Skip to content

The San Diego County Health and Human Services Agency is advising gay and bisexual men, homeless individuals, and people with compromised immune systems that they could be at an increased risk for the intestinal disease shigellosis.

According to the Centers for Disease Control and Prevention, young children and travelers to developing countries are also at risk for shigellosis.

Last year, the County saw the highest number of cases in 20 years, including a disproportional increase in the gay and bisexual community and among the homeless population.

The number of cases typically increases in the late summer and fall and there have already been 98 cases of shigellosis reported in the county so far in 2018. In 2017, a total of 334 cases were reported, representing a 37 percent increase compared to 2016 when there were 232 cases.

A larger proportion of 2017 cases (63 percent) were among men, many of whom self-identified as gay or bisexual, compared to previous years. Additionally, the percentage of homelessness cases also experienced an increase from 7 percent of total cases to 12 percent from 2016 to 2017.

So far in 2018, 25 percent of the reported cases involve gay or bisexual men and 7 percent involve homeless people.

The Shigella infection or Shigellosis causes a diarrheal illness lasting for 5 to 7 days. Shigella is very contagious. Infection can occur through person-to-person contact, eating food contaminated by someone who has shigellosis, or swallowing water from pools and ponds or drinking water that was contaminated with the bacteria.

“Shigellosis is a very contagious disease, but there are many steps people can take to reduce their chances of getting it,” said Wilma Wooten, M.D., M.P.H., County public health officer. “The infection can be prevented by conducting frequent and thorough hand washing; disinfecting any areas that may be contaminated, such as restrooms or diaper changing areas; avoiding swallowing water from untreated pools and ponds, and not preparing or serving food to others when having diarrhea.”

HHSA is recommending that those at risk, including gay and bisexual men and homeless people:

  • Practice good hand hygiene at all times washing your hands with soap and water, especially before eating or preparing food for others or changing diapers
  • Avoid swallowing water from ponds, lakes or untreated swimming pools
  • Be aware of your HIV status
  • Be aware of the local increase in shigellosis, which can be a severe illness, particularly in those with reduced immunity.
  • Seek care for diarrheal illness, especially with fever or bloody diarrhea, and be sure that their healthcare provider tests to see if symptoms are caused by Shigella.
  • Discuss antibiotic treatment for shigellosis with their doctors to shorten the duration of illness and reduce the risk of infecting others.
  • Abstain from sex, for several days after you stop having diarrhea, to prevent spreading the illness to others.

In early September 2017, an over-30-year-old male who resides in northern Taiwan traveled to Bali, Indonesia with 18 tour group members. On the following day the case returned, he sought medical attention after developing symptoms, including fever, diarrhea and nausea, and was diagnosed with shigellosis. After a further investigation conducted by the health authority, a female group member who is over 20 years old had also experienced symptoms, including vomiting and diarrhea and was also diagnosed with shigellosis. According to the cases, they consumed mostly cooked food while in Bali. However, they had seafood at a restaurant with poor hygiene. Hence, it was determined that these two cases constitute a cluster. As of now, none of the contacts residing in the same household with the 2 cases has developed suspected symptoms. Moreover, the local health authority has collected specimens from the other 13 tour group members who experienced symptoms for laboratory testing.

Ventura County Public Health was notified on Thursday, June 22nd, of an unusually high number of Shigella cases in the county. Shigellosis is an infectious disease caused by a group of bacteria called Shigella (shih-GEHL-uh), which most often causes diarrhea and fever. It is highly contagious.

Through a series of interviews with those affected, it has been determined that a number of the cases reported to have eaten at the Souplantation in Camarillo. Of the diners interviewed, there are a total of eight individuals with laboratory evidence of Shigella infection.

Ventura County Public Health’s laboratory sent the culture confirmed samples to the State laboratory for typing.

“We’re tracking these cases closely,” said Public Health Officer Dr. Robert Levin, “and are working closely with Ventura County Environmental Health, which has completed two inspections of the restaurant in the past two days.” Dr. Levin credits Souplantation corporate office for making the decision to close the restaurant, starting Thursday through the weekend, to make certain that all steps have been taken to prevent further cases.

The Souplantation Chief Operating Officer has arrived at the Camarillo location and has been joined by a vice- president and the quality assurance manager. All employees are being put through a sanitary training refresher course, the restaurant is being thoroughly cleaned and all food on the premises is being thrown out.

“Souplantation’s actions have been exemplary. This is the kind of swift and decisive action, which leads to a collaboration with Public Health that results in a rapid resolution of the problem,” added Dr. Levin.
It is not currently clear what the source of the infection is. No one food item has been indicated. All employees are being tested and will need to be cleared before returning to work. There are approximately 40 employees at the restaurant.

Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. Shigellosis usually resolves in 5 to 7 days. Some people who are infected may have no symptoms at all, but may still pass the Shigella bacteria to others. The spread of Shigella can be stopped by frequent and careful hand-washing. Antibiotic treatment is known to decrease the length of illness and to end shedding of the organism within a day or two of starting therapy. People most at risk of serious illness are those with underlying immunosuppressive conditions. Those who may have been exposed who are feeling ill should consult their physician.

shigella-spp-300pxShigella sonnei has spread via international travelers to 32 states and Puerto Rico, US health officials say.

Between May 2014 and February 2015, a drug-resistant strain of shigella has infected 243 people across the US, according to the US Centers for Disease Control and Prevention (CDC). The CDC’s findings were first published in the agency’s Morbidity and Mortality Weekly Report.

The CDC found that 90 percent of cases of the shigellosis infection analyzed in Massachusetts, California, and Pennsylvania were resistant to ciprofloxacin (Cipro), the top shigellosis antibiotic in the US.

The agency found that the potent, Cipro-resistant strain was “repeatedly introduced as ill travelers returned and was then infecting other people in a series of outbreaks around the country.” Many shigella strains in the US were already considered too advanced for other drugs, including ampicillin and trimethoprim/sulfamethoxazole.

The CDC added that shigellosis spreads quickly among nursing homes, “childcare facilities, homeless people and gay and bisexual men, as occurred in these outbreaks.”

“These outbreaks show a troubling trend in Shigella infections in the United States,” said CDC Director Tom Frieden in a public statement.

The CDC was first alerted to the new breed of shigella – which causes diarrhea in those infected – in December. Further investigation found that the strain was resistant to Cipro. The agency found that international travelers were largely responsible for the strain’s introduction, while other cases, including around 100 infections among the homeless population in San Francisco, were contracted by other means.

Wife of active duty U.S. Navy diver is one of 275 people who became ill with Shigellosis

Attorneys Bill Marler and Drew Falkenstein of Marler Clark, the nation’s only law firm dedicated to representing victims of foodborne illness, have filed a lawsuit in the Circuit Court of Benton County, Arkansas on behalf of married couple Delida Groom and James Groom. Mrs. Groom was visiting the area when she was sickened with Shigellosis after consuming food from Salsarita’s Restaurant located in the Wal-Mart Home Office Café in Bentonville, Arkansas. Case number is V 14-1029-1 in the Circuit Court of Benton County, Arkansas, Civil Division

In late June 2014, the Arkansas State Health Department announced that an outbreak of Shigella had occurred at the Wal-Mart Home Office in Bentonville, Arkansas. At or about the time of the announcement, Salsarita’s restaurant had temporarily closed its doors. The health department has stated that 275 cases of Shigellosis have occurred in nine states as part of this outbreak. After investigation, health officials indicated that Salsarita’s restaurant was the source of the outbreak. The outbreak stemmed from a few simple and preventable violations; some of which included employees not washing their hands and employees touching ready-to-eat food without wearing gloves.

In June 2014, Mrs. Groom traveled to Bentonville, Arkansas to visit her parents. While in Arkansas, on Friday, June 13, 2014, she attended a luncheon that included multiple foods from the Wal-Mart Home Office Café, including chips, salsa, and other items produced at the Salsarita’s restaurant located in the Café. The following evening, June 14, 2014, Mrs. Groom began to feel slightly fevered, light-headed, and nauseated. Over the next several days, her symptoms spiraled and included bloody diarrhea and severe gastrointestinal issues. She was later given treatment for metabolic disturbances given her immense gastrointestinal losses and hospitalized in the ICU for several days receiving critical care. Mrs. Groom developed long-term complications and continues to suffer from the effects of the Shigellosis illness.

“After thousands of cases, I am still amazed at how these outbreaks start,” said Marler. “Washing your hands and putting on gloves is not rocket science and it only takes a minute or two.”

Shigellosis is an infectious disease caused by a group of bacteria called Shigella. Most who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. The diarrhea is often bloody. Shigellosis usually resolves in 5 to 7 days. Persons with Shigellosis in the United States rarely require hospitalization. A severe infection with high fever may be associated with seizures in children less than 2 years old.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Shigella outbreaks. The Shigella lawyers of Marler Clark have represented thousands of victims of Shigella and other foodborne illness outbreaks and have recovered over $600 million for clients.  Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our Shigella lawyers have litigated Shigella cases stemming from outbreaks traced to a variety of sources, such as tomatoes, airplane and restaurant food.

Researchers have launched an early-stage human clinical trial of two related candidate vaccines to prevent infection with Shigella, bacteria that are a significant cause of diarrheal illness, particularly among children. The Phase I clinical trial, funded by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, will evaluate the vaccines for safety and their ability to induce immune responses among 90 healthy adults ages 18 to 45 years. The trial is being conducted at the Cincinnati Children’s Hospital Medical Center, one of the eight NIAID-funded Vaccine and Treatment Evaluation Units in the United States.

Shigella infection, called shigellosis, is an intestinal disease spread via contact with infected feces, by consumption of contaminated food or water or by contact with a contaminated surface. Symptoms include diarrhea, abdominal pain, fever, nausea and vomiting. In healthy adults, the infection generally clears on its own in five to seven days, but if left untreated, can lead to hospitalization or death, especially among young children and adults with weakened immune systems.

According to the World Health Organization, shigellosis causes roughly 90 million cases of severe disease each year and 108,000 deaths, most of which occur in the developing world and affect children under 5 years of age. In the United States, 14,000 shigellosis cases are reported annually, with most cases occurring among children ages 1 to 4 years.

Antibiotics are the standard treatment for patients with shigellosis, but drug-resistant strains of the bacterium are becoming more common.

“It seems that Shigella bacteria know our immune system better than we do,” said William Alexander, Ph.D., a program officer in NIAID’s Enteric and Hepatic Diseases Branch, Division of Microbiology and Infectious Diseases. “They’ve become very good at evading the human immune response and causing significant illness, so developing vaccines and better treatments is critical.”

Led by principal investigator Robert W. Frenck, Jr., M.D., director of clinical medicine at Cincinnati Children’s, the new clinical trial will evaluate two related candidate vaccines, known as WRSs2 and WRSs3, which have been found to be safe and effective when tested in guinea pigs and nonhuman primates. Both target Shigella sonnei, one of the bacteria’s four subtypes and the cause of most shigellosis outbreaks in developed and newly industrialized countries. Though neither candidate vaccine has been tested in humans, a precursor to both, known as WRSs1, was found to be safe and generated an immune response in small human trials in the United States and Israel. This early work was supported by NIAID, the U.S. Department of Defense and the Walter Reed Army Institute of Research. All three versions of the vaccine were developed by researchers at the Walter Reed institute.

WRSs2 and WRSs3 are live, attenuated vaccines, which means that the bacteria they contain are weakened such that they do not cause illness but still can induce an immune response. The weakened versions of S. sonnei used in WRSs2 and WRSs3 cannot spread between human cells, limiting their ability to cause disease. They are designed to improve upon WRSs1 by reducing the mild diarrhea associated with that vaccine in some patients. In addition, WRSs3 is designed to reduce the fever that accompanied some WRSs1 vaccinations.

After undergoing informed consent, study participants will be split into 10 groups of eight participants each, with each group receiving an increasing dose of WRSs2 or WRSs3. The remaining 10 participants will receive placebo. All doses will be given orally and will be preceded with a sodium bicarbonate (baking soda) suspension to neutralize stomach acid, which prevents the bacteria in the vaccine from being killed too quickly. Immediately after vaccination, participants will be admitted to inpatient care. Eight days later, or sooner if serious shigellosis symptoms occur, participants will begin a course of antibiotics until they pass two consecutive stools that test negative for S. sonnei. During the hospital stay, which can last up to 13 days, participants will be closely monitored and receive physical exams several times daily. Once discharged, participants are expected to collect and supply a stool sample at follow-up physical exams on study days 14, 28 and 56.

Additional information about the clinical trial is available at under the identifier NCT01336699.

NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID website at

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit

Scientists have found new genetic information that shows how harmful bacteria cause the acute diarrheal disease shigellosis, which kills more than a million people worldwide each year.

The research, which could lead to the development of future treatments, was published today in the journal PLoS ONE. The study was led by Ohio University scientist Erin Murphy and doctoral student William Broach, with contributions from University of Nevada, Las Vegas and University of Texas at Austin researchers.

When the disease-causing bacterium Shigella invades a human host, environmental conditions there, such as changes in temperature or pH, stimulate a genetic expression pathway within the bacterium that allows it to survive and cause disease. Central to this genetic pathway are two proteins, VirF and VirB. VirF functions to increase production of VirB which, in turn, promotes the production of factors that increases the bacterium’s virulence, or ability to cause illness in its host.

“It’s like a domino effect,” says Murphy, assistant professor of bacteriology in the Ohio University Heritage College of Osteopathic Medicine.

Murphy and Broach’s new study, however, suggests that production of VirB can be controlled independently of VirF. It also shows that the VirF-independent regulation is mediated by a specific small RNA, a special type of molecule whose job is to control the production of particular targets. This is the first study to demonstrate that transcription of virB is regulated by any factor other than VirF, Murphy explained.

The research not only reveals the intricate level of gene expression the bacteria employ to survive in the human body, but potentially could lead to new treatments. Currently, antibiotics are prescribed to patients with the disease.

“These findings are feeding into the basic understanding of this gene expression so that future researchers can work to disrupt it,” Broach said. “The more we know about it, the more targets we have to disrupt it and to possibly develop targeted antibiotic treatments.”

For those living in developing countries, where access to clean drinking water can be scarce, an improved medical treatment for shigellosis could mean the difference between life and death.

“In the United States, if we get severe diarrhea we can go to the store and get Gatorade,” Murphy says. “But if you’re already starving to begin with because you don’t have access to good food and clean water, then you get shigellosis on top of that—and you don’t have good water to rehydrate yourself—that’s when the deaths happen.”

The disease, which is transmitted person to person or through contaminated food or water sources, has an infectious dose of just 10 organisms, meaning as few as 10 organisms can cause disease in a healthy person. This infectious dose is exceedingly low compared to other bacteria that require tens of thousands of organisms to cause disease.

While it is often thought to be a Third-World problem, shigellosis causes a reported 14,000 cases in the United States each year. The Centers for Disease Control suggests that the actual number may be 20 times higher, as mild cases often aren’t reported or diagnosed.

“In the United States it’s probably even more underreported than in developing countries because of access to healthy, clean drinking water,” Murphy says. “If you’re a healthy individual and you’ve got access to clean drinking water, chances are you’re going to get severe diarrhea, but you’re not going to die.”

The research was funded by the National Institutes of Health, the Ohio University Research Committee and the Ohio University Heritage College of Osteopathic Medicine.

The collaborators on the PLoS ONE paper are University of Nevada, Las Vegas scientists Nicholas Egan and Helen Wing and University of Texas at Austin researcher Shelley Payne.

Bad Bug Book – Foodborne Pathogenic Microorganisms and Natural Toxins – Second Edition

shigella1.jpeg.jpg1. Organism

Shigella are Gram-negative, non-motile, non- sporeforming, rod-shaped bacteria. Shigella species, which include Shigella sonnei, S. boydii, S. flexneri, and

S. dysenteriae, are highly infectious agents. Some strains produce enterotoxins and Shiga toxin. The latter is very similar to the toxins produced by E. coli O157:H7.

Humans are the only host of Shigella, but it has also been isolated from higher primates. The organism is frequently found in water polluted with human feces.

In terms of survival, shigellae are very sensitive to environmental conditions and die rapidly. They are heat sensitive and do not survive pasteurization and cooking temperatures. In terms of growth, shigellae are not particularly fastidious in their requirements and, in most cases, the organisms are routinely cultivated in the laboratory, on artificial media. However, as noted in subsequent sections, the relative difficulty of cultivating this organism is dependent, in part, on the amount of time within which stool or food samples are collected and processed.

Shigella species are tolerant to low pH and are
able to transit the harsh environment of the
stomach. These pathogens are able to survive
and, in some cases, grow in foods with low pH,
such as some fruits and vegetables. They are
able to survive on produce commodities
packaged under vacuum or modified
atmosphere and can also survive in water, with a slight decrease in numbers.

2. Disease

The illness caused by Shigella is shigellosis (also called bacillary dysentery), in which diarrhea may range from watery stool to severe, life-threatening dysentery. All Shigella spp. can cause acute, bloody diarrhea. Shigella spp. can spread rapidly through a population, particularly in crowded and unsanitary conditions.

S. dysenteriae type 1 causes the most severe disease and is the only serotype that produces the Shiga toxin, which may be partially responsible for cases in which hemolytic uremic syndrome (HUS) develops. S. sonnei produces the mildest form of shigellosis; usually watery diarrhea.

S. flexneri and S. boydii infections can be either mild or severe.
In developed countries, S. sonnei is the Shigella species most often isolated, whereas S. flexneri predominates in developing countries.

• Mortality: In otherwise healthy people, the disease usually is self-limiting, although some strains are associated with fatality rates as high as 10-15%. (See Illness / complications section, below.)

• Infective dose: As few as 10 to 200 cells can cause disease, depending on the age and condition of the host.

• Onset: Eight to 50 hours.

• Illness / complications: In otherwise healthy people, the disease usually consists of self- limiting diarrhea (often bloody), fever, and stomach cramps. Severe cases, which tend to occur primarily in immunocompromised or elderly people and young children, are associated with mucosal ulceration, rectal bleeding, and potentially drastic dehydration. Potential sequelae of shigellosis include reactive arthritis and hemolytic uremic syndrome.

• Symptoms: May include abdominal pain; cramps; diarrhea; fever; vomiting; blood, pus, or mucus in stools; tenesmus (straining during bowel movements).

• Duration: Uncomplicated cases usually resolve in 5 to 7 days. Most of the time, the illness is self-limiting. In some circumstances, antibiotics are given; usually trimethoprim-sulfamethoxazole, ceftriaxone, or ciprofloxacin.

• Route of entry: The fecal-oral route is the primary means of human-to-human transmission of Shigella. With regard to foods, contamination is often due to an infected food handler with poor personal hygiene.

• Pathway: The disease is caused when Shigella cells attach to, and penetrate, colonic epithelial cells of the intestinal mucosa. After invasion, they multiply intracellularly and spread to contiguous epithelial cells, resulting in tissue destruction. As noted, some strains produce enterotoxin and Shiga toxin similar to those produced by E. coli O157:H7.

3. Frequency

A recent Centers for Disease Control and Prevention (CDC) report on foodborne illnesses acquired annually in the United States revealed that about 15,000 laboratory-confirmed isolates are reported each year, with estimates of actual occurrence ranging from 24,511 to 374,789 cases (average of 131,243). About 31% of these are estimated to be foodborne. Estimates of foodborne illness episodes (mean) caused by 31 pathogens placed Shigella as the sixth most frequent cause (after norovirus, Salmonella species, Clostridium perfringens, Campylobacter, and Staphylococcus aureus, in that order).

Episodes of shigellosis appear to follow seasonal variations. In developed countries, the highest incidences generally occur during the warmer months of the year.

4. Sources

Most cases of shigellosis are caused by ingestion of fecally contaminated food or water. In the case of food, the major factor for contamination often is poor personal hygiene among food handlers. From infected carriers, this pathogen can spread by several routes, including food, fingers, feces, flies, and fomites.

Shigella is commonly transmitted by foods consumed raw; for example, lettuce, or as non- processed ingredients, such as those in a five-layer bean dip. Salads (potato, tuna, shrimp, macaroni, and chicken), milk and dairy products, and poultry also are among the foods that have been associated with shigellosis.

5. Diagnosis

Diagnosis is by serological or molecular identification of cultures isolated from stool. Shigella may be more difficult to cultivate if stool samples are not processed within a few hours.

6. Target Populations

All people are susceptible to shigellosis, to some degree, but children 1 to 4 years old, the elderly, and the immunocompromised are most at risk. Shigellosis is very common among people with AIDS and AIDS-related complex.

7. Food Analysis

Shigellae remain a challenge to isolate from foods. A molecular-based method (PCR) that targets a multi-copy virulence gene has been developed and implemented by FDA. Improvements in the bacterial isolation method continue and should be available in the near future.

The window for collecting and processing Shigella from foods, for cultivation, may be days (rather than hours, as is the case with stool), depending on the food matrix and storage conditions; e.g., temperature. Shigella species can be outgrown by the resident bacterial populations found in foods, which may reflect the usual low numbers of the organism present in foods and, in some foods, a very large number of non-Shigella bacteria. Another factor that reduces the chance of isolating Shigella from foods may be the physiological state of the pathogen at the time of analysis. Environmental conditions could affect its ability to either grow or survive in any food matrix.

8. Examples of Outbreaks

The CDC’s Morbidity and Mortality Weekly Reports provide information about Shigella outbreaks.

9. Other Resources

• Loci index for genome Shigella spp.

• GenBank Taxonomy database

• More information about Shigella and shigellosis can be found on the CDC website.

Continue Reading Bad Bug Book – Foodborne Pathogenic Microorganisms and Natural Toxins – Second Edition – Shigella species

According to press reports, the Escambia County Health Department has reminded the public that people can reduce the spread of gastrointestinal illnesses by practicing simple hygiene. “We like to be proactive about this, and we’ve started seeing cases of Shigella, or shigellosis, which is a bacterial illness that can produce nausea, vomiting, diarrhea and sometimes fever in young people,” said Dr. John Lanza, director of the Escambia County Health Department.

Lanza said the county usually sees three to 30 cases of Shigella a month, and this month there have been about 12 to 15 cases.

“We’re seeing this in child-care centers, and that’s where our most-vulnerable population center is — our children — and we just want child-care providers and parents to know what to look for,” Lanza said.

He said simple hygiene practices can keep gastrointestinal illnesses like Shigella at bay.

“The No. 1 way of transmitting these kind of diseases is by not washing your hands with soap and water,” Lanza said. He said it’s important to thoroughly wash hands after using the bathroom, changing diapers and handling food.

Lanza had another health message: If you or your child has a gastrointestinal illness, stay home instead of spreading the germs.

“If you as an adult, or your child, are sick, for at least 48 hours, stay at home. Don’t go to work,” he said.

After a person has recovered from shigellosis, Shigella bacteria remain active for a week or two. It is even possible for a person to be infected with Shigella without exhibiting symptoms.  Individuals who exhibit no symptoms are known as asymptomatic, but can pass the illness on to others. 

Small children acquire Shigella at the highest rate.

Prevent the spread of Shigella from an infected person to others with frequent and careful handwashing with soap.

If a child in diapers has shigellosis, everyone who changes the child’s diapers should be sure the diapers are disposed of properly in a closed-lid garbage can, and should wash his or her hands and the child’s hands carefully with soap and warm water immediately after changing the diapers. After use, the diaper changing area should be wiped down with a disinfectant such as diluted household bleach or bactericidal wipes.  When possible, young children with a Shigella infection who are still in diapers should not be in contact with uninfected children.

Basic food safety precautions and disinfection of drinking water prevents outbreaks of shigellosis from food and water. However, people with shigellosis should not prepare food or drinks for others until they have been shown to no longer be carrying Shigella bacteria, or if they have had no diarrhea for at least 2 days. 

At swimming beaches, having enough bathrooms and handwashing stations with soap near the swimming area helps keep the water from becoming contaminated.  Daycare centers should not provide water play areas.

When traveling in developing countries, only treated or boiled water, and eat only cooked hot foods or fruits you peel yourself.