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Despite increased regulation regarding animal exhibits intended for human contact in North Carolina (NC), Shiga toxin-producing Escherichia coli(STEC) outbreaks continue to occur in these settings. On October 8, 2012, the NC Division of Public Health was notified and began to investigate 4 STEC infections among attendees of a county fair.
METHODS:
In conjunction with local health departments, we conducted a case-control study to determine the source of infection. Cases were identified through active surveillance and defined as a person with diarrhea, hemolytic uremic syndrome (HUS), or culture-confirmed STEC who had attended the fair within10 days before illness onset. Controls were selected from associates of cases who also attended the fair and frequency-matched to cases by age strata. We assessed food, animal and fair activity exposures. We collected environmental specimens in animal exhibit areas, food service venues, and restrooms. Pulsed-field gel electrophoresis (PFGE) and multiple-locus variable number tandem repeat analysis (MLVA) testing were performed on culture isolates.
RESULTS:
We identified 106 cases with illness onset during September 29–October 17. Among cases, the median age was 14 years (range: 0–61 years). Eleven (10%) cases were hospitalized, seven (7%) experienced HUS, four (4%) required dialysis, and one died. Twenty-three (22%) cases had laboratory confirmation of E. coli O157:H7 with one of two matching PFGE and MLVA patterns. Of 24 cases and 161 controls enrolled in the study, visiting the petting zoo, particularly petting or feeding animals within the petting zoo, was associated with illness (odds ratio: 22.2; 95% confidence interval: 2.8–177.7). Ten environmental samples from the petting zoo and one other non-contact animal exhibit also grew E. coliO157:H7 with PFGE and MLVA patterns identical to the case isolates.
CONCLUSIONS:
The petting zoo was the source of this outbreak. Since 2004, NC has experienced three STEC outbreaks associated with animal contact at a county or state fair. These outbreaks not only illustrate the importance of careful adherence to public health prevention measures set forward in the National Association of Public Health Veterinarians (NASPHV) Compendium of Measures to Prevent Disease Associated with Animals to prevent future STEC outbreaks but also that even when prevention measures are followed, outbreaks can still occur. More discussion related to prevention and regulation is required in order to address this continued risk.