Classical Zoonoses

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Published on October 3, 2008

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Epidemiology and Control of Zoonotic Infections : Epidemiology and Control of Zoonotic Infections Lecture 3: Brucellosis, Psittacosis, and other classical zoonoses Drs. Gundula Dunne and Jason Stull Part I : BrucellosisPart II: PsittacosisPart III: Other Diseases Q-fever Tuberculosis Cat Scratch Disease Leptospirosis Hantavirus : Part I : BrucellosisPart II: PsittacosisPart III: Other Diseases Q-fever Tuberculosis Cat Scratch Disease Leptospirosis Hantavirus Brucellosis : Brucellosis Dr. Gundula Dunne Brucellosis : Brucellosis Bacterial disease Reservoir = animals Global Distribution Other names Undulant fever, Malta fever, Mediterranean fever (humans) Contagious abortion, Bang’s disease, epizootic abortion (animals) Brucellosis: History : Brucellosis: History David Bruce – English doctor Discovered in 1887 British soldiers sick in Malta Identified in goats’ milk Pasteurization Eliminates organism Reduced human cases Brucellosis: Microbiology : Brucellosis: Microbiology Small, gram-negative bacilli Non-motile Facultative intracellular organism Multiplication in uterus growth favored by mesoerythritol (a carbohydrate produced by fetus and fetal membranes) Brucellosis: Animal Disease : Brucellosis: Animal Disease Chronic infection Localization to reproductive organs Clinicial Signs: abortion and sterility Shed in large numbers in milk, urine, and reproductive tissues Brucella abortus : Brucella abortus Most common species in U.S. Cattle reservoir Globally has poor surveillance and reporting due to lack of recognition Reportable disease Humans – Health Department Animals – Dept. of Food & Agriculture Brucellosis in Cattle & Bison : Brucellosis in Cattle & Bison Third trimester abortions with B. abortus Retained placenta Birth of dead or weak calves Respiratory distress and lung infections Low milk yield Once cow has aborted, subsequent gestations are normal Small percentage (5%) have residual sterility Will shed organisms in milk for life Brucella melitensis : Brucella melitensis Most common species in the world Latin America Middle East Mediterranean Eastern Europe Asia parts of Africa Goats, camels reservoir Recent emergence in cattle on Middle Eastern intensive dairy farms Brucellosis in Sheep & Goats : Brucellosis in Sheep & Goats Late term abortions Birth of dead or weak lambs/kids Retained placenta Goats – Skeletal lesions articular periarticular Males Epididymitis Orchitis Fertility problems Brucella suis : Brucella suis Swine reservoir Worldwide problem Some countries free or eradicated United Kingdom Canada Holland Denmark United States and Australia Feral swine reservoir Crossover problems with domestic swine Brucellosis: Dogs : Brucellosis: Dogs Susceptible to B. canis, B. melitensis, B. abortus, and B. suis B. canis Abortions last trimester Prolonged vaginal discharge Bacteremia for up to 18 months post-exposure Failure to conceive, stillbirths, prostatitis, epididymitis Transmission in Animals : Transmission in Animals Sexual transmission Swine, sheep, goats, dogs Ingestion of infected tissues, body fluids Contact with infected tissues, body fluids Mucous membranes, injections Inhalation of aerosols in stables, pens Diagnosis in Animals : Diagnosis in Animals Bacterial culture Isolation of organism Blood, semen, other tissues Serology Brucellosis card test, ELISA Brucella milk ring test Fluorescent antibody Placenta, fetus Treatment of Animals : Treatment of Animals Combination antibiotic therapy has the best efficacy Surgical drainage plus antibiotics Often expensive High rate of failure U.S. Eradication Program Brucellosis: Eradication Program : Brucellosis: Eradication Program U.S. Department of Agriculture Cooperative State-Federal Brucellosis Eradication Program Started in 1934 Approach: test, slaughter, trace back, investigate, and vaccinate Surveillance Brucellosis ring test (pooled milk) Market Cattle Identification (blood test on individual animals) Brucellosis in Yellowstone National Park : Brucellosis in Yellowstone National Park WHAT CAN BE DONE ABOUT WILD ANIMAL RESERVIORS? An Ongoing Risk Brucellosis: Transmission to Humans : Brucellosis: Transmission to Humans Direct Contact conjunctiva or broken skin in contact with infected tissues Blood, urine, vaginal discharges, aborted fetuses, placentas Ingestion Raw milk & unpasteurized dairy products Rarely undercooked meat Brucellosis: Transmission to Humans : Brucellosis: Transmission to Humans Inhalation of infectious aerosols Pens, stables, slaughter houses Laboratory transmission Inoculation with animal vaccines B. abortus strain 19 B. melitensis Rev-1 No evidence of person-to-person transmission Brucellosis: Human Disease : Brucellosis: Human Disease Organism enters lymphatics and replicates within regional lymph nodes Survives and multiplies within phagocytic cells Hematogenous dissemination results in localization, often liver, spleen, bone marrow GOT BRUCELLOSIS? : GOT BRUCELLOSIS? Liver Phagocytic Cells Brucellosis: Human Disease : Brucellosis: Human Disease Incubation varies Usually 5-60 days; 1-2 months common B. melitensis and B. suis more virulent than B. abortus or B. canis United States- B. abortus Less than 0.5 cases/ 100,000 people Mostly California, Florida, Texas, Virginia Approximately 100 cases per year Reported Cases : 0 50 100 Reported Cases 150 200 250 300 350 Year 1970 1975 1980 1985 1990 1995 2000 Brucellosis: Risk Factors : Occupational disease Cattle ranchers / dairy farmers Veterinarians Abattoir workers/meat inspectors Lab workers Hunters Travelers Raw dairy consumption California – Latinos affected disproportionately Brucellosis: Risk Factors Brucellosis: Human Disease : Brucellosis: Human Disease Undulant fever characteristic Intermittent or irregular fever with variable duration Nonspecific and variable symptoms Headache, weakness, arthralgia, depression, weight loss, fatigue, liver dysfunction Any organ or system can be affected CNS or heart disease more difficult and outcome may be affected Difficult to categorize into acute vs. chronic Chronic usually caused by persisting deep foci of infection Bone, joints, liver, spleen, kidneys Human Disease : Human Disease Nervous system Depression, mental inattention common complaints Direct invasion of CNS in <5% of cases Cardiovascular system Endocarditis in <2% of cases but responsible for majority of brucellosis deaths Respiratory system Ranges from flu-like symptoms with normal CXR to bronchitis, bronchopneumonia, lung nodules, abscesses, hilar adenopathy, pleural effusions Human Disease : Human Disease Osteoarticular complications 20-60% of cases Arthritis, spondylitis, osteomyelitis, tenosynovitis, bursitis Sacroiliitis most commonly reported Large weight-bearing joints more often involved Hepatobiliary system Probably always involved, however varied pathologic findings Liver function tests usually only slightly elevated May see suppurative abscesses with B. suis Gastrointestinal complications Up to 70% of patients Anorexia, abdominal pain, nausea, vomiting, diarrhea Genitourinary involvement Orchitis in up to 20% of men Rare cases of salpingitis, cervicitis and pelvic abscesses in women Brucellosis: Human Diagnostics : Brucellosis: Human Diagnostics Isolation of organism Blood, bone marrow, other tissues Serum agglutination test Fourfold or greater rise in titer Samples 2 weeks apart Demonstration by immunofluorescence of organism in clinical specimen Brucellosis: Human Treatment : Brucellosis: Human Treatment Combination therapy has the best efficacy Doxycycline for six weeks in combination with streptomycin for 2-3 weeks or rifampin for 6 weeks CNS and endocarditis Doxycycline in combination with 2 or more other drugs Treat for many (6-9?) months Endocarditis may also require surgical replacement of valves Prognosis : Prognosis Disease may last days, months, or years Recovery is common Disability is often pronounced Approximately 5% of treated cases relapse Failure to complete the treatment regimen Sequestered infection requiring surgical drainage Case-fatality rate in untreated cases < 2% Generally due to endocarditis caused by B. melitensis Prevention and Control : Prevention and Control Avoid consumption of raw dairy products Report disease and illegal dairy operations Decrease risk with education Consumers of unpasteurized dairy Farmer, veterinarian, abattoir worker, and butcher Notification for laboratory personnel Use Personal Protective Equipment For infected animals/ tissues For laboratory testing Gloves, mask/respiratory, goggles Eradicate disease in reservoir species Identify, segregate, and/or cull infected animals Brucellosis: TAKE HOME : Brucellosis: TAKE HOME Reproductive disease in animals No person to person transmission Risk Factors Unpastuerized milk and dairy Travel Animal contact sheep, goats, and cattle less commonly dogs and pigs Psittacosis(Chlamydophila psittaci) : Psittacosis(Chlamydophila psittaci) Jason Stull, VMD, MPVM CDHS, Veterinary Public Health Section JStull@dhs.ca.gov (916) 552-9782 Psittacosis - Overview : Psittacosis - Overview Background Organism Epidemiology - Animals Epidemiology - Humans Transmission Diagnostic Testing Treatment Prevention/Control Psittacosis - Background : Psittacosis - Background Chlamydophila psittaci Zoonotic (typically transmitted from birds to humans) In humans = psittacosis (AKA parrot fever, ornithosis) A reportable disease C. psittaci – The Organism : C. psittaci – The Organism Chlamydophila psittaci Formally Chlamydia psittaci Chlamydia (Genus) C. pneumoniae C. trachomatis C. psittaci C. psittaci – The Organism (2) : C. psittaci – The Organism (2) Obligate intracellular bacterium Environmentally labile Elementary bodies Survive outside the host (in litter/feces) and inside host cells for days to weeks Transmission: air circulation, vertical (birds) C. psittaci - Animals : C. psittaci - Animals Wide host spectrum among birds and mammals Pet psittacine birds are most often implicated in human infection When birds are infected = avian chlamydiosis (AC) Parakeet C. psittaci - Birds : C. psittaci - Birds Not an unusual disease among pet birds C. psittaci is shed in feces and nasal/ocular discharges Incubation is usually 3 days to several weeks Latent infections - disease may appear years after exposure C. psittaci - Birds : C. psittaci - Birds Clinical signs include shivering, depression, emaciation, weight loss, dyspnea, diarrhea, ruffled feathers, ocular/nasal discharge Outcome varies with Species of bird Strain virulence Infectious dose Host/environmental factors C. psittaci - Birds : C. psittaci - Birds Birds can appear healthy and shed intermittently for months Shedding can be activated by stress - shipping, crowding, cold, breeding, etc. Diagnosis – culture, IFA, titers, histology Can be difficult, requiring several methods Birds with confirmed or probable psittacosis should be isolated and treated under the care of a Veterinarian An important consideration in any lethargic bird with nonspecific illness - especially in a recently acquired bird C. psittaci - Birds : C. psittaci - Birds Confirmed case (at least one of the following) Isolation of C. psittaci C. antigen by IFA of tissues Four fold rise in serologic titer (2 weeks apart) ID of C. in macrophages Probable case - Clinical illness compatible with psittacosis and: Single high titer obtained after onset, OR C. antigen by ELISA, PCR or FA from feces, cloacal swab, respir. or ocular exudates C. psittaci - Birds : C. psittaci - Birds Treatment Many different protocols (species specific) Doxycycline Usually 45 days Fatalities may occur Isolation during treatment Supervised by a veterinarian Avian chlamydiosis: CA Regulations : Avian chlamydiosis: CA Regulations Pet Birds Quarantine authority given to local health officer or State DHS Reporting to local health department and CDHS encouraged Poultry Reportable to CA Dept. of Food and Agriculture within 2 days of discovery Avian chlamydiosis: Report form : Avian chlamydiosis: Report form **Contact Veterinary Public Health Section for a copy** 916-552-9740 C. psittaci - Humans : C. psittaci - Humans Routes of infection Inhalation (feather dust, resp. secretions, dried feces) Mouth-to-beak contact Handling of infected bird’s plumage and tissues Even brief exposures can lead to infection Psittacosis: Signs and Symptoms : Psittacosis: Signs and Symptoms Incubation ~ 5-14 d Inapparent to systemic illness (pneumonia) Acute fever, chills, headache, malaise, myalgia, nonproductive cough, dyspnea Psittacosis – Signs and Symptoms (2) : Psittacosis – Signs and Symptoms (2) Can affect other organ systems Cardiac Liver Joints Conjunctivitis Encephalitis Severe illness and fetal death has been reported in pregnant women Psittacosis – Diagnosis : Psittacosis – Diagnosis Antibodies to C. trachomatis, C. pneumoniae, and C. psittaci, C. felis tend to cross-react Microimmunoflurosecence (MIF) is more sensitive and specific than complement fixation (CF) Acute and convalescent samples (at least 2 weeks apart) Culture - rarely done (difficult/safety concerns) PCR Psittacosis - Case Definition (CDC, 1996) : Psittacosis - Case Definition (CDC, 1996) Confirmed case – illness compatible with psittacosis and at least one of the following: Isolation of C. psittaci from respiratory secretions Fourfold or greater increase in antibody against C. psittaci by CF or MIF to a reciprocal titer  32 between paired acute and convalescent serum specimens IgM against C. psittaci by MIF to a reciprocal titer  16 Probable case - a clinically compatible case that is epidemiologically linked to a confirmed case or that has supportive serology Psittacosis - Treatment : Psittacosis - Treatment Tetracyclines - drugs of choice Must treat for at least 10-14 days after fever abates Symptoms improve in 48-72 hours, but relapse is common if inadequately treated 15-20% fatality pre antibiotics, today <1% if properly treated Psittacosis: Public Health : Psittacosis: Public Health Reportable disease: CA: 3 to 8 cases/yr USA: 923 cases reported to CDC (1988 to 2002) True incidence likely much higher Psittacosis: Public Health (2) : Psittacosis: Public Health (2) Occupational hazard to workers in bird industry Pet birds Turkey-processing plants Sporadic cases associated with pet bird ownership Psittacosis: Controlling Infection : Psittacosis: Controlling Infection Identify source and those at risk Protect those at risk Gloves, gowns, fitted respirator (N95) when cleaning cages or handling infected birds Maintain records of bird transactions for at least 1 yr Do not sell/purchase ill birds Isolate (30 d) newly acquired, ill, or exposed birds Psittacosis: Controlling Infection (2) : Psittacosis: Controlling Infection (2) Prevent generation of aerosols and dust during cleanup Practice good bird husbandry Psittacosis - When to investigate? : Psittacosis - When to investigate? A confirmed or probable avian case obtained from a store/dealer/breeder within 60 days of illness onset A confirmed or probable human case Multiple suspect avian cases identified from the same source Other Psittacosis Investigation : Psittacosis Investigation Contact owner and veterinarian for details of diagnosis, info on human illnesses, other birds at location, duration of ownership, and source of birds Site visit to home, pet store (aviary) to evaluate exposed and affected animals, husbandry practices Quarantine affected/exposed birds Resources : Resources Available at http://www.dhs.ca.gov/ps/dcdc/disb/disbindex.htm Conclusions - Psittacosis : Conclusions - Psittacosis Transmission: via aerosolized bird feces Birds: Intermittent shedding Symptomatic and asymptomatic shedding Reporting: Human cases: reportable to CDHS Birds: reportable to CDFA (poultry) and encouraged reporting to local health dept. (pet birds) VPHS is here to help : VPHS is here to help Psittacosis Questions? Part IIIClassic Zoonoses : Part IIIClassic Zoonoses Q-fever Leptospirosis Cat Scratch Disease Hantavirus Tuberculosis Q-fever : Q-fever Coxiella Burnetii Q-fever: Coxiella burnetii : Q-fever: Coxiella burnetii Obligate intracellular rickettsia Highly infectious - one organism may cause disease Found worldwide Reservoir = animals Hardy organism Q-fever: Reservoir Species : Q-fever: Reservoir Species Goats, sheep and cattle: No obvious illness in animals Can cause abortions Cats Rabbits Birds Rodents ???? Q-fever: Transmission to Humans : Q-fever: Transmission to Humans Organism is excreted in urine, feces, milk, and especially in birth fluids Humans are usually infected by inhalation of the organism from contaminated environments Occasionally raw milk Potential Sources of Infection : Potential Sources of Infection Contaminated wool Soiled laundry Livestock trucks Livestock Air conditioner ducts in common with animal quarters Contaminated airborne dust particles Q-fever : Q-fever High concentrations in animal tissues, especially placenta Survives for long periods in environment Highly resistant to physical and chemical agents Q-fever: Risk Factors : Q-fever: Risk Factors Direct contact with infected animals Farmers Veterinarians Slaughterhouse workers Sheep researchers Q Fever: Human Illness : Q Fever: Human Illness Incubation period is 20 days (14 - 39 days) Symptoms may include headache, weakness, malaise, chills, severe sweats, retro-orbital pain Pneumonia Abnormal liver function tests Granulomatous hepatitis Q Fever: Human Illness : Q Fever: Human Illness Self-limited febrile illness of 2-14 days Chronic Q fever endocarditis results in less than 1% of Q fever cases Endocarditis may develop in 1 to several years after infection Osteomyelitis and/or neurologic manifestations are also possible Preventive Measures : Preventive Measures Education of high risk individuals restrict access to birthing areas disposal of birth products Pasteurization of milk Currently, no commercially available vaccine in the United States Surveillance in researchers who work with sheep Leptospirosis : Leptospirosis Leptospirosis : Leptospirosis Spirochete Mobile, aerobic with hooked ends Animal reservoirs Worldwide Distribution Multiple Serovars Regional distribution Specific host species Slide 79: Leptospirosis: Transmission Cycle Urine Soil and Water Tissues Contaminated with Leptospires Leptospirosis: Animals : Leptospirosis: Animals Cattle Fever, anorexia, decreased milk production, abortion, infertility Swine Abortion, jaundice, hemoglobinuria, nervous symptoms Horses Fever, abortion, recurrent anterior uveitis (moon blindness) Dogs Fever, renal and liver failure Sea Lions Renal failure Shedding of leptospires in urine may be abundant and prolonged (months to years) Leptospirosis: Human Illness : Leptospirosis: Human Illness Incubation usually 7-14 days (range 2-21 days) Bacteremic for 7-10 days Leptospiruric 1 week to several months Leptospirosis: Human Illness : Leptospirosis: Human Illness Symptoms subclinical – mild – severe Mild illness: fever, chills, headache, myalgia, abdominal pain Severe manifestations Biphasic Short afebrile phase Later high fever, renal failure, jaundice, meningitis, hemorrhage, and hem. pneumonitis Conjunctival suffusion (pathognomonic) Leptospirosis: Diagnosis : Leptospirosis: Diagnosis Serologic testing 4-fold titer increase over 2 weeks MAT (Microscopic Agglutination Test) gold standard ELISAs Indirect fluorescent antibody tests (IFATs) PCR (serum & urine) Immunoflourescence (blood & CFS) by dark-field or phase-contrast microscopy Cat Scratch Disease : Cat Scratch Disease Bartonella sp. Cat Scratch Disease : Cat Scratch Disease Bartonella sp. (henselae) Bacteria Transmission: bite or scratch from infected cat Reservoir: Cats Asymptomatic Fleas may be part of life cycle Cat Scratch Disease : Cat Scratch Disease Incubation 7-12 days Papules at inoculation site persist several weeks Subsequent lymphadenopathy +/- fever, fatigue, pain Recovery weeks to months Treatment is supportive Antibiotics not indicated Antibiotics do not change clinical course Cat Scratch Disease : Cat Scratch Disease Common cause of regional adenopathy especially in children 6000 cases and 2100 hospitalizations per year (CDC estimate) 40-60 cases of encephalitis and 4-6 deaths annually (CDC estimate) Tuberculosis : Tuberculosis Mycobacterium sp. Humans, Cattle, and Birds Tuberculosis: Humans : Tuberculosis: Humans Mycobacterium tuberculosis Human host Person-to-person aerosol transmission Animal Incidental Infections Primates Elephants Birds Pigs Dogs Cattle Tuberculosis: Cattle : Tuberculosis: Cattle Mycobacterium bovis Cattle host All warmblooded vertebrates Uncommon disease Transmission Foodborne: unpasteurized milk and raw meat Droplet/aerosols US Eradication Program Started 1917 All states free except Michigan, California, and Texas Tuberculosis: Birds : Tuberculosis: Birds Mycobacterium avium Can be infected with M. genevense and M. tuberculosis GI tract disease Rarely affects respiratory tract Shed in feces M. avium risk for immunocompromised persons (elderly, HIV, chemotherapy) Tuberculosis: Diagnosis : Tuberculosis: Diagnosis TB skin test Culture Very slow growing Acid-fast staining PCR Radiographs QuantiFERON-TB test (Humans only) Tuberculosis: Treatment in Animals : Tuberculosis: Treatment in Animals Difficult to treat Long-term Expensive May be unsuccessful Control in animal flocks or herds may be elimination Hantavirus : Hantavirus Sin Nombre Virus (SNV) Slide 96: Hantavirus Pulmonary Syndrome Sin Nombre virus--previously unrecognized hantavirus Deer mice Host reservoir Vector for transmission Virus shed in urine, feces, saliva Transmission through inhalation of aerosolized rodent excreta Hantavirus: Clinical Signs : Hantavirus: Clinical Signs Non-specific flu-like prodrome fever, headache, myalgia, malaise, GI respiratory signs PE: hypotension, tachycardia, tachypnea Hematology: thrombocytopenia inc. % bands immature WBCs Thoracic radiographs: interstitial infiltrates Rapid progression to respiratory failure "leaky capillaries" -> noncardiogenic pulmonary edema Hantavirus: California Rodent Surveillance : Hantavirus: California Rodent Surveillance Over 10,000 rodents and other small mammals collected and serologically tested 26 genera 43 species Evidence of SNV is rare No evidence of SNV in lagomorphs, carnivores, or domestic rodents Yearly surveillance continues TAKE HOME : TAKE HOME Zoonoses are common Non-specific symptoms Diagnostic tests difficult to interpret Ask about risk factors QUESTIONS? : QUESTIONS?

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