Georgia epidemiology report, Vol. 21, no. 8 (Aug. 2005)

August 2005

volume 21 number 08

Reptile Associated Salmonellosis in Georgia Residents

INTRODUCTION
Salmonella is a bacterial pathogen that has the potential to cause severe disease, especially in young children, the elderly, and people with immuno-compromising conditions. Common symptoms include diarrhea, fever, cramps, vomiting, and headache. The average incubation period is 12-36 hours, and the duration of illness is normally a few days but can be longer (1).
There is a large burden of disease associated with Salmonella infections in the United States. The Centers for Disease Control and Prevention (CDC) Emerging Infections Program (EIP) estimates that 1.4 million cases of Salmonella occur annually in the U.S. Of these cases, it is estimated that, each year, 15,000 people are hospitalized and 400 die (2). In addition, the economic burden of Salmonella infections (due to factors such as health care costs, loss of productivity, residential-care costs, etc.) is also devastating; the United States Department of Agriculture (USDA) has estimated that the annual burden could be several billion dollars (3).
The south Atlantic region of the US has the highest number of reported cases of salmonellosis each year and accounts for 21% of all U.S. cases (4). In Georgia, the estimated annual rate of Salmonella infections (based upon laboratory confirmed cases) is 21.9 per 100,000 (5). In 2004, 30.4% of the 2,129 total reported cases in Georgia were hospitalized. The 2004 case fatality rate for Georgia cases was 0.72% which is consistent with the national estimate of 0.5-5% (3). However, many people with salmonellosis do not seek medical care and are therefore not counted in the statistics.
The most common method of laboratory testing for Salmonella is by stool culture. Since different serotypes of Salmonella have specific risk factors, it is important to distinguish the isolate further by serotyping and other characterization. In Georgia, clinical laboratories routinely send Salmonella isolates to the Georgia Public Health Laboratory (GPHL) for further characterization. GPHL serotypes the isolate and performs "molecular fingerprinting" via pulse-field gel electrophoresis (PFGE).

SALMONELLA RISK FACTORS
Salmonella can be spread through contaminated food from the farm, cross-contamination during food preparation, personto-person transmission, waterborne transmission, and numerous environmental and animal exposures. Reptiles serve as reservoirs of Salmonella and can shed Salmonella organisms in fecal material. Many Salmonella serotypes have been associated with reptiles. These serotypes include Pomona, Java, Marina, Stanley, Chameleon, Poona, and Javiana (7). In the United States, contact with pet reptiles causes an estimated 70, 000 cases of salmonellosis annually (6).
Reptile associated cases tend to occur most often in young children. Nationally, 9 million reptiles were owned as pets in 2001 (3.9 million households), 2.34 million of these households have minors living in the household. In over 10% of these households, children under 12 care for the animals routinely (8). Young children are at an increased risk of infection and are often not educated about the risk of disease. Unfortunately, many adults are also uninformed or underestimate the risk of illness associated with these pets.
SALMONELLOSIS IN GEORGIA
In Georgia during 2004, there were 2,129 reported cases of salmonellosis. Animal exposure information was obtained for 456 cases; 184 cases reported having exposure to animals. Only 14 (3%) of these cases reported contact with a reptile or amphibian. Contact with turtles was most commonly reported (8 cases); other animal contact included contact with frogs, lizards, a salamander, and an iguana. The risk of Salmonella acquisition due to exposure to reptiles, amphibians, or other small animals is presumably underestimated because persons do not often report direct (actually touching the animal) or indirect (touching a surface the animal touched) contact with these animals.
In this article, the recent epidemiology of Salmonella Pomona and Salmonella Javiana infections in Georgia residents are highlighted.

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Salmonella Pomona
On April 8, 2005, the Georgia Division of Public Health began an investigation of a cluster of two cases of Salmonella Pomona infections, which is a rare serotype that has been associated with reptile exposure.
Case 1 Case 1 was a 31-year old female from central Georgia. She first became ill in November 2004 but was not tested for Salmonella until being hospitalized in February 2005 with diarrhea, vomiting, headache, nausea, and abdominal pain. The patient had direct contact with red-eared slider turtles. The pet turtles had been in her household for two years. No other established risk factors for Salmonella infection were reported. Environmental testing of the turtle's habitat was not performed.
Case 2 Case 2 was a 7-week-old infant residing in metro Atlanta. The infant became ill in February 2005 and was hospitalized. His clinical course was characterized by a 103 fever, diarrhea, vomiting, and abdominal pain. At the time of illness onset, he was only consuming infant formula and filtered municipal water. The infant was exposed to two red-eared slider turtles that were allowed to crawl on the kitchen counter. Thus, he had indirect contact with the turtles and environmental surfaces may have also played a role in transmission. The infant's babysitter, the owner of the turtles, was also ill with vomiting and diarrhea one week prior to the infant's illness but was not tested for salmonellosis.
The turtles were obtained for Salmonella testing. Water collected from their habitat on April 28, 2005 was tested by the GPHL and was positive for Salmonella Pomona. Salmonella isolates from the turtle water and the case patient (infant) had indistinguishable PFGE patterns.
Salmonella Javiana
In the US, Salmonella Javiana infections have increased 159% from 1993 to 2003, and S. Javiana is now the fifth most common Salmonella serotype in the United States (4). S. Javiana is also highly prevalent in Georgia, accounting for more than 14% of Georgia salmonellosis cases with known serotype in 2004. To better characterize the epidemiology of S. Javiana infections in Georgia, the Division of Public Health (GDPH) interviewed 56 individuals who were documented to have S. Javiana in 2004 . Cases were asked about direct and indirect reptile and amphibian exposures and various food and water exposures. A number of the S. Javiana cases reported contact with reptiles or amphibians when compared to the general population. An analytic study to explore the relationships between living in a rural area, gender, age, and environmental and animal risk factors for S. Javiana infections is planned in the near future.

FDA BAN
From 1967 to 1975, approximately 250,000 infants and small children acquired salmonellosis due to direct or indirect contact with turtles (8). In 1975, the U.S. Food and Drug Administration (FDA) banned the interstate and intrastate sale and distribution of viable turtle eggs and turtles with shells less than 4 inches except in certain circumstances. The purpose of the ban is to prevent turtle-associated salmonellosis in children (9). This ban, supported by Georgia legislature, has been successful at decreasing the number of turtle-associated Salmonella cases, especially in young children (8).
CONCLUSION
The estimated rate of Salmonella infections in Georgia is 21.9 per 100,000 people. However, the National Health Objective as cited in Healthy People 2010 is 6.8 cases per 100,000 people (5). Enormous progress must be made in order to reach the goal. Increased education about risk factors and prevention will help decrease the number of Salmonella infections. Thus, pet stores and veterinarians are encouraged to provide educational material about the safe handling of reptiles. Additionally, owners of pet reptiles should follow the CDC's guidelines on proper handling of reptiles (6).
CDC GUIDELINES
The CDC has provided guidelines for reducing the number of reptile- associated Salmonella infections: Pet store owners, health care practitioners, and
veterinarians should provide information to owners and potential purchasers of reptiles and amphibians about the risk of acquiring salmonellosis from their pets. Persons should always wash their hands with soap and water after handling reptiles and amphibians or their cages. Persons at increased risk for infection with serious complications from salmonellosis (e.g., children <5 years old and immunocompromised persons) should avoid contact with reptiles or amphibians. Reptiles and amphibians should be kept out of households containing children <5 years old or immunocompromised persons; families expecting a new child should give their pet reptiles and amphibians away before the infant arrives. Reptiles and amphibians should not be kept in childcar centers. Reptiles and amphibians should not be allowed to roam freely throughout the house. Reptiles and amphibians should be kept out of kitchens and other food preparation areas to prevent contamination; kitchen sinks should not be used to bathe pets or to wash their dishes, cages, or aquariums; if bathtubs are used for these purposes, they should be thoroughly cleaned afterwards.

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Article written by Jennifer L. Gillespie, M.P.H., Melissa Tobin-D'Angelo, M.D., M.P.H., and Stepy Thomas, M.S.P.H. A special thanks to Helen Ellis, Heidi Davidson, and Phil McDevitt for interviewing the S. Pomona cases and facilitating the transfer of the two red-eared slider turtles.
REFERENCES
1. Heymann D. Control of Communicable Diseases Manual. American Public Health Association. 18th Edition. 469-472.
2. Voetsch AC, Van Gilder TJ, Angulo FJ, Farley MM, Shallow S, Marcus R, et al. FoodNet estimate of the burden of illness caused by Nontyphoidal Salmonella infections in the United States. Clin Infect Dis. 2004; 38:S12734.
2. Hogue, A. Situation Accessment: Salmonella Typhimurium DT 104, December 1997. Retrieved July 5, 2005 from the U.S. Department of Agriculture Food Safety and Inspection Service web site: http:// www.fsis.usda.gov/OPHS/stdt104.htm.
4. CDC Annual Summary: Salmonella 2003. Retrieved June 22, 2005 from The Center for Disease Control web

site: http://www.cdc.gov/ncidod/dbmd/phlisdata/ salmtab/2003/SalmonellaAnnualSummary2003.pdf. 5. Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food: 10 Sites, United States, 2004. MMWR. 2005; 54(14);352-356. 6. Reptile-Associated Salmonellosis--Select States, 19961998. MMWR. 1999; 48(44);1009-1013. 7. Recommendations for preventing transmission of Salmonella from reptiles and amphibians to humans. CDC. 2005. Retrieved June 14, 2005 from the Centers for Disease Control and Prevention Web site: http:// www.cdc.gov/healthypets/animals/reptiles.htm. 8. Franke, J, Telecky, TM. Reptiles as Pets: An Examination of the Trade in Live Reptiles in the United States. The Humane Society of the United States: 2001. 2,7,7273. 9. Ban on Interstate and Intrastate Sales and Distribution. Sec 170.100 Turtles. Retrieved June 14, 2005 from the U.S. Food and Drug Administration web site: http:// www.fda.gov/ora/compliance_ref/cpg/cpggenl/cpg170100.html.

New Vibrio vulnificus Resource for Medical Professionals

The peak season for Vibrio infections in Georgia begins in July and continues into the fall; 9 Vibrio cases have already been reported in Georgia so far this year. There are many different species of Vibrio that can infect humans, but one of the most concerning is Vibrio vulnificus. Although Georgia normally has less than 5 reported cases of V. vulnificus annually, this organism is of specific concern because it is associated with severe disease and high mortality, especially in immunosupressed individuals.
V. vulnificus is most often contracted through the consumption of raw or undercooked shellfish, such as oysters and clams, or by exposing open wounds to seawater. Patients with liver disease, diabetes, cancer, alcoholism, AIDS/HIV, gastric disorders, hemochromatosis, and chronic renal failure are at high risk for life-threatening V. vulnificus infections. V. vulnificus infections can progress rapidly in

these populations; therefore, it is important for physicians to quickly identify Vibrio as the agent and appropriately treat patients. The mortality rate for these infections can approach fifty percent.
The SafeOysters.org website has been created as a V. vulnificus resource specifically for medical professionals. SafeOysters.org provides information about the risk of V. vulnificus infection, its impact on public health, and how to diagnose, treat, and prevent it. The website stresses patient education and tells how to obtain free patient brochures in both English and Spanish. It also contains numerous medical references and sources for additional online information. SafeOysters.org is a collaborative effort of the University of Georgia Marine Extension Service and Georgia and California Sea Grant Programs and is sponsored by the National Sea Grant College Program.

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. Director
State Epidemiologist

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S. Susan Lance, D.V.M., Ph.D.
Stuart T. Brown, M.D. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
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Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517

Georgia Department of Human Resources
Division of Public Health

Please send comments to: Gaepinfo@dhr.state.ga.us

The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

August 2005

Volume 21 Number 08

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for May 2005

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for May 2005
2005 49 2485 7 3 44 1084 5 6 6 5 0 2 0 5 0 107 48 1 12 9 28 0 30

Previous 3 Months Total

Ending in May

2003

2004

2005

18

24

136

8345

8194

8018

9

9

30

0

0

5

72

71

139

3816

3291

3449

0

2

25

7

2

16

31

27

28

0

0

7

0

0

0

0

0

3

0

0

1

0

2

11

0

0

0

41

53

285

36

43

133

16

26

12

77

91

68

140

74

45

91

113

131

0

0

0

40

47

92

Previous 12 Months Total

Ending in May

2003

2004

2005

74

79

289

32658

32255

32385

31

38

81

0

0

10

322

309

520

15919

14227

14489

0

3

67

16

20

44

97

120

159

0

0

10

0

0

0

0

0

10

0

0

1

4

3

22

0

0

0

305

401

847

190

136

287

52

78

60

284

345

318

418

343

157

298

349

501

0

0

0

148

164

248

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period
Latest 12 Months: 08/04-07/05 Five Years Ago: 08/00-7/01 Cumulative: 07/81-07/05

Total Cases Reported* <13yrs >=13yrs Total

5

1,607 1,612

10

1,244 1,254

224

28,616 28,840

Percent Female
25.1
25.9
19.3

Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

31.9

5.8

2.4

11.3

1.4

47.3

30.5

10.6

2.7

17.0

2.0

37.2

45.5

15.9

4.9

14.4

1.9

17.5

Race Distribution (%) White Black Other

22.7 75.2

2.1

19.5 76.0

4.5

31.9 65.5

2.5

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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