Psittacosis in birds and people

ISAZA, 2017 1

Ramiro Isaza, DVM, MS, MPH, DACZM, DECZM

Professor, Zoological MedicineCollege of Veterinary Medicine

University Florida

Psittacosis in birds and people

Definition of Terms

� Old names for C. psittici infections– Pseudotyphus

– Parrot fever

– Parrot disease

– Ornithois

– Chlamydiosis

– Chlamydophilosis

� Psittacosis

Definition of Terms

� Official terms

– “Psittacosis” is the disease caused by C. psittaci in humans

– “Avian Chlamydiosis” is the disease caused by C. psittaci, C. avium, orC. gallinacean in birds

Definition of Terms

� For this lecture

– “Psittacosis” is the disease caused by C. psittaci in both humans and any other animal species

Lecture Update

� New Compendium 2017

Introduction

� Why is psittacosis interesting to me?– Important individual animal pathogen

– Important captive population pathogen

– Important zoonotic pathogen

– Pathogen with regulatory concerns

– Interesting history

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Introduction

� Why is psittacosis interesting to Argentina?

Introduction

� Argentina’s history with psittacosis

–First major psittacosis outbreak was 1891-1892 in Paris� 50 human cases with 16 deaths

� The source was 500 parrots imported from Buenos Aires

� 300 of the parrots died during transport to France

Introduction

� Argentina’s history with psittacosis

–Global psittacosis outbreak 1929–1930� Linked to parrots from Cordoba, Argentina

� 1,000 human cases, with 200-300 deaths

Introduction

� Argentina’s history with psittacosis

–Newspaper reports 2013

Introduction

� Argentina’s history with psittacosis

Introduction

� Argentina’s history with psittacosis

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Introduction

� Argentina’s history with psittacosis

–Recent scientific report 2017 (in-press)� 846 human respiratory and ocular samples from sick patients (5.6% positive)

� Studied 8 human and 4 bird samples

– All genotype “A”

– 5 had bird contact

Lecture Outline

� Biology of the disease

� Importance to birds and humans

� Current recommendations to avoid zoonotic outbreaks

History of psittacosis

� First described by Ritter in 1879

–Called “pneumityphus”

–Associated with parrots and finches

� Called “parrot fever” by Nocard 1893

� Bedson and others in 1930 described a causative “virus”

� Identified as bacteria 1965 with EM

Biological characteristics

� Obligate intracellular bacteria

–Very small bacteria

–Cytoplasmic inclusions with membranes

–Two unique life stages

� Reproductive “Reticulate bodies”

� Infectious “Elementary bodies”

Biological characteristics

� Obligate intracellular bacteria

–2 stage life cycle� “Reticulate bodies”

� “Elementary bodies”

Biological characteristics

� Obligate intracellular bacteria

–2 stage life cycle� “Reticulate bodies”

� “Elementary bodies”

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Biological characteristics

� Obligate intracellular bacteria

R = Reticulate bodiesDR = Dividing reticulate bodyE = Elementary bodies

Biological characteristics

� Obligate intracellular bacteria

– “Reticulate bodies” are reproductive� Divide by binary fusion like a bacteria

Biological characteristics

� Obligate intracellular bacteria

– “Elementary bodies ” are infectious and spread into the environment

Biological characteristics

� Obligate intracellular bacteria

– “Elementary bodies” killed with 5-10 minute contact with:� Quaternary ammonium compounds

� Phenols

� Diluted (1:32) bleach solution

� Hydrogen peroxide oxidizing agents

� Alcohol

Classification

� Historical classification

–First confused with viruses

–Often misidentified in early literature

–Classification often changed

Classification

� Domain: Bacteria

� Phylum: Chlamydiae

� Order: Chlamydiales

� Family: Chlamydiaceae

� Genus: Chlamydia (Chlamydophila)

� Species: Chlamydia psittaci

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Classification

� “Chlamydophila” vs “Chlamydia”

– Changed to Chlamydophila in 1999

– Currently that name is ignored

– Chlamydia is the correct species name!

Classification

� Current species

–11 Chlamydia species

Classification

� C. psittaci genotypes (ompA)

–Bird genotypes (7)� “A” = Parrots (classic psittacosis strain)

� “B” = Pigeons and Doves

� “C” = Ducks and Geese

� “D” = Turkeys, Gulls, and Egrets

� “E” = Many bird species

� “F” = Only 1 Parrot and 1 Turkey (rare)

� “E/B” = Ducks, Turkeys, and Pigeons

Classification

� C. psittaci genotypes (ompA)

–Mammalian genotypes (2)� “WC” = Cows

� “M56” = Rodents

Classification

� C. psittaci genotypes (ompA)

–Many exceptions and “host” jumps!

Bird Psittacosis

� Bird “psittacosis” epidemiology

–Psittacosis in “wild” birds� More than 30 orders of birds

� 465 different bird species

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Bird Psittacosis

� Bird “psittacosis” epidemiology

–Psittacosis in “wild” birds� 45% of tested Parrot species

� 28% Gull species

� 26% Auk species

� 25% Penguin species

� 21% Duck species

Bird Psittacosis

� Bird “psittacosis” epidemiology

–Prevalence survey of captive parrots in Costa Rica� Used PCR and genotyping

� Found 3.4% positive

Bird Psittacosis

� Bird “psittacosis” epidemiology

–Prevalence survey of captive parrots in Brazil� Used immunofluorescence from cloacal swabs

� Found 17%-56% positive

Bird Psittacosis

� Clinical signs in Parrots

–Acute� Pneumonia, rhinitis, sinusitis

� Lethargy, anorexia

–Chronic� Conjunctivitis, air sacculitis

� Hepatitis, splenetic, pericarditis

–Sub-clinical � No clinical signs or only mild conjunctivitis

Bird Psittacosis

� Clinical signs in Pigeons

–Acute/Chronic� Rhinitis, blepharitis, sinusitis

� Conjunctivitis

� Lethargy, anorexia

–Sub-clinical� No clinical signs

Bird Psittacosis

� Clinical signs in Ducks

–Acute/Chronic� Rhinitis

� Conjunctivitis

� Trembling

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Bird Psittacosis

� Diagnosis

–Antigen� Culture (BSL3 pathogen)

� PCR (various tests)

� Indirect fluorescence antibody (IFA)

–Serology� Elementary body agglutination (EBA)

� Complement fixation (CF)

� Diagnosis (Using 2017 compendium case definition)

–Confirmed case� Antigen detection with culture or PCR

� 4-fold rise in titer with EBA or CF

� Histopathological identification

–Suspected case� Linked epidemiologically to a C. Psittaci case

� Swab PCR or fluorescent antibody positive

–Both reportable!

Bird Psittacosis

Bird Psittacosis

� Treatment

–Supportive care� ICU care

� Hydration

� Force feeding

Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics� Doxycycline

– Individual oral (25-30 mg/kg PO once daily)

– Individual IM (75-100 mg/kg IM every 7 days)

– Medicated feed (300 mg/ per kg of food)

– Medicated water (400-600 mg/per liter)

Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics� Doxycycline

� Azithromycin

– 40 mg/kg PO once daily tested in cockatiels

Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics� Doxycycline

� Azithromycin

� Oxytetracycline

– “LA-200” 75 mg/kg SC every 3 days

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Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics� Doxycycline

� Azithromycin

� Oxytetracycline

� Chlortetracycline

– 1% pellets

Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics� Doxycycline

� Azithromycin

� Oxytetracycline

� Chlortetracycline

� (Enrofloxacin and other quinolones)

Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics

–Duration of treatment� Classic quarantine treatment = 45 days

� Shorter 21-30 also effective

Bird Psittacosis

� Treatment

–Supportive care

–Antibiotics

–Duration of treatment

–Post treatment testing

Human Psittacosis

� Human “Chlamydia” infections

Zoonotic

Primary Human

Pathogens

Human Psittacosis

� Multiple species hosts and zoonotic chlamydial infections

–C. psittaci

–C. abortus

–C. felis

– (C. caviae)

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Human Psittacosis

� Genotypes of C. psittaci in humans

–Associated with typical bird species� “A” with parrots

� “B” with pigeons

� “C” with turkeys

–Sometimes unexpected findings� Mammalian “WC” in Cordoba, Argentina

� New genotypes in The Netherlands

Human Psittacosis

� Preliminary clinical Diagnosis– Community-acquired pneumonia or influenza-like symptoms

– Often linked to a history of “bird” exposure

Human Psittacosis

� Classic clinical signs – Fever, headache, malaise, myalgia

– Sore throat, dry cough, dyspnea

– Splenomegaly, hepatitis

� Additional clinical signs– Myocarditis, endocarditis

– Encephalitis, coma

– Fetal death, abortion

Human Psittacosis

� Diagnosis– The chest radiographs often

have lower lobe, dense consolidation

– Also can be nodular, military or interstitial infiltrates

– On computed tomography, the pulmonary infiltrates may be nodular surrounded by ground-glass opacities

45 year old male, with Chlamydial pneumoniaCenter for Food Security and Public Health Iowa

State University - 2004

Human Psittacosis

� Diagnostic tests

–Antigen� Culture (BSL3 pathogen)

� PCR (various tests)

� Direct fluorescence antibody (DFA)

–Serology� Microimmunoflorescence (MIF)

� Complement fixation (CF)

Human Psittacosis

� Diagnosis (Using CDC case definition)

–Confirmed case� Antigen detection with culture

� 4-fold rise in IgG titer with MIF or CF

–Probable case� Antigen detection with PCR

� Single elevated IgM titer ≥1:32 detected by MIF

–Both reportable!

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Human Psittacosis

� Treatment– Primary =Tetracycline or Doxycycline

– Secondary = Azithromycin or erythromycin

– (Quinolones?)

� “Psittacosis” epidemiology

–World-wide distribution

–Reportable disease in the US� Rare disease, but under diagnosed

– Only 58 cases between 2006-2012 (2-21 cases/year)

� Treatment is usually successful

–Mortality 10%-40% when not treated

Zoonotic Outbreaks

� Zoonotic transmission to humans

– Inhalation of dried droppings or feather dust with “elementary” bodies� Direct bird contact

� Environmental exposure

Zoonotic Outbreaks Zoonotic Outbreaks

� Veterinary school outbreak

–Caused by C. psittaci genotype “A”

–Parrots used for teaching students� 66% parrots were positive

– 34% of students and veterinarians became positive after exposure

� Horse abortion (new odd case)– Veterinary student cases in Australia

– Possibly from wild birds

– (Also possibly C. abortus)

Zoonotic Outbreaks

� Occupational risks– Veterinarians and technicians

– Pet bird owners

– Pet shop employees

– Zoo keepers

– Poultry processing workers

– Wildlife rehabilitators

– Laboratory workers handling Chlamydia samples

Zoonotic Outbreaks

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Zoonotic Outbreaks

� Environmental exposure � Why is zoonotic psittacosis misdiagnosed?– Usually mild clinical signs

– Other human pneumonias are similar

– Few specific diagnostic tests in humans

– Bird exposure difficult to identify

Zoonotic Outbreaks

� Other respiratory diseases associated with bird exposure– Allergic alveolitis

– Aspergillosis

– Cryptococcosis

– Influenza

Zoonotic Outbreaks Recommendations

� CDC Website

–Available online

https://www.cdc.gov/pneumonia/atypical/psittacosis.html

Recommendations

� 2017 Compendium

– Journal of Avian Medicine and Surgery

Recommendations

� 2017 Compendium

–Public Health Veterinarian Web site

http://www.nasphv.org/documentsCompendiaPsittacosis.html

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Recommendations

� Apparently healthy collections

–Use good husbandry standards� Keep accurate records

� Avoid mixing species

� Avoid mixing birds from multiple sources

� Provide routine hygiene

� Provide good ventilation

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Apparently healthy collections

–Use good husbandry standards

–Educate� Employees

� Clients

� Health care providers

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Apparently healthy collections

–Use good husbandry standards

–Educate

–Quarantine and test new birds

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Apparently healthy collections

–Use good husbandry standards

–Educate

–Quarantine and test new birds

–Screen birds regularly

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Infected birds

– Isolate during treatment

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Infected birds

– Isolate during treatment

–Educate hospital staff� Modes of transmission to people

– Avoid making hospital aerosols

� Warn pregnant women

� Warn immunosuppressed people

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

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Recommendations

� Infected birds

– Isolate during treatment

–Educate hospital staff

–Personal protection� Face mask (N95)

� Gloves

� Eye protection

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Infected birds

– Isolate during treatment

–Educate hospital staff

–Personal protection

–Disinfection� Clean all hospital cages

� Remove disposable items

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Disinfectants for chlamydia

–Soap and water to remove organics

–Quaternary ammonium (Roccal)

–Phenols (1% Lysol)

–Bleach (1:32 chlorox)

–Contact time is 5-10 minutes

http://www.nasphv.org/Documents/PsittacosisCompendium.pdf

Recommendations

� Public Health Veterinarian Web site

–Prevention handout� Available in Spanish

http://www.nasphv.org/Documents/Psittacosis%20Prevention%20Checklist%20for%20Pet%20Stores%20and%20Aviaries%20(Spanish).pdf

Recommendations

� Public Health Veterinarian Web site

–For bird owners� Available in Spanish

http://www.nasphv.org/Documents/Psittacosis%20Checklist%20for%20Owners%20of%20Infected%20Birds%20(Spanish).pdf

Conclusions

� C. psittaci is biologically interesting

� Similar clinical problems in both birds and humans

� Important zoonotic disease