Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2017

Risk Factors for Non-O157 Shiga Toxin-Producing Escherichia coli Infections, United States

Shiga toxin-producing Escherichia coli (STEC) causes acute diarrheal illness. To determine risk factors for non-O157 STEC infection, we enrolled 939 patients and 2,464 healthy controls in a case-control study conducted in 10 US sites. The highest population-attributable fractions for domestically acquired infections were for eating lettuce (39%), tomatoes (21%), or at a fast-food restaurant (23%). Exposures with 10%-19% population attributable fractions included eating at a table service restaurant, eating watermelon, eating chicken, pork, beef, or iceberg lettuce prepared in a restaurant, eating exotic fruit, taking acid-reducing medication, and living or working on or visiting a farm. Significant exposures with high individual-level risk (odds ratio >10) among those >1 year of age who did not travel internationally were all from farm animal environments. To markedly decrease the number of STEC-related illnesses, prevention measures should focus on decreasing contamination of produce and improving the safety of foods prepared in restaurants.

Petting Zoos as an Unsuspected Source of Pediatric Infections

Children are at risk for infection following animal exposure at petting zoos owing to suboptimal hand hygiene and frequent hand-to-mucosal surface contact. Public health surveillance is limited, and infectious risk is likely underrecognized. Most reported infections are enteric. Here, we describe two children with unusual, nonenteric infections following petting zoo exposure.

A RETROSPECTIVE ANALYSIS OF THE MORBIDITY AND MORTALITY OF CAPTIVE NORTHERN BALD IBIS (GERONTICUS EREMITA), AFRICAN SACRED IBIS (THRESKIORNIS AETHIOPICUS), AND SCARLET IBIS (EUDOCIMUS RUBER) HOUSED AT THE LONDON ZOO FROM 2000 TO 2020

Necropsy (n = 144) and medical (n = 121) records of captive northern bald ibis (NBI; Geronticus eremita), African sacred ibis (ASI; Threskiornis aethiopicus), and scarlet ibis (SCI; Eudocimus ruber) housed at the Zoological Society of London's London Zoo (LZ) from 2000 to 2020 were reviewed. Pododermatitis was a common cause of morbidity in all species (79 cases in 247 examinations). Trauma (58 of 144), the majority being caused by suspected collisions with stationary objects in the zoo's habitats, infectious diseases (32 of 144), predominantly valvular endocarditis (10 of 32), and aspergillosis (9 of 32) were major causes of mortality. The odds of a morbidity being related to toxicosis were 4.4 times greater in NBI than for ASI (95% CI, 1.5-13.3; P < 0.05); all cases in the NBI were plumbism. Overall, females of all species had 3.4 times greater odds of undetermined morbidity than males (95% CI, 1.5-7.9; P < 0.05), and the majority (16 of 25) were birds that were thin without an apparent cause. Nestlings had 11.3 times greater odds of nutritional morbidity than adults (95% CI, 1.7-73.0) and 5.5 times greater than juveniles (95% CI, 0.7-41.0; P < 0.05). These data have identified areas that require further study in the population of NBI, ASI, and SCI held at LZ.

Fur, Fin, and Feather: Management of Animal Interactions in Australian Residential Aged Care Facilities

Animal-assisted interventions (AAI) have been occurring in Australian Residential Aged Care Facilities (RACF) for more than 40 years and may relieve loneliness and improve quality of life. The presence of animals in RACF poses an inherent risk to residents and the animals involved. Little is known about the policies and guidelines for including animals in the Australian RACF. We anticipated that most RACFs would have some policies, but they may lack the detail necessary to keep humans and animals safe. Using an adapted survey, we surveyed and interviewed a small but representative sample of Australian RACF managers. The results demonstrated that RACF did have animal policies; however, the content regarding the need for hand washing, infection prevention, and animal welfare was lacking. Including unregulated family pets in RACF was an unexpected additional risk factor identified during data analysis. There is a need for national guidelines tied to the national aged care policy, which includes training and educational resources for RACF and AAI providers.

Outbreak of Multidrug-Resistant Salmonella Heidelberg Infections Linked to Dairy Calf Exposure, United States, 2015-2018

In August 2016, the Wisconsin Department of Health Services notified the U.S. Centers for Disease Control and Prevention of multidrug-resistant (MDR) Salmonella enterica serovar Heidelberg infections in people who reported contact with dairy calves. Federal and state partners investigated this to identify the source and scope of the outbreak and to prevent further illnesses. Cases were defined as human Salmonella Heidelberg infection caused by a strain that had one of seven pulsed-field gel electrophoresis (PFGE) patterns or was related by whole genome sequencing (WGS), with illness onset from January 1, 2015, through July 2, 2018. Patient exposure and calf purchase information was collected and analyzed; calves were traced back from the point of purchase. Isolates obtained from animal and environmental samples collected on-farm were supplied by veterinary diagnostic laboratories and compared with patient isolates using PFGE and WGS. Antimicrobial susceptibility testing by standardized broth microdilution was performed. Sixty-eight patients from 17 states were identified. Forty (63%) of 64 patients noted cattle contact before illness. Thirteen (33%) of 40 patients with exposure to calves reported that calves were sick or had died. Seven individuals purchased calves from a single Wisconsin livestock market. One hundred forty cattle from 14 states were infected with the outbreak strain. WGS indicated that human, cattle, and environmental isolates from the livestock market were genetically closely related. Most isolates (88%) had resistance or reduced susceptibility to antibiotics of ≥5 antibiotic classes. This resistance profile included first-line antibiotic treatments for patients with severe salmonellosis, including ampicillin, ceftriaxone, and ciprofloxacin. In this outbreak, MDR Salmonella Heidelberg likely spread from sick calves to humans, emphasizing the importance of illness surveillance in animal populations to prevent future spillover of this zoonotic disease.

Agritourism and Kidding Season: A Large Outbreak of Human Shiga Toxin-Producing Escherichia coli O157 (STEC O157) Infections Linked to a Goat Dairy Farm-Connecticut, 2016

The objective of this study was to determine sources of Shiga toxin-producing Escherichia coli O157 (STEC O157) infection among visitors to Farm X and develop public health recommendations. A case-control study was conducted. Case-patients were defined as the first ill child (aged <18 years) in the household with laboratory-confirmed STEC O157, or physician-diagnosed hemolytic uremic syndrome with laboratory confirmation by serology, who visited Farm X in the 10 days prior to illness. Controls were selected from Farm X visitors aged <18 years, without symptoms during the same time period as case-patients. Environment and animal fecal samples collected from Farm X were cultured; isolates from Farm X were compared with patient isolates using whole genome sequencing (WGS). Case-patients were more likely than controls to have sat on hay bales at the doe barn (adjusted odds ratio: 4.55; 95% confidence interval: 1.41–16.13). No handwashing stations were available; limited hand sanitizer was provided. Overall, 37% (29 of 78) of animal and environmental samples collected were positive for STEC; of these, 62% (18 of 29) yielded STEC O157 highly related by WGS to patient isolates. STEC O157 environmental contamination and fecal shedding by goats at Farm X was extensive. Farms should provide handwashing stations with soap, running water, and disposable towels. Access to animal areas, including animal pens and enclosures, should be limited for young children who are at risk for severe outcomes from STEC O157 infection. National recommendations should be adopted to reduce disease transmission.

Farm animal contact is associated with progression to Hemolytic uremic syndrome in patients with Shiga toxin-producing Escherichia coli - Indiana, 2012-2018

Background

Hemolytic uremic syndrome (HUS) is a life-threatening complication of Shiga toxin-producing Escherichia coli (STEC) infection. The relationship between STEC exposure and severity of clinical outcomes is not well documented. We examined whether direct contact with farm animals increased the likelihood of HUS among Indiana residents diagnosed with STEC.

Methods

Exposure data for laboratory-confirmed STEC cases among Indiana residents during 2012–2018 were retrieved. Logistic regression and mediation analysis were performed to determine the extent to which a history of direct contact with farm animals was associated with post-diarrheal HUS independent of age and mediated by stx2 gene presence.

Results

A total of 784 STEC cases were retrieved. Of these, 46 (6%) developed HUS. Complete exposure data were available for 600 (77%) cases. A total of 24 (52%) HUS patients reported direct contact with farm animals, while 114 (21%) STEC patients who did not develop HUS reported this exposure. Among all STEC cases, HUS was associated with direct farm animal contact after adjusting for age (OR = 3.40, 95% CI: 1.81, 6.40). Detection of stx2 genes mediated 12% of the association between farm animal contact and HUS.

Conclusions

Direct farm animal contact was a risk factor for development of HUS among laboratory-confirmed STEC cases, independent of stx2 presence. Direct farm animal contact should be considered a potential predictor of progression to HUS when patients present for care and the mechanism for its effect on virulence investigated.

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Independent of stx2 presence, contact with farm animals is a risk factor for the development of HUS.

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Stx2 gene detection mediated 12.2% of the association between farm animal contact and HUS.

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Exposure source may impact virulence of STEC and thus the severity of clinical outcomes.

Animal agriculture exposures among Minnesota residents with zoonotic enteric infections, 2012-2016

Prospective, population-based surveillance to systematically ascertain exposures to food production animals or their environments among Minnesota residents with sporadic, domestically acquired, laboratory-confirmed enteric zoonotic pathogen infections was conducted from 2012 through 2016. Twenty-three percent (n = 1708) of the 7560 enteric disease cases in the study reported an animal agriculture exposure in their incubation period, including 60% (344/571) of Cryptosporidium parvum cases, 28% (934/3391) of Campylobacter cases, 22% (85/383) of Shiga toxin-producing Escherichia coli (STEC) O157 cases, 16% (83/521) of non-O157 STEC cases, 10% (253/2575) of non-typhoidal Salmonella enterica cases and 8% (9/119) of Yersinia enterocolitica cases. Living and/or working on a farm accounted for 61% of cases with an agricultural exposure, followed by visiting a private farm (29% of cases) and visiting a public animal agriculture venue (10% of cases). Cattle were the most common animal type in agricultural exposures, reported by 72% of cases. The estimated cumulative incidence of zoonotic enteric infections for people who live and/or work on farms with food production animals in Minnesota during 2012–2016 was 147 per 10 000 population, vs. 18.5 per 10 000 for other Minnesotans. The burden of enteric zoonoses among people with animal agriculture exposures appears to be far greater than previously appreciated.

Retrospective analysis of equestrian-related injuries presenting to a level 1 trauma center

OBJECTIVE

Report the incidence, pattern, and severity of equestrian-related injuries presenting to a rural level 1 trauma center and detail the total radiation dose, imaging, and hospital charges related to those injuries.

METHODS

An IRB-approved retrospective review of patients presenting to our facility following equine-related trauma was conducted. Demographics, mechanism of injury, types and number of imaging exams, approximate radiation dose administered, imaging findings, Injury Severity Score (ISS), rate/length of hospitalization, and approximate cost of care were recorded.

RESULTS

A total of 222 patients (161 F:61 M; mean age 38.5 years (range 4-79)) presented to our emergency department following horse-related injury. Mechanisms of injury included the following: fall (n = 186), kick (n = 18), stepped on (n = 9), and other (n = 9). Body part injured included extremity (26.1%), torso (26.6%), spine (25.7%), and head/neck (18.5%). Longer hospital admission, higher expenditure, increased CT/MR imaging, higher ISS, and radiation dose were noted in older patients and those injured by a fall or kick. Head injuries were more frequent following a horse kick (p = 0.006). Spinal and torso injuries were more common in patients older than 54 years (p = < 0.001) and those with falls (p < 0.04). Extremity injuries were more common in older patients (p < 0.001).

CONCLUSION

Patient age greater than 54 years and mechanism of injury are strong predictors of the ISS, injury localization, healthcare expenditure, and mean hospital stay. With the exception of obvious minor wounds, full trauma work-ups (CT chest/abdomen/pelvis and cervical spine) are encouraged for equestrian-related injuries in older patients and those injured by a fall.