Cryptosporidiosis and petting zoos: England and Wales

Petting zoos are very common in the UK (as in many other regions), where approximately 2 million people visit 1000 different petting zoos every year. While the vast majority of petting zoo visits are simply pleasant outings associated with no problems, some people leave with more than just memories... they leave with an infectious disease.  A letter in the latest edition of Emerging Infectious Diseases (Gormley et al 2011) describes one of the diseases people can pick up at petting zoos: cryptosporidiosis.

From 1992-2009, 55 outbreaks of intestinal infections associated with petting zoos were reported in England and Wales. (There were presumably many more unidentified cases or even outbreaks.) Of these, 55% were caused by E. coli O157.  The second most common cause was Cryptosporidium, a protozoal parasite that is commonly found in feces of calves and lambs, which was responsible for 42% of the outbreaks and affected 1078 people. (Again, this is probably an underestimation of the true numbers because typically there are many undiagnosed or unreported cases of illness for every case that is identified). The number of people involved ranged from 2-541 per outbreak. Twenty-nine people were hospitalized due to the infection.

Factors associated with outbreaks were things that we know are issues with petting zoos:

  • Contact with young lambs, calves or kids
  • Inadequate hand hygiene facilities

Cryptosporidium outbreaks were also more common in the spring, as opposed to E. coli outbreaks which were more common in the summer. This may be explained by the association of the pathogen with contact with young calves, lambs and kids, since these animals are mainly born in the spring.

Alcohol-based hand sanitizers, while excellent for most bacteria, are ineffective against Cryptosporidium.  This can also be a contributing factor to outbreaks of cryptosporidiosis, particularly if hand washing stations are replaced with hand sanitizers. While alcohol-based hand sanitizers are certainly better than nothing, their usefulness is limited when resistant pathogens (such as Cryptosporidium) may be present, and when peoples' hands might be contaminated with large amounts of dirt or other debris (e.g. feces).

Petting zoos can be great events, particularly for kids. However, kids, especially young kids (less than five years of age), are at high risk for certain infectious diseases they may encounter at such venues. While petting zoos seem to be improving and governments are paying more attention to making them safer, visitors need to look out for themselves.

  • Make sure a hand hygiene station, preferably a hand washing station, is available. Do this before you touch animals.
  • Always wash your hands after leaving the petting zoo, regardless of whether or not you touched an animal (since other surfaces you touched may have been contaminated).
  • Do not have contact with young calves, lambs, kids (i.e. baby goats) or poultry.
  • Do not have contact with diarrheic animals, or animals that appear to have any other health problems.
  • Don't take food, drink or anything that might go into a child's mouth (e.g. baby bottles) into the petting zoo area.
  • Closely supervise children.
  • If you see a poorly equipped or run event, don't be afraid to contact your local public health office. While most petting zoos seem to be improving, some are still pretty bad and may need to be forced to do things right.

Cryptosporidiosis from wildlife centre lambs

The May 2010 edition of Emerging Infectious Diseases contains a report about an outbreak of cryptosporidiosis in Scotland (McGuigan et al. 2010). Cryptosporidiosis is a common parasitic disease caused by Cryptosporidium, a protozoal parasite. It causes diarrhea, which is usually annoying (to say the least) but self-limiting in healthy people, but the infection is potentially fatal in people with compromised immune systems.

An investigation was launched after a single case of cyrptosporidiosis was diagnosed by a Scottish laboratory. The reason a single infection caused such concern is that it was suspected to have originated from contact with lambs at a wildlife centre, so there was potential for exposure of many people. The concerns were valid, since a total of 128 cases of cryptosporidosis were uncovered during their investigation, and 117 of the people affected had visited the wildlife centre. Another 252 unconfirmed cases were also identified.

The investigation suggested that direct contact with diarrheic lambs was the source of infection. Lambs (and calves) are high risk for shedding Cryptosporidium, even when they're healthy.  Diarrhea increase the risk of transmission from these animals even more, because diarrheic animals are more likely to (1) shed the parasite and (2) have fecal staining of their haircoats, which increases the likelihood of fecal contact for every person and animal around them. That's why young ruminants (e.g. lambs, calves) as well as young poultry are considered inappropriate for petting zoos and other similar public animal contact events. This outbreak is yet another example of why these recommendations are in place.

At the wildlife centre in this study, children were apparently encouraged to pick up the lambs, despite visible diarrhea. No handwashing facilities were near the lamb petting area and it took "considerable effort" to find a location to wash your hands anywhere on site. Alcohol hand sanitizers were available, however Cryptosporidium is resistant to alcohol. Handwashing is a critical component of disease prevention, but unfortunately it is very underused. In general, people are becoming much more aware of the need for handwashing, but even so, if handwashing facilities are not conveniently located, people tend not to go to much effort to find them. That leads to increased risk of infections, as was the case here.

Control measures at the wildlife centre implemented after the investigation included removal of the lambs (who should never have been there anyway), disinfection of the premises with bleach (although disinfecting a farm environment is very difficult, and Cryptosporidium is also resistant to bleach), and stopping direct contact between animals and visitors.

As we enter the season when there are more fairs, petting zoos and other animal contact events, facility managers need to pay attention to important factors like:

  • Readily available hand hygiene facilities
  • Good design to control the types of human-animal contact and to steer people towards hand hygiene stations
  • Appropriate animals: no calves, lambs or chicks
  • Proper supervision of people and animals

A little common sense goes a long way. The goal is to set up these events so that there is still a beneficial impact of seeing and interacting with animals while reducing (but never eliminating) the risk of disease transmission. A 100% safe petting zoo is not achievable (there's always some risk in life), but some pretty simple measures can greatly reduce the risks while still providing excellent entertainment and educational opportunities.

Boil water advisories: What to do with dogs?

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.

HIV/AIDS, kids and pets

The Centers for Disease Control and Prevention (CDC) has released updated Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-exposed and HIV-infected Children. A small but still important part of this document involves recommendations for contact with animals. It's a nice, balanced document that acknowledges the risk but doesn't make unnecessarily restrictive recommendations.

Among the important recommendations regarding animals:

  • When getting a new pet, avoid dogs and cats less than 6 months of age or strays: These animals are at higher risk for shedding various infectious diseases and are more likely to have problems with biting and scratching.
  • Avoid contact with animals that have diarrhea.
  • Wash hands after handling pets.
  • Avoid contact with pet feces.
  • Avoid contact with reptiles, chicks and ducklings: These are very high risk for Salmonella.
  • Avoid contact with calves or lambs at farms or petting zoos: These animals are high risk for various infectious diseases such as Cryptosporidium and Salmonella.

These recommendations also largely apply to other high-risk groups, including people (of all ages) with compromised immune systems and young children (especially less than 5 years of age). A key point is normal contact with common household pest using basic hygiene practices is considered a low risk. Infection control isn't rocket science. It involves basic and practical measures that can reduce risks associated with animal contact.

Parasite exposure from pets

A recent study from the Netherlands investigated the prevalence of zoonotic parasites in pet feces and on pets' haircoats. The authors sampled feces and fur from dogs and cats, and looked for Toxocara (roundworms), Toxoplasma, Giardia and Cryptosporidium. All these parasites are of concern from a public health standpoint because they can be found in healthy pets and can also infect people.

Toxocara eggs were found on the haircoats of 12% of dogs and 3.4% of cats. Levels were low, ranging from 1-31 eggs per sample. An important aspect of this study was that they also assessed viability of these eggs, and found that none were viable.  Therefore, even though eggs were present, they were not relevant because they were dead. Exposure to UV light and lack of humiditiy were cited as possible reasons for the death of the eggs.

Toxocara were found in the feces of 4.4% of dogs and 4.6% of cats, which is consistent with other studies of healthy pets.

Toxoplasma was not found in the feces of any cat. (Cats are the hosts for this parasite so dogs weren't tested.)

Giardia was found in the feces of 15% of dogs and 13.6% of cats. However, when these strains were typed, the vast majority were species-specific types that do not cause disease in people. Only 2 of the 15 Giardia samples were assemblage A, a type that is transmissible from pets to people. This is very important to know because crude Giardia numbers don't tell you the whole story

Cryptosporidium was found in feces of 8.7% of dogs and 4.6% of cats. However, they were not able to type these parasites to determine if they were species that typically cause infection in humans, or whether they were Cryptosporidium felis or C. canis, which rarely cause disease in people.

The discussion section of the paper contains an interesting and relevant point about exposure to Toxocara eggs on the haircoat of pets. The authors state "Even in the worst case scenario of highly contaminated fur, e.g. with the highest Toxocara [eggs per gram] of 300 and an embryonated rate of 4% from the study of Wolfe and Wright, it is necessary to ingest more than 4 grams of hair, with 12 embryonated eggs per gram, to ingest 50 infective eggs."  Based on these data, exposure to parasites from the haircoat of pets is quite unlikely.  It might be a greater concern with stray or debilitated animals, or with puppies/kittens, who could have much greater coat contamination.

The take home message: Normal contact with healthy pets likely poses minimal risk of transmission of zoonotic parasites. That being said, regularly washing your hands is still a good idea because of the potential for exposure to other types of microorganisms (e.g. bacteria), and in rare circumstances where there may be large parasite burdens on a pet. Good deworming practices, particularly for puppies and kittens, also need to be considered.

Reference: Overgaauw et al, Veterinary Parasitology, 2009.

Water Foul - Cryptosporidiosis

Cryptosporidiosis is a diarrheal disease caused by several species of the genus Cryptosporidium, which are single-celled parasites. The disease can cause severe diarrhea.  It tends to make the news when outbreaks occur associated with contaminated drinking water, but outbreaks only account for the minority of cases reported each year. Infection can be very serious (even fatal) in immunocompromised individuals, such as HIV/AIDS patients, but even immunocompetent (i.e. otherwise healthy) people can get sick. Different animals have their own species of Cryptosporidium. It is still unclear which of these species can normally infect people as well, and make them sick. Frequently cats and dogs with Cryptosporidium don’t look sick. Here are some facts:
  • Cryptosporidium hominis primarily infects humans. Clearly it can make people sick, whether their immune systems are weakened or not.
  • Cryptosporidium parvum primarily infects calves, and clearly makes people (and calves) sick. However, because it is relatively common in people as well, in many cases it is hard to say if a person with C. parvum was infected by contact with calf stool or human sewage.
  • Both the dog-associated C. canis and cat-associated C. felis have been found in people, and C. felis can cause diarrhea even in immunocompetent individuals. Infection with these species in humans is very uncommon compared to C. hominis and C. parvum
  • The largest outbreak of cryptosporidiosis ever reported in North America occurred in Milwaukee in 1993, when an estimated 1.6 million people were exposed to the parasite and over 400 000 people became sick as a result of the infection.
  • In most studies, contact with pets is either not associated with the risk of cryptosporidiosis or may even have a slight protective effect. One study showed no significant association between pet ownership and cryptosporidiosis in HIV patients.
A scientific review of the transmission of Cryptosporidium (and Giardia, another common waterborne parasite) is available from the International Journal of Parasitology. For more information on Cryptosporidium in pets, check out the information sheets on the Worms & Germs Resources page.