1. MULTI-RESISTANT Salmonella enterica Thyphimurium OUTBREAK PUBLIC HEALTH AND PRUDENT USE OF ANTIBIOTICS Additional material: Manual on DISEASE OUTBREAK INVESTIGATION Manual on PRUDENT USE OF ANTIBIOTICS

2. CASE BEGINNING; DISEASE IN HUMANS European city It started on 12th June of 2004 A four year old child was admitted to hospital. He had high temperature (40ºC), fluid diarrhoea and abdominal distress A microbiological test was done and Salmonella enterica Typhimurium was detected This germ was multi-resistant to antibiotics

3. OUTBREAK CASE IN HUMANS A second child, who was 5 years old, went to the hospital 2 days later. He also had high temperature (39ºC), fluid diarrhoea, abdominal distress and vomiting Salmonella enterica Typhimurium was detected again On the next day, a 40 yrs old person was admitted to hospital with the same symptoms The same microorganism was isolated: Salmonella enterica Typhimurium

4. CASE INVESTIGATION - I In your view, how would you study this case taking into account that the course of the outbreak is generating a growing concern and the outbreak seems to become very serious? Another case appeared, it’s a 12 yrs old child from the nearby city, with the same symptoms and microbiological results. The connection between these people was investigated

5. CASE INVESTIGATION - II There is no direct or occasional connection between these people The food they had eaten seems not to have anything to do with the case A hamster was given to one of the children fifteen days before, and four days later the animal died Do you think this fact has got something to do with the disease’s outbreak detected? If you think it was involved in the problem, how would you go on with the investigation trying to solve it?

6. CASE INVESTIGATION - III The sick adult worked in a pet shop The two first children had hamsters which were bought in that shop These hamsters had arrived to the shop seventeen days before from a farm of a nearby city - At the time of the arrival, both hamster were put on sale and were kept in a plastic cage whithout any contact with other animals. The third child (who lived in a different town) visited the farm one week ago

7. DIAGNOSTIC INVESTIGATION Samples were taken from the shop’s animals, from the farm’s animals and from the second child’s hamster. A microbiological analysis was done: Shop’s animals were negative 20% of the farm’s animals were positive: Salmonella enterica Typhimurium was detected The secound child’s hamster was also positive to S. enterica Thyphimurium

8. SOME MORE INTERESTING FACTS - I Last days there had been some animals with diarrhoea in the farm. Three of them died Thirty days ago a ferret had been brought over The ferret was located in a cage of the farm for four days, later, a group of hamsters was put there Some of them were sold to a nearby city’s shop and the rest was relocated in the farm With the available information, could you explain the outbreak? Define the transmission chain and explain the subsequent mistakes done

9. SOME MORE INTERESTING FACTS - II The investigation done in the farm showed that: Antibiotics had been constantly used in the last years to prevent digestive diseases They used half a therapeutic treatment dose A mix of spectinomycin, tetracyclin and nitrofurazone was used This treatment has been used during the last four years...

10. Which involvements would this MULTI- RESISTANT bacteria have in Public Health? In case you choose to carry on a disease control program, would you include an antibiotic treatment for a specific group of animals? In this case, which rules to select the drug and to use it would you consider essential? Case developed by the SAPUVETNET II member – University of Zaragoza, Fac_Med_Vet. (contact: Carmelo Ortega/Olga Gimeno epidemio@unizar.es)epidemio@unizar.es