First, see www.fair-safety.com – this is nothing new.
The North Dakota Department of Health is investigating a possible cluster of Shiga toxin-producing E. coli (STEC) infections in eastern North Dakota.
Three cases have been reported, all are less than 18 years of age and all reported attending the Red River Valley Fair in West Fargo which was held July 7 through 12.
One of the cases has been diagnosed with hemolytic uremic syndrome (HUS), a severe complication of STEC infections, in which red blood cells are damaged and can cause kidney damage and kidney failure.
“We are in the early stages of this investigation and are asking people who became sick with diarrhea or bloody diarrhea for more than 24 hours within ten days of attending the fair to let us know,” said Michelle Feist, a health department epidemiologist. “Although the cases reported having contact with animals while at the fair, we are looking into other possible exposures as well.”
STEC is a bacterial infection that can cause abdominal cramping, nausea, vomiting, diarrhea and bloody diarrhea. Symptoms can be severe resulting in dehydration and electrolyte imbalances. People usually get sick within 3 to 4 days from the time of infection, but it can take as long as 10 days for symptoms to appear.
People who have symptoms of STEC should consult with their health care provider.
STEC is shed in the stool of infected animals and people. STEC infections can result from eating contaminated food, drinking contaminated water, coming into contact with animals that are carrying STEC and can be spread from person to person through inadequate hygiene. Undercooked meats, especially ground beef, contaminated produce or sprouts and attending petting zoos have all been implicated in STEC outbreaks in the U.S. Animals may be infected and not have symptoms but can shed the bacteria.
Livestock exhibitions, petting zoos, county and state fairs, frankly any “farm experience,” are “as American as apple pie.”
Unfortunately, these same places have been the source of large outbreaks of zoonotic diseases over the last decades. And, just as unfortunately, despite the severe illnesses and a death attributed to these activities, little seems to be learned from outbreak to outbreak despite previously existing standards for safer exhibition of animals being encoded more forcefully into law. After each outbreak it is hoped that future exhibitors will, one hopes, heed the calls previously issued by the Centers for Disease Control and Prevention (CDC) and by veterinarians: to take steps to reduce the likelihood of zoonotic-disease transmission to animal exhibition patrons – and to young children in particular.
Now we see another one. During April’s Milk Maker’s Fest at the Washington Fairgrounds at least 25 were sickened by E. coli O157:H7 with 10 hospitalized and six developing hemolytic uremic syndrome (HUS). The cause of this outbreak is clearly set forth in recommendations for future event organizers:
- Evaluate and update plans for cleaning and disinfection before, during, and after events, particularly surfaces with high levels of hand contact (such as seats, door or fence handles, and hand railings).
- Evaluate and update measures to restrict access to areas more likely to be contaminated with animal manure.
- Ensure access to hand washing facilities with soap, running water, and disposable towels.
- Display signs and use other reminders to attendees to wash hands when leaving animal areas.
- Store, prepare, or serve food and beverages only in non-animal areas.
Seeing this I feel a bit frustrated since I gave a speech 10 years ago to the Washington State Fair Association about the risks of animal contact in these types of settings and recommendation on how to avoid outbreaks.
The risk of transmission in exhibition settings of zoonotic diseases in general and E. coli O157:H7 in particular is not – or should not be – news. A survey as far back as 2003 of the literature, including CDC’s Morbidity and Mortality Weekly Report (MMWR), revealed at least 23 outbreaks of zoonotic disease, including illnesses from E. coli O157:H7, associated with animal exhibitions in the United Kingdom and the United States. These prior outbreaks included an E. coli O157:H7 outbreak associated with a county fair in Medina, Ohio, in August, 2000; two E. coli O157:H7 outbreaks in Pennsylvania in 2000 and 2001 associated with farm animals; 92 E. coli O157:H7 cases associated with the Wyandot County Fair in Ohio in September 2001; and the largest E. coli O157:H7 outbreak in Oregon history at the Lane County Fair in September 2002. And, over the last decade there is not a year that has gone by that many other outbreaks have left hundreds and hundreds sickened.
In addition, research has shown that E. coli O157:H7 is prevalent even among the prize livestock exhibited at agricultural fairs. A 2003 study on the prevalence of E. coli O157: H7 in livestock at 29 county and three large state agricultural fairs in the United States found that E. coli O157:H7 could be isolated from 13.8 percent of beef cattle, 5.9 percent of dairy cattle, 3.6 percent of pigs, 5.2 percent of sheep, and 2.8 percent of goats. Over 7 percent of pest-fly pools also tested positive for E. coli O157:H7.
Against this backdrop, the CDC published recommendations for reducing the risk that enteric pathogens will be transmitted at petting zoos, open farms, and animal exhibits. The most updated version of these recommendations can be found on CDC’s MMWR Web site. These recommendations arise out of several documented outbreaks in which enteric pathogens were passed to humans in such settings. Draft recommendations were published in MMWR on April 20, 2001; readers were invited to submit comments and suggestions; and the final recommendations were posted on the Internet on October 26, 2001. The recommendations encapsulated on the CDC Web site and in MMWR were created by the National Association of State Public Health Veterinarians (NASPHN). Many of the recommendations are common sense and most, if not all were likely ignored by those involved with the Milk Maker’s Fest:
Venue operators should take the following steps:
- Become familiar with and implement the recommendations in this compendium.
- Consult with veterinarians, state and local agencies, and cooperative extension personnel on implementation of the recommendations.
- Become knowledgeable about the risks for disease and injury associated with animals and be able to explain risk-reduction measures to staff members and visitors.
- Be aware that direct contact with some animals is inappropriate in public settings, and this should be evaluated separately for different audiences.
- Develop or obtain training and educational materials and train staff members.
- Ensure that visitors receive educational messages before they enter the exhibit, including information that animals can cause injuries or carry organ- isms that can cause serious illness.
- Provide information in a simple and easy-to-under- stand format that is age and language appropriate.
- Provide information in multiple formats (eg, signs, stickers, handouts, and verbal information) and languages.
- Provide information to persons arranging school field trips or classroom exhibits so that they can educate participants and parents before the visit.
Venue staff members should take the following steps:
- Become knowledgeable about the risks for dis- ease and injury associated with animals and be able to explain risk-reduction recommendations to visitors.
- Ensure that visitors receive educational messages regarding risks and prevention measures.
- Encourage compliance by the public with risk- reduction recommendations, especially compliance with hand-washing procedures as visitors exit animal areas.
Recommendations for nonanimal areas are as follows:
- Do not permit animals, except for service animals, in nonanimal areas.
- Store, prepare, serve, or consume food and beverages only in nonanimal areas.
- Provide hand-washing facilities and display hand- washing signs where food or beverages are served.
- Entrance transition areas should be designed to facilitate education.
- Post signs or otherwise notify visitors that they are entering an animal area and that there are risks associated with animal contact.
- Instruct visitors not to eat, drink, smoke, and place their hands in their mouth, or use bottles or pacifiers while in the animal area.
- Establish storage or holding areas for strollers and related items (eg, wagons and diaper bags).
- Control visitor traffic to prevent overcrowding.
- Exit transition areas should be designed to facilitate hand washing.
- Post signs or otherwise instruct visitors to wash their hands when leaving the animal area.
- Provide accessible hand-washing stations for all visitors, including children and persons with disabilities. Position venue staff members near exits to encourage compliance with proper hand washing.
Recommendations for animal areas are as follows:
- Do not allow consumption of food and beverages in these areas.
- Do not allow toys, pacifiers, spill-proof cups, baby bottles, strollers, or similar items to enter the area.
- Prohibit smoking and other tobacco product use.
- Supervise children closely to discourage hand-to- mouth activities (eg, nail biting and thumb sucking), contact with manure, and contact with soiled bedding. Children should not be allowed to sit or play on the ground in animal areas. If hands become soiled, supervise hand washing immediately.
- Ensure that regular animal feed and water are not accessible to the public.
- Allow the public to feed animals only if contact with animals is controlled (eg, with barriers).
- Do not provide animal feed in containers that can be eaten by humans (eg, ice cream cones) to decrease the risk of children eating food that has come into contact with animals.
- Promptly remove manure and soiled animal bedding from these areas.
- Assign trained staff members to encourage appropriate human-animal interactions, identify and reduce potential risks for patrons, and process reports of injuries and exposures.
- Store animal waste and specific tools for waste removal (eg, shovels and pitchforks) in designated areas that are restricted from public access.
- Avoid transporting manure and soiled bedding through nonanimal areas or transition areas. If this is unavoidable, take precautions to prevent spillage.
- Where feasible, disinfect the area (eg, flooring and railings) at least once daily.
- Provide adequate ventilation both for animals and humans.
- Minimize the use of animal areas for public activities (eg, weddings and dances). • If areas previously used for animals must be used for public events, they should be cleaned and disinfected, particularly if food and beverages are served.
In addition, the Pennsylvania legislature enacted a law mandating standards for animal exhibition sanitation. The Pennsylvania law requires animal exhibit operators to “promote public awareness of the risk of contracting a zoonotic disease” by posting notices. The law further requires adequate hand-cleansing facilities and prohibits the exhibition of any animal not properly cared for by a veterinarian.
Thus, even before the outbreaks in North Carolina and Florida in the fall and winter of 2004-2005, the risk of disease transmission and the means of reducing that risk were well known. This common knowledge forms the basis of legal liability for both the private and governmental entities that operate animal exhibitions. While laws vary from state to state, the liability of these entities to those sickened through exposure to animals on site would be based in the premises of both liability and negligence.
Under premises liability law, the entity or entities responsible for managing an animal exhibition have a duty of care to those it invites onto the premises. This duty includes the responsibility to adequately reduce risks the entity is or should be aware of. The duty also carries a responsibility to warn fairgoers of risks present at the exhibition.
The principles of negligence also revolve around the risks to fairgoers that animal exhibitors know of or reasonably should know of. To successfully bring a negligence claim, a sickened person would need to show that the actions of an animal exhibitor fell below a reasonable standard of care in the operation of the exhibit. Failing to implement the well-established recommendations of the CDC and NASPHV constitutes falling below that standard of care.
Both bases for liability on the part of animal exhibitors-premises liability and negligence-carry with them a burden of education on the part of the exhibitor. Because the law holds people to a standard of what they reasonably should know, ignorance of the risks involved is not an effective defense. The law thus provides no impetus to stray from the course of action that is best for both customers and exhibitors in the first place-recognizing the risk and taking steps to reduce it.
Following the E. coli O157:H7 outbreak in North Carolina, the Terry Sanford Institute of Public Policy at Duke University contracted with the North Carolina Department of Health and Human Services to develop recommendations on regulating petting zoos. The researchers concluded:
In response to the largest outbreak of Escherichia coli (E. coli) in North Carolina history, we recommend that the North Carolina Department of Health and Human Services (DHHS) issue guidelines and pursue legislation that will control public contact with animals, inform the public of risks related to animal contact, provide transition areas, regulate animal care, and license petting zoos.
The North Carolina Legislature subsequently adopted “Aedin’s Law,” named after a young child who was severely injured in the outbreak. According to the preamble of the bill, the child was hospitalized for 36 days and will suffer lifelong injury from complications of HUS. Aedin’s Law requires that animal exhibitors acquire a public permit. The bill further requires the North Carolina State Board of Agriculture to adopt regulations in line with those of the Duke University study and CDC.
There are benefits to continuing the tradition of animal exhibits – it is a recreational and educational link to our country’s ongoing agricultural heritage. Slowly heeding the hard lessons learned, private, public, and legal forces are at work to reduce the risks associated with this pastime. Animal exhibitors are unwise to view these changes as a threat, or those working for change as enemies. Likewise, it is shortsighted to resist the recommendations and guidelines offered to make the animal exhibits safer. The long-term existence of animal exhibits to the public cannot be assured in an environment that permits the possibility of large-scale, life-threatening disease outbreaks like those that occurred in North Carolina and Florida. And, the best way to keep the lawyers out of it is to keep the children safe.
- See E. coli O157:H7 outbreak in Whatcom County, Washington Final Investigation Summary – http://wa-whatcomcounty.civicplus.com/CivicSend/ViewMessage/Message?id=5760
- See http://www.fair-safety.com/fair-outbreaks.htm
- Keen, T.E. Wittum, J.R. Dunn, J.L. Bono, and M.E. Fontenot. 2003. “Occurrence of STEC O157, O111, and O26 in Livestock at Agricultural Fairs in the United States,” Proc. 5th Int. Symp. on Shiga Toxin-Producing Escherichia coli Infections, Edinburgh, UK 22 (2003) – http://www.ars.usda.gov/research/publications/Publications.htm?seq_no_115=144426
- National Association of State Public Health Veterinarians, Inc. (NASPHV). “Compendium of Measures to Prevent Disease Associated with Animals in Public Settings – http://nasphv.org/documentsCompendiumAnimals.html
- CDC, “Notice to Readers: Availability of Final Recommendations on Reducing the Risk for Transmission of Enteric Pathogens at Petting Zoos, Open Farms, Animal Exhibits, and Other Venues,” 50 MMWR Weekly, 928 (October 25, 2001) – http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5042a6.htm
- Outbreak Response and Surveillance Unit, Recommendations: Farm Animal Contact, (Atlanta, CDC September 2002) – http://www.cdc.gov/foodborneoutbreaks/publication/recomm_farm_animal.htm
- See 3 Pa. C.S. [section]2501 et seq
- Dustyn Baker, Tugba Gurcanlar, Emily Hildebrand, Matthew Perault, & Kuang-zhen Wu, “E. coli Outbreak Creates Need for Government Regulation” (Terry Sanford Institute of Public Policy May 2005) – http://www.fair-safety.com/ecoli-public-policy.pdf
- See N.C. S. L. 2005-191
- Marler speech to Washington State Fair Association 2005 – http://www.slideshare.net/marlerclark/2005-washington-fair-assoc
Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of E. coli outbreaks and hemolytic uremic syndrome (HUS). The E. coli lawyers of Marler Clark have represented thousands of victims of E. coli and other foodborne illness infections and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our E. coli lawyers have litigated E. coli and HUS cases stemming from outbreaks traced to ground beef, raw milk, lettuce, spinach, sprouts, and other food products. The law firm has brought E. coli lawsuits against such companies as Jack in the Box, Dole, ConAgra, Cargill, and Jimmy John’s. We have proudly represented such victims as Brianne Kiner, Stephanie Smith and Linda Rivera.