Spanish statement about euthanized Ebola virus-exposed dog

Spanish authorities have issued a statement through ProMED-mail about their decision to euthanize the dog owned by a nursing assistant with Ebola virus disease.

Regarding the news [that] appeared in the magazine "Veterinary Record", dated 18 Oct 2014, where it was questioning the scientific reasons on which euthanasia of the dog Excalibur were based, we are
sending a report based on the opinion of the leading Spanish and European renowned specialists on this subject, epidemiologists, virologists and experts in preventive medicine on animal health.

Case background: [On] 6 Oct 2014 afternoon, the 1st indigenous clinical case of Ebola virus (EBOV) disease was confirmed in a health worker in Spain. The health worker had been involved in the care of a severely diseased missionary who had contracted the virus in Sierra Leone and had died on 25 Sep 2014. The patient developed fever on 29 Sep 2014, and at the time of the confirmation of the diagnosis, she presented with high fever and other typical clinical signs like vomiting and diarrhea. The cohabitation between the patient and the animal was close and constant during some of the period of virus excretion, and therefore the potential for disease transmission could not be ruled out.

In the epidemiological investigation, it was noticed that the health worker was cohabiting with her dog Excalibur in their apartment during the acute phase of her infection and before admission to the hospital. She kept close contact with the dog during the 5 days previous to the confirmation. Thus, the exposure of Excalibur to the virus was very likely, as well as the risk of its contagion.

There are numerous knowledge gaps related to the infection of dogs with EBOV. Allela et al. (2005) studied the potential role of dogs in the epidemiology of EBOV disease. They observed specific antibodies against the virus in pet dogs living in Gabon during the 2001-2002 epidemics. In fact, the apparent seroprevalence reached up to 25 percent in villages with confirmed viral activity. Although the study failed to detect the virus, the authors hypothesized that dogs may carry the virus without showing any clinical sign. Also not determined is possible  viral excretion from dogs, the viral loads in these excretions and the lapse of time between the infection of animals and the potential viral shedding. Thus, the risk of EBOV transmission from dogs to humans cannot be ruled out.

The desire of the Spanish authorities would have been to move the dog to quarantine and confirm its infection. Unfortunately, there are no veterinary medical means in Spain to do so respecting the biosafety level 4 (BSL4) requirements pertaining to this virus (CDC, 2009). These missing minimal needs include proper means to carry the dog alive, contrasted protocols for this situation, BSL4 facilities for its quarantine, and training of personnel handling the animal. In addition, the procedure followed the 'precautionary principle', due to the lack of sufficient evidence to eliminate the potential role of EBOV transmission from dogs or other pets to humans, as stressed by Dr. Bernard Vallat, Director General of the World Organization for Animal Health (OIE) to AFP [Agence France-Presse].

Due to these uncertainties and the highly possible risk of infection, the Madrid regional government authorized the euthanasia of Excalibur on 8 Oct 2014 through a court order due to the rejection of the
husband of the patient to allow the health operatives to enter the apartment. The procedure was performed by highly qualified staff of the Health Surveillance Centre of Madrid (VISAVET) and following the strictest animal welfare measures.

The Spanish episode has been repeatedly compared with another EBOV case in Dallas (Texas, United States), although epidemiological and logistic differences exist. The American case occurred in a nurse who had contact with Thomas Eric Duncan and was confirmed on 12 Oct 2014. This nurse also has a dog, which was living with her before the diagnosis confirmation. In contrast to the Spanish case, the period of contact between the patient and the dog comprised the 1st 2 days of clinical infection, in which the viral load in the excretions is lower, so the contagion was less likely than in the Spanish dog. In addition, the US government has sufficient means to maintain the animal in quarantine.

In conclusion, the euthanasia of Excalibur was not an automatic procedure, but a health measure carried out in the best available way and always aimed to protect public health.

Secretaria
Direccion General de Ordenacion e Inspeccion Consejeria de Sanidad
Comunidad de Madrid
c/ Aduana 29 - 4a
28013 Madrid
Spain

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Fake service animals in action

I go on periodic rants about people abusing service animal rules to take their pets places they cannot normally go (while potentially compromising the critically important need for true service animals to have unfettered access).

Sometimes, it's nice to know I'm not the only one.

A recent article (pointed out by a writer from the VIN News Service) in The New Yorker describes the exploits of the article's author, Patricia Marx, as she tested the ability to talk your way into various situations with over-the-top examples.

While I have some concerns about some of the scenarios (e.g. turtle bathing in a bowl of water in a deli, a stressed out turkey...) it showed how easy it is for people to manipulate the system. If you can get away with things like she did, it's easy to see how it's so easy for people with fake service dogs (complete with fake ID, vests and other paraphernalia) to do it.

(click image for source)

Skunk + late vaccine + inflexibility = dead dog

A Brockton, MA dog was euthanized after being bitten by a rabid skunk, because of a combination of the skunk's rabies diagnosis, a relatively minor lapse in the dog's vaccinations, and regulatory inflexibility. The ten-year-old Schnauzer cross was bitten in its own yard, and the skunk was subsequently caught, tested and diagnosed as rabid.

Clearly, this needs to be considered rabies exposure. But, what needs to be done?

  • If the dog was up-to-date on its vaccines, it would receive a booster vaccination and be subject to a 45 day observation period (typically at home).
  • If unvaccinated, it would be boosted and quarantined for 6 months, or euthanized.

However, a dog doesn’t suddenly go from protected to unprotected immediately after the 1 year or 3 year vaccination duration passes. One year and 3 years are nice easy dates to remember and vaccines are known to provide that degree of protection because they've been tested at these intervals.  However, since vaccine-induced antibodies aren’t programmed to self-destruct on a specific "best-before-date", there’s a grey area with animals whose vaccination has lapsed by only a short period. Here, the dog was two weeks overdue - immunologically probably almost identical to what its protection status was at the time its vaccination lapsed.

“It is really sad. My heart goes out to the animal’s owner,” Animal Inspector Megan Hanrahan said. “But those two weeks make the animal not covered.”

Yet, it’s not that clear-cut. NASPHV guidelines state “Animals overdue for a booster vaccination should be evaluated on a case-by-case basis based upon severity of exposure, time elapsed since last vaccination, number of previous vaccinations, current health status, and local rabies epidemiology to determine need for euthanasia or immediate revaccination and observation/isolation."

It’s definitely grey, and being bitten by a rabid skunk is concerning, but a ten-year-old dog that was two weeks overdue (and hopefully previously vaccinated many times over its life) certainly deserved some consideration of this grey area. I think a 45-day observation period would be entirely justifiable here.

Regardless, this is a good reminder of why people need to pay close attention to vaccination dates and ensure that their animals are properly covered at all times (and, no, testing antibody titres does not replace the need for vaccination).

Photo credit: http://www.birdphotos.com (click image for source)

Another Capnocytophaga infection in a healthy person

OK…time to get back to work writing. A couple weeks of conference organizing and uncountable Ebola calls are hopefully winding down, so back to the neglected blog.

This bug is an obscure one that I write about regularly: Capnocytophaga canimorus. It’s found in the mouth of most dogs, so people are commonly exposed to it. It almost never causes a problem, but when it does, it’s bad. Capnocytophaga infections classically occur in people who don’t have a functional spleen, alcoholics or those who have a compromised immune system. We focus on education of these high-risk people in terms of avoiding exposure to dog saliva and good bite-management practices. But, as with most things in infectious diseases, there are very few true “nevers”, and there are sporadic reports of Capno infections in people who are (seemingly, at least) otherwise healthy.

Another report appeared in a recent volume of Infection, “A case of Capnocytophaga canimorsus sacral abscess in an immunocompetent patient “(Joswig et al. 2014). Long story short, this person developed an abscess in the sacrum (the bone at the base of your spine), with a pet dog being the presumed source. There was no obvious incident of exposure such as a bite, and the person had no apparent risk factors, so it’s an unusual case. The fact that it was an abscess and not an overwhelming systemic infection (as is often the case) is also unusual, and may relate to the fact that this person had a normal immune system that was able to prevent a rapid, life-threatening infection.

This report doesn’t really change anything, but it’s another example of how some of these potentially nasty infections that we associate mainly with high-risk people can also occur in healthy individuals. This doesn’t mean we should be paranoid of dog saliva, but we should be practically cautious. Avoiding contact with saliva, avoiding bites and proper bite first-aid are all basic measures that can presumably go a long way to helping prevent a wide range of infections.

 

More on Ebola

Since I’ve spent most of my day answering questions about Ebola, here are some of the common Q&As.

Can dogs be infected with Ebola?

Yes, but what that really means is unclear. Most of the available information comes from a study in Gabon where they tested dogs in a community during an Ebola outbreak. They found antibodies against the virus in a large percentage of dogs. That’s not really surprising, as these dogs were apparently scavenging bodies of people and animals that had died from Ebola. So, it’s not hard to see how they’d be exposed.

Having antibodies against the virus means the virus got into their body and the body mounted an immune response. That doesn’t mean the dogs got sick or that they were shedding the virus. In that study, they could not find evidence of the virus in the dogs’ bodies. That doesn’t mean it was never there at relevant levels, but they couldn’t find it at the time.

Can dogs infect people with Ebola?

That’s the big question. Dogs can get infected (see above), but IF the virus can reproduce in a dogs and IF the virus is then present in adequate levels in blood and other secretions, THEN there would be the potential for dogs to be a source of human infection. That’s a lot of IFs for which we don’t have good information.

What do I think?

I think the risk of transmission of Ebola from dogs is very low. There’s currently no evidence that dogs have an important (or any) role in transmission of the virus in natural situations. It’s not zero risk (there aren’t many "it can never happen" situations with emerging diseases), and considering the how deadly the disease is the measures that can be used to mitigate that risk (small though it may be) are important.

So, how can we reduce the risk with an exposed dog?

Basically, treat the dog the same way you would treat a person with Ebola exposure or infection. An exposed person is quarantined and monitored for signs of disease. People are not infectious until they are sick.  A sick person is handled with strict infection control precautions because of the potential that the virus is present in various body secretions.

With a dog, it’s probably warranted to err on the side of caution and treat an exposed dog like an infected person. Why? Because we don’t know that dogs are not infectious until they’re sick. So, it might be best to have them isolated and handled with strict biosafety practices, rather than just watch them at home (particularly given the potential for the dog to escape the house).

Is that degree of containment practical?

Maybe. It depends on the facility, personnel and motivation. Last week, I sketched out a containment plan for our facility in case we had a suspect case. It was done knowing there’s virtually no chance it would be needed, but it was a good mental exercise to consider what to do. The more you think about it, the more complex it can get. Containment is possible for a good facility with reliable personnel and a clear containment plan. However, you can’t just drop the dog off at any kennel, shelter or veterinary clinic and say "we’ll be back for it in 21 days." You need the right facility and personnel, and access to that will be variable.

Ebola kills dog...indirectly

There’s prudence and then there’s "let’s kill it so we don’t have to think about it."

The Spanish response to Ebola in a nursing assistant is a demonstration of the latter. Health Officials in Spain have obtained a court order to "euthanize and incinerate" the dog owned by a nursing assistant who was infected with Ebola virus while caring for a Spanish priest who acquired the infection in Sierra Leone. The case has received a lot of attention, as the first case of Ebola from this outbreak that was acquired outside of Africa.

There’s obviously cause for concern and prudence, and the woman’s husband is logically in quarantine. However, euthanasia of the dog seems like overkill. Yes, we have to be careful. But we don’t need to overreact.

The odds of this dog being infected are very, very slim. Even if the dog was infected, there is no evidence that dogs are a source of infection. The concern about dogs has been around dogs eating carcasses of other animals that have died of Ebola virus infection, and direct contact with people with active disease. In one study in a village in Gabon during an Ebola outbreak, a large percentage of dogs had antibodies against the virus, indicating exposure (Allela et al, Emerging Infectious Diseases 2005). But, exposure doesn’t mean the dogs were ever able to transmit the virus, and eating a body full of Ebola virus is very different from living in the house with one person in the early stage of infection.

I’m not saying transmission from a dog in some form or another is impossible, or that no precautions are required for pets that have been in contact with an infected person. In some ways, it’s good to see animals considered in this scenario. However, why not take the opportunity to quarantine and test the dog to see if it was infected? That would be better for the dog, for its owner, and for the next time the situation occurs. You can’t answer all the questions with one dog, but you can start to gather information. Euthanasia is the easy knee-jerk approach that removes all risk, but there are ways to house and monitor a dog for a few weeks with no contact. Since Ebola virus is spread by direct contact with infectious body fluids, it’s containable with good facilities and appropriate precautions. To me, that would have been a better approach from many aspects.

Ebola: precautions and paranoia

Awareness is good.

Being proactive is wise.

Being paranoid? That’s another story.

As this unprecedented Ebola virus outbreak in West Africa continues to expand, many people in North America have journeyed from ignoring it, to considering it a disease that you only get if you’re in Africa, to thinking they need for move to some remote island and live in a bio-bubble to avoid it.

With news reports of people being quarantined in North American hospitals because they returned from West Africa with a fever, and with a confirmed case in a person who travelled from Liberia to Dallas, some people are freaking out. Among the frequent alarmist responses is a demand for a full ban on any travel from West Africa (or even Africa as a whole, from people who don’t realize the distance from Liberia to South Africa is over 5000 km, similar to the distance from New York to Alaska).

With a virus that is relatively poorly transmissible and only transmitted when people are symptomatic, reasonable travel controls and attention by healthcare workers (a big "oops" occurred in Dallas in this case) should prevent this virus for establishing any kind of foothold in North America.

People need to put things in perspective. Most likely, there will be no locally transmitted North American Ebola deaths this year. At the same time, tens of thousands of people in North America will die from seasonal flu.

...I wonder how many of the people screaming for a lock-down on Africa got a flu shot last year.

More hatching chick associated salmonellosis

The salmonellosis outbreak in the US associated with hatching chicks continues to expand. The outbreak, ironically associated with Mt. Healthy Hatcheries in Ohio, has now sickened at least 344 people in 42 US states and Puerto Rico with a variety of Salmonella serotypes (S. Infants, S. Newport and S. Hadar). The outbreak shows no sign of abating, with another 42 cases identified in the past 6 weeks.

As is often the case, young people are more often affected, with 33% of sick individuals being 10 years of age or younger. Thirty-two percent of infected individuals have been hospitalized.

Unfortunately, the regulatory response in situations like this is most often to give places like the hatchery in question "guidance" as opposed to imposing mandatory measures. However, this is really a "buyer beware" situation, in which people purchasing hatching chicks need to be aware of the high risks associated with young poultry, and take appropriate precautions to manage them. While Salmonella-free eggs and chicks would be ideal, it’s not particularly realistic.  People need to be more proactive themselves and listen to established infection control practices, which include keeping kids less than five years of age away from young poultry.

Hopefully schools will pay attention to these recommendations when they’re planning their annual (and often poorly managed) hatching chick activities in the spring.

Parvo poop and the outdoor environment

Here’s a question that I get commonly: “What do I do to an outdoor area that might have been contaminated by a dog with parvovirus?

There’s not a lot of research to back anything up, but understanding the virus and some basic principles helps us come up with some reasonable recommendations.

Parvovirus is…

  • Highly tolerant of environmental exposure, disinfectants and other things that kill most viruses.
  • Shed in potentially massive amounts in the feces of sick animals, but also potentially by some healthy animals.
  • The cause of a potentially fatal disease.
  • A pathogen against which we have effective vaccines.
  • Really only a concern for unvaccinated (or inadequately vaccinated) dogs.

There’s definitely cause for concern if a puppy with parvo infection has passed diarrhea outside. We can assume there’s lots of virus there, and that the virus is going to be able to survive there for some time. We don’t know how long, and it will certainly vary with environmental conditions (e.g. temperature, pH of the soil, humidity, sunlight), but it’s safe to assume that it will be a fairly long time in most situations.

So, what do we do?

  • Disinfection of outdoor surfaces is pretty futile. Disinfectants don’t work well in the presence of organic debris (dirt), so pouring disinfectants on grass or gravel will not likely do much (except put a lot of disinfectant residue into the environment). Unless it’s happened on a surface like concrete or asphalt (both of which can still be hard to adequately disinfect because they are porous), leave the bleach bottle in the cupboard.
  • Removing feces is a good first step. This actually removes the vast majority of virus that has been passed. It might require using a shovel to get rid of some of the diarrhea-soaked grass or soil, but removing as much of the visible contamination as possible is key.
  • Restricting access to the area can’t hurt, when it’s feasible. That doesn’t mean cordoning it off and keeping everyone away. The focus should be to keep young, unvaccinated or incompletely vaccinated dogs (and dogs that have contact with those dogs) away from the area.
  • Raking the site can help turn over the substrate (e.g. dirt, soil, gravel) and get more exposure to UV light. Sunlight is our best outdoor disinfectant, and raking can help expose virus particles that are hidden away.

As always, prevention is better than cure. Preventing these situations is ideal, but admittedly not always possible. Things that can help include:

  • Making sure all puppies are properly vaccinated.
  • Keeping unvaccinated puppies away from high dog-traffic areas.
  • Keeping sick animals away from public areas.
  • Promptly picking up feces from any dog, healthy or not.

 

More bad news on the MRSP front

Well, "news" perhaps isn’t the best description since we’ve been seeing it for a while, but a paper in an upcoming edition of the Journal of Clinical Microbiology (Gold et al. 2014) entitled "Amikacin resistance in Staphylococcus pseudintermedius isolated from dogs" provides published support for the trend we’ve been seeing.

Staphylococcus pseudintermedius is an important cause of infections in dogs, and a resistant form, MRSP (methicillin-resistant Staph pseud) is a major problem. MRSP also does a great job of becoming resistant to additional antibiotics, usually by picking up resistance genes from other bacteria. We’ve rapidly lost most of our typical antibiotic treatment options for many MRSP strains, and are left with only a couple of viable drugs. One of those is amikacin, an antibiotic we try not to use when we don’t have to because it has to be injected, and because it can be hard on the kidneys. However, it’s literally a lifesaver in some cases.

Over the past year or two (unsurprisingly, really), we’ve been seeing some amikacin resistance in MRSP strains. I say that’s unsurprising because, with bacteria in general (and MRSP in particular), we’re trapped in a game of "use it and lose it." Any time we use an antibiotic, there is some potential for resistance to develop.

The study by Gold et al looked at 422 Staph pseud from dogs, and found that MRSP were significantly more likely to be amikacin resistant, with a rather astounding 37% amikacin resistance rate in their MRSP collection. Amikacin-resistant strains were also more likely to be resistant to a range of other antibiotics, regardless of their methicillin-resistance.

What do we do?

Tough question. Bacteria eventually seem to outsmart us most of the time (or we seem to "out-dumb" them, since it’s often our poor use of antibiotics that leads to problems).

So, what can be done?

Prevention is better than cure: MRSP infections are almost invariably secondary problems. Preventing or limiting underlying disease (e.g. controlling allergic skin disease) can greatly reduce the number of infections and the amount of antibiotics used to treat them.

Infection control: MRSP surgical site infections are increasingly common, and using good infection control practices should help limit them.

Use them right: Making sure drugs are given as prescribed with proper dosing (amount and frequency), and limiting the use of the few remaining MRSP treatment options for cases that really need them are important.

Antibiotic alternatives: Antibiotics aren’t always needed to treat infections. Topical therapy with things like chlorhexidine shampoo can be highly effective for skin infections, and can save antibiotics for infections that can't be treated otherwise.

Will these steps stop the scourge of antibiotic resistance?

No. But they might buy us some more time to figure out how to better handle this and to save some of our limited remaining antibiotic options.