From: Subject: Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2007

National Association of State Public Health Veterinarians, Inc. (NASPHV) Date: Tue, 9 Sep 2008 14:04:07 -0400 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C91284.ECFDD150" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C91284.ECFDD150 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5605a1.htm Compendium of Measures to Prevent Disease Associated = with Animals in Public Settings, 2007 </P><P>National Association of = State Public Health Veterinarians, Inc. (NASPHV)
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Compendium of Measures to = Prevent=20 Disease Associated with Animals in Public Settings, 2007=20

National Association of State Public Health=20 Veterinarians, Inc. (NASPHV)

Prepared by NASPHV=20

Summary

This report has been endorsed by CDC, the = Council of State=20 and Territorial Epidemiologists, and the American Veterinary = Medical=20 Association. The material in this report originated in the = Coordinating=20 Center for Infectious Diseases, Mitch Cohen MD, Director; and the = Division=20 of Foodborne, Bacterial, and Mycotic Diseases, David Warnock PhD,=20 Director.

Corresponding preparer: J.B.=20 Bender DVM, Co-chair, NASPHV Animal Contact Compendium Committee,=20 University of Minnesota, Veterinary Public Health, 136F Andrew = Boss, 1354=20 Eckles Avenue, St. Paul, MN 55108, Telephone: 612-625-6203; Fax:=20 612-624-4906; E-mail: bende002@umn.edu.

Certain venues encourage or permit the public to contact = animals,=20 resulting in millions of human-animal interactions each year. = These=20 settings include county or state fairs, petting zoos, animal swap = meets,=20 pet stores, zoologic institutions, circuses, carnivals, farm = tours,=20 livestock-birthing exhibits, educational exhibits at schools, and = wildlife=20 photo opportunities. Although multiple benefits of human-animal = contact=20 exist, infectious diseases, rabies exposures, injuries, and other = human=20 health problems associated with these settings are possible. = Infectious=20 disease outbreaks reported during the previous decade have been = caused by=20 Escherichia coli O157:H7, Salmonella,=20 Cryptosporidium, Coxiella burnetii, = Mycobacterium=20 tuberculosis, ringworm, and other pathogens. Such incidents = have=20 substantial medical, public health, legal, and economic effects. =

This report provides recommendations for public health = officials,=20 veterinarians, animal venue staff, animal exhibitors, visitors to = animal=20 venues, physicians, and others concerned with minimizing risks = associated=20 with animals in public settings. The recommendation to wash hands = is the=20 single most important prevention step for reducing the risk for = disease=20 transmission. Other critical recommendations are that venues not = allow=20 food in animal areas, venues include transition areas between = animal areas=20 and nonanimal areas, visitors be educated about disease risk and=20 prevention procedures, and animals be properly cared for and = managed.=20

Introduction

Contact with animals in public settings (e.g., fairs, farm = tours,=20 petting zoos, and schools) provides opportunities for = entertainment and=20 education. However, inadequate understanding of disease = transmission and=20 animal behavior can increase the likelihood of infectious = diseases, rabies=20 exposures, injuries, and other health problems among visitors, = especially=20 children, in these settings. Zoonotic diseases (i.e., zoonoses) = are=20 diseases transmitted from animals to humans. Of particular concern = are=20 instances in which large numbers of persons become ill. Since = 1991,=20 approximately 50 human infectious disease outbreaks involving = animals in=20 public settings have been reported to CDC (1). During the = preceding=20 10 years, an increasing number of enteric disease outbreaks = associated=20 with animals in public settings (e.g., fairs and petting zoos) = have been=20 reported (1).

The National Association of State Public Health Veterinarians = (NASPHV)=20 understands the positive benefits of human-animal contact. = Although=20 eliminating all risk from animal contacts is not possible, this = report=20 provides recommendations for minimizing disease and injury.

NASPHV recommends that local and state public health, = agricultural,=20 environmental, and wildlife agencies use these recommendations to=20 establish their own guidelines or regulations for reducing the = risk for=20 disease from human-animal contact in public settings. Multiple = venues=20 exist where public contact with animals is permitted (e.g., animal = displays, petting zoos, animal swap meets, pet stores, zoological=20 institutions, nature parks, circuses, carnivals, farm tours,=20 livestock-birthing exhibits, county or state fairs, schools, and = wildlife=20 photo opportunities). Persons responsible for managing these = venues should=20 use the information in this report to reduce risk for disease=20 transmission.

Guidelines to reduce risks for disease from animals in = health-care and=20 veterinary facilities and from service animals (e.g., guide dogs) = have=20 been developed (2--5). These settings are not specifically=20 addressed in this report, although the general principles and=20 recommendations are applicable to these settings.=20

Methods =

NASPHV periodically reviews the "Compendium of Measures to = Prevent=20 Disease Associated with Animal in Public Settings". This includes=20 reviewing recent literature; updating reported outbreaks, = diseases, or=20 injuries attributed to human-animal interactions in a public = setting; and=20 soliciting comments or suggestions from the NASPHV membership and=20 questions posed by the public. During November 27--29, 2006, = NASPHV=20 members and external expert consultants met at CDC in Atlanta, = Georgia.=20 The first day of the meeting was dedicated to reviewing scientific = information regarding recent outbreaks, associated risk factors, = pathogen=20 biology, and interventional studies. A moderated discussion of = each=20 section of the recommendations was conducted. The committee = reviewed=20 scientific evidence and expert opinion in revising the document. A = committee consensus was needed to add or modify existing language = or=20 recommendations.=20

Enteric (Intestinal)=20 Diseases

Infections with enteric bacteria and parasites pose the highest = risk=20 for human disease from animals in public settings (6). = Healthy=20 animals can harbor human enteric pathogens. Many of these = organisms have a=20 low infectious dose (7--9). Because of the popularity of = animal=20 venues, a substantial number of persons might be exposed. Illness = and=20 outbreaks of enteric diseases among visitors to fairs, farms, and = petting=20 zoos are well documented. Pathogens responsible for outbreaks = include=20 Escherichia coli O157:H7 and other Shiga toxin-producing = E. coli=20 (STEC), Campylobacter, Salmonella, and = Cryptosporidium=20 (10--22). Although reports often document cattle, sheep, or = goats=20 as sources for infection, poultry (23--26), rodents=20 (25--27), and other domestic and wild animals also are = potential=20 sources.

The primary mode of transmission for enteric pathogens is = fecal-oral.=20 Because animal fur, hair, skin, and saliva (28) can become=20 contaminated with fecal organisms, transmission can occur when = persons=20 pet, touch, feed, or are licked by animals. Transmission has = occurred from=20 fecal contamination of food, including raw milk (29--31), = sticky=20 foods (e.g., cotton candy [32]), and water (33--35). = Illness=20 also has been associated with contaminated clothing and shoes=20 (11,17), animal bedding, flooring, barriers, and other=20 environmental surfaces (15,17,25,36--38).

Animals carrying enteric organisms pathogenic to humans (e.g., = STEC,=20 Salmonella, and Campylobacter) frequently exhibit no = signs=20 of illness and can shed these pathogens intermittently. Removing = ill=20 animals (especially those with diarrhea) is necessary but not = sufficient=20 to protect animal and human health. Animals that appear to be = healthy=20 often shed pathogens that contaminate the environment (39). = Some=20 pathogens live for months or years in the environment = (40--44).=20 Because of intermittent shedding and limitations of laboratory = tests,=20 culturing fecal specimens or attempting to identify, screen, and = remove=20 infected animals might reduce, but will not eliminate, the risk = for=20 transmission. Antimicrobial treatment of animals cannot reliably = eliminate=20 infection and shedding of enteric pathogens or prevent = reinfection.

Multiple factors increase the probability of disease = transmission at=20 animal exhibits. Animals are more likely to shed pathogens because = of=20 stress induced by prolonged transportation, confinement, crowding, = and=20 increased handling by persons (45--51). Commingling = increases the=20 probability that animals shedding organisms will infect other = animals=20 (52). The prevalence of certain enteric pathogens is often = higher=20 in young animals (53--55), which are frequently used in = petting=20 zoos and educational programs. Shedding of STEC and = Salmonella is=20 highest in the summer and fall when substantial numbers of = traveling=20 animal exhibits, agricultural fairs, and petting zoos are = scheduled=20 (50,55,56).

The risk for infections is increased by certain human factors = and=20 behaviors, especially in children. These factors include lack of = awareness=20 of the risk for disease, inadequate hand washing, lack of close=20 supervision, and hand-to-mouth activities (e.g., use of pacifiers, = thumb-sucking, and eating) (57). Children are particularly=20 attracted to animal venues and have increased risk for serious = infections.=20

The layout and maintenance of facilities and animal exhibits = also can=20 affect the risk for infection (58). Risk factors include = inadequate=20 hand-washing facilities (59), structural deficiencies = associated=20 with temporary food-service facilities (12,14,17), = inappropriate=20 flow of visitors, and incomplete separation between animal = exhibits and=20 food preparation and consumption areas (60). Other factors = include=20 contaminated or inadequately maintained drinking water and sewage- = or=20 manure-disposal systems (33--35,38).=20

Lessons from Outbreaks

In 2000, two E. coli O157:H7 outbreaks in Pennsylvania = and=20 Washington prompted CDC to establish recommendations for enteric = disease=20 prevention associated with farm animal contact. Risk factors = identified in=20 both outbreaks were direct animal contact and inadequate hand = washing=20 (60,61). In the Pennsylvania outbreak, 51 persons (median = age: 4=20 years) became ill within 10 days after visiting a dairy farm. = Eight (16%)=20 of these patients acquired hemolytic uremic syndrome (HUS), a = potentially=20 fatal consequence of STEC infection. The same strain of E. = coli=20 O157:H7 was isolated from cattle, patients, and the farm = environment. In=20 addition to the reported cases, an increased number of diarrhea = cases in=20 the community were attributed to visiting the farm. An assessment = of the=20 farm environment determined that no areas existed for eating and = drinking=20 separate from the animal contact areas, and the limited = hand-washing=20 facilities were not configured for children (60).

The protective effect of hand washing and the persistence of = organisms=20 in the environment were demonstrated in an outbreak of = Salmonella=20 infections at a Colorado zoo in1996. A total of 65 cases (most = among=20 children) were associated with touching a wooden barrier around a=20 temporary Komodo dragon exhibit. Children who were not ill were=20 substantially more likely to have washed their hands after = visiting the=20 exhibit. Salmonella was isolated from 39 patients, a Komodo = dragon,=20 and the wooden barrier (17).

In 2005, an E. coli O157:H7 outbreak among 63 patients,=20 including seven who had HUS, were associated with multiple fairs = in=20 Florida. Both direct animal contact and contact with sawdust or = shavings=20 were associated with illness (12). Persons who reported = feeding=20 animals were at increased risk. Among persons who washed their = hands after=20 leaving the animal area, using soap and water was protective for = those who=20 created a lather (62). Drying hands on clothes increased = the risk=20 for illness. Persons were less likely to become ill if they = reported=20 washing their hands before eating or drinking or were aware of the = risk=20 for illness before visiting the fair.

During 2000--2001 at a Minnesota children's farm day camp, = washing=20 hands with soap after touching a calf and washing hands before = going home=20 were protective factors in two outbreaks involving multiple = enteric=20 organisms. A total of 84 illnesses were documented among = attendees.=20 Implicated organisms for the human infections were E. coli = O157:H7,=20 Cryptosporidium parvum, non-O157 STEC, Salmonella = enterica=20 serotype Typhimurium, and Campylobacter jejuni. These = organisms=20 and Giardia were isolated from calves. Risk factors for = children=20 included caring for an ill calf and getting visible manure on = their hands=20 (20).

Enteric pathogens can contaminate the environment and persist = in animal=20 housing areas for long periods. For example, E. coli = O157:H7 can=20 survive in soil for months (38,40,42,63). Prolonged = environmental=20 persistence of pathogens was documented in an Ohio outbreak in = 2001 of=20 E. coli O157:H7 infections in which 23 persons became ill = at a fair=20 after handling sawdust, attending a dance, or eating and drinking = in a=20 barn where animals were exhibited during the previous week = (38).=20 Fourteen weeks after the fair, E. coli O157:H7 was isolated = from=20 multiple environmental sources within the barn, including sawdust = on the=20 floor and dust on the rafters. Forty-two weeks after the fair, = E. coli=20 O157:H7 was recovered from sawdust on the floor. In 2004, an = outbreak=20 of E. coli O157:H7 infection was associated with attendance = at the=20 North Carolina State Fair goat and sheep petting zoo (12). = Health=20 officials identified 108 patients, including 15 who had HUS. The = outbreak=20 strain was isolated from the animal bedding 10 days after the fair = was=20 over, and from the soil 5 months after the animal bedding and = topsoil were=20 removed (58). In 2003, a total of 25 persons acquired E. = coli=20 O157:H7 at a Texas agricultural fair. The strain isolated from = patients also was found in environmental samples 46 days after the = fair=20 ended (15).

Transmission can occur even in the absence of direct animal = contact if=20 the pathogen is disseminated in the environment. In an Oregon = county fair=20 outbreak, 60 cases occurred, mostly among children (25). = Illness=20 was associated with visiting an exhibition hall that housed goats, = sheep,=20 pigs, rabbits, and poultry; however, illness was not associated = with=20 touching animals or their pens, eating, or inadequate hand = washing. The=20 same organism was recovered from ill persons and the building.=20 Transmission of E. coli O157:H7 from contaminated dust was=20 implicated in two outbreaks in Ohio and Oregon (25,38). =

Improper facility design and inadequate maintenance might = increase=20 risk, as illustrated by one of the largest waterborne outbreaks in = the=20 United States (34,35). In 1999, approximately 800 suspected = cases=20 of E. coli O157:H7 and Campylobacter infection = were=20 identified among attendees of a New York county fair where the = water and=20 sewage systems had deficiencies. Temporary facilities are = particularly=20 vulnerable to design flaws (12,17). Such venues include = those that=20 add an animal display or petting zoo for the purpose of attracting = children to zoos, festivals, roadside attractions, farm stands,=20 pick-your-own-produce farms, and Christmas tree lots. In 2005, an = E.=20 coli O157:H7 outbreak in Arizona was associated with a = temporary=20 petting zoo at a municipal zoo (12). Child care and school = field=20 trips to a pumpkin patch with a petting zoo resulted in 44 cases = of E.=20 coli O157:H7 infection in British Columbia (14). The = same=20 strain of E. coli was found both in children and in a = petting zoo=20 goat. Running water and signage recommending hand washing were not = available, and alcohol hand sanitizers were at a height that was=20 unreachable for some children. A total of 163 persons became ill = with=20 STEC O111:H8 and/or Cryptosporidium at a New York = farm stand=20 that sold unpasteurized apple cider and had a petting zoo with = three=20 calves (64).

Several outbreaks have occurred because of failure to = understand and=20 properly implement disease-prevention recommendations. Following a = Minnesota outbreak of cryptosporidiosis with 31 ill students at a = school=20 farm program, specific recommendations provided to teachers were=20 inadequately implemented (18). A subsequent outbreak = occurred with=20 37 illnesses. Hand-washing procedures were inadequate (e.g., only = water=20 available, crowding at sink, and drying hands on clothes). = Coveralls and=20 boots were dirty, cleaned infrequently, and removed after = hand-washing. In=20 addition, inadequate hand washing and cleaning of contact surfaces = resulted in an outbreak of salmonellosis associated with = dissection of owl=20 pellets in elementary schools (65).=20

Sporadic Infections

Although not identified as part of recognized outbreaks, = sporadic=20 infections have been associated with animal environments. A study = of=20 sporadic E. coli O157:H7 infections in the United States = determined=20 that patients, especially children, were more likely than healthy = persons=20 to have visited a farm with cows (66). Additional studies = also=20 documented an association between E. coli O157:H7 infection = and=20 visiting a farm (67) or living in a rural area (68). = Studies=20 of human cryptosporidiosis have documented contact with cattle or = visiting=20 farms as risk factors for infection (69--71). A = case-control study=20 identified multiple factors, including raw milk consumption and = contact=20 with farm animals, associated with Campylobacter infection=20 (72). In other studies, farm residents were at a lower risk = for=20 infection with Cryptosporidium (71) and E. = coli=20 O157:H7 (73) than farm visitors, presumably because the = residents=20 had acquired immunity as a result of their early and frequent = exposure to=20 these organisms. However, livestock exhibitors became infected = with E.=20 coli O157:H7 in at least one fair outbreak (15).=20

Additional Health=20 Concerns

Although enteric diseases are the most commonly reported = illnesses=20 associated with animals in public settings, other health risks are = of=20 concern. For example, allergies can be associated with animal = dander,=20 scales, fur, feathers, body wastes (e.g., urine), and saliva=20 (74--76). Additional health concerns addressed in this = report=20 include injuries, rabies exposures, and other infections.=20

Injuries

Injuries associated with animals in public settings include = bites,=20 kicks, falls, scratches, stings, crushing of the hands or feet, = and being=20 pinned between the animal and a fixed object. These injuries have = been=20 associated with big cats (e.g., tigers), monkeys, and other = domestic and=20 zoo animals. The settings have included public stables, petting = zoos,=20 traveling photo opportunities, schools, children's parties, and = animal=20 rides (M. Eidson, DVM, New York State Department of Health, = personal=20 communication, 2003; J.B. Bender, DVM, University of Minnesota, = personal=20 communication, 2003; M.T. Jay-Russell, DVM, California Department = of=20 Health, personal communication, 2003; G.L. Swinger, DVM, Tennessee = Department of Health, personal communication, 2003). For example, = a Kansas=20 teenager was killed while posing for a photograph with a tiger = being=20 restrained by its handler at an animal sanctuary (77).=20

Rabies Exposures

Contact with rabid mammals can expose persons to rabies virus = through=20 bites or contamination of mucous membranes, scratches, or other = wounds=20 with infected saliva or nervous tissue. Although no human rabies = deaths=20 caused by animal contact in public exhibits have been recorded, = multiple=20 rabies exposures have occurred, requiring extensive public health=20 investigation and medical follow-up. For example, thousands of = persons=20 have received rabies postexposure prophylaxis (PEP) after being = exposed to=20 rabid or potentially rabid animals (including cats, goats, bears, = sheep,=20 ponies, and dogs) at a variety of venues: a pet store in New = Hampshire=20 (78), a county fair in New York State (79), petting = zoos in=20 Iowa (80,81) and Texas (J. Wright, Texas Department of = Health,=20 personal communication, 2004), and school and rodeo events in = Wyoming=20 (59). Substantial public health and medical care challenges = associated with potential mass rabies exposures include difficulty = in=20 identifying and contacting persons, correctly assessing exposure = risks,=20 and providing timely medical prophylaxis. Prompt assessment and = treatment=20 are critical to prevent this disease, which is usually fatal.=20

Other Infections

Multiple bacterial, viral, fungal, and parasitic agents have = been=20 associated with animal contact. These organisms are transmitted = through=20 various modes. Infections from animal bites are common and = frequently=20 require extensive treatment or hospitalization. Bacterial = pathogens=20 associated with animal bites include Pasteurella,=20 Francisella tularensis (82), Staphylococcus,=20 Streptococcus, Capnocytophaga canimorsus, = Bartonella=20 henselae (cat-scratch disease), and Streptobacillus=20 moniliformis (rat-bite fever). Certain monkey species = (especially=20 macaques) kept as pets or used in public exhibits can be infected = with=20 herpes B virus, either asymptomatically or with mild oral lesions. = Human=20 exposure through monkey bites or bodily fluids can result in a = fatal=20 meningoencephalitis (83,84).

Skin contact with animals in public settings is also a public = health=20 concern. In 1995, a total of 15 cases of ringworm (club lamb = fungus)=20 caused by Trichophyton species and Microsporum = gypseum were=20 documented among owners and family members who exhibited lambs in = Georgia=20 during a show season (85). Ringworm in 23 persons and = multiple=20 animal species was traced to a Microsporum canis infection = in a=20 hand-reared zoo tiger cub (86). Orf virus infection = (contagious=20 ecthyma or sore mouth) has occurred following contact with sheep = at a=20 public setting (E. Lederman, CDC, personal communication, 2006). = In=20 addition, orf virus infection has been described in goats and = sheep at a=20 children's petting zoo (87) and in a lamb used for an = Easter photo=20 opportunity (M. Eidson, New York State Department of Health, = personal=20 communication, 2003). After handling various species of infected = exotic=20 animals, a zoo attendant experienced an extensive papular skin = rash from a=20 cowpox-like virus (88). In 2003, multiple cases of = monkeypox=20 occurred among persons who had contact with infected prairie dogs = either=20 at a child care center (89,90) or a pet store (J.J. = Kazmierczak,=20 Wisconsin Department of Health and Family Services, personal=20 communication, 2004).

Ecto- and endoparasites pose concerns when humans and exhibit = animals=20 interact. Sarcoptes scabiei is a skin mite that infests = humans and=20 animals, including swine, dogs, cats, foxes, cattle, and coyotes = (91,=20 92). Although human infestation from animal sources is usually = self-limiting, skin irritation and itching might occur for = multiple days=20 and can be difficult to diagnose (92,93). Animal flea bites = to=20 humans increase the risk for infection or allergic reaction. In = addition,=20 fleas can carry a tapeworm species that can infect children who=20 unintentionally swallow the flea (94,95). Animal parasites = also can=20 infect humans who ingest soil or other materials contaminated with = animal=20 feces. Parasite control through veterinary care and proper = husbandry=20 combined with hand washing reduces the risks associated with ecto- = and=20 endoparasites (96).

Tuberculosis (TB) is another disease of concern in certain = animal=20 settings. In 1996, a total of 12 circus elephant handlers at an = exotic=20 animal farm in Illinois were infected with Mycobacterium=20 tuberculosis, and one handler had signs consistent with active = disease=20 after three elephants died of TB. Medical history and testing of = the=20 handlers indicated that the elephants had been a probable source = of=20 exposure for most of the human infections (97). During = 1989--1991=20 at a zoo in Louisiana, seven animal handlers who were previously = negative=20 for TB tested positive after a Mycobacterium bovis outbreak = in=20 rhinoceroses and monkeys (98). In 2003, the U.S. Department = of=20 Agriculture (USDA) developed guidelines regarding removal of = TB-infected=20 animals from public contact as a result of concerns over the risk = for=20 exposure to the public (99).

Zoonotic pathogens also can be transmitted by direct or = indirect=20 contact with reproductive fluids, aborted fetuses, or newborns = from=20 infected dams. Live-birthing exhibits, usually involving livestock = (e.g.,=20 cattle, pigs, goats, or sheep), are popular at agricultural fairs. = Although the public usually does not have direct contact with = animals=20 during birthing, newborns and their dams are frequently available = for=20 petting afterwards. Q fever (Coxiella burnetii), = leptospirosis,=20 listeriosis, brucellosis, and chlamydiosis are serious zoonoses = that can=20 be acquired through contact with reproductive materials = (100).

Coxiella burnetii is a rickettsial organism that most = frequently=20 infects cattle, sheep, and goats. The disease can cause abortion = in=20 animals, but more frequently the infection is asymptomatic. During = birthing, infected animals shed substantial numbers of organisms = that=20 might become aerosolized. Most persons exposed to C. = burnetii=20 develop an asymptomatic infection, but clinical illness can range = from an=20 acute influenza-like illness to life-threatening endocarditis. A Q = fever=20 outbreak involving 95 confirmed patients and 41 hospitalizations = was=20 linked to goats and sheep giving birth at petting zoos in indoor = shopping=20 malls (101). Indoor-birthing exhibits might pose an = increased risk=20 for Q fever transmission attributed to inadequate ventilation. =

Chlamydophila psittaci infections cause respiratory = disease=20 (commonly called psittacosis) and are usually acquired from = psittacine=20 birds (102). For example, an outbreak of C. psittaci = pneumonia occurred among the staff at the Copenhagen, Zoological = Garden=20 (103). On rare occasions, chlamydial infections acquired = from=20 sheep, goats, and birds result in reproductive problems in humans=20 (102,104,105).=20

Recommendations

Guidelines from multiple organizations contributed to the=20 recommendations in this report (106--108). No federal laws = in the=20 United States address the risk for transmission of pathogens at = venues=20 where the public has contact with animals. Certain states have = specific=20 legislation for venues where animals are present in public = settings=20 (59,61,109--111). In 2005, after a state fair outbreak, = North=20 Carolina passed a law requiring agricultural fairs to obtain a = permit from=20 the Department of Agriculture for all animal exhibits open to the = public=20 (http://www.ncleg.net/Sessions/2005/Bills/Senate/html/S268v4.html).=20

Certain federal agencies and associations in the United States = have=20 developed standards, recommendations, and guidelines for venues = where=20 animals are present in public settings. The Association of Zoos = and=20 Aquariums has accreditation standards for reducing risk for animal = contact=20 with the public in zoologic parks (112). In accordance with = the=20 Animal Welfare Act, USDA licenses and inspects certain animal = exhibits for=20 humane treatment of animals; however, the act is not intended for = human=20 health protection. In 2001, CDC issued guidelines to reduce the = risk for=20 infection with enteric pathogens from farm visits (61). CDC = also=20 has issued recommendations for preventing transmission of=20 Salmonella from reptiles to humans (113). The = Association=20 for Professionals in Infection Control and Epidemiology (APIC) = developed=20 guidelines to address risks associated with the use of service = animals in=20 health-care settings (2).=20

Recommendations for Local, State, and Federal Agencies =

Communication and cooperation among human and animal health = agencies=20 should be enhanced and include cooperative extension offices. = Additional=20 research should be conducted into the risk factors and effective=20 prevention and control methods for health issues associated with = animal=20 contact. To improve use of these recommendations, agencies should: =

  • Disseminate this report to venue operators. Most states do = not have=20 a complete list of animal contact venues (59). States = should=20 strive to develop a complete list to facilitate dissemination of = recommendations.=20
  • Disseminate educational and training materials to venue = operators=20 and other interested persons. Material formats could include = PowerPoint=20 slide presentations, videos, and written guidelines=20 (109,110,114).=20
  • Encourage or require oversight to ensure compliance with=20 recommendations at animal contact venues.

To evaluate and improve these recommendations, surveillance for = health=20 issues associated with animal contact should be enhanced. Agencies = should:=20

  • Conduct thorough epidemiologic investigations of outbreaks.=20
  • Include questions about exposure to animals and their = environment on=20 disease report forms and outbreak investigation questionnaires.=20
  • Follow appropriate protocols for sampling of humans, = animals, and=20 the environment and for testing and subtyping of isolates.=20
  • Report outbreaks to state health departments and CDC. =

Recommendations for Education

Education is essential to reduce risks associated with animal = contact=20 in public settings. Experience from outbreaks suggests that = visitors=20 knowledgeable about potential risks are less likely to become ill=20 (12). Even in well-designed venues with operators who are = aware of=20 the risks for disease, outbreaks can occur when visitors do not = understand=20 and apply disease-prevention recommendations.

Venue operators should:

  • Know the risks for disease and injury associated with = animals and be=20 able to explain risk-reduction measures to staff and visitors.=20
  • Be familiar with and implement the recommendations contained = in this=20 report.=20
  • Consult with state and local agencies and county extension = agents on=20 implementation of the recommendations.=20
  • Develop or obtain training and education materials and train = staff.=20
  • Assure that visitors receive educational messages before = they enter=20 the exhibit, including information that animals can cause = injuries or=20 carry organisms that can cause serious illness (Appendix=20 A and B).=20
  • Provide information in a simple and easy-to-understand = format that=20 is age- and language-appropriate.=20
  • Provide information in multiple formats (e.g., signs, = stickers,=20 handouts, and verbal information).=20
  • Provide information to persons arranging school field trips = or=20 classroom exhibits so they can educate participants before the = visit.=20
     

Venue staff should:

  • Know the risks for disease and injury associated with = animals and be=20 able to explain risk-reduction recommendations to visitors.=20
  • Assure that visitors receive educational messages.=20
  • Encourage compliance by the public with risk-reduction=20 recommendations, especially compliance with hand-washing = procedures (Appendix=20 C) as the visitors exit animal areas.=20
  • Comply with local and state requirements for reporting = animal bites,=20 scratches, or other injuries.

Recommendations for Managing Public and Animal Contact =

The recommendations in this report were developed for settings = in which=20 direct animal contact is encouraged (e.g., petting zoos) and in = which=20 animal contact is possible (e.g., county fairs). They should be = tailored=20 to specific settings and incorporated into guidelines and = regulations=20 developed at the state or local level. The public's contact with = animals=20 should occur in settings where measures are in place to reduce the = potential for injuries or disease transmission and to increase the = probability that incidents or problems identified with animal = contact=20 settings will be reported, documented, and handled appropriately. =

The design of facilities and animal pens (Figure= )=20 should minimize the risk associated with animal contact, including = contact=20 with manure, and should encourage hand washing (Appendix=20 C). The design of facilities or contact settings might include = double=20 barriers to prevent contact with animals or contaminated surfaces = except=20 for specified interaction areas. Temporary exhibits should be = carefully=20 planned, designed, and managed to avoid problems identified from = previous=20 outbreaks. Common problems include inadequate barriers, floor = surfaces=20 that are difficult to keep clean, insufficient plumbing, and = inadequate=20 hand-washing facilities (12,17,34,35). Specific guidelines = might be=20 necessary for certain settings (i.e., schools [Appendix=20 D]).

Recommendations for cleaning procedures also should be tailored = to the=20 specific situation. All surfaces should be cleaned thoroughly to = remove=20 organic matter before disinfection. A 1:32 dilution of household = bleach=20 (e.g., half a cup of bleach per gallon of water) is needed for = basic=20 disinfection. Quaternary ammonium compounds (e.g., = Roccal=AE or=20 Zephiran=AE) also can be used per the manufacturer = label. For=20 disinfection when a particular organism has been identified, = additional=20 guidance is available at http://www.cfsph.iastate.edu/BRM/resources/disinfecta= nts/Disinfection101Feb2005.pdf.=20 All compounds require a contact time of >10 minutes. =

The venue should be divided into three types of areas: = nonanimal areas=20 (areas in which animals are not permitted, with the exception of = service=20 animals), transition areas (located at both entrances and exits to = animal=20 areas), and animal areas (where animal contact is possible or = encouraged)=20 (Figure= ).=20

Nonanimal Areas

Nonanimal areas are those in which animals are not permitted. =

  • Do not permit animals, except service animals, in nonanimal = areas.=20
  • Prepare, serve, and consume food and beverages only in = nonanimal=20 areas.=20
  • Provide hand-washing facilities and display hand-washing = signs where=20 food or beverages are served (Appendix=20 C).

Transition Areas Between Nonanimal and Animal Areas

Establishing transition areas through which visitors pass when = entering=20 and exiting animal areas is critical. One-way visitor flow is = preferred=20 with separate entrance and exit points. The transition areas = should be=20 designated as clearly as possible, even if they must be conceptual = rather=20 than physical (Figure= ).=20

Entrance transition areas should be designed to facilitate = education.=20

  • Post signs or otherwise notify visitors that they are = entering an=20 animal area.=20
  • Instruct visitors not to eat, drink, smoke, place their = hands in=20 their mouth, or use bottles or pacifiers while in the animal = area.=20
  • Exclude strollers, food, and beverages (establish storage or = holding=20 areas for these items).=20
  • Control visitor traffic to avoid overcrowding.

Exit transition areas should be designed to facilitate hand = washing.=20

  • Post signs or otherwise instruct visitors to wash their = hands.=20
  • Provide accessible hand-washing stations for all visitors, = including=20 children and persons with disabilities (Figure= ).=20
  • Position venue staff near exits to encourage compliance with = hand=20 washing.

Animal Areas

  • Provide adequate ventilation for both animals = (115)=20 and humans.=20
  • Exclude food and beverages. Animal feed and water should not = be=20 accessible to the public.=20
  • Exclude toys, pacifiers, spill-proof cups, baby bottles, and = strollers.=20
  • Prohibit smoking.=20
  • Promptly remove manure and soiled animal bedding from animal = areas.=20
  • Store animal waste and specific tools for waste removal = (e.g.,=20 shovels and pitchforks) in designated areas restricted from = public=20 access.=20
  • Avoid transporting manure and soiled bedding through = nonanimal areas=20 or transition areas. If this is unavoidable, take precautions to = prevent=20 spillage.=20
  • Where feasible, disinfect animal areas (e.g., flooring and = railings)=20 at least once daily.=20
  • Supervise children closely to discourage hand-to-mouth = activities=20 (e.g., thumb-sucking), contact with manure, and contact with = soiled=20 bedding. If hands become soiled, supervise hand washing.=20
  • Assign trained staff to encourage appropriate human-animal=20 interactions, to identify and remove potential risks for patrons = (e.g.,=20 by promptly cleaning up wastes), and to process reports of = injuries and=20 exposures.=20
  • Allow feeding only when contact with animals is controlled = (e.g.,=20 with barriers).=20
  • Do not provide animal feed in containers that can be eaten = by=20 persons (e.g., ice cream cones) to prevent children from eating = food=20 that has come into contact with animals.=20
  • Use animals or animal products (e.g., animal pelts, animal = waste,=20 and owl pellets) (65) for educational purposes only in = designated=20 animal areas (Figure= ).=20 Animals and animal products should not be brought into school = cafeterias=20 and other food-consumption areas.=20
  • Do not use animal areas for public (nonanimal) activities. = Zoonotic=20 pathogens can contaminate the environment for substantial = periods of=20 time (38). If animal areas must be used for public events = (e.g.,=20 weddings and dances), these areas should be cleaned and = disinfected,=20 particularly if food and beverages are served. Materials with = smooth,=20 impervious surfaces (e.g., steel, plastic, and sealed concrete) = are=20 easier to clean than other materials (e.g., wood or dirt = floors). Remove=20 organic material (e.g., bedding, feed, and manure) before using=20 disinfectants.=20
  • For animals in school classrooms, specific areas must be = designated=20 for animal contact (Appendix=20 D). Designated animal areas must be thoroughly cleaned after = use.=20 Parents should be informed of the benefits and potential risks=20 associated with animals in school classrooms.

Animal Care and Management

The risk for disease or injuries from animal contacts can be = reduced by=20 carefully managing the specific animals used for such contacts. = These=20 recommendations should be considered for management of animals in = contact=20 with the public.

  • Animal care: Monitor animals daily for signs of = illness, and=20 ensure that animals receive appropriate veterinary care. Ill = animals,=20 animals known to be infected with a pathogen, and animals from = herds=20 with a recent history of abortion or diarrhea should not be = exhibited.=20 Animals should be housed to minimize stress and overcrowding, = which can=20 increase shedding of pathogens.=20
  • Veterinary care: Retain and use the services of a = licensed=20 veterinarian. Vaccination, preventive care, and parasite control = appropriate for the species should be provided. Certificates of=20 veterinary inspection from an accredited veterinarian should be=20 up-to-date according to local or state requirements for animals = in=20 public settings. A herd or flock inspection is a critical = component of=20 the health certificate process. Routine screening for diseases = is not=20 recommended, except for TB in elephants (97-99) = and=20 primates, and for Q fever in ruminants in birthing exhibits=20 (116,117).=20
  • Rabies: All animals should be housed to reduce = potential=20 exposures from wild animal rabies reservoirs. Mammals should = also be=20 up-to-date on their rabies vaccinations (118). These = steps are=20 particularly critical in areas where rabies is endemic and in = venues=20 where animal contact is encouraged (e.g., petting zoos). Because = of the=20 extended incubation period for rabies, unvaccinated mammals = should be=20 vaccinated at least 1 month before they have contact with the = public. If=20 no licensed rabies vaccine exists for a particular species used = in a=20 setting where public contact occurs (e.g., goats, swine, llamas, = and=20 camels), consultation with a veterinarian is recommended = regarding the=20 off-label use of rabies vaccine. Use of off-label vaccine cannot = provide=20 the same level of assurance as vaccines labeled for use in = particular=20 species; however, off-label use of vaccine might provide = protection for=20 certain animals and thus decrease the probability of rabies=20 transmission. Vaccinating slaughter-class animals before = displaying them=20 at fairs might not be feasible because of the vaccine withdrawal = period=20 that occurs as a result of antibiotics used as preservatives in = certain=20 vaccines. Mammals that are too young to be vaccinated should be = used=20 only if additional restrictive measures are available to reduce = risks.=20 These measures can include using only animals that were born to=20 vaccinated mothers and housed to avoid rabies exposure.=20
  • Dangerous animals: Because of their strength,=20 unpredictability, venom, or the pathogens that they might carry, = prohibit certain domestic, exotic, or wild animals in exhibit = settings=20 where a reasonable possibility of animal contact exists. Species = of=20 primary concern include nonhuman primates (e.g., monkeys and = apes) and=20 certain carnivores (e.g., lions, tigers, ocelots, = wolves/wolf-hybrids,=20 and bears). In addition, rabies-reservoir species (e.g., bats, = raccoons,=20 skunks, foxes, and coyotes) should not be used for direct = contact.=20
  • Animal births: Ensure that the public has no contact = with=20 animal birthing by-products. In live-birth exhibits, the = environment=20 should be thoroughly cleaned after each birth, and all waste = products=20 should be properly discarded. Holding such events outside is = preferable.=20 If held indoors, ventilation should be maximized.

Additional Recommendations

  • Populations at high risk: Children aged <5 years = are at=20 particularly high risk for serious infections. Other groups at = increased=20 risk include persons with waning immunity (e.g., older adults) = and=20 persons who are mentally impaired, pregnant, or = immunocompromised (e.g.,=20 persons with human immunodeficiency virus/acquired = immunodeficiency=20 syndrome, without a functioning spleen, or on immunosuppressive=20 therapy). Persons at high risk should take precautions at any = animal=20 exhibit. In addition to thorough and frequent hand washing, = heightened=20 precautions could include avoiding contact with animals and = their=20 environment (e.g., pens, bedding, and manure). Animals of = particular=20 concern for transmitting enteric diseases include young = ruminants, young=20 poultry, reptiles, amphibians, and ill animals.=20
  • Consumption of unpasteurized products: Prohibit the=20 consumption of unpasteurized dairy products (e.g., milk, cheese, = and=20 yogurt) and unpasteurized apple cider or juices.=20
  • Drinking water: Local public health authorities = should=20 inspect drinking water systems before use. Only potable water = should be=20 used for consumption by animals and humans. Back-flow prevention = devices=20 should be installed between outlets in livestock areas and water = lines=20 supplying other uses on the grounds. If the water supply is from = a well,=20 adequate distance should be maintained from possible sources of=20 contamination (e.g., animal-holding areas and manure piles). = Maps of the=20 water distribution system should be available for use in = identifying=20 potential or actual problems. The use of outdoor hoses should be = minimized, and hoses should not be left on the ground. Hoses = that are=20 accessible to the public should be labeled "water not for human=20 consumption." Operators and managers of these settings in which = treated=20 municipal water is not available should consider alternative = methods for=20 disinfection of their water supply or should consider methods to = disinfect their water supply.

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  117. Ross C, Morrow PS. Q fever: an issue in occupational health = &=20 safety? An overview of the methods of control and the effects of = Coxiella burnetii on the human host. J R Soc Health=20 1994;114:151--2.=20
  118. National Association of State Public Health Veterinarians.=20 Compendium of animal rabies prevention and control, 2006. = Available at=20 http:// www.nasphv.org/83416/inde= x.html.=20

    National Association of State Public Health=20 Veterinarians, Inc., Committee

    Co-Chairpersons: = Jeffrey B.=20 Bender, DVM, MS, DACVPM, University of Minnesota, St. Paul, MN; = Carina=20 Blackmore, DVM, PhD, Florida Department of Health, Tallahassee, = FL.=20

    Members: John R. = Dunn, DVM,=20 PhD, Tennessee Department of Health, Nashville, TN; Kirk E. Smith, = DVM,=20 MS, PhD, Minnesota Department of Health, St. Paul, MN; James H. = Wright,=20 DVM, MPVM, DACVPM, Texas Department of State Health Services, = Tyler, TX.=20

    Consultants to the Committee:=20 Casey Barton Behravesh, DVM, DrPH, CDC, Atlanta, GA; Sue K. = Billings, DVM,=20 MSPH, National Assembly of State Animal Health Officials; James E. = Keen,=20 DVM, PhD, U.S. Department of Agriculture, Washington, D.C.; John = P.=20 Huntley, DVM, MPH, Council on Public Health and Regulatory = Veterinary=20 Medicine, Schaumburg, IL; Timothy F. Jones, MD, Council of State = and=20 Territorial Epidemiologists, Atlanta, GA; Thomas P. Meehan, DVM,=20 Association of Zoos and Aquariums, Silver Spring, MD.


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