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

While in London (UK) last week, I went with a group of people to the John Snow pub. It's a bit of an epidemiologist pilgrimage, where you can sit in a pub named after one of the "fathers of epidemiology" and sign the guest book.

John Snow was a physician in London in the mid-1800's. Cholera outbreaks were a problem in Victorian London because of contaminated communal wells (for drinking water). Unlike many others, Snow did not believe in the miasma theory, which stated that noxious vapours in the air were the cause of many illnesses. While the "germ theory" of disease was not yet on the scene, Snow thought there must be some other way that diseases like cholera were transmitted, and he suspected (correctly) that the water supply was the problem.

During a cholera outbreak in 1854, he determined that a well in central London (Broad St, now Broadwick St) was a major source of the disease. Removing the handle from the pump (so that people could no longer use the well) stopped the outbreak.  Although Snow himself suggested that the outbreak was already in decline, removing that source undoubtedly played a large role in saving many lives. Back then (and even still commonly today), getting people to accept and adhere to infection control measures was not easy. After the outbreak ended, public officials fixed the pump, despite the fact that it was clearly associated with the outbreak. In hindsight, it's not surprising that this well was associated with disease, since it was shallow and very close to a cesspool.

The John Snow pub is located at the original site of the Broad Street pump.  You can see the location of the original pump from the window of the pub (there's a replica pump there and a marking on the ground at the exact site of the original pump). So, you can visit the source of a great cholera outbreak, peer out at the simple solution that helped stop it,  and have a drink in the pub named after John Snow - something that's more than a little ironic, since Snow was also famous as a teetotaler.

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At the ongoing ASM-ESCMID conference on methicillin resistant staphylococci in animals, Dr. Engeline van Duijkeren of Utrecht University (The Netherlands) presented a study on an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in their equine hospital.

From 2006-2008, several horses that underwent surgery at their hospital developed MRSA infections.  MRSA was also isolated from some healthy horses and personnel at the clinic. Early in the process, the hospital was closed for a thorough disinfection and the outbreak stopped, however another outbreak occurred later.  Further study again found people in the clinic that were MRSA carriers. Close to 15% of people in the hospital who handled equine patients were MRSA carriers, which is really astounding when you consider that less than 0.1% of the general population in the Netherlands carries MRSA. When they started testing horses coming into the clinic, they found that 9.3% of horses were carriers when they arrived. Weekly sampling of all hospitalized horses over a five-week period determined that 43% of all horses in the hospital carried MRSA at one point or another during their stay. Additionally, 53% of environmental surface samples were positive for MRSA, which is really not surprising if that many people and horses are carriers.

If horses keep coming into a facility carrying MRSA and people keep getting colonized, MRSA is hard to control. These experiences led the equine hospital at Utrecht to implement more stringent infection control practices to try to contain the problem, but the high MRSA rate in their referral population is going to pose a continual risk.

MRSA outbreaks in horses aren’t new. They’ve been reported by a few hospitals (including ours) and occur in many, many, (many!) more without ever being published. Since MRSA is present in the horse population, equine hospitals are at continual risk of MRSA outbreaks. If a large percentage of horses in the general population are carriers, the risk of outbreaks is higher.

MRSA is clearly a problem in horses in many areas. It’s important to realize that it’s a problem in the general population, not just horses in hospitals. Equine hospitals can amplify the spread of MRSA, but ultimately a lot (if not most) MRSA-positive horses originate from farms, not clinics or hospitals. Equine hospitals need solid infection control programs to reduce  the risk of outbreaks, but the risk will never be completely eliminated. Farms need good infection control programs to reduce the risk of spread of MRSA between horses and between farms, as well as from horses to people (and back). Antibiotics need to be used prudently since antibiotic use is a risk factor for MRSA carriage and infection.

More information about MRSA in horses can be found on the equIDblog Resources page.

This Worms & Germs blog entry was originally posted on equIDblog on 26-Sep-09.

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More from the ASM-ESCMID MRSA in animals meeting…

Dr. Joe Rubin presented some data on antibiotic resistance in Staphylococcus aureus bacteria from dogs and people in Saskatoon, Saskatchewan (Canada). The bacterial isolates came from dogs carrying S. aureus and from dogs infected with MRSA. When you look at the resistance patterns of the S. aureus isolates from the carrier dogs (these are an indicator of what’s around in the general population, and they can cause infections given the right circumstance), resistance was uncommon. Multidrug resistance was present in the methicillin-resistant S. aureus (MRSA) isolates, as expected.

Saskatoon’s an interesting area in terms of resistant bacteria. Various studies from the University of Saskatchewan have reported very low antibiotic resistance rates in bacteria from animals. Certainly, they have some problems like everywhere else, but I find some of their data quite remarkable. They can have a lot more confidence in the use of various first-line antibiotics compared to other regions where resistance is more common and drug options are more limited. I’m not really sure why this is the case.

• Maybe it has to do with the fact that there is less animal movement between Saskatchewan and other regions where there are more resistance problems.
• Maybe the low population density in Saskatchewan plays a role.
• Maybe multidrug resistant bacteria don’t like the frigid Saskatchewan winter (or the fact that there’s no NHL team in the province).
• Maybe they use antibiotics in animals in a much more controlled manner.

Trying to figure out why resistance rates in Saskatchewan tend to be lower would be useful because it might provide some information about how to reduce the risks in other regions.

So, if you’re in Saskatoon and your pet gets an infection, take some consolation in the fact that there’s probably a lower risk that you’re dealing with a resistant bacterium and that your first-line antibiotics will probably work.

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I'm in London (UK) for the ASM-ESCMID conference on methicillin-resistant staphylococci in animals: veterinary and public health consequences. I’ll provide various updates on interesting presentations over the next few days.

Dr. Armando Hoet from the Ohio State University (OSU) presented data on MRSA screening of dogs admitted to the OSU Veterinary Teaching Hospital. They sampled a subset of dogs admitted to the hospital every month over the course of a year.

• 5.7% of the dogs were identified as MRSA carriers. That’s a pretty impressive (and concerning) number. We know that a small percentage of dogs and cats in the general population are positive, but I’ve generally assumed the rate of carriage to be around 1-4%. However, you have to consider the study population whenever you look at numbers like this. Sixty-eight percent of the positive dogs were referral cases, meaning they had had previous contact with the veterinary healthcare system, may have been treated previously with antibiotics and may have had other diseases that increased the risk of MRSA.
• Ownership by people in the human or veterinary healthcare fields were risk factors for infection.  This is not very surprising since such owners would be more likely to pick up MRSA at work and bring it home to infect their pets.

Hopefully the true percentage of dogs in Ohio carrying MRSA is lower than this. Presumably, the rate of MRSA carriage by healthy dogs that are not owned by high-risk people is quite a bit lower. Regardless, it shows that MRSA can be found in a reasonable percentage of animals in the study area (as well as presumably other areas) and that good infection control practices are needed in veterinary hospitals to reduce the risk of transmission.

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

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A Yonkers, New York school has barred a service dog from a school. On the surface, that sounds like a problem and an invitation for a lawsuit (particularly in the US considering the Americans with Disabilities Act (ADA)), but when you hear the details is seems like an entirely logical response.

The "service dog" is a four-month-old puppy that the child, an 8-year-old boy with juvenile diabetes, uses to monitor his blood glucose levels. The boy's family has battled the school board for a year and the the state Division of Human Rights has declared this year that the Spataros had grounds to sue the district over the issue. Of to court they go...

Service animals need to have full access to do their jobs. The question comes down to is it really a proper service animal?  That's pretty subjective and the weakness of the ADA complicates things. In this case, it certainly seems that this is not truly a proper service dog.

• This dog is four months old. That's too young to be a highly trained service animal. It's also too young to properly assess its temperament, and temperament testing is very important for animals with such open access.
• School board officials claim the dog has not been properly trained and is "not a service dog under the existing service animals standards and guidelines."  A minimum of 120 hours of training over 6 months or more is recommended by the International Association of Assistance Dog Partners, something that obviously has not happened with this dog. The person that trained the dog says that the IAADP's guidelines are just suggestions rather than rules that have to be followed. That's true, but they are suggestions by a recognized and informed group, and I'd put their opinions well above someone who thinks a four-month-old puppy can be a proper service animal.
• The school board has also offered to provide a person to assist the child in the classroom, so that the child can attend school without any barriers.

This isn't going to end well. It's going to cost the family and the school board (i.e. the general public) lots of money in lawyer fees. It's going to draw unnecessary attention to this boy and his disease at school.

If someone needs a service animal, they need to get a real service animal. Otherwise, it's just a pet coming along for the ride. There needs to be better regulation of service animals. In the US, the ADA needs to be reviewed so that patients' rights are protected but also so that the public is protected from inappropriate animals. Bad service animals hurt the credibility of real service animals and the people they serve.

Image from http://www.lohud.com.

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Here's a reader's question: "Our local water authority here on the East Bay of RI has issued a "boil water" alert because of the presence of e-coli as found in a routine test. My question is:  Do we need to boil dogs' and cats' drinking water as well? Seems that they eat the worst stuff and may have stronger systems?  I gave my dog boiled water at home but then at day care they did not boil the water. "

There’s not a clear answer to this question. Ingestion of bacteria is not necessarily a bad thing. In fact, we ingest huge numbers of bacteria every day. Some dogs (like my dog that eats anything she finds outside) ingest more, and usually no problems develop. Boil water advisories are usually enacted based on detection of E. coli as an indication of fecal contamination. While many (or most) E. coli are harmless, the fact that fecal bacteria are present means that other potentially harmful microorganisms that can be found in feces may also be present. This includes E. coli O157 and Cryptosporidium.

What is the risk for dogs? It’s hard to say. E. coli O157 can cause infection in dogs but this is rare. Dogs that ingest E. coli O157 might shed the bacterium in their stool and potentially infect people. That’s a concern but it’s rare as well. Cryptosporidium is not an important cause of disease in dogs. So, when we look at the highest profile microorganisms in people, the risk to dogs is pretty low. However, we don’t know much about waterborne disease in dogs and it’s certainly possible that other microorganisms could cause disease and that dogs could act as an indirect source of infection of people (i.e. water to dog to person).

So, what should we do during a boil water advisory? I’d probably give my pets boiled water, since I’d be doing it for myself already. It’s not hard to boil a little more water for my pets. Is it really necessary? Who knows? Probably not, but it’s a pretty easy thing to do to reduce any risks that might be present.

It’s never a bad idea to err on the side of caution.

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The investigation into a large E. coli O157 outbreak linked to a UK petting zoo continues, and the number of potentially exposed people is astounding. There are a couple of reasons that I write a fair bit about petting zoos, and they are highlighted here: the potential for exposure of a large number of people and the predominance of children. In this outbreak, it is feared that tens of thousands of people may have been exposed since problems started in August. The exact number of infected people is currently unclear but is in the "dozens," including some with hemolytic uremia, a severe kidney disorder. One report says there are 36 sick people, including 12 children under the age of 10. It's pretty likely that these numbers will increase, and that even more cases will go undiagnosed because they were mild and people didn't get tested. 

This week, testing has been performed on animals and environmental areas on the farm to look at sources of E. coli O157. I'm not sure why this wasn't done a while ago. However, at this point, it's mainly going to be useful to confirm that the E. coli strain infecting people is also present in animals on the farm. Finding or not finding the bacterium at various environmental sites at one point in time really doesn't say much about where it was when people were getting infected. If E. coli was in the animals, it's likely to contaminate various environmental areas. If petting zoo design and hygiene were not optimal, this could result in contamination of visitors' areas.

Some parents have complained that the farm was allowed to remain open for more than two weeks after the first cases of E. coli were reported. That's a very valid concern and one that should be clearly addressed. Once there was reasonable suspicion of the farm being involved, measures should have been taken to reduce further exposure. A good synopsis of these events is available here.  It certainly depicts a less-than-stellar response to a potential outbreak. Although you don't want to over-react and close a facility that was not actually the source, given the potential severity of disease and massive number of people that could be exposed, public health concerns need to supercede economic concerns in situations like this.

Petting zoos will never be "no risk." There is an inherent risk of infectious disease transmission any time you interact with an animal. That being said, there are standard recommendations that are in place to greatly reduce the risk of disease transmission. I don't know much about the quality of infection control practices on this farm, but it's likely they could be better. One writer to timesonline describes how kids are allowed to climb in with the animals and chase after herds of pigs, which certainly suggests a lack of proper control.

People running petting zoos need to take their role in protecting the public seriously. That includes protection from infectious disease and injuries such as bites. Public health authorities need to take a more proactive role. Instead of the standard approach of just providing documents or signs, these events need to be inspected and any problems need to be identified and addressed. The key is to use basic, practical measures that reduce the risk while maintaining the positive aspects of the petting zoo. It's getting better in many areas, but there's clearly still room for improvement.

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The last time I visited the Aberfoyle (Ontario) Fall Fair, the petting zoo was so bad that I ended up writing to the fair organizers and the Wellington-Dufferin-Guelph Public Health Unit. (Neither group replied). It was pretty bad. Young poultry are inappropriate petting zoo animals because of the risk of transmission of bacteria like Salmonella, yet baby chicks were being passed around to young children. One chick was injured by rough handling and the petting zoo supervisor just threw it (still alive) in the garbage. There was a diarrheic calf, poor hand hygiene facilities, and other problems.

We went back to the fair yesterday and I was quite pleasantly surprised: no chicks, no calves, all appropriate and healthy-looking animals, a clean facility and good hand hygiene stations. There were still a couple of suboptimal things, like not having hand sanitizers by one exit, and having a "supervisor" who was staring off into the wilderness and smoking inside the tent filled with kids and straw, but it was night-vs-day compared to the last time. I doubt my letter had much to do with it, but you never know.  I think it's important that people not accept inadequacies that put the public (particularly children) at risk. People need to raise a stink when they see a problem. I wrote earlier today about a child who had her finger bitten off by a petting zoo zebra that had bitten other people. The previous bites may not have been reported because they were minor, but we need to report apparently minor problems so they don't escalate into major injuries, disease outbreaks or other bad scenarios.

Anyway, it was great to see an improvement, and people in the petting zoo appeared to be having a good time. Now if they'd just work on "Big Ned's" food concession, where the only sink seems to be a storage area with no soap or paper towels, and which appeared to be in need of a serious cleaning, or on the little midway, where they were hand cranking the questionable kiddie ferris wheel to get kids off when all the rides stopped working. Baby steps, I guess.

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A friend recently asked me about having service dogs in classrooms. Her sister, who is a learning resources teacher, told her about an autistic child who will be attending her school with a dog. The dog prevents the child from bolting and helps reduce anxiety. She thought this was an interesting topic because of the various pros and cons that need to be considered, and I certainly agree. It may seem simple at first glance, but when you think about it, it's a rather complex situation.

Contact with animals always comes with some risk. We can never eliminate the risk entirely. What we need to do is determine how to maximize the benefits and minimize the concerns, and ultimately decide whether the benefits are worth the risks.

In this situation:

Potential concerns/risks (to the child and/or those around him/her):

• Zoonotic disease transmission
• Bites/scratches
• Allergies
• Anxiety in children/adults who are fearful of dogs
• Management issues (e.g. who's responsible for making sure the dog gets walked)
• Classroom disruption (e.g. barking, whining, wandering)

Benefits:

• Letting the child attend and get the most out of school
  

That's a pretty big benefit, and it's clear this is a good situation as long as the risks are controllable.

What should be done in a situation like this?

• The true need for the dog has to be assessed. Is it really beneficial? Presumably yes, but the question has to be part of the assessment. There should be a formal evaluation/way to determine that "yes, this animal is needed so we should do everything we can to facilitate it." It doesn't  need to be a restrictive process at all, but it should be in place. (The situation in the US with the ADA complicates this - pretty much anyone can say they have a service animal and the amount of scrutiny that can be applied is minimal. More discussion about this can be found in a previous post, just click here).
• The dog should, ideally, come from a recognized service dog organization. This ensures that the dog/person pair is properly evaluated and the dog is trained. If this is not possible, then the next best thing is for the pair to be involved with a service organization so they get similar (but after-the-fact) training. Getting a formally trained dog may be difficult under some conditions because, while some service dog types (e.g. guide dogs for the blind) are well established, formal programs to provide trained dogs for many other conditions are uncommon or or non-existent.
• The school board should be notified as early as possible. This gives them the chance to make any necessary arrangements.
• Parents of other children in the classroom should be notified. They don't need to be told why the dog is needed (privacy of the student bringing the dog is an important issue), but they should be told a service dog will be in the class and what the school will do to reduce any potential problems. If there are any concerns (e.g. serious allergies, fear of dogs) they should be allowed to move their children to another class without any hassles. Ideally this should be done before the school year starts to reduce any possible stigma of someone being moved because of the dog.
• The teacher should be educated about risks and benefits of therapy dogs. The teacher is a critical link as he/she will oversee routine management of the animal. The teacher needs to understand the benefits of service animals in order to accept the animal in the class. The teacher also needs to understand the potential problems so he/she takes his/her role in management of the situation seriously.
• General hygiene practices (e.g. hand washing after touching the dog) should be emphasized and enforced.
• Any "incidents" must be recorded and reported. Furthermore, follow up to figure out  what happened, why and how it can be prevented is crucial. Any aggressive or other disruptive behaviour by the dog cannot be tolerated and requires an immediate review. A proper service dog should not pose any significant behavioural risks (e.g. biting, barking during class, wandering around). The less the scrutiny of the dog at the start, and the less the specific training, the greater the likelihood of such problems occuring.
• The dog's veterinarian should know it's a service animal. The dog must be examined by a vet at least yearly, and at a minimum it must be properly vaccinated against rabies. If the dog becomes sick, it must be taken to a vet promptly. If the vet identifies a disease that might be transmissible to people, the dog must not go to school until the risk period for transmission has passed.
• A plan must be established for walking the dog and handling feces. The dog should not be taken to defecate on the playground. It should have a separate grassed area in which to defecate that is away from where children play. Feces must be promptly removed and disposed of, and hands washed.

Service animals can be a contentious and emotional topic. They certainly do provide tremendous benefits to some people, so we need to do what we can to facilitate them. At the same time, we need to properly manage the situation to reduce risks to others. Usually, a thorough proactive review of risks and benefits, and a detailed discussion of what will be done, can greatly reduce any concerns and maximize the benefits. They key is actually thinking about these issues and doing something about them before there is a problem.

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In April, I wrote about an ongoing rabies outbreak in the popular tourist destination of Bali. Because of widespread rabies in stray dogs and fatal human infections, there were calls for the government to take aggressive action and for tourists to be aware of the risk. Apparently, things haven't improved much since then.

At least 9 people have died of rabies in Bali in slightly over a year. That's completely unacceptable for a preventable disease.

The latest victim (whose father-in-law died of rabies in August) was from an area that has not been officially declared as being part of the epidemic, so it has not received much government support. She was bitten by a stray dog in August. In any rabies-endemic area (even in the absence of an outbreak), that's clearly an indication for post-exposure treatment. However, she did not receive post-exposure treatment until 15 days after the bite, by which point it was obviously ineffective.

• Rabies post-exposure treatment must be started as soon as possible. If you wait until signs of rabies are present, death is almost certain.
• Be informed and be your own advocate. The family in this case may very well have pushed for post-exposure treatment, but it's critical to look out for yourself. If you have potentially been exposed to rabies, make sure you get treated.
• If you are going to Bali, don't be paranoid about rabies. Be smart. Avoid any contact with dogs (especially strays) and other wildlife. If you are bitten, get medical care immediately. If the animal isn't identified and quarantined for 10 days to make sure it doesn't have signs of rabies, you need post-exposure treatment. If you can't get it in Bali, get out and get to somewhere where you can be properly treated.
• If you are traveling to Bali (or any other rabies-endemic area) with the intention of working with wild or stray animals (especially dogs), get vaccinated before you go.
• More aggressive rabies control and education (including physician education) efforts are needed in Bali. Clearly, this outbreak is not under control and the fact that the latest death occurred in a new region suggests that this problem could be spreading.

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

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A Montreal man is undergoing rabies post-exposure treatment after being bitten by a bat in Lachine's Summerlea Park. He found the bat lying on the ground and when he picked it up to take a closer look (surprise, surprise) the bat bit him.

This incident shows yet again the need for better rabies education. While we don't want to create fear and loathing of bats, we should consider them rabies-positive until proven otherwise. That doesn't mean we want to eradicate them. It means we want to educate people to enjoy them from a distance and never have direct contact with them.

Never try to touch a bat. A bat lying on the ground in a park is not a healthy bat. It may be sick for various reasons, but rabies is certainly a possibility. If you come across a sick bat, call animal control. They can safely remove it so that no one has the chance of being bitten. If someone has had contact with the animal, the bat must be tested for rabies, as was done here. Rabies is preventable using proper post-exposure treatment, but it's very expensive, a hassle and a series of vaccine's isnt' exactly fun.

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As a vet, I've been bitten by a wide range of animal species. When people talk about animal bites, they usually think about dogs and cats. Horses can (and do) bite as well. Most horse bites are probably playful nips that hurt a little yet don't cause major problems, but some bites can cause serious injuries and infections can result.

A recent paper in the Journal of Agromedicine (Langley and Morris 2009), with the rather unwieldy title of "That Horse Bit Me: Zoonotic Infections of Equines to Consider after Exposure Through the Bite or the Oral/Nasal Secretions". Bites apparently account for 3-4.5% of the approximately 100 000 annual emergency room visits in the US that are associated with horses. The authors of the paper review infections associated with bites and contact with organisms in the mouth and nose of horses.

A large number of bacteria have been associated with horse bite infections in people, including Actinobacillus, Streptococcus, Psuedomonas and Staphylococcus species. Some viruses can theoretically be transmitted by bites, but there's little evidence that this actually happens.

Although viruses are not of as much of a concern overall, rabies needs to be considered in every bite from a mammal. We pay a lot of attention to rabies with dogs, cats and wildlife, but it often gets ignored with horses. While I'm not aware of any reports of rabies transmission from horses to humans by a bite, it could happen.  Fortunately, rabies is rare in horses so the likelihood of exposure from this species is very low. However signs of rabies aren't always obvious initially, and rabies in horses may mimic other diseases. Sometimes, rabies looks like colic, and human exposure through bites or other contact is possible when handling, evaluating and treating affected horses.

Unlike with dogs and cats, there are no clearly defined protocols for dealing with bites from horses. Any dog or cat that bites a person is supposed to be quarantined for 10 days. The reason for this is if the animal is rabid and the disease is advanced enough for the animal to be capable of spreading rabies virus, it would invariably develop signs of rabies and die within this time period. We don't have similar guidelines for horses. I suspect the 10 day observation period would be adequate but we don't have good data. The paper states that in Kentucky, a 14 day observation period has been used by the state Department of Public Health.

At the conclusion of the paper, the authors make a few important general recommendations for reducing the risk of disease transmission from bites and oral or nasal secretions of horses:

• Use good general hygiene, especially hand hygiene, after any contact with horses.
• Use gloves and gown or lab coat when examining horses in a veterinary clinic or hospital. (This might be overkill for all horses. We don't require gloves for every horse contact, just contact with mucous membranes (e.g. mouth, nose), wounds, incision sites and other high-risk areas. I think bare hands are fine for general contact as long as there is good attention to handwashing after.)
• Consider mask and goggles if the horse is coughing or sneezing.
• Develop standard operating procedures for handling sick horses.
• Use isolation when needed.

I'd add a few more points:

• Avoid bites. Pay attention to what you are doing around horses to reduce the risk of being bitten. Do not encourage playful behaviours (e.g. nipping) that could lead to bites.
• If you are bitten and it breaks the skin, clean the site thoroughly with soap and water. If there is significant trauma, or if the bite is over a joint, hand, foot, or a prosthetic device, you should see a doctor immediately because antibiotics are most likely indicated. If you have a weakened immune system, you should be evaluated by a doctor after any bite.
• Avoid contact with the horse's mouth or nose if you have skin lesions. Cuts and scrapes can allow bacteria to enter your body and cause infections. If you have a cut on your hand, make sure it is covered with a glove or waterproof dressing if you are going to have contact with the horse's mouth or something that came from its mouth (e.g. a bit).

This Worms & Germs blog entry was originally posted on equIDblog on 02-Sep-09.

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