Human exposures to Brucella canis from a pregnant dog during an international flight: Public health risks, diagnostic challenges and future considerations

AIMS

This report documents the exposure of passengers and crew of a commercial international flight to the zoonotic pathogen Brucella canis after an infected dog aborted in the passenger cabin of the aircraft. This case demonstrates the challenges associated with brucellosis screening and the risks that airline personnel, airport employees and travellers face when animals with unrecognized zoonotic infections are transported.

METHODS/RESULTS

The public health investigation of this case was conducted by the Centers for Disease Control, the Illinois Department of Health and the Illinois Department of Agriculture, in collaboration with a local veterinary clinic and several academic and federal diagnostic laboratories. It included an extensive diagnostic evaluation of the dam and aborted foetuses to confirm a diagnosis of canine brucellosis. Passengers, airline personnel and staff from the veterinary clinic where the dogs were treated underwent risk assessments, and clinic staff also received detailed guidance regarding infection prevention practices.

CONCLUSIONS

Animal shelters and breeding programs are recommended to screen dogs routinely for brucellosis, but it is not unusual for domestic or imported animals to have unknown health histories, including the dog's brucellosis status, at the time of purchase, adoption, or re-homing. Testing recommendations and requirements vary by state, making it challenging for state public health and animal health agencies to monitor and respond appropriately. This case highlights the importance of Brucella spp. screening in sexually intact dogs prior to breeding, purchase, or domestic or international transportation of the dogs. The transportation of pregnant dogs may present a previously unrecognized public health threat in addition to contributing to unnecessary stress and health risks for pregnant animals.

Vaccine Preventable Zoonotic Diseases: Challenges and Opportunities for Public Health Progress

Zoonotic diseases represent a heavy global burden, causing important economic losses, impacting animal health and production, and costing millions of human lives. The vaccination of animals and humans to prevent inter-species zoonotic disease transmission is an important intervention. However, efforts to develop and implement vaccine interventions to reduce zoonotic disease impacts are often limited to the veterinary and agricultural sectors and do not reflect the shared burden of disease. Multisectoral collaboration, including co-development opportunities for human and animal vaccines, expanding vaccine use to include animal reservoirs such as wildlife, and strategically using vaccines to interrupt complex transmission cycles is needed. Addressing zoonoses requires a multi-faceted One Health approach, wherein vaccinating people and animals plays a critical role.

Risk factors for Brucellosis and knowledge-attitude practice among pastoralists in Afar and Somali regions of Ethiopia

BACKGROUND

Brucellosis is a neglected bacterial zoonotic disease with substantial economic impact on households. Pastoral communities are a potential risk group due to their way of life being closely interlinked with their large livestock herds.

METHODOLOGY

A semi-structured questionnaire survey was conducted in households in the pastoral Afar and Somali (SRS) regions. All households had people and animals serologically tested for brucellosis. Questions were related to husbandry, consumption habits, and knowledge-attitude-practice towards the disease and zoonoses. Descriptive statistics and logistic analysis were performed to assess potential risk factors for having households with positive humans and/or animals.

RESULT

647 households were included in the survey. Herd brucellosis prevalence was 40.3 % (15.9-86.3 % in Afar; 4-72.2 % in SRS). Over half (56.3 %) of the households in Afar and 41.8 % in SRS had at least one human reactor. Nearly a quarter of the households (22.8 %), recalled abortions in goats in the last 12 months, whereas 52.5 % and 50.3 % recalled stillborn in all species and membrane retentions respectively. All respondents drank raw milk and discarded animal afterbirths in the direct surroundings with minimal protection. Risk factors for animal reactors were goat herd size, and goat abortion. There was no identified risk factor for having human reactors in households. None of the households knew about brucellosis.

CONCLUSION

Although being endemic in Afar and SRS, Brucellosis is not known by the pastoralists. Brucellosis control programs will have to be tailored to the pastoral context, accounting for their mobility, large, multi-species herds and habits.

Integrated human-animal sero-surveillance of Brucellosis in the pastoral Afar and Somali regions of Ethiopia

Background

Brucellosis is widespread in Ethiopia with variable reported prevalence depending on the geographical area, husbandry practices and animal species. However, there is limited information on the disease prevalence amongst pastoral communities, whose life is intricately linked with their livestock.

Methodology

We conducted an integrated human-animal brucellosis sero-surveillance study in two adjacent pastoral regions, Afar and Somali region (SRS). This cross-sectional study included 13 woredas (districts) and 650 households. Blood samples were collected from people and livestock species (cattle, camel, goats and sheep). Sera were analyzed with C-ELISA for camels and shoats (sheep and goats), with I-ELISA for cattle and IgG ELISA for humans. Descriptive and inferential statistics analyses were performed.

Results

A total of 5469 sera were tested by ELISA. Prevalence of livestock was 9.0% in Afar and 8.6% in SRS (ranging from 0.6 to 20.2% at woreda level). In humans, prevalence was 48.3% in Afar and 34.9% in SRS (ranging from 0.0 to 74.5% at woreda level). 68.4% of all households in Afar and 57.5% of households in SRS had at least one animal reactor. Overall, 4.1% of animals had a history of abortion. The proportion of animals with abortion history was higher in seropositive animals than in seronegative animals. Risk factor analysis showed that female animals were significantly at higher risk of being reactors (p = 0.013). Among the species, cattle had the least risk of being reactors (p = 0.014). In humans, there was a clear regional association of disease prevalence (p = 0.002). The older the people, the highest the odds of being seropositive.

Conclusion

Brucellosis is widespread in humans and animals in pastoral communities of Afar and SRS with the existence of geographical hotspots. No clear association was seen between human and particular livestock species prevalence, hence there was no indication as whether B. abortus or B. melitensis are circulating in these areas, which warrants further molecular research prior to embarking on a national control programs. Such programs will need to be tailored to the pastoral context.

Brucellosis is a neglected disease of livestock that can be transmitted to people through consumption of raw animal products and direct contact with animal birth material. Although prevalent in Ethiopia, there is limited information on the disease prevalence amongst pastoral communities, whose life is intricately linked with their livestock. We therefore, conducted a disease surveillance in people and their livestock in Afar and Somali region (SRS), two pastoral regions of Ethiopia. The study included 13 districts and 650 households. A total of 5469 blood samples were collected from people and livestock species (cattle, camel, sheep and goats) and analyzed using commercial brucellosis ELISA assays. Livestock brucellosis prevalence was 9% in Afar and 8.6% in SRS (ranging from 0.6 to 20.2% at woreda level). In humans, prevalence was 48.3% in Afar and 34.9% in SRS (ranging from 0 to 74.5% at woreda level). 68.4% of all households in Afar and 57.5% of households in SRS had at least one positive animal. This study showed that the disease is widespread in human and their livestock in pastoral communities of Afar and SRS with the existence of geographical hotspots. Results will advise on tailored surveillance programs in pastoral communities.

Oncology urgent care to decrease unnecessary emergency room visits

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Background: In March 2019, Columbia University Irving Medical Center (CUIMC)/New York Presbyterian (NYP) piloted an oncology urgent care center, Oncology Care Initiation Unit (OCIU). Patients currently on therapy were referred to OCIU Nurse Practitioners (NP) by primary Oncology Teams for acute, non-life threatening complaints for management. We evaluated the impact of the OCIU on preventing unnecessary emergency room (ER) visits, patient wait times, and patient satisfaction. Prior to the OCIU, 52% of oncology patients presenting to the ER were discharged indicating that an ER visit most likely was not needed. Average wait time for evaluation in ERs for non-critical patients is 7 to 9 hours and can be another 7 to 9 hours for intervention. Methods: We opened the 8-week OCIU pilot to Thoracic and Gastrointestinal (GI) Oncology, and Sarcoma patients who had an acute, non-life threatening complaint from, 8AM to 6PM, Monday to Friday. We collected data on all OCIU patient referrals from 3/7/2019 to 5/2/2019, including patient demographics, primary cancer diagnosis, chief complaint, wait times, interventions, disposition and patient satisfaction using a validated 5 question satisfaction survey. Results: During the pilot, we received 51 referrals, 44 (86%) were considered OCIU appropriate and evaluated; 25 (57%) had a GI cancer diagnosis, 14 (32%) Thoracic cancer diagnosis, and 5 (11%) Sarcoma. Primary chief complaints in order of frequency were pain, GI distress, and dyspnea. 44 (100%) had no wait to be evaluated by the OCIU NP. 33 (75%) of OCIU patients were discharged home, 9 (20%) were directly admitted, and 2 (5%) were transferred to the ER. Patients not requiring invasive intervention were discharged home within thirty minutes of their appointment. Patients requiring infusions, radiology services, and/or paracentesis or thoracentesis were discharged within 4 hours of appointment time. 100% patient satisfaction was reported. Conclusions: Implementation of the OCIU has led to decreased ER visits, wait times for evaluation and management, and increased patient satisfaction. These findings support the need for the OCIU, as well as increasing access to the OCIU by extending to additional HICCC patients.

SUN-209 Clinical Hypogonadism Related to Incidentally Discovered Adrenal Insufficiency: Case Report

Introduction Hypogonadism can be primary or secondary. There are several causes of hypogonadism that include but are not limited to, congenital abnormalities, infections, systemic diseases, radiation therapy and glucocorticoid use. Addressing the primary cause tends to resolve the sex hormone deficiency. Case presentation Patient is a 46-year-old man with a history of HIV (on therapy), treated syphilis, and rheumatoid arthritis who presented to the office due to low testosterone levels found on laboratory tests done the prior year as well as complain of decreased libido and erectile dysfunction. He was sexually active with one male partner only and denied taking any testosterone-augmenting agents in the past. Physical exam was pertinent for truncal obesity, normal hair distribution, normal penis and testicles with no masses. Patient also endorsed taking a short course of steroids (prednisone) a few months before due to joint pain. On laboratory studies, patient had a normal prolactin, growth hormone, IGF-1 and thyroid function. Morning cortisol was low at 0.8 ug/dL (6.2 - 19.4 ug/dL) on two separate occasions, with borderline low ACTH. He also had low total and free testosterone at 203 ng/dL and 1.8 pg/ml, respectively. FSH and LH were inappropriately normal for the level of testosterone deficiency, and CD4 count was within normal limits. MRI of the brain showed a small 2.5 mm microadenoma, which was most likely a non-functional adenoma. Given low cortisol levels, the patient was started on hydrocortisone with subsequent transition to prednisone. After three months of treatment for adrenal insufficiency, his testosterone levels improved to normal range with no need for androgen replacement therapy, and his symptoms also improved significantly. Discussion Secondary hypogonadism has several causes, including but not limited to hyperprolactinemia, testosterone supplementation, opiate abuse, or glucocorticoid treatment. In this case, our patient developed adrenal insufficiency, possibly due to previous steroid administration. Glucocorticoid use is an uncommon but known cause of secondary hypogonadism, as it alters FSH and LH secretion. Low testosterone and hypogonadism have been studied and are relatively common in men with HIV (1), although how much of a role the HIV infection played in our patient’s findings is unclear, given that he was well controlled. Since the patient responded to steroid treatment with correction of his testosterone levels, his hypogonadism was most likely due to hypothalamic-pituitary axis dysfunction, also resulting in adrenal insufficiency. Reference: Mirza, F. S., Luthra, P., & Chirch, L. (2018). Endocrinological aspects of HIV infection. Journal of Endocrinological Investigation, 41(8), 881-899. doi:10.1007/s40618-017-0812-x

Brucellosis in Dogs and Public Health Risk

Brucella canis infects dogs and humans. In dogs, it can cause reproductive failure; in humans, it can cause fever, chills, malaise, peripheral lymphadenomegaly, and splenomegaly. B. canis infection in dogs is underrecognized. After evaluating serologic data, transmission patterns, and regulations in the context of brucellosis in dogs as an underrecognized zoonosis, we concluded that brucellosis in dogs remains endemic to many parts of the world and will probably remain a threat to human health and animal welfare unless stronger intervention measures are implemented. A first step for limiting disease spread would be implementation of mandatory testing of dogs before interstate or international movement.

Leaching of Mycobacterium avium Subsp paratuberculosis in Soil under In Vitro Conditions

Mycobacterium avium subsp paratuberculosis (Map), the causative agent of Johne's disease, has a robust ability to survive in the environment. However, the ability of Map to migrate through soil to drainage tiles or ground water, leave the farm, and leak into local watersheds is inadequately documented. In order to assess the ability of Map to leach through soil, two laboratory experiments were conducted. In the first study, 8 columns (30 cm long each) of a sandy loam soil were treated with pure cultures of Map. Two soil moisture levels and two Map concentrations were used. The columns were leached with 500 mL of water once a week for three weeks, the leachate was collected, and detection analysis was conducted. In the second experiment, manure from Map negative cows (control) and Map high shedder cows (treatment) were deposited on 8 similar columns and the columns were leached with 500 mL of water once a week for four weeks. Map detection and numeration in leachate samples were done with RT-PCR and culture techniques, respectively. Using RT-PCR, Map could be detected in the leachates in both experiments for several weeks but could only be recovered using culture techniques in experiment one. Combined, these experiments indicate the potential for Map to move through soil as a result of rainfall or irrigation following application.

Isolation and genetic analysis of bovine viral diarrhea virus from infected cattle in indiana

Species and biotype distribution was determined in 44 bovine viral diarrhea virus- (BVDV-) positive samples submitted to the Animal Disease Diagnostic Laboratory (ADDL) in Indiana during 2006–2008. BVDV RNA was detected in the 5′-untranslated region and N^pro region using reverse transcriptase PCR followed by sequencing analysis of the PCR product. Additionally, cases were classified into one of six categories according to history and/or lesions: acute symptomatic, hemorrhagic, respiratory distress, reproductive, persistent infection (PI), and mucosal disease (MD). Of 44 BVDV-positive samples, 33 were noncytopathic (ncp), 10 were cytopathic (cp), and one presented both ncp and cp biotypes. Sequencing analysis demonstrated that all samples belonged to BVDV-1a, BVDV-1b, or BVDV-2. The most common isolate was ncp BVDV-1b, (44%) followed by ncp BVDV-2a (24%). Among the six categories, respiratory clinical signs were the most common (36%) followed by PI (25%) and MD (16%).

Experimental infection of colostrum-deprived calves with bovine viral diarrhea virus type 1a isolated from free-ranging white-tailed deer (Odocoileus virginianus)

The objective of this study was to experimentally infect calves with bovine viral diarrhea virus (BVDV) isolated from free-ranging white-tailed deer. Twelve colostrum-deprived male Holstein calves were used. Eight were inoculated intranasally with a BVDV type 1a isolated from free-ranging white-tailed deer, and the other four were inoculated with the cell culture medium only and served as a control group. Whole blood, saliva, and nasal and rectal secretions were collected on days 0, 3, 7, 10, 14, 17, and 21 after inoculation for virus isolation and real-time reverse-transcriptase polymerase chain reaction (RT-PCR). On days 14 and 21, 4 calves in the infected group and 2 in the control group were euthanized; multiple tissue samples were collected for histopathologic study. Histopathologic changes included thymic atrophy and lymphoid depletion of the Peyer's patches in all 8 infected calves. The RT-PCR gave positive results with the buffy coat of all 8 infected calves, the nasal samples of 7, and the saliva samples of 2. Virus neutralization testing of the serum gave positive results for 4 of the 8 infected calves, and enzyme-linked immunosorbent assay of the serum gave positive results for 3. All of the samples from the control calves yielded negative results.

β2-Adrenoceptor Genotype Affects Vasopressor Requirements during Spinal Anesthesia for Cesarean Delivery

Background

Maternal hypotension is common after spinal anesthesia for cesarean delivery. There is wide variability in the incidence and severity of hypotension and in the response to treatment. The beta2 adrenoceptor (beta2AR) possesses several polymorphic sites. Codons 16 (Arg16Gly) and 27 (Glu27Gln) have been shown to affect desensitization of the receptor. The goal of this study was to determine whether genetic variants of the beta2AR alter incidence of hypotension or the amount of vasopressor treatment required during spinal anesthesia for cesarean delivery.

Methods

One hundred seventy healthy women undergoing elective cesarean delivery were studied. Spinal anesthesia was performed with 12 mg hyperbaric bupivacaine, 25 microg fentanyl, and 200 microg morphine. Hypotension was treated with ephedrine and/or phenylephrine intravenously, and beta2AR genotype at codons 16 and 27 was determined. Analysis of variance was used to compare variables between genotypes, with data expressed as mean +/- SD.

Results

Ephedrine or phenylephrine was used in more than 90% of patients, with no difference in the incidence of hypotension between beta2AR genotypes. However, there was a significant effect of genotype on the amount of vasopressor required. Gly16 homozygotes received significantly less ephedrine (18 +/- 14 mg) than Arg16 homozygotes (28 +/- 13 mg) and Arg16Gly heterozygotes (30 +/- 20 mg; P = 0.0005). Glu27 homozygotes required significantly less ephedrine than Gln 27 homozygotes (14 +/- 13 vs. 30 +/- 19 mg; P = 0.002). Gln27Glu heterozygotes received less ephedrine than Gln27 homozygotes (23 +/- 16 vs. 30 +/- 19 mg; P = 0.03).

Conclusions

Glycine at position 16 and/or glutamate at position 27 of the beta2AR leads to lower vasopressor use for treatment of hypotension during spinal anesthesia.

Prophylactic Ephedrine and Combined Spinal Epidural

OBJECTIVE

Labor analgesia with the combined spinal epidural approach has been associated with maternal hypotension and fetal heart rate (FHR) changes. The purpose of this study was to estimate whether prophylactic intramuscular ephedrine before combined spinal epidural prevents these complications.

METHODS

In a prospective double blind trial, 100 healthy patients with term singletons received intramuscular ephedrine 25 mg or placebo by random allocation before combined spinal epidural. During the first hour after analgesia, maternal heart rate, blood pressure, and need for treatment of significant hypotension were recorded. Fetal heart rate tracings for 1 hour before and for 1 hour after administration of anesthetic were evaluated. Categorical variables were compared with Fisher exact test. Continuous variables were compared with one way analysis of variance for repeated measures. P < .05 was considered significant.

RESULTS

Prophylactic ephedrine reduced the incidence of maternal hypotension after combined spinal epidural (P < .007). In controls, there was a significant increase in the incidence and frequency of late decelerations in the hour following combined spinal epidural compared with the previous hour (P < .005 and P < .01). Compared with controls, there was an increased incidence of fetal tachycardia in patients who received prophylactic ephedrine (P < .006), which was associated with increased FHR reactivity (P < .03).

CONCLUSION

Although prophylactic ephedrine prevents maternal hypotension and fetal late decelerations, it is associated with fetal tachycardia. The value of prophylactic ephedrine at combined spinal epidural should be weighed against potential changes in fetal heart rate patterns.

LEVEL OF EVIDENCE

I.

Dobutamine stress testing in the cardiac catheterization laboratory

Dobutamine stress ventriculography is a safe test that appears to separate groups of patients with and without significant coronary artery stenoses. In this study, all 7 patients with significant coronary artery stenoses who reached a heart rate > or = 110 beats/min had a positive stress test, whereas 9 of 10 control patients had a negative stress test.