Zoonoses in the Bedroom
http://www.cdc.gov/eid/content/17/2/167.htm
EID Journal Home > Volume 17, Number 2–February 2011 Volume 17, Number 2–
February 2011
Perspective
Zoonoses in the Bedroom
Bruno B. Chomel and Ben Sun Comments to Author Author affiliations:
University of California, Davis, California, USA (B.B. Chomel); and
California Department of Public Health, Sacramento, California, USA (B.
Sun)
Abstract
In most industrialized countries, pets are becoming an integral part of
households, sharing human lifestyles, bedrooms, and beds. The estimated
percentage of pet owners who allow dogs and cats on their beds is 14%–62%.
However, public health risks, including increased emergence of zoonoses,
may
be associated with such practices.
As modern society is becoming more urbanized, the presence in our
households
of traditional pets, or even exotic creatures, is increasing in popularity.
Pets have become an integral part of the family and are often considered to
be extended family (1). Having pets brings many benefits, such as
psychological support, friendship, and even good health practices
(exercising or reducing stress) (1). However, in many countries, pets have
become substitutes for childbearing and child care, sometimes leading to
excessive pet care. For example, one of the most recent trends in pet care
in Asia is hair dyeing. A recent news story claims, "Dyeing pets is popular
in many developed countries like Japan and Korea, but China is quickly
catching on"
(www.wibw.com/home/headlines/101783553.html [cited 2010 Nov 29]). Not only
are pets present in our daily environment, but they have also conquered our
bedrooms. Sharing our resting hours with our pets may be a source of
psychological comfort, but because pets can bring a wide range of zoonotic
pathogens into our environment, sharing is also associated with risks.
Sleeping with "Man's Best Friends"
In the United States, >60% of households have pets (2); pet ownership
increased from 56% in 1988 to 62% in 2008
(www.americanpetproducts.org/press_industrytrends.asp [cited 2010 Jun 23]).
Among dog owners, 53% consider their dog to be a member of the family. A
surprising 56% of dog owners sleep with their dog next to them; ≈50% of
dogs sleep on the bed. Among dogs that sleep with their owners, 62% are
small dogs, 41% are medium sized, and 32% are large
(http://pets.webmd.com/features/pets-in-your-bed [cited 2010 Jun 23]).
In a 2005 survey about dog ownership conducted by the American Kennel Club,
21% of dog owners interviewed said that they slept with their dog
regularly;
women were more likely than men to allow the practice (25% to
16%)
(www.akc.org/pdfs/press_center/press_releases/2006/ValentineSurvey.pdf
[cited 2010 Nov 29]). Another 16% said that their dogs snuck into their
beds
at least once in a while (Sacramento Bee, April 9, 2006, L1–L2).
Among cats, 62% slept with their adult owners and another 13% slept with
children.
In the United Kingdom, an estimated 6.5 million dogs live in ≈25% of
households (3). In a survey of 260 dog-owning households in a community in
Cheshire, 19% of the dogs were sleeping on the bedroom floor and 14% on
their owner's bed (3). A survey conducted in 1995 with regard to cats
>12 years of age throughout the United Kingdom found that among 1,236 of
these older cats, 45% were sleeping regularly on the owner's bed
(www.fabcats.org/behaviour/ understanding/oldcats.html [cited 2010 Jun
23]).
In the Netherlands, the pet population is ≈2 million dogs and 3 million
cats (1). The percentage of households with pets increased from 50% in
1999 to 55% in 2005. A recent study indicated that among 159 households
with
pets, 50% of pet owners interviewed allowed the pet to lick their face; 60%
of pets visited the bedroom; 45% of dogs and 62% of cats were allowed on
the
bed; and 18% and 30% of the dogs and cats, respectively, were allowed to
sleep with the owner in bed (1).
In France, the estimated pet population is ≈8.1 million dogs in 25% of
households and ≈9 million cats in 26% of households. The number of dogs
increased from ≈4 million in the late 1950s to its current 8.1 million
(www.naturanimal.com/chiens/pratique/chiffres-chiens.php [cited 2010 Nov
29]). Le Monde in 2002 reported that ≈45% of cat owners and ≈30% of dog
owners slept with their pet
(www.lemonde.fr/cgi-bin/ACHATS/acheter.cgi?offre=ARCHIVES&type_item=ART_ARCH
_30J&objet_id=785025
[cited 2010 Jun 23]).
Although such trends (Table 1) should be considered with some caution
because they were obtained from media sources and may not accurately
reflect
the true prevalence of this behavior, the zoonotic disease risks associated
with such behavior should be evaluated on the basis of the scientific
literature. We therefore searched PubMed for any peer-reviewed publication
that clearly documented human exposure to zoonotic diseases by sleeping
with, sharing a bed with, kissing, or being licked by pets.
Bacterial, Parasitic, and Viral Zoonoses
Plague
During a 1974 outbreak of plague in New Mexico, USA, 7 cases of bubonic
plague were investigated. One patient noticed flea bites the morning after
he allowed his flea-infested cat to share his bed (4). Similarly, in a
series of 23 cases of plague related to cat exposure, a 9-year-old boy from
Arizona had handled and slept with a sick cat (5). Another case, which
occurred in 1983 in New Mexico, was likely acquired after indoor/outdoor
cats slept with the patient (6). More recently, a 2008 matched case–control
study (7) surveyed 9 plague survivors, 12 household members of these
survivors, and 30 age- and neighborhood-matched controls about household
and
individual exposures. Four (44%) survivors and 3 (10%) controls (matched
odds ratio 5.7, 95% confidence interval [CI] 1.0–31.6) reported sleeping in
the same bed with a pet dog, which remained significantly associated with
infection in a multivariate logistic regression model (p = 0.046). Such
behavior is of concern because dogs may facilitate transfer of infected
fleas into the home and, unlike cats, rarely show clinical signs of
infection that could serve as a warning.
Chagas Disease
A study in northwest Argentina showed that dogs and cats infected with the
Chagas disease agent, Trypanosoma cruzi, increased risk for domestic
transmission of T. cruzi to the Chagas disease vector, Triatoma infestans
bugs (8). Infection rates were significantly higher when infected dogs
shared sleeping areas with humans than when they did not (relative risk
1.79; 95% CI 1.1–2.91).
Cat-Scratch Disease
Cat-scratch disease is mainly transmitted to humans when they are scratched
by a cat that harbors Bartonella henselae–infected fleas and flea feces
(9). However, a few documented cases have been associated with sleeping or
being licked by a household pet. For example, a systemic case of
cat-scratch
disease with hepatic, splenic, and renal involvement caused by B. henselae
was diagnosed by immunofluorescence assay, PCR, computed tomography, and
histologic examination. The patient was a 9-year-old aboriginal girl from
Taiwan, who had been sleeping with a cat at night (10). In addition, B.
hensalae infection was suspected and confirmed by serologic testing of a
50-year-old man from Japan, who had left cervical lymphadenopathy and owned
a dog that often licked his face (11). In a study of risk factors
associated
with cat-scratch disease in Connecticut, USA, case-patients were more
likely
than matched controls to have been scratched or bitten by a kitten, licked
on the face by a kitten, slept with a kitten, or combed a kitten (12).
Pasteurella spp. and Capnocytophaga canimorsus Infections
Several reports describe human infections by Pasteurella spp. that were
acquired after close contact with pets, including sharing a bed, being
licked by, or kissing the pets. In 1985, a case of meningitis caused by P.
multocida in a 60-year-old housewife living in the United Kingdom was
reported (13). She admitted to regularly kissing the family dog. P.
multocida isolates from buccal and nasal swabs of the dog were identical to
isolates from the woman. Two cases of meningitis in newborn children
(<1 month of age) have been reported; 1 was associated with a pet cat
stealing a baby's pacifier and using it as a toy, and the other was
associated with a pet dog that often licked the baby's face (14). Of 38
reported cases of P. multocida meningitis in infants, 27 (87%) of 31
infants
that had been exposed to animals had been exposed directly or indirectly to
the animals' oropharyngeal secretions through licking or sniffing (14). A
case of P. multocida infection of a hip replacement site occurred in a
69-year-old man (15). This man indicated that the dog had shared his bed
before and after his operations, sleeping under the covers on the side of
the affected leg, as it had done every night for the past 10 years (15).
Being licked by pets is a common source of human infection with P.
multocida (16–19), but in a case described by Wade et al. (16),
transmission to an infant occurred from another person. After the 2 family
dogs had licked the hands of the infant's 2-year-old brother, the older boy
allowed the infant to suck on his little finger. Heym et al.
(18) describe a case in France in which a total knee arthroplasty site
became infected with P. multocida after the patient's dog licked a small
wound on the third toe of the leg that had been operated on. In another
case, P. multocida was cultured from a wound abscess that developed in a
48-year-old obese woman 6 weeks after hysterectomy and panniculectomy for
endometrial cancer (20); her cat had licked the wound. In France,
meningitis
caused by P. multocida developed in a 67-year-old patient with chronic,
purulent otorrhea of the right ear. His dog frequently licked the patient's
right ear (21), and cultures from the dog's saliva also grew P. multocida.
The isolates had identical biochemical patterns, and pulsed-field gel
electrophoresis (PFGE) confirmed genotypic similarities. After digestion of
genomic DNA with the infrequently cleaving restriction endonuclease SmaI,
banding-pattern analysis showed clonal similarity between the isolates from
the patient and the dog. In Japan, paranasal sinusitis caused by P.
multocida was diagnosed for a 39-year-old woman with rhinorrhea and
headache
(22). The patient's cat awakened her every morning by licking her. P.
multocida isolates from the woman's nasal discharge and the cat's saliva
were similar with respect to biochemical properties, serotype, and drug
susceptibility.
Kissing pets can also transmit zoonoses. A study in Japan of 24 pet owners
(11 cats and 3 dogs) found no Pasteurella spp. in the oral cavity of the 19
owners who had not kissed their cat, but isolated P. stomatis from the oral
cavity of 1 of 2 owners who had kissed their cat and in 2 of 3 dog owners
who had kissed their dog (23). Also in Japan, meningitis caused by P.
multocida developed in a 44-year-old woman who admitted that she was
regularly kissing the dog's face and feeding it by transferring food mouth
to mouth (24). As suggested by Kawashima et al.
(24), "recent increase in pet ownership is likely to increase human
exposure
to P. multocida." These authors identified at least 2 other cases of P.
multocida meningitis between 2000 and 2010; these cases developed after the
patients kissed a pet dog and a pet rabbit.
Capnocytophaga canimorsus infections in humans have been associated with
being licked by or sleeping with a dog or cat. In Finland from 1988 through
1994, several cases of C. canimorsus septicemia were identified;
2 cases were associated with sleeping with and/or being licked by a pet
(25). For an 81-year-old woman with cellulitis of the right leg and an
ulcer
between the fourth and fifth toe, C. canimorsus was isolated from a blood
culture. This patient indicated that she slept with her cat in her bed and
that the cat licked her feet and toes. A 60-year-old patient with chronic
eczema died of septic shock and renal failure and disseminated
intravascular
coagulation caused by C. canimorsus (25). The ulcerous chronic eczema of
his
legs was the most probable port of entry for the organism because his dog
used to lick his legs. In Kansas, USA, a splenectomized 44-year-old man
died
after infection with C. canimorsus (26). The man had lived in a trailer and
collected scrap metal to sell; he had several cuts and scratches on his
forearms and hands. His recently acquired German shepherd puppy reportedly
licked the open abrasions on the man's hands, but no bite was reported. In
Australia, septicemia and multiorgan failure developed in a 48-year-old
woman after her fox terrier puppy licked a minor burn wound on the top of
her left foot (27).
Staphylococcus intermedius Infections
Staphylococcus intermedius is a common commensal bacterium in dogs and cats
and has rarely been identified as causing human infection (28).
However, in Japan, S. intermedius developed in the mastoid cavity of a
51-year-old woman after mastoidectomy for chronic otitis media with
cholesteatoma (28). Her dog had licked her ears, and bacterial strains from
the dog's saliva and the patient's otorrhea were confirmed by PFGE to be
identical. Similarly, a 28-year-old woman with a history of endoscopic
pituitary adenoma resection reported 3 weeks of foul-smelling nasal
discharge (29). Nasal endoscopy indentified a purulent sinus infection
caused by methicillin-resistant S. intermedius. Cultures from the patient's
pet bulldog also grew S. intermedius strains that were confirmed by PFGE to
be identical to those of the patient. The patient reported having had close
physical contact with her dog, including frequent licking of her face, and
that the dog had recent bouts of pyoderma requiring treatment with
antimicrobial drugs.
Methicillin-Resistant Stapylococcus aureus Infections
A 48-year-old man with diabetes and his wife had recurrent
methicillin-resistant Staphylococcus aureus (MRSA) infections (30).
Culture of nares samples from the family dog grew mupirocin-resistant MRSA
that had a PFGE chromosomal pattern identical to the MRSA isolated from the
patient's nares and his wife's wound. The couple reported that the dog
routinely slept in their bed and frequently licked their faces.
Further recurrence of MRSA infection and nasal colonization in the couple
was prevented only after successful eradication of MRSA from the dog's
nares.
Rabies
In many developing countries, being licked by dogs that are rabid or
suspected to be rabid is considered to pose a major risk. A survey of
rabies
exposure among 296 Norwegian missionaries and foreign aid workers traveling
abroad showed that of 48 persons for whom postexposure vaccination was
recommended, two thirds had only cared for or been licked by the suspected
rabid animal (31). Rabies remains a problem in Southeast Asia, where many
backpackers visit each year. In the early 1990s, foreign travelers (74% of
whom were European), who had been in Thailand for an average of 17 days,
were surveyed about potential rabies exposure during their visits. Among
1,882 travelers, 1.3% had been bitten and 8.9% had been licked by dogs
(32).
During May–June 2008, another survey of 870 foreign backpackers (median age
25.5 years) in Bangkok, Thailand, found that 3.56% had been licked by a dog
(33).
Parasitic Infections
In the United States, the most common parasitic zoonoses associated with
dogs are caused by hookworms (Ancylostoma spp.) and roundworms (Toxocara
canis) (2). In the Netherlands, prevalent parasitic zoonoses are caused by
Toxocara spp., Giardia spp., Cryptosporidium spp., and Toxoplasma spp. (1).
Among the ways that toxocariasis can be transmitted to humans, contact with
embryonated eggs on a dog's hair coat was recently proposed (34).
Similarly,
a recent study in the Netherlands identified Toxocara spp. eggs on the fur
of 18 dogs (12.2%) and 2 cats (3.4%) and in the feces of 4 dogs and 1 cat
(1). That same study found Giardia spp. in the feces of 14 dogs and 3 cats
and Cryptosporidium spp. in feces of 8 dogs and 1 cat (1). A case of
Cheyletiella blakei infection was reported in a 76-year-old woman with
pruritic eruption of vesicles and bullous lesions on her trunk and arms
(35). Cheyletiella spp. dermatitis was suspected because of the appearance
and distribution of the elementary lesions and because before the eruption,
the patient had acquired a cat that sometimes slept in her bed. The
diagnosis was confirmed by a veterinary examination and isolation of C.
blakei from the cat's skin. The patient's condition resolved after the cat
was treated with ivermectin, the household was disinfected with permethrin,
and the patient was treated with benzyl benzoate.
Other Dangers
Another major health hazard can be created by keeping dominant and
possessive dogs in a bedroom where young infants are sleeping. An analysis
of risk factors associated with nonplay dog bites in Kingston, Jamaica,
found that a dog sleeping in a family member's bedroom was a risk factor
for
biting (relative risk 2.54, 95% CI 1.4–4.54) (36). In a review of fatal dog
attacks in the United States during 1989–1994, Sacks et al. (37) reported
that among 109 dog bite–related deaths, 57% were of children <10 years old
and 11 were of a sleeping infant.
Recommendations
Zoonotic infections acquired by sleeping with a pet are uncommon.
However, severe cases of C. canimorsus infection or plague in humans have
been documented. More zoonotic agents that are transmitted by kissing a pet
or being licked by a pet have been identified, especially zoonotic
pathogens
that are commensal in the oral cavity of carnivores, such as Pasteurella
spp. and C. canimorsus. Because young children are often at higher risk
than
adults for exposure to zoonotic pathogens, especially when animals are
displayed in public settings, the National Association of State Public
Health Veterinarians issued specific recommendations (38). However, the
concerns associated with sharing a bed with pets, being licked by pets, or
kissing pets were not addressed in these recommendations. Similarly,
although the risk for introduction of zoonotic agents by pets in hospitals
or nursing homes has been evaluated (39) and recommendations made (40), the
recommendations do not specifically address the risk for transmission
through being licked by, kissing, or even sleeping with a pet.
Our review suggests that persons, especially young children or
immunocompromised persons, should be discouraged from sharing their bed
with
their pets or regularly kissing their pets. Any area licked by a pet,
especially for children or immunocompromised persons or an open wound,
should be immediately washed with soap and water. Pets should be kept free
of ectoparasites (especially fleas), routinely dewormed, and regularly
examined by a veterinarian. Preventive measures such as anthelmintic drug
intervention for puppies within the first few weeks after birth or, even
better, for bitches during the last few weeks of pregnancy, could help
prevent most cases of human toxocariasis.
Similarly, evaluation of patients with recurrent MRSA colonization or
infection or Pasteurella spp. infection with no obvious source should
prompt
queries about any regular contact with pet dogs, particularly in household
settings.
Conclusion
Although uncommon with healthy pets, the risk for transmission of zoonotic
agents by close contact between pets and their owners through bed sharing,
kissing or licking is real and has even been documented for
life-threatening
infections such as plague (Table 2). Carriage of ectoparasites or internal
parasites is certainly of major concern when it comes to this type of
behavior. To reduce such risks, pet owners should seek regular veterinary
care for their pets.
Dr Chomel is a professor of zoonoses at the School of Veterinary Medicine,
University of California, Davis, with an interest in the epidemiology of
zoonotic diseases, especially new and emerging zoonoses.
Dr Sun is the state public health veterinarian for California and is
involved with several national committees concerning zoonotic diseases.
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Tables
Table 1. Estimated pet dog and cat populations in developed countries and
estimated percentage of these pets sleeping on/in owner's bed , 1974–2010
Table 2. Zoonoses acquired from close contact with pet, 1974–2010 Suggested
Citation for this Article
Chomel BB, Sun B. Zoonoses in the bedroom. Emerg Infect Dis [serial on the
Internet]. 2011 Feb [date cited].
http://www.cdc.gov/EID/content/17/2/167.htm
DOI: 10.3201/eid1702101070
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