A recent rat bite fever death in a six-month-old Pennsylvania baby raises several issues that parents need to consider.
The child died of meningitis and myocarditis (inflammation of the heart) caused by the bacterium Streptobacillus moniliformis. This bacterium is present in the mouths of virtually all rats, and is the cause of rat bite fever. Human infections are uncommon but they can be severe, especially in young children, individuals with compromised immune systems and/or when infection is not diagnosed promptly. Rat bite fever is (not surprisingly, given the name) mainly associated with rat bites, but can also occur if there is other contact of rat (or other rodent) saliva with a person's mucous membranes (e.g. mouth, nose) or broken skin.
In this case, the baby was bitten by a rat that was to be fed to the family’s snakes. A few days later, a fever and rash were noted (classical rat bite fever signs) and the child was taken to an Emergency Room, but discharged with "medication" (probably just something to lower the fever). Two days later, the baby was returned to hospital with fever and lethargy, and died later that day.
Besides the tragedy of the situation, there are several things about this case worth pointing out:
- Babies should not have any contact with rats. Infants are at increased risk of infection from a lot of things, and they get little benefit from touching a rat. The risks outweigh any benefits.
- If an infant is bitten by any animal, antibiotics are often indicated to prevent infection. Good bite first aid and knowing when to get medical care should be an integral part of pet ownership
- Pet owners need to know about infectious disease risks associated with their animals (and any animals they may feed to their animals, as in this case), especially when there are high risk indiviualds in the household.
- Physicians need to know about bites and other animal exposures. It’s not reported whether the physicians asked, and given the fact that rat bite + fever + rash absolutely screams "RAT BITE FEVER," they must not have.
- Patients/parents need to volunteer information about pet ownership and high risk incidents like bites. If the physician had asked about animal contact, or the parents had mentioned the bite, odds are good that the baby would have been treated for rat bite fever the first time the family went to the hospital, and then likely would have survived.
- Snakes (or any other reptile) should not be kept in households with babies. The risk of Salmonella exposure is too high.
- Live rodents should not be fed to reptiles. There are humane issues for both the rodent and the snake, as snakes can be seriously injured by prey.
People talk about "one medicine" and "one health" all the time, but application of the concept is poor. There needs to be better communication about zoonotic diseases and animal exposure, especially in situations like this.
More information about rat bite fever is available on the Worms & Germs Resources - Pets page.
As reported on WKTR NewsChannel 3 in Virginia:
“An employee at PetSmart [in Williamburg, Virginia] says she was bitten by a rat on display and is now worried she has rabies. She feels the store isn’t doing enough to help her find out if she has it.
Victoria Verbeeck says she was working at the Williamsburg store on Wednesday morning when a rat bit her finger. The rat had been acting oddly lately, she said, but she had handled it before. “It turned around and just chomped down on my finger,” she said. “I was more like that really just happened.”
Since it happened, she says PetSmart hasn’t been acting fast enough in helping to get the rat tested. With the holidays, she says she was told she’d have to wait until Monday to get help from PetSmart because corporate offices are closed until then.
A spokesperson from PetSmart says the company is taking the situation seriously. The health department is now overseeing the testing, according to the spokesperson. It’s not clear when the results will be available.”
What is the risk of rabies?
- Exceptionally low. Although rodents can be infected with rabies (as can any mammal) they rarely carry it (likely because they are usually killed by whatever animal may have transmitted it to them in the first place). However, low risk doesn’t mean zero, so the woman's concerns shouldn’t be dismissed out of hand.
Is rabies the only concern?
- No. In fact, there are other more concerning issues, such as rat bite fever, a potentially nasty infection transmitted most commonly by (not surprisingly) rat bites.
Is the delay in testing that the woman has encountered a problem?
- For rabies, no, particularly for a minor bite of an extremity. There’s time to get things sorted out and a few days isn’t a concern. The stress of the wait is the biggest problem.
- The wait is most relevant in terms of other potential infections, since those develop quicker.
How will they figure out if rabies is a concern?
- For some species (e.g. dogs, cats), it’s well defined. If the biter is still alive and normal 10 days after the bite, the animal could not have been shedding rabies virus at the time of the bite. Rules are less clear for other species and those are handled on a case-by-case basis, but given the very low risk of rabies in rats and the fact that rats are not a reservoir species, a quarantine period would probably be reasonable in a case like this. However, figuring out why the rat was acting "oddly" and if there is any evidence of a neurological disease component is important. If the rat has neurological abnormalities, immediate euthanasia and rabies testing would probably be recommended.
What’s the big issue here?
- It amazes me that a company like this would not have a comprehensive and well-communicated bite policy. A well-thought-out and scrutinized policy should be available in all stores and readily accessible to all personnel. It takes time to get a good policy developed, but it’s worth it based on the amount of time that’s saved down the road after bites like this (which are probably quite common but not typically reported) and it can help prevent bite-related complications and concerns. Hopefully they actually have a good policy, but the fact that they have to wait until corporate offices are open to find it highlights a problem.
A couple months ago, I wrote about a family suing PetsMart over a case of rat bite fever in a child.
Now, a San Diego family is suing PetCo after their ten-year-old son died of the same infection. Rat bite fever is a bacterial infection caused by Streptobacillus moniliformis, and it is almost always associated with bites from rats.
The San Diego family’s situation is tragic. Fortunately fatal zoonotic diseases from pets are rare. But when they happen, who’s to blame?
Part of figuring that out is thinking about what has to happen for an infection to develop, and where that cascade can be interrupted.
What has to happen for rat bite fever to develop?
The rat has to be carrying the bacterium in its mouth.
- The bacterium is found in basically all rats, so you have to assume that every rat is infected. (So, it’s hard to blame the supplier.)
The bacterium has to get into the person's body, usually by a bite.
- Bite avoidance is therefore key, and involves proper handling of the rat and selecting a rat that has a good temperament.
When the bacterium gets into the body, it has to be able to cause disease.
- Most often, the immune system takes care of it. However, the number of bacteria that get into the body, the weakness of the immune system, and the whims of biology all play roles. In an otherwise healthy child, bite first aid is critical to help remove as many bacteria as possible from the wound before they invade the rest of the body.
To me, it all boils down to education.
- Pet stores need to inform purchasers about infectious disease risks and preventive measures.
- People need to take responsibility to learn about any pets they may purchase (before they get them), and take measures to reduce the risk of zoonotic pathogen exposure.
- Physicians need to be more aware of zoonotic diseases and ask about pet ownership and animal contact.
Would any of these have made a difference here? It’s hard to say. However, these are all relatively easy things to do and could probably prevent a lot of infections.
More information about Rat Bite Fever can be found on the Worms & Germs Resources - Pets page.
A local county newspaper had a front page headline about a zoning amendment that was approved to allow for a feeder rodent facility that will produce about 10 000 rodents a week (I know, apparently there aren't a lot of big things happen around here). Co-incidentally, a couple days later, I received an alert and fact sheet from the Ontario Ministry of Health and Longterm Care and the Office of the Chief Veterinarian of Ontario about Salmonella and feeder rodents because of an increase in human Salmonella Typhimurium infections in people in Ontario and a link to feeder rodents in some cases.
It’s not really a surprise. Large and sustained outbreaks of salmonellosis associated with feeder rodents have been reported for a while. These rodents are often produced at large facilities with hundreds of thousands of rodents, and if Salmonella gets in the facility, thousands (or millions) of biohazardous small-and-fuzzy snake snacks can get shipped around the world.
The fact sheet is attached here, and it contains good information about the standard reptile and rodent handling practices that I always keep coming back too: wash your hands, keep high risk people away, prevent cross-contamination of snake food with people food (e.g. don’t thaw frozen rodents in an open container in the fridge (yuck… but it happens) or cross contaminate kitchen surfaces) and other basic hygiene practices.
Infection control isn’t complicated, it’s often just ignored.
A year or two ago, I received an email from Dr. Chelsea Himsworth, who was doing some interesting work looking at different bacteria found in rats in Vancouver's Downtown Eastside. This is an impoverished urban neighbourhood with lots of homeless people, IV drug users and HIV-infected individuals... and lots of rats. Dr. Himsworth, a veterinary pathologist working on a PhD at the University of British Columbia, is assessing potential health risks posed by rats to this type of population. The reason she got ahold of me was to see if I was interested in looking for some different bacteria, like methicillin-resistant staphylococci, in these rodents.
If you look, you often find, and that was the case here with methicillin-resistant Staphylococcus pseudintermedius (MRSP). This multidrug resistant bacterium was found in nasal or oral swabs from 2.1% of rats (Himsworth et al, Emerging Infectious Diseases 2013). So it was relatively uncommon but certainly present.
One question: from where did it come? Most MRSP isolates found were the same as the most common strain found in dogs, so presumably the rats picked it up directly or indirectly from pets or stray dogs. However, there was also a type we've never run across before. That could mean that there is a separate rat-associated MRSP strain, but more likely it means this strain is present in dogs in Vancouver and we just haven't found in dogs elsewhere yet (there aren't many of us typing MRSP, and we find new strains not uncommonly). While dogs and rats presumably don't spend time lounging around together, there is certainly potential for direct or indirect contact between dogs and rats, and rats have been found to harbour dog-associated oral bacteria in the past.
Another question: what's the risk to people? The risk of infection is probably limited, but not zero. MRSP can cause infections in people but doesn't do so very often. MRSP is unfortunately becoming fairly common in dogs, so people are commonly exposed, yet human infections are still rarely diagnosed. So, the risk to humans from these rats carrying MRSP is pretty low overall, although we'd rather not see new reservoirs for this bug.
What about the rats? Rats may be the innocent bystander here, having been infected by dogs. We don't know whether MRSP causes infections in rats. It probably can in certain circumstances.
Can rats spread this to dogs? I guess it's possible. Rats are probably not contaminating the environment too heavily with this bug from their noses or mouths (compared to dogs), but direct transmission if a dog caught a carrier rat could certainly be possible. The risk to the dog population is pretty low since this pathogen is well established in dogs already and there's a lot more dog-dog than rat-dog contact.
Why does an antibiotic-resistant bacterium live in these rats when they're not receiving antibiotics? Good question. Antibiotics certainly help when it comes to selecting for resistant bacteria, but they're not absolutely required. There are a lot of other factors that can also play a role, so rats don't need direct or indirect exposure to antibiotics to acquire MRSP (or other multidrug-resistant bacteria). It could be that they are just commonly exposed and the bacterium only hangs around for a short period of time, or that there are some other factors in the rats, their food or their environment that select for these resistant bacteria.
A recent report in the journal Infection (Chean et al. 2012) describes rat bite fever in a patient with AIDS. I’ve written about rat bite fever before, and it’s not really a surprising case report. Streptobacillus moniliformis, the bug that causes the disease, is found in the mouths of most rats (and in the mouths of dogs more often than we’ve previously assumed). Rat bite fever is uncommon but far from rare, and this report focuses on the fact that it was in an AIDS patient. The case report itself isn’t too noteworthy since we know infection with S. moniliformis can happen even in healthy people, and someone with AIDS is going to be at increased risk of any type of infection.
However, there are a few interesting aspects to this particular case. The report described a 30-year-old AIDS patient who had a rather prolonged course of disease with fever, aches, diarrhea and weight loss, with subsequent development of joint pain and swelling. A large battery of tests didn’t identify the underlying cause. Eventually, "it was noted that he had two pet rats, one of which bit the man on his right index finger 1 month prior to presentation." That should have been a "eureka!' moment for the physician. It doesn’t mean the disease was caused by the bite, but it made it clear that rat bite fever should be considered. The diagnosis was then made and the man received appropriate treatment.
While the clinical aspects of the case aren’t remarkable, there are some noteworthy points to consider:
- It wasn’t until re-evaluation that it was discovered that the patient had rats and had been bitten. It’s quick and easy for a doctor to ask “Do you have pets or have you had contact with animals?” and in a case like this, it could have sped up the diagnosis and appropriate treatment.
- The paper repeats the important statement that pet ownership rates among HIV/AIDS patients are similar to that of the general population. That’s also true for other groups at increased risk of infection.
- They say “Physicians need to be cognisant of this [pet/human] relationship in order to prevent missing the diagnoses of zoonotic infections in their patients.” That’s a critical step. It’s easy to do. It’s not often done right.
Earlier this year, a troop of Boy Scouts in the US beat off a rabid beaver that was attacking their leader (I wonder if there's a badge for that). Boy Scouts and infectious diseases are in the news again, but not with as happy a story.
In the recent incident reported on ProMED, ten Boy Scouts that attended a camp on the banks of the Semois River in Belgium developed leptospirosis - a potentially severe bacterial infection caused by Leptospira bacteria. The bacteria are shed in the urine of a variety of animal species, and people can become infected through contact with contaminated water or animals. The boys reported having played with a rat, which was likely actually a muskrat, based on the description of its size.
Three of the boys were hospitalized. Hopefully all are on the way to recovering.
This is yet another reminder that wildlife should be left alone. It's possible the boys were infected from the environment, but handling a muskrat (which was presumably sick if they were able to get that close to it) certainly increases the risk of exposure to a variety of infectious diseases.
Image of a North American muskrat (photo credit: Linda Tanner)(click image for source)
I’ve written about lymphocytic choriomeningitis virus (LCMV) before, as an interesting but pretty uncommon rodent-associated disease. Human infections are mainly associated with handling rodents, although other routes of transmission, such as organ transplantation from an infected donor, have also been reported. Being a disease associated with rodents and considering how rodents are produced in North America (i.e. mass production in large breeding colonies, followed by transportation to large distributors and massive mixing of animals), LCMV is bound to be a recurring problem associated with the pet rodent trade.
An issue of the CDC's ominously titled Morbidity and Mortality Weekly Report describes the risk of infection with LCMV to people who work in rodent breeding facilities. It all started with the diagnosis of meningitis in a person who worked in a rodent breeding facility in Indiana. An astute doctor suspected LCMV and the diagnosis was confirmed. The breeding facility was a pretty large one, housing approximately 155 000 (!) mice and 14 000 rats. An investigation of facility personnel ensued and approximately 25% of employees had antibodies against the virus, indicating previous infection. A large percentage of the workers reported having had signs consistent with disease (e.g flu-like illness), indicating that they were likely infected and not just exposed.
Considerable effort was put into testing the animals. Of over 1000 animals tested, 21% of mice had detectable levels of the virus in their bodies. That’s pretty impressive and concerning, both for employees and anyone receiving animals from this facility.
In response to this investigation, all mice at the facility were euthanized, and the facility was thoroughly cleaned and disinfected.
This report highlights the risk of exposure to LCMV for people who work with rodents, especially in large facilities such as this. It also highlights the risks posed to people buying rodents from these facilities, which also includes other diseases in addition to LCMV. Good general hygiene and infection control practices should greatly reduce the risk of LCMV transmission to rodent owners. In particular, efforts should be directed at new rodents, since LCMV shedding is probably greatest during the initial period after an animal enters a household or other facility. Virus shedding it often transient, and once they get out of the high-risk facility and become acclimatized to their new home, shedding rates in these rodents probably decrease over a short period of time. Overall, the risk of LCMV in someone with a pet rodent is low, but these basic preventive practices are easy to do and make a lot of sense.
Photo: Female mouse with her litter. (Photo credit: Seweryn Olkowicz) (click image for source)
Plague cases tend to get a lot of press. The fact that this disease killed a large percentage of the human population in a few different pandemics (albeit centuries ago for the most part) probably plays a role in that. Despite the impression by some that it's just a historical disease, plague is alive and well in certain parts of the world, including parts of the US, and infects a few thousand people every year.
Plague is caused by the bacterium Yersinia pestis, which lives in various wild rodents and is circulated by fleas. Transmission to people historically has been via fleas that jump from rats to people. However, plague isn't just a rat-human disease, as it can infect other animal species. Among domestic animals, cats seem to be most commonly infected, probably because of exposure while hunting.
The problem with plague and pets has been shown once again a case of plague in an Oregon man who likely picked up the infection from his cat. (Oregon is outside of the main range of plague in the US, where the disease is most common in the southwest). The man was bitten by the cat while retrieving a dried, decayed mouse carcass from its mouth. He developed septicemic plague (infection of the bloodstream), and then pneumonic plague (infection of the lungs), which is the worst case scenario. At last report, he was in critical condition and the prognosis for survival is probably guarded.
There's no mention of the cat's health. Most cases of cat-human plague occur in people taking care of sick cats (especially veterinarians). If a person is infected by a cat bite, I would expect the cat to have been sick with plague, although transmission has been reported from apparently healthy cats. Some other possible routes may need to be considered. If the cat in this case was exposed to plague, then plague's obviously in wildlife in the area, so you have to consider that the infected man might have been bitten by an infected flea (that came directly from an infected wild animal or that the cat tracked in) or from direct contact with wildlife, especially if his house had a rodent infestation.
Regardless, it's important for people in plague-endemic (and neighbouring) areas to be aware of plague and take measures to reduce the risk of exposure for themselves and their pets, such as:
- Avoid contact with wild rodents (and wildlife in general, since larger wildlife species can also be infected).
- Keep cats inside.
- Don't let pets with outdoor access roam unobserved, where they might be more likely to encounter wildlife.
- Have a flea control program for pets.
- Address any animal/household flea infestations promptly and aggressively.
- Make sure sick pets get prompt and appropriate medical attention, since diagnosing plague in a pet may be a critical factor in prompt treatment of people infected by the pet. Plague is an example of a disease for which diagnosing infection in the pet might save the owner's life.
Today's Toronto Star has an article about a reptile club in a Toronto Elementary School. Teacher Jim Karkavitsas runs a session every day that teaches students about a range of reptiles. His menagerie has expanded from one snake five years ago to more than 40 different species in his classroom. Some are loaned out to other classroom's on request and two lizards now make their home in the school's main office.
- Learning about, and interacting with, animals can be very important for kids, especially those who don't get exposure to animals at home and outside of school. It can teach responsibility and empathy, and be the springboard for a range of educational discussions.
- The animals are kept in a room adjoining the classroom, so they are relatively contained and all students aren't forced to be around them (since some kids might be afraid of them). Housing the reptiles in a different room also means students presumably aren't eating in the same room in which the reptiles are housed.
- Kids use hand sanitizer before and after contact with reptiles. This is a very important preventive measure for the problems outlined below, but it's not 100% protective (or usually performed all the time or done properly).
- Mr. Karkavitsas takes the animals home during the summer. A problem with some classroom pets is people don't assume ownership for them to take care of them properly when school's not in session. Similarly, the school's parent council provides $5000 to cover the cost of keeping the reptiles. Hopefully, that also means that veterinary care would be provided if something happens, which can be a problem in many cases when classroom pets need care but no one has a mandate to arrange or pay for it.
The bad and the ugly
- Salmonella. That's the big one. Reptiles are classic sources of Salmonella. You can almost guarantee that more than one of these reptiles are shedding the bacterium. If a reptile is shedding Salmonella in its feces, it will also likely have the bacterium on its skin, in its cage and in any areas where it roams. It also means that anyone touching it (or its environment, or contaminated areas) can pick up Salmonella on their hands, with subsequent transfer into the mouth. This is a high-risk situation since reptiles are a major source of salmonellosis, especially in kids. Reptile-associated salmonellosis does occur in classroooms.
- Mr. Karkavitsas buys frozen rats to feed the snakes. Frozen rats can also be contaminated with Salmonella, and frozen rats have caused salmonellosis in kids in a school (which was also brought home and spread other family members). There's also been a large (and likely ongoing) international salmonellosis outbreak associated with frozen rodents.
- Standard recommendations are that children less than five years of age (along with pregnant women, elderly individuals and people with compromised immune systems) not have contact with reptiles. This is a grade 5-6 classroom, so the students would be older than this, but I wouldn't be surprised if younger kids in the school also have contact with the reptiles. Additionally, the immunocompromised group is an issue, since many people have compromised immune systems due to various diseases or treatments. Teachers may not know about all of these and parents may not realize that their high-risk child is having contact with high-risk animals in school. When you can't be sure that high-risk people won't have direct or indirect contact, that's a problem.
The sentiment is great and I applaud the teacher's efforts to engage kids and teach them about animals, However, it's a cost/benefit situation and the potential costs (which may be extreme) outweigh the benefits (significant as they may be). While reptiles can be great pets in certain situations, they're not meant for schools where there are lots of kids, challenges with supervision, difficulty implementing good infection control practices and potentially individuals at high risk for infection.
The CDC is investigating CDC is investigating more cases of salmonellosis associated with feeder rodent contact, caused by the less-than-catchy-named Salmonella I 4,,12:i:-. This strain is the same one that was implicated in a large and prolonged outbreak in the US and UK in 2009-2010 which was also associated with frozen feeder rodents (rodents sold frozen as reptile food) from a single US supplier. The current outbreak has affected people in 22 US states from August 2011-February 2012, and involvement of the same strain from the same source certainly leads to suspicion that this is actually an ongoing problem.
In the latest outbreak:
- 46 people have become sick. As is common, kids have borne the brunt of this outbreak, with the median age of affected persons being 11 years.
- 37% of affected people were kids five years of age or younger. Since this outbreak involved feeder rodents, clearly people aren’t heeding the guidelines that kids of that age shouldn’t be in households with reptiles.
- No two affected people reported buying rodents from the same store. This shows how widespread the problem is and that it must be originating from the place where the rodents are bred and/or distributed, not a focal pet store issue.
Record-keeping at the pet stores complicated figuring out the source. However, two breeders that supplied pet stores received mice from the company that was the source of the 2009-2010 outbreak. This suggests that not only were people exposed from frozen feeder rodents in the earlier outbreak, but that breeding colonies in different areas were infected from that source. This may have allowed wide dissemination of this Salmonella strain into numerous rodent breeding colonies, creating many possible sources of exposure for members of the public purchasing feeder rodents. The large-scale commercial nature of rodent breeding and wide distribution network creates a great opportunity for widespread outbreaks, as is apparent here and with various other outbreaks (including salmonellosis outbreaks from guinea pigs and baby poultry).
If you are going to buy feeder rodents:
- Treat them as if they are carrying Salmonella, because they just might be.
- Keep them away from human food. Keep them in a separate freezer or fridge, or in a sealed container if they have to be in the same fridge as human food.
- Don't handle them in the kitchen.
- Wash your hands thoroughly after handling.
- Keep them away from young children, as well as people with compromised immune systems, elderly individuals and pregnant women. None of these groups should have contact with reptiles either.
Image: A package of frozen rats, as sold commercially for feeding reptiles.
Rat bite fever is an infection caused by the bacterium Streptobacillus moniliformis (the main cause in most countries) or Spirillum minus (the main cause in Asia). The condition is, not surprisingly, associated with being bitten by a rat, although it can be transmitted by other routes such as dog bites. The bacteria live in the mouths of most rats (and a less-well-understood percentage of other animals). Disease occurs when these bacteria make it into the body via a bite, or other high-risk contact such as kissing the animal or letting it lick an open wound.
The Australian case report describes a 26-year-old woman who had a fever and sore throat, which progressed to a severe unrelenting headache with nausea, vomiting, sensitivity to light, neck stiffness and pneumonia. Streptobacillus moniliformis was isolated from a blood sample. The strain was fortunately susceptible to the antibiotics that had been started earlier. It wasn't until a couple of days later that a rash (a classic sign of rat bite fever) developed. Fortunately at that point the diagnosis had already been made and the woman was responding to treatment.
After "further history taking" it was revealed that the patient owned two rats and, while she had not been bitten, she had close contact with them, including kissing. It's not clear when the "further history taking" occurred, but it probably happened after they found the S. moniliformis and made diagnosis, which rounds out the case report nicely but doesn't speed up the diagnosis or improve case care. The animal contact question needs to be asked at the start. One of the Lessons from Practice that the article highlights is "A thorough history, including history of animal exposure and pet ownership, should be taken for all febrile patients." Remove "febrile" and I agree completely.
Anyway, the woman responded to treatment and went home after 17 days in hospital. Most people that are properly diagnosed and treated survive, but rat bite fever can be fatal.
Most rats carry at least one of the two bacteria that cause this disease. There's no indication to test pet rats (since we assume they all have the bug until proven otherwise, and we can't confidently prove otherwise) or treat them (since we have no evidence we can eliminate the bug from the mouth of a healthy rat). It's a limited but ever-present risk of rat ownership, and one that can be greatly reduce by avoiding kissing rats, preventing bites, proper wound care should bites occur, and ensuring that physicians know about potential rat contact if illness develops.
A Montreal pediatrics resident has expressed concern about rat bite fever in kids. Dr. Karine Khatchadourian described three cases of this bacterial infection in a paper called "The rise of the rats: a growing paediatric issue," published last year in the journal Paediatrics and Child Health. The article didn't really present any evidence that this is a "growing" issue, but it is a disease of concern.
Rat bite fever is a bacterial infection most commonly (but not exclusively) associated with bites from rats. Healthy rats often carry the bacterium that causes the disease (Streptobacillis moniliformis in North America), and infection can occur when the bacterium is inoculated into the body by a bite, or when it's spread to mucous membranes like the mouth through direct mouth-mouth contact with pet rats (yes, some people kiss their rats).
The disease can be serious, and even fatal, if not properly diagnosed and treated. It's also a classic example of why physicians need to ask their patients about pet contact and why people need to take bites from pets seriously. Knowing that a rat is in the house, and particularly if a bite has occurred, is a key factor in helping make the diagnosis. If the physician doesn't ask the question, this critical piece of information may be missed, along with the diagnosis.
Being concerned about rat bite fever (and other zoonoses) is good, and ways to educate pet owners and physicians about such diseases are needed. However, extrapolating "rat bite fever is bad" to "rats are bad" is a stretch. The statement in the paper "Should we, as health care professionals, advocate to have rats banned from being sold in pets stores?" is over the top.
Every animal carries many microorganisms that can cause disease in people, given the right circumstances. Similarly, every person you meet is carrying something infectious. The key things to consider are:
- What is the likelihood of infection?
- How severe is the disease that may occur?
- What can be done to reduce the risk of infection?
- What is the cost-benefit, i.e. how do the potential risks compare to the potential benefits?
How can the risks be reduced?
- Rat owners need to be aware of the disease.
- Good handling practices are needed to reduce the risk of bites.
- Any bites that occur should be promptly cleaned and a physician contacted if there are concerns.
- Contact of rat saliva with broken skin or mucous membranes (e.g. kissing the rat) should be avoided.
- Physicians need to know whether their patients own pets, including rats, and know what diseases may be associated with those types of animals.
With this type of approach, the risk of infection can be reduced and the ability to properly and promptly diagnose the disease, in the odd case that it occurs, can be maximized.
I don't want to downplay rat bite fever. It certainly can cause illness, particularly in children under the age of 12. A recent paper reported a fatal case in a 14-month-old boy, however in that case the infection was associated with ferrets, not a rat.
Parents of small children need to think about the risks of zoonotic diseases, as well as injuries (e.g. bites) when deciding whether to get a pet, and what type of pet to get. If people like rats, take care of them properly and communicate well with their physician (and if their physician is aware of the issues), then the risks of serious disease are quite low.
Dr. Khatchadourian suggests that parents "should stick to cats and dogs, and steer clear of rats." However, that's no assurance that a zoonotic infection will not occur. There's no evidence indicating the risk of disease is less with those species. It doesn't even eliminate the risk of rat bite fever, since Streptobacillus moniliformis can be found in the mouths of dogs too.
Rather than banning rats from pet stores, we should focus on educating pet owners, veterinarians and physicians about zoonotic diseases.
Cowpox virus is an example of a virus with a misleading name. It's place in history is from Jenner's observation that milkmaids who had been infected with cowpox were resistant to smallpox, leading to the use of cowpox (which causes very mild disease) to protect against smallpox (which is very, very bad). While cattle can be infected, they are not the true host of this virus, and infections in cattle are actually quite rare.
Various rodents are the true reservoir of cowpox. Other species can be infected from contact with infected rodents, including people and pets. Among pets, cats are most commonly infected, with most reports coming from central Europe. Cats may be infected more often because they may more often have close encounters with rats, but they are probably also inherently more susceptible to the disease than dogs.
Cowpox infections in dogs are very rare, but a case was recently described in Veterinary Dermatology (von Bomhard et al 2011). It involved a five-month-old Rottweiller from Germany that developed a very mild case of cowpox, with a single nodule on its muzzle. The dog recovered uneventfully, but it was an interesting case of a rare disease in a dog, and one that has some human health considerations.
People can be infected with cowpox from pets. In particular, infections from pet rats have been a problem in central Europe over the past few years. Outbreaks of human infections have been identified associated with widespread dissemination of infected rats from infected breeding or distribution facilities. Infections have also been reported from cats, and cats are a significant concern because of their ability to be a bridge between wild rodents and people, and because of the close contact they tend to have with people.
It's not surprising that disease was so mild in this Rottweiller puppy, and the risk to people in contact with the dog was probably limited because of the mild nature of the infection. No human cases were reported associated with this dog. Human infections from dogs have not been reported, largely because the disease is so rare in dogs and perhaps because when they are infected, dogs tend to have very mild disease. Cowpox is of minimal concern for most pet owners, but it something to be aware of when obtaining a new rodent, especially in regions where cowpox is an issue, and when dealing with cats in areas where cowpox is endemic in wild rodents. Some basic preventive measures include:
- Pet rodents and cats (especially newly obtained rodents) that develop skin lesions should be handled with care and be examined promptly by a veterinarian.
- Wild rodents should never be caught and kept as pets (for various other reasons, as well).
- Contact between domestic pets (particularly pet rodents and cats) and wild rodents should be prevented.
A Phoenix, Arizona man is suing a pet store after he contracted rat bite fever from a rat he had purchased. It's not surprising to see a lawsuit following a serious illness, considering people in the US often try to sue for just about anything, but I'm not sure it won't get very far. I don't doubt that the man had rat bite fever, or that he got it from the rat he purchased - the question is, is the pet store really liable? Specifically, did they do anything inappropriate?
"Rats being sold to people should not have rat-bite fever," Heitzman's lawyer, M.E. "Buddy" Rake Jr., tells New Times.
Actually, the rats don't have rat bite fever... rats are healthy carriers of the bacteria that cause rat bite fever. There are two different bacteria that can cause the disease, Streptobacillus moniliformis and Spirillum minus. Streptobacillus moniliformis is presumably the cause here since it's the main cause of rat bite fever in the US. This bacterium is very commonly found in healthy rats, with upwards of 100% of healthy rats being carriers. You have to assume that every rat is carrying this bacterium.
"It wouldn't be any different if they sold someone a dog with rabies," he says. "I'm not in the nuisance-lawsuit business - he was in rough shape."
It would certainly be a different story if the store sold someone a dog that had signs of rabies. It's possible that someone could buy a dog that had been exposed to rabies but which was healthy at the time of sale, but that's pretty unlikely. However, a big difference is that there is a highly effective vaccine against rabies. There is no such thing for rat bite fever. If a pet store sells an unvaccinated dog of unknown origin that could have been exposed, despite knowing the need for rabies vaccination, there certainly could be liability issues. Selling a rat that is carrying a bacterium that we assume most or all rats carry anyway is different.
PetCo did not immediately return telephone calls this afternoon, but in its defense, there is an information pamphlet explaining exactly how to avoid contracting rat-bite fever available on the company's Web site. ...though it seems the pamphlet's best suggestion is to not get bitten in the first place.
It would be better if everyone who bought a rat was given the information sheet, but it's a start. The fact is, the best way to avoid rat bite fever IS to avoid getting bitten by a rat! Proper rat handling is a very important aspect of disease prevention, since you can never rule out the possibility that a rat is a carrier.
Our suggestion: Don't have a disgusting rat for a pet.
Whoa. Rats can make excellent pets. They can also carry infectious diseases. However, EVERY animal can carry infectious diseases, and rats are probably no more risky than most other domestic pets. The key is to take common sense precautions to reduce the risk of injury and infection (though the risk can never be completely eliminated). For rats, this includes selection of a rat that is not aggressive or fearful, knowing how to properly take care of a rat, knowing how to take care of a bite should it happen and being aware of some diseases for which you might be at increased risk because you own a rat.
Image source: http://commons.wikimedia.org
Cab drivers have to put up with a lot of risks, but attacks from marauding rats probably aren't high on their list of concerns. However, a Ukrainian cab driver was recently attacked by a rat, and the rat was subsequently killed and found to be positive for rabies. The cab driver is now undergoing post-exposure treatment, and authorities are vaccinating pets and trying to eliminate mice and rats in the nearby neighbourhoods.
This is another good example of why it's important not to ignore a bite from any mammal, because rabies can affect any mammal. People often don't consider rodents a concern when it comes to rabies transmission, because most rodents would die from an attack by a rabid animal, thus preventing them from becoming infected and passing on the virus. This is probably true in most circumstances, but there have been enough reports of rabies in rodents, and potential human exposure from contact with rabid rodents, that we have to pay attention to this risk. Overall, the likelihood of acquiring rabies from a rat bite is pretty minuscule, and much less than the risk of contracting other diseases such as rat bite fever, but it's not zero. Since rabies is almost invariably fatal, even seemingly low risk situations need to be carefully assessed. In the case of this cab driver, there was definitely a risk of rabies exposure. If the rat had not been caught and tested, the potential for rabies exposure might have been dismissed, which could have had catastrophic consequences for the cabbie.
More information about rabies can be found on the Worms & Germs Resources page.
A recent edition of the Veterinary Record contains a case report of Weil's disease in a person that adopted a feral (wild) rat (Strugnell et al, 2009). Weil's disease is a severe disease of the kidneys, liver and other body systems that can develop after acute leptospirosis (infection by Leptospira bacteria). This group of bacteria can infect a wide range of animals and is typically shed in the urine. The person that was affected adopted the rat after it was caught by her neighbour's cat. The paper says that the rat was "urinary incontinent" - not something we usually notice about rats since they are not typically litter or house trained. I presume this means the rat was urinating frequently when out of its cage, including when it was being handled. Because of this, the owner reported that she "aimed" to wash her hands after every time she touched the rat.
A couple of weeks after adopting the rat, the woman was admitted to hospital because of lethargy, muscle aches, mild abdominal pain, cough and a bloody nose. Blood tests showed that she had decreased levels of white and red blood cells, as well as liver and kidney disease. After further testing she was diagnosed with leptospirosis. She had to be treated in the ICU, but eventually made a complete recovery. The adopted rat and the other rat that she owned were euthanized by the owner's partner shortly after she was admitted to hospital. Testing of the adopted rat identified Leptospira in the kidneys.
This is another example of why wild animals should be left in the wild, and another case highlighting the need for veterinarians, physicians and public health personnel to work together.
Rats can be really interesting pets. They can be quite social and are interesting to watch. Being larger than hamsters and gerbils, they can also be more easily and safely handled. They can still bite, however, particularly if they are not properly socialized and/or they are handled by people who don't know how to do it properly. Even though rats have tiny teeth, bites can still cause problems. One concern is rat bite fever. This disease is actually caused by two completely separate bacteria. Streptobacillus moniliformis is the most common cause in North America and Europe, while Spirillum minus is the main cause in Asia.
I'll focus on Streptobacillus moniliformis today. This bacterium is very commonly found in the mouths of healthy rats. Up to 100% of rats can be carriers. It doesn't cause disease in the rats, but it can be transmitted to people by bites or scratches. It can also be spread simply by handling rats (especially if a person has any cuts or broken skin), and through close contact with rats' mouth, such as kissing and sharing food (yes, some people do).
In most people, rat bite fever causes a high fever, headache, chills, vomiting, joint and muscle pain and a rash, most commonly over the soles of the feet, palms of the hands and the extremities. While the disease will resolve on its own in many cases, treatment with antibiotics is indicated because severe complications such as inflammation of the heart, pneumonia and meningitis can also develop.
Common sense can help reduce the risk of rat bite fever.
- Assume all rats are carrying S. moniliformis in their mouths.
- Only handle rats if you know how to do so properly, and if you know the rat is amenable to being handled. Avoid contact with the rat's mouth (e.g. kissing).
- If you have open sores or cuts on your hands, avoid handling rats or wear gloves.
- Always wash your hands thoroughly after handling a rat or cleaning its cage.
- Thoroughly clean any bites from any rodent immediately with lots of soap and water.
- If you develop signs consistent with rat bite fever after being bitten, consult your physician as soon as possible, and be sure to let your physician know about the bite.