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H7 Infections After Petting Zoo Visits, North Carolina State Fair, October-November 2004

Brant Goode, BSN/RN, MPH; Ciara O’Reilly, PhD; John Dunn, DVM, PhD; Kathleen Fullerton, MPH; Stacey Smith, MD; George Ghneim, DVM, PhD; James Keen, DVM, PhD; Lisa Durso, PhD; Megan Davies, MD; Sue Montgomery, DVM, MPH

Arch Pediatr Adolesc Med. 2009;163(1):42-48.

Objectives  To identify cases, describe the outbreak, implement control measures, and identify factors associated with infection or protection from infection, including contact with animals and hand hygiene practices.

Design  Case finding, a case-control study of 45 cases and 188 controls, environmental investigation, and molecular subtyping of clinical and environmental Escherichia coli O157:H7 isolates.

Setting  The 2004 North Carolina State Fair.

Participants  Case patients were fair visitors who had laboratory-confirmed E coli O157 infections, hemolytic uremic syndrome (HUS) diagnoses, or bloody diarrheal illnesses. Control subjects were recruited from a randomized list of persons who had purchased fair tickets online. Environmental samples from the fairgrounds were obtained from locations that had held animals during the fair.

Main Exposure  Visiting a petting zoo.

Main Outcome Measures  Case finding: Summary descriptive statistics of suspected, probable, or confirmed E coli O157:H7 infections, signs, symptoms, and HUS. Environmental investigation: E coli O157:H7 isolates, pulsed-field gel electrophoresis patterns, and spatial distribution of source locations. Case-control study: Odds ratios (ORs) comparing reported fair-related activities, hygiene practices, and zoonotic disease knowledge with outcome.

Results  A total of 108 case patients were ascertained, including 41 with laboratory-confirmed illness and 15 who experienced HUS. Forty-five case patients and 188 controls were enrolled in the case-control study. Visits to a petting zoo having substantial environmental E coli O157:H7 contamination were associated with illness (age-adjusted OR, 8.2; 95% confidence interval [CI], 3.3-20.3). Among children 5 years or younger who had visited the implicated petting zoo, contact with animal manure (OR, 6.9; 95% CI, 2.2-21.9) and hand-to-mouth behaviors (OR, 10.6; 95% CI, 2.0-55.0) were associated with illness. Reported hand hygiene practices did not differ significantly (OR, 1.8; 95% CI, 0.3-9.5). Reported awareness of the risk for zoonotic disease was protective (OR, 0.1; 95% CI, 0.03-0.5). Environmental samples from the petting zoo implicated in the case-control study yielded E coli O157:H7, with indistinguishable pulsed-field gel electrophoresis patterns from the predominant strain.

Conclusions  We describe one of the largest petting zoo outbreaks of E coli O157:H7 to date. Persons became infected after contact with manure and engaging in hand-to-mouth behaviors in a petting zoo having substantial E coli O157:H7 contamination. Use of alcohol-based hand-sanitizing gels was not protective, although knowledge of the risk for zoonotic infection was protective. Future investigations in similar outbreaks should assess risks for infection and protective measures (eg, physical barriers separating visitors from animal manure, education, and appropriate hand hygiene practices).

Author Affiliations: Epidemic Intelligence Service (Mr Goode) assigned to North Carolina Division of Public Health, Epidemiology Section, General Communicable Diseases Control Branch (Drs Ghneim and Davies), Raleigh, North Carolina; Epidemic Intelligence Service (Drs O’Reilly and Dunn) assigned to the Enteric Diseases Epidemiology Branch, Division of Foodborne, Bacterial, and Mycotic Diseases, Centers for Disease Control and Prevention (CDC) (Ms Fullerton and Drs Smith and Montgomery), Atlanta, Georgia; and Agriculture Research Service, US Department of Agriculture, Clay Center, Nebraska (Drs Keen and Durso). Mr Goode is currently with the Hawaii State Department of Health; Dr O’Reilly is currently with the Enteric Diseases Epidemiology Branch, Division of Foodborne, Bacterial, and Mycotic Diseases, CDC; Dr Dunn is currently with the Tennessee Department of Health, Nashville; and Dr Montgomery is currently with the Division of Parasitic Diseases, CDC.

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