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BACKGROUND: Exclusion of ill high-risk individuals with enteric disease (i.e., food handlers, childcare workers and attendees, and healthcare workers) is a common control measure used in public health. Public health recommendations vary and do not address the emergence of culture-independent testing. In Tennessee, regulations have been based on the 1976 Food Code, which was recently updated. Tennessee created updated guidance for exclusion, restriction, and reinstatement of high-risk groups with enteric disease with the intent of providing standardization statewide.
METHODS: We reviewed existing resources including The Red Book, 28th edition and the Control of Communicable Diseases Manual, 19thedition. Expert opinion was solicited from the Enteric Diseases Epidemiology Branch at the Centers for Disease Control and Prevention (CDC), as well as from participating states within the CDC FoodCORE Program about their current exclusion guidelines and incorporation of culture-independent testing. Additionally, the 2009 Food Code (effective 7/14/2015 in Tennessee) was reviewed extensively in order to maintain consistency with upcoming regulation.
RESULTS: Guidance was constructed for high-risk categories of food handlers, childcare workers, childcare attendees, and healthcare workers. Guidance was given for each of the primary foodborne pathogens specified by the Food and Drug Administration: norovirus, Hepatitis A virus, Salmonella Typhi, Shigella spp., and Shiga toxin-producing Escherichia coli (STEC). Additional recommendations were given concerning non-Typhi Salmonella infections and other enteric pathogens commonly reported. Guidance on culture-independent testing was incorporated. For high-risk groups with diagnoses of STEC, ill individuals are recommended to remain excluded from work or the childcare environment until two negative stool cultures are produced, collected 48 hours after the discontinuation of antimicrobial therapy and 24 hours apart. For Shigella, only one negative stool culture is needed for reinstatement. Members of high-risk groups with diagnoses of Hepatitis A are recommended to be excluded until at least one week after onset of illness or jaundice. Variations exist in recommendations across different high-risk groups for Salmonella Typhi infections. Members of a high-risk group diagnosed with norovirus, non-Typhi Salmonella, and other enteric infections are recommended to remain excluded until 48 hours after symptoms resolve.
CONCLUSIONS: Published exclusion recommendations vary and emerging culture-independent testing methods present challenges in determining infectious risks. The finalized Tennessee Exclusion Guidance was distributed statewide to promote standardization between health department jurisdictions and is offered as a reference to other states to aid the construction of their exclusion recommendations.