Backup Documents 10/08/2019 Item #12A CDC Presentation ML (2)Pet stores,
Center For Disease Control and
Campylobacter jejuni
1
•In August 2017, the Florida Department of Health notified CDC of six
Campylobacter jejuni infections linked to company A, a national pet store
chain based in Ohio.
•CDC examined whole-genome sequencing (WGS) data and identified six
isolates from company A puppies in Florida that were highly related to an
isolate from a company A customer in Ohio.
•By February 28, 2018, a total of 118 persons meeting the case definition
for Campylobacter infection, including 29 pet store employees, were
reported from 18 states.
Multidrug-Resistant Campylobacter jejuni Outbreak
Linked to Puppy Exposure —United States, 2016–
2018 Final Report
2
States Case Count
Connecticut 2
Florida 21
Georgia 4
Illinois 11
Kansas 7
Massachusetts 2
Maryland 5
Missouri 2
New Hampshire 2
New York 2
Ohio 32
Oklahoma 1
Pennsylvania 6
Tennessee 2
Utah 3
Wisconsin 8
Wyoming 3
Total 113
Case Count Map
3
4
US Department of Health and Human
Services/Centers for Disease Control and
Prevention
MMWR / September 21, 2018 / Vol. 67 / No.
37
Morbidity and Mortality Weekly Report
1032 MMWR / September 21, 2018 / Vol. 67 / No. 37 US Department of Health and Human Services/Centers for Disease Control and Prevention
Multidrug-Resistant Campylobacter jejuni Outbreak Linked to Puppy
Exposure — United States, 2016–2018
Martha P. Montgomery, MD1,2; Scott Robertson, DVM2,3; Lia Koski, MPH3,4; Ellen Salehi, MPH1; Lauren M. Stevenson, MHS3,5; Rachel Silver, MPH3,4; Preethi Sundararaman, MPH3,6; Amber Singh, DVM1; Lavin A. Joseph, MS3; Mary Beth Weisner7; Eric Brandt1; Melanie Prarat, MS7; Rick Bokanyi, PhD1; Jessica C. Chen, PhD3,8; Jason P. Folster, PhD3; Christy T. Bennett3,8; Louise K. Francois Watkins, MD3; Rachael D. Aubert, PhD3;
Alvina Chu, MHS9; Jennifer Jackson, MPH9; Jason Blanton, PhD10; Amber Ginn10; Kirtana Ramadugu, MPH10; Danielle Stanek, DVM10; Jamie DeMent, MNS10; Jing Cui, DVM7; Yan Zhang, DVM, PhD7; Colin Basler, DVM3; Cindy R. Friedman, MD3; Aimee L. Geissler, PhD3; Samuel J. Crowe, PhD3; Natasha Dowell, MPH3,8; Staci Dixon, MA3; Laura Whitlock, MPH3; Ian Williams, PhD3; Michael A. Jhung, MD3; Megin C. Nichols, DVM3; Sietske de Fijter, MS1; Mark E. Laughlin, DVM3
Campylobacter causes an estimated 1.3 million diarrheal illnesses
in the United States annually (1). In August 2017, the Florida
Department of Health notified CDC of six Campylobacter jejuni
infections linked to company A, a national pet store chain based
in Ohio. CDC examined whole-genome sequencing (WGS) data
and identified six isolates from company A puppies in Florida that
were highly related to an isolate from a company A customer in
Ohio. This information prompted a multistate investigation by
local and state health and agriculture departments and CDC to
identify the outbreak source and prevent additional illness. Health
officials from six states visited pet stores to collect puppy fecal
samples, antibiotic records, and traceback information. Nationally,
118 persons, including 29 pet store employees, in 18 states were
identified with illness onset during January 5, 2016–February 4,
2018. In total, six pet store companies were linked to the out-
break. Outbreak isolates were resistant by antibiotic susceptibility
testing to all antibiotics commonly used to treat Campylobacter
infections, including macrolides and quinolones. Store record
reviews revealed that among 149 investigated puppies, 142 (95%)
received one or more courses of antibiotics, raising concern that
antibiotic use might have led to development of resistance. Public
health authorities issued infection prevention recommendations
to affected pet stores and recommendations for testing puppies to
veterinarians. This outbreak demonstrates that puppies can be a
source of multidrug-resistant Campylobacter infections in humans,
warranting a closer look at antimicrobial use in the commercial dog industry.
Epidemiologic Investigation
Campylobacteriosis became a nationally notifiable condition in
2015, and many states routinely interview patients with campylo-
bacteriosis.* For this investigation, a standardized, supplemental
questionnaire was used by state and local health departments to collect dog exposure information from persons with Campylobacter
infection who reported recent dog or pet store exposure during
routine interview. A case definition relevant to this outbreak (Box)
was developed to aid in case finding and characterization.
* https://wwwn.cdc.gov/nndss/conditions/campylobacteriosis/case-definition/2015/.
By February 28, 2018, a total of 118 persons meeting the case
definition for Campylobacter infection, including 29 pet store
employees, were reported from 18 states.† Age was available for 115
persons and ranged from <1 year to 85 years (median = 26 years);
74 of 115 (63%) infected persons were female. Among 107 persons
for whom hospitalization information was available, 26 (24%)
were hospitalized; no deaths occurred. In total, 105 of 106 (99%)
infected persons reported dog exposure, including 101 (95%) who
had contact with a pet store puppy (Table). Eight patients reported
† Connecticut (two patients), Florida (20), Georgia (five), Illinois (11), Kansas
(seven), Massachusetts (two), Maryland (five), Michigan (one), Missouri (two), New Hampshire (two), New York (two), Ohio (34), Oklahoma (one),
Pennsylvania (six), Tennessee (two), Utah (four), Wisconsin (nine), and Wyoming (three).
BOX. Case definition for multidrug-resistant Campylobacter jejuni outbreak linked to puppy exposure — United States, 2016–2018*
Confirmed case
Campylobacteriosis in a patient with onset during
January 1, 2016–February 28, 2018 who had either
• A clinical isolate closely related* to the outbreak
strains by whole-genome sequencing (WGS), or
• Other laboratory evidence (culture or culture-
independent diagnostic testing) of Campylobacter
infection and worked in, visited, or had contact with a
puppy from a pet store within 7 days before illness onset.
Probable case
An illness compatible with Campylobacter infection in a
patient who had worked in, visited, or had contact with a
puppy from a pet store within 7 days before illness onset, but
without laboratory confirmation of Campylobacter infection.
Exclusion criteria
Exposure criteria met, but isolate unrelated to the out-
break strains by WGS.
* Relatedness of outbreak strains was determined by whole-genome multilocus sequence typing (wgMLST). Because no published wgMLST cutoff values exist, genetic relatedness was determined based on epidemiologic concordance and comparison with background Campylobacter jejuni isolates.
Multidrug-Resistant Campylobacter jejuni
Outbreak Linked to Puppy Exposure —United
States, 2016–2018 Final Report
5
•“Epidemiologic, laboratory, and trace-back evidence indicates
that puppies sold through the commercial dog industry, an
uncommon source of Campylobacter outbreaks, were the source
of a multistate outbreak of multidrug-resistant Campylobacter
infections.”
•“However, potential for Campylobacter transmission among puppies
exists because puppies from different breeders were co-mingled at
distributors, during transport, and in stores.”
Multidrug-Resistant Campylobacter jejuni Outbreak Linked
to Puppy Exposure —United States, 2016–2018 Final
Report 6
•“This evidence, combined with the prolonged
nature of the outbreak and the potential for puppy co-mingling,
indicates a potential for continued transmission of
multidrug-resistant Campylobacter industrywide, including at
breeders, distributors, transporters, and stores, and ultimately
in customers’ homes.”
•“Although the investigation is completed,
the risk for multidrug-resistant Campylobacter transmission to
employees and consumers continues.”
Multidrug-Resistant Campylobacter jejuni Outbreak Linked
to Puppy Exposure —United States, 2016–2018 Final
Report 7
•“Of significant concern, Petland also did not appear to fully cooperate with the CDC during the
investigation.Emails obtained via public records requests indicate that Petland did not allow CDC to
share traceback information with state health department partners and that Petland failed to provide
requested information to the CDC that would have assisted with their investigation. CDC noted in an
email to Petland attorneys that the agency had requested specific information from Petland on several
occasions and that: ‘Any further delay in providing this information to CDC hinders our ability to
conduct a thorough and expedient investigation which in turn hinders our ability to prevent potential
additional infections with this multidrug resistant pathogen’.”
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Pet Industry’s Inaction Contributed to the Ongoing Threat
CDC internal email ”During the course of this
investigation, information
was collected for 22
Campylobacter-positive
puppies…These animals
were traced back through
8 distributors to 30
individual breeders across
8 states. 9 breeders are
located in Indiana as well
as 1 distributor. The names
and addresses of the dog
breeding facilities are in
the attached document.”9
According to the CDC internal email, Levi Graber of Blue Ribbon Puppies was one
of the distributors where Campylobacter could be traced back.
10
9 breeders are located in Indiana as well as 1 distributor.
“The names and addresses of the dog breeding facilities are in the attached document.”