Seagulls, beaches and bad bugs
Just as I'm getting ready to go on vacation (that will hopefully involve some time on the beach), I read an article in the latest edition of Emerging Infectious Diseases about seagulls and beaches as reservoirs of multidrug-resistant E. coli (Simoes et al 2010). In this study, the researchers collected seagull poop from beaches in Porto, Portugal and tested them for the presence of extended spectrum beta-lactamase (ESBL) E. coli, a highly drug resistant form of this common bacterium. Thirty-two percent (32%) of the E. coli they isolated were ESBL, a pretty impressive rate in wild birds that would not be directly exposed to antibiotics. Various E. coli strains were present, including some that can cause severe disease.
In some respects this is pretty concerning, and in other respects not too surprising. We know that birds in various (including remote) regions can carry multidrug-resistant bacteria. The ability of wild birds to carry these bacteria, combined with the wide geographic range that some bird species have, raises concern about the role of birds in the spread of antibiotic-resistant bacteria, as well as the potential for contracting a nasty drug-resistant infection while on the beach. Birds certainly have the ability to help spread certain types of bacteria over wide ranges. However, their overall role is probably very limited compared to the role played by people and (domestic) animals. For birds to become carriers of these bacteria, they have to pick them up from somewhere, which presumably doesn't occur until the bacteria have built up to a good level in people and/or animals. I doubt that birds account for many human infections. Antibiotic exposure through antibiotic residues in water or food sources could also play a role in the presence of these bacteria in birds, but that's an area that's not well understood.
So, how does this influence my time on the beach? Not much. I wasn't really planning on having contact with seagull poop, and this paper just reinforces that basic precaution. Other basic measures such as keeping open sores covered, avoiding cuts by wearing shoes in rough areas or sand that might be contaminated with sharp objects, avoiding contamination of food with sand, avoiding areas with obvious bird poop contamination, and hand washing before eating and after leaving the beach are easy to do.
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.
Petting zoo outbreak investigation continues
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.
Testing petting zoo animals
I received the following comment in response to a recent E. coli O157 and petting zoos post, and thought that it merited a post of its own.
"Why doesn't the petting zoo owners have a fecal swab sample taken from each animal in the petting zoo and submitted for STx PCR screen testing. If a positive is found isolate the animal and continue to monitor it. I would assume The University of Guelph's extension service would have some information about this."
That's a great question. When we start talking about infectious disease risks, people often ask about testing. However, testing is not always useful and I think that's the case here. Here's a few reasons why:
- Animals don't shed E. coli O157 all the time. It's been shown in cattle that if you sample animals regularly, you will find the bacterium in the manure some days but not others. Therefore, a single negative result does not mean that the animal is definitely negative.
- No test is 100% accurate. While current tests are quite good, it cannot be stated with absolute certainty that an animal that is negative on a test for E. coli O157 is truly negative.
- Even if the animals are all truly negative for E. coli O157, they may still be shedding other potentially harmful microorganisms (e.g. Salmonella, Campylobacter, Cryptosporidium ) for which people need to take the same kind of precautions as for E. coli.
- If petting zoo operators had to pay hundreds or thousands of dollars a year per animal for diagnostic testing (a reasonable estimate if they had to do multiple tests on each animal, possibly for multiple organisms), there wouldn't be many petting zoos around.
For any test, whether it's being used for screening or to make a diagnosis on a sick animal, it's critical that it be thought of in terms of "what will I do with the results." In this case, negative results would not change recommendations for running or visiting a petting zoo. I'd assume that animals could still be shedding E. coli O157 intermittently, or that they could be shedding various other pathogens, and I'd still recommend use of good infection control practices like hand washing. Efforts are best spent working on petting zoo design and hand hygiene, rather than testing the animals, because these are more likely to have a positive impact by reducing the risk of disease transmission.
Photo source: http://www.microvet.arizona.edu/Faculty/songer/diag.htm
Verotoxigenic E. coli in petting zoo animals: UK
I’ve written several posts about petting zoos, mainly about the potential negative aspects, although I still think they’re valuable if run properly. A major concern with these events is exposure of people to zoonotic infectious diseases, particularly harmful bacteria that can be carried by healthy animals. One of the more common pathogens that causes disease outbreaks associated with petting zoos, including severe or even fatal infections in people, is verotoxigenic E. coli, particularly E. coli O157.
A recent study by Pritchard et al. in the Veterinary Record highlights some of the concerns with this pathogen. Samples were collected from various animals on 31 different farms in the UK. They found verotoxigenic E. coli on 61% of premises. The premises selected were evaluated due to suspicion that they may have been sources of infection for people, so it’s possible that the numbers reported in the study are higher than they would be for all such farms overall, nonetheless the numbers are impressive. Risk factors for finding verotoxigenic E. coli on a given farm were the presence of young cattle and (surprisingly) adult pigs. Verotoxigenic E. coli were most commonly identified in cattle (29%). It wasn’t surprising that cattle, especially young cattle (calves), were the most common carriers based on what we know about the bacterium. However, it was impressive how commonly it was found in other species, including sheep (24%), donkeys (15%), pigs (14%), horses (12%) and goats (10%). On most farms where verotoxigenic E. coli was found, the same strain was identified in multiple animal species, indicating that the bacterium can be wide spread on the property. This may be because different animal species in petting zoos are often mixed together, as opposed to the situation on conventional farms where they are usually housed separately.
Does this mean we should consider petting zoos biohazardous and avoid them? Well, the answer really is "yes" and "no". We should consider petting zoos as potential sources of harmful bacteria. High-risk people (e.g. very young, very old, weakened immune system) should probably avoid them. We should also think about ways to reduce the risks, such as using lower risk species, having good petting zoo design and, most important, encouraging and enforcing hand hygiene on the part of all petting zoo visitors. As the authors of this study stated “It is also necessary to balance this small risk against the undoubted benefits of allowing the public to interact with farm animals. The risk of people acquiring an infection from animals depends more on the degree of contact and the precautions adopted than the prevalence of infection in a particular species. ”
If you get verotoxigenic E. coli on your hands but you promptly and properly disinfect them (before contaminating something or putting your fingers in your mouth), you’ll be fine. The quality of petting zoos varies quite a lot, as we showed in a previous study, and pressure should be put on petting zoo operators to have well-designed and well-run events.
More information about petting zoos can be found on the Worms & Germs Resources page.
E. coli outbreak at a petting zoo
The latest edition of the CDC's Morbidity and Mortality Weekly Reports describes an E. coli O157:H7 outbreak associated with a petting zoo. The outbreak, which occurred at a day camp in Florida in 2007, involved 7 infected individuals. Two children were hospitalized. The same E. coli strain affecting the people was found in the stool of goats at the petting zoo.
During the investigation of the facility, it was noted that many of the general recommendations for petting zoos were followed, including providing handwashing stations, promoting hand hygiene compliance, prominent signage, and restricting eating and drinking in the zoo area. This shows that outbreaks can occur even at facilities that seem to be doing a reasonably good job of infection control. However, several key issues were identified:
- Campers were not instructed how to wash their hands properly.
- Handwashing was not carefully monitored.
- There was unlimited (and presumably not completely supervised) contact with animals throughout the day.
Numerous outbreaks of disease associated with petting zoos have been reported, often involving E. coli O157, a strain of E. coli that can cause serious or even fatal disease. This E. coli strain can be found in healthy cattle, sheep and goats. Other potentially harmful microorganisms can also be found in healthy animals of these, and other, species (particularly in their manure). Because you never know whether an animal is “potentially infectious,” taking measures to reduce the risk of disease after possible exposure is critical, particularly meticulous hand hygiene. Restricting high-risk animals (e.g. calves, baby chicks, pregnant sheep and goats) from petting zoos is also important.
Petting zoos can be great events, but carry any inherent risk of disease. More information about petting zoos and the diseases associated with them can be found in a new information sheet on the Worms & Germs Resources page. The National Association of State Public Health Veterinarians has also just released its revised Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, a comprehensive document about measures to reduce the risks associated with petting zoos and other animal contact events.
Possible E. coli O157 infections from dogs
Escherichia coli (E. coli) O157 is a particularly important bacterium that can cause very serious disease in people, including diarrhea and a severe kidney disorder called hemolytic uremic syndrome (HUS). Infection in people typically results from ingesting the bacterium from contaminated food products. The main reservoir of E. coli O157 is in the intestinal tract of cattle. There have been a few reports of suspected transmission of E. coli O157 from pets, but overall pets are thought to play a very minor role in the spread of this disease.
However, minor role does not mean no role. A recent report in the journal Veterinary Record described suspected transmission of E. coli O157 from dogs to people. Three children and two adults in a household developed diarrhea, and E. coli O157 was isolated from their stool, as well as from the stool of a healthy sibling in the house. Molecular testing showed that all the people were infected with the same strain of E. coli. An "outbreak response" was initiated by the UK's Health Protection Agency to determine the source of infection. One of the affected children, the first to get sick, visited a farm five days before developing diarrhea, so the investigation focused on that farm.
The same E. coli strain was found in 7/29 samples collected from the farm: three samples from calves, two from dogs, one from a manure pile and one from a calf pen gate. Finding E. coli in samples from the calves was not surprising, as it is commonly found in healthy cattle. However, the visiting child did not have direct contact with the calves. Finding the bacterium in the dogs was somewhat surprising. Since the child had contact with both dogs, this was thought to be the most likely source of infection. Cattle were probably the source that infected the dogs, the dogs were then probably able to transmit the infection to the child, and the child then infected other people in the house. Infection from contact with E. coli in the environment is also possible, but considering there was confirmed contact with dogs who were carrying the same strain, the conclusion that the dogs were likely the source is reasonable.
Like many of the other bacteria we worry about, E. coli is transmitted by the fecal-oral route - infection is spread by swallowing feces/stool/manure (even in minute quantities) that contains E. coli. This can occur more easily than people think, as low-level fecal contamination of hands and other surfaces is common. Identifying animals that carry this bacterium is not practical. The most important protective measure is close attention to handwashing after contact with animals, especially farm animals or pets exposed to farm animals.
This study provides more information about dogs as potential sources of E. coli O157 and the need to include testing of pets during outbreak investigations. However, dogs are probably still a minor source of this important pathogen, and it's most likely only of concern in dogs with close contact with cattle.
E. coli O157 outbreak tentatively linked to livestock show
An outbreak of E. coli O157 - the particularly nasty strain of E. coli that can cause hemolytic uremia (a serious kidney disease) and death - has been identified in Colorado, and signs are pointing toward a livestock show as the source. So far, 20 people have been identified as infected, including 19 children. The exact source of the infection is not clear, and could be food, water or contact with animals. However, considering the high percentage of children, the petting zoo is a likely source.
As we've discussed previously, petting zoos can be fun and educational events (particularly for children) but are always associated with some degree of infectious disease risk. Petting zoos are often poorly equipped to handle these risks, as we reported in a paper in Clinical Infectious Diseases a little while ago. Petting zoos are a risk because animals that appear healthy can still carry infectious diseases. This is particularly true for E. coli O157, which can be carried by perfectly healthy cattle. Despite the possibility of exposure to E. coli and other potentially harmful microorganisms, the potential for disease can be greatly reduced with some very basic measures, like handwashing, not eating in the petting zoo, handwashing, keeping baby bottles and other items out of the petting zoo, handwashing, and having signs encouraging people to wash their hands. The people in charge of this event stated that they had a well organized petting zoo with handwashing stations available, and that may very well be true. Having access to handwashing facilities is a critical step, but it doesn't do anything if people don't use them. Unfortunately, poor compliance with handwashing is very common and is one of the weakest links in infection control at petting zoos.
- Always wash your hands after leaving a petting zoo.
- Don't eat in a petting zoo area.
- Don't take items into the petting zoo that will go into a child's mouth, like bottles, cups and soothers.
Sharing E. coli with your dog
A recent study, published in the American Journal of Veterinary Research, investigated the relationship of E. coli bacteria in people and their pets. This study reported a number of interesting findings:
- When they compared the molecular fingerprints of E. coli from people and pets, they were the same 10% of the time. This means that E. coli is likely often spread between people and pets in households, although there is no way to know in which direction this occurs. It's also possible, though less likely, that people are pets don't transmit E. coli to each other, but rather that they get it from the same source.
- Antibiotic resistance was common, especially in strains from people.
- They did not detect an association between bonding behaviors (e.g. sharing the bed, allowing licks on the face) and sharing E. coli. There was, however, an association between having antibiotic resistant E. coli and owners that did not wash their hands after petting their dogs or before cooking meals.
Care should be taken with the study's conclusion that close contacts like licking aren't a risk for transmitting germs. They only looked at E. coli, which is but one of many organisms that can be passed between animals and people. Licking of the face, particularly around the ears in children, has been associated with a risk of infection from the multitude of bacteria that are present in the dog's mouth.
Nonetheless, this study has some good information. My key take-home points are:
- We routinely "share" bacteria with our close contacts, including our pets. I've been saying this for a while, and this is another piece of evidence showing how closely we interact (physically, emotionally and microbiologically) with our animal companions.
- Handwashing is an important and effective infection control tool.
- We shouldn't fear our pets in terms of infectious diseases. There are always risks but for the average person with the average pet, these are very low, particularly is good hygiene practices are used.
- There are either some dedicated pet owners in Kansas or Dr. Stenske is a very good negotiator. Getting people to provide stool samples for research studies is usually very difficult! (They'll give us all the dog poop we want, but getting their own is a completely different story!)
In a University press release, Dr. Stenske sums it up nicely: "We have a lot to learn," Stenske said. "In the meantime, we should continue to own and love our pets because they provide a source of companionship. We also need to make sure we are washing our hands often."
Raw meat feeding revisited: what are the risks and benefits of raw diets for dogs?
Feeding raw meat diets to dogs is a very controversial issue. Some proponents passionately advocate these diets (e.g. the BARF diet) based on vague and unproven recommendations. Opponents cite various studies showing that pets fed raw meat (not surprisingly) have high carriage rates of potentially harmful bacteria such as Salmonella, and reports of diarrhea or nutritional imbalances in these animals. However, there have been only a few good studies looking at the true health benefits and risks of feeding these diets to dogs.
A recent study in the journal Zoonoses and Public Health described the risks of therapy dogs shedding Salmonella and other potentially harmful bacteria. The authors tested 200 dogs over a 1 year period, 20% of which were fed raw meat as part of their normal diet. Dogs fed raw meat were 23 times more likely to shed Salmonella compared to other dogs. They were also 17 times as likely to be shedding extended spectrum beta-lactamase (ESBL) Escherichia coli (a highly drug-resistant form of E. coli).
The study concluded that, because of the risk of Salmonella shedding and the high-risk nature of the patients and other people that therapy dogs interact with, dogs that are involved with hospital/patient visitation programs should not be fed raw meat.
What does this tell us about feeding raw meat to pets?
Although this study doesn't answer all of the questions about the risks of raw meat diets, it reinforces the fact that pets fed raw meat have significantly higher rates of shedding of potentially harmful bacterial such as Salmonella and antibiotic-resistant E. coli. Eating pig ear treats has also been associated with Salmonella shedding. However, there was no association between a dog being fed raw meat and the animal itself developing diarrhea. In fact, raw-fed dogs had a lower incidence of extra-intestinal infections (combination of eye, ear, skin and urinary tract infections).
In general, raw meat diets should be avoided. While adverse health effects were not reported in this study, disease (including deaths) from Salmonella has been reported in dogs in other studies. While the overall risk may be low, feeding raw meat is an avoidable risk. However, it would be inappropriate to completely ignore the finding that raw-fed dogs had lower rates of certain infections. It is possible that there can be health benefits from feeding raw meat in certain dogs, but the potential benefits must be weighed against the potential risks to the animals and people with which the has contact. Raw meat diets should never be fed to pets that have contact with immunocompromised people (in the household or as part of visitation program), infants or the elderly.
If you are going to feed raw meat to your pet, make sure you take precautions to reduce the risk of infecting yourself or someone else. We'll post more on that aspect soon.
Coroner blames cat in owner's death from E. coli
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The inquest was told that there were three main possible sources of E. coli: food, travel and animals. The coroner determined that the owner most likely acquired E. coli from handling the cat or cleaning its litter box.There is no indication why this conclusion was reached, and it seems to be a rather strange conclusion based on the reported information. There is no reported evidence that the same strain of E. coli was even present in the cat. I suspect that they are blaming the cat because there is no other obvious source (e.g. an identified foodborne outbreak of E. coli). I doubt the cat played any role in this person's illness.
The risk of contracting E. coli from contact with a cat is very low. However, common sense should be used when handling cats and particularly cat stool. The most important measures are avoiding contact with stool and appropriate hand washing after handling a cat or its litter. More information about litter box management is available on the Worms & Germs Resources page.
E. coli and dogs
While E. coli can be a serious problem in people and some animals, it is usually not a major problem in dogs. E. coli can cause diarrhea in dogs - it is most often linked to a disease called granulomatous colitis that is classically found in Boxer dogs. However, it is not a common cause of disease nor is it often associated with hemolytic-uremic syndrome in dogs. The O157:H7 strain of E. coli is rarely found in dogs, although transmission to people from the small number of dogs it has been found in has been reported. Almost all of the dogs that were found to be carrying E. coli O157:H7 were from farms, where they were probably exposed to the bacteria by eating cattle manure. The risk of transmission of E. coli O157:H7 from dogs to humans is very low.
- Even though E. coli O157:H7 is very rare in dogs, a number of other kinds of bacteria that can infect people can be present in the stool of both diarrheic and healthy dogs.
- All dog stool should be considered potentially infectious. Avoid contact with dog stool, and always wash your hands thoroughly if you have direct or indirect contact with dog stool.
- Because E. coli O157:H7 can be found in raw meat, it is reasonable to suspect feeding raw meat to a dog may increase the risk that it will have E. coli O157:H7 in its stool.
- The most important things you can do to avoid E. coli O157:H7 are:
- Handle raw meat properly to avoid contamination of other foods and surfaces.
- Make sure you cook meat at an appropriate temperature and for an adequate amount of time.
- Handle raw meat properly to avoid contamination of other foods and surfaces.
Dog stool and garbage
For approximately 20 years I have been involved in waste collection for the Parks Division. A considerable amount of the waste which I collect on a daily basis is dog excrement. This is usually, but not always contained in a plastic bag and thrown into a large garbage barrel which I man-handle and dump in a waste truck. Years ago I contacted the local Health Unit and asked if there was any special health risks associated with this job. They advised me at that time the main danger to health would be with E.coli contamination. I use neoprene gloves while carrying out my duties and of course try to ensure that I do not come in contact with any debris. This is not always possible.
There are 3 main risks with handling dog stool: exposure to bacteria that cause diarrhea, exposure to intestinal parasites and infection of wounds.
Various bacteria that can cause diarrhea can be present in dog stool. These include Salmonella and Campylobacter. E. coli is not a major concern because strains found in dogs are not typically those that cause disease in people. A few intestinal parasites are also of concern, including Giardia and roundworms. The risk of exposure to these is hard to say because you don't know anything about the health status of the dogs, but it's wise to treat all stool as infectious. However, for these to cause disease, they must go from the garbage and into your mouth. The risk of this should be minimal with basic common-sense precautions.
A large number of bacteria present in stool can cause infections of wounds like cuts and scratches, or other skin lesions such as eczema. Direct contact of these lesions with stool would be required to cause infection. The risks of this can also be greatly reduced with basic preventative measures.
Some basic precautions (many of which you are doing) include:
- Wear gloves when handling bags containing stool.
- Change your gloves if they become contaminated with stool.
- Have your gloves cleaned periodically, and whenever they become contaminated. Otherwise, use disposable gloves.
- Promptly wash or disinfect your hands if they become contaminated. Carrying an alcohol-based hand sanitizer in your truck would be useful.
- Wear coveralls or some other sort of outerwear that can be removed easily if contaminated. If your clothing becomes contaminated, change it (and wash your hands after).
- Wash your hands after removing your gloves (and especially before eating).
Overall, the risks to you should be very low.
