Reptile- and amphibian-associated salmonellosis in Childcare Centers, United States.
Article Type: Letter to the editor
Subject: Amphibians (Health aspects)
Reptiles (Health aspects)
Salmonellosis (Health aspects)
Authors: Vora, Neil M.
Smith, Kristine M.
Machalaba, Catherine C.
Karesh, William B.
Pub Date: 12/01/2012
Publication: Name: Emerging Infectious Diseases Publisher: U.S. National Center for Infectious Diseases Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. National Center for Infectious Diseases ISSN: 1080-6040
Issue: Date: Dec, 2012 Source Volume: 18 Source Issue: 12
Organization: Government Agency: United States. Centers for Disease Control and Prevention
Accession Number: 313345676
Full Text: To the Editor: Salmonella spp. infection represents a major public health problem in the United States; nearly 1.4 million human cases and 600 associated deaths are reported each year (1). Reptile and amphibian exposures might cause >70,000 of these cases annually (2). Furthermore, children are at increased risk of acquir ing Salmonella spp. and experiencing severe manifestations of disease (3,4). Given the increasing popularity of reptiles and amphibians as pets, reptile- and amphibian-associated salmonellosis is a substantial public health concern (5).

The public has a generally low level of awareness that Salmonella spp. can be acquired from reptiles and amphibians (6); a poll conducted by the US Centers for Disease Control and Prevention (CDC) during 2003 showed that as few as 4 of 49 states require pet stores to provide information about salmonellosis to persons purchasing reptiles (4). A Food and Drug Administration ban, activated in 1975, on the sale of small turtles subsequently prevented an estimated 100,000 cases of salmonellosis in children each year (7). To further reduce the risk of reptile- and amphibian-associated salmonellosis, the CDC has issued recommendations advising that children <5 years of age avoid contact with reptiles and amphibians and that these animals not be kept in childcare centers. The CDC also recommends that all persons wash their hands after handling reptiles and amphibians (8).

We reviewed the regulations as of December 2011 for childcare centers in all US states aimed at preventing reptile- and amphibian-associated salmonellosis (Table). To gather these data, we searched the websites for each state's public health department or the state's equivalent of an early childhood learning agency. When searches on the Internet did not yield the desired information, the appropriate state agencies were contacted by phone or email. In some instances, we corresponded with the designated State Public Health Veterinarian.

Overall, only 50% of states had regulations that required staff and/ or children to wash their hands after touching any animals in childcare centers. Twelve states banned reptiles from childcare centers; 3 of these 12 states also banned amphibians, and these were the only states we found to have banned amphibians from childcare centers. While some states did not allow potentially dangerous or harmful animals in childcare centers, a minority of these states went further to expressly ban reptiles as well (of the 23 states that banned potentially dangerous or harmful animals, 8 states also banned reptiles). One state (Colorado) explicitly banned reptiles, amphibians, and potentially dangerous or harmful animals from childcare centers and also required staff and children in the center to wash their hands after touching animals.

This survey has several limitations. Given the ambiguity in the language used in some regulations and that the language was not standardized between states, we might have misinterpreted some of the documents we reviewed. Furthermore, we might have unintentionally overlooked regulations that were already in place during our investigation, and hence our findings might underestimate the true number of states that have such policies. In some cases, cities and counties have regulations that provide increased protection beyond those implemented at the state level.

In summary, we found great variation between state regulations for childcare centers aimed at reducing transmission of Salmonella spp. from reptiles and amphibians to humans. The discrepancy in the regulations of states that banned potentially danger ous or harmful animals from childcare centers but that did not also specifically ban reptiles and amphibians was paradoxical, considering the well-recognized risk that these animals pose for transmitting Salmonella spp. We do not know how many childcare centers across the United States currently house reptiles or amphibians. However, our data suggest that there is room for revision of the regulations in many states which could in turn augment efforts to prevent Salmonella spp. transmission from reptiles and amphibians. We believe that the recommendations issued by the CDC for the prevention of salmonellosis from reptiles and amphibians (4) could serve as a practical guide as state regulations are updated. Our own experience has indicated that greater collaboration between public health organizations and the agencies responsible for setting regulations for childcare centers can be informative and productive. Similarly, state agencies can work with the pet industry and childcare centers to develop approaches that are mutually beneficial.

Although pets provide many benefits to humans, particularly during the early years of life (9), any exposure that children have to animals must pose minimal risk to the children's health. Ultimately, keeping reptiles and amphibians out of childcare centers and requiring that staff and children wash their hands after touching animals offers a simple way to better safeguard the health of children while having a minimal effect on practices of childcare centers.

Acknowledgments

We thank Casey Barton Behravesh, Carina Blackmore, Bryan Cherry, John Dunn, Karl Musgrave, Joni Scheftel, Sally Slavinski, Faye Sorhage, and Carl Williams for their clarification on state and national regulations aimed at reducing the risks of salmonellosis and their advice on conducting this survey. We also thank members and staff of the National Association of State Public Health Veterinarians and the National Resource Center for Health and Safety in Child Care and Early Education for their assistance.

This survey was generously funded by the Mars Foundation and New York Community Trust.

Neil M. Vora, Kristine M. Smith, Catherine C. Machalaba, and William B. Karesh

Author affiliations: Columbia University, New York, New York, USA (N.M. Vora); and EcoHealth Alliance, New York (N.M. Vora, K.M. Smith, C.C. Machalaba, W.B. Karesh)

DOI: 10.3201/eid1812.120784

References

(1.) Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Food-related illness and death in the United States. Emerg Infect Dis. 1999;5:607-25. http:// dx.doi.org/10.3201/eid0505.990502

(2.) Mermin J, Hutwagner L, Vugia D, Shallow S, Daily P, Bender J, et al. Reptiles, amphibians, and human Salmonella infection: a population-based, case-control study. Clin Infect Dis. 2004;38(Suppl 3):S25361. http://dx.doi.org/10.1086/381594

(3.) Mermin J, Hoar B, Angulo FJ. Iguanas and Salmonella Marina infection in children: a reflection of the increasing incidence of reptile-associated salmonellosis in the United States. Pediatrics. 1997;99:399-402. http://dx.doi. org/10.1542/peds.99.3.399

(4.) Centers for Disease Control and Prevention. Reptile-associated salmonellosis--selected states, 1998-2002. MMWR Morb Mortal Wkly Rep. 2003;52:1206-9.

(5.) Pickering LK, Marano N, Bocchini JA, Angulo FJ. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics. 2008;122:876-86. http://dx.doi. org/10.1542/peds.2008-1942

(6.) Centers for Disease Control and Prevention. Multistate outbreak of human Salmonella Typhimurium infections associated with aquatic frogs--United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;58:1433-6.

(7.) Cohen ML, Potter M, Pollard R, Feld man RA. Turtle-associated salmonellosis in the United States. Effect of Public Health Action, 1970 to 1976. JAMA. 1980;243:1247-9. http://dx.doi. org/10.1001/jama.1980.03300380027016

(8.) Centers for Disease Control and Prevention. Turtle-associated salmonellosis in humans--United States, 2006-2007. MMWR Morb Mortal Wkly Rep. 2007;56:649-52.

(9.) National Association of State Public Health Veterinarians, Inc, Compendium of measures to prevent disease associated with animals in public settings, 2011: National Association of State Public Health Veterinarians, Inc. MMWR Recomm Rep. 2011;60(RR-04):1-24.

Address for correspondence: Neil M. Vora, 460 W 34th St, 17th Floor, New York, NY 100012320, USA; email: neilvora@gmail.com
Table. State regulations for contact between children and
animals in childcare centers, United States, 2011

Description of state regulation              No.(%) states

Bans all animals that show evidence of       22 (44)
disease from childcare centers
Bans all potentially dangerous or            23 (46)
harmful animals from childcare centers
Bans all reptiles from childcare centers     12 (24)
Bans all amphibians from childcare centers   3  (6)
Requires staff and/or children to wash       25 (50)
harmful animals from childcare centers
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