As reported on barfblog.com (with, as ever, an entertaining title: You see a cute turtle, I see a bug factory: Infant botulism from C. butyricum) a recent paper in the journal Epidemiology and Infection (Shelley et al. 2015) reports an unusual turtle-associated disease.
When we think about turtles and infections (especially infections of young kids), the first thing that comes to mind is Salmonella. That’s fair because it’s common and can be serious. However, like any animal, turtles can carry a range of microbes that can infect people. Apparently, we need to add the bacterium Clostridium butyricum to the list.
The paper describes botulism in two infants caused by this bacterium and related to turtle exposure. Botulism is classically caused by Clostridium botulinum, a bacterium that can produce some of the most potent neurotoxins known to science. However, a couple of other bacteria, including C. butyricum, can produce similar toxins and cause the same disease. Infants are highly susceptible to disease caused by ingestion of the bacterium, since it is able to grow in their gut because of their poorly developed intestinal bacterial flora. (In more mature individuals, botulism isn’t usually caused by ingestion of the bacterium itself. Rather, it's caused by eating food that contains the toxin that was produced when the bacterium was able to grow in the food).
The first case was an 11-day-old boy that was presented to a hospital with various neuromuscular abnormalities. As is common, he had to be put on a ventilator to help him breathe, but fortunately he made a full recovery over the next 10 days. Botulism was suspected early in the course of disease and he received antitoxin (antibodies against the toxins), which probably played a key role in his response. However, C. butryicum, not C. botulinum, was identified in his stool and it was confirmed that the bacterium was able to produce botulinum toxin E.
The second case was a child of about the same age admitted to hospital with breathing problems and a few other issues. Botulinum toxin E was found in his stool, and C. butyricum was isolated.
Investigation of possible sources of the bacterium ensued. Various food and environmental surfaces, plus feces from the parents, were tested. For the first boy, C. butyricum was isolated from his mother’s feces, as well as their turtle aquarium water, sediment and turtle food. The same batch of food from the pet store was negative, so the food was probably contaminated in the house.
The only positive location in the second child’s case was the turtle tank water in a relative’s house, not the child’s house. The relative had held and fed the baby.
These cases also led to a review of a case of C. butyricum botulism that had occurred in 2010. It was assumed to have been caused by honey ingestion, but further investigation revealed the presence of the same type of turtle (yellow-bellied terrapin) in the house.
This report doesn’t change anything in terms of recommendations regarding how to manage turtles, but is good to raise awareness. Turtles should not be in households that have kids less than 5 years of age, for multiple disease reasons. Infection of the second child via a relative who owned turtles raises concern about how pathogens can be spread indirectly from turtles to high-risk individuals. The relative was reported to have put her finger in the baby’s mouth to soothe him at one point, and that would be a logical source of exposure, highlighting the need for good hygiene practices after having contact with animals and their environments, especially high-risk species such as turtles.
As the authors conclude “Adherence to advice that reptiles, including terrapins, should not be kept as pets in homes where there are children aged <5 years, primarily to prevent salmonellosis, would also prevent cases of infant botulism associated with terrapins. The importance of hand washing after handling these pets also needs to be stressed, especially while visiting families with small children.”
A recent paper in Zoonoses and Public Health (Whitten et al, 2014) describes reptile-associated salmonellosis cases in Minnesota between 1996-2011. Like similar reports, the data underestimate the problem because it’s thought that for every documented case, approximately 30 cases go undiagnosed. Regardless, there are some useful findings.
Twelve to 30 cases of reptile-associated salmonellosis were identified in the state each year. That represented about 3.5% of all sporadic (non-outbreak-associated) cases.
- This is lower than is often reported, but Minnesota is also known to have one of the lowest pet ownership rates among states, which might account for this discrepancy, at least in part.
Kids bore the brunt of disease (as is normal), with the median age of victims being 11 years. 17% were less than one year of age, 31% were less than five years of age, and 67% were under 20.
- The very young kids presumably had little or no direct contact with reptiles. This highlights the fact that living in the house with a reptile is a risk factor, even if there’s no direct contact. That’s why reptiles shouldn’t be in the house if there are high risk people present (i.e. kids less than five years of age, elderly individuals, pregnant women, immunocompromised individuals). Just trying to keep the high risk people from having contact with the reptile isn’t enough.
23% of cases had to be hospitalized. Fifteen (5%) had invasive infections, where Salmonella made it out of the intestinal tract and into the rest of the body.
- These types of infection are a major concern, and the report included one case where the bacterium was found in the cerebrospinal fluid (indicating the person presumably had Salmonella meningitis).
Fortunately, none died.
Over half of the people who got sick and who were asked (i.e. not including the young kids) reported knowing that reptiles can be sources of Salmonella.
Almost half reported exposure to a lizard, with 20% reporting snake contact, 19% reporting turtle contact and some reporting contact with more than one type of reptile.
A quarter of those who reported turtle contact and indicated the size of the turtle said the turtle was less than four inches in length.
- That’s relevant because it’s illegal to sell turtles that small in the US. The rule was put in place due to the increased risk of kids handling small turtles and getting exposed to Salmonella. The finding isn't surprising, though, since this law is widely ignored.
Some people consented to having their reptile tested. 86% of the tested reptiles were shedding Salmonella at the time the follow-up was performed. 96% of those were the same strain that caused disease in the person.
Overall, not a lot has changed, which is concerning. There’s a risk of disease with any pet contact, but reptiles are undeniably high risk. We’ll never completely eliminate the problem, but logical pet ownership and animal management are needed to reduce the risk. A good start is getting young kids away from reptiles. Reptiles can make great pets… but not for young kids, and not without some risk.
Pet aquatic turtles have been implicated in three outbreaks of salmonellosis involving 43 US states over the past year and a half. Disappointing, but not surprising.
Disappointing, obviously, because people are getting sick. Disappointing also because these outbreaks have occurred over and over, despite availability of good information on how to reduce the risks.
It’s not surprising, though, because it’s happened so often.
Why? It’s a combination of people not researching these animals properly before buying them, pet stores not providing information, turtle farmers in denial that there is a problem, people flouting the small turtle ban, and poor overall awareness (and application) of basic infection control measures (more on that in a minute).
The Michigan Department of Community Health (MDCH) has reported that 5 people from Michigan have become ill as part of these outbreaks. As is typical, most were kids.
So, if you own a pet turtle, what do you do?
“We don’t recommend that they release them into the wild. Instead, we recommend that you contact a pet retailer, a pet store, to talk to them about it. Also, you can speak with a local animal shelter or a veterinarian for other options as well.” said MDCH spokesperson Angela Minicuci.
That’s not bad advice. However, the pet store and vet probably aren’t going to take the turtle. The humane society might (and those that do might try to find it a home or might just euthanize it right away). There’s another step here that’s forgotten: doing a risk assessment.
Are there high-risk people in the household (kids less than five years of age, elderly, pregnant women, people with compromised immune systems)?
- If yes, the turtle should be re-homed.
- If no…
Are you willing to accept some degree of risk, risk that can be mitigated with some basic practices?
- If no, the turtle needs a new home. (There’s always some degree of risk with turtle (and any animal) ownership).
- If yes…
Are you willing/able to take some basic measures to reduce the risk of Salmonella exposure, on the assumption that your turtle is Salmonella positive?
- If no… (take a guess here) the turtle needs a new home.
- If yes...
I received an email from a relative the other day with a pet question. I get lots of these, but the surprising part is this relative doesn't have any pets (and I think is generally of the opinion that pets are okay, as long as they're not hers). She was asking about turtles. As a responsible prospective pet owner should, she was looking into the issues pertaining to the pet before getting the pet. I think she was more focused on general aspects of care and management, but zoonotic disease risks play into the equation too. This one was a no-brainer, since they have a young child in the house and reptiles shouldn't be present in households with children less than five years of age. So, problem averted, and the need to make a decision later about removing an inappropriate pet from a household was also avoided (along with the awkward "oh, you got a turtle?" Christmas dinner conversation).
But, what happens when people aren't so proactive? Turtles are often passed from house to house as people get bored with them, as they outgrow small aquariums or as parents of young or otherwise high-risk children tune into the Salmonella risks or owning such a pet. If you don't have a friend willing to take your turtle, what do you do?
Petco, a pet products company in the US, has launched a "turtle relinquishment program," whereby they take in "wayward" or unwanted turtles. As of a few weeks ago, 111 people from 10 US states had surrendered their turtles to Petco. The turtles are sent to a turtle farm in Louisiana.
So, this is an option for individuals (at least in the US) with no local way to rehome their turtle. The fact that the turtles are going somewhere to make more turtles (and more Salmonella) is a bit of a concern, but I can see the greater good. Staff at the farm say that turtles are treated for any signs of Salmonella when they arrive. This is a bit strange, since turtles don't typically develop disease from this bacterium - they simply shed it with no signs. Hopefully that doesn't mean the farm is just treating all the animals. It's basically impossible to eradicate Salmonella from turtles, so if they are routinely treating, they're probably breeding drug-resistant Salmonella along with baby turtles.
I know the typical round of emails is going to follow, from reptile advocates who have pretty much done everything except burn me in effigy (or in real life, fortunately). As I've said before, reptiles can make great pets, just not in all households. I've owned various reptiles myself, but reptiles and small kids don't go together. Too many kids get sick every year from pets like turtles. A small number die. That's just unacceptable.
More information about turtles and Salmonella can be found on the Worms & Germs Resources - Pets page.
.A five-month-old Britich baby was hospitalized with salmonellosis that was presumably acquired from a family pet. The baby developed severe diarrhea and was rushed to hospital. Fortunately, the child has recovered, something that's far from assured in such cases, since salmonellosis can be life-threatening in infants.
As expected, an investigation followed the diagnosis of salmonellosis. Typically, these investigations focus on food and animal contact, and since this family had a bearded dragon (see picture) and tortoises, the investigation honed in on the reptiles. Reptiles are high risk for Salmonella shedding and are commonly implicated in human infections. Further, the type of Salmonella that infected the infant, S. Pomona, is commonly associated with reptiles. It doesn't sound like they've confirmed that the same strain of Salmonella was present in the reptiles, but I assume that testing is underway.
Reptiles should not be present in households with infants. It doesn't matter if the animal never leaves its enclosure, because while the critter may not leave the enclosure, Salmonella will.
In low risk households (households without kids less than five years of age, elderly persons, pregnant women or immunocompromised individuals), good management practices can be used to minimize the risk of transmission of Salmonella, but given the potentially fatal nature of salmonellosis in infants and other high-risk individuals, these precautions are not adequate in high-risk households. While reptiles can be great pets, they're just not worth the risk in some situations.
The CDC has announced an investigation of three multistate outbreaks of salmonellosis linked to pet turtles. At last report, 66 affected people had been identified, and since most outbreaks like this only identify a minority of cases, it's safe to assume there are many others.
- Three different types of Salmonella have been implicated; S. Sandiego, S. Pomona and S. Poona.
- Infected people have been identified in 16 US states (see map).
- 11 people have been hospitalized, but no one has died.
- Most cases (55%) have involved children under the age of 10.
- Almost all infected individuals who provided information about turtle contact with said the turtles were less than 4 inches long.
This ongoing outbreak, dating back to September 2011, has all the hallmarks of a pet turtle-associated outbreak: a large number of cases over a wide area and prolonged period of time, a predilection for young children, and the potential for severe disease. While far from novel, this outbreak also highlights some recurring themes.
The potential for widespread outbreaks from mass production and distribution of pets has been repeatedly demonstrated with a range of diseases, including recent examples involving chicks and guinea pigs. That doesn't mean that mass production is necessarily higher risk (although it certainly can be), but when something goes wrong, it can go very wrong because of the large number of infectious animals that get sent out.
Sale of turtles with shell lengths under 4 inches has been banned in the US since 1975. This is because small turtles are more likely to be handled (and potentially put in the mouth) by young kids. Despite extensive lobbying by US turtle breeders, the law remains in effect, but it's widely flaunted. It's surprising more efforts aren't put into enforcing this regulation given the number of people who are sickened every year from contraband turtles. (It's also surprising that infected people in the US haven't started large lawsuits against people distributing small turtles.)
Anyway, this is yet another reminder about the risks associated with reptiles and high risk individuals (i.e. young children, elderly, pregnant, immunocompromised) and the need for pet turtle owners to follow basic hygiene and infection control practices. More information about turtles - for owners, veterinarians and healthcare professionals - can be found on the Worms & Germs Resources page.
Yet another outbreak of salmonellosis traced back to pet turtles has been investigated by CDC and Pennsylvania's State Health Department. Pet turtles are notorious Salmonella vectors, for several reasons, including the fact that small aquatic turtles very commonly carry the bacterium, they are marketed towards young kids (who are increased risk of infection), and people tend to use poor (or no) hygiene practices when handling turtles or having contact with their environments. Efforts to restrict the sale of small (less than 4-inch long) turtles have greatly reduced Salmonella infection rates in people in the US, but have come under continual pressure from the turtle breeding industry, and the regulation is often flaunted by pet stores and road-side turtle sellers.
From August 5 to September 26, 2011, 132 cases of Salmonella Paratyphi B infection were identified in 18 US states.
- The median age of infected individuals was 6 years, and 2/3 were less than 10 years of age. This is consistent with a pet-associated outbreak.
- 56 patients (and their families, presumably) were interviewed, and 64% of them reported turtle exposure. That's a lot higher than one would expect if a random sample of the general US population was surveyed, and suggests that turtles were an important source.
- Of the 15 people who could provide details about the turtle, 14 of them described turtles that would have been too small to be legally sold in the US. This isn't surprising, and shows both the risk associated with these small turtles and the fact that this law is being widely ignored.
- The same strain of Salmonella was isolated from turtle tank water in five homes (it's not clear if only five were tested or if there were some negative tanks too). That's further evidence implicating the turtles.
This is yet another reminder of the risks posed by small turtles, particularly to young kids. Small turtles have high Salmonella shedding rates, are easy to handle and are even small enough for kids to put in their mouths (yuck!). That's a bad combination.
In 2007, Louisiana turtle breeders sued to reverse the FDA's small turtle ban. Fortunately they weren't successful, however it's clear that the turtle ban needs to be enforced, but that's hard to do. Perhaps more important, then, is increasing public awareness of the risks. If people are better informed of the issues, they can make better decisions about acquiring pets and how to properly manage them. One such resource for the public is the Turtles fact sheet that we have freely available on the Worms & Germs Resources page.
A UK hairdresser is recovering from necrotizing fasciitis (flesh-eating disease) that was linked to his pet turtle. The problem started when he cut his finger while cleaning out the turtle's tank. An infection developed, which isn't too surprising since a turtle terrarium is full of a variety of bacteria. However, instead of a mild, local infection, he developed an aggressive infection that started to spread up his arm. "His finger turned black and his arm became swollen and red." Amputation was discussed, which is not infrequently necessary in cases of such severe infection.
It doesn't sound like there were any cultures taken from the wound at the start, but after the infection didn't respond to the initial course of antibiotics, the man ended up in hospital in IV antibiotics. The infection progressed from his finger to his bloodstream and a bacterium, a Group G Streptococcus, was isolated from his blood.
Here's where more details would be useful. The news article simply says "...and the terrapin, called Cosmo, was identified as the culprit."
It doesn't say how Cosmo was implicated. To make a link, they'd have to find the same bacterium in the turtle's tank. Ideally, beyond just isolating the bug, they'd show that it was the same strain. It's possible this was done, but rarely do people go to that extent, so it's possible that the link was just presumptively made because the initial injury occurred in the tank. The problem with that is Group G strep can also be found in healthy people (10-25% in some studies). Therefore, while he set the scene for the infection in the tank, by breaking his skin, he could have become infected from bacteria already on or in his body. Additionally, other animal sources are possible, such as dogs (since one type of Group G strep is Streptococcus canis). If he cut his finger, then had contact with another animal, it could have been the source.
Most of the attention paid to turtles and infectious disease revolves around Salmonella, and that risk is real. However, turtles, like any other animal (or person), also carry a variety of other potentially harmful bacteria. These usually don't cause problems, but in certain situations, the risk of disease is higher. The skin is a wonderful barrier to infection, and any time it gets broken, there is a risk of disease.
In general, we recommend a few things when cleaning out an aquarium of any kind (be it for fish, reptiles or amphibians):
- Avoid having sharp objects in the aquarium. If any sharp or rough objects are present, take care to avoid contact with them while cleaning.
- Wear gloves, particularly if you have open wounds or if there are sharp/rough surfaces in the aquarium.
- Wash your hands thoroughly after having contact with aquarium water or contents. If you were wearing gloves, wash your hands after glove removal.
- Avoid contaminating other areas, especially kitchen sinks or counters, with aquarium water.
- If you cut yourself while cleaning out an aquarium, wash out the wound thoroughly as soon as possible.
- If you have a compromised immune system, try to avoid any contact with aquarium water or contents by getting someone else to clean out the tank.
The Texas Department of State Health Services has proposed a series of changes to warnings that are already required of retailers that sell reptiles. The warnings are focused on prevention of salmonellosis, and retailers must post signs and provide written warnings to anyone buying a reptile about the risk of salmonellosis from reptiles.
Signs must include the following recommendations (new or revised text is underlined):
- People should always wash their hands with soap and running water after handing reptiles or reptile cages or after contact wtih reptile feces or the water from reptile containers or aquariums. Wash your hands before you touch your mouth.
- Persons at risk for infection or severe complications of salmonellosis, such as children younger than 5 years of age, the elderly, and persons whose immune systems have been weakened by pregnancy, disease or certain medical treatments should avoid contact with reptiles and any items that have been in contact with reptiles.
- Reptiles should be kept out of households or facilities that include children younger than 5 years of age, the elderly, persons whose immune systems have been weakened by pregnancy or disease, or certain medical treatments. Families expecting a new children should remove any reptile from the home before the infant arrives.
- Reptiles should not be allowed to roam freely throughout the home or living area. Wash and disinfect surfaces that the reptile or its cage has contacted.
- Reptiles should be kept out of kitchens or other areas where food and drink is prepared. Kitchen sinks should not be used to bathe reptiles or to wash their dishes, cages or aquariums. If bathtubs are used for these purposes, they should be thoroughly cleaned and disinfected with bleach. Wear disposable gloves when washing the dishes, cages or aquariums.
- The sign must also contain a statement that reptiles may carry Salmonella bacteria, which can make people sick, but reptiles may not appear to be sick.
Image: Texas Horned Lizard, Phrynosoma cornutum (photo credit: Shawn Billerman, click for source)
A 10-year-old girl was traveling with her pet turtle, Neytiri, on an AirTran flight from Atlanta to Milwaukee. The airline has a no-reptiles policy (actually, a no-pets-at-all-in-the-cabin policy) and when one crew member spotted the turtle in a cage under the girl's seat, she was told that she had to get off the plane.
This is where things start to fall apart a little. Apparently, the girl and her sister threw the turtle and its cage in the trash. They say that they were told to do so, although AirTran disputes this. Regardless, the turtle was tossed and the girls got back on the plane.
Banning turtles from plane cabins makes complete sense. I'm not sure why anyone would really need to travel with their pet turtle, particularly in the cabin. Turtles are notorious vectors of Salmonella and a huge number of Salmonella infections in people are attributed to contact with pet reptiles. People under the age of five, the elderly, pregnant women and people with compromised immune systems are at particular risk and should not have contact with reptiles. The problem with a plane is you can't be sure whether or not such high-risk individuals are on it (or will be on subsequent flights). A turtle in a cage is probably of fairly low risk. The problem would be the owner handling the turtle or its cage, then touching common hand-contact sites in the plane. Those sites could then be touched by someone else, creating a theoretical risk of transmission.
What's the real risk in this situation? Probably minimal. However, you have to think about whether risks, even minimal ones, are worth taking when they are completely avoidable by keeping turtles and other high-risk species out of cramped and hygiene-limited public spaces like airplane cabins - places they don't need to be.
Did the airline over-react? I don't think so (although recommending someone toss a live animal in the garbage, if it happened, is completely unethical). They have a policy. It's a reasonable policy. If you fly on an airline, you have to abide by their rules. If you are going to do something unusual like travel with a pet, it's your responsibility to determine what the rules are.
The story has a happy ending, fortunately. It seems that an airline employee recovered the turtle from the trash, and the girl was re-united with her pet a couple of days later, after flying home on an AirTran plane... in the cargo hold.
One other interesting note about this story - the turtle, Neytiri, was only two-inches long. In the US, the sale of pet turtles with a carapace length of less than four-inches has been illegal since 1975, due to high rates of turtle-associated salmonellosis among children, who were more likely to extensively handle tiny turtles.
Photo (left): Carley Helm and her pet turtle Neytiri.
Among the various things I've been called in response to blog posts is "anti-reptile." Actually, I like reptiles. I've owned and treated them, and think many of them are quite fascinating species. They can be reasonable pets in certain situations. The main problem is that they have high rates of Salmonella carriage and are the cause of a large number of infections in people. That's why the CDC, among other groups, recommends that people under the age of 5, the elderly, pregnant women and people with compromised immune systems avoid them.
Why do I bring this up (again)? I read an article today about the Fall River, Massachusetts, library and their resident tortoise, Franklin. Why am I concerned?
- Who goes to a library? Lots of people. Kids and elderly individuals probably go more than average. Those are the high risk groups.
- You could try to make the argument that having a tortoise in a library wouldn't necessarily pose much of a risk if it was kept in a cage or terrarium. That's probably reasonable, as long as good management and hygiene practices were used, but it's not a guarantee. Infections have been reported in households where the reptile never leaves its enclosure and in people who never have direct contact with it.
- Regardless, Franklin doesn't spend his days in a cage of any kind. He gets out and cruises around the library, especially in the carpeted Children's Room. That's a bigger problem. This tortoise is certainly not house trained (my tortoises' repertoire was pretty much limited to eat, poop, wander around, repeat... I don't think there was an extra neuron for something like litterbox training). Tortoises can also easily contaminate their feet and shell with feces. So, we have a potentially poop-contaminated tortoise who may also leave a fecal present at any time wandering around a carpeted (almost impossible to disinfect) surface on which young kids play. Not a good combination.
- See the picture above. The person is described as a "library senior aide" and is presumably in the high-risk group based on age. The tortoise has its leg (which presumably walked over some tortoise poop sometime in the recent past) practically in her mouth. That's not good either.
What should the library do?
1) Ideally find a good home for Franklin. One with no high-risk people.
2) If that's not an option, a protocol should be in place for how to manage Franklin and reduce the risk of Salmonella transmission. This would involve:
- Keeping him in a proper enclosure. Not letting him roam around public areas. Visits outside to walk around on the grass (during the appropriate seasons) are fine, but there should be no walking around general library areas (especially not the Children's Room).
- Not letting the general public handle him. Reptiles are "look but don't touch" pets.
- Emphasizing hand hygiene for anyone that has contact with Franklin or his environment, and facilitating hand hygiene by having convenient access to a properly equipped sink or alcohol-based hand sanitizers.
- Excluding high-risk groups from contact, if people are allowed to have direct contact with Franklin at all. Any public contact should be supervised and there must be immediate washing of hands or use of a hand sanitizer afterwards. Since this is unlikely to be done properly, avoiding all public contact makes the most sense.
- Using Franklin to help teach. Perhaps he could be brought out in a small glass terrarium and people could watch him as part of stories or other events. He (and the way he's handled) could also be used to explain things about infectious diseases and infection control.
Image source: www.wickedlocal.com
You'd think, after countless outbreak of salmonellosis associated with pet turtles, that people would learn and things would start to improve. I guess not. A paper published this week in Pediatrics (Harris et al) described a large outbreak of Salmonella Java associated with pet turtles. Between May 2007 and January 2008, 107 infections were identified. The median age (the age in the middle of the range of affected people) was seven years old. Sixty percent of infected people reported exposure to turtles during the week before they got sick; 87% were small (<4 inch) turtles, and 34% were purchased at a retail store (despite the fact that the sale of turtles less than 4 inches long is banned in the US). Five infected people, all less than 10 years of age, reported kissing the turtle or putting it in their mouths.
When they compared people with Salmonella Java infection to people without the infection, 72% of people with Salmonella reported contact with turtles versus only 4% of controls.
Salmonella is far from rare but it's nothing to ignore. Thirty-three percent of infected people were hospitalized. Fortunately, no one died.
The link between turtles and Salmonella has been known for a long time. Healthy turtles can carry the Salmonella bacterium and be a source of infection, particularly for children. The sale of small turtles is banned in the US to reduce the likelihood of close contact between turtles and kids, but this law is widely flouted. An understanding of the link between turtles and Salmonella is surprisingly uncommon - only 32% of Salmonella patients in this study (and 28% of controls) reporting knowledge of this link. Clearly, there are a lot of areas which could be improved.
- If banning the sale of small turtles is truly an effective measure, then it should be enforced. "Black market' turtles are far too easy to find.
- More public education is needed, among the general population and particularly people buying turtles. You shouldn't be able to take a turtle home from a store without an information sheet about the risk of Salmonella and how to avoid it.
- People with turtles (or any reptile) need to recognize the risk and act appropriately. Good general infection control and hygiene measures are needed to reduce the risk of Salmonella exposure.
- Households with children under five years of age, or with immunocompromised individuals should not have pet turtles.
- Antibiotics are not the solution. Attempts to create Salmonella-free turtles with drugs have just led to the production of turtles carrying antibiotic-resistant Salmonella.
- Common sense needs to be a little more common. The picture above (from http://www.familylovezone.com/js_DeepAndWide.htm) was proudly posted by a parent.
More information about infectious disease risks associated with turtles can be found on the Worms & Germs Resources page.
In response to recent posts about Salmonella and turtles, a reader posed these questions:
Okay, so turtles and tortoises can carry salmonella. Does that mean that all do?
- Not all, but a lot of them do. Aquatic turtles are probably a greater risk than tortoises.
If a vet analyzes a poop sample from my Russian Tortoise and there is no Salmonella, does that mean we can quit worrying about it?
- Unfortunately no. We can never be confident in declaring a reptile "Salmonella-free." Salmonella can be shed intermittently, so a single negative sample doesn't mean the reptile is truly negative. We don't know what the optimal testing protocol is in terms of what to sample, how often to do it and how many samples are needed. I'd never tell anyone a turtle or tortoise is Salmonella-free. To err on the side of caution, we have to assume that all reptiles are carrying Salmonella.
Conversely, if the poop does show Salmonella, is there any way to eliminate it from the tortoise and then quit worrying about it? Our tortoise is isolated from other pets and only eats what we consider clean, fresh produce - so I am hoping the chance of reinfection would be minimal.
- Unfortunately, no again. There's no proven way of eliminating Salmonella from a reptile. Getting rid of Salmonella in an animal that is a carrier is different than treating a typical bacterial infection. Salmonella is a commensal bacterium in reptiles, meaning it can be a normal component of the animal's bacterial microflora. It is very difficult to eliminate commensal bacteria since they have evolved to survive in (or on) their host. Unlike in clinical infections, which tend to be short term infections of a site where the bacterium does not normally live, using antibiotics to eliminate Salmonella carriage is unlikely to be successful. Giving antibiotics can also upset the normal intestinal bacterial population, which can actually make it more likely for bacteria like Salmonella to proliferate. Salmonella can also live inside intestinal cells, where most antibiotics can't reach them. Treatment, therefore, is unlikely to be ineffective, and might just result in increased antibiotic resistance (something we certainly want to avoid).
Check out the Worms & Germs Resources page for more information.
Following a report on black market turtle sales in Maryland, a letter to the Baltimore Sun by Maryland veterinarian Dr. Jeffery Rhody wanted to "set the record straight".
"All reptiles carry salmonella as part of the normal bacterial population in their body."
- Not really true, however Salmonella can commonly be found in healthy reptiles, so the overall sentiment is valid.
"The risk of getting infected with salmonella from a reptile can be greatly reduced with common sense hygiene practices."
- Absolutely. General infection control practices are critical to reduce (but they do not eliminate) the risk of Salmonella transmission.
"In fact, the incidence of reptile-borne salmonella infections is much less than salmonella infections obtained from improperly handled poultry products."
- Statistics can be manipulated to either support or refute this. The absolute number of Salmonella cases from food is certainly greater than those from turtles. However, I'm not so sure turtles end up looking good when you consider the number of cases compared to the number of people exposed to these factors - a lot more people eat food than own turtles. The number of cases of Salmonella associated with reptile contact every year is stunning, even though only a small percentage of people own reptiles. Fatal infections can occur, so it's not something to take lightly. Statements like the one above can get into some questionable logic, like saying that a machine gun can kill more people than a handgun, so handguns must be safe. Certainly, Salmonella is a risk with handling raw poultry, and efforts are taken to get people to reduce risky behaviours (like contaminating kitchen surfaces with raw meat). The same should apply to reducing risky behaviours with regard to pet contact.
"Of course, if you lick a turtle, the risk of salmonella infection is greatly increased."
- Yep. That's why the focus is on small turtles. But, people get Salmonella from larger turtles too.
"No one who owns a slider should be concerned about breaking the law."
- They should, however, be concerned about getting sick. Turtle owners should learn about risks and preventive measures from sources such as a the information sheet in our Resources page.
As someone who has owned turtles, I understand the appeal of these animals. As someone involved in zoonotic diseases, I understand the risks. People need to have enough information to understand the risks and benefits, to make logical, informed decisions. The risks to healthy adults who handle the animals properly is quite low. That's why the focus is on high risk households like those with young children, the elderly or immunocompromised individuals. There are good reasons for the ban on the sale of small turtles. Banning the sale of small turtles doesn't hurt anyone (except for people wanting to profit from selling them), and may prevent disease. Seems logical to me.
There is apparently a thriving black market for baby red-eared slider turtles in Baltimore. The sale (and possession) of small turtles is illegal in Maryland, like many other regions, largely because of public health concerns regarding Salmonella.
Over 100 hatchling turtles have been seized in the past 2 weeks. Baby turtles offer a good profit margin for black market vendors. They can be purchased from farms in the southern US for about $1 each and then resold for many times that amount. One person was caught selling turtles out of the back of a van. (Why anyone would buy anything from someone selling out of the back of a van is beyond me!)
People buy turtles thinking they make cute pets, not realizing what they need to do to keep them healthy as they grow. Turtles that are fortunate enough to be raised properly create another problem, since most people are not willing or able to take care of adult turtles that reach 10-12 inches in length. This can result in turtles being killed or abandoned.
Another major problem in the risk of Salmonella. Turtles very commonly carry this potentially harmful bacterium, and they are an important source of infection in people. The concerns are greatest with young children who may handle small turtles and put them in their mouths. People need to think before they buy. Before getting any pet, learn about the animal, including requirements for care and human health risks (and also if it's legal). A little common sense goes a long way.
More information about Salmonella and turtles can be found on the Worms & Germs Resources page.
One more post about illogical and dangerous activities associated with animals and young children and I'll hopefully get off the subject for awhile. I came across this daycare's website today. Keep in mind (again) that the the Centers for Disease Control and Prevention (CDC) recommends that children less than 5 years of age not have contact with reptiles, and that the Compendium of Measures to Prevent Disease Associated with Animals in Public Settings published by the National Association of State Public Health Veterinarians states that wild or exotic animals may not be appropriate in school settings. The photo gallery from this particular daycare included some great pictures of things that you should NOT do with young children. Some of the more striking example are below:
1) Letting a large snake wrap its body around the neck of a young child.
2) Letting a young child kiss a snake.
3) Letting a child touch a turtle.
4) Letting a young child pet a pygmy hedgehog. (Like reptiles, hedgehogs very often carry infectious pathogens, including Salmonella.)
- whether anyone made sure these children immediately washed their hands after they touched the animals.
- how may kids but their hands in their mouths before they washed their hands. (Probably almost all of them, considering the "animal visit" probably went on for quite a while.)
- whether this activity took place in the same area where the children later ate lunch or a snack.
- whether the parents knew that this was going to happen.
I'm not against young children having contact with animals. I think pet contact can be very rewarding for young children. However, these individuals are at higher risk for infection and it is our responsibility to protect them. Putting them in high risk situations like these is inappropriate. Animal visitation in daycares is not necessarily a bad thing, if it involves animals that are a low risk species (e.g. dogs and cats), that are healthy, and that have been temperament tested (to show they are at low likelihood of biting). It is also important that parents provide consent for their children to participate, that good hygiene practices are used (and enforced), and that the people bringing in the animals know what they are doing.
BarfBlog is a food safety blog run by Dr. Doug Powell, who used to be at the University of Guelph, before moving to Kansas State. (I played hockey with him and can confidently state that he is one of the better hockey goalies working in food safety in Kansas). Doug and his group have put together numerous useful, and often entertaining, fact sheets about food safety issues, as well as some related infectious disease and infection control topics. One of those is about Salmonella in pet turtles, something we've discussed on Worms&Germs periodically. The info sheet, and associated commentary from Ben Chapman, can be found here.
A report about the health risks in children associated with nontraditional pets was recently published in Pediatrics, the official journal of the American Academy of Pediatrics. The report also discusses diseases associated with animals in public settings such as petting zoos and pet stores. Although contact with pets and animals can be beneficial to growth and development in children, it is very important to be aware of the risks associated with certain kinds of animals. Physicians, veterinarians and public health personnel can help parents select appropriate pets in order to maximize the benefits while minimizing the risks to children.
One of the most important pathogens discussed in the report is Salmonella. Although Salmonella can be transmitted by many animal species, including traditional pets like dogs and cats, it is a particularly high risk with certain other kinds of pets, including reptiles, amphibians and baby poultry (chicks and ducklings). It has been estimated that direct or indirect contact with reptiles or amphibians is responsible for 6% of all sporadic Salmonella infections in the US, and 11% of cases among people younger than 21 years. There is also a relatively high risk of Salmonella transmission associated with animal-derived pet treats, such as pig ears, and raw meat.
The report makes several recommendations about how to reduce the risk of infection, injury and allergies from nontraditional pets, many of which you may have seen before on the Worms & Germs website. Just a few of these are:
- Always wash your hands after contact with animals, animal products or their environment, and after contact with animal-derived pet treats.
- Supervise hand washing for children less than five years old
Children less than five years of age and individuals with weakened immune systems should avoid contact with reptiles, amphibians, rodents, ferrets and baby poultry. These animals:
- Should not be kept as pets in households where children less than five years of age or individuals with a weakened immune system live.
- Should not be brought to childcare centres.
- Should not be allowed to roam freely in ANY house or living area.
- Should not be permitted in kitchens or anywhere food is prepared.
More information about Salmonella in pets and the risks associated with feeding raw meat and animal-derived treats to pets can now be found on the Worms & Germs Resources page.
Yet another reminder of the risks associated with handling turtles (and other reptiles) comes to us from a report published earlier this year regarding an outbreak of salmonellosis in people tied to contact with turtles. In this case, more than 100 people in 33 US states were affected. The report sparked additional public education efforts in Los Angeles county, CA, where eight of the cases occurred.
The report comes as no surprise - turtles are actually relatively commonly implicated in cases of salmonellosis in people (although still not nearly as commonly as foodborne transmission). It's particularly a concern in children, because kids may have close contact with pet turtles and may be more susceptible to serious infection.
In response to the cases in Los Angeles, the county Department of Public Health emphasized that parents must be wary of buying turtles for their children. Even though the sale of small turtles (less than 4 inches long) was banned in the US over 30 years ago, unfortunately these animals are still widely available in many pet stores, flea markets, and from other sources. Los Angeles Public Health personnel reported that children were getting sick because they were kissing their pet turtles - something that is very risky and should never be done by anyone, especially children. If people have pet turtles, they must be very diligent to practice good hygiene to reduce the risk of transmission of Salmonella.
More information about the risks associated with pet turtles, and measures that should be taken by people who own turtles, is available on the Worms & Germs Resources page.
INFORMATION SHEETS specifically for KIDS, for VETERINARIANS, for PHYSICIANS and for PUBLIC HEALTH PERSONNEL are also available on the Worms & Germs RESOURCES page!
Click on the highlighted topics below for information sheets. Topics that are not highlighted are in development and coming soon. Sheets for other animal species and diseases are also under development and will be added when they are available.
- Your veterinarian and physician are your ultimate resource for information about the health of your pets or your family.
- Information provided here is accurate to the best of our knowledge, but infectious diseases can be unpredictable and these sheets are for general information purposes only.
- There can be great variation in disease risks in different geographic areas. The information provided was developed for Ontario, Canada, but most of the information is relevant for other regions as well.