A Brockton, Massachusetts was euthanized after being bitten by a rabid skunk, because of a combination of the rabies diagnosis, vaccination lapse and regulatory inflexibility. The 10 yr-old schnauzer cross was bitten in its yard, and the skunk was subsequent caught, tested and diagnosed as rabid.
Clearly, this needs to be considered rabies exposure. But, what needs to be done?
- If the dog was up-to-date on its vaccines, it would receive a booster vaccination and be subject to a 45d observation period.
- If unvaccinated, it would be boosted and quarantined for 6 months, or euthanized.
However, a dog doesn’t suddenly go from protected to unprotected immediately after the 1 yr or 3 yr vaccination duration passes. 1 yr and 3 yr are nice easy dates and vaccines are known to provide that degree of protection, but since vaccine-induced antibodies aren’t programmed to self-destruct on a specific best before date, there’s a grey area with animals whose vaccination has lapsed. Here, the dog was two weeks overdue….immunologically probably almost identical to what its rabies status was at the time his vaccination lapsed.
“It is really sad. My heart goes out to the animal’s owner,” Animal Inspector Megan Hanrahan said. “But those two weeks make the animal not covered.”
Yet, it’s not that clearcut. NASPHV guidelines state “Animals overdue for a booster vaccination should be evaluated on a case-by-case basis based upon severity of exposure, time elapsed since last vaccination, number of previous vaccinations, current health status, and local rabies epidemiology to determine need for euthanasia or immediate revaccination and observation/isolation.”
It’s definitely grey and being bitten by a rabid skunk is concerning but a 10 yr old dog that was 2 weks overdue (and probably vaccinated many times over its life) certainly deserved some consideration of this grey area. I think a 45d observation period would be entirely justifiable here.
Regardless, this is a good reminder of why people need to pay attention to vaccination dates and ensure that their animals are properly vaccinated (and, no, testing antibody titres does not replace the need for vaccination).
OK…time to get back to work writing. A couple weeks of conference organizing and uncountable Ebola calls are hopefully winding down, so back to the neglected blog.
This bug is an obscure one that I write about regularly, Capnocytophaga canimorus. It’s found in the mouth of most dogs, so people are commonly exposed to it. It usually never causes a problem, but when it does, it’s bad. Capnocytophaga infections classically occur in people that don’t have a functional spleen, alcoholics or that have compromised immune systems. We focus on education of those high-risk people about avoiding dog saliva and bite-management practices. But, as with most things in infectious diseases, there are few “never’s”, and there are sporadic reports of infections in people that are (seemingly, at least) otherwise healthy.
Another report appeared in a recent volume of Infection, “A case of Capnocytophaga canimorsus sacral abscess in an immunocompetent patient “(Joswig et al). I’ll spare you all the details, but this person developed an abscess in the sacrum (the bone at the base of your spine), with a pet dog being the presumed source. There was no obvious source of exposure such as a bite, and the person had no apparent risk factors, so it’s an unusual case. The fact that it was an abscess and not an overwhelming systemic infection (as is often the case) is also unusual, and may relate to the fact that this person had a normal immune system that was able to prevent a rapid, life-threatening infection.
This report doesn’t really change anything, but it’s another indicator that some of these potentially nasty infections that we associate mainly with high-risk people can also occur in healthy individuals. This doesn’t mean we should be paranoid of dogs, but we should be practically cautious. Avoiding contact with saliva, avoiding bites and proper bite first aid are all basic measures that can presumably go a long way to helping prevent a wide range of infections.
Since I’ve spent most of my day answering questions about Ebola, here are some of the common Q&As.
Can dogs be infected with Ebola?
Yes, but what that really means is unclear. Most of the available information comes from a study in Gabon where they tested dogs in a community during an Ebola outbreak. They found antibodies against the virus in a large percentage of dogs. That’s not really surprising, as these dogs were apparently scavenging bodies of people and animals that had died from Ebola. So, it’s not hard to see how they’d be exposed.
Having antibodies against the virus means the virus got into their body and the body mounted an immune response. That doesn’t mean the dogs got sick or that they were shedding the virus. In that study, they could not find evidence of the virus in the dogs’ bodies. That doesn’t mean it was never there at relevant levels, but they couldn’t find it at the time.
Can dogs infect people with Ebola?
That’s the big question. Dogs can get infected (see above), but IF the virus can reproduce in a dogs and IF the virus is then present in adequate levels in blood and other secretions, THEN there would be the potential for dogs to be a source of human infection. That’s a lot of IFs for which we don’t have good information.
What do I think?
I think the risk of transmission of Ebola from dogs is very low. There’s currently no evidence that dogs have an important (or any) role in transmission of the virus in natural situations. It’s not zero risk (there aren’t many "it can never happen" situations with emerging diseases), and considering the how deadly the disease is the measures that can be used to mitigate that risk (small though it may be) are important.
So, how can we reduce the risk with an exposed dog?
Basically, treat the dog the same way you would treat a person with Ebola exposure or infection. An exposed person is quarantined and monitored for signs of disease. People are not infectious until they are sick. A sick person is handled with strict infection control precautions because of the potential that the virus is present in various body secretions.
With a dog, it’s probably warranted to err on the side of caution and treat an exposed dog like an infected person. Why? Because we don’t know that dogs are not infectious until they’re sick. So, it might be best to have them isolated and handled with strict biosafety practices, rather than just watch them at home (particularly given the potential for the dog to escape the house).
Is that degree of containment practical?
Maybe. It depends on the facility, personnel and motivation. Last week, I sketched out a containment plan for our facility in case we had a suspect case. It was done knowing there’s virtually no chance it would be needed, but it was a good mental exercise to consider what to do. The more you think about it, the more complex it can get. Containment is possible for a good facility with reliable personnel and a clear containment plan. However, you can’t just drop the dog off at any kennel, shelter or veterinary clinic and say "we’ll be back for it in 21 days." You need the right facility and personnel, and access to that will be variable.
There’s prudence and then there’s "let’s kill it so we don’t have to think about it."
The Spanish response to Ebola in a nursing assistant is a demonstration of the latter. Health Officials in Spain have obtained a court order to "euthanize and incinerate" the dog owned by a nursing assistant who was infected with Ebola virus while caring for a Spanish priest who acquired the infection in Sierra Leone. The case has received a lot of attention, as the first case of Ebola from this outbreak that was acquired outside of Africa.
There’s obviously cause for concern and prudence, and the woman’s husband is logically in quarantine. However, euthanasia of the dog seems like overkill. Yes, we have to be careful. But we don’t need to overreact.
The odds of this dog being infected are very, very slim. Even if the dog was infected, there is no evidence that dogs are a source of infection. The concern about dogs has been around dogs eating carcasses of other animals that have died of Ebola virus infection, and direct contact with people with active disease. In one study in a village in Gabon during an Ebola outbreak, a large percentage of dogs had antibodies against the virus, indicating exposure (Allela et al, Emerging Infectious Diseases 2005). But, exposure doesn’t mean the dogs were ever able to transmit the virus, and eating a body full of Ebola virus is very different from living in the house with one person in the early stage of infection.
I’m not saying transmission from a dog in some form or another is impossible, or that no precautions are required for pets that have been in contact with an infected person. In some ways, it’s good to see animals considered in this scenario. However, why not take the opportunity to quarantine and test the dog to see if it was infected? That would be better for the dog, for its owner, and for the next time the situation occurs. You can’t answer all the questions with one dog, but you can start to gather information. Euthanasia is the easy knee-jerk approach that removes all risk, but there are ways to house and monitor a dog for a few weeks with no contact. Since Ebola virus is spread by direct contact with infectious body fluids, it’s containable with good facilities and appropriate precautions. To me, that would have been a better approach from many aspects.
Awareness is good.
Being proactive is wise.
Being paranoid? That’s another story.
As this unprecedented Ebola virus outbreak in West Africa continues to expand, many people in North America have journeyed from ignoring it, to considering it a disease that you only get if you’re in Africa, to thinking they need for move to some remote island and live in a bio-bubble to avoid it.
With news reports of people being quarantined in North American hospitals because they returned from West Africa with a fever, and with a confirmed case in a person who travelled from Liberia to Dallas, some people are freaking out. Among the frequent alarmist responses is a demand for a full ban on any travel from West Africa (or even Africa as a whole, from people who don’t realize the distance from Liberia to South Africa is over 5000 km, similar to the distance from New York to Alaska).
With a virus that is relatively poorly transmissible and only transmitted when people are symptomatic, reasonable travel controls and attention by healthcare workers (a big "oops" occurred in Dallas in this case) should prevent this virus for establishing any kind of foothold in North America.
People need to put things in perspective. Most likely, there will be no locally transmitted North American Ebola deaths this year. At the same time, tens of thousands of people in North America will die from seasonal flu.
...I wonder how many of the people screaming for a lock-down on Africa got a flu shot last year.
The salmonellosis outbreak in the US associated with hatching chicks continues to expand. The outbreak, ironically associated with Mt. Healthy Hatcheries in Ohio, has now sickened at least 344 people in 42 US states and Puerto Rico with a variety of Salmonella serotypes (S. Infants, S. Newport and S. Hadar). The outbreak shows no sign of abating, with another 42 cases identified in the past 6 weeks.
As is often the case, young people are more often affected, with 33% of sick individuals being 10 years of age or younger. Thirty-two percent of infected individuals have been hospitalized.
Unfortunately, the regulatory response in situations like this is most often to give places like the hatchery in question "guidance" as opposed to imposing mandatory measures. However, this is really a "buyer beware" situation, in which people purchasing hatching chicks need to be aware of the high risks associated with young poultry, and take appropriate precautions to manage them. While Salmonella-free eggs and chicks would be ideal, it’s not particularly realistic. People need to be more proactive themselves and listen to established infection control practices, which include keeping kids less than five years of age away from young poultry.
Hopefully schools will pay attention to these recommendations when they’re planning their annual (and often poorly managed) hatching chick activities in the spring.
Here’s a question that I get commonly: “What do I do to an outdoor area that might have been contaminated by a dog with parvovirus?”
There’s not a lot of research to back anything up, but understanding the virus and some basic principles helps us come up with some reasonable recommendations.
- Highly tolerant of environmental exposure, disinfectants and other things that kill most viruses.
- Shed in potentially massive amounts in the feces of sick animals, but also potentially by some healthy animals.
- The cause of a potentially fatal disease.
- A pathogen against which we have effective vaccines.
- Really only a concern for unvaccinated (or inadequately vaccinated) dogs.
There’s definitely cause for concern if a puppy with parvo infection has passed diarrhea outside. We can assume there’s lots of virus there, and that the virus is going to be able to survive there for some time. We don’t know how long, and it will certainly vary with environmental conditions (e.g. temperature, pH of the soil, humidity, sunlight), but it’s safe to assume that it will be a fairly long time in most situations.
So, what do we do?
- Disinfection of outdoor surfaces is pretty futile. Disinfectants don’t work well in the presence of organic debris (dirt), so pouring disinfectants on grass or gravel will not likely do much (except put a lot of disinfectant residue into the environment). Unless it’s happened on a surface like concrete or asphalt (both of which can still be hard to adequately disinfect because they are porous), leave the bleach bottle in the cupboard.
- Removing feces is a good first step. This actually removes the vast majority of virus that has been passed. It might require using a shovel to get rid of some of the diarrhea-soaked grass or soil, but removing as much of the visible contamination as possible is key.
- Restricting access to the area can’t hurt, when it’s feasible. That doesn’t mean cordoning it off and keeping everyone away. The focus should be to keep young, unvaccinated or incompletely vaccinated dogs (and dogs that have contact with those dogs) away from the area.
- Raking the site can help turn over the substrate (e.g. dirt, soil, gravel) and get more exposure to UV light. Sunlight is our best outdoor disinfectant, and raking can help expose virus particles that are hidden away.
As always, prevention is better than cure. Preventing these situations is ideal, but admittedly not always possible. Things that can help include:
- Making sure all puppies are properly vaccinated.
- Keeping unvaccinated puppies away from high dog-traffic areas.
- Keeping sick animals away from public areas.
- Promptly picking up feces from any dog, healthy or not.
Well, "news" perhaps isn’t the best description since we’ve been seeing it for a while, but a paper in an upcoming edition of the Journal of Clinical Microbiology (Gold et al. 2014) entitled "Amikacin resistance in Staphylococcus pseudintermedius isolated from dogs" provides published support for the trend we’ve been seeing.
Staphylococcus pseudintermedius is an important cause of infections in dogs, and a resistant form, MRSP (methicillin-resistant Staph pseud) is a major problem. MRSP also does a great job of becoming resistant to additional antibiotics, usually by picking up resistance genes from other bacteria. We’ve rapidly lost most of our typical antibiotic treatment options for many MRSP strains, and are left with only a couple of viable drugs. One of those is amikacin, an antibiotic we try not to use when we don’t have to because it has to be injected, and because it can be hard on the kidneys. However, it’s literally a lifesaver in some cases.
Over the past year or two (unsurprisingly, really), we’ve been seeing some amikacin resistance in MRSP strains. I say that’s unsurprising because, with bacteria in general (and MRSP in particular), we’re trapped in a game of "use it and lose it." Any time we use an antibiotic, there is some potential for resistance to develop.
The study by Gold et al looked at 422 Staph pseud from dogs, and found that MRSP were significantly more likely to be amikacin resistant, with a rather astounding 37% amikacin resistance rate in their MRSP collection. Amikacin-resistant strains were also more likely to be resistant to a range of other antibiotics, regardless of their methicillin-resistance.
What do we do?
Tough question. Bacteria eventually seem to outsmart us most of the time (or we seem to "out-dumb" them, since it’s often our poor use of antibiotics that leads to problems).
So, what can be done?
Prevention is better than cure: MRSP infections are almost invariably secondary problems. Preventing or limiting underlying disease (e.g. controlling allergic skin disease) can greatly reduce the number of infections and the amount of antibiotics used to treat them.
Infection control: MRSP surgical site infections are increasingly common, and using good infection control practices should help limit them.
Use them right: Making sure drugs are given as prescribed with proper dosing (amount and frequency), and limiting the use of the few remaining MRSP treatment options for cases that really need them are important.
Antibiotic alternatives: Antibiotics aren’t always needed to treat infections. Topical therapy with things like chlorhexidine shampoo can be highly effective for skin infections, and can save antibiotics for infections that can't be treated otherwise.
Will these steps stop the scourge of antibiotic resistance?
No. But they might buy us some more time to figure out how to better handle this and to save some of our limited remaining antibiotic options.
While having nothing to do with my previous rants on the topic, the FDA has issued warning letters to the manufacturers of Angels' Eyes and similar products that are vaguely disguised antibiotics sold for purely cosmetic reasons, and without a veterinary prescription. These products have been widely available to decrease tear staining (hardly a life-threatening problem) in dogs, fully at odds with any concepts of prudent antibiotic use.
Here’s some of the FDA letter text:
“We have determined that your tear stain remover products containing tylosin tartrate are intended for use in the mitigation, treatment, or prevention of disease in animals, and/or to affect the structure or function of the body of animals, which makes them drugs under section 201(g)(1) of the Federal Food, Drug, and Cosmetic Act (the FD&C Act) [21 U.S.C. § 321(g)(1)]. Statements on your labeling, including your website and product labels, that establish these intended uses of your products include, but are not limited to, the following:
• "The active ingredient in Angels' Eyes®, Tylosin as Tartrate, will prevent your dog from contracting Ptyrosporin (Red Yeast) and bacterial infections which causes excess tearing and staining."
• "May help keep tear stains away by reducing oxidation released through tear ducts."
• "Angels' Eyes® is the first product specifically developed for BOTH DOGS & CATS to help eliminate unsightly tear stains from the inside out!"
• "Only ANGELS' EYES® helps give your pets tear stain free eyes and bright coats."
In addition, your tear stain remover products containing tylosin tartrate are new animal drugs, as defined by section 201(v) of the FD&C Act, [21 U.S.C. § 321(v)], because they are not generally recognized among experts qualified by scientific training and experience to evaluate the safety and effectiveness of animal drugs, as safe and effective for use under the conditions prescribed, recommended, or suggested in the labeling. You are using Tylovet Soluble (tylosin tartrate) as an ingredient in the formulation of your product. Although Tylovet Soluble is an approved drug, your use of Tylovet Soluble in your product is not a use covered by its approved application, and your products are not the subject of an approved new animal drug application, conditionally approved new animal drug application, or index listing under sections 512, 571, and 572 of the FD&C Act [21 U.S.C. §§ 360b, 360ccc, and 360ccc-1]. Therefore, the products are unsafe within the meaning of section 512(a) of the FD&C Act, [21 U.S.C. § 360b(a)], and adulterated under section 501(a)(5) of the FD&C Act [21 U.S.C. § 351(a)(5)]. Introduction of an adulterated drug into interstate commerce is prohibited under section 301(a) of the FD&C Act [21 U.S.C. § 331(a)].
We acknowledge the receipt of three written responses submitted after the inspection in December 2013. These responses discuss your facility's compliance with the Current Good Manufacturing Practices for Finished Pharmaceuticals (Title 21 Code of Federal Regulations Part 211 ). However, your responses do not adequately address our concerns regarding the approval status of your products and your use of tylosin tartrate in those products, as discussed above.
Failure to promptly correct the violations specified above may result in enforcement action without further notice. Enforcement action may include seizure of violative products and/or injunction against the manufacturers and distributors of violative products. “
Interestingly, there’s no mention of anything on the Angels' Eyes website. It will be interesting to see what happens, but it’s great to see some attention paid to this completely illogical use of antibiotics. Hopefully the FDA follows through with this and doesn’t leave it at the warning letter stage.
Sorry… nothing to do with zoonotic diseases, but still entertaining. Our two iPads stopped working over one weekend last October. Figuring they were destined for recycling, I came across some internet posts that said “whack it.” I figured that I had nothing to lose and if nothing else, I’d get the satisfaction of beating on an Apple product. However, it worked. They came back to life with some pretty solid impacts (my knee was sore after) and have needed periodic "re-treatments" since. Lately, one has required a pretty solid thrashing with a rubber mallet, as can be seen in the video.