US Outbreak of Human Salmonella Infections Associated With Aquatic Frogs

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US Outbreak of Human Salmonella Infections Associated With Aquatic Frogs, 2008–2011
Shauna L. Mettee Zarecki, RN, MSN, MPHa,b,c,d, Sarah D. Bennett, MD, MPHa,b,d, Julia Hall, MPHe, Jill Yaeger, BSf, Kate Lujan, RN MPHg, Marguerite Adams-Cameron, MPHh, Kim Winpisinger Quinn, MSi, Rita Brenden, PhDj, Gwen Biggerstaff, MSPHb, Vincent R. Hill, PhD, PEb, Kari Sholtes, MSEEk, Nancy Marie Garrett, BSb, Patti C. Lafon, MSb, Casey Barton Behravesh, MS, DVM, DrPHb,d, Samir V. Sodha, MD, MPHb,d,l, on behalf of the Salmonella Typhimurium Outbreak Investigation Team
+ Author Affiliations

aEpidemic Intelligence Service,
bDivision of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging Zoonotic and Infectious Diseases,
cPreventive Medicine Residency and Fellowship,
kDivision of Emergency and Environmental Health Services, National Center for Environmental Health, and
lGlobal Immunization Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
dUnited States Public Health Service Commissioned Corps
eUtah Department of Health, Salt Lake City, Utah;
fMadera County Environmental Health Department, Madera, California;
gDisease Control Environmental Epidemiology Division, Public Health Nurse Consultant Office of Planning and Partnership, Colorado Department of Public Health and Environment, Grand Junction, Colorado;
hEpidemiology and Response Division, New Mexico Department of Health, Albuquerque, New Mexico;
iOutbreak Response and BT Investigation Team, Ohio Department of Health, Columbus, Ohio; and
jMicrobial Diseases Laboratory Branch, Division of Communicable Disease Control, Center for Infectious Disease, California Department of Public Health, Richmond, California


Abstract
OBJECTIVE: Although amphibians are known Salmonella carriers, no such outbreaks have been reported. We investigated a nationwide outbreak of human Salmonella Typhimurium infections occurring predominantly among children from 2008 to 2011.

METHODS: We conducted a matched case-control study. Cases were defined as persons with Salmonella Typhimurium infection yielding an isolate indistinguishable from the outbreak strain. Controls were persons with recent infection with Salmonella strains other than the outbreak strain and matched to cases by age and geography. Environmental samples were obtained from patients’ homes; traceback investigations were conducted.

RESULTS: We identified 376 cases from 44 states from January 1, 2008, to December 31, 2011; 29% (56/193) of patients were hospitalized and none died. Median patient age was 5 years (range <1–86 years); 69% were children <10 years old (253/367). Among 114 patients interviewed, 69 (61%) reported frog exposure. Of patients who knew frog type, 79% (44/56) reported African dwarf frogs (ADF), a type of aquatic frog. Among 18 cases and 29 controls, illness was significantly associated with frog exposure (67% cases versus 3% controls, matched odds ratio 12.4, 95% confidence interval 1.9–infinity). Environmental samples from aquariums containing ADFs in 8 patients’ homes, 2 ADF distributors, and a day care center yielded isolates indistinguishable from the outbreak strain. Traceback investigations of ADFs from patient purchases converged to a common ADF breeding facility. Environmental samples from the breeding facility yielded the outbreak strain.

CONCLUSIONS: ADFs were the source of this nationwide pediatric predominant outbreak. Pediatricians should routinely inquire about pet ownership and advise families about illness risks associated with animals.

ownership and advise families about illness risks associated with animals.

Key Words:childrenpediatricSalmonellaoutbreakzoonosesa mphibiansfrogspets•Abbreviations:
ADF — African dwarf frog
CDC — Centers for Disease Control and Prevention
CI — confidence interval
CDPH — California Department of Public Health
MLVA — multiple-locus variable number tandem repeat analysism
OR — matched odds ratio
PFGE — pulsed-field gel electrophoresis
Accepted November 29, 2012.
Copyright © 2013 by the American Academy of Pediatrics

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