Illness Outbreaks Linked to Enteric Zoonoses and the Interconnectedness of Human and
Animal Health
Megin Nichols, DVM, MPH, DACVPMEnteric Zoonoses Activity LeadCenters for Disease Control and Prevention
April 24th, 2019
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Speaker Introduction
Megin Nichols, DVM, MPH, DACVPMEnteric Zoonoses Activity LeadCenters for Disease Control and Prevention
Welcome Dr. Megin Nichols!Enteric Zoonoses Activity Lead at the Centers for Disease Control and Prevention
Investigates multistate outbreaks of Salmonella and E. coli Principal Investigator of the Active Bacterial Core Surveillance
Program at the New Mexico Department of Health for 5 years
Education Bachelor of Science degree in Animal Science NMSU Doctor of Veterinary Medicine from Colorado State
University Master of Public Health in Food Safety and Biosecurity
from the University of Minnesota Epidemiologic Intelligence Service (EIS) Officer 2008–2010
New Mexico Department of Health Spent several years as a clinical veterinary assistant Interests include zoonotic disease, food safety, and pediatric
health
Question Who is in the audience today?
a. Clinical practice veterinariansb. Public practice/governmentc. Teaching and researchd. Militarye. Other
National Center for Emerging and Zoonotic Infectious Diseases
Enteric Zoonoses Outbreaks and the Interconnectedness of Human and Animal Health
Megin Nichols, DVM, MPH, DACVPM
Enteric Zoonotic ActivityOutbreak Response and Prevention BranchDivision of Foodborne, Waterborne and Environmental Diseases
April 24, 2019
Objectives
Review the enteric disease risks associated with pets Examine cleaning and sanitation practices veterinarians can use to
prevent illness Discuss how CDC communicates regarding illnesses linked to
contact with pets and steps you can take to stay healthy
Yes, pets do carry enteric bacteria
Zoonotic Diseases or Zoonoses
Disease or infection naturally transmissible between vertebrate animals and humans
Bacterial, viral, fungal, or parasitic
Prevent efficient production of food of animal origin
Create obstacles to international trade in animal products
Hale, C. et al. Estimates of Enteric Illness Attributable to Contact With Animals and Their Environments in the United States, Clinical Infectious Diseases, Volume 54, Issue suppl_5, 1 June 2012, Pages S472–S479, https://doi.org/10.1093/cid/cis051
What is an Outbreak?
An incident in which two or more people experience a similar illness after contact with a common exposure and epidemiologic analysis implicates the exposure as the source of the illness
Outbreak Detection: PulseNet USA National Molecular sub-typing network for enteric disease surveillance
– Includes 87 public health and regulatory laboratories Creates DNA “fingerprints” of bacteria isolated from ill persons using
pulsed-field gel electrophoresis (PFGE)– Indistinguishable PFGE patterns likely share a common source
=
Whole Genome Sequencing (WGS) Provides a higher resolution view of the bacterial genome
Detecting Outbreaks with PulseNet WGS data from illness-causing bacteria uploaded to the PulseNet USA
database Monitored for temporal and geographic clustering When a cluster is identified, PulseNet notifies epidemiologists
PulseNet-Confirmed Cases: The Tip of the Iceberg
*Foodborne Illness Acquired in the United States – Major Pathogens. Scallan, et al. EID 2011
Antibiotic Resistance and Food Safety Most foodborne infections are mild and do not require treatment Antibiotics can be lifesaving in severe illnesses Antibiotic resistance compromises our ability to treat infections Salmonella and Campylobacter cause an estimated 410,000 antibiotic-
resistant infections in the United States each year
What if the outbreak isn’t foodborne?
Animal-associated Foodborne
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Campylobacterspp.
Cryptosporidiumspp.
Salmonella spp.non-typhoidal
STEC non-O157 STEC O157 Listeriamonocytogenes
Yersiniaenterocolitica
Disease Attribution for Animal Contact
14% of all illnesses caused by 7 groups of pathogens were attributable to animal contact
Estimated 445,213 illnesses annually for the 7 groups combined
Perc
ent
Pathogen
Hale, C. et al. Estimates of Enteric Illness Attributable to Contact With Animals and Their Environments in the United States, Clinical Infectious Diseases, Volume 54, Issue suppl_5, 1 June 2012, Pages S472–S479, https://doi.org/10.1093/cid/cis051
Enteric Zoonoses Epidemiology
Demographics Exposure type Seasonality Regulation Duration
Demographics
387
623312
248546 362 70
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
< 1 1 to 4 5 to 9 10 to 19 20 to 49 50 to 74 75+
Animal Contact Food
Perc
ent
Age Group (years)
Percent of Total Illnesses in Each Age Group, by Primary Mode of Transmission, reported to the National Outbreak Reporting System (NORS), 2009–2014
Marus, JR, Magee, MJ, Manikonda, K, Nichols, MC. Outbreaks of Salmonella enterica infections linked to animal contact: Demographic and outbreak characteristics and comparison to foodborne outbreaks—United States, 2009–2014. Zoonoses Public Health. 2019; 00: 1– 7. https://doi.org/10.1111/zph.12569
Exposure: Direct vs. Indirect Contact Direct Contact
– Touching, snuggling kissing animals– Petting zoos, farms, homes
Indirect Contact – Cleaning animal feces or environment– Touching animal cages, bedding, litter boxes– Pet stores, multi-purpose spaces (barns)
Exposure: Occupation Ranchers Dairy workers Veterinarians Slaughterhouse workers Postal workers Pet store workers Zoo keepers
Question True or False?
– Veterinarians are immune to Salmonella infections because they are routinely exposed in the course of their work
Evidence of immunity among people frequently
exposed to Campylobacterand E. coli O157, but NOT
Salmonella
Enteric Zoonoses Seasonality Month of outbreak onset by primary mode of transmission, NORS, 2009–2014
0
10
20
30
40
50
60
JAN FEB MAR AP RIL MAY JUN JULY AUG SEP T OCT NOV D EC
Animal Contact Food
Cou
nt
Month of Outbreak Onset
Marus, JR, Magee, MJ, Manikonda, K, Nichols, MC. Outbreaks of Salmonella enterica infections linked to animal contact: Demographic and outbreak characteristics and comparison to foodborne outbreaks—United States, 2009–2014. Zoonoses Public Health. 2019; 00: 1– 7. https://doi.org/10.1111/zph.12569
Regulation
Public Health Interventions and Recommendations
Foodborne Outbreak Enteric Zoonotic Outbreak
Public Health Interventions and Recommendations: A Multi-tiered Approach Animal production and raising Retail stores and industry Consumer homes
Communication Regarding Outbreaks
Multistate Outbreak of Multidrug Resistant Campylobacter Linked to Pet Store Puppies
Background: Campylobacter Characteristics
Gram-negative, microaerophilic Ideal temperature range 37°C to 42°C Greater than 20 species
– Campylobacter jejuni causes most human illness Infection usually from consumption of contaminated food
Background: Human Campylobacter Infection CDC estimates 1.3 million people are affected each year in the U.S. Severe diarrhea, can be hemorrhagic Incubation: 2 to 5 days Duration: approximately 7 days Complications
– Immune-mediated arthritis – Irritable bowel syndrome – Guillain-Barré syndrome
Background: Campylobacter Antibiotic Resistance Most treatment for Campylobacter infection is supportive Fluoroquinolone and macrolide antibiotics are first-line choice Increasing resistance since 1997
– Fluoroquinolone• 27%
– Macrolide• 2%
Background: Campylobacter in Dogs
Dogs can be healthy carriers of Campylobacter Dogs in crowded conditions are more likely to be infected Clinical infection occurs more frequently in puppies (<12 month of age) Dogs with suspected Campylobacter infection are usually treated supportively
– In severe cases antibiotics are selected empirically
Communication with New Puppy Owners
Vaccinations
Diet
Training De-worming
Exam
Ask questions
Zoonotic Disease?
Occupational Health?
Outbreak Investigation Objectives
1. Identify additional human illnesses
2. Determine the source of Campylobacter infection
3. Develop recommendations to stop the current outbreak and prevent additional illnesses
Results: Patient Demographics and Outcomes 113 cases from 17 states
– 38 (34%) of cases identified by whole genome sequencing (WGS)
Reported and estimated illness onset dates: 1/12/16–1/7/18
Age range Less than 1 year to 86 years, median = 27 years Sex
– Female = 69 (63%) Hospitalized
– 23 (22%) hospitalizations and no deaths
Results: Descriptive Epidemiology
99% (104/105) report puppy exposure
87% (89/102) report Retail Chain P exposure from 12 states
– 25 (23%) employees
10 cases without exposure to Retail Chain P report exposure to another pet store
Communication Regarding the Outbreak
Results: People with Campylobacter infection linked to Retail Chain P puppies, by state of residence, as of January 18, 2018 (n=113)
Results: People with Campylobacter infection linked to Retail Chain P puppies, by date of illness onset*
*n=111 for whom information was reported as of January 18, 2018
Num
ber o
f Peo
ple
0
5
10
15
20
25
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
2016 2017 2018
Month of Illness Onset
Don’t all dogs carry Campylobacter?
Methods: Stool Sampling 5 to 10 puppy samples per store Fresh stool in two containers Storage and transportation Additional items to collect
– Breeder– Distributor– Antibiotic records
Whirl-pakCary Blair
Whole Genome Sequencing: 48 Isolates
10 38
Created by Hysen Drogu from the Noun Project
Puppy
Human
Up to 282 alleles
Up to 59 alleles
32 alleles
21 alleles
30 alleles
Puppy
Human
Predicted resistant/resistant
Predicted susceptible/susceptible
Where is the multidrug resistance coming from?
Most Common Antibiotic Classes by Number of Days Administered (i.e. Dog-Days)
997
620
422
253
111
67
37
37
37
17
Nitroimidazoles
Sulfa drugs
Tetracyclines
Macrolides
Quinolones
Penicillins
Phenicols
Aminoglycosides
Cephalosporins
Lincosamide
Indication for Antibiotics Administered to 141 Puppies
5%
55%
38%
1%
None
Prophylaxis only
Treatment and prophylaxis
Treatment only
But metronidazole isn’t going to cause any harm,
right?
Recommendations
Pet owners Pet store employees
Healthcare providers
Veterinarians
Recommendations
Pet owners Pet store employees
Healthcare providers
Veterinarians
– Hand washing
– Sanitation
– When to seek veterinary care
Recommendations
Pet owners Pet store employees
Healthcare providers
Veterinarians
– Hand washing
– Sanitation
– When to seek veterinary care
– Hand washing
– Sanitation
– Personal protective equipment
– Food storage away from animal areas
Recommendations
Pet owners Pet store employees
Healthcare providers
Veterinarians
– Hand washing
– Sanitation
– When to seek veterinary care
– Hand washing
– Sanitation
– Personal protective equipment
– Food storage away from animal areas
– Antibiotic resistance
– Case management
– Avoid antibiotics to which the outbreak strain is resistant
Recommendations
Pet owners Pet store employees
Healthcare providers
Veterinarians
– Hand washing
– Sanitation
– When to seek veterinary care
– Hand washing
– Sanitation
– Personal protective equipment
– Food storage away from animal areas
– Antibiotic resistance
– Case management
– Avoid antibiotics to which the outbreak strain is resistant
– Campylobacter testing
– Sanitation
– Pet owner communication
– Antibiotic stewardship
Conclusions Large, multistate Campylobacter illness outbreak linked to dogs
Animal caregivers at greater risk for illness
No single source of infection, but likely disseminated throughout the industry
Outbreak strain is resistant to common first-line antibiotics used to treat Campylobacter infections
Highlights antibiotic resistance and the need for ongoing antibiotic stewardship
Additional Resources Healthy Pets, Healthy People
– https://www.cdc.gov/healthypets/specific-groups/veterinarians.html Outbreaks
– https://www.cdc.gov/healthypets/outbreaks.html
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank you!
Acknowledgments
Enteric Disease Epidemiology Branch– A. Geissler– C. Friedman– L. Francois-
Watkins– M. Hughes– M. Laughlin– R. Silver– P. Sundararaman– S. Crowe– S. Dixon
Ohio Department of Health– R. Bokanyi– E. Brandt– S. de Fijter– L. King– G. McGillivary– J. Mowery– E. Salehi– J. Seikel– A. Singh
Ohio Department of Agriculture– B. Byrum– J. Cui– M. Prarat– M. Beth Weisner– Y. Zhang
Outbreak Response and Prevention Branch– C. Basler– I. Williams– L. Koski– L. Stevenson– L. Whitlock– S. Uong– M. Jhung– M. Nichols– N. Dowell– J. Jackson
Enteric Diseases Laboratory Branch– L. Joseph– R. Aubert– C. Bennett– J. Chen– H. Caidi– K. Tagg– J. Folster– J. Pruckler– J. Whichard
Florida Department of Health– A. Ginn– D. Stanek– J. Blanton– J. Nasir– M. Schimenti– N. Pickens
United States Department of Agriculture-Animal and Plant Health Inspection Service– T. Gomez– W. Stokes
Pet Industry Joint Advisory Counsil– T. Edling
Iowa Department of Public Health– A. Garvey– D. Schmitt– K. Oni
Missouri Department of Health and Senior Services– A. Grim– E. Anderson– H. Pue– J. Bos– J. Schmidt– L. Hickam
Indiana State Department of Health– B. Marsh– B. Schroeder– C. Clark– D. Derrer– G. Haynes– J. Brown– J. Lovejoy– K. Shipman– M. Ash– M. Justice– N. Stone– P. Pontones– S. Norman– S. Richards
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