Zachary D. McCormic, MPH Infectious Disease Epidemiologist New Hampshire Department of Health and Human Services InFORM 2017 November 8, 2017

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1 Zachary D. McCormic, MPH Infectious Disease Epidemiologist New Hampshire Department of Health and Human Services InFORM 2017 November 8, 2017

2 Diarrheal disease caused by the parasite Cryptosporidium 1 Parasite oocysts are incredibly resistant Transmitted fecal-orally Recreational water, contact with infected individuals, farm animals, contaminated raw fruits and vegetables Cryptosporidium is a common cause of calf diarrhea 2 Incubation period 2-10 days Symptoms include: Watery diarrhea, abdominal cramps, dehydration Lasts for 1-2 weeks, with possible relapse

3 Average 48 cases per year More common in the summer months 56% female, median age 34 years

4 NH participates in CryptoNet First molecular surveillance system for a parasitic disease, integrating molecular typing and epidemiologic data 3 Leverages existing infrastructure to facilitate the national, systemic characterization of Cryptosporidium specimens to understand transmission and cryptosporidiosis epidemiology 4 Cases in NH are interviewed using a standard CryptoNet Case Investigation Form 3 Launching the First Molecular-based Surveillance System for a Parasitic Disease CryptoNet, 2016, CSTE

5 Using the CryptoNet Case Investigation Form, we are able to track common exposures In 2016 (n=23) International travel 21% Recreational water exposure 38% Raw/Unpasteurized dairy products 12% Raw/unpasteurized fruit or vegetable juices 0% Visit a farm, ranch, zoo, etc. 28% Have contact with farm-related animals 28%

6 In April 2017, 6 cases of cryptosporidiosis were reported 5 of 6 cases reported farm animal contact All 5 reported contact with a calf Feeding, cleaning after, petting, etc. 3 reported contact with the same calf 1 additional epi-linked case identified No additional cases linked to these cases

7 On May 15, 2017, 5 cases of cryptosporidiosis were reported All 5 saw the same provider 3 in 1 family (Family X), 2 in another family (Family Y) 8 cases reported to date in May, 7 with farm animal exposure

8 Family Y Investigation Identified 3 additional probable cases in family members Family had received 2 calves through a 4-H contact in mid-april Both calves developed scours, one calf died Purchased replacement calf at end of April at same time as Family X All ill family members cared for calves

9 Family X Investigation No additional family members ill Family had received 2 calves through a 4-H contact at end of April, along with Family Y Both calves developed scours and recovered All ill family members cared for calves in some way Family X provided name of 4-H contact, who knew where cows were purchased from

10 What we know so far: Calves purchased at same time from same person Owners were new to raising farm animals Calves developed scours after arriving at new farm Persons who cared for calves developed illness Persons who cared for calves did not know what Cryptosporidium was What we want to know next Where were the calves purchased from? Were there any other illnesses related to the source farm? Did this source farm sell raw milk?

11 Contacted 4-H contact Confirmed purchase date and location Explained their experience with farm animals Was very familiar with scours and how to treat it Offered to treat ill calves Did not think illnesses were related to calves Received another case report Only exposure was to calf at Family Y s farm One additional epi-linked case identified

12 Environmental assessment conducted by State Veterinarian Calves were healthy when sold Stress of transportation increases likelihood of developing scours Cryptosporidium is common in calves No active milking cows were present on this farm No workers reported illness in past month

13 Identified 10 cases of cryptosporidiosis, all linked to calves with scours purchased at same time Cases did not know much about Cryptosporidium, either in cows or in people No other human illnesses were identified outside of this cluster at this time

14 Pic of cow **Identity withheld to protect the innocent

15 Education Cases did not know about Cryptosporidium, either in cows or humans Prevention Cases should be aware of risks of Cryptosporidium, and how to prevent them Collaboration One Health Approach Healthy Pets, Health People 5 5

16 22 cases identified in April-May lab identified, 8 epi-linked 20 (91%) reported farm animal exposure 16 of 20 (80%) had contact with a calf 2/3 of cases were in novice farm animal owners Public health should educate owners of livestock about illnesses in their animals Persons with contact to farm animals should be educated about risks of diarrheal illness

17 Authors: Maureen MacDonald, Jill Drouin, Darlene Morse, Stephen Crawford, Elizabeth Daly Chris Benton Katherine Dzenis Krystle Mallory Katrina Hansen Christine Bean Benjamin Chan Abigail Mathewson Katie Fullerton, Michele Hlavsa, Bryanna Cikesh, Hunter Seabolt, Dawn Roelling, CDC CryptoNet Megin Nichols, CDC OneHealth

18 Zachary D. McCormic, MPH Foodborne Disease Epidemiologist NH Department of Health and Human Services