On May 7, 2010, 42 residents and 12 staff members at a Louisiana state psychiatric hospital experienced vomiting, abdominal cramps, and diarrhea. Within 24 hours, three patients had died. The three fatalities occurred among patients aged 41–61 years who were receiving medications that had anti–intestinal motility side effects. For two of three decedents, the cause of death found on postmortem examination was necrotizing colitis. Investigation by the Louisiana Office of Public Health (OPH) and CDC found that eating chicken served at dinner on May 6 was associated with illness. The chicken was cooked approximately 24 hours before serving and not cooled in accordance with hospital guidelines. C. perfringens enterotoxin (CPE) was detected in 20 of 23 stool specimens from ill residents and staff members. Genetic testing of C. perfringens toxins isolated from chicken and stool specimens was carried out to determine which of the two strains responsible for C. perfringens foodborne illness was present. The specimens tested negative for the beta-toxin gene, excluding C. perfringens type C as the etiologic agent and implicating C. perfringens type A. This outbreak underscores the need for strict food preparation guidelines at psychiatric inpatient facilities and the potential risk for adverse outcomes among any patients with impaired intestinal motility caused by medications, disease, and extremes of age when exposed to C. perfringens enterotoxin.

Clostridium perfringens, the third most common cause of foodborne illness in the U.S., most often causes a self-limited, diarrheal disease lasting 12–24 hours. Fatalities are very rare, occurring in <0.03% of cases. Death usually is caused by dehydration and occurs among the very young, the very old, and persons debilitated by illness.

The full report is available from the U.S. Centers for Disease Control at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a1.htm?s_cid=mm6132a1_x.

In 2004, 187 people became ill with E. coli O157 after visiting the North Carolina State fair in Raleigh. One of those visitors was a two-year-old who was hospitalized for 36 days with hemolytic uremic syndrome. That led to the passage of Aedin's Law, which directs the Commissioner of Agriculture to adopt rules establishing sanitation requirements for petting zoos and animal exhibitions.

The law says that all animal events need to be permitted, and it is the responsibility of the permit holder to follow rules around signage, education, provision of handwashing facilities and risk-reducing animal care and management practices. Changes happened because a bunch of people got sick.

In 2011, 25 attendees at the same fair acquired E. coli O157 by walking through the Kelley Building where a livestock competition was held. The epidemiology didn't point to animal contact as a risk factor. In response to the outbreak, Ag Commissioner Steve Troxler formed a multiagency group to evaluate management practices and come up with changes to be implemented at future events.

These changes were released last week and focus on limiting access to animal areas (including show areas and washing areas where the poop is knocked off of animals), increasing the availability of handwashing stations, evaluating their use, and increased communication about risks.

Not sure what that last one means.

Outbreaks of zoonotic disease at petting zoos demonstrates that although contact with animals in public settings (such as fairs, petting zoos, and schools) can provide educational and entertainment opportunities, the potential to spread disease exists at these events if proper hygiene measures and precautions are not taken and reinforced. Human illness outbreaks have been linked to visiting petting zoos or similar settings with animal contact in the U.S., Canada, U.K., New Zealand, Australia, Ireland and the Netherlands.

The U.S. Centers for Disease Control and Prevention (CDC) has documented approximately 150 outbreaks of human infectious disease involving animals in public settings from 1996-2010.

Children have an increased risk of infection in animal-contact settings due to certain factors and behaviors, including lack of awareness of the risk for disease, inadequate handwashing, lack of close supervision, and frequent hand-to-mouth activities (e.g., use of pacifiers, thumb-sucking, and eating).

In the fall of 2009, an E. coli O157:H7 outbreak at Godstone Petting Farm in the U.K resulted in 93 illnesses – primarily little kids.

The investigation into the Godstone outbreak identified evidence of environmental contamination outside the main barn, indicating acquisition of illness through both direct animal or fecal contact, and indirect environmental contact (e.g. contacting railings or soiled footwear).

Aerosolization of potential pathogens is also possible, as suggested in an E. coli O157:H7 outbreak at a county fair in Oregon, in which 60 people fell ill.

As part of the response to the Godstone outbreak, U.K. health types recommended handwashing stations with soap and water only (no wipes or sanitizers, because they don’t work that well under certain conditions).

Ihekweazu et al. subsequently concluded that in the Godstone outbreak, “handwashing conferred no demonstrable protective effect. …

“Moreover, from the findings of many previous published studies, it must be assumed that all petting or open farms are potentially high-risk environments for the acquisition of VTEC O157 infection.”

Against this backdrop, the Raleigh News Observer wrote in an editorial last week that Commissioner Troxler has instituted some common sense changes to the fair like limiting contact with animals and moving some food vendors away from the animal buildings.

That may be common sense after two E. coli outbreaks at the same fair, but it’s not common sense unless organizers have actually thought about it. At the Ekka yesterday in Brisbane, we saw untold amounts of food, water bottles, pacifiers, and baby bottles being consumed or transported, all while petting animals through a fence.

Troxler also said, “Handwashing, handwashing, handwashing.”

This means that as folks go through the fairgrounds, they ought to take advantage of well-placed handwashing stations and lather up (or use sanitizer) often. Very often. And it means giving the little ones a frequent handwashing exercise as well.

Sanitizers have limited effectiveness, and in a petting zoo situation, so does handwashing; it’s only one component of an overall strategy to reduce risk. But it’s easy to say handwashing because that blames the patrons, not something else.

A table of petting zoo outbreaks is available at http://bites.ksu.edu/petting-zoos-outbreaks.

Yesterday we joined over 70,000 for our second People’s Day at the Ekka.

The petting zoo was a mess.

The Brisbane Exhibition, or Ekka, runs over 10 days and is similar to American-style state fairs or the CNE in Toronto: bad food, hucksters of various wares, a large midway, and the best livestock from across the state.

There was a petting zoo, a short of controlled-chaos the like of which I’d never seen (left, exactly as shown) where hundreds of parents and their kids roamed in a large enclosure with goats, sheep, cattle, and shelled out some cash to feed the animals from a cup. Kids were crying and falling in poop, animals were scarfing down food, parents were chatting with friends and not noticing their toddler doing things that shouldn’t be done in a petting zoo.

At one point, Amy told Sorenne not to put her fingers in her mouth after petting an animal; the mother next to her told her kid, “Yeah, don’t put your fingers in your mouth.”

Amy couldn’t tell if it was sarcasm or sincere.

Both hand sanitation and handwashing stations were available at the departure point, which was good, although reminders could have been more effective: the compliance rate appeared low. As Anderson and Weese found in 2011 at a temporary petting zoo in Guelph using video observation, 58 per cent of visitors performed some form of hand hygiene (either using water, soap and water, or hand sanitizer), and two interventions (improved signage while offering hand sanitizer, and verbal hand hygiene reminders by venue staff) were associated with increased hand hygiene compliance. U.K. health officials currently recommend handwashing stations with soap and water only (no wipes or sanitizers).

There was a person collecting feed cups at the exit (which we did not buy) but she said nothing about handwashing as I left.

And handwashing is never enough. While some studies suggest inadequate handwashing facilities may have contributed to enteric disease outbreaks or washing hands was protective against illness, others suggest relevant infectious agents may be aerosolized and inhaled. Handwashing tool selection may also contribute to the success of hand hygiene as a preventive measure, as some outbreak investigations have reported alcohol-based hand sanitizer was not protective against illness, especially when hands are soiled.

All the refs can be found in our recent paper, a sorta secret petting zoo shopper, Observation of public health risk behaviors, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011.

Snappy title.

I’m fine with animal interactions; but people, and organizers, should be a lot more careful than they thought. That’s what I told my 3-year-old’s daycare as they prepared for a chicken coop. I’m not sure people like that message.

A table of petting zoo outbreaks is available at http://bites.ksu.edu/petting-zoos-outbreaks.

Erdozain G, Kukanich K, Chapman B, Powell D. 2012. Observation of public health risk behaviours, risk communication and hand hygiene at Kansas and Missouri petting zoos - 2010-2011. Zoonoses Public Health. 2012 Jul 30. doi: 10.1111/j.1863-2378.2012.01531.x. [Epub ahead of print]

Abstract:

Observation of public health risk behaviors, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011Outbreaks of human illness have been linked to visiting settings with animal contact throughout developed countries. This paper details an observational study of hand hygiene tool availability and recommendations; frequency of risky behavior; and, handwashing attempts by visitors in Kansas (9) and Missouri (4), U.S., petting zoos. Handwashing signs and hand hygiene stations were available at the exit of animal-contact areas in 10/13 and 8/13 petting zoos respectively. Risky behaviors were observed being performed at all petting zoos by at least one visitor. Frequently observed behaviors were: children (10/13 petting zoos) and adults (9/13 petting zoos) touching hands to face within animal-contact areas; animals licking children’s and adults’ hands (7/13 and 4/13 petting zoos, respectively); and children and adults drinking within animal-contact areas (5/13 petting zoos each). Of 574 visitors observed for hand hygiene when exiting animal-contact areas, 37% (n=214) of individuals attempted some type of hand hygiene, with male adults, female adults, and children attempting at similar rates (32%, 40%, and 37% respectively). Visitors were 4.8x more likely to wash their hands when a staff member was present within or at the exit to the animal-contact area (136/231, 59%) than when no staff member was present (78/343, 23%; p<0.001, OR=4.863, 95% C.I.=3.380-6.998). Visitors at zoos with a fence as a partial barrier to human-animal contact were 2.3x more likely to wash their hands (188/460, 40.9%) than visitors allowed to enter the animals’ yard for contact (26/114, 22.8%; p<0.001, OR= 2.339, 95% CI= 1.454-3.763). Inconsistencies existed in tool availability, signage, and supervision of animal-contact. Risk communication was poor, with few petting zoos outlining risks associated with animal-contact, or providing recommendations for precautions to be taken to reduce these risks.

They found my passport. In Cedar Rapids, Iowa. About six hours after I cancelled it via the nice folks at the Canadian consulate in Dallas.

Cedar Rapids is also finding a lot of E. coli in area streams and figure some of that is coming from doggie doo.

The City of Cedar Rapids claims the roughly two tons of pet waste produced in Cedar Rapids every day is contributing to water pollution in the city.

To fight the fecal problem, Cedar Rapids launched a ‘pick-up the poo pledge’ to encourage dog owners to clean up dog droppings. City employees passed out information on runoff to pet owners and asked them to sign a pledge to pick-up after their pooches.

To learn more about improving and protecting water quality visit www.CityofCR.com/stormwater.