Ritual slaughter of animals has a special place in the socio-cultural matrix of several countries. A recent correspondence from Israel, published by the U.S. Centers of Disease Control and Prevention journal Emerging Infectious Diseases highlights a small case series where the only identifiable route of transmission was the contact shared by the exposed individuals during a ritual slaughter of sheep purchased from Bedouins. Israel has been experiencing a rapid rise in the number of cases of brucellosis owing to the scrapping of “test, slaughter and compensate” policies for small ruminants in 1997, in addition to some other contributory factors. This article highlights the unusual route of transmission through ritual slaughter of infected animals.
Image Credit: Syrian Bedouin Shepherd via Wikimedia
The case series speaks of five people who were diagnosed with severe brucellosis, the clinical summaries of whom are given in the image below:
Noticeably, each of the five cases had a long winded history with inappropriately high fever-to-diagnosis lags. This indicates the huge amount of clinical confusion that still surrounds the diagnosis of Brucellosis, especially in cases where the exposure is through unconventional routes, as in this case, or where the exposure history is not clearly elucidated, as may be the case in many of the fever syndrome patients that go around with the amorphous and somewhat clinically dissatisfactory diagnosis of pyrexia of unknown origin.
The authors of the correspondence have also shed some light on why this delay in diagnosis may have resulted and have forwarded the following explanations:
Several circumstances might have led to the failure to include brucellosis in the initial differential diagnosis for these patients, even in a disease-endemic region. First, we can assume that physicians are unfamiliar with the ceremonial slaughter central to the celebrations of Ethiopian Jews. The tradition includes slaughtering, skinning, and eviscerating a sheep, followed by mincing of the sheep meat. This venerated ritual is performed by trained members of the Ethiopian community and supervised by the spiritual leader, the Kes (5). Second, patients were consistently reluctant to disclose their participation in ceremonial slaughter to medical staff. Third, the managing physicians considered differential diagnoses for febrile respiratory illness in line with the patients’ Ethiopian origins: reactivation of TB or chronic pulmonary disease exacerbation (6). Patients 3 and 5 had a history of prolonged cough at admission; patient 3 had chest radiograph results suggestive of miliary TB. Finally, for patient 5, Actinobacillus ureae was initially but erroneously identified as the cause of bacteremia.
In highly endemic areas with a disproportionately large burden of the disease, this novel route of transmission of brucellosis, resulting in severe disease in the exposed, needs to be explored to understand the transmission dynamics of a disease that is increasingly being recognized to be a bigger problem than it has traditionally been thought to be.
Fuchs I, Osyntsov L, Refaely Y, Ciobotaro P, Zimhony O. Ritual slaughter as overlooked risk factor for brucellosis [letter]. Emerg Infect Dis. 2016 [date cited]. http://dx.doi.org/10.3201/eid2204.151192