Worms and Germs Blog : Animal Health & Diseases : University of Guelph : Ontario Veterinary College : Zoonotic Diseases : Guelph, Hamilton, Ontario

Pasteurella multocida is a bacterium that's commonly found in the mouths of dogs and cats. It's a common cause of cat and dog bite infections in people, but can also be spread through close contact with pets (without bites). It's logical to assume that the closer the contact, the greater the risk of transmission. A recent report in Clinical Infectious Diseases (Myers et al 2012) describes three people with life-threatening Pasteurella infections. A unique aspect was all three people got sick from nursing dying pets.

Case 1

• A 55-year-old woman with sore throat, fever and difficulty swallowing was diagnosed with epiglottitis (inflammation of the epiglottis, a part of the throat region) and hospitalized. Pasteurella multocida was identified on a blood culture.  It was subsequently revealed that she had provided palliative care to her dying dog. As part of this, she was dropper-feeding the dog honey, and also eating honey with the dog from the same dropper.

Case 2

• A 63-year-old woman with sore throat, difficulty swallowing and hoarseness was diagnosed with uvulitis (inflammation of a different part of the throat region) and narrowing of her airway. As with Case 1, P. multocida was isolated from her blood. Her cat had died six weeks earlier and she had "continuously held, caressed, hugged and kissed her cat during its last 7 days of life."

Case 3

• A 66-year-old woman was hospitalized with fever, chills, cough and difficulty breathing. She had severe pneumonia and P. multocida was grown from a sample of respiratory secretions. Two weeks before she got sick, she had provided palliative care for her dying cat, by "holding, hugging, and kissing the head of the cat and allowing the cat to lick her hands and arms."

Fortunately all three women recovered from their infections, but the severity of disease is certainly a concern. As is common, there was no attempt to see whether the implicated pets actually carried the same Pasteurella multocida strain as the owners, but here the authors at least had a good excuse, since all of the pets had died before the owners got sick.

There are some interesting points in the Discussion section of the paper.

"Our 3 patients’ histories of having recently provided palliative pet care to their dying animals were obtained only after P. multocida was identified in cultures and only after subsequent detail-oriented, animal contact histories were obtained."

• Pet contact (or animal contact in general) is still not asked enough by physicians investigating unknown illnesses. It's unclear whether it would have made a difference in these cases, but knowing more and knowing it earlier can help speed the path to the right diagnosis. Here, pet contact was only considered after a pet-associated bacterium was identified.

"Simply asking whether or not the patient had a pet would not have uncovered the defined association of these respiratory illnesses with palliative pet care. The patient with P. multocida uvulitis even denied having a pet (it had died 6 weeks previously) and only admitted to having provided palliative pet care when asked specifically if she had any animal contacts in the past 3 months."

• This shows some of the challenges and how care must be taken when asking about pet contact. Simply asking "Do you have a pet?" doesn't cover it.

"Only diligence and very detail-oriented, pet-related histories will likely uncover further patients with invasive P. multocida infection related to the pet owner’s provision of palliative pet care to dying animals."

• This shouldn't be focused on palliative pet care, since that's a minor component of pet contact. Many other people have close contact with their pets, even when the pets are healthy. It's something that should be considered at all times.

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While it shouldn't come as a surprise considering other studies, a recent study in PLoS One (O'Brien et al 2012) has caused a bit of a stir in the US. This study, headed up by Dr. Tara Smith's research group in Iowa, looked for methicillin-resistant Staphylococcus aureus (MRSA) in retail pork. They bought pork from different stores in Iowa, Minnesota and New Jersey, and tested it for the presence of MRSA. They focused on pork because MRSA can be found widely in pigs internationally, including in the US.

Not surprisingly, they found MRSA. Overall, they tested 395 pork samples from 36 stores, including both "conventional" pork (300 samples) and "alternative" pork (95 samples). The latter consisted of samples labelled "raised without antibiotics" or "raised without antibiotic growth promotants." MRSA was found in 6.6% of samples; 6.3% of conventional pork samples and 7.4% of alternative pork samples.

When they looked at the MRSA types that were present, 27% were the ST398 "livestock-associated" MRSA that's most commonly found in pigs.  However, like our earlier Canadian studies, they found common "human-associated" MRSA strains more often. These strains can also be found in pigs, albeit less commonly than ST398, and it's unclear whether meat contamination with these strains comes from pigs or from people who handle the meat throughout the processing chain.

The fact that there was no difference between conventional and antibiotic-free pork isn't surprising to me, although it catches some people off-guard because of some basic over-assumptions about the relationship between antibiotics and MRSA in food animals. We can find MRSA quite commonly on both regular and antibiotic-free farms.  While it's reasonable to assume that antibiotics were a key factor in driving the emergence of MRSA in pigs, there's not much evidence showing that ongoing antibiotic use is an important factor in determining whether MRSA is present on specific farms or in specific pigs. One potential explanation is that in order to control infections, farms that stop using antibiotics start using other substances such as zinc in feed to help control overgrowth of certain intestinal bacteria, and these compounds may be just as effective at selecting for certain resistant bugs as classical antibiotics. That's just one possible explanation, but it shows how complex the issue of antibiotic-resistance is, and it shows that simply saying "stop using antibiotics," without really looking at the overall problem, won't necessarily reduce MRSA.

What does the presence of MRSA in food mean? Who knows? MRSA is a pretty high profile bug, and with good reason, because it's a very important cause of infection in people. A key aspect of MRSA in food is that cooking food will kill the bacteria (as well as many of the other harmful bacteria that often contaminate raw meat). So proper attention to food safety, including thorough cooking, cleaning of surfaces, prevention of cross-contamination and hand hygiene, should greatly reduce any risk (the problem is a lot of these things aren't usually done very well).

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Case reports of infections acquired from pets are sporadically found in the human medical literature. A common problem with these reports is the failure to look for true evidence of zoonotic transmission. The typical thought process is "We found this bug in a person, it's most often found in animals, so this person must have gotten it from their pet." Often, this likely is actually the case (although some evidence would be nice). In other instances, like the Pasteurella bone infection described in the Orthopedics paper I wrote about recently, this assumption is probably completely off-base.

Something that is usually missing from these reports is any investigation of the suspected pet. Finding the bacterium in question in/on the pet, and showing that it's the same strain as was found in the person goes a long way to supporting the conclusion that the pet was the source. It's not a 100% guarantee, since you can't say whether it went from pet-to-person or person-to-pet, but with a typically pet-associated bacterium its much more likely to have come from the pet, so finding the same strain in both pet and person is pretty solid evidence. Most case reports don't bother even trying to get this much information (but they still get published...).

A case report in an upcoming edition of Zoonoses and Public Health (Register et al 2012) is another example of a study that provides some information about a potential pet-associated infection, but stops short of the type of proof that is needed. To their credit, the pet wasn't available for testing and they are clear that it's a "possible" case of zoonotic transmission, which puts them a step up on other studies, but it's still too bad the additional information couldn't be reported.

The case report describes an 11-year-old girl with cystic fibrosis (CF). People with CF are at greatly increased risk of respiratory infections, including infections caused by microorganisms that typically don't cause disease in other people. This child had a sputum sample collected during a routine doctor's visit, when she didn't have any signs of respiratory infection. Bordetella bronchiseptica, a bacterium most often found in dogs and cats (and one of the causes of kennel cough (aka canine infectious respiratory disease syndrome) in dogs), was isolated from the sample. When this was explored further, it was revealed that child's family had obtained a new kitten three weeks earlier, and the kitten had signs of respiratory disease.

Unfortunately, the kitten had been removed from the household by the time B. bronchiseptica was diagnosed in the girl, so it couldn't be tested. (They don't say why the family got rid of the cat.) However, the authors at least took it a step further and did some detailed molecular characterization of the bacterial strain they recovered from the sputum sample. Different genetic traits suggested that the strain was feline in origin, and, combined with the fact that the child had contact with the kitten, this provided a little more support to the hypothesis that the cat was the source. It's not proof, but still interesting. They also determined that the B. bronchiseptica strain was missing a gene that's associated with helping cause disease, suggesting it's not as able to make people sick. That might explain why the child was carrying the strain in the absence of disease, although people can carry lots of different bacteria that can potentially cause disease without being clinically ill.

In the end, it was an interesting little report and the authors conclude with a couple of good statements:

"Acquisition of detailed clinical and epidemiological data paired with discriminatory genetic comparison of case isolates and contact isolates is needed to more firmly establish transmission patterns and identify likely contact risks." (A fancier way to say what I said above.)

"...it seems advisable to counsel CF patients regarding adherence to practices that minimize opportunities for zoonotic transmission of B. bronchiseptica from family pets or other potentially infected animals."

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No, not gravy made from bearded dragons (a type of reptile), but foodborne Salmonella with a link to the reptile.

Reptiles are an important source of Salmonella, which is why standard guidelines recommend that high-risk people (e.g. children less than 5 years of age, elderly individuals, people with compromised immune systems, pregnant women) not have contact with reptiles or have them in the house. A report in Zoonoses and Public Health (Lowther et al 2011) highlights another possible risk.

The report describes a Salmonella outbreak that was traced back to a potluck dinner. Nineteen cases were identified, 17 primary cases (people that attended the dinner) and two secondary cases (household members of people that attended the dinner). Overall, 29% of people that attended the dinner got sick. A further 18 people had some intestinal disease but strictly speaking didn't fit the definition for a case (however it is suspected that they were part of the outbreak). Salmonella subspecies IV (a type mainly associated with reptiles) was isolated from the stool of five people, confirming the occurrence of an outbreak.

As is typical, food consumption history was evaluated. Sixteen of the 17 primary cases reported consuming turkey gravy, which was a statistically higher proportion than that of people who did not get sick. The gravy was made at the private home of a person who didn't attend the dinner. This was the only home of the people involved where reptiles were kept. Two healthy bearded dragons lived in the house, in a terrarium in the living room.

The investigation focused on the reptiles, since the Salmonella strain found is typically associated with reptiles, and the turkey (the source of the gravy) had no evidence of Salmonella contamination based on testing. Samples from the environment of the household where the gravy was made were collected, and two types of Salmonella were identified. One of these Salmonella types (Salmonella Labadi, which was different from the outbreak strain) was isolated from one of the bearded dragons, as well as the inside and outside of the terrarium glass, other terrarium surfaces, surfaces around the terrarium, the bathroom sink drain and kitchen sink drain.

A common question that comes up when people have reptiles and high risk people in the house is "If I don't take the critter out of the cage, I should be ok, right?" Unfortunately, that's not true. Human Salmonella infections have been clearly identified in situations where reptiles don't leave the terrarium because (as was the case here), while the reptile may not leave the terrarium, Salmonella often does.

The person who made the gravy said that the bearded dragons had not been out of the terrarium when food was being prepared. A child was responsible for feeding the reptiles and cleaning the terrarium, and was supposed to use the bathroom for terrarium cleaning. However, it was reported that the reptiles' dishes "might have" been cleaned in the kitchen sink during the the day period when food was being prepared for the party.

The overall conclusion was that this outbreak "probably resulted from environmental contamination from bearded dragon faeces." It's a reasonable conclusion. Even though the same Salmonella strain wasn't found in the reptile, it makes sense because the reptiles were the most likely source of environmental contamination in the household, and that was the most likely source of the foodborne contamination. Reptiles can shed various Salmonella strains and they can shed intermittently. It takes multiple samples over time to get a real idea of the scope of Salmonella shedding, and I assume that one or both of these reptiles were shedding the outbreak strain at some point.

How can something like this be prevented, since the standard recommendation of having high risk people avoid contact with reptiles doesn't apply to this type of situation?

• Good hygiene practices should be used when handling reptiles and their environments. In particular, there should be proper attention to hand hygiene after contact with reptiles or their cages.
• Reptiles should not be allowed in the kitchen. Ever.
• Food and water bowls should not be cleaned in kitchen sinks. Terrariums should not be cleaned in kitchen sinks. Ideally, they shouldn't be cleaned in bathroom sinks either. (If possible they should be cleaned outdoors with a hose.)
• Good food handling practices are critical. Here, gravy wasn't re-heated to a high enough temperature to kill the contaminating Salmonella. Adequate re-heating would have prevented this outbreak.

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The Redlands Animal Shelter in California is looking into bird control measures after blaming Giardia infections in dogs on exposure to wild bird poop. On Facebook, Redlands Friends of Shelter Animals have declared "We have a serious problem with birds at the shelter. They land on the kennels and poop goes into the water bowls and give the dogs giardia - which is a parasite that gives them explosive diarrhea."

Giardia is a protozoal parasite that can cause diarrhea in dogs and other species. It can also be carried by healthy dogs, at relatively high rates in some groups. The scope of the problem at the Redlands shelter isn't clear since the news article only talks about one case. Whatever the scope, shelter management is blaming the birds.

Apparently, discussions are underway with different companies about a solution to the bird problem, something that is anticipated to be expensive. However, it's all too common for people to jump the gun on expensive interventions when there's an outbreak and overlook the root causes. While news reports don't always give the whole story, I'd be wary about blaming birds without much more evidence.

Can wild birds carry Giardia? Yes. However, there's more to the Giardia story than that. It doesn't sound like they've actually tested the bird feces to determine whether Giardia is there. Additionally (and critically) it doesn't sound like they've determined the type of Giardia that's infecting the dogs. There are different types (assemblages) of Giardia and most have a limited range of species they can infect. The vast majority of dogs with Giardia in most regions are infected by Assemblage D, a dog-specific strain that comes from other dogs and poses no risk to people. I'm not aware of Assemblage D being found in birds. Dogs can also be infected by Assemblage A, a type that infects people, and also can infect birds.

So, if Assemblage D is involved, they need to look at transmission between dogs within the shelter. If Assemblage A is involved, they still need to focus on dogs but could investigate birds as a potential source.

Overall, Giardia transmission is much more likely due to breakdowns in cleaning, disinfection, hand hygiene and general shelter practices rather than birds pooping in water bowls. It's a lot cheaper to address these shelter management practices (which will also help control various other infectious diseases) rather than dumping a lot of money into controlling bird exposure when in fact that may not be causing the problem. Trying to reduce exposure to bird poop is a good thing as a general practice, but it's important to focus efforts and resources on finding and addressing the true root problems during an outbreak. 

More information about Giardia can be found on the Worms & Germs Resources page.

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