title: A Cluster of Group A Streptococcal Infections in a Skilled Nursing Facility-the Potential Role of Healthcare Worker Presenteeism.
abstract: To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case-patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control.
  
  
  
  Cross-sectional analysis and retrospective review.
  
  
  
  Skilled nursing facility (SNF).
  
  
  
  SNF residents and staff.
  
  
  
  The initial cluster was identified through laboratory notification and screening of SNF residents with wounds. Laboratory and SNF administrative records were subsequently reviewed to identify additional residents with GAS, oropharyngeal and wound (if present) swabs were collected from SNF staff and residents to examine GAS colonization, staff were surveyed to assess infection control practices and risk factors for GAS colonization, epidemiologic links between case-patients and persons colonized with GAS were determined, and facility infection control practices were assessed.
  
  
  
  No additional invasive case-patients were identified. Oropharyngeal swabs obtained from all 167 SNF residents were negative; one wound swab grew GAS that was the same as the outbreak strain (T2, emm 2.0). The outbreak strain was not identified in any of the 162 staff members. One of six staff members diagnosed with GAS pharyngitis worked while ill and had direct contact with invasive case-patients within a few weeks before their onset of symptoms. Additional minor breaches in infection control were noted.
  
  
  
  Sick healthcare workers may have introduced GAS into the SNF, with propagation by infection control lapses. "Presenteeism," or working while ill, may introduce and transmit GAS to vulnerable in SNF populations. Identification of an invasive GAS case-patient should trigger a prompt response by facilities to prevent further transmission and workplace culture, and policies should be in place to discourage presenteeism in healthcare settings.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.|Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Miwako
authors.initials: M
authors.lastname: Kobayashi
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.|Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Meghan M
authors.initials: MM
authors.lastname: Lyman
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.|Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Louise K
authors.initials: LK
authors.lastname: Francois Watkins
authors.affiliation: Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Karrie-Ann
authors.initials: KA
authors.lastname: Toews
authors.affiliation: South Carolina Department of Health and Environmental Control, Columbia, South Carolina.
authors.forename: Leon
authors.initials: L
authors.lastname: Bullard
authors.affiliation: South Carolina Department of Health and Environmental Control, Columbia, South Carolina.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Radcliffe
authors.affiliation: Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Bernard
authors.initials: B
authors.lastname: Beall
authors.affiliation: Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Gayle
authors.initials: G
authors.lastname: Langley
authors.affiliation: Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Chris Van
authors.initials: CV
authors.lastname: Beneden
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Nimalie D
authors.initials: ND
authors.lastname: Stone
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003428:Cross Infection / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D017053:Infection Control; D017757:Infectious Disease Transmission, Professional-to-Patient; D008297:Male; D000069597:Presenteeism; D015995:Prevalence; D012189:Retrospective Studies; D012866:Skilled Nursing Facilities; D013022:South Carolina / Q000453:epidemiology; D013290:Streptococcal Infections / Q000453:epidemiology* / Q000635:transmission*; D000078329:Workforce
keywords:  “presenteeism”; Group A Streptococcus; infection control; outbreak; skilled nursing facility