amounts of dust if theyre in these
Symptoms of Valley Fever (Coccidioidomycosis)
Cough and fever are common symptoms of valley fever
Skin lesions due to Coccidioides immitis
Most people (60%) who are exposed to the fungus Coccidioides never
have symptoms.1 Other people may have flu-like symptoms that go usually
away on their own after 2-3 months. If your symptoms last for more than a
week, contact your healthcare provider.
Symptoms of valley fever include:
 Fatigue (tiredness)
 Shortness of breath
 Night sweats
 Muscle aches or joint pain
 Rash on upper body or legs


In extremely rare cases, the fungal spores can enter the skin through a cut,
wound, or splinter and cause a skin infection.
Symptoms of valley fever may appear between 1 and 3 weeks after a
person breathes in the fungal spores.
Duration of Symptoms
The symptoms of valley fever usually last for a few weeks to a few
months.However, some patients have symptoms that last longer than this,
especially if the infection becomes severe.
Severe valley fever
Approximately 5 to 10% of people who get valley fever will develop serious
or long-term problems in their lungs.4 In an even smaller percent of people
(about 1%), the infection spreads from the lungs to other parts of the body,
such as the central nervous system (brain and spinal cord), skin, or bones
and joints.
Anyone who lives in or travels to the southwestern United States (Arizona,
California, Nevada, New Mexico, Texas, or Utah), or parts of Mexico or
Central or South America can get valley fever. Valley fever can affect
people of any age, but its most common in adults aged 60 and older.
Certain groups of people may be at higher risk for developing the severe
forms of valley fever, such as:
 People who have weakened immune systems, for example, people
 Have had an organ transplant
 Are taking medications such as corticosteroids or TNF-inhibitors3
 Pregnant women
 People who have diabetes
 People who are Black, or Filipino
The fungus that causes valley fever, Coccidioides, cant spread from the
lungs between people or between people and animals. However, in
extremely rare instances, a wound infection with Coccidioides can spread
valley fever to someone else, or the infection can be spread through an
organ transplant with an infected organ.


Prevention of Valley Fever

Its very difficult to avoid breathing in the fungus Coccidioides in areas
where its common in the environment. People who live in these areas can
try to avoid spending time in dusty places as much as possible. People who
are at risk for severe valley fever (such as people who have weakened
immune systems, pregnant women, people who have diabetes, or people
who are Black or Filipino) may be able to lower their chances of developing
the infection by trying to avoid breathing in the fungal spores.
The following are some common-sense methods that may be helpful to
avoid getting valley fever. Its important to know that although these steps
are recommended, they havent been proven to prevent valley fever.
Try to avoid areas with a lot of dust like construction or excavation sites. If
you cant avoid these areas, wear an N95 respirator (a type of face mask)
while youre there.
Stay inside during dust storms and close your windows.
Avoid activities that involve close contact to dirt or dust, including yard
work, gardening, and digging.
Use air filtration measures indoors.
Clean skin injuries well with soap and water to reduce the chances of
developing a skin infection, especially if the wound was exposed to dirt or
Take preventive antifungal medication if your healthcare provider says you
need it.
Valley Fever treatment
For many people, the symptoms of valley fever will go away within a few
months without any treatment. Healthcare providers choose to prescribe
antifungal medication for some people to try to reduce the severity of
symptoms or prevent the infection from getting worse.
medication is typically given to people who are at higher risk for developing
severe valley fever. The treatment is usually 3 to 6 months of fluconazole
or another type of antifungal medication. There are no over-the-counter
medications to treat valley fever. If you have valley fever, you should talk to

your healthcare provider about whether you need treatment. The

healthcare provider who diagnoses you with valley fever may suggest that
you see other healthcare providers who specialize in treating valley fever.
People who have severe lung infections or infections that have spread to
other parts of the body always need antifungal treatment and may need to
stay in the hospital. For these types of infections, the course of treatment is
usually longer than 6 months. Valley fever that develops into meningitis is
fatal if its not treated, so lifelong antifungal treatment is necessary for those
C. neoformans cryptococcosis
Cryptococcosis is an infection caused by fungi that belong to the genus
Cryptococcus. There are over 30 different species of Cryptococcus, but two
species Cryptococcus neoformans and Cryptococcus gattii cause
nearly all cryptococcal infections in humans and animals. Although many
people who develop cryptococcosis have weakened immune systems,
some are previously healthy.
C. neoformans can be found in soil throughout the world. People at risk can
become infected after inhaling microscopic, airborne fungal spores.
Sometimes these spores cause symptoms of a lung infection, but other
times there are no symptoms at all. In people with weakened immune
systems, the fungus can spread to other parts of the body and cause
serious disease.
Cryptococcosis is an infection caused by fungi that belong to the genus
Cryptococcus. Cryptococcus neoformans (C. neoformans) is a type of
fungus that is found in the soil throughout the world, usually in association
with large amounts of bird droppings.
Symptoms of Cryptococcosis
Infection with C. neoformans may cause a pneumonia-like illness.
Symptoms include shortness of breath, cough, and fever. C. neoformans
can also infect the central nervous system and cause inflammation of the
brain and meninges, which is called meningoencephalitis. Symptoms of a
central nervous infection may include fever, headache, or a change in
mental status. If you experience symptoms that you think may be related to
Cryptococcus neoformans, it is important to see your doctor right away.


Clincial Features (information intended for healthcare providers)

Depending on the virulence of the yeast strain and the immune status of
the host, C. neoformans can either cause latent infection (in which the
yeast cells remain dormant in the body) or symptomatic disease.
Because the fungus enters the body through the respiratory system,
infection with C. neoformans causes a pneumonia-like illness, with cough
being the most common symptom. Other symptoms of acute pulmonary
cryptococcosis include fever, chest pain, and weight loss.
C. neoformans can also disseminate to the central nervous system and
cause meningoencephalitis. Symptoms of a central nervous infection may
include fever, headache, lethargy, and mental status changes. Central
nervous system infections with Cryptococcus are more common among
people who have weakened immune systems, particularly those with HIV
infection. In patients who are severely immunosuppressed, cryptococcal
infection can also disseminate to the skin, eyes, bones, and joints.
C. neoformans meningitis may lead to permanent neurologic damage.
Mortality rate varies by geographic location and access to medical care.
C. neoformans infections are more common among people with weakened
immune systems, but on very rare occasions, they can occur in people who
are otherwise healthy. Risk factors for infection with C. neoformans include:
 Corticosteroids and other immunosuppressive medications
 Solid organ transplantation
 Heart, lung, or liver diseases
Preventing infection with Cryptococcus neoformans
It is difficult to prevent exposure to C. neoformans because it is present
throughout the environment. Most people breathe in small amounts of
many different types of fungal spores every day but never become sick.
However, people who have weakened immune systems should avoid areas
contaminated by bird droppings, and should avoid contact with birds. If you
have symptoms that you think may be caused by C. neoformans, you
should see a doctor.


C. neoformans spores are typically found in bird droppings (especially

pigeon droppings) or in soil contaminated with bird droppings. Humans can
become infected after inhaling microscopic, airborne fungal spores from the
environment. Cryptococcosis is not known to be spread from person to
person, from animal to animal, or from animals to humans.
Treatment and Outcomes for Cryptococcosis
Cryptococcosis requires treatment with prescription antifungal medication
for at least 6 months, usually longer. Treatment of severe cryptococcal
infections, including those with central nervous system involvement, usually
begins with amphotericin B, often in combination with flucytosine. For
patients with asymptomatic or mild-to-moderate cryptococcosis,
fluconazole or itraconazole are the preferred forms of treatment.
Fluconazole can also be used for maintenance therapy in HIV-infected
patients with cryptococcal meningoencephalitis.
C. gattii cryptococcosis
Cryptococcosis is a fungal infection caused by fungi that belong to the
genus Cryptococcus. There are over 30 different species of Cryptococcus,
but two species Cryptococcus neoformans and Cryptococcus gattii
cause nearly all cryptococcal infections in humans and animals. Most
people who develop cryptococcosis have weakened immune systems,
although healthy people can also become infected, particularly with C.
Definition of C. gattii cryptococcosis
Cryptococcus gattii (C. gattii) is a type of fungus that is found in the soil and
in association with certain trees, particularly eucalyptus trees. C. gattii has
been found throughout tropical and sub-tropical regions of the world. Since
1999, C. gattii has also been found in the U.S. Pacific Northwest,
Vancouver Island, and mainland British Columbia. C. gattii infection is
considered to be an emerging infectious disease in these areas.
Symptoms of C. gattii cryptococcosis
The most common symptoms of C. gattii infection include shortness of
breath, cough, fatigue, fever, and headache. C. gattii can also infect the
central nervous system and cause inflammation of the brain and meninges,
which is called meningoencephalitis. Symptoms of a central nervous
system infection may also include altered mental status. Disseminated


infection can lead also lead to cryptococcomas (fungal growths) in the

lungs, skin, brain or other organs.
Symptoms of C. gattii infection are estimated to begin anywhere from 2 to
14 months after exposure to the fungus. If you experience symptoms that
you think may be caused by C. gattii, it is important to see a doctor right
Cryptococcus gattii Infection
Anyone can get a C. gattii infection, even people who are otherwise
healthy. People who have weakened immune systems are at increased
risk. This includes people who have HIV/AIDS, have had an organ
transplant, or are undergoing treatment for cancer. Animals, including
domestic cats and dogs, can also get C. gattii infections; however, the
infection cannot pass between animals and humans.
Cryptococcus gattii is thought to be endemic (native and common) in the
U.S. Pacific Northwest, Vancouver Island, and mainland British Columbia.
Preventing Cryptococcus gattii infection
There are no formal recommendations for preventing C. gattii infection.
Most people breathe in small amounts of many different types of fungal
spores every day but never become sick. However, if you have symptoms
that you think may be caused by C. gattii, you should see a doctor.
C. gattii lives in the environment in association with certain trees and the
soil around trees. Humans can become infected after inhaling microscopic,
airborne fungal spores from the environment.
Cryptococcus gattii lives in the environment (1), usually in association with
certain trees or soil around trees. Humans and animals can become
infected with C. gattii after inhaling airborne, dehydrated yeast cells or
spores (2), which travel through the respiratory tract and enter the lungs of
the host (3). The small size of the yeast and/or spores allows them to
become lodged deep in the lung tissue. The environment inside the host
body signals C. gattii to transform into its yeast form, and the cells grow
thick capsules to protect themselves (4). The yeasts then divide and
multiply by budding. After infecting the lungs, C. gattii cells can travel
through the bloodstream (5)either on their own or within macrophage


cells to infect other areas of the body, typically the central nervous
system (6).
Treatment and Outcomes for C. gattii cryptococcosis
Cryptococcosis requires treatment with prescription antifungal medication
for at least 6 months, usually longer. Treatment of severe cryptococcal
infections, including those with central nervous system involvement, usually
begins with amphotericin B, often in combination with flucytosine. For
patients with mild-to-moderate cryptococcosis, fluconazole or itraconazole
are the preferred forms of treatment. Fluconazole can also be used for
maintenance therapy in HIV-infected patients with cryptococcal
Dermatophytes (Ringworm)
Dermatophytes are fungi that cause skin, hair, and nail infections.
Infections caused by these fungi are also sometimes known as "ringworm"
or "tinea." Despite the name "ringworm," this infection is not caused by a
worm, but by a type of fungus. Dermatophytes can live on moist areas of
the skin, on environmental surfaces, and on household items such as
clothing, towels, and bedding.
Definition of Dermatophytes (Ringworm)
Dermatophytes are fungi that cause skin, hair, and nail infections.
Infections caused by these fungi are also sometimes known as "ringworm"
or "tinea." Despite the name "ringworm," this infection is not caused by a
worm, but by a type of fungus. There are many types of infections caused
by this fungus. The infections are generally identified by its location on the
Some common ringworm infections:
Tinea barbae ringworm of the bearded parts of the face and neck
Tinea capitis ringworm of the scalp
Tinea corporis ringworm of the body
Tinea cruris ringworm of the groin, skin folds, inner thighs, or buttocks,
also known as jock itch
Tinea faciei ringworm of the face (other than bearded parts)
Tinea pedis - ringworm of the feet, also known as athletes foot
Tinea unguium / onychomycosis - ringworm of the toenail or fingernail
There are many different species of dermatophytes that can cause infection
in humans. Some species spread from person to person (Trichophyton


rubrum and Trichophyton tonsurans) and other species (Microsporum

canis) spread to people from animals like cats and dogs.
Dermatophytes like to live on moist areas of the skin, such as places where
there are skin folds. They can also live on household items, such as
clothing, towels, and bedding.
Symptoms of Dermatophytes (Ringworm) Infections
Dermatophyte infections can affect the skin on almost any area of the body,
such as the scalp, legs, arms, feet groin, and nails. These infections are
usually itchy. Redness, scaling, cracking of the skin, or a ring-shaped rash
may occur. If the infection involves the scalp or beard, hair may fall out.
Infected nails become discolored, thick, and may possibly crumble. More
serious infections may lead to an abscess or cellulitis.
Dermatophyte infections are very common. They can affect anyone,
including people who are healthy. Dermatophyte infections may be more
common among people with suppressed immune systems, people who use
communal baths, and people who are involved in contact sports such as
wrestling, and people who have close contact with animals. Some species
are found more commonly in hot, humid environments. Outbreaks of
infections can occur in schools, households, and institutional settings.
Preventing dermatophyte infections
Good hygiene, such as regular handwashing, is important. People should
avoid sharing hairbrushes, hats, and other articles of clothing that may
come into contact with infected areas. Pets with signs of skin disease
should be seen by a veterinarian. Beauty salons and barbershops should
disinfect instruments with approved disinfectants after each use. Contact
your local and/or state health department for specific guidelines and
regulations in your area.
Sources of Dermatophytes (Ringworm) Infections
Dermatophyte infections are usually spread through direct contact with an
infected person or animal. Clothing, bedding and towels can also become
contaminated and spread the infection. Symptoms typically appear
between 4 and 14 days following exposure.


Treatment for Dermatophyte (Ringworm) Infections

The particular medication and duration of treatment depends on the
location of the infection. Scalp infections usually require treatment with an
oral antifungal medication. Infections of other areas of the skin can be
treated with topical antifungal medications. Nail infections can be
challenging to treat, and may be treated with oral and/or topical antifungal
medications. Courses of treatment may range from 2 to 6 weeks or more,
depending on the severity of the infection and your doctor's
Fungal Keratitis
Keratitis is an inflammation of the cornea (the clear, front part of the eye)
and is often caused by an infection. Bacteria, viruses, amoeba, and fungi
can all cause keratitis. Fungal keratitis is an inflammation of the cornea that
is caused by a fungus. Types of fungi that have been known to cause
fungal keratitis include:
Fusarium species
Aspergillus species
Candida species
Fusarium and Aspergillus species live in the environment, often in
association with plant matter. Candida species are some of the
microorganisms that normally live on human skin and mucous membranes.
Although fungal keratitis can be a serious condition, it is very rare.
Definition of Fungal Keratitis
Keratitis is an inflammation of the cornea (the clear, front part of the eye)
and is often caused by an infection. Bacteria, viruses, amoeba, and fungi
can all cause keratitis. Fungal keratitis is an inflammation of the cornea that
is caused by a fungus.
Symptoms of Fungal Keratitis
Symptoms of fungal keratitis include:
Eye pain and redness
Blurred vision
Sensitivity to light
Excessive tearing or discharge
If you experience any of these symptoms, remove your contact lenses (if
you wear them) and call your eye doctor right away. Fungal keratitis is a

very rare condition, but if left untreated, it can become serious and result in
vision loss or blindness.
Risk & Prevention
Fungal keratitis most commonly occurs in tropical and sub-tropical regions
of the world. In temperate areas of the world such as the United States, risk
factors for developing fungal keratitis include:
Recent eye trauma, particularly involving plant matter (for example, thorns
or sticks)
Underlying ocular (eye) disease
Weakened immune system
Contact lens use
Prevention of fungal keratitis
Protective eyewear is recommended for people who are at risk for eye
trauma involving organic matter, such as agricultural workers.
People who wear contact lenses should continue to follow proper lens care
Wash your hands with soap and water before handling contact lenses.
Wear and replace your contact lenses according to the schedule prescribed
by your doctor.
Follow the specific lens cleaning and storage guidelines from your doctor
and the solution manufacturer.
Keep your contact lens case clean and replace it every 3 to 6 months.
If you experience symptoms such as eye redness, pain, tearing, increased
light sensitivity, blurry vision, discharge, or swelling, remove your lenses
and consult your doctor immediately.
Sources of Fungal Keratitis
The most common way that someone gets fungal keratitis is after
experiencing trauma to the eye, especially if the trauma is caused by plant
matter such as a stick or a thorn. Fungal keratitis cannot be spread from
person to person.
In 2006, CDC investigated an outbreak of Fusarium keratitis that was
associated with a specific type of contact lens solution, which was later
withdrawn from the market.

Your eye doctor will examine your eye and may possibly take a tiny
scraping of your cornea. The sample will be sent to a laboratory to be
examined under a microscope or cultured. Polymerase chain reaction
(PCR) and confocal microscopy are also being used as newer, faster forms
of diagnosis; however, culture from corneal scrapings is considered to be
the standard for definitive diagnosis of fungal keratitis.
Treatment and Outcomes for Fungal Keratitis
Fungal keratitis must be treated with prescription antifungal medicine for
several months. Natamycin is a topical ophthalmic antifungal medication
that works well on superficial corneal infections, particularly those caused
by filamentous fungi such as Aspergillus and Fusarium species. However,
corneal infections that are deeper and more severe usually require
treatment with systemic antifungal medication such as amphotericin B,
fluconazole, or voriconazole. Patients who do not get better after topical
and oral antifungal medications may require surgery, including corneal
Fungal Keratitis Statistics
The exact incidence in the general population is unknown, but fungal
keratitis is thought to be more common in warmer climates.
Fungal keratitis is not a notifiable condition. However, healthcare providers
who are concerned about an unusual number of new cases of fungal
keratitis should contact their state or local health departments.
Histoplasmosis is a disease caused by the fungus Histoplasma
capsulatum. The fungus lives in the environment, usually in association
with large amounts of bird or bat droppings. Lung infection can occur after
a person inhales airborne, microscopic fungal spores from the environment;
however, many people who inhale the spores do not get sick. The
symptoms of histoplasmosis are similar to pneumonia, and the infection
can sometimes become serious if it is not treated.
Definition of Histoplasmosis
Histoplasmosis is a disease caused by the fungus Histoplasma
capsulatum. The fungus lives in the environment, usually in association
with large amounts of bird or bat droppings. Lung infection can occur after
a person inhales airborne, microscopic, fungal spores from the

environment; however, many people who inhale the spores do not get sick.
The symptoms of histoplasmosis are similar to pneumonia, and the
infection can sometimes become serious if it is not treated, especially if the
infection spreads from the lungs to other organs.
Symptoms of Histoplasmosis
Many people who are infected with the fungus do not show any symptoms.
In areas of the world where the fungus is very common in the environment,
many people may have been infected with Histoplasma capsulatum without
having any symptoms. If symptoms occur, they usually start within 3 to 17
days after being exposed to the fungus.
In people who develop disease, the most common symptoms are similar to
those of pneumonia, and include: fever, chest pains, and a dry or
nonproductive cough. Some people may also experience joint pain. If the
disease is not treated, it can disseminate (spread) from the lungs to other
Risk & Prevention
Anyone can get histoplasmosis, even people who are otherwise healthy.
However, infants, young children, and older people, particularly those with
chronic lung disease, are at increased risk for developing severe disease.
Disseminated disease is most frequent in people who have weakened
immune systems, such as people with cancer or HIV/AIDS.
Histoplasma capsulatum, the fungus that causes histoplasmosis, can be
found throughout the world, but it is most common in North and Central
America. In the United States, the fungus is endemic (native and common)
in the Mississippi and Ohio River Valleys.
Prevention of Histoplasmosis
There is no vaccine to prevent histoplasmosis, and it is not always possible
to prevent exposure to the fungus in areas where the fungus is endemic.
However, you should avoid areas with accumulations of bird or bat
droppings, especially if you have a weakened immune system. Areas with
accumulations of bird or bat droppings should be cleaned up by
professional companies that specialize in the removal of hazardous waste.


Sources of Histoplasmosis
H. capsulatum grows in soil and material contaminated with bat or bird
droppings. The microscopic fungal spores can become airborne when the
soil is disturbed, and breathing in the spores can cause infection in the
lungs. Histoplasmosis cannot be transmitted from person to person or from
animals to people.
There are multiple tests available to diagnose histoplasmosis. One way to
diagnose the infection is to perform a fungal culture. Doctors take small
samples from tissues or body fluids, such as blood, sputum, bone marrow,
liver, or skin and see if the fungus will grow from these samples in a
A urine test is available that can check for recent infection from
Histoplasma, by measuring the presence of antigen. Histoplasmosis can
also be diagnosed by looking at a small sample of infected tissue under a
microscope. A blood test can measure prior exposure to the fungus by
detecting Histoplasma antibodies.
Treatment & Outcomes of Histoplasmosis
The mild pulmonary (lung) form of histoplasmosis will generally resolve
within about a month without treatment.
Prescription antifungal medications are needed to treat severe cases of
acute histoplasmosis, and all cases of chronic or disseminated disease.
Itraconazole is one commonly used antifungal medication. Treatment may
continue for 3 to 12 months, depending on the severity of the disease and
the immune status of the person. Past infection can provide partial
protection against severe disease if a person becomes re-infected later in
Histoplasmosis Statistics
Between 50% and 80% of people who live in areas where Histoplasma
capsulatum is common in the environment will show evidence of having
been exposed to the fungus at some point in their lifetime. In these areas,
10% to 25% of HIV-infected people will develop disseminated
Histoplasmosis is reportable in some states, including Kentucky,
Minnesota, Illinois, Mississippi, Michigan, Indiana, and Pennsylvania. No

national surveillance exists, so physicians should contact their local health

department for information regarding reporting of histoplasmosis.
Mucormycosis (also called zygomycosis) is a rare infection caused by
organisms that belong to a group of fungi called Mucoromycotina in the
order Mucorales. At one time these fungi were called Zygomycota, but this
scientific name has recently been changed. These fungi are typically found
in the soil and in association with decaying organic matter, such as leaves,
compost piles, or rotten wood.
Definition of Mucormycosis
Mucormycosis (also called zygomycosis) is a rare infection caused by
organisms that belong to a group of fungi called Mucoromycotina in the
order Mucorales. At one time these fungi were called Zygomycota, but this
scientific name has recently been changed. These fungi are typically found
in the soil and in association with decaying organic matter, such as leaves,
compost piles, or rotten wood.
Symptoms of Mucormycosis
The symptoms of mucormycosis depend on where in the body the fungus
is growing. Mucormycosis most commonly affects the sinuses or lungs.
Symptoms of sinus infections include fever, headache, and sinus pain.
Lung infections with the fungus can cause fever and cough.
Skin infections can develop after the fungus enters through a break in the
skin caused by surgery, burns, or trauma. A skin infection can look like
blisters or ulcers, and the infected tissue may turn black. Other symptoms
of a skin infection include fever and tenderness, pain, heat, excessive
redness, or swelling around a wound.
If the infection is not treated quickly, the fungus can spread throughout the
body, and the infection is often fatal.
Outbreaks and Investigations
Outbreaks and clusters of mucormycosis are rare but when they do occur
they are often serious. In hospitals, mucormycosis outbreaks of skin and
soft tissue infection have been linked to contact with contaminated objects,
such as tongue depressors. Additionally, clusters of mucormycosis have
occurred in association with organ transplantation. The most recent

investigation was in response to an outbreak of mucormycosis among

victims of the Joplin, Missouri tornado in May 2011.
Information about Mucormycosis following the Joplin, Missouri Tornado
CDC is assisting the Missouri Department of Health and Senior Services
(MDHSS) with an investigation into a number of reports of fungal skin
infection in people who were injured by the tornado that struck Joplin in
May 2011.
People who had trauma that resulted in an open wound that is not healing
or are experiencing continued symptoms, such as worsening redness,
tenderness, pain, heat in the area of the wound, or fever, should see a
health care provider for evaluation.
People at Risk For Mucormycosis
Mucormycosis is a rare infection caused by fungi typically found in the soil
and in decaying organic matter, including leaves and rotten wood. The
infection is more common among people with weakened immune systems,
but it can occur (rarely) in people who are otherwise healthy. Risk factors
for developing mucormycosis include:
 Uncontrolled diabetes
 Organ transplant
 Neutropenia (low white blood cells)
 Skin trauma (cuts, scrapes, punctures, or burns)
Because these fungi are common in the environment, such as soil and
decaying wood, preventing exposure is difficult. There is no vaccine
available to prevent an infection with mucormycosis. To help reduce the
risk for disease, wear protective clothing, such as gloves, pants and longsleeved shirts, if you are handling decaying wood.
Disinfect cuts and scrapes after contact with soil and decaying wood and
remove items that are lodged under your skin, such as dirt or splinters.
See your health care provider if you are concerned about cuts, scrapes, or
other skin injuries.


Sources of Mucormycosis
There are two main types of infection that people can get, and these
depend on the route of exposure. In the pulmonary or sinus form, exposure
occurs by inhaling fungal spores from the environment. These spores can
cause an infection to develop in the lungs, sinuses, eyes, and face, and in
rare cases the infection can spread to the central nervous system. In the
cutaneous form, the fungus can enter the skin through cuts, scrapes,
puncture wounds, or other forms of trauma to the skin. Mucormycosis is not
contagious and does not spread from person to person.
Several different fungi can cause mucormycosis, but the most common is
Rhizopus arrhizus (oryzae). Less frequent causes of infection include
Cunninghamella bertholletiae, Rhizomucor pusillus and Saksenaea
vasiformis. All cause similar diseases in humans, and the diagnostic and
treatment approaches are similar.
The fungi that cause mucormycosis are found in the soil and decomposing
organic matter, such as leaves or wood.
Most human infections follow inhalation of fungal spores that have been
released into the air. Less frequently, infection occurs during traumatic
inoculation, when fungal organisms gain entrance to deep body tissues
following a traumatic event that damages the skin. Infection can also occur
following ingestion of contaminated food.
Treatment & Outcomes of Mucormycosis
Mucormycosis needs to be treated with antifungal medication prescribed by
a health care provider. These medications are given by mouth or through a
vein. Skin infections with the fungus may require surgery to cut away the
infected tissue.
In cutaneous mucormycosis, wounds should be thoroughly debrided and
resected in conjunction with antifungal-based therapy debrided and
resected, antifungal therapy (conventional or lipid formulations of
amphotericin B) should be administered, and control of the underlying
immunocompromising condition should be attempted when possible.

The prognosis is poor if the underlying disease cannot be controlled. The

efficacy of other treatments, including the antifungal drug posaconazole,
and hyperbaric oxygen therapy, is uncertain, but these agents have been
described as useful in certain situations.
The overall prognosis of the infection depends on several factors, including
the rapidity of diagnosis and treatment, the site of infection, and underlying
conditions and degree of immunosuppression in the patient. The overall
mortality rate is approximately 50%, although early identification and
treatment can lead to better outcomes.
Mucormycosis Statistics
Mucormycosis is an uncommon infection. In the United States, active
population-based surveillance, conducted in 1992 and 1993, showed that
mucormycosis developed in 1.7 persons per million population per year.
Nosocomial (healthcare-associated) outbreaks of mucormycosis have been
reported, but most cases in hospitalized patients are sporadic and it is often
difficult to determine whether or not these infections were acquired within
the healthcare setting.
Pneumocystis pneumonia
Pneumocystis pneumonia (PCP) is a serious illness caused by the fungus
Pneumocystis jirovecii. PCP is one of the most frequent and severe
opportunistic infections in people with weakened immune systems,
particularly people with HIV/AIDS. Although people with HIV/AIDS are less
likely to get PCP today than in recent years, PCP is still a significant public
health problem.
Definition of Pneumocystis pneumonia
PCP is a serious illness caused by infection with the fungus Pneumocystis
jirovecii (pronounced NEW-mo-SIS-tis yee-row-VET-zee). It is one of the
most common opportunistic infections in people with HIV/AIDS. Although
people with HIV/AIDS are less likely to get PCP today than in recent years,
PCP is still a significant public health problem.
Symptoms of Pneumocystis pneumonia
The symptoms of PCP are fever, dry cough, shortness of breath, and
fatigue. In people with weakened immune systems, PCP can be very
serious, so it is important to see a doctor if you have these symptoms.

In HIV-infected patients, PCP usually presents sub-acutely, and symptoms

include a low-grade fever. In HIV-uninfected patients, symptoms of PCP
tend to develop more quickly and patients typically experience a high fever.
Risk & Prevention
PCP is extremely rare in healthy people. Most people who get PCP have
weakened immune systems due to HIV/AIDS, cancer treatments, or organ
transplants. Other groups of people who are at risk for PCP include:
 HIV-exposed but uninfected children
 People who are receiving immunosuppressive therapies, such as
organ transplant patients
 People with connective tissue diseases or chronic lung diseases
 How can I prevent pneumocystis pneumonia (PCP)?
 There is no vaccine to prevent PCP. Some groups of people who are
at high risk of developing PCP may need to take a medication called
TMP-SMX to prevent the illness from occurring. If your doctor thinks
you are at risk for developing PCP, he or she might prescribe this
medicine for you. TMP-SMX prophylaxis is currently recommended
 All HIV-infected patients with CD4 < 350 cells / L
 Infants born to HIV-infected mothers
 Children with a history of PCP
 Stem cell transplant patients
Sources of Pneumocystis pneumonia
Scientists are still learning about how people get PCP. Studies have shown
that many people are exposed to the fungus as children, but they do not
get sick because their immune systems are strong. Some healthy adults
carry the fungus in their lungs and never develop symptoms of PCP.
However, if a person's immune system stops working normally, the fungus
can start causing symptoms.
Treatment and Outcomes for Pneumocystis pneumonia
PCP requires treatment with prescription medicine that must be taken for
three weeks. The best form of treatment for PCP is trimethoprim
sulfamethoxazole (TMP-SMX), which is also known by the brand names
Bactrim, Septra, and Cotrim. This medicine is given orally or through a


TMP-SMX can cause negative side effects such as a rash and nausea, but
the benefits of treating the PCP usually outweigh the risks of these side
effects. Without treatment, PCP can be fatal.
Pneumocystis pneumonia Statistics
Before the beginning of the HIV/AIDS epidemic in the 1980s, PCP was very
uncommon. In fact, unusual clusters of PCP were one of the first signs that
the HIV/AIDS epidemic was beginning. PCP soon became one of the main
AIDS-defining illnesses in HIV-infected patients in the United States. Since
then, the incidence of PCP in HIV/AIDS patients has declined in the U.S.
due to the introduction of highly active antiretroviral therapy (HAART) and
TMP-SMX prophylaxis. However, PCP is still a serious health concern for
people with HIV/AIDS or other conditions that weaken the immune system.
In the U.S., the incidence of PCP is estimated to be 9% among hospitalized
HIV/AIDS patients and 1% among solid organ transplant recipients. In
immunocompromised patients, the mortality rate ranges from 5% to 40% in
those who receive treatment. The mortality rate approaches 100% without
Sporotrichosis is an infection caused by a fungus called Sporothrix
schenckii. The fungus lives throughout the world in soil, plants, and
decaying vegetation. Cutaneous (skin) infection is the most common form
of infection and usually occurs after handling contaminated plant material,
when the fungus enters the skin through a small cut or scrape.
Definition of Sporotrichosis
Sporotrichosis is an infection caused by a fungus called Sporothrix
schenckii. The fungus lives throughout the world in soil, plants, and
decaying vegetation. Cutaneous (skin) infection is the most common form
of infection, although pulmonary infection can occur if a person inhales the
microscopic, airborne fungal spores. Most cases of sporotrichosis are
sporadic and are associated with minor skin trauma like cuts and scrapes;
however, outbreaks have been linked to activities that involve handling
contaminated vegetation such as moss, hay, or wood.
Symptoms of Sporotrichosis
The first symptom is usually a small painless nodule (bump) resembling an
insect bite. The first nodule may appear any time from 1 to 12 weeks after
exposure to the fungus. The nodule can be red, pink, or purple in color, and

it usually appears on the finger, hand, or arm where the fungus has entered
through a break in the skin. The nodule will eventually become larger in
size and may look like an open sore or ulcer that is very slow to heal.
Additional bumps or nodules may appear later near the original lesion.
Most Sporothrix infections only involve the skin. However, the infection can
spread to other parts of the body, including the bones, joints, and the
central nervous system. Usually, these types of disseminated infections
only occur in people with weakened immune systems. In rare cases, a
pneumonia-like illness can occur after inhaling Sporothrix spores, which
can cause symptoms such as shortness of breath, cough, and fever.
Risk & Prevention
People who handle thorny plants, sphagnum moss, or bales of hay are at
increased risk of getting sporotrichosis. The infection is more common
among people with weakened immune systems, but it can also occur in
otherwise healthy people. Outbreaks have occurred among florists, plant
nursery workers who have handled sphagnum moss, rose gardeners,
children who have played on bales of hay, and greenhouse workers who
have handled thorns contaminated by the fungus.
Prevention of sporotrichosis
There is no vaccine to prevent sporotrichosis. You can reduce your risk of
sporotrichosis by wearing protective clothing such as gloves and long
sleeves when handling wires, rose bushes, bales of hay, pine seedlings, or
other materials that may cause minor cuts or punctures in the skin. It is also
advisable to avoid skin contact with sphagnum moss.
Sources of Sporotrichosis
The fungus lives in sphagnum moss, hay, other plant materials, and soil.
The fungus can enter the skin through small cuts or punctures from thorns,
barbs, pine needles, or wires. In rare cases, inhalation of the fungus can
cause pulmonary infection. Sporotrichosis is not spread from person to
person; however, a small number of human cases have been caused by
scratches or bites from infected animals such as cats.
Sporotrichosis Diagnosis and Testing
Sporotrichosis is typically diagnosed when your doctor obtains a swab or a
biopsy of the infected site and sends the sample to a laboratory for a fungal
culture. Serological tests are not always useful in the diagnosis of
sporotrichosis due to limitations in sensitivity and specificity.

Treatment and Outcomes for Sporotrichosis

Most cases of sporotrichosis only involve the skin and/or subcutaneous
tissues and are non-life-threatening, but the infection requires treatment
with prescription antifungal medication for several months. The most
common treatment for this type of sporotrichosis is oral itraconazole for 3 to
6 months. Itraconazole may also be used to treat bone and joint infections,
but treatment should continue for at least 12 months.
For patients with severe disease, and/ or an infection that has spread
throughout the body, a lipid formulation of amphotericin B should be used.
Itraconazole can be used for step-down therapy once the patient has
stabilized. Supersaturated potassium iodide (SSKI) is another treatment
option for cutaneous or lymphocutaneous disease. SSKI and azole drugs
like itraconazole should not be used during pregnancy. Treatment
recommendations may differ for children.
Sporotrichosis Statistics
The exact incidence of sporotrichosis is unknown, but people at increased
risk for sporotrichosis usually have occupational or recreational exposures
related to agriculture, horticulture, forestry, or gardening.
Sporothrix schenckii can be found throughout the world in soil and plant
matter. Peru is suspected to be an area where S. schenckii is extremely
common in the environment. Outbreaks of sporotrichosis have been
documented in the United States, Western Australia, and Brazil.
Exserohilum is a common mold found in soil and on plants, especially
grasses, and it thrives in warm and humid climates. Exserohilum is a very
rare cause of infection in people, but it has been known to cause several
different types of infections, including infection in the skin or the cornea (the
clear, front part of the eye), which are typically due to skin or eye trauma.
Exserohilum can also cause more invasive forms of infection in the
sinuses, lungs, lining of the heart, and bone, which are thought to be more
likely to occur in people with weak immune systems. Like other fungal
infections, Exserohilum infections cannot be transmitted from person to


Exserohilum rostratum has been identified as one of the predominant

pathogens in the multistate outbreak of fungal meningitis and other fungal
infections associated with contaminated steroid injections.
Cladosporium is a mold that is common in the environment. Outdoors, it
can be found on plants and other organic matter. Indoors, Cladosporium is
common in the air and on surfaces such as wallpaper or carpet, particularly
where moisture is present. Cladosporium is a very rare cause of human
illness, but it has been known to cause several different types of infections,
including skin, eye, sinus, and brain infections. Cladosporium has also
been associated with allergies and asthma.
Cladosporium has been identified in clinical specimens as one of the
pathogens in the multistate outbreak of fungal meningitis and other fungal
infections associated with contaminated steroid injections.
Recent Fungal Outbreaks
Histoplasmosis in an Illinois Prison expanded
Histoplasmosis outbreak at a state prison in Illinois, August September
This investigation is ongoing; information below may be subject to change.
Number of cases: 78
Pathogen: Histoplasma capsulatum
Type of infection: pulmonary
Setting: adult prison in east-central Illinois
Source: likely related to disruption of soil contaminated with bird droppings
Outbreak investigation partners: Illinois Department of Public Health and
Illinois Department of Corrections
Coccidioidomycosis (Valley fever) in California Prisons expanded
High rates of coccidioidomycosis (Valley fever) at two state prisons in
California's Central Valley, June 2013
This investigation is ongoing; information below may be subject to change.
Pathogen(s): Coccidioides
Type of infection: mostly pulmonary

Setting: Two prisons in Californias Central Valley

Source: Natural environment
Outbreak investigation partners: California Department of Public Health,
California Correctional Healthcare Services, and California Department of
Corrections and Rehabilitation
Resources and publications
Fungal meningitis after contaminated steroid injections expanded
Multistate outbreak of fungal meningitis and other fungal infections
associated with contaminated steroid injections, October 2012
This investigation is ongoing. For more details about this investigation,
please see the Multistate Fungal Meningitis Outbreak Investigation page.
Number of cases: 751
Pathogen(s): Exserohilum rostratum and others
Type of infection: Meningitis, localized spinal or paraspinal infections, and
infections in a peripheral joint space, such as a knee, shoulder, or ankle
Setting: Outpatient clinics in 20 states
Source: Contaminated steroid injections from a compounding pharmacy
Outbreak investigation partners: State and local health departments and
the U.S. Food and Drug Administration
Blastomycosis in Wisconsin expanded
Outbreak of blastomycosis, Marathon County, Wisconsin, 2010-2011
Number of cases: 55
Pathogen(s): Blastomyces dermatitidis
Type of infection: Mostly pulmonary
Setting: Marathon County, Wisconsin
Source: Likely multiple foci in the natural environment
Outbreak investigation partners: Marathon County Health Department,
Wisconsin Department of Health Services, Marshfield Clinic Research
Foundation, and the University of Wisconsin


Chapter 6: Parasites
A parasite is an organism that lives on or in a host organism and gets its
food from or at the expense of its host. There are three main classes of
parasites that can cause disease in humans: protozoa, helminths, and
Parasitism is the relation between two different kinds of organisms in which
one receives benefits from the other by causing damage to it. Usually a
parasite refers to organisms with lifestages that need more than one host
(e.g. Taenia solium). These are now called macroparasites (typically
protozoa and helminths). The word parasite also refers to microparasites,
which are typically smaller, such as viruses and bacteria, and can be
directly transmitted between hosts of the same species.
Parasites are generally much smaller than their host and show a high
degree of specialization, they reproduce at a faster rate than their hosts.
Classic examples of parasites include animals like tapeworms, flukes, ticks
and fleas.
The word parasite comes from the Latin parasitus, the latinisation of the
Greek (parasitos, "one who eats at the table of another" and that from para,
"beside, by" + sitos, "wheat".
Pediculus humanus capitis
Pediculosis is an infestation of lice. These are blood-feeding insects of the
order Phthiraptera. The condition can occur in almost any species of warmblooded animal including humans. Although "pediculosis" in humans may
properly refer to lice infestation of any part of the body, the term is
sometimes used loosely to refer to pediculosis capitis, the infestation of the
human head with the specific head louse.
Head-lice infestation is most frequently found on children aged 310 and
their families. Approximately 3% of school children in the United States
contract head lice. Females are more frequently infested than males,
probably due to the fact that they generally have more hair. African
Americans generally suffer less infestations due to the difference in hair


Head lice are spread through direct head-to-head contact with an infested
person or by sharing hats, combs and other hair products. From each egg
or "nit" may hatch one nymph that will grow and develop to the adult louse.
Lice feed on blood by piercing the skin with their tiny needle-like
mouthparts; their saliva irritates the skin and causes the characteristic
itching. They do not burrow into the skin.
To diagnose a lice infestation the scalp is combed thoroughly with a louse
comb and the teeth of the comb are examined for the presence of living lice
after each time the comb passes through the hair.
The most obvious symptom of infestation is pruritus (itching) on the head
which normally intensifies 3 to 4 weeks after the initial infestation.
Excessive scratching of the infested areas can cause sores, which may
then become infected. In addition, body lice can be a vector for other
diseases, such as louse-borne typhus, louse-borne relapsing fever or
trench fever.
Around 6-12 million people (mostly children) are treated for head lice in the
United States each year. Head lice infest a new host by close contact
between individuals, making social contacts among children and parent
child interactions the most likely routes of infestation. Shared hats, combs,
brushes, towels, clothing, and beds are also routes of lice transmission.
Body lice
This condition, is caused by body louse (Pediculus humanus humanus,
sometimes called Pediculus humanus corporis) is a louse which infests
humans and lays eggs in their clothing, rather than at the base of hairs.
Pubic lice
The pubic or crab louse (Pthirus pubis) is another offshoot of the original
louse and is adapted to body hair. Humans have the dubious honor of
being the only known host of this parasite. Arent we AWESOME?
Scabies (from Latin: scabere, "to scratch") is a contagious skin infection
that occurs among humans and other animals. It has been classified by the
WHO as a water-related disease. It is caused by a tiny parasite that is not

visible to the naked eye, which burrows under the host's skin and causes
an intense itching. The infection in animals (caused by different but related
mite species) is called sarcoptic mange.
Scabies are microscopic, but sometimes are visible as pinpoints of white.
The pregnant females tunnel into the outermost layer of a host's skin and
deposit eggs in shallow burrows. The eggs then hatch into larvae in around
310 days. These young mites move about on the skin and molt into a
"nymphal" stage, before maturing as adults, which live 34 weeks in the
host's skin. Males roam on top of the skin, occasionally burrowing into the
skin. This movement of mites on and inside the skin produces an intense
itch, which has the characteristics of a delayed cell-mediated inflammatory
response to allergens.
The disease is most often transmitted by direct skin-to-skin contact, with
the probability of transmission increasing with the duration of contact. Initial
infections require four to six weeks to become symptomatic. Reinfection,
however, may manifest symptoms within as little as 24 hours. Because the
symptoms are allergic, their delay in onset is often mirrored by a significant
delay in relief after the parasites have been eradicated.
Signs and symptoms
The primary symptom of a scabies infection is an intense itching and a
superficial burrowing. The burrow tracks often form a neat "line" of four or
more equally developed "bites". These are often found in crevices of the
body, such as on the webs of fingers and toes, around the genital area, and
under the breasts of women.
Generally the itch is made worse by the application of warmth and is worse
at night (although that is probably because the person experiencing it has
less distraction at night, so it just seems worse).
The burrows are created by the excavation (digging) of the adult mite in the
skin. It generally occurs in the areas of the hands, feet, wrists, elbows,
back, buttocks, and external genitals. The infection doesnt usually appear
on the face or scalp except in people with compromised immune systems
or very young children.


Symptoms typically appear 26 weeks after infestation for individuals never

before exposed to scabies. For those having been previously exposed, the
symptoms can appear within several days after infestation.
Crusted scabies
Formerly called "Norwegian scabies, this appears on those with a weaker
immune system, the host becomes a more fertile breeding ground for the
mites, which spread over the host's body, except the face. This causes
scaly rashes, slight itching, and thick crusts of skin that contain thousands
of mites.
The elderly and people with an impaired immune system, such as HIV,
cancer or those on immunosuppressive medications, are susceptible to
crusted scabies
Scabies are contagious they can be spread by scratching an infected area.
When the area is scratched the mites are picked up under the fingernails
and can be moved to another area or person. They can also be transmitted
by direct skin-to-skin physical contact or through contact with other objects,
such as clothing, bedding, furniture, or surfaces with which a person
infected with scabies might have come in contact. Scabies mites can
survive without a human host for 24 to 36 hours. As with lice, scabies can
also be transmitted through sexual intercourse and of course a condom will
not stop it, since it is transmitted from skin-to-skin at sites other than sex
A person is positively diagnosed with scabies after the burrowing trail is
viewed with magnification. If the burrow itself is not visible the suspected
area is rubbed with ink from a pen or a topical tetracycline solution, which
glows under a special light. The skin is then wiped with an alcohol pad. If
the person is infected with scabies, the characteristic zigzag or "S" pattern
of the burrow will appear across the skin; however, interpreting this test
may be difficult, as the burrows are scarce and may be obscured by
scratch marks. A definitive diagnosis is made by finding either the scabies
mites or their eggs and fecal pellets.
There is no vaccine available for scabies, but mass treatment programs
utilizing topical permethrin or oral ivermectin have been effective in

reducing the outbreaks of scabies in large populations. Objects in the

environment pose little risk of transmission except in the case of crusted
scabies, thus cleaning is of little importance. Rooms used by those with
crusted scabies require thorough cleaning.
Protozoa are microscopic, one-celled organisms that can be free-living or
parasitic in nature. They are able to multiply in humans, which contributes
to their survival and also permits serious infections to develop from just a
single organism. Transmission of protozoa that live in a human's intestine
to another human typically occurs through a fecal-oral route (for example,
contaminated food or water or person-to-person contact). Protozoa that live
in the blood or tissue of humans are transmitted to other humans by an
arthropod vector (for example, through the bite of a mosquito or sand fly).
The protozoa that are infectious to humans can be classified into four
groups based on their mode of movement:
Sarcodina the ameba, e.g., Entamoeba
Mastigophora the flagellates, e.g., Giardia, Leishmania
Ciliophora the ciliates, e.g., Balantidium
Sporozoa organisms whose adult stage is not motile e.g.,
Plasmodium, Cryptosporidium
Helminths are large, multicellular organisms that are generally visible to the
naked eye in their adult stages. Like protozoa, helminths can be either freeliving or parasitic in nature. In their adult form, helminths cannot multiply in
humans. There are three main groups of helminths (derived from the Greek
word for worms) that are human parasites:
Flatworms (platyhelminths) these include the trematodes (flukes) and
cestodes (tapeworms).
Thorny-headed worms (acanthocephalins) the adult forms of these
worms reside in the gastrointestinal tract. The acanthocephala are thought
to be intermediate between the cestodes and nematodes.

Roundworms (nematodes) the adult forms of these worms can reside in

the gastrointestinal tract, blood, lymphatic system or subcutaneous tissues.
Alternatively, the immature (larval) states can cause disease through their
infection of various body tissues. Some consider the helminths to also
include the segmented worms (annelids)the only ones important
medically are the leeches. Of note, these organisms are not typically
considered parasites.
Although the term ectoparasites can broadly include blood-sucking
arthropods such as mosquitoes (because they are dependent on a blood
meal from a human host for their survival), this term is generally used more
narrowly to refer to organisms such as ticks, fleas, lice, and mites that
attach or burrow into the skin and remain there for relatively long periods of
time (e.g., weeks to months). Arthropods are important in causing diseases
in their own right, but are even more important as vectors, or transmitters,
of many different pathogens that in turn cause tremendous morbidity and
mortality from the diseases they cause.
Parasitic Infections
Parasitic infections cause a tremendous burden of disease in both the
tropics and subtropics as well as in more temperate climates. Of all
parasitic diseases, malaria causes the most deaths globally. Malaria kills
approximately 660,000 people each year, most of them young children in
sub-Saharan Africa.
The Neglected Tropical Diseases (NTDs), which have suffered from a lack
of attention by the public health community, include parasitic diseases such
as lymphatic filariasis, onchocerciasis, and Guinea worm disease. The
NTDs affect more than 1 billion peopleone-sixth of the world's
populationlargely in rural areas of low-income countries. These diseases
extract a large toll on endemic populations, including lost ability to attend
school or work, retardation of growth in children, impairment of cognitive
skills and development in young children, and the serious economic burden
placed on entire countries.
However, parasitic infections also affect persons living in developed
countries, including the United States.


Parasitic infections are typically associated with poor and often

marginalized communities in low-income countries. However, these
infections are also present in the United States.
The neglected parasitic infections (NPIs) are a group of five parasitic
diseases that have been targeted by the CDC as priorities for public health
action based on:
Number of people infected
Severity of the illnesses
Ability to prevent and treat them
These infections are considered neglected because relatively little attention
has been devoted to their surveillance, prevention, and/or treatment.
Anyone, regardless of race or economic status, can become infected
although minorities, immigrants, and people living in poor or disadvantaged
communities appear to be most at risk.
Parasitic infections affect millions of people in the United States every year.
More than 300,000 persons living are infected with Trypanosoma cruzi, the
cause of Chagas disease.
At least 1,000 people are hospitalized with neurocysticercosis every year.
Each year at least 70 people, most of them children, are blinded by the
parasite that causes Toxocariasis.
More than 60 million persons are chronically infected with Toxoplasma
Each year 1.1 million people are newly infected with Trichomonas.
Recreational Water Illnesses (RWIs)
Contrary to popular belief, chlorine does not kill all germs instantly. There
are germs today that are very tolerant to chlorine and were not known to
cause human disease until recently. Once these germs get in the pool, it

can take anywhere from minutes to days for chlorine to kill them.
Swallowing just a little water that contains these germs can make you sick.
Recreational water illnesses (RWIs) are caused by germs spread by
swallowing, breathing in mists or aerosols of, or having contact with
contaminated water in swimming pools, hot tubs, water parks, water play
areas, interactive fountains, lakes, rivers, or oceans. RWIs can also be
caused by chemicals in the water or chemicals that evaporate from the
water and cause indoor air quality problems.
RWIs include a wide variety of infections, such as gastrointestinal, skin,
ear, respiratory, eye, neurologic, and wound infections. The most
commonly reported RWI is diarrhea. Diarrheal illnesses are caused by
germs such as Crypto (short for Cryptosporidium-see below), Giardia,
Shigella, norovirus and E. coli O157:H7.
With RWI outbreaks on the rise, swimmers need to take an active role in
helping to protect themselves and prevent the spread of germs. It is
important for swimmers to learn the basic facts about RWIs so they can
keep themselves and their family healthy every time they swim.
In the past two decades, there has been a substantial increase in the
number of RWI outbreaks associated with swimming. Crypto, which can
stay alive for days even in well-maintained pools, has become the leading
cause of swimming pool-related outbreaks of diarrheal illness. From 2004
to 2008, reported Crypto cases increased over 200% (from 3,411 cases in
2004 to 10,500 cases in 2008).
Although Crypto is tolerant to chlorine, most germs are not. Keeping
chlorine at recommended levels is essential to maintain a healthy pool.
However, a 2010 study found that 1 in 8 public pool inspections resulted in
pools being closed immediately due to serious code violations such as
improper chlorine levels.
Knowing the basic facts about recreational water illnesses (RWIs) can
make the difference between an enjoyable time at the pool, beach, or water
park, and getting a rash, having diarrhea, or developing other, potentially
serious illnesses.


Recreational water illnesses (RWIs) are caused by germs spread by

swallowing, breathing in mists or aerosols of, or having contact with
contaminated water in swimming pools, hot tubs, water parks, water play
areas, interactive fountains, lakes, rivers, or oceans. RWIs can also be
caused by chemicals in the water or chemicals that evaporate from the
water and cause indoor air quality problems. RWIs can be a wide variety of
infections, including gastrointestinal, skin, ear, respiratory, eye, neurologic
and wound infections. The most commonly reported RWI is diarrhea.
Diarrheal illnesses can be caused by germs such as Crypto (short for
Cryptosporidium), Giardia, Shigella, norovirus and E. coli O157:H7.
RWIs are caused by germs spread through contaminated water in
swimming pools, water parks, water play areas, hot tubs, decorative water
fountains, oceans, lakes, and rivers.
Swimming Pools, Water Parks, Water Play Areas
The most common RWI is diarrhea. Swallowing water that has been
contaminated with feces containing germs can cause diarrheal illness.
Swimmers share the waterand the germs in itwith every person who
enters the pool. On average, people have about 0.14 grams of feces on
their bottoms which, when rinsed off, can contaminate recreational water.
In addition, when someone is ill with diarrhea, their stool can contain
millions of germs. This means that just one person with diarrhea can easily
contaminate the water in a large pool or water park. People may not realize
that although there is no standing water in interactive fountains/water play
areas, the spray water will rinse any contaminants (for example, diarrhea,
vomit, and dirt) down into the water holding area and be sprayed again. In
other words, the water is recycled through the system.
Swallowing even a small amount of recreational water that has been
contaminated with feces containing germs can make you sick.
Hot Tubs
Skin infections like "hot tub rash" are a common RWI spread through hot
tubs and spas. Respiratory illnesses are also associated with the use of
improperly maintained hot tubs.
The high water temperatures in most hot tubs make it hard to maintain the
disinfectant levels needed to kill germs. Thats why its important to check


disinfectant levels in hot tubs even more regularly than in swimming pools.
The germs that cause "hot tub rash" can also be spread in pools that do not
have proper disinfectant levels and in natural bodies of water such as
oceans, lakes, or rivers.
Decorative Water Fountains
Not all decorative fountains are chlorinated or filtered. Therefore, when
people, especially diaper-aged children, play in the water, they can
contaminate the water with fecal matter. Swallowing this contaminated
water can then cause diarrheal illness.
Oceans, Lakes, and Rivers
Oceans, lakes, and rivers can be contaminated with germs from sewage
spills, animal waste, water runoff following rainfall, fecal incidents, and
germs rinsed off the bottoms of swimmers. It is important to avoid
swallowing the water because natural recreational water is not disinfected.
Avoid swimming after rainfalls or in areas identified as unsafe by health
Cryptosporidium is a microscopic parasite that causes the diarrheal
disease cryptosporidiosis. Both the parasite and the disease are commonly
known as "Crypto."
There are many species of Cryptosporidium that infect humans and
animals. The parasite is protected by an outer shell that allows it to survive
outside the body for long periods of time and makes it very tolerant to
chlorine disinfection.
While this parasite can be spread in several different ways, water (drinking
water and recreational water) is the most common method of transmission.
Cryptosporidium is one of the most frequent causes of waterborne disease
among humans in the United States.
Cryptosporidiosis is a diarrheal disease caused by microscopic parasites,
Cryptosporidium, that can live in the intestine of humans and animals and
is passed in the stool of an infected person or animal. Both the disease and
the parasite are commonly known as "Crypto." The parasite is protected by
an outer shell that allows it to survive outside the body for long periods of

time and makes it very resistant to chlorine-based disinfectants. During the

past 2 decades, Crypto has become recognized as one of the most
common causes of waterborne disease (recreational water and drinking
water) in humans in the United States. The parasite is found in every region
of the United States and throughout the world.
How cryptosporidiosis is spread
Cryptosporidium lives in the intestine of infected humans or animals. An
infected person or animal sheds Crypto parasites in the stool. Millions of
Crypto germs can be released in a bowel movement from an infected
human or animal. Shedding of Crypto in the stool begins when the
symptoms begin and can last for weeks after the symptoms (e.g., diarrhea)
stop. You can become infected after accidentally swallowing the parasite.
Cryptosporidium may be found in soil, food, water, or surfaces that have
been contaminated with the feces from infected humans or animals. Crypto
is not spread by contact with blood.
Crypto can be spread:
 By putting something in your mouth or accidentally swallowing
something that has come into contact with stool of a person or animal
infected with Crypto.
 By swallowing recreational water contaminated with Crypto.
Recreational water is water in swimming pools, hot tubs, Jacuzzis,
fountains, lakes, rivers, springs, ponds, or streams. Recreational
water can be contaminated with sewage or feces from humans or
 By swallowing water or beverages contaminated with stool from
infected humans or animals.
 By eating uncooked food contaminated with Crypto. Thoroughly wash
with uncontaminated water all vegetables and fruits you plan to eat
raw. See below for information on making water safe.
 By touching your mouth with contaminated hands. Hands can
become contaminated through a variety of activities, such as touching
surfaces (e.g., toys, bathroom fixtures, changing tables, diaper pails)
that have been contaminated by stool from an infected person,
changing diapers, caring for an infected person, changing diapers,
caring for an infected person, and handling an infected cow or calf.
 By exposure to human feces through sexual contact.


The symptoms of cryptosporidiosis

The most common symptom of cryptosporidiosis is watery diarrhea. Other
symptoms include:
 Stomach cramps or pain
 Weight loss
Some people with Crypto will have no symptoms at all. While the small
intestine is the site most commonly affected, Crypto infections could
possibly affect other areas of the digestive tract or the respiratory tract.
Symptoms of cryptosporidiosis generally begin 2 to 10 days (average 7
days) after becoming infected with the parasite.
In persons with healthy immune systems, symptoms usually last about 1 to
2 weeks. The symptoms may go in cycles in which you may seem to get
better for a few days, then feel worse again before the illness ends.
People who are most likely to become infected with Cryptosporidium

Children who attend day care centers, including diaper-aged children

Child care workers
Parents of infected children
People who take care of other people with cryptosporidiosis
International travelers
Backpackers, hikers, and campers who drink unfiltered, untreated
People who drink from untreated shallow, unprotected wells.
People, including swimmers, who swallow water from contaminated
People who handle infected cattle
People exposed to human feces through sexual contact

Contaminated water may include water that has not been boiled or filtered,
as well as contaminated recreational water sources (e.g., swimming pools,
lakes, rivers, ponds, and streams). Several community-wide outbreaks of

cryptosporidiosis have been linked to drinking municipal water or

recreational water contaminated with Cryptosporidium.
Although Crypto can infect all people, some groups are likely to develop
more serious illness.
Young children and pregnant women may be more susceptible to the
dehydration resulting from diarrhea and should drink plenty of fluids while
Treatment for cryptosporidiosis
Nitazoxanide has been FDA-approved for treatment of diarrhea caused by
Cryptosporidium in people with healthy immune systems and is available
by prescription. Consult with your health care provider for more information.
Most people who have healthy immune systems will recover without
treatment. Diarrhea can be managed by drinking plenty of fluids to prevent
dehydration. Young children and pregnant women may be more
susceptible to dehydration. Rapid loss of fluids from diarrhea may be
especially life threatening to babies. Therefore, parents should talk to their
health care provider about fluid replacement therapy options for infants.
Anti-diarrheal medicine may help slow down diarrhea, but a health care
provider should be consulted before such medicine is taken.
People who are in poor health or who have weakened immune systems are
at higher risk for more severe and more prolonged illness. The
effectiveness of nitazoxanide in immunosuppressed individuals is unclear.
HIV-positive individuals who suspect they have Crypto should contact their
health care provider. For persons with AIDS, anti-retroviral therapy that
improves immune status will also decrease or eliminate symptoms of
Crypto. However, even if symptoms disappear, cryptosporidiosis is often
not curable and the symptoms may return if the immune status worsens.


Chapter 7: Massage Environment Hygiene

Safety is an ethical concern
Im sure you would agree that when your client is on your massage table
you are responsible for their safety. In an ethical (and legal) sense you are
equally responsible for them from the moment they walk through the front
door of your business.
According to the NCBTMB Standards of Practice Standard IV: Business
a. Provide a physical setting that is safe and meets all applicable legal
requirements for health and safety
So regardless of whether your massage business is just a small treatment
room in a chiropractors office, a massage room in Salon or a Medical
Massage Clinic you are responsible for your clients safety from the moment
they enter.
The transmission of disease to clients in a massage setting is a public
health concern that is regulated by the state and local public health
agencies. To counteract the potential negative impact of government
regulation, the massage industry should be proactive in teaching safety
standards as a matter of course in massage education.
Massage businesses must adhere to strict protocols and practice "extreme
sanitation" to protect therapists and clients. This means using the universal
precautions mentality, assuming that each person on the table could have
a skin disease, and taking appropriate precautions to avoid contamination.
This doesnt mean not touching them, it means never skipping a step in
washing and disinfecting your hands after a massage, and strict adherence
to the one time only rule-never reusing any linens that touch the clients
skin without laundering them first. This obviously applies to the linens on
the table, but also the face rest covers, eye pillows, and any thing else that
touches the clients skin. This includes hot stones or other implements used
during a massage.
Keep in mind that hot stones are not self cleaning-more than one
massage therapist has used hot stones on a client and then put them back
in the warm water with the unused stones

Failure to provide a clean and safe environment violates the key principle of
non-maleficence, the do no harm aspect of medical ethics.
In the massage industry, following strict procedures and sterilization
techniques is critically important not only for clients but for the protection of
Massage therapists are in the 'paramedical' arena, are protected by the
Occupational Safety and Health Act of 1970 (the Act), 29 U.S.C. 655, which
minimizes occupational exposure to Hepatitis B Virus (HBV), Human
Immunodeficiency Virus (HIV) and other bloodborne pathogens.
OSHA has made a determination that employees face a significant health
risk as the result of occupational exposure to blood and other potentially
infectious materials because they may contain bloodborne pathogens. The
Agency further concludes that this exposure can be minimized or
eliminated using a combination of engineering and work practice controls,
personal protective clothing and equipment, training, medical surveillance,
Hepatitis B vaccination, signs and labels, and other provisions.
The environment in the massage setting is obviously different than in a
medical setting. The material published in connection with the Occupational
Safety and Health Administration (OSHA) standard, 'Occupational
Exposure to Bloodborne Pathogens' (29 CFR 1910.1030) does not include
any information on the risks of transmission of diseases in the massage
profession. Under the standard, it is the responsibility of the employer to
evaluate the potential for contact with blood, bacterial, fungi or other
potentially infectious material among his or her employees.
Laundering your massage linens
What both medical massage and luxury massage have in common is that
they often launder their own linens and towels in ordinary washers and
dryers that do not deliver hygienically clean linens, putting their clients at
risk for healthcare acquired infections (HAIs) and other easily transmitted
skin diseases and infections. In contrast, other healthcare facilities such as
hospitals and ambulatory surgery centers are under increased scrutiny and
regulation to develop superior infection prevention programs due to the
alarming rise in HAIs. Laundry tends to be the most outsourced department
and while commercial laundries certainly improve hospital efficiencies and

are better for the environment, quality control, infection control, and other
safety issues are still a concern. Day spas should take note.
So, what are the recommended quality practices and processes for medical
spa and day spa laundry operations, and how can commercial healthcare
laundries deliver hygienically clean textiles that minimize any risk of
spreading infection?
Accreditationthe industry's highest rating on quality and safetyfrom the
Healthcare Laundry Accreditation Council (HLAC) provides assurance that
spa textiles, just like healthcare textiles, cleaned by a company that
adheres to the highest possible standards. The HLAC is a non-profit
organization formed for the purpose of inspecting and accrediting laundries
processing healthcare textiles for hospitals, ambulatory surgery centers,
nursing homes, and other healthcare facilities. Standards incorporate
stringent requirements for healthcare linen processing that addresses
proper techniques for washing and extraction, drying, finishing, quality
control, packaging, storage, and delivery to the healthcare facility. They
ensure that healthcare textiles processed at an HLAC-accredited laundry
plant carry negligible risk to healthcare workers and patients, providing the
clean products are not inadvertently contaminated before use.
Additionally, proper wash formulas in the laundering process are constantly
monitored to assure consistent delivery of hygienically clean linens,
adequately removing any bio-burden so they can be used without fear of
being a contamination source. Wash water quality and usage, temperature,
pH, oxidation, chemical sanitizers, drying, ironing and equipment
performance are all carefully controlled. The HLAC also incorporates the
Occupational Safety and Health Care Act (OSHA) Standard Precautions
that must be included as part of a healthcare laundrys daily operations in
order to protect its employees who handle and sort soiled healthcare
Using proper hygiene is necessary for massage therapists to protect them
and the public they serve from infectious diseases and to keep them from
spreading between their clients.
The goal of proper hygiene is to prevent the growth and spread of
pathogens and allergens.


In a massage establishment this means sanitizing your table, face cradle,

linens, bottles of lotion/oil, hydrotherapy equipment as well as regularly
shampooing the carpet, and cleaning the walls and counters.
Keep in mind that your clients may have allergies and sensitivities to mold
and any scents or laundry detergent that you use so using hypo-allergetic
products can help. This is especially a concern when Aromatherapy
essential oils are used in the practice.
After each and every massage treatment you must wash your hands and
forearms to keep them free from bacteria and fungi.
Keeping hands clean through improved hand hygiene is one of the most
important steps we can take to avoid getting sick and spreading germs to
others. Many diseases and conditions are spread by not washing hands
with soap and clean, running water.
The right way to wash your hands
Wet your hands with clean, running water (warm or cold) and apply soap.
Rub your hands together to make a lather and scrub them well; be sure to
scrub the backs of your hands, between your fingers, and under your nails.
Continue rubbing your hands for at least 20 seconds. Need a timer? Hum
the "Happy Birthday" song from beginning to end twice.
Rinse your hands well under running water.
Dry your hands using a clean towel or air dry them.
Proper manicure skills will keep nail beds clean and smooth to not leave
scratches on clients.
Cleaning Massage Equipment
Remove all linens, including sheets, pillowcases, blankets and face rest
covers. Wash all these items.
Place your linens in the washing machine. Turn it on to the hottest setting
and fill it to the highest level. Add 1 cup of chlorine bleach and detergent
according to the manufacturer's instructions.

Wash any blankets and pillows the same way. If you cannot bleach them,
add 1 cup of a phenol or other disinfectant.
Wipe down the massage tables surface and the any bolster used with a
Proper use of Disinfectants
Disinfectants are chemical substances that are applied to non-living objects
to kill microorganisms that are living on the surface of the objects. It is
important to know that disinfections does not necessarily kill all
microorganisms present, some species of bacterial spores are very hard to
Disinfections are less effective than total sterilization, which is an extreme
physical and/or chemical process that kills all types of life. Disinfectants
work by destroying the cell wall of microbes or interfering with their
metabolic processes.
Disinfectants are not the same as antibiotics,
microorganisms within the body, or antiseptics,
microorganisms on the surface of living tissue.



Disinfectants are also different from biocides the latter are intended to
destroy all forms of life, not just microorganisms. This would include
humans, so obviously it is not used to clean your massage room.
Bacterial endospores are most resistant to disinfectants, but some viruses
and bacteria possess some tolerance as well, which is why simply using a
hand sanitizer is not the same as washing your hands properly.
A perfect disinfectant would offer complete microbiological sterilization,
without harming us humans, be cheap, and good for the environment.
They dont exist.
Most disinfectants are potentially harmful, even toxic to us humans (they
are poisons, after all). Most modern disinfectants contain Bitrex, an


exceptionally bitter substance added to discourage accidentally adding it to

a milkshake.
When using disinfectants indoors you must be careful to not mix them with
other cleaners, since the result could be a surprisingly deadly cloud of gas.
Aerosol disinfectants
Air disinfectants are chemicals capable of disinfecting microorganisms that
are suspended in the air. We are most accustomed to thinking of
disinfectants as being applied to surfaces, and in a massage room that is
where they do the most good, but they can be successful in killing
microorganisms that are in the air.
Massage rooms tend to be small, confined spaces (generally 12x15 or
less) and a client with a contagious respiratory condition can make the
room a veritable hot box of germs during the hour of the massage.
An air disinfectant must be dispersed either as an aerosol or vapor at a
sufficient concentration in the air to cause the number of viable infectious
microorganisms to be significantly reduced. This would obviously be done
after the massage, and with enough time to allow the chemical smell to not
be offensive to the next client.
Alcohols, usually ethanol or isopropanol, are sometimes used as a
disinfectant, but more often as an antiseptic (the distinction being that
alcohol tends to be used on living tissue rather than nonliving surfaces).
They are non-corrosive, but can be a fire hazard. They also have limited
residual activity due to evaporation, which results in brief contact times
unless the surface is submerged, and have a limited activity in the
presence of organic material. Alcohols are most effective when combined
with purified water to facilitate diffusion through the cell membrane; 100%
alcohol typically denatures only external membrane proteins.
A mixture of 70% ethanol or isopropanol diluted in water is effective against
a wide spectrum of bacteria, though higher concentrations are often
needed to disinfect wet surfaces. Additionally, high-concentration mixtures
(such as 80% ethanol + 5% isopropanol) are required to effectively
inactivate lipid-enveloped viruses (such as HIV, hepatitis B, and hepatitis
C). The efficacy of alcohol is enhanced when in solution with the wetting

agent dodecanoic acid (coconut soap). The synergistic effect of 29.4%

ethanol with dodecanoic acid is effective against a broad spectrum of
bacteria, fungi, and viruses. Further testing is being performed against
Clostridium difficile (C.Diff) spores with higher concentrations of ethanol
and dodecanoic acid, which proved effective with a contact time of ten
Alcohols are non-corrosive, but are usually flammable. Unfortunately
Alcohols evaporate rather quickly which means they have limited residual
activity. In other words, it is really only effective when it is applied, and not
Many household cleaning chemicals use Phenolics. They can also be
found in varying amounts in disinfecting soaps and mouthwashes. One of
the most well known commercial disinfectants, Phenol was first used by
Lister (Listerine) under the name carbolic acid.
Phenol can be corrosive to the skin and can make some people very sick,
so there are a variety of chemicals in the phenol family that are
o-Phenylphenol is often used as an alternative to phenol since it is less
Chloroxylenol is the principal ingredient in Dettol, a household disinfectant
and antiseptic.
Thymol, derived from the herb thyme, is the active ingredient in many of the
environmentally friendly disinfectants.
Quaternary ammonium compounds
Quaternary ammonium compounds, which in the beauty industry is
affectionately referred to as "quats", is a widely used low-level disinfectant.
It is used in Barbershops and Hair Salons around the country to protect
against fungi, amoeba, and enveloped viruses.
In your massage practice Quaternary ammonium compounds can be used
to clean the stones used in a Hot Stone massage.


Air disinfectants
Air disinfectants are typically chemical substances capable of disinfecting
microorganisms suspended in the air. Disinfectants are generally assumed
to be limited to use on surfaces, but that is not the case. In 1928, a study
found that airborne microorganisms could be killed using mists of dilute
bleach. An air disinfectant must be dispersed either as an aerosol or
vapour at a sufficient concentration in the air to cause the number of viable
infectious microorganisms to be significantly reduced.
In the 1940s and early 1950s, further studies showed inactivation of diverse
bacteria, influenza virus, and Penicillium chrysogenum (previously P.
notatum) mold fungus using various glycols, principally propylene glycol
and triethylene glycol. In principle, these chemical substances are ideal air
disinfectants because they have both high lethality to microorganisms and
low mammalian toxicity.
Although glycols are effective air disinfectants in controlled laboratory
environments, it is more difficult to use them effectively in real-world
environments because the disinfection of air is sensitive to continuous
action. Continuous action in real-world environments with outside air
exchanges at door, HVAC, and window interfaces, and in the presence of
materials that adsorb and remove glycols from the air, poses engineering
challenges that are not critical for surface disinfection. The engineering
challenge associated with creating a sufficient concentration of the glycol
vapours in the air have not to date been sufficiently addressed.
A Review of the Principles of Universal Precautions include:
Assume that all individuals you have contact with as a result of job
responsibilities, are potential carriers for blood born pathogens.
Assume that all blood and other potentially infectious material (OPIM:
human blood, semen, vaginal secretions, wound drainage, fluids visibly
contaminated with blood, cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid, unfixed tissue or organs,
and any body fluids in situations where it is difficult or impossible to
differentiate between body fluids are infectious for bbp and must be treated
as infectious.
Universal precautions do not apply to feces, nasal secretions, sputum,
sweat, tears, urine, and vomitus unless they contain visible blood.

Universal precautions do not apply to saliva except when visibly

contaminated with blood or in the dental setting where blood contamination
of saliva is predictable.
Vomit, feces, urine, saliva, and tears can not transmit bloodborne
pathogens. They may contain other infectious agents. To be safe, treat with
basic infection control and body substance isolation. Body Substance
Isolation is similar to universal precautions except that it involves all body
Avoid contact whenever possible with a client's blood, body fluid or
any areas of local infection.
Do not eat, drink, smoke, handle contact lenses, or apply make-up without
washing hands first. A group of approaches (Universal Precautions) is
more effective than any one approach to preventing the spread of bbp.
Non sterile disposable vinyl or latex gloves shall be worn and changed
 Handling any items (e.g. laundry, dressings, and clothing) that are
contaminated with another person's blood or OPIM.
 Providing care involving potential contact with blood, OPIM, mucous
membranes or non-intact skin.
 Providing care involving potential contact with all body fluids (Note:
this is basic infection control and body substance isolation, not
universal precautions).
Massage therapists should keep open wounds or inflamed dermatitis
covered whenever possible while working. Gloves should be worn by
bodyworker's who have sores, cuts, or a rash on their hands and are
providing care to individuals.
Vinyl gloves are preferred because of the high rate of allergies to latex
products and because oils break down latex gloves very quickly making


them permeable. Clients should be encouraged to keep wounds or

inflamed dermatitis covered.
Routinely and effectively wash hands at least before and after glove use; at
the start and end of the work shift; before and after use of bathrooms; after
any personal hygiene; before and after every session; and after touching
any objects that are likely to be contaminated.
Handwashing and skin washing should be done immediately if blood or
OPIM gets on intact or broken skin. Proper handwashing includes warm
running water, soap, friction, proper nail care, and proper technique. Hand
sanitizers can be used as an intermittent substitute for proper handwashing
but they do not completely replace it.
Vaccination for Hepatitis B
Hepatitis B Vaccination is a relatively risk free means of greatly reducing
the potential for infection with the hepatitis B virus. The Vaccination is given
as a series of three injections over a six-month period. People at risk for
exposure to hepatitis B should consult with their health care provider about
receiving the hepatitis B vaccination.
Most Massage therapists are considered low risk for potential exposure to
the hepatitis B virus. The hepatitis B vaccination does not offer immunity to
other hepatitis viruses such as hepatitis A or hepatitis C.
All potentially contaminated laundry should be handled minimally. It should
not be sorted or rinsed as these activities increase the risk of exposure.
Linens and towels must be changed between each client. Dirty linens
should be stored in a separate, closed container away from clean linens
until washed. Machine washing & drying with soap and hot water will clean
laundry. Do not let oily sheets sit for long period, they have been known to
spontaneously combust. Really, its not just an old wives tale, it can
Oils and some lotions will go rancid on sheets and make them smell.


Good Housekeeping
Keeping a clean work environment is absolutely critical when it comes to
protecting the public and yourself.
Broken glass should never be handled by hand. Use a dustpan and broom
to clean up any hazardous materials.
Clean environmental work surfaces when they become contaminated with
blood or OPIM and immediately secure the area, disinfect the area, and
clean the area. (Bleach and water is considered the most universal
disinfectant, otherwise read labels, 1 part Bleach to 9 parts water, mixed as
needed, do not store overnight.)
Double bag and label any contaminated waste before proper disposal.
Clean and disinfect all equipment: massage table, mechanical massage
devices, face cradles, bolsters, oil/lotion bottles, etc. between clients.
Use germicidal cleaners, diluted beach, rubbing alcohol for routine
disinfecting of equipment.
Personal Protective Equipment (PPE)
(a) When there is anticipated potential of exposure to blood/OPIM PPE
must be used. The most common piece of PPE is gloves. Other types of
PPE may include gowns, goggles, face shield, masks, and CPR Micro
shields. (b) The rule of thumb for PPE is dress for the occasion. Use the
right equipment for the right potential situation.
Massage therapists and bodyworkers should always have gloves (vinyl or
latex) and CPR micro shields available in their work area for potential
Post Exposure
Anytime someone else's blood or OPIM gets into your body (puncture,
mucous membranes, open areas, etc.) in a work situation, report and follow
the procedure of the employer and seek medical follow up immediately.
Infection Control
Massage therapists, due to the physical connection with others can be at
risk of spreading infections. As well they can be susceptible to receiving

infections from their clients. It is imperative that we be familiar with basic

infection control principles in order to protect themselves and others.
There are four common types. Viruses, such as those that cause the
common cold, are one. Bacteria, such as staph or strep, which can cause
sore throats and skin infections, are another. Fungi, such as that
responsible for athlete's foot, make up a third kind. And parasites such as
lice and scabies are the fourth.
The Chain of Infection
The Chain of Infection is Source, Means, and Host. It helps us understand
the spread communicable (infectious) diseases. If we can "break" just one
link, then we have broken the chain and stopped the spread of a
communicable disease. When we say source we are referring to a
person, environment, food, water, animal, insect, soil carrying or infected
with a pathogen or microorganism. The means is the method or mode of
transmission of the pathogen. The means can be direct or indirect contact.
Some methods of transmission include airborne, contact, vehicle.
When we say host we are referring to a susceptible/ highly susceptible
person. Infections are more likely if the agent comes in contact with breaks
in skin or with the mouth, eyes, or nose.
Factors included in susceptibility are
1. The subjects general health
2. The strength of the infectious agent
3. The ability of the immune system to fight the infection.
Preventing Infections
Handwashing is the most important step you can take to prevent infections.
The most important aspect of handwashing is the action of rigorously
scrubbing your hands with soap under running water.
Keep fingernails short, trimmed, and clean. Fingernails can harbor a lot of
microorganisms. You may have learned how to perform your massage
techniques without scratching people, but if your fingernails are long you
are definitely getting some of your clients skin cells and possibly
microorganisms lodged in there during the massage. Long fingernails might
be pretty, but they are not worth it.


Broken skin must always be avoided on clients. Therapists should always

keep cuts and scrapes covered while working.
Jewelry should not be worn while working
Massage therapists should avoid wearing jewelry on their finger, hands or
If you are unwilling to remove a ring (Frodo) be sure to wash your hands
with the ring on as well.
Liquid soap is hygienically easier to dispense than bar soap.
Keep clothing, uniforms, and aprons clean. Use care not to have a client
come in contact with uniform or apron that may have come in contact with
the previous client.
Clean the outside of oil and lubricant containers between clients to prevent
the spread of microorganisms.
If using a tub for cream or lotion, dispense what will be used during the
session into a paper cup using a spatula or spoon before the session. This
will prevent contaminating the inside of the container during a massage.
Use clean linens for each client. I know this one is kind of a no-brainier, but
the course wouldnt be complete if I didnt mention it.
Properly clean and disinfect all equipment between each session.
In addition to wearing gloves for anticipated or potential contact with
mucosal surfaces, blood, non-intact skin, and other potentially infected
material (OPIM), always wear gloves when coming in contact with urine,
feces, vomit, and sputum. These fluids do not transmit bloodborne
diseases such as HIV or hepatitis B but can transmit other types of
I hate canceling appointments as much as the next massage therapist
(probably more, I really hate doing it!), but when you are sick you HAVE to
do it. Microorganisms travel both ways, you have an obligation to keep
your clients and the public in general safe and free from disease.


So if you have a fever, frequent sneezing/coughing, a sore throat, diarrhea,

or a draining skin wound, just give yourself the day off.


Summary of Controlling Infectious Agents in the Massage Room

Much of the material covered in this course is new to massage therapists,
and that is because we have a bad habit of assuming that the only dangers
to our clients or us are the few communicable diseases covered in
massage school.
Our massage businesses do not exist in a sterile bubble; we are
surrounded by potentially harmful bacteria, fungi and viruses in our
environment and in and on the bodies of our clients.
Take the fungus Histoplasma capsulatum, for example. It causes the
disease Histoplasmosis. This is a fungus that is found near large amounts
of bird droppings, so most massage therapists would dismiss it as not
being a concern. But that is not the way the world works.
I have a client whose husband is a manager at a large poultry farm. Every
day when he comes home he stops on the porch and removes his coat and
boots before going into the house. Why? Because he is potentially exposed
to the fungus Histoplasma capsulatum every day at his job, and it is very
possible to bring the microscopic fungal spores home on your clothing.
For massage therapists that works in or owns a day spa the information
about food and waterborn diseases are extremely relevant, and of course
those working in a health care setting cannot afford to ignore the dangers
they are surrounded by.
Nobody likes reading about diseases, parasites and fungus, and I certainly
dont like writing about them, but if it helps keep you and your clients safe
than I consider it my privilege.


Certificate of Completion and Transcript

In order to receive your certificate of completion and an updated transcript
for this course you must complete and pass the quiz.
Once we have received your quiz we will generate your certificate and
transcript and both will be emailed to you. If you completed the last quiz
during our business hours (Monday-Friday 8:00 am-5:00 pm Pacific
Standard Time) it should be emailed to you within a few minutes.
If you complete the last quiz after business hours, or on a weekened it will
still be emailed to you as quickly as possible. We check the system every
hour until midnight most days so it should go out within an hour of you
taking it.
If you take the last quiz after midnight you will probably have to wait until
the next morning, we do sleep.
Please give us a full 24 hours before you call us if you have not received
your certificate and transcript. We pride ourselves on being very fast, but if
there is a condition beyond our control (the Internet Service Provider is
down, etc) it may take us longer than usual.
Also please be aware that many people wait until the last minute to do their
courses. For this reason, the last few days of the month (28th, 29th, 30th,
etc) are usually very, very busy times for us so our turn around time may be
a little slower-but it should still be within 24 hours.
If it has been more than 24 hours and you still have not received your
emailed certificate, by all means call us! The number is (209) 777-6305.
Lost Certificates and Transcripts
If you need another copy of your documents emailed to you we will gladly
do that for free at any time, just go to the contact page on our website and
ask for it.


Course Evaluation
Read the lecture notes. When you feel ready to take the quiz you can pay
to access the quiz by clicking the blue button on the website underneath
this embed on the website.
You can also download a copy of the quiz in advance to prepare.
If you are reading this on a mobile device (Kindle, Nook, cellphone or tablet) you may need to
download the FREE Scribd app. You can find a link to it on our webpage.

If you found a typo PLEASE LET US KNOW what page it is on and the
paragraph and we will fix it ASAP. This book has 45,000 words in the
course content alone. Some of those are going to be misspelled. Were not
perfect, but we strive to be- so help us out.
Help and Technical Support
We have worked hard to make this course as easy to use as possible, but it
does rely on technology and sometimes there are factors that are out of our
control (like your local internet provider, your computer, your browser
version, the device you are using etc).
If for some reason you are not able to access the quiz you can call us and
let us know, and we will problem solve it for you. We have office hours,
Monday-Friday 8:00 am-5:00 pm PST but you can call or email for help at
any time after hours, I monitor the system every hour until I go to sleep, so
call if you need to and I will do my best to help you. The number is (209)


All information regarding bacteria, fungus and viruses in this course are
from the Center for Disease Control (CDC.GOV) as are the rules for
Universal Precautions in a health care setting.
Herpes Simplex Demystified By Ruth Werner, LMP, NCTMB, Massage
Therapy Foundation President Massage Today November, 2004, Vol. 04,
Issue 11
Mosby's Pathology for Massage Therapists Susan G. & Craig Salvo