october 2009 conference call slides for upload
TRANSCRIPT
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1
Selected Zoonotic Diseases Conference Call
October 7, 2009
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Casey Barton Behravesh, DVM, DrPH, DACVPM, Veterinary Epidemiologist, Outbreak Net, Division of Foodborne, Bacterial and Mycotic Diseases, CDC; 404-639-0367; [email protected]
Selected Zoonotic Diseases Conference Call
October 7, 2009
Human Salmonellosis Linked to Contact with Live Poultry From Mail-Order Hatcheries
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Human Salmonellosis Linked to Contact with Live Poultry From
Mail-Order Hatcheries
Casey Barton Behravesh, DVM, DrPH, DACVPM
Anagha Loharikar, MD
Division of Foodborne, Bacterial and Mycotic DiseasesNational Center for Zoonotic, Vector-Borne and Enteric
DiseasesCenters for Disease Control and Prevention
October 7, 2009
For internal use only, please do not distribute
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The Mail-Order Hatchery Industry in US• Estimated <100
hatcheries supply baby birds
• Any one hatchery may supply birds to customers in several states
• Little regulatory oversight of industry
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Shipping Live Poultry
• Hatcheries ship birds– To customers– To agricultural feed
stores– 100 - 125 chicks or 60
ducklings per box
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Drop Shipping
• Common practice in hatchery industry• Hatchery 1 can not complete customer
order because no birds are available• Hatchery 1 contacts Hatchery 2 for
availability• Hatchery 2 ships order to customer
under Hatchery 1 name
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Contact with Live Poultry as Source of Human Salmonella
Infections• > 25 outbreaks since 1950s
– Young children– Baby chicks as pets– Seasonal pattern– Montevideo, Typhimurium
serotypes
• Appear healthy
• Mail-order hatcheries
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Recent Outbreaks• Salmonella Montevideo, Outbreak Strain A
– Hatchery A
• Salmonella Montevideo, Outbreak Strain B– Hatchery B
• Salmonella Johannesburg– Hatchery C
• Salmonella Thompson– Hatchery D
• Salmonella Typhimurium– Hatchery C
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Salmonella MontevideoOutbreak Strain A, 2005-2009
• Outbreaks annually since 2005• Human Salmonella infections linked to contact
with live baby poultry from Hatchery A• Multiple environmental samples from hatchery
match the outbreak strain• Case-patients primarily children• Hatchery working with USDA-NPIP to improve
hatchery sanitation, administered autogenous vaccine
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18 2
1300
625
2648348
1019895
585577535
308
9727136
0200400600800
100012001400
Year
Num
ber
of Is
olat
es
Isolates of Salmonella Montevideo in PulseNet-USA by Year, 1999-2009
Outbreak Strain A
Other strains
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Salmonella MontevideoOutbreak Pattern B, 2007-2009
• Outbreaks annually since 2007• Human Salmonella infections linked to contact with
live poultry from Hatchery B• Multiple specimens from poultry and environment of
3 case-patient households matched outbreak strain• This outbreak is different from previous live poultry
contact outbreaks:– Cases less concentrated in spring months– Proportion of adults was higher than children– Patients reported purchasing birds primarily for meat and
eggs
• Hatchery working with USDA-NPIP, administering autogenous vaccine
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Salmonella MontevideoOutbreak Pattern B, 2009
• One family reunion, two weddings catered by unlicensed caterer in North Dakota
• 41 PFGE confirmed cases– Onset date range from 6/13/2009 - 6/17/2009
• Food prepared in caterer’s home kitchen• Caterer owns 20-25 chicks sourced from
Hatchery B• Suspect cross-contamination in kitchen
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Isolates of S. Montevideo in PulseNet, Pattern 21 Outbreak
Strain and Non-Outbreak Strains, 1999-2009 (N=6,412)
Nu
mb
er
of
Iso
late
s
Year
678869222221248411
0
200
400
600
800
1000
1200
1400
Outbreak Strain Non-outbreak strains
* Data as of July 10, 2009
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Salmonella Johannesburg, 2009
• 7 case-patients from 4 states – Median age: 1 year (range <1 to 5 years)
• 86% exposed to baby poultry• Poultry traced to common hatchery,
Hatchery C• Day care attended by a case-patient
has back yard flock of chickens• Outbreak strain isolated from
chickens at day care
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Salmonella Thompson, 2009
• 25 case-patients from 7 states– Median age: 19 years (range: <1 to 86
years)
• 77% exposed to baby poultry
• 31% exposed to adult poultry
• 54% exposed at home
• Poultry traced to common hatchery, Hatchery D
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Multistate Outbreak of Salmonella Typhimurium Infections Linked to Live Poultry from a Mail-Order
Hatchery, 2009
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Outbreak Detection, Pennsylvania
• May, 2009
– PulseNet identified an isolate of Salmonella Typhimurium• Indistinguishable pulsed-field gel
electrophoresis (PFGE) pattern • Outbreak strain – 0905PAJPX-1
– States had begun initial evaluation of cases using general form
– CDC contacted states with outbreak strain
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Isolates of Salmonella Typhimurium with the Outbreak Strain in PulseNet by Upload Date
(N=139), February – September, 2009
Isolation Date
# o
f Is
ola
tes
0
1
2
3
4
5
6
7
2/20 3/13 4/3 4/24 5/15 6/5 6/26 7/17 8/7 8/28 9/18
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CA1
CT5
WI3
KY3
MD5
MA16
MI6
NH2
NJ7
NY34
NC2
OH2
PA30
RI2
UT8 VA
7
AL1
AK
DE2
Isolates of Salmonella Typhimurium with the Outbreak Strain in PulseNet by State (N=139),
February – September, 2009
1-5
6-10
11 and over
IL1
MO
1
ND1
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Salmonella Typhimurium 0905PAJPX-1 Patient Characteristics (n=139)
• Female – 49%
Age group # case patients %
0 – 5 years 50 36%
6 – 19 years 30 22%
> 20 years 51 37%
Unknown 8 5%
• Median age – 12 years (range: 0 – 79 yr)
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Initial Investigation
• State and local health department conducted initial patient interviews– Exposure to live baby poultry– Reported purchasing/contacting live poultry at feed stores
• Epi-Aid requested by Pennsylvania– Case-control study– Feed store survey
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Case Definition
• Illness after February 23, 2009
• Yielding Salmonella Typhimurium from a clinical specimen with PFGE XbaI pattern JPXX01.0302
• Living in Pennsylvania and New York states
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Case-Control Study Methods
• Developed questionnaire tool modeled after past live poultry contact survey
• Enrolled case-patients from Pennsylvania and New York
• Control Selection– One control for each case-patient– Geographic matching
• Reverse phone lookup generated by case-patient address
– Age matching (0-3 years; 4-17 years; 18-39 years; >40 years)
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Questionnaire
• Clinical information– Illness, past medical history
• Contact with animals• Attending event or visiting location with
animals• Contact with live poultry• Purchase of live poultry• Poultry management practice in home• Supplemental questionnaire for National
Poultry Improvement Plan– Sex and breeds of birds purchased
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Exposure%
Cases(n=37)
% Controls
(n=33)mOR CI
Live poultry contact
50 9 13 2-552.5
Chick contact 43 3 13 2-552.5
Duckling contact 24 3 8 1.1-355
Household member with poultry contact
41 9 6 1.3-55.2
Visiting a feed store
32 6 6 1.3-55.2
Visiting Feed Store X
27 6 5 1.1-46.9
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Descriptive Statistics – Case patients
• Types of contact with live poultry* (n=18)– Touched live poultry – 89%– Held poultry – 61%– Kissed poultry or put near mouth – 22%
• Purchased live poultry at a feed store (n=10)• Received no information from place of purchase – 60%• Cases who reported contact with poultry in a home (n=17) Poultry kept inside home – 35%
Poultry kept in basement – 29%
*Respondents could select more than one means of contact.
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Additional Laboratory Findings
• Multiple-Locus Variable-Number Tandem Repeat Analysis (MLVA) performed on PA & NY isolates (n=49)
• Matched MLVA pattern seen for 36 (73%)– 19 PA and 17 NY cases – Suggests point source of infection
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Feed Store Survey
• Evaluate poultry management practices at agricultural feed stores in PA– Number and types of birds sold– Hatcheries used; method of delivery from hatchery– Method of packaging for sale– Medication and antibiotic use– Display of birds in store; hand-washing station and signs– Customer education provided– Knowledge of Salmonella and its association with live
poultry
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Feed Store Survey Results
• 102 agricultural feed stores contacted by either in-store visit or by phone• 50 stores identified as having sold poultry in 2009• Live Poultry Sales
– Season of sales: March – May– ~ 60 to 20,000 birds sold per season– Mainly chicks and ducklings– No artificial coloring of birds
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Feed Store Customers
• Feed Store X– Display of live poultry in store
• Other Farm and Feed Stores– “Chick Days” for Order-only purchases– Long-time customers (smaller feed stores)– No display of poultry in some stores
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Feed Store Survey Comparison 2006 & 2009
New Mexico 2006 Pennsylvania 2009
Awareness that poultry can cause Salmonella
46/54 (85%) 38/50 (76%)
Warn customers that poultry can cause Salmonella
26/54 (56%) 14/50 (28%)
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Hatchery Traceback
• Feed Store X utilizes Hatchery C– Delivery with US Postal Service
• Other feed stores utilize various hatcheries– Many use local hatcheries– Delivery by private hatchery truck
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Public Education • All persons should wash their hands with soap and warm
water for at least 20 seconds after touching live poultry or surfaces in contact with live poultry
• Live poultry should not be kept in facilities with children aged <5 years
• Children aged <5 years should not be allowed to have direct contact with live poultry
• Chicks and other live poultry should not be given as gifts to young children
• Live poultry should be kept separate from areas where food and drinks are prepared or consumed
• All surfaces that come into contact with live poultry (e.g., hands, floors, tables, rugs, shipment boxes, dust, and chicken enclosures) might be contaminated with Salmonella
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Recommendations for Feed Stores
• Provide educational material for customers• Warning signs and hand-washing stations by
displayed poultry• Chick days for order only purchase• Keeping poultry in back of store to limit customer
access• Displaying poultry in covered or glass tanks out of
reach of children• Follow advice in 2009 Compendium of Measures to
Prevent Diseases Associated with Animals in Public Settings – http://www.cdc.gov/mmwR/PDF/rr/rr5805.pdf
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Poultry Specific Questionnaire
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Summary
• Multiple live poultry-associated outbreaks identified in recent years
• Multiple outbreak strains linked to single hatcheries annually
• Peak season for live poultry sales is March-May, though sales occur year round
• Feed stores are aware of risks, but few warn customers• State and local health departments should consider
educational messages targeted at feed stores and the public
• CDC requests states to use poultry specific questionnaire
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Contact Information
Casey Barton Behravesh DVM, DrPH, DACVPM
LCDR, U.S. Public Health Service
Outbreak Response and Prevention Branch (proposed); Centers for Disease Control and Prevention
Phone: (404) 639-0367Fax: (404) 639-2205 e-Mail: [email protected]
Anagha Loharikar, MD
LT, U.S. Public Health Service
Epidemic Intelligence Service, Class of 2009
Enteric Disease Epidemiology Branch; Centers for Disease Control and Prevention
Phone: (404) 639-3510Fax: (404) 639-2205 e-Mail: [email protected]
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38
Selected Zoonotic Diseases Conference Call
October 7, 2009