{"id":10352,"date":"2025-03-01T14:07:44","date_gmt":"2025-03-01T19:07:44","guid":{"rendered":"https:\/\/www-test.dhss.delaware.gov\/dph\/dhan376\/"},"modified":"2025-03-02T00:53:54","modified_gmt":"2025-03-02T05:53:54","slug":"dhan376","status":"publish","type":"page","link":"https:\/\/www-test.dhss.delaware.gov\/dph\/php\/alerts\/dhan376\/","title":{"rendered":"php\/alerts\/dhan376 ~  Division of Public Health  &#8211; Delaware Health and Social Services &#8211; State of Delaware"},"content":{"rendered":"<div data-swiftype-index=\"true\">\n\n\n\n  <br>\n\n\n\n  <div class=\"container\" id=\"main_header\"> \n\n    <!-- BEGIN readspeaker div -->\n\n    <div class=\"rs_skip rsbtn rs_preserve\" id=\"readspeaker_button1\">\n\n      <a accesskey=\"L\" class=\"rsbtn_play\" href=\"https:\/\/app-na.readspeaker.com\/cgi-bin\/rsent?customerid=7262&#038;lang=en_us&#038;readid=main_content&#038;url=https:\/\/dhss.delaware.gov\/dph\/php\/alerts\/dhan376.html\" title=\"Listen to this page using ReadSpeaker\">\n\n        <span class=\"rsbtn_left rsimg rspart\"><span class=\"rsbtn_text\"><span>Listen<\/span><\/span><\/span>\n\n        <span class=\"rsbtn_right rsimg rsplay rspart\"><\/span>\n\n      <\/a>\n\n    <\/div>\n\n    <!-- END readspeaker div -->\n\n\n\n    \n\n    <header class=\"pull-left\">\n\n      <h1>Delaware Health Alert Network #<!--[type=EDIT name=\"DHAN Number\"]-->376 <!--[END]--> <\/h1>\n\n      <h2> <!--[type=EDIT name=\"DHAN Date\"]-->April 19, 2017 4:10 pm <!--[END]--> <\/h2>\n\n    <\/header>\n\n  <\/div><br>\n\n \n\n  <div class=\"container\">\n\n    <div class=\"row\">\n\n      <div class=\"col-md-3\" id=\"leftCol\">\n\n        <div class=\"panel-group\" id=\"accordion\">\n\n          <div class=\"panel sectionmenu_panel\">\n\n            <div class=\"panel-heading\">\n\n              <p class=\"panel-title\"><a class=\"agency_nav\" data-parent=\"#accordion\" data-toggle=\"collapse\" href=\"#collapseOne\"><strong><i class=\"fa fa-align-justify fa-fw\"><\/i> Public Health Menu<\/strong><\/a><\/p>\n\n            <\/div>\n\n\n\n            <div class=\"panel-collapse collapse in\" id=\"collapseOne\">\n\n              <div class=\"panel-body\" id=\"clf_nav\">\n\n                  <ul class=\"nav nav-stacked nav-pills-clf\" id=\"agency_sidebar\">\n    <li><a href=\"\/dph\/\"><h2>Home <i class=\"fa fa-home fa-fw\"><\/i><\/h2><\/a><\/li>\n    <li class=\"toplevel\"><a data-parent=\"#agency_sidebar\" data-toggle=\"collapse\" href=\"#HomeMenu\"><h2>About <i class=\"fa fa-caret-right fa-fw\"><\/i><\/h2><\/a>\n      <ul class=\"panel-collapse collapse\" id=\"HomeMenu\">\n        <li><a href=\"\/dph\/about.html\">About DPH<\/a><\/li>\n        <li><a href=\"\/dph\/sections.html\">Sections &#038; 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Current \n\n\n\n\n\ninterpretive criteria provided by the Clinical and Laboratory Standards Institute (CLSI) categorize these strains \n\n\n\n\n\nas susceptible to ciprofloxacin, which is a fluoroquinolone antibiotic and a key agent in the management of <em>Shigella<\/em>\n\n\n\n\n\ninfections.<\/p>\n\n\n\n\n\n<p>However, recent data from the Centers for Disease Control and Prevention (CDC) and state and local public\n\n\n\n\n\nhealth partners show that these strains often have a quinolone resistance gene that may lead to clinically significant \n\n\n\n\n\nreduced susceptibility to fluoroquinolone antibiotics. Clinicians treating patients with multidrug-resistant shigellosis \n\n\n\n\n\nfor whom antibiotic treatment is indicated should avoid prescribing fluoroquinolones if the ciprofloxacin MIC is 0.12 \u03bcg\/mL \n\n\n\n\n\nor higher even if the laboratory report identifies the isolate as susceptible, and should work closely with their clinical \n\n\n\n\n\nmicrobiology laboratory and infectious disease specialists to determine appropriate antimicrobial therapy.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>Shigellosis is a nationally notifiable condition, and all cases of shigellosis should be reported to local health departments.<\/p>\n\n\n\n\n\n<br>\n\n\n\n\n\n<h3>Background<\/h3>\n\n\n\n\n\n<p>CDC has identified an increase in <em>Shigella<\/em> isolates in the United States with minimum inhibitory concentration (MIC) \n\n\n\n\n\nvalues of 0.12\u20131 \u03bcg\/mL for the fluoroquinolone antibiotic ciprofloxacin. Preliminary data suggest that all <em>Shigella<\/em> \n\n\n\n\n\nisolates with ciprofloxacin MICs in this range for which results are available harbor at least one quinolone resistance gene known \n\n\n\n\n\nto confer reduced susceptibility in enteric bacteria.\u00a0 Shigella isolates without a quinolone resistance gene typically have a \n\n\n\n\n\nciprofloxacin MIC of \u22640.015 \u03bcg\/mL. Current CLSI criteria<em> <\/em>categorize<em> Shigella<\/em> isolates with a ciprofloxacin \n\n\n\n\n\nMIC of \u22641 \u03bcg\/mL as susceptible to ciprofloxacin (1).<\/p>\n\n\n\n\n\n<p>CDC does not yet know whether fluoroquinolone treatment of a <em>Shigella<\/em> infection with a ciprofloxacin MIC of 0.12\u20131 \u03bcg\/mL \n\n\n\n\n\nis associated with a worse clinical outcome for the patient or if such treatment increases the risk of transmission to other individuals.\n\n\n\n\n\nIn <em>Salmonella<\/em> isolates, ciprofloxacin MICs of 0.12\u20131 \u03bcg\/mL have been associated with reduced susceptibility, prolonged \n\n\n\n\n\nclinical illness, and treatment failures and are now categorized by CLSI as intermediate or resistant to ciprofloxacin in <em>Salmonella<\/em> \n\n\n\n\n\nspecies.<\/p>\n\n\n\n\n\n<p>Fluoroquinolone resistance is of particular concern given that data from the National Antimicrobial Resistance Monitoring System indicate \n\n\n\n\n\nthat many <em>Shigella<\/em> isolates with a quinolone resistance gene also are resistant to many other commonly used treatment agents, such \n\n\n\n\n\nas azithromycin, trimethoprim-sulfamethoxazole, amoxicillin-clavulanic acid, and ampicillin. This susceptibility profile may encourage \n\n\n\n\n\nclinicians to prescribe fluoroquinolone antibiotics to patients who require treatment.<\/p>\n\n\n\n\n\n<p>Rising fluoroquinolone MIC values among <em>Shigella<\/em> isolates may be related to the emergence of plasmid-mediated quinolone resistance \n\n\n\n\n\n(PMQR) genes in <em>Shigella<\/em> species in the United States. <em>Shigella<\/em> strains harboring PMQR genes were identified earlier this \n\n\n\n\n\nyear following whole genome sequencing of isolates from a multistate outbreak of multidrug-resistant <em>Shigella<\/em> <em>flexneri <\/em>infections\n\n\n\n\n\npredominantly affecting adult men, many of whom identify as men who have sex with men, according to epidemiologic data collected by CDC\u2019s \n\n\n\n\n\n<em>Shigella<\/em> program as part of outbreak response. PMQR genes have also been identified in sporadic cases of <em>Shigella<\/em> <em>sonnei<\/em>. \n\n\n\n\n\nPlasmid-mediated resistance genes are of particular concern because of their ability to spread between bacteria and their ability to promote \n\n\n\n\n\nchromosomal mutations conferring quinolone resistance, potentially resulting in rapid spread of fluoroquinolone resistance within or between \n\n\n\n\n\npopulations of bacteria. The prevalence of PMQR genes among all U.S. <em>Shigella<\/em> isolates is currently unknown.<\/p>\n\n\n\n\n\n<p>Any patient with a <em>Shigella<\/em> infection could carry a strain harboring a quinolone resistance gene with a ciprofloxacin MIC of 0.12\u20131 \u03bcg\/mL.<\/p>\n\n\n\n\n\n<p>The emergence of <em>Shigella<\/em> species with ciprofloxacin MICs of 0.12\u20131 \u03bcg\/mL and their association with quinolone resistance genes raises the following concerns:<\/p>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Fluoroquinolone treatment of <em>Shigella<\/em> infection with a strain harboring a quinolone\n\n\n\n\n\nresistance gene may be less effective and may increase the risk of a more severe clinical course \n\n\n\n\n\nfor the individual (e.g., increased duration or severity of symptoms, increased need for hospitalization \n\n\n\n\n\nor admission to an intensive care unit, increased length of hospitalization, or increased risk of death).<\/li>\n\n\n\n\n\n<li>Fluoroquinolone treatment of <em>Shigella<\/em> infection with a strain harboring a quinolone\n\n\n\n\n\nresistance gene also may increase the risk of secondary cases, if the treatment prolongs the duration \n\n\n\n\n\nor increases the quantity of organisms shed in the stool, given the very low infectious dose required \n\n\n\n\n\nfor transmission of <em>Shigella<\/em>bacteria<em>.<\/em><\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<p>\u00a0<\/p>\n\n\n\n\n\n<h3>RECOMMENDATIONS FOR CLINICIANS<\/h3>\n\n\n\n\n\n<h3>Diagnosis<\/h3>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li><b>Order stool culture for patients suspected of having a <em>Shigella<\/em> infection to\n\n\n\n\n\nobtain isolates for antimicrobial susceptibility testing.<\/b>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Culture-independent diagnostic testing does not provide an isolate and therefore cannot be used to\n\n\n\n\n\nassess susceptibility.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<\/li><li><b>Order antimicrobial susceptibility testing when ordering stool culture for <em>Shigella.<\/em><\/b>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>When antimicrobial susceptibility testing is performed by broth microdilution,\n\n\n\n\n\nrequest ciprofloxacin testing that includes dilutions of 0.12 \u03bcg\/mL or lower.<\/li>\n\n\n\n\n\n<li>Even when treatment is not indicated, identifying patients with drug-resistant\n\n\n\n\n\ninfections (i.e., ordering susceptibility testing) will help to inform public\n\n\n\n\n\nhealth management, such as when to return to work, school, and group settings.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<h3>Management<\/h3>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li><b>Do not routinely prescribe antibiotic therapy for <em>Shigella<\/em> infection.\n\n\n\n\n\nInstead, reserve antibiotic therapy<\/b> <b>for patients for whom it\n\n\n\n\n\nis clinically indicated or when public health officials advise treatment in an\n\n\n\n\n\noutbreak setting.<\/b>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Shigellosis is generally a self-limited infection lasting 5-7 days.<\/li>\n\n\n\n\n\n<li>Unnecessary treatment with antibiotics promotes resistance.<\/li>\n\n\n\n\n\n<li>Treatment can shorten the duration of some illnesses, though typically only by 1-2 days.<\/li>\n\n\n\n\n\n<li>Empiric treatment with an antibiotic to which the organism is resistant may worsen\n\n\n\n\n\nsymptoms or prolong the duration of shedding of the organism.<\/li>\n\n\n\n\n\n<li>If empiric treatment is clinically indicated before antimicrobial susceptibility\n\n\n\n\n\nresults are available, refer to recent hospital, clinical laboratory, or public\n\n\n\n\n\nhealth agency antibiograms.<\/li>\n\n\n\n\n\n<li>Antibiotic treatment is recommended for patients who are immunocompromised or who develop\n\n\n\n\n\nsevere illness (e.g., patients requiring hospitalization, those with invasive\n\n\n\n\n\ndisease, or those with complications).<\/li>\n\n\n\n\n\n<li>Local or state health officials may advise antibiotic treatment to mitigate or\n\n\n\n\n\nprevent outbreaks in certain settings (e.g., childcare, food handling).<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<\/li><li><b>When antibiotic treatment is indicated, tailor antibiotic choice to antimicrobial\n\n\n\n\n\nsusceptibility results as soon as possible with special attention given to the\n\n\n\n\n\nMIC for fluoroquinolone antibiotics.<\/b>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Avoid prescribing fluoroquinolones if the ciprofloxacin MIC is 0.12 \u03bcg\/mL or higher\n\n\n\n\n\neven if the laboratory report identifies the isolate as susceptible.<\/li>\n\n\n\n\n\n<li>Know the potential risks of fluoroquinolone treatment of <em>Shigella<\/em> infections\n\n\n\n\n\nwith ciprofloxacin MICs in this range, including possible treatment failure and\n\n\n\n\n\nincreased risk of secondary transmission.<\/li>\n\n\n\n\n\n<li>The interpretation of MIC values varies for the different fluoroquinolone\n\n\n\n\n\nantibiotics; if susceptibility results are reported for a fluoroquinolone other\n\n\n\n\n\nthan ciprofloxacin, contact the microbiology laboratory for assistance with\n\n\n\n\n\ninterpretation.<\/li>\n\n\n\n\n\n<li>If MIC values are not reported to the clinician with susceptibility results, consider\n\n\n\n\n\ncontacting the microbiology laboratory where the susceptibility testing was\n\n\n\n\n\nperformed to determine the ciprofloxacin MIC value before treating a patient\n\n\n\n\n\nwith a fluoroquinolone agent. Some susceptibility testing methods do not\n\n\n\n\n\nproduce a MIC value; the impact of a quinolone resistance gene on test results\n\n\n\n\n\nby other methods (e.g., disk diffusion) is not yet known.<\/li>\n\n\n\n\n\n<li>Consult an infectious disease specialist for cases where the <em>Shigella<\/em> isolate is\n\n\n\n\n\nresistant to multiple antibiotics and appropriate treatment is unclear.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<\/li><li><b>Obtain follow-up stool cultures<\/b> <b>in shigellosis patients who have\n\n\n\n\n\ncontinued or worsening symptoms despite antibiotic therapy.<\/b><\/li><li><b>Consult your local or state health department for guidance on when patients may return\n\n\n\n\n\nto childcare, school, or work.<\/b><\/li><li><b>Counsel patients with active diarrhea on how they can prevent spreading the infection\n\n\n\n\n\nto others, regardless of whether antibiotic treatment is prescribed.<\/b>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Wash hands with soap and water for at least 20 seconds, especially after using the\n\n\n\n\n\ntoilet, after handling a soiled diaper, and before eating.<\/li>\n\n\n\n\n\n<li>Avoid preparing food for others, when possible.<\/li>\n\n\n\n\n\n<li>Children with active diarrhea should not attend childcare, school, or group activities\n\n\n\n\n\nwhile they are ill.<\/li>\n\n\n\n\n\n<li>Wait to have sex (vaginal, anal, and oral) for two weeks after you no longer have\n\n\n\n\n\ndiarrhea. Use safe sex practices for several weeks after resuming sex, because <em>Shigella<\/em>\n\n\n\n\n\nbacteria may still be in stool for several weeks.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<\/li>\n\n\n\n\n\n\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<h3>Reporting<\/h3>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Shigellosis is a nationally notifiable condition. Report all cases of shigellosis to your\n\n\n\n\n\nlocal health department.<\/li>\n\n\n\n\n\n<li>Clinicians who identify a patient with shigellosis and a ciprofloxacin MIC of 0.12\u20131 \u03bcg\/mL\n\n\n\n\n\nshould include this finding along with other information regarding the case to\n\n\n\n\n\ntheir local health department to facilitate further testing of the isolate. <\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<h3>RECOMMENDATIONS FOR LABORATORIES<\/h3>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Know that a <em>Shigella <\/em>isolate with a ciprofloxacin MIC of 0.12\u20131 \u03bcg\/mL may be\n\n\n\n\n\nassociated with the presence of a quinolone resistance gene.<\/li>\n\n\n\n\n\n<li>Test <em>Shigella<\/em> isolates using susceptibility panels that include 0.12, 0.25,\n\n\n\n\n\nand 0.5 \u03bcg\/mL dilutions for ciprofloxacin, when using a commercially available\n\n\n\n\n\nautomated system (such as BD Phoenix, MicroScan, Vitek 2, or similar system)\n\n\n\n\n\nfor susceptibility testing.<\/li>\n\n\n\n\n\n<li>Include MIC values for fluoroquinolone agents in the susceptibility testing report for <em>Shigella\n\n\n\n\n\n<\/em>isolates.<\/li>\n\n\n\n\n\n<li>Report all findings of strains of <em>Shigella<\/em> with a ciprofloxacin MIC of 0.12\u20131\n\n\n\n\n\n\u03bcg\/mL to the state public health laboratory, and submit isolates to it to facilitate further \n\n\n\n\n\nphenotypic and genetic testing.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<h3>RECOMMENDATIONS FOR PUBLIC HEALTH OFFICIALS<\/h3>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>Know that a <em>Shigella<\/em> isolate with a ciprofloxacin MIC of 0.12\u20131 \u03bcg\/mL may be\n\n\n\n\n\nassociated with the presence of a quinolone resistance gene.<\/li>\n\n\n\n\n\n<li>Contact CDC at <a href=\"mailto:EntericBacteria@cdc.gov\">EntericBacteria@cdc.gov<\/a> if\n\n\n\n\n\nyou receive reports of patients with <em>Shigella <\/em>infection and possible\n\n\n\n\n\nfluoroquinolone treatment failure.<b>\u00a0<\/b><\/li>\n\n\n\n\n\n<li>Submit <em>Shigella<\/em> isolates with a ciprofloxacin MIC of 0.12\u20131 \u03bcg\/mL to the state\n\n\n\n\n\npublic health laboratory for whole genome sequencing, if possible. If the state laboratory does not \n\n\n\n\n\nhave capacity to sequence the isolate, please notify CDC at <a href=\"mailto:EntericBacteria@cdc.gov\">\n\n\n\n\n\nEntericBacteria@cdc.gov<\/a>.<b>\u00a0<\/b><\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<h3>What CDC is Doing<\/h3>\n\n\n\n\n\n<p>CDC is working with state and local public health departments and clinical partners to investigate if\n\n\n\n\n\nclinical outcomes are worse for patients infected with <em>Shigella<\/em> strains harboring a quinolone \n\n\n\n\n\nresistance gene who receive ciprofloxacin treatment.<\/p>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>CDC has notified representatives at the U.S. Food and Drug Administration and CLSI,\n\n\n\n\n\nwho will review CDC\u2019s findings to determine whether a change to the susceptible\n\n\n\n\n\nrange of MIC values for ciprofloxacin in <em>Shigella<\/em> is warranted.<\/li>\n\n\n\n\n\n<li>CDC will continue to monitor trends in antimicrobial susceptibility of <em>Shigella <\/em>isolates\n\n\n\n\n\nand will perform genetic testing on select strains with ciprofloxacin MICs of\n\n\n\n\n\n0.12\u20131 \u03bcg\/mL or higher to confirm the presence and type of quinolone resistance\n\n\n\n\n\ngenes.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<h3>For More Information<\/h3>\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>For general information about <em>Shigella<\/em> or shigellosis, visit <a href=\"https:\/\/www.cdc.gov\/shigella\/\">\n\n\n\n\n\nhttps:\/\/www.cdc.gov\/shigella\/<\/a>.<\/li>\n\n\n\n\n\n<li>For technical information about <em>Shigella <\/em>or shigellosis, including information about national surveillance \n\n\n\n\n\nand other educational resources for medical and public health professionals, visit <a href=\"https:\/\/www.cdc.gov\/shigella\/resources.html\">\n\n\n\n\n\nhttps:\/\/www.cdc.gov\/shigella\/resources.html<\/a>. <\/li>\n\n\n\n\n\n<li>For information about prevention and control of shigellosis, including recommendations for men who have sex with men, \n\n\n\n\n\nvisit <a href=\"https:\/\/www.cdc.gov\/shigella\/prevention-control.html\">https:\/\/www.cdc.gov\/shigella\/prevention-control.html<\/a>. <\/li>\n\n\n\n\n\n<li>For more information about the serious public health threat posed by antimicrobial resistant <em>Shigella<\/em>, \n\n\n\n\n\nrefer to \u201cAntibiotic Resistance Threats in the United States, 2013\u201d\n\n\n\n\n\navailable at <a href=\"https:\/\/www.cdc.gov\/drugresistance\/threat-report-2013\/pdf\/ar-threats-2013-508.pdf\">\n\n\n\n\n\nhttps:\/\/www.cdc.gov\/drugresistance\/threat-report-2013\/pdf\/ar-threats-2013-508.pdf<\/a>. <\/li>\n\n\n\n\n\n<li>For more information about ciprofloxacin and azithromycin-nonsusceptible shigellosis in the United States, refer to previous Health Alert Network\n\n\n\n\n\nAdvisory 379 at <a href=\"https:\/\/emergency.cdc.gov\/han\/han00379.asp\">https:\/\/emergency.cdc.gov\/han\/han00379.asp<\/a>.<\/li>\n\n\n\n\n\n<li>For specific inquiries related to this Health Advisory, email <a href=\"mailto:EntericBacteria@cdc.gov\">EntericBacteria@cdc.gov<\/a>.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n\n\n\n\n\n\n<h3>Reference<\/h3>\n\n\n\n\n\n<p>1.\u00a0\u00a0\u00a0\u00a0Clinical and Laboratory Standards Institute. <em>Performance Standards for Antimicrobial\n\n\n\n\n\nSusceptibility Testing. <\/em>27<sup>th<\/sup> ed. CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.<\/p>\n\n\n\n\n\n<br>\n\n\n\n\n\n<p class=\"center\"><em>The Centers for Disease Control and Prevention (CDC) protects people&#8217;s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.<\/em><\/p>\n\n\n\n\n\n<br>\n\n\n\n\n\n<p>To contact the Delaware Division of Public Health with\n\n\n\n\n\nquestions or to report cases, please call 302-744-4990 during regular business hours or 1-888-295-5156 (24\/7) or email reportdisease@delaware.gov<\/p>\n\n\n\n\n\n<p>************************************<\/p>\n\n\n\n\n\n<p>You are receiving this email because you are a registered member of the Delaware Health Alert Network.\n\n\n\n\n\nIf you are not a member and would like to subscribe, please register at <a href=\"https:\/\/healthalertde.org\">https:\/\/healthalertde.org<\/a><\/p>\n\n\n\n\n\n<p>\n\n\n\n\n\n<br>\n\n\n\n\n\n<br><\/p>\n\n\n\n\n\n<p class=\"smalltext\"><a href=\"http:\/\/www.adobe.com\/products\/acrobat\/readstep2.html\"><img loading=\"lazy\" decoding=\"async\" alt=\"Download Adobe Acrobat Reader\" height=\"21\" src=\"\/wp-content\/uploads\/dhss\/img\/getacro60.gif\" width=\"60\"><\/a> Please note: Some of the files available on this page are in Adobe PDF format which requires Adobe Acrobat Reader.  A free copy of Adobe Acrobat Reader can be downloaded directly from <a href=\"http:\/\/www.adobe.com\/products\/acrobat\/readstep2.html\">Adobe <\/a>. If you are using an assistive technology unable to read Adobe PDF, please either view the corresponding text only version (if available) or visit Adobe&#8217;s <a href=\"http:\/\/access.adobe.com\">Accessibility Tools page<\/a>.<\/p>\n<!--[END]-->\n\n  \n\n        <div class=\"panel panel-danger\">\n\n          <div class=\"panel-heading\">    \n\n      <h2>Categories of Health Alert messages:<\/h2>\n\n       <\/div>\n\n       <div class=\"panel-body\">\n\n      <ul>\n\n        <li><strong>Health Alert:<\/strong> Conveys the highest level of importance; warrants immediate action or attention.<\/li>\n\n        <li><strong>Health Advisory:<\/strong> Provides important information for a specific incident or situation; may not require immediate action.<\/li>\n\n        <li><strong>Health Update:<\/strong> Provides updated information regarding an incident or situation; unlikely to require immediate action.<\/li>\n\n            <\/ul>\n\n         <div><strong>NOTE: This page is for informational purposes only and dated material (e.g. temporary websites) may not be available.<\/strong><\/div>\n\n          <\/div> \n\n        <\/div><br>  \n\n\n\n      <\/div>\n\n    <\/div>\n\n  <\/div><!-- \/container -->\n\n  <\/div>","protected":false},"excerpt":{"rendered":"<p>Listen Delaware Health Alert Network #376 April 19, 2017 4:10 pm Public Health Menu Home About About DPH Sections &#038; Programs Office Locations Contact Info Calendar Services A-Z Services Air &#038; Water Quality Birth, Death, &#038; Marriage Records Clinics Health Data &#038; Statistics Emergency Preparedness Health &#038; Wellness Healthy Homes Healthy Workplaces Laboratory Restaurant Inspections [&hellip;]<\/p>\n","protected":false},"author":8,"featured_media":0,"parent":9294,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-10352","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10352","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/comments?post=10352"}],"version-history":[{"count":1,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10352\/revisions"}],"predecessor-version":[{"id":11528,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10352\/revisions\/11528"}],"up":[{"embeddable":true,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/9294"}],"wp:attachment":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/media?parent=10352"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}