Wednesday, July 11, 2007

Turtle-Associated Salmonellosis in Humans United States, 2006-2007

Turtles and other reptiles are reservoirs of Salmonella and have long been a recognized source of Salmonella infection in humans (1)। 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 (2). 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 less than 4 inches in length) in the United States (3). That prohibition led to a substantial decline in human salmonellosis cases associated with turtles (4). However, because the prohibition is not fully enforced and contains exceptions (e.g., sales for educational purposes), human turtle-associated cases continue to occur. 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.

Case history

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>

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