1. Three Outbreaks of Salmonellosis Associated With
Baby Poultry From Three Hatcheries—United States,
2006
Online article and related content JAMA. 2007;297(22):2468-2472 (doi:10.1001/jama.297.22.2468)
current as of April 13, 2009.
http://jama.ama-assn.org/cgi/content/full/297/22/2468
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2. FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION
Alternative parenteral single-dose with recommended or alternative regi-
Three Outbreaks
regimens for urogenital and anorectal mens. Persons with persistent symp-
of Salmonellosis
gonorrhea include ceftizoxime 500 toms of gonococcal infection or whose
mg, cefoxitin 2 g with probenecid 1 g symptoms recur shortly after treat-
Associated With
orally, or cefotaxime 500 mg. How- ment with a recommended or alterna-
ever, these cephalosporin regimens do tive regimen should be reevaluated by
Baby Poultry
not offer any advantage over ceftriax- culture for N. gonorrhoeae; positive iso-
From Three
one. For persons with penicillin or lates should undergo antimicrobial-
cephalosporin allergies, a single intra- susceptibility testing. Clinicians and
Hatcheries—
muscular dose of spectinomycin 2 g is laboratories should report treatment
United States, 2006
a recommended alternative. However failures or resistant gonococcal iso-
spectinomycin is not available in the lates to CDC at 404-639-8373 through
United States. Updated information state and local public health authori- MMWR. 2007;56:273-276
from CDC regarding the availability ties.
DURING 2006, STATE HEALTH DEPART-
of cefixime and spectinomycin will be With fluoroquinolones no longer rec-
ments notified CDC of three out-
available at http://www.cdc.gov/std ommended for the treatment of gono-
breaks of Salmonella species infec-
/gonorrhea/arg. coccal infections, only one class of drug,
tions in persons who had been in
For pharyngeal gonorrhea, CDC now cephalosporins, is still recommended
contact with chicks and other baby
recommends a single intramuscular and available. Therefore, state and lo-
poultry (ducklings, goslings, and baby
dose of ceftriaxone 125 mg (see side- cal health departments must remain
turkeys) purchased at agricultural feed
bar); pharyngeal gonococcal infec- vigilant for the emergence of cephalo-
stores. The feed stores received the
tions often are asymptomatic and more sporin resistance.
poultry from hatcheries, and each of the
difficult to eradicate than urogenital and With use of nonculture tests to
anorectal infections.4 Spectinomycin, three outbreaks was traced to a single
diagnose N. gonorrhoeae increasing
hatchery. For decades, baby poultry,
cefixime, cefpodoxime, and cefurox- and with local data on antimicrobial
particularly chicks and ducklings, have
ime axetil do not appear adequate for susceptibility less available, CDC
been known to be a source of salmo-
treating pharyngeal gonococcal infec- strongly recommends that all state and
nellosis.1-4 More recently, the source of
tions. local health department laboratories
birds associated with salmonellosis out-
A single oral dose of azithromycin maintain or develop the capacity to
perform culture.10 CDC also encour- breaks has been traced back to indi-
2 g is effective against uncomplicated
vidual hatcheries. Many persons who
gonococcal infections, but CDC does ages all state and local health depart-
purchase baby poultry remain un-
not recommend widespread use of ment laboratories to maintain the
aware that contact with these birds puts
azithromycin because of concerns re- capacity to perform antimicrobial-
them and others who are exposed to the
garding rapid emergence of resis- susceptibility testing or form partner-
birds, especially children and immu-
tance, as evidenced by the increase in ships with experienced laboratories
nocompromised persons, at risk for sal-
azithromycin MICs documented since that can perform such testing. At a
monellosis. This report describes the
1999 in the United States and interna- minimum, antimicrobial-susceptibility
tionally.4,5,7-9 However, azithromycin three outbreaks and provides recom-
testing should be performed for ceftri-
mendations for preventing transmis-
might be an option for treatment of un- axone, spectinomycin, azithromycin,
sion of Salmonella infection from birds
complicated gonococcal infections from and any other regimens that are used
to humans.
any site (i.e., urogenital, anorectal, and locally for gonorrhea treatment.
Hatchery A. In May 2006, during rou-
pharyngeal) in persons with docu-
Acknowledgments tine surveillance of laboratory results, the
mented severe allergic reactions to peni-
This report is based, in part, on contributions by J public health laboratory at the Michi-
cillins or cephalosporins.
Thomas, T Sullivan, Emory Univ, Atlanta, Georgia; LJ
gan Department of Community Health
Persons in whom gonococcal infec- Doyle, The Cleveland Clinic Foundation, Cleveland,
detected a cluster of cases that were cul-
tion is diagnosed should be treated for Ohio; CJ Lenderman, P Dixon, Univ of Alabama at Bir-
mingham, Birmingham, Alabama; K Winterscheid, Univ
ture positive for Salmonella serotype
possible coinfection with Chlamydia of Washington, Seattle, Washington; JM Ehret, Univ
4,5,12,i:-. Laboratory analysis of the iso-
trachomatis with a single dose of of Colorado Health Sciences Center, Denver, Colo-
rado; and M Grabenstein, S Bowers, K Pettus, M lates by pulsed-field gel electrophore-
azithromycin 1 g by mouth or with Parekh, J Knapp, Laboratory Reference and Research
sis (PFGE)* yielded an indistinguish-
doxycycline 100 mg twice a day, by Br, Div of Sexually Transmitted Diseases Prevention,
National Center for HIV/AIDS, Viral Hepatitis, STD, able DNA pattern that was later
mouth for 7 days, if chlamydial infec-
and TB Prevention, CDC.
tion has not been ruled out.4 designated as the outbreak strain. Dur-
ing April-July, the laboratory isolated the
Test of cure is not recommended rou-
outbreak strain from a total of 21 clini-
tinely for patients with uncompli- REFERENCES
cal samples obtained from ill persons
cated gonorrhea who have been treated 10 Available.
©2007 American Medical Association. All rights reserved.
2468 JAMA, June 13, 2007—Vol 297, No. 22 (Reprinted)
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3. FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION
in Michigan. Ill persons were inter- nella serotype Montevideo. Of the four of these patients reported being un-
viewed† by state public health officials total positive stool samples, all yielded aware that baby poultry could be a
and asked about symptoms and pos- Salmonella serotype Montevideo iso- source of Salmonella species infection.
sible sources of exposure. All 21 pa- lates with indistinguishable PFGE DNA The hatchery source of the baby poul-
tients reported diarrhea, and six (29%) patterns. Three of the four children had try was determined for nine (21%) of
reported bloody diarrhea. Twelve (57%) handled the chicks, and the fourth had the 42 patients who had been exposed
patients reported vomiting. Seven (33%) the opportunity to do so, although di- to baby poultry; seven of these nine pa-
of the 21 ill patients were hospitalized rect contact could not be confirmed. tients purchased the baby poultry from
for a median of 4 days (range: 1-9 days); During April-June, state public health three feed stores that all received birds
complete data on recovery status were laboratories identified in the national from hatchery B in New Mexico. PFGE
not available at the time of interview. The PulseNet database‡ the same strain of analysis of isolates from baby poultry
median age of hospitalized patients was Salmonella serotype Montevideo in a and environmental swabs from hatch-
31 years (range: 7 months–79 years). total of 56 patients (including those ery B yielded a DNA pattern that was
The median age of all patients was 18 from the Nebraska day care center) indistinguishable from the Salmonella
years (range: 7 months–79 years). from 21 states.§ Forty-eight of these pa- Montevideo outbreak strain in the pa-
Twelve (57%) patients reported expo- tients were interviewed during May- tients. Hatchery B also had been iden-
sure to baby poultry in the 7 days be- July by state public health officials and tified previously as the source of chicks
fore illness onset; eight of these pa- asked about symptoms and possible ex- that caused outbreaks of human Sal-
tients reported purchasing the birds as posures. All interviewed patients re- monella species infections in 2002 and
a source of meat or eggs, two patients ported diarrhea (three or more loose 2005 (New Mexico Department of
reported purchasing the birds as family stools in 24 hours), and 25 (52%) re- Health, unpublished data, 2007).
pets, and for two patients, the reason for ported bloody diarrhea. Eight (17%) pa- Hatchery C. During March-May
purchase was unknown. The hatchery tients were hospitalized for a median 2006, the Oregon State Public Health
source of the baby poultry was deter- of 2 days (range: 1-7 days), and all fully Laboratory identified four patients with
mined for eight (67%) of the 12 pa- recovered; the median age of hospital- Salmonella serotype Ohio isolates;
tients who reported exposure; two pa- ized patients was 10 months (range: 27 PFGE analysis yielded indistinguish-
tients purchased birds directly from days–53 years). The median age of all able DNA patterns. All four patients
hatchery A in Michigan, and six pa- interviewed patients was 24 months were interviewed by public health of-
tients purchased birds from five differ- (range: 27 days–82 years). Forty-two ficials and asked whether they had been
ent agricultural feed stores that had all (88%) of the 48 interviewed patients re- hospitalized and about possible sources
received birds from hatchery A. This ported exposure to baby poultry in the of exposure. The median age of pa-
hatchery also was the source of chicks 5 days before illness onset. Seventeen tients was 32 years (range: 1-77 years).
and ducklings that caused salmonello- (40%) of the interviewed patients pur- One patient was hospitalized.
sis outbreaks in Michigan in 1999 and chased the birds for meat or eggs, 18 All four patients reported exposure
2000.6 (43%) purchased them as pets, and for to baby poultry in the days before ill-
Hatchery B. On May 3, 2006, the Ne- seven patients, the reason for pur- ness onset. Three of the four patients
braska Health and Human Services Sys- chase was unknown. Thirty-seven had purchased chicks from one agri-
tem received a report of two children (88%) of 42 patients with exposure to cultural feed store; the source for the
with stool-culture–confirmed salmo- baby poultry purchased the birds at a fourth patient was unknown. After a re-
nellosis. The health department began store, including at least 14 different ag- view of invoices from the feed store, the
an investigation on May 4 and learned ricultural feed stores and one general source for the chicks was determined
that the two patients both attended the store; other patients did not report the to be hatchery C in neighboring Wash-
same Nebraska day care center, where facility from which they purchased the ington. Hatchery C had been identi-
they had handled pet chicks brought birds. fied previously as the source of chicks
into the center by a parent. Additional All 37 patients who purchased baby that caused outbreaks of salmonello-
interviews at the day care center de- poultry from a store were asked whether sis in 1995, 1996, 2003, 2004, and 2005
tected a total of 10 persons (nine stu- the store provided information on pre- (Oregon Department of Public Health,
dents and one staff member) with di- venting transmission of Salmonella spe- unpublished data, 2007).
arrhea (three or more loose stools in 24 cies infection from birds to humans; To assess the prevalence of Salmo-
hours), and three (30%) with bloody three patients reported receiving this nella species in chicks at retail stores,
diarrhea. None of the 10 persons were type of information. In addition, 31 pa- the Oregon Department of Agricul-
hospitalized. Stool samples were re- tients who reported exposure to baby ture and the Oregon Public Health Di-
quested of all persons with diarrhea. Of poultry were asked whether they were vision surveyed 16 agricultural feed
the six additional stool samples ob- aware that they could contract salmo- stores in western Oregon during Feb-
tained, two were positive for Salmo- nellosis from baby poultry; 24 (77%) ruary-March 2006. Although the
©2007 American Medical Association. All rights reserved.
2470 JAMA, June 13, 2007—Vol 297, No. 22 (Reprinted)
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4. FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION
surveys began before the outbreak was salmonellosis outbreaks. Such out- possibly resulting in infection. In ad-
detected, the data were used to assist breaks might be prevented by control dition, all items that have been in con-
in the subsequent outbreak investiga- measures at these and other hatcher- tact with birds, such as floors, tables,
tion. Store representatives were asked ies and at agricultural feed stores, where rugs, sinks, and fingers, can be con-
about conditions under which birds most persons purchase baby poultry. taminated with a fecal film.
were purchased, housed, and sold. In Providing information to customers To reduce the risk for illness or
addition, cloacal swabs from 137 chicks about the health risks of bird contact death from salmonellosis, persons
from the 16 stores were cultured for Sal- and providing adequate handwashing should be educated about the risks of
monella; serotypes Ohio, Montevideo, facilities might prevent such infec- contact with baby poultry, should
tions. 8 Certain state health depart-
or Tennessee were recovered from 25 avoid contact with bird feces, and
(18%) of the chicks from 10 of the 16 ments (e.g., in Washington and Or- should wash their hands with soap
stores. All agricultural feed stores with egon) have urged feed stores to display and warm water after handling baby
chicks whose swabs yielded Salmo- warnings and provide point-of-sale edu- poultry or anything that has been in
nella Ohio received these chicks from cational materials to persons purchas- contact with them. In addition, chil-
hatchery C. ing baby poultry; however, such cam- dren aged 5 years should not be
paigns are voluntary and might not be allowed to handle baby chicks or
Reported by: S Bidol, MPH, M Stobierski, DVM, Michi-
implemented. Increased emphasis on other baby birds. At the community
gan Dept of Community Health. D Leschinsky, Ne-
such point-of-sale educational materi- level, hatcheries should provide writ-
braska Health and Human Svcs System. P Ettestad,
DVM, C Smelser, MD, D Sena-Johnson, J Jungk, MPH,
als might reduce numbers of infec- ten information for customers at agri-
N Tafoya, P Torres, MS, New Mexico Dept of Health;
tions. Evaluation of the effectiveness of cultural feed stores and customers
F Taylor, DVM, New Mexico Dept of Agriculture. W
Keene, PhD, M Plantenga, B Progulske, DVM, Or- mandated point-of-sale education in re- who purchase directly from hatcher-
egon Dept of Public Health; R TenEyck, R Rada, L Ef-
ducing baby-poultry–associated salmo- ies, recommending ways to prevent
finger, MA, Oregon Dept of Agriculture. J Lockett, N
Patel, Enteric Disease Laboratory Br; F Angulo, DVM, nellosis might help guide future pre- transmission of Salmonella organisms
H Bair-Brake, DVM, Enteric Disease Epidemiology Br,
vention programs. from birds to humans. Additional
Div of Foodborne Bacterial and Mycotic Diseases, Na-
Although the purchase of baby poul- information regarding health risks
tional Center for Zoonotic, Vector-Borne, and En-
teric Diseases; N Gaffga, MD, EIS Officer, CDC.
try from agricultural feed stores by per- posed by contact with baby poultry is
sons for meat or eggs or as pets is legal available at http://www.cdc.gov
CDC Editorial Note: This report de- in all states, a 2005 survey indicated that /healthypets/easter_chicks.htm.
scribes three concurrent outbreaks of the sale of chicks to individual per-
salmonellosis that occurred during sons is regulated by law in certain states.
REFERENCES
2006, the first year during which more For example, 13 states and the Dis-
8 Available.
than one baby-poultry–associated sal- trict of Columbia (DC) prohibit the sale
monellosis outbreak has been recog- of birds that have been dyed. Arkan- *PFGE provides a DNA pattern for each isolate; closely
nized. These outbreaks demonstrate sas, Kentucky, New York, and Wiscon- related or indistinguishable PFGE patterns suggest a
common source and can be used to distinguish out-
that salmonellosis associated with baby sin have laws establishing a minimum
break cases from concurrent sporadic cases. Persons
poultry purchased from agricultural number of birds that can be sold to in- with indistinguishable PFGE patterns might be in-
feed stores is a source of Salmonella in- dividual persons, and 12 states¶ and DC cluded in the case count, regardless of whether ex-
posure to the outbreak source is confirmed.
fection in humans and an ongoing pub- have laws restricting the youngest age †For all investigations described in this report, if the
lic health problem. at which birds can be sold. The effec- patient was a young child, a family member was in-
terviewed.
Each year in the United States, an es- tiveness of such legislation is un- ‡PulseNet is the molecular subtyping network for food-
timated 1.4 million Salmonella infec- known. None of the hatcheries or stores borne disease surveillance in the United States. Par-
ticipants are public health laboratories in all 50 states
tions result in thousands of hospital- implicated in the outbreaks were in vio-
and federal regulatory agency laboratories. PulseNet
izations and hundreds of deaths.7 The lation of state laws related to the sale participants perform standardized molecular subtyp-
percentage caused by contact with baby of baby poultry. ing (or “fingerprinting”) of foodborne disease-
causing bacteria by PFGE in real time. The results (DNA
poultry remains unknown, and few The hatchery B outbreak investiga- fingerprints, or patterns) are then submitted electroni-
measures have been implemented to tion described in this report indicates cally to central databases located at CDC, which en-
ables rapid comparison of PFGE patterns by public
prevent transmission of Salmonella or- that persons who purchase baby poul- health professionals nationwide.5
ganisms from baby poultry to hu- try usually are unaware that Salmo- §California, Colorado, Iowa, Illinois, Kentucky, Maine,
Massachusetts, Minnesota, Missouri, Nebraska, New
mans. nella species infections can be trans- Jersey, New Mexico, New York, Oregon, South Da-
Fewer than 20 hatcheries in the mitted from poultry to humans. kota, Texas, Utah, Virginia, Washington, Wisconsin,
and Wyoming.
United States provide the majority of Although baby birds such as chicks and
Arkansas, Florida, Illinois, Kentucky, Massachusetts,
baby poultry sold in agricultural feed ducklings might not appear dirty, they Michigan, Montana, New Jersey, New York, Penn-
stores in the nation, and certain hatch- can have feces on their feathers and sylvania, South Carolina, Tennessee, and Vermont.
¶Alabama, Arkansas, Florida, Kentucky, Massachu-
eries have been implicated repeatedly beaks, areas that children are more setts, Montana, New Jersey, New York, North Caro-
as sources of baby-poultry–associated likely to touch or place in their mouths, lina, Pennsylvania, South Carolina, and Wisconsin.
©2007 American Medical Association. All rights reserved.
2472 JAMA, June 13, 2007—Vol 297, No. 22 (Reprinted)
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