Over the last week I spoke to two families of very young children stricken by E. coli O111 after they both attended a small town Maine fair and petting zoo. One child was just released from the hospital after suffering from acute kidney failure and the other child was buried a week before from complications to exposure to the same toxic E. coli. After every one of this tragedies, comes the praise of the value of the petting zoo and the small town fair – that somehow if we keep saying it, that the pain suffered by these families is somehow equal to the arguable benefits to the pubic of exposure to petting animals. True, we all yearn for the late summer days at the fair – the cotton candy, the blue ribbon animals and all the variety of deep fried foods – but, if the last decade is any indicator, the aspirational desire has come face to face with a pathogenic reality. Much like when the President drags himself out before the press after another mass shooting, I too felt the inevitable feeling that we have seen this all before and will more likely see it again. And, a quick glance over that last dozen years shows just that: Following the 2001 outbreaks, the CDC in Atlanta published, “Reducing the Risk for Transmission of Enteric Pathogens at Petting Zoos, Open Farms, Animal Exhibits, and Other Venues Where the Public Has Contact With Farm Animals” – 2001 CDC Recommendations:

1. Information should be provided. Persons providing public access to farm animals should inform visitors about the risk for transmission of enteric pathogens from farm animals to humans, and strategies for prevention of such transmission. This should include public information and training of facility staff. Visitors should be made aware that certain farm animals pose greater risk for transmitting enteric infections to humans than others. Such animals include calves and other young ruminant animals, young poultry, and ill animals. When possible, information should be provided before the visit.

2. Venues should be designed to minimize risk. Farm animal contact is not appropriate at food service establishments and infant care settings, and special care should be taken with school-aged children. At venues where farm animal contact is desired, layout should provide a separate area where humans and animals interact and an area where animals are not allowed. Food and beverages should be prepared, served, and consumed only in animal-free areas. Animal petting should occur only in the interaction area to facilitate close supervision and coaching of visitors. Clear separation methods such as double barriers should be present to prevent contact with animals and their environment other than in the interaction area.

3. Hand washing facilities should be adequate. Hand washing stations should be available to both the animal-free area and the interaction area. Running water, soap, and disposable towels should be available so that visitors can wash their hands immediately after contact with the animals. Hand washing facilities should be accessible, sufficient for the maximum anticipated attendance, and configured for use by children and adults. Children aged <5 years should wash their hands with adult supervision. Staff training and posted signs should emphasize the need to wash hands after touching animals or their environment, before eating, and on leaving the interaction area. Communal basins do not constitute adequate hand washing facilities. Where running water is not available, hand sanitizers may be better than using nothing. However, CDC makes no recommendations about the use of hand sanitizers because of a lack of independently verified studies of efficacy in this setting.

4. Hand-mouth activities (e.g., eating and drinking, smoking, and carrying toys and pacifiers) should not be permitted in interaction areas.

5. Persons at high risk for serious infections should observe heightened precaution. Everyone should handle farm animals as if the animals are colonized with human enteric pathogens. However, children aged <5 years, the elderly, pregnant women, and immunocompromised persons (e.g., those with HIV/AIDS) are at higher risk for serious infections. Such persons should weigh the risks for contact with farm animals. If allowed to have contact, children aged <5 years should be supervised closely by adults, with precautions strictly enforced.

However, not surprisingly, few fairs and petting zoos took the recommendations to heart and the outbreaks and illnesses continued. Pennsylvania was somewhat of an exception. Following the same outbreak that moved the CDC to action the Pennsylvania enacted 3 Pa.C.S. § 2502 creating sanitation standards to minimize the risk of contracting a zoonotic disease at an animal exhibition: (1) An operator shall promote public awareness of the risk of contracting a zoonotic disease at the animal exhibition and of the measures necessary to minimize the risk of contraction by posting appropriate notices at the animal exhibition. (2) An adequate hand-cleansing facility for adults and children shall be conveniently located on the animal exhibition grounds. The operator shall post appropriate notices which designate the location of the hand-cleansing facility required by this paragraph and encourage the cleansing of hands after touching animals, using the restroom and before eating. (3) A person may not bring an animal to an animal exhibition unless the person provides the operator with one of the following: (i) Except as provided under subparagraph (ii), a valid Pennsylvania health certificate or interstate certificate of veterinary inspection. (ii) A signed statement by the person attesting that a veterinary consultation relationship exists with regard to each animal to be exhibited, if a Pennsylvania health certificate or interstate certificate of veterinary is not specifically required under Chapter 23 (relating to domestic animals) and regulations promulgated under Chapter 23. After yet another outbreak – this one in North Carolina, the North Carolina General Assembly passed G.S. 106-520.3A, also known as Aedin’s Law: G.S. § 106-520.3A. Animal exhibition regulation; permit required; civil penalties. (a) Title. – This section may be referred to as “Aedin’s Law”. This section provides for the regulation of animal exhibitions as they may affect the public health and safety. (b) Definitions. – As used in this section, unless the context clearly requires otherwise: (1) “Animal” means only those animals that may transmit infectious diseases. (2) “Animal exhibition” means any sanctioned agricultural fair where animals are displayed on the exhibition grounds for physical contact with humans. (c) Permit Required. – No animal exhibition may be operated for use by the general public unless the owner or operator has obtained an operation permit issued by the Commissioner. The Commissioner may issue an operation permit only after physical inspection of the animal exhibition and a determination that the animal exhibition meets the requirements of this section and rules adopted pursuant to this section. The Commissioner may deny, suspend, or revoke a permit on the basis that the exhibition does not comply with this section or rules adopted pursuant to this section. (d) Rules. – For the protection of the public health and safety, the Commissioner of Agriculture, with the advice and approval of the State Board of Agriculture, and in consultation with the Division of Public Health of the Department of Health and Human Services, shall adopt rules concerning the operation of and issuance of permits for animal exhibitions. The rules shall include requirements for: (1) Education and signage to inform the public of health and safety issues. (2) Animal areas. (3) Animal care and management. (4) Transition and nonanimal areas. (5) Hand-washing facilities. (6) Other requirements necessary for the protection of the public health and safety. (e) Educational Outreach. – The Department shall continue its consultative and educational efforts to inform agricultural fair operators, exhibitors, agritourism business operators, and the general public about the health risks associated with diseases transmitted by physical contact with animals. (f) Civil Penalty. – In addition to the denial, suspension, or revocation of an operation permit, the Commissioner may assess a civil penalty of not more than five thousand dollars ($5,000) against any person who violates a provision of this section or a rule adopted pursuant to this section. In determining the amount of the penalty, the Commissioner shall consider the degree and extent of harm caused by the violation. A variety of regulations followed including: SUBCHAPTER 52K – ANIMAL EXHIBITIONS SECTION .0300 – SIGNAGE An animal contact exhibit shall provide visible signage at the entrance and exit of the exhibit to educate the public regarding: (1) the fact that animal contact may pose a health risk; (2) items that are prohibited in animal areas; (3) the identity of high risk populations, including: (a) the elderly; (b) children under the age of six; (c) women who are pregnant; (d) people with an existing health condition; and (4) the location of hand-washing stations. SECTION .0400 – OPERATIONS AND STAFFING (a) Animals and bedding shall be separated from the public with fencing to minimize the public’s contact with manure and bedding. This does not apply to: (1) animal rides (including pony, camel, and elephant rides); (2) milking booths; or (3) the petting of an animal held or restrained outside of its housing area by an exhibit operator or patron as part of an educational or photographic opportunity where there is limited possibility of contact with manure and bedding. (b) Fencing shall be at least 29 inches high. On the side(s) of the exhibit intended for public contact, the fencing shall have a solid board or panel at the bottom at least eight inches high to contain manure and bedding. (c) Fencing may allow children to reach through or over to pet and feed animals. NCAC 52K .0402 PROHIBITED ITEMS In order to minimize hand to mouth contact, no pacifiers, baby bottles, drink cups, food, drink or smoking shall be allowed in animal contact exhibits. NCAC 52K .0403 AGE REQUIREMENTS Unsupervised children less than six years old shall not be permitted in animal contact areas. NCAC 52K .0404 FEEDING OF ANIMALS Only food provided by the animal contact exhibit may be fed to the animals. Animal food shall not be provided in containers that are human food items, such as ice cream cones. NCAC 52K .0405 STAFFING; COMPLIANCE An animal contact exhibit shall be staffed at all times of operation by at least one person who has the authority to ensure that the exhibit complies with this Subchapter. The owner, operator or person in charge of an animal contact exhibit shall be responsible for compliance with this Subchapter, and shall not knowingly permit violations by its employees, agents or patrons. NCAC 52K .0406 SURFACES; EXHIBIT AREAS (a) Surfaces in the animal contact exhibit that can be touched by both fair patrons and animals shall be made of impervious material, and shall be cleaned and disinfected daily and at any time visible contamination is present. (b) All animal fencing, feed troughs, and open watering systems shall be disinfected prior to and at the end of each fair. (c) Contact animal exhibits shall be held on impervious surfaces whenever feasible. (d) Impervious exhibit areas shall be cleaned and disinfected at the end of the fair. (e) Exhibit areas that are not impervious shall be cleaned of all manure at the end of the fair and shall not be used for human activities for at least six months after cleaning. NCAC 52K .0407 WASTE DISPOSAL The fair shall designate a manure disposal area and shall control wastewater runoff. The animal contact exhibit shall have a designated area for temporary storage of animal waste and shall not transport such waste through areas occupied by fair patrons. Manure disposal and storage areas shall be inaccessible to the public, unless waste is bagged and placed in a closeable dumpster. NCAC 52K .0501 HAND-WASHING STATIONS (a) Hand-washing stations with soap, running water, paper towels and disposal containers shall be located within 10 feet of the exit of an animal contact exhibit, wherever feasible. (b) Hand-washing stations suitable for small children shall be available in the same area as the stations in Paragraph (a) of this Rule. (c) Signage shall be provided to direct patrons to hand-washing stations. (d) In order to promote hand-washing with soap and water, dispensers for waterless hand sanitizing lotions, gels or hand wipes shall not be provided in the transition or exhibit area. Such dispensers may be placed at the entrance of milking booths to reduce the potential for introduction of disease to the exhibit animals. NCAC 52K .0502 FOOD AND DRINK Food and beverages for human consumption shall not be sold, prepared, served, or consumed in transition areas. SECTION .0600 – ANIMAL KEEPING, CERTIFICATIONS AND EXHIBITION – NCAC 52K .0601 HEALTH CERTIFICATE; VACCINATIONS (a) An official health certificate as defined in 02 NCAC 52B .0202, a rabies vaccination certificate (when applicable), and any other documentation required by 02 NCAC 52B for species or state of origin, shall accompany all animals contained in a public contact setting. (b) An animal for which there is an approved rabies vaccine, but which is too young to receive rabies vaccination, is prohibited from animal contact exhibits unless proof of rabies vaccination, within the preceding 12 months, of the mother is provided. (c) Initial rabies vaccination shall be administered at least 30 days prior to the event. Subsequent vaccinations for livestock shall be no more than one year prior to the event and may be within 30 days of the event if proof of previous vaccination is provided. Dogs and cats shall be in compliance with the North Carolina rabies law, G.S. 130A, Article 6, Part 6. (d) If no licensed rabies vaccine exists for a particular species (such as rabbits, goats, llamas, and camels), no vaccination is required. NCAC 52K .0602 DAILY MONITORING Animals shall be monitored daily by exhibit personnel for signs of illness. Animals that exhibit signs of illness shall be removed from public contact immediately. NCAC 52K .0603 HIGH RISK ANIMALS Animals that pose a high disease risk to humans, as determined by the State Veterinarian or his representative, shall not be allowed in animal contact exhibits. NCAC 52K .0604 BIRTHING ANIMALS No near-birth or birthing sheep, cattle or goats and no sheep, cattle or goats that have given birth within the previous two weeks shall be allowed in animal contact exhibits. Although these were comprehensive regulations, Aedin’s Law, did not prevent another outbreak in 2012. Now the North Carolina State Fair will likely proceed without a petting zoo at all. In part because, the petting zoo venue is almost uninsurable do to the risk of yet another outbreak. Washington took up the cause next in passing WAC 246-100-192. Animals in public settings — Measures to prevent human disease. (1) The purpose of this rule is to protect the public from diseases transmitted to humans from animals in public settings. (2) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise:

(a) “Animal exhibitor” means a person with a valid class C certification as an exhibitor under the Animal Welfare Act, 7 U.S.C. 2131-2159.

(b) “Animal venue operator” means a person furnishing a setting where public contact with animals is encouraged such as a petting zoo, county fair, or horse or pony rides.

(c) “Immunocompromised” means having the immune system impaired or weakened as by drugs or illness.

(d) “Person” means any individual, corporation, company, association, society, firm, partnership, joint stock company, or governmental agency; or the authorized agents of these entities. (3) Animal venue operators shall:

(a) Provide an accessible hand-washing station or alternative hand sanitizing method approved by the local health officer;

(b) Post a prominent sign in a simple and easy to understand format for visitors to see before they enter the animal exhibit area which warns that:

(i) Animals can carry germs that can make people sick, even animals that appear healthy;

(ii) Eating, drinking, or putting things in a person’s mouth in animal areas could cause illness;

(iii) Older adults, pregnant women, immunocompromised people, and young children are more likely to become ill from contact with animals;

(iv) Young children and individuals with intellectual disabilities should be supervised in animal exhibit areas; and

(v) Strollers, baby bottles, pacifiers, and children’s toys are not recommended in animal exhibit areas.

(c) Post a prominent sign at each exit of the animal exhibit area reminding visitors to wash their hands. (4) To meet the requirements of subsections (3)(b) and (c) of this section, animal venue operators may use materials provided by the department and available at www.doh.wa.gov. (5) Animal exhibitors and other persons legally responsible for animals in public settings shall:

(a) Observe animals daily for signs of illness;

(b) Prevent public contact with sick animals;

(c) As applicable, comply with WAC 246-100-197, Rabies — Measures to prevent human disease;

(d) As applicable, comply with WAC 246-100-201, Psittacosis — Measures to prevent human disease; and

(e) Comply with, and have in their possession, any local, state, or federally required documents allowing the exhibition of animals in public settings. (6) Animal venue operators, animal exhibitors, other persons legally responsible for animals in public settings, and veterinarians shall cooperate with local health officer investigations and control measures for zoonotic disease. Yet, despite Washington’s rules, another outbreak occurred in 2015, not directly related to a petting zoo, but at a venue where animals had been and no measures to clean up or protect children occurred. Over the last several years, many of the top veterinarians have been consistently tried to keep county fairs and petting zoos in business while at the same time protecting visitors – especially young children. Yearly for the last decade they have published a “Compendium of Measures to Prevent Disease Associated with Animals in Public Settings.” The most recent National Association of State Public Health Veterinarians Animal Contact Compendium Committee 2013: Venue operators should take the following steps:

• Become familiar with and implement the recommendations in this compendium.
• Consult with veterinarians, state and local agencies, and cooperative extension personnel on implementation of the recommendations.
• Become knowledgeable about the risks for disease and injury associated with animals and be able to explain risk-reduction measures to staff members and visitors.
• Be aware that direct contact with some animals is inappropriate in public settings, and this should be evaluated separately for different audiences.
• Develop or obtain training and educational materials and train staff members.
• Ensure that visitors receive educational messages before they enter the exhibit, including information that animals can cause injuries or carry organ- isms that can cause serious illness.
• Provide information in a simple and easy-to-under- stand format that is age and language appropriate.
• Provide information in multiple formats (e.g., signs, stickers, handouts, and verbal information) and languages.
• Provide information to persons arranging school field trips or classroom exhibits so that they can educate participants and parents before the visit.

Venue staff members should take the following steps:

• Become knowledgeable about the risks for dis- ease and injury associated with animals and be able to explain risk-reduction recommendations to visitors.
• Ensure that visitors receive educational messages regarding risks and prevention measures.
• Encourage compliance by the public with risk- reduction recommendations, especially compliance with hand-washing procedures as visitors exit animal areas.

Recommendations for nonanimal areas are as follows:

• Do not permit animals, except for service animals, in nonanimal areas.
• Store, prepare, serve, or consume food and beverages only in nonanimal areas.
• Provide hand-washing facilities and display hand- washing signs where food or beverages are served.
• Entrance transition areas should be designed to facilitate education.
• Post signs or otherwise notify visitors that they are entering an animal area and that there are risks associated with animal contact.
• Instruct visitors not to eat, drink, smoke, and place their hands in their mouth, or use bottles or pacifiers while in the animal area.
• Establish storage or holding areas for strollers and related items (e.g., wagons and diaper bags).
• Control visitor traffic to prevent overcrowding.
• Exit transition areas should be designed to facilitate hand washing.
• Post signs or otherwise instruct visitors to wash their hands when leaving the animal area.
• Provide accessible hand-washing stations for all visitors, including children and persons with disabilities. Position venue staff members near exits to encourage compliance with proper hand washing.

Recommendations for animal areas are as follows:

• Do not allow consumption of food and beverages in these areas.
• Do not allow toys, pacifiers, spill-proof cups, baby bottles, strollers, or similar items to enter the area.
• Prohibit smoking and other tobacco product use.
• Supervise children closely to discourage hand-to- mouth activities (e.g., nail biting and thumb sucking), contact with manure, and contact with soiled bedding. Children should not be allowed to sit or play on the ground in animal areas. If hands become soiled, supervise hand washing immediately.
• Ensure that regular animal feed and water are not accessible to the public.
• Allow the public to feed animals only if contact with animals is controlled (e.g., with barriers).
• Do not provide animal feed in containers that can be eaten by humans (e.g., ice cream cones) to decrease the risk of children eating food that has come into contact with animals.
• Promptly remove manure and soiled animal bedding from these areas.
• Assign trained staff members to encourage appropriate human-animal interactions, identify and reduce potential risks for patrons, and process reports of injuries and exposures.
• Store animal waste and specific tools for waste removal (e.g., shovels and pitchforks) in designated areas that are restricted from public access.
• Avoid transporting manure and soiled bedding through nonanimal areas or transition areas. If this is unavoidable, take precautions to prevent spillage.
• Where feasible, disinfect the area (e.g., flooring and railings) at least once daily.
• Provide adequate ventilation both for animals and humans.
• Minimize the use of animal areas for public activities (e.g., weddings and dances).
• If areas previously used for animals must be used for public events, they should be cleaned and disinfected, particularly if food and beverages are served.

Honestly, like guns, petting zoos are not going to be banned, and perhaps they should not. Perhaps being in touch with the small town fair is an important part of our heritage. However, trying to stay in touch with our inner rural lifestyle needs to pay attention to the pathogens of the day. If we want petting zoos we need rules to deal with these bugs that are far more deadly that many that plagued our great grandparents. If we want to protect children and save petting animals, we do need “A Petting Zoo Preservation Act.” Frankly, simply adopting and enforcing the 2013 National Association of State Public Health Veterinarians Compendium would likely get us to a point where the inevitable outbreak perhaps fades further into the distance.  Look for a Model Act coming to you in the next month with a few additions like animal vaccinations and testing before they are allowed at the fair.