Chapter 16

Zoonotic tuberculosis in humans, elephants, and other animals in Nepal

Mahesh Bhandari and Charles O. Thoen

Tuberculosis in elephants

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Nepal has endangered Asian elephants living confined in privately or publicly owned groups or in the wild. There are a total of 208 captive elephants living in national parks, wildlife reserves, or with private owners near the national parks. Most of the privately owned elephants are present either in or around Chitwan National Park and are mainly used for tourism purposes [3,6]. At present, the number of resident wild elephants is estimated to be between 109 and 142 animals [3]. However, it has been suggested that many more animals migrate annually between Nepal and India.
Zoonotic Tuberculosis: Mycobacterium bovis and Other Pathogenic Mycobacteria, Third Edition. Edited by Charles O. Thoen, James H. Steele, and John B. Kaneene. 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc.

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Tuberculosis (TB) is a highly contagious global anthropozoonotic bacterial disease caused by the Mycobacterium tuberculosis complex, which includes M. tuberculosis and M. bovis [1]. There is an increasing awareness of the impact of disease at the human livestockwildlife interface in developing countries like Nepal [13] that are heavily dependent on animal agriculture and tourism. It is estimated that 45% of the total Nepalese population are infected with TB; 40,000 people are reported to contract TB each year, 20,000 new sputum positive cases are reported each year, and 5,000 7,000 people die each year from TB [4]. In the developing countries of the world the real incidence and differential diagnosis of M. bovis and M. tuberculosis is roughly underestimated due to inadequate laboratory capability to isolate and differentiate them [1]. Importantly, the recent reporting of XDR (extensively drug r esistant) TB in a Nepalese man detained at the U.S. border has highlighted the situation of TB in Nepal. The situation requires medical attention since there is no reporting of human/ animal XDR-TB. In addition, it has been reported that there is widening TB drug resistance in India, which is a neighbor of Nepal with an open border [5]. People move freely between the two countries without any testing or quarantine measures. The condition may be even worse in the coming days because of the human livestockwildlife interface in Nepal.

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Iowa State University, USA

192 Zoonotic Tuberculosis: Mycobacterium bovis and other pathogenic mycobacteria

Elephant tuberculosis is a chronic disease that affects captive elephants worldwide [7]. TB infects 11%25% of tested captive elephant populations in the United States, India, and Nepal [2]. In Nepal, tuberculosis in captive elephants was first identified in Chitwan National Park in 2002 [8]. In the seven-year period from 2002 to 2009, seven captive elephants died of tuberculosis [2, 3]. To address this problem the Government of Nepal, in collaboration with Elephant Care International and partners, initiated the first comprehensive range-country testing of elephants for TB [2] in 2006 and began TB treatment in 2008 with a standardized treatment protocol [3]. The Nepal Elephant Healthcare and TB Surveillance Program is a collaboration between the Department of National Parks and Wildlife Conservation, the Institute of Agriculture and Animal Science, World Wildlife FundNepal, the National Trust for Nature Conservation, Elephant Care International, the Cummings School of Veterinary Medicine at Tufts University, and the Zoological Society of London [2]. The principle method for surveillance has been through serology, utilizing the USDA-approved Elephant TB STAT-PAK assay (Chembio Diagnostic Systems, Inc.) [9]. Positively reacting animals selected for treatment are given a combination of isoniazid, rifampin, ethambutol, and/or pyrazinamide for one year following a very specific protocol [10]. Recently the government of Nepal endorsed the Nepal Elephant Tuberculosis Control and Management Action Plan, which aims to minimize the risk of TB transmission from captive elephants to wild elephants by managing tuberculosis at the captive wild interface [3]. A significant number of elephants have tested positive for tuberculosis. Mycobacterium tuberculosis complex has been reported to infect elephants [2, 11]. The intradermal tuberculin skin test has not been accurate in elephants and is not recommended [2]. In a study conducted on mRNA levels of different cytokines and chemokines using elephant- specific, real-time reverse transcription-polymerase chain reaction (RT-PCR) assays in RNA-preserved whole blood samples from 106 Asian elephants, 15% were Mycobacterium tuberculosis complex positive [9]. Seven elephants (~4% of the total Nepal population) with TB died in Nepal between 2002 and 2009 [2]. Twenty-two percent (36 of 164) of captive elephants in Nepal have tested positive for TB using the Elephant TB STAT-PAK assay [2, 12]. It is important to emphasize that mycobacteriologic examinations are necessary to identify the etiologic agent to confirm a diagnosis of tuberculosis [13]. However, the method of collection of trunk washes for mycobacteriologic examination is difficult to accomplish in Nepal because of different collection and laboratory procedures, and the tests may yield some false negative results [11]. Difficulty arises because elephants may not be shedding at time of collection. In addition, multiple freezes/thaws of specimens, quality of chemicals, and limited laboratory equipment cause problems [9]. The cost of drugs to treat one typical adult elephant averages about US$3,500. This does not include the overhead costs of transportation, supervision, veterinary care, laboratory fees for monitoring treatment, and other expenses, which vary greatly depending on the number of elephants being treated, their locations, protocols of treatment, and other factors [2]. Captive elephants are critical to Nepals conservation program. They patrol the national parks, including Chitwan, a World Heritage site that provides habitat for elephants, tiger, rhinoceri, gaurs, and other endangered species. Private elephants engage in ecotourism activities, which generate financial support for the parks. Elephants in other countries have similar conservation roles [3].

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Tuberculosis in cattle and buffalo

It has been reported that 5% of cattle and buffalos surveyed in Nepal were positive on cervical single intradermal skin test (SID), using M. bovis tuberculin purified protein derivative (PPD) [16]. In a recent study, positive responses were observed in 18% of the cattle and buffalo on cervical SID, whereas 32 % of buffalos had positive responses [17]. Animals were tested using an SID test whereby 0.1mL of USDA M. bovis PPD tuberculin (2 mg/mL protein) was injected by trained veterinarians using a standard tuberculin syringe with a 26-gauge needle into the skin in the cervical region [17]. Ingestion of unpasteurized dairy products as well as inhalation of the bacteria can lead to human infection with M. bovis. It is a common practice that Nepalese people heat milk over a wood fire to approximately 75C and then quickly cool it by immersing the heated container in cold water, a practice that is considered to be effective in killing M. bovis [18]. However, if the milk foams during boiling, the organism may not be destroyed. Ingestion is likely the most important route of infection of humans with M. bovis [1]. Transmission of M. bovis in cattle is via either the oral route or the respiratory route through aerosol exposure [19]. The highest incidence of bovine tuberculosis in cattle is generally found where intensive dairy production is practiced, such as Chitwan District, which is a center of milk production and is home to Nepals fastest growing human population. A preproject survey in 2003 found that 32.2% of the buffalos in Chitwan District had response to the cervical SID test using PPD of M. bovis that is believed to be the most common cause of tuberculosis in water buffalo in Asia [16]. Similarly in another study, mycobacteriologic examination of milk and feces from cattle and water buffalo positive on the cervical SID were subjected to genetic analysis. A total of 36 mycobacterial strains were isolated from 39% of the buffaloes and 34% of the cattle. Of the 36 strains, 13 were identified as M. bovis, and these strains were isolated from 17% of the buffalos and 16% of the cattle. The remaining 23 strains were atypical mycobacteria [20]. In a recent study, 15% (total of 100 animals) of bovines were shown to be positive for single intradermal tuberculin test. The animals selected were raised in 60 farms of TB-infected patients [21]. A limiting factor in control of bovine tuberculosis in Nepal is that the animals that test positive are not culled because of cultural beliefs and economic factors.

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Humans contract diseases from animals, such as SARS, bird flu, and West Nile virus; but it is important to emphasize that humans also infect animals. In Nepal, humans appear to have infected elephants with M. tuberculosis types that have been reported to infect elephants [2]. Multidrug resistant (MDR) tuberculosis has been found among elephants inthe United States [14, 15]. Tuberculosis is readily treatable in humans and in trained elephants. Because of the interaction between humans, livestock, and elephants, MDR tuberculosis may become a risk factor for elephants in Nepal [1]. MDR strains of M.tuberculosis have not been identified in wild elephants in Nepal. Effective control measures are very important to limit the spread of tuberculosis so it does not affect free-living wild elephants and other endangered wildlife.

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Utilization of One Health interdisciplinary/multidisciplinary collaborative efficacious principles provides an essential tool for all global regions [22]. This modernized information is and will be of significant value to public health officials, research workers, allied health scientists, state and federal regulatory veterinarians, medical and veterinary medical practitioners, and producers interested in and associated with the importation of valuable blood lines for herd additions of domestic animals and for captive and free-living wild endangered species for collections in zoos and animal parks.

References

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Zoonotic tuberculosis in humans, elephants, and other animals in Nepal 195 15. West, G., and C.O. Thoen. 2010.Tuberculosis in elephants: In: J. E. Napier and K. C. Gamble (eds.), Manual of infectious disease of free living and captured wild animals. Yulee, FL: American Association of Zoo Veterinarians. 16. Pun, M.B., T.P. Prasai, M. Dhakal, et al. 2004. Single intradermal tuberculin tests of milking buffaloes and cattle in Nepal. Nepal veterinary Record 154:124. 17. Robyn, M., C. Jost, L. Ng, R. Khadkha, P. Dhakal, and I.P. Dhakal. 2012. Tuberculosis in water buffalo in Nepal: knowledge and behavior of farmers for prevention and control. Tufts International Student Summer Research Projects. 131. 18. Dhakal, M., R.G. Shrestha, V.C. Jha, and P.R. Dhakal. 2004. Heat treatment effects on Mycobacterium spp. isolated from ruminants in Nepal. Letter to the editor. Veterinary Microbiology 106:303304. 19. Thoen, C.O., and R.G. Barletta. 2006. Pathogenesis of Mycobacterium bovis. In: C.O. Thoen, J.H. Steele, and M.J. Gilsdorf (eds.), Mycobacterium bovis infection in animals and humans (pp. 1833). Ames, IA: Blackwell. 20. Jha, V.C., Y. Morita, M. Dhakal, B. Besnet, T. Sato, A. Nagai, M. Kato, K. Kozawa, S.Yamamoto, and H. Kimura. 2007. Isolation of Mycobacterium spp. from milking buffaloes and cattle in Nepal. Journal of Veterinary Medical Science 69(8):819825. 21. Pandey, G., S. Dhakal, A. Sadaula, G. KC, S. Subedi, K.R. Pandey, and I.P. Dhakal. 2012. Status of tuberculosis in bovine animals raised by tuberculosis-infected patients in Western Chitwan, Nepal. Int J Infect Microbiol 1(2):4953. 22. Kaneene, J.B., B. Kaplan, J.H. Steele, and C.O. Thoen. 2014. Zoonotic tuberculosis: Mycobacterium bovis and other pathogenic mycobacteria. Ames, IA: Wiley-Blackwell.

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