1

Selected Zoonotic Diseases Conference Call

October 7, 2009

Casey Barton Behravesh, DVM, DrPH, DACVPM, Veterinary Epidemiologist, Outbreak Net, Division of Foodborne, Bacterial and Mycotic Diseases, CDC; 404-639-0367; cbartonbehravesh@cdc.gov

Selected Zoonotic Diseases Conference Call

October 7, 2009

Human Salmonellosis Linked to Contact with Live Poultry From Mail-Order Hatcheries

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

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

Shipping Live Poultry

• Hatcheries ship birds– To customers– To agricultural feed

stores– 100 - 125 chicks or 60

ducklings per box

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

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

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

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

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

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

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

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

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

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

Multistate Outbreak of Salmonella Typhimurium Infections Linked to Live Poultry from a Mail-Order

Hatchery, 2009

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

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

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

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)

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

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

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)

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

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

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.

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

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

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

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

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%)

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

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

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

Poultry Specific Questionnaire

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

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: dlx9@cdc.gov

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: igd2@cdc.gov

38

Selected Zoonotic Diseases Conference Call

October 7, 2009