On February 20, 2015, a northeastern university’s student health center was notified
of five veterinary medicine students with gastrointestinal symptoms. An investigation
was conducted to establish the existence of an outbreak, determine the etiology, evaluate
risk factors, and recommend control measures.
All five students had attended a training session at the university’s bovine obstetrics
laboratory on February 13, which included the handling of two euthanized calves. Patient
symptoms, date of onset, and history of calf exposure suggested cryptosporidiosis.
Infection with Cryptosporidium, a protozoa that causes watery diarrhea and is transmitted
by infectious oocysts via the fecal-oral route (1), is common among calves (2). Symptoms
in humans typically begin 7 days (range = 2–10 days) after infection and include intermittent
abdominal cramps, nausea, vomiting, fever, and weight loss, lasting approximately
1–2 weeks (3).
Two calves used in the training sessions had been euthanized and frozen at −1.4°F
(−17.0°C) on February 11. Approximately 28 hours later, the calves were thawed and
detergent-washed by laboratory staff in accordance with standard protocols. Necropsies
were performed on both animals on February 23, and revealed Cryptosporidium oocysts
on an acid-fast stain of an intestine smear from one of the calves.
Interviews revealed that 22 students had attended the training session. Sixteen students
reported symptoms, including diarrhea (13 students), abdominal cramps (13), nausea
(12), fatigue (eight), vomiting (seven), anorexia (five), headache (four), and chills
or sweats (four), lasting 2–10 days. Among the 16 symptomatic students, the median
age was 25 years (range = 24–30 years), and 13 were female.
Four symptomatic students submitted stool specimens. One case was confirmed by detection
of Cryptosporidium oocysts using direct fluorescent antibody testing; the other 15
were classified as probable cases, based on CDC case definitions (1). To account for
the possibility of other infectious etiologies, stool specimens were also tested for
Giardia, Cyclospora cayetanensis, Isospora, Salmonella, Shigella, Escherichia coli,
and Campylobacter; all tests were negative. The positive acid-fast stain from one
of the calves and one of the students with a confirmed case implicated the obstetrics
laboratory as the source of the outbreak.
The bovine obstetrics laboratory personal protective equipment (PPE) protocol includes
donning of gloves and coveralls before animal handling and cleaning boots and doffing
of gloves and coveralls after animal handling, followed by 30 seconds of hand washing
with warm water and soap. Face protection is not included in PPE protocols for this
laboratory. Although all of the 22 students wore gloves during the training session,
the number of students who removed their coveralls or washed their hands afterwards
is unknown. At least four of the symptomatic students reported that they did not immediately
doff their coveralls.
Cryptosporidiosis outbreaks have been reported among veterinary students (4), usually
through contact with infected calves, and are associated with lapses in hygiene (5).
In this outbreak, students were infected through contact with euthanized calves that
had been frozen and thawed before the training session. Cryptosporidium oocysts can
survive various environmental pressures, including extended exposures at temperatures
as low as −7.6°F (−22.0°C) for >700 hours (6). This cluster highlights the importance
of appropriate hygiene and proper animal cadaver handling. Since the likelihood of
calves being infected with cryptosporidiosis is high, veterinary medical institutions
should ensure that recommendations for PPE and proper hygiene techniques for students
and staff are fully implemented.