Rare tickborne infection in Minnesota woman
A Minnesota woman has died of Powassan virus encephalitis, a very rare neurological disease transmitted by ticks. Powassan virus is most often found in parts of Ontario, Quebec and New Brunswick, but there is evidence of it in many other parts of North America as well, and as far away as Russia. Human infections are very rare, but when they occur neurological disease is severe, mortality rates are high, and survivors often have residual neurological problems.
Powassan virus is a flavivirus, related to St. Louis encephalitis virus and West Nile virus, but unlike these, the reservoir of Powassan virus seems to be wild small mammals, with transmission via ticks (as opposed to a bird reservoir and transmission via mosquitoes for the others). The virus has been detected in mosquitoes but it's not known whether they can transmit the virus. Ticks are considered the major (and possibly only) route of infection.
The risk to animals in areas where Powassan virus can be found is very limited. Natural infections of dogs, cats or horses have not been reported, as far as I know. However, that doesn't 100% rule out the possibility of disease, since you have to look in order to find, and specific investigation of Powassan virus transmission is uncommon. Neurological disease has been reproduced experimentally in horses, but not dogs and cats.
Overall, the risk to pet owners and pets posed by Powassan virus is very low. Taking measures to avoid ticks is the key, and such precautions should be taken for many reasons beyond Powassan virus exposure.
Aquarium sued over child's infection
The Tennessee Aquarium in Chattanooga is being sued for $2.4 million by the parents of a child who allegedly acquired an infection after petting stingrays and sharks. The news report contains very little information, but the reference to "fish-handler's bacteria" means the infection was presumably caused by the bacterium Erysipelothrix rhusiopathiae. This bacterium can be found in various animal species, particularly pigs, and can be spread to people. The risk of infection is greatest in people with pre-existing skin lesions, since these allow the bacterium to bypass the normal skin barrier. It can also be found in/on fish, and infections in fish handlers tend to occur because they have close contact with fish and they often have skin lesions from fish, knives or other sharp objects, hence the name fish-handler's disease. When infection occurs, it is usually limited to a local skin infection, but more invasive infections involving deeper tissues or infections that spread to other parts of the body can rarely occur. In this case, the child must have had a deeper infection since according to the report he's had to undergo multiple surgeries.
Aquarium officials (unsurprisingly) refute the suggestion that the aquarium was the source, pointing to five negative water tests after the child's visit to the facility. Unfortunately, water tests taken after the suspected time of exposure don't really tell you much. It's going to be hard to prove anything, but it's reasonable to suspect that the aquarium was the source. This is a rare infection that can be associated with contact with fish and their environment, and the child had that kind of contact. Looking at other potential sources of exposure like pig contact is also necessary.
Even if no other potential sources of exposure are identified, it's still not definitive that the child acquired the infection at the aquarium, nor does it necessarily mean that the aquarium is at fault. Every contact with an animal or its environment (just like any contact with a person) carries some degree of infectious disease risk. The key issue is whether the facility took reasonable precautions to reduce that risk. In particular, this would include providing easy access to a handwashing or hand sanitizer station immediately after the contact occurred, and clear signs indicating the need for hand hygiene. Any animal contact event, be it a traditional petting zoo, pony rides or aquatic contact exhibits like this one, need to take those basic precautions. If proper measures are used, infections can still occur, but that's a fact of life. We cannot prevent 100% of infectious diseases. What we try to do is reduce the risk as much as possible, while maintaining the benefits of activities that involve animal contact. It's a balancing act and it's never perfect, but that's all we can do and what we need to expect from animal contact events.
MRSA transmission between hamster and human
The more we look, the more we find when it comes to MRSA (methicillin-resistant Staphylococcus aureus). As people start looking for it in different animal species, it's often found. We've found it in many species already, including dogs, cats, rabbits, pigs, walruses, dolphins and alpacas, so it's not a big surprise to see a recent paper in the Journal of Clinical Microbiology (Ferreira et al 2011) about suspected MRSA transmission between a human and a hamster.
The case report describes a person with advanced cystic fibrosis who had undergone a lung transplant and had various other medical problems. Prior to another surgical procedure, MRSA was identified through routine pre-operative screening. Nasal and rectal swabs were then collected from the person's three pet hamsters, one of which was positive. The MRSA isolates from the human and hamster were the same, supporting transmission from one to the other. Given the person's underlying health problems, frequent contact with the healthcare system, the typical human origin of the strain that was found, and limited contact of hamsters with other animals or people, it is most likely that MRSA was transmitted from human to hamster in this case.
The paper concludes with: "Should testing of the pets of MRSA-positive patients be recommended? At this point, we recommend that MRSA-positive patients be informed that their companion animals can be potential sources of infection or reinfection. In the presence of a MRSA-positive human or animal, heightened hygiene practices should be instituted and unnecessary close contact should be avoided. Screening of household pets might be indicated in situations of recurrent MRSA infections despite adequate treatment or when immunocompromised patients live in the household."
That's consistent with our standard recommendations and hits most of the key points:
- Awareness is critical. People need to know what the risks might be and what they can do about them so that they can make informed decisions and realize why recommendations are being made.
- Testing of pets is rarely useful, particularly in the absence of a recurrent MRSA problem.
- Good hygiene practices are critical.
I don't really agree with the comment that testing of pets might be indicated when immunocompromised people are in the household (although the comment is properly hedged by saying "might be indicated"). A large percentage of the population has some degree of immunocompromise, and there's a huge spectrum from minimal risk to tremendous risk. Even in high-risk patients, screening is questionably useful to me because it doesn't really change what I'd do.
- If I screened a hamster from a high-risk person and found MRSA, I'd say that it probably came from the person, that it's possible it could be transmitted back to the person, that good hygiene practices should be followed and close contact should be restricted. There's no indication (or ability, in reality) to treat the hamster.
- If the hamster was negative, I'd say it was possibly negative because screening is not 100%, that the hamster could be exposed to MRSA from the owner at any time, and so to manage unknown colonization and reduce human-hamster transmission, I'd recommend good hygiene practices and restriction of close contact.
- If I'm going to do the same thing with a positive and negative result, I don't do a test.
This paper should be yet another reminder that we live in a complex relationship with our pets, including microbiologically. While we need to consider the role of pets in human infection (and the role of humans in pet infection), and we need to balance that with the positive aspects of pet ownership in order to maximize the benefits while minimizing the costs.
A dog's tongue is not a medical device
Using logic akin to "Chocolate cake? It has flour, eggs and milk. It's virtually health food. You should eat it every day.", AllPetNews.com has an article on its site entitled "Dog saliva has healing properties." The article focuses on potential beneficial compounds in saliva, with specific reference to a University of Florida (Gainesville) discovery of nerve growth factor (NGF) in saliva (although I can't find any reference to nerve growth factor in dog saliva on PubMed).
The article states "Wounds that were treated with NGF actually healed twice as fast as untreated wounds, indicating that if a dog does lick a humans wound, it could in fact lead to a faster recovery."
The problem here is taking some controlled research data and spinning it out of control. Putting synthesized or concentrated nerve growth factor on a wound in a controlled manner is different from putting saliva on a wound, which is also different from having a dog lick it. You have to consider the whole picture when evaluating potential treatments. For example, rubbing alcohol kills bacteria nicely but that doesn't mean it's a good idea to put it on a wound to prevent infection. It hurts and it damages tissue. While it may kill superficial bacteria, the tissue damage can ultimately increase the risk of infection.
While there are certainly some compounds in dog (and human) saliva that stimulate healing, those potential benefits need to be weighed against the potential adverse effects, particularly infection. The oral cavity of the dog contains billions of bacteria from hundreds of different bacterial species. Many of these are able to cause infection given the right circumstances. A wound helps create the right circumstance by breaking down the body's normal protective barriers.
The article does mention some dangers, although only with licking of deep wounds (a wound doesn't have to be deep to become infected), and concludes with:
"Although the healing properties outweigh the negative impacts there will always be a number of people that find it in their best interest to treat a wound by cleaning it with soap and water...."
- At this point, there's no evidence that the beneficial properties of dog saliva outweigh the negative impacts. In reality, people would be better off if they carefully cleaned wounds with soap and water. Licking may not cause a problem in many (or even most) situations, but it can lead to serious infection, and the lack of clear evidence of benefit alongside documented risks indicate that this is an inappropriate activity.
Rabies post-exposure prophylaxis failure, India
A report from India of apparent failure of rabies post-exposure prophylaxis raises a significant concern. Few details are available, but it is reported that the affected person is currently in a coma, and if that is the case, death is almost certain. This case requires careful investigation, given the almost invariably fatal nature of rabies and the assumption that proper post-exposure treatment is basically 100% effective.
From my standpoint, I'd want to confirm that:
- the person actually completed the proper treatment course (one dose of anti-rabies antibodies and a series of four rabies vaccinations over a few weeks) - the article says the course was completed but doesn't give details of what that entailed.
- proper antibody and vaccine were used.
- correct doses were administered.
- the antibody and vaccines had been handled properly (e.g. kept at required temperatures - which at times may be easier said than done in a country as hot as India).
If all of these factors are confirmed, I'd want to know whether the person had some other disease or a compromised immune system that might have prevented him/her from responding properly to vaccination.
If no underlying problem was present, I'd want to see some testing of the lots of antibody and vaccine that were administered to ensure that they were adequate.
The timeline from when the person was exposed to when he/she received the post-exposure treatment to when he/she developed clinical signs of rabies is also critical. Delaying treatment for too long can also result in treatment failure.
Undertaking such an investigation is very important because the cause for any treatment failure needs to be understood if at all possible to help prevent it from happening again.
In the same news article, another man is also reported to be in a coma due to rabies infection, because he failed to complete the full course of treatment. That's a more common problem and can be caused by lack of awareness of the importance of completing the full treatment course, inadequate communication with healthcare providers and, in some regions, shortage of vaccine.
These cases show that while post-exposure treatment is a critical aspect of rabies prevention, it shouldn't be relied on as the sole line of defense. Feral dog control, rabies vaccination of animals and education regarding bite avoidance are critical rabies-control measures that often get ignored.
Image: Vaccines (and certain other medications) may lose their effectiveness if they are not constantly kept cool during transportation (known as the "cold chain"). (click image for source)
Dirty dog ears, dirty dog ear cleaners?
An interesting study published recently in Veterinary Dermatology (Bartlett et al 2011) looked at bacterial contamination of ear cleaning solutions used on dogs at home. Ear cleaners are widely used by dog owners, but since the bottles the cleaners come in are used repeatedly and can have direct contact with the ear, there’s a chance for contamination of the bottle and/or its contents.
In this study, the researchers collected ear cleaner bottles from dog owners and cultured both the applicator tips and the contents. Bacterial contamination was detected on 10% of the bottle tips and in 2% of the solutions. The relative numbers make sense, since the tips are most likely to have contact with the ear. Regardless, this shows that a small but still reasonable percentage of bottles contain bacteria that could be inoculated into the ear.
Finding bugs is one thing, but determining if they are types that can cause disease is another. The researchers identified a few different bacteria, including Staphylococcus pseudintermedius, which is an important cause of ear infections. This isn't too surprising since the bugs that cause infection are typically those that are also normally found in (healthy) ears at low levels (and therefore the types of bugs with which cleaner bottles might have contact).
Expired ear cleaners were more often contaminated. This doesn’t necessarily mean that age leads to increased risk of contamination. It could just indicate that bottles that have been used more and over longer periods of time are more likely to become contaminated. Similarly, large bottles more often had contaminated tips, probably because of more overall use (and correspondingly more chance for contamination).
An interesting aspect was the finding that solutions containing Tris-EDTA had higher contamination rates. Tris-EDTA is a solution that is often included in ear cleaners as it has been shown to be useful for treatment of infections caused by Gram-negative bacteria.
What does this mean for people that clean their dogs’ ears? It’s hard to say. We don’t know whether a little bit of bacterial contamination poses a realistic risk. However, it’s reasonable to consider using smaller bottles and discarding them after they are used to treat a dog with an ear infection (as opposed to regular ear cleaning).
Another Salmonella outbreak linked to chicks and ducklings
The US CDC is investigating yet another multistate outbreak of salmonellosis associated with contact with chicks and ducklings. As of June 18, 39 people have been diagnosed with Salmonella Altona infection (with a large number of others presumably infected, since o
nly a minority of cases tend to be diagnosed). People in at least 15 states have been affected, as indicated by the map on the right.
Reported cases so far occurred between February and the end of May, but the outbreak could still be ongoing. Of all the affected individuals, 28% have been hospitalized but there have been no deaths.
Outbreaks like this lead to investigation of possible sources, starting with the usual suspects of high-risk foods and animal contact. In interviewing people that became sick, 81% of them reported having contact with live poultry before getting sick. In people that identified the type of poultry, all reported contact with chicks, ducklings or both. All 19 people that provided information about the source of chicks or ducklings reported getting them from different locations of a nationwide agriculture feed store (which is not being identified). The same strain of Salmonella was isolated from ill people and chick/duckling displays in two store locations. A single mail-order hatchery was then identified as the source of the animals.
Large distributors of animals, especially high-risk animals like chicks and ducklings, can be the sources of large outbreaks since they can supply large numbers of infected animals to a large region. While cute, chicks and ducklings are high risk for carrying Salmonella and they can shed large numbers of Salmonella in their feces without showing any signs of disease. That's why standard recommendations are that high risk persons (e.g. children less than 5 years of age, immunocompromised or elderly individuals) should avoid contact with baby poultry.
In the context of this outbreak, since the store is not being named (and since it's possible the hatchery sent chicks to other sources), anyone who has had contact with chicks and ducklings needs to be aware of the potential for Salmonella exposure. In reality, this is also true outside of the context of this outbreak, since Salmonella exposure needs to be considered after any contact with chicks and ducklings. It doesn't mean that people who have had contact with baby poultry should go to the doctor, get tested, or do anything different. However, it is important that people notify their physician about poultry contact should they get sick. For more information about reducing the risk of Salmonella exposure from poultry, click here.
Research posters now available
In trying to keep up with technology, my lab has started adding a QR code to posters presented at research meetings. The code links to a page on the Worms & Germs Blog Resources page that houses a collection of research posters that people can view and download. You can also go directly to the poster site by clicking Research Posters on the "Topics" bar on the left side of the Worms & Germs Blog homepage, or through the Resources tab at the top of the homepage. Check back regularly to see new additions to the list.
Infection from raccoon to parrot
An article in the May/June edition of Canadian Vet Newsmagazine (a magazine, not to be confused with Canadian Veterinary Journal, a scientific journal), described an interesting case of an indoor pet bird acquiring an infection from a wild raccoon, despite no direct contact.
The bird was an African Grey Parrot that was admitted to the Ontario Veterinary College because it had developed neurological abnormalities over the preceding few weeks: a head tilt, unsteadiness and problems climbing. Infection of the brain caused by the raccoon roundworm Baylisascaris procyonis was suspected and treatment was started, however unfortunately (but not surprisingly) the bird continued to deteriorate and was eventually euthanized. Baylisascaris infection was confirmed at necropsy.
Baylisascaris procyonis, the raccoon roundworm, is extremely common in raccoons, with the majority of raccoons in some areas shedding the eggs of this parasite in their feces. The eggs are extremely hardy and can survive for long periods of time in the environment. The tendency of raccoons to defecate in the same areas (raccoon latrines) means that very high concentrations of eggs can be found in some spots. While this is a raccoon-origin parasite, it can occasionally cause infection in other species (including people and dogs, albeit very rarely). After ingestion of the parasite eggs, the eggs hatch and parasite larvae migrate through the body, causing damage to various tissues as they go. If they migrate through the brain, severe neurological disease can occur.
An interesting aspect of this case is the fact that it was an indoor parrot. If this was a dog that had been exposed to a raccoon latrine, while it would have been a rare occurrence of disease, the origin of infection would have made sense. Here, the parasite eggs had to somehow make it into the house and then into the parrot. The suspected source was branches that were collected from the backyard and placed in the bird's cage. The branches were presumably contaminated with Baylisascaris eggs, and the bird ingested some while chewing on the branches.
This is a very rare situation, but the article includes some basic recommendations:
- Never adopt a raccoon (for many reasons beyond the Baylisascaris risk to pet birds).
- Don't keep parrots in outdoor enclosures where raccoons have access.
- Don't put parrots in outdoor enclosures that may have previously housed raccoons.
- Avoid putting objects from raccoon-inhabited areas into parrot cages or treat them to kill eggs. Heating objects to 62C for 1 minute should kill any eggs that are present.
- Ensure that cage bedding and bird feed are not potentially contaminated with raccoon feces.
Serious infection from a fish tank
A California teen has been battling a chronic and severe infection acquired from a fish tank. Five years ago, Hannele Cox cut her hand when she pulled it out of an aquarium. It sounds like it was a pretty minor scratch, but it doesn't take much to cause an infection under the right circumstances.
A while after the injury, infection was apparent. A round of antibiotics didn't fix it (no word on whether any bacterial cultures were performed at that point). Eventually, a dermatologist diagnosed the problem: Mycobacterium marinum infection. One problem with infections like this is that they are sometimes not diagnosed until they are quite advanced. If the patient doesn't mention the aquarium exposure and/or the physician doesn't ask about pets, an infection like M. marinum might not be considered.
Mycobacterium marinum infection is sometimes called "fish tank granuloma" in testament to its common association with fish tanks. It can be found in both freshwater and marine fish (and the water in their tanks), and most often infected fish don't have any signs of disease. Therefore, you have to assume that any fish and any aquarium could be infected, and therefore a potential source of human infection.
Infections with M. marinum usually develop a couple of weeks after exposure and are characterized by small bumps (papules) on the skin that progress to shallow ulcers. Typically, infection is not very invasive and responds to treatment, although months of treatment may be required. Sometimes, the infection can spread to deeper tissues, making it much harder to treat. Unfortunately, that's what happened to Hannele Cox. Her infection has not responded well to treatment and has spread to deeper tissues, including bone. She's had two surgeries to try to save her hand, and at least one more is planned. Amputation isn't outside of the realm of possibility, but will hopefully be avoided.
Fish owners should be aware of the risk of M. marinum infection. While fish are often ignored as a potential causes of infection and the overall risk is low, there are simple measures that can be undertaken to reduce the risk of acquiring an infection from fish tanks. These mainly involve limiting contact with fish tank water and the use of good general hygiene practices:
- Contact with aquarium water should be minimized
- Never dump aquarium water into kitchen or bathroom sinks.
- Promptly clean up any aquarium water spills.
- Take care when putting your hands in the aquarium, especially if there are sharp surfaces (e.g. rock, coral) that might result in cuts or abrasions.
- Hands should be washed thoroughly after contact with aquarium water.
- People with compromised immune systems should not have contact with aquarium water. They should have someone else clean their fish tank.
Giardia in dogs and cats in Ontario
Dr. Andrew Peregrine, a veterinary parasitologist at the Ontario Veterinary College, presented some data about the types of Giardia found in dogs and cats in Ontario at this week's University of Guelph Centre for Public Health and Zoonoses annual meeting.
A lot of attention has been paid to Giardia types in recent years. That's because, contrary to earlier thoughts, it's now known that certain types (also called assemblages) of Giardia can infect multiple species while others are host specific (i.e. they only infect one species). This is very important because if a dog or cat is shedding Giardia in their stool, the type determines whether there is any risk to people.
In the Ontario study, 75 canine and 13 feline Giardia-positive fecal samples were typed. In canine samples, assemblage D accounted for 68% of samples, while assemblage C accounted for 31%. These two are dog-specific, meaning 99% of typed canine samples contained only dog-specific types and were therefore no risk to human health. The other sample contained assemblage B, a zoonotic type that infects humans and animals. In contrast, 13/13 of the feline samples were assemblage A, a zoonotic type of Giardia.
These recent Ontario data indicate a low risk of transmission of Giardia from dogs to people, but some risk from cats - at least in Ontario. It's important to note that there appears to be geographic variation in this trend. Other recent studies have reported similar results, with the predominance of dog-specific types in dogs. However, a few studies have shown a predominance of the zoonotic assemblage A in dogs. These have mainly been in low socioeconomic status areas with infrastructure challenges that could increase the chance of dogs being exposed to human feces. Therefore, it may be that in areas where there is good sanitation, dogs are most likely to get Giardia from other dogs. When there are sanitation challenges, dogs may be more likely to be exposed to human types. So, it's important to know trends in different geographic regions to understand the risk of transmission from pets to humans.
Newmarket OSPCA ringworm "outbreak" investigation report
As many of you know, there was a large ringworm "outbreak" at the Newmarket (Ontario) OSPCA shelter in 2010 that led to a public outcry in response to plans to depopulate the shelter. In the aftermath of the event, an independent investigation was launched, headed by Mr. Patrick LeSage (former Chief Justice of the Ontario Superior Court) and Dr. Alan Meek (former Dean of the Ontario Veterinary College). The investigation involved a comprehensive examination of activities pertaining to the outbreak and shelter operations, in conjunction with relevant experts (disclosure: I was one of those).
The report of the investigation is now available, and covers important aspects such as whether an outbreak was actually present (short answer: no) and whether there were major problems in shelter operation (short answer: yes). Most importantly, it provides a comprehensive set of recommendations to improve the operations of the Newmarket shelter and OSPCA as a whole.
The report, in its entirety, was released today by the OSPCA and is available for download on their website. The report is on the site in multiple files: the main report is listed as "Index" and contains the ~90 page overview and recommendations. The expert reports, which might also be of interest, are tables D1-3, E, F and G.
Aromatherapy, topical treatment and toxicity
I have no problem with people considering "alternative" therapies for the treatment of infections. I perform research on non-antibiotic alternatives and hope that results pan out in the field. I have problems, however, with people that use unproven alternative therapies in lieu of proven conventional treatment or stray from the "do no harm" philosophy.
I read an article on aromatherapy in pets that highlighted my concern. Someone can make Fluffy or Fido smell whatever they want (although my dog Meg's concept of what smells nice certainly differs from mine - she'd rather roll around on a decomposing carcass than a lavender plant). I don't think it's going to help, but it shouldn't hurt. This article went beyond that, though, talking about application of substances to treat infections. Putting tea tree oil into a dog's ear isn't aromatherapy, it's topical therapy.
Is it an issue of semantics? No.
Essential oils like tea tree oil have some powerful properties. Just because it's "natural" doesn't mean it's safe. We know that tea tree oil has antibacterial properties. However, we also know it can be toxic. There are reports of serious adverse effects in people from tea tree oil ingestion and I know of severe reactions in dogs (including 1 death) thought to be due to excessive tea tree oil application. Adverse effects can result from the dog ingesting the oil by licking it off its coat or from direct effects on the skin.
A research study presented by Dr. Becky Valentine at the 2011 North American Veterinary Dermatology Forum highlighted this concern. Her research showed that while tea tree oil was able to kill methicillin-resistant Staphylococcus pseudintermedius (MRSP), a leading cause of canine ear and skin infections, it was also quite toxic to canine skin cells. So, the cost-benefit of tea tree oil is unclear since it certainly has some toxic properties, particularly when compared to other topical therapies such as chlorhexidine, that are essentially non-toxic.
Additionally, in a good demonstration of "all pain, no gain," Dr. Valentine's research showed that grapefruit seed extract, another compound available over the counter, had no effect on MRSP but had significant toxic effects on canine skin cells.
What does this mean? It means that essential oils and any other alternative therapies need to be studied, just like any other treatment. We need safety studies to know they won't cause problems, dosage studies to know how to use them and efficacy studies to know if they work. Natural products can be quite powerful and potentially useful, but they need proper testing.
