Sweden Reports Rare Outbreak Of Parrot Fever

Photo Credit USDA

 

# 7510

 

 

Although relatively rare, an outbreak of Psittacosis (parrot fever) is in the news once again, this time in Sweden where a 75-year old man has died, and 8 others have been infected.  

 

Chlamydophila psittaci bacteria – which is shed in the feces of infected Psittaciformes (cockatoos, parrots, parakeets, lories, etc.) and poultry (ducks & turkeys primarily, less often in chickens) - can cause serious pneumonia in humans.

 

The route of infection is almost always via direct contact with birds or bird feces, but a few instances of human-to-human transmission have been either documented, or strongly suspected.

 

First the report from Sweden – where we learn about an outbreak that occurred last March (no word why we are just now hearing about it) and appears to have involved H-2-H transmission.  I’ll have more on this rare form of bacterial pneumonia when you      return.  

 

Sweden hit by outbreak of rare parrot fever

Published: 24 Jul 2013 09:38 CET

A Swedish man who died of parrot fever in southern Sweden has transmitted the rare disease to at least eight people, with experts pointing out that human-to-human transmission is exceptionally uncommon.

 

After a 75-year-old man died in Kronoberg in March from parrot fever, the illness has spread among those who were near to him during his illness, including care personnel.

 

"This person was very sick and it was an extreme case. It's still hugely uncommon though, no one was infected third hand from the secondary cases we had," Arne Runehagen, doctor at the Swedish Institute for Infectious Disease Control (Smittskyddsinstitutet), told the TT news agency.

(Continue . . .)

 

Sweden reports 5 to 10 cases of Psittacosis each year, but outbreaks of this size are very rare. In 2007, in neighboring Norway, we did see a very large outbreak where `dozens’ were reportedly sickened after attending a bird show (see To You, My Heart Cries Out Chlamydia).

 

Today’s report refers to a previously documented case of human-to-human transmission of Psittacosis in Scotland, which is likely this one from the May of 2012 in the journal Eurosurveillance on an outbreak in Tayside, Scotland, where H-2-H transmission appears to have occurred.

 

Psittacosis outbreak in Tayside, Scotland, December 2011 to February 2012

C C McGuigan , P G McIntyre, K Templeton

A Tayside outbreak of psittacosis December 2011–February 2012 involved three confirmed and one probable cases. Confirmed cases were indistinguishable by sequencing of polymerase chain reaction (PCR) products.

 

The epidemiological pattern suggested person-to-person spread as illness onset dates were consistent with the incubation period and no single common exposure could explain the infections. In particular the only common exposure for a healthcare worker case is overlap in place and time with the symptomatic index case.

 

 

Last November in Psittacosis Identified In Hong Kong Respiratory Outbreak, we saw a limited outbreak among personnel at an agricultural station where smuggled birds seized by customs agents had been quarantined. Subsequently 3 parrots died, and 10 were euthanized.

 

While outbreaks are uncommon, the CDC reports roughly 50 cases are diagnosed each year in the United States. As it can be difficult to diagnose, the true incidence of this disease probably much higher.

 

Treatment is via antibiotics, primarily with tetracycline.

 

One of the concerns with this disease is the widespread and essentially unregulated use of antibiotics by bird owners in treating their flocks.  Overuse of antibiotics can lead to the development of resistant bacteria.

 

In 2007, an EID Journal report Chlamydophila psittaci Transmission from Pet Birds to Humans looked at the use of antibiotics at 39 breeding bird breeding facilities in Belgium, and found that more that 40% had used antibiotics to treat sick birds in the previous 12 months. More than 10% routinely gave antibiotics to birds prophylactically.

 

Although a small study, their findings suggested that bird owners may be infected – and display only mild symptoms - more often than previously suspected. 

 

That said, among a small survey of bird owners - roughly 25% had reported having had pneumonia after acquiring a Psittaciforme as a pet - a number far greater than would normally be seen in the general population.

 

Prior to the development of antibiotics in the middle of last century, the mortality rate from psittacosis pneumonia was on the order of 15% to 20%. Today, if properly diagnosed and treated, deaths are rare.

 

One of the most fascinating stories regarding Parrot Fever came just 10 years after the end of the Spanish Flu Pandemic, when a multi-state outbreak of Parrot Fever briefly stoked pandemic fears once again.

 

I wrote about It’s surprising long term impact in How Parrot Fever Changed Public Health In America.

 

The CDC maintains a Psittacosis website, with the following information.

 

Clinical Features
In humans, fever, chills, headache, muscle aches, and a dry cough. Pneumonia is often evident on chest x-ray.

Etiologic Agent
Chlamydia psittaci, a bacterium

Incidence
Since 1996, fewer than 50 confirmed cases were reported in the United States each year. Many more cases may occur that are not correctly diagnosed or reported.

Sequelae
Endocarditis, hepatitis, and neurologic complications may occasionally occur. Severe pneumonia requiring intensive-care support may also occur. Fatal cases have been reported.

Transmission
Infection is acquired by inhaling dried secretions from infected birds. The incubation period is 5 to 19 days. Although all birds are susceptible, pet birds (parrots, parakeets, macaws, and cockatiels) and poultry (turkeys and ducks) are most frequently involved in transmission to humans.

Risk Groups
Bird owners, pet shop employees, and veterinarians. Outbreaks of psittacosis in poultry processing plants have been reported.

Surveillance
Psittacosis is a reportable condition in most states.

 

Psittacosis Identified In Hong Kong Respiratory Outbreak

Photo Credit USDA

 

# 6742

 

Yesterday, in Hong Kong: Investigating An Unidentified Respiratory Illness Outbreak, we learned of five workers at an animal management center in Sheung Shui who had contracted an as-yet unidentified respiratory infection.  

 

Psittacosis (parrot fever) was suspected because they had been in direct contact with 16 seized parrots, three of which had subsequently died.

 

Today we get word that three patients have now tested positive for Chlamydophila psittaci, a bacteria shed in the feces of infected Psittaciformes (cockatoos, parrots, parakeets, lories, etc.) and poultry (ducks & turkeys primarily, less often in chickens) that can cause serious pneumonia in humans.

 

Human-to-human transmission, while rare, has been strongly suspected in the past (more on this after the HPC announcement below).

 

First, the statement from the Hong Kong Centre for Health Protection, then I’ll return with a bit more.

 

Update on psittacosis outbreak in Sheung Shui

The Centre for Health Protection (CHP) of the Department of Health today (November 27) provided an update on its joint investigation with the Agriculture, Fisheries and Conservation Department (AFCD) into an outbreak of psittacosis respiratory disease involving five AFCD male staff working in the New Territories North Animal Management Centre (NTNAMC) in Sheung Shui.

 

A CHP spokesman said that the respiratory specimens from three patients (a 55-year-old patient at Queen Mary Hospital, a 62-year-old patient in Alice Ho Miu Ling Nethersole Hospital and a 27-year-old patient who has been discharged from Yan Chai Hospital) tested positive for Chlamydophila psittaci by polymerase chain reaction as confirmed by the CHP's Public Health Laboratory Centre, suggesting that they were suffering from psittacosis infection.

 

So far, a total of five AFCD staff working in the NTNAMC have developed respiratory symptoms (mostly pneumonia) requiring admission to hospitals. One has recovered and the other four are currently in hospitals in Hong Kong (three) and Australia (one).

 

The CHP has successfully contacted 59 AFCD staff working in the NTNAMC and eight of them are found to currently have upper respiratory symptoms. Arrangements will be made with the Hospital Authority for these eight persons to undergo medical assessment and laboratory investigation to rule out psittacosis.

 

The joint investigation is under way. The total number of laboratory confirmed cases so far in this outbreak is three.

 

The spokesman said that psittacosis is a disease caused by Chlamydophila psittaci. It is usually transmitted to humans by inhaling the agent from the dried droppings and secretions of infected birds. Pet birds such as parrots, cockatiels, parakeets, macaws and poultry (turkeys and ducks) are most frequently involved. Person-to-person transmissions are rare.

 

Common symptoms include fever, headache, rash, muscle pain, chills and dry cough. Pneumonia may occur in serious cases. Encephalitis, myocarditis and thrombophlebitis are occasional complications. The incubation period ranges from one to four weeks. Psittacosis can be effectively treated with antibiotics.

 

To prevent psittacosis, members of the public are advised to take heed of the following measures:

• Wear gloves and face masks when handling the droppings and secretions of birds;
• Wash both hands thoroughly after handling birds;
• Avoid close contacts with birds;
• Disinfect bird cages and surfaces contaminated by bird droppings and secretions; and
• Seek medical treatment if symptoms develop.

Ends/Tuesday, November 27, 2012
Issued at HKT 19:01

 

 

Last March, in How Parrot Fever Changed Public Health In America, I briefly mentioned an ongoing investigation into a suspected parrot fever outbreak in Tayside, Scotland. 

 

Two months later, the journal Eurosurveillance carried the following Rapid Communications that looked at onset dates and exposures in that outbreak (involving four family members and a health-care worker), all of which suggested human-to-human transmission.

 

Psittacosis outbreak in Tayside, Scotland, December 2011 to February 2012

C C McGuigan , P G McIntyre, K Templeton

A Tayside outbreak of psittacosis December 2011–February 2012 involved three confirmed and one probable cases. Confirmed cases were indistinguishable by sequencing of polymerase chain reaction (PCR) products.

 

The epidemiological pattern suggested person-to-person spread as illness onset dates were consistent with the incubation period and no single common exposure could explain the infections. In particular the only common exposure for a healthcare worker case is overlap in place and time with the symptomatic index case.

 

While outbreaks are uncommon, the CDC reports roughly 50 cases are diagnosed each year in the United States. As it can be difficult to diagnose, the true incidence of this disease probably much higher. 

 

Treatment is via antibiotics, primarily with tetracycline.

 

One of the concerns with this disease is the widespread and essentially unregulated use of antibiotics by bird owners in treating their flocks.  Overuse of antibiotics can lead to the development of resistant bacteria.

 

In 2007, an EID Journal report Chlamydophila psittaci Transmission from Pet Birds to Humans looked at the use of antibiotics at 39 breeding bird breeding facilities in Belgium, and found that more that 40% had used antibiotics to treat sick birds in the previous 12 months. More than 10% routinely gave antibiotics to birds prophylactically.

 

Although a small study, their findings suggested that bird owners may be infected – and display only mild symptoms - more often than previously suspected. 

 

That said, among a small survey of bird owners - roughly 25% had reported having had pneumonia after acquiring a Psittaciforme as a pet - a number far greater than would normally be seen in the general population.

 

Prior to the development of antibiotics in the middle of last century, the mortality rate from psittacosis pneumonia was on the order of 15% to 20%.  Today, if properly diagnosed and treated, deaths are rare.

 

However, should antibiotic resistance develop in Chlamydophila psittaci due to overuse, we could see a return to the bad old days.

Hong Kong: Investigating An Unidentified Respiratory Illness Outbreak

 

Photo Credit USDA

 

# 6740

 

 

From Hong Kong’s Centre for Health Protection today a report on five workers at an agricultural station who have contracted an – as yet unidentified – respiratory illness.

 

These patients have tested negative for the `usual suspects’, including influenza, RSV, and Legionnaire’s Disease. They all work at an animal management center that recently took in 16 seized parrots, 3 of which subsequently died.  

 

Testing is now underway for Psittacosis (parrot fever).  First the report, then I’ll return with a few brief notes.

 

 

Joint investigation into suspected outbreak of respiratory disease in Sheung Shui

The Centre for Health Protection (CHP) of the Department of Health is today (November 26) conducting a joint investigation with the Agriculture, Fisheries and Conservation Department (AFCD) into a suspected outbreak of respiratory disease involving five AFCD staff working in the New Territories North Animal Management Centre (NTNAMC) in Sheung Shui. They were all males aged between 27 and 64 with onset of symptoms from November 6 to November 24.

The first case affected a 64-year-old man who presented with upper respiratory symptoms since November 6. He was admitted to a hospital in Australia since November 12.

 

The second case is a 55-year-old man. He developed chills, cough and sore throat since November 8 and fever, shortness of breath, headache and myalgia since November 19. He was admitted to Queen Mary Hospital (QMH) on November 22. His chest X-ray showed bilateral upper zone patchiness and the clinical diagnosis was pneumonia. He is now receiving care in the Intensive Care Unit of QMH in stable condition.

 

Respiratory and urine specimens taken from the 55-year-old patient at QMH tested by the hospital yielded negative results for influenza virus, respiratory syncytial virus (RSV) and Legionnaires' Disease, while test results for psittacosis and leptospirosis are pending. CHP's Public Health Laboratory Centre performed tests on the patient's respiratory specimens and it was negative for Novel Coronavirus associated with Severe Respiratory Disease.

 

The third case affected a 62-year-old man who developed bilateral red eyes on November 12, and was admitted to Alice Ho Miu Ling Nethersole Hospital on November 17 because of cough with blood-stained sputum, malaise, chills, rigors and sore throat. His condition was stable. The diagnosis was pneumonia. Preliminary laboratory testing for influenza virus, parainfluenza virus, RSV and adenovirus was negative.

 

The fourth case is a 27-year-old man. He developed fever, headache and malaise on November 14 and was admitted to Yan Chai Hospital on November 18. The diagnosis was pneumonia. He recovered after treatment and was discharged home on November 22 and his condition was stable.

 

The fifth case affected a 62-year old man who presented with cough, chills and rigor since November 24 and was admitted to Princess Margaret Hospital for further management on November 26. His condition is stable.

 

The home contacts of the patients are asymptomatic.

 

CHP staff conducted a site visit to NTNAMC today and provided health advice to the staff.

 

According to the information provided by AFCD, there is a batch of 16 seized parrots being kept in NTNAMC since October 20. Subsequently, three died and 10 were euthanised as precautionary measures. The health condition of the three surviving birds is being closely monitored.

 

The possibility of psittacosis outbreak among these staff is being actively investigated.

 

 

While we don’t yet know if Psittacosis is behind this outbreak, parrot fever continues to cause small outbreaks around the world. It is caused by Chlamydia psittaci, one of several microorganisms in the genus Chlamydia that is shed in the feces of many birds.

 

In 2007 (see To You, My Heart Cries Out Chlamydia) I wrote about a small outbreak that occurred at a Bird lovers Society show in Weurt, Norway.

 

And earlier this year I told the fascinating story of how parrot fever was responsible for the creation of the NIH in the United States (see How Parrot Fever Changed Public Health In America).

 

The CDC maintains a Psittacosis website, with the following information.

 

Clinical Features
In humans, fever, chills, headache, muscle aches, and a dry cough. Pneumonia is often evident on chest x-ray.

Etiologic Agent
Chlamydia psittaci, a bacterium

Incidence
Since 1996, fewer than 50 confirmed cases were reported in the United States each year. Many more cases may occur that are not correctly diagnosed or reported.

Sequelae
Endocarditis, hepatitis, and neurologic complications may occasionally occur. Severe pneumonia requiring intensive-care support may also occur. Fatal cases have been reported.

Transmission
Infection is acquired by inhaling dried secretions from infected birds. The incubation period is 5 to 19 days. Although all birds are susceptible, pet birds (parrots, parakeets, macaws, and cockatiels) and poultry (turkeys and ducks) are most frequently involved in transmission to humans.

Risk Groups
Bird owners, pet shop employees, and veterinarians. Outbreaks of psittacosis in poultry processing plants have been reported.

Surveillance
Psittacosis is a reportable condition in most states.

Trends
Annual incidence varies considerably because of periodic outbreaks. A decline in reported cases since 1988 may be the result of improved diagnostic tests that distinguish C.psittaci from more common C. pneumoniae infections.

Challenges
Diagnosis of psittacosis can be difficult. Antibiotic treatment may prevent an antibody response, thus limiting diagnosis by serologic methods. Infected birds are often asymptomatic. Tracebacks of infected birds to distributors and breeders often is not possible because of limited regulation of the pet bird industry.

Opportunities
Characterize new and rapid diagnostic tests for human and avian psittacosis, and determine value of screening flocks for avian psittacosis to prevent human infection.

 

How Parrot Fever Changed Public Health In America

 

 

 

Dr. Charles Armstrong - credit National Library of Medicine

 

# 6222

 

We’ve a report today out of the UK of a suspected outbreak of Chlamydophila psittaci, or `Parrot Fever’, in Tayside, Scotland. While somewhat rare, this form of pneumonia usually responds well to antibiotics if it is diagnosed and treated in time.

 

It’s an interesting enough report (h/t Shiloh on FluTrackers), but unlikely to turn into a big story. It does, however, allow me to revisit a fascinating piece of American history.

 

The STV story is linked below, but when you return, I have the tale of how the 1929 Parrot Fever epidemic in the United States helped to change public health in America.

 

 

Suspected outbreak of potentially fatal 'parrot fever' cases

A number of patients thought to have contracted the bug from inhaling dust from dry bird droppings.

13 March 2012 16:04 GMT

 

 

Just 10 years after the end to the horrific Spanish flu pandemic, which claimed more than 600,000 American lives (and tens of millions worldwide), a new and mysterious pneumonia began to spread in the northeast.

 

It began when Simon Martin, a worker at the Chamber of Commerce in Annapolis, Maryland bought a parrot for his wife Lillian 10 days before Christmas.

 

Hoping to keep it a surprise, he enlisted his daughter (Edith) and son-in-law (Lee) to keep the bird until Christmas day, but by Christmas Eve, the bird began to show signs of illness.

 

By morning, in a scene reminiscent of a Monty Python sketch, they had a late parrot on their hands.

 

Unfortunately, by New Years, Lillian, Edith & Lee were all seriously ill. A local doctor, who had read about a parrot fever outbreak in South America, put the pieces together about a week later.

 

In no time, newspapers had the story, and the country – still reeling from the Stock Market crash of October – and with memories of the 1918 Spanish Flu still relatively fresh – suddenly began to fear a new pandemic was on the way.

 

 Sarasota Times Newspaper – Jan 8th, 1930

 

It didn’t help that 1929 also saw the biggest surge in influenza and pneumonia cases since the end of the great influenza. Newspapers, looking for something other than bad economic news to print, banged the `pandemic gong’ loudly.

 

By now, several employees at the pet shop were sick, and the mayor of Baltimore telegrammed the U.S. Public Health Service urgently requesting assistance. Within hours, Dr. Charles Armstrong – a pathologist with the USPHS – was put in charge of the investigation.

 

Three days later, more cases were detected hundred of miles away in Toledo, Ohio. By January 11th, there were two deaths and more than a dozen cases reported.

 

 

Lawrence Journal-World - Jan 11, 1930

The newspapers had a field day, and `Polly Pandemic Paranoia’ swept the nation.

 

Upon discovering that the pet store in Baltimore had sold 36 parrots before Christmas, Armstrong and his team began tracking them down. Meanwhile, the health department began notifying local health departments around the country to be on the look out for possible cases.

 

Fortunately, it doesn’t take long before it becomes apparent that only those in close contact with parrots were at risk, and that actual the number of cases was very, very small.

 

Curiously, most of the victims were elderly widows.

 

While their age may have predisposed them to pneumonia, it was also suggested that some of them allowed their birds pluck seeds from between their lips or teeth (a trick I can remember my Grandmother performing in the 1950s!).

 

After a week of screaming headlines, the newspapers did an about-face and began to ridicule the story – even going so as to begin printing parrot jokes. Overnight the Polly Pandemic became a national joke.

 

But the investigative work continued.

 

Within a week, the story would take horrific turn, as a number of the investigators began to fall seriously ill. 

 

Several of them died.

 

On February 8th, lead investigator Charles Armstrong was admitted to the hospital with a 104 degree fever. George McCoy, director of the US Public Health Services’ very small and underfunded Hygienic lab, took over and in a daring move created a serum (this was before antibiotics were available) from the blood of a recovered patient, which he gave to Armstrong.

 

Armstrong would recover, and eventually wrote that there had been 169 cases of parrot fever nationwide, along with 33 deaths (including Dr. Daniel S. Hatfield and Dr. William Stokes of the Baltimore Health Department, and Henry (Shorty) Anderson of the Hygienic Lab)

 

 

In March, 9 more employees at the Hygienic Laboratory became sick, and McCoy ordered the lab evacuated, the test animals euthanized and incinerated, and the lab fumigated.

 

The outbreak was finally quashed, but out of it (and concerns over the recent rise in flu) came funding from Congress for a new, better staffed and equipped laboratory to replace the old Hygienic Lab.

 

They also gave it a new name: The National Institute of Health.

 

 

I’ve only covered the highlights of this fascinating story, and I would invite you to read Jill Lepore’s  New Yorker article from June 1st, 2009 for a far more detailed and vivid account:

 

American Chronicles

It’s Spreading

Outbreaks, media scares, and the parrot panic of 1930.

by Jill Lepore June 1, 2009

 

Jill Lapore also was interviewed on NPR’s All things Considered:

In 1929, Parrot Fever Gripped The Country

 

 

Dr. Charles Armstrong (September 25, 1886 – June 23, 1967) would go on to investigate many more disease outbreaks in his career, and would contract St. Louis Sleeping Sickness (St. Louis encephalitis) during the 1934 epidemic (but would recover).

 

The NIH has a full biography of this early disease detective available for free download (PDF) at:

 

"Charles Armstrong, M.D.: A Biography"

 

You can also find other accounts of this famous episode in public health in the 1939 book, Modern Miracle Men by John Drury Ratcliff (available HERE on Google Books) and in 2007’s Government and public health in America by by Ronald Hamowy (also available through Google Books here).

 

 

And you can review some of the early history of the NIH, including the origins of the Hygienic Laboratory after the Civil War, at the following NIH site:

 

---

 

 

As a parting shot, I wrote about another `Parrot Fever’ outbreak in the Netherlands back in 2007, in my blog To You, My Heart Cries Out Chlamydia.

 

(No apologies for the title)