Prevention and Control of Youth Camp–Associated Acute Gastroenteritis Outbreaks

Abstract

Background.

Approximately 14 million children attend more than 14 000 US camps every year. Shared accommodations and activities can facilitate acute gastroenteritis (AGE) outbreaks.

Methods.

We analyzed data from the National Outbreak Reporting System on US youth camp–associated AGE outbreaks that occurred between 2009 and 2016. We also conducted a systematic literature search of youth camp–associated AGE outbreaks that have occurred around the world and a gray literature search for existing recommendations on outbreak prevention and control at camps worldwide.

Results.

Thirty-nine US jurisdictions reported a total of 229 youth camp–associated AGE outbreaks to the National Outbreak Reporting System. Of the 226 outbreaks included in our analyses, 120 (53%) were reported to have resulted from person-to-person transmission, 42 (19%) from an unknown transmission mode, 38 (17%) from foodborne transmission, 19 (8%) from waterborne transmission, 5 (2%) from animal contact, and 2 (<1%) from environmental contamination. Among 170 (75%) outbreaks with a single suspected or confirmed etiology, norovirus (107 [63%] outbreaks), Salmonella spp (16 [9%]), and Shiga-toxin producing Escherichia coli (12 [7%]) were implicated most frequently. We identified 43 additional youth camp–associated AGE outbreaks in the literature that occurred in various countries between 1938 and 2014. Control measures identified through the literature search included camp closure, separation of ill campers, environmental disinfection, and education on food preparation and hand hygiene.

Conclusions.

Youth camp–associated AGE outbreaks are caused by numerous pathogens every year. These outbreaks are facilitated by factors that include improper food preparation, inadequate cleaning and disinfection, shared accommodations, and contact with animals. Health education focused on proper hygiene and preventing disease transmission could help control or prevent these outbreaks.

Each year >14 million children and adults attend more than 14 000 overnight or day camps in the United States [1]. Camps can encourage healthy lifestyles and social skills, but factors such as shared activities and accommodations [2], rural settings with limited access to municipal drinking water and sewer systems [3], and minimal health education of campers and staff [3] can facilitate outbreaks of communicable disease, including those of acute gastroenteritis (AGE). In a 2005 study of camper illnesses, gastrointestinal illness was most frequently reported, indicated by over 43% of campers who reported any illness [4]. Although AGE is generally mild and self-limiting, some cases can be severe and result in a visit to the camp infirmary, emergency department (ED), or hospital admission [5].

Youth camp–associated AGE outbreaks (hereafter referred to as “camp AGE outbreaks”) can have numerous potential contamination sources and transmission routes [6, 7]. Because parental consent might be required to interview children, and further, because children can be poor historians, determining specific exposures can be challenging [7]. Additionally, since most camp attendees participate in the same group activities and meals, it can be difficult to determine the exposures associated with illness through analyses of non-ill comparison groups [7]. Once a camp outbreak is recognized, controlling transmission can be difficult. There can be multiple camp sessions at the same facility, and new campers might be exposed to environmental contamination or direct contact with recovered (or ill) campers who are still infectious. Campers can also infect their home communities and expand the geographic spread of the outbreak [8].

Because of the high potential for transmissibility and difficulties in control, camp AGE outbreaks pose unique challenges. We analyzed data on camp AGE outbreaks to evaluate their frequency, etiologies, and outcomes and inform guidance regarding prevention and control.

METHODS

National Outbreak Reporting System Data

The National Outbreak Reporting System (NORS) is an Internet-based platform used by local, state, and territorial public health agencies to report to the Centers for Disease Control and Prevention all foodborne and waterborne disease outbreaks, as well as enteric disease outbreaks resulting from person-to-person contact, environmental contamination, animal contact, and indeterminate or unknown modes of transmission [9, 10]. We obtained data on outbreaks reported to NORS with a first illness onset date between January 1, 2009, and December 31, 2016. Waterborne disease outbreak reports for the years 2015 to 2016 were provisional. Data were analyzed using SAS 9.4 (SAS Institute, Inc, Cary, North Carolina). Differences in outbreak sizes and durations were assessed using the Kruskal-Wallis and Dunn’s multiple-comparison tests.

Definitions

Outbreaks reported to NORS were defined as ≤2 cases of a similar illness associated with a common exposure. Settings of interest included youth camps (eg, scout camps, day camps, sleepaway camps) but not private camping. Because outbreak settings are reported differently to NORS according to mode of transmission, we reviewed comments in NORS reports of camp-associated outbreaks and contacted reporting jurisdictions regarding outbreaks that did not seem to meet our definition; outbreaks were included or excluded after clarification. We excluded outbreaks from the NORS data set that were also described in reports from our literature search.

Any etiology reported to NORS was considered “confirmed” if ≤;2 laboratory-confirmed cases were reported, and an etiology with ≤1 laboratory-confirmed case was considered “suspected.” Outbreaks with multiple suspected or confirmed etiologies were categorized as “multiple,” and if no etiology was reported, it was considered “unknown.” Outbreak durations were calculated as the time between the first reported illness-onset date and the last reported illness-onset date.

Literature Search

We conducted a systematic literature search using the MEDLINE, Embase, Global Health, and Scopus databases for all indexed camp AGE outbreak reports published through December 2016 in English (the complete search strategy and review process is detailed in Supplementary Appendices 1 and 2). Two independent reviewers screened titles, abstracts, and full-text articles. Outbreak reports associated with military camps, refugee camps, or private groups were excluded. Each reviewer independently abstracted data on outbreaks that met our inclusion criteria and compared the data for accuracy. Data abstracted included camp location, outbreak duration, number of epidemiologically suspected and laboratory-confirmed cases of illness, outbreak etiology, outbreak source and transmission mode, risk factors for transmission, and control measures implemented during the outbreak.

To identify existing recommendations for prevention and control of camp AGE outbreaks not captured in the systematic literature search, we also conducted a search of gray literature (ie, not formally published in a peer-reviewed journal or other academic source) [11, 12]. Because the recommendations of interest are generally compiled by state or local public health agencies and might not be indexed in academic databases, 2 reviewers independently searched Google and Google Scholar on February 1, 2017, using the keywords “outbreak,” “camp,” “gastroenteritis,” “guidelines,” “recommendations,” and “control” [11, 12]. The reviewers screened the first 10 pages of results from each search to identify potentially relevant Web sites. These Web sites were subsequently reviewed, and applicable recommendations for prevention and control of camp AGE outbreaks were abstracted and synthesized.

RESULTS

NORS Outbreak Data

In total, 229 camp AGE outbreaks were reported to NORS by 39 US jurisdictions for the 2009–2016 period; 46 (20%) outbreaks involved campers from multiple states (Figure 1). Three outbreaks involved contaminated food items that were reported to have been consumed at youth camps in addition to other settings and were excluded from further analyses. A median of 28 (range, 14–41) outbreaks were reported each year, and most (192 [85%]) of them occurred during warm-weather months (May-August). The median outbreak duration was 7 days (range, 1–50 days), and a median of 20.5 (range, 2–350) primary cases were reported per outbreak (Table 1). During the same reporting period, an additional 19 986 AGE outbreaks in all other (non–youth camp–associated) settings were reported to NORS. These noncamp AGE outbreaks had a median duration of 9 days (range, 1–1362 days) and a median of 19 (range, 2–2500) primary cases.

Figure 1.

Numbers of youth camp–associated outbreaks of acute gastroenteritis in the United States, including Puerto Rico, reported to the National Outbreak Reporting System from 2009 through 2016 according to reporting jurisdiction (N = 229). Outbreak reporting largely depends on surveillance activities in the individual states and does not necessarily indicate the true incidence of outbreaks in a given state.

Table 1.

Etiologies and Case Information for Youth Camp-Associated AGE Outbreaks Reported to NORS From 2009 Through 2016

Etiology	Total No. of Outbreaks	No. of Outbreaks With a Suspected Etiologya	No. of Outbreaks With a Confirmed Etiologya	Total No. of Casesb	Median No. of Cases per Outbreak [Range]	Median Outbreak Duration [Range] (days)c
Viruses
Norovirus	107	50	57	4396	28 (2–350)	7 (1–36)
Sapovirus	2	1	1	28	14 (11–17)	7 (7–7)
Bacteria
Campylobacter spp	6	0	6	98	8 (7–39)	6 (3–18)
Clostridium spp	5	3	2	242	52 (32–72)	1 (1–5)
STEC	12	3	9	135	6 (2–56)	7 (2–22)
Salmonella spp	16	1	15	286	9 (2–62)	7.5 (1–28)
Shigella sonnei	2	0	2	15	7.5 (7–8)	23 (8–38)
Staphylococcus spp	2	1	1	25	12.5 (11–14)	1 (1–1)
Parasites
Cryptosporidium spp	10	0	10	124	12 (2–23)	10 (1–50)
Giardia spp	3	0	3	11	4 (3–4)	15 (5–30)
Multiple etiologies
Aeromonas hydrophilia and STEC	1	0	1 (only STEC confirmed)	5	—	7
Blastocystis hominis and Giardia duodenalis	1	0	1 (only G duodenalis confirmed)	21	—	10
Cryptosporidium parvum and STEC	2	0	2 (C parvum confirmed in only 1)	44	22 (10–34)	11 (10–12)
Norovirus and S sonnei	1	0	1	81	—	13
Unknown	56	—	—	1661	17(2–200)	4 (1–29)
Total	226	59	111	7172	20.5 (2–350)	7 (1–50)

Abbreviations: AGE, acute gastroenteritis; NORS, National Outbreak Reporting System; STEC, Shiga toxin–producing Escherichia coli.

^aThese categories are mutually exclusive.

^bEstimated total number of primary cases among all outbreaks, with or without laboratory confirmation.

^cRestricted to outbreaks with a reported date of last illness onset (n = 197).

Ninety-nine (44%) outbreak reports included the total number of people exposed and ill, stratified by campers and staff. Sixty (61%) of these reports indicated that both campers and staff became ill, 35 (35%) indicated that only campers became ill, and 3 (3%) indicated that only staff became ill. The median AGE attack rate was 18% (range, 0%–75%) among campers and 13% (range, 0%–100%) among staff.

Most (120 [53%]) of the outbreaks were reported to have resulted primarily from person-to-person transmission, 42 (19%) from an unknown transmission mode, 38 (17%) from foodborne transmission, 19 (8%) from waterborne transmission, 5 (2%) from animal contact, and 2 (<1%) from environmental contamination (Figure 2). Reports that summarized 23 (10%) outbreaks indicated illness transmission to secondary cases (ie, cases who were not directly exposed to the primary exposure source); a median of 3 (range, 1–69) epidemiologically suspected or laboratory-confirmed secondary cases were reported. Among these 23 outbreak reports, 13 (57%) included a secondary transmission mode, all of which were person-to-person transmission.

Figure 2.

Numbers of youth camp–associated outbreaks of acute gastroenteritis reported to the National Outbreak Reporting System from 2009 through 2016 according to pathogen type and primary mode of transmission (N = 226). Etiology categories are defined in Table 1. The waterborne disease outbreak data for 2015 to 2016 are provisional.

At least 1 etiology was reported for 170 (75%) outbreaks. Of them, 111 (65%) reports documented at least 1 laboratory-confirmed etiology; the remaining 59 (35%) etiologies were suspected (Table 1). Five (3%) reports indicated multiple confirmed or suspected etiologies. Viruses were the most frequently identified single etiology among outbreaks spread via person-to-person transmission (80 [67%] of 120) (Figure 2). Among foodborne outbreaks, bacteria were implicated most frequently (21 [55%] of 38). Parasites, specifically Cryptosporidium spp, were the most frequently identified single etiology among waterborne outbreaks (9 [47%] of 19). Overall, norovirus (107 [63%] outbreaks), Salmonella spp (16 [9%]), and Shiga-toxin producing Escherichia coli (STEC) (12 [7%]) were the most frequently implicated single etiologies (Table 1). Among outbreaks with a single suspected or confirmed etiology, outbreaks of Clostridium spp were significantly larger (P < .05) than those caused by another etiology; we found no significant differences in outbreak durations (Table 1).

Among case-patients for whom aggregate healthcare-seeking data were reported, 725 (16.7%) outpatient visits, 203 (4.6%) ED visits, and 60 (1.1%) hospitalizations were reported (Table 2). The percentage of case-patients who visited an outpatient healthcare provider was highest among Giardia spp outbreaks; 90.9% of those with data reported an outpatient visit. The percentages of case-patients who visited the ED and those who were hospitalized were highest in STEC outbreaks; 14.5% visited the ED, and 9.6% were hospitalized. No deaths were reported.

Table 2.

Healthcare-Seeking Among Case-Patients in Youth Camp–Associated AGE Outbreaks Reported to NORS from 2009 through 2016 (N = 226)^a

Etiology	Case-Patients Who Sought Outpatient Healthcareb,c		Case-Patients Who Visited the EDc		Hospitalized Case-Patientsc
	n	%	n	%	n	%
Viruses
Norovirus	445	19.3	125	5.1	31	1.0
Sapovirus	17	60.7	1	3.6	1	3.6
Bacteria
Campylobacter spp	20	21.5	9	9.9	0	0.0
Clostridium spp	8	3.8	0	0.0	0	0.0
STEC	18	23.7	11	14.5	13	9.6
Salmonella spp	70	25.2	22	12.1	12	4.5
Shigella sonnei	2	15.4	1	7.7	1	7.7
Staphylococcus spp	0	0.0	0	0.0	0	0.0
Parasites
Cryptosporidium spp	32	38.6	5	5.2	0	0.0
Giardia spp	10	90.9	1	9.1	0	0.0
Multiple etiologiesd	38	55.9	6	8.7	1	1.4
Unknown	65	5.7	22	1.9	1	0.1
Total	725	16.7	203	4.6	60	1.1

Abbreviations: AGE, acute gastroenteritis; ED, emergency department; NORS, National Outbreak Reporting System; STEC, Shiga toxin–producing Escherichia coli.

^aNot all percentages total to 100%, because each percentage was calculated using a different denominator.

^bDoes not include ED visits.

^cCategories are not mutually exclusive. Each case-patient was counted only once per visit type (ie, outpatient visit, ED visit, hospital admission); however, any patient who sought multiple types of healthcare was counted in each column.

^dEtiologies are listed in Table 1.

Of 38 reports on foodborne camp AGE outbreaks, 24 (63%) identified specific factors that contributed to the outbreak. Improper timing or temperature control (for cooking, holding, or reheating food) was identified in 13 (54%) of these reports, consumption of raw/undercooked food in 11 (46%) reports, and food-handling by an infected food worker in 8 (33%) reports. Of 19 waterborne camp AGE outbreaks, 10 (53%) were reported to result from exposure to contaminated recreational water venues; 6 of these venues were untreated, and 4 were treated. Five (26%) waterborne outbreaks were caused by exposure to a contaminated drinking water source, and 4 (21%) were caused by drinking from a water source not intended for human consumption. Two (40%) of 5 animal contact-associated outbreak reports noted contact with calves, 2 (40%) with goats, and 1 with baby chicks, ducks, and goats.

Literature Review

Our systematic literature search yielded 476 publications, of which we assessed 63 full-text articles for eligibility (Supplementary Appendix 2). We included 38 articles that detailed 43 camp AGE outbreaks that occurred from 1938 through 2011. Twenty of these publications included data on 24 individual outbreaks that occurred in 15 US states, and the other 18 articles characterized 19 camp AGE outbreaks in 8 countries: Australia, Canada, the Netherlands, New Zealand, Romania, Spain, Trinidad and Tobago, and the United Kingdom. Outbreaks took place at camps in both rural (eg, agricultural showgrounds [3], farms [8]) and urban (eg, college campus [13]) settings. The median outbreak duration was 12 days (range, 4–48 days), with a median of 67 (range 6–326) primary cases were reported per outbreak. Publications describing 15 outbreaks indicated potential secondary transmission, which resulted in 1 to 90 additional cases; 3 reports noted suspected transmission to family members outside the camp [8, 14].

Fourteen (33%) outbreaks were reported to have spread by foodborne transmission, 11 (26%) by waterborne transmission, 8 (19%) by person-to-person contact, 3 (7%) through animal contact, and 7 (16%) by multiple potential transmission modes. Forty-one (95%) outbreak investigations identified at least 1 laboratory-confirmed etiology; norovirus (12 [29%]), STEC (8 [20%]), and Campylobacter spp (8 [20%]) were identified most frequently.

Although data on control measures are not reported to NORS, publications on 24 (56%) outbreaks detailed specific control measures for preventing further transmission. Control measures implemented during foodborne or waterborne illness outbreaks included camp closure [15–19], changes in water source or water-treatment practices [15, 19–25], and education on proper food preparation and storage [5, 24]. For outbreaks caused by environmental contamination or person-to-person contact, control measures included cancellation of camp sessions [13, 14], cohorting and exclusion of ill individuals (eg, from food preparation and group activities) [26, 27], education on proper hand-washing and installation of soap dispensers [26–28], and thorough disinfection of all surfaces, including toilets and floors [13, 14, 26–28]. Most publications provided minimal information regarding the impact or effectiveness of control measures, although some indicated that no new cases were identified after implementation.

Through our gray literature search, we identified camp-specific outbreak prevention and control recommendations from 7 sources, that is, 3 from US state health departments [29–31], 3 from health departments in other countries [32–34], and 1 from a professional organization [35]. The camp-specific documents were supplemented with additional resources on infection control for developing the synthesized recommendations (Supplementary Appendix 3). Recommendations covered several major themes for prevention (food safety, hand hygiene, pre-camp preparation) and control (disinfection and cleaning, communication, and isolation) (Table 3).

Table 3.

Key Recommendations for the Prevention and Control of Youth Camp–Associated Outbreaks of AGE, Synthesized From a Gray Literature Search

Parents should sign a pre-camp arrival agreement requiring campers to be healthy on arrival and requesting the pick-up of ill campers when necessary [35]

After vomiting/diarrheal incidents, affected areas should be cleaned thoroughly and then disinfected by trained individuals wearing proper personal protective equipment (eg, gloves) and using proper disinfectants of sufficient concentration [29–34]

Campers and staff with AGE symptoms (ie, diarrhea or vomiting) should be isolated and provided designated dining and restroom facilities until at least 48 hours after their symptoms have resolved [29, 30, 35]

At the start of the camp session, campers and staff should be instructed on proper hand-washing practices; hand-washing facilities should be equipped with soap, running water, and disposable towels [29, 30, 35]

Before the camp session, food handlers should be trained in food safety and preparation practices and use gloves and utensils when handling or preparing ready-to-eat foods, beverages, or ice [29, 30, 35]

Food handlers and campers with AGE symptoms should be excluded from food service areas until at least 48 hours after their symptoms have resolved [29, 30, 35]

Campers and staff should not consume or cook with untreated water [29–31]

Campers with AGE symptoms should not swim or participate in recreational water activities until at least 1 week after their symptoms have resolved [39]

Abbreviation: AGE, acute gastroenteritis.

DISCUSSION

This analysis provides a comprehensive description of camp AGE outbreaks reported to NORS and published in the literature, which can help inform recommendations for the prevention and control of such outbreaks. Although camp AGE outbreaks comprised 1% of approximately 20 000 outbreaks reported to NORS during the study period, they represent an important public health concern for camp operators and administrators, campers, and their families. We found that >50% of US states reported camp AGE outbreaks, many of which affected campers from multiple states, and some that led to secondary transmission to individuals outside the camp. Our literature search also found reports of camp AGE outbreaks in 8 other countries, which suggests that such outbreaks are a global concern.

Over half of camp AGE outbreaks reported to NORS were the result of person-to-person transmission. Norovirus was the most commonly reported etiology, which is consistent with previous reports that indicated that norovirus is the leading cause of AGE and is spread most commonly via person-to-person transmission [9, 36]. Control of person-to-person transmission might be especially difficult in camps, where campers participate in group activities and might share accommodations [27]. General infection-control guidelines suggest that campers and staff with AGE symptoms (ie, vomiting and/or diarrhea) be excluded from activities, especially those that involve food preparation, until ≥48 hours after their symptoms have resolved [29, 30, 35]. However, during a large or persistent outbreak, exclusion of ill individuals alone might not be adequate for preventing transmission. An analysis of a norovirus outbreak at a scout camp in the Netherlands found that restriction of highrisk activities (eg, food preparation) and enhanced hygiene measures (eg, separate restrooms for ill campers and education on proper hand-washing techniques) led to a reduction in the number of cases but did not curtail transmission completely [27]. The authors suggested that the addition of more stringent control methods, such as strict isolation of case-patients, might have further decreased transmission. In such situations, it might be necessary for ill campers to be picked up by their parents; a signed pre-camp agreement can be helpful in enforcing this practice [35].

Although not commonly identified as a primary mode of transmission, environmental contamination in areas such as shared bathrooms and sleeping facilities can further propagate outbreaks, as fomites can be contaminated by improperly washed hands or by vomiting or fecal incidents [13]. For example, environmental swabbing of bathrooms and other residence hall surfaces after a norovirus outbreak detected virus on surfaces after initial cleaning [13]. The percentage of rooms in which norovirus was detected on fomites decreased after the staff were trained properly on cleaning and disinfection procedures and the facilities were cleaned and disinfected again [13]. This result highlights the importance of education on the appropriate methods for cleaning and disinfecting surfaces. Training on and implementation of proper cleaning and disinfection of common areas is essential for limiting additional transmission.

Foodborne and waterborne camp outbreaks were also reported to NORS and were the most frequently reported transmission modes in the literature. More than 50% of reported foodborne outbreaks that included information on contributing factors pointed to either improper time or temperature control for cooking, holding, or reheating food, or the consumption of raw or undercooked food as a factor. Because campers and staff often eat the same meals together, foods contaminated by improper handling or preparation can lead to numerous illnesses. For example, an Escherichia coli O157:H7 outbreak among 20 campers and counselors, including 3 who were hospitalized, was traced to ground beef that was cooked improperly over a campfire [37]. This underscores the necessity for food handlers, especially campers and counselors who participate in food service, to be trained properly in safe food-preparation practices [35].

Similarly, >50% of waterborne camp AGE outbreaks reported to NORS were associated with recreational water exposure, including treated-water venues such as pools and untreated water venues such as lakes. Most recreational water outbreaks at camps were caused by Cryptosporidium spp, which are highly tolerant to chlorine [38, 39]. Campers and staff should be educated on healthy swimming practices, including not swallowing the water while swimming. Those with AGE should not swim for at least 1 week after their symptoms end, and those infected with Cryptosporidium spp should not swim for at least 2 weeks after their symptoms end [40].

Animal contact–associated camp AGE outbreaks were less frequently reported to NORS and described in the literature. However, 2 of 5 animal contact-associated camp AGE outbreaks reported to NORS and 2 identified in the literature took place at camps that provide agricultural education, which can result in multiple opportunities for children to have contact with animals. Camps should ensure that all staff and campers are educated on the potential for illness transmission from animals and reinforce proper hand-washing with soap and water after animal contact [41].

General food-, water-, and animal-safety and infection-control guidelines can help prevent camp AGE outbreaks, but the combination of factors that facilitate the occurrence and perpetuation of these outbreaks supports the need for camp-specific recommendations, which include consideration of food-preparation practices, accommodations, activities, and water sources at the camp. Despite the number of camp AGE outbreaks reported to NORS and described in the literature, our Internet search for existing recommendations tailored specifically for camps yielded only those documents detailed herein, which suggests that camp managers or other individuals searching for publicly available recommendations for camp AGE outbreaks might have some difficulty accessing these materials. The synthesis of the documents presented in Supplementary Appendix 3 and summarized in Table 3, can therefore serve as a useful resource for camp managers or counselors.

Our analysis is subject to some limitations. Because NORS is a passive reporting system, outbreaks are subject to various degrees of underreporting. State and local health departments are generally notified of outbreaks through public complaints, facility administrators, and healthcare providers [42]. Because outbreak reporting requirements vary according to state and pathogen, and because many individuals with AGE do not seek healthcare or receive testing, many outbreaks can go unreported [36, 42]. In addition, outbreak investigations and NORS data entry are not standardized across reporting jurisdictions. Only 4 fields (estimated number of primary cases, date of first illness, reporting jurisdiction, and primary transmission mode) are required to create a NORS report; all other fields are voluntary. It can also be difficult for investigators to reach all outbreak-associated case-patients, especially children, for interview, so the reported data might reflect only a subset of the actual outbreak-associated cases. Lastly, additional recommendations compiled by health departments or camps might not be publicly accessible and therefore were not identified by our gray literature search. These documents might supplement the recommendations presented by providing additional prevention and control measures for camp AGE outbreaks.

AGE can spread quickly at youth camps, and preventing transmission is important for curtailing outbreaks. Camp staff and management should assess the potential for illness transmission associated with their respective camp activities and remain vigilant for signs of communicable disease outbreaks. When outbreaks are identified, staff should notify their local health department, cooperate with public health investigations to determine the source of the outbreak, and implement applicable control measures to prevent further transmission. Educating both staff and campers on routine cleaning, food preparation, safe animal contact practices, and healthy water, sanitation, and hygiene practices can minimize the transmission of illness and ensure a healthy camp experience for everyone.