clinicalreport exposure to nontraditional pets at home and ... · animals,” “pets,”...

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Exposure to Nontraditional Pets atHome and to Animals in PublicSettings Risks to ChildrenK Larry Pickering MD Nina Marano DVM MPH A Joseph Bocchini MD J Frederick Angulo DVM PhD and the Committee onInfectious Diseases

abstract

Exposure to animals can provide many benefits during the growth anddevelopment of children However there are potential risks associated withanimal exposures including exposure to nontraditional pets in the home andanimals in public settings Educational materials regulations and guidelineshave been developed to minimize these risks Pediatricians veterinarians andother health care professionals can provide advice on selection of appropriatepets as well as prevention of disease transmission from nontraditional petsand when children contact animals in public settings

INTRODUCTION

The majority of households in the United States own 1 or more pets Innational surveys conducted by the American Pet Products ManufacturersAssociation the percentage of US households that have 1 or more petsincreased from 56 in 1998 to 63 (711 million homes) in 20071 Dogs areowned by 448 million households cats are owned by 384 million freshwaterfish are owned by 142 million birds are owned by 64 million small animalsare owned by 60 million horses are owned by 43 million and saltwater fishare owned by 08 million Total US pet industry expenditure in 2007 isestimated at $408 billion1 In recent years the number of families that havechosen nontraditional pets has increased1

Many pet owners and people in the process of choosing a pet often areunaware of the potential risks posed by certain animals especiallynontraditional pets These risks are associated with changes in physical andbehavioral characteristics as young animals reach maturity Pediatriciansveterinarians and other health care professionals are in a unique position tooffer advice on proper pet selection to provide information about safe petownership and responsibility and to minimize risks to infants and children

In addition to exposure to animals in their homes children may come incontact with animals in a variety of public settings2 Although there aremany benefits to experiences with animals outside the home contact with

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmedrevised or retired at or before that time

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care Variations takinginto account individual circumstances may be appropriate

DOI httpsdoiorg101542peds2008-1942

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2020 by the American Academy of Pediatrics

To cite Larry K Joseph A Frederick J AAP and theCommittee on Infectious Diseases Exposure toNontraditional Pets at Home and to Animals in PublicSettings Risks to Children Pediatrics 2008122(4)e20081942

PEDIATRICS Volume 122 number 4 October 2008e20081942 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on February 21 2021wwwaappublicationsorgnewsDownloaded from

animals in public settings also can beassociated with significant risks tochildren including infections andinjuries These potential risks areenhanced when there is an inadequateunderstanding of disease transmissionmethods of preventing transmissionanimal behavior or appropriatefacilities for animals

This report deals with the potentialexposure of infants children andadolescents to nontraditional pets inthe home and to animals in publicsettings The objectives of this reportare to (1) summarize informationregarding emerging and reemerginginfectious diseases injuries andallergies associated with exposure tonontraditional pets in the home and toanimals in a variety of public settings(2) outline regulations andrecommendations applicable to theseexposures and (3) define measures tominimize or prevent illness and injuryin children from exposure to theseanimals and cite resources foradditional information for health careprofessionals and families

METHODS

To identify original researchpublications and review articlesdealing with infections injury andallergies in children resulting fromnontraditional pets including exoticanimals in the home and fromanimals in public settings a search ofthe National Library of MedicinersquosMedline database was performed byusing PubMed and the CochraneLibrary was searched for articlespublished between 1975 and 2007

The terms ldquonontraditional petsrdquo ldquoexoticanimalsrdquo ldquofarm animalsrdquo ldquopetsrdquoldquowildlife hybridsrdquo ldquoindigenous wildliferdquoldquoreptilesrdquo and ldquorodentsrdquo were selectedas Medical Subject Headings (MeSH)and text words were combined in thesearch strategy In addition the ldquorelatedlinksrdquo option on PubMed was usedReferences in all relevant publishedarticles including reviews letterscommentaries and Web sites alsowere reviewed to identify originalresearch

Studies were assessed as to whetherthey should be included in this reviewon the basis of their reporting orsummarizing original data thatexamined infections or injuries inchildren resulting from nontraditionalpets in the home or animals in publicsettings Previously publishedrecommendations to preventinfections and injuries were reviewed

For the purpose of this reportnontraditional pets include exoticanimals defined either as importednonnative species or species thatoriginally were nonnative but noware bred in the United Statesindigenous wildlife and wildlifehybrids (wildlife crossbred withdomestic animals producing offspringknown as hybrids) The definition ofnontraditional pets includes reptilesand certain species of mammals

NONTRADITIONAL PETS

Nontraditional pets are increasing inpopularity among a pet-loving publicas lifestyle choices of owners dictate theneed for smaller or more unusual pets

Table 1 provides examples of animalsthat are considered nontraditional petsas well as animals to which childrenmay be exposed in public settings

Since 1992 the number of exoticanimals available in the United Stateshas increased 751 In 2005 87 991mammals (including 29 species ofrodents) 13 million reptiles and 203million fish were imported legally intothe United States The US Fish andWildlife Service estimates that in 2002365 000 birds were imported legallyReptiles are now in 44 million homes1

In addition there is a worldwide illegaltrade of exotic animals estimated at $6to $10 billion dollars annually3ndash5 onlyexceeded by the trafficking of arms anddrugs This illegal trade subverts rulesestablished by regulatory agencies toreduce introduction of disease andpotentially dangerous animals throughimportation restriction inspectionandor quarantine5

A number of public health concerns arerelated to human contact withnontraditional pets and specifically toexotic animals Most importednonnative species are caught in the wildrather than bred in captivity Healthscreening often is not performed beforeshipment of these animals to the UnitedStates and there is mixing of animalspecies in holding locations includinganimals that might be ill or incubatingillness or carriers of potentialpathogens In addition the significantwildlife black market through whicha large number of exotic animals enterthe United States compounds the risksof introduction of zoonoses6

TABLE 1 Animals That Are Considered Nontraditional Pets andor Animals That May Be Encountered in Public Settings

Categories Examples

Amphibians Frogs toads newts salamandersFish Many typesMammals wildlife Raccoons skunks foxes coyotes civet cats tigers lions bears nonhuman primatesDomesticated livestock Cattle pigs goats sheepEquines Horses mules donkeys zebrasWeasels Ferrets minks sables skunksLagomorphs Rabbits hares pikasRodents Mice rats hamsters gerbils guinea pigs chinchillas gophers lemmings squirrels chipmunks prairie dogs hedgehogsFeral animals Cats dogs horses swineReptiles Turtles lizards iguanas snakes alligators

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on February 21 2021wwwaappublicationsorgnewsDownloaded from

Despite the popularity ofnontraditional pets after makingthe initial decision to acquirea nontraditional pet owners maydiscover that they are unable toprovide the animal with theenvironment or nutrition required fora healthy life and often subsequentlyabandon or release the animal intothe wild which poses risks forzoonotic disease and injury topeople and other animals7

ZOONOSES ASSOCIATED WITHNONTRADITIONAL PETS

Zoonotic diseases or zoonoses areinfections transmitted between othervertebrate animals and humans Mostemerging infectious diseases inhumans are zoonotic in origin68ndash11 Alist of 1415 human pathogensdemonstrates that 61 are known tobe zoonotic and pathogens withmultiple host species are twice as likelyto be associated with an emerginginfectious disease9 From 1980 to 2003more than 35 new infectious diseaseshave emerged in humans many ofwhich are zoonoses10 The leadingcauses of their emergence are humanbehavior (travel and leisure activitiespreferences for pet ownership) andmodifications of natural habitatsincluding expansion of humanpopulations and encroachment onwildlife habitats changes in food-production processes changes inagricultural practices and global tradein wildlife5610 Domestic animals andhumans may acquire zoonoticpathogens from nontraditional petsWild animals also can serve asreservoirs for transmission of zoonoticagents to domesticated animals and tohumans8 An outbreak of tularemia inUS wild-caught prairie dogs held ina commercial facility in Texas led tohuman transmission12 Some of theinfected animals were distributed toa pet shop in Texas and were exportedas far away as the Czech Republic

Exotic animals imported to the UnitedStates have been associated withintroduction of infectious agents

otherwise not present in the UnitedStates Contact between animals fromdifferent areas of the world can leadto the appearance of disease in a newspecies and establishment ofa pathogen in a new geographicarea13 An example occurred in2003 when human monkeypoxwas introduced into the UnitedStates Investigators determinedthat the source of monkeypox wasimportation of African Gambianrats which in turn ultimatelyinfected prairie dogs being sold aspets which infected humans in closecontact with the prairie dogs14 Inthis case prompt recognition andpublic health efforts controlled thisoutbreak and may have beenresponsible for preventingestablishment of monkeypox inNorth America

Zoonotic transmission of infections byhousehold pets or animals with whichchildren come in contact in theirhomes or public settings is a commonevent Infections can be caused bybacteria viruses fungi and parasitesTransmission may be direct orindirect through contact aerosolsbites or scratches contamination ofthe environment food or water ordisease-carrying vectors Animalsmay become ill or more commonlyare asymptomatic carriers of specificorganisms and may contaminate theenvironment to which children areexposed Infants and childrenyounger than 5 years are at thegreatest risk in part because theyhave less-than-optimal hygienepractices attraction to or curiosityabout animals and developingimmune systems15 but also becausethese infections tend to be moresevere in infants and young childrenPeople of all ages with primary orsecondary immunodeficiencies are atrisk of more severe disease as arepregnant women and elderlypeople16

REPTILES

Among nontraditional pets reptilespose a particular risk because of highcarriage rates of Salmonella speciesthe intermittent shedding ofSalmonella organisms in their fecesand persistence of Salmonellaorganisms in the environment1517ndash19

The US Food and DrugAdministration (FDA) ban oncommercial distribution of turtleswith shells less than 4 inches long in1975 resulted in an important andsustained reduction of humanSalmonella infections as a result ofprevention of transmission ofSalmonella from these reptilesalthough illegal distribution of smallturtles with subsequent disease inhumans continues to occur2021

Amphibians also can serve asa source of salmonellosis inhouseholds15 Six percent of allsporadic Salmonella infections in theUnited States (11 among peopleyounger than 21 years)mdashapproximately 74 000 cases annuallymdashare the result of direct or indirectcontact with reptiles or amphibians15

RODENTS

Multistate outbreaks of salmonellosisattributable to contact withhamsters22 and other rodents23

purchased from retail pet stores havebeen described Hamsters also havebeen associated with outbreaks ofdisease attributable to lymphocyticchoriomeningitis virus24 Hedgehogsoriginally from Europe Asia andAfrica and now estimated to be inapproximately 40 000 US householdshave proven to be an importantsource of Salmonella serotype Tilenein the United States25 OtherSalmonella serotypes as well asYersinia pseudotuberculosisMycobacterium marinum and rabiesalso have been shown to be zoonoticdiseases carried by hedgehogs

The natural reservoir of plague iswild rodents with humans becominginfected through bites of infected

PEDIATRICS Volume 122 number 4 October 2008 3 by guest on February 21 2021wwwaappublicationsorgnewsDownloaded from

rodent fleas and through handlinginfected animals especially rodentslagomorphs and domestic cats2627

In parts of the United States whereplague is endemic people withrodent-seeking animals can beexposed to Yersinia pestis throughdirect contact with plague-infectedpets or their fleas27 People who livein areas where plague is endemicshould follow a flea-control programdesigned by their veterinarians tokeep their cats and dogs freefrom fleas

Skin infections also can be acquiredfrom nontraditional pets and includeringworm monkeypox orf cutaneousanthrax tularemia erysipeloidectoparasites and endoparasites28ndash33

Hedgehogs pose a significant riskbecause their spines readily penetrateskin and can be the source of Mmarinum and Y pseudotuberculosisinfections25

NONHUMAN PRIMATES

Herpes B virus (cercopithecineherpesvirus 1) is a zoonotic agentthat can be found in macaquemonkeys that are kept as pets ordisplayed in public exhibits The virusis endemic in macaque monkeyswhich may remain asymptomatic ormay develop mild oral lesions HerpesB virus infections in humans havebeen reported after animal bitesscratches or percutaneousinoculation with infected material orsplashes to mucous membranesHuman infections most often result infatal meningoencephalitis34

FISH

Mycobacterial infections are amongthe major zoonoses that can betransmitted by aquarium fish35 butother organisms have been reportedafter exposure to aquarium waterusually sporadically or inimmunocompromised people Theseorganisms include Aeromonasspecies Vibrio species Edwardsiellaspecies Salmonella species

Streptococcus iniae and Erysipelothrixrhusiopathiae36

OTHER SOURCES OF INFECTION

Infection attributable to Salmonellaspecies can be acquired from othersources Outbreaks of Salmonellaspecies infections in people who havebeen in contact with chicks and otherbaby poultry purchased atagricultural feed stores have beenreported37 Parents who purchasethese birds for their childrengenerally are not aware thatSalmonella infections can betransmitted from poultry to humansIn addition to direct exposure toanimals exposure to animal-derivedpet food treats and pet food hasresulted in human infectionsattributable to Salmonella3839

Animals may become colonized withSalmonella after ingestingcontaminated pet food treats or rawmeats These animals may remainasymptomatic and becomeunrecognized sources ofcontamination in the householdHandling of pet food treats byhumans may result in infection39 Inthe United States pet treats areregulated by the FDA Salmonella-contaminated pet treats areconsidered adulterated under theFederal Food Drug and Cosmetic Act(21 USC x301ndash399) The AmericanPet Products ManufacturersAssociation published guidelines toeducate its members about risks ofcontamination of pet treats40 In2004 the FDA initiated annualnationwide testing of pet treats forSalmonella species

DISEASES ASSOCIATED WITHANIMALS IN PUBLIC SETTINGSInfants and children can come incontact with numerous differentanimal species (Table 1) in a numberof public settings (Table 2)potentially resulting in millions ofhuman-animal interactions annuallyPublic animal exhibits can bepermanent such as zoos and science

museums temporary such as inshopping malls schools orcommunity events or recurring suchas agricultural fairs and pettingzoos41 Petting zoos are common atagricultural fairs animal parks andother public events Althoughnumerous positive benefits of human-animal contacts exist includingopportunities for education andentertainment infectious diseasesinjuries and other health problemsassociated with these venues are welldocumented Infections with entericbacteria and parasites pose thehighest risk of human disease fromanimals in public settings Althoughruminant livestock (cattle sheep andgoats) are the major source ofinfection poultry rodents and otherdomestic and wild animals are alsopotential sources2

From 1991 to 2005 more than 55outbreaks of human disease the mostcommon of which were entericinvolved animals in public settings3

Serious infections with Escherichiacoli O157H7 have been associatedwith multiple animals in publicsettings42ndash55 The primary reservoirof E coli O157H7 is ruminantlivestock which are colonizedasymptomatically In many studiesthe primary route of transmission hasbeen foodborne49 but person-to-person spread direct animal contactand contact with environmental itemscontaminated by animals arecommon44 In 2004 and 2005 therewere 3 E coli O157H7 outbreaksaccounting for 173 cases from 3states associated with direct andindirect animal contact at pettingzoos45 Outbreaks17 and sporadiccases of salmonellosis and outbreaksof cryptosporidiosis56ndash58 have beendescribed after visits to farms atwhich visitors had either direct orindirect contact with animalsAdditional illnesses includesalmonellosis campylobacteriosistuberculosis rabies orf virusinfection giardiasis tularemiaringworm and infected bites or


wounds12182851535960 Directcontact with animals (especiallyyoung animals) contamination of theenvironment or food or watersources inadequate hand-washingfacilities or lack of education abouthand hygiene and inappropriatelayout and maintenance of facilities atanimal exhibits have been implicatedas sources of or reasons for infectionin these public settings2 As anexample in a study of observations ofpractices at petting zoos in Canadahand-hygiene facilities were providedbut often not used items that wouldcome into contact with mouths ofinfants and children (pacifiers infantbottles sippy cups) were carried intothe petting zoos and education abouthygiene was lacking61 Therecommendation to wash handsimmediately after leaving an animalexhibit is the single most importantprevention step to reduce the risk ofdisease transmission even if ananimal is not touched

RABIES

Rabies is a fatal viral zoonosis anda serious public health problem6263

Although human rabies deaths causedby animal contact in public exhibitshave not been reported exposure torabid mammals at pet stores64

county fairs65 petting zoos6667 androdeo events67 have requiredextensive public health investigationsand medical follow-up For exampleraccoon-variant rabies in pet rabbitsand a guinea pig have led topostexposure prophylaxis of adultsand children68 Prevention ofrabies in domestic cats dogs andferrets can be achieved by regularrabies immunization andreimmunization6263 Control of rabiesamong wildlife reservoirs is difficultand use of licensed oral vaccinesfor mass immunization of free-ranging wildlife depends on thecircumstances surrounding eachanimal rabies outbreak and isrestricted to use in state and federalrabies-control programs62 Noparenteral rabies vaccine is licensedfor use in wild animals or hybridsBecause of the risk of rabies in wildanimals (especially raccoons skunkscoyotes foxes and bats) theAmerican Veterinary Medical

Association (AVMA) NationalAssociation of State and PublicHealth Veterinarians (NASPHV)and Council of State and TerritorialEpidemiologists (CSTE) recommendenactment and enforcement of statelaws that prohibit importationdistribution andor relocation ofthese animals The AVMA hasrecommended that wild animalsor hybrids not be kept as pets(wwwavmaorgcareforanimalsanimatedjourneyspetselectionconsiderasp)

INJURIES AND ALLERGIES

Infants and children younger than5 years are at increased risk ofinjuries associated with animalinteractions because of their size andbehavior Bites scratches kicks fallsand crush injuries of hands or feet orfrom being pinned between an animaland a fixed object can occur at homeor during exposure to animals ina public setting Serious and fatalinjuries can be caused by a largeanimal or an animal with aggressivebehavior Some nontraditional petsare chosen when they are young and

TABLE 2 Potential Exposures of Children to Animals in Public Settings

Area Animal Involved Organism

Metropolitan zoo Elephants giraffes rhinoceroses buffaloes M tuberculosis5960

Komodo dragons Salmonella serotype enteritidis18

County or stateagricultural fairs

Cattle calves E coli O157H741485467

Cattle Campylobacter species53

Reptiles Salmonella species17

Goats Rabies6567

Farm tours or visits Cattle calves E coli O15741ndash43464749505565

Raw milk Campylobacter species Salmonella species67

Calves Cryptosporidium species E coli O157H7 Salmonella speciesCampylobacter species51

Sheep goats calves Cryptosporidium species4156ndash5867

Sheep Orf28

Livestock exhibits Cattle E coli O15748

Pet stores Hamsters mice rats Salmonella species23

Kittens Rabies64

Hamsters Tularemia12 lymphocytic choriomeningitis24

Prairie dogs Monkeypox14

Petting zoos Cattle sheep goats E coli O15741455267

Rabbits Giardia species67

Bear cubs Rabies66

Rodeo events Ponies Rabies63

Fish tanks Fish Mycobacterium species35 Salmonella species36

Agricultural feed store Baby poultry (chicks ducklings goslings turkeys) Salmonella species37


small without consideration that theymay grow into dangerous aggressiveadults For example iguanas soldshortly after birth measure less than8 inches but grow to several feet in 2to 3 years and baby chicks becomefull-grown chickens and have a lifespan of up to 20 years

An estimated 4 to 5 million animalbites occur in the United Statesannually Although approximately90 of bites are from dogs or catssevere and fatal bites can occur fromlarge or aggressive nontraditionalpets Animal bites or scratches oftenbecome infected Infectiousorganisms depending on the bitinganimal include Pasteurella multocidaFrancisella tularensisCapnocytophaga canimorsusStreptobacillus moniliformis Spirillumminor Bartonella henselae leptospiraand herpes B virus Tularemiaoccurred in a 3-year-old child whowas bitten by an infected hamsterthat was purchased at a pet store33

Reptiles can produce injuries by biteswith claws or with tails Severe handinjury32 and cellulitis29 have beenreported after green iguana bitesUnprovoked attacks by ferrets onchildren particularly infants sleepingor lying down can be severe withmutilation of the ears or nose6970

Attacks on sleeping infants aresimilar to those inflicted by rats71

Although the frequency is not knownthe potential for having an allergy tonontraditional pets is likely to besignificant The American Academy ofAllergy Asthma amp Immunologyestimates that approximately 15 ofthe population experiences allergiesto dogs and cats72 Allergy to animalsusually is attributable to sensitizationto their dander scales fur feathersbody waste or saliva Flea bites alsocan lead to allergic manifestationsHives have been described in peoplewho have contact with hedgehogs73

Although scaly animals are not aslikely to be as allergenic as furryanimals there are case reports ofallergic rhinitis asthma and contact

hypersensitivity reactions to iguanasIn 1 case a person with respiratoryallergic symptoms was found to beallergic to iguana scales31 In additionan iguana bitendashinducedhypersensitivity reaction has beenreported32

REPORTABLE DISEASES ACQUIREDFROM NONTRADITIONAL PETS ANDANIMALS IN PUBLIC SETTINGS

Many national and state-notifiablediseases can be transmitted fromanimals Public health officials at statehealth departments and personnelfrom the Centers for Disease Controland Prevention (CDC) collaborate indetermining which infectiousdiseases should be notifiablenationally states determine whichdiseases are reportable within theirborders A disease may be added tothe national or state list as a newpathogen emerges or a disease maybe removed from the list as diseaseincidence decreases Because diseasereporting varies according to statespecific requirements should beobtained from the appropriate statehealth department Provisional dataare published weekly in the Morbidityand Mortality Weekly Report and finaldata are published each year by theCDC in the annual ldquoSummary ofNotifiable Diseasesrdquo which can befound online (wwwcdcgovncphidisssnndssphsinfdishtm) Thesedata are necessary for the study ofepidemiologic trends anddevelopment of disease-preventionpolicies Physicians and other healthcare professionals should reportsuspected cases of human illness tolocal and state health departments assoon as possible especially when thepatient has a history of visiting ananimal exhibit during the incubationperiod

IMPORTATION LAWS AND REGULATIONSREGARDING EXOTIC ANIMALS

Addressing importation andregulation of animals in the United

States is complex No single federalagency has the authority to limitimportation interstate distributionmovement sale or ownership ofexotic animals in the United StatesFederal agencies that do haveregulatory authority over someaspects of the exotic-animal trade asit relates to their individual missioninclude the CDC the Animal and PlantHealth Inspection Service of the USDepartment of Agriculture the FDAand the US Fish and Wildlife ServiceThere also is a patchwork of statebans permits and tracking systemsfor exotic animals Agenciesresponsible for enforcing regulationsvary among states

Among the federal agencies the CDCis responsible for regulationsregarding importation of dogs andcats nonhuman primates smallturtles terrapins and tortoisesAfrican rodents civets and birdsfrom countries with H5NI influenzaIn addition CDC regulations includeetiologic agents hosts and vectorsunder which importation of bats isregulated The US Fish and WildlifeService requires permits to importfish reptiles spiders wild birdsrabbits bears wild members of thecat family and other wild orendangered animals The FDAregulates interstate transactionsinvolving turtles molluscan shellfishpsittacine birds prairie dogs andAfrican rodents Many states alsohave laws that make it illegal to ownor keep certain wild animals ora variety of exotic pets includingnonhuman primates

The Animal Welfare Act (7 USCx2131-216) covers the sale andexhibition of wildexotic animals andthe wholesale distribution of petanimals Wholesale breeders dealersexhibitors and research laboratoriesare covered by this act Birds ratsand mice are exempted dogs catsand other animals have limitedcoverage and cold-blooded speciessuch as reptiles are not regulatedunder this act Small retail breeders


and pet shops that sell only domesticpet animals are not regulated underthis act these animals usually arecovered by local (state county)anticruelty laws and in someinstances by local animal regulationsor public health laws The USDepartment of Agriculture has issueda position statement on risks ofownership of large wild and exoticcats (wwwaphisusdagovanimalndashwelfaredownloadsbigndashcatpositionpdf)

CDC efforts are underway togalvanize partner agencies intofurther actions to enhance protectionof humans from zoonotic diseases Ameeting of stakeholder organizationswas held at the CDC in 2006a summary of which was published inthe Federal Register74 The AVMACSTE and NASPHV have each issuedposition statements calling fora coordinated federal approach tobetter control of infectious diseaserisks associated with the exotic-animal trade (these publications areavailable through the Web sites of therespective organizations) Uniformimportation laws better quarantineand surveillance methods for animalscoming into the country andprevention of illegal wildlife trade arenecessary components of an overallplan to protect the public

PREVENTION MEASURES AND THE ROLEOF PEDIATRICIANS ANDVETERINARIANS

Pediatricians and veterinarians playan important role in guiding parentsand their children about mitigation ofrisks associated with ownership ofnontraditional pets or contact withanimals in public settings Parentsand pet owners typically lackknowledge about the multiple modesof transmission of zoonotic infectiousdiseases from pets Althoughpediatricians recognize theimportance of anticipatory guidanceabout pet-related hazards only 5reported that they regularly educatedpatients or families about pet-

associated salmonellosis ortoxoplasmosis75

Pediatricians and veterinarianstogether can remind parentschildren and pet owners about theimportance of measures to avoidillness Simple and effective adviceincludes frequent hand-washing andavoiding direct contact with animalsand their environments This isparticularly important with animalsfrom which transmission of entericpathogens is a risk including youngruminants young poultry reptilesrodents amphibians and animals thatare ill Young children always shouldbe supervised closely when in contactwith animals in public settings TheNASPHV has developed an excellentcompendium with standardizedrecommendations for use by publichealth officials veterinarians animalvenue operators animal exhibitorsand others who are concerned withdisease control and minimizing risksassociated with animals in publicsettings2

To reduce the possibility of injuryhealth care professionals shouldremind pet owners about matchingthe size and temperament of a pet tothe age and behavior of their infant orchild providing close supervision ofyounger children and educating allchildren about appropriate human-animal interactions

The decision to obtaina nontraditional pet by parents withchildren in the household is often notdiscussed with a physician orveterinarian However as trustedsources of health care informationpediatricians and veterinarians are ina unique position to offer informationand advice to families considering thepurchase of a nontraditional pet or tofamilies who already havea nontraditional pet in the householdInformational brochures and postersavailable for display in physician andveterinarian offices could allow forparent education withoutsignificantly increasing time of a visit

Parents can be made aware of Websites that provide guidelines for safepet selection and appropriate handlingof pets Proper pet health maintenanceimmunization flea and tick controldeworming and diet and activity canminimize the risk of infection or injuryand ensure the health of the petReferral to a veterinarian also can behelpful when parents arecontemplating purchase ofa nontraditional animal Veterinarianscan provide information aboutappropriate pet selection the size of ananimal when it attains adulthood thetemperament and husbandry needs ofan animal and suitability as a pet

A history of contact with pets in thehome or animals in public settingsshould be part of every well-childevaluation and especially should bepart of an evaluation of a suspectedinfectious disease A history ofnontraditional pets in the home orcontact with animals in public settingscan lead to specific testing andadditional managementrecommendations and occasionally willresult in early identification of anunusual infection from another part ofthe world

AVAILABLE RECOMMENDATIONS ANDGUIDELINES

Recommendations from severalorganizations dealing withnontraditional pets and animals inpublic settings have been developedand are summarized in Table 3 Inaddition Table 4 provides Web-siteaddresses for health careprofessionals and parents at whichinformation for prevention of humandisease from nontraditional pets andanimals in public settings can befound Recommendations forprevention of enteric diseasetransmission from animal contact inpublic settings resulted fromoutbreaks of E coli O157H7 at farmsopen to the public at which animalcontact and inadequate hand hygieneoccurred43 The NASPHV and CDChave established recommendations to


prevent disease outbreaks associatedwith animals in public settings2 TheCDC has issued recommendations forpreventing transmission ofSalmonella organisms from reptiles tohumans21 and information regardinghealth risks from Salmonella species

posed by contact with baby poultry37

Guidelines for prevention of zoonosesin immunosuppressed people also areavailable1676

The AVMA supports the view thatexotic animals wildlife and

wildlifendashdomestic animal hybrids donot make good pets These animalsare dangerous and are a hazard tohuman health other animals and theenvironment The AVMA alsorecommends that ferret owners haveknowledge about the species andstress that no one who is incapableof removing himself or herself fromthe bite of a ferret should be leftunattended with a ferret Measuresto control and prevent psittacosis inhumans and birds were published bya committee formed by the NASPHVand were endorsed by the AVMA77

the CSTE and the Association ofAvian Veterinarians

Guidelines for animals that mighthave contact with children in a child-care setting have been published bythe National Resource Center forHealth and Safety in Child Care andEarly Education78 These guidelinesstate that any pet or animal present atthe facility indoors or outdoorsshould be in good health show noevidence of carrying any disease befully immunized and be maintainedon a flea- tick- and worm-controlprogram A current (time-specified)certificate from a veterinarian shouldbe on file in the facility and statethat the specific pet meets theseconditions All contact betweenanimals and children should besupervised by a caregiver who isclose enough to remove the childimmediately if the animal shows signsof distress or the child shows signs oftreating the animal inappropriatelyThe caregiver should instructchildren on safe procedures to followwhen in close proximity to theseanimals (eg not to provoke or startleanimals or touch them when theyare near their food) Potentiallyaggressive animals should not be inthe same physical space withchildren The facility should not keepor bring in turtles iguanas lizards orother reptiles ferrets psittacinebirds or any wild or dangerousanimals Recommendations for hand-washing by staff volunteers and

TABLE 3 Guidelines for Prevention of Human Diseases From Nontraditional Pets at Home andExposure to Animals in Public Settings

GeneralWash hands immediately after contact with animals animal products or their environmentSupervise hand-washing for children younger than 5 yWash hands after handling animal-derived pet treatsNever bring wild animals home and never adopt wild animals as petsTeach children never to handle unfamiliar wild or domestic animals even if the animals appear

friendlyAvoid rough play with animals to prevent scratches or bitesChildren should not be allowed to kiss pets or put their hands or other objects into their mouths

after handling animalsDo not permit nontraditional pets to roam or fly freely in the house or allow nontraditional or

domestic pets to have contact with wild animalsDo not permit animals in areas where food or drink are prepared or consumedAdminister rabies vaccine to mammals as appropriateKeep animals clean and free of intestinal parasites fleas ticks mites and licePeople at increased risk of infection or serious complications of salmonellosis (eg children younger

than 5 y older adults and immunocompromised hosts) should avoid contact with animal-derivedpet treats

Animals visiting schools and child-care facilitiesDesignate specific areas for animal contactDisplay animals in enclosed cages or under appropriate restraintDo not allow food in animal-contact areasAlways supervise children especially those younger than 5 y during interaction with animalsObtain a certificate of veterinary inspection for visiting animals andor proof of rabies immunization

according to local or state requirementsProperly clean and disinfect all areas where animals have been presentConsult with parents or guardians to determine special considerations needed for children who are

immunocompromised or who have allergies or asthmaAnimals not recommended in schools child-care settings and hospitals include nonhuman primates

inherently dangerous animals (lions tigers cougars bears wolfdog hybrids) mammals at highrisk of transmitting rabies (bats raccoons skunks foxes and coyotes) aggressive animals oranimals with unpredictable behavior stray animals with unknown health history reptiles andamphibians

Ensure that people who provide animals for educational purposes are knowledgeable regardinganimal handling and zoonotic disease issues

Public settingsVenue operators must know about risks of disease and injuryVenue operators and staff must maintain a safe environmentVenue operators and staff must educate visitors about the risk of disease and injury and provide

appropriate preventive measuresAnimal specificChildren younger than 5 y and immunocompromised people should avoid contact in public settings

with reptiles amphibians rodents ferrets baby poultry (chicks ducklings) and any items thathave been in contact with these animals or their environments

Reptiles amphibians rodents ferrets and baby poultry (chicks ducklings) should be kept out ofhouseholds that contain children younger than 5 y immunocompromised people or people withsickle cell disease and should not be allowed in child-care centers

Reptiles amphibians rodents and baby poultry should not be permitted to roam freely throughouta home or living area and should not be permitted in kitchens or other food-preparation areas

Disposable gloves should be used when cleaning fish aquariums and aquarium water should not bedisposed in sinks used for food preparation or for obtaining drinking water

Mammals at high risk of transmitting rabies (bats raccoons skunks foxes and coyotes) should notbe touched by children


children as well as maintenance ofanimals housed on the premises areprovided in the guidelines78 Inaddition to exposures to animalswithin a center child-care and schoolfield trips can result in disease A fieldtrip to a petting zoo at which hand-hygiene facilities were not adequateresulted in 44 cases of E coli O157H7infection in British Columbia79

Guidelines for infection control inhealth care facilities are not part ofthis document but are available(wwwcdcgovncidoddhqppdfguidelinesEnvirondashguidendash03pdf)

FUTURE

In 2006 the CDC hosted a meetingdealing with infectious disease risksassociated with exotic-animalimportation and trade The CSTENASPHV and AVMAmdash3 organizationsinvolved in the issue of infectiousdisease risks associated with theexotic-animal trademdashpresented

policy statements of theirorganizations or calls to action Therewas a consensus that rules andregulations need to be strengthenedand standardized to reduce risksassociated with exotic pets and thatfederal and state efforts are needed toeliminate illegal wildlife trade Inaddition the Zoonoses EducationCoalition organized by the CDC aimsto increase partnerships betweengovernment and industry An effort isunderway by a number of regulatoryand public health agencies andveterinary organizations to addressissues raised by legal and illegalimportation of exotic animals and todevelop a comprehensive set ofregulations to protect the public(J McQuiston DVM [veterinaryepidemiologist Viral and RickettisialZoonoses Branch National Centerfor Zoonotic Vector-Borne andEnteric Diseases CDC] verbalpersonal communication August2007)

SUMMARY

Most nontraditional pets pose a riskto the health of young children andtheir acquisition and ownershipshould be discouraged in householdswith young children Exposuresto animals in public settings alsopose specific risks Parents need tobe educated about the increasedrisks of exposure to nontraditionalpets and animals in public settingsfor infants and for childrenyounger than 5 years and forimmunosuppressed people of allages and should be made aware ofthe general recommendations forreduction of risks of infection injuryand allergy Resources are availablefor physicians veterinarians andparents and recommendationsincluding specific guidelines forreducing the risk of Salmonellainfection from reptiles are offeredby a number of organizationsIn addition physicians and

TABLE 4 Web Sites With Information on Prevention of Human Diseases Transmitted From Nontraditional Pets and Wild Animals

Health care professionals

CDC Health Pets Healthy People site for resources and recommendations related toanimal contact

wwwcdcgovhealthypetshealthndashprofhtm

FDA tips on keeping pets and people healthy wwwfdagovfdacfeatures2004104ndashpetshtmlCDC and Healthcare Infection Control Practices Advisory Committee guidelines forinfection control in health care facilities

wwwcdcgovncidoddhqppdfguidelinesEnvirondashguidendash03pdf

Guidelines for veterinarians for prevention of zoonotic transmission of ascarids andhookworms of dogs and cats

wwwcdcgovncidoddpdparasitesascarispreventionhtm

Educational materials for physician officesparentsCDC search engine for diseases associated with specific animals wwwcdcgovhealthypetsbrowsendashbyndashanimalhtmDepartment of Public Health Commonwealth of Massachusetts recommendations forpetting zoos petting farms animal farms and other events and exhibits wherecontact between animals and people is permitted

wwwmassgovdphcdcepiirabiespetzoohtm

NASPHV report of standardized recommendations for public health officialsveterinarians animal venue operators animal exhibitors visitors to animal venuesand exhibits and others concerned with disease control and with minimizing risksassociated with animals in public settings

wwwnasphvorgdocumentsCompendiahtml and wwwcdcgovmmwrpreviewmmwrhtmlrr5605a1htm

NASPHV safety at animal exhibits and hand-washing posters wwwnasphvorgdocumentscompendiaAnimalshtmlCDC information on health risks posed by contact with baby poultry wwwcdcgovhealthypetseasterndashchickshtmGuidance for pet selectionCDC information about health-related risks of owning and caring for animals wwwcdcgovhealthypetsGuidance for minimizing risk of disease transmissionCDC Pet-Scription guidelines for staying healthy while enjoying your pet and foranimal-specific diseases

wwwcdcgovhealthypetspetscriptionndashgenhtm

CDC regulations for importation of pets other animals and animal products intothe United States

wwwcdcgovncidoddqanimalindexhtm

NASPHV recommendations on hand-washing venue design animal care andmanagement and risk communications regarding disease and injury preventionassociated with animals in public settings

wwwnasphvorgdocumentsCompendiahtml and wwwnasphvorgDocumentsAnimalsInPublicSettingspdf

Association of Zoos amp Aquariums guide to accreditation of zoological parks andaquariums

wwwazaorgAccreditationDocumentsAccredGuidepdf and wwwazaorgAccreditationDocumentsAccredStandPolpdf


veterinarians are encouraged towork together to educate oneanother and to communicatea common message to petowners regarding the benefitsand risks of pet ownership andof contact with animals outsidethe home Joint training seminarsand joint sponsorship of health-communication campaigns inpediatrician and veterinarianoffices would greatly increaseawareness in pet owners TheldquoOne Medicinerdquo initiativesupported by the AVMA to increaseveterinary collaboration withcounterparts in human medicine isan excellent step forward to benefitclinical medicine and public healthand will build and reinforcepartnerships between the 2professions to reduce human illnessand injury related to contact withanimals80

COMMITTEE ON INFECTIOUS DISEASES2007ndash2008

Joseph A Bocchini Jr MD ChairpersonHenry H Bernstein DOJohn S Bradley MDMichael T Brady MDCarrie L Byington MDPenelope H Dennehy MDRobert W Frenck Jr MDMary P Glode MDHarry L Keyserling MDDavid W Kimberlin MDSarah S Long MDLorry G Rubin MD

LIAISONS

Robert Bortolussi MDCanadian Paediatric SocietyRichard D Clover MDAmerican Academy of Family PhysiciansMarc A Fischer MDCenters for Disease Control and PreventionRichard L Gorman MDNational Institutes of HealthR Douglas Pratt MDFood and Drug AdministrationAnne Schuchat MDCenters for Disease Control and PreventionBenjamin Schwartz MDNational Vaccine Program OfficeJeffrey R Starke MDAmerican Thoracic Society

EX OFFICIO

Carol J Baker MDRed Book Associate EditorLarry K Pickering MDRed Book Editor

CONSULTANTS

Edgar O Ledbetter MDH Cody Meissner MD

CONTRIBUTORS

Nina Marano DVM MPHFrederick J Angulo DVM PhD

STAFF

Alison Siwek MPH

2019 REFERENCE UPDATEACKNOWLEDGMENTS

William Steinbach MD FAAPJennifer M Frantz MPH

ABBREVIATIONS

FDA Food and DrugAdministration

AVMA American VeterinaryMedical Association

NASPHV National Association ofState and Public HealthVeterinarians

CSTE Council of State andTerritorial Epidemiologists

CDC Centers for Disease Controland Prevention

REFERENCES

1 American Pet Products ManufacturersAssociation Industry statistics andtrends pet ownershipmdashAPPMAnational pet owners survey 2007ndash08Available at wwwappmaorgpressndashindustrytrendsasp Accessed January23 2008

2 National Association of State PublicHealth Veterinarians Inc (NASPHV)Centers for Disease Control andPrevention (CDC) Council of State andTerritorial Epidemiologists AmericanVeterinary Medical AssociationCompendium of measures to preventdisease associated with animals inpublic settings 2007 MMWR Recomm

Rep 200756(RR-5)1ndash14 Available atwwwcdcgovmmwrpreviewmmwrhtmlrr5605a1htm AccessedJanuary 23 2008

3 Steinmuller N Demma L Bender JBEidson M Angulo FJ Outbreaks ofenteric disease associated with animalcontact not just a foodborne problemanymore Clin Infect Dis 200643(12)1596ndash1602

4 Check E Health concerns prompt USreview of exotic-pet trade Nature 2004427(6972)277

5 Karesh WB Cook RA Bennett ELNewcomb J Wildlife trade and globaldisease emergence Emerg Infect Dis200511(7)1000ndash1002

6 Chomel BB Belotto A Meslin FXWildlife exotic pets and emergingzoonoses Emerg Infect Dis 200713(1)6ndash11

7 Chomel B Diseases transmitted byless common house pets MicrobiolSpectr 20153(6)

8 Kruse H Kirkemo AM Handeland KWildlife as source of zoonotic infectionsEmerg Infect Dis 200410(12)2067ndash2072

9 Taylor LH Latham SM Woolhouse MERisk factors for human diseaseemergence Philos Trans R Soc Lond BBiol Sci 2001356(1411)983ndash989

10 Institute of Medicine Committee onEmerging Microbial Threats to Health inthe 21st Century Microbial Threats toHealth Emergence Detection andResponse Smolinski MS Hamburg MALederberg J eds Washington DCNational Academies Press 2003

11 Souza M One Health zoonoses inthe exotic animal practice Vet ClinNorth Am Exot Anim Pract 201114(3)421-426

12 Petersen JM Schriefer M Carter LGet al Laboratory analysis of tularemiain wild-trapped commercially tradedprairie dogs Texas 2002 Emerg InfectDis 200410(3)419ndash425

13 Smith K Smith K Auria J Exoticpets health and safety issues forchildren and parents J PediatrHealth Care 201226(2)e2ndashe6

14 Guarner J Johnson BJ Paddock CDet al Monkeypox transmission andpathogenesis in prairie dogs EmergInfect Dis 200410(3)426ndash431


15 Mermin J Hutwagner L Vugia D et alReptiles amphibians and humanSalmonella infection a population-based case-control study Clin InfectDis 200438(suppl 3)S253ndashS261

16 Kotton CN Zoonoses in solid-organ andhematopoietic stem cell transplantrecipients Clin Infect Dis 200744(6)857ndash866

17 Centers for Disease Control andPrevention Reptile-associatedsalmonellosis selected states1998ndash2002 MMWR Morb Mortal WklyRep 200352(49)1206ndash1209

18 Friedman CR Torigian C Shillam PJet al An outbreak of salmonellosisamong children attending a reptileexhibit at a zoo J Pediatr 1998132(5)802ndash807

19 Burnham BR Atchley DH DeFusco RPet al Prevalence of fecal shedding ofSalmonella organisms among captivegreen iguanas and potential publichealth implications J Am Vet MedAssoc 1998213(1)48ndash50

20 Centers for Disease Control andPrevention Turtle-associatedSalmonellosis in humans United States2006ndash2007 MMWR Morb Mortal WklyRep 200756(26)649ndash652

21 Centers for Disease Control andPrevention Multistate outbreak ofhuman Salmonella infectionsassociated with exposure to turtlesUnited States 2007ndash2008 MMWR MorbMortal Wkly Rep 200857(3)69ndash72

22 Centers for Disease Control andPrevention Outbreak of multidrugresistant Salmonella typhimuriumassociated with rodents purchased atretail pet stores United StatesDecember 2003ndashOctober 2004 MMWRMorb Mortal Wkly Rep 200554(17)429ndash433

23 Swanson SJ Snider C Braden CR et alMultidrug-resistant Salmonellaenterica serotype typhimuriumassociated with pet rodents N EnglJ Med 2007356(1)21ndash28

24 Biggar RJ Woodall JP Walter PDHaughie GE Lymphocyticchoriomeningitis outbreak associatedwith pet hamsters fifty-seven casesfrom New York State JAMA 1975232(5)494ndash500

25 Riley PL Chomel BB Hedgehogzoonoses Emerg Infect Dis 200511(1)1ndash5

26 Centers for Disease Control andPrevention Human plague four states2006 MMWR Morb Mortal Wkly Rep200655(34)940ndash943

27 Gage KL Dennis DT Orloski KA et alCase of cat-associated human plague inWestern US 1977ndash1998 Clin Infect Dis200030(6)893ndash900

28 Centers for Disease Control andPrevention Orf virus infection inhumans New York Illinois Californiaand Tennessee 2004ndash2005 MMWRMorb Mortal Wkly Rep 200655(3)65ndash68

29 Hsieh S Babl FE Serratia marcescenscellulites following an iguana bite ClinInfect Dis 199928(5)1181ndash1182

30 Kelsey J Ehrlich M Henderson S Exoticreptile bites Am J Emerg Med 199715(5)536ndash537

31 Kelso JM Fox RW Jones RT YungingerJW Allergy to iguana J Allergy ClinImmunol 2000106(2)369ndash372

32 Levine EG Manilov A McAllister SCHeymann WR Iguana bite-inducedhypersensitivity reaction ArchDermatol 2003139(12)1658ndash1659

33 Centers for Disease Control andPrevention Brief report tularemiaassociated with a hamster bitemdashColorado 2004 MMWR Morb MortalWkly Rep 200553(51)1202ndash1203

34 Cohen JI Davenport DS Stewart JAet al Recommendations for preventionof and therapy for exposure to B virus(cercopithecine herpesvirus 1) ClinInfect Dis 200235(10)1191ndash1203

35 Aubry A Chosidow O Caumes E RobertJ Cambau E Sixty-three cases ofMycobacterium marinum infectionclinical features treatment andantibiotic susceptibility of causativeisolates Arch Intern Med 2002162(15)1746ndash1752

36 Lowry T Smith SA Aquatic zoonosesassociated with food bait ornamentaland tropical fish J Am Vet Med Assoc2007231(6)876ndash880

37 Centers for Disease Control andPrevention Three outbreaks ofsalmonellosis associated with babypoultry from three hatcheries United

States 2006 MMWR Morb Mortal WklyRep 200756(12)273ndash276

38 Centers for Disease Control andPrevention Multistate outbreak ofhuman Salmonella infections caused bycontaminated dry dog food UnitedStates 2006ndash2007 MMWR Morb MortalWkly Rep 200857(19)521ndash524

39 Finley R Reid-Smith R Weese JSHuman health implications ofSalmonella-contaminated natural pettreats and raw pet food Clin Infect Dis200642(5)686ndash691

40 American Pet Products ManufacturersAssociation Guidelines for theManufacturing of Natural Part Treatsfor Pets Greenwich CT American PetProducts Manufacturers AssociationInc 2006 Available at wwwappmaorglawlawlibraryndasharticleasptopic=20Accessed January 23 2008

41 LeJeune JT Davis MA Outbreaks ofzoonotic enteric disease associatedwith animal exhibits J Am Vet MedAssoc 2004 224(9)1440ndash1445

42 Pritchard GC Willshaw GA Bailey JRCarson T Cheasty T Verocytotoxin-producing Escherichia coli O157 ona farm open to the public outbreakinvestigation and longitudinalbacteriological study Vet Rec 2000147(10)259ndash264

43 Crump JA Sulka AC Langer AJ et al Anoutbreak of Escherichia coli O157H7infections among visitors to a dairyfarm N Engl J Med 2002347(8)555ndash560

44 Rangel JM Sparling PH Crowe C GriffinPM Swerdlow DL Epidemiology ofEscherichia coli O157H7 outbreaksUnited States 1982ndash2002 Emerg InfectDis 200511(4)603ndash609

45 Centers for Disease Control andPrevention Outbreaks of Escherichiacoli O157H7 associated with pettingzoos North Carolina Florida andArizona 2004 and 2005 MMWR MorbMortal Wkly Rep 200554(15)1277ndash1280

46 Centers for Disease Control andPrevention Outbreaks of Escherichiacoli O157H7 infections among childrenassociated with farm visitsPennsylvania and Washington 2000MMWR Morb Mortal Wkly Rep 200150(15)293ndash297


47 Chapman PA Cornell J Green CInfection with verocytotoxin-producingEscherichia coli O157 during a visit toan inner city open farm EpidemiolInfect 2000125(3)531ndash536

48 Durso LM Reynolds K Bauer N Jr KeenJE Shiga-toxigenic Escherichia coliO157H7 infections among livestockexhibitors and visitors at a TexasCounty Fair Vector Borne Zoonotic Dis20055(2)193ndash201

49 Kassenborg HD Hedberg CW HoekstraM et al Farm visits and undercookedhamburgers as major risk factors forsporadic Escherichia coli O157H7infection data from a case-controlstudy in 5 FoodNet sites Clin Infect Dis200438(suppl 3)S271ndashS278

50 Shukla R Slack R George A Cheasty TRowe B Scutter J Escherichia coli O157infection associated with a farm visitorcentre Commun Dis Rep CDR Rev 19955(6)R86ndashR90

51 Smith KE Stenzel SA Bender JB et alOutbreaks of enteric infections causedby multiple pathogens associated withcalves at a farm day camp PediatrInfect Dis J 200423(12)1098ndash1104

52 Warshawsky B Gutmanis I Henry Bet al An outbreak of Escherichia coliO157H7 related to animal contact ata petting zoo Can J Infect Dis 200213(3)175ndash181

53 Centers for Disease Control andPrevention Outbreak of Escherichia coliO157H7 and Campylobacter amongattendees of the Washington CountyFair New York 1999 MMWR MorbMortal Wkly Rep 199948(36)803ndash805

54 Keen JE Wittum TE Dunn JR et alShiga-toxigenic Escherichia coli O157 inagricultural fair livestock UnitedStates Emerg Infect Dis 200612(5)780ndash786

55 Payne CJ Petrovic M Roberts RJ et alVero cytotoxin-producing Escherichiacoli O157 gastroenteritis in farmvisitors North Wales Emerg Infect Dis20039(5)526ndash530

56 Evans MR Gardner D Cryptosporidiosisoutbreak associated with aneducational farm holiday Commun DisRep CDR Rev 19966(3)R50ndashR51

57 Kiang KM Scheftel JM Leano FT et alRecurrent outbreaks ofcryptosporidiosis associated with

calves among students at aneducational farm programmeMinnesota 2003 Epidemiol Infect 2006134(4)878ndash886

58 Sayers GM Dillon MC Connolly E et alCryptosporidiosis in children whovisited an open farm Commun Dis RepCDR Rev 19966(10)R140ndashR144

59 Lewerin SS Olsson SL Eld K et alOutbreak of Mycobacteriumtuberculosis infection among captiveAsian elephants in a Swedish zoo VetRec 2005156(6)171ndash175

60 Oh PR Granich R Scott J et al Humanexposure following Mycobacteriumtuberculosis infection of multipleanimal species in a metropolitan zooEmerg Infect Dis 20028(11)1290ndash1293

61 Weese JS McCarthy L Mossop MMartin H Lefebvre S Observation ofpractices at petting zoos and thepotential impact on zoonotic diseasetransmission Clin Infect Dis 200745(1)10ndash15

62 Centers for Disease Control andPrevention National Association ofState Public Health VeterinariansCompendium of animal rabiesprevention and control 2007 MMWRRecomm Rep 200756(RR-3)1ndash8

63 Manning SE Rupprecht CE Fishbein Det al Human rabies prevention UnitedStates 2008mdashrecommendations of theAdvisory Committee on ImmunizationPractices MMWR Recomm Rep 200857(RR-3)1ndash28

64 Centers for Disease Control andPrevention Mass treatment of humansexposed to rabies New Hampshire1994 MMWR Morb Mortal Wkly Rep199544(26)484ndash486

65 Chang HG Eidson M Noonan-Toly Cet al Public health impact ofreemergence of rabies New YorkEmerg Infect Dis 20028(9)909ndash913

66 Centers for Disease Control andPrevention Public health response toa potentially rabid bear cub Iowa 1999MMWR Morb Mortal Wkly Rep 199948(42)971ndash973

67 Bender JB Shulman SA Reports ofzoonotic disease outbreaks associatedwith animal exhibits and availability ofrecommendations for preventingzoonotic disease transmission fromanimals to people in such settings

Animals in Public ContactSubcommittee National Association ofState Public Health Veterinarians J AmVet Med Assoc 2004224(7)1105ndash1109

68 Eidson M Matthews SD Willsey ALCherry B Rudd RJ Trimarchi CV Rabiesvirus infection in a pet guinea pig andseven pet rabbits J Am Vet Med Assoc2005227(6)932ndash935

69 Applegate JA Walhout MF Childhoodrisks from the ferret J Emerg Med199816(3)425ndash427

70 Paisley JW Lauer BA Severe facialinjuries to infants due to unprovokedattack by pet ferrets JAMA 1988259(13)2005ndash2006

71 Elliott SP Rat bite fever andStreptobacillus moniliformis ClinMicrobiol Rev 200720(1)13ndash22

72 American Academy of Allergy Asthma ampImmunology Tips to remember indoorallergens Available at wwwaaaaiorgpatientspublicedmattipsindoorallergensstm Accessed January23 2008

73 Fairley JA Suchniak J Paller ASHedgehog hives Arch Dermatol 1999135(5)561ndash563

74 Centers for Disease Control andPrevention Discussions regardingexotic animal importation sale anddistribution summary of informationpresented at public meeting FedRegist 200671(151)44698ndash44699Available at httpa257g akamaitechnet7257242201jan20061800edocketaccessgpogov2006pdfE6-12736pdfAccessed January 23 2008

75 Villar RG Connick M Barton LL MeaneyFJ Davis MF Parent and pediatricianknowledge attitudes and practicesregarding pet-associated hazards ArchPediatr Adolesc Med 1998152(10)1035ndash1037

76 Centers for Disease Control andPrevention USPHSIDSA guidelines fortreatment and prevention ofopportunistic infections in children andadolescents infected with HIV MMWRMorb Mortal Wkly Rep 2008 in press

77 Smith KA Bradley KK Stobierski MGTengelsen LA National Association ofState Public Health VeterinariansPsittacosis Compendium CommitteeCompendium of measures to controlChlamydophila psittaci (formerly


Chlamydia psittaci) infection amonghumans (psittacosis) and pet birds2005 J Am Vet Med Assoc 2005226(4)532ndash539

78 American Academy of PediatricsAmerican Public Health AssociationCaring for Our Children NationalHealth and Safety Performance

StandardsmdashGuidelines for Out-of-HomeChild Care Programs 2nd ed Elk GroveVillage IL American Academy ofPediatrics 2002 Available at httpnrcuchsceduCFOCindexhtml AccessedJanuary 23 2008

79 David ST MacDougall L Louie K et alPetting zoo-associated Escherichia coli

O157H7 secondary transmissionasymptomatic infection and prolongedshedding in the classroom CanCommun Dis Rep 200430(20)173ndash180

80 Enserink M Medicine initiative aims tomerge animal and human healthscience to benefit both Science 2007316(5831)1553


DOI 101542peds2008-19422008122876Pediatrics

K Larry A Joseph J Frederick and and the Committee on Infectious DiseasesRisks to Children

Exposure to Nontraditional Pets at Home and to Animals in Public Settings

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1224876including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1224876BIBLThis article cites 71 articles 3 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectionepidemiology_subEpidemiologybhttpwwwaappublicationsorgcgicollectioninfectious_diseases_suInfectious Diseaseous_diseaseshttpwwwaappublicationsorgcgicollectioncommittee_on_infectiCommittee on Infectious Diseasesfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on February 21 2021wwwaappublicationsorgnewsDownloaded from




httppediatricsaappublicationsorgcontent1224876located on the World Wide Web at

The online version of this article along with updated information and services is

httppediatricsaappublicationsorgcontentsuppl20200406peds2008-1942DCSupplementalData Supplement at

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2008has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it


animals in public settings also can beassociated with significant risks tochildren including infections andinjuries These potential risks areenhanced when there is an inadequateunderstanding of disease transmissionmethods of preventing transmissionanimal behavior or appropriatefacilities for animals

This report deals with the potentialexposure of infants children andadolescents to nontraditional pets inthe home and to animals in publicsettings The objectives of this reportare to (1) summarize informationregarding emerging and reemerginginfectious diseases injuries andallergies associated with exposure tonontraditional pets in the home and toanimals in a variety of public settings(2) outline regulations andrecommendations applicable to theseexposures and (3) define measures tominimize or prevent illness and injuryin children from exposure to theseanimals and cite resources foradditional information for health careprofessionals and families

METHODS

To identify original researchpublications and review articlesdealing with infections injury andallergies in children resulting fromnontraditional pets including exoticanimals in the home and fromanimals in public settings a search ofthe National Library of MedicinersquosMedline database was performed byusing PubMed and the CochraneLibrary was searched for articlespublished between 1975 and 2007

The terms ldquonontraditional petsrdquo ldquoexoticanimalsrdquo ldquofarm animalsrdquo ldquopetsrdquoldquowildlife hybridsrdquo ldquoindigenous wildliferdquoldquoreptilesrdquo and ldquorodentsrdquo were selectedas Medical Subject Headings (MeSH)and text words were combined in thesearch strategy In addition the ldquorelatedlinksrdquo option on PubMed was usedReferences in all relevant publishedarticles including reviews letterscommentaries and Web sites alsowere reviewed to identify originalresearch

Studies were assessed as to whetherthey should be included in this reviewon the basis of their reporting orsummarizing original data thatexamined infections or injuries inchildren resulting from nontraditionalpets in the home or animals in publicsettings Previously publishedrecommendations to preventinfections and injuries were reviewed

For the purpose of this reportnontraditional pets include exoticanimals defined either as importednonnative species or species thatoriginally were nonnative but noware bred in the United Statesindigenous wildlife and wildlifehybrids (wildlife crossbred withdomestic animals producing offspringknown as hybrids) The definition ofnontraditional pets includes reptilesand certain species of mammals

NONTRADITIONAL PETS

Nontraditional pets are increasing inpopularity among a pet-loving publicas lifestyle choices of owners dictate theneed for smaller or more unusual pets

Table 1 provides examples of animalsthat are considered nontraditional petsas well as animals to which childrenmay be exposed in public settings

Since 1992 the number of exoticanimals available in the United Stateshas increased 751 In 2005 87 991mammals (including 29 species ofrodents) 13 million reptiles and 203million fish were imported legally intothe United States The US Fish andWildlife Service estimates that in 2002365 000 birds were imported legallyReptiles are now in 44 million homes1

In addition there is a worldwide illegaltrade of exotic animals estimated at $6to $10 billion dollars annually3ndash5 onlyexceeded by the trafficking of arms anddrugs This illegal trade subverts rulesestablished by regulatory agencies toreduce introduction of disease andpotentially dangerous animals throughimportation restriction inspectionandor quarantine5

A number of public health concerns arerelated to human contact withnontraditional pets and specifically toexotic animals Most importednonnative species are caught in the wildrather than bred in captivity Healthscreening often is not performed beforeshipment of these animals to the UnitedStates and there is mixing of animalspecies in holding locations includinganimals that might be ill or incubatingillness or carriers of potentialpathogens In addition the significantwildlife black market through whicha large number of exotic animals enterthe United States compounds the risksof introduction of zoonoses6

TABLE 1 Animals That Are Considered Nontraditional Pets andor Animals That May Be Encountered in Public Settings

Categories Examples

Amphibians Frogs toads newts salamandersFish Many typesMammals wildlife Raccoons skunks foxes coyotes civet cats tigers lions bears nonhuman primatesDomesticated livestock Cattle pigs goats sheepEquines Horses mules donkeys zebrasWeasels Ferrets minks sables skunksLagomorphs Rabbits hares pikasRodents Mice rats hamsters gerbils guinea pigs chinchillas gophers lemmings squirrels chipmunks prairie dogs hedgehogsFeral animals Cats dogs horses swineReptiles Turtles lizards iguanas snakes alligators








REPTILES




RODENTS









NONHUMAN PRIMATES


FISH












RABIES















Goats Rabies6567





Sheep Orf28



Kittens Rabies64





Bear cubs Rabies66





























































FUTURE



SUMMARY


























LIAISONS


EX OFFICIO


CONSULTANTS


CONTRIBUTORS


STAFF

Alison Siwek MPH



ABBREVIATIONS






REFERENCES






















































































































REPTILES




RODENTS









NONHUMAN PRIMATES


FISH












RABIES















Goats Rabies6567





Sheep Orf28



Kittens Rabies64





Bear cubs Rabies66





























































FUTURE



SUMMARY


























LIAISONS


EX OFFICIO


CONSULTANTS


CONTRIBUTORS


STAFF

Alison Siwek MPH



ABBREVIATIONS






REFERENCES




















































































































NONHUMAN PRIMATES


FISH












RABIES















Goats Rabies6567





Sheep Orf28



Kittens Rabies64





Bear cubs Rabies66





























































FUTURE



SUMMARY


























LIAISONS


EX OFFICIO


CONSULTANTS


CONTRIBUTORS


STAFF

Alison Siwek MPH



ABBREVIATIONS






REFERENCES

















































































































RABIES















Goats Rabies6567





Sheep Orf28



Kittens Rabies64





Bear cubs Rabies66





























































FUTURE



SUMMARY


























LIAISONS


EX OFFICIO


CONSULTANTS


CONTRIBUTORS


STAFF

Alison Siwek MPH



ABBREVIATIONS






REFERENCES








































































































































































FUTURE



SUMMARY


























LIAISONS


EX OFFICIO


CONSULTANTS


CONTRIBUTORS


STAFF

Alison Siwek MPH



ABBREVIATIONS






REFERENCES



















































































































LIAISONS


EX OFFICIO


CONSULTANTS


CONTRIBUTORS


STAFF

Alison Siwek MPH



ABBREVIATIONS






REFERENCES














































































































