CDC ZOHU Call October 2, 2019
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CDC ZOHU Call October 2, 2019


>>Welcome and thank
you for standing by. All participants are
in a listen-only mode until the question and answer
session of today’s conference. At that time, you
may press star 1 on your phone to ask a question. I would now like to turn the
conference over to Laura Murell. You may begin.>>Thank you, Shawna. Good afternoon everyone. My name is Laura Murell and I
work in the One Health Office of the National Center
for Emerging and Zoonotic Infectious
Diseases, at the Centers for Disease Control
and Prevention. On behalf of the
One Health Office, I’m pleased to welcome you
to the monthly Zoonoses and One Health Updates
Call on October 2nd, 2019. ZOHU Call content is directed to
epidemiologists, laboratorians, scientists, physicians,
nurses, veterinarians, animal health officials, and other public health
professionals at the federal, state, and local levels. Please be aware that CDC has no
control over who participates on this conference call. Therefore, please
exercise discretion on sensitive content material as confidentiality during these
calls cannot be guaranteed. Today’s call is being recorded, so if you have any
objections, you may disconnect. Detailed instructions for obtaining free continuing
education are available on our website and will be
given at the end of this call. These presentations will
not include any discussion of the unlabeled use of
a product or a product under investigational use. The planning committee
reviewed content to ensure there is no bias. CDC did not accept commercial
support for this activity. CDC, our planners,
presenters, and their spouses or partners disclose they
have no financial interests or other relationships
with the manufacturers of commercial products, suppliers of commercial
services, or commercial supporters. Before we begin today’s
presentation, Dr. Casey Barton Behravesh, Director of CDCs One Health
Office will share some news and updates. Dr. Barton Behravesh.>>Thanks, Laura. Hello everyone and
thanks for joining us. For today’s ZOHU Call,
and welcome to all of our new call participants. The ZOHU Call audience
continues to grow with subscribers representing
professionals from government, non-governmental
organizations, industry, and academia, including
students. We appreciate your
help spreading the word about the ZOHU Call. Please continue to share
the ZOHU Call website link with your colleagues, from
human, animal, environment, and other relevant sectors. The site includes links
to past call recordings, information on free continuing
education for a variety of professionals, and
a link to subscribe to the ZOHU Call email list. To begin today’s call, I’d
like to share a few highlights from the One Health News
from CDC, which are included in today’s ZOHU Call newsletter. First, CDC has released the
annual report on Surveillance for Foodborne Disease Outbreaks
in the United States for 2017. Some upcoming observances
include the Infectious Diseases or ID Week annual meeting,
which started today in D.C. And the Rabies in the
Americas Conference, which will take place
in October 27th through November
1st in Kansas City. Also, One Health Day is
coming up on November 3rd. So, please join CDC and
partners around the world in celebrating One Health Day. There are three new One Health
related expert commentaries from CDC that are now
available on Medscape’s website. We’ve shared links to
recent publications on several topics including,
salmonella infections linked to whole roasted pigs,
and a multistate outbreak of E. coli infections
linked to soy nut butter. Highlighted MMWR topics
include, surveillance for coccidioidomycosis
in the United States, the zoonotic mycobacterium
bovis disease in deer hunters in Michigan, and hantavirus
pulmonary syndrome in Colorado. Regarding outbreaks,
the outbreak of multidrug resistant
salmonella infections linked to contact with pig ear dog
treats has been updated. We’ll learn more about this
outbreak during today’s third presentation. Final updates to the outbreak
of salmonella infections linked to papayas, and the
outbreak of E. coli linked to ground bison has been posted. And the selected list of
ongoing and past U.S. outbreaks of zoonotic diseases as well
as information on staying safe and healthy around animals is
available on CDC’s healthy pets, healthy people website. As always, the complete
CDC current outbreak lists, including foodborne outbreaks is
available at cdc.gov/outbreaks. As always, if you’d like
for us to share news from your organization
or if you want to suggest presentation topics
or volunteer to present, please reach out to us
at [email protected] Again, thank you for
supporting the ZOHU Call and for joining us today. I’ll now turn the call
back over to Laura.>>Thank you. Today’s presentations
will address one or more of the following objectives. Describe two key points
from each presentation. Describe how a multi-sectorial
One Health approach can be applied to the presentation
topics. Identify an implication for
animal and human health. Identify a One Health approach
strategy for prevention, detection, or response
to public health threats. And identify two new
resources from CDC partners. Questions for all
presenters will be taken at the end of the call. Call 1 800 593-8936 and enter
participant pass code 9611836. Press star one and give
the operator your name and affiliation. Please name the presenter
or topic at the beginning
of each question. You’ll find resources and
links for all presentations on our website and in
today’s ZOHU Call email. Our first presentation, Evaluation of aste
anesthetic gas exposure at a veterinary hospital,
will be given by Jessica F. Li
and Dr. Sophia Chiu. Please begin when you’re ready.>>Good afternoon everyone. My name is Jessica Li, and my
co-presenter is Dr. Sophia Chiu. We work for the Health Hazard
Evaluation or HHE program within the, NIOSH the
National Institute for Occupational Safety
and Health or NIOSH. For those who aren’t
familiar, NIOSH is an institute within the CDC that focuses
on conducting research in occupational health
and safety. NIOSH’s mission is to develop
new knowledge in the field of occupational safety
and health and to transfer that knowledge into practice. The HHE program is a
program within NIOSH that conducts workplace
epidemiologic and industrial hygiene
investigations at the request of employees, employers,
or unions. Our objective is to determine if there are harmful workplace
exposures or conditions that could be causing
injuries or illnesses. One of the hallmarks
of our program is that we involve all
parties at every step, and our service is
provided at no cost. Next, we’ll dive
into the HHE request. In March of 2017, the Health
Hazard Evaluation program received a request from
three anonymous employees at a veterinary hospital. They were concerned about
waste anesthetic gas — or I’m going to refer to
it as WAG from now on — exposure, and reproductive
health effects, including miscarriage
and infertility. So, WAG is defined as
anesthetic gas that leaks into the air during
delivery of anesthesia. At this hospital, isoflurane
was the primary inhalational anesthetic used for most
procedures including surgeries. In February of 2017, a
veterinarian technician in the surgery department
discovered that both active
scavenging systems, which are engineering
controls for WAG, in the two operating rooms
were incorrectly connected. The employees were concerned about potential WAG
exposures during this incorrect connection. The veterinary hospital did
correct these connections immediately upon discovery. So, isoflurane is a general
inhalational anesthetic approved by the FDA in 1979. An Occupational Exposure Limit or OEL is a maximum
concentration limit that a worker can be exposed
to for a particular substance. OELs are set by various
governmental agencies and related organizations. Ideally, using health data to prevent occupational
illness and injury. The Occupational Safety and
Health Administration or OSHA, has not set an OEL
specific to isoflurane. NIOSH has not set an OEL
specific to isoflurane, but instead uses an OEL that is
designated for exposure to WAG, of two parts per million
for a 60-minute time period. It is important to note that this OEL was
determined using health data on halogenated anesthetic agents that are considered more
harmful than isoflurane is. Other countries and
agencies have set isoflurane specific OELs. And just to briefly go
over, the main controls for WAG are scavenging
systems, which include active and passive scavenging systems. Active scavenging systems, using
a source of negative pressure, are the preferred
method when possible. For this evaluation,
we spent two days in the veterinary hospital. Our objectives were to determine
if the scavenging systems and building ventilation system
where effectively removing WAG to assess employee
exposure to isoflurane, and to determine the
prevalence of employee symptoms and learn more about
reproductive health concerns and outcomes among employees. In the interest of time,
we will be focusing on the last two objectives
for this presentation. In order to meet our objectives, we evaluated employee
isoflurane exposure before, during, and after surgery. And measured area concentrations of isoflurane throughout
the vet hospital, using the following industrial
hygiene sampling methods and equipment. We also interviewed employees
about their work and health, focusing on reproductive health. We ended up collecting personal
air samples for isoflurane on veterinary technicians,
veterinary surgeons, and a veterinary surgeon intern. In total, we collected
10 full-shift samples, most of which were under
the limit of detection. One veterinary technician did
have a full-shift exposure that was measurable
at 0.076 PPM. We also ended up collecting 36 to 60-minute samples
for isoflurane. These are the results of
our 60-minute samples. All but one were under
the NIOSH OEL of two PPM. The overexposure was collected on a veterinary technician
while they recovered a dog after surgery. We observed that factors
such as body position, length of recovery and animal
size could have affected the amount of exposure
that that employee had. We also collected full-shift
area air samples for isoflurane in the following areas,
and all samples came back under the limit of detection. And with that, I will turn
it over to Dr. Sophia Chiu to discuss the medical results.>>Thank you, Jessica. So, let’s switch gears and
talk about the interviews. There were 36 employees
working during the site visit, and all of them participated
in the interviews. Median age at the time of the site visit was
32 and a half years. And the median job tenure was
almost two years at 23 months. Seventy eight percent of all
interviewed employees were women of childbearing age, defined
as 15 to 44 years old. Twenty two percent of
employees had concerns about reproductive
health related to work. All of these employees with concerns were women
of reproductive age. Nine employees reported 21
pregnancies while working at this veterinary
hospital represented as circles on this slide. Of these, seven employees
reported 12 miscarriages while working at this veterinary
hospital. All 12 occurred during
the first trimester and were considered
early miscarriages, i.e., during the first 13 weeks. Two employees had three
miscarriages each. One employee had
two miscarriages, and four employees had
one miscarriage each. Six of the seven employees
reported ever working in the operating room. Five employees were aged 40
or more years at the time of the miscarriage and that was
the most common age category. In summary, we did not have
enough information to conclude that there was a substantially
higher rate of miscarriages at this veterinary hospital
after taking into accounts, maternal age, reproductive
history, and other non-occupational
risk factors. Miscarriages in general
are common with 10 to 25% of all clinically
recognized pregnancies ending in miscarriage. In conclusion, we found
one isoflurane overexposure in a veterinary technician
recovering an animal. We also found 12 miscarriages
among 21 known pregnancies, but that might not be
excessive after taking into account maternal
age, reproductive history, and other risk factors. Miscarriages while employed at this veterinary
hospital cannot be linked to waste anesthetic
gas exposures. We made recommendations to
reduce employee exposures to waste anesthetic gases. Recommended steps included, replacing passive
scavenging systems with active scavenging systems. Consulting with a
ventilation engineer to ensure that the hospital’s ventilation
system prevents exposure to waste anesthetic gases. Properly maintaining
existing anesthesia machines and scavenging systems
to minimize leaks. Avoiding being near an animal’s
head before and during surgery, and while recovering an
animal after surgery. And educating employees, at
least annually, on procedures for reducing exposures to
waste anesthetic gases. Thank you to everyone
who helped us with this evaluation
and presentation. Please let us know if
you have any questions and you can find a report
at the link on the screen. Thank you.>>Thank you. Our next presentation. Antimicrobial use
and Stewardship on Cattle Feedlot,
and Swine Operations. An update on the
NAHMS 2017 survey, is by Dr. Chelsey Shively. Please begin when you’re ready.>>Thank you. Good afternoon everyone. My name is Chelsey Shively and I am a Veterinary
Epidemiologist working on antimicrobial
use and resistance with the National Animal Health
Monitoring System or NAHMS within USDA APHIS
Veterinary Services. Today, I’m going to
share some of the results from the 2017 NAHMS
antimicrobial use and stewardship studies
that we conducted in swine and feedlot cattle. As stated by my Ph.D.
advisor, Dr. Temple Grandin, you manage what you measure,
which is where NAHMS come in. So why should we measure
antimicrobial use? So there’s a few
different reasons. And first of all, for
animal health reasons. Antimicrobials are powerful
tools that can be used to combat infectious diseases
in our animal population, which can be important for improving animal
health and welfare. Secondly, antimicrobial
resistance concern. If animal pathogens
develop resistance, the antimicrobials
will stop working and animals will no longer
respond to treatment, which can negatively impact
their health and welfare. And finally, we are
concerned about public health. So antimicrobial
resistance pathogens in livestock may be able
to pass their resistance onto human pathogens. This could result in antimicrobial drugs
not being effective for treating human
infections as well. NAHMS is here to help tell a
story about antimicrobial use in livestock as well
as reporting on trends in use overtime. In 2015, the U.S. government
published the first National Action Plan for Combating
Antibiotic-Resistant Bacteria, providing a roadmap
for federal agencies to summarize their
activities on this issue. The USDA then developed the
USDA Antimicrobial Resistance Action Plan. USDA possesses in-depth
knowledge of the management, practices, and technologies
associated with animal health, welfare, productivity,
and food safety. As such, USDA is uniquely
positioned to contribute to the body of scientific
knowledge about antimicrobial resistance
and specifically about the role of antimicrobial
use in livestock. Currently, the U.S. government
is developing the next National Action Plan for years
2020 through 2025. And USDA has been actively
involved in this development. The USDA initiated the National
Animal Health Monitoring System or NAHMS in 1983 to collect,
analyze, and disseminate data on animal health
management and productivity across the United States. NAHMS conducts national
studies that are designed to meet the information needs
of the industries associated with these commodities,
as identified by people within those industries
and other stakeholders. So, why NAHMS for
antimicrobial use information? NAHMS has over 30 years
of sharing information from animal agriculture
through our national studies, including historic information about antimicrobial
use and resistance. NAHMS has decades of
being a trusted partner with the Livestock
Commodity Group. Continued responsible use of antimicrobials will help
preserve their effectiveness well into the future for
both human and animal use. The hallmarks of
a NAHMS study are that our studies are
national in scope. The unique design of
NAHMS studies allows us to provide national estimates. Our studies are collaborative. We work with industry
representatives, producers, veterinarians and
other stakeholders to develop our studies. We also work with the USDA
National Agricultural Statistics Service or NASS, for
most of our studies. NAHMS studies are voluntary. We do not have regulatory
authorities, therefore producer participation
is entirely voluntary. Our studies protect
producer’s privacy and this is very important to
ensure that producers continue to participate in our studies. Our studies are all
scientifically based and statistically valid. This is the core value of NAHMS. We have other recent
and future NAHMS studies that have collected information
on antimicrobial use. And in some cases, we have
collected biological samples to test for bacterial prevalence and antimicrobial
susceptibility. These include the Dairy 2014
Study where we have information on antimicrobial use in
all ages of cattle as well as biological samples, testing
for antimicrobial resistance. The Equine 2015 Study and
the Cow-Calf 2017 Study. We are currently conducting
our Goat 2019 Study, and we’ll be collecting
information on antimicrobial use. In 2017, NAHMS conducted
the first focus studies on antimicrobial use in
food producing animals, including swine and cattle
on feed, with a focus on antimicrobial use
in feed and water. The NAHMS approach is to
develop national estimates of overall antimicrobial
use and not to provide detailed
antimicrobial use metrics or quantified numbers. The study objectives include
describing antimicrobial use practices in feed and water. Estimating the percentage
of operations administering and the percentage of
animals receiving specific antimicrobials, by
reasons for use. Providing baseline data on
antimicrobial use practices in 2016, in order to
evaluate trends over time. And describing antimicrobial
use practices on these production sites. We collected antimicrobial
use and stewardship practices in 2016 in order to
capture information about practices before the FDA
guidance for industry number 209 and 213 were fully
implemented in January of 2017. And these studies were
designed to be repeated over time to evaluate trends. These studies were
conducted under CIPSEA or the Confidential
Information Protection and Statistical Efficiency Act. CIPSEA studies provide
the strongest protection for data collected by
the federal government for statistical purposes, and it protects the
data from FOIA requests. However, CIPSEA requires
additional burden on the people involved with
collecting the information. And it makes the information
collection a one-way street so we cannot provide individual
results back to producers. For the Swine 2017
Study, the overall — the states that were sampled
represented 92% of market pigs and 94% of sites with a
thousand or more pigs. According to the 2012 Ag. census data. We had a total of 13
states that participated and we sampled nursery,
grower/finisher and wean-to-finish operations. And for the Swine Study, we focused on a six-month data
collection period of July 1st through December 31st, 2016. The cattle on feed study,
we had a total of 22 states that participated with
50 or more had capacity of cattle on their feedlot. And the data collection
period was January 1st through December 31st, 2016. Overall, these states
represented 94% of cattle on feed and 93% of feedlots,
according to 2012 Ag. census data. This study was conducted
similarly to most of our NAHMS studies. We started with our study design
phase where we received input from industry representatives
and other stakeholders. We then worked with NASS to
select the sample of operations to participate in
each of the studies, based on their list frame. And the selection was stratified
by state and size of operation. NASS then had the initial
consent which conduct — was conducted between
May and July of 2017. They also received
consent to be able to share the contact information
with veterinary services. The veterinary services
questionnaire was administered from July through
September of 2017. And this was where we collected
the information from producers. Once we collected all of
the questionnaire data, the questionnaires were
mailed to Fort Collins, Colorado for data entry, followed by an in-depth
data validation process, as well as data analysis. And finally, the
reporting phase. Our reports were published on the NAHMS website
in May of 2019. Our survey responses
for these studies. Overall, we had a hundred
and ninety-six swine sites and 378 feedlots
that participated in providing complete
information for the survey. I will note that the Swine Study
was updated in August of 2019 because we found that three of
the sites originally included, did not meet the
eligibility criteria. Now, I would like to share
some of the selected results from the Swine 2017 survey. Overall, 98% of swine sites used
any antimicrobials from July 1st through December 31st, 2016. Which includes all
types of antimicrobials, including ionophores
and multiple routes of administration, including
water, feed, and injection. So, orientation to this graph. The X-axis shows the
route of administration, and the Y-axis shows
the percent of sites. Overall, antimicrobial
use in swine by route of administration. Most sites were using some
antimicrobials with 98% of all sites using
any antimicrobials. For more detailed information
about this graph by size of sites, please see the report. This graph shows antimicrobial
use in swine by age and by route of administration. Information about injectable
antimicrobials was not captured by age. Regardless of age, more
sites used antimicrobials in feeds than water. For water use, all age pigs —
the primary reason for use was for respiratory disease
and diarrhea. For in-feed use of
antimicrobials, the primary reason for use
in nursery age pigs was for respiratory disease
and diarrhea, and for grower/finisher
age pigs, it was for respiratory
disease and growth promotion. Overall use of medically
important antimicrobials in swine by size of
site and by the route of administration is shown here. Overall, 76% of sites
used medically important antimicrobials in water, 89% in
feed and 94% in water or feed. And these medically important
antimicrobials were defined by the FDA guidance for
industry number 152. This graph here shows
the percent of sites that ever recorded information about the date antimicrobial
use began. The date the antimicrobial
use ended. What antimicrobials were used, and the treatment
withdrawal period. Overall, most sites recorded
the date antimicrobial use began and the antimicrobial
that was used. Regarding veterinary use, almost all sites
had a veterinary client-patient relationship. And about two-thirds
of sites were visited by a veterinarian during
the six-month period for data collection. Moving on to selected
feedlot results. Overall, 88% of feedlots used
any antimicrobials in 2016, which again, included all types of antimicrobials including
ionophores and multiple routes of administration, including
feed water and injectable. Here we see the antimicrobial
use in cattle by route of administration. Feed and inject — individual
injections were the route used by the highest percentage
of feedlots. A total of 88% of feedlots
used any anti-microbials, and very few feedlots
administered antimicrobials in water. Here we see the antimicrobial
use in feed by placement weight and this information was
only captured by feed use. About 70% of feedlots
used antimicrobials in feeds regardless
of placement weight. Here, we have antimicrobial
use in feed in cattle by medical importance as
determined by the FDA. The only non-medically
important antimicrobials used in feedlots where ionophores. And these were often
used in combination with another medically
important antimicrobial. All antimicrobials used in water
or by injection are considered to be medically important. This graph here shows
the information that was ever recorded. For use in feed and water, the
date antimicrobial use began, date antimicrobial use ended, and the antimicrobial
used was recorded by about 60% of feedlots. Also, antimicrobials were rarely
used in water on feedlots. Overall, 80% of feedlots used
the veterinarian in 2016. And all feedlots that did
not use a veterinarian said that they did not need one. Ninety-seven percent of
feedlots were familiar with the
veterinary-client-patient relationship in 2016. And 85% said that
they had a VCPR. We expect the percent of
feedlots with the VCPR to match the percent of feedlots
using antimicrobials in feed in next survey due to
changes in FDA policies. Overall, we encountered a
few challenges along the way with these studies. We had lower than
expected response rate, which required additional
exploration of potential bias
due to non-response. Ultimately, we determined that the results are nationally
representative, but we would like to see better
participation in future studies. We must balance between
reducing the burden and collecting information. But next to go around, we will
be adding additional questions related to animal health,
for future studies, in order to broaden the scope
and provide additional context about antimicrobial use. Finally, we recognize that antimicrobial use is a
sensitive topic for producers, and there’s nothing that
we can do about that. However, we would
like to continue to share the positive changes that industries have made
regarding antimicrobial use and stewardship. Our reports can be found
on the NAHMS website. However, it’s easiet just to
Google NAHMS and find them under the antimicrobial use
and stewardship section. And we will be repeating
this data collection in 2020. For the swine part,
it will be included in the larger NAHMS
Swine 2020 Study. And for feedlots, we will
have a health management on US feedlots 2020 study that
will be questionnaire based. That will — conducting these
surveys again will allow us to report on trends in
antimicrobial use over time. We are also developing
tableau dashboards to be able to better visualize the results of these studies beyond our
reports that we publish. These studies would not be
possible without a number of people, but I especially
want to thank the producers who participated in the surveys
and all of those who helped us with the development
and implementation. Thank you. And I’ll take any
questions at the end of this presentation
today, or I’m happy to answer questions via email.>>Thank you. Our final presentation, Outbreak of Multidrug Resistant
Salmonella Infections Linked to Pig Ear Dog Treats,
is by Dr. Megin Nichols and Dr. David Rotstein. Please begin when you’re ready.>>Good afternoon everyone. This is Megin Nichols
at the Centers for Disease Control
and Prevention. And I’ll be presenting
today with my colleague, David Rotstein, from the
Food and Drug Administration. So, to start, I’d like
to describe a little bit about the multistate
outbreak that occurred and it started back in May. So I’m part of a group
that does enteric zoonotic outbreak investigation. And a lot of our
work is coordination, working with stakeholders
and partners to investigate the outbreaks and
to provide some recommendations and potential prevention
messages. We collaborate very
closely with the Food and Drug Administration, the
U.S. Department of Agriculture, and many other public and animal
health organizations during these outbreaks. One of the pathogens
that seen most common in our outbreaks is salmonella. And today, we’re going
to talk about pig ears and that’s the treat that’s
most commonly provided to dogs and cats. So, I thought it
would be appropriate to discuss what salmonella
illness looks like in these species. So, salmonella, especially
in dogs and cats, can be symptomatic,
but not always. If symptoms occur — excuse me
— it’s usually asymptomatic, not always symptomatic. And when symptoms occur,
we can see enterocolitis, abdominal pain, or septicemia,
such as what’s referred to as song bird fever in cats. And there’s a paper that was
done that actually looked at salmonella isolation. And you can see that in animals
that have diarrhea and dogs that are healthy,
you see similar rates of salmonella shedding
and isolation. However, if you look at animals
such as shelter animals or dogs that are eating raw food diets, there you might see
increased shedding of salmonella in their stool. In previous years, we’ve investigated
quite a few outbreaks in both the United States and
Canada that have been linked to either pet foods
or pet treats. And I’ve listed some of
them here on the slide. Of note, you can see
that there is a report of a pig ear dog treat
outbreak back in 2001. And this includes also dry cat and dog foods over
multiple years. And I want to highlight
something that has been on
the FDA website. And so, this is actually
dating back to 2013, just to demonstrate that
salmonella has been found in pig ears before, and
it’s something that a lot of our agencies are
aware of and tracking. So, specific to this particular
outbreak of salmonella, we started to notice
in May of 2019 that we were seeing
human infections with salmonella 1,
4, 5, 12 I minus. And there were two particular
PFGE patterns that were noted. This was before our
full transition to whole genome sequencing
at CDC. And one of these patterns
was actually unique. We hadn’t seen it before in the database prior
to November, 2018. So, there was something a little
bit distinct about this strain. And we had, at that time,
25 cases from 10 states. When we looked at the double
genome sequences for the cases, there were about 15 sequences
available at that time and all were within zero to eight single nucleotide
polymorphisms, indicating that the strain of
salmonella shared a genetic — was genetically related. And we had these isolates that
went back to December of 2018, all the way through May. And what we started
to see emerging when ill people were
interviewed by states is that many people
reported contacts — contact with dogs and
contact with pet treats. So given this signal,
given the salmonella strain and what we’re starting
to see emerge, what we did was actually
supplemental questionnaire. So, for the initial 25 cases, our state partners
conducted these interviews and we asked questions
about contact with dogs and pet treats. And then we also asked questions
about pet food exposure, including raw pet food, just to make sure we weren’t
potentially missing something, with respect to illnesses
and exposures. And once we had collected
that data, we wanted to compare the data we
were receiving from ill people, with the data that was obtained
through our population survey. So, this is a survey
that is done here — coordinated here at
CDC, in conjunction with the Emerging
Infections Program. And what we saw from the data that had previously been
collected is that 61% of healthy people
reported contact with dogs when interviewed. And 16% of healthy people
reported handling dog treats such as pig ears. So, we wanted to
compare those numbers to what we were seeing
among our human illnesses. So, in this case,
we actually saw 89% of ill people reporting
dog contact. And this was a little — this
was done actually in August, to look at some of
the more recent cases. And 73% of cases reported
contact with pig ear dog treats or dogs that had been
fed pig ear dog treats. So, you can see, especially
if the general population or a population survey
indicates that 16% of people indicate
they’ve had contact with — healthy people indicate
they’ve had contact with pig ear dog treats. And 73% of our ill people
indicate they’ve had contact with these pet treats, that this
is certainly a significant type of exposure. So, the next step
after collecting a lot of the epidemiologic
data was that health and regulatory officials
in several states, and I’ve listed some
of them there, along with FDA collected pig
ears for product testing. Some of these pig ears came
from ill people’s home, retail locations, supplier
locations and distributors. And when testing was done,
there was salmonella identified in over 90 samples with many,
many different serotypes. And one thing that I do want
to also call attention to and thank you again to our
partners and helps who took some of these pictures while they
were out at the pet stores. But one of the things that was
interesting is we had products — and this is the picture
there on the lower right of the pig ear — that said it
was treated by irradiation and yet they were still testing
positive for salmonella. The other interesting thing
is that when we looked across the whole genome
sequencing data — and again this is back in
August — we had 92 isolates, 87 of those isolates
were from ill people, and five from pig ears. When we looked at that, we saw that 90 isolates had
predicted antibiotic resistance or decreased susceptibility
to at least one of the following antimicrobials. So, we were seeing multidrug
resistance in this outbreak. We were even detecting
genes, resistance genes, that hadn’t previously been seen
before in the United States. And we are finding
them in the pig ears and in the people who were sick. So as of August 22nd, 2019, you can see our outbreak epi
curve is here with the month across the X axis and the number
of ill people on the Y axis. And you can see that the
outbreak had likely started, maybe back in 2015, 2016,
at a very low level. And then, with what we did
with extra surveillance and case finding, we
really saw that uptick in late 2018 and 2019. So, to warn the public about
the potential risk to people and to their animals from these
contaminated pig ear dog treats, the CDC and FDA issued
an advisory not to buy or feed any pig ear dog
treats, including those that were already in the home. We also talked about what you
can do and steps you can take to prevent illness
when feeding your pet. And if you look at the
map of reported illnesses, we saw that there were cases
ranging from the West Coast, all the way to the East
Coast with the majority of cases being in the Midwest. Now, on the questionnaire
we administered. We also asked for information about how often people
washed their hands after handling pet foods
and additional treats. And what we found
is, of those — of 32 people who had a
questionnaire completed with this question, 69%
said they never, rarely, or sometimes washed their hands. So, this demonstrated to us that perhaps more hand
washing was needed after handling pet foods and
pet treats to prevent illness. So, in continuing to craft
our message, our goal here was to prevent additional illnesses
and provide advice to consumers. And we wanted it to be
specific, clear, and complete. So, we have a section
on that outbreak notice that includes advice to pet
owners and to retailers. And we have an infographic
that we thought — we’re big fans of this
infographic, it’s available. I included the link
below in case you would like to download
that and use it. But it does talk a little bit about the potential
contamination of pet food with germs. It covers both raw pet foods
and there’s a section on there that talks about hand hygiene. Thank you. And with that, I’ll turn it
over to my colleague, David.>>A good afternoon to
everyone, and thank you so much for this opportunity to
present our work that we did with FDA, the States, and CDC. So, Megin’s already
pointed this out, but from our investigation
partners working with CDC and — I’ve highlighted certain
states or specific states because of some of the sampling
works that they did that was so helpful from our side of
things, which is the regulatory. Here at FDA, we have our
partners that are involved in — including our communications
staff, our Veterinary Laboratory
Investigation and Response Network that for
some listeners may be familiar, some may be veterinary partners, but Vet-LIRN is established
by FDA. And we work with
veterinary colleges and state diagnostic labs. So, it really helps us with
the animal diagnostics, which is something that we don’t
do in FDA with our testing. So that’s really supportive
for our regulatory efforts. We have a division
of animal feeds, our post-market compliance feed
team, and the team that I am on, which is the Complaint Emergency
Recall and Reconditioning Team. So, it’s kind of a multi — multiple groups that
are involved in the scientific efforts,
the regulatory efforts, and basically any plans
that we have to follow up after the investigation
concludes. The work in this that I’m going
to talk about is our traceback, and our product testing. Dr. Nichols already pointed out about the 90 samples
that were collected. But with our product testing, we also had our FDA regulatory
samples that were collected. And this is any product
that is sealed in its original container. For us, we got some
product that was at distribution centers
but also retail. We also had states that had
done non-regulatory testing where they collected product,
for example, from bulk bin, which for us it’s —
from a regulatory stance, it’s difficult to
completely use for any sort of regulatory action
like recalls. And then we had states that
had done some regulatory work of collecting individually
wrapped or small bagged product. This included retail stores
that were brick and mortar as well as online as well. As far as the traceback, I
won’t show the entire traceback diagrams for all of this
because it’s quite extensive. And — but the basics of it that
you’re looking at is that we go, for example, from
a point of sale. Looking at receipts, invoices,
bills of lading, any information that provides to us where
that product originated. So, in other words, we’re going
backwards to find out basically where the source of
the product is from. And sometimes it’s
very clear cut. Sometimes, it’s a little
bit more complicated. Firms sometimes do not use the
same, for example, lot numbers, that may not be coming from — the supplier might have a lot
number, but by the time it gets to a point of sale, it has a
completely different lot number. Some lot number information
is not as clear cut. So that makes things
a little bit tricky. But this is just to give you an
example of using that trace back from three different human
cases, and going back to where their suppliers
are from, to either distribution
center or main source, getting all the way back
to the initial supplier. And in this case, for this
particular investigation, based on the human cases
that we had information from, we were able to determine there
were four foreign suppliers, one from Columbia, one from
Argentina, and two from Brazil, as well as a US manufacturer that were all the
sources of products. And so, this does not support
a point source, but does get into more of the overall
preventative controls or production methods
that are involved. As far as those samples, and
I’m not going to show all 90, but I just want to get into
our regulatory samples, just to show you just —
there’s a lot involved. The samples included
our samples from FDA, as well as state samples. And by using those positive
results, we’re able to key in on the manufacturing source,
all the isolates information with the whole genome sequence, which we do on every regulatory
sample that we get, whether it’s from us or from the state. We want to ensure that — and
to help support the efforts to looking at the outbreak. So that provided us
a lot of information for this particular
outbreak investigation. In addition to the human
cases and the samples that were collected
in support of that. Once we have recalls that occur, sometimes that had
happened before, but usually when we have
a recall, when we start to get the public — starts
to put things together with their own pet, and we receive approximately
14 complaints. With these complaints, two involved those
with human illness. We at CVM do not — will
not test any human samples. In those cases, we do reach
out to let the people know to make sure to contact
the doctor, or their state public
health department. As part of our actions when
we receive these complaints, we do a medical record
interview — review rather. We may be collecting fecals or
other samples, if there’s a — happens to be a death, we’ll
go ahead and do a necropsy with a full histopath. We will test products. That learning is not
necessarily regulatory. So, the labs that they use will
test open product that’s not just pig ears, but if
we’re looking at a cat food or a dog food or even
cattle feed, any of that. This gives us a signal
of what’s going on. But other subset of complaints, five we were able
to follow up on. The majority involved
bulk product exposures. So, the — they’re
purchased from bulk bin or a bulk order online. We had one product
that was bagged. As far as our results,
we did have cases where either the fecal or
the pig ear was positive and we did have one
product in which the fecal and the pig ear were positive. But we got different
salmonella from these. And — so, we still have some
additional work into this, but hopefully this
highlights the importance of that One Health approach,
because we’re able to look at the human side, the animal
side, and then the products. So, we’re getting
all this information to help support the
work that we’re doing. So, the outcome from
all of this — and there’s still
ongoing work with it. So, for example, we have
what’s called a post — kind of a post-response. And that’s where we get into
more of the long-term things like inspections, or
working with foreign firms, outreach through
our communication. Those are things that are
more of our long-term outcomes that we are working on. We are also working to make
sure that we communicate with industry over
what we’re finding, and also getting
industry to look at their own practices as well. One of the outcomes — it’s
a little bit more obvious — is when we do have
these recalls. And we did have five firms that
did do recalls and provided that information
in press release, and these are all
online and available. And you can also find
it both through the CDC and the FDA web updates,
you can get links to those. As far as foreign firms — and
this is publicly available. You can look up — you can
Google FDA import alert 72-03. When we have firms that
have violated products, we can basically put these
firms on import alert. That is, they can’t
bring in their products, but we do provide provisions for how they can
eventually bring products in. But it’s a good way for stopping
things from coming through. Last thing I’ll just
mention is that — Dr. Nichols mentioned is that,
we did have a mix of product that was both irradiated
and non-irradiated. And so, in terms of a
long-term, there is a lot that we still need to learn about these products
and its production. So, with that, I will —
thank you all for your time. Thanks.>>Thank you. At this time, we’d
like to take questions for any of our presenters. Call 1 800 593-8936 and enter
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of your question. I think we only have time
for one or two questions. Shawna, do we have any?>>There are no questions
in queue at this time.>>Okay, let’s give
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