Worms and Germs Blog : Animal Health & Diseases : University of Guelph : Ontario Veterinary College : Zoonotic Diseases : Guelph, Hamilton, Ontario

Following reports of a veterinarian warning colleagues and horse owners about West Nile infection in a British Columbia horse, Dr Brian Radke, a Public Health Veterinarian at the BC Ministry of Agriculture, has clarified the situation.

"The BCCDC co-ordinates WNV surveillance for the province of BC including monitoring of mosquitoes, birds, horses and humans. The BC Ministry of Agriculture supplies information to BCCDC on horse cases. In Canada, equine cases of WNV are reportable the Canadian Food Inspection Agency (CFIA).

The CFIA has no reports of WNV consistent with the Prince George horse. Discussions with the veterinary practitioner have clarified that the horse's illness, which occurred in November, was not due to WNV.

The testing discussed in the article was not conducted at the provincial government animal health laboratory. The BC Ministry of Agriculture is following up to determine the nature of the WNV testing and the appropriate interpretation of the test results.

BCCDC WNV surveillance indicates the following:

• In 2011 no humans, mosquitoes, or birds were detected with WNV infection in BC. One horse in the Central Okanagan was reported as positive and that report is under review.
• There have been no positive WNV indicators in the Prince George area.
• In BC, WNV has been detected in southern parts of the province, all below N50 latitude. (By comparison, Prince George is N54 latitude.)
• Risk modelling by BCCDC suggests that Northern BC, including Prince George, experience insufficient sustained heat during the short summer for WNV to amplify and be transmissible by the low density of vector mosquito species.
• The risk modelling also suggests that even in the warmest (that is, southern interior) areas of the province, the risk of WNV infection decreases significantly in September as the vector typically ceases seeking blood meals.

The BC Ministry of Agriculture and BCCDC look forward to working with the province's equine practitioners to interpret WNV testing results and epidemiology to assess the risk of WNV to horses in the various regions of BC. The assessment of risk could then inform decisions about the appropriate interventions for WNV infection in horses in the various regions."

We thank Dr. Radke for the information.

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Although the weather in Southwestern Ontario seems quite confused lately regarding whether it wants to be winter or spring, at least we're still a few months off from having to worry about mosquitoes and the viruses they carry once again.  Warmer parts of the world, however, are in the midst of their mosquito season, and some chickens are lending a hand to give people in the area a "heads up" about what's around.

The Health Department of Western Australia has detected Murray Valley encephalitis virus (MVEV)  in chicken flocks in East Kimberley.  The department has also tested and found the virus in its sentinel chickens in Wyndham and Kununurra.  These sentinel birds play an important role as an early warning system when viruses like MVEV are circulating in the area.  Just like West Nile virus, MVEV typically circulates between birds and the mosquitoes that like to feed on them, but problems occur when the same mosquitoes start to bite people (or other susceptible animals such as horses), particularly when there are a lot of mosquitoes, like when the weather is very wet or when there's been flooding.  Although most people who are infected with MVEV or WNV fight off the virus with no difficulty, or may simply develop short-term, non-specific signs of illness like mild fever and malaise, in some people these viruses can cause severe infection of the brain (encephalitis) and may even be fatal.

Knowing that MVEV has been found in these "guardian" chickens lets people know (via warnings issued by the health department) to take extra precautions against mosquito bites, such as:

• Staying indoors during peak mosquito activity - dusk and dawn
• Wearing protective clothing including long-sleeves and long pants
• Applying insect repellent

In North America, you can pretty much substitute West Nile for Murray Valley in a case like this.  Sentinel chickens have been used to provide early warnings of circulating WNV here, before cases are detected in people or horses.  Another means of early detection that is also used is testing pools of mosquitoes directly.

It just goes to show you can still be an important part of the country's defenses, even if you're a little chicken :p

(click image for source)

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Bob Katter, an Australian Member of Parliament and leader of the Australian Party, has proposed culling flying foxes (fruit bats) as a way to control Hendra virus, which is spread by these large Australian bats. He's not the first person to make such a proposal, but it's a knee-jerk reaction that in reality doesn't make a lot of sense.

It's not completely clear whether Mr. Katter is proposing a plan to completely eradicate the flying foxes altogether, or to simply let people kill any such bats they find on their property, but neither approach is likely to be effective in terms of decreasing the risk of Hendra virus transmission.

If people kill flying foxes on their property, they'll just be replaced in short order by bats from neighbouring areas.

Trying to eradicate the entire species is a bad idea for a variety of reasons:

• Tinkering with a complex ecosystem doesn't often turn out the way you want it to. Australians certainly know from past experiences that bad things can happen when new species are introduced (rabbits are just one example). The same might happen when a species is removed.
• Eradication of the species is probably impossible or at least very difficult. I don't know much about the reproductive rate of flying foxes, but if the species can reproduce at a reasonable rate, they can probably replace the culled animals unless people are really aggressive and seek out all remote breeding sites. The limitations of culling have been clearly shown in rabies control, where it doesn't do much because culled dogs are quickly replaced by new dogs.
• Eradicating flying foxes would be very expensive. What could that money do if put into research on vaccination, treatment, and other worthwhile ventures? What if efforts were focused on eliminating flying fox roosting sites in horse pastures? Overall, the impact would probably be much greater.

Why stop with flying foxes? Australia has lots of nasty critters, ranging from spiders to saltwater crocodiles. Should we kill all of those too? Dog bites kill more people than Hendra every year. Should we kill all dogs?

Hendra virus is not something to ignore. While infections in horses are rare, they are usually fatal and there's the risk of transmission to people. Human infections are very rare but often fatal. So, ways to reduce infection of horses as a means of reducing both human and horse disease are important, but the slaughter of flying foxes doesn't make a lot of sense.

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Marion County (Florida) public health personnel recently issued a rabies alert after a horse in the area tested positive for the virus. It’s a standard alert, emphasizing avoiding contact with wildlife, reducing things that attract wildlife to houses (e.g. accessible pet food or garbage) and recommending vaccination. Interestingly, while this alert was prompted by a case of rabies in a horse, it only mentions vaccination of dogs, cats and ferrets. That may have been because it was an off-the-shelf alert, not really tailored to this situation, but it shows how horses can be overlooked when it comes to rabies.

Fortunately, rabies is a rare disease in horses. In 2010, there were 37 reported cases of equine rabies in the US and only one in Canada (two Canadian cases have been identified so far this year). That’s a very low rate, especially considering the number of horses out there, but it’s still more cases than there should be for a very serious yet highly preventable disease.

Unfortunately, rarity sometimes breeds complacency, so despite the fact that rabies is invariably fatal in horses and rabid horses pose a risk to people, vaccination of horses is often overlooked. While rabies is rare in horses, rabies vaccination shouldn’t be rare. Every horse in a rabies endemic region (or that might be traveling to such a region) should be vaccinated against rabies. It’s cheap insurance against a very dangerous and deadly disease.

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Unfortunately, because of funding challenges (translation... there was no more money), we were no longer able to maintain our equine infectious disease blog (equIDblog) as a separate site. However, based on the positive feedback we had and the amount of traffic on the original site, we still think it serves a role and are dedicated to maintaining equIDblog in some form. So, we are going to merge equIDblog with the Worms & Germs Blog. We have already moved the equIDblog Resources page, which can be accessed through the link in the title bar.  We will also gradually move all of the current archived blog posts from the site and place them under the equIDblog topic category which can be found in the left index bar.  Here we will maintain all of the site's current content and continue to provide information and commentary on equine infectious disease issues. Thanks to all of our loyal equIDblog readers for making the blog such a success, and we hope you'll continue to follow us here on the Worms & Germs Blog!

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A two-part study (Maddox et al. 2011) was recently published online in the Equine Veterinary Journal looking at antimicrobial resistant "superbugs" in horses in the UK.  The first part of the study had the simple objective of estimating the prevalence of both MRSA nasal colonization and fecal shedding of antimicrobial resistant E. coli in the UK horse population. The reason they were looking at E. coli is because this bacterium is part of the normal intestinal flora of most animals (including horses), so it's easy to find, and it is frequently exposed to antimicrobials whenever a horse is treated systemically (i.e. with either oral or injectable antibiotics), so researchers use it as an "indicator" for resistance that may develop in other bacteria as well.  E. coli doesn't typically cause gastrointestinal disease in horses like it can in people, nonetheless E. coli is a common cause of uterine, urinary and wound infections in horses, as well as septicemia in foals, and antimicrobial resistant infections in these situations can certainly be a big problem.

Out of 678 nasal swabs (taken from horses on over 500 premises), only 4 (0.6%) were positive for MRSA.  That's good to see, as it's very easy for MRSA to spread in a horse population "under the radar," because colonized horses do not have any outward signs that they are carrying the pathogen.  The overall low prevalence in the community setting is similar to previous community studies in the UK and other areas.  Out of 650 fecal samples, 452 (72.2%) were positive for an E. coli that was resistant to at least one antimicrobial.  That's not too surprising.  The bigger concern is that 233 (37.6% - over one third of all horses tested) samples contained multidrug-resistant E.coli (defined in this study as resistance to more than three antimicrobial classes) and 42 (6.3%) samples contained an E. coli that produced an extended-spectrum beta-lactamase (ESBL).  ESBLs are particularly problematic because they can be relatively easily transferred between bacteria, they confer resistance to a large number of commonly used antimicrobials in the beta-lactam class (which includes penicillins and cephalosporins), and are frequently associated with genes that confer resistance to other antimicrobial classes as well.  Bacteria that produce ESBLs are a significant problem in human medicine and have been reported to cause infection in horses as well.

The second part of the study used information collected from questionnaires filled out by the horse owners to try to determine risk factors that affected the odds of a particular horse shedding antimicrobial-resistant E. coli.  They used some pretty heavy-duty statistical analysis because they were looking at so many factors and different outcomes, and any time that happens you have to take the final numbers with a grain of salt. Nonetheless, the results can help point the way for future studies to help determine which factors may have the biggest impact on the risk. The authors found recent hospitalization and veterinary treatment for various conditions over the last six months were associated with higher odds of shedding multidrug-resistant strains of E. coli, and the type of farm/facility also affected the odds.  In addition, having a recently hospitalized horse on the premises (among other things) increased the odds of a horse shedding ESBL E.coli.

What does all this mean for the average horse owner?  The results really aren't new or startling.  We already know that antimicrobial resistance is a growing problem in equine medicine, as it is in veterinary and human medicine in general, and this is one more set of studies that provides evidence to that effect.  I have no doubt that if a similar study was performed in North America the same kinds of resistant bacteria would be detected, although the numbers may vary somewhat one way or another.  The second part of the study also re-emphasize the role that antimicrobial use plays in promoting development of and selection for resistant bacteria, and the potential for the treatment of certain horses to affect the microbes being carried and shed by the animals around them.  In the end, it comes down to being responsible about how we use antimicrobials in order to curb the development of resistance, so that these important drugs remain effective for treating serious infections in the future.  This applies equally to their use in people and animals of all kinds.

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There are a lot of recommendations out there for establishing or improving sound infection control practices on horse farms, many of which can be found on this very blog.  Some refer to such practices as "biosecurity," but what's done on horse farms compared to the often very strict biosecurity protocols at facilities such as swine or poultry operations (e.g. all-in all-out management, closed barns, shower in) is very different, so we prefer to call it an infection control program, rather than "biosecurity."  Regardless, one of the biggest challenges with regard to infection control, in almost any setting, is getting people to comply with all the various policies and recommendations.  Unfortunately, it's not enough to just tell people what needs to be done (that'd be too easy!) - knowledge by itself usually won't change people's behaviour.  They also need to be motivated to change their behaviour, for example by the potential for a positive reward (e.g. they get to take their horses to shows) or the potential to avoid a negative outcome (e.g. their horses don't get sick).  Furthermore, individuals need to really believe they are capable (physically and mentally) of performing the required tasks - if they don't think they can do it or be effective at it, they're unlikely to try.  In reality, getting people to change their behaviour to adopt sound infection control practices can be quite complex.

A study soon to be published in Preventative Veterinary Medicine (Schemann et al. in press) looked at some of the factors that affect horse owners' biosecurity practices and perceptions.  The study was performed in Australia one year after the devastating equine influenza outbreak that occurred in 2007, using an online questionnaire to which 759 horse owners responded.  Each owner's biosecurity compliance was rated as low (30%), medium (20%) or high (50%) based on how often they reported using 16 different infection control measures.

Factors that were associated with low compliance or poor biosecurity practices included people who:

• were younger in age
• had two or more children
• were not involved with horses commercially
• had no long-term business impact from the 2007 equine flu outbreak
• were not fearful of a future outbreak of equine flu in Australia
• thought their current hygiene and access control practices were not very effective in protecting their horses

Now, studies based on surveys of this kind always need to be taken with a grain of salt, as the study population itself was difficult to define and the information was all self-reported by owners, which can lead to confounding and misclassification bias.  Nonetheless, the results are still interesting and on the whole are consistent with behaviour theory.  Those whose income and livelihood were not dependent on the horse industry, and those who were not fearful of another outbreak, would be less motivated to put the effort into infection control measures.  Furthermore, those who felt that what they were doing already wasn't really effective (for whatever reason) would be less motivated to try harder because they can't see the benefit.  It's quite possible (as the authors speculate) that having two or more children results in less compliance with infection control simply due to the time constraints associated with having kids.  Lack of time to properly perform infection control procedures is a major barrier to compliance, even in human hospitals, particularly with understaffing issues. The lower compliance among young people is also common to studies looking at protective behaviour in human health, possibly because young people have a sense of certain degree of invulnerability that results in riskier behaviour overall.

When it comes to infection control, the old adage "a chain is only as strong as its weakest link" is very important to remember.  Although 50% of the horse owners in this study reported having high biosecurity compliance, the 30% with low compliance could ruin all their efforts should another outbreak occur, by contributing to the transmission and propagation of the disease on their own farms as well as to others.  Hopefully this study will help the horse industry and government identify specific groups (i.e. young people, those not financially dependent on horses) at which educational and motivational campaigns can be targeted in the future.

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Equine protozoal myeloencephalitis (EPM) is a frustrating disease. It's been referred to as one of the most overdiagnosed, underdiagnosed and misdiagnosed equine diseases - an apt description. In some areas, every horse (particularly every racehorse) that has any real or perceived abnormality (such as not running fast enough) gets treated, usually without any attempt to make a true diagnosis. Most of these animals don't have EPM, but some might, along with horses displaying a range of sometimes vague neurological signs. When an effort is made to really establish a diagnosis, unfortunately it's not straightforward, which leads to more confusion about the disease and how to manage it.

The Animal Health Diagnostic Center at Cornell University have released a document on EPM testing and diagnosis. This document discusses when and why to test, along with important information about the available, recommended tests. It's a nice, comprehensive overview of the subject and worth a look for equine veterinarians as well as horse owners wondering whether their horse may have this enigmatic disease.

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After an extensive development and review process, an Equine Biosecurity Risk Calculator (click here) is now available online on the Equine Guelph website. This joint venture of Equine Guelph and Colorado State University, with support from the AAEP Foundation and Vetoquinol, is designed to offer practical advice on equine infectious disease risk and control.

While no one can really give an exact number regarding "risk" of infectious diseases on any particular equine facility, it is possible to identify areas in need of improvement. That's what this "calculator" is designed to do. Horse owners can complete the online questionnaire and get a general assessment of risk, plus detailed information about areas of concern. The calculator is free to use and no identifying information is collected.

Every horse owner should try this and see what areas are identified that could be improved. While facilities are quite variable in their application of infection control practices, I've yet to encounter a "perfect" facility - undoubtedly everyone will get at least a few ideas to consider to help reduce the risk of infectious disease in their animals.

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The recent (or, I guess, not so recent, since it seems to have been lingering in the background for a while) contagious equine metritis (CEM) outbreak in the US was a good demonstration of the potential impact venereally transmitted diseases can have on the horse industry. Concerns about such things are greatest in breeds that only allow live cover, since an individual stallion may be exposed to a large number of mares every year, and with the mobile nature of the horse population, it's possible for one infected horse to disseminate an infection widely across or between countries.

While CEM is probably the highest profile venereal disease in horses, it's not the only one. Other pathogens like equine arteritis virus and equine herpesvirus type-3 (equine coital exanthema virus) are also of concern, along with various opportunistic bacteria.

Proper management and infection control practices can greatly reduce, but not eliminate, the risk of sexually transmitted infections in horses. Unfortunately, such practices aren't always used. Sometimes it's because of lack of consideration or laziness. Sometimes it's because of lack of awareness. To help improve awareness and make it easier for people to take appropriate precautions, the American Association of Equine Practitioners (AAEP) has recently released Biosecurity Guidelines for Control of Venereally Transmitted Diseases. It's an excellent resource for veterinarians and horse owners, and should be part of the infection control program for anyone breeding horses.

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Like human influenza, equine influenza can be a seasonal disease with periods of particularly high activity. It's possible that we are in a period of high flu activity in horses in Ontario, based on cases we've seen and anecdotal information from the general population. We've seen a couple of confirmed cases of influenza over the past week (which is rather unusual), and unconfirmed rumours suggest that there may be many influenza cases in horses in the province, particularly at racetracks. Given the non-reportable nature of influenza, the often tight-lipped nature of horse owners when it comes to disease, and the typical lack of diagnostic testing to confirm flu in horses with flu-like disease, it's hard to say what's really happening.

Regardless, people should be on the lookout for influenza. Horses that develop a fever and/or signs of respiratory disease should be evaluated and isolated unless a non-infectious cause is identified. Facilities with affected horses should implement effective infection control practices to reduce the spread both on the farm and to other farms. People should discuss the risk of influenza exposure in their horses and talk to their veterinarian about whether influenza vaccination is indicated. Veterinarians can also use this situation as a reminder to owners of the ever-present risk of various infectious diseases, and as a lead-in to an assessment of the regular farm infection control plan (and if the farm doesn't have one, get started on it).

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The mosquito-borne diseases eastern equine encephalitis (EEE) and West Nile (WNV) continue to rear their ugly heads in the northeast as we get further into the late summer season during which they are most common.

On August 13 there was an unconfirmed report of a case of West Nile in a horse at Woodbine Racetrack, just north of Toronto.  No additional details have been forthcoming regarding the severity of the infection or the status of the horse, if WNV infection has in fact been diagnosed.  Nonetheless, the Ontario HBPA is urging horse owners to ensure the vaccination status of their animals for West Nile is up-to-date.  Unfortunately, if horses are not already vaccinated at this point, even vaccinating them immediately may still leave them susceptible to virus for the next few weeks until they are able to fully respond to the vaccine.  This news follows close on the heels of news reports regarding increased numbers of WNV-positive mosquito pools in various regions north of Toronto, and thus is not altogether surprising.

The first case of West Nile in a human in New Jersey was recently diagnosed in a man from Mercer County.  Again, no additional details about the severity of the infection or the man's condition are available, but the public is once again being urged to protect themselves against mosquitoes by wearing long sleeves and pants, using insect repellant, and eliminating standing water in which mosquitoes may breed on their property.  Elsewhere the death on August 14 of a four-year-old girl in New York from infection with EEE has been reported.  She is the fifth person in New York state to die from the disease in 40 years.  The girl first began showing signs of infection earlier this month, but the diagnosis of EEE infection was only reached last week.  EEE has a high mortality rate in humans as well as horses.  Just as infection in animals can act as sentinel indicators for disease risk in humans, these human cases indicate that WNV and EEE are active in these respective areas, and humans and horses alike are at risk of infection.  Mosquito avoidance can help protect both, and in addition timely vaccination of horses can help decrease the risk of disease.

This Worms & Germs blog entry was originally posted on equIDblog on 17-Aug-11.

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Earlier this year, there was a large recall of pre-packaged alcohol wipes made by Triad Group because of bacterial contamination and implication of the wipes in a large number of human infections. While alcohol is used as an antiseptic, bacterial spores are inherently resistant to the effects of alcohol and contamination with spore-forming bacteria can turn wipes into disease vectors. In the latest outbreak, alcohol wipes were contaminated with Bacillus cereus and implicated in the deaths of 7 people.

As an extension of the earlier recall, Creative Pet Products and MAI/Genesis (Veterinary Concepts) have recalled first aid kits marketed for use in pets and horses. In addition to the potential for contaminated alcohol wipes there is concern that the "sterile" lubricant jelly may not be so sterile, and could also be contaminated with Bacillus cereus. Additionally there is mention that the iodine pads could be contaminated with another bacterium, Elizabethkingia meningoseptica. (It sounds like they have some pretty major quality control issues. Not surprisingly, production at the plant has been suspended pending an ongoing FDA investigation.)

Anyway, anyone with one of these first aid kits should check to see if their kit is involved in the recall:

Alcohol prep pads – Kits affected:
10140 Horse Aid™ Kit
10145 Sporting Dog Kit
10148 Sporting Dog II Kit
10151 K9 First Aid Police & Military Kit
Brands: Triad or NovaPlus
All Lot Numbers

Iodine prep pads – Kits affected:
10140 Horse Aid™ Kit
10145 Sporting Dog Kit
10148 Sporting Dog II Kit
Brands: Triad or H&P Industries
Lot Numbers starting with 8, 9, 0, 1

The kits were distributed in the United States, Australia, the United Kingdom, Taiwan and Costa Rica.

If you have one of these kits, you should get rid of the affected items. For further details (and presumably how to get a refund) click here.

This Worms & Germs blog entry was originally posted on equIDblog on 09-May-11.

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Yesterday, I wrote an equIDblog post about an outbreak of unexplained neurological disease in horses in the Murray River region of Australia.  Today, a ProMed report indicates that Murray Valley encephalitis is now being considered as a possible cause of death in a man from the area.

Murray Valley encephalitis (MVE) is one of the possible causes of the equine neurological disease outbreak, and it's quite likely that if it caused disease in one species in the region, it did the same to another. This rare mosquito-borne disease hasn't been seen in decades in the region, but it's possible that high mosquito numbers following heavy rainfall and flooding have increased the risk of transmission.

While this virus poses a risk to both humans and horses, humans and horses pose no risk to each other.  Both acquire the disease the same way - from mosquitoes - and neither can pass it on to the other.  This is also true of other insect-borne viruses such as West Nile virus and Eastern Equine Encephalitis (EEE) virus.

This is a good example of why human and animal disease surveillance need to be linked, and why governments need to put resources into testing of animals beyond food animals. Rapidly identifying a disease in horses or other animal species can help determine whether there is any risk to humans, and hopefully lead to preventive measures being taken earlier.

Prevention of this disease is focused predominantly on mosquito avoidance. It's impossible to completely prevent mosquito exposure, but some basic practices can help reduce the risk.  Click here for some practical tips on protecting yourself and your horses from mosquitoes.

Image: Location of the Murray River in Australia (click for source)

This Worms & Germs blog entry was originally posted on equIDblog on 13-Mar-11.

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Glanders, a very serious disease of horses, donkeys and mules caused by infection with the bacterium Burkholderia mallei, has made the news again in a rather unusual manner – it has been reported as the cause of an outbreak in lions and a tiger at an Iranian zoo in Tehran.

The story goes that two Amur tigers arrived at the Tehran zoo from Eastern Russia in April 2010 as part of an exchange program between the two countries. The tigers were supposed to be used to help restore the tiger population in northern Iran on the Miankaleh nature reserve, but their living quarters there were apparently still not ready, and thus they were being kept at the zoo. One of the tigers died in December 2010.

And that’s were the story starts to get a little dicey. The Iranians claim the tigers were imported already carrying the disease, and that the last case of glanders at the zoo was 50 years ago. The tigers had already been at the zoo for eight months - although the incubation period for glanders can be months in some cases, it is normally only weeks. The Russians of course insist that the tigers were completely healthy when they were transferred – they’d been thoroughly examined and quarantined prior to being moved. (This makes the most sense to me, since transporting an animal such a long distance is a major stress and increases the risk of illness, and transporting an animal that is already sick would be even more risky. Not a chance I would take with two members of a species of which there are fewer than 900 individuals left in the world.) They also pointed out that a sick tiger from the cold regions of Russia would be much more likely to succumb to illness during the very hot Iranian summer, not during the winter.

Another report said that three lions at the zoo also died from glanders in the last two months, and subsequently another 14 lions were diagnosed with the disease, all of which were put down by the authorities. The main concern seemed to be the spread of the disease from the big cats to the feral cat population, and then to the human population. This second report states that “the tiger died after being fed contaminated meat, though it is possible it could also be related to the glanders.”  Yet another report said that the tiger was infected with feline immunodeficiency virus (FIV - the feline equivalent of HIV).

Facts to keep in mind:

• Glanders is an highly contagious disease, and highly fatal (B. mallei is even classified as a Class B bioterrorism agent).
• Animals that do recover from the disease can become long-term carriers of B. mallei, and are a risk to other animals (and people). Prompt euthanasia of affected animals is therefore often the primary means of controlling outbreaks (but the bacterium is susceptible to antibiotics).
• The infection can be transmitted to other animals (and people), usually through close direct contact or contact with oral and nasal secretions and discharge from skin ulcers. It can also be transmitted by eating tissues from infected animals.
• The bacterium is killed by most disinfectants, and UV radiation (sunlight).

Glanders can affect species other than equids, including people and cats, however there is very little information available about glanders in any felids, let alone lions and tigers. Theoretically it might be possible for the disease to spread from the zoo animals to feral cats and then to people, but I don’t know how many feral cats are brave (or stupid) enough to wander into a lion enclosure. There’s also a possibility that a glanders-positive feral cat may have infected the zoo cats (but again, it would have to be very brave, or very stupid). It is also unclear what tests were used to confirm that the big cats were infected with glanders, and it is unknown if other animals at the zoo have been tested. Since this is typically a disease of equids (and has also been found in goats and camels), I would certainly be checking these animals first.

The big question is, where did the glanders come from in the first place? It seems unlikely that the tigers brought it from Russia, when the disease is actually endemic in Iran (even though they’d had no diagnosed cases at the zoo for many years). Is there a carrier animal in the zoo? Were the animals infected by eating contaminated meat? Was it brought in by feral cats?  The source needs to be identified and addressed or animals will continue to be infected, which is particularly bad news for the kinds of rare species that may be found in a zoological collection. Some more details about the testing would also be appreciated – given the severity of this disease, and the severity of the consequences for positive animals (euthanasia), one needs to be as sure as possible that these animals are infected with B. mallei and not something else.

Photo: Amur Tiger (Panthera tigris ssp. altaica) (click image for source)

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You never want to be the subject of a medical case report. A 37-year-old British woman was featured in a recent edition of Lancet (Brouwer et al 2010), in a paper entitled "A horse bite to remember."

The woman was admitted to hospital with a fever, headache, neck stiffness, confusion, difficulty speaking and nausea. These signs are suggestive of meningitis and a spinal tap was supportive of that presumptive diagnosis. Blood samples were also taken, and the same bacterium, Streptococcus zooepidemicus, was isolated from both blood and spinal fluid, confirming a diagnosis of S. zooepidemicus meningitis. She was treated and improved, but did not fully recover.

Streptococcus zooepidemicus is primarily associated with horses, although it can occasionally be found in other species such as dogs. After the diagnosis, the woman's family was questioned about her hobbies and it was revealed that she was an avid horsewoman. Further, she had been bitten by her horse the previous week. That was the presumed source of infection, but it doesn't appear that any further investigation was undertaken.

Associating the meningitis with the bite is reasonable, but it's not definitive. Streptococcus zooepidemicus infections in people have occurred in the absence of bites or other clear sources of exposure to horses, so the bite wasn't necessarily the problem. Regardless, it indicates the need to be proactive and properly treat any horse-associated wound, be it a bite or any another wound that gets contaminated with bacteria from the horse or its environment.

This was a very unusual case. People shouldn't be overly concerned about getting S. zooepidemicus meningitis from their horse. However, it should serve as a reminder that bad things can happen periodically and that proper attention to general hygiene practices and bite wound care is always important.

On a side-note, I thought the title "A horse bite to remember" was a bit crass, since the woman is now unable to live independently because of severe amnesia (memory problems) as a result of the infection. Maybe they were trying to be ironic, but it seems below a journal such as Lancet.

This Worms & Germs blog entry was originally posted on equIDblog on 10-Oct-10.

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TheHorse.com's latest reader poll asked the question "If you knew rabies had been found in wildlife in your area, would you vaccinate your horse for it?"

• 79% of respondents said they already vaccinate against rabies annually.
• 16.5% said they don't currently vaccinate but would if it was found in wildlife in the area.
• 4% still wouldn't vaccinate.

The high vaccination rate is very encouraging and is a good sign, considering that rabies, while rare, is 100% fatal in horses and is preventable with early vaccination.

Here are some reader comments (with some additional commentary from me):

Develop a strong immune system instead try to avoid all the drugs

• Keeping your horse healthy is a good disease prevention measure, but it is not good enough for prevention of rabies. This is a foolish approach to rabies prevention.

Used to yrly. vaccinate in MI, but vets here in KY don't recommend it/My Vet keeps telling me it is not necessary, same with my daughter horses. I disagree.

• This, and a few other comments about veterinarians not recommending vaccination is very surprising and concerning. Rabies vaccination is considered a "core" vaccine in North America and it makes no sense for veterinarians to be actively discouraging vaccination.

Too many adverse reactions...bad outbreak, might reconsider/There have been too many adverse reactions to the vaccine, I won't take the risk of vaccinating.

• Adverse reactions can occur with any vaccine, but they are quite rare with rabies vaccine. Sometimes, horses react when they are given a variety of vaccines at the same time, and it might not be rabies vaccine with that caused the problem. Often, the risk of adverse reactions is just used as an excuse not to vaccinate, even if the horse has never had a problem. 

Vaccination is necessary when horses are turned out nearly 24/7

• Yes. It's also necessary when horses are inside 24/7. Wildlife (especially bats) easily and often get into barns.

I don't vaccinate yearly because I test titers and they remain high for many years.

• Titre testing is not useful because we don't know what a protective titre is. You can take a titre and get a result, but that doesn't mean the horse is protected. Also, if your horse is exposed, it would be considered unvaccinated by government officials if it had not been recently vaccinated, regardless of titres.
  

I would be especially diligent to vaccinate if aware of a wildlife outbreak of rabies/I have only vaccinated when there have been cases of rabies, otherwise, I don't.

• I have a couple of problems with this type of approach. Firstly, you only recognize an outbreak AFTER a large number of animals get sick. Waiting until someone reports an outbreak doesn't help you if your horses are among the first ones affected. Also, rabies isn't a disease that mainly occurs in outbreaks. It is a sporadic disease, where single cases or small numbers of cases pop up all the time. Only worrying about it during an outbreak doesn't help.

I would vaccinate my dogs and cats, but not my horse.

• Why? If there is a risk of the dogs and cats being exposed, there's a risk of the horse being exposed. (Maybe they like their dogs and cats more!)

I can't buy rabies vaccine only vets can get it so I don't give rabies shots.

• So, if I can't do it myself (translation, if I can't do it very cheaply), I won't do it. Not a good infection control program.

NEED ANOTHER CHOICE! I run titers. Vac. is indicated every 3-5 years

• Nope. Vaccination is safe and effective. Standard recommendations are for yearly vaccination. Could we extend that, as is now done with dogs and cats (in which 3 year vaccines are now widely used)? Probably, but we don't have the data to guide us. We can make some reasonable guesses, but do you really want to use a vaccination program designed to protect against a fatal disease to be based on guesses?

The chances of my horses being bit by a rabid critter are slim to none. I don't believe in vaccines

• I don't think anyone can say that the chance of their horse encountering a rabid critter is slim to none. People encounter rabid critters inside their houses, while walking down the street and in various other situations. I certainly didn't plan on catching a rabid bat in my house, but it happened.
• Not believing in vaccines is just ignorance. Vaccination is critical for protection against a wide range of diseases. Can adverse reactions occur? Sure, but they are very uncommon (internet rumour mills aren't facts). Do vaccines prevent infections and save lives? Undoubtedly. What happened when people started avoiding MMR vaccines in kids because of now-discredited autism concerns? Lots of people got sick.

Live in UK, no rabies here generally

• Good reason. Rabies vaccination isn't needed in rabies-free countries.

Fortunately, there were also a lot of logical comments like:

• I never go without this vaccination. it's way to risky!!!
• With all the wildlife around, it's not worth risking an unintended encounter causing big problems.
• Why would you take a chance and not vaccinate...
• Ever since my uncle's horse died of rabies, I have vaccinated all my horses annually.
• Are you kidding? Who'd take a chance with rabies?

And as one person so eloquently put it "DUH!"

Apart from the extremely small small number of horses with known and potentially severe reactions to rabies vaccine (not just any vaccine, specifically rabies vaccine), and those living in rabies-free countries, all horses should be vaccinated.

Image: A Little Brown Bat (Myotis lucifugus) roosting under the eaves of a house (click image for source)

This Worms & Germs blog entry was originally posted on equIDblog on 15-Sep-10.

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Streptococcus zooepidemicus is an important cause of infections in horses. This bacterium can also be found in healthy horses. When you consider the large number of horses that are infected and the larger number of healthy horses that are carriers, along with the close contact that people have with horses, it's pretty obvious that people are regularly exposed to "Strep zoo". This bacterium is not well-adapted to survive in people and cause infections, so human infections are quite uncommon, but they can occur. There are periodic reports of S. zooepidemicus infections in people, with varying degrees of association with horse-contact.

An upcoming edition of journal Epidemiology and Infection contains a report of S. zooepidemicus meningitis in a 51-year-old woman (Minces et al, 2010). This person had a mild upper respiratory tract infection, then developed signs of meningitis (including fever, unresponsiveness, respiratory distress). A spinal tap was performed and S. zooepidemicus was isolated. The woman fortunately responded to treatment and recovered.

Upon initial questioning of the patient's mother, no animal contact or ingestion of unpasteurized dairy products (another risk factor) was reported. However, it was later revealed that the woman's daughter had started horseback riding at a friend's farm approximately one month earlier. The type of contact that the woman had with horses (if any) at the farm was not reported, nor was there any investigation of S. zooepidemicus shedding by horses on the farm.

Based on the fact that this is typically an equine-associated bacterium and the history of contact (albeit potentially limited or indirect) with horses, horse contact was blamed for the infection. It's a reasonable conclusion but it's far from certain because of the nature of the contact, the lack of any proof of the same strain of S. zooepidemicus in horses on the farm, and previous reports of infections occurring in people with no contact with horses.

Exposure to S. zooepidemicus is an inherent risk of having contact with horses. It's nothing to lose sleep over and is probably relatively low on the list of potential health problems associated with horse contact. The risk is probably greatest in people with compromised immune systems and other general risk factors for disease such as advancing age and pregnancy. Good general hygiene measures, avoiding contact with sick horses and close attention to hand hygiene probably minimize these already low risks.

(click image for source)

This Worms & Germs blog entry was originally posted on equIDblog on 25-May-10.

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A recently reported outbreak affecting horses in Bahrain has been diagnosed as glanders, a very serious bacterial infection caused by the highly contagious bacterium Burkholderia mallei. So far, it has been reported that 8 horses were euthanized over the past 3 weeks because of the infection.

Bahrain's cabinet has allocated BD150 000 to fight the outbreak. Authorities have apparently stated that the outbreak can be "easily" managed, "We have sent samples from nearly 400 horses to a specialist laboratory in the UAE and the 10 results we have got so far give us the all-clear. We now know we can manage this quite easily and are taking appropriate action."

That's a pretty dangerous sentiment to be expressing (and believing) early in an outbreak, but hopefully it's true. "Easily" and "outbreak" aren't often uttered in the same sentence, and it's far from unusual to be fooled by an allegedly contained or controlled outbreak. I'd be very surprised if all of the positive horses have already been identified. Control of glanders involves widespread testing of horses, typically with euthanasia of any infected animals. It sounds like testing is underway and results of this will give a good indication of the extent of the problem. Ten negative samples don't mean that much to me. As more results come in (and if they continue to be negative), more confidence can be had in the assessment that this outbreak is truly contained.

Glanders is not solely a concern for horses. It's a zoonotic disease that can cause rare but serious infection in humans, with a high mortality rate (almost 100% if proper treatment is not administered). People can become infected by direct contact with infected horses, with the bacterium gaining entry through skin abrasions, inhalation or contact with tissues of the mouth and nose. Pneumonia, bloodstream infections and other problems can develop. Burkholderia mallei is a Class B bioterrorism agent. Hopefully, people working around infected horses are using appropriate infection control precautions to reduce the risk of infection.

Hopefully, more information will be available soon about this outbreak and results of ongoing testing.

Image: A horse with glanders (Burkholderia mallei infection), exhibiting the characteristic infectious nasal discharge.  Glanders is a reportable disease which has been eradicated from North America, Australia and most of Europe.

This Worms & Germs blog entry was originally posted on equIDblog on 26-Apr-10.

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The latest edition of the journal Emerging Infectious Diseases contains a paper describing the 2008  Australian Hendra virus outbreak in horses and people.

In this outbreak, there were five horses infected and two humans infected. The horses predominantly had signs of neurological disease, not respiratory disease like some other reports describing this disease. Four horses died. One recovered but was euthanized for public health reasons.

Two people became infected after working with the sick horses, which represents 10% of the total veterinary staff that were exposed to the infected horses.  Both people started off with influenza-like illness, which seemed to improve initially, but then signs of severe neurological disease developed. They were treated with ribavirin, an antiviral drug, as part of an experimental treatment. One of them died after 40 days of illness, the other person survived.

The authors stressed that the effectiveness of ribavirin could not be determined, but they recommend it nonetheless because of the severity of Hendra virus infection and lack of other options. Ribavirin was also used in the 2009 outbreak, but it is clearly not 100% effective since one person died there also.

A number of concerning activities occurred that put people at risk of infection, including a "percutaneous blood exposure while euthanizing an infected horses" (they didn't explain exactly what this was, but it could have been a needlestick), low use of personal protective equipment, and contact with potentially infectious body fluids. This is unfortunately not surprising since the approach to infection control (particularly in terms of zoonotic infections) is often lax in equine medicine. That certainly has to change, particularly in areas where Hendra virus may be present.

Much more information about how to control this potentially devastating virus is needed. Fortunately, infections are uncommon and it is restricted to a fairly small geographic range in Queensland, Australia.

Image source: http://animalphotos.info/

This Worms & Germs blog entry was originally posted on equIDblog on 27-Jan-10.

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I received newsletter today from Intervet (a pharmaceutical company) that is targeted at equine veterinarians. One article discussed rabies in horses. It wasn't bad overall, but I thought the section on what to do when a horse might have been exposed to rabies was worth discussing.

The article asks, "If your client suspects that a horse has been bitten by a rabies-infected animal, what should be done?"

Answer: "Contacting you as the veterinarian is always the first step."

Great first step.  A second step that wasn't mentioned should be, "Try to identify and (safely) capture the animal that bit the horse." This is often impossible but certainly worthwhile if it can be done.  However, if you're trying to catch the offending animal, make sure you don't put yourself at risk of exposure to rabies in the process.  If the animal can be caught, it's rabies status at the time of the bite can be determined (either through testing or quarantine). If it can be shown that the animal wasn't rabid, a lot of stress, hassle and expense can be saved.

"If the horse was previously vaccinated... Then isolate and observe the animal for 45 to 90 days (your clinical evaluation will involve gait analysis, radiography and a spinal tap)."

Boosting the rabies vaccine is also a good idea. The next step, however, needs to be contacting local regulatory officials to find out what you have to do. They determine if, how and how long an animal needs to be quarantined - this is NOT the decision of the local veterinarian nor the animal's owner. Most likely, they will recommend a 45 day quarantine for a vaccinated horse, since this is what is recommended in the NASPHV Compendium on Rabies. The discussion of diagnostic testing makes no sense. There is absolutely no indication to perform diagnostic tests on a horse that has been bitten by a rabies suspect. None. There are no tests that can be used to diagnose rabies in live horses (also exposed horses don't instantly develop signs of rabies). Horses should be monitored closely for signs of rabies during the quarantine period, but that's it.

"...and have the client make a list of all people who had contact with the horse."

This is often done when horses have or are suspected of having rabies, but not horses that are potentially exposed. It is done to help public health personnel contact people that may have been exposed to rabies. A horse that was just bitten by an animal is not a risk for transmission of rabies.  (However, keeping a list of people who have contact with the horse after it's been bitten (i.e. durng the quarantine period) - which should be as short a list as possible - is a reasonable precaution in the unlikely event that the horse does develop rabies.)

"If the animal was not vaccinated, your options are to euthanize and perform a postmortem examination of the brain (the only way to definitely confirm rabies)..."

Euthanasia is one of the options that needs to be considered in an unvaccinated horse that has been exposed, which is one of the reasons that identifying the biting animal and testing it is critical, if it can be done. The last part of the above sentence (from the atricle) is complete nonsense. Why would you test the brain of a normal horse that has been euthanized because it's just been bitten by a potentially rabid animal? The horse isn't being euthanized because it has rabies, it's being euthanized because of the likelihood  of it developing rabies weeks to months later. Testing of the brain will tell you absolutely nothing if the animal was only bitten recently.

"...or isolate and observe the horse for six months and develop the human contact list."

Again, this needs to be decided based on discussions with regulatory personnel who are responsible for dictating what is to be done. A six-month quarantine is a pretty standard recommendation for an unvaccinated animal. Creating a human contact list should not be necessary, since quarantine involves severely restricting contact of people with the horse and only a few (ideally one) person would have any type of contact.

The article wraps up with the very true emphasis on vaccinating horses. It's a cheap measure to prevent a relatively rare but invariably fatal disease.

Click image for source.

This Worms & Germs blog entry was originally posted on equIDblog on 05-Jan-10.

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Streptococcus equi subspecies zooepidemicus (usually just called Strep zooepidemicus) is a common cause of infection in horses. It is an "opportunist" that is often found in healthy horses, but which can cause disease in certain situations. While horses are the natural host of this bacterium, sporadic infections and outbreaks are occasionally reported in dogs at cats, particularly in shelters or other crowded situations. Severe (including fatal) pneumonia can occur, as was reported in a recent outbreak in a humane society in Ottawa. Rarely, S. zooepidemicus can also cause infections in people.

A report in the Journal of Medical Microbiology (Abbott et al) describes a serious S. zooepidemicus infection in a person, that was traced back to a dog. The dog lived on a farm that also had horses. It developed pneumonia and S. zooepidemicus was isolated from its respiratory tract. The dog was treated and recovered. However, the dog owner also became ill with fever, headache, a stiff neck and general malaise. Penicillin was prescribed, but the person's condition did not improve and he/she ended up in the hospital. Streptococcus zooepidemicus was also isolated from this person's nose and throat.  When the dog and human strains were compared using molecular tests, they were related. An investigation of the farm was performed, and while all the horses present at the time were negative for S. zooepidemicus, the bacterium was isolated from a healthy dog.

This is a rare situation and one that shouldn't result in too much concern. It does highlight a couple points that are good to remember:

• Getting cultures is very important for obtaining a diagnosis.
• Animal contact and pet health should be considered whenever someone is sick with a potential infectious disease. Physicians need to know whether their patients have contact with animals. They need to be told if a sick animal is present so they can consider whether the pet and human illness might be related. Knowing to what someone may have been exposed might speed up diagnosis and appropriate treatment.
• Rare things are rare, but they happen. We shouldn't focus on rare events but we have to keep our minds open and recognize that strange things happen with infectious diseases.

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At the ongoing ASM-ESCMID conference on methicillin resistant staphylococci in animals, Dr. Engeline van Duijkeren of Utrecht University (The Netherlands) presented a study on an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in their equine hospital.

From 2006-2008, several horses that underwent surgery at their hospital developed MRSA infections.  MRSA was also isolated from some healthy horses and personnel at the clinic. Early in the process, the hospital was closed for a thorough disinfection and the outbreak stopped, however another outbreak occurred later.  Further study again found people in the clinic that were MRSA carriers. Close to 15% of people in the hospital who handled equine patients were MRSA carriers, which is really astounding when you consider that less than 0.1% of the general population in the Netherlands carries MRSA. When they started testing horses coming into the clinic, they found that 9.3% of horses were carriers when they arrived. Weekly sampling of all hospitalized horses over a five-week period determined that 43% of all horses in the hospital carried MRSA at one point or another during their stay. Additionally, 53% of environmental surface samples were positive for MRSA, which is really not surprising if that many people and horses are carriers.

If horses keep coming into a facility carrying MRSA and people keep getting colonized, MRSA is hard to control. These experiences led the equine hospital at Utrecht to implement more stringent infection control practices to try to contain the problem, but the high MRSA rate in their referral population is going to pose a continual risk.

MRSA outbreaks in horses aren’t new. They’ve been reported by a few hospitals (including ours) and occur in many, many, (many!) more without ever being published. Since MRSA is present in the horse population, equine hospitals are at continual risk of MRSA outbreaks. If a large percentage of horses in the general population are carriers, the risk of outbreaks is higher.

MRSA is clearly a problem in horses in many areas. It’s important to realize that it’s a problem in the general population, not just horses in hospitals. Equine hospitals can amplify the spread of MRSA, but ultimately a lot (if not most) MRSA-positive horses originate from farms, not clinics or hospitals. Equine hospitals need solid infection control programs to reduce  the risk of outbreaks, but the risk will never be completely eliminated. Farms need good infection control programs to reduce the risk of spread of MRSA between horses and between farms, as well as from horses to people (and back). Antibiotics need to be used prudently since antibiotic use is a risk factor for MRSA carriage and infection.

More information about MRSA in horses can be found on the equIDblog Resources page.

This Worms & Germs blog entry was originally posted on equIDblog on 26-Sep-09.

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As a vet, I've been bitten by a wide range of animal species. When people talk about animal bites, they usually think about dogs and cats. Horses can (and do) bite as well. Most horse bites are probably playful nips that hurt a little yet don't cause major problems, but some bites can cause serious injuries and infections can result.

A recent paper in the Journal of Agromedicine (Langley and Morris 2009), with the rather unwieldy title of "That Horse Bit Me: Zoonotic Infections of Equines to Consider after Exposure Through the Bite or the Oral/Nasal Secretions". Bites apparently account for 3-4.5% of the approximately 100 000 annual emergency room visits in the US that are associated with horses. The authors of the paper review infections associated with bites and contact with organisms in the mouth and nose of horses.

A large number of bacteria have been associated with horse bite infections in people, including Actinobacillus, Streptococcus, Psuedomonas and Staphylococcus species. Some viruses can theoretically be transmitted by bites, but there's little evidence that this actually happens.

Although viruses are not of as much of a concern overall, rabies needs to be considered in every bite from a mammal. We pay a lot of attention to rabies with dogs, cats and wildlife, but it often gets ignored with horses. While I'm not aware of any reports of rabies transmission from horses to humans by a bite, it could happen.  Fortunately, rabies is rare in horses so the likelihood of exposure from this species is very low. However signs of rabies aren't always obvious initially, and rabies in horses may mimic other diseases. Sometimes, rabies looks like colic, and human exposure through bites or other contact is possible when handling, evaluating and treating affected horses.

Unlike with dogs and cats, there are no clearly defined protocols for dealing with bites from horses. Any dog or cat that bites a person is supposed to be quarantined for 10 days. The reason for this is if the animal is rabid and the disease is advanced enough for the animal to be capable of spreading rabies virus, it would invariably develop signs of rabies and die within this time period. We don't have similar guidelines for horses. I suspect the 10 day observation period would be adequate but we don't have good data. The paper states that in Kentucky, a 14 day observation period has been used by the state Department of Public Health.

At the conclusion of the paper, the authors make a few important general recommendations for reducing the risk of disease transmission from bites and oral or nasal secretions of horses:

• Use good general hygiene, especially hand hygiene, after any contact with horses.
• Use gloves and gown or lab coat when examining horses in a veterinary clinic or hospital. (This might be overkill for all horses. We don't require gloves for every horse contact, just contact with mucous membranes (e.g. mouth, nose), wounds, incision sites and other high-risk areas. I think bare hands are fine for general contact as long as there is good attention to handwashing after.)
• Consider mask and goggles if the horse is coughing or sneezing.
• Develop standard operating procedures for handling sick horses.
• Use isolation when needed.

I'd add a few more points:

• Avoid bites. Pay attention to what you are doing around horses to reduce the risk of being bitten. Do not encourage playful behaviours (e.g. nipping) that could lead to bites.
• If you are bitten and it breaks the skin, clean the site thoroughly with soap and water. If there is significant trauma, or if the bite is over a joint, hand, foot, or a prosthetic device, you should see a doctor immediately because antibiotics are most likely indicated. If you have a weakened immune system, you should be evaluated by a doctor after any bite.
• Avoid contact with the horse's mouth or nose if you have skin lesions. Cuts and scrapes can allow bacteria to enter your body and cause infections. If you have a cut on your hand, make sure it is covered with a glove or waterproof dressing if you are going to have contact with the horse's mouth or something that came from its mouth (e.g. a bit).

This Worms & Germs blog entry was originally posted on equIDblog on 02-Sep-09.

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I received the following question the other day: "I have a friend who had chemo embolization on tumor on liver in late June. She is in hospital now, and an abscess was discovered on liver.  Pathology results said "equine strep".  Her brother visited immediately after procedure, and he works with horse full time."

Streptococcus is a group of bacteria that includes many different species. There are two main species in horses Streptococcus equi subsp. equi (aka S. equi, the cause of strangles) and Streptococcus equi subsp. zooepidemicus (aka S. zooepidemicus, a cause of various types of infections). As you can guess by the 'equi' name, their natural host is the horse. Strep infections are very common in people, but rarely involve these two species. Nonetheless, infections with either Streptococcus equi or S. zooepidemicus can be found in people, but S. zooepidemicus is most common. Usually, these infections develop in people who are already sick for another reason, have compromised immune systems, or in young children. Interestingly, not everyone that is infected reports direct or even indirect contact with horses.

Back to the question: it's hard to say what's going on here based on the the general term "equine strep", but presumably the person has an infection with S. equi or S. zooepidemicus. Whether horses are actually involved will be tough (or impossible) to determine. It's a tempting hypothesis that the patient's brother carried the bacterium from the farm to the hospital, but I'd be wary about making a definitive statement about the bacterium's origin solely based on that. There are ways to investigate this further, such as trying to isolate Streptococcus species from horses on the farm, typing them and comparing them to the strain that caused disease in the person, but this type of testing is very costly and almost never performed, as human infection with these species is so uncommon.

This should be a good reminder that people who are sick and in hospital are at higher risk for developing infections, and they can get infections from bacteria that rarely cause disease in healthy individuals. While there is no proof of a link to horses (at least in this case), good infection control practices should be used whenever anyone visits someone in the hospital. That would include not wearing barn clothes to the hospital and paying close attention to handwashing.

This Worms & Germs blog entry was originally posted on equIDblog on 26-Aug-09.

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A horse in Harford county Maryland has been euthanized because of rabies. The horse first starting showing signs of disease in mid-July, which manifested as "striking changes in behaviour." The report doesn't say when the horse died, but animals typically die within a few days of the onset of neurological disease. The horse was transferred to the New Bolton Center where rabies was diagnosed. Subsequent testing showed it was a raccoon rabies strain, although that does not mean that a raccoon was the actual source of infection.

Public health officials implemented a 45 day quarantine of the farm. Stray cats (about 25) were caught and euthanized. Fortunately, the family pets were properly vaccinated and have received booster shots (plus presumably a period of observation at home... a much better situation than if they were not vaccinated).

People that had contact with the horse have received rabies post-exposure treatment. This includes one person who had to be tracked down overseas.

Harford County Health Department spokesperson Bill Wiseman said "There was never a risk to public safety. This incident was a great example of public health work in action and cooperation between local, state and in this case, international authorities." I don't buy the statement that there was no risk to public health. While the risk of rabies transmission from infected horses is very low, it's not zero. Rabid horses have killed people because of their abnormal and sometimes aggressive behaviour. Further, the fact that this horse had rabies means that it got it from something. Rabies can have a long incubation period so it's not guaranteed that it acquired it on the farm, but you have to be prudent and assume that there is infected wildlife in the area that could pose a risk for other animals or people. Public health authorities managed the situation well and reduced the public health risks, but there were certainly still risks.

Rabies vaccination is highly effective. There is no statement about whether this horse was adequately vaccinated but it's unlikely. Proper vaccination would likely have prevented this horse's death, as well as the death of the stray animals, cost of vaccination of people, cost of veterinary care for this horse, quarantine of the farm and the associated financial and emotional costs. A dose of vaccine that costs a few dollars could have saved thousands of dollars and emotional stress.

Rabies is a rare disease in horses but its severity means it should not be ingored. Vaccinate your horses.

This Worms & Germs blog entry was originally posted on equIDblog on 14-Aug-09.

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Hendra virus, a virus that can kill horses and people, has resurfaced in Queensland, Australia. This bat-borne disease has caused periodic fatalities in horses and people that work with horses. The latest outbreak is thought to have killed up to three horses and resulted in the potential exposure of at least 30 people. The likelihood of these people getting sick depends on how close their contact was with the sick horses. Close contact with secretions from infected horses seems to be required to transmit disease. One person reported being snorted on by an infected, dying horse and being "covered" in blood, which is certainly concerning. An outbreak last year killed a veterinarian and hospitalized a veterinary nurse.

The farm in question is under quarantine and people that have been exposed are being monitored. There is no treatment for potentially exposed individuals, so they are in the unenviable position of having to wait and see if they get sick.

A virus like this is very hard to control. It's lives in fruit bats and only occasionally crosses into horses. The sporadic nature of disease makes it hard to control and predict when cases will occur. The key is early identification so that there is minimal exposure to other horses and people. People also need to take routine infection control precautions. One veterinarian handled an infected horse without using gloves or a face mask, as recommended, because he had left them in the car. Exposure to a potentially fatal infectious disease is not worth the few minutes of time saved by not following recommended precautions.

This Worms & Germs blog entry was originally posted on equIDblog on 10-Aug-09.

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Rhodococcus equi is a very well recognized pathogen in horses – it is a common cause of pneumonia in foals between the ages of 1-6 months, and infection is also sometimes associated with other problems such as diarrhea, swollen joints and abscesses in other parts of the body. The infection can be very difficult to treat because the bacteria are able to live inside white blood cells, which helps protect them from the body’s immune system, and because they often cause abscesses to form, which are difficult for antibiotics to penetrate. Rhodococcus equi infection in foals has been studied extensively, but there’s still a lot we don’t know how the body defends itself against this organism.  These are a few things we do know:

• Almost all foals are exposed to R. equi as neonates, but most of them never develop signs of infection.
• Giving newborn foals hyperimmune plasma (plasma with extra antibodies against R. equi) may have some beneficial effects on farms where the infection is a recurrent problem, but this practice is still controversial.
• Adult horses are essentially immune to the infection.
• In almost all cases if clinical disease in foals, the R. equi strain involved carries a special gene called vapA.
• Mortality rates in foals vary considerably from 0% to 30%.
• So far, efforts to develop a vaccine to help protect foals have been unsuccessful, but research in this area is ongoing.

People can also be infected with R. equi, and as in foals, pyogranulomatous pneumonia (infection of the lungs which results in the formation of many abscesses) is one of the most common conditions caused by this organism. However, there are a few important differences between infection in people and infection in horses:

• 85% to 90% of people with R. equi infection are immunocompromised, meaning their immune system is weakened or suppressed for some reason, e.g. HIV infection, or immunosuppressive drugs taken by organ transplant or cancer patients.
• Among people infected with R. equi who have normal immune systems (i.e. immunocompetent), about half of the infections are localized, meaning they only affect one small part of the body. Many of these are associated with wound infections.
• Only 20% to 25% of the R. equi isolates in people carry the vapA gene.
• Infection in immunocompetent people can be fatal in approximately 11% of cases, but among HIV-infected patients the mortality rate from R. equi infection can be as high as 50% to 55%.

Rhodococcus equi is actually a soil organism, and this is likely the most common source of the organism for both horses and people. Only approximately 1/3 of humans infected with R. equi report that they have had contact with horses or pigs (pigs can also carry the bacterium). So we don't know how much of a risk an infected foal is to a person.  However, it is prudent for people, particularly those with weakened immune systems, to take precautions to avoid potential transmission of R. equi from horses.

• Try to reduce dust levels on the farm. Because R. equi most often lives in the soil, it can get stirred up into the air in dusty areas, which can then lead to inhalation by animals and people. Doing things like planting grass or other vegetation, installing windbreaks in high-traffic areas, or wetting down dusty stalls or paddocks can help reduce dust levels in the air.
• Keep open wounds and other broken skin covered when working around animals.
• Always wash your hands after handling a foal (or any horse)
• If you have a foal that develops signs of R. equi infection, make sure you have your veterinarian examine it as soon as possible so the diagnosis can be determined and the foal can be treated properly as soon as possible. Some foals with R. equi may develop severe pneumonia very quickly, so it’s important that they are examined right away.

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I was at the annual conference of the Society for Healthcare Epidemiology of America on the weekend. This is a hospital infection control organization, and one of the talks I gave was about animals in healthcare facilities. One question that came up was about unusual service animal species like monkeys. Service animals are specially trained animals that help disabled individuals with specific tasks. The most common examples are seeing-eye dogs. In the US, the American Disabilities Act protects service animals and dictates that they must be allowed to go wherever the person goes. I don't think people have a problem with that in general. However, there are concerns with respect to non-traditional species being used in these roles, and the question at the meeting was about service monkeys. Monkeys can be incredibly strong physically, and they can carry some important infectious zoonotic diseases, so there are concerns about them being allowed in hospitals. Part of the issue is what really makes an animal a service animal.  Should all animals that help someone out (in any capacity) be considered service animals?

That same topic came up in a recent ABC News article that described a seeing-eye horse in Texas, including a video of the owner riding the horse while grocery shopping. 

I have no doubt that this horse helps out its owner and provides great joy, if not increased freedom. However, I'm not convinced that a horse is necessary to fulfill this person's need for a service animal. Why use a horse when a dog could do as good (or a better) job? How was the horse trained? Was it trained under a formal program so that it is truly helpful? What types of health and behaviour screening have been used? What are the additional risks associated with using such a large farm-animal species?

Horses, even based solely on their size, can easily cause injury to members of the public without meaning to, simply by stepping on a person's foot or bumping into them, for example.  Some people might be scared of horses, especially indoors. Horses aren't litter trained, and horse manure can carry potentially infectious agents. I have a big problem with the video of this horse in a grocery store.  At end of the day, is a horse really necessary for what this person needs, and has the horse been adequately evaluated to ensure that it is low risk to the public? I don't think the answer is yes to either question, let alone both.

We certainly must do all that we can to allow full access of appropriate service animals, but we also need ensure that novelty "service" animals don't cloud the picture and potentially have a negative impact on true service animals.  The article states "...the government has begun rethinking whether the regulations should be changed to exclude some animals." That sounds like a great idea to me. Careful review of this issue, including the benefits to people, risks to the public and the need for new species over traditional options all need to be considered. 

Image: captured from video at http://www.abcnews.go.com/GMA/story?id=7157206

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An important step in diagnosing infectious diseases and determining the optimum approach to treatment and management is rapid and accurate diagnostic testing. Many different testing methods are used, particularly bacterial culture (at least for bacterial diseases). Molecular testing has revolutionized the field of microbiology, and is making inroads into the field of diagnostic testing. Polymerase chain reaction (PCR) testing is a very powerful tool that can be used to detect DNA or RNA from specific microorganisms.  This technique can be very useful, but it can also be easily misused or misinterpreted.

The potential PROS of molecular diagnostic testing include:

• Rapid turnaround time: Testing can take as little as a few hours versus a few days for other tests like bacterial culture.
• Sensitivity: Organisms that are difficult or impossible to grow in a lab can be detected, and they can often be detected at lower levels than with other diagnostic methods.

The potential CONS of molecular diagnostic testing include:

• Sample contamination: This is a common concern with highly sensitive molecular tests - even a minute amount of contamination in the sample can cause a false positive result.
• Test inhibition: Samples from complex biological sites (e.g. stool) can contain substances that interfere with the many complex molecular reactions upon which the tests rely. Without good (and proven) methods to prepare the sample, this can result in a false negative result.
• Biologically irrelevant results: Some bacteria that cause disease are also commonly found as part of the normal microflora in healthy animals - simply finding it does not tell you that it is necessarily relevant to the problem. For example, Clostridium difficile can be found in the intestine of approximately 10% of healthy dogs and cats (or more, in some situations), but the diagnosis of C. difficile diarrhea requires detection of the bacterial toxins in stool samples, not just the bacterium itself.  A molecular test that simply identifies the presence of C. difficile, even if it identifies strains that possess the genes to produce toxins, tells you nothing about whether the bacterium was actually producing toxins in the animal.
• Lack of validation: This is a common problem with many (if not most) molecular tests. Some companies, especially those that just run molecular tests, offer a huge array of completely unvalidated and sometimes illogical tests.  It is also important to remember that tests must be validated for each species in which they are used - a test that works well in people will not necessarily work on a sample from a horse or a dog.

Molecular testing can be useful in some situations. If you are unsure, here are some things to ask the lab:

• Do they have a validated test that provides relevant results?  If they don't have good data (ideally published data) that their test is useful, accurate and reproducible, I'd avoid it.
• Do they have a quality control program, which includes running positive and negative control samples with each test batch?

Finally, as with any test that we use in veterinary (or human) medicine, it's important to evaluate all  results in the context of what is happening with the animal - treat the patient, not the test result.

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I spent some time the other night looking at different internet pet pharmacy sites. (Yes, I know that sounds strange, but it was interesting and sometimes appalling.) It's well known that you can buy virtually anything over the internet. Pharmaceuticals are no different. There are numerous online pharmacies that offer drugs for animals. Some are presumably highly reputable companies that do what they are supposed to do: dispense drugs only with a valid prescription from a veterinarian, dispense only drugs that they can sell legally, and ensure that everything they sell is of appropriate quality.

However, it's clear that not all pet pharmacies are equal. Most state that a prescription is required, yet it is unclear how many actually follow this requirement. Some will have their own veterinarian write the prescription (which is illegal because the vet would not have a valid relationship with you and your pet, and would not have examined your pet). Some sites offer products that members of the general public cannot legally obtain or possess in most areas, like rabies vaccine. Virtually all the sites offered a wide range of antibiotics. Few had information about the origin of the products or shipping issues to other countries.  Import regulations are very important because, for example, an individual cannot legally import vaccines into Canada.

Certain things raised some big red flags on some sites:

• No indication of where the pharmacy is geographically. (I'm sure this is because if they don't say they are from a particular country, then it is less likely that the regulatory authorities in that country will look at them.)
• No information about shipping issues.
• No clear statement about how they verify valid veterinary prescriptions.
• Offering a very wide range of drugs, including things like rabies vaccine and narcotics which are not legally obtainable by the public.
• No contact information.

An article from the FDA also has some good points to consider.

Online pharmacies are very much a "buyer beware" situation. The last thing you want is to buy important drugs like antibiotics online and not be certain that you are actually getting the real thing. Counterfeit drugs have been obtained from some of these websites.  If you're treating your pet with an ineffective "fake" antibiotic, your pet's infection will only get worse, and your pet may develop more severe complications.

If you are going to use an internet pharmacy, do some research first, and talk to your veterinarian (you'll need a prescription from him/her anyway).

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We're happy to announce the launch of a sister site to the Worms & Germs blog. This site, equIDblog (available at www.equIDblog.com), is a resource on equine infectious diseases, and has many similarities to this site, with regular blog posts and a collection of information materials pertaining to equine infectious diseases as well as infection control on horse farms and equine hospitals. If you like horses, stop by!

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A recent report in the Journal of the American Veterinary Medical Association by Jesse Blanton and colleagues provided a detailed report of rabies infection in the US in 2007. Here are some of the more interesting points:

• Rabies was diagnosed in 7 258 animals and 1 person. That's a 4.6% increase in animals from 2006, but 2 fewer human cases.
• 93% of cases were wildlife: 37% raccoons, 27% bats, 20% skunks, 7% foxes.
• 0.8% of cases were in cattle and 0.6% were in horses.
• 4% of cases were cats, with the largest numbers of feline cases in Virginia, Florida, Pennsylvania, North Carolina, Maryland, New Jersey, New York, Georgia, Texas and Kansas.  Cat cases peaked in June and July.
• 1.3% of cases were dogs, with the largest number of canine cases in Texas, Georgia and North Dakota. Dog cases did not appear to have a seasonal pattern.
• Small numbers of a variety of other species were diagnosed, including pigs, wolves, opossums, bobcats, coyotes, otters, bears, deer, mongooses (in Puerto Rico), groundhogs and beavers.
• The largest number of rabies cases occurred in Texas (969).
• The infections that occurred were due to several rabies virus variants in circulation in North America, including raccoon rabies virus, skunk rabies virus, arctic fox rabies virus, bat rabies virus and Texas gray fox rabies virus.  In each region of the continent, one or more of these rabies virus variants may be more common.
• No infections with canine rabies virus were identified. Dogs and coyotes were infected by other variants of the rabies virus, but not with the dog variant.  It is believed that dog-to-dog transmission of canine rabies virus no longer occurs in the US.
• The one human rabies case in 2007 occurred in Minnesota, and was probably due to exposure to a rabid bat.

More information on rabies can be found on the  Worms & Germs Resources page, and in the rabies archives.

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For more information on ringworm, see the Worms & Germs post Ringworm: Skin fungus by any other name.  The photos here show ringworm lesions on a person's arm and on a cat's face, respectively.  (Photo credits: A. Yu, Ontario Veterinary College)

Over the past several years, studies have shown that many environmental disinfectants sold and labeled for use against the fungi that cause ringworm (which are called dermatophytes) in animals and people are, in fact, not effective when used in households and veterinary clinics.  The problem is the chemicals are typically tested against a suspension of the organisms in a test tube, but in the “real world” the fungi are usually found on small fragments of infected hairs.  Its possible that the hair shaft protects the fungus from the actions of some disinfectants.

There are a few disinfectants that have been shown to be effective against dermatophytes even when they are found on infected hairs and skin cells in the environment.  The most readily available one is household bleach, used at concentrations of 1:10 to 1:100.  Other effective products include Virkon-S® (a detergent-peroxide based product) and Peroxigard® (an accelerated hydrogen peroxide product) . An environmental spray containing enilconazole (an antifungal agent that is also found in the topical medication Imaverol®) was also found to be very effective. This product is not approved for household use, but it is approved for use in catteries. It is also licensed as a topical treatment for dogs and horses in most of Europe and Canada.

Eliminating ringworm from the household or clinic environment can be difficult, because the fungus can be found anywhere that an infected animal (or person) sheds hair or skin cells.  Here are some guidelines for environmental disinfection of dermatophytes:

• All bedding, brushes, combs, rugs, cages, etc. should be vacuumed, scrubbed, and washed with hot water, detergent, and 1:100 chlorine laundry bleach, or another effective disinfectant (see above). It is best to throw out any items that cannot be thoroughly disinfected.
• Walls, floors, lamps, etc. should be scrubbed and cleaned in a similar manner.
• Carpeted areas may be impossible to effectively decontaminate. If possible, remove the carpet and either wash in hot water and bleach, or discard it. Otherwise, frequent vacuuming with immediate disposal of the collection bag is necessary.
• Vehicle interiors should be decontaminated as much as possible in a similar manner.
• Curtains can be “dry-cleaned” at a professional cleaner.
• Clean heating vents (from the house furnace) as well as possible. If the house is heated by hot air, change the furnace filter once weekly throughout the decontamination process.
• Cleaning and disinfection of the environment should be repeated at least once every 4-6 weeks (the more often, the better) until all affected animals and people have eliminated the fungal infection.

Obviously, environmental clean-up for ringworm is quite an undertaking.  If infection can be identified early, lesions can potentially be kept covered and movement of pets can be restricted to reduce the extent and amount of environmental contamination.

Special thanks to Dr. Anthony Yu (one of the veterinary dermatologists at the Ontario Veterinary College) for providing much of the information in this post, as well at the photos.

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You may notice a recurring theme in many of our posts and on virtually all of the information sheets on the Worms & Germs Resources page: an emphasis on handwashing. There is increasing emphasis on hand hygiene (i.e. hand washing and use of alcohol hand sanitizers) education in hospitals because the hands of healthcare workers are a major (if not the most important) means of disease transmission between patients. Despite hand hygiene being easy, cheap and effective, people rarely wash their hands as often as they should, and they often don't do it properly.

Most of the research about hand hygiene that has been published has focused on its use and impact in human hospitals, but this area is now also being studied more with regard to animals and veterinary medicine. A study published earlier this year in Veterinary Microbiology provided more evidence that hand hygiene is a critical infection control measure when dealing with animals. The study, coordinated by Dr. Maureen Anderson (of Worms&Germs fame) looked at MRSA carriage rate in veterinarians who work with horses. In addition to finding a high rate of MRSA carriage among these veterinarians (which was consistent with other reports indicating that equine vets are at higher than average risk for exposure to MRSA), the study looked at factors associated with MRSA carriage. Vets that reported routinely washing their hands between farms and those that reported washing their hands after contact with potentially infectious cases had a significantly lower rate of MRSA carriage. That should come as absolutely no surprise, but it's one more piece of evidence that we need to pay more attention to this routine infection control measure, in human hospitals, in veterinary environments and in households.

Remember, the 10 most important sources of infection are the fingers on your hands!

Click here for instructions on how to wash your hands properly.

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In Ontario, and many other regions, mid-August is the beginning of the high risk period for West Nile virus infection in people and animals such as horses. The Ontario Veterinary College has published an informational video on YouTube. This video has information about measures you can take to reduce the risk of West Nile virus exposure and disease, for both people and horses. Click on the image to watch the video.  More information about West Nile virus is also available in the blog post entitled West Nile virus in dogs and cats.

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A small outbreak of the potentially deadly Hendra virus was identified in a group of horses near Brisbane, Australia. This virus has caused periodic cases of illness and death in horses, and can be transmitted to people working closely with infected horses. In the latest outbreak, 3 horses have died, making this the worst outbreak since 1994 when 14 horses and 2 people died.  Now, a human case has been identified. This person works at a veterinary clinic that treated infected horses. This individual was admitted to hospital overnight but was discharged, so is presumably not very ill.

While Hendra virus (genus Henipavirus) is only found in Australia, it is a good reminder for everyone about the strange nature of some infectious diseases. The natural reservoir of the virus is the fruit bat. It is believed that horses become exposed when infected fruit bats give birth and contaminate horse pastures with uterine fluids. Horses develop respiratory disease ranging from mild to fatal. Human cases have been reported in people working closely with infected horses. A horse trainer and veterinarian's assistant died in the 1994 outbreak. Close contact is required for transmission to people.

Picture: Locations of previous Henipavirus outbreaks (red stars – Hendra virus; blue stars – Nipah virus) and distribution of Henipavirus flying fox reservoirs (red shading – Hendra virus; blue shading – Nipah virus)

It's very difficult to take specific measures to protect horses, people or other animals from sporadic, rare diseases such as Hendravirus infection. However, common sense infection control measures can reduce the risks associated with any animal contact.

• Wash your hands after contact with any animal.
• Avoid contact with sick animals - consider sick animals to be potentially infectious until proven otherwise.
• Remember that  new animal diseases are regularly being identified, and that they might be able to infect people.
• People that work in veterinary clinics must be diligent and use good infection control practices because they are at higher risk of exposure to various diseases.

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Recently, a story about a man who brought a horse into a hospital to visit his father was widely reported. The horse apparently made it to the man’s room, which included a trip in an elevator. The son, who appeared intoxicated, was eventually asked to leave (and take the horse with him). Said a hospital spokesperson “We do have a pet visitation policy, but it does not include a horse”. Strangely, the horse that was brought to the hospital apparently wasn’t even the father’s horse (which supports suspicions of the son’s lack of sobriety).

There are guidelines about which animals are appropriate for hospital visits, although it shouldn’t take an expert to figure out that a horse is not an appropriate candidate. Kicks, bites, and trauma from being crushed or run over are among the most obvious concerns. Horses can also carry a variety of bacteria that are potentially dangerous, especially to people in hospitals. These include Salmonella and methicillin-resistant Staphylococcus aureus (MRSA). There also aren’t that many house-trained horses out there.

So, while I can easily see how someone in a hospital would like to see his or her horse, there’s no way this should even be considered.

Some closing thoughts
-    Would you like to ride in an elevator with a horse?
-    Would you like to be stuck in an elevator with a horse?
-    Do you think the horse was house trained?
-    Do you think any of the healthcare personnel washed their hands after touching the horse?

This isn't the first time a horse has been in hospital, and some even get invited. The picture is from a story in Veterinary Practice News that described a program where horses were brought into hospitals!

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2011 ASM-ESCMID Conference on Methicillin-resistant staphylococci in animals

• Miconazole susceptibility of MRSA and MRSP
• Livestock associated MRSA in community hospitals in Ontario
• Equine hospital MRSA surveillance
• Biofilm production by S. pseudintermedius
• Methicillin-resistant staphylococcal pyoderma in dogs, and impact of treatment on colonization rates
• Surgical site infections in a small animal hospital

2011 University of Guelph Centre for Public Health and Zoonoses Symposium

• Pet ownership, interactions and animal-associated disease risks in Canadian households
• Metagenomic investigation of the oral microflora in healthy dogs

2011 Canadian Animal Health Laboratorians Conference

• Metagenomic investigation of the equine gastrointestinal microflora

2011 Canadian Association of Clinical Microbiology and Infectious Diseases

• MRSA contamination of the environment in 3 Ontario community hospitals

Coming soon

• 2011 American College of Veterinary Internal Medicine Forum, June
• 2011 ASM-ESCMID conference on methicillin-resistant staphylococci in animals, Sept

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