1. Do humans get foot-and-mouth disease? Suzanne Burnham, DVM Strategic Preparedness Branch Texas Department of State Health Services

2. Foot-and-Mouth Disease Foot-and-mouth disease (FMD) is a highly contagious, viral disease of domestic cloven-hoofed and many wild animals. Foot-and-mouth disease (FMD) is a highly contagious, viral disease of domestic cloven-hoofed and many wild animals. Emergency Responders will face very difficult issues in controlling the spread of this disease Emergency Responders will face very difficult issues in controlling the spread of this disease

3. Foot-and-Mouth Disease This devastating disease is considered to be the most important livestock disease in the world. This devastating disease is considered to be the most important livestock disease in the world.

4. Archives of Virology 1997 (Suppl) 13: 95-97. Man’s susceptibility to the virus of foot-and- mouth disease (FMD) was debated for many years. Today the virus has been isolated and typed (type O, followed by type C and rarely A) in more than 40 human cases. So no doubt remains that FMD is a zoonosis. Considering the high incidence of the disease (in animals) in the past and in some areas up to date, occurrence in man is quite rare.” Konrad Bauer Landesuntersuchungsamt für das Gesundheitswesen Nordbayern, Nürnberg, Federal Republic of Germany

5. “The virus of foot and mouth disease causes severe epizootics in animals and infrequently evokes painful, but transient clinical signs in man. Adults in certain occupational groups and children are particularly exposed to risk.” “Predisposing factors play an important role in the development of overt foot and mouth disease in man. Subclinical infection occurs” N. ST. G. HYSLOP Principal Scientific Officer, Animal Virus Research Institute, Pirbright Transmission of the virus of FMD between animals and man. Bulletin of the World Health Organization. 1973;49:577-585.

6. Literature Search Limitations of our search: 1834 – present with concurrent FMD outbreak in animals Articles in English and 7 foreign languages Does not include articles from FMD endemic areas of China, Asia, Africa, the Middle East

7. FMD World Distribution July – Dec 2007 OIE World Animal Health Information Database (WAHID)

8. Search for articles published in U.S. 1915 USDA Farm Bulletin 666 – subchapter on FMD in humans 1915 USDA Farm Bulletin 666 – subchapter on FMD in humans 1915 Clough – medical student at Johns Hopkins University 1915 Clough – medical student at Johns Hopkins University 1916 Sutton and O’Donnell – stockman from Kansas 1916 Sutton and O’Donnell – stockman from Kansas

9. Search results 468 References 468 References –5 Bibliographies –11 Dissertations –119 Reports of 381 Case Descriptions Ministry of Agriculture Prussia 1880s (16 epidemics 1600 humans BUSSENIUS AND SIEGEL )

10. 1834 Story Drs. Hertwig, Mann, Villain veterinary surgeons of Prussia Drank 1 quart of fresh raw, warm milk from a cow severely infected with FMD Day 1, 2 and 4 Article charts the symptoms of all 3 Repeated by Krajewski in 1901

11. Summary of findings Reported mostly by physicians Reported mostly by physicians In all ages from infants to adults In all ages from infants to adults Only when remarkable in severity Only when remarkable in severity Often no epidemiology reported Often no epidemiology reported Photographs of lesions in many articles Photographs of lesions in many articles Case definitions by symptoms and then by diagnosis Case definitions by symptoms and then by diagnosis

12. Mild Case Symptoms Headache, malaise, chills, thirst, dry mouth Headache, malaise, chills, thirst, dry mouth Primary vesicle Primary vesicle Itchiness; pharyngitis; GI symptoms Itchiness; pharyngitis; GI symptoms Fever (38 ˚C – 39.5 ˚C) Fever (38 ˚C – 39.5 ˚C) Multiple vesicles, some coalesce Multiple vesicles, some coalesce Vesicles rupture, erosions heal rapidly Vesicles rupture, erosions heal rapidly

13. More serious symptoms Excessive salivation, inflammation of tongue Excessive salivation, inflammation of tongue Vesicles in mouth, tongue, lips Vesicles in mouth, tongue, lips Vesicles on hands, between fingers Vesicles on hands, between fingers Fingernails, bed of nails damaged Fingernails, bed of nails damaged Vesicles on feet, soles, between toes Vesicles on feet, soles, between toes Large coalesced blisters sloughed Large coalesced blisters sloughed Erosions caused painful swallowing, walking Erosions caused painful swallowing, walking Gastro-enteritis reported especially in children who drank raw milk Gastro-enteritis reported especially in children who drank raw milk

21. Less frequently reported symptoms Conjunctivitis (from hand contact?) Conjunctivitis (from hand contact?) Change in voice quality Change in voice quality Typical odor of necrosis, halitosis Typical odor of necrosis, halitosis GI complications from ulcerations GI complications from ulcerations Temporary bilateral facial paresis Temporary bilateral facial paresis

22. October 28, 2008, USAHA MUSSER, BURNHAM October 28, 2008, USAHA MUSSER, BURNHAM FMD virus Types reported in humans FMD virus Types reported in humans Type O Type C Type A Russia A 22 Russia B 1960’s3828931 1950’s5651 1940’s18 1930’s40 1920’s1

23. For Descriptions that included Virus Type in the Report Type O: 49% Type C: 45% Type A: 9%

24. “Clinical diagnosis” –Clinical signs –FMD in local livestock “Presumptive diagnosis” –Clinical signs –FMD in local livestock –Single test of guinea pig or calf passage, suckling mouse passage –Language barrier “Confirmed diagnosis” –Clinical signs –FMD in local livestock –Confirmatory laboratory diagnosis from serum neutralization, complement fixation or virus isolation testing Sero-positive only –Serological identification –No clinical signs reported or investigated

25. October 28, 2008, USAHA MUSSER, BURNHAM October 28, 2008, USAHA MUSSER, BURNHAM Diagnosis Diagnosis TotalClinicalPresumConfirmedA/S-P 1970’s44 1960’s94632362 1950’s841121358 1940’s338718 1930’s672061922 1920’s14761

26. October 28, 2008, USAHA MUSSER, BURNHAM October 28, 2008, USAHA MUSSER, BURNHAM 1960’s Summary Confirmed by lab + clinical signs Sero-positive only Employed at FMD research lab or vaccine production facility 8 Type O 2 Type C 62 52% Type O 31% Type C 17% Type A No association with research or vaccine production 2 Type O 9 Type C 2 Type A 22Russia ? ? ? No report

27. Risk factors emerged 1. Ingesting high quantity of FMD virus in raw milk 2. Daily direct contact and broken skin 3. Inoculation / lab accident PLUS Pre-existing disease (resulting in dermatitis or immune suppression)

28. Most at-risk population groups noted in the literature search Children Children Animal caretakers Animal caretakers Dairy employees Dairy employees Veterinarians Veterinarians Farmers Farmers Butchers Butchers Lab technicians Lab technicians

29. October 28, 2008, USAHA MUSSER, BURNHAM BBC News HEALTH: Monday, 23 April, 2001, 21:25 GMT 22:25 UK 'A mild and transient disease' Bobby Brewis suffered from adverse publicity When Bobby Brewis was found to have the last confirmed case of human foot-and-mouth disease in the UK he became a minor celebrity. http://news.bbc.co.uk/2/hi/health/1293311.stm

31. October 28, 2008, USAHA MUSSER, BURNHAM

32. A Zoonosis but generally not a Public Health Concern

33. Public Health Considerations Human cases occur singly Human cases occur singly Symptoms often not reported, Symptoms often not reported, Pasteurization eliminates 95% of FMD virus in milk. Pasteurization eliminates 95% of FMD virus in milk. Biosecurity Biosecurity

34. Why it matters

35. Questions? Bobby Brewis