Advisory

Advisory / en Tue, 22 Oct 2024 23:27:53 -0500 Wed, 29 Jan 20 12:22:40 -0600 Novel Coronavirus EVS Advisory /novel-coronavirus-evs-advisory <h1 class="text-align-justify">COVID-19 Resources</h1> <hr /> <h3>ADVISORY: Novel Coronavirus EVS Advisory (formerly Novel Coronavirus or 2019-nCoV)&nbsp;</h3> <h4>Updated February 20, 2020</h4> Background On Jan. 21, 2020, officials announced the first COVID-19 United States (U.S.) case with 14 additional confirmed cases since then, and another 14 added within the last couple of days as passengers from a cruise ship were evacuated from Japan. COVID-19, formerly known as 2019-nCoV, emerged in 2019 and is spreading in a growing number of countries. On January 30, 2020, the World Health Organization (WHO) declared the outbreak of a COVID-19 a global health emergency. The Centers for Disease Control and Prevention (CDC) is closely monitoring, and collaborating with WHO on the outbreak, which was first identified in Wuhan, Hubei Province, China.&nbsp; &nbsp; <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200219-sitrep-30-covid-19.pdf">As of Feb. 19, 2020, WHO has reported</a> more than 74,000 confirmed cases globally and more than 2000 deaths, the majority of which are in China. Effective Jan. 27, 2020, the <a href="https://www.hhs.gov/about/news/2020/01/31/secretary-azar-declares-public-health-emergency-us-2019-novel-coronavirus.html">U.S. Department of Health and Human Services (HHS) declared a public health emergency</a> for the entire U.S. to aid the nation’s health care community in responding to COVID-19. The CDC is working closely with state health departments on disease surveillance, contact tracing, and providing interim guidance for clinicians on identifying and treating coronavirus infections. &nbsp;&nbsp; <a href="https://www.cdc.gov/coronavirus/index.html">Human coronaviruses</a> are common throughout the world. Human coronaviruses commonly cause mild to moderate illness. Two newer human coronaviruses, MERS-CoV and SARS-CoV, have been known to cause severe illness. COVID-19 is the newest coronavirus that is causing concern.&nbsp; What is <a href="https://www.cdc.gov/coronavirus/2019-nCoV/summary.html">2019 Novel Coronavirus (COVID-19)</a>? <ul> <li>In confirmed cases, clinical signs and symptoms range from mild symptoms to severe illness and death. Symptoms can include fever, cough and shortness of breath. CDC believes at this time that symptoms of COVID-19 may appear in as few as two days or as long as 14 days after exposure.&nbsp;</li> <li>The situation with COVID-19 is still unclear and evolving rapidly. Person-to-person transmission has been reported in health care workers who were caring for patients in China. In the U.S., cases in health care settings, like hospitals, could also occur.&nbsp;</li> </ul> What are the <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control.html">health care infection control precautions</a> for COVID-19 as it relates to environmental hygiene and hand hygiene? CDC currently recommends a cautious approach to patients under investigation for COVID-19:&nbsp; <ul> <li>Meticulous hand hygiene and environmental hygiene play a key role in these isolation precautions. &nbsp;</li> <li>Health care professionals should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment (PPE), including gloves. If hands are visibly soiled, use soap and water before returning to alcohol-based hand sanitizer.</li> <li>Health care facilities should ensure that hand hygiene supplies are readily available in every care location.</li> <li>Health care professionals must be cleared, trained and fit tested for respiratory protection device use. They must also be educated, trained and have practiced appropriate PPE use, including correct use to prevent contamination of skin, clothing or the environment, prior to caring for a patient with known or suspected cases of COVID-19.</li> <li>Health care professionals entering a patient’s room should use standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles or a face shield).&nbsp;</li> <li>The Environmental Protection Agency (EPA) and the CDC recognize environmental surfaces as a vector for transmission of coronaviruses. The CDC has developed a <a href="https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp-preparedness-checklist.pdf">hospital preparedness checklist</a> which recommends that hospitals assess the effectiveness of environmental cleaning and consider providing refresher training on environmental hygiene best practices as outlined in the <a href="https://www.cdc.gov/hai/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf">CDC Toolkit: Options for Evaluating Environmental Cleaning</a>.</li> <li>The CDC strengthened recommendations to state that facilities must ensure that health care professionals receive job or task-specific education and training on transmission of infectious agents, including refresher training. &nbsp;</li> <li>Routine cleaning and disinfection are appropriate for COVID-19 in health care settings, including those patient-care areas in which aerosol-generating procedures are performed.&nbsp;</li> </ul> What hand hygiene products are effective against COVID-19?&nbsp; Washing your hands often with soap and water is one of the best ways to avoid transmission of emerging pathogens. If soap and water aren’t available, use an alcohol-based hand sanitizer. The Food and Drug Administration regulates claims on both medicated, antimicrobial soaps and on alcohol-based hand sanitizers. Claims related to efficacy against viruses are not allowed on any medicated, antimicrobial soaps nor on any alcohol-based hand sanitizers in the U.S. What disinfectants are effective against COVID-19? The EPA recognizes environmental surfaces as a vector for transmission of coronaviruses. The EPA has developed the “<a href="https://www.epa.gov/pesticide-registration/emerging-viral-pathogen-guidance-antimicrobial-pesticides">Guidance to Registrants: Process for making claims against emerging viral pathogens not on EPA-registered disinfectant labels</a>”. This document provides general guidance to disinfectant manufacturers and addresses public concerns on a process that can be used to identify effective disinfectants for use against emerging viral pathogens. It permits manufacturers to make limited claims about their product’s efficacy against such pathogens. The criteria required to make such claims is outlined in the table below. The American Chemistry Council's Center for Biocide Chemistries has <a href="https://www.americanchemistry.com/Novel-Coronavirus-Fighting-Products-List.pdf">compiled a list</a> of products that have been pre-approved by the EPA for use against emerging enveloped viral pathogens and can be used during the COVID-19 outbreak. This product list is not exhaustive but can be used by business owners, health professionals, and the public to identify products suitable for use against COVID-19. &nbsp; <hr /> <a href="https://www.epa.gov/pesticide-registration/emerging-viral-pathogen-guidance-antimicrobial-pesticides">Guidance to Registrants: Process for making claims against emerging viral pathogens not on EPA-Registered disinfectant labels</a> An eligible product should meet both of the following criteria:&nbsp; <ol> <li class="text-align-justify">The product is an EPA-registered, hospital/health care or broad-spectrum disinfectant with directions for use on hard, porous or non-porous surfaces.*&nbsp;</li> <li class="text-align-justify">The currently accepted product label from an <a href="https://www.americanchemistry.com/Novel-Coronavirus-Fighting-Products-List.pdf">EPA registered product</a> should have disinfectant efficacy claims against at least one of the following viral pathogen groupings:&nbsp;</li> </ol> a) A product should be approved by EPA to inactivate at least one large or one small non-enveloped virus to be eligible for use against an enveloped emerging viral pathogen.&nbsp; b) A product should be approved by EPA to inactivate at least one small, nonenveloped virus to be eligible for use against a large, non-enveloped emerging viral pathogen.&nbsp; c) A product should be approved by EPA to inactivate at least two small, nonenveloped viruses with each from a different viral family to be eligible for use against a small, non-enveloped emerging viral pathogen. * Product Performance Test Guidelines: OCSPP 810.2200 Disinfectants for Use on Hard Surfaces – Efficacy Data Recommendations [EPA 712-C-07-074]. <hr /> What work is still ongoing? •&nbsp;&nbsp; &nbsp;The U.S. is temporarily prohibiting entry to Chinese foreign nationals who visited China in the 14 days prior to their arrival to the United States. Restrictions also apply to U.S. citizens who have been in China’s Hubei province, the epicenter of the COVID-19 outbreak, in the two weeks prior to their return to the U.S. Upon their return, those citizens will be placed under a mandatory quarantine of up to 14 days. U.S. citizens returning from the rest of mainland China in the 14 days prior will undergo health screenings at selected ports of entry and be under self-monitored quarantine for 14 days. •&nbsp;&nbsp; &nbsp;Identifying the origin of the virus, which could lead to recommended guidance related to transmission from animals. •&nbsp;&nbsp; &nbsp;Disease progression among ill people and how they may have acquired the infection, including the frequency and likelihood of person-to-person transmission. Current knowledge about COVID-19 transmission is based on what is known about similar coronaviruses. Based on this, it is believed that spread from person-to-person occurs most often among close contacts. Person-to-person spread is thought to occur mainly via respiratory droplets produced when an infected person coughs or sneezes, similar to how influenza and other respiratory pathogens spread. It is currently unclear if a person can get COVID-19 by touching a contaminated surface or object and then touching their own mouth, nose, or eyes. Typically, with most respiratory viruses, people are thought to be most contagious when they are most symptomatic (the sickest). For More Information <a href="https://www.cdc.gov/coronavirus/index.html">Centers for Disease Control and Prevention, Coronavirus Summary</a>&nbsp; <a href="https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/novel-coronavirus-covid-19">Food and Drug Administration Landing Page</a> <a href="https://www.who.int/health-topics/coronavirus">World Health Organization, Coronavirus</a>&nbsp; <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters">World Health Organization, Coronavirus disease (COVID-19) advice for the public: Myth busters&nbsp;</a> <a href="https://www.osha.gov/SLTC/covid-19/">Occupational Safety and Health Administration, 2019 Novel Coronavirus</a>&nbsp; &nbsp; Wed, 29 Jan 2020 12:22:40 -0600 Advisory Advisory: Hand and Environmental Hygiene: Preventing Pathogen Transmission /advisory-hand-and-environmental-hygiene-preventing-pathogen-transmission <h1>Hand and Environmental Hygiene: Preventing Pathogen Transmission</h1> <hr /> In health care settings such as hospitals and long-term care facilities, fundamental infection prevention measures such as hand hygiene and environmental hygiene are critical to prevent the transmission of pathogens (<a href="//C:/Users/ffp0/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/FG09VH0T/(https:/www.cdc.gov/infectioncontrol/guidelines/index.html">Centers for Disease Control and Prevention Reference</a>). Recent outbreaks of acute flaccid myelitis (AFM) and adenovirus among children have raised questions about ways to prevent transmission when those affected are admitted to a health care facility. This advisory offers information regarding AFM, viruses that are currently implicated, modes of transmission and measures of prevention. Acute Flaccid Myelitis: The CDC has confirmed 90 cases of AFM in 27 states so far this year, triple the number in 2017. AFM is a serious condition causing sudden muscle weakness in the arms or legs, sometimes following a respiratory illness. Other symptoms may include neck weakness or stiffness, drooping eyelids or a facial droop, and difficulty swallowing or slurred speech. Pathogen or Cause. The specific cause of AFM paralysis in the current outbreak has not been determined, but several viruses have been implicated, including enterovirus and rhinovirus (<a href="https://www.cdc.gov/acute-flaccid-myelitis/afm-surveillance.html">CDC Reference</a>). Similar outbreaks reported in 2014 and 2016 were caused by enterovirus, but other viruses—including poliovirus, non-polio enteroviruses, West Nile Virus (WNV), other viruses in the same family as WNV, and adenoviruses—have also caused AFM or other similar neurologic conditions.<a href="https://www.cdc.gov/acute-flaccid-myelitis/about-afm.html#causes"> CDC Reference</a> Mode of Transmission. The mode(s) of transmission remains unknown at this time because the cause has not yet been determined. However, many of these viruses are transmitted through direct contact with respiratory secretions, such as saliva, nasal mucus, sputum, stool, contaminated surfaces, or via an insect bite such as WNV (<a href="https://www.cdc.gov/non-polio-enterovirus/about/transmission.html">CDC Reference</a>). Prevention Measures: Hand Hygiene. While it is unknown if hand hygiene is effective in preventing AFM, performing hand hygiene with soap and water or alcohol-based hand rub is one of the best ways to avoid getting sick and spreading germs to others (<a href="https://www.cdc.gov/acute-flaccid-myelitis/about-afm.html#prevention">CDC Reference</a>). Maintaining clean hands should be a cornerstone to all infection prevention activities at work and at home.&nbsp; Environmental Hygiene. Environmental disinfection of surfaces in health care settings should be performed using a hospital-grade disinfectant with an Environmental Protection Agency label claim for any of the several non-enveloped viruses (e.g., norovirus, poliovirus, and rhinovirus). Disinfectant products should be used in accordance with the manufacturer’s instructions for the specific label claim and in a manner consistent with environmental infection control recommendations. Pest Management. Given the question of the role WNV infection may play in AFM, it is prudent for health care facilities to ensure an integrated pest management plan is in place that includes identification of local areas that may promote mosquito breeding. Removing standing water, clearing brush and vegetation, and monitoring of mosquito presence are examples of such a plan. Presenteeism. Health care personnel remain committed to the care of patients, employees, their own families, and others within their communities. Commitment to patients is often demonstrated by taking unscheduled days off, including sick days. If health care personnel report to work sick, this action may cause transmission of an illness from that health care worker to patients or others within their facility. To that end, health care personnel should stay home from work when ill. This is also an opportunity to verify immunization status with age-appropriate vaccines to ensure adherence with the CDC’s Advisory Committee on Immunization Practices immunization schedule. Further Questions: Please contact Patti Costello, 91��executive director, at ahe@aha.org and 312-422-3860. 91�� the Association for the Health Care Environment The Association for the Health Care Environment (AHE) is a Professional Membership Group of the 91��. 91��is the organization of choice for professionals responsible for establishing and maintaining health care environments that are free of surface contamination and that support safety, service, and efficient and effective operations. 91��is the go-to resources for best-in-class tools, products, education and training that raise the standard of the health care environmental services field and shape the future workforce for over 2,300 professionals committed to pathogen free, healing environments across all care settings. www.ahe.org Tue, 13 Nov 2018 09:55:10 -0600 Advisory Advisory: Immediate Need for Healthcare Facilities to Review Procedures /advisory-immediate-need-healthcare-facilities-review-procedures <h1>Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices</h1> <hr /> Centers for Disease Control and Prevention HEALTH UPDATE Please share this information with your management team, infection preventionist and the sterile processing department. As a follow-up to a health update entitled <a href="http://www.mmsend35.com/link.cfm?r=1413230953&amp;sid=82847440&amp;m=11194437&amp;u=AHA_2&amp;j=30173215&amp;s=http://emergency.cdc.gov/han/han00382.asp">HAN 00382</a> and distributed by Centers for Disease Control and Prevention (CDC) on September 11, 2015, the CDC and U.S. Food and Drug Administration (FDA) are providing this update to rescind the following recommendation: if health care facilities contract maintenance and repair of these devices to third-party vendors, health care facilities should verify that these vendors are approved or certified by the manufacturer to provide those services. We are making this change because there are currently no formal standardized programs or processes through which all manufacturers certify third-party vendors. We are also further clarifying that health care facilities which hire contractors to perform device reprocessing should verify that the contractor has an appropriate training program (i.e., consistent with what would be required in the health care facility) and that the training program includes the specific devices used by the health care facility. <a href="http://emergency.cdc.gov/han/han00383.asp">More&gt;&gt;</a> Fri, 11 Sep 2015 11:21:19 -0500 Advisory Advisory: 91��Member Communication Regarding Ongoing CRE Outbreak Investigation /advisory-ahe-member-communication-regarding-ongoing-cre-outbreak-investigation <h1>91��Member Communication Regarding Ongoing CRE and Shigella sonnei Outbreak Investigations</h1>We have two very important updates for you regarding two different outbreak investigations.**This information is current as of publication date of April 9,2015**<hr><h4>Communication Regarding Ongoing CRE Outbreak</h4>Background on CRE:<ul><li>CRE, stands for carbapenem-resistant Enterobacteriaceae, a family of germs that are difficult to treat because they have high levels of resistance to most antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria, which can become carbapenem-resistant. Types of CRE organisms are sometimes known as KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase). KPC and NDM are enzymes that break down carbapenem antibiotics and render them ineffective.</li><li>CRE is not a single microorganism, but rather several microorganisms such as the ones identified above that fall into a family of dangerous pathogens.</li><li>Carbapenem is an antibiotic used to treat severe infections.</li><li>Currently the US Centers for Disease Control and Prevention (CDC) is investigating an outbreak of Carbapenem-resistant Enterobacteriaceae (CRE) associated with inadequate cleaning and disinfection of duodenoscopes</li><li>Duodenoscopes are medical devices that are inserted down the patient’s throat and used in a variety of procedures, and in the case of this outbreak for a specific type of procedure called an endoscopic retrograde cholangiopancreatography (ERCP).</li><li>CRE organisms are resistant to multiple and in some cases all known antibiotic therapies, and therefore pose a risk to both the patient and the health care team including the environmental services technician.</li></ul>Environmental Impact of CRE in Health Care Settings:<ul><li>CRE can be spread via the hands of the patient and health care personnel</li><li>CRE organisms are transmitted in the same manner as many other Multi-Drug Resistant Microorganisms (MDRO’s), and core infection prevention and control measures such as hand hygiene, environmental cleaning and disinfection with an EPA registered, hospital-grade disinfectant for environmental surfaces, patient and staff cohorting and appropriate use of isolation precautions will mitigate risk for transmission of CRE organisms and most MDRO’s.</li><li>When not used correctly and according to manufacturer’s instructions, hospital-grade disinfectants may not have full efficacy against CRE organisms. It is important to completely follow all manufacturer’s instructions for use including dilution, contact time, etc. in accordance with the EPA Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA).</li></ul>Recommended Actions for Mitigation of CRE in Health Care Settings:Process duodenoscopes according to manufacturer's instructions for use with a minimum of a high-level disinfection process.For Environmental Services Professionals:<ul><li>Collaboration between infection preventionists, infectious disease/epidemiology staff, biomedical engineering and facilities teams to understand CRE organisms, how to manage the environmental impact</li><li>Diligent hand hygiene, proper glove and PPE use</li><li>Collaborate with the medical laboratory to monitor any environmental cultures collected from the patient care environment for potential identification of CRE organisms</li><li>Employ an EPA-registered, hospital-grade disinfectant for environmental cleaning and disinfection with clinically relevant claims for MDRO’s.</li><li>Infection prevention measures for MDRO’s such as CRE microorganisms should be treated in the same manner as other pathogens such as MRSA</li><li>Collaborate with your facility’s infection disease, epidemiology, and infection prevention departments and conduct a risk analysis to evaluate potential action items necessary to respond to and/or mitigate risk for transmission of CRE organisms.&nbsp;</li></ul>The CDC recommends several core measures for health care settings to follow to mitigate risk for transmission of CRE. These recommendations are the same as those for many other pathogens and include:<ul><li>Hand Hygiene for the Health Care Team and Patient: Hand hygiene is the single most important infection prevention intervention to reduce the risk for transmission of Health Care Associated Infections (HAI’s) including CRE.</li><li>Contact Precautions: Health care professionals and Technicians should receive adequate training on the proper use of contact precautions and personal protective equipment (PPE).&nbsp;</li><li>Provide Health Care Personnel Education: Health care personnel &nbsp;should be educated about the modes of transmission of CRE organisms and evidence-based mitigation recommendations. Use the CDC Vitals Signs Report (see webpage link below) to educate health care personnel on the risk of CRE and basic prevention strategies.</li><li>Cohort &nbsp;Health Care Staff with Suspected or Confirmed CRE Infections: This will reduce the risk for potential transmission between staff members and also other patients and environmental surfaces.&nbsp;</li><li>Create a System for CRE Screening: Proactive screening for potential CRE infections at the time of admission should be conducted in collaboration with Infection Prevention, the Emergency Department, and Medical Laboratory teams to facilitate rapid identification and isolation of potential cases, and timely communication to the health care team about necessary isolation precautions.</li></ul>What actions is 91��taking to keep environmental services professionals informed about developments associated with this outbreak:<ul><li>91��is closly monitoring the situation in collaboration with our partners at both the FDA and CDC.</li><li>91��has provided resource documents on its website that are available for environmental services professionals to download for reference at their facilities, and to facilitate conversations with internal partners such as the biomedical engineering and infection prevention departments</li><li>91��will provide input on environmental disinfection and the potential environment of care impact of CRE as requested by the FDA</li></ul>Additional Information and Resources<ul><li><a href="http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm">US Food and Drug Administration Resource Center on CRE:</a></li><li><a href="http://www.cdc.gov/hai/outbreaks/cdcstatement-LA-CRE.html">US Centers for Disease Control and Prevention Resource Center on CRE:</a></li><li><a href="http://www.cdc.gov/vitalsigns/hai/cre">US Centers for Disease Control and Prevention CRE Vital Signs Report</a></li></ul>References<ul><li>US Food and Drug Administration (FDA)</li><li>US Centers for Disease Control and Prevention (CDC)</li><li>The Joint Commission&nbsp;</li><li>US Centers for Medicare and Medicaid Services (CMS)</li></ul><hr><h4>Communication Regarding Ongoing Shigella sonnei Outbreak</h4>Background of Shigella sonnei and Current Outbreak:<ul><li>Currently the US Centers for Disease Control and Prevention (CDC) is investigating an outbreak of Shigella sonnei bacteria in 32 states and Puerto Rico with a total of 157 cases from May 2014-February 2015. Half of these cases were associated with international travel.</li><li>This microorganism causes an estimated 500,000 cases of diarrhea in the United States annually according to CDC estimates.</li><li>The bacteria is transmitted easily from person to person and through contaminated food and recreational water sources.</li><li>The bacteria can become resistant to commonly used antibiotic therapies for the infection.</li><li>The bacteria can cause severe and in some cases fatal infections in immunocompromised people.</li><li>Shigellosis is the infection caused by the bacteria, and the infection will typically resolve on its own within 5-7 days. &nbsp;</li></ul>Environmental Impact of Shigella sonnei in Health Care Settings:&nbsp;<ul><li>Shigella sonnei can be spread via the hands of the health care providers, environmental services professionals and technicians, or the patients themselves, as well as thru contaminated environmental surfaces.</li><li>When not used correctly and according to manufacturer’s instructions, hospital-grade disinfectants may not have full efficacy against Shigella sonnei organisms. It is important to completely follow all manufacturers’ instructions for use including dilution, contact time, etc. in accordance with the EPA Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA).</li></ul>Recommended Actions for Prevention of Shigella sonnei in Health Care Settings:&nbsp;<ul><li>Regularly practice hand hygiene as indicated using a soap and water or an alcohol-based hand rub according to facility protocol. When the hands are visibly soiled, the CDC recommends the use of soap and water for hand hygiene purposes.&nbsp;</li><li>For environmental cleaning and disinfection, use an EPA-registered, hospital-grade disinfectant with clinically relevant claims for organisms such as Shigella sonnei and other MDRO’s.&nbsp;</li><li>Promptly clean and disinfect any patient bathrooms contaminated with diarrhea using an EPA-registered, hospital-grade disinfectant as previously noted.</li><li>It is important for the Environmental services technician to wear appropriate PPE per facility protocol to safely dispose of soiled diapers as significant amounts of the microorganism can be found in the fecal material and lead to transmission.</li><li>The CDC recommends several core measures for health care settings to follow to mitigate risk for transmission of Shigella sonnei. These recommendations include:<ul><li>Hand Hygiene for the Health Care Team and Patient: Hand Hygiene is the single most important infection prevention intervention to reduce the risk for transmission of Health Care Associated Infections (HAI’s).</li><li>Contact Precautions: Health care personnel should receive proper training on the correct use of contact precautions and personal protective equipment (PPE).</li></ul></li></ul>Additional Information and Resources:<ul><li><a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6412a2.htm?s_cid=mm6412a2_x">US Centers for Disease Control and Prevention MMWR-Importation and Domestic Transmission of Shigella sonnei Resistant to Ciprofloxacin-United States, May 2014-February 2015</a></li><li><a href="http://www.cdc.gov/media/releases/2015/p0402-multidrug-resistant-shigellosis.html">US Centers for Disease Control and Prevention Resources for Shigella infection</a></li><li><a href="http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=75">US Centers for Disease Control and Prevention Drug Resistant Threat Report</a></li></ul>References:<ul><li>US Centers for Disease Control and Prevention (CDC)</li></ul> Thu, 09 Apr 2015 11:29:09 -0500 Advisory