By Hal B. Jenson, MD, FAAP
Dr. Jenson is Professor of Pediatric and Adolescent Medicine, and Dean, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI.
Dr. Jenson reports no financial relationships relevant to this field of study.
SYNOPSIS: Eight outbreaks with 473 cases of salmonellosis associated with small turtles occurred in the United States from 2011-2013, despite the 1975 ban of the sale and distribution of small pet turtles. The outbreaks disproportionately affected children younger than 5 years of age (55% of case-patients) and Hispanics (45% of case-patients).
SOURCE: Walters MS, Simmons L, Anderson TC, et al. Outbreaks of salmonellosis from small turtles. Pediatrics 2016;137:1-9.
Using epidemiologic reports of Salmonella isolates to the Centers for Disease Control and Prevention, or to PulseNet, which is the national molecular subtyping network for foodborne disease surveillance, eight outbreaks of symptomatic salmonellosis were identified during 2011-2013. These included a total of 473 cases (range, 7 to 124 cases) from 41 states, Washington DC, and Puerto Rico. The median case-patient age was 4 years (range, 5 weeks to 94 years). Children younger than 18 years of age accounted for 74% of case-patients; 55% of case-patients were younger than 5 years of age; and 23% were younger than 1 year of age. Among 191 case-patients with available information, 85 (45%) were Hispanic. Knowledge of the association between Salmonella and turtles did not vary by ethnicity. Among 274 case-patients with available information, 78 (28%) patients were hospitalized, with a median duration of hospitalization of 3 days (range, 1-24 days).
In the 7 days preceding illness, 68% (187 of 273) of case-patients who were interviewed reported turtle exposure, defined as direct contact (61%; 54 of 88 case-patients) or in the same room as a turtle. Among these, 88% (124 of 141 case-patients) described small turtles (shell length less than 4 inches). Turtle exposure by outbreak ranged from 47% to 74%. Water samples from turtle habitats linked to human illness were cultured for Salmonella, with outbreak strains isolated from turtle habitats linked to human cases in seven outbreaks. Turtles were owned for a median of 84 days before illness onset (range, 1-1278 days). Turtles from one outbreak were traced to a Louisiana turtle farm.
COMMENTARY
In the United States each year, Salmonella enterica causes an estimated 1 million cases, 19,000 hospitalizations, and 400 deaths. Salmonella are normal intestinal flora in turtles and other reptiles and may be shed throughout their lifetime. Human exposure to reptiles (e.g., turtles and snakes) and amphibians (e.g., frogs) is associated with about 6% of human cases. During 1970-1971, exposures to turtles accounted for an estimated 280,000 human cases annually. In 1975, the U.S. Food and Drug Administration banned the sale and distribution of small pet turtles in the United States except for turtles for exhibition, education, or export. Although the federal ban remains in place, household turtle ownership has increased from 0.6% in 2001 to 1.1% in 2011.
Since the 1975 ban, five outbreaks of Salmonella were reported from 2006 to 2011. This report describes eight additional outbreaks from 2011 to 2013.
Despite the federal ban, and additional bans in some states and local jurisdictions, small turtles remain a significant source of salmonellosis in humans. Physicians should be aware of this resurgent risk in evaluating acute illness, and also educate families about the risk of turtles in households, especially households with children.
Eight outbreaks with 473 cases of salmonellosis associated with small turtles occurred in the United States from 2011-2013, despite the 1975 ban of the sale and distribution of small pet turtles. The outbreaks disproportionately affected children younger than 5 years of age (55% of case-patients) and Hispanics (45% of case-patients).
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