Public health officials have known for a long time that small children and small turtles are a very bad combination. The reason: Turtles carry salmonella bacteria. Kids handling turtles can and do get sick.

Four decades ago, to curb that risk, the Food and Drug Administration banned the sale of turtles with shells measuring less than four inches, a size that would be small enough to fit inside children’s mouths.

But a new study suggests the ban isn’t working as well as it once did. Scientists from the Centers for Disease Control and Prevention and several state health departments have detailed eight salmonella outbreaks linked to turtles that occurred between 2011 and 2013.

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“Despite the 1975 federal ban against the sale of small pet turtles, these animals are readily available to a public that is largely unaware of the association between reptiles and salmonella,” the authors wrote in an article published Wednesday in the journal Pediatrics.

The problem isn’t pet shops, but more informal vendors — people who set up stalls at flea markets or outside baseball games, or sell the reptiles on beaches. When a case of salmonella caused by a turtle comes to light, it is often impossible to find the people who sold the reptiles.

One common pitch involves selling the tank, but giving away the turtles for free. The lead author of the study said some vendors think they are allowed to do so without violating the FDA ban. They’re wrong.

“Any distribution of these small turtles as pets is illegal,” Maroya Walters of the CDC’s division of foodborne, waterborne, and environmental diseases, told STAT. “So that is whether they are sold directly as a pet or whether they are offered for free with the purchase of an aquarium.”

Walters and her coauthors reported a total of 473 people in 41 states plus the District of Columbia and Puerto Rico were infected in these turtle-related outbreaks. One was an infant whose bottles were washed in a sink also used to clean a turtle tank.

The CDC recommends people not use a kitchen sink to clean a turtle habitat, Walters said. And if they use a sink or a bathtub, the basin should be disinfected afterward.

The age range of people sickened in the outbreaks was substantial — from one month to 94 years. But children made up the vast majority of cases — 78 percent — and 55 percent of cases were under the age of 5.

When the researchers questioned a subset of 94 cases or their parents, only 15 percent knew the reptiles are a source of salmonella. They suggested doctors and state governments have a role to play in reducing the incidence of turtle-associated salmonella, or TAS, for short.

“Given the large pediatric population affected, pediatricians and their staff are uniquely well-positioned to educate families about steps they can take to reduce the risk of TAS,” the authors wrote. “To reduce the number of illicitly marketed small pet turtles, state and local jurisdictions should consider enacting regulations against the sale of small pet turtles to complement federal enforcement activities.”

That’s because it’s much easier to enforce local laws than to require the FDA to move in, Walters said. “You really need to be able to act swiftly, at the point of sale. And that’s where these state and local authorities can really make a big impact.”

Every year about 1 million people in the United States have a close encounter of the gastrointestinal kind with salmonella bacteria. Most people recover on their own but about 19,000 a year require a hospital stay and about 380 people die from the infection, according to the CDC.

Most salmonella infections are contracted through contaminated food. The bacteria cause diarrhea, fever, and abdominal pains; a bout can last anywhere from four to seven days.

There are other ways to get salmonella, however. Baby chicks, for instance, are also a source of the bacteria, and while they aren’t the subject of an FDA ban, public health officials wish parents would consider the risk before letting young children play with them.

In a subset of people in the turtle study — 274 patients — 78, or 28 percent, needed to be hospitalized. The median length of their hospital stays was three days. There were no deaths.

Young children, the elderly, and people with weakened immune systems are at highest risk of getting really sick from salmonella.

Reptiles and amphibians carry the bacteria in their guts. Their feces can be laced with the stuff. So their skin, or shells, in the case of turtles, can be coated in salmonella. Anyone handling turtles — holding them, cleaning out their tanks, preparing food on a counter across which a turtle has roamed — can become infected with salmonella if they don’t clean the sink or counter thoroughly and wash their hands carefully afterward.

Children aren’t generally the best at hand hygiene — or as the authors put it, kids “are more likely to exhibit hand-to-mouth behaviors that increase the risk of infection.” They are also not the best at recognizing risks to their health.

The study authors don’t explore why the ban on turtle sales isn’t working as well as it used to, noting only that while it worked very well in the early days, from 2006 onward, turtle-linked salmonella cases started to climb once more.

In an interview, Walters said the belief is the surge in sales — and salmonella cases — resulted from a downturn in the international market for turtles. US producers had been selling turtles to Asia for consumption, but demand for US turtles fell when local producers eventually moved into the market.

The FDA declined to make an expert available for an interview about the study. In a statement, however, an agency spokesman said that parents should stop buying turtles as pets. “While FDA has been working closely with state authorities on efforts to address salmonellosis associated with small turtles,” the statement said, “it is important that parents avoid buying these pets to avoid the potential spread of salmonella to their children.”

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