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Salmonella Enteritidis in backyard poultry flocks in Alberta Are owners at risk? ILONA HOUSTON ADED ROUNDS MARCH 20, 2017 1 OneHealth Interconnectedness of human and animal (and environmental) health demands an interdisciplinary approach Zoonoses and foodborne diseases 33 million DALYs attributable to foodborne diseases (WHO, 2015) http://www.phgfoundation.org/file/16911/ 2 Salmonella Salmonella spp. ● Gram negative rods; two species and many many many serovars with varying host-specificities ● Numerous diseases in poultry ● Numerous diseases in humans >93 million cases of gastroenteritis and >100,000 deaths due to Salmonella infection globally/year Serovar of interest: Salmonella enterica Enteritidis (SE) second most common serotype isolated in human salmonellosis cases http://www.sc.chula.ac.th/agtechinter/ 3 Epidemiology and pathology of SE Poultry ● often introduced to a flock via infected eggs/chicks ●horizontal transmission: contaminated feces, litter, fomites ● wildlife, rodents, insects ●vertical transmission: eggs ●adult birds often asymptomatic carriers: shed bacteria Humans ● direct contact with infected animals ● indirect contact/environmental transmission ● foodborne (eggs, poultry) ●acute onset typically self-limiting diarrhea, non-specific flu-like illness ●children, elderly and immunocompromised most vulnerable ●severe cases may require hospitalization, bacteremia can lead to mortality http://greenbeandelivery.com/healthytimes/news/going-local-for-breakfast/ 4 Control of SE and small flocks ● Largely successful integrated SE control programs for commercial flocks in Europe and North America feature sampling and routine testing for SE, including hatcheries ●SE is reportable in poultry: positive results require quarantine/depopulation/C&D and enhanced sampling protocol to ensure premises decontaminated ●Eggs from commercial facilities that test SE+ may be held from distribution or pasteurized for safety ●Backyard flocks: Growing in popularity, poorly characterized demographics, no central representative organization, challenges in applying similar control measures, enforcing regulations and distributing information ●Non-commercial production is also often thought of as a higher risk due to lower biosecurity measures and closer interaction between birds http://agr.georgia.gov/backyard-poultry-owners.aspx 5 Outbreak timeline OFFICIAL START OF OUTBREAK START OF HIGH RISK HATCHING PERIOD ONSET OF HUMAN CASES 1 Mar PHAC POSTS PUBLIC HEALTH ALERT AH ACTIVATES INVESTIGATION 1 Apr FIRST REPORTED HUMAN CASE: UNCONFIRMED LAST NEGATIVE SE RESULT FOR HATCHERY 1 May POSITIVE SE RESULT FOR HATCHERY LAST POSITIVE SE AT HATCHERY END OF HIGH RISK HATCHING PERIOD 1 Jun END OF HUMAN CASES REPORTED 1 Jul 6 Aims and Objectives ● describe and analyze data gathered by MoAF during the investigation SE outbreak in backyard flocks in Alberta ● interpret these in conjunction with the findings revealed by the parallel public health authority investigation to assess the risk of salmonellosis posed to backyard flock owners by birds from a known-contaminated source and those confirmed to be infected with SE, and further identify opportunities and recommendations for mitigation of the threat of SE to public health. Sick humans 7 Methods ● Data collection by MoAF: Gathered during outbreak investigation - similar to an observational cross-sectional study, using a convenience sample of self-selected owners who purchased chicks from the identified hatchery source during the defined risk period, received notification of the outbreak and elected to contact the OCPV ● Environmental sampling kits internally validated industry-accepted RT-PCR method ●PHAC: further molecular diagnostics (serotyping, phage typing, PFGE, MLVA, and WGS) Outcome of interest: self-reported illness at the household level (Y/N) Exposures of interest: SE sample kit result (+/-), morbidity/mortality in flock (Y/N), layers on premises (Y/N) ● Preliminary analysis for association was performed using Pearson’s chi squared test at p<0.05 significance level ● More robust multivariable analysis of association, logistic regression was used to test the binary variables with the outcome of any reported illness in humans per household. 8 9 Results Variable Positive (n) Proportion Negative (n) Proportion (%) Total (n) Self-reported illness at the household level 53 19.85% 214 80.15% 267 SE environmental sample result 159 44.92% [39.65,50.26] 195 55.08% [49.74, 60.35] 354 Bird morbidity/mortality 63 23.86% 201 76.14% 264 Layers on premises 136 92.52% 11 7.48% 147 10 Results Variable Pearson’s chi2 p-value Flock tested SE+ 20.6473 <0.001* Morbidity/mortality reported in flock 7.4935 0.006* Layers on premises 2.6325 0.105 Univariate Pearson’s chi2 analysis of the association between predictor variables and outcome of self-reported illness in humans; degrees of freedom = 1. * Significant at p<0.05 11 Results Odds Ratio 95% CI p-value SE+ Morbidity/mortality reported in flock Layers on premises 4.49 2.48 0.334 2.27, 8.89 1.27, 4.18 0.08, 1.32 <0.001* 0.007* 0.118 Adjusted SE+ Morbidity/mortality reported in flock 4.75 1.95 2.28, 9.86 0.97, 3.92 0.0633 50.63 4.72, 543.12 0.001* Self-reported illness in humans Layers on premises SE+ 12 Public Health Investigation Findings: ● median time between receiving birds and the onset of symptoms was 10 days (1-78) ● ~ two thirds of people became ill in the two weeks following obtaining affected poultry ● majority of case patients (87%) reported direct contact with the poultry and their environment 79% handled poultry directly; 10% reported kissing birds ● 82% reported exposure to poultry at home poultry were kept inside the home in 17% of cases ● 56% of owners surveyed had knowledge of the link between salmonellosis and contact with poultry. ● PHAC diagnostics (serotype, PFGE, MLVA, WGS) results revealed human patients all infected by the same strain, supporting a single source The majority (86%) of poultry samples submitted by owners to MoAF were consistent with these results https://www.youtube.com/watch?v=mi80y6FP21s Centre for Foodborne Environmental and Zoonotic Infectious Diseases, Outbreak management Division report. 13 Discussion Conclusions: statistically significant association between self-reported illness in humans and backyard poultry flocks that test positive for SE. Sick birds: did not improve the multivariate logistic model of association, possibly due to the ability for infected birds to shed the bacteria while remaining asymptomatic. morbidity in birds may also have gone undetected and thus unreported by owners, particularly inexperienced or new owners who are unfamiliar with poultry health; this study does not capture symptoms nor mortality rates, and did not include testing for other pathogens Role of layers: included as a variable due to transovarial transmission infection of layers already present in the flock by infected chicks; has implications for time period before onset of symptoms, and owners whose flock tests positive and they maintain layers in the flock or inadequately decontaminate premises before introducing new layer birds. Analysis revealed that when layers were reported on farm, there was approximately a fiftyfold increase odds of that flock having a positive SE test result. Possible explanations for this may be that laying breeds were sent out during a period of higher contamination from the hatchery, that most flocks contained layers, or that there are other unknown and unmeasured characteristics of flocks that contain layers? Sick humans 14 Discussion ● PHAC diagnostics :reliable, robust and specific support for the relatedness of the SE isolates ● vast majority of flock samples in AB were this same strain supports that prevalence of SE found in backyard flock samples is due to the outbreak, rather than representative of high levels of endemic SE that were being picked up incidentally during the investigation. Outbreak prevalence: 44.9% (convenience sample, very high) Australia: 10% Iran, Uruguay: 3.5-5.8% Ontario: <1% 7 flocks yielded non-outbreak related Salmonella: Insight into the baseline prevalence? ● 53 owners reported illness in the household to MoAF; PHAC confirmed 35 human cases limitations of using self-reported illness? Barriers to diagnosis? FBDs are thought to be largely underreported and under-diagnosed, these numbers may support this 15 Conclusions Recommendations ●Surveillance: Establish baseline SE prevalence and characterize the backyard flock sector (practices) ●Education and awareness to mitigate risks to owners and the general public 84% of backyard flock owners in a U.S. survey think that eggs and meat from their own flock is safer than commercial animal products Follow-up with owners regarding decontamination, ongoing management/biosecurity ●Hatchery as a focus for prevention, contact point with the public and aid in distribution of materials/information ●Consideration of under-reporting and under-diagnosis of SE 16 https://memegenerator.net/instance/56529202 Limitations ● Generalizability of these findings has some limitations: outbreak scenario, convenience sample, self-selected participants limited to AB, ~25% of owners presumed to have received contaminated chicks submitted samples… representativeness of this small sample of the entire backyard flock population of Alberta, or Canada should be carefully considered ● missing values ● convenience sample ● numerous potential sources of bias ● reliability of SE test results 17 So! There is strong evidence to support the conclusion that during this outbreak scenario, yes. 18 Acknowledgements I would like to extend sincere gratitude for the support by the Alberta Ministry of Agriculture and Forestry, in providing funding, access to data, and the expert contributions by the Animal Health Branch. In particular, Drs. Keith Lehman, Chunu Mainali, Simon Otto and Delores Peters for their work towards supporting the process of allowing me to collaborate with AF on this project, and for providing me with not only the necessary information to complete the work but also invaluable insight into this investigation. Additional thanks to Robin King, Senior Laboratory Scientist, for providing me with information on molecular biology and testing processes, and to Dr. Simon Otto for his assistance with statistical analyses. 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