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Tuberculosis Genotyping Network, United States Human Exposure following Mycobacterium tuberculosis Infection of Multiple Animal Species in a Metropolitan ZooPeter Oh,* Reuben Granich,* Jim Scott,* Ben Sun, Michael
Joseph,* Cynthia Stringfield,§ Susan Thisdell,§ Jothan Staley,
Donna Workman-Malcolm, Lee Borenstein,# Eleanor Lehnkering,# Patrick Ryan,#
Jeanne Soukup,# Annette Nitta,# and Jennifer Flood*
Outbreaks of Mycobacterium tuberculosis have been documented in environments such as hospitals, schools, factories, homeless shelters, and prisons (1-5). In more unconventional settings, such as circuses and exotic animal facilities, outbreaks pose unique tuberculosis (TB) control challenges because transmission may involve animals as well as humans (6,7). Zoos are a particular public health concern because of the close contact between TB-susceptible animals and humans, specifically animal handlers and visitors to the facility or exhibit. Infection and disease related to M. tuberculosis have been reported for a variety of species ranging from birds to primates (8-10). Although evidence for human-to-animal transmission of M. tuberculosis has been described (11), little documentation of zoonotic transmission to humans exists (7). We describe the first reported multispecies epizootic of genotypically identical strains of M. tuberculosis in a zoo and the results of an investigation of exposed zoo employees. Synopsis of Animal TB CasesFrom 1997 to 2000, M. tuberculosis was identified in six animals at the Los Angeles Zoo. In March 1997, an Asian elephant (Elephas maximus) (elephant 1) died of salmonellosis. During the necropsy, pulmonary lesions were discovered, and a lymph node specimen showed M. tuberculosis. In April 1997, a positive trunk wash culture of M. tuberculosis was obtained from a second Asian elephant (elephant 2), which had resided in the same barn as elephant 1. In July 1998, a Rocky Mountain goat (Oreamnos americanus) (goat 1) suffered deterioration associated with worsening pneumonia; the pathologic examination was consistent with TB, and culture confirmed M. tuberculosis. Tuberculin skin tests of two cohabiting goats (goats 2 and 3) were positive, but their cultures were negative. In September 1998, a black rhinoceros (Diceros bicornis) had a positive M. tuberculosis culture. In February 2000, routine chest radiographs of goats 2 and 3 showed abnormalities consistent with TB. We isolated M. tuberculosis from both animals. Veterinary Epidemiologic InvestigationWe examined medical and location histories of the affected animals as well as handling practices, health-care procedures, and other means of potential exposure to M. tuberculosis. An epidemiologic link was defined as documented exposure to an infectious human or animal with TB. We conducted an infection control assessment of the animal compounds and health-care facilities and measured air flow in the compounds by smoke testing (12). Examination of Animal IsolatesElephant isolates (e.g., trunk washes) were obtained according to United States Department of Agriculture guidelines (13). We used saline nasal washes to gather rhinoceros isolates and tracheal washes to gather isolates from goats, as well as specimens for pathologic examination. The Los Angeles County Public Health Laboratory performed restriction fragment length polymorphism (RFLP) analyses on the isolates. Southern blots of PvuII-restricted chromosomal DNA were run in 0.08% agarose gels, probed with a DNA fragment corresponding to IS6110, and detected by chemiluminescence (14). Employee TB Screening
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No active TB cases in humans were found during employee TB screening, medical records review, or query of the state case registry. Of 1,088 employees, no matches were identified in the database of cases reported from 1985 to 2000.
Of 336 employees screened for TB during this investigation, 332 (99%) completed the questionnaire, and 307 (91%) had a tuberculin skin test. Of the 323 employees who responded to the job category question, most were veterinarians or animal keepers (112 [35%]) and administrative staff (73 [23%]); other job categories included maintenance workers (38 [12%]), custodians (29 [9%]), and groundskeepers (24 [7%]). Sixty-two percent of the animal handlers were Caucasian, and 61% of the groundskeepers were Hispanic. Sixty percent of all employees reported contact with animals.
Of the 307 employees who had tuberculin skin tests, 55 (18%) reported a positive result. Of these, none reported TB symptoms, and chest radiographs showed no abnormalities suggesting active TB. Persons with positive tuberculin skin tests were more likely than persons with negative tests to be men (RR 3.7, 95% confidence interval [CI] 2.0 to 6.8), groundskeepers (RR 2.6, 95% CI 1.5 to 4.7), construction workers (RR 2.5, 95% CI 1.3 to 4.8), or attendees at the elephant necropsy (RR 2.9, 95% CI 1.5 to 5.5). However, animal caretaking and animal contact were not associated with a positive tuberculin skin test. In this group of employees, we found no true converters, 10 (18%) probable converters, 5 (9%) possible converters, and 40 (73%) nonconverters.
Risk factors for tuberculin skin-test conversion are described in the table. Employees reporting attendance at elephant 1's necropsy were more likely to have documented tuberculin skin-test conversions than those not present (RR 6.3, 95% CI 2.1 to 18.9). Furthermore, employees who trained elephants were more likely to have tuberculin skin-test conversions than those who did not train elephants (RR 4.1, 95% CI 1.3 to 13.1). Groundskeepers (n=24) had an increased risk of tuberculin skin-test conversion compared with other job categories (RR 7.1, 95% CI 2.6 to 19.1). Four of five groundskeepers with tuberculin skin-test conversions were born in the United States; 11 of 14 employees with negative skin tests and none of the 5 groundskeepers with positive tuberculin skin tests (in the nonconverter group) were born in the United States. A lower likelihood of tuberculin skin-test conversion was associated with visiting the animal nursery (RR 0.2, 95% CI 0.0 to 0.7) and the health center (RR 0.3, 95% CI 0.1 to 0.9).
Although 55 zoo employees showed evidence of M. tuberculosis infection, no person with active TB disease was identified. Given the public's distance from the animals and the absence of active TB among employees with closer contact with these animals, M. tuberculosis was likely not transmitted from humans to animals at this zoo.
The finding that groundskeepers and not animal handlers were associated with a higher risk of tuberculin skin-test conversion was unexpected. Because groundskeepers as a group were more likely to be born outside of the United States than animal keepers, we hypothesized that tuberculin skin-test conversion may have resulted from infections acquired outside of the zoo. However, within this group, only one of five groundskeepers with a tuberculin skin-test conversion was born outside of the country. This finding suggests that a recent exposure may have been responsible for tuberculin skin-test conversion in this occupational category, although small numbers limit the inference.
Genotyping evidence strongly suggested transmission from one species to another, although corroborating epidemiologic evidence of transmission was not discovered. One explanation for transmission is that the elephants may have been exposed to TB at the animal facility in which they resided before their arrival at the zoo. The distances to other animal compounds at the zoo make airborne spread unlikely. In addition, we found no employees with active TB. Since interspecies transmission routes were not found, we suggest that continued vigilance for sources of ongoing transmission is warranted.
Finally, we did discover a significant association between tuberculin skin-test conversion and attending the elephant necropsy and training elephants in the compound. This report emphasizes the importance of adhering to strict infection control measures during large animal necropsies and medical procedures, even when TB is not suspected, because of potentially large bacillary loads.
We thank Charles Sedgwick and the zoo administrative office, staff veterinarians, animal health and animal care staff, occupational health nurses, and zoo employees for their participation in the questionnaire. We also thank the TB Control Program staff and David Sasai for conducting the ventilation assessment.
This investigation was supported by the Centers for Disease Control and Prevention cooperative agreement funds for the National Tuberculosis Genotyping and Surveillance Network.
Mr. Oh is an epidemiologist in the TB Control Branch, Division of Communicable Disease Control at the California Department of Health Services. His main interests are TB surveillance, outbreak investigations, and international health.
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This page posted October
10, 2002 |
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Emerging
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