1. MENINGITIS STREPTOCOCICA PORCINA; ANTIBIOTIC RESISTANCE FROM PIGS PUBLIC HEALTH INVOLVEMENTS Additional material: Manual on DISEASE OUTBREAK INVESTIGATION Manual on PRUDENT USE OF ANTIBIOTICS

2. The case: a little region of a developing country where stock breeding is trying to develop to improve the economy of the region First case of disease in humans appeared on 15 th June of 2005 In the next week, 12 cases were described: - Slight cutaneous symptoms on hands and arms - Inflammation and red skin in these zones. - Little grazes On the 21 th June, one person died with septicaemia, toxic shock, meningitis and subcutaneous haemorrhage

3. A bacterial cause was suspected, so: penicillinA treatment with broad spectrum penicillin was carried out was changedquinoloneIt wasn’t effective and three days later the treatment was changed to a quinolone antibiotic of third generationIt wasn’t effective too, so doctors started to look for a antibiotic of third generation another person died septicaemiaWhile this was happening, another person died. He also had a septicaemia

4. As a Veterinary Public Health (VPH) expert do you think they (doctors) have acted in a right way to deal with the human cases? In case they did not In case they did not: Which mistakes do you think they made? What do you think they should do?

5. The microbiological investigation of the two dead patients detected the presence of Streptococcus suis. Moreover this micro-organism was resistant to almost all antibiotic assessed As public concern was growing, a working team involving doctors, veterinarians and politicians was created. The veterinarians suggested to study if this micro organism had an animal origin

6. How would you carry out the STUDY OF THE DISEASE? Which aspects do you think would be important to study?

7. The investigation showed that: Before 15 th June, some more 20 (minor) cases have came up during the year. Those people got better in 12-15 days There have been higher mortality than normal in two pig farms during the last months. The pigs died with meningitis. No cause was found for these deaths, but it was thought that it happened because of over- crowding and very humid and hot weather

8. One of the dead patients worked in the pig farm and the other worked in the slaughterhouse. Most of the affected people had taken part in domestic pig slaughtering (which is a tradition in the area) Other affected people were slaughterhouse workers and the others were close relatives of the affected people In the last years some people had been sick with similar but less severe symptoms, and cases in pigs had been also described The investigation showed that: What is your conclusion with the information so far available?

9. The study in pigs of the region showed that Streptococcus suis type 2 was detected in the 70% of the farms This bacteria has the same serotype and genotype as the bacteria isolated from the dead people Also the same antibiotic resistance patterns were showed All these strains were multi-resistant. Pig farms related people were also investigated and the bacteria was isolated in 40% of them.

10. Do you still held your previous conclusion with the available information? Could you now think of a new / different conclusion?

11. The study at the pig farms showed that: Most of the famers didn’t have veterinary advice There were a constant movement and mixing of animals amongst the farms The farmers gave antibiotics to animals in order to prevent diseases: –Antibiotics are given with food and half of the standard dosis –During the last two years, at the farms a mix of two penicillins and a tetracicline had been used …Cont. 

12. The farms were cleaned with running water once a month When a animal died, the carcases were disposed of (thrown away) without any treatment With all these information: Do you consider that these practices are appropriate? Cont.

13. How would you suggest to solve this problem both in animals and humans? Case study developed by the SAPUVETNET II member – University of Zaragoza, Fac. Veterinary Medicine (contact: Carmelo Ortega/ola Gimeno epidemio@unizar.es)epidemio@unizar.es Do you think these practices are related with Public Health problems or may have something to do with it in future? In that case, explain which practices, why and how