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Call Transcript: Love the Pets, Not the Germs: CDC Update on Enteric Zoonoses

Moderators:Loretta Jackson Brown

Presenter:Kara Jacobs Slifka, MD, MPH and Colin Basler, DVM, MPH

Date/Time:July 17, 2014 2:00 pm ET

Coordinator:
Welcome and thank you for standing by. At this time, all participants are in a listen-only mode until the question and answer session. At that time, if you would like to ask a question please press star, 1 and record your first and last name when prompted. Today’s conference is being recorded. If you have any objections, you may disconnect at this time.

Now I’d like to turn the conference over to your host, Loretta Jackson Brown. Thank you. You may begin.

Loretta Jackson Brown:
Thank you (Jovanna). Good afternoon, I’m Loretta Jackson Brown and I’m representing the Clinician Outreach and Communication Activity, COCA, with the Division of Strategic National Stockpile at the Centers for Disease Control and Prevention. I am delighted to welcome you to today’s COCA Webinar, Love the Pets, Not the Germs: CDC update on Enteric Zoonoses.

We are pleased to have with us today Dr. Kara Jacobs Slifka and Dr. Colin Basler from CDC. They will discuss enteric zoonoses and the One Health approach to helping patients prevent illness and maintain optimal health. You may participate in today’s presentation by audio only, via Webinar, or you may download the slides if you are unable to access the Webinar. The PowerPoint slide set and the Webinar link can be found on our COCA Website at emergency.cdc.gov/coca, click on COCA calls. The Webinar link and slide set are located under the call-in number and call passcodes.

At the conclusion of this session, the participant will be able to accomplish the following: 1) describe the epidemiology and clinical features of enteric zoonoses, 2) discuss recent enteric outbreaks involving animal contact in the U.S., 3) state how the concept One Health links clinicians, veterinarians, epidemiologists and other health care professionals, 4) and identify prevention messages and materials supporting safe human and animal interaction.

In compliance with continuing education requirements CDC, our planners, and our presenters, and their spouses/partners, wish to disclose they have no financial interests or other relationship with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Planners have reviewed content to ensure there is no bias.

The presentation will not include any discussion of the unlabeled use of a product or a product under investigational use. CDC does not accept commercial support. Free continuing education is available for today’s Webinar.

At the end of the presentation, you will have the opportunity to ask the presenter questions. On the phone dialing star, 1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your, excuse me, typing in your question.

Our first presenter, Dr. Kara Jacobs Slifka is an Epidemic Intelligence Service Officer in the Division of Foodborne, Waterborne, and Environmental Diseases at CDC. Her current work involves investigating outbreaks of enteric illness associated with animals. Prior to working at CDC, she was involved in counseling and educating patients in hospitals and primary care settings. Dr. Jacobs Slifka holds a medical degree from Michigan State University and completed her internal medicine residency at the University of Michigan. She also has a Masters of Public Health from the University of Michigan.

Our second presenter is Dr. Colin Basler. He also is an Epidemic Intelligence Service Officer with the Division of Foodborne, Waterborne, and Environmental Diseases at CDC. Dr. Basler works on a number of zoonotic enteric outbreak investigations. Prior to working at CDC, he practiced in a small animal hospital in Cambridge, Massachusetts. He obtained a Doctorate of Veterinary Medicine and Masters of Public Health from Tufts University.

Again, the PowerPoint slide set and Webinar links are available from our COCA Web page at emergency.cdc.gov/coca. At this time, please welcome Dr. Jacobs Slifka.

Kara Jacobs Slifka:
Thank you and good afternoon. When we talk about enteric zoonoses, we are referring to infections in which the route of transmission is primarily through the mouth and intestinal tract and that most commonly results in gastrointestinal symptoms with zoonoses indicating the transmission of pathogens from animals to humans likely resulting in human disease.

Although we often refer to enteric illnesses, or GI illness, as food borne illnesses, these infections are not solely due to the ingestion of food. Vomiting, diarrhea, and abdominal pain are the most frequent symptoms associated with these types of infections, although more severe illnesses can occur, including bloodstream infections, joint infections, hemolytic-uremic syndrome and Guillan-Barré.

All people are considered to be at risk for enteric zoonoses. Although children under the age of five, and the elderly, immunocompromised persons, as well as pregnant women, are considered to be at highest risk. The increased infection risk for children younger than five years of age is thought to be due, at least in part, to children’s less than optimal hygiene practices and developing immune systems.

Young children are also at increased risk of injury, such as bites, scratches, or falls from animals because of their size and behavior. These behaviors may increase the risk of direct exposure to animals. The public health burden of enteric illnesses is quite large. These illnesses are common with an estimated 48 million illnesses occurring every year, resulting in 128,000 hospitalizations and at least 3,000 deaths. Costs are estimated at over $77 billion annually.

Human interaction with animals are also quite common. As an example, companion animals, or pets, can be found in about one out of every four households. The American Veterinary Medical Association estimates that 74.1 million U.S. households have at least 1 pet. Over 43 million American households own a dog and 36.1 million own a cat.

In the general population, animal exposures, regardless of pet ownership, in the previous 7 days was reported at over 60% for dogs and over 40% for cats. And while we don’t have estimates for dog food specifically 16.2% of people report handling dog treats.

Exposure to animals is far broader than just dogs and cats. Millions of human-animal interactions occur each year, both at home and outside of the home, through settings such as classrooms, petting zoos and farms. The number of households with reptiles and certain types of exotic pets is increasing, as are livestock in urban settings and backyards.

Animal contact can be very positive and provide for learning, entertainment and bonding. But animals can also make humans sick. In fact, 14% of all enteric illnesses caused by the 7 major pathogens listed in the U.S. can be attributed to animal contact.

These include salmonella, E. coli, as well as Listeria monocytogenes, Campylobacter, Cryptosporidium, and Yersinia enterocolitica. This works out to an estimated 6.7 million illnesses due to animal contact each year.

Salmonella is one of the most common enteric infections and 11% of all salmonella infections are due to animal contact. Zoonotic Salmonellosis is so common that it’s responsible for the highest morbidity and mortality among the enteric zoonoses. Children are disproportionately affected, likely due to many of the reasons I previously mentioned.

Salmonella typically lives in the intestinal tract of many different animals. The animal acts as an asymptomatic carrier, but can shed Salmonella in their feces, easily contaminating their body and anything in the area in which they live and roam.

We also know that shedding can occur intermittently, so even screening may not be able to detect whether or not an animal is a carrier. Stress can increase shedding and treatment may not reliably eliminate pathogens and may even increase duration of shedding. And, although most animals act as asymptomatic carriers some can become ill with Salmonellosis.

So the problem with animals, especially the small, cute and fuzzy ones, is that they may not look sick, but still have the ability to spread germs to humans. So let’s discuss transmission in a little bit more detail.

Transmission between humans and animals can occur in numerous different ways. Even foodborne transmission is frequently associated with contamination of animal products or contamination of food by nearby animals.

For example, chickens can carry Salmonella, which can infect humans if chicken products are not cooked properly, or if cross contamination occurs around the time of preparation. Unpasteurized milk can be contaminated even if the animal appears clean and healthy, as fecal contamination of the milk or cross contamination during processing can occur.

Transmission can also occur via direct contact with infected animals. As Colin will discuss shortly, CDC has investigated many outbreaks that trace back to direct human-animal interactions, such as petting, holding, or even cuddling reptiles and small animals.

The route is typically oral after coming into contact with any part of the animal, animal bedding, flooring, or barriers, or even clothing worn in these areas and around animals.

Indirect contact with animals is another method of transmission between animals and humans. Animal fur, feathers, or feces, such as from the birds in the top picture, can contaminate environmental surfaces, which can then act as a vector for transmission of germs to humans.

The railings in the picture, especially at lower levels where a child may hold on to them and put their fingers in their mouth, or even put their mouth directly on the railings, provide a great example of indirect animal contact.

Now we’ll move on to talking about detection of enteric zoonoses and outbreaks and the role that all of us play in recognizing these illnesses. When we talk about the detection of enteric zoonoses it’s important to first share information about the “One Health” approach, an integrative effort of multiple disciplines working together locally, nationally, and globally to attain optimal health.

A “One Health” approach considers human, animals, and environmental health and involves multiple disciplines from health care professionals caring for all ages, to veterinarians, epidemiologists, environmental scientists and many others. A “One Health” approach is critical for effective detection, control and prevention of infectious diseases.

On the laboratory side the surveillance that we use to detect foodborne outbreaks is called PulseNet. PulseNet is the National Molecular Subtyping Network for enteric disease surveillance and is made up of over 80 public health and regulatory laboratories.

These laboratories perform molecular subtyping of disease causing bacteria, including human clinical isolates and even some non-human isolates. Non-human isolates typically include isolates from food, animals, or the environment, typically collected as a part of routine surveillance, but also during outbreaks.

The current subtyping method used is called Pulsed-Field Gel Electrophoresis, or PFGE for short, which creates a PFGE pattern, or DNA fingerprint, for each bacterial isolate. These DNA fingerprints are then electronically uploaded to a national database at CDC and shared by members of PulseNet.

PulseNet monitors the database for collection of similar patterns in the last two to four months. When a cluster of similar patterns is identified, PulseNet notifies enteric disease epidemiologists. Members can also query the PulseNet database for specific PFGE patterns they have isolated.

The image here shows an example of different PFGE patterns for individual patients. Each horizontal line is an isolate from a patient. The red box indicates a cluster of indistinguishable patterns that make up a possible outbreak.

So by looking at the PulseNet database we can identify clusters of illness caused by bacteria with the same fingerprint at the same time even if the patients are spread across many counties or states.

Although PulseNet can detect widely dispersed multi-state outbreaks there are inherent delays in reporting cases. The reporting of foodborne infections can take weeks. First the patient has animal contact or eats contaminated food, then anywhere from one to three days later the patient might become ill. That patient may then wait one to five days before contacting the health care system.

And, once seen by a health care provider a stool sample is hopefully collected. It can then take about one to three days to make the diagnosis and identify bacteria by culture, for example, Salmonella. Once Salmonella is identified the case may be reported, but that is of little use without subtyping.

The subtype, the Salmonella isolate, is shipped to the public health laboratory, taking up to seven days in transit. Once the public health laboratory receives the sample it can take an additional two to ten days to conduct the subtyping, including PFGE, and finally confirm the case as a part of the outbreak. It’s at this point, that potentially links to other cases may be revealed.

Unfortunately, by the time the patient interviews are conducted epidemiologists are often asking about food exposures more than three weeks prior to the interview date.

Once we think we’re seeing an enteric zoonoses outbreak we move into hypothesis generation and must consider the large number of exposures that may be the source or vehicle of infection.

We must then narrow the list of exposures reported by many of the ill patients. This process usually involves interviews of case patients to find out where and what they came in contact with, or ate, in the few days to weeks before they got sick.

CDC’s Standard Structured Hypothesis Generating questionnaire asks about over 400 exposure items consisting of food and animal exposures, as well as travel, events, grocery stores and even restaurants.

Structured interviews can only suggest hypothesis that are contained on the questionnaire. So it will not be able to identify new or unexpected vehicles. Intensive open-ended interviews in which the interviewer broadly asks about illness history and detailed exposure history without any list can help in this situation.

Sometimes we then move on to performing a case control study to help determine the significance of risk factors. In a case control study a group of people with the disease, or the cases, are compared to a group of people without the disease or the controls.

These two groups are then compared to each other to determine whether there are any significant differences in risk factors, such as being exposed to a particular animal.

Each of the federal agencies then have distinct roles regarding enteric zoonoses and outbreaks. CDC is responsible for disease surveillance, outbreak detection and investigation, and education and training of public health staff. FDA and USDA are responsible for food safety policies, inspection and enforcement, product recall and traceback, and investigation of farms and production facilities.

Clinicians and other health care providers play a critical role in the prevention and control of foodborne outbreaks and enteric zoonoses. Only a fraction of people who experience gastrointestinal symptoms from an enteric illness will actually seek medical care.

Although implication of a specific source and the disease transmission is difficult from a single patient encounter, every outbreak begins with an index case and this patient may present to you.

Also, every ill person involved can make a contribution to learning more about the epidemiology of the outbreak. Ideally, the more we know the faster we can hope to solve an outbreak in order to prevent further illness.

Important clues to determine etiology, including learning more about the incubation period; the duration of illness; clinical symptoms; and any information about animal contact, hand washing and foods eaten.

If you suspect enteric zoonoses or a foodborne illness, submitting appropriate specimens for laboratory testing is necessary. This may help you and the patient understand better through diagnosis, but will also guide public health.

Contacting your local and state health department is very important if you have positive results of your illness or any suspicious clustering of illnesses as they may only become aware of enteric illnesses once testing has been performed and has indicated a specific pathogen.

Laboratory testing may be helpful, especially in settings where the patient has prolonged or bloody diarrhea, severe abdominal pain, dehydration, or is immunocompromised. And it’s important to keep in mind that routine stool testing may only include screening for a few select organisms, so you may need to request additional testing from your lab if indicated.

Now Colin will discuss recent outbreaks that CDC has been involved in investigating.

Colin Basler:
Thanks Kara. In the past couple of years, CDC has been involved in investigating a growing number of enteric zoonotic outbreaks that have been sourced from both animals, as well as animal food products. The majority of these outbreaks have involved Salmonella, but zoonotic E. coli outbreaks have also been seen.

First, I will begin by discussing some recent research in the area of Salmonella outbreaks associated with backyard poultry, mainly because we’ve been seeing such an increase in the number of poultry related outbreaks on a yearly basis.

So for a little bit of back history, live poultry associated Salmonellosis outbreaks have been documented in the United States since 1955, however in the past they have generally been few and far between. Most outbreaks occurred in the springtime, usually right around the Easter holiday, and they primarily affected young children who had been given the dyed birds as pets, again for the Easter holiday.

In more recent years we have been seeing some different trends. These backyard related salmonellosis outbreaks have been associated - or well we’ve been seeing them as multiple multi-state outbreaks on a yearly basis.

These outbreaks are lasting longer, so we’re seeing them last many months and we’re sometimes seeing year-round outbreaks. The patient population has changed from just young children to affecting children and adults and they definitely seem to be associated with people raising backyard flocks of poultry and occasionally people keeping chickens as pets.

Backyard flocks are typically small and normally consist of less than 50 birds. They’re becoming increasingly popular in urban and suburban settings and they’re also popular with the increases in the organic and the locally sourced food movements.

This new found poultry popularity has led to new products, such as chicken diapers, celebrity endorsements, and high-end chicken coups, such as this model from Neiman Marcus that has a retail price of $100,000.

Due to this increase in poultry popularity and in the increase in poultry outbreaks we have undertaken a review of poultry outbreaks over the last 24 years.

This graph shows the number of live poultry associated Salmonellosis outbreaks identified by year, with year on the X axis and the number of confirmed outbreaks on the Y axis. The number of outbreaks have been steadily increasing over the last decade with a peak of 8 outbreaks reported in 2012.

The red line represents the number of live poultry associated salmonellosis cases identified as part of these outbreaks. The number of Salmonellosis cases have also been steadily increasing over the last 20 years with a dramatic increase in cases reported in 2012 and 2013. The largest single outbreak occurred in 2013 with 356 ill persons.

During the course of this investigation, or during the course of this review, we discovered 51 live poultry associated Salmonellosis outbreaks. These outbreaks included 2,228 illnesses, 306 hospitalizations and 5 deaths. The median number of illnesses associated with an outbreak was 25 with a range from 4 to 356 illnesses. The median outbreak length was 4.7 months and ranged from 1 to 12 months.

This graph shows the distribution of patients among different age groups with the patient age and years on the X axis and the number of patients on the Y axis. Thirty-two percent of patients were children under 5 years of age and 45% of patients were children under 10 years of age.

While only 20% of respondents reported contact with adult poultry, 64% reported contact with baby poultry. The percentage of ill persons in these outbreaks reporting contact with adult and baby poultry is substantially higher than the percentage of respondents who reported contact with live poultry in a recent national survey.

Of those who reported baby poultry contact 57 reported contact with only chicks, 17% reported contact with only ducklings, and 22% reported contact with both chicks and ducklings.

Seventy-four percent of baby poultry contact occurred in the patients home, 75% of patients reported touching baby poultry, 49% reported holding or snuggling baby poultry, and 14% admitted to kissing baby poultry. This information has been very helpful in focusing additional consumer education campaigns.

Surprisingly 46% of patients reported keeping baby poultry indoors. The fact that 12% reported keeping baby poultry in the kitchen and 10% reported keeping them in the bedroom and/or bathroom is especially concerning because these locations provide ample opportunity for environmental contamination.

So now I’m going to move on some additional recent enteric zoonotic outbreaks. A few years ago there was an outbreak of Shiga toxin-producing E. coli in Pennsylvania that ended up affecting a total of 51 persons, most of whom was children.

During the outbreak investigation it was determined that the majority of person of these patients had visited a dairy farm. And 8, or 16%, of patients infected with this particular strain of E. coli ended up developing hemolytic uremic syndrome and some went into kidney failure from that point.

During the outbreak investigation it was determined that major risk factors for developing E. coli were - included direct contact with animals, inadequate hand washing, inadequate separation of eating and animal contact areas, and poor maintenance of hand washing stations.

In addition to poultry and livestock, a number of different pet species have been implicated in recent enteric zoonotic outbreaks. Hedgehogs are a great example of these species. Hedgehogs are considered an exotic or pocket pet and both - pocket pets are made up of - are primarily small mammals and these types of pets have been growing in popularity in the recent years.

Hedgehogs are actually illegal in a number of states and cities, but despite this fact a recent survey estimated that hedgehogs were present in about 40,000 households nationwide.

Two years ago an outbreak of Salmonella was determined to affect 26 ill persons from 12 states, 35% of patients in this outbreak were hospitalized and 35% of ill persons were under 10 years of age.

During the outbreak investigation, it was determined that 80% of patients had reported hedgehog exposure and during the traceback investigation that followed public health departments were able to take samples from both patient pets, as well as in the environment. And these samples included samples from the hedgehog cages, as well as other areas in patient households.

They were able to - a number of these samples turned out to be positive for Salmonella so they were able to trace it back specifically to contact with these hedgehogs.

So in addition to small mammals, reptiles have also been involved in a number of Salmonella outbreaks in the past. Turtle-associated Salmonella has been known for a while. Back in the 60’s and 70’s turtles were very popular pets and one study found that approximately 4% of households had at least 1 turtle as a pet at that time.

About 15 million turtles were produced annually in the United States for pet sale and it was estimated that 280,000 cases of Salmonella were attributed to turtle exposure each year.

Because of all of this turtle related Salmonella a federal law was enacted in 1975, which prohibited the sale of turtles that were less than 4 inches of length for pets. This sale was - this ban was intended to prevent children from interacting with baby turtles, and from treating them as toys, and from possibly putting them in their mouths.

This ban seemed to be relatively effective throughout the late 70’s, 80’s and 90’s and few additional Salmonella related turtle outbreaks were seen. However, in recent years a number of turtle related Salmonella outbreaks have been discovered.

In 2012, there was what we’ve called The Turtle Apocalypse around here. This began when eight separate salmonella outbreaks were being investigated and these included eight different salmonella serotypes.

During the outbreak investigation it was determined that patients from all eight investigations reported turtle exposure. Environmental sampling of turtles and turtle tank water were positive for all of these Salmonella strains.

Eventually these different strains and serotypes of Salmonella were incorporated into one massive outbreak investigation because a number of environmental samples were positive for multiple of the affected - a multiple of the implicated strains. So they were able to show that through the large web of testing that was done that all of these outbreaks were in fact related.

So when this - when all of these outbreaks were combined it was a total of 473 ill persons from 41 states were included in this outbreak investigation, 29% of ill persons ended up being hospitalized, and 70% of ill persons were less than 1 year of age. Surprisingly 31% of ill persons were 1 year of age or less and additionally this outbreak had 44% of ill persons that were of Hispanic ethnicity.

The high increase in both patients that were children really goes to the point that many people don’t realize that turtles can cause, or can carry, Salmonella and can shed it even when they’re healthy. Many people don’t realize that there’s actually a federal ban against the sale of baby turtles for pets and the very high percentage of ill persons that were one year of age or less points to the fact that direct contact was not needed for all of these people to get sick.

A lot of these babies and very small children got sick from environmental contamination, so having the turtles in the household. Many people were cleaning the turtle tanks in kitchen sinks or were letting turtles walk or wander around different parts of the house. And those exposures allowed Salmonella to lead to environmental contamination of Salmonella, which then caused these illnesses in these small children.

Loretta Jackson Brown:
Hey Colin, this is Loretta. Can you go back to that slide?

Colin Basler:
Sure.

Loretta Jackson Brown:
I just want to clear up something that you said, especially for the transcript and those who will be reviewing this later.

On your slide you have 70% were less than 10 years of age. You stated though that 70% were less than 1 year of age.

Colin Basler:
Oh I am so sorry for that. Yes, 70% were less than 10 years of age and 31% were 1 year of age or less.

All right, so another recent reptile investigation that the CDC has been participating with has involved Salmonella outbreak associated with bearded dragons.

In April of this year, the Wisconsin Public Health Department contacted the CDC because they had ten patients that all had a very rare serotype of Salmonella and the majority of these patients all reported contact with bearded dragons.

This led to a national investigation, which found 150 ill persons from 35 states who all had been infected with the same rare serotype of Salmonella. Forty-three percent of ill persons were hospitalized and 57% of ill persons were 5 years of age or younger.

Bearded dragons have also - or have been another pet that have been growing in popularity in recent years and bearded dragons are commonly seen as a trainer pet reptile. This is because these are really friendly pets, they’re easy to care for, and they are rarely aggressive towards owners.

So these are often given to children and teenagers who are interested in having reptiles as pets as a way to sort of introduce them into having pet reptiles. Because of this outbreak investigation bearded dragons have actually been removed from sale from a major nationwide pet store chain.

So in addition to contact with animals contact with animal food products has also led to a number of Salmonella outbreaks in the recent years. Recently 49 ill persons were part of a Salmonella outbreak from 20 states. This outbreak had a high percentage of patients reporting dog ownership, however owners reported feeding multiple types of - or feeding a variety of dog food brands.

During the traceback investigation, it was determined that this outbreak was linked to multiple brands of dry dog food that had all been produced from a single facility. So a lot of these dog food producing plants will produce dog food from a number of different brands and so that’s how we were able to link it all up and find the source for this one large investigation.

As can be expected people weren’t actually eating the dog food. They were just feeding their dogs and then not necessarily washing their hands after then going to feed - to prepare human food. A lot of these dogs were fed in the kitchen or in other food preparation areas and only a few of these dogs had any signs of Salmonella infection.

So once again this goes to show how many pets can appear healthy, can appear totally fine, and can still be shed - can possibly shed Salmonella. So, you know, some people could have been affected from handling feces of - and cleaning up after feces from dogs or they could have been infected just from handling the dog food.

Another recent Salmonella related - another recent outbreak of Salmonella related to pet food happened in New Jersey last summer when 21 people came down with the same serotype of Salmonella. It was determined that they also all reported owning dogs, and more importantly they all reported feeding the same brand of chicken jerky treat.

These chicken jerky treats - when New Hampshire went and did their traceback and did their environmental investigation, it was determined that they were all - that the chicken jerky treats were produced in a non-hygienic way and that they were all filled with - they were all contaminated with Salmonella.

In addition, a recent FDA study that involved random sampling of different types of pet food found that 7% of raw pet foods tested positive for Salmonella. And even more disturbingly 15% of raw pet foods tested positive for Listeria monocytogenes.

Raw pet foods are pet foods that owners and some people think are more healthy and think that they’re better for dogs and cats because they more closely resemble their diets in the wild. A lot of these dog foods never really undergo a kill step, so they can definitely be filled with Salmonella or other organisms that can be pathogenic for humans.

This really goes back to the point that especially if owners are feeding the raw pet food diet that they’re at risk for possibly contracting Salmonella or other disease causing organisms and really need to make sure that they wash their hands appropriately and try and practice safe pet food handling techniques to limit environmental contamination.

Our final outbreak investigation that I wanted to talk about also happened this year in 2014. This was another Salmonella outbreak that involved 41 ill persons. Once again this outbreak - these patients reported reptile exposure, specifically most patients reported owning corn snakes.

When people went out to do the traceback investigation and to do environmental testing at these patient homes they found the matching Salmonella strain in both the reptiles, as well as their frozen feeder rodents.

Frozen feeder rodents are common food items for snakes and other lizards and it’s - I think this is our second or third outbreak, Salmonella outbreak, associated with this food item, or this pet food item.

They are, again, common for sale for snakes and lizards. And our main education points for this is to make sure that people are washing their hands after feeding these items to their pets so they can, again, limit, you know, possible exposure to themselves and also limit environmental contamination.

So one of our main take home messages from all of these recent zoonotic outbreaks are that direct contact is needed for transmission of pathogenic organisms from pets to people.

The picture on the screen here shows a small turtle aquarium, which was kept on the sink right next to baby bottles, bottle brushes and baby formula. And so whenever they cleaned that tank it was very easy for Salmonella to splash into these surrounding locations and it was very easy for cross contamination to occur. And we think that’s how the very small child in this household contracted Salmonella.

Finally, I just want to go over some more contributing factors to how zoonotic diseases can spread. Many animals carrying zoonotic agents often show no clinical signs. These animals shed organisms intermittently, making detection difficult. Treating animals is not - may not reliably eliminate pathogens and can actually prolong shedding for - in some instances. And finally stressed animals are more likely to shed organisms.

All right that’s all for my part and I am going to hand it back over to Kara, who’s going to go over treatment and prevention.

Kara Jacobs Slifka:
Thanks Colin. Most episodes of acute gastroenteritis are self-limited and require only fluid replacement and supportive care. Oral rehydration is typically sufficient, but intravenous therapy may be required for severe dehydration.

Routine use of antidiarrheal agents is not recommended because many of these agents potentially have serious adverse effects or complications, especially in infants and young children.

Antimicrobial therapy should be based on clinical signs and symptoms, the organism detected in clinical specimens, antimicrobial susceptibility testing and appropriateness of antibiotic treatment.

Based on illnesses and outbreaks that we have seen in the past, the CDC has put together recommendations and best practices for patients or consumers. First and foremost we recommend washing your hands right after touching poultry, reptiles, small mammals, or pet food, or coming into contact with anything in the area where the animal lives and roams.

We recommend against certain groups handling poultry, reptiles, or small animals, including children younger than five years of age, older adults and immunocompromised persons. And we strongly recommend against letting live poultry inside of the house. As with the examples Colin shared, this can lead to environmental contamination and illness even in persons not directly handling the animals.

The CDC Website offers information about enteric zoonoses online, including information about outbreaks and information such as posters, brochures and even Web buttons, such as the three that are indicated on the bottom of the screen. These can be added to your Web pages and linked directly back to CDC Websites for educational information.

Next I have our amphibian and reptile poster, which is available on the Healthy People, Healthy Pets Web site under the Publications and Material section and is available in English, Spanish, French and Chinese.

These posters can be downloaded as a PDF in multiple different sizes and printed directly from the Web site. We encourage you to take advantage of these educational resources and hang them in your office, or waiting rooms, or anywhere that patients may read them.

Another example here is our baby poultry poster. This poster is available in English, Spanish and French. We also have posters, such as this one, to educate about safe practices regarding pet food. This poster is available in English and Spanish. Additional posters and materials are available on our Website, as well as some educational videos.

So in summary, human and animal interaction is very beneficial, but people are often unaware of the potential risks. Health care providers, veterinarians and public health officials have the unique opportunity to educate and share information to help people consider the risks and make educated decisions.

Thank you and we will now open up the presentation for any questions.

Loretta Jackson Brown:
Thank you Dr. Jacobs Slifka and Dr. Basler for providing our COCA audience with such a wealth of information. We’ll now open up the lines for the question and answer session. And also remember you can submit questions through the Webinar system. Operator?

Coordinator:
At this time we’ll begin the question and answer session. To ask a question please press star, 1 and record your name when prompted. If you wish to withdraw your question you may press star, 2 and one moment while we wait for our first question.

Loretta Jackson Brown:
And while we’re waiting for the questions from the phone we do have one through the Webinar system.

And the comment is, health care industry is being inundated with fake service animals that don’t have the appropriate health care maintenance nor behavior that trained service animals maintain. Local veterinarians are reporting some infections in pets with diseases like MRSA. Is CDC involved in the attempt to educate the public and government services about this? Kara or Colin do you want to take that question?

Colin Basler:
Thank you for - that’s a really good question and a very good point. So we - as far as I know - so we both work in food and water and I don’t know of any sections of the CDC that are involved currently with sort of false pet, service pet animals.

I do know that the MRSA infections, both in pets and in veterinary hospitals, are something that different areas are doing a fair amount of research on right now, however I don’t know what areas of the CDC would be involved in those types of research projects.

Kara Jacobs Slifka:
This is, however, a great area for us to continue to work on developing educational materials because as the caller has identified this is definitely an area of concern.

Colin Basler:
And this also, just one final point, this also is a great opportunity for sort of a “One Health” approach for collaboration between physicians, veterinarians and other researchers.

Loretta Jackson Brown:
Thank you. Operator, do we have any questions from the phones?

Coordinator:
Yes. The first question comes from Dr. (Caroline Mark). Your line is open.

(Caroline Mark):
Thank you very much and it’s Dr. (Caroline Mark). I want to follow-up and see if there’s any statistics regarding the link between companion animals and antibiotic resistant infections?

Colin Basler:
That’s something I can get back to you on. I don’t have any numbers in front me between antibiotic resistant infections in animals, but that is something that sort of antidotally, and from my time at vet school, we were seeing more cases of antibiotic resistance in veterinary patients.

And I know - I was - there has been some recent publications on MRSA infections being - having very similar infections, both in patients, in human patients, and in their pets. I don’t know if there has been a lot of research on the direction of those infections, if they were zoonotic, if the patients got the infections from the animals, or vice versa, but it’s an area that additional research is definitely needed.

And we’re also seeing - for other antibiotic resistant issues the veterinary profession is starting to see a lot of the same issues that have been seen for the past couple of decades in human medicine regarding an increase in antibiotic resistance.

(Caroline Marks):
Okay. Thank you.

Kara Jacobs Slifka:
And this is Kara. I also just wanted to comment that this is a question that we also have asked at times during outbreak investigations. When we see antimicrobial resistance in human isolates we question whether this is the same resistance seen in animals or whether the same pathogen is in a human that then after different antibiotic exposures within that human has developed antibiotic resistance. So it’s an excellent question and definitely something that we may be able to provide more information to you about.

(Caroline Marks):
Thank you very much, appreciate it.

Loretta Jackson Brown:
Operator, the next question.

Coordinator:
The next question comes from (Darlene). Your line is open.

(Darlene):
Hi, this is (Darlene) from Florida. And I am curious if there are any laws that allow or require the removal of animals after an illness has happened in a home that would help protect the family and/or the animal itself?

Colin Basler:
Hi, this is Colin. At this point, there are no national laws that I know of, but I think that there are some state and possible local jurisdiction laws in different areas regarding the removal of animals after they have caused infection. Sorry, I can’t give you more information than that at this point.

Loretta Jackson Brown:
I have a question from the Webinar system. It says, would you please provide some information regarding what common Salmonella stereotypes, excuse me, serotypes have been seen in these enteric zoonotic Salmonellosis? Any particular serotypes associated with reptile exposure or pet foods?

Colin Basler:
That’s a great question. So starting with live backyard poultry, we’ve been seeing a number of Salmonella Infantis, Salmonella Montevideo and Salmonella Typhimurium have been the three most common serotypes associated with backyard poultry outbreaks. That being said, there’s been a very wide variety of different serotypes associated with backyard poultry.

For reptiles the recent bearded dragon outbreak was associated with Salmonella Cotham and Salmonella Kisarawe. Both of those were very, very rare serotypes that do not commonly infect humans, which is why we were able to link those with bearded dragon exposure.

For turtles, I believe Salmonella Typhimurium and Salmonella Santiego have been some of the more common ones that we’ve been seeing with turtles. Also Salmonella Pomona and Salmonella Poona have been implicated.

For pet food, the chicken jerky outbreak in New Hampshire was, I believe, Typhimurium and the Salmonella in the pet food was Schwarzengrund. But we’ve been seeing a sort of - there’s been other - Salmonella in pet food is considered an adulterant, so there have been a number of other Salmonella being found in pet food by the FDA that has led to a number of pet food recalls that have now been associated with human illness.

Loretta Jackson Brown:
Thank you. Operator, do we have another call, excuse me, question from the phone?

Coordinator:
The next question comes from (Jasmine). Your line is open.

(Jasmine):
Hello, this is (Jasmine) from New York. The part that worries me the most about the entire presentation is - deals with Slide 54 about the Salmonella outbreak in 2014.

So let’s say someone has a snake and is very careful, like they know that that snake has a good background and doesn’t have Salmonella and gets everything checked out. Now do you know if these frozen feeder rodents were from places that weren’t really reputable and that’s kind of how they got the Salmonella? Or were these unfortunate circumstances from say like bigger pet stores or things like that?

Colin Basler:
That’s a great question. These are actually from - these were sold from a number of large nationwide chains. And so it was a larger, more reputable, source of frozen feeder rodents.

And this is something that there are some different companies that sell these products use a variety of different methods to try and reduce, or remove, Salmonella from the frozen feeder rodents before they end up in people’s houses and also in people’s freezers because a lot of people will buy them in bulk and keep them for a long period of time and hopefully aren’t thawing them out in their microwave.

So there are different - so there are ways to reduce the burden and not all production facilities are employing the same methods, if that makes sense.

Kara Jacobs Slifka:
But this is something, this is Kara, this is something that is very concerning for us as well and why it is so important for everyone to be aware of the potential exposures that you can encounter when interacting with animals and animal products and make sure that we spread the education, as well as making sure that people are washing their hands and are very cautious.

(Jasmine):
Then do you have any recommendations for people who use these products? Like anything they can do beforehand, like aside from, or afterwards, aside from washing their hands?

Colin Basler:
Honestly washing their hands is our biggest recommendation. We also recommend not storing feeder rodents anywhere where human food is stored, not doing any sort of frozen feeder rodent thawing or prepping in other food production areas, not letting small children handle frozen feeder rodents, and also just being aware that salmonella infections can be transmitted from the frozen feeder rodent to the reptile and then the reptile can possibly shed intermittently.

So if you have a larger snake or a lizard that eats these frozen rodents it’s probably a good idea to not let them wander around the house and to clean their terrariums or cages either outside, or at the very least in a non-food preparation area because it could - you could still easily cause environmental contamination, which becomes very problematic if you have small children in the household as well.

(Jasmine):
I see. And I guess my final question would be, if you don’t mind, would be that Salmonella - let’s say that something that has Salmonella touches a surface. How long would it last on that surface?

Kara Jacobs Slifka:
So we believe that it is possible that Salmonella can be quite hardy and potentially could last for very long periods of time on an environmental surface.

(Jasmine):
Okay. Thank you.

Loretta Jackson Brown:
Operator, do we have another question from the phones?

Coordinator:
The next question comes from (Latoya Simmons). Your line is open.

(Latoya Simmons):
Thank you. Great job on the presentation too, both of you, and thank you for sharing the wealth of information. I just had a couple of comments to add based on some of the questions that were asked.

One person asked about antibiotic resistance in some of the animals that were mentioned today. I actually had the privilege of being at the - on two of the investigations that were listed, which was with turtles and bearded dragons.

And in both cases, for the turtles specifically, there were no human illnesses or turtles that were tested that were resistant to any commonly used antibiotics for treatment. For the bearded dragons there were a couple of human cases, I think maybe actually one human case at the beginning of the investigation, that exhibited antibiotic resistance, but no other human cases or bearded dragons that were associated also exhibited the same resistance pattern.

As far as removal from animals from home, I only have researched turtles specifically with the law group here within CDC and there are no laws that exist per state within the United States that can remove turtles from homes. Turtles can, however, be removed from pet stores or other facilities that are selling them based on the state.

And as far as the question that was asked about which type of Salmonella do we commonly see in pet foods, in my limited experience with the foodborne group we have seen a lot of Typhimurium, or Salmonella Typhimurium, reported.

Loretta Jackson Brown:
Thank you. And you - are you still there?

(Latoya Simmons):
Yes.

Loretta Jackson Brown:
Okay. You’re a CDC colleague?

(Latoya Simmons):
Yes.

Loretta Jackson Brown:
Okay. And I’m sorry, state your name again.

(Latoya Simmons):
(Latoya Simmons).

Loretta Jackson Brown:
(Latoya Simmons). Okay thank you for that.

(Latoya Simmons):
Yes. Thank you.

Loretta Jackson Brown:
And since we’re kind of talking about these pet stores we actually have several questions tied together, so I am going to kind of summarize them here.

So one is, you know, are the pet stores covered by regulations at state, or local, federal level? And there is also a comment that one of the pet stores is actually having a reptile rally this Saturday, July 19. And they want to know if CDC is working with some of the large pet chains for appropriate prevention messages and also how do you increase that “One Health” approach between clinicians and veterinarians?

Colin Basler:
That is a great series of questions. All right so to start with we have done - we have been trying to do a fair amount of outreach to different pet stores chains and organizations.

There is an organization called PJAC, which is, I forget what it stands for, but it’s the Pet Joint Advisory Council I believe, which is actually sort of an umbrella organization of large and small scale pet stores. We are also - so getting a lot of our, specifically our reptile and hedgehog, information distributed to those stores has been very helpful for us in the recent past.

CDC is also part of the Zoonotic Education Coalition, which involves the CDC, the State Public Health Veterinarians, the American Veterinarian and Medical Association, as well as representatives from PJAC and from a couple of the other major nationwide pet store chains, primarily PetSmart and Petco, as well as some reptile veterinary researchers.

So this committee has been working on coming up with additional education material specifically for the issue regarding reptile zoonoses and primarily salmonella at this point. So we’ve had a good outreach with pet stores to-date.

As far as laws go they’re different - it’s another issue of there being different state and local laws in different areas regarding removal of animals, like what (Latoya) was saying about removing turtles from pet stores and other issues regarding pet stores. And am I missing one of the sections?

Kara Jacobs Slifka:
And this is Kara. Just to comment on the question regarding the “One Health” approach, one of the things that we are doing are calls just like this to try to reach out to people in multiple different areas of public health, in clinical medicine, veterinary, and environmental scientists, trying to reach out to everyone to spread these messages and to share these educational materials.

And that’s why we included a few different slides about some of the educational materials that we have put together already and we do continue to work on those. But we encourage trying to share that information, to post that information widely, so that patients, consumers, out there are able to access that information and spread those messages.

Loretta Jackson Brown:
Wonderful. Operator, do you have any more questions for us on the phone?

Coordinator:
We do have one question I am showing from (Dustin Holly), I believe. Your line is open.

(Dustin Holly):
Hello. That was a very nice presentation. My question has to do with Campylobacter and I was wondering are there specific animals that are more likely to be carriers and transmitters of Campylobacter? And also in the diagnosis wouldn’t that be a more difficult diagnosis than Salmonella?

Colin Basler:
Thank you for the question. Yes, Campylobacter has actually been found in a number of different species. It’s fairly common in cows. It’s also been seen in poultry and actually Campylobacter infections, I believe, have also been seen occasionally in companion animals, so in cats and dogs as well.

We haven’t - as far as I know there haven’t been any major large multi-state outbreaks associated with Campylobacter and animal exposure, but I don’t have great information on that. And I do agree that it would be a little more difficult to identify an animal as the cause of source for that. The majority of, at least for some of the recent Campylobacter outbreaks that CDC has been investigating, have been associated with raw chicken products or undercooked chicken products.

Kara Jacobs Slifka:
So still potentially animal related, but the exposure type may be foodborne, but it is definitely possible. We believe that it could be spread through other methods of exposure. And so, yes, and with all of these diagnosis it can be challenging, but we believe, do see, and follow outbreaks, so we definitely know that they are happening.

Loretta Jackson Brown:
Thank you. Operator, are there any more questions from the phone?

Coordinator:
There are no questions in queue at this time.

Loretta Jackson Brown:
Okay so we’ll end with a final question from the Webinar. It has to do with feeder rodents.

So they say that feeder rodents can be purchased online. Any suggestions on how to address providing public education for Internet based purchases of frozen rodents, or is that feeder rodents?

Colin Basler:
Yes. So that’s actually been a big issue, both with frozen feeder rodents being purchased online and we’ve actually also seen there have been some ways to purchase baby turtles online, as well as there have been some people selling hedgehogs and other small - some of the other small pocket pets over the Internet or through Craigslist.

So getting to those online retailers is definitely going to be a challenge. We’re hoping that we can at least - having the Web information, and specifically the new Web buttons, as CDC resources and getting those distributed out through the PIJAC network we’re hoping that some of those distributors of turtles and of (back) (end) of frozen feeder rodents would be able to link their Websites to the CDC just to provide additional education and information regarding safe handling techniques and just the fact that those products can pose a risk. So we’re doing as best as we can to try and reach those different product distributors as well.

Loretta Jackson Brown:
So on behalf of COCA, I would like to thank everyone for joining us today with a special thank you to Dr. Jacobs Slifka and Dr. Basler. We invite you to communicate with our presenters after the Webinar. If you have additional questions for today’s presenters, please e-mail us at coca@cdc.gov. Go ahead and put July 17 COCA Call in the subject line of your e-mail and we will ensure that your question is forwarded to the presenters for a response. Again the e-mail address is C-O-C-A@cdc.gov.

The recording of this call and the transcripts will be posted to the COCA Web site at emergency.cdc.gov/coca within the next few days.

Free continuing education credits is available for this call. Those who participated in today’s COCA Webinar and would like to receive continuing education should complete the online evaluation by August 18, 2014, using Course Code WC2286, the letters SC. For those who will complete the online evaluation between August 19, 2014, and July 16, 2015, use Course Code WD2286(SC).

All continuing education credits and contact hours for COCA calls are issued online through TCE Online, CDC’s training and continuing education online system at www.cdc.gov/tceonline.

Save the date, Thursday, September 18, from 2:00 to 3:00 pm Eastern Time for an upcoming COCA call on influenza recommendations for children. Call information will be posted in the next few weeks on our COCA Webpage at emergency.cdc.gov/coca.

To receive information on upcoming COCA calls subscribe to COCA by sending us an e-mail at coca@cdc.gov and write “Subscribe” in the subject line. Also CDC has a Facebook page for health partners. Like our page at Facebook.com/cdchealthpartnersoutreach to receive COCA updates.

Thank you again for being a part of today’s COCA Webinar. Have a great day.

Coordinator:
Thank you for your participation in today’s conference. Participants you may disconnect at this time. Speakers, please standby for post-conference.

END

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