FRYEBURG — As a sick toddler remained hospitalized Wednesday at Maine Medical Center, state health officials were trying to pin down the strain of E. coli that led to his illness and the death of another toddler who visited the same petting zoo at the Oxford County Fair.

State health officials were doing lab work, and the state veterinarian was taking samples of animal manure and bedding at the Oxford fairgrounds Wednesday in an effort to determine where or how the toddlers were exposed, said John Martins, spokesman for the Maine Center for Disease Control and Prevention.

Martins said officials had confirmed that both boys were at the petting zoo, but it’s too soon to say that is where they were exposed to the deadly strain of E. coli. State officials were still investigating other possible explanations, work that involves talking to family members and filling out “a very complex questionnaire.”

“We are in the process of doing that work right now,” he said Wednesday. The state began its investigation Friday, he said. “Clearly, we still cannot say with 100 percent certainty that the cause is the exposure at the Oxford Fair, but we can say that both children (visited) the petting zoo and both have the presence of toxins associated with E. coli. Further testing and surveillance are needed.”

Myles Jacob Herschaft

Myles Jacob Herschaft Facebook photo

Martins said the department is not putting out a public notice or health alert because it is still investigating.

“If we are investigating cases like the current situation, we do not release information until an investigation has concluded,” Martins wrote in an email, adding that sometimes outbreaks are linked to one thing and it turns out there was another cause.

Myles Herschaft of Auburn was in fair condition late Wednesday at Maine Med, after being in critical condition earlier in the day, hospital officials said. He was being treated for hemolytic uremic syndrome, or HUS, a result of exposure to a particular strain of E. coli, according to a Facebook post from his father, Victor Herschaft.

Colton James-Brian Guay

Colton James-Brian Guay

“Myles is keeping up the battle,” he wrote late Tuesday. In an earlier post, he wrote, “If your child has symptoms of an illness please don’t take it lightly and please get your children checked out. Myles’ initial symptoms appeared as a stomach flu and progressed rapidly.”

Another child, 20-month-old Colton Guay, died of HUS a week after visiting the fair, according to his father, Androscoggin County Sheriff’s Deputy Jon Guay.

TAKING PRECAUTIONS AT THE FAIR

At the Fryeburg Fair on Wednesday, the person admitting children and their parents into the petting area reminded them to wash their hands or use hand sanitizer.

Jenny Pofahl, who was at the fair with her 2-year-old daughter, Vivian, said she had heard about the child at the Oxford fair, but wasn’t deterred from visiting the Fryeburg petting zoo.

This sign is posted near the petting zoo at the Fryeburg Fair.

This sign is posted near the petting zoo at the Fryeburg Fair.

“It didn’t keep us from going,” Pofahl said as she and Vivian ate pizza at a picnic table near the petting zoo. “We went and made sure to wash our hands very well afterward. … I did notice there is hand sanitizer all over the fair.”

Nineteen-month-old Benjamin Roche ricocheted in glee among the goats and chickens and ducks, while his father, Stephen Roche, hovered nearby. Benjamin, in a red flannel coat and jeans, smiled as he picked himself up after a tumble and made his way over to more goats.

His mom, Jessica Roche, was watching from the fence, holding sanitizing wipes.

“You can never be too careful,” said Roche, a certified nursing assistant.

Mark Anderson, one of the veterinarians hired full time by the Fryeburg Fair and a large-animal veterinarian for 29 years, heard about the E. coli infection Monday.

“The nature of E. coli being shared by an animal was so rare and random, it didn’t cause us much concern,” Anderson said. Contamination requires that infected manure enters the mouth. “Clearly this cycle can be broken by washing hands,” he said.

“This fair for a number of years has had hand sanitizers everywhere. It’s just a matter of getting everyone to use it,” he said. Neither Anderson nor other veterinarians hired by the fair have heard of someone contracting E. coli from the petting zoo before.

“The only other case of a youngster getting E. coli was my own son a year ago. He’s 14,” Anderson said. He attributed his son’s case to the many animals Anderson has at his farm and because he treats sick animals there.

The fair veterinarians are there to check animals when they arrive to make sure they are not sick and, if they become sick during the fair, to treat them. They are precautions to prevent diseases from spreading to other livestock.

Last year there were no swine at the fair because of a virulent virus that was making the rounds in pigs in New York and Vermont, Anderson said.

“It’s almost never because they might infect humans,” he said.

Benjamin Roche roams the petting zoo at the Fryeburg Fair. His mother, Jessica Roche, watched from a nearby fence with sanitizing wipes ready to use on her 19-month-old.

Benjamin Roche roams the petting zoo at the Fryeburg Fair. His mother, Jessica Roche, watched from a nearby fence with sanitizing wipes ready to use on her 19-month-old. Shawn Patrick Ouellette/Staff Photographer

MOST TYPES HARMLESS, SOME DEADLY

Martins said laboratory tests done Tuesday at the Health and Environmental Testing Lab in Augusta showed the presence of “Shiga toxins” associated with E. coli in the two sick children. He said the presence of Shiga toxins in their blood means they had E. coli at some time.

Martins said some strains of E. coli cause dysentery by creating a Shiga toxin. The bacteria that make these toxins are called “Shiga toxin producing” E. coli, or STEC.

Martins said doctors are required to report cases of STEC to the state. There have been 26 reported cases so far in 2015.

Most types of E. coli are harmless, but some cause symptoms that can lead to death. The infection can be contracted through contact with human or animal feces.

According to the federal Centers for Disease Control and Prevention, the incubation period for STEC is usually three to four days after the exposure, but may be as short as one day or as long as 10 days. The symptoms often begin slowly with mild belly pain or non-bloody diarrhea that worsens over several days. Hemolytic uremic syndrome, if it occurs, develops an average of seven days after the first symptoms, when the diarrhea is lessening.

Using that timeline, a hypothetical exposure on the last day of the Oxford fair, on Sept. 19, could result in a person developing the first symptoms as late as Sept. 29, and developing HUS on Tuesday.

Some types of STEC frequently cause severe disease, including bloody diarrhea and HUS, which is a type of kidney failure. Guay said his son died of HUS.

“It is believed that he contracted it through simple interaction with farm animals at a local fair (based on other similar cases). It began with severe diarrhea and ended with massive brain seizures that ultimately took his life,” Guay wrote on his Facebook page. The boy, who attended the fair Sept. 17 and Sept. 19, was treated at Maine Med.

The state CDC has been criticized in the past for not releasing some information regarding diseases that could threaten the public, such as a potential hepatitis A exposure at an unnamed Cumberland County restaurant in November 2014. The state said at the time that it did not learn of the potential exposure until two weeks had already passed and it was too late to vaccinate restaurant patrons.

Martins said the state has criteria for when to notify the public of a health threat.

A hand-washing station is mounted outside a barn at the Old McDonald's Farm petting zoo at the Fryeburg Fair on Wednesday.

A hand-washing station is mounted outside a barn at the Old McDonald’s Farm petting zoo at the Fryeburg Fair on Wednesday. David Hench/Staff Writer

“The trigger tends to be whether the public can take action,” he said Wednesday. He used the example of a public notification in April that a person with measles had been shopping in Kittery. In that case, the department issued a news release and notified health providers through a statewide alert system, telling people to check their immunization records and be aware of symptoms. By contrast, he noted a recent rash of viral meningitis, which is common and doctors are not required to report to the state CDC.

“There’s not a magic number” of cases, Martin said. “It’s about the type of action the public could take.”

University of Maine Associate Professor Anne Lichtenwalner said state officials need to know what is causing an illness while weighing when to send out a public notice.

“First, they want to be sure of their facts. That’s critically important. The last thing you want to do is cause a panic,” said Lichtenwalner, a veterinarian and director of the UMaine Animal Health Laboratory.

There are many factors that go into determining the kind of E. coli infections that cause illness, referred to as pathogenic E. coli. People are usually exposed to pathogenic E. coli by eating undercooked hamburger or drinking raw milk, and young people with less developed immune systems or people with compromised immune systems are more vulnerable.

Most federal regulations regarding public notification about E. coli exposure apply to public drinking water. On diseases associated with animals in public settings, the federal CDC is not specific, saying that states should ensure people are educated about the risks of animal-to-human exposure.

Dora Anne Mills, who headed the Maine CDC for 14 years before leaving in 2010, said states have “quite a bit of latitude” under federal regulations on when to notify the public of possible exposure.

“If it’s outside 10 days and people are past the incubation period, it’s a judgment call. There is no completely right or wrong answer,” she said. “It is certainly a common conundrum as to when to notify the public.”

In this instance, it could be the two boys were exposed some other way, which is why the state needs to complete its investigation, she said, emphasizing that she didn’t have any specific knowledge about the fair cases.

“You can easily inadvertently close a business down, and you want to be careful that you are not having a negative impact unnecessarily,” she said. “Some say it’s better to warn, but you have to be careful not to scare the public unnecessarily to the point where no one wants to go to the fair or the Kittery Mall.”

EMPHASIZING HYGIENE EACH YEAR

Elizabeth Clock, 17, of Lyman trims the coat of her cow Jelly at the Fryeburg Fair Wednesday.

Elizabeth Clock, 17, of Lyman trims the coat of her cow Jelly at the Fryeburg Fair Wednesday. Shawn Patrick Ouellette/Staff Photographer

State Veterinarian Michele Walsh said Wednesday that she was collecting samples at the site of the Oxford fair as part of the protocol after the visitors got sick. But she noted that E. coli is normally found in all mammals, including people. Officials at the state CDC lab will decide which tests to run on the samples, she said.

“This is a very, very sad situation,” Walsh said, adding that the emphasis remains on preventing illness through basic hygiene. “The message is the same. When we interact with farm animals and any animals, you have to be aware that there are pathogens that can pass between us,” she said. “Proper hand washing is critically important. One thing that is a challenge every year is to make that message newly relevant to people. We all get jaded from being told over and over again the same message.”

There are 26 agricultural fairs in Maine each year, and Walsh said she conducts random drop-in inspections at all of them, looking not only for sick animals, but checking anyplace where visitors and animals interact, such as the petting zoo.

“We’re looking to make sure it’s clean, that the manure is picked up and all animals appear healthy,” Walsh said. “It’s not feasible to screen all animals for the normal constellation of bacteria and viruses. What we can do is remind the public to wash hands and use hand sanitizers.”

Fairs are required to post signs and provide hand sanitizer stations. Some signs also note that in some areas, animals are not to be touched. Other signs ask that ill people not to visit the animals so the animals don’t get sick.