1 figure omitted
On October 18, 2002, the nurse at an elementary school in Westbrook,
Maine, notified the Maine Bureau of Health (MBOH) of an increase in the number
of students with conjunctivitis. During September 23–October 18, a total
of 31 students in kindergarten and in first and second grades either were
reported by parents to the nurse as having conjunctivitis or had conjunctivitis
diagnosed by the nurse at school. Conjunctival swab cultures from five (38%)
of the 13 students who were tested initially grew Streptococcus
pneumoniae. This report documents additional cases in the community
and summarizes preliminary results of the investigation of this outbreak,
which indicated that the outbreak was caused by the same nontypeable strain
of pneumococcus that caused an outbreak of conjunctivitis among college students
in New Hampshire during January-March 2002.1 This
is the first time that this strain has been reported as the cause of a conjunctivitis
outbreak among schoolchildren. Health-care providers and public health officials
should be aware that nontypeable S. pneumoniae can
cause outbreaks of conjunctivitis in school-age children and college students;
outbreaks should be reported to state health departments and CDC.
School nurses and child care center managers were asked to report to
MBOH any children or staff member who had onset of conjunctivitis during September
20–December 6. Reported episodes of conjunctivitis were considered culture-confirmed
if S. pneumoniae was isolated from eye secretions.
A questionnaire to identify children and family members with conjunctivitis
was sent home with all children attending the index elementary school. Among
361 students, 101 (28%) (median age: 6 years; range: 5-8 years) had at least
one episode of conjunctivitis, and 11 (55%) of 20 students tested had an episode
of culture-confirmed pneumococcal conjunctivitis. The attack rate was highest
among first-grade students (51 [38%] of 136), followed by morning kindergarten
(20 [29%] of 70), second-grade (28 [26%] of 108), and afternoon kindergarten
students (two [4%] of 47). Among school staff, three (13%) of 23 classroom
teachers and three (15%) of 20 other staff members had conjunctivitis during
the study period. Of 709 family members who did not attend the school, 37
(5%) (median age: 4 years; range: <1-42 years) reported conjunctivitis;
28 (76%) of the 37 were household contacts of students who were ill previously.
Of 221 household contacts of students with conjunctivitis, 28 (13%) reported
having conjunctivitis with onset after the student's illness.
A second questionnaire was distributed to all students in selected classrooms.
Among 65 students with conjunctivitis who responded, the symptoms reported
most commonly were red eyes (55 [85%]); itchy, painful, or burning eyes (45
[69%]); crusty eyes in the morning (42 [65%]); grey or yellow discharge from
eyes (42 [65%]); and swelling of the eyelids (30 [46%]). Redness in both eyes
was reported for 35 (64%) of the 55 students who had red eyes. The median
duration of symptoms was 3 days (range: 1-14 days). Of the 65 students, 53
(82%) missed school during their illness, with a median absence from school
of 2 days (range: 1-7 days). Symptoms of systemic pneumococcal infections
were not identified in any of the students or contacts.
School nurses and child care staff in the community reported an additional
77 students who had conjunctivitis with onset during September 20–December
2, including 53 (4%) of 1,313 students, ranging from kindergarten through
grade 12 at four schools, and 24 (9%) of 271 children attending three community
child care centers. Among the 53 students with conjunctivitis at other schools,
10 (19%) had a family member at the index school, and seven (29%) of 24 ill
child care attendees had a sibling at the index school.
Of 20 conjunctival specimens collected from students at the index school
and 15 collected from students at other schools, 11 (55%) and five (33%),
respectively, grew S. pneumoniae. All seven isolates
that were tested for antimicrobial susceptibility were resistant to erythromycin
but susceptible to penicillin and third-generation cephalosporins. Nine isolates
were sent to CDC for serotyping; eight could not be typed by using CDC antisera,
and one isolate from a conjunctival swab collected from an index school student
was serotype 38. Nontypeable isolates, but not the serotype 38 isolate, produced
identical electrophoretic patterns by pulsed field gel electrophoresis to
pneumococcal isolates from an outbreak of conjunctivitis on a college campus
in New Hampshire during January-March 2002.1 Viral
cell cultures of specimens from 30 students were negative for adenovirus (i.e.,
no cytopathic effect in cell culture was identified after 10 days' incubation).
To prevent transmission at the school, students and teachers were encouraged
to wash hands frequently with soap and water and to clean and limit the sharing
of objects in the classroom. In addition, symptomatic children were excluded
from school. Implementing prevention measures in this setting was difficult.
Teachers reported that increased hand washing at school was disruptive to
classes, and excluding symptomatic students from school placed a burden on
parents. One student from the index school was reported as having conjunctivitis
during Thanksgiving recess (November 25-29), and no children were reported
with conjunctivitis after the recess. Five students at other schools were
reported to have had conjunctivitis after the recess. Surveillance for additional
cases of conjunctivitis at area schools is continuing.
C Leighton, Westbrook School District, Westbrook; D Piper, MS, NorDx
Laboratories, Scarborough; J Gunderman-King, V Rea, MPH, K Gensheimer, MD,
J Randolph, R Danforth, L Webber, E Pritchard, MS, G Beckett, MPH, Maine Bur
of Health. V Shinde, MPH, R Facklam, PhD, C Whitney, MD, Div of Bacterial
and Mycotic Diseases, National Center for Infectious Diseases; N Hayes, MD,
Div of Applied Public Health Training, Epidemiology Program Office; B Flannery,
PhD, EIS Officer, CDC.
This report describes an outbreak in an elementary school of conjunctivitis
attributed to a nontypeable strain of S. pneumoniae.
Nontypeable pneumococci have been implicated previously in outbreaks of conjunctivitis
among university students1,2 and
military recruits2,3 and
in sporadic cases of conjunctivitis.4 This
is the first report of an outbreak of conjunctivitis caused by nontypeable
pneumococci involving young children, with documented transmission to persons
in the community outside the institutional setting. Although children were
not seriously ill, the outbreak resulted in lost school days for ill children
and in economic losses and inconvenience for parents of ill children for health-care
provider visits and missed work.
The effectiveness of prevention measures for interrupting the transmission
of conjunctivitis is not known. Person-to-person transmission of the outbreak
strain is believed to occur through contact with eye secretions or respiratory
droplets. In schools, ensuring regular hand washing might improve hygiene
among students but might not be sufficient to stop transmission of a highly
contagious organism, especially one transmitted through respiratory droplets.
Use of alcohol-based hand gels has been shown to prevent the transfer of pathogens
in health-care settings,5 but their use
in schools has not yet been evaluated. Although the effectiveness of excluding
students with symptoms of conjunctivitis from school to limit a recognized
outbreak is not known, such exclusion is recommended during the acute phase
of symptoms.6 In the absence of clinical
signs of systemic infection, the American Academy of Pediatrics recommends
readmission of school children with conjunctivitis after therapy is initiated.7 Although antibiotic eye drops are prescribed commonly
as empiric therapy for conjunctivitis, the effect of topical antibiotic therapy
on transmission of pneumococcal conjunctivitis is unknown. The results from
one trial indicated that persons treated with bacitracin/polymyxin opthalmic
ointment were more likely to have eradication of eye pathogens at 3-5 days
than persons treated with a placebo.8
Health-care providers who see a substantial increase in visits for conjunctivitis
should consider obtaining bacterial and viral cultures of eye secretions to
determine the etiology. CDC is interested in evaluating the effectiveness
of control measures and the usefulness of topical antibiotic therapy in future
outbreaks caused by S. pneumoniae. Outbreaks of S. pneumoniae conjunctivitis should be reported to state
health departments, which may contact CDC, telephone 404-639-2215, for additional
This report is based on data contributed by J Flaherty, P Sanfino, L
Allen, E Greaterex, D Bruns, Westbrook School District; A Hebert, T Levesque,
D Porter, Westbrook; local health-care providers, Cumberland County, Maine.
J Elliott, PhD, D Jackson, MS, R Besser, MD, Div of Bacterial and Mycotic
Diseases; W Trick, MD, S Fridkin, MD, Div of Healthcare Quality Promotion,
National Center for Infectious Diseases, CDC.
Pneumococcal Conjunctivitis at an Elementary School—Maine, September 20–December 6, 2002. JAMA. 2003;289(9):1097–1098. doi:10.1001/jama.289.9.1097