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Pets and DaycareInfections in the Pediatric Population
Heather Becker, MDAssistant Attending
St. Barnabas HospitalPediatric Emergency Department
Salmonellosis
• 3% of households in US have at least one reptile
• 70,000 people in US get salmonellosis from reptiles (turtles, lizards, snakes) each year
• 1975 FDA banned commercial distribution of small turtles (<4 in. long) – est. 100,000 cases/yr of salmonellosis were prevented
• But reptile pets remained popular: 1991-2001 est. households with a reptile pet increased from 850,000 to 1.7 million
• Number of pet turtles in US: 950,000 (1996) up to 2 million (2006)
• CDC reported in 2006-07: nontyphoidal human Salmonella infections est. 1.4 million annually; with approx 15,000 hospitalizations and 400 deaths per year
Salmonellosiscase report
Florida (2/20/07): 3 week old female with 1 day of poor feeding and lethargy presented to ED; transferred to tertiary-care pediatric hospital where she was found febrile and in septic shock; despite antibiotic treatment pt died on 3/1/07
CSF and Blood cxs: + Salmonella
Florida DOH determined that family friend had bought a turtle (1.25 in long) at a flea market in Nov 2006; was given to family as a pet in Jan 2007; fecal sample from turtle yielded exact same isolate as found in infant’s cxs
Salmonellosisoutbreak
In 2007-08:
2 girls swimming with pet turtle in backyard pool became ill (one hospitalized with kidney failure)
investigation revealed girls had same strain of Salmonella that was eventually traced to a total of 107 cases in 34 states (1/3 of these cases needed hospitalization)
Salmonella(non-Typhi)
• Animals are the principal reservoir– Including reptiles, poultry, livestock– Often transmitted through foods of animal origin or drinking water or
other foods contaminated by the animal, animal product or an infected human
– PETS include: turtles, iguanas, lizards, snakes• Range of clinical manifestations:
– Gastroenteritis– Bacteremia– Focal Infections (i.e. meningitis, osteomyelitis)– Asymptomatic Carriage
• Incubation for gastroenteritis: 6 to 48 hrs• Can culture stool, blood, urine or fluid from foci of infection• Antibiotics not indicated in gastroenteritis unless patient is at an
increased risk of invasive disease
Salmonellosis
• Attack rate highest in kids younger than 4 years of age
• Best way to prevent – proper hand hygiene, prohibition of sale of pet turtles and restricting sale of other reptiles
• Do not keep reptiles or wash cages near areas where food is prepared or where others bathe (unless cleaned with bleach afterwards)
• Kids do not need to be kept out of school unless symptomatic
Salmonella
Human Salmonellosis Associated with Animal-Derived Pet Treats --- United States and Canada, 2005
During 2004--2005, contact with Salmonella-contaminated pet treats of beef and seafood origin resulted in nine culture-confirmed human Salmonella Thompson infections …. Public health practitioners should consider pet treats a potential source for
Salmonella transmission. From: MMWR Weekly; 6/30/2006 / 55(25); 702-705.
Dogs
• Can be reservoirs for diarrheal illnesses: Campylobacter Cryptosporidium Salmonella
• Also Dogs and their environment can be source of parasitic infections: – Hookworms, Tapeworms,
Roundworms – Giardia (will discuss with daycare)
• Also rare infections:Leptospira
Campylobacter
• Mostly from GI tract of birds, farm animals and PETS• Get infection from ingestion of contaminated food, water
or unpasteurized milk; or from contact with feces of infected animals or people
• Sxs: Diarrhea, abdominal pain, malaise, fever• Stools can have visible or occult blood• Most get mild infection; up to 20% can relapse or have a
prolonged or severe illness• Incubation 1-7 days• Can culture from feces or blood• Rx: erythromycin, azithromycin (5-7 days)• Kids in diapers should stay out of child care until
diarrhea is gone
Cryptosporidium
• Cryptosporidium parvum – spore-forming protozoan; oocytes are infectious (excreted in feces)
• Waterborne outbreaks most common • Oocyte is resistant to chlorine!• Frequent, nonbloody, watery diarrhea; children commonly
get fever and vomiting too• Can be asymptomatic• Dangerous for immunosuppressed pts• Incubation 7 days (range 2-14); usually self-limited, lasts 1-
20 days • Oocytes continue to be shed in stool for 1-2 weeks after
symptoms stop • Routine Lab O&P tests – will not detect it! Have to tell lab to
specifically look for the oocyte using special methods
Cryptosporidium ova in stool
Hookworm Cutaneous Larva Migrans
• Ancylostoma caninum and braziliense • Infective larvae enter through skin and advance to cause
a “creeping eruption”• Intensely itchy serpiginous tracks or bullae• Usually affects children, gardeners, sunbathers• Most prevalent in Southeast US• Usually self-limited infection (lasts weeks to months)• Can use oral albendazole or ivermectin or topical
thiabendazole• Rarely: can develop Löeffler syndrome or eosinophilic
enteritis
ToxocariasisVisceral Larva Migrans
• Toxacara canis and T. Cati• Usually in children age 1-4 who have h/o pica• From ingesting soil containing eggs of the
parasite; beware of sandboxes!• Marked by fever, leukocytosis, eosinophilia,
hypergammaglobulinemia and hepatomegaly• Liver biopsy with larvae is diagnostic but rarely
found; so negative bx won’t exclude diagnosis• Rx: Albendazole or mebendazole• Need to treat puppies and kittens with
antihelminitics at 2,4,6 and 8 wks of age
Dipylidium(Tapeworm)
• Most common tapeworm of cats and dogs in US – Dipylidium caninum
• Animals get it from swallowing a flea infected with larva while grooming self
• Become adult tapeworm in gut of pet – and proglottids (containing eggs) are released into stool – they are size of grain of rice and can be seen around anus of animal or on freshly passed stool
• Children can be infected in same way (swallowing flea from pet) – but is thankfully rare
• Rx: praziquantel• Flea control very important for pets
Leptospirosis
• Leptospira (spirochete) excreted in animal urine, amniotic fluid, or placenta
• Are viable in soil or water for weeks to months• Humans are infected thru contact of mucosal surfaces or
broken skin with contaminated soil, water or animal tissues• Causes a generalized vasculitis• 90% have a self-limited illness• Very non-specific symptoms (fever, chills, HA, N/V, rash),
often get non-purulent conjunctivitis (30-40%) and myalgias of lower legs and lower back (80%)
• Incubation 5-14 days• Rx: IV Pen G
– Can get a Jarisch-Herxheimer reaction
Cats
• Like dogs can be source of:SalmonellaCampylobacterCryptosporidiaTapewormHookwormRoundwormGiardia
• + Other important infections to consider
Bartonella henselae(Cat-scratch disease)
• Most infections in pts aged < 20 yrs• More than 90% have had contact with a cat (usually a
kitten)• Starts with skin papule at site of scratch, followed by a
regional lymphadenopathy (at the nodes that drain the site of inoculation) by 1-2 weeks
• Incubation: 7-12 days for primary lesion; 5-50 days for lymphadenopathy
• Can have fever and mild systemic symptoms• Typically skin over node is tender, warm, red and
indurated• Self-limited infection
Cat-scratch Disease
Toxoplasmosis• Toxoplasma gondii – more than 60 million people in US carry the parasite
– but immune system prevents them from having symptoms
• If acquired after birth usually asymptomatic; congenitally acquired can lead to mental retardation, learning disabilities, seizures, deafness, chorioretinitis and visual impairment, death
• Cats are definitive host (parasite replicates in sm. Intestine)
• Cats get it from feeding on mice or undercooked meats of animals that are infected
• Cats (especially kittens) excrete oocyst in stool
• Human usually become infected by raw or undercooked meat of intermediate hosts (sheep, pigs, cows) or from accidental ingestion of oocysts from soil, contaminated foods or KITTY LITTER!
“Pocket Pets”
• Including rats, mice, gerbils, hamsters, guinea pigs, ferrets, rabbits
Salmonella again…
Outbreak of Multidrug-Resistant Salmonella Typhimurium Associated with Rodents Purchased at Retail Pet Stores --- United States, December 2003--October 2004
…This report describes two of the first identified human cases associated with this outbreak, summarizes the multistate investigation of human S. Typhimurium infections associated with exposure to rodents (e.g.,
hamsters, mice, and rats) purchased at pet stores…
From: MMWR Weekly; 5/6/2005 / 54(17); 429-433
Lymphocytic Choriomeningitis Virus (LCMV)
• An arenavirus – passed to humans from rodents (primary host for virus)
• Humans infected by aerosol or ingestion of dust or food contaminated by the virus from urine, droppings, saliva
• Usually get from exposure to “house mice” not pets; but has been reported in pet hamsters
• Sxs are similar to “flu”: fever, stiff neck, malaise, anorexia, myalgias, retro-orbital HA, photophobia, nausea, vomiting -- occur 1–2 weeks after exposure.
• Usually complete recovery; can last 1-3 wks• Pet rodents are infected from contact with wild rodents at
a breeding facility, pet store or home
Daycare
Daycare• Respiratory and diarrheal illnesses are at least twice as common in
pre-schoolers who go to daycare then those who stay home
• On average: toddler will put hand or toy in mouth every 3 minutes
• Direct contact with nose secretions, eye secretions or saliva from other kids is common – increasing risk for viral (ie rhinovirus, adenovirus, RSV, paraflu) and bacterial (s. pneumo, non-typable H.flu, moraxella) infections
• Toilet trained children are often not supervised in restroom; staff who change diapers often not educated about importance of hand washing and cleaning surfaces
• Some of the pet-borne infections we already talked about are also spread in childcare facilities: Salmonella, Campylobacter, Cryptosporidium
Giardia
• Most common protozoan-caused diarrhea in North America
• G. lamblia cysts ingested from unwashed hands that were in contact with infected feces
• Outbreaks often human to human transmission, but can come from contaminated drinking water, pools, pets
• Contagious for as long as infected person excretes cysts• Diarrhea is non-bloody, but voluminous and odiferous• Usually self-limited but can last a long time• Some otherwise healthy kids can get prolonged diarrhea
that can cause weight loss of 10-15%, failure to thrive or stunting of growth for 2 years or more
Giardia
• Suspect in any child whose diarrhea lasts more than 5 days; infection can persist for months
• Asymptomatic infection is very common (>20% of well children < 3 yrs who attend daycare harbor organism)
• Very contagious b/c low inoculum necessary for infection• Incubation period: 1-4 wks• Diagnosis made by detecting antigen in stool• Asymptomatic kids need not be treated• Rx: Metronidazole (15mg/kg) x 10 days• Often co-infection of Cryptosporidium and Giardia –
treated with Nitazoxanide x 3 days
Shigella
• Humans are natural host• Spread fecal-oral• Low inoculum (10-200
orgs)• Incubation 1-7 days• Watery stools (but can be
mucoid +/- blood)• Mostly self-limited• Amp, Bactrim for severe
infection but there is resistance
Rotavirus
• Most common cause of severe diarrhea in kids under 2 yrs
• Fecal-oral spread• Present in stool up to 21 days
before diarrhea develops; incubation 2-4 days
• Can be spread by fomites• Nonbloody diarrhea preceded
by vomiting and fever• Lasts 3-8 days• Virtually all children are
infected by 3 years of age• Rotateq
Hepatitis A• Fecal-oral spread; highest titers are in stool 1-2 wks before onset of
illness
• Mild illness in infants and young kids, but substantial morbidity in adults
• Usually self-limited infection (fever, malaise, jaundice, nausea, anorexia)
• In older kids and adults symptoms can last several weeks
• 13-40% of reported Hepatitis A community outbreaks had some association to a daycare outbreak
• Children or staff with infection need to be excluded from childcare facility or school for at least 7 days after onset of illness
• Vaccine-preventable disease!
Ringworm(Tinea infections)
• Spread by direct contact with infected humans, animals or fomites
• Unknown incubation period
• Treat topically with miconazole or clotrimazole BID; or ketoconazole, econazole daily
• Treat for at least 4 weeks (even though usually gone in 2 wks)
Pinworm
• Enterobius vermicularis• Humans are only known natural host• Asymptomatic or pruritus ani (sometimes pruritus vulvae)• Tends to spread within families• Can be a cause of nonspecific urethritis, vaginitis• Female worm dies after depositing eggs on perianal
skin; reinfection occurs by reingestion of eggs• Incubation: from ingestion of egg until female gets to
anus (1-2 months); eggs can stay infective for 2-3 weeks• Worms can be seen in perianal area 2-3 hrs after child
asleep• Treat with mebendazole, pyrantel pamoate or
albendazole – one dose, repeated 2 weeks later
Scabies
• Spread by direct contact with infected skin• Transmission usually through prolonged, close, personal
contact• Very itchy eruption – caused by hypersensitivity reaction
to the proteins of the parasite• Adult female mites burrow into upper layers of epidermis • Transmissible for as long as the patient remains infected
and untreated• Incubation 4-6 weeks if no previous exposure, 1-4 days if
previous infestation• Rx: permethrin 5% cream
Pediculosis Capitis(Head Lice)
• Spread by direct contact with infected hair (often from fomites)
• Usually itchy but can be asymptomatic• Adult lice or nits (eggs) usually found behind ears and
near nape of neck• Incubation from egg to first hatch 6-10 days (adult lice
that can lay eggs appear 2-3 weeks later)• Exclude from daycare until day after treatment
(permethrin 1%) – “no-nit” policy is not recommended• Screen classmates and family members and treat if
infested
Cytomegalovirus
• Children with CMV infection are usually asymptomatic but excrete virus in urine and saliva intermittently for years
• Excretion rate in childcare centers – 70% for kids 1-3 years of age
• Risk is not to other kids but to pregnant childcare workers and mothers
• Annual seroconversion rate for adults who have children in daycare is 15%
• All you can do is wash your hands!
Case
• 18 month old female from an orthodox Jewish family presents to NYC hospital emergency department with new onset focal seizures
• No history of travel
Cysticercosis• Taenia solium – pork tapeworm
• Taeniasis = intestinal tapeworm infection (usually only one worm present), acquired by eating undercooked pork that contains encysted larvae, often asymptomatic
• Cysticercosis = infection acquired by ingesting eggs
• Humans are definitive host so eggs found in human feces only
Neurocysticercosis
• Cysts in brain: can cause seizures, behavioral disturbances, obstructive hydrocephalus
• Host reaction to degenerating cysts can cause meningitis symptoms
• Cysts in spinal column: gait disturbance, pain, transverse myelitis
• Can get ocular involvement and visual impairment
• Diagnosis: based on CT or MRI• Treatment based on number and viability of
cysticerci and where they are located
References
• Behrman, RE, Klegman R, JensonHB. Nelson’s Textbook of Pediatrics. Philadelphia: WB Saunders Co.,2000.
• Goodman RA, Osterholm MT, et al. Infectious Diseases and Child Day Care. Pediatrics 1984; 74; 134-139.
• “Guidelines for Veterinarians: Prevention of Zoonotic Transmission of Ascarids and Hookworms of Dogs and Cats.” (2004) From www.cdc.gov
• James C, Schneider J, et al. Turtle-Associated Salmonellosis in Humans – United States, 2006-2007. MMWR Weekly 2007; 56(26); 649-652.
• Keating JP. Chronic Diarrhea. Pediatr. Rev. 2005;26;5-14.
References
• Pickering, LK ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003.
• Reporter R, Sun B, et al. Reptile-Associated Salmonellosis --- Selected States, 1998-2002. MMWR Weekly 2003; 52(49);1206-1209.
• Robinson J. Infectious Diseases in Schools and Child Care Facilities. Pediatr. Rev. 2001; 22; 39-46.
• www.cdc.gov/healthypets
