Sunday, July 22, 2007


Turtle-associated salmonellosis in humans--United States, 2006-2007

Turtle-associated salmonellosis in humans--United States, 2006-2007

MMWR Morb Mortal Wkly Rep. 2007 Jul

Centers for Disease Control and Prevention (CDC).

Turtles and other reptiles are reservoirs of Salmonella and have long been a recognized source of Salmonella infection in humans. Small turtles have posed a particular danger to young children because these turtles might not be perceived as health hazards and can be handled like toys. Salmonella infections in children can be severe and can result in hospitalization and occasionally in death.

The association between Salmonella infection in children and exposure to turtles led to a 1975 law prohibiting the sale or distribution of small turtles (i.e., those with a carapace of <4>

This report describes several recent cases of turtle-associated salmonellosis reported to CDC by state and local health departments since September 2006, including a fatal case in an infant. These cases illustrate that small turtles remain a source of human Salmonella infections. Although ongoing public education measures aimed at preventing reptile-acquired Salmonella infections are helpful, prohibiting the sale of small turtles likely remains the most effective public health action to prevent turtle-associated salmonellosis.

Salmonella Pomona Infections --- Multiple States

On February 20, 2007, a female infant aged 3 weeks with a 1-day history of poor feeding and lethargy was evaluated in an emergency department at a Florida hospital. The patient was transferred immediately to a tertiary-care pediatric hospital; on arrival, she was febrile and in septic shock. Antibiotics were administered. She died on March 1. Cultures of cerebrospinal fluid and blood samples yielded Salmonella serotype Pomona.

The parents of the patient were interviewed by the Florida Department of Health. A family friend had purchased a small turtle with a carapace of 1.25 inches from a flea market in north central Florida in mid-November 2006. The turtle was purchased as a pet and given to the patient's family in late January 2007. After the death of the infant, laboratory testing of the turtle and its environment was performed by the Florida Bureau of Laboratories. A fecal sample from the turtle yielded S. Pomona. The S. Pomona isolates from the patient and the turtle were indistinguishable by pulsed-field gel electrophoresis (PFGE).

A total of 19 other S. Pomona isolates from 19 patients in 11 states (Alabama, Arizona, California, Florida, Massachusetts, Nevada, New Mexico, New York, Pennsylvania, South Carolina, and Texas) with a PFGE pattern closely related to the isolate from the Florida patient and turtle were submitted to PulseNet,* with isolation dates ranging from October 2, 2006 to April 23, 2007. To determine whether these cases of S. Pomona infection were associated with turtle exposure, CDC staff, through OutbreakNet,† coordinated an investigation with state and city health departments, which conducted interviews with patients or their parents or guardians. The median age of patients was 3 years (range: 2 months--59 years). Illness onsets occurred during September 30, 2006--April 23, 2007. Of the 15 interviewed patients, 12 (80%) had direct or indirect contact with a turtle within 7 days before illness onset. Among those 12 patients, nine (75%) had turtles as household pets. The duration of turtle ownership before illness onset ranged from <1>

Salmonella I 4,[5],12:i:- Infections --- Ohio and Tennessee

Ohio. In September 2006, a previously healthy boy aged 8 years had onset of bloody diarrhea with cramping, headache, vomiting, and fever of 101.0°F (38.3°C). The Ohio Department of Health Laboratory isolated Salmonella I 4,[5],12:i:- from a stool specimen. The patient recovered at home after 3 days. No family member reported a similar illness while the patient was ill. However, the next month, the patient's brother, aged 12 years, had onset of bloody diarrhea; a stool specimen yielded Salmonella I 4,[5],12:i:-.

Two weeks before the first patient became ill, the family had purchased three red-eared slider turtles as pets, each with a carapace of <4>

County health officials visited the patient's home and collected a stool specimen from the child, an external surface swab from both turtles, and a water sample from the aquarium. Specimens from the child and turtles yielded Salmonella I 4,[5],12:i:- isolates, which were indistinguishable from the mother's isolate based on PFGE performed at the Tennessee Department of Health Laboratory. The aquarium water sample yielded Salmonella Pomona.

Reported by: D Chatfield, MSEH, Clark County Combined Health District; K Winpisinger, MS, Ohio Dept of Health. P Sumner, N Grossman, MD, Marion County Health Dept; R Hammond, PhD, D Windham, P Fiorella, PhD, Florida Dept of Health. ME Ress, Sullivan County Regional Health Dept; H Hardin, MPA, Tennessee Dept of Health Laboratory Svcs; J Dunn, DVM, Tennessee Dept of Health. M Iwamoto, MD, T-A Nguyen, MPH, N Patel, J Lockett, M Sotir, PhD, Div of Foodborne, Bacterial, and Mycotic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC.

Editorial Note:

Despite a federal law prohibiting the sale or distribution of small turtles as pets, such sales still occur. Salmonella can be transmitted to humans by direct or indirect contact with a turtle or its feces. No reliable methods are available to guarantee that a turtle is free of Salmonella. Most turtles are colonized with Salmonella and shed the bacteria intermittently in their feces.

Certain techniques to eliminate Salmonella from turtles have been unsuccessful and have resulted in Salmonella isolates with increased antibiotic resistance (7). In addition, turtles not shedding Salmonella species under normal circumstances have been shown to actively shed the bacteria when stressed (8). Moreover, water in turtle bowls or aquariums can amplify any Salmonella shed by turtles. For these reasons, all turtles, regardless of carapace size, should be handled as though they are infected with Salmonella.

In 1980, CDC estimated that the 1975 federal prohibition of the sale of small turtles in the United States had prevented an estimated 100,000 cases of turtle-associated salmonellosis in children aged 1--9 years in 1976 (4). These additional cases might have resulted in approximately 1,500 hospitalizations and 40 deaths that year (4--6). Reductions in human illnesses associated with turtle-associated Salmonella strains were observed in other countries when similar small turtle sale prohibitions were enacted (9,10). When Sweden joined the European Union in 1996 and sale prohibitions were repealed, the number of human salmonellosis cases from reptile-associated Salmonella strains increased substantially, with children being most affected (9).

Centers for Disease Control


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