2. Investigation of Severe, Acute Hematochezia in Chimpanzees (Pan troglodytes) North America

3. Summer 1996 A 1.0 Adult (35yr) B 0.1 Adult (45yr) C 0.1 Adult (32yr) D 0.1 Adult (17yr) E 0.0.1 Juvenile (3yr) The method of entering the animals gender into computer programs is: MALE. FEMALE. UNKNOWN So, a male is denoted as 1.0.0 Female: 0.1.0 Unknown: 0.0.1 Multiple animals can be entered in this way as well. 1.1.0 would denote 1 male, 1 female, 2 animals total. This entire troop could be denoted as 1.3.1

4. Environment Flooring: Concrete Flooring: Concrete Enclosure: Metal bar surrounding structure Enclosure: Metal bar surrounding structure Substrate: NO natural substrate Substrate: NO natural substrate Atmosphere: Open to outside, sealed from public areas Atmosphere: Open to outside, sealed from public areas

5. Diet Complete commercial biscuit Complete commercial biscuit Fed to age/weight Fed to age/weight Produce (varied) Produce (varied) Leafy greens Leafy greens Vegetables Vegetables Produce Produce Free choice water Free choice water Daily multivitamin Daily multivitamin Once monthly pyrantel pamoate by weight of animal for Enterobius control Once monthly pyrantel pamoate by weight of animal for Enterobius control

6. Index Case-Summer 1996 Day 1 Day 1 Early morning: Early morning: Quiet, not interested in food Quiet, not interested in food Mid-morning: Mid-morning: Diarrhea Diarrhea Liquid, but solid debris of apparently undigested food items Liquid, but solid debris of apparently undigested food items Frequent bowel movements throughout day Frequent bowel movements throughout day Sticky, sweet, pervasive odor Sticky, sweet, pervasive odor

7. Index Case-Day 1 Treatment Treatment Oral electrolyte replacement Oral electrolyte replacement Well-accepted Well-accepted Pepto-bismol® Pepto-bismol® Not accepted Not accepted Fecal submitted: O & P O & P Direct smear Stained smear

8. Fecal results 2+ cysts Balantidium coli 2+ cysts Balantidium coli Heavy epithelial cell population Heavy epithelial cell population Some RBC’s Some RBC’s Moderate WBC’s Moderate WBC’s Phagocytized bacteria in WBC

9. Index Case-Day 1 Late Afternoon Late Afternoon Progressive lethargy, inappetance Progressive lethargy, inappetance Plan for further diagnostics in morning if progression Plan for further diagnostics in morning if progression Early Evening Early Evening Prostration Prostration Copious diarrhea, hematachezia Copious diarrhea, hematachezia Tacky, hyperemic gingiva Tacky, hyperemic gingiva

10. Index Case-Day 1 Evening Treatment Treatment Sedated with Telazol® Sedated with Telazol® IV catheter IV catheter 0.9% saline 0.9% saline LRS LRS Cefazolin Cefazolin Banamine IM Banamine IM Diagnostics Blood Draw CBC, Biochemistry CBC Temp: 101.0 F Rectal culture Rectal culture

11. Diagnostic tests for Great Ape Hematochezia: Fecal culture Fecal culture Gold standard Gold standard Fecal smear/Direct stain Fecal smear/Direct stain Within outbreak Within outbreak Fecal O&P Fecal O&P Parasite loads Parasite loads

12. Bacterial Causes of Hematochezia in Great Apes Shigella Shigella Salmonella Salmonella Campylobacter Campylobacter Yersinia Yersinia Acha, P.N., and B. Szyfres. Year. Shigellosis. In: Zoonoses and communicable diseases common to man and animals, 3 rd ed., vol. 1. Pan American Health Organization, Washington, D.C.: 247-251. Acha, P.N., and B. Szyfres. Year. Shigellosis. In: Zoonoses and communicable diseases common to man and animals, 3 rd ed., vol. 1. Pan American Health Organization, Washington, D.C.: 247-251. Paul-Murphy, J. 1999. Bacterial enterocolititis in nonhuman primates. In: Fowler, M.E., and R.E. Miller (eds.) Zoo and Wild Animal Medicine, 4 th ed. Pp: 344-351. Paul-Murphy, J. 1999. Bacterial enterocolititis in nonhuman primates. In: Fowler, M.E., and R.E. Miller (eds.) Zoo and Wild Animal Medicine, 4 th ed. Pp: 344-351.

13. CBC, Biochemistry Results Left shift Left shift Azotemia Azotemia Hypokalemia Hypokalemia Acidotic Acidotic

14. Questions: What is your case definition? What is your case definition?case definitioncase definition Is this a potential outbreak? Is this a potential outbreak?potential outbreakpotential outbreak

15. Case Definition: Lethargy Lethargy Hematochezic diarrhea with undigested food apparent Hematochezic diarrhea with undigested food apparent Stained smear of feces with WBCs, RBCs, and epithelial cells Stained smear of feces with WBCs, RBCs, and epithelial cells

16. Potential Outbreak? Have great apes ever produced hematochezia at any zoo? Have great apes ever produced hematochezia at any zoo? YES YES Have great apes ever produced hematochezia at this zoo? Have great apes ever produced hematochezia at this zoo? YES YES How many great apes would you expect with hematochezia at this time? How many great apes would you expect with hematochezia at this time? Expected n<1 as occasional great ape may have hematochezia at this zoo for other reasons Expected n<1 as occasional great ape may have hematochezia at this zoo for other reasons NO, not an outbreak NO, not an outbreak

17. INDEX CASE

18. Day 2: Subsequent Cases (E) presented weak and clingy to dam C who appeared normal (E) presented weak and clingy to dam C who appeared normal Diarrhea not present initially but fecal collected Diarrhea not present initially but fecal collected Diarrhea began midday in both E and C Diarrhea began midday in both E and C Both sedated with Telazol for diagnostics, fluids, antibiotics presumptively Both sedated with Telazol for diagnostics, fluids, antibiotics presumptively

19. Day 2 of Index Case (A) Remained weak Remained weak Diarrhea continued Diarrhea continued Treatment continued Treatment continued Balanced electrolytes by mouth Balanced electrolytes by mouth No food No food IM antibiotics and anti-inflammatories IM antibiotics and anti-inflammatories

20. Questions: Do these new animals meet the case definition from yesterday? Do these new animals meet the case definition from yesterday?case definition case definition What is your revised case definition from clinical diagnostics? What is your revised case definition from clinical diagnostics?revised case definition revised case definition Is this a potential outbreak? Is this a potential outbreak?potential outbreakpotential outbreak

21. Do these new animals meet the case definition from yesterday? Partially Partially Lethargy and diarrhea present Lethargy and diarrhea present Hematachezia NOT present Hematachezia NOT present Fecal smear RBC’s, WBC’s NOT present Fecal smear RBC’s, WBC’s NOT present

22. What is your revised case definition from clinical diagnostics? Diarrhea of any sort within this given time frame Diarrhea of any sort within this given time frame Stained smear of feces with WBC’s, RBC’s, and epithelial cells Stained smear of feces with WBC’s, RBC’s, and epithelial cells

23. Is this a potential outbreak Have great apes ever produced hematochezia at any zoo? Have great apes ever produced hematochezia at any zoo? YES YES Have great apes ever produced hematochezia at this zoo? Have great apes ever produced hematochezia at this zoo? YES YES How many great apes would you expect with hematochezia at this time? How many great apes would you expect with hematochezia at this time?

24. How many great apes would you expect with hematochezia at this time? All of troop, with 3 animals similarly affected, expected n  1 is exceeded All of troop, with 3 animals similarly affected, expected n  1 is exceeded

25. Hematochezia diagnosis Fecal smear/direct stain--within outbreak Fecal smear/direct stain--within outbreak WBC’s (neutrophils) WBC’s (neutrophils) Sloughed intestinal mucosa Sloughed intestinal mucosa RBC’s RBC’s Twice yearly fecal O&P for parasite loads, treatments Twice yearly fecal O&P for parasite loads, treatments Appearance grossly Appearance grossly Watery, mucoid, undigested material Watery, mucoid, undigested material Odor is nearly pathognomonic Odor is nearly pathognomonic CBC CBC Left shift with neutrophilia, leukocytosis Left shift with neutrophilia, leukocytosis Biochemistry--consistent with dehydration Biochemistry--consistent with dehydration Azotemia, hyperkalemia Azotemia, hyperkalemia

26. Day 3 (A) Shigella sonnei cultured (A) Shigella sonnei culturedShigella sonnei Shigella sonnei A,C,E continued on treatment A,C,E continued on treatment

27. Shigella sp. 4 serovars: S. dysenteria, S. sonnei, S. flexneri, S. boydii 4 serovars: S. dysenteria, S. sonnei, S. flexneri, S. boydii S. dysenteriae and S.sonnei are nearly exclusively human source although they can infect NHP’s S. dysenteriae and S.sonnei are nearly exclusively human source although they can infect NHP’s S. flexneri is nearly exclusive NHP source, but can infect humans S. flexneri is nearly exclusive NHP source, but can infect humans Gram--, non-motile bacilli bacteria that penetrates the colonic mucosa Gram--, non-motile bacilli bacteria that penetrates the colonic mucosa Can identify specific isolates by DNA Can identify specific isolates by DNA Feco-oral transmission Feco-oral transmission Short incubation period, 1-few days, contagious Short incubation period, 1-few days, contagious Sensitive to disinfectants Sensitive to disinfectants

28. Day 4 C, E Shigella sonnei cultured C, E Shigella sonnei cultured Diarrhea abated over the following 24 hours, odor abated as well Diarrhea abated over the following 24 hours, odor abated as well

29. Day 5 B,D Remained sub-clinical with only softened feces of normal appearance otherwise B,D Remained sub-clinical with only softened feces of normal appearance otherwise BUT, due to potential outbreaks feces were cultured and stained smear examined BUT, due to potential outbreaks feces were cultured and stained smear examined 3 days later S. sonnei cultured 3 days later S. sonnei cultured

30. Questions: Do these new animals meet the case definition from yesterday? Do these new animals meet the case definition from yesterday?case definition case definition What is your revised case definition from clinical diagnostics? What is your revised case definition from clinical diagnostics?revised case definition revised case definition Is this a potential outbreak? Is this a potential outbreak?potential outbreakpotential outbreak

31. Do these new animals meet the case definition from yesterday? Partially Partially Softened feces Softened feces Culture + for S. sonnei Culture + for S. sonnei

32. What is your revised case definition from clinical diagnostics? Diarrhea of any sort within this given time frame Diarrhea of any sort within this given time frame Stained smear of feces with WBC’s, RBC’s, and epithelial cells Stained smear of feces with WBC’s, RBC’s, and epithelial cells Culture of Shigella sonnei Culture of Shigella sonnei

33. Is this a potential outbreak? Have great apes ever produced hematochezia at any zoo? Have great apes ever produced hematochezia at any zoo? YES YES Have great apes ever produced hematochezia at this zoo? Have great apes ever produced hematochezia at this zoo? YES YES How many great apes would you expect with hematochezia at this time? How many great apes would you expect with hematochezia at this time?

34. How many great apes would you expect with hematochezia at this time? With 3 animals confirmed and 5 animals affected, expected n  1, as occasional great ape may have confirmed hematochezia at this zoo for other DDX but none for Shigella at the zoo, outbreak confirmed With 3 animals confirmed and 5 animals affected, expected n  1, as occasional great ape may have confirmed hematochezia at this zoo for other DDX but none for Shigella at the zoo, outbreak confirmed

35. Details of outbreak ALL chimpanzees cultured S. sonnei ALL chimpanzees cultured S. sonnei ALL chimpanzees sedated, placed in squeezes for 14 day treatment of IM cefuroxime based on sensitivity to 3rd generation cephalosporins ALL chimpanzees sedated, placed in squeezes for 14 day treatment of IM cefuroxime based on sensitivity to 3rd generation cephalosporinsIM cefuroxime IM cefuroxime 100% attack rate 100% attack rate Curve shape suggests a point source Curve shape suggests a point source Curve shape suggests resolution as all animals affected, no new cases, and responding to treatment Curve shape suggests resolution as all animals affected, no new cases, and responding to treatment Notice that treatment begins BEFORE outbreak concluded Notice that treatment begins BEFORE outbreak concluded

36. Antibiotic treatment and choices Important to complete culture/sensitivity Important to complete culture/sensitivity Sensitivity is still routine to 3 rd generation cephalosporins, quinolones Sensitivity is still routine to 3 rd generation cephalosporins, quinolones Antibiotic resistance is easily developed Antibiotic resistance is easily developed Rehydration is important Rehydration is important Anti-endotoxic regimens (Banamine)/anti- inflammatories/analgesics can be used Anti-endotoxic regimens (Banamine)/anti- inflammatories/analgesics can be used NO anti-diarrheals (traps toxins and bacteria) NO anti-diarrheals (traps toxins and bacteria) Administration options are challenging Administration options are challenging If parenteral, dart vs. squeeze If parenteral, dart vs. squeeze If oral, unreliable consumption If oral, unreliable consumption Shedding may be reduced by treatment in epizootic Shedding may be reduced by treatment in epizootic

37. Resolution of signs Clinical signs resolved completely within the 1 st seven days of treatment Clinical signs resolved completely within the 1 st seven days of treatment Following treatment, chimp troop was reunited without incident or recrudescence of disease Following treatment, chimp troop was reunited without incident or recrudescence of disease

38. End of Scenario? In the clinical sense, the scenario is done. In the clinical sense, the scenario is done. The problem was diagnosed and resolved The problem was diagnosed and resolved The epidemiology was strictly CONTROL The epidemiology was strictly CONTROLCONTROL

39. Looking Beyond Where did this outbreak originate? Where did this outbreak originate?originate What permitted all 5 animals to become infected? What permitted all 5 animals to become infected?become infected?become infected? Could it happen again? Could it happen again? The epidemiology now becomes PREVENTION The epidemiology now becomes PREVENTION Stopping the investigation with here and now, will leave you vulnerable to WHY and HOW! Stopping the investigation with here and now, will leave you vulnerable to WHY and HOW!

40. Long term effects of Shigella in NHPs Carrier status Carrier status Carrier status Carrier status Reactive arthritis Reactive arthritis Gingivitis (macaques) Gingivitis (macaques) Other NHPs infected, including humans Other NHPs infected, including humans

41. Carrier Status Can be induced by inappropriate antibiotic choice or duration Can be induced by inappropriate antibiotic choice or duration Minimal clinical signs support not treating to minimize development of a carrier state Minimal clinical signs support not treating to minimize development of a carrier state Potential environmental contamination with keepers/staff becoming fomites to other NHPs Potential environmental contamination with keepers/staff becoming fomites to other NHPs Natural exhibits are virtually impossible to disinfect Natural exhibits are virtually impossible to disinfect Stress can induce recrudescence of infected carriers Stress can induce recrudescence of infected carriers

42. Food sources/Reservoirs Anthropormorphic view of how humans consume bananas Anthropormorphic view of how humans consume bananas Peeled, chimps consumed unpeeled Peeled, chimps consumed unpeeled Other unpeeled produce was cut and animals rarely consumed peels entirely Other unpeeled produce was cut and animals rarely consumed peels entirely Produce source Mexico Produce source Mexico HACCP HACCP Hazardous Analysis of Critical Control Points Hazardous Analysis of Critical Control Points Food safety monitoring that will be critical to zoo food supplies and will minimize/prevent source issues like these Food safety monitoring that will be critical to zoo food supplies and will minimize/prevent source issues like these Documentation that simply washing water is good/better than disinfectants for this organism Documentation that simply washing water is good/better than disinfectants for this organism

43. Environmental Investigation People, Source, Equipment People, Source, Equipment Remember, feco-orally transmitted Remember, feco-orally transmitted Rectal culture of commissary workers --> neg Rectal culture of commissary workers --> neg Rectal culture of chimpanzee caretakers --> neg Rectal culture of chimpanzee caretakers --> neg Review of commissary procedure Review of commissary procedure Unpeeled bananas were NOT being washed Unpeeled bananas were NOT being washed

44. Zoonoses and Control Concern for NHP caretakers Concern for NHP caretakers Appropriate personal hygiene and protection is key Appropriate personal hygiene and protection is key COMMUNICATION will prevent transmission to other NHPs and humans COMMUNICATION will prevent transmission to other NHPs and humans Risks Risks Protection Protection

45. Quarantine Measures: Within Outbreak Review of personal hygiene Review of personal hygiene NO eating/drinking in area NO eating/drinking in area Washing hands Washing hands PPE PPE Masks, gloves, dedicated coveralls, dedicated boots, dedicated daily caretakers Masks, gloves, dedicated coveralls, dedicated boots, dedicated daily caretakers Daily disinfection with phenol based products Daily disinfection with phenol based products Tools, holding areas Tools, holding areas Foot baths with phenol based products Foot baths with phenol based products Pest control measures stepped up in area Pest control measures stepped up in area Minimize mechanical carriers Minimize mechanical carriers

46. Onset-Presentation Age stratum Age stratum Smaller body weight and younger animals seemed most susceptible rather than aged animals Smaller body weight and younger animals seemed most susceptible rather than aged animals Troop Status Troop Status Male received most of the bananas Male received most of the bananas Infant would have dose issues as well as favored status Infant would have dose issues as well as favored status Clinical signs Clinical signs Lethargy, febrile, diarrhea, abdominal pain, and reduced appetite Lethargy, febrile, diarrhea, abdominal pain, and reduced appetite Can be fatal epizootics Can be fatal epizootics IMPORTANT to prevent IMPORTANT to prevent through food hygiene through food hygiene

47. Setting the Stage for Future Outbreaks Summer 1997 Summer 1997 A 1.0 Adult (35yr) A 1.0 Adult (35yr) B 0.1 Adult (45yr) B 0.1 Adult (45yr) C 0.1 Adult (32yr) C 0.1 Adult (32yr) D 0.1 Adult (17yr) D 0.1 Adult (17yr) E Juvenile (3yr) E Juvenile (3yr) F Juvenile (8 yr) F Juvenile (8 yr) G Juvenile (7yr) G Juvenile (7yr)

48. History 1.1 Chimpanzee 1.1 Chimpanzee (hand-reared) Considered for integration into this troop History of Shigella sonnei cultured intermittently throughout their first years of life with minor clinical signs and response to antibiotics (p.o., multiple courses)

49. Prevention Considerations Pre-shipment examination CBC, chemistry panel (Within normal limits) Rectal cultures (negative for Shigella) Quarantine examination included CBC, chemistry panel (WNL) Rectal culture (negative for Shigella). Approach for original troop Remains similar to post-outbreak

50. Quarantine Measures Long Term Review of personal hygiene (NO eating/drinking in area, washing hands) PPE (masks when feces aerosolized, gloves w/ contact with feces, dedicated coveralls, dedicated boots, dedicated daily caretakers) Routine disinfection of tools, holdings with phenolic based products Dedicated tools to affected area Foot baths with phenolic based products RE-washing all produce daily (zoo wide)

51. Break-Out Disease and Response Improved due notes and reports of the complete prior investigation – confirming that carriers occurred in one or both troops! After 45 days, G was introduced to C and E Diarrhea within 72 hours from G – culture positive for Shigella sonnei. ALL chimpanzees placed on p.o. cefapirin for 10 days before introduction proceeded.

52. Break-Out Disease and Response NO additional episodes of diarrhea during introduction and no additional Shigella cultures for the following three years. Infant born 18 month after introduction completed (C and F) and no clinical shigellosis occurred in dam or infant. Transfer at 24 months following introductions Transfer at 24 months following introductions No clinical shigellosis occurred. No clinical shigellosis occurred. However, troop and exhibit were maintained as carrier-status However, troop and exhibit were maintained as carrier-status Justified by break out and zoonotic concern Justified by break out and zoonotic concern

53. References 1. Acha, P.N., and B. Szyfres. Year. Shigellosis. In: Zoonoses and communicable diseases common to man and animals, 3 rd ed., vol. 1. Pan American Health Organization, Washington, D.C.: 247-251. 2. Banish, L.D., R. Sims, D. Sack, R.J. Montali, L. Phillips, and M. Bush. 1993. Prevalence of shigellosis and other enteric pathogens in a zoologic collections of primates. J Am Vet Med Assoc 203(1): 126-132. 3. Banish, L.D., R. Sims, M. Bush, D. Sack, and R.J. Montali. 1993. Clearance of Shigella flexneri carriers in a zoologic collection of primates. J Am Vet Med Assoc 203(1): 133-136. 4. Gravani, R.B., and E.A. Bihn. 2001. Good agricultural practices program: fruit and vegetable microbiological safety issues. http://www.gaps.cornell.edu. 5. Ketz-Riley, C.J. 2003. Salmonellosis and shigellosis. In: Fowler, M.E., and R.E. Miller (eds.) Zoo and Wild Animal Medicine, 5 th ed. Pp: 686-689. 6. Nizeyi, J.B., R.B. Innocent, J. Erume, G.R.N.N. Kalema, M.R. Cranfield, and T.K. Graczyk. 2001. Campylobacteriosis, salmonellosis, and shigellosis in free-ranging human-habituated mountain gorillas of Uganda. J Zoo Wildl Med 37(2): 239-244. 7. Paul-Murphy, J. 1999. Bacterial enterocolititis in nonhuman primates. In: Fowler, M.E., and R.E. Miller (eds.) Zoo and Wild Animal Medicine, 4 th ed. Pp: 344-351. 8. Raiden, R.M., S.S. Sumner, J.D Eifert, and M.D. Pierson. 2003. Efficacy of detergents in removing Salmonella and Shigella spp. from the surface of fresh produce. J. Food Protection 66: 2210-2215. 9. Stetter, M.D., R.A. Cook, P.P. Calle, M..Shayegani, and B.L. Raphael. 1995. Shigellosis in captive western lowland gorillas (Gorilla gorilla gorilla). J Zoo Wildl Med 26(1): 52-60. 10. Wolfensohn, S. 1998. Shigella infection in macaque colonies: case report of an eradication and control program. Lab. Anim. Sci. 48: 330-333.