There was a lot of hand-washing going onÂ during the Northwest Washington Fair last week in Lynden, WA. Yes, there were the usual farm exhibits, carnival rides, food booths, music, talent shows, and much more. But the 24 hand-washing stations placed around the animal barns, along with a team of specially trained â€œHand-Washing Ambassadors,â€ underscored the fairâ€™s commitment to providing a safe and healthy gathering place for the approximately 200,000 people who attend the popular event each year.
â€œThis yearâ€™s focus at the fair is all about health and safety, and how visitors can enjoy all that the fair has to offer while exercising healthy hygiene habits and practices,â€ said Steve VanderYacht, president of the fairâ€™s board of directors, in a press releaseÂ prior to the fairâ€™s opening on Aug. 17.
Triggering that commitment was an E. coli outbreak in April that sickened 25 children (confirmed cases) and was linked to the fairâ€™s dairy barn â€” the very barn that fairgoers were strolling through last week to see 4-H, FFA, and other young people tending to and showing their cows and calves.
Put on by the countyâ€™s dairy women each spring for the past 23 years, the Milk Makers Fest offers children an up-close view of dairy farming. This past April, more than 1,000 elementary students, mainlyÂ first-graders, attended. The event included a milking demonstration, a hay maze, posters showing a cowâ€™s four stomachs, charts describing how much milk a cow produces, and a petting zoo featuring dairy calves.
It is believed to be the first time in the eventâ€™s history that anyone had become infected with this especially dangerousÂ form of E. coli (E. coli O157:H7), Cheryl DeHaan, a dairy woman and coordinator of the event for all 23 years, told Food Safety News.
â€œWe were devastated,â€ she said. â€œWe have to be cognizant of what happened this year. Weâ€™ll be thinking a lot more about the details.â€
Of the 25 children who were sickened, 10 were hospitalized and 6 developed HUS (hemolytic uremic syndrome), a type of kidney failure that can be fatal. Fortunately, no one died.
According to the countyâ€™s final investigation summaryÂ about the outbreak, samples with the same strain of E. coli that caused the outbreak were found at the fairgrounds in the manure bunker, the hay-maze area, and the bleachers by the east and west walls. The investigators concluded that the bacteria had likely been in the contaminated parts of the barn before the Milk Makers Fest.
â€œAny environment where the animals have been kept, such as barns, should be considered contaminated,â€ statesÂ the summary, referring to a 2003 article in the Journal of the American Medical Association noting that the bacteria can survive in the environment up to 42 weeks.
The summary also listed several probable reasons that some of the children were infected: â€œLeaving the animal areas without washing hands or eating in animal areas might have contributed to an increased risk of transmission.â€ It added that the children who reported washing or sanitizing their hands before eating lunch were less likely to become ill.
This spring,Â the fairâ€™s board of directors decided to have the barns cleaned and disinfected before the fairâ€™s opening and double from 12 to 24 the number of hand-washing stations, in addition to hiring a team of Hand-Washing Ambassadors to coach fairgoers on the most effective way to wash their hands.
â€œThat (hand-washing) is our focus,â€ fair manager Jim Baron told Food Safety News, pointing out that experts agree that hand-washing is key to â€œtaking care of the problem.â€
He said while itâ€™s important to clean the barns and disinfect them before the fair, he added, â€œWe are keenly aware that as soon as the animals come into the barn, E. coli comes back. The animals are carriers.â€
Veterinarian Glenda Dvorak of Iowa State Universityâ€™s Center for Food Security & Public Health and the author of â€œDisinfection 101,â€Â would agree.
â€œYou wonâ€™t ever get it all,â€ she told Food Safety News.Â â€œThe animals shed it. Are we ever going to eliminate the risk? No, not unless you set up barriers between the people and animals like they do in zoos. But part of going to a fair is being able to get close to the animals.â€
Even so, â€œAnytime you clean a barn, youâ€™re minimizing the risk,â€ she noted.
Dvorak is pleased that fairs are getting better at providing hand-washing stations and putting up signs informing people about the health risks farm animals can present.
â€œBut thereâ€™s a fine line between empowering people with information and scaring them,â€ she said.
Baron explained that, in preparing for the fair, fair directors referred to recommendations in the 2013 update of â€œThe Compendium of Measures to Prevent Disease Associated with Animals in Public Settings,â€Â by the National Association of State Public Health Veterinarians Animal Contact Compendium Committee 2013. In the world of agricultural fairs and petting zoos, the compendium is viewed as a bible of sorts.
Tom Kunesh, Food and Living Environment Program supervisor with the Whatcom County Health Department in Bellingham, calledÂ cleaning and disinfecting barns part of a â€œmulti-faceted prevention strategyâ€ fairs are advised to take, which includes these additional recommendations:
- Avoid hand-to-mouth activities, such as eating, applying lip balm, and biting fingernails while in the animal exhibit areas.
- Avoid touching animals and other potentially contaminated surfaces in animal exhibit areas when possible.
- Always wash hands immediately upon leaving animal exhibit areas.
- Always wash hands again immediately before eating.
- Avoid taking strollers into barns where the wheels may spread contamination back to cars and home settings.
- Routinely clean and disinfect surfaces that peopleâ€™s hands may contact as this is an important element of reducing pathogen loads in animal-exhibit areas.
Â Thumbs up for hand-washing
â€œItâ€™s great,â€ said Alexandra Monroe, 7, one of the first-graders who participated in the Milk Makers Fest this past spring but was not infected with E. coli.
â€œItâ€™s awesome that theyâ€™ve doubled the number of hand-washing stations,â€ her equally enthusiastic sister Victoria, 10, said. â€œNo one will get sick anymore.â€
Their grandmother, Cathy Kelly, who had gone to the Milk Makers Fest with her granddaughter, said that hand-washing is an absolute must.
â€œItâ€™s too easy to catch a germ when weâ€™re around animals,â€ she said. â€œMy son is a professional polo player, and he knows how important it is to be safe about this. You have to be smart.â€
â€œWe love these stations,â€ said Candie Tallquist said as her 8-year-old son Riley got a card stamped showing that he had been to the station. His goal was to get his card stamped at three of the stations and earn prizes for his efforts.
Tallquist said she comes to the fair every year and is happy to see that the hand-washing stations are more accessible.
â€œIt makes things safer,â€ she said. â€œThe kids want to touch everything, especially the animals.â€
â€œEveryoneâ€™s really liking it,â€ said Emily Stadt, the Hand-Washing Ambassador at the same station as theÂ Tallquists. â€œWe tell them to use a lot of soap, to wash both sides of their hands, and to sing Happy Birthday twice while theyâ€™re washing their hands. This is definitely increasing peopleâ€™s awareness. A lot of people donâ€™t realize how many germs are on animals or even on the benches or railings.â€
Older people appreciated having the additional hand-washing stations as well. Sherman Polinder, a dairy farmer who has displayed his cows at the fairâ€™s dairy barn for 62 years, said that, â€œItâ€™s wise to be cautious. Itâ€™s good to have them near any livestock, not just dairy.â€
â€œGerms are everywhere,â€ noted retiree Robert Tichbourne. â€œWeâ€™ve got to keep them away. Hygiene is very important.â€
Over at the Small Farm Experience, where a petting zoo was set up, kids were flocking to the animals and eagerly reaching out to touch them â€” or at least to touch the fences some of them were behind. At the exit, Janna Gripp was â€œbusy, busyâ€ telling people who had touched any of the animals to wash their hands.
Pushing a stroller with her 16-month-old daughter eagerly looking at everything, Holly Morado said that even though she had heard about the E. coli outbreak in the spring, she still wanted her baby to see the animals.
â€œBut I want her to be safe,â€ she added.
After petting a rabbit at the exhibit, Jasmine Terpstra, 5, went over to the sink and throughly washed her hands.
â€œWeâ€™re believers,â€ her father Brandon said. â€œWe know that weâ€™ve got to keep the hands clean.â€
There was some â€œblack magicâ€ over at the Adventures in Agriculture Center. Public Health Nurse Olivia Rutherford and intern Allie Moore, both with the Whatcom County Health Department, were helping kids and adults alike to check on how well they actually wash their hands.
Squirting a dab of solution on peopleâ€™s hands, they had participants rub it all over their hands, back and front. Then participants put their hands into the â€œGerm Glowâ€ box lit with a black light, where they could see the solution glowing orange on their hands. The next step was to go outside to the hand-washing station and wash their hands as well as they could.
The final step was the telling one. Any spots that they hadnâ€™t washed thoroughly enough, such as the fingertips, the back of their hands, and the lines on their palms, would still glow orange. In that case, theyâ€™d head back to the hand-washing station and wash their hands more thoroughly.
Hannah Stremler, 7, ran back to the hand-washing station to rewash the backs of her hands. â€œTheyâ€™re cleaner now,â€ she said happily.
The health departmentâ€™s exhibit also had a poster includingÂ common myths about hand-washing. For example: You donâ€™t have to dry your hands after washing them (wrong). It doesnâ€™t matter how long you wash your hands as long as you use soap (wrong). Using gloves makes hand-washing unnecessary (wrong). And, hand sanitizers can replace washing your hands with soap and water (wrong because they donâ€™t remove â€œbad bacteriaâ€ as well as soap.)
Thereâ€™s a quick rundownÂ hereÂ on hand-washing from the U.S. Centers for Disease Control and Prevention (CDC).
Baron said the hand-washing stations had proven to be very popular, with 350 passport cards turned in the first day.
â€œIt exceeded our expectations,â€ he said.
Kunesh agreed. â€œWeâ€™re definitely seeing a lot more people stopping and washing their hands,â€ he said. â€œThatâ€™s good. It means theyâ€™re learning how important it is.â€
But is it enough?
Although proper hand-washing after being around animals and before eating is an excellent way to help prevent E. coli, there can be more to it than that. Thatâ€™s because E. coli can actually be airborne. That was likely the case in 2002 at the Lane County Fair in Eugene, OR, when 82 fairgoers (74 confirmed cases and 8 presumed cases), almost two-thirds of them children younger thanÂ six, came down with E. coli infections.
It was baffling to say the least, but some sleuthing on the part of Dr. William Keene, then a senior epidemiologist with Oregon Public Health Division, revealed that all three samples that tested positive in the goat and sheep expo hall were in locations 15 to 18 feet up off the ground.
He told a reporter with a Eugene newspaper that finding it there â€œindicates it blew up there.â€
The assumption was that once the bacteria were airborne, they could also settle down on railings, animal fur, human skin or food people had in the barn. Perhaps some of the people in the barn had even swallowed the contaminated dust.
That meant, Keene said, that fairgoers wouldnâ€™t have even had to touch an animal to get infected.
Although hand-washing is considered the single most effective way to prevent the spread of E. coli, it didnâ€™t appear to be the silver bullet during the Lane County Fair. The percentage of sickened people who washed their hands after leaving the animal barns â€” 31 percent â€” was only slightly lower than the 36 percent of healthy people who washed their hands.
Earlier that same year, 23 people at the Lorain County Fair in Ohio came down with E. coli infections.Â Public health investigators traced that outbreak to a barn where a teen dance was held. After swabbing the barn and finding E. coli in the rafters, on the bleachers and walls, and in the sawdust on the floor, investigators began to suspect that the bacteriaÂ had become airborne in the dust and then settled on the food and drinks of the fairgoers in the barn.
Lane County Fairâ€™s manager, Corey Buller, told Food Safety News that after the E. coli outbreak, the fair turned to the non-profit International Association of Fairs & Expositions for guidance.
In 2005, in response to a wave of E. coli O157:H7 outbreaks at agricultural fairs, the association and Technical Solutions International developed the Consumer Protection Program workshop.
In an email to Food Safety News, Marla J. Calico, COO of the association, said that the goal was to provide awareness of, and information about, the risks of contact with pathogens such as E. coli O157:H7 to people operating fairs, petting zoos, and similar activities that bring humans and farm animals into close proximity.
Topics covered in the workshop include the key item, â€œThe Compendium of Measures to Prevent Disease Associated with Animals in Public Settings.â€Â The program also provides an awareness of outbreaks that have occurred, a basic overview of the E. coli O157:H7 pathogen, potential areas of contact, and corrective measures to be considered.
Calico said that approximately 600 fairs across the U.S.Â have participated in the workshops.
â€œItâ€™s a very good program â€” a great resource,â€ he said, adding that it includes reports, checklists and protocols.
Following the programâ€™s recommendations, the fair added some additional hand-washing stations and restricted food and drinks in the barns. Pressure washing and disinfecting the barns was another step in the process of keeping the barns as safe as possible for fairgoers.
Dust control is also important, and teams regularly wiped down the pen railings with bleach or a disinfecting chemical during the fair.
How confident does Buller feel about the safety of the fair?
â€œVery confident,â€ he said. â€œBut there will always be some inherent risk. There will never be zero risk.â€
As for the hand-washing station in front of every barn exit, Buller said that in the first year or two, some people used them. But with the public becoming more aware of the importance of preventing E. coli, their use has significantly increased.
â€œNow if you watch the barns, almost everyone out the door makes sure their kids use them,â€ he said.
Buller isÂ optimistic that steps like this will help keep county fairs going.
â€œAgriculture is enjoying a new regrowth of interest, and people are becoming more aware,â€ he said.
Inherent risk with fairs and petting zoos?
The probability of disease transmission at animal exhibits can be attributed to a variety of causes, according the the National Association of Public Health Veterinariansâ€™s report on minimizing risks from animal contact with humans.
Here are some of the reasons cited in the report:
- Animals are more likely to shed pathogens such as E. coli O157:H7Â because of the stress they suffer from prolonged transportation, confinement, crowding, and increased handling.
- Co-mingling increases the probability that animals shedding pathogens will infect other animals.
- The presence of certain enteric pathogens such as E. coli O157:H7Â is higher in young animals, which are frequently in petting zoos and educational programs, more so than in mature animals.
- Shedding of these types of pathogens and Salmonella organisms is highest in the summer and fall, when substantial numbers of traveling exhibits, agricultural fairs, and petting zoos are scheduled.
The report also points out that although farm residents might have some acquired immunity to certain pathogens, livestock exhibitors have become infected with E. coli O157:H7 in outbreaks at fairs.
Why E. coli O157:H7 is so dangerous
First discovered in 1982, E. coli O157:H7 is an especially virulent form of the bacterium E. coli. AÂ mere 50 of them can make someone ill. Theyâ€™re also difficult to detect; 100,000 can fit on the head of a pin.
Yet E. coli O157:H7 does not sicken cows and other livestock that have it in their systems. (Making things more complicated, it can come and go, meaning that a cow that has it wonâ€™t always have it, and a cow that doesnâ€™t have it can get it.)
But because the animals that do have E. coli in their systems shed it through their manure, people can become exposed to it through various ways, such as petting animals that have traces of manure on their hides, or coming into contact with contaminated bedding, rails, fencing or gates. TheseÂ people can then become ill if they donâ€™t properly wash their hands before eating.
In other words, you donâ€™t want even a microscopic trace of poop on your hands when you eat. And you donâ€™t want any of the airborne bacteria to get on your food, hands, or silverware.
In addition, a person with traces of E. coli on his or her hands, clothing, or mouth can actually infect another person. After the Milk Makers Fest, nine people (including a baby) who didnâ€™t attend the event came down with E. coli through what is referred to as secondary infections.
For the most part, itâ€™s young children and babies, the elderly, and those whose systems are immunocompromised who are the most vulnerable. And theyâ€™re also the ones who become the sickest from it.
Symptoms range from slight digestive discomfort to bloody diarrhea and extreme pain. An occasional complication of E. coli is hemolytic uremic syndrome, or HUS, a serious kidney condition that can be fatal. Symptoms usually occur 3-4 days after exposure, but they may be as short as 1 day or as long as 10 days. Anyone with these symptoms should contact a doctor.
E. coli can also be foodborne, for example, in hamburger that hasnâ€™t been cooked long enough to kill bacteriaÂ that might have gotten on the meat during slaughtering, or in raw milk, which hasnâ€™t been pasteurized. It can also contaminate water.
Go hereÂ for more information about E. coli O157:H7.
(To sign up for a free subscription to Food Safety News, clickÂ here.)
Â© Food Safety News