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Impact of Rurality, Broiler Operations, and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland

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Impact of Rurality, Broiler Operations, and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland ABSTRACT Title of Document: IMPACT OF RURALITY, BROILER OPERATIONS, AND COMMUNITY SOCIOECONOMIC FACTORS ON THE RISK OF CAMPYLOBACTERIOSIS IN MARYLAND Barbara Zappe Pasturel, Master of Public Health in Applied Environmental Health, 2013 Directed By: Dr. Amy R. Sapkota, Associate Professor Maryland Institute for Applied Environmental Health The combined impact of community-level environmental and socioeconomic factors on the risk of campylobacteriosis were evaluated. Campylobacter case data (2002-2010, n=3,694) were obtained from the Maryland Foodborne Diseases Active Surveillance Network. Community- level socioeconomic and environmental data were obtained from the 2000 U.S. Census and the 2007 U.S. Census of Agriculture. Data were linked by zip code. Incidence rate ratios were derived by Poisson regressions. A subset of zip code-level characteristics was mapped. In zip codes that were 100% rural, incidence rates of campylobacteriosis were 6 times (IRR=6.18; 95%CI=3.19-11.97) that of urban zip codes. In zip codes with broiler chicken operations, incidence rates were 1.45 times that of zip codes without broilers (IRR=1.45, 95%CI=1.34-1.58). Higher rates were also observed for zip codes that were predominantly white and had high median incomes. Findings suggest that the risk of campylobacteriosis could be significantly influenced by the community and environment where one lives. IMPACT OF RURALITY, BROILER OPERATIONS, AND COMMUNITY SOCIOECONOMIC FACTORS ON THE RISK OF CAMPYLOBACTERIOSIS IN MARYLAND By Barbara Zappe Pasturel Thesis submitted to the Faculty of the Graduate School of the University of Maryland, College Park, in partial fulfillment of the requirements for the degree of Master of Public Health 2013 Advisory Committee: Dr. Amy R. Sapkota, Chair Dr. Amir Sapkota Dr. Paul Turner Copyright by Barbara Zappe Pasturel 2013 DEDICATION For my parents, who have remained sturdy sources of wisdom throughout. For my daughters, whose cheerful patience and boundless appreciation have shown me the wisdom that endurance can reveal. 七転び八起き Fall down seven times, stand up eight. ii Acknowledgements I would like to thank my parents and siblings for their long-standing support of my efforts to embark on a new path. I would also like to thank my children for waiting patiently so many evenings “while Mommy just had to finish one more thing before the bedtime story.” My friends have provided me emotional, material and logistic support, without which I could not have juggled the array of spinning balls that have been in the air for far longer than is restful. Rachel, Shirley, Kristie and Joanne, all MIAEH veterans, have waited for me patiently with outstretched hands to come over to the finishers’ side. Thank you for the comic relief. Dr. Sam W. Joseph was on the project from its inception and provided a foundation of support, in addition to encouragement, warmth, and healthy dose of humor. Dr. Rachel Elizabeth Rosenberg Goldstein was a key member of the research team and is responsible for a significant portion of the descriptive spatial analysis. A founding member of the project, Rachel has been a patient teacher and guide, as well as a sounding board and statistics tutor. Thank you. Dr. Raul Cruz-Cano and Dr. Min Qi Wang were invaluable in data cleaning, input and analysis. The FoodNet team at DHMH, led by Dr. David Blythe, was instrumental in getting the project off the ground. My thesis committee has demonstrated patient flexibility and willingness to work according to my own timeline, and for that I am truly grateful. Thanks are owed to Maurice Rocque, the infallibly optimistic and ceaselessly helpful assistant of our department. Lastly, Dr. Amy R. Sapkota has been my advisor and my biggest cheerleader, convincing me that self-doubt is only a wrinkle in the smoothing out of any new path. Unfailingly supportive, she has understood the limitations that seemed to hinder my progress, and gently removed the obstacles from my way one by one, showing me the possibility of a future. I cannot thank her enough for providing endless opportunities for me to learn and grow. She is the reason this thesis was finally achieved and I thank her from the bottom of my heart. iii Table of Contents Dedication Acknowledgements List of Tables and Figures Chapter 1: Introduction . 4 Public Health Significance . 4 Risk Factors . 4 Research Rationale . 6 Chapter 2: Background on Campylobacter . 9 Overview . 9 Clinical Presentation . 9 Genus and Species Description . 10 Growth and Survival Characteristics . 11 Animals as a reservoir for Campylobacter . 12 Wild Avian Species Domestic Avian Species, notably poultry Ubiquity of Campylobacter in chicken Methods of rearing chicken Industrial cross-Contamination Mammals Livestock, notably ruminants Domestic animals Water . 20 Seasonality . 22 Antimicrobial Susceptibility . 25 Chapter 3: Factors for Campylobacteriosis in Humans . 28 Commonly Reported Risk Factors . 29 Chicken and Poultry Raw or undercooked Fresh vs. frozen Eating in restaurants Poultry husbandry Contaminated Water Overview of Contamination Sources Groundwater Recreational ingestion of untreated surface water Untreated drinking water Private well water Private water sources and poultry flocks Contaminated Foods iv Contaminated Milk Other Contaminated Foods Food Preparation Practices Other factors Pets Travel Abroad Malnutrition Environmental Risk Factors . 43 Rurality Farming, Farm Animals and Animal Husbandry Animal Density Sociodemographic Risk Factors . 49 Gender/Age Ethnicity Socioeconomic Status and Level of Education. Overall Research Gaps in Risk Factors for Campylobacteriosis . 53 Chapter 4: Manuscript . 56 Chapter 5: Discussion and Overall Conclusions . 87 References . 92 v List of Tables and Figures Table 1: Characteristics of reported campylobacteriosis cases in Maryland, 2002-2010. Table 2: Incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) for campylobacteriosis in association with environmental and socioeconomic factors. Figure 1: (A) Incidence of Campylobacter infection per 100,000 population and Campylobacter case counts by season for the state of Maryland, 2002-2010. (B) Incidence of Campylobacter infection per 100,000 population by age, sex, and degree of rurality in the state of Maryland. Figure 2:Spatial distribution of campylobacteriosis incidence rates, degree of rurality and presence/absence of broiler chicken operations by zip code in Maryland: (A) average annual campylobacteriosis incidence rates by zip code; (B) degree of rurality by zip code; and (C) presence or absence of broiler chicken operations by zip code. vi CHAPTER 1: INTRODUCTION Public Health Significance Campylobacter is a leading cause of bacterial gastroenteritis in much of the developed and developing world (CDC, 2009; Butzler, 2004). In addition to the diarrhea and vomiting associated with gastroenteritis, infection with Campylobacter can lead to more serious sequelae, ranging from bloody diarrhea to reactive arthritis and Guillain- Barré syndrome, a demyelinating autoimmune disorder leading to nerve damage and sometimes death (Riddle, 2012). Scallan et al. (2011) estimated that Campylobacter causes approximately 845,000 domestically acquired illnesses in the United States each year, along with 8,463 hospitalizations and 76 deaths (Scallan, 2011). While the majority of these illnesses are estimated to be foodborne (Scallan, 2011), attributing specific infections to specific sources has been challenging. Risk Factors Common Risk Factors The most commonly reported risk factors for Campylobacter outbreaks include exposure to undercooked poultry (Friedman, 2004), unpasteurized milk, (CDC, 2007; Heuvelink, 2009) and contaminated water (Carrique-Mas, 2005). Eating in restaurants (Kassenborg, 2004), not observing proper food preparation practices (van Asselt, 2009) and traveling abroad (Kassenborg, 2004; Ravel, 2011), have also been associated with both outbreaks and sporadic (non-outbreak) cases of campylobacteriosis. Common risk factors in developing countries include extensive exposure to contaminated foods through 1 local markets (Bodhidatta, 2013) and a potential predisposition to enteric infection arising from malnutrition (Brown, 2003; Gupta, 2011). Environmental Risk Factors Additional risk factors for sporadic infections include contact with pets (Friedman, 2004; Acke, 2011), contact with farm animals and livestock (Doorduyn, 2010; Potter, 2003), and contact with animal feces (Chaban, 2010), especially among ruminants. (Arsenault et al., 2012) Significant associations between living in rural areas and risk of campylobacteriosis also have been identified in Europe and Canada (Green, 2006; Spencer, 2012; Fitzenberger, 2010). Moreover, a specific feature of rural environments, animal density, has been identified as a significant predictor of Campylobacter incidence in Canada and New Zealand (Green, 2006; Spencer, 2012). Sociodemographic Risk Factors Several sociodemographic risk factors for campylobacteriosis have also been identified, the two most consistent being gender (males) and age (less than 5 yr) (Carrique-Mas, 2005; Green, 2006; Spencer, 2012; Fitzenberger, 2010). Previous studies have also evaluated socioeconomic factors associated with the incidence of Campylobacter infection and the findings suggest that these infections may occur more frequently among individuals characterized by higher socioeconomic status (Green, 2006; Simonsen, 2008). Moreover, Samuel et al. (2004) reported that the incidence of campylobacteriosis among African-Americans
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