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 outbreak. 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.
Longhill Farms is recalling raw, unpasteurized milk in New Zealand because it has been found to be contaminated with Campylobacter bacteria.
The product is sold in 1 liter or 2 liter glass bottles or in customer supplied containers. Affected products have batch numbers: D-0608 to D-1508 inclusive and use-by dates of Aug. 10 to Aug. 19, inclusive.
It was sold from a vending machine at Longhill Farms in Kawakawa, Northland, and is not exported. There have been no reports of illness. Customers are advised to return the products to Longhill Farms for a full refund.
Milk goes from the cow into a refrigerated vat where it is chilled down to under 4 degrees C, according to Longhill Farms’ website.
“To ensure the freshness and good quality, our milk is tested by Fonterra, MilkTestNZ & Eurofins daily, every 10 days, or seasonal if required. All tests are also monitored by AsureQuality,” according to the farm operators.
From March 2016 in New Zealand, registered farmers have been required to sell raw milk directly from the farm gate or by home delivery. Collection points are no longer allowed. The government is scheduled to review the raw milk policy in November this year, two years after full implementation, to ensure it is working effectively.
The Ministry of Primary Industries (MPI) in New Zealand says raw unpasteurized milk from any animal may be contaminated with bacteria such as Shiga toxin-producing E. coli (STEC), Listeria and Campylobacter.
Between 2009 and 2016 there were 46 outbreaks where consuming raw milk was a risk factor. At least 70 percent involved children, ranging from 1 to 16 years old. Of those outbreaks, 28 were caused by Campylobacter and four by STEC.
MPI said raw milk is risky for anybody but some groups are especially vulnerable, including young children and babies, the elderly, pregnant women, and people with weakened immune systems.
Recommendations for those who choose to consume raw milk or serve it to children or other people include:
Keep it chilled while transporting it home from the farm;
Keep it in the coldest part of your fridge, usually the lower levels are 4 degrees C or cooler;
Throw out if it’s been left out for two or more hours;
When you want to drink your raw milk, heat it until just boiling or to 70 degrees C for one minute before drinking it;
Drink it by the use-by date;
If you’re serving raw milk to friends or visitors, make sure to let them know the risks; and
Buy raw milk only from a registered supplier. From November 2016 forward, producers who sell raw unpasteurized milk have been required to register with MPI.
Consumers who purchased raw whole milk from Conoco View Dairy in Blain, Pennsylvania, should immediately discard the milk, which was sold in plastic half gallons, gallons and glass half gallons with the sell-by date of Feb. 16.
The warning was issued by the state Department of Agriculture, which reported that during routine sampling the product tested positive for campylobacter bacteria.
The plastic half gallon and gallon containers were sold in Perry County at Newport Health Foods, Leid’s Market, Skyline Market, Mountain Supply and The Pantry, as well as Castle Creek Farm in York County.
The glass half gallons were sold at the on-farm market.
Campylobacter can cause gastrointestinal illness including diarrhea, cramps, fever and pain. No illnesses have been attributed to the product, but people who consumed the milk should consult their physicians if they become ill.
In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy.
In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).
Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.
Investigation and Results
On August 23, 2016, El Paso County Public Health notified CDPHE of two culture-confirmed cases of C. jejuni infection; campylobacteriosis is a reportable disease in Colorado. Both patients reported drinking unpasteurized milk from the same herdshare dairy in Pueblo County. Since 2005, obtaining raw milk by joining a herdshare program has been legal for Colorado residents, but selling raw milk is illegal. By purchasing a share of a herd (cows or goats), shareholders are entitled to a portion of the raw milk.
Because the prevalence of consuming unpasteurized milk is low (2.4% in Colorado, 2006–2007 FoodNet Population Survey; 3.1%, 2009 Colorado Behavioral Risk Factor Surveillance System), two cases of enteric illness with a common exposure to raw milk are unlikely to occur by chance (3,4). In this outbreak, a confirmed case was defined as diarrheal illness with onset on or after August 1, 2016, in a person with known consumption of unpasteurized milk from the same herdshare dairy and culture-confirmed C. jejuni infection. A probable case was defined as diarrhea onset on or after August 1, lasting 1 or more days, in a person with either known consumption of milk from the same herdshare dairy or with an epidemiologic link to a confirmed case.
Cases were identified through routine passive reporting with follow-up interviews, a Health Alert Network broadcast to area providers, and attempts to contact all shareholders. A public health order was issued to obtain a list of shareholders with their contact information after it was not provided by the dairy within 5 days of the initial request. CDPHE attempted to contact shareholders to inform them about the outbreak and assess possible illness. Up to three calls were made to each shareholder household. Epidemiologists contacted laboratories to request that isolates from potential outbreak-associated cases be forwarded to the state public health laboratory.
Among 91 (53%) of 171 shareholder households that responded to requests for follow-up interviews, representing 207 persons in five or more Colorado counties, 12 confirmed and five probable cases were identified (Figure). Among confirmed cases, patients ranged in age from 12 to 68 years (median = 58 years); nine were male. Duration of illness ranged from 3 to >10 days. One hospitalization occurred; there were no deaths. In addition to diarrhea, among the 12 confirmed cases, the majority of patients also experienced fever (10), abdominal pain or cramps (eight), headache (eight), and myalgia (seven); vomiting and bloody diarrhea were reported less frequently (in five and four persons, respectively).
Four milk samples were tested for C. jejuni; pathogen identification and PFGE were performed on available isolates from persons epidemiologically linked to the outbreak. C. jejuni with one of two outbreak PFGE patterns (PulseNet DBRS16.0008 using the enzyme Sma and PulseNet DBRK02.1272 or DBRK02.0028 using the enzyme Kpn) was confirmed in 10 isolates that were available at the public health laboratory and two of the four raw milk samples. The National Antimicrobial Resistance Monitoring System performed antimicrobial susceptibility tests on five representative isolates; all were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).
Public health responses to this outbreak consisted of notifying shareholders about the outbreak on three occasions and requiring the dairy to provide additional written notification about the outbreak at milk distribution points. A press release was issued by two LPHAs in response to detecting at least one infection in a person who was not a shareholder but was given milk by shareholders. In addition, a number of shareholders reported sharing milk with nonshareholders who might have been unaware of the outbreak. Although milk sample results were positive for C. jejuni, CDPHE did not close the dairy or stop distribution of its milk because without pasteurization CDPHE could not create standards for safely reopening the dairy (5). Shareholders were, however, urged to discard raw milk distributed since August 1 and were reminded that Colorado statute prohibits redistribution of raw milk.
Raw milk from a herdshare dairy was the source of this outbreak of C. jejuni infections, and the investigation highlighted the difficulties inherent in addressing an outbreak related to unpasteurized milk from a herdshare dairy. During three previous herdshare-associated outbreaks in Colorado, public health authorities temporarily took action to stop milk distribution until a series of negative tests were obtained from the milk (Alicia Cronquist, CDPHE, personal communication, December 2017). However, because CDPHE could not ensure that unpasteurized milk would be safe in the future, the decision was made not to close the dairy during this outbreak. In addition, CDPHE’s Division of Environmental Health and Sustainability chose not to make formal recommendations on the dairy’s processes because no protocol improvements short of pasteurization could ensure the product’s safety, even with improved sanitation (5).
All tested isolates’ resistance to three antibiotics was concerning, particularly as fluoroquinolones are frequently used to treat Campylobacter infections in those cases where treatment is indicated. Treatment of antibiotic-resistant Campylobacter infections might be more difficult, of longer duration, and possibly lead to more severe illness than treatment of nonresistant Campylobacter infections (6–8). In 2015, approximately 25.3% of U.S. C. jejuni isolates were resistant to ciprofloxacin, an increase from 21.6% a decade earlier (1).
In collaboration with LPHAs, CDPHE is creating guidelines to address future outbreaks related to raw milk from herdshares. As more states legalize the sale or other distribution of unpasteurized milk, the number of associated outbreaks will likely increase (9,10). The role of public health in responding to raw milk–related outbreaks should be further defined. State-level guidelines might assist with this process.
Corresponding author: Alexis Burakoff, email@example.com, 303-692-2745.
1Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 2Colorado Department of Public Health and Environment, Denver, Colorado; 3Pueblo City-County Health Department, Pueblo, Colorado; 4El Paso County Public Health, Colorado Springs, Colorado; 5Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC.
CDC. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): human isolates surveillance report for 2015 (final report). Atlanta, Georgia: US Department of Health and Human Services, CDC; 2018.
CDC. Food safety: raw milk. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html
CDC. Foodborne diseases active surveillance network (FoodNet) population survey atlas of exposures, 2006–2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. https://www.cdc.gov/foodnet/PDFs/FNExpAtl03022011.pdf
Colorado Department of Public Health and Environment. Colorado Behavioral Risk Factor Surveillance System, 2009. [Data on raw milk]. Denver, CO: Colorado Department of Public Health and Environment; 2009. http://www.chd.dphe.state.co.us/Resources/brfss/BRFSS2009results_raw%20milk.pdf
Longenberger AH, Palumbo AJ, Chu AK, Moll ME, Weltman A, Ostroff SM. Campylobacter jejuni infections associated with unpasteurized milk—multiple states, 2012. Clin Infect Dis 2013;57:263–6. CrossRef PubMed
Evans MR, Northey G, Sarvotham TS, Rigby CJ, Hopkins AL, Thomas DR. Short-term and medium-term clinical outcomes of quinolone-resistant Campylobacter infection. Clin Infect Dis 2009;48:1500–6. CrossRef PubMed
Helms M, Simonsen J, Olsen KE, Mølbak K. Adverse health events associated with antimicrobial drug resistance in Campylobacter species: a registry-based cohort study. J Infect Dis 2005;191:1050–5. CrossRef PubMed
Nelson JM, Smith KE, Vugia DJ, et al. Prolonged diarrhea due to ciprofloxacin-resistant Campylobacter infection. J Infect Dis 2004;190:1150–7. CrossRef PubMed
Langer AJ, Ayers T, Grass J, Lynch M, Angulo FJ, Mahon BE. Nonpasteurized dairy products, disease outbreaks, and state laws—United States, 1993–2006. Emerg Infect Dis 2012;18:385–91. CrossRef PubMed
Mungai EA, Behravesh CB, Gould LH. Increased outbreaks associated with nonpasteurized milk, United States, 2007–2012. Emerg Infect Dis 2015;21:119–22. CrossRef PubMed
Outbreak of Fluoroquinolone-Resistant Campylobacter jejuni Infections Associated with Raw Milk Consumption from a Herdshare Dairy — Colorado, 2016
Morbidity and Mortality Weekly Report; February 9, 2018; 67(5);146–148
Alexis Burakoff, MD; Kerri Brown, MSPH; Joyce Knutsen; Christina Hopewell; Shannon Rowe, MPH; Christy Bennett; Alicia Cronquist, MPH
CDC, several states, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS) investigated a multistate outbreak of multidrug-resistant Campylobacter infections. Epidemiologic and laboratory evidence indicated that contact with puppies sold through Petland stores were a likely source of this outbreak. This outbreak investigation is over. Illnesses could continue to occur because people may be unaware of the risk of Campylobacter infections from puppies and dogs.
A total of 113 people with laboratory-confirmed infections or symptoms consistent with Campylobacterinfection were linked to this outbreak. Illnesses were reported from 17 states. Illnesses started on dates ranging from January 12, 2016 to January 7, 2018. Ill people ranged in age from less than 1 year to 86, with a median age of 27. Sixty-three percent of ill people were female. Of 103 people with available information, 23 (22%) were hospitalized. No deaths were reported. Whole genome sequencing (WGS) showed that isolates from people infected with Campylobacter were closely related genetically. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection.
Campylobacter bacteria isolated from clinical samples from people sickened in this outbreak were resistant to commonly recommended, first-line antibiotics. This means it may be difficult to treat these infections with the antibiotics usually prescribed for Campylobacter infections. Antibiotic resistance may be associated with increased risk of hospitalization, development of a bloodstream infection, or treatment failure in patients. Using WGS, we identified multiple antimicrobial resistance genes and mutations in most isolates from 38 ill people and 10 puppies in this outbreak. This finding matched results from standard antibiotic susceptibility testing methods used by CDC’s National Antimicrobial Resistance Monitoring System laboratory on isolates from five ill people and seven puppies in this outbreak. The 12 isolates tested by standard methods were resistant to azithromycin, ciprofloxacin, clindamycin, erythromycin, nalidixic acid, telithromycin, and tetracycline. In addition, 10 were resistant to gentamicin, and 2 were resistant to florfenicol.
In interviews, ill people answered questions about the foods they ate and any animal contact in the week before they became ill. Ninety-nine percent of people reported contact with a puppy in the week before illness started, and 87% reported they had contact with a puppy from Petland stores, or had contact with a person who became sick after contact with a puppy from a Petland store. Twenty-five ill people worked at Petland stores.
During the investigation, officials collected samples from pet store puppies for laboratory testing and identified the outbreak strain of Campylobacter in the samples. WGS showed that the Campylobacterisolates from sick people in this outbreak and isolates from pet store puppies were closely related genetically, providing additional evidence that people got sick from contact with pet store puppies.
Ill people reported contact with different breeds of puppies at different store locations in several states. The investigation did not identify a common breeder where puppies infected with the outbreak strain of Campylobacter originated. Puppies in this outbreak may have become infected at various points along the distribution chain when they had contact with infected puppies from other breeders or distributors during transport to pet store locations. Enhanced infection prevention measures throughout the distribution chain may help reduce the spread of Campylobacter infections among puppies.
This multidrug-resistant outbreak highlights the need for responsible use of antibiotics in pets. Education about best practices for Campylobacter disease prevention, diarrhea management in puppies, and responsible antibiotic use is essential throughout the distribution chain to help prevent the emergence and spread of antibiotic resistance. Pet owners should be aware that any puppy or dog, regardless of where it is purchased or adopted, may carry germs like Campylobacter that can make people sick. Always wash your hands thoroughly with soap and water right after touching puppies and dogs or after picking up their poop. Work with your veterinarian to keep your animal healthy to prevent disease. More information about how to prevent illness when handling puppies and dogs is available for pet owners.
CDC, several states, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS) are investigating a multistate outbreak of multidrug-resistant Campylobacter infections.
Campylobacter bacteria isolated from clinical samples from people sickened in this outbreak are resistant to commonly recommended, first-line antibiotics. This means it may be difficult to treat these infections with the antibiotics usually prescribed for Campylobacter infections.
Since the last update on October 30, 2017, 30 more ill people have been reported from 11 states. The most recent illness began on October 23, 2017.
As of December 12, 2017, 97 people with laboratory-confirmed infections or symptoms consistent with Campylobacter infection have been linked to this outbreak. Illnesses have been reported from 17 states.
Twenty-two (24%) of 91 ill people with available information have been hospitalized. No deaths have been reported.
Illnesses started on dates ranging from June 17, 2016 to October 23, 2017.
Epidemiologic and laboratory evidence indicates that contact with puppies sold through Petland stores is a likely source of this outbreak.
According to Poultry World, levels of campylobacter in chicken sold by the UK’s major retailers continue to fall, according to statistics released by the Food Standards Agency on Wednesday 18 October.
Just 5.9% of chickens had high levels of campylobacter in the survey – which sampled 1,437 birds between April and July – down from 20.1% for the same period in 2014.
The FSA announced last month that it was changing its annual campylobacter retail survey with the top 9 retailers publishing their own results. Instead, the Agency would concentrate on smaller retailers, independent traders and markets stalls where levels of campylobacter have been stubbornly high.
Full results from the third annual retail survey, running from August 2016 to July 2017, showed:
- The figure for high-level campylobacter prevalence (more than 1,000 cfu/g) among the top nine retailers (based on market share) was 5.6%
- The ‘Others’ group, consisting of smaller retailers and butchers, had a significantly higher prevalence at 17.1%
- The retailers with significantly lower prevalence than the average among all retailers were Morrisons (2.9%), Tesco (4.2%) and Waitrose (2.7%)
- There was a significant fall in the percentage of chickens positive for campylobacter at any level – down from 73.2% in 2014/5 to 54% in 2016/7.
According to the CDC, at least 39 people across seven states have confirmed or suspected cases of Campylobacter bacteria, which can cause diarrhea, abdominal pain and fever. While the investigation is ongoing, federal officials have linked it to contact with puppies sold by Petland, a chain of pet stores based in Ohio.
Twelve of the confirmed cases are in Petland employees, and 27 other people who fell ill either visited a Petland, recently purchased a puppy there, or visited or live in a home with a Petland puppy. According to the CDC’s announcement, nine people have been hospitalized and there are no reported deaths.
The State Department of Agriculture and Markets announced Monday that milk from Martin Yoder Farm, 2594 Murdock Rd., was contaminated by Campylobacter jejuni, a bacteria that is a common cause of food poisoning, in samples conducted last week.
Ag & Markets Commissioner Richard A. Ball warned consumers in Orleans County and the surrounding area not to consume unpasteurized raw milk from the farm, but noted that no illnesses have been associated with the product.
“The Department recommends that any consumers who purchased raw milk from the Martin Yoder Farm immediately dispose of it,” the department said in a statement.
According to Ag & Markets, symptoms from Campylobacter jejuni exposure typically develop within two to five days after exposure and include abdominal pain, diarrhea, fever and malaise. These symptoms generally last about seven days but Campylobacter jejuni has been linked to incidents of Guillain-Barre syndrome, which may occur weeks after exposure.
Inspectors discovered the bacteria in a preliminary test completed on Sept. 13, and the farm immediately voluntarily suspended sales of the product. Further laboratory testing, completed on Friday, confirmed the presence of Campylobacter jejuni in the raw milk sample.
The farm, founded by the late Martin Yoder, is part of an Amish community that came to northwestern Orleans County from families in Ohio. Yoder’s farm, as of 2013, had 45-head of grazing cows on a fully-organic operation.
Consumers were able to purchase raw milk directly from the farm, but those sales have been prohibited until additional sampling is completed that confirms the product is bacteria-free.
Unpasteurized raw milk is supported by some consumers as a healthier and less industrial product, but skipping the heating process does not eliminate the possibility for bacteria. Consumers who may have purchased this product and have questions may call the Department at (518) 457-1772.
The campylobacter bacteria, often found in raw poultry, fresh produce and unpasteurized milk, was the leading cause of food-related infection in 2016, according to new national estimates from the Centers for Disease Control and Prevention (CDC).
Campylobacter is one of four primary causes of diarrheal diseases, which affect more than 500 million people worldwide every year, notes the World Health Organization (WHO). Upon infection, it produces abdominal pain, diarrhea, fever, headache and nausea, with symptoms that can last between three to six days.
The bacteria is found naturally in the intestines of chickens, cattle and other animals, and poor cooking hygiene of food derived from these animals can lead to infection, says the WHO.